Perspectives on the effect of nodal downstaging and its implication of the role of surgery in stage IIIA (N2) non-small cell lung cancer

Multimodality Treatment and Salvage Surgery for the Treatment of Lung Cancer

Lung cancer remains the leading cause of cancer deaths in the United Kingdom. For locally advanced disease, multimodality treatment is recommended, which includes a combination of chemotherapy, radiotherapy, surgery and, more recently immunotherapy. Options depend on the resectability of the cancer and there has been debate about the optimal treatment strategy: surgery may be planned to follow chemoradiotherapy (CRT), be offered for residual disease after CRT, or given as salvage therapy for patients treated with CRT who have later relapse of their disease. We conducted a retrospective analysis of all patients who underwent CRT and surgical resection under a single surgical team and performed a descriptive study after dividing the patients into these three groups. For the planned trimodality group, 30-day mortality this was 7% (n = 1) and 1-year survival was 78.6%; the residual disease group had a 30-day mortality rate of 0% and 1-year survival of 81.3%; for the salvage group, the figures were 0% and 62.5%, respectively. The median overall survival of the study population was 35.8 months. Median overall survival in the trimodality group was 35.4 months (20.1-51.7 interquartile range IQR), for the residual group was 34.2 months (18.5-61.0 IQR). and for the salvage group was 35.8 months (32.4-52.7 IQR).).

Neoadjuvant atezolizumab and chemotherapy in patients with resectable non-small-cell lung cancer: an open-label, multicentre, single-arm, phase 2 trial

BACKGROUND

Approximately 25% of all patients with non-small-cell lung cancer present with resectable stage IB-IIIA disease, and although perioperative chemotherapy is the standard of care, this treatment strategy provides only modest survival benefits. On the basis of the activity of immune checkpoint inhibitors in metastatic non-small-cell lung cancer, we designed a trial to test the activity of the PD-L1 inhibitor, atezolizumab, with carboplatin and nab-paclitaxel given as neoadjuvant treatment before surgical resection.

METHODS

This open-label, multicentre, single-arm, phase 2 trial was done at three hospitals in the USA. Eligible patients were aged 18 years or older and had resectable American Joint Committee on Cancer-defined stage IB-IIIA non-small-cell lung cancer, an Eastern Cooperative Oncology Group performance status of 0-1, and a history of smoking exposure. Patients received neoadjuvant treatment with intravenous atezolizumab (1200 mg) on day 1, nab-paclitaxel (100 mg/m²) on days 1, 8, and 15, and carboplatin (area under the curve 5; 5 mg/mL per min) on day 1, of each 21-day cycle. Patients without disease progression after two cycles proceeded to receive two further cycles, which were then followed by surgical resection. The primary endpoint was major pathological response, defined as the presence of 10% or less residual viable tumour at the time of surgery. All analyses were intention to treat. This study is registered with ClinicalTrials.gov, NCT02716038, and is ongoing but no longer recruiting participants.

FINDINGS

Between May 26, 2016, and March 1, 2019, we assessed 39 patients for eligibility, of whom 30 patients were enrolled. 23 (77%) of these patients had stage IIIA disease. 29 (97%) patients were taken into the operating theatre, and 26 (87%) underwent successful R0 resection. At the data cutoff (Aug 7, 2019), the median follow-up period was 12·9 months (IQR 6·2-22·9). 17 (57%; 95% CI 37-75) of 30 patients had a major pathological response. The most common treatment-related grade 3-4 adverse events were neutropenia (15 [50%] of 30 patients), increased alanine aminotransferase concentrations (two [7%] patients), increased aspartate aminotransferase concentration (two [7%] patients), and thrombocytopenia (two [7%] patients). Serious treatment-related adverse events included one (3%) patient with grade 3 febrile neutropenia, one (3%) patient with grade 4 hyperglycaemia, and one (3%) patient with grade 2 bronchopulmonary haemorrhage. There were no treatment-related deaths.

INTERPRETATION

Atezolizumab plus carboplatin and nab-paclitaxel could be a potential neoadjuvant regimen for resectable non-small-cell lung cancer, with a high proportion of patients achieving a major pathological response, and manageable treatment-related toxic effects, which did not compromise surgical resection.

FUNDING

Genentech and Celgene.

Salvage surgery for advanced non-small cell lung cancer after targeted therapy: A case series

Background

Tumor recurrence or residual tumor after targeted therapy is common in patients with advanced non‐small cell lung cancer (NSCLC). There is a lack of high‐level evidence on which type of treatment should be employed for these patients and the role of salvage surgery has not been well reported in the literature.

Methods

A retrospective analysis of patients who underwent salvage surgery in our center between January 2016 and June 2019 for advanced NSCLC after targeted therapy was performed.

Results

A total number of nine patients were identified, including five males and four females, with a median age of 56 years (range, 40–65 years), all diagnosed with lung adenocarcinoma stage IIIa–IVb. All patients had received targeted therapy according to individual positive mutation of driver gene(s). Salvage surgery was performed for tumor recurrence or residual tumor after a duration of 2–46 months of targeted therapy. A negative surgical margin was achieved in all cases. Postoperative complication rate was 11.1% (1/9). All patients were alive at the time of this analysis and two patients had disease progression. After a median follow‐up of 17 months (range: 5–44 months), the median event‐free survival and postoperative survival was 14 months (range: 2–44 months) and 17 months (range: 5–44 months) respectively.

Conclusions

Salvage surgery may be a feasible and promising therapeutic option for tumor recurrence or residual tumor in advanced NSCLC in selective patients after targeted therapy.

Key points

Salvage surgery is feasible in selected patients with advanced NSCLC and provides promising survival outcomes after targeted therapy failure.

Salvage surgery provides precise molecular and pathological information which is most important for subsequent therapy.