Cytoreductive surgery and hyperthermic intrapleural chemotherapy for malignant pleural diseases: preliminary experience

de Hingh I, Houwink AP, Stoevelaar HJ, Sonke GS, van Driel WJ. Standardizing HIPEC and perioperative care for patients with ovarian cancer in the Netherlands using a Delphi-based consensus

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Implementation of HIPEC for ovarian cancer is ongoing, aiming to offer this treatment to all eligible patients in the Netherlands.

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Standardization reduces unwanted variation in clinical treatment.

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We intend to standardize patient selection, technical aspects, and perioperative care of CRS and HIPEC.

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This consensus study comprised a two-phase modified Delphi approach.

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Consensus was reached on 82% of items.

Objective

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is standard of care in the Netherlands in patients with stage III epithelial ovarian cancer following interval cytoreductive surgery (CRS). Differences in patient selection, technical aspects, and perioperative management exist between centers performing HIPEC. Standardization aims to reduce unwanted variation in clinical practice. As part of an implementation process, we aimed to standardize perioperative care for patients treated with CRS and HIPEC using a Delphi-based consensus approach.

Methods

We performed a two-phase modified Delphi method involving a multidisciplinary panel of 40 experts who completed a survey on CRS and HIPEC. During a consensus meeting, survey outcomes and available scientific evidence was discussed. Items without consensus (<75% agreement) were adjusted and evaluated in a second survey.

Results

Consensus was reached in the first round on 51% of items. After two rounds, consensus was reached on the majority of items (82%) including patient selection, preoperative workup, technical aspects of CRS and HIPEC, and postoperative care. No consensus was reached on the role of HIPEC in rare ovarian cancer types, preoperative bowel preparation, timing to create bowel anastomoses, and manipulation of the perfusate.

Conclusions

Dutch experts reached consensus on most items regarding interval CRS and HIPEC for ovarian cancer. This consensus study may help to align treatment protocols and to minimize practice variation. Topics without consensus may be put on the research agenda of HIPEC for ovarian cancer.

Medical Thoracoscopic Thermal Ablation Therapy for Metastatic Pleural Tumors with Malignant Effusion: An Exploratory Retrospective Study

Purpose

Malignant pleural effusion (MPE) is an intractable condition. The current mainstream therapies for MPE, ie, indwelling pleural catheter and pleurodesis, have some drawbacks. In this retrospective study, we explored the efficacy and safety of medical thoracoscopic thermal ablation (argon plasma coagulation, APC) therapy for metastatic pleural tumors with MPE.

Patients and Methods

A total of 176 patients were enrolled and divided into catheter pleural drainage (CPD) group (n = 77), non-ablation group (n = 46), and thermal ablation group (n = 53). Propensity score matching (PSM) was used for between-group comparisons to minimize bias. The primary endpoints were pleural effusion objective response rate (ORR) and time to progression (TTP); secondary endpoints included overall survival (OS), chest-tube duration, and safety.

Results

Thermal ablation group and non-ablation group showed significantly higher ORR and shorter chest-tube duration versus the CPD group (ORR: thermal ablation, 88.2% vs 66.7%, P = 0.004; non-ablation, 88.4% vs 64.4%, P = 0.042; chest-tube duration: thermal ablation, 4.90 vs 7.24 days, P < 0.001; non-ablation, 5.73 vs 7.33 days, P = 0.010). Thermal ablation group exhibited longer TTP than the CPD group (median, 13.7 vs 7.3 months, P = 0.001) and the non-ablation group (median, 13.6 vs 10.3 months, P = 0.037). OS in the thermal ablation group was numerically longer than that in the CPD group with marginally significant difference (P = 0.055). There was no significant difference in the frequency of adverse events or changes in vital signs between thermal ablation and non-ablation groups.

Conclusion

Medical thoracoscopic thermal ablation (APC technique) therapy was effective and safe in the treatment of metastatic pleural tumors with MPE for improving ORR and TTP.

Better effect of intrapleural perfusion with hyperthermic chemotherapy by video-assisted thoracoscopic surgery for malignant pleural effusion treatment compared to normothermic chemoperfusion of the pleural cavity

Objective

The aim of this study was to assess the efficacy and safety of intrapleural perfusion with hyperthermic chemotherapy (IPHC) in treating malignant pleural effusion (MPE) compared to normothermic chemoperfusion of the pleural cavity (NCPC), and to investigate the better treatment to control MPE.

Methods

Malignant pleural effusion patients were enrolled in the study and treated with NCPC or IPHC under video‐assisted thoracoscopic surgery (VATS). The chest drainage duration, clinical characteristics, and recurrence time of pleural effusion of patients were collected for statistical analysis. The chi‐squared test and the Fisher's exact test were applied to compare the distribution differences in categorical variables. Progression‐free survival (PFS) was estimated by the Kaplan–Meier method and was compared by the log‐rank test. The survival analysis was performed using the Cox proportional hazards method.

Results

A total of 37 MPE patients were enrolled in this study. Twenty‐seven patients received NCPC and 10 patients received IPHC under VATS. Significant differences were found in pathological types (p = 0.011), chest drainage duration (p = 0.005), and remission rate (p = 0.009) between two different treatment groups. The chest drainage duration of IPHC under VATS was shorter than the NCPC group (t = 2.969, p = 0.005). The remission rate of MPE in IPHC group was better than the NCPC one (OR = 0.031, 95% CI: 0.002–0.507, p = 0.015). The result of the Kaplan–Meier method showed that IPHC group could significantly prolong the PFS of patients with MPE compared to NCPC group (log‐rank p = 0.002). Univariate cox regression analysis showed that patients with MPE in the IPHC group presented significant longer PFS than the NCPC group (HR = 0.264, 95% CI: 0.098–0.713, p = 0.009). Multivariate cox regression analysis further verified this conclusion (HR = 0.268, 95% CI: 0.096–0.753, p = 0.012).

Conclusion

Compared to the NCPC, the IPHC under VATS presents a better control effect on MPE, shorter tube placement time, and longer complete remission time. For this reason, we recommend IPHC under VATS as the first‐line treatment for patients with MPE those who can tolerate minimally invasive surgery.

Assessment of concentration and penetration depth of cisplatin in human lung tissue after decortication and hyperthermic exposure

Background

Hyperthermic perfusion of the pleural cavity with cisplatin after pleurectomy/decortication is an additional therapeutic option to reduce local relapse of malignant pleural tumours. Although there are data on the clinical effect, only little is known about the local impact on human lung tissue by cisplatin. The objective of this experimental study is to evaluate both the concentration and the penetration depth of cisplatin in human lung tissue after normothermic and hyperthermic exposure under ex-vivo-in-vitro conditions.

Methods

This study was approved by the local ethics committee. In total, 46 patients underwent elective lobectomy and wedge resections were taken from the resected lobes. A decortication of the visceral pleura was performed under ex-vivo conditions, and the tissue samples were incubated with cisplatin (c =0.05 mg/mL) at 37, 42 or 45 °C for 60 minutes. Then the mass concentration of platinum was measured with flameless atomic absorption spectroscopy and then converted into cisplatin concentration. In addition, the current data were compared with previous data of our working group (42 °C, without decortication).

Results

The overall maximum penetration depth was 7.5 mm due to limitations of our methods. The functional maximum penetration depth did not vary with temperature (P=0.243) but by decortication (P<0.001). The cisplatin concentration decreased with increasing penetration depth (P<0.001). An increase of temperature showed no effect on the cisplatin concentration in decorticated tissue samples (P=0.985). However, decortication at 42 °C significantly increased the cisplatin concentration in comparison to not decorticated tissue samples (P=0.005).

Conclusions

Decortication of the visceral pleura increases the cisplatin concentration in the lung tissue. Therefore, it possibly reduces the likelihood of a local relapse. An increase of temperature did not show any effect.

Hyperthermic intrathoracic chemotherapy (HITHOC): narrative review of the current literature, recommendations and future studies

Although the method of hyperthermic intrathoracic chemotherapy (HITHOC) after cytoreductive surgery is known for more than 20 years now, the interest of the scientific community has been growing especially in recent years with annually increasing numbers of publications. The feasibility and safety of HITHOC has already been demonstrated. The primary objective now is to reach a consent about the optimal implementation and standardization of the procedure. In the international clinical practice of HITHOC the parameters of temperature, duration, type and number of chemotherapeutic agents vary, making a comparison of the short- and long-term results difficult. For about ten years, the combination of surgical cytoreduction and HITHOC has been performed more routinely in several departments of thoracic surgery in Germany, especially in university hospitals. Recently, a group of experts for thoracic surgery of five departments of thoracic surgery elaborated recommendations for the HITHOC procedure in Germany. These recommendations represent a standardized and consistent implementation of HITHOC. Through this, postoperative complications associated to HITHOC should be reduced and a better comparison of the results should be enabled. This article is intended to give a brief overview of the literature, current recommendations in the implementation of HITHOC and also aims to show future perspectives of this procedure.

Protocol of a retrospective, multicentre observational study on hyperthermic intrathoracic chemotherapy in Germany

INTRODUCTION

Objective of the 'German hyperthermic intrathoracic chemotherapy (HITOC) study' is to evaluate the HITOC as additional treatment after surgical cytoreduction for malignant pleural tumours. Even though HITOC is applied with increasing frequency, there is no standardised therapy protocol concerning the technique of HITOC, the selection as well as dosage of chemotherapeutic agents and perioperative management in order to provide a safe and comparable, standardised treatment regime.

METHODS AND ANALYSIS

This trial is a retrospective, multicentre observational study, which is funded by the German Research Foundation. Approximately 300 patients will be included. Four departments of thoracic surgery, which are performing the most HITOC procedures in Germany, are contributing to this study: Center for Thoracic Surgery at the University Hospital Regensburg, Thoracic Clinic Heidelberg of the University of Heidelberg, Center for Thoracic Surgery of the Hospital University of Munich and the Department of Thoracic Surgery at the University Hospital Freiburg. All patients who underwent surgical cytoreduction and subsequent HITOC at one of the four centres between starting the HITOC programme in 2008 and December 2019 will be included. Information on the performed HITOC will be obtained, focusing on the technique as well as the applied perfusion solution including the chemotherapeutic agent. Furthermore, parameters of the patient's postoperative recovery will be analysed to determine 30-day morbidity and mortality.

ETHICS AND DISSEMINATION

The approvals by the local ethics committee of the respective clinic and the three participating clinics have been obtained. The results will be presented in conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00015012; Pre-results).

Does cytoreduction surgery and hyperthermic intrathoracic chemotherapy prolong survival in patients with N0-N1 nonsmall cell lung cancer and malignant pleural effusion?

INTRODUCTION

Debulking surgery and hyperthermic intrathoracic chemotherapy (HITHOC) has been successfully used in the treatment of thoracic tumours. Few authors report on the feasibility of its use in patients with lung cancer and malignant pleural effusion. The aim of this study was to evaluate the efficacy and results of debulking surgery and HITHOC in the treatment of selected patients with nonsmall cell lung cancer (NSCLC) and malignant pleural effusion.

METHODS

A systematic review was conducted in MEDLINE in accordance with PRISMA guidelines. The word search included: "hyperthermic intrathoracic chemotherapy and/or HITHOC or hyperthermic intrapleural". Inclusion criteria were only those studies reporting a sufficient amount of data on HITHOC and surgery for lung cancer. Single case reports and review articles were excluded.

RESULTS

20 articles were selected as they related to the topic of HITHOC and lung cancer. Most were from China (n=8) and Japan (n=6). Only four out of the 20 articles had sufficient data for this review. In total, data for 21 patients were collected. Debulking surgery ranged from wedge resection to pneumonectomy and pleurectomy. Mean survival was 27 months and median survival was 18 months (range 1-74 months). 13 patients out of 21 (62%) were alive at 1 year and six (28.5%) were alive at 2 years. 10 patients were still alive at the time of the respective publication in the 21 patients included. Systemic toxicity and treatment-related mortality were nil. There were insufficient data to perform a meta-analysis.

CONCLUSION

Although reported survival in this systematic review is encouraging, available evidence concerning debulking surgery and HITHOC in N0-N1 NSCLC with malignant pleural effusion is weak. Better evidence in the form of a randomised controlled trial is mandatory.

[Hyperthermic intrathoracic chemotherapy in thoracic surgery]

In regional chemotherapy of the pleural space a differentiation is made between intrapleural hyperthermic perfusion (IHP) and hyperthermic intrathoracic chemotherapy (HITOC). The HITOC in particular is carried out as an additive procedure after surgical cytoreduction of the pleural tumor manifestation. The main indications are for malignant pleural mesothelioma and thymoma with pleural spread (stage IVa), whereas treatment of secondary pleural carcinomatosis is indicated only in selected patients suitable for resection followed by HITOC. Cisplatin is the standard chemotherapeutic agent and a concentration of 150-175 mg/m² body surface area is recommended. Postoperative, HITOC-related complications (e.g. renal insufficiency) can be minimized by an adapted perioperative management. Safety measures should be accomplished adhered to for the protection of personnel. The aim of HITOC is to achieve a better local tumor control with a corresponding longer recurrence-free and overall survival.

Extended pleurectomy decortication: the current role

Extended pleurectomy/decortication (EPD) has been formally defined but there remain technical areas of debate between practitioners. This is partly attributable to the relative rarity of this operation which is largely confined to a small number of specialist centres. Nevertheless, there is a widespread acceptance that extended pleurectomy/decortication (P/D) is a realistic and favourable alternative to extrapleural pneumonectomy. There may, however, remain a small number of clinical cases where this more extensive operation may be indicated. Preservation of the lung has widened the selection criteria for this form of radical mesothelioma surgery but there remain important factors to consider when offering extended P/D. In many patients with poorer prognostic factors the less radical operation of video assisted partial pleurectomy may be preferable. However, a randomized trial showed no survival benefit for this operation over simple talc pleurodesis. The future for P/D may also lie in the outcome of the MARS2 randomized controlled trial which will report in the next few years. Meanwhile there is a clinical and ethical dilemma when asked to perform this operation outside of the context of a clinical trial in the face of the lack of high grade evidence. The role of P/D is in one respect expanding but this may be short lived pending the findings of its assessment against non-surgical treatment.

Effect of hyperthermic intrathoracic chemotherapy on the malignant pleural mesothelioma: a systematic review and meta-analysis

Surgery-based multimodality therapies have been used to control the malignant effusion and its recurrence in malignant pleural mesothelioma (MPM). Hyperthermic intrathoracic chemotherapy (HITHOC) has been used in the treatment of malignant pleural mesothelioma, but the results were controversial. The aim of the current study was, therefore, to conduct a systematic review and meta-analysis on the effect of HITHOC on MPM therapy. After thorough searching of online databases, total 21 articles were included into qualitative systematic review and 5 of them were used to conduct qualitative meta-analysis. It was found that most of HITHOC was used in combination of surgical resection including extrapleural pneumonectomy or pleurectomy/decortication. Patients who received HITHOC had significantly longer median survival length compared to the patients without HITHOC (Hedges's g = 0.384 ± 0.105, 95% CI: 0.178∼0.591, P < 0.001). In addition, HITHOC as palliative therapy was favored (Hedges's g = 0.591 ± 0.201, 95% CI: 0.196∼0.967, P < 0.001) in terms of recurrence free interval. The findings of the current study suggested that HITHOC is one of the safe and effective therapies in prolonging patients' median survival time and extending recurrence free interval.

Therapeutical effect of intrapleural perfusion with hyperthermic chemotherapy on malignant pleural effusion under video-assisted thoracoscopic surgery

BACKGROUND

Patients with malignant pleural effusions (MPEs) have limited life expectancy. This study aims to investigate the feasibility of intrapleural perfusion with hyperthermic chemotherapy (IPHC) under video-assisted thoracoscopic surgery on MPE patients.

METHODS

MPE patients were enrolled in the study and treated with IPHC. The treatment response was classified as complete response (CR, no re-accumulation of pleural fluid for 4 weeks), partial response (PR, re-accumulation above the post-IPHC level but below the pre-IPHC level for four weeks), no response (NR; re-accumulation or above the pre-IPHC level). The change of Karnofsky performance score (KPS) and tumour markers were also recorded. Follow-up was done every two weeks during first month and monthly thereafter until death.

RESULTS

Eighty patients included 46 males and 34 females were included in the study. The total response rate was 100%, with 71.3% of CR and 28.7% of PR. The KPS scores were significantly elevated and the level of tumour markers in pleural effusion were dramatically decreased after IPHC. The median survival was 16.8 months ranged from 2.1 to 67.4 months. One-year and two-year survival rates were 82.5% and 23.8%, respectively. There were no serious clinical compilations during IPHC treatment.

CONCLUSIONS

IPHC is a safety, effective and promising approach for MPE patients. It provides well survival benefit and minor toxicities.

Intrapleural perfusion thermo-chemotherapy for pleural effusion caused by lung carcinoma under VATS

BACKGROUND

The aim of this study was to assess the effectiveness of intrapleural perfusion thermo-chemotherapy (IPTC) under video-assisted thoracoscopic surgery (VATS) for malignant pleural effusion (MPE) caused by lung carcinoma.

METHODS

In this retrospective study, fifty-four patients with moderate or large amounts of ipsilateral MPE secondary to non-small cell lung cancer (NSCLC) underwent pleural biopsy and IPTC under VATS. IPTC was performed by perfusing the pleural cavity with 43.0 °C saline solution containing cisplatin (200 mg/m²) using a devised circuit through mechanical circulation for 60 minutes. Blood pressure, heart rate, oxygen saturation (SpO₂), and esophageal and rectal temperatures were monitored throughout the surgery. At the end of the perfusion, pleural biopsy was performed again for histological analysis.

RESULTS

The temperature at the pleural surface was stabilized at 43 °C, and pleural effusion was controlled in all patients. KPS scores increased in 89.3% of patients. No patient developed bone marrow suppression reactions with noticeable bleeding after treatment, and no liver and kidney malfunctions were observed. Apoptosis was detected by light and electron microscopy after IPTC. CEA markedly decreased in all patients 1 month after IPTC. The median survival time was 21.7 months, with a one-year survival rate of 74.1%.

CONCLUSIONS

IPTC under VATS is a new, safe, less invasive and more effective approach for MPE caused by lung carcinoma.

Effect of hyperthermic intrathoracic chemotherapy (HITHOC) on the malignant pleural effusion: A systematic review and meta-analysis

BACKGROUND

Although hyperthermic intraperitoneal chemotherapy (HIPEC) has been widely used to treat malignant ascites or as a preventive strategy for microscopic carcinomatosis following surgical resection of abdominal tumors, application of hyperthermic intrathoracic chemotherapy (HITHOC) in the treatment of malignant pleural effusion is limited. The objective of the current study was to conduct a systematic review and meta-analysis on the application of HITHOC in the palliative treatment of malignant pleural effusion.

METHODS

After thorough searching of online databases, total 27 articles were included into qualitative systematic review and 5 of them were used to conduct qualitative meta-analysis.

RESULTS

It was found that most of HITHOC was used in combination of cytoreductive surgery (CRS) including pleurectomy/decortication or after surgical resection of primary tumors, which mainly were lung cancer, thymoma or thymic carcinoma, breast cancer, and ovarian cancer. Patients who received HITHOC had significantly longer median survival length compared to the patients without HITHOC (Hedges g = 0.763, P < 0.001). In addition, HITHOC therapy was favored (Hedges g = 0.848, P < 0.001) in terms of median survival length, tumor-free survival rate, with tumor survival rate or Karnofsky performance status (KPS) scale.

CONCLUSION

HITHOC is a safe and effective therapy in controlling pleural effusion and increasing patient's survival rate.

Intensity-modulated radiotherapy for relapsed malignant pleural mesothelioma

The use of novel radiotherapy techniques is widely increasing, allowing clinicians to treat diseases that were previously difficult to treat with radiation therapy. Malignant pleural mesothelioma is a clear example of this clinical challenge. We describe our first experience with intensity-modulated radiotherapy technique which was used to treat a 73-year-old patient with multiple relapsing malignant pleural mesothelioma. Intensity-modulated radiation therapy has allowed to respect the QUANTEC (quantitative analyses of normal tissue effects in the clinic) dose constraints, patient has experienced a 14 months progression-free time, without relevant subacute or late lung toxicity.

Management of recurrence after initial surgery for malignant pleural mesothelioma: a mini-review

Recurrence after surgery in the multimodality therapy for malignant pleural mesothelioma is a common problem. As the majority of patients experience not only local but also distant metastases, a systemic treatment strategy in addition to local control measures remains necessary. Nevertheless, none of the chemotherapy regimens have achieved clinical success. Local management modalities such as stereotaxic treatments, cryoablation and redo surgery on the other hand have promising results, but provide palliative outcomes.

Pleurectomy/decortication and hyperthermic intrapleural chemotherapy for malignant pleural mesothelioma: initial experience

Cytoreductive surgery and hyperthermic intraoperative intrapleural chemotherapy (HITHOC) are a known option for malignant pleural mesothelioma (MPM). This prospective study was started to prove that pleurectomy/decortication and HITHOC could be successfully performed in a low volume center. Criteria of inclusion were a proven diagnosis of MPM, early-stage disease and good performance status. Six consecutive patients were enrolled. After pleurectomy/decortication, intrapleural cisplatin was administered for 60 min at 42.5 °C. Wedge resections and diaphragmatic reconstruction were added in two and one patient, respectively. Morbidity was 16.6%. Mortality was nil. Hospital stay was 7.8 days. Mean survival was 21.5 months (range: 6-30). This small experience confirms that pleurectomy/decortication and HITHOC are a good therapeutic option in the multimodality treatment of MPM. A randomized controlled trial is necessary.

Clinical outcomes of cytoreductive surgery combined with intrapleural perfusion of hyperthermic chemotherapy in advanced lung adenocarcinoma with pleural dissemination

BACKGROUND

This study aimed to investigate the safety and feasibility of intrapleural perfusion hyperthermic chemotherapy (IPHC) followed by cytoreductive surgery as a part of multimodal strategy for the treatment of advanced lung adenocarcinoma.

METHODS

Medical records of advanced lung cancer patients with pleural dissemination who underwent surgical treatment between 2003 and 2013 were reviewed retrospectively. Enrolled patients were divided into a surgery group comprising patients who underwent surgery only and an IPHC group, which consisted of patients who underwent surgery combined with IPHC.

RESULTS

A total of 33 patients were enrolled in this study. Twenty-three patients underwent IPHC after surgical resection, and 10 patients underwent surgical resection only. The complication rate of the IPHC group was estimated to be 34.8% (8 cases), none of which included postoperative mortality. The complication rate of the surgery group was 40.0% (4 cases), which included one postoperative mortality. The 6-month, 1-year, and 3-year overall survival rates for the IPHC group were 95.7%, 91.3% and 38.6%, respectively, while those of the surgery group were 80.0%, 80.0% and 37.5%. The 6-month, 1-year and 3-year progression-free survival rates for the IPHC group were 87.0%, 47.8% and 24.3%, while those of surgery group were 44.4%, 33.3% and 0.0%, respectively. There were significant differences in overall survival rates between two groups (P=0.045); however, progression-free survival was not different between the two groups.

CONCLUSIONS

IPHC combined with cytoreductive surgery for advanced lung adenocarcinoma associated with pleural seeding could be performed safely and feasible. It would be part of multimodality therapy for certain category of advanced lung adenocarcinoma. However, the long-term benefits for survival is uncertain. More extensive and precisely designed studies are warranted to further evaluate the effectiveness of IPHC.

How does the timing of chemotherapy affect outcome following radical surgery for malignant pleural mesothelioma?

OBJECTIVES

There is little evidence regarding the use of chemotherapy as part of multimodality treatment of malignant pleural mesothelioma (MPM). We aimed to determine whether, in those patients fit for chemotherapy, a delay in this treatment affected survival.

MATERIALS AND METHODS

We analysed postoperative variables of 229 patients undergoing either extrapleural pneumonectomy (EPP) (81 patients) or extended pleurectomy-decortication (EPD) (197 patients) for MPM at a single centre. There was no standard protocol for additional chemotherapy and varied with referral centre. Outcome was compared between 4 chemotherapy strategies: true adjuvant therapy, neo-adjuvant therapy, therapy reserved until evidence of disease progression in those otherwise fit in the post-operative setting, and those unfit for chemotherapy.

RESULTS

There was no effect of the timing of chemotherapy on overall or progression free survival in patients fit enough for treatment (p=0.39 and p=0.33 respectively). However delaying chemotherapy until evidence of disease progression in patients with non-epithelioid disease had a detrimental effect on overall survival (OS), and on progression free survival (PFS) in lymph node positive patients (15.6 vs. 8.2 months p=0.001, and 14.9 vs. 6.0 months p=0.016). Further analysis of 169 patients receiving platinum/pemetrexed as first line treatment, showed similar results; there was no effect of the timing of chemotherapy on OS or PFS (p=0.80 and p=0.53 respectively) and an improved OS in patients with non-epithelioid disease, and improved PFS in those with lymph node metastases, if chemotherapy was given in the immediate adjuvant setting (p=0.001 and 0.038) when therapy was not delayed until disease progression.

CONCLUSION

Our results suggest that the timing of additional chemotherapy may be important in those with a poorer prognosis on the basis of cell type and nodal stage. In these patients additional postoperative chemotherapy should not be delayed.