Non-resectable Stage IIIa-b lung carcinoma: a phase II study on continuous infusion of cisplatin and concurrent radiotherapy (plus adjuvant surgery)

The Role of Radiotherapy in the Treatment of Stage III Non-Small Cell Lung Cancer: A Survey of Clinical Practices in Lombardy, Italy, by the Airo-Lombardia Cooperative Group

Aims and background

The role of radiotherapy in the treatment of stage III non-small cell lung cancer is controversial. The aim of this survey was to investigate the use of this modality in current clinical practice in Lombardy, a highly industrialized region of northern Italy.

Methods

A questionnaire was sent to all 13 radiotherapy centers in Lombardy, covering statistical, clinical, technical and strategical aspects, and the responses were analyzed.

Results

A wide range of attitudes was observed among participating radiation oncologists; the percentage of cases treated with curative intent varied largely between centers (4-100%), as did the proportion of patients given to radiation only rather than combined modality treatment (5-100% vs 0-90%).

Conclusions

An urgent need exists for better cooperation between all clinicians involved in lung cancer treatment, pursuing the goals of a more uniform clinical practice and a more aggressive clinical research attitude.

Surgically Proven Complete Response of Stage III Non-Small Cell Lung Cancer after Cisplatin-Enhanced Radiotherapy. Clinical Implications and Long-Term Results

Aims and Background

Pathologic complete response in locally advanced non-small cell lung cancer is the main end point of combined therapies (chemotherapy and/or radiotherapy). Surgery after an induction treatment can improve local control, allowing the histologic assessment of treatment activity by means of resection or extensive biopsies.

Methods

Thirty patients surgically assessed without viable tumor after concurrent radiotherapy and continuous infusion of low-dose cisplatin, owing to an initially unresectable stage III non-small-cell lung cancer, were the object of evaluation to assess clinical implications, short- and long-term surgical results.

Results

The specificity rate of the preoperative restaging was 36.6%. The surgical procedures consisted of 22 resections and of extensive biopsies in 8 cases. The operative mortality was 4% (1/25) for procedures other than right pneumonectomy (3/5). No patient received postoperative chemotherapy. Eleven distant progressions, 4 local recurrences, and 4 new primary tumors were assessed as initial failures. The 8-year overall survival was 36%.

Conclusions

Pathologic complete response after cisplatin-enhanced radiotherapy cannot be satisfactorily assessed by clinical means. Surgery is required to obtain a reliable evaluation; however, right pneumonectomy should be contraindicated because of prohibitive risk. Although an effective local treatment can cure patients with advanced stage III disease, the addition of chemotherapy seems advisable to improve tumor relapse control.

Radiosensitization with chemotherapeutic agents

The combination of low-dose chemotherapy and thoracic radiotherapy is one of the treatments proposed in an attempt to improve the prognosis of locally advanced non-small cell lung cancer. Chemotherapeutic drugs administered at subtoxic doses act by means of a radiosensitization mechanism. Platinum-derived drugs have been historically used as radiosensitizers, without cumulative unacceptable toxicity. Many new chemotherapeutic agents, which have shown promising results in terms of disease control in advanced non-small cell lung cancer, show also a radiosensitizing activity. However, the optimal dose and timing of such drugs when used concurrently to radiotherapy are unknown. This paper will review the results obtained using new chemotherapeutic drugs as radiosensitizers.

Radiotherapy and concurrent continuous infusion of cisplatin with adjuvant surgery in nonresectable Stage III lung carcinoma: short- and long-term results of a Phase II study

PURPOSE

Cisplatin-enhanced radiotherapy plus adjuvant surgery was evaluated in nonresectable non-small cell lung carcinoma (NSCLC).

METHODS AND MATERIALS

Doses of 50 Gy (administered in standard fractionation in 5 weeks) were delivered with concurrent cisplatin in continuous infusion (daily dose: 4 mg/m2), to 32 Stage IIIa and 45 Stage IIIb patients enrolled in a Phase II study. Patients without progression underwent surgery.

RESULTS

Esophagitis (64%), nausea/vomiting (34%), and pulmonary toxicity (14%) were the main side effects. Grade 3 toxicity occurred in 4 instances. A clinical locoregional major response was achieved by 55 patients (there were 10 complete responses). Forty patients underwent surgery, 7 with a nonradical procedure. Seven patients died due to surgery-related complications, which were significantly impacted by right pneumonectomy (71% vs. 6% of the other procedures, p < 0.0001). Eighteen of the 40 surgical patients were assessed to be without viable tumor and 11 with microresidual carcinoma. There were 13 disease-free, 5-year survivors.

CONCLUSIONS

Toxicity was low but activity high with the chemoradiotherapy. Adjuvant surgery increased the rate of complete responses, but right pneumonectomy had an unacceptable mortality. The role of surgery needs further refinement. Integration of the chemoradiotherapy schedule with cisplatin-based induction chemotherapy is advisable.

Hyperfractionated radiotherapy and concomitant cisplatin in stage III non-small cell lung cancer: a phase II study by the AIRO-Lombardia Cooperative Group

A multicenter Phase II study was performed by the AIRO-Lombardia Cooperative Group on 36 patients with Stage III non-small cell lung cancer. The treatment schedule included hyperfractionated radiotherapy, 1.2 Gy twice daily (5 days/week) up to a total dose of 69.6 Gy, and concomitant cisplatin by continuous infusion using a portable pump, 16 mg/m2/week for 6 weeks. Overall, adequate treatment (defined as a total dose > 66 Gy in < 46 days and 6 weeks of infusional cisplatin) was received by 56% of accrued patients. Response was complete in 6% and partial in 56% of patients; median survival was 8 months and 1-year survival rate was 37%. Site of first failure was local in 43%, distant in 43%, local and distant in 10% and unknown in 3% of failing patients. Grade 3 esophagitis was recorded in 14% of patients and a fatal case of late pulmonary toxicity was reported. On the basis of feasibility, toxicity and survival results, the planned extension to Phase III was abandoned by the Group.

Ambulatory low-toxicity chemotherapy in non-small-cell lung carcinoma by continuous 28-day infusion of alternating cisplatin and 5-fluorouracil

BACKGROUND

One regimen consisting of a continuous infusion of cisplatin and fluorouracil was designed to be minimally toxic, and suitable for application with radiotherapy in non-small-cell lung carcinoma (NSCLC).

PATIENTS AND METHODS

Forty-four NSCLC patients received daily 8 mg/m2 of cisplatin on days 1-2, 8-9, 15-16, 22-23, and 300 mg/m2 of fluorouracil on days 3-7, 10-14, 17-21, 24-28 (35-day courses).

RESULTS

Two patients experienced grade 3-4 toxicities. Eleven achieved objective responses. The median progression-free and observed survival was 22 and 39.5 weeks.

CONCLUSIONS

The schedule management was fully ambulatory. Toxicity was negligible. The activity was moderate, but the combination with radiotherapy is advisable due to the radioenhancing properties of both of the drugs.

Determination of platinum in plasma of patients affected by inoperable lung carcinoma treated with radiotherapy and concurrent low-dose continuous infusion of cis-dichlorodiammine platinum(II)

Platinum microquantities were determined in plasma of patients affected by lung carcinoma during treatment with radiotherapy (RT) and concurrent low-dose continuous infusion of cis-dichlorodiammineplatinum(II) (CDDP). RT was given at 50 Gy in continuous course; CDDP was continuously infused at 4 mg/m2 daily for 100 h/week for 5 weeks, and the infusions were separated by 68 h of rest. The percentage of free drug versus total drug in plasma was about 3%. It did not vary with therapy duration and was not significantly different from that found in 5-day continuous infusions at much higher daily doses. Nevertheless, maximal values of free Pt in plasma were very low and agreed with the low level of CDDP toxicity encountered on the present administration schedule.

Surgery after radiochemotherapy for stage III lung cancer: postoperative complications and late results

Fifty-seven stage III lung cancer patients underwent radiochemotherapy and subsequent surgery. Forty radical (R-), six non-radical, and eleven exploratory operations were performed. Pneumonia (five cases), pulmonary insufficiency (one case), bronchial fistula (one case) were the major non-fatal complications. Four deaths due to adult respiratory distress syndrome (ARDS) or pulmonary embolism occurred. Sixty percent of the 10 patients who had no viable tumor at operation survived 3 years, as well as 41% of those who achieved a complete remission by resection and 11% of those with residual disease (R+) after operation. However, the 1- and 2-year survival rates were similar. The main pattern of failure in R- and R+ patients was extra- and intra-RT-field progression, respectively. A slightly higher rate of postoperative complications, with respect to current practice, was observed. However, data lead to argument on the improvement of locoregional control and long-term survival following radical surgery.