Simultaneous cisplatin fluorouracil infusion and radiation followed by surgical resection in regionally localized stage III, non-small cell lung cancer

Before or After: Evolving Neoadjuvant Approaches to Locally Advanced Non-Small Cell Lung Cancer

The treatment of patients with stage IIIA (N2) non-small cell lung cancer (NSCLC) is one of the most challenging and controversial areas of thoracic oncology. This heterogeneous group is characterized by varying tumor size and location, the potential for involvement of surrounding structures, and ipsilateral mediastinal lymph node spread. Neoadjuvant chemotherapy, administered prior to definitive local therapy, has been found to improve survival in patients with stage IIIA (N2) NSCLC. Concurrent chemoradiation has also been evaluated in phase III studies in efforts to improve control of locoregional disease. In certain instances, a tri-modality approach involving concurrent chemoradiation followed by surgery, may offer patients the best chance for cure. In this article, we provide an overview of the trials evaluating neoadjuvant therapy in patients with stage IIIA (N2) NSCLC that have resulted in current practice strategies, and we highlight the areas of uncertainty in the management of this challenging disease. We also review the current ongoing research and future directions in the management of stage IIIA (N2) NSCLC.

The role of chemotherapy in the management of stage IIIA non-small cell lung cancer

Patients with confirmed stage IIIA non-small cell lung cancer (NSCLC) represent a very heterogeneous group which includes those with limited microscopic ipsilateral mediastinal lymph node involvement discovered after a surgical resection, as well as those who have radiologically evident bulky subcarinal lymph node involvement at presentation. Different therapeutic options in stage IIIA disease include neoadjuvant chemo- or chemoradiotherapy followed by surgery, primary surgery followed by adjuvant chemotherapy with or without sequential adjuvant radiation therapy or definitive chemoradiation without surgery. The roles of surgery and radiation in stage IIIA disease are controversial, and there is inadequate data from randomized trials to inform the optimal therapeutic strategy. In contrast, chemotherapy has a clear indication in the curative setting. Data from randomized trials indicates that cisplatin-based chemotherapy should be given in either adjuvant or neoadjuvant settings to patients who are undergoing curative surgical resection and who are candidates for cisplatin therapy. In definitive chemoradiotherapy, cisplatin-based therapy is recommended although a carboplatin-based regimen may be given if patients cannot receive cisplatin. Finally, all patients with stage IIIA NSCLC should be evaluated early in a multidisciplinary setting that includes medical and radiation oncologists and thoracic surgeons with experience in lung cancer therapy.

Enduring challenge in the treatment of nonsmall cell lung cancer with clinical stage IIIB: results of a trimodality approach

BACKGROUND

Stage IIIb (T4/N3) non-small-cell lung cancer (NSCLC) is considered an inoperable disease and treatment is an enduring challenge. Surgery after induction therapy seems to improve locoregional control. We report the results of a phase II prospective trimodality trial (chemotherapy and concomitant radiotherapy plus surgery) in patients with stage IIIb NSCLC.

METHODS

From November 1992 to June 2000, 39 patients (37 men and 2 women, mean age 65 years) with clinical stage IIIb (34 T4N0 to 2, 4 T2 to 3N3, 1 T4N3, excluding T4 for malignant pleural effusion) entered the study. They received intravenous infusions of cisplatin 20 mg/m(2) and 5-fluorouracil 1,000 mg/m(2) (days 1 to 4 and 25 to 28) combined with a total dose of 50.4 Gy radiotherapy delivered over 4 weeks (1.8 Gy daily). Upon clinical restaging responders underwent surgery.

RESULTS

All patients were available for clinical restaging. No complete response was observed. Twenty-one patients had partial response (53.8%), 16 had stable disease (41%), and 2 had progressive disease (5.2%). Hematologic toxicity was moderate. Twenty-two patients (56.4%), 21 with partial response and 1 with stable disease, underwent surgery with no perioperative death. A radical resection was possible in 21 cases. Nine lobectomies, 3 bilobectomies, and 9 pneumonectomies were performed. Complications occurred in 5 patients (23.6%). Fourteen of the patients who underwent surgery (66.6%) showed a pathologic downstaging. A complete pathologic response was obtained in 9 cases (49%). Overall 5-year survival (Kaplan-Meier) was 23%. Resected versus non-resected patients showed a significant difference: 38% versus 5.6% (p = 0.028, log rank).

CONCLUSIONS

This trimodal approach for stage IIIb NSCLC appears safe and effective. It provides good therapeutic results with acceptable morbidity in surgical cases.

A phase II single-institution study of neoadjuvant stage IIIA/B chemotherapy and radiochemotherapy in non-small cell lung cancer

BACKGROUND

The relevance of a trimodal strategy in the treatment of lung cancer, consisting of neoadjuvant radiochemotherapy followed by surgery, is a subject of ongoing clinical trials. We tested whether improvement of long-term survival can be achieved for patients with stage III non-small cell lung cancer by this therapeutic approach.

METHODS

We performed a retrospective analysis of a single-institution phase II study. Of 33 patients enrolled in the protocol between 1992 and 1995, we reviewed the clinical outcomes of 26 patients with locally advanced non-small cell lung cancer (stage IIIA and IIIB), which had been resected after combined chemotherapy and radiochemotherapy.

RESULTS

After neoadjuvant therapy, resection of the tumor was accomplished in all patients, and R0 resection was achieved in 92%. Histologic remission was found in 76% of these patients. Involvement of mediastinal lymph nodes was crucially important for the outcome. First, histologic clearance of the mediastinal compartment by neoadjuvant therapy resulted in a 27% 5-year survival rate. Second, patients with viable tumor in any of the mediastinal lymph nodes removed had a poor outcome (median survival 11.4 and 34.7 months in patients with and without viable tumor cells in the specimens, respectively; p = 0.01).

CONCLUSIONS

Histopathologic regression after neoadjuvant multimodal therapy including chemotherapy and radiotherapy was an important prognostic factor in a selected group of patients with locally advanced lung cancer.

[Preoperative chemotherapy and chemoradiotherapy for non-small-cell bronchial cancers]

The very disappointing results obtained by surgery in resectable non-small-cell lung cancer have led to a high active clinical research concerning pre- or postoperative treatment. Preoperative treatment has several distincts goals: to increase survival for patients suitable for surgery, to limit surgery or transform borderline or non resectable cancer into resectable tumors. Available datas on preoperative treatments for non-small-cell lung cancer provide from three types of therapeutics trials: 1/Some phase II studies of neoadjuvant chemotherapy have demonstrated that the neoadjuvant approach was feasible, and didn't compromise surgery. 2/Phase II trials of neoadjuvant chemoradiotherapy, performed for the majority on more extensive cancers, have demonstrated that this approach was also feasible at the expense of higher but still tolerable toxicity. 3/Phase III randomised published trials exclusively deal with preoperative chemotherapy with different results: two of them concerned a small number of patients presenting with non-small-cell lung stage IIIA cancer: they are positive. The third concerned 373 patients presenting with stage I, II, IIIA cancer: the three-year survival was increased by 11%, but this difference is not yet significant. The benefit essentially appeared for stage I and II. One trial comparing preoperative chemotherapy and radiochemotherapy has been reported, concluding to the superiority of the association. These observations suggest that the clinical research should now be different for stages I and II, and stage IIIA.

Primary tumors and mediastinal lymph nodes after neoadjuvant concurrent chemoradiotherapy of lung cancer: serial CT findings with pathologic correlation

PURPOSE

The purpose of this work was to describe the changes of primary tumor and mediastinal lymph nodes on CT after neoadjuvant concurrent chemoradiotherapy and to correlate the CT findings with pathology.

METHOD

Twenty-one consecutive patients [N2 disease (n = 19) or resectable T4 and N2 disease (n = 2)] with non-small cell lung cancer underwent neoadjuvant concurrent chemoradiotherapy. Changes of primary tumor and mediastinal nodes before and after the therapy were assessed using CT. The CT findings were correlated with pathologic findings.

RESULTS

With neoadjuvant therapy, decrease in T stage was achieved in 9 of 21 (43%) patients on CT. On pathology, the remaining tumor consisted mostly of fibrosis and necrosis with little proportion of viable tumor cells (mean volume 17%, range 0-55%). Decrease in nodal stage was achieved in 14 of 21 (67%) patients on pathologic examination. Seven patients had cancer cells in mediastinal lymph nodes: in 6 of 9 (67%) patients with adenocarcinoma and 1 of 12 (8%) patients with squamous cell carcinoma (p = 0.016).

CONCLUSION

With neoadjuvant concurrent chemoradiotherapy, the remaining tumor consists mostly of fibrosis or necrosis. Decreased nodal stage on pathology is achieved especially in patients with N2 disease of squamous cell carcinoma. The CT findings of the tumor and mediastinal nodes are not helpful in predicting the pathology after the therapy.

Induction chemoradiotherapy for advanced stage III non-small cell lung cancer: long-term follow-up in 42 patients

This multi-institutional phase II study was designed to assess the feasibility, efficacy, toxicity, and long-term survival of induction chemoradiotherapy followed by surgery in previously untreated patients with advanced stage III non-small cell lung cancer. Chemotherapy regimen included cisplatin 20 mg/m2 on days 1-5 and 29-33, and VP-16 40 mg/m2 on days 1-5 and 29-33. Radiotherapy (50 Gy in 25 fractions) began on day 1. Clinically downstaged patients underwent thoracotomy 3-5 weeks after the completion of radiotherapy. Forty-two eligible patients (ten stage IIIA and 32 IIIB) were followed for a median period of 64 months. The response rate was 81%, and 20 patients had a clinically good response. Twenty-one patients underwent thoracotomy. Nineteen patients had complete resections and there were seven pathologic complete responses. There were four treatment related deaths (all stage IIIBs). There were significant survival differences between stage IIIA versus IIIB patients (P = 0.028; median survivals, 24.9 vs. 11.1 months; 5-year survival rates, 20% vs. 8.3%), and patients that achieved pathologic complete response (CR) versus those that did not (P = 0.045; median survivals 30.1 vs. 11.1 months; 5-year survival rates, 28.6% vs. 8.3%). Although the induction chemoradiotherapy employed in this study was not appropriate for stage IIIB patients, it proved feasible in stage IIIA patients in whom it resulted in good 5-year survival rates. It also provided good survival rates in patients achieving pathologic CR.

Current strategies for radiation therapy in non-small cell lung cancer

Thoracic radiotherapy is widely used in patients with non-small cell lung cancer. Its role as adjuvant treatment before or after surgery has not been established clearly. In patients with locally advanced disease, the main cause of failure is the absence of local control. Recently, three treatment approaches have shown a beneficial effect on overall survival in randomized trials conducted in this group of patients: sequential combination of thoracic radiotherapy and cisplatin-based chemotherapy, concomitant use of radiation and daily low-dose cisplatin therapy, and hyperfractionated accelerated radiotherapy. Another area that merits further investigation is the role of adjuvant surgery.

Cisplatin, mitomycin, and vindesine followed by intraoperative and postoperative radiotherapy for stage III non-small cell lung cancer: final results of a phase II study

Sixty-two patients with stage III non-small cell lung cancer (NSCLC) were treated with neoadjuvant chemotherapy consisting of cisplatin 120 mg/m2 day 1, mitomycin 8 mg/m2 day 1, and vindesine 3 mg/m2 days 1 and 14. Each cycle was repeated every 4 weeks for a total of 1 to 6 cycles (median, 3 cycles). Resection was attempted 4 to 5 weeks after the last course of chemotherapy. Intraoperative radiation therapy (IORT) (10-15 Gy) was delivered during surgery and postoperative external beam radiotherapy (EBRT) (46 Gy) was begun 4 weeks after surgery. Fifty-five patients (25 IIIA, 30 IIIB) were evaluable. Only partial responses occurred (64%), and 29 patients (53%) underwent resection. Complete resection rates were 85% (12/14) and 40% (6/15) in stage IIIA and IIIB, respectively (p = 0.01). In 3 of 29 patients (10%), no tumor was found in the resected specimen. There was one chemotherapy-related death and three postoperative-related deaths. The median survival time was 10 months, and the 5-year survival rate was 29 and 7% for stage IIIA and stage IIIB, respectively (p = 0.3). High complete resection rates and modest increase in 5-year survival have been observed in stage IIIA NSCLC. Although a number of stage IIIB patients can be made technically resectable, the low complete resectability rate reflects the lack of survival benefit in these patients.

Histopathological grading of response to induction chemotherapy in non-small cell lung cancer: a preliminary study

Management of locally advanced NSCLC is controversial. Induction chemotherapy followed by surgery has become an accepted approach for Stage III disease. However, the clinical assessment of the efficacy of preoperative treatment is inaccurate. We propose a four-grade histopathological evaluation of the response to chemotherapy based on the analysis of 20 evaluable cases and compared with clinical outcome. Follow-up ranged from 12 to 68 months. Correlation between different grading of necrosis and survival is statistically significant. Based on these preliminary results, we suggest that grading of response is a valid parameter to evaluate standard regimens and novel drug associations in larger trials.

Preoperative concurrent chemoradiotherapy for unresectable Stage III nonsmall cell lung cancer

PURPOSE

We carried out a Phase II trial in an attempt to improve resectability and survivability of inoperable Stage III A and III B nonsmall cell lung cancer (NSCLC) patients by implementing a neoadjuvant chemoradiotherapy treatment program.

METHODS AND MATERIALS

Thirty-six patients with locally advanced Stage III NSCLC received neoadjuvant therapy consisting of 50.4 Gy in 5.5 weeks concurrent with two cycles of chemotherapy, using cisplatin and etoposide. No postsurgical consolidation therapy was given.

RESULTS

Assessment at 3 to 6 weeks after treatment suggested that 26 (72%) patients had been rendered resectable. Toxicities were common but usually tolerable; however, one toxic death occurred. Of 24 patients who proceeded to thoracotomy, complete resection was achieved in 20 (56%). There were two surgically related deaths. Surgical-pathological staging showed downstaging in 18 patients, including complete sterilization of the tumor in 3 (8%). The median survival for all 36 patients is 15 months, but at the time of analysis, median survival of resectable patients had not been reached. The actuarial 2-year survival is 39% for all study groups, 57% for resectable patients, and 16% for the remaining (p < 0.005).

CONCLUSIONS

While this preoperative neoadjuvant appears to improve survival of patients with Stage III NSCLC, comparison with previous reports of other similar trials indicate a superior survival advantage in association with higher doses of radiotherapy.

Chemoradiation in advanced nonsmall cell lung cancer

PURPOSE

Resectability, local control, and survival were evaluated in advanced stage nonsmall cell lung cancer treated with simultaneous chemoradiation therapy delivered in an accelerated, interrupted twice-a-day schedule.

METHODS AND MATERIALS

Forty-seven consecutive patients with Stage IIIA or IIIB nonsmall cell lung cancer, consenting to participation in the study, received cisplatin, 30 mg/m2 for 3 days, etoposid, 80 mg/m2 for 3 days, and 5-fluorouracil, 900 mg/m2 for 4 days. Radiation therapy consisted of 2 Gy given twice a day for 5 days. Two weeks rest was planned between cycles. Patients were evaluated for resectability after the second cycle. Any patient with unresectable tumor received a third cycle of treatment.

RESULTS

Forty-seven patients were evaluable for acute toxicity: eighteen (38%) required an extended rest period for esophagitis or low blood count; 3 (6%) had sepsis, of whom 1 (2%) expired. Three patients (6%) had multiple blood transfusions for low hemoglobin. Median follow-up is 23.6 months, with a range of 10-49 months. Nine patients (19%) failed locally; 15 (32%) had local and distant failure; 7 (15%) failed only at distant sites. Twelve patients (25.5%) are alive with no evidence of disease; 4 patients were lost to follow-up with disease. The 2-year actuarial survival is 49%, and the 4-year is 28.2%.

CONCLUSION

Simultaneous chemoradiation is well tolerated with acceptable toxicity. The overall 2- and 4-year actuarial survival is somewhat better than that reported in the literature. Resectability in Stage IIIB patients was not increased with this regimen nor was any surgical specimen free of cancer. The 47% distant failure rate is not different from those reported by others.

Pre-treatment prognostic factors in patients with stage III non-small cell lung cancer treated with hyperfractionated radiation therapy with or without concurrent chemotherapy

We analyzed prognostic factors for non-small cell lung cancer (NSCLC) treated with hyperfractionated radiotherapy (HFX RT) with or without concurrent chemotherapy. One-hundred sixty-nine patients with histologically or cytologically proven, Stage III NSCLC, Karnofsky performance status (KPS) > or = 50, and no previous therapy were treated in a randomized trial as follows: Group 1--HFX RT to a total dose of 64.8 Gy (61 patients); Group 2--the same HFX RT with chemotherapy consisting of 100 mg of carboplatin on days 1 and 2 and 100 mg of etoposide on days 1-3 of each week during the RT course (52 patients); and Group 3--the same HFX RT with chemotherapy consisting of 200 mg of carboplatin on days 1 and 2 and 100 mg of etoposide on days 1-5 of the first, third, and fifth weeks of the RT course (56 patients). The median survival time for all 169 patients was 13 months and the 5-year survival rate was 13.4%. The median time to relapse (local or distant) was 11 months and the 5-year relapse-free survival was 12.8%. Group 2 patients had a better prognosis than Group 1 patients (P = 0.0028) but there were no differences in prognosis between Groups 2 and 3 and between Groups 1 and 3. Of potential prognostic factors examined, female gender (P = 0.00012), age > or = 60 (P = 0.00000), KPS > or = 80 (P = 0.00000), Stage IIIA (P = 0.00000), and previous weight loss < or = 5% (P = 0.00000) were associated with better prognosis. These findings were confirmed by multivariate analysis.

Risk analysis and long-term survival in patients undergoing extended resection of locally advanced lung cancer

Although locally advanced lung cancer frequently necessitates extended resections to preserve a chance for cure, a higher morbidity is associated with extended resections. It is not known whether the increased morbidity is of relevance for the long-term outcome. It also remains unclear whether exclusion of certain patients according to their risk factors can diminish mortality in these patients. This study therefore investigated whether certain risk factors predispose patients undergoing extended pulmonary resections to increased morbidity or mortality. It also assessed the long-term survival. The cases of 126 consecutive patients with locally advanced lung cancer (stage T3 or T4) were prospectively documented. Seventy-five percent of the patients required an extended resection and 25% a nonextended resection. Extended resections were associated with a significantly increased overall morbidity (p < 0.002). However, mortality, severe complications, or multiple complications were not significantly increased after extended resections. No risk factor predisposed to an increased mortality. Risk factors that were associated with particular postoperative complications were pathologic ergonometry (p < 0.002), a positive cardiac score (p < 0.003), coronary artery disease (p = 0.021), and an increased pulmonary risk score (p < 0.05). Overall 3-year survival was 31%. Patients undergoing extended resections for stage T3 or T4 tumors with no residual tumor (70% of the patients) showed a 3-year survival of 33%. We conclude that postoperative mortality cannot be reduced by excluding patients on the basis of particular risk factors from operations that require extended resections. If a patient is considered to be eligible to undergo pulmonary resection, he or she can be considered to be eligible to undergo extended pulmonary resection. Because prognosis is dismal in nonresected locally advanced lung cancer, we recommend an aggressive surgical approach.

Future directions in non-small cell lung cancer. A personal view

At the 1991 6th World Conference on Lung Cancer sponsored by IASLC and held in Melbourne, the Future Directions summary described several critical clinical trials that were underway, reviewed the progress in cellular and molecular biology and decried the excessive nihilism and pessimism then rampant. The theme today is identical, but the baseline has advanced significantly. There is now a clear consensus that combined modality therapy is superior to single modality therapy for locally advanced NSCLC. The issues for future clinical trials are related to increasing the effectiveness of regimens known to be active in reducing toxicity. Radiation alone for Stage IIIB NSCLC and surgery alone for Stage IIIA NSCLC need not serve as control arms. The availability of several new, and significantly more active, chemotherapeutic compounds will drive the clinical trials in this arena for several years. Meta-analyses also demonstrate a clear benefit for chemotherapy over supportive care and only in the area of post-operative adjuvant therapy for resected NSCLC is the efficacy of therapy still in question. Our comprehension of the number and sequence of genetic mutations leading to clinical cancer is rapidly growing, although it is not likely that attempts to reverse specific mutations will lead to successful therapy for established tumors. On the other hand, early detection and prevention are becoming very real possibilities. Knowledge of specific mutations and the development of pharmacologic approaches to overcome them is the next area for clinical development. Optimism remains an appropriate response to developments in the area of NSCLC.

Neoadjuvant chemotherapy of locally advanced non-small cell lung cancer

Neoadjuvant chemotherapy was tested in non-small cell lung cancer in an attempt to increase the resectability of the tumor and to treat the microscopic metastatic disease known to be responsible for the majority of failures in surgically treated patients. This review deals with published trials. Most of them are feasibility studies in Stage III NSCLC. Obviously, the heterogeneity of eligibility criteria from one study to another prevents general conclusions on the usefulness of neoadjuvant chemotherapy. However, it is possible to conclude that neoadjuvant chemotherapy has an antitumor activity; the majority of the studies report a 60% objective response rate including a significant number of complete responses and a 50% complete resection rate. Neoadjuvant chemotherapy does not increase morbidity after surgery except when it is combined with preoperative radiation therapy. At the time of writing, one Phase III randomized study comparing neoadjuvant chemotherapy followed by surgery with surgery alone has been published. This study concludes that the combined modality treatment improves the survival of patients with locally advanced non-small cell lung cancer. Taken as a whole, the literature deserves further studies to determine the place of neoadjuvant chemotherapy in lung cancer.

Chemotherapy in non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer can no longer be regarded as resistant to chemotherapy, and there have recently been considerable improvements in the use of the older agents and advances in the identification of new drugs. Recent meta-analysis has also confirmed the view that chemotherapy can have small but modest survival benefits. Although in the treatment of stage IV disease the criteria of efficacy have concentrated on tumour response rates, more recently it has become obvious that these patients can also benefit in terms of improved symptom control.

RECENT ADVANCES

For patients with locally advanced stage III disease there have been important developments indicating the benefit of combined modality treatment with chemotherapy and thoracic irradiation. Furthermore, the use of neoadjuvant chemotherapy indicates that resection is possible in about half the patients, and on pathological examination of 15%-20% of the resected specimens there is no evidence of residual tumour. These results justify an increase in the use of systemic chemotherapy in this disease.

A four-drug combination chemotherapy with cisplatin, mitomycin, vindesine and 5 fluorouracile: a regimen associated with major toxicity in patients with advanced non-small cell lung cancer

The purpose of this study was to determine the activity of a 4-drug combination chemotherapy: cisplatin, mitomycin C, vindesine and 5-fluorouracil (5-FU) in patients with advanced non-small cell lung cancer (NSCLC). Chemotherapy consisted of the administration of cisplatin (30 mg/m2 d 1-4), mitomycin C (10 mg/m2 d 1), vindesine (3 mg/m2 d 1) and 5-FU (1 g/m2 d 1-4 by continuous intravenous infusion). In patients older than 70 years, and in those who received prior irradiation or chemotherapy, cisplatin and 5-FU were omitted on day 4. Courses were repeated every 4 weeks and evaluation of response was performed after the first 2 courses. In case of response, treatment was continued until best response or untolerable toxicity. Among 182 eligible patients, 75% had received no prior therapy; 41% had locoregional disease and 59% metastatic disease; 41% lost more than 5% of their pretherapy body weight. A 34% objective response rate was observed in the 164 evaluable patients (31% in all the eligible patients) including 4 complete and 52 partial responses. Patients with locoregional disease had a significantly better response rate than those with metastases (44% vs 27%). The overall median survival was 26 weeks. Significant hematological toxicity was documented but the most serious adverse event was the occurrence of 18 (10%) cardiac or sudden deaths. These toxic deaths were significantly associated with a 5% loss of body weight prior to therapy. The addition of 5-FU to combination of cisplatin, mitomycin C and vindesine does not improve antitumoral effect but results in very significant cardiac toxicity.

Long-term results of neoadjuvant ifosfamide, cisplatin, and etoposide combination in locally advanced non-small-cell lung cancer

Thirty-three patients with T3,N2,M0 or T4,N2,M0, non-small-cell lung cancer (NSCLC) took part in a phase 2 study in an attempt to evaluate the feasability of neoadjuvant chemotherapy followed by surgery and thoracic radiotherapy. Chemotherapy consisted of daily administration of the following treatment: etoposide, 100 mg/m2; cisplatin, 25 mg/m2; ifosfamide, 1.5 g/m2; and mesna, 1.8 g/m2 for 4 days. Three cycles were planned starting every 21 days. Responding patients underwent a thoracotomy in order to attempt a resection and then received a 45 Gy of thoracic radiotherapy. The results of response and resection rates have been published and the present final report deals with the long-term results. Chemotherapy induced a 55 percent partial response rate and a 15 percent complete response rate allowing a complete resection in 55 percent of the patients. Complete remission was histologically confirmed for the five complete responders. Although the median survival was short (10 months), six patients were long-term survivors (3-year survival rate: 19 percent). Survival was significantly influenced by the type of resection: patients for whom a complete resection was possible survived the longest with a median survival three times that of the other patients. Modalities of relapses differed according to the results of surgery: 8 of the 15 patients who did not undergo a complete surgical resection experienced a local relapse during the first 18 months of follow-up whereas in the complete resection group, central nervous system metastasis was the main site of relapse. We conclude that the neoadjuvants ifosfamide, cisplatin, and etoposide in patients with locally advanced NSCLC are feasible to use and allow a 19 percent 3-year survival rate. These results are the rationale of an ongoing randomized study comparing neoadjuvant chemotherapy followed by surgery and surgery alone. This study is designed to test whether neoadjuvant chemotherapy improves survival of patients with locally advanced NSCLC.

Three-dimensional conformal radiotherapy in bronchogenic carcinoma: considerations for implementation

Lung cancer continues to be a major health problem worldwide. In spite of significant technological and scientific medical progress, the final outcome of this disease is still dismal. Except for a small percentage of patients with early stage who undergo complete surgical resection, local control continues to be disappointingly low. In a recent report by Arriagada et al. (Arriagada R, Le Chevalier T, Quoix E, Rufie P, de Cremoux H, Douillard J-Y, Tarayre M, Pignon, J-P, LaPlanche, A. Effect of chemotherapy on locally advanced non-small cell lung carcinoma: a randomized study of 353 patients. Int J Radiat Oncol Biol Phys 1991; 20:1183-1190), biopsy proven local control by RT alone was only 17%. This team also found that the addition of combination chemotherapy, although it has decreased distant metastasis, has not had any impact on local control. There are some indications in the literature to suggest that higher doses of radiation to the target volume (tumor) may result in improved local control in inoperable non-small cell lung cancer. This temptation for increasing dose to target volume, however, should not result in inappropriate normal tissue side-effects and complications. Three-dimensional (3D) conformal radiation therapy has shown a significant potential for improving radiation treatment planning in several sites, both for tumor coverage and sparing normal tissue. Using this technology, progress in uncomplicated locoregional control of lung cancer may become a reality. The following is a review of literature and analysis of the currently available information on this subject.

The role of induction chemotherapy before radiation therapy in non-operative management of stage III NSCLC

Radiation therapy alone has been 'standard' management of patients with Stage III non-small cell lung cancer for several decades. Palliative benefits are routinely achieved but significant survival benefits have not been documented. Patterns of failure in Stage III patients emphasize the need to pursue better treatment for both local macroscopic disease and distant micrometastatic sites. Improved control in both areas will be necessary to meaningfully enhance outcome for the universe of Stage III NSCLC patients. Several randomized trials show a significant survival benefit when cisplatin-containing induction chemotherapy is administered prior to locoregional treatment. In the favorable subset of Stage III patients selected for study by CALGB, the surviving fraction at 2-5 years post-therapy was > or = 2-fold larger in the chemoradiation group than in the cohort treated with radiation alone. The French trial documented a significant decrease in distant metastases rate among the chemotherapy treated patients. In all the trials where patterns of failure are discussed, local disease persistence is the overwhelming rule. Future trials must evaluate improved induction chemotherapy approaches. Stage III patients are an ethical population in which to test induction therapy with new drug combinations randomized against already 'active' regimens for comparative efficacy. End points would be initial response rates, patterns of failure, and overall survival. The feasibility of high-dose chemotherapy regimens with growth factor and hematopoietic support followed by aggressive radiation must be tested. If feasible, trials randomizing high dose versus conventional dose induction programs within the context of sequential multimodality therapy should follow. Intensified radiation approaches such as hyperfractionation or CHART should be paired with active concurrent chemotherapy following induction chemotherapy alone. Pursuit of these approaches over the next several years will hopefully produce major improvements in treatment efficacy and lead to enhanced survival expectations for the large group of patients worldwide with Stage III NSCLC.

Phase II study of neoadjuvant chemotherapy and radiation therapy with thoracotomy in the treatment of clinically staged IIIA non-small cell lung cancer

BACKGROUND

The purpose of this study was to assess the ability of administering to patients induction chemotherapy with carboplatin and etoposide (VP-16), followed by full-course radiation therapy and weekly carboplatin with tolerable toxicity as preoperative therapy to down-stage disease thus allowing the resection of clinically staged IIIA non-small cell lung cancer.

METHODS

Twenty-eight eligible patients with good performance status and previously untreated, marginally resectable stage IIIA non-small cell lung cancer received induction chemotherapy with carboplatin (dosed per the Egorin formulation), and VP-16 (100 mg/m2) followed by 6000 cGy of chest radiotherapy over six weeks administered concurrently with weekly doses of 100 mg/m2 of carboplatin. Patients who had either responsive or stable disease underwent thoracotomy, with attempted surgical resection of the primary lung lesion and the areas of abnormal adenopathy. Procedures involving less than a pneumonectomy were used whenever feasible.

RESULTS

Fifty-two cycles of induction chemotherapy were administered. The average initial dose of carboplatin was 407 mg/m2. Toxicity was tolerable with grade 3-4 neutropenia and/or thrombocytopenia in 48 and 27% of the patients. There were no septic deaths. Full-dose radiotherapy was administered to 82% of patients, with 73% receiving at least five weekly doses of carboplatin. The radiographically assessed response rate to the neoadjuvant treatment was 64% (partial response, 46%; minimal response, 18%). Sixteen patients underwent gross tumor resection with 12 (43%) having negative pathologic margins. Six patients had pneumonectomy. There were three perioperative deaths (19%); two were secondary to respiratory failure after the patients underwent a pneumonectomy. The median survival for all 28 patients was 15 months, and for the 16 patients undergoing thoracotomy was 23 months. Eight patients were alive and in remission, with follow-up ranging from 8 to 31 months.

CONCLUSIONS

The authors conclude that (1) carboplatin and VP-16, followed by full-dose radiotherapy with weekly carboplatin administration, is a well tolerated and effective regimen in the treatment of patients with marginally resectable stage IIIA non-small cell lung cancer; and (2) full-course radiotherapy can be administered before surgical resection without additional surgical morbidity or mortality.

Combined modality treatment using BID radiation for locally advanced non-small cell lung carcinoma

BACKGROUND

From February 1988 to August 1991, 82 patients were treated on Phase II trial of split-course multimodality treatment for locally advanced, non-small cell lung cancer (NSCLC).

METHODS

Treatment consisted of twice-daily radiation (150 cGy/fraction) delivered with concomitant infusional cisplatin, etoposide, and fluorouracil for 1 week every third week. Patients were classified before initial treatment as either potentially resectable (eligible for surgery [ES]) or ineligible for surgery (IES). The ES group consisted of 38 Stage IIIA and 7 Stage IIIB patients. The IES group had 5 patients staged as IIIA and 32 staged as IIIB. Most patients were staged clinically. ES patients received three cycles of treatment (39 Gy) before resection. IES patients received four cycles (60 Gy) delivered with curative intent.

RESULTS

Thirty-nine of 45 ES patients underwent resection. The pathologic response rate was 27%. Three-year actuarial local control was 86% for 41 evaluable ES patients. Three-year actuarial survival for the whole ES group was 39%, with a median follow-up for living patients of 32 months. The IES group faired less well, with an 18% 3-year actuarial survival. Treatment was well tolerated with a median weight loss of one-half pound, mild or moderate pneumonitis in 5%, mild esophagitis in 15%, and severe nausea and/or vomiting in 10% of patients. Treatment-related mortality was 5%.

CONCLUSIONS

Patients treated with conventional radiation alone for Stage III NSCLC are rarely cured. This well tolerated Phase II study demonstrated encouraging results for such patients. Both local control and survival appeared promising, especially in patients rendered resectable after combined-modality treatment.

Concomitant chemoradiotherapy for non-small cell lung cancer

Concomitant chemoradiotherapy represents an investigational approach to the treatment of locoregionally advanced non-small cell lung cancer. The theoretical rationale, and clinical experience are reviewed in brief. Clinical trials conducted at the University of Chicago are summarized.

Treatment evaluation of combined modality therapy: 'what can we obtain today from phase II trials?'

Demonstration of activity is the major goal of Phase II studies. Other end points-duration of response, survival (relapse free in complete responders), progression free interval, changes in performance status and quality of life also provide useful information. From these data a decision to continue or discard a particular therapy can be considered. Various handicaps including variability in response reporting, heterogeneity of patient populations, inadequate reporting of failure patterns, causes of death, performance status changes and quality of life hinder interpretation of Phase II data. Nevertheless, Phase II studies have defined prognostic groups, beneficial changes in performance status and have helped formulate novel management approaches. Targeting particular prognostic groups, investigating dose-intensive regimens with haemopoietic growth-factor support and novel combined-modality approaches have all been generated through Phase II investigations.

Challenges of preoperative chemotherapy in non-small cell lung cancer

Surgical extirpation of a non-small cell lung cancer (NSCLC) represents an individual's best opportunity for cure. Unfortunately, only a small percentage of patients present with surgically resectable disease. Many patients are diagnosed with tumor confined to the thorax but which is technically unresectable. In the setting of locally advanced disease, combination chemotherapy is capable of effecting tumor shrinkage in a majority of cases. When this occurs, it is tempting to subject the patient to thoracotomy in an attempt to resect the previously unresectable lesion. Use of chemotherapy in this manner is generally referred to as neoadjuvant or preoperative chemotherapy. Recently, several groups have demonstrated that such an approach is feasible but the impact on patient survival remains ill defined. Further studies designed to ascertain the feasibility of neoadjuvant chemotherapy are no longer warranted. It is time for a prospective, randomized trial designed to determine the true potential of neoadjuvant chemotherapy. The optimal design of such a trial is a matter of debate but several options are reasonable. This article will review the available data on preoperative chemotherapy in locally advanced non-small cell lung cancer and will review areas of controversy.

Carboplatin, etoposide, and radiotherapy, followed by surgery, for the treatment of marginally resectable non-small cell lung cancer

The present study was undertaken in order to determine the feasibility and efficacy of induction chemotherapy with carboplatin and etoposide, followed by weekly carboplatin and full-course radiotherapy as pre-operative therapy for marginally resectable non-small cell lung cancer (NSCLC). Twenty-eight patients with good Eastern Cooperative Oncology Group (ECOG) performance status ratings and stage IIIA NSCLC received induction chemotherapy with carboplatin (dose computed with the Egorin formula, days 1 and 29) and etoposide (100 mg/m2/day, days 1 through 3 and 29 through 31). This was followed by 100 mg/m2 weekly carboplatin given over 6 weeks, concurrently with 60 Gy radiotherapy. Patients with either responsive or stable disease underwent thoracotomy 4 weeks after the completion of combined-modality therapy. All 28 patients received the first chemotherapy cycle (average carboplatin dose, 407 mg/m2; range, 195 to 586 mg/m2). World Health Organization (WHO) grade 3/4 neutropenia and thrombocytopenia were observed in 53 and 34% of patients, respectively. There were three febrile neutropenic episodes, but no septic deaths. Five patients (18%) required dose reductions prior to the second chemotherapy cycle, but the dose intensity of carboplatin was maintained (average dose, 390 mg/m2; range, 195 to 586 mg/m2). In all, 82% of patients received full-dose radiotherapy, and 73% received at least five of six planned concurrent weekly carboplatin doses. Carboplatin doses were most frequently delayed for thrombocytopenia and/or leukopenia. Carboplatin did not increase the incidence of radiation-induced esophagitis. Only three patients required interruption of radiotherapy, for esophagitis (two patients) and persistent thrombocytopenia (one patient). The response rate to pre-operative therapy was 64%. In this study, we demonstrated the ability to deliver escalated doses of carboplatin with standard-dose etoposide as induction chemotherapy with reasonable myelotoxicity. The combined-modality therapy was well tolerated, and the addition of weekly carboplatin did not result in increased radiation-related toxicity. This neoadjuvant regimen is active in the treatment of locally advanced NSCLC, and compares favorably to other cisplatin-based regimens.

Effect of radiologic stage III substage on nonsurgical therapy of non-small cell lung cancer

BACKGROUND

Patients with Stage III non-small cell lung cancer (NSCLC) whose cases are staged or treated surgically have different prognoses, depending on the substage (IIIa, IIIb). It is not known whether the prognostic differences apply to clinically staged nonsurgical cases. The authors wanted to determine whether radiologic Stage III substages, determined by computerized axial tomography (CT) scans, are prognostically important in these patients with NSCLC: In addition, they wanted to determine whether the observed superior survival of selected patients with Stage III NSCLC receiving chemotherapy in addition to radiation therapy (chemo-RT) (Cancer and Leukemia Group B protocol 8433: N Engl J Med 1990; 323:940-5) was influenced by an imbalance in the radiologic Stage III substage.

METHODS

Review of pretreatment chest radiographs and CT scans with determination of TNM status and stage was done by the consensus of three readers, who were unaware of which treatment each patient had received (radiation therapy alone [RT] or chemo-RT).

RESULTS

Patient characteristics in the two treatment arms were similar. Fifty-five percent of patients receiving RT had Stage IIIa and 33% Stage IIIb disease; in the chemo-RT treatment arm, 73% had Stage IIIa and 25% Stage IIIb disease (P = 0.11). Seven patients (12%) who received RT and one in the chemo-RT treatment arm (2%) had Stage I-II disease on CT scan. Patients with Stage IIIa disease had superior survival to those with Stage IIIb disease (median, 16.5 versus 10.5 months, respectively; P = 0.0045). Within each substage, survival was superior in the chemo-RT (versus RT) treatment arm (Stage IIIa, 17.2 versus 10.7 months, respectively; P = 0.16; Stage IIIb, 12.0 versus 6.9 months, respectively; P = 0.089).

CONCLUSIONS

The survival advantage for selected patients with Stage III NSCLC treated with chemo-RT in this study did not result from a more favorable pretreatment radiologic Stage III substage. An advantage for induction chemotherapy was seen in patients with Stage IIIa and IIIb disease. Future studies in this population should prospectively assess and consider stratification for Stage III substage.

Report of phase II trial of concurrent chemoradiotherapy with radical thoracic irradiation (60 Gy), infusional fluorouracil, bolus cisplatin and etoposide for clinical stage IIIB and bulky IIIA non-small cell lung cancer

PURPOSE

To assess the response rate, median and long-term survival of patients (pts) with locally advanced, initially inoperable non-small cell lung cancer (NSCLC) treated on a phase II study of radical thoracic radiotherapy (TRT) and concurrent radiosensitizing chemotherapy.

METHODS AND MATERIALS

From 3/87 to 7/90, 41 previously untreated patients at Fox Chase Cancer Center with locally advanced non-small cell lung cancer, 24 with bulky clinical Stage IIIA, and 17 with IIIB disease, received concurrent thoracic radiotherapy (60 Gy/2.0 Gy/d in 6 weeks) and 2 cycles of infusional 5FU (640-800 mg/m2/24 hrs x 5 d); cisplatin (20 mg/m2 qd x 5); and etoposide (50 mg/m2 d 1, 2, 5) administered days 1 and 28 of TRT.

RESULTS

Forty of 41 were evaluable. Response rate was 90%, with radiographic CR in 20%. Thirteen pts (33%) underwent thoracotomy and complete resection with clinical downstaging in 10, including three pathologic CR's. Overall median survival was 14 months and 2-year survival was 38% with no difference between CS IIIA and IIIB pts (p = 0.2224). At median potential follow-up of 42 months, 8/40 pts. (20%) are alive and progression-free, including 4 of 13 resected pts. The chief toxicity was esophagitis, occurring in 32 pts. (80%), Grade 3-4 in 21 (52%), with 13 (33%) requiring hospitalization and 7 (18%) needing TPN. Grade 3-4 granulocytopenia was noted in 20 pts. (50%) with ten episodes of fever mandating intravenous antibiotics. Cardiac ischemia was documented in 2 (5%). Of 13 thoracotomy pts, six underwent lobectomy without perioperative mortality; 3 of 7 pneumonectomy pts died post-operatively, two from broncopleural fistula, and one from ARDS.

CONCLUSION

This aggressive regimen produced a 2-year survival (38%) comparable to the best arm of cancer and leukemia groups B study 8433, which administered radical thoracic radiotherapy after protoadjuvant vinblastine and cisplatin in similar and earlier stage non-small cell lung cancer patients. Toxicity, particularly esophagitis, was severe, but of short duration. An unacceptably high complication rate was seen following pneumonectomy, but not lobectomy.

Induction chemotherapy for locally advanced non-small cell lung cancer

The poor survival of patients with stage III non-small cell lung cancer has led to a reevaluation of the role of systemic chemotherapy administered before operation. The results of 15 phase-II pilot trials of induction chemotherapy (5 with chemotherapy alone; 4 with chemotherapy and radiotherapy; and 6 with chemotherapy and concurrent radiotherapy) are reviewed in this article, and recommendations for future randomized studies are made. For most trials, only patients in stage IIIa were eligible, but five trials included both IIIa and IIIb patients. The studies employed a variety of chemotherapy and radiotherapy induction protocols, but no superiority could be demonstrated for the administration of chemotherapy and radiotherapy over chemotherapy alone. Response was observed in more than 50% of patients overall, although the complete clinical remission rate was always less than 15%, and the pathologic complete response rate was usually less than 10%. After induction therapy, approximately 70% of patients were eligible for a thoracotomy, and complete resection was possible in 60% of patients. The median survival ranged from 8 to 32 months, with a median of approximately 1 1/2 years. Two-year to 3-year survival ranged from 25% to 30%. The studies reviewed showed that induction therapy followed by surgical resection is feasible and is not associated with unacceptable toxicity. The apparent survival benefit conferred by such combined modality treatment may be due to patient selection, and until randomized trials are undertaken, induction therapy and surgical intervention for locally advanced non-small lung cancer must be viewed as experimental.

Preoperative chemotherapy for stage IIIa (N2) lung cancer: the Sloan-Kettering experience with 136 patients

From 1984 to 1991, 136 patients with histologically confirmed non-small cell lung cancer and stage IIIa (N2) disease received two to three cycles of MVP (mitomycin + vindesine or vinblastine + high-dose cisplatin) chemotherapy. All patients had clinical N2 disease, defined as bulky mediastinal lymph node metastases or multiple levels of lymph node involvement in the ipsilateral mediastinum or subcarinal space on chest roentgenograms, computed tomographic scans, or mediastinoscopy. The overall major response rate to chemotherapy was 77% (105/136). Thirteen patients had a complete response and 92 patients had a partial but major response (> 50%). The overall complete resection rate was 65% (89/136) with a complete resection rate of 78% (82/105) in patients with a major response to chemotherapy. There was no histologic evidence of tumor in the resected specimens of 19 patients. The overall survival was 28% at 3 years and 17% at 5 years (median, 19 months). For patients who had complete resection, the median survival was 27 months and the 3-year and 5-year survivals were 41% and 26%, respectively. There were seven treatment-related deaths, five of which were postoperative deaths. To date, 33 patients, all of whom had complete resection, have had no recurrence after treatment. These results demonstrate that (1) preoperative chemotherapy with MVP produces high response rates in stage IIIa (N2) disease, (2) high complete resection rates occur after response to chemotherapy, and (3) survival is longest in patients who have a complete resection after major response to chemotherapy.

Postoperative complications after combined neoadjuvant treatment of lung cancer

Preoperative chemotherapy and radiation administered separately or in combination have been used in the treatment of locally advanced non-small cell lung cancer. To assess the postoperative morbidity and mortality associated with aggressive neoadjuvant therapy, we reviewed the records of 13 patients who underwent resection of locally advanced non-small cell lung cancer after two monthly cycles of infusional 5-fluorouracil, 640 to 800 mg/m2 (days 1 through 5); cisplatin, 20 mg/m2 (days 1 through 5); etoposide, 50 mg/m2 (days 1, 3, and 5); and concomitant radical thoracic irradiation (6,000 cGy) administered in 200-cGy daily fractions. Six patients underwent lobectomy with no mortality, whereas 7 pneumonectomies were associated with three deaths (43%). Culture-negative, diffuse pulmonary infiltrates developed 3 to 6 days after operation in 5 of 7 pneumonectomy patients and in 1 of 6 lobectomy patients. Two patients who had undergone pneumonectomy died of progressive adult respiratory distress syndrome. A third death resulted from a bronchopleural fistula that developed 30 days after pneumonectomy. Morbidity and mortality were not associated with preoperative pulmonary function test results, nutritional status, or intraoperative inspired oxygen fraction (p > 0.05 by chi 2 test). Only pneumonectomy correlated with increased morbidity and mortality (p < 0.05 by chi 2 test). We conclude that lobectomy may be performed safely after this combination of aggressive chemotherapy and high-dose radiation, but pneumonectomy is associated with unacceptable morbidity and mortality.

Simultaneous chemoradiation in advanced non-small cell lung cancer

We designed our study to evaluate the safety and efficacy of simultaneous chemoradiation therapy in an accelerated, twice-a-day schedule to improve local control and survival in advanced lung cancer patients. Forty-one patients were entered into the study. Twenty-three had stage IIIB and 18 had stage IIIA disease. They received cisplatin 30 mg/m2, VP-16 80 mg/m2, and 5-Fluorouracil (5-FU) 900 mg/m2 in iv infusion. Radiation therapy consisted of 2G twice a day for 5 days, followed by a 2-week rest. This cycle was repeated 3 times. Patients were evaluated for surgical resection after the second cycle. Acute toxicity was acceptable: 3 patients expired (1 congestive heart failure, 1 sepsis, 1 pulmonary embolism). The 1-year actuarial survival was 60.3%; the 2-year actuarial survival was 55.3%. Our results show that this regimen is well tolerated and that the 2-year actuarial survival appears to be comparable to that reported in the literature.

Multidisciplinary approach to the treatment of locally and regionally advanced non-small cell lung cancer: University of Miami experience

An intensive multimodality therapy protocol incorporating neoadjuvant chemotherapy was initiated in July 1985 for patients with either borderline resectable or unresectable non-small cell carcinoma of the lung. Thirty-five patients, 21 men and 14 women were entered till March 1991. The median age was 58 years (27-74). Histology was squamous in 15, adenocarcinoma in 11, large cell in 6, and adenosquamous carcinoma in 3. Initial stages were IIIA in 19 patients, IIIB in 14 and II in 2. All patients tolerated preoperative chemotherapy with 5-FU, etoposide and cisplatin (FED). The response to chemotherapy was complete response in 2 (6%), and partial response in 22 (63%). Thirty-two patients underwent surgery. 26 patients were rendered disease free including two found disease free at surgery. Fifteen underwent pneumonectomy, 14 lobectomy and 3 biopsy only. Interstitial radiation therapy was used in 7 patients. The median survival of all patients was 19 months, those who underwent incomplete surgical resection was 12 months and patients rendered disease free at operation 21 months. Thirteen patients are alive and free of disease, including 6 patients alive longer than 5 years. Only patients who responded to chemotherapy and also had complete resection survived more than 2 years. Aggressive neoadjuvant therapy with FED, followed by resection, brachytherapy, postoperative radiation therapy, and adjuvant chemotherapy can be safely accomplished with encouraging survival in stage III patients.

Concurrent Carboplatin (CBDCA), Vindesine (VDS) and Radiotherapy in Stage III Non Small Cell Lung Cancer (NSCLC)

Aims

Aim of the study was to test, in a cooperative and prospective trial, the effectiveness and feasibility of a chemo-radio-therapy program in stage III non small cell lung cancer (NSCLC).

Methods

The schedule consisted in carboplatin (CBDCA) 150 mg/m2/iv on days 1, 3, 5 and vindesine VDS 2.5 mg/m2/iv on days 1, 8, 15, 22 every 4 weeks for 2 cycles followed by radiotherapy 60 Gy with CBDCA 50 mg/m2 weekly as radioenhancer. The same schedule was proposed as neoadjuvant treatment in 10/47 patients (stage III A) and as exclusive treatment in 37/47 (stage III B) admitted patients.

Results

In the neoadjuvant subgroup partial remission was obtained in 5/10 patients, and 3 of them underwent surgery with consequent CR. In the stage III B subgroup, 2 complete remissions were obtained (survival 14 and 9+ months). Toxicity was mild.

Conclusions

Our results confirm the feasibility of the schedule in stage III NSCLC.

Combined modality therapy for stage IIIA non-small cell carcinoma of the lung

53 patients with stage IIIA non-small cell carcinoma of the lung (NSCCL) were treated with multimodality therapy consisting of induction radiotherapy (55.8 Gy) and two cycles of concurrent chemotherapy with cisplatin, 25 mg/m2 for 4 days by continuous infusion and bolus etoposide, 100 mg/m2 on days 2 and 4 of each cycle followed by surgery and adjuvant chemotherapy. Of 53 evaluable patients, 47 achieved clinical responses (9 complete response, 38 partial response) after induction therapy for a response rate of 89%. 47 patients were resectable after induction therapy, but 8 patients refused surgery and 6 patients were not eligible for surgery based on poor pulmonary function (medical contraindications). 33 patients underwent thoracotomy and in 6 patients, resection was technically unfeasible. Thus complete surgical resection was accomplished in 27 patients. After all therapy, 28 patients achieved a complete response (53%) and 19 patients a partial response (36%). Toxicities were mild. At a maximum of 75 months (median, 28 months) of follow-up, the median survival of the entire group is 24 months. The median survival of resected patients has not been reached; their 6-year survival rate is 55%. Unresected patients survived for a median of 11 months. This multimodality regimen is well-tolerated, induces a high response and resectability rate and prolongs survival in resected patients.

Low-versus high-energy photon beams in radiotherapy for lung cancer

This retrospective study analyzed the outcome of lung cancer patients who were treated with either 4-MV or 10-MV photons. From October 1979 through December 1982, 126 patients with locally advanced, unresectable or medically inoperable, nonmetastatic non-small cell lung cancer were treated in a prospective trial in which they were randomly assigned to one of three chemotherapy combinations and thoracic radiotherapy. The patients were stratified by cell type, extent of operation, age, sex, and status of supraclavicular lymph nodes. All patients were followed until death or for a minimum of 4.8 years. Of the 102 evaluable patients, 98 were treated with either 4-MV or 10-MV photons (49 patients in each group). Outcomes examined included best primary tumor response, time to first local (in-field) recurrence, disease-free survival, and overall survival. No significant differences were detected between the patients treated with 4-MV or 10-MV photons for several important prognostic and treatment factors or for any of the study outcomes, including first local (in-field) recurrence, disease-free survival, and overall survival. For the group of 98 patients treated with either 4-MV or 10-MV photons, the estimated 2-year freedom from first local (in-field) recurrence was 47.7%. The estimated 2-year disease-free and overall survivals were 21.6% and 28.6%, respectively.