Randomized Controlled Trial of Resection Versus Radiotherapy after Induction Chemotherapy in Stage IIIA-N2 Non-small Cell Lung Cancer

Risk prediction of multiple-station N2 metastasis in patients with upfront surgery for clinical single-station N2 non-small cell lung cancer

To investigate long-term outcomes and develop a risk model for pathological multi-station N2 (pN2b) in patients who underwent upfront surgery for clinical single-station N2 (cN2a) non-small cell lung cancer (NSCLC). From 2006 to 2018, 547 patients who had upfront surgery for suspected cN2a NSCLC underwent analysis. A risk model for predicting pN2b metastasis was developed using preoperative clinical variables via multivariable logistic analysis. Among 547 clinical cN2a NSCLC patients, 118 (21.6%), 58 (10.6%), and 371 (67.8%) had pN0, pN1, and pN2. Among 371 pN2 NSCLC patients, 77 (20.8%), 165 (44.5%), and 129 (34.7%) had pN2a1, pN2a2, and pN2b. The 5-year overall survival rates for pN2a1 and pN2a2 were significantly higher than for pN2b (p = 0.041). Histologic type (p < 0.001), age ≤ 50 years (p < 0.001), preoperatively confirmed N2 metastasis (p < 0.001), and clinical stage IIIB (vs. IIIA) (p = 0.003) were independent risk factors for pN2b metastasis. The risk scoring system based on this model demonstrated good discriminant ability for pN2b disease (area under receiver operating characteristic: 0.779). In cN2a NSCLC patients, those with multiple N2 metastases indicate worse prognosis than those with a single N2 metastasis. Our risk scoring system effectively predicts pN2b in these patients.

Organ preservation strategies after neoadjuvant chemoimmunotherapy in resectable non-small cell lung cancer: a multicenter retrospective cohort study

BACKGROUND

Neoadjuvant chemoimmunotherapy has shown a good therapeutic effect on non-small cell lung cancer (NSCLC), which also opens up the possibility of applying organ preservation strategies. This study investigated the feasibility of modified surgery after potent neoadjuvant chemoimmunotherapy in central type NSCLC.

METHODS

In this multicenter retrospective cohort study, patients with central type NSCLC who received 2-4 cycles of neoadjuvant chemoimmunotherapy between January 2019 and June 2022 at Air Force Medical University Tangdu Hospital and Peking University People's Hospital were eligible. Patients were divided into modified and nonmodified groups according to the extent of surgery, after which, the safety and long-term prognosis of surgery were investigated.

RESULTS

A total of 84 patients were enrolled. Of 36 (42.9%) patients who underwent modified surgery, 21 patients underwent lobectomy, 12 patients underwent lobectomy with bronchoplasty, 2 patients underwent sleeve lobectomy, and 1 patient underwent bilobectomy. The modification rate for the initially estimated pneumonectomy, sleeve lobectomy, and bilobectomy was 48.6, 44.8, and 30%, respectively. Grades II-V postoperative complications were found in 5 (13.9%) patients in the modified group and 17 (35.4%) patients in the nonmodified group (relative risk, 0.393; 95% CI, 0.016-0.963; P =0.026). No significant difference was observed regarding the surgical approach, operative duration, blood loss, or R0 resection rate. The 2-year local recurrence rate was 3.7% (95% CI, 0.004-0.175) and 5.2% (95% CI, 0.012-0.168) in the modified group and nonmodified group, respectively. The 1-year PFS rate of modified and nonmodified groups was 97.1% (95% CI, 83.7-99.8) and 86.9% (95% CI, 73.4-94.4), respectively, while 2-year PFS were 89.8% (95% CI, 74.1-96.9) and 71.8% (95% CI, 56.7-83.4), respectively.

CONCLUSION

Applying organ preservation strategies, that is, undergoing modified surgery after neoadjuvant chemoimmunotherapy, is feasible for selected central type NSCLC patients with favorable safety and long-term survival.

Deep learning-based bone suppression in chest radiographs using CT-derived features: a feasibility study

Background

Bone suppression of chest X-ray holds the potential to improve the accuracy of target localization in image-guided radiation therapy (IGRT). However, the training dataset for bone suppression is limited because of the scarcity of bone-free radiographs. This study aims to develop a deep learning-based bone suppression method using CT-derived features to reduce the reliance on the bone-free dataset.

Methods

In this study, 59 high-resolution lung CT scans were processed to generate the lung digital radiographs (DRs), bone DRs, and bone-free DRs, for the training and internal validation of the proposed cascade convolutional neural network (CCNN). A three-stage image processing framework (CT segmentation, DR simulation, and feature expansion) was developed to expand simulated lung DRs with different weightings of bone intensity. The CCNN consists of a bone detection network and a bone suppression network. In external validation, the trained CCNN was evaluated using 30 chest radiographs. The synthesized bone-suppressed radiographs were compared with the bone-suppressed reference in terms of peak signal-to-noise ratio (PSNR), mean absolute error (MAE), structural similarity index measure (SSIM), and Spearman's correlation coefficient. Furthermore, the effectiveness of the proposed feature expansion method and CCNN model were assessed via the ablation experiment and replacement experiment, respectively.

Results

Evaluation on real chest radiographs showed that the bone-suppressed chest radiographs closely matched with the bone-suppressed reference, achieving an accuracy of MAE =0.0087±0.0030, SSIM =0.8458±0.0317, correlation of 0.9554±0.0170, and PNSR of 20.86±1.60. After removing the feature expansion from the CCNN model, the performance decreased in terms of MAE (0.0294±0.0093, -237.9%), SSIM (0.7747±0.0.0416, -8.4%), correlation (0.8772±0.0271, -8.2%), and PSNR (15.53±1.42, -25.5%) metrics.

Conclusions

We successfully demonstrated a novel deep learning-based bone suppression method using CT-derived features to reduce the reliance on the bone-free dataset. Implementation of the feature expansion procedures resulted in a remarkable reinforcement of the model performance. For the application of target localization in IGRT, the clinical testing of the proposed method in the context of radiation therapy is a necessary procedure to move from theory into practice.

Comparison of Treatment Strategies for Patients With Clinical Stage T1-3/N2 Lung Cancer

BACKGROUND

The therapeutic strategies for clinical stage T1-3N2 (cT1-3N2) lung cancer are controversial. For operable tumors, treatment can vary by center, region, and continent. This study aimed to identify the optimal therapeutic method and type of surgical strategy for cT1-3N2 lung cancer.

METHODS

This retrospective evaluation analyzed the records of 17,954 patients with cT1-3N2 lung cancer treated in 2010 through 2015 from the SEER database. The effects of different therapeutic methods and types of surgical strategies on overall survival (OS) were assessed. Univariate and multivariate analyses were performed using a Cox proportional hazards model.

RESULTS

The 5-year OS rates were 27.7% for patients with T1N2 disease, 21.8% for those with T2N2 disease, and 19.9% for T3N2 disease. Neoadjuvant therapy plus operation (OP) plus adjuvant therapy, and OP plus adjuvant therapy, provided better 5-year OS rates than OP alone or concurrent chemoradiotherapy (34.1%, 37.7%, 29.3%, and 16.1%, respectively). In the T1N2, T2N2, and T3N2 groups, lobectomy provided better 5-year OS than pneumonectomy, sublobectomy, and no surgery. Both univariate and multivariate analyses showed that young age, female sex, well-differentiated histologic grade, adenocarcinoma cell type, neoadjuvant and adjuvant therapy, lobectomy, and T1 stage were statistically associated with better 5-year OS rates.

CONCLUSIONS

In cT1-3N2 lung cancer, multimodal treatments tended to provide better 5-year OS than OP alone or concurrent chemoradiotherapy. In addition, lobectomy was associated with better survival than other operative methods.

Optimal managements of stage IIIA (N2) non-small cell lung cancer patients: a population-based survival analysis

Background

This study aimed to investigate the optimal management of stage IIIA (cN2) non-small cell lung cancer (NSCLC) patients and determine potential predictive factors.

Methods

We extracted patients diagnosed as NSCLC stage IIIA (cN2) between 2004 and 2011 from Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) and lung cancer-specific survival (LCSS) were compared among patients given different clinical managements by Kaplan-Meier method. Other variables such as age, sex and tumor size were analyzed to explore the factors associated with outcomes.

Results

A total of 98,700 IIIA-cN2 NSCLC patients were identified from SEER database. Survival of patients treated with surgery was better than that of patients treated by radiotherapy alone (P<0.001). Radiation prior to surgery significantly improved the survival in comparison with surgery alone (P<0.001). In the subgroups of OS analysis, age >65 (P=0.902), adenocarcinoma (P=0.279), tumor size ≤3 cm (P=0.170), well differentiated (P=0.360) patients, preoperative radiotherapy improved survival insignificantly compared with surgery alone.

Conclusions

Preoperative radiation with surgery had the most encouraging survival outcomes in stage IIIA-cN2 NSCLC patients compared with radiation or surgery alone. No significant outcome improvement was shown between postoperative radiotherapy (PORT) and surgery alone.

[Efficacy and Potential Application of Neoadjuvant Chemotherapy in Patients with IIIa Stage Non-small Cell Lung Cancer]

背景与目的

新辅助化疗应用于可手术切除的Ⅲa期非小细胞肺癌（non-small cell lung cancer, NSCLC）患者的确切疗效及安全性尚存争议。本研究旨在探讨新辅助化疗对可手术切除Ⅲa期NSCLC患者的近期疗效，并分析其与术后并发症的相关性。

方法

根据纳入及排除标准，回顾性分析2011年1月-2013年10月重庆医科大学附属第一医院收治的明确临床诊断为Ⅲa期NSCLC 370例患者完整资料，根据术前是否接受新辅助化疗分为两组，其中A组为新辅助化疗+手术组97例，B组为直接手术组273例，比较两组患者的临床资料，分析新辅助化疗后肿瘤降期率，并将两组患者的手术情况、术后并发症进行对比，统计两组患者3年无病生存期（disease-free survival, DFS）。

结果

A组患者新辅助化疗后肿瘤总降期率为65.98%（64/97）；两组患者R0切除率分别为96.91%（94/97）和90.48%（247/273），手术时间、术中出血量、术后平均住院日差异均无统计学意义（P > 0.05）；术后并发症总发生率A组稍高于B组，分别为76.29%（74/97）和72.52%（198/273），差异无统计学意义（P > 0.05）；所有患者术后随访2个月-36个月，中位随访时间12.7个月，两组患者术后总体复发转移率分别为63.92%（62/97）和94.87%（259/273），有统计学差异（P < 0.05）；A、B两组患者中位DFS分别为19.46个月和11.34个月，差异有统计学意义（P < 0.001）。

结论

新辅助化疗可使Ⅲa期NSCLC患者受益，能有效降低肿瘤分期，提高肿瘤切除率，可降低术后局部复发率及远处转移率，提高患者的无进展生存期；且并不明显增加术后并发症的发生率。

Clinical outcomes of surgery after induction treatment in patients with pathologically proven N2-positive stage III non-small cell lung cancer

BACKGROUND

To assess the effect of preoperative neoadjuvant therapy on resectability, downstaging, and the prognosis in patients with stage IIIA-N2 non-small cell lung cancer (NSCLC).

METHODS

Eighty-four patients who underwent resections after induction therapy [76 with neoadjuvant chemotherapy (CTx) and 8 with induction chemoradiotherapy (CRTx)] for clinically evident [larger than 1 cm on computed tomography (CT)] and pathologically confirmed ipsilateral N2 positive NSCLC (stage IIIA) between January 2009 and July 2013 were reviewed retrospectively.

RESULTS

Partial response (PR) was observed in 39 patients (46.4%). Standard lobectomy was performed in 63 cases (75.0%), and extensive resection was conducted in 21 cases (25.0%), including four pneumonectomies. Pathologic nodal downstaging (pN2 to pN0-1) was confirmed in 38 cases (45.2%). After induction therapy plus resection, 5-year progression-free survival (PFS) and overall survival (OS) in cases with radical resections were 37.9% and 34.2%, respectively. Patients who underwent lobectomy or pathologic nodal downstaging had better prognosis than those who had extensive resection or persistent N2 in PFS (P=0.036; P=0.025) and OS (P=0.023; P=0.024). On univariate analysis, lobectomy and pathological nodal downstaging were favourably predictive factors both in PFS and OS. Cox multivariate analyses identified only pathologic nodal downstaging to predict better PFS, and lobectomy to be significantly prognostic for OS.

CONCLUSIONS

These data suggest that neoadjuvant therapy was feasible, and helpful for tumor and pathologic nodal downstaging with promising rates of survival in patients with stage IIIA-N2 NSCLC. After induction therapy, patients with potentially radical lobectomy were more likely to benefit from operation. Pathological nodal downstaging of pN2 to pN0-1, rather than clinical response was predictive of a favorable outcome, and was correlated with a better chance of survival.

Randomized controlled trials of induction treatment and surgery versus combined chemotherapy and radiotherapy in stages IIIA-N2 NSCLC: a systematic review and meta-analysis

BACKGROUND

The efficacy of induction treatment plus surgery for improving postoperative survival in patients with non-small-cell lung cancer (NSCLC) in stages IIIA-N2 is controversial, especially compared with the combined chemotherapy and radiotherapy. We therefore performed a systematic review and meta-analysis of the published phase III randomized clinical trials (RCTs) to quantitatively evaluate the survival benefit of preoperative induction treatment vs. combined chemoradiotherapy.

METHODS

We systematically searched for trials that started after January, 1980. We excluded relevant studies using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards. Our primary endpoint, overall survival (OS), was defined as the time from randomisation until death (any cause). Secondary endpoint was progression free survival (PFS). PubMed, EMBASE and Cochrane library were used for the study search. All analyses were by intention to treat.

RESULTS

Three studies (1,084 patients) were centrally selected and analyzed for the present meta-analysis. Combination of the three randomized controlled trials showed that there was no significant benefit of induction treatment plus surgery compared to combined chemoradiotherapy on 2-year OS [risk ratio (RR) =1.00; 95% CI, 0.85-1.17; P=0.98] and 4-year OS (RR =1.13; 95% CI, 0.85-1.51; P=0.39). However, from the subgroup analysis, it showed a significant PFS benefit (RR =1.78; 95% CI, 1.08-2.92; P=0.02) regarded chemoradiotherapy as preoperative induction treatment, compared with chemotherapy alone for induction treatment (PFS) (RR =1.05; 95% CI, 0.61-1.81; P=0.86).

CONCLUSIONS

There was no significant OS benefit of induction treatment plus surgery compared with combined chemoradiotherapy in patients with NSCLC (stages IIIA-pN2) at 2 and 4 years. However, we could conclude PFS could be improved when radiation therapy was added into preoperative induction treatment. Given the potential advantages of adding radiation preoperatively, clinicians should consider using this treatment strategy in the stage IIIA-N2 disease after fully assessment of the patients.

The impact of positive nodal chain ratio on individualized multimodality therapy in non-small-cell lung cancer

This study aimed to analyze the prognostic significance of the positive nodal chain ratio (NCR) in non-small-cell lung cancer (NSCLC). A total of 208 pIIIa-N2 NSCLC patients who underwent complete surgical resections with a systematic nodal dissection were enrolled. The median values of NCR and the positive lymph node ratio (LNR) were used to grouping patients. The differences of overall survival (OS) and disease-free survival (DFS) between the different groups were compared. The median values of NCR and LNR were 0.31 and 0.45, respectively. The patients were separated into group A (NCR ≤0.45 and LNR ≤0.31; 91 cases), group B (NCR ≤0.45 and LNR >0.31 or NCR >0.45 and LNR ≤0.31; 51 cases), and group C (NCR >0.45 and LNR >0.31; 66 cases) according to their combined LCR and LNR values. Groups A, B, and C exhibited significantly different prognoses (5-year OS: 43.7, 25.2, and 12.3 %, respectively, p < 0.0001; 5-year DFS: 30.4, 23.3, and 8.6 %, respectively, p < 0.0001). Multivariate analyses revealed that this novel grouping method based on the combination of NCR and LNR was an independent prognostic factor for 5-year OS and 5-year DFS in pIIIa-N2 NSCLC. In group C, patients who received no postoperative treatment, adjuvant chemotherapy alone, or chemoradiotherapy exhibited different 5-year OS rates (0.0, 11.6, and 37.5 %, respectively, p = 0.003) and 5-year DFS rates (0.0, 7.5, and 25.0 %, respectively, p = 0.009). Therefore, postoperative chemoradiotherapy may significantly improve the prognosis of patients displaying NCR >0.45 and LNR >0.31. NCR combined with LNR may be more effective to guide individualized multimodality therapy including postoperative chemoradiotherapy for pIIIa-N2 NSCLC.

[Resected non-small cell bronchogenic carcinoma stage pIIIA-N2. Which patients will benefit most from adjuvant therapy?]

BACKGROUND

Controversy persists as regards the indications and results of surgery in the treatment of patients with stage pIIIA-N2 non-small cell lung cancer (NSCLC). The objective of this study was to analyze the overall survival of a multicentre series of these patients and the role of adjuvant treatment, looking for factors that may define subgroups of patients with an increased benefit from this treatment.

METHODS

A retrospective study was conducted on 287 patients, with stage pIIIA-N2 NSCLC subjected to complete resection, taken from a multi-institutional database of 2.994 prospectively collected consecutive patients who underwent surgery for lung cancer. Adjuvant treatment was administered in 238 cases (82.9%). Analyses were made of the age, gender, histological type, administration of induction and adjuvant chemotherapy and/or radiation therapy treatments.

RESULTS

The 5-year survival was 24%, with a median survival of 22 months. Survival was 26.5% among patients receiving with adjuvant treatment, versus 10.7% for those without it (P=.069). Age modified the effect of adjuvant treatment on survival (interaction P=.049). In patients under 70 years of age with squamous cell carcinoma, adjuvant treatment reduced the mortality rate by 37% (hazard ratio: 0,63; 95% CI; 0,42-0,95; P=.036).

CONCLUSIONS

Completely resected patients with stage pIIIA-N2 NSCLC receiving adjuvant treatment reached higher survival rates than those who did not. Maximum benefit was achieved by the subgroup of patients under 70 years of age with squamous cell carcinoma.

Prognostic factors of resected node-positive lung cancer: location, extent of nodal metastases, and multimodal treatment

Objective: To investigate the prognostic significance of location and extent of lymph node metastasis in resected non-small cell lung cancer (NSCLC), and to weigh up the influence of treatment modalities on survival.

Patients and method: On exploratory analysis, patients were grouped according to location and time of diagnosis of nodal metastasis: group I, pN2-disease in the aortopulmonary region (N=14); group II, pN2-disease at other level (N=30); group III, cN2-disease with response to induction treatment (ypN0; N=21); group IV, cN2-disease without response to induction treatment (ypN1-2; N=27); group V, pN1-disease (N=66).

Results: From 1999 to 2005, 158 patients (median age: 64 years) with node-positive NSCLC were treated at our institution either by neoadjuvant chemo-radiotherapy plus surgery or by surgery plus adjuvant therapy (chemotherapy, radiotherapy, or both). Operative mortality and major morbidity rates were 2% and 15%. Five-year survival rates were 19% for group I, 12% for group II, 66% for group III, 15% for group IV, and 29% for group V (P<.05). On multivariate analysis, time of N+-diagnosis, extent of nodal involvement and therapy approach were significantly linked to prognosis.

Conclusion: The survival of patients with node-positive NSCLC does not depend on anatomical location of nodal disease, but strongly correlates to extent of nodal metastases and treatment modality. Combined therapy approaches including chemotherapy and surgery may improve long-term survival.

[Indications for surgery in non-small cell lung cancer with lymph node invasion]

Surgery is indicated for N1 non-small cell lung cancer and performed, with good results in some patients, when N2 disease is not diagnosed preoperatively "minimal N2". Following the publication of the "EORTC 08941" and "Intergroup 0139" trials, it remains debatable for patients with proven N2 disease. Good prognostic factors before treatment or post-induction favour surgery, which seems superior to radiochemotherapy if the operative risk is low (lobectomies, and some pneumonectomies). N3 status is a contraindication to surgery, except in some rare cases with a strong response to induction treatment.

Role of surgery for stage IIIA-N2 non-small cell lung cancer

Perhaps no topic other than stage IIIA-N2 non-small-cell lung cancer management is as controversial among surgeons, radiologists and medical oncologists. Much of the debate relates to the choice between surgical resection and radiation as the local control modality. Although limited, available evidence from randomized controlled trails raised concerns about the role of surgical resection. However, there is no perfect study, and the results should not be over-interpreted. This mini review will scrutinize these trials, focusing on the study design, results and, most importantly, limitations, and will explore the possible role of surgery for stage IIIA-N2 non-small-cell lung cancer.

Intensity-modulated radiotherapy for locally advanced non-small-cell lung cancer: a dose-escalation planning study

PURPOSE

To evaluate the potential for dose escalation with intensity-modulated radiotherapy (IMRT) in positron emission tomography-based radiotherapy planning for locally advanced non-small-cell lung cancer (LA-NSCLC).

METHODS AND MATERIALS

For 35 LA-NSCLC patients, three-dimensional conformal radiotherapy and IMRT plans were made to a prescription dose (PD) of 66 Gy in 2-Gy fractions. Dose escalation was performed toward the maximal PD using secondary endpoint constraints for the lung, spinal cord, and heart, with de-escalation according to defined esophageal tolerance. Dose calculation was performed using the Eclipse pencil beam algorithm, and all plans were recalculated using a collapsed cone algorithm. The normal tissue complication probabilities were calculated for the lung (Grade 2 pneumonitis) and esophagus (acute toxicity, grade 2 or greater, and late toxicity).

RESULTS

IMRT resulted in statistically significant decreases in the mean lung (p <.0001) and maximal spinal cord (p = .002 and 0005) doses, allowing an average increase in the PD of 8.6-14.2 Gy (p ≤.0001). This advantage was lost after de-escalation within the defined esophageal dose limits. The lung normal tissue complication probabilities were significantly lower for IMRT (p <.0001), even after dose escalation. For esophageal toxicity, IMRT significantly decreased the acute NTCP values at the low dose levels (p = .0009 and p <.0001). After maximal dose escalation, late esophageal tolerance became critical (p <.0001), especially when using IMRT, owing to the parallel increases in the esophageal dose and PD.

CONCLUSION

In LA-NSCLC, IMRT offers the potential to significantly escalate the PD, dependent on the lung and spinal cord tolerance. However, parallel increases in the esophageal dose abolished the advantage, even when using collapsed cone algorithms. This is important to consider in the context of concomitant chemoradiotherapy schedules using IMRT.

Current vaccine updates for lung cancer

Current treatments for lung cancer are far from optimal. Several immunotherapeutic strategies involving vaccines incorporating different tumor-associated antigens to induce immune responses against tumors are being tested in clinical trials internationally. Although small, benefits have indeed been observed from the early studies of these vaccines, and the future is looking brighter for lung cancer patients as a handful of these immunotherapies reach Phase III trials. In addition, optimizing the induced immune response by these vaccines has become a priority, and a number of techniques are being considered, including addition of adjuvants and combining vaccines, which affect synergy based on their mechanism of action. This review is an update on the current vaccines in production, the benefits observed from their most recent studies, and the upcoming plans for improvements in these immunotherapies.

Results of cutting-edge surgery in stage IIIA-N2 nonsmall cell lung cancer

PURPOSE OF REVIEW

To describe the state-of-the-art of the surgical management of stage IIIA-N2 nonsmall cell lung cancer.

RECENT FINDINGS

When completely resected, occult N2 found at thoracotomy, skip metastases, and single-level N2 in selected locations are reported to portend acceptable survival rates. Conversely, preoperatively proven ipsilateral mediastinal nodal involvement requires a multidisciplinary approach on the basis of neoadjuvant chemotherapy or chemoradiation. In these patients, complete resection of the primary tumor remains among the strongest prognosticators of survival. When technically feasible, radical mediastinal lymphadenectomy could be of added value. Given the demonstrated increase in postoperative morbidity and mortality, pneumonectomy should be avoided when possible, whereas lobectomy and parenchymal sparing resections should be favored if compatible with the resection of the original extent of the primary on tumor-free margins.

SUMMARY

Only selected patients with N2 disease may benefit from primary surgery. The impact of postoperative morbidity after induction treatment is still being evaluated. In this setting, differences in treatment sequence and combination (chemotherapy alone or chemoradiation) may influence postsurgical outcome. Patients' selection revolves around the modern concepts of oncologic operability and surgical resectability intended as assessment of survival benefit and ability to completely resect all residual tumor after neoadjuvant therapy.

Effect of preoperative chemoradiation in addition to preoperative chemotherapy: a randomised trial in stage III non-small-cell lung cancer

BACKGROUND

Preoperative chemotherapy improves survival in patients with stage III non-small-cell lung cancer (NSCLC) amenable to resection. We aimed to assess the additional effect of preoperative chemoradiation on tumour resection, pathological response, and survival in these patients.

METHODS

Between Oct 1, 1995, and July 1, 2003, patients with stage IIIA-IIIB NSCLC and invasive mediastinal assessment from 26 participating institutions of the German Lung Cancer Cooperative Group (GLCCG) were randomly assigned to one of two treatment groups. The intervention group were scheduled to receive three cycles of cisplatin and etoposide, followed by twice-daily radiation with concurrent carboplatin and vindesine, and then surgical resection (those with positive resection margins or unresectable disease were offered further twice-daily radiotherapy). The control group were scheduled to receive three cycles of cisplatin and etoposide, followed by surgery, and then further radiotherapy. The primary endpoint was median progression-free survival (PFS) in patients eligible for treatment after randomisation. Secondary endpoints in patients eligible for treatment after randomisation were overall survival (OS) and the proportion of patients undergoing surgery. Secondary endpoints in patients with tumour resection were the proportion with negative resection margins, the proportion with complete resection, the proportion with histopathological response, and the proportion with mediastinal downstaging. Additionally, exploratory (not prespecified) post-hoc analyses in terms of PFS and OS were done on patients not amenable to resection and on further subgroups of patients undergoing resection. Analyses were by intention to treat. This trial is registered on the ClinicalTrials.gov website, number NCT 00176137.

FINDINGS

558 patients were randomly assigned. 34 patients did not meet inclusion criteria and were excluded. Of 524 eligible patients, 142 of 264 (54%) in the interventional group and 154 of 260 (59%) in the control group underwent surgery; 98 of 264 (37%) and 84 of 260 (32%) underwent complete resection. In patients with complete resection, the proportion of those with mediastinal downstaging (45 of 98 [46%] and 24 of 84 [29%], p=0.02) and pathological response (59 of 98 [60%] and 17 of 84 [20%], p<0.0001) favoured the interventional group. However, there was no difference in PFS (primary endpoint) between treatment groups-either in eligible patients (median PFS 9.5 months, range 1.0-117.0 [95% CI 8.3-11.2] vs 10.0 months, range 1.0-111.0 [8.9-11.5], 5-year PFS 16% [11-21] vs 14% [10-19], hazard ratio (HR) 0.99 [0.81-1.19], p=0.87), in those undergoing tumour resection, or in patients with complete resection. In both groups, 35% of patients undergoing surgery received a pneumonectomy (50/142 vs 54/154). In patients receiving a pneumonectomy, treatment-related mortality increased in the interventional group compared with the control group (7/50 [14%] vs 3/54 [6%]).

INTERPRETATION

In patients with stage III NSCLC amenable to surgery, preoperative chemoradiation in addition to chemotherapy increases pathological response and mediastinal downstaging, but does not improve survival. After induction with chemoradiation, pneumonectomy should be avoided.

FUNDING

German Cancer Aid (Bonn, Germany).

What is the optimal treatment of stage IIIA-N2 non-small-cell lung cancer after EORTC 08941?

The results of a randomized trial investigating the role of local therapies after induction chemotherapy in patients with stage IIIA-N2 non-small-cell lung cancer lend themselves to a review of the available evidence and speculation about the routine and future treatment in these patients. An algorithm for future treatment is proposed.