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

Evaluation of treatment strategies for patients with stage IIIA non-small cell lung cancer in the immunotherapy era

BACKGROUND

Optimal treatment for patients with stage IIIA NSCLC is controversial. Growing evidence indicates surgery with adjuvant or neoadjuvant chemotherapy (SC) may be superior to non-surgical treatments. Direct comparisons have not been performed between SC and chemoradiation with immunotherapy (CRI) among patients diagnosed with stage IIIA NSCLC since consolidation immunotherapy was added to treatment guidelines.

METHODS

This retrospective study compared surgical and systemic non-surgical treatments (except targeted therapy) among adults diagnosed with stage IIIA NSCLC 2017-2021. Data was from ConcertAI's curated EHR Patient360™ NSCLC real-world care product. Real-world progression-free survival (rwPFS) and overall survival (rwOS) were evaluated among patients treated with SC or CRI using Kaplan-Meier and Cox proportional hazard methods. Baseline differences were balanced using propensity score-derived inverse probability treatment weights (IPTW).

RESULTS

Among 1718 eligible, the two main comparator groups (SC and CRI) had 431 (25%) and 576 (34%) patients; 711 patients received chemoradiation or monotherapy. A wide range of treatment strategies was observed across included oncology clinics (e.g., 0-67% clinic patients received surgery). IPTW-adjusted analyses showed reduced hazards in the SC group vs. CRI for rwPFS (HR 0.78, 95% CI: 0.63-0.97) and rwOS (HR 0.63, 95% CI: 0.49-0.82). SC was similarly beneficial for patients across nodal status groups and appeared especially beneficial for patients with resectable squamous-cell tumors.

CONCLUSION

Stage IIIA NSCLC treatment is highly variable. Real-world studies can provide valuable evidence to support surgery as a treatment option for stage IIIA patients, who currently may only be offered chemoradiation with or without immunotherapy.

Development and validation of a nomogram for predicting overall survival in patients with stage III-N2 lung adenocarcinoma based on the SEER database

Background

There is variability in the prognosis of stage III-N2 lung adenocarcinoma (LUAD) patients. The current tumor-node-metastasis (TNM) staging is not sufficient to precisely estimate the prognosis of stage III-N2 LUAD patients. The Surveillance, Epidemiology, and End Results (SEER) database collected first-hand information from a large number of LUAD patients. Based on the SEER database, this study aimed to determine the prognostic factors that affect overall survival (OS) in stage III-N2 LUAD patients and then establish a nomogram for predicting OS in this type of cancer to identify the high-risk population that may require more frequent surveillance or intensive care.

Methods

Data for 1,844 stage III-N2 primary LUAD patients who were registered between 2010 and 2015 were obtained from the SEER database. These patients were randomly assigned to either training (n=1,290) or validation (n=554) cohorts at a 7:3 ratio. The univariate and multivariate Cox regression (UCR and MCR) analyses were performed to find the relevant independent prognostic factors. To predict the OS based on these prognostic factors, a nomogram was then developed. The performance of the nomogram was examined based on the calibration curves, and receiver operating characteristic (ROC) curves. The ability of nomogram to stratify patient risk was validated by Kaplan-Meier survival analysis.

Results

Age, gender, tumor location, T-stage and treatment modality (chemotherapy, radiation therapy, surgery and scope of lymph node dissection) of stage III-N2 LUAD patients were significantly associated with prognosis. The area under the curve (AUC) values of OS predicted by the nomogram constructed with these factors at 12-, 36- and 60-month were 0.784, 0.762 and 0.763 in the training cohort, whereas 0.707, 0.685 and 0.705 in the validation cohort, respectively. Additionally, calibration curves demonstrated concordance between predicted and observed outcomes. Nomogram risk stratification provides a meaningful distinction between patients with various survival risks.

Conclusions

A survival prediction model that may be useful for risk stratification and decision-making is developed and validated for stage III-N2 LUAD patients. A high-risk patient predicted by the prediction model may require more frequent surveillance or intensive care.

The impact of postoperative radiotherapy on the survival of patients with stage III non-small cell lung cancer: A CONSORT-compliant analysis using the SEER database

BACKGROUND

Postoperative radiotherapy (PORT) is commonly used to treat patients with resected stage III non-small cell lung cancer (NSCLC), but its effectiveness remains uncertain. This retrospective cohort study aimed to investigate the impact of PORT on overall survival (OS) and evaluate its heterogeneity among subgroups of patients.

METHODS

A total of 6305 patients with resected stage III NSCLC were included in this study from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching was conducted to balance baseline characteristics between the patients who received PORT and those who did not. OS was used as the primary outcome. Subgroup analysis was performed to identify which patient subgroups might benefit more from PORT.

RESULTS

Overall, no significant difference was observed in OS between the 2 groups with or without propensity score matching. However, subgroup analysis demonstrated that PORT improved OS in patients with certain characteristics, including stage IIIA/N2, stage IIIB, squamous cell carcinoma, tumor grade III-IV, or lymph node ratio (LNR) > 1/3. Multivariate analysis showed that several variables were associated with adverse prognostic factors for OS, such as marital status (others), race (white), male gender, squamous cell carcinoma, elderly age, advanced stage, poor histological differentiation grade, high LNR, and not receiving chemotherapy.

CONCLUSION

In patients with resected stage III NSCLC, PORT may not be beneficial for all patients. However, it may improve survival time in certain patient subgroups, such as those with stage IIIA/N2, stage IIIB, squamous cell carcinoma, tumor grade III to IV, or LNR > 1/3. These findings provide important information for clinical decision-making and future research regarding the use of PORT in patients with resected stage III NSCLC.

The efficacy of postoperative radiotherapy for patients with non-small cell lung cancer: An updated systematic review and meta-analysis

The controversy over the efficacy of postoperative radiotherapy (PORT) has existed for a long time. The present study reassessed the overall survival (OS) and disease-free survival (DFS) data to investigate whether PORT can improve survival in resectable non-small cell lung cancer (NSCLC) patients. The following databases were used to perform literature search: PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), and Embase (from January 1, 1986 to July 5, 2021). The results of overall survival (OS) and disease-free survival (DFS) were calculated as hazard ratio (HR). Confidence intervals are chosen with 95% confidence intervals. A total of 12 RCTs and 19 retrospective cohort studies were found to meet the inclusion criteria. A significant DFS improvement was detected in the PORT group (4111 patients from 15 studies), although statistical difference was not detected for OS between the non-PORT and PORT groups (31 studies, 49,342 total patients). PORT prolonged OS in patients undergoing PORT plus postoperative chemotherapy (POCT) and in pN2 patients. Patients with a median radiation dose of 50.4 Gy and a median radiation dose of 54 Gy had a better OS after PORT. However, if the total radiotherapy dose went up to 60 Gy, PORT increased the risk of death in NSCLC patients. Significant difference in OS was not found in the results of studies with regard to treatment methods, pathologic stages, study type, radiation beam quality, and radiation dose. Patients undergoing postoperative chemoradiotherapy and pN2 patients can benefit from PORT. Patients exposed to median radiation doses of 50.4 and 54 Gy demonstrated relatively good efficacy. For patients with non-small-cell lung cancer, PORT has not been proven to extend OS, but its effect on DFS remains strong.

Case Report: Aumolertinib as Neoadjuvant Therapy for Patients With Unresectable Stage III Non-Small Cell Lung Cancer With Activated EGFR Mutation: Case Series

Background

There is no standard treatment for stage III lung cancer due to its low surgical resection rate, and improving PFS and survival of patients with III NSCLC has become an urgent challenge in clinical treatment. For EGFR mutation-positive patients, targeted therapy has the remarkable feature of high efficiency and low toxicity compared with first-line standard chemotherapy, and targeted neoadjuvant therapy needs to be further explored.

Method

We report 3 diagnosed cases of locally advanced unresectable NSCLC with EGFR-sensitive mutations who first received 1-2 cycles of preoperative chemotherapy neoadjuvant therapy and were treated with 110 mg daily of 3rd-generation EGFR-TKI aumolertinib instead because of poor efficacy or safety intolerance.

Result

After 2 cycles of aumolertinib treatment, all 3 patients achieved symptomatic remission and significant tumor size reduction and achieved downstaging to allow surgical treatment. No additional operative difficulties were added during the surgery. They continued to receive adjuvant therapy with the original dose of aumolertinib after surgical treatment, and no evidence of tumor recurrence was found until the most recent imaging examination. In addition, the course of neoadjuvant and adjuvant therapy was free of serious adverse effects.

Conclusion

Perioperative treatment of these three cases of locally advanced unresectable NSCLC with EGFR-sensitive mutations with the third-generation EGFR-TKI aumolertinib showed significant efficacy and excellent safety and may be a new option for targeted therapy in the perioperative period.

Efficacy and Safety of Neoadjuvant Targeted Therapy vs. Neoadjuvant Chemotherapy for Stage IIIA EGFR-Mutant Non-small Cell Lung Cancer: A Systematic Review and Meta-Analysis

Purpose: The role of targeted therapy in the neoadjuvant field of stage IIIA epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC) is still controversial. We sought to evaluate the efficacy and safety of neoadjuvant targeted therapy (NTT) with neoadjuvant chemotherapy (NCT) used as a benchmark comparator.

Methods: A systematic search was conducted in four databases (Pubmed, Cochrane Library, Embase, CNKI) for eligible studies on NTT published before October 2020. The primary endpoints were overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and grade 3/4 adverse events (AEs). Statistical analysis and bias assessment were performed by RevMan 5.3.

Results: A total of 319 patients, including 3 randomized controlled trials and 2 non-randomized controlled trials, were included in the meta-analysis. Perform the second subgroup analysis after excluding 2 non-randomized controlled trials. The meta-analysis reveals that, for EGFR mutation-positive stage IIIA NSCLC patients, compared with NCT, NTT can significantly increase ORR (relative risk [RR]:1.70, 95% confidence interval [CI]:1.35–2.15; subgroup-RR:1.56, 95% CI 1.23–2.0) and significantly reduce grade 3/4 AEs (RR:0.5, 95% CI 0.34–0.75; subgroup-RR: 0.53, 95% CI 0.26–1.08). The OS of the NTT arm is slightly higher, but the difference is not significant (hazards ratio [HR]: 0.74, 95% CI: 0.43–1.27; subgroup-HR: 0.64 95% CI 0.40–1.03). No difference in PFS was found (HR: 0.81, 95% CI 0.27–2.44).

Conclusion: In neoadjuvant setting, targeted therapy has a definitive effect on patients with EGFR mutation-positive stage IIIA NSCLC and is even better than chemotherapy in terms of toxicity and tumor response rate.

Systematic Review Registration: PROSPERO, identifier CRD42021221136.

Applicability of the PACIFIC trial results in patients not eligible for the PACIFIC trial: Canadian rapid consensus statement and recommendations

BACKGROUND

The PACIFIC study established durvalumab as a standard of care for consolidation therapy in patients treated with radical intent chemoradiation for stage III inoperable non-small cell lung cancer. In clinical practice, many patients are not eligible for trials, yet radical intent chemoradiation may still be used.

METHODS

A virtual anonymous tumour board Delphi-model was used in order to generate consensus on the use of durvalumab in six clinical situations where chemoradiation is used in clinical practice and recommended in guidelines, yet not PACIFIC eligible. Two anonymous iterations were sent and recommendations were circulated for approval and comment. Results are presented using a modified PICOT format (patients, intervention, control, outcomes, and ongoing trials).

RESULTS

In three of the scenarios, consensus was reached and recommendations were for the use of consolidation durvalumab, but being respectful of potentially increased toxicity/reduced benefit in comparison to PACIFIC results (treatment of stage IIB inoperable, recurrent mediastinal disease, and residual gross disease post attempted surgical removal). There was a recommendation against using durvalumab in resected stage III disease with R1 or R0 margins, even if chemoradiation were considered. There was not consensus on the use of consolidation durvalumab in the setting of oligometastatic disease or in the setting of large cell neuroendocrine carcinoma or combined small cell carcinoma.

CONCLUSION

Treatment of 'real-world' lung cancer often involves chemoradiation in settings outside of stage III and eligible for the PACIFIC study. This paper offers recommendations in these scenarios based on a consensus approach.

Prognostic factors for overall survival of stage III non-small cell lung cancer patients on computed tomography: A systematic review and meta-analysis

INTRODUCTION

Prognosis prediction is central in treatment decision making and quality of life for non-small cell lung cancer (NSCLC) patients. However, conventional computed tomography (CT) related prognostic factors may not apply to the challenging stage III NSCLC group. The aim of this systematic review was therefore to identify and evaluate CT-related prognostic factors for overall survival (OS) of stage III NSCLC.

METHODS

The Medline, Embase, and Cochrane electronic databases were searched. After study selection, risk of bias was estimated for the included studies. Meta-analysis of univariate results was performed when sufficient data were available.

RESULTS

1595 of the 11,996 retrieved records were selected for full text review, leading to inclusion of 65 studies that reported data of 144,513 stage III NSCLC patients andcompromising 26 unique CT-related prognostic factors. Relevance and validity varied substantially, few studies had low relevance and validity. Only four studies evaluated the added value of new prognostic factors compared with recognized clinical factors. Included studies suggested gross tumor volume (meta-analysis: HR = 1.22, 95%CI: 1.05-1.42), tumor diameter, nodal volume, and pleural effusion, are prognostic in patients treated with chemoradiation. Clinical T-stage and location (right/left) were likely not prognostic within stage III NSCLC. Inconclusive are several radiomic features, tumor volume, atelectasis, location (pulmonary lobes, central/peripheral), interstitial lung abnormalities, great vessel invasion, pit-fall sign, and cavitation.

CONCLUSIONS

Tumor-size and nodal size-related factors are prognostic for OS in stage III NSCLC. Future studies should carefully report study characteristics and contrast factors with guideline recognized factors to improve evidence evaluation and validation.

The impact of order with radiation therapy in stage IIIA pathologic N2 NSCLC patients: a population-based study

BACKGROUND

The aim of this study was to investigate the optimal order of radiation therapy in patients affected by stage IIIA pathologic N2 (IIIA/N2) non-small-cell lung cancer (NSCLC) and to identify its potential risk factors.

METHODS

17,654 (8786 men and 8868 women) diagnosed with NSCLC stage IIIA-N2 from 2004 to 2015 patients were identified in the Surveillance, Epidemiology, and End Results (SEER) database. Among the relevant clinical parameters, we evaluated overall survival (OS), lung cancer-specific survival (LCSS) and other variables such as age, sex and tumor size in patients who were treated with different combinations of surgery and radiotherapy strategies.

RESULTS

We discovered that surgery benefit in younger IIIA/N2 NSCLC patients (age ≤ 75), and compared with surgery only, preoperative radiotherapy significantly improved the survival rate most (p < 0.001). When we performed the OS and LCSS analysis in the subgroup of patients' age > 75 years old, who underwent postoperative radiotherapy (PORT) had the highest survival rate (p < 0.001). Multivariate analyses showed that the following parameters had a negative impact on survival: female sex, older age, no chemotherapy, large tumor size, high tumor grade, no surgery or radiotherapy.

CONCLUSIONS

In IIIA/N2 NSCLC patients, surgery, radiotherapy and chemotherapy were associated with improved OS and LCSS. Younger patients underwent surgical resection and chemotherapy, the main population we studied, benefited most from preoperative radiotherapy in all orders with radiation therapy (p < 0.001). In patients more than 75 years old, there was no clear benefit from only surgery, and PORT was recommended in case of having surgery.

Postoperative radiotherapy option based on mediastinal lymph node reclassification for patients with pN2 non-small-cell lung cancer

Background

In this research, we used the mediastinal lymph node reclassification proposed by the International Association for the Study of Lung Cancer (iaslc) to screen for patients with pathologic N2 (pN2) non-small-cell lung cancer (nsclc) who might benefit from postoperative radiotherapy (port).

Methods

The study enrolled 440 patients with pN2 nsclc who received complete surgical resection and allocated them to one of three groups: N2a1 (single-station skip mediastinal lymph node metastasis), N2a2 (single-station non-skip mediastinal lymph node metastasis), and N2b (multi-station mediastinal lymph node metastasis). Rates of local recurrence at first recurrence in patients receiving and not receiving port were compared using the chi-square test. Overall (os) and disease-free survival (dfs) were then compared using Kaplan-Meier survival analysis with log-rank test. In addition, the factors potentially influencing os and dfs were analyzed using univariate and multivariate Cox regression.

Results

The rate of local recurrence for the N2a2 and N2b groups was significantly lower in patients receiving port (p = 0.044 and p = 0.043 respectively). The log-rank test revealed that, for the N2a1 group, differences in os and dfs were not statistically significant between the patients who did and did not receive port (p = 0.304 and p = 0.197 respectively). For the N2a2 group, os and dfs were markedly superior in patients who received port compared with those who did not (p = 0.001 and p = 0.014 respectively). For the N2b group, os was evidently better in patients who received port compared with those who did not (p = 0.025), but no statistically significant difference in dfs was observed (p = 0.134). Multivariate regression analysis revealed that, in the N2a1 group, port was significantly associated with poor os [hazard ratio (hr): 2.618; 95% confidence interval (ci): 1.185 to 5.785; p = 0.017]; in the N2a2 group, port was associated with improved os (hr: 0.481; 95% ci: 0.314 to 0.736; p = 0.001) and dfs (hr: 0.685; 95% ci: 0.479 to 0.980; p = 0.039).

Conclusions

For patients with pN2 nsclc who receive complete resection, port might be beneficial only for patients with single-station non-skip metastasis (N2a2). Patients with single-station skip metastasis (N2a1) and multi-station metastasis (N2b) might not currently benefit from port.

The role of postoperative radiotherapy for completely resected pIIIA-N2 non-small cell lung cancer patients with different clinicopathological features: a systemic review and meta-analysis

Background: The role of postoperative radiotherapy (PORT) in completely resected pathological stage IIIA-N2 (pIIIA-N2) non-small cell lung cancer (NSCLC) remains controversial. This meta-analysis aimed to assess the effect of PORT in patients with pIIIA-N2 NSCLC on the basis of clinicopathological features. Methods: The PubMed, PubMed Central (PMC), Embase, Web of Science, and Cochrane Library were searched for relevant studies. The main outcomes were overall survival (OS) and disease-free survival (DFS), which were compared using the hazard ratio (HR). Results: One randomized trial and 12 retrospective studies were eligible for the analysis. PORT significantly improved both OS [HR = 0.85; 95% confidence interval (CI): 0.79-0.92] and DFS (HR = 0.57; 95% CI: 0.38-0.85) compared with non-PORT treatment in patients with multiple N2 metastases or multiple N2 station involvement. No significant difference in either OS (HR = 1.03; 95% CI: 0.86-1.24) or DFS (HR = 1.08; 95% CI: 0.70-1.65) was found between PORT and non-PORT groups for patients with single N2 station involvement. No significant heterogeneity was observed. No significant differences in OS were observed between PORT and non-PORT groups for patients of different ages, sex, tumor sizes or pT stages, and histological types. Conclusions: The findings of this meta-analysis supported a role for PORT in patients with completely resected pIIIA-N2 NSCLC having multiple N2 metastases and favored withholding PORT to patients with single N2 station involvement. Further prospective randomized controlled trials are needed to confirm the findings.

Erlotinib Versus Gemcitabine Plus Cisplatin as Neoadjuvant Treatment of Stage IIIA-N2 EGFR-Mutant Non-Small-Cell Lung Cancer (EMERGING-CTONG 1103): A Randomized Phase II Study

PURPOSE

To assess the benefits of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors as neoadjuvant/adjuvant therapies in locally advanced EGFR mutation-positive non-small-cell lung cancer.

PATIENTS AND METHODS

This was a multicenter (17 centers in China), open-label, phase II, randomized controlled trial of erlotinib versus gemcitabine plus cisplatin (GC chemotherapy) as neoadjuvant/adjuvant therapy in patients with stage IIIA-N2 non-small-cell lung cancer with EGFR mutations in exon 19 or 21 (EMERGING). Patients received erlotinib 150 mg/d (neoadjuvant therapy, 42 days; adjuvant therapy, up to 12 months) or gemcitabine 1,250 mg/m² plus cisplatin 75 mg/m² (neoadjuvant therapy, two cycles; adjuvant therapy, up to two cycles). Assessments were performed at 6 weeks and every 3 months postsurgery. The primary end point was objective response rate (ORR) by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1; secondary end points were pathologic complete response, progression-free survival (PFS), overall survival, safety, and tolerability.

RESULTS

Of 386 patients screened, 72 were randomly assigned to treatment (intention-to-treat population), and 71 were included in the safety analysis (one patient withdrew before treatment). The ORR for neoadjuvant erlotinib versus GC chemotherapy was 54.1% versus 34.3% (odds ratio, 2.26; 95% CI, 0.87 to 5.84; P = .092). No pathologic complete response was identified in either arm. Three (9.7%) of 31 patients and zero of 23 patients in the erlotinib and GC chemotherapy arms, respectively, had a major pathologic response. Median PFS was significantly longer with erlotinib (21.5 months) versus GC chemotherapy (11.4 months; hazard ratio, 0.39; 95% CI, 0.23 to 0.67; P < .001). Observed adverse events reflected those most commonly seen with the two treatments.

CONCLUSION

The primary end point of ORR with 42 days of neoadjuvant erlotinib was not met, but the secondary end point PFS was significantly improved.

The lymph node status and histologic subtypes influenced the effect of postoperative radiotherapy on patients with N2 positive IIIA non-small cell lung cancer

BACKGROUND AND OBJECTIVE

To investigate the role of postoperative radiotherapy (PORT) in IIIA-N2 non-small cell lung cancer (NSCLC) patients and subgroups which derived benefit from PORT.

METHODS

A total of 576 patients with pathological IIIA-N2 NSCLC, who underwent complete resection, were identified. Propensity score matching (PSM) methods were used to balance the patients' characteristics between two groups. Overall survival (OS) and relapse-free survival (RFS) were compared between PORT and non-PORT patients.

RESULTS

On multivariable analysis, improved OS remained correlated with younger age, single N2 station involvement, less positive lymph nodes, and chemotherapy. After PSM, 121 PROT patients and 242 non-PORT patients were matched. PORT was not associated improved patients' OS (P = 0.735) or RFS ( P = 0.483). For patients who underwent postoperative chemotherapy (POCT), PORT could improve OS in single N2 station involved patients (HR: 0.572, 95%CI: 0.312 to 1.05, P = 0.040). Patients with papillary predominant adenocarcinoma also benefited from PORT with an increase in OS (HR: 0.350, 95%CI: 0.126 to 0.972, P = 0.033).

CONCLUSIONS

For patients with completely resected IIIA-N2 NSCLC, mediastinal lymph node metastasis and histologic subtypes could influence the effect of PORT. Single N2 station involvement and papillary predominant subtype were predictors of benefit from PORT.

Male patients with resected IIIA-N2 non-small-cell lung cancer may benefit from postoperative radiotherapy: a population-based survival analysis

AIM

Our analysis was performed to assess the efficacy of postoperative radiotherapy (PORT) on the survival for pathologic IIIA-N2 Non-small-cell lung cancer patients.

PATIENTS & METHODS

We identified 2949 patients from 2004 to 2013 in the SEER database. Propensity score-matching was used to reduce the selection bias. Overall survival (OS), cancer-specific survival (CSS) and the factors associated with survival prognosis were evaluated.

RESULTS

There was no significant difference in OS and CSS between PORT and non-PORT groups. However, subgroup analysis revealed an OS (p = 0.007) and CSS (p = 0.006) detrimental for male patients not receiving PORT. Multivariate analysis showed that old age, male sex, high pathologic grade, squamous carcinoma, bigger tumor size and larger number of positive lymph nodes had a negative impact on survival.

CONCLUSION

PORT could improve OS and CSS in male patients with resected IIIA-N2 non-small-cell lung cancer.