Preoperative chemotherapy in stage III non-small cell lung cancer: long-term outcome

Korrelation histologischer und nuklearmedizinischer Befunde der Tumorregression in behandelten bösartigen Lungentumoren

CT cannot provide useful information in a timely manner after neoadjuvant treatment. To evaluate the role of (18)F FDG PET after neoadjuvant chemoradiation for early therapy response and its effect on survival as compared to histopathologic tumor response, findings in 32 patients were analyzed prospectively in an ongoing multicenter trial (LUCAS-MD).

INCLUSION CRITERIA

histologically confirmed NSCLC stage IIIA/IIIB. Neoadjuvant treatment: 2-3 cycles with paclitaxel/carboplatin and a block of chemoradiation followed by surgery. Pretherapeutic staging: PET scan in addition to a spiral CT and/or MRI. Second PET scan after completion of neoadjuvant therapy prior to surgery. Documentation of lymph node involvement. Assessment of SUV and the metabolic tumor index for primary tumor and metastatic lymph nodes. Image fusion of PET with CT data followed by molecular radiation treatment planning. Evaluation of histologic regression grade and correlation with PET for primary tumor and each lymph node location. All patients (10/32) with complete response in lymph node metastases detected by PET prior to surgery, had no vital tumor cells (i.e. histologic regression grade/RG III, sensitivity 100%). In primary tumors showing complete response, the RG was IIb or III, in one patient IIa (false negative in PET). False positive findings in PET are due to inflammation (5 patients, histologically confirmed). Univariate analyses: actuarial tumor-specific survival for complete metabolic remission vs. incomplete remission after 24 months: 76 vs. 20% (p=0,0079); for RG III/IIb vs. RG IIa/I after 24 months: 63 vs. 36% (p=0,0123).(18)F FDG PET precedes CT in measuring the tumor response and may predict (long term) therapeutic outcome in stage III NSCLC. Histologic regression grade correlates well with metabolic remission as detected by PET.

A preoperative alternating chemotherapy and radiotherapy program for patients with stage IIIA (N2) non-small cell lung cancer

The objective of the present study was to evaluate the feasibility and toxicity of a preoperative alternating chemotherapy and radiotherapy program followed by surgery in stage IIIA non-small cell lung cancer (NSCLC). The tumor response, resection rate, tumor/lymph node downstaging, and survival were also evaluated. The positive predictive value (PPV) in the diagnosis of mediastinal lymph node metastasis was 81% using conventional magnetic resonance imaging (MRI) with short inversion-time inversion recovery (STIR) technique (STIR-MRI) on our criteria. Eligible patients had clinical N2 lesions (stage IIIA) and a World Health Organization (WHO) performance status of 0-2. The treatment program consisted of two courses of preoperative cisplatin, vindesine, and ifosfamide; alternating with radiotherapy, including two courses of 20 Gy radiation. Surgery was performed within 4 weeks after the treatment. Twenty-two patients with stage IIIA (N2) NSCLC (20 men and two women, age 35-71 years) were enrolled into the study. Hematologic and other toxicities were within an acceptable range. Surgery was not indicated for two patients because of distant metastasis; one patient with renal dysfunction and one with pancytopenia during this treatment underwent surgery subsequently. The clinical response rate was 50% (partial response in 11/22). Definitive surgery was indicated for 18 patients resulting in 17 patients with complete resection and one exploratory thoracotomy. A pathologic complete response of the primary tumor occurred in 41% of the patients (seven of 17; without residual tumor), whereas 58% (ten of 17) were pathologic N0. The median survival was 33 months with an actuarial 4-year survival rate of 33% in 17 patients with complete resection and 30 months with 28% 4-year survival rate in all entered patients. A randomized phase-III study using this approach for stage IIIA (clinical N-2 disease) is warranted.