Phase II study of induction docetaxel/cisplatin with rhG-CSF followed by concurrent pulsed docetaxel chemoradiation for stage III non-small cell lung cancer (NSCLC)

17034

Background: Both local and distant failures contribute to poor outcome in chemoradiation (CRT) for stage III NSCLC. Our previous study applied pulsed low-dose paclitaxel CRT for stage III NSCLC yielded 97.6% in-field tumor control and a modest survival gain. A follow-up study was designed to target distant micrometastasis up-front by one-cycle induction (IND) chemotherapy (CT) w/o further delay of local therapy. This was followed by low-dose sensitizing docetaxel (Doc) CRT. Methods: IND CT consisted of day 1 Doc 75 mg/m2 & cisplatin 75 mg/m2, and rhG-CSF (150 mg/m2 days 2–10). CRT started 3–6 wks later. Twice-weekly Doc at 12 mg/m2 was given with daily RT of 64.8 Gy to gross dz and 45–57.6 Gy to subclinical dz. Toxicity (Tox), response and survival were assessed. Results: 22 pts enrolled with 16 evaluable. 6 did not complete due to: allergy, intercurrent dz or progressive dz prior-to/during RT. Overall response was 69%. Kaplan-Meier survival was 67%, 55%, and 55% for years 1, 2, and 3. Grade (Gd) 3 Tox of IND CT included: allergy (10%), infection/nl ANC (20%), nausea (10%), HTN (5%) hyperglycemia (5%), H/A (5%), fatigue (10%), dyspnea/gd 4 hyperglycemia/fatigue (5%). No gd 3/4 hematologic Tox. Esophagitis was the main Tox of CRT. Doc was reduced after 10th pt enrolled for high incidence of gd 3 esophagitis: 4/8 (50%) at Doc dose of 12 mg/m2. Subsequent pts received reduced Doc of 10 mg/m2 and 1/8 had gd 3 esophagitis (12.5%). Other gd 3 Tox of CRT included: fatigue (14%), appetite loss (14%), flushing (7%), chest pain (7%), diarrhea (7%), and nausea (28%). No other gd 3 or 4 Tox from CRT. Conclusion: The regimen is associated with low hematologic Tox. Despite published MTD of twice-weekly Doc/RT at 15 mg/m2, 50% treated at 12 mg/m2 had gd 3 esophagitis. This was reduced to 12.5% at 10 mg/m2. Local response was 69% and survival was much better compared with our previous study of pulsed paclitaxel/RT w/o IND CT, which yielded 2 and 3-year survival of 33% and 18% for all, and 40% and 21% for pts completed protocol (Chen et al Clin Cancer Res 9:969–975,2003). Data suggest that one-cycle IND CT followed by low-dose taxane-based CRT improves survival of stage III NSCLC pts and deserves further investigation. Study partly supported by Sanofi-Aventis.

No significant financial relationships to disclose.

Adjuvant chemotherapy in stage IB non-small cell lung cancer (NSCLC): Update of Cancer and Leukemia Group B (CALGB) protocol 9633

7007

Background: In 2004, preliminary results of CALGB 9633 demonstrated statistically significant evidence that adjuvant chemotherapy with paclitaxel and carboplatin (PC) improved disease-free (DFS) and overall survival (OS) in resected stage IB NSCLC. Indeed, the study was closed early by the DSMB after a planned interim analysis demonstrated a p value for OS less than a prespecified stopping boundary. However, two larger trials, NCIC-JBR10 and ANITA, have shown significant OS advantages with adjuvant chemo, but failed to demonstrate improved survival in the stage IB subset. This report provides more mature data from CALGB 9633. Methods: InCALGB 9633, stage IB patients (pts) were randomized following resection to paclitaxel 200 mg/m2 and carboplatin AUC 6 q3wks ×4 cycles or to observation. While initially planned to accrue 500 pts, the accrual rate was <50% of expected. Because slow accrual allowed longer observation times for each pt, the accrual target was reduced to 384 pts. OS is the primary endpoint. The redesigned study had 80% power to detect a hazard ratio (HR) of 0.67 after 150 observed deaths using a 1-tailed logrank test conducted at the 0.05 level of significance. Results: Between 9/15/96 and 11/26/03, 344 pts were randomized. Median follow-up is 54 mo. Demographics and toxicity has been previously reported (JCO Sup, 22:621a, 2004). The current intent-to-treat analysis shows a significant improvement in DFS favoring adjuvant chemo (HR=0.74; 90% 2-sided CI: 0.57–0.96; p=0.027). There is a trend toward improvement in OS that is not significant (HR=0.80; 90% CI: 0.60–1.07; p=0.10). There is, however, a significant advantage in 3-yr survival (79% vs. 70%; p=0.045). Five-yr survival is not different (60% vs. 57%; p=0.32), although median follow-up is <5 yrs and CIs are wide. Continued follow-up is planned since only 131 of 150 deaths required for final analysis have been observed. Conclusions: This updated but “preliminary” analysis no longer shows a significant OS advantage for adjuvant chemotherapy in stage IB NSCLC. However, the re-designed study does not have adequate power to detect small differences in OS that may be clinically significant. Advantages in DFS and 3-yr survival support continued consideration of adjuvant PC in stage IB NSCLC.

[Table: see text]

Trial of a novel synthetic sealant in preventing air leaks after lung resection

BACKGROUND

Postoperative air leaks are a major cause of morbidity after lung resections. This study was designed to evaluate the efficacy and safety of a new synthetic, bioresorbable surgical sealant in preventing air leaks after pulmonary resection.

METHODS

In a multicenter trial, 172 patients undergoing thoracotomy were randomized intraoperatively in a 2:1 ratio to receive surgical sealant applied to sites at risk for air leak after standard methods of lung closure (treatment group) or to have standard lung closure only (control group). The primary outcome variable was the percentage of patients free of air leakage throughout hospitalization. Secondary outcome variables were the control of air leaks intraoperatively and the time to postoperative air leak cessation. Time to chest tube removal, time to hospital discharge, and safety outcomes were also evaluated.

RESULTS

Air leaks were identified before randomization in 89 of 117 patients in the treatment group and in 39 of 55 patients in the control group. Application of the sealant resulted in control of air leaks in 92% of treated patients (p < or = 0.001). A significantly higher percentage of treated patients than control patients remained free of air leaks during hospitalization (39% versus 11%, p < or =0.001). The mean times to last observable air leak were 30.9 hours in the treatment group and 52.3 hours in the control group (p = 0.006). In the treatment group, trends were observed for reduced time to chest tube removal and earlier discharge. No significant difference was identified in postoperative morbidity and mortality between the two groups.

CONCLUSIONS

Air leaks after lung resection occur in most patients. The application of this novel surgical sealant appears to be effective and safe in preventing postoperative air leaks.

Palliation of inoperable esophageal carcinoma with the Wallstent endoprosthesis

BACKGROUND

Palliation of malignant dysphagia can be achieved by insertion of an endoprosthesis. Recently, metallic self-expanding prostheses have been introduced that offer the advantage of a lower complication rate over their plastic counterpart.

METHODS

Thirteen patients with dysphagia due to inoperable carcinoma of the esophagus were treated with coated Wallstent (Schneider (USA) Inc, Minneapolis, MN) endoprostheses, which were placed under fluoroscopic control. All patients were given general anesthesia during the procedure.

RESULTS

After successful insertion of all endoprostheses, the dysphagia of 12 of the patients improved while in the hospital. Average length of stay was 4.4 days. Two patients required a second stent because of migration or tumor overgrowth. Seven patients died with a mean survival of 54 days (range, 14 to 144 days), and 6 are alive a mean of 112 days (range, 32 to 263 days) after treatment.

CONCLUSIONS

Coated Wallstent insertion is an effective, single treatment that quickly improves the patients' quality of life. Its effect on survival is yet to be established when used as a last resort in patients with inoperable esophageal carcinoma and poor general condition.

Obliteration of empyema tract with deepithelialized unipedicle transverse rectus abdominis myocutaneous flap

Four patients with chronic empyema after pneumonectomy have undergone successful obliteration of the empyema tract with a deepithelialized transverse rectus abdominis myocutaneous flap. The deepithelialized skin island has provided sufficient bulk for tract obliteration. Rotation of the skin island into the long axis of the rectus muscle has added considerable length to this flap, allowing it to reach the apex of the thoracic cavity. A recurrent loculation developed 4 months after the obliteration procedure in one patient. This was successfully treated with open pleural drainage and a second Clagett procedure. Over a mean follow-up period of 35 months, all four patients are free of further infectious sequelae. Chest roentgenograms have confirmed eradication of the tracts in all four patients.

Chylothorax

The management of chylothorax requires a thorough understanding of the anatomy and pathophysiology of the major thoracic lymphatics, prompt diagnosis, and (with rare exception) conservative management, including evacuation of the pleural space, nutritional support, and measures to reduce chyle production. A minority of chylothoraces will fail to resolve with these measures. Surgical intervention is then required to prevent chronic metabolic deterioration and death.

Gastric duplication cyst communicating with the pancreatic duct: a rare cause of recurrent abdominal pain

A 41-year-old woman with recurrent attacks of postprandial abdominal pain was found on endoscopic retrograde cholangiopancreatography and subsequent computed tomographic scan to have an enteric duplication within the substance of the pancreas with communication to the pancreatic duct. Celiotomy demonstrated a noncontiguous gastric duplication cyst. Internal drainage was curative.

Flattening of affect and personal constructs

Affective flattening is a disorder of emotional expression, of which a good definition is ‘a gross lack of emotional response to the given situation’ (Fish, 1962). It is a clinical sign whose assessment depends upon the clinician's intepretation of the patient's facial expression, tone of voice and content of talk (Harris ' Metcalfe, 1956). Although these are subtle cues, it has been shown that experienced clinicians can assess the severity of affective flattening with a high level of inter-rater agreement (Miller et al., 1953; Harris ' Metcaife, 1956; Wing, 1961; Dixon, 1968). The disorder is usually associated with a diagnosis of schizophrenia, although it may occur in other conditions, such as the organic psychoses (Bullock et al., 1951).