Stage IIIA

[john]

There may be better outcomes for induction chemo/radiation for Stage IIIa. The important thing is to get staged as accurately as possible, so the chemo/radiation can be done before the surgery.

Not sure how this compares to adjunctive chemo.

Trimodality Therapy May Be Superior to Bimodality Therapy

Albain and colleagues[20] presented the initial results of RTOG 9309, an intergroup trial evaluating the role of surgery in locally advanced, stage IIIA (N2) NSCLC. Enrollees in this effort were randomized to chemoradiation or to chemoradiation followed by surgery. Initial therapy was identical: Patients received thoracic RT (45 Gy) and concomitant chemotherapy with cisplatin (50 mg/m2 days 1, 8, 29, and 36) and etoposide (50 mg/m2 days 1-5 and 29-33). At 45 Gy, patients went on to full-dose RT (61 Gy) or to surgical resection. Both cohorts received 2 additional cycles of adjuvant or "consolidative" etoposide-cisplatin. A total of 429 patients were randomized between March 1994 and November 2001. Data were analyzable on 329. There was no age cut-off: 16% were older than 70 years; 35% were women. Compliance to the initial induction chemotherapy was quite good: >/= 95% in both arms. Of those on the trimodality arm, 97% were able to get the scheduled dose of RT, while only 81% on the bimodality arm completed RT as planned. In addition, 75% of those on the trimodality arm were able to receive consolidative chemotherapy; 89% were able to do so on the bimodality arm. The incidence of grade >/= 3 neutropenia was 73% on the bimodality effort compared with 64% for those completing RT at 45 Gy. Esophagitis was also worse: 18% vs 9%. But grade 5 toxicity was higher in the trimodality effort, at 7% vs only 1.6% in the bimodality arm; 10 of the 14 treatment-related deaths in the surgical arm occurred in the postoperative period. Of those randomized to the surgical arm, 96% underwent thoracotomy, and 88% had R0 resections. Progression-free survival was significantly better for those undergoing surgery (log-rank P = .02), and while median survival time was equivalent, the survival curves cross at the median, so that by year 3, overall survival appeared to favor the trimodality approach (Table 4).

Table 4. Trimodality vs Bimodality Therapy

Arm CT/RT --> S CT/RT

PFS (mo) 14 11.7

3 yr PFS (%) 29 19

MST (mo) 22.1 21.7

3 yr OS (%) 38 33

Local recurrence (%) 13 21

CT, chemotherapy; RT, radiotherapy; S, surgery; PFS, progression-free survival; MST, median survival time; OS, overall survival.

Because of treatment-induced complications, more patients on the surgical arm died without disease progression (P = .004), but by the same token, more patients on that arm were still alive without disease progression (P = .003). Consequently, more patients on that arm were alive at 3 years. Whether this apparent advantage will translate into a long-term survival benefit remains to be seen, though certainly chemoradiation followed by surgical resection is a valid approach in the carefully selected individual with N2 disease. The Intergroup is contemplating follow-up studies for this population, including a prospective comparison of induction chemotherapy vs chemoradiation to determine if toxicity can be reduced without compromising efficacy, as well as potential tests of targeted agents in the preoperative and postoperative period.

[mhutch1366]

This sounds a lot like what I was on. I was diagnosed in late March/early April 2000. The clinical protocol I was put on, literally days before palliative surgery, was from a phase II clinical trial that was stopped at 12 months for immediate implementation. I was the first to be treated at NIH under this treatment regimen, and at that time the surgeons believed this was going to become standard treatment. I had a large (9 x 14 cm plus) pancoast tumor of the upper left lobe and into my shoulder region, up into my neck. The blood vessels had regrown to allow blood flow through the right side of my brain, bypassing the tumor. The tumor subsumed five ribs and was encroaching on my spine. During surgery I lost my collarbone, which had been radiated. I had a new chest wall built out of Goretex. Although initially I lost use of my left arm, I regained most of the function back, with some restriction of motion above and behind.

Neuropathy was truly minimal. Although I wll be taking pain medication for the rest of my life, I know through God's grace I truly beat the odds. Some might have thought the radiation/chemo plus surgery was overkill, but better preventive than the alternative.

Anyway, when I was treated three years ago, they didn't have long term statistics on this procedure. I was afraid to look them up. telling myself I was a statistic of 100 per cent, group of one. Never mind what happened to other people, I was going to worry about getting myself through this, one step at a time. Bottom line, this is an effective therapy for tumors that will be responsive to cisplatin and vp-16. My surgeons didn't tell me which nsclc I had, as they said it would not alter my treatment options. I thank God the pancoast tumor I had spread or crept, but did not metastasize. In that I was indeed fortunate.

Again, if you have questions, ASK ASK ASK.

There are always things the doctors won't think to volunteer if you don't jog their memories. Do your own research, and be proactive in your own treatment.

God bless you all.

MaryAnn