stage iiia lung cancer


In contrast to the European study, pneumonectomies were performed in 35% of patients randomly assigned to surgery, and 71% had an R0 resection. However, in part because of the heterogeneity of the disease, identification of such patients has been extremely challenging.10 Our institutional approach is to offer surgery for patients who have stage IIIA disease if only one mediastinal lymph node station is involved and if that node is smaller than 3 cm. Although surgical resection after full-dose chemoradiotherapy is feasible,26 most patients with stage III disease are not surgical candidates to begin with and have received maximum doses of radiation. In conclusion, stage III NSCLC occurs in a heterogenous group of patients, and many questions about how to best treat these patients remain unanswered. Follow-up for those receiving resection included a CT scan at 1 month, CT scans every 6 months for 2 years, PET scan at 1 year, and CT scans annually during years 3 through 5. Mortality rates resulting from lung resections have been reported to range from 1% to 6% among patients who did not receive preoperative therapy, with higher rates among those undergoing pneumonectomy compared with lobectomy [1517].Corresponding rates among those receiving neoadjuvant therapy range from 2% to 12% [7,1720]. Multidisciplinary Treatment of Stage IIIA NonSmall-Cell Lung Cancer. The debate thus is no longer if neoadjuvant chemotherapy works but rather why does it fail or why is it not used more often. Veeramachaneni NK, Feins RH, Stephenson BJ, et al. During this time patients with proven N2 disease were not considered for up-front surgery with adjuvant therapy. Molnar TF, Baliko Z, Sarosi V, Horvath PO. Cookies. Patients in the surgical group were found to be significantly younger than those receiving chemoradiation alone (60.1 vs. 67.9 years, respectively; p=0.001). Survival of patients with clinical stage IIIA non-small cell lung cancer after induction therapy: Age, mediastinal downstaging, and extent of pulmonary resection as independent predictors. ASCO Author Services The management of stage IIIA lung cancer patients remains controversial because of a lack of evidence-based treatment guidelines [10] mainly resulting from concerns related to treatment toxicities, surgical complications, and other factors [7]. Published online Although technically more difficult and with potentially higher morbidity, salvage lung resection can be safely performed, as evidenced by multiple, mostly single-institutional case series, which include our own, that show that both lobectomies and pneumonectomies are feasible, have acceptable toxicities, and can be associated with long-term survival when the patients are chosen appropriately.26-28 We recommend that, just as in the initial presentation, treatment for patients with recurrent disease without evidence of distant metastatic sites be discussed in a multidisciplinary conference. Does intensive follow-up alter outcome in patients with advanced lung cancer? This initial assessment should confirm the presence of N2 disease and rule out N3 involvement, which would stage the disease as IIIB and therefore exclude surgery from treatment. The findings were comparable between the surgical and nonsurgical treatment modalities, and the noted survival rates were consistent with those reported by SEER. Disease progression was noted in 5% to 15% of patients in this group. MR-imaging of the brain of neurologic asymptomatic patients with large cell or adenocarcinoma of the lung. A third strategy for treating advanced (resectable) lung cancer is to add a radiation regimen to the neoadjuvant chemotherapy protocol. Thus, it remains unclear whether the noted benefits are as compelling in patients with more advanced disease. Significant toxicities and high morbidity profiles have been reported among patients receiving chemoradiation [4,14], and surgical and postsurgical complications resulting from resection also represent serious concerns. The reason behind the failure of the experimental arm is a matter of debate. Enter words / phrases / DOI / ISBN / authors / keywords / etc. Accessibility Available data from the Radiation Therapy Oncology Group phase III trial for stage IIIA NSCLC, which aimed to compare survival outcomes in patients receiving induction chemotherapy followed by either surgery (n=29) or radiotherapy (n=32) [23], found that the 1-, 3-, and 4-year survival rates for the surgery group were 70%, 33%, and 22%, respectively. Burdett SS, Stewart LA, Rydzewska L. Chemotherapy and surgery versus surgery alone in non-small cell lung cancer. Another 7% of patients with NSCLC have a translocation, which leads to a fusion gene between echinoderm microtubule-associated protein-like 4 and anaplastic lymphoma kinase. Clamon GH, Parekh KR. Additionally, it is worth noting that in this investigation, 5-year survival among patients receiving chemoradiation alone (in the absence of surgery) was twice as high as national reported averages [2224]. Advertisers, Journal of Clinical Oncology Our findings indicate that neoadjuvant chemotherapy followed by surgery results in improved 5-year survival of stage IIIA N2 lung cancer patients compared with definitive chemoradiation alone. reproduced permission iiib iiia diagnosis detterbeck

FOIA Yet, for patients with stage III disease, such advances have been limited. Contact Us Among those receiving neoadjuvant chemotherapy, tumor size was reduced in 48% of patients and remained stable in 39% of those treated, prior to surgery.

Nivolumab and pembrolizumab, both antibodies directed against PD-1, have been recently approved for the treatment of NSCLC. TAPUR Study, Terms of Use | Privacy Policy |

Currently, for patients who have enlarged mediastinal lymph nodes on CT scans or high uptake on PET scans, a negative endoscopic bronchial ultrasound or esophageal ultrasound should be followed by a surgical biopsy.3, Up to 16% of patients with apparent stage III lung cancers have brain metastases at diagnosis, which greatly influences prognosis.4 Current National Comprehensive Cancer Network (NCCN) guidelines recommend a brain MRI as part of the initial staging tests for stage III lung cancer.5. ASCO Career Center Martin J, Ginsberg RJ, Abolhoda A, et al. The effect of treatment modality on survival, while adjusting for age and gender, was estimated using HRs resulting from Cox Proportional Hazard Models. Phase III study comparing chemotherapy and radiotherapy with preoperative chemotherapy and surgical resection in patients with non-small-cell lung cancer with spread to mediastinal lymph nodes (N2); Final report of RTOG 89-01. The results indicated that surgery did not improve overall survival; however, those undergoing lobectomy (but not pneumonectomy) had improved outcomes compared with those receiving an additional radiotherapy regimen without resection [4]. Conversely, patients treated with a pneumonectomy had a worse outcome with surgery and had a high perioperative mortality of 26%.8, Despite the negative results of these studies, it is clear that a subset of patients benefits from surgery. Cox proportional hazard models were used to provide estimates of the treatment effects on survival while adjusting for age and gender. The second reason for the radiologic follow-up is to make an early diagnosis of progression. September 21, 2016.

Confining the current discussion to stage IIIA lung cancer patients with N2 disease, the National Cancer Institute guidelines suggest that if complete resection of the tumor and lymph nodes is possible, such patients may benefit from surgery followed by postoperative chemotherapy, with the debate over the benefit of complete mediastinal lymph node dissection versus lymph node sampling ongoing despite a current stalemate [11]. Table 3 presents the 1-, 3- and 5-year survival outcomes for study patients stratified by treatment group. In the present investigation, one-quarter of our patients underwent surgery after responding to neoadjuvant chemotherapy. There was no difference in OS (21.2 v 23.2 months; P = .88), and patients treated with consolidation had higher incidences of grade 3 or 4 toxicities.22 Similarly, a phase III study conducted in Korea, China, and Taiwan randomly assigned 437 patients to chemoradiation and weekly cisplatin and docetaxel followed by three cycles of the same agents (35 mg/m2 each on days 1 and 8, every 3 weeks) or to best supportive care.23 No differences in the primary end points of PFS or OS were seen between the arms. The https:// ensures that you are connecting to the Surgery has been evaluated as part of multimodality therapy in patients with stage IIIA disease. about navigating our updated article layout. Subscribers Main Advances in the Past Decade in the Management of NSCLC. One hundred consecutive pneumonectomies after induction therapy for non-small cell lung cancer: An uncertain balance between risks and benefits. About Treatment of non-small cell lung cancer-stage IIIA: ACCP evidence-based clinical practice guidelines (2nd edition). The median OS was 28.7 months for patients who received standard-dose radiotherapy and was 20.3 months for those included in the high-dose radiotherapy arm (HR, 1.38; 95% CI, 1.09 to 1.76; P = .004). When surgery is considered, it is paramount to involve the surgery team in the initial evaluation. Five-year survival rates among stage IIIA lung cancer patients range between 2% and 15%, and there is currently no consensus regarding optimal treatment approaches for these patients. As new therapies are beneficial in the metastatic setting, and as we begin to use them in earlier-stage disease, many of these questions will remain unanswered and many new ones will surface, which underscores the need to prioritize clinical trials in this patient population. Permissions, Authors Overall survival for both groups was compared at 1, 3, and 5 years, respectively, beginning at the date of diagnosis. Proposed arguments for the benefits of adding preoperative chemotherapy to the treatment plan include a possible reduction in tumor size that may facilitate surgical resection, possible contribution to early eradication of developing metastases, and the fact that chemotherapy is often better tolerated preoperatively than postoperatively. This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0), Antineoplastic Agents, Carcinoma, Non-Small-Cell Lung, Thoracic Surgery. Although it has been hypothesized that surgery may improve survival by removing microscopic disease [6], patients undergoing resection have been shown to experience higher treatment-related mortality due to respiratory issues and have been less able to complete postoperative chemotherapy protocols compared with patients who do not receive surgery [4]. Upstaged patients after surgery were not included. Gilligan D, Nicolson M, Smith I, et al. Among 32 patients with pathologically confirmed disease, one-half were diagnosed with adenocarcinoma and approximately one-third with squamous cell carcinoma. This investigation included 127 patients with stage IIIA lung cancer confined to lung and mediastinum. This recommendation is shared among others cancer centers; in fact, a survey done among institution members of the NCCN showed that 90% of the responders would consider surgery as part of the therapy in this same clinical scenario.11. Multidisciplinary Treatment of Stage IIIA NonSmall-Cell Lung Cancer, Treatment of Stage IIIA NonSmall-Cell Lung Cancer: Charting the Next Steps, Silvestri GA, Gonzalez AV, Jantz MA, et al: Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Acceptable survival rates and determinations regarding an acceptable percentage of stage IIIA patients deemed eligible for surgery have not been established. Rusch VW, Giroux DJ, Kraut MJ, et al. 12, no. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or jop.ascopubs.org/site/misc/ifc.xhtml. All patients initially underwent positron emission tomography/computed tomography (PET/CT) scan with endobronchial ultrasound bronchoscopy (adopted by Stony Brook Cancer Center as a standard practice in 2001) to assess the mediastinum. Bulky disease, as defined by lymph nodes 2.5 cm, was significantly more common in the definitive chemoradiation group than in the surgery group (p<0.0002). If the mediastinoscopy was positive for residual N2 disease, the patients were treated with definitive chemoradiation, which included 4 cycles of concomitant platinum-based chemotherapy (50 mg/m2/week and carboplatinum AUC=2.0] and 58G over 30 sessions. Standardized uptake value (SUV) tumor and lymph node measurements decreased by more than 50% as a result of the neoadjuvant therapy regimen. Seder CW, Allen MS, Cassivi SD, et al. Rowell NP, ORourke NP. Additionally, Gilligan et al. Medical Science Monitor : International Medical Journal of Experimental and Clinical Research, http://www.cancer.org/research/acsresearchupdates/more/2014-cancer-survivorship-statistics-10-key-facts. The survival outcomes found among LCEC patients in this study who received neoadjuvant chemotherapy plus surgery were 34 times higher than those in other reports [22,23]. The purpose of this concise review is to address some of these. Inarguably, the healthiest patients were offered a surgical resection after neoadjuvant chemotherapy. Survival rates at 1 year postsurgery in the neoadjuvant group were 94% compared with 63% in the chemoradiation group (p=0.001).

A recent study used Surveillance, Epidemiology, and End Results and Medicare combined data to evaluate the survival of patients with lung and esophageal cancer on the basis of the number of PET scans done to detect recurrences.40 Comparison between groups with the highest and lowest utilization of PET scans showed no difference in survival. In a second study, however, the 3-year overall survival rate for a selected group of resectable stage IIIA NSCLC patients receiving induction chemotherapy plus radiotherapy followed be surgery was significantly higher (51.7%) [7]. Morbidity and mortality after neoadjuvant therapy for lung cancer: the risks of right pneumonectomy. Tumor characteristics for patients receiving neoadjuvant therapy prior to surgery. Despite the fact that therapy of stage III has changed little during the past decade, a number of open questions remain about its management. Findings from this study indicate that preoperative chemotherapy followed by resection can improve survival outcomes for stage IIIA lung cancer patients compared with chemoradiation alone. The up-front definitive chemoradiation group received 6 cycles of concomitant platinum-based chemotherapy (50 mg/m2/week and carboplatinum AUC=2.0) and 58G over 30 sessions Follow-up in this group included CT scans every 3 months and PET/CT at 1 year and 2 years, followed by a CT scan every 7 months thereafter, including at year 5. This could, theoretically, prevent the development of cancer symptoms with early initiation of palliative therapy or even allow for curative therapy in selected cases. 8600 Rockville Pike Induction chemoradiation is not superior to induction chemotherapy alone in stage IIIA lung cancer. Improved results of induction chemoradiation before surgical intervention for selected patients with stage IIIA-N2 non-small cell lung cancer. 2014 Cancer Survivorship Statistics 10 Key Facts 2014. Although this treatment approach is highly selective, with the healthiest and best-suited candidates being offered surgery, the findings add to a relatively limited evidence base regarding optimal treatment approaches for patients with stage IIIA lung cancer. The 5-year Kaplan-Meier survival curves are presented in Figure 1 and indicate that rates were significantly more favorable among those treated with neoadjuvant therapy followed by surgery, with 5-year survival rates found to be 3 times higher among those resected compared with patients who did not undergo surgery (63% vs. 19%, respectively; p<0.001). PMC legacy view A retrospective investigation of patients attending the Lung Cancer Evaluation Center (LCEC) at the Stony Brook Cancer Center, Stony Brook, New York, was undertaken to evaluate survival outcomes of stage IIIA lung cancer patients. Other regimens recommended by the NCCN guidelines are cisplatin plus vinblastine and carboplatin plus pemetrexed.5 In the absence of a clear preferred regimen, clinicians and patients need to make a decision about which regimen to prescribe after the following are considered: histology (pemetrexed is only useful for patients with nonsquamous histology), potential toxicities (eg, kidney injury for cisplatin, neuropathy for paclitaxel), length of treatment (CP and pemetrexed-containing regimens have always been studied with consolidation cycles, whereas the role of consolidation for EP and vinblastine-containing regimens is controversial), and cost (pemetrexed is significantly more expensive). The overall outcome of patients treated with definitive chemoradiation is poor, and less than 20% of patients have long-term survival in contemporary trials.19 In the adjuvant setting, four cycles of a platinum doublet are given in the majority of the trials,20 which is similar to the four to six cycles of chemotherapy given in the metastatic setting, where no benefit in OS is seen when the duration of the initial treatment is lengthened.21 Because most patients will experience recurrence and metastatic disease, an extended duration of chemotherapy beyond what is given during chemoradiation in patients with stage III disease, a practice also known as consolidation chemotherapy, has made theoretical sense. 1Department of Surgery, Stony Brook University (SUNY), Stony Brook, NY, U.S.A. 2Department of Medicine, Stony Brook University (SUNY), Stony Brook, NY, U.S.A. 3Department of Family, Population and Preventive Medicine, Stony Brook University (SUNY), Stony Brook, NY, U.S.A. In the absence of conclusive evidenced-based trials, the controversy as to which treatment approach or combination of approaches is ongoing. SPSS version 21 was used to conduct these analyses.

Doddoli C, Barlesi F, Trousse D, et al. Cancer.Net, ASCO.org The .gov means its official. The first is to detect a new primary lesion to which curative therapy can be delivered. Potential explanations include a higher incidence of treatment-related deaths in the high-dose arm potentially related to heart radiotoxicity and the finding that concurrent chemotherapy was more difficult to complete in the high-dose group. JCO Oncology Practice ASCO Meetings IS THERE BENEFIT OF INTENSE RADIOLOGIC FOLLOW-UP AFTER CURATIVE THERAPY FOR STAGE III DISEASE? The site is secure. Patients were treated either with neoadjuvant chemotherapy followed by resection or a regimen of chemoradiation alone. Due to the toll that anatomic resection takes on the body, patients deemed suitable to receive surgical intervention are typically healthier and have a lower likelihood of operative complications [1517,09,21]. Five-year Kaplan-Meier survival curve for stage IIIA lung cancer patients receiving either neoadjuvant therapy followed by resection or definitive chemoradiation. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST, Treatment of Stage IIIA NonSmall-Cell Lung Cancer: A Concise Review for the Practicing Oncologist. Shah AA, Berry MF, Tzao C, et al. The only clear toxicity difference was a higher incidence of neutropenia in patients treated with EP (54.8% v 44.5%; P .05). Kaplan-Meier curves and log-rank tests were used to display and evaluate the differences in survival outcomes between groups. We compared stage IIIa patients with proven N2 disease who were treated with neoadjuvant chemotherapy followed by resection with patients who received definitive chemoradiation. Inductive chemotherapy combined with resection resulted in significantly better outcomes at 5 years compared with a regimen of definitive chemoradiation alone (5-year survival rates: 63% vs. 19%, respectively).

Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas: Long-term results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). Final approval of manuscript: All authors, Accountable for all aspects of the work: All authors. Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer: Initial results of the randomized, prospective ACOSOG Z0030 trial. After the conclusion of local therapy, patients were to receive two additional cycles of chemotherapy.