LOCALLY ADVANCED

T1 TO T3 AND N2

General Information

  • potentially resectable, ultimate prognosis is much worse.

“Minimal” N2 Disease.

  • OS-5 range from 10% to 20% (higher with complete resection)
  • Few survivor beyond 3 years with incomplete resection

“Bulky” N2 Disease.

chemoradiotherapy

  • considered the standard treatment for local control for most of these patients.
  • Surgery alone is poor even with adjuvant therapy, < 10% OS-5 years with surgery, despite adjuvant therapy

radiation dose in chemoradiation

  • RTOG 73-01 established 60 Gy as the optimal standard radiation dose for locally advanced NSCLC.
  • RTOG 73-01: 375 pts. with unresectable stage III NSCLC randomized to
    • 40 Gy split-course
    • 40-, 50-, or 60- Gy continuous daily doses of 2 Gy.
    • Intrathoracic failure 44-53% vs 33-45% in for patient treated with 50- and 60 Gy.
  • Based on this trial, doses from 55-66 Gy are still used in most studies.
  • It is important to realize that the dose of 60 Gy was established as optimal before the advent of modern imaging.

neoadjuvant chemotherapy

  • may make tumors resectable.(Rusch)
  • Chemo-> Surg -> PORT Randomized trials
  • 20% OS benefit with Chemo -> CR -> Surg -> XRT
  • Rosell l(MIP x 3)->50 Gy to all. 17% vs 0% 5-yr OS
  • Roth (CEPx3)-> 66 Gy for (+) margins. 36% vs 15% 5-yr OS
  • No benefit (Depierre) Chemo: mitomycin, ifosfamide and cisplatin x 2 cycles and 2 cycles post-op.
  • 60-75% will respond to neoadjuvant chemo.
  • Nonresponders should not undergo surgery (Bueno)
  • OS improves about 20% from surgery alone.
  • Each study included post-operative radiation

Neoadjuvant ChemoRadiation

  • neoadjuvant chemoRT → RT vs. Surgery (INT 0139)
  • PFS 14 mo[s] vs 11.7 mo[RT] in favor of surgery but greater treatment related deaths for surgical arm
  • No difference in OS in the two arms. 22 mo [S] vs 21.7 mo [RT]
  • Matched subgroup analysis showed OS-5 benefit 36% vs 18% OS-5 favoring CRT → lobectomy over CRT alone.
Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-Share Alike 2.5 License.