Stage IIIA NSCLC Treatment
- In the first trial, the combination of mitomycin C, vindesine, and cisplatin were given concurrently with split-course daily radiation therapy to 56 Gy compared with chemotherapy followed by continuous daily radiation therapy to 56 Gy.
- Five-year OS favored concurrent therapy (27% vs. 9%).
- Myelosuppression was greater among patients in the concurrent arm, but treatment-related mortality was less than 1% in both arms.
- In the second trial, 610 patients were randomly assigned to sequential chemotherapy with cisplatin and vinblastine followed by 60 Gy of radiation therapy, concurrent chemotherapy, or concurrent chemotherapy with cisplatin and vinblastine with twice-daily radiation therapy.
- Median and 4-year survival were superior in the concurrent chemotherapy with daily radiation therapy arm (17 mo vs. 14.6 mo and 21% vs. 12% for sequential regimen [P = .046]).
- Two smaller studies also reported OS results that favored concurrent over sequential chemotherapy and radiation, although the results did not reach statistical significance.[34,35][Level of evidence: 1iiA]
- A meta-analysis of three trials evaluated concurrent versus sequential treatment (711 patients).
- The analysis indicated a significant benefit of concurrent over sequential treatment (RR = 0.86; 95% CI, 0.78-0.95; P = .003). All studies used cisplatin-based regimens and once-daily radiation therapy.
- More deaths (3% OS rate) were reported in the concurrent arm, but this did not reach statistical significance (RR = 1.60; CI, 0.75-3.44; P = .2).
- There was more acute esophagitis (grade 3 or worse) with concurrent treatment (range = 17%-26%) compared with sequential treatment (range = 0%-4%; RR= 6.77; P = .001). Overall, the incidence of neutropenia (grade 3 or worse) was similar in both arms.
Standard Treatment Options for Superior Sulcus Tumors (T3, N0 or N1, M0)
Standard treatment options for superior sulcus tumors include the following:
- Radiation therapy alone.
- Radiation therapy and surgery.
- Concurrent chemotherapy with radiation therapy and surgery.
- Surgery alone (for selected patients).
NSCLC of the superior sulcus, frequently termed Pancoast tumors, occurs in less than 5% of patients.[36,37] Superior sulcus tumors usually arise from the apex of the lung and are challenging to treat because of their proximity to structures at the thoracic inlet. At this location, tumors may invade the parietal pleura, chest wall, brachial plexus, subclavian vessels, stellate ganglion, and adjacent vertebral bodies. However, Pancoast tumors are amenable to curative treatment, especially in patients with T3, N0 disease.
Adverse prognostic factors include the presence of mediastinal nodal metastases (N2 disease), spine or subclavian-vessel involvement (T4 disease), and limited resection (R1 or R2).
While radiation therapy is an integral part of the treatment of Pancoast tumors, variations in dose, treatment technique, and staging that were used in various published series make it difficult to determine its effectiveness.[36,37]