Long-term follow-up after chemoradiotherapy (CRT) and surgery in patients (pts) with stage III non-small cell lung cancer (NSCLC): Is bulky mediastinal nodal disease of prognostic importance

Abstract

7168 Background: Bulky mediastinal nodal involvement at presentation has been considered a poor prognostic factor in pts with stage III NSCLC. We present long-term follow-up from a phase II trial of accelerated fractionation radiation (AFR), concurrent chemotherapy and surgery, to address this issue. Methods: Between 10/94 and 9/00, 105 pts with surgically proven stage IIIA (N=78) or IIIB (N=27) NSCLC underwent induction treatment consisting of a 96-hour continuous cisplatin infusion (20 mg/m2/day) and a 24-hour infusion of paclitaxel (175 mg/m2) concurrent with AFR (1.5 Gy bid) to a dose of 30 Gy. Surgery was scheduled 4 weeks later, with a second identical course of CRT given 4–6 weeks post-operatively to a total dose of 60–63 Gy. Results: With a median follow-up of 59 (range 35–102) months, the projected Kaplan-Meier (KM) 5-year overall survival is 29%. KM 5-year locoregional and distant control are 85% and 39% respectively. KM 5-year survival was better in clinical stage IIIA vs. IIIB pts (33% vs. 19%, P=0.03); clinical responders to induction vs. non responders (36% vs. 17%, P=0.004); and pathologic responders vs. non-responders (45% vs. 11%, P < 0.001). Pathologic stage after surgery also predicted 5-year survival (stage 0-II: 55%; IIIA: 23%; IIIB - IV: 4%; P < 0.001). Pre-treatment mediastinoscopy identified 20 pts with only microscopic intra-nodal involvement in one or more ipsilateral nodes, and 61 pts with gross macroscopic, but ipsilateral, nodal disease. These two groups did not differ in median or 5-year KM survival (27 vs. 29 months, 45% vs. 27%, P= 0.45). The extent of ipsilateral nodal involvement contributed no prognostic information about survival in a Cox multivariable analysis. Conclusions: Clinical stage IIIA disease, clinical and pathologic response to induction, and a lower pathologic stage are important predictors for survival after this CRT protocol for pts with stage III NSCLC. Bulky ipsilateral mediastinal nodal involvement at diagnosis is of no prognostic importance for survival in these pts and should not be a consideration in treatment planning. No significant financial relationships to disclose.