Sulcus Non-small Cell Lung Cancer Research Articles

EP08.02-27 Trimodality Treatment of Superior Sulcus non-Small Cell Lung Cancer. An Institutional Series of 47 Consecutive Patients.

EP08.02-27 Trimodality Treatment of Superior Sulcus non-Small Cell Lung Cancer. An Institutional Series of 47 Consecutive Patients.

Prospective Feasibility and Phase 1/2 Trial of Preoperative Proton Beam Therapy With Concurrent Chemotherapy for Resectable Stage IIIA or Superior Sulcus Non-Small Cell Lung Cancer

This is the first prospective clinical trial (NCTXXXX) evaluating proton beam therapy (PBT) with concurrent chemotherapy as part of trimodality management for resectable stage IIIA or superior sulcus non-small cell lung cancer (NSCLC). The starting PBT dose level was 50.4 Gy in 1.8 Gy fractions (feasibility study), followed by sequential dose escalation to determine maximum tolerated dose (MTD) of PBT based on dose-limiting toxicities (DLTs) (phase I/II study). DLTs were defined as 30-day postoperative mortality, grade ≥4 hematologic toxicity requiring >14-day treatment breaks, or any grade ≥3 non-hematologic/esophagitis/pneumonitis toxicities attributable to PBT. Primary outcomes included feasibility, MTD, and pathologic complete response (pCR) rate. Twenty patients underwent neoadjuvant PBT and chemotherapy, of which 19 subsequently underwent surgery. There were 13 patients in the feasibility study (at 50.4 Gy) and 6 in the phase I/II study (at 59.4 Gy). The trial closed early due to slow accrual prior to reaching the MTD. Treatment was deemed feasible. There were no DLTs, including no post-operative deaths within 30 days. Two patients (10%) experienced PBT-related acute grade 3 adverse events (post-operative atrial fibrillation and esophagitis/dysphagia); no grade 4-5 acute non-hematologic adverse events were noted. Overall and nodal pCR rates were 5/19 (26%) and 8/18 (44%), respectively; nodal pCR was 4/13 (31%) at 50.4 Gy versus 4/5 (80%) at 59.4 Gy (p=0.12). Median follow-up was 8.5 years. Median and 5-year progression-free survival were 1.8 years and 25%, and median and 5-year overall survival were 3.6 years and 40%, respectively. Eleven patients experienced disease failure, most with a distant component (10 of 11). Concurrent PBT and chemotherapy is feasible as part of trimodality management with favorable oncologic outcomes and low toxicity rates.

Trimodality Treatment of Superior Sulcus Non-Small Cell Lung Cancer: An Institutional Series of 47 Consecutive Patients

Treatment of superior sulcus tumors (SST) using concurrent chemoradiation followed by surgery is a current standard. However, due to the rarity of this entity, clinical experience in its treatment remains scarce. Here, we present the results of a large consecutive series of patients treated with concurrent chemoradiation followed by surgery at a single academic institution. The study group included 48 patients with pathologically confirmed SST. The treatment schedule consisted of preoperative 6-MV photon-beam radiotherapy (45-66 Gy delivered in 25-33 fractions over 5-6.5 weeks) and concurrent two cycles of platinum-based chemotherapy. Five weeks after completion of chemoradiation, pulmonary and chest wall resection was performed. From 2006 to 2018, 47 of 48 consecutive patients meeting protocol criteria underwent two cycles of cisplatin-based chemotherapy and concurrent radiotherapy (45-66 Gy) followed by pulmonary resection. One patient did not undergo surgery due to brain metastases that occurred during induction therapy. The median follow-up was 64.7 months. Chemoradiation was well tolerated, with no toxicity-related deaths. Twenty-one patients (44%) developed grade 3-4 side effects, of which the most common was neutropenia (17 patients; 35.4%). Seventeen patients (36.2%) had postoperative complications, and 90-day mortality was 2.1%. Three- and five-year overall survival (OS) were 43.6% and 33.5%, respectively, and three- and five-year recurrence-free survival were 42.1% and 32.4%, respectively. Thirteen (27.7%) and 22 (46.8%) patients had a complete and major pathological response, respectively. Five-year OS in patients with complete tumor regression was 52.7% (95% CI 29.4-94.5). Predictive factors of long-term survival included age below 70 years, complete resection, pathological stage, and response to induction treatment. Chemoradiation followed by surgery is a relatively safe method with satisfactory outcomes.

Surgical management of superior sulcus tumors: A twenty-year experience of an oncological high volume referral centre.

Superior sulcus tumour, which affects the lung's apex, is an uncommon subtype of non-small cell lung cancer (NSCLC). The current study examined the clinical characteristics and management of superior sulcus NSCLC patients in a high-volume referral oncological centre over 22 years. Retrospective review of 100 surgeries with curative intent for superior sulcus NSCLC over 22 years (July 1998 - December 2020). The surgical approach was defined according to the lesion site and the anatomy of the thoracic inlet. Survival curves, including non-cancer-related deaths, were drawn using the Kaplan-Meier methods, and the log-rank test was used to evaluate differences in survival across groups of patients. Cox proportional hazards regression was used to assess the association between selected clinical and pathologic characteristics on OS. 54 patients received induction treatments. The surgical approach was anterior thoracotomy in 53 patients, Paulson incision in 30, and a combined in 8. The median postoperative length of stay was 11 days (range: 5 - 27 days). Overall 90-day mortality was 6.93%. The median OS was 24.3 months. After a median follow-up of 3 years, 5-year and 10-year OS rates were 33.9% and 26.4%, respectively. A significantly lower 5-year OS was observed in patients with the nodal disease (46.6% in pN0 vs 13.2% in pN+; p = 0.024), without preoperative treatments (41.0% in patients without preoperative treatments versus 17.4%; p = 0.09) and anteriorly located tumour (anterior vs posterior: 17.4% vs 49.1%; p = 0.032). Cox proportional hazards regression showed better survival in the pT1 stage (HR = 4.6; 95% CI: 1.9 - 11.2; p = 0.00076) and in R0 (HR = 4.2; 95% CI: 1.4 - 12.5; p = 0.010). Superior sulcus tumours still represent a life-threatening condition that, while curable in a significant proportion of cases, requires complex procedures with high surgical risks and a multimodality treatment setting. An optimal surgical approach should be planned to maximise resection completeness and survival. Other factors affecting survival are related to tumour staging, emphasising the importance of a meticulous preoperative workup and candidate selection to identify those expected to benefit from a survival benefit.

Surgical Management of Superior Sulcus Tumours: A 20-Year Experience of an Oncological Referral Centre

The authors present a study that investigated the clinical features and therapy of superior sulcus non-small cell lung cancer during a 22-year period.

Prognostic factors following complete resection of non-superior sulcus lung cancer invading the chest wall.

Locally advanced non-small-cell lung cancer (NSCLC) with chest wall invasion carries a high risk of recurrence and portends poor survival (30-40% and 20-50%, respectively). No studies have identified prognostic factors in patients who underwent R0 resection for non-superior sulcus NSCLC. A retrospective review was conducted for all chest wall resections for NSCLC from 2004 to 2018. Patients with superior sulcus tumours, partial (<1 rib) or incomplete (R1/R2) resection or distant metastasis were excluded. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Cox proportional hazards modelling was used to determine factors associated with DFS and OS. A total of 100 patients met inclusion criteria. Seventy-three (73%) patients underwent induction therapy, and all but 12 (16%) patients experienced a partial radiological response. A median of 3 ribs was resected (range 1-7), and 67 (67%) patients underwent chest wall reconstruction. The 5-year DFS and OS were 36% and 45%, respectively. Pathological N2 status [hazard ratio (HR) 3.12, confidence interval (CI) 1.56-6.25; P = 0.001], intraoperative blood transfusion (HR 2.24, CI 1.28-3.92; P = 0.005) and preoperative forced vital capacity (per % forced vital capacity, HR 0.97, CI 0.96-0.99; P = 0.013) were associated with DFS. Increasing pathological stage, lack of radiological response to induction therapy (HR 7.35, CI 2.35-22.99; P = 0.001) and cardiovascular comorbidity (HR 2.43, CI 1.36-4.36; P = 0.003) were associated with OS. We demonstrate that blood transfusion and forced vital capacity are associated with DFS after R0 resection for non-superior sulcus NSCLC, while radiological response to induction therapy greatly influences OS. We confirm that pathological nodal status and pathological stage are reproducible determinants of DFS and OS, respectively.

Treatment of clinical T4 stage superior sulcus non-small cell lung cancer: a propensity-matched analysis of the surveillance, epidemiology, and end results database.

Purpose/Objective(s): Treatments for superior sulcus non-small cell lung cancer (SS-NSCLC) have evolved, but adequate treatments of T4 disease have not been found. The aim of our study was to evaluate the prognostic factors and optimal treatment strategy for patients with T4 SS-NSCLC. Materials/Methods: We utilized the Surveillance, Epidemiology, and End Results (SEER) database (1973–2015) to identify patients diagnosed with T4 stage SS-NSCLC (according to the 7th edition American Joint Committee on Cancer (AJCC) staging system) from 2004 to 2015; those with M1 disease were excluded. Propensity score matching (PSM) with Kaplan–Meier and Cox proportional hazards’ models was performed to estimate prognosis. Results: A total of 384 patients were included. The majority was male (59.4%) at stage IIIB (56.6%), with N2 accounting for 45.3%. A total of 47 patients underwent cancer-directed surgery, while radiotherapy alone was received by 60.2% of patients. Median overall survival (OS) and lung cancer-specific survival (LCSS) were 12 and 17 months, respectively, and the 5-year OS and LCSS rates were 15.8 and 25.4%, respectively. In the matched population, the median survival outcomes were better following surgery (OS: 25 compared with 9.0 months, P<0.001; LCSS: not available (NA) compared with 11.0 months, P<0.001). Multivariate Cox analysis showed that ages ≥ 66 years (hazard ratio (HR) = 1.639, P=0.001), unmarried status (HR = 1.356, P=0.034), and tumor size ≥ 6.0 cm (HR = 1.694, P<0.001) were associated with inferior OS. Cancer-directed surgery (HR = 0.537, P=0.009) and radiotherapy (HR = 0.644, P=0.006) were independent prognostic factors for patients with T4 SS-NSCLC. Conversely, in the subgroup analysis, favorable impacts of radiotherapy were observed for nonsurgical patients (OS: HR = 0.58, P<0.001; LCSS: HR = 0.55, P<0.001). Conclusion: Our study showed that T4 stage SS-NSCLC patients had a poor prognosis. Surgical resection remains the best option for those with resectable disease. For nonsurgical T4 SS-NSCLC patients, radiotherapy should be actively considered.

P1.17-18 Treatment for Patients with T4 Superior Sulcus Non-Small Cell Lung Cancer: A Propensity-Matched Analysis of SEER Database

P1.17-18 Treatment for Patients with T4 Superior Sulcus Non-Small Cell Lung Cancer: A Propensity-Matched Analysis of SEER Database

ED10.02 The Role of Surgery in Stage III NSCLC

ED10.02 The Role of Surgery in Stage III NSCLC

Palliative sequential chemoradiotherapy for pulmonary sulcus tumor: A case report.

Pulmonary sulcus tumors are occasionally encountered in non-small-cell lung cancer (NSCLC) patients. If the patients have a good clinical condition, concurrent chemoradiotherapy is indicated. However, palliative chemotherapy and chemoradiotherapy for patients exhibiting a poor overall condition have not been reported to date. We herein report the case of a 54-year-old female patient with a pulmonary sulcus tumor, who had a poor performance status. The patient received sequential chemoradiotherapy, with no severe complications. There was no local recurrence until the time of death, 8 months after the initiation of therapy. Palliative sequential chemoradiotherapy for pulmonary sulcus NSCLC must be effective and carry low risk of complications. Palliative sequential chemoradiotherapy may be considered in certain patients with pulmonary sulcus NSCLC. Either chemotherapy or radiotherapy is administered first and, if there is no apparent deterioration of the patient's general condition, the next treatment modality is administered.

Superior sulcus non-small cell lung carcinoma: A comparison of IMRT and 3D-RT dosimetry

AimA dosimetric study comparing intensity modulated radiotherapy (IMRT) by TomoTherapy to conformational 3D radiotherapy (3D-RT) in patients with superior sulcus non-small cell lung cancer (NSCLC). BackgroundIMRT became the main technique in modern radiotherapy. However it was not currently used for lung cancers. Because of the need to increase the dose to control lung cancers but because of the critical organs surrounding the tumors, the gains obtainable with IMRT is not still demonstrated. Material and methodsA dosimetric comparison of the planned target and organs at risk parameters between IMRT and 3D-RT in eight patients who received preoperative or curative intent irradiation. ResultsIn the patients who received at least 66Gy, the mean V95% was significantly better with IMRT than 3D-RT (p=0.043). IMRT delivered a lower D2% compared to 3D-RT (p=0.043). The IH was significantly better with IMRT (p=0.043). The lung V5Gy and V13Gy were significantly higher in IMRT than 3D-RT (p=0.043), while the maximal dose (Dmax) to the spinal cord was significantly lower in IMRT (p=0.043). The brachial plexus Dmax was significantly lower in IMRT than 3D-RT (p=0.048). For patients treated with 46Gy, no significant differences were found. ConclusionOur study showed that IMRT is relevant for SS-NSCLC. In patients treated with a curative dose, it led to a reduction of the exposure of critical organs, allowing a better dose distribution in the tumor. For the patients treated with a preoperative schedule, our results provide a basis for future controlled trials to improve the histological complete response by increasing the radiation dose.

Clinical Prediction of Pathologic Complete Response in Superior Sulcus Non-Small Cell Lung Cancer

Management of superior sulcus non-small cell lung cancer (NSCLC) continues to evolve, with preoperative chemoradiotherapy (CXRT) followed by surgical intervention supported by several studies. Rates of pathologic complete response (pCR) have varied, and previous attempts to identify clinical predictors of pCR have been unsuccessful. We analyzed our experience with resected superior sulcus NSCLC to elucidate clinical features suggestive of pCR among patients after preoperative treatment. A multiinstitutional retrospective review was performed in patients who underwent resection for superior sulcus NSCLC between January 1988 and July 2013. Data pertaining to comorbidities, staging, therapy, imaging, and outcomes were collected. Logistic regression was performed to identify predictors of survival and pCR. During the study, 102 patients underwent preoperative therapy, consisting of CXRT in 75 (73.5%), chemotherapy in 15 (14.7%), and radiotherapy in 12 (11.8%). After median follow-up of 18.0 months, overall and disease-free survivals were 51.0% and 45.1%, respectively. On multivariate regression, independent predictors of survival included pCR (p = 0.001; hazard ratio [HR], 0.243; 95% confidence interval [CI], 0.106-0.555) and age (p = 0.007; HR, 1.049; CI, 1.013-1.085). Among those who received CXRT, 24 of 75 (32%) achieved pCR. Multivariate regression analysis of the CXRT group revealed that pCR was independently predicted by extent of size reduction on imaging (p = 0.015; HR, 1.042; CI, 1.008-1.078), with histologic examination showing a trend toward significance (p = 0.073). Preoperative chemoradiation frequently resulted in pCR, and treatment response on imaging was associated with the likelihood of achieving pCR. Future investigations are warranted to further predict pCR from preoperative clinical variables such as symptom resolution, as identification of accurate predictors may ultimately permit the application of selective surgical intervention in superior sulcus NSCLC.

En Bloc Resection of Pulmonary Sulcus Non-small Cell Lung Cancer Invading the Spine: A Systematic Literature Review and Pooled Data Analysis.

To conduct a systematic literature review and pooled data analysis focusing on outcome after en bloc resection of pulmonary sulcus non-small cell lung cancer (NSCLC) invading the spine. This rare type of NSCLC has historically been considered unresectable and fatal. Nowadays, carefully selected patients can be cured when treated surgically within a multimodality concept. The MEDLINE database was searched using the PubMed engine to retrieve relevant articles. Corresponding authors were contacted, and shared data were pooled and analyzed. Search strategy yielded 134 articles. Six were relevant and nonduplicative. Four authors shared updated data on 135 patients. All tumors were resected en bloc with the lung, chest wall, and spine. Induction was administered in 85 patients (63%) and consisted of chemotherapy (n = 32), radiation (n = 1), or concurrent chemoradiation (n = 52). Spine resections included total (n = 23), hemi- (n = 94), and partial (n = 18) vertebrectomies. R0 resection was achieved in 120 patients (89%). Adjuvant treatment was administered to 70 patients (52%) and included chemotherapy (n = 16), radiotherapy (n = 22), or chemoradiation (n = 32). Overall, 3-, 5-, and 10-year survival rates were 57%, 43%, and 27%, respectively. Univariate analysis identified the type of resection (R0 vs R1/R2, P < 0.001) as significant prognostic factor among the variables tested (age, histology, pT/pN, type of induction/adjuvant treatment, type of lung/spine resection). Multimodality therapy including en bloc resection for pulmonary sulcus NSCLC invading the spine provides excellent long-term survival in selected patients. This result establishes a benchmark against which the effects of new treatments can be compared in the future.

Trimodality Therapy for Superior Sulcus Non-Small Cell Lung Cancer: Southwest Oncology Group-Intergroup Trial S0220

Although preoperative chemotherapy (cisplatin-etoposide) and radiotherapy, followed by surgical resection, is considered a standard of care for superior sulcus cancers, treatment is rigorous and relapse limits long-term survival. The Southwest Oncology Group-Intergroup Trial S0220 was designed to incorporate an active systemic agent, docetaxel, as consolidation therapy. Patients with histologically proven and radiologically defined T3 to 4, N0 to 1, M0 superior sulcus non-small cell lung cancer underwent induction therapy withcisplatin-etoposide, concurrently with thoracic radiotherapy at 45 Gy. Nonprogressing patients underwent surgical resection within 7 weeks. Consolidation consisted of docetaxel every 3 weeks for 3 doses. The accrual goal was 45eligible patients. The primary objective was feasibility. Of 46 patients registered, 44 were eligible andassessable; 38 (86%) completed induction, 29 (66%) underwent surgical resection, and 20 (45% of eligible, 69% surgical, and 91% of those initiating consolidation therapy) completed consolidation docetaxel; 28 of 29 (97%) underwent a complete (R0) resection; 2 (7%) died of adult respiratory distress syndrome. In resected patients, 21 of 29 (72%) had a pathologic complete or nearly complete response. The known site of first recurrence was local in 2, local-systemic in 1, and systemic in 10, with 7 in the brain only. The 3-year progression-free survival was 56%, and 3-year overall survival was 61%. Although trimodality therapy provides excellent R0 and local control, only 66% of patients underwent surgical resection and only 45% completed the treatment regimen. Even in this subset, distant recurrence continues to be a major problem, particularly brain-only relapse. Future strategies to improve treatment outcomes in this patient population must increase the effectiveness of systemic therapy and reduce the incidence of brain-only metastases.

Metabolic activity measured by FDG PET predicts pathological response in locally advanced superior sulcus NSCLC

ObjectivesPathological complete response and tumor regression to less than 10% vital tumor cells after induction chemoradiotherapy have been shown to be prognostically important in non-small cell lung cancer (NSCLC). Predictive imaging biomarkers could help treatment decision-making. The purpose of this study was to assess whether postinduction changes in tumor FDG uptake could predict pathological response and to evaluate the correlation between residual vital tumor cells and post-induction FDG uptake. MethodsNSCLC patients with sulcus superior tumor (SST), planned for trimodality therapy, routinely undergo FDG PET/CT scans before and after induction chemoradiotherapy in our institute. Metabolic end-points based on standardized uptake values (SUV) were calculated, including SUVmax (maximum SUV), SUVTTL (tumor-to-liver ratio), SUVpeak (SUV within 1 cc sphere with highest activity), and SUVPTL (peak-to-liver ratio). Pathology specimens were assessed for residual vital tumor cell percentages and scored as no (grade 3), <10% (grade 2b) and >10% vital tumor cells (grade 2a/1). Results19 and 23 patients were evaluated for (1) metabolic change and (2) postinduction PET-pathology correlation, respectively. Changes in all parameters were predictive for grade 2b/3 response. ΔSUVTTL and ΔSUVPTL were also predictive for grade 3 response. Remaining vital tumor cells correlated with post-induction SUVpeak (R=0.55; P=0.007) and postinduction SUVPTL (R=0.59; P=0.004). Postinduction SUVPTL could predict both grades 3 and 2b/3 response. ConclusionIn NSCLC patients treated with chemoradiotherapy, changes in SUVmax, SUVTTL, SUVpeak, and SUVPTL were predictive for pathological response (grade 2b/3 and for SUVTTL and SUVPTL grade 3 as well). Postinduction SUVPTL correlated with residual tumor cells.

Significance of Multimodality Therapy in Patients with a Superior Sulcus Tumor of the Lung: A Review Article

Despite the aggressive pursuit of diagnostic and treatment modalities for lung cancer, the treatment outcomes are still not satisfactory, and even patients with surgically resectable non-small cell lung cancer (NSCLC) are often at considerable risk of suffering recurrence and/or death from lung cancer. Regarding the treatment of patients with locally advanced, resectable NSCLC, several retrospective and prospective studies have shown the significance of multimodality treatments with preoperative chemoradiotherapy and surgical treatment. However, no definitive treatment strategies for locally advanced NSCLC patients have yet been established. One of the reasons for the lack of established treatment strategies for patients with locally advanced NSCLC is considered to be the heterogeneity of the population, i.e., cT4N0, cT3-4N1 and cT1a-3N2 tumors are included in stage IIIA disease, and superior sulcus tumors (SSTs) are also included in this classification. With regard to SST, two representative prospective phase II trials indicated the efficacy of surgical treatment following concurrent radiation and chemotherapy. In a study conducted by the Southwest Oncology Group, 110 patients with superior sulcus NSCLC were treated with two cycles of cisplatin and etoposide concurrently with 45 gray (Gy) of radiation, followed by surgical treatment and two additional cycles of chemotherapy postoperatively. The response rate (RR) to the preoperative chemoradiotherapy was 86%, and 83 patients (76%) were able to undergo complete resection. A pathological complete response (CR) was observed in 61 patients (56%), and the five-year survival of all patients and those undergoing complete resection was 44% and 54%, respectively. A phase II study conducted by the Japan Clinical Oncology Group examined the safety and efficacy of preoperative concurrent chemoradiotherapy using mitomycin, vinblastin and cisplatin followed by surgical treatment. Seventy-six patients with SST were enrolled in this study, and all received chemotherapy using two cycles of MVP concurrently with 45 Gy of radiation, followed by surgery. Neoadjuvant chemoradiotherapy resulted in a 61% RR, and pathological complete resection was successfully achieved in 51 patients (68%). A pathological CR was observed in 12 patients (16%), and the disease-free and overall survival rates at five years were 45% and 56%, respectively. Both studies showed the efficacy and tolerability of the multimodality treatment for SST, thus suggesting that multimodality treatment with preoperative chemoradiotherapy followed by surgery may therefore be an effective treatment for resectable SST. We herein review the results of retrospective and prospective studies while assessing the treatment outcomes of NSCLC patients with SST.

Analyse rétrospective monocentrique française du contrôle local des cancers bronchiques non à petites cellules de l’apex après radiothérapie de haute dose avec ou sans chimiothérapie

PurposeSuperior sulcus non-small cell lung cancer represents less than 5% of all lung cancers and is a challenge for the physicians because of clinical presentation, treatments related toxicities and poor prognosis. The aim of this preliminary retrospective report is to present outcomes of patients affected by a superior sulcus non-small cell lung cancer, treated by high dose radiotherapy (>60Gy) with or withour chemotherapy. Patients and methodsAll adult inoperable or unresectable patients (≥18years) with a clinical and radiological diagnosis of superior sulcus non-small cell lung cancer treated in our department by radiotherapy with or without chemotherapy were retrospectively analysed. Primary endpoint was the local control. Overall survival, metastasis free survival and toxicity rates were also analysed and reported. ResultsFrom January 1999 to June 2009, 12 patients were treated by exclusive high-dose radiochemotherapy. Median age was 53years (range: 33–64years); mean follow-up time was 20months (range: 2–75months). Mean local control, overall survival and metastasis free survival were 20.2, 22 and 20months, respectively. At the time of this analysis, seven patients died of cancer and three of them presented only a metastatic disease progression. One patient died of acute cardiac failure 36months after the end of radiochemotherapy and was disease free. Treatment was well tolerated and any acute and/or late G3-4 toxicity was recorded (NCI-CTC v 3.0 score). ConclusionThis analysis confirms the interest of exclusive high-dose radiochemotherapy in treating inoperable superior sulcus non-small cell lung cancer patients, in achieving good local control and overall survival rates.

Induction concurrent chemoradiotherapy compared with induction radiotherapy for superior sulcus non‐small cell lung cancer: a retrospective study

To evaluate the efficacy of current chemoradiotherapy on improvement of survival in patients with superior sulcus non-small cell lung cancer (NSCLC). We retrospectively reviewed the data of 39 patients with superior sulcus NSCLC treated with induction therapy followed surgery. The patients were divided into two groups according to the induction approach: the induction radiotherapy (RT) group (1993-1999), and the induction chemoradiotherapy (CT/RT) group (since 1999). The rate of complete resection was 65 percent in the RT group (n = 17) compared with 91 percent in the CT/RT group (n = 22, P = 0.024). Complete pathological responses from induction therapy were 12 percent in the RT group and 45 percent in the CT/RT group (P = 0.032). Overall survival (OS) was significantly longer in patients who received CT/RT than that in those who received RT, with 2- and 5-year survival rates of 77.3 percent and 36.4 percent versus 41.2 percent and 11.8 percent, respectively (P = 0.007). CT/RT also associated with a markedly longer tumor-free survival (TFS), with a median TFS of 40 and 17 months, respectively (P = 0.007). Patients achieved complete resection or complete pathological response had a significantly better survival than those with incomplete resection or pathological partial responses and no change (P < 0.0005 and P = 0.001, respectively). Our results indicate that CT/RT followed by surgery can significantly improve OS and TFS, and may be considered as an optimal option in treatment of patients with superior sulcus NSCLC.

Superior sulcus tumors with vertebral body involvement: A multimodality approach

Superior sulcus tumors with involvement of the spine have historically been considered unresectable. We have previously documented a 2-year survival of 54% in patients treated with a multimodality approach. This work builds on our previous experience and examines the long-term outcomes. A retrospective review was performed on patients with superior sulcus non-small cell lung cancer tumors with involvement of the vertebral column (n = 39) treated at The University of Texas MD Anderson Cancer Center from 1990 to 2006. Their clinical and pathologic data were analyzed for short- and long-term outcomes. Group 1 included 8 (21%) patients with neuroforamen or transverse process involvement, group 2 had 16 (41%) patients with partial vertebrectomy, and group 3 had 15 (38%) patients with total vertebrectomy. There were 2 (5%) postoperative deaths, and 11 (28%) patients had major complications. Margins were positive in 17 (44%) patients. Recurrence occurred in 23 (59%) patients and was local in 11 (28%) patients, distant in 11 (28%) patients, and both in 1 (3%) patient. Median time to local recurrence was 7 months in patients with positive margins and has not been reached for patients with negative margins (P = .007). Median, 2-year, and 5-year overall survival was 18 months, 47%, and 27%, respectively. On multivariate analysis, the only independent predictor of shorter survival was nodal metastases (P = .001; hazard ratio, 6.5; 95% confidence interval, 2.2-19.2). An aggressive multimodality approach involving surgical resection can be performed with acceptable morbidity in highly selected patients with superior sulcus tumors and vertebral invasion at a specialized center. Encouraging long-term survival can be achieved in patients with negative margins and no lymph node involvement.

Trimodal regimen for superior sulcus cancer

A multimodal regimen is safe and eff ective for the treatment of superior sulcus non-small-cell lung cancer (NSCLC; J Clin Oncol 2008; 26: 644–49). 76 patients with superior sulcus nonsmall-cell lung cancer were enrolled in a Japanese study and treated with two cycles of chemotherapy (mitomycin 8 mg/m2 on day 1, vindesine 3 mg/m2 on days 1 and 8, and cisplatin 80 mg/m2 on day 1) every 4 weeks. Radiotherapy directed at the tumour and the ipsilateral supraclavicular nodes was started on day 2 of each cycle, with a total dose given of 45 Gy in 25 fractions. Thoracotomy was done 2–4 weeks after completion of chemoradiotherapy. Those patients with unresectable disease received booster radiotherapy. 57 patients had surgical resection, and complete resection was achieved in 51 patients. 12 patients had a pathological complete response. Major postoperative respiratory disease was noted in eight patients, and there were two deaths from post-surgical complications and one from sepsis during chemoradiotherapy. 3-year disease-free and overall survival were 49% and 61%, and at 5 years were 45% and 56%, respectively. Lead author Hideo Kunitoh (National Cancer Center Hospital, Tokyo, Japan) says, “our results have confi rmed those of a prior study, and have established the trimodality approach as the standard of care for patients with superior sulcus tumour. The signifi cance of our study is the reproducibility of such an intensive approach”. “This is an important study because it addresses superior sulcus tumours, and there have been very few prospective trials with this type of lung cancer”, says James Jett (Mayo Clinic, Rochester, MN, USA). James Rigas (Norris Cotton Cancer Center, Lebanon, NH, USA) adds, “this multicentre trial confi rms the benefi ts of concurrent chemoradiation followed by surgical resection for superior sulcus NSCLC.” However, Jett added that mitomycin has potential pulmonary and other unusual toxicities, and is therefore unlikely to be employed as a standard treatment for lung cancer. Rigas agrees: “this chemotherapy regimen is very myelosuppressive, and mitomycin followed by surgical resection in the setting of thoracic radiotherapy is associated with higher rates of pulmonary disease. I think the US approach of concurrent etoposide, cisplatin, and thoracic radiotherapy followed by attempted surgical resection will remain the standard of care”.