Non-Small Cell Lung Cancer Professional Information

STAGE II NON-SMALL CELL LUNG CANCER

Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. Refer to the PDQ levels of evidence summary for more information.

T1, N1, M0 or T2, N1, M0 or T3, N0, M0

Surgery is the treatment of choice for patients with stage II non-small cell lung cancer (NSCLC). Careful preoperative assessment of the patient's overall medical condition, especially the patient's pulmonary reserve, is critical in considering the benefits of surgery. The immediate postoperative mortality rate is age-related, but up to 5% to 8% with pneumonectomy or 3% to 5% with lobectomy can be expected.

Inoperable patients with stage II disease and with sufficient pulmonary reserve may be considered for radiation therapy with curative intent.[1] Among patients with excellent performance status, up to a 20% 3-year survival rate may be expected if a course of radiation therapy with curative intent can be completed. In the largest retrospective series reported to date, 152 patients with medically inoperable NSCLC treated with definitive radiation therapy achieved a 5-year overall survival rate of 10%; however, the 44 patients with T1 tumors achieved an actuarial disease-free survival rate of 60%. This retrospective study also suggested that improved disease-free survival was obtained with radiation therapy doses greater than 6,000 cGy.[2] Primary radiation therapy should consist of approximately 6,000 cGy delivered with megavoltage equipment to the midplane of the volume of known tumor using conventional fractionation. A boost to the cone-down field of the primary tumor is frequently used to further enhance local control. Careful treatment planning with precise definition of target volume and avoidance of critical normal structures to the extent possible is needed for optimal results and requires the use of a simulator.

Many patients treated surgically subsequently develop regional or distant metastases.[3] Therefore, patients should be considered for entry into clinical trials evaluating the use of adjuvant treatment with chemotherapy or radiation therapy following surgery. One controlled trial has failed to demonstrate an overall survival benefit for patients with carefully staged squamous cell carcinoma receiving postoperative irradiation, although local recurrences were significantly reduced.[4] A meta-analysis of 9 randomized trials evaluating postoperative radiation versus surgery alone showed a 7% reduction in overall survival with adjuvant radiation in patients with stage I or II disease.[5][Level of evidence: 1iiA] It will be important to determine whether these outcomes can potentially be modified with technical improvements, better definitions of target volumes, and limitation of cardiac volume in the radiation portals. In 2 controlled trials in carefully staged, surgically resected patients, adjuvant combination chemotherapy with cisplatin, doxorubicin, and cyclophosphamide produced modestly increased disease-free survival and a trend toward improved overall survival, especially in the first year after surgery.[6,7] Based on these data, participation in clinical trials evaluating adjuvant therapy after surgical resection should be encouraged.

Treatment options:

1. Lobectomy, pneumonectomy, or segmental, wedge, or sleeve resection as appropriate.

2. Radiation therapy with curative intent (for potentially operable patients who have medical contraindications to surgery).

3. Clinical trials of adjuvant chemotherapy with or without other modalities following curative surgery.[6-8]

4. Clinical trials of radiation therapy following curative surgery.[8]

1. Komaki R, Cox JD, Hartz AJ, et al.: Characteristics of long-term survivors after treatment for inoperable carcinoma of the lung. American Journal of Clinical Oncology 8(5): 362-370, 1985.
2. Dosoretz DE, Katin MJ, Blitzer PH, et al.: Radiation therapy in the management of medically inoperable carcinoma of the lung: results and implications for future treatment strategies. International Journal of Radiation Oncology, Biology, Physics 24(1): 3-9, 1992.
3. Martini N, Bains MS, Burt ME, et al.: Incidence of local recurrence and second primary tumors in resected stage I lung cancer. Journal of Thoracic and Cardiovascular Surgery 109(1): 120-129, 1995.
4. Weisenburger TH, Holmes EC, Gail M, et al.: Effects of postoperative mediastinal radiation on completely resected stage II and stage III epidermoid cancer of the lung. New England Journal of Medicine 315(22): 1377-1381, 1986.
5. PORT Meta-analysis Trialists Group: Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomised controlled trials. Lancet 352(9124): 257-263, 1998.
6. Holmes AC: Surgical adjuvant therapy for stage II and stage III adenocarcinoma and large cell undifferentiated carcinoma. Chest 106(6 Suppl): 293S-296S, 1994.
7. Lad T, Rubinstein L, Sadeghi A: The benefit of adjuvant treatment for resected locally advanced non-small-cell lung cancer. Journal of Clinical Oncology 6(1): 9-17, 1988.
8. Holmes EC: Adjuvant treatment in resected lung cancer. Seminars in Surgical Oncology 6(5): 263-267, 1990.

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