Induction chemotherapy, concurrent chemoradiation and surgery for Pancoast tumour

Abstract

The traditional treatment of Pancoast tumour with local approaches (surgery, radiotherapy or a combination of both) leads to a poor outcome due to the high rate of incomplete resection and the lack of systemic control. The aim of the present prospective feasibility study was to determine whether a trimodality approach improves local control and survival.Patients with stage IIB-IIIB Pancoast tumour received induction chemotherapy (three courses of split-dose cisplatin and etoposide or paclitaxel) followed by concurrent chemoradiotherapy (a course of cisplatin/etoposide combined with 45 Gy hyperfractionated accelerated radiotherapy). After restaging, eligible patients underwent surgery 4-6 weeks post-radiation.A total of 31 consecutive patients with T3 (81%) or T4 (19%) Pancoast tumour were enrolled in the study. Induction chemoradiotherapy was completed in all patients without treatment-related deaths. Grade 3-4 toxicity was observed in 32% of cases. In total, 29 (94%) patients were eligible for surgery. Complete resection was achieved in 94% of patients. The post-operative mortality rate was 6.4% and major complications arose in 20.6% of the patients. The median survival was 54 months with 2-and 5-yr survival rates of 74 and 46%, respectively.In conclusion, this intensive multimodality treatment of Pancoast tumour is feasible and improves local resectability rates and long-term survival as compared with historical series.

Superior sulcus tumors (Pancoast tumors)

“…Operative mortality rate ranges from 0% to 6.9% and morbidity from 11% to 47% (25,29,(35)(36)(37)(38)(39)(40)(41)(42)(43). In particular, the SWOG 9416 (35) and JCO 9806 (36) phase II trials showed operative mortality rates of 2.3% and 3% and morbidity rates of 52% and 14%, respectively.…”

“…In particular brachial plexus invasion (59), vertebral body (11,52,53) and great vessels involvements (11,53) are correlated to an higher risk of tumor recurrence. The presence of Horner syndrome at the diagnosis of Pancoast tumor is, equally, a poor prognostic factor (17,54) implying extensive neural involvement; (IV) positive lymph node status, as in NSCLC tumor, is also a significantly poor prognostic factor in Pancoast tumor (17,21,39,(52)(53)(54)(55). In the revised series of Alifano and colleagues (60), the presence of (V) associated major illness and the completeness of resection are the two most important factors affecting the long-term outcome.…”

“…No statistical difference in brain metastasis rate were observed in PCI treated and non-PCI treated patients, although the PCI group was far less numerous than non-PCI group. Another study (39) analyzed 31 patients treated with chemotherapy and surgery for Pancoast tumor: of 13 patients subjected to PCI, one turned out to have brain metastasis, while 3 out of 13 non-PCI patients had the same relapse; the authors concluded that PCI seemed to offer adequate protection against brain metastases. In 2011 the RTOG 0214 trial (66) evaluated the efficacy of PCI in patients with advanced lung cancers (stage IIIA or IIIB) with a randomized study: they observed a decreased number of brain metastases in patients treated with PCI, without significant impact on survival (1-year follow-up).…”

“…Even long-term (5-year) survival rates resulted improved reaching 44% (SWOG 9416) and 56% (JCO 9806), respectively. Based on these data, the modern standard treatment for sulcus superior tumors has become the combination of induction CT/RT followed by radical surgical resection (25,29,(35)(36)(37)(38)(39)(40)(41)(42)(43) (Table 1).…”

Surgery for nonsmall cell lung cancer

“…En-bloc resection of the upper lobe, ribs, nerves (brachial plexus) plus or minus vessels is recommended. Many studies published in the past 10 years have established the gold standard in the field as induction therapy consisting of high dose radiotherapy with concurrent cisplatin-based chemotherapy, followed by surgery 4-6 weeks later [124][125][126][127][128][129]. Using this multimodality scheme, perioperative mortality is low and 5-year survival rates are now consistently .40%.…”