Postoperative adjuvant therapy for stage II non-small-cell lung cancer

BACKGROUND: Stage II non-small-cell lung cancer is regarded as one of the early lung cancers. Although resection, including the mediastinal lymph nodes, is currently regarded as the standard treatment, the survival rate of this disease is not encouraging. It is well known that the most common causes of death are locoregional recurrences or distant metastases, or both. However, the best adjuvant treatment to improve survival is as controversial an issue as ever. METHODS: This study was designed as a randomized, blinded, two-armed study with operation and adjuvant radiotherapy in one arm, versus operation and adjuvant mitomycin C (10 mg/m2), vinblastine (6 mg/m2), and cisplatin (100 mg/m2) (MVP) chemotherapy in the other arm. We assigned 57 resected patients with pathologic proven stage II non-small cell lung cancer to the groups according to our eligibility criteria. RESULTS: The most common pattern of recurrence was distant metastases, and nearly all the recurrences (17 of 18 patients) in both groups were found within 2 years after operation. The rates of the locoregional and distant metastases were 3.6% and 46.4% in the adjuvant radiotherapy group and 6.9% and 10.3% in the adjuvant chemotherapy group (p = 0.018). The 5-year disease-free survival rates were 52.0% in the adjuvant radiotherapy group and 74.0% in the adjuvant chemotherapy group (p = 0.16, log-rank test). The 2-year, 5-year, and 6-year survival portions were 60.3%, 56.5%, and 28.3% in the adjuvant radiotherapy group, and 82.8%, 70.1%, and 60.1% in the adjuvant chemotherapy group (p = 0.01, p = 0.17, and p = 0.03, Z-test). The difference of the actuarial survival between these two groups was somewhat significant (p = 0.09, log-rank test). CONCLUSIONS: Our results suggest that the addition of adjuvant MVP chemotherapy may reduce the distant metastasis rates and prolong the survival of the surgically resected stage II non-small-cell lung cancer patients.     

Postoperative adjuvant chemotherapy for stage I non-small cell lung cancer

Objective: Surgery constitutes the mainstay of treatment in stage I non-small cell lung cancer (NSCLC). However, a significant fraction of patients after surgical resection die mainly due to systemic relapse. Nonetheless, the best adjuvant treatment to improve survival and decrease relapse rate remains as an ever controversial issue. Therefore, we conducted a randomized trial to determine whether postoperative adjuvant chemotherapy is beneficial in prolonging survival and decreasing recurrence in patients with completely resected stage I NSCLC. Methods: It was designed as a randomized, prospective two-armed study with surgery only (control group, 59 patients) versus surgery plus adjuvant MVP (mitomycin C, vinblastin and cisplatin) chemotherapy (study group, 59 patients). Results: Data for all the patients were complete. Twenty-four patients in the control group and nine patients in the study group experienced tumor recurrence during the follow-up. Neither histological type nor surgical extent correlated with recurrence. However, the addition of adjuvant MVP chemotherapy could decrease the rate of recurrence and the incidence of cancer-related death after surgery in the patients of stage I NSCLC (P<0.05). We followed up at least 5 years, and the duration of mean follow-up was 7.3 years. The rates of the loco-regional and distant metastases were 3.4 and 40.7% in the control group, and 3.4 and 11.9% in the study group, respectively. The 5- and 10-year survival rates were 74.6 and 56.3% in the control group, and 81.4 and 65.0% in the study group, respectively (P=0.19, log-rank test). The 5- and 10-year disease-free survival rates were 64.8 and 54.8% in the control group, and 88.8 and 76.8% in the study group, respectively (P=0.002, log-rank test). Conclusions: Our results suggest that the addition of adjuvant MVP chemotherapy may reduce the incidence of distant metastasis and prolong the disease-free survival of the patients with stage I NSCLC after surgery.     

Postoperative chemotherapy for resected non-small-cell lung cancer

Surgical resection is the treatment of choice for patients with stage I and stage II non-small-cell lung cancer (NSCLC—squamous cell, adenocarcinoma, and large-cell carcinoma). Distant recurrence is an important cause of death after complete surgical resection, occurring in 30–60% of patients. Postoperative adjuvant chemotherapy has been studied for over three decades in randomized controlled trials but is not considered standard therapy for this group of patients. The use of multidrug regimens including cisplatin has produced a prolongation of disease-free survival, but until recently no overall survival benefit has been shown. A new generation of studies is now warranted, employing the more active combinations identified in the 1980s or incorporating one of the many promising new agents being tested in NSCLC. The use of improved supportive care measures, such as the new serotonin receptor antagonist antiemetics, is required to increase compliance with chemotherapy in this group of patients. With this approach, the real goal of adjuvant system chemotherapy—to increase the number of patients actually cured of their cancer—may be attained in early stage NSCLC.

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Resumen La resección quirúrgica es el tratamiento de la elección para pacientes con cáncer pulmonar de células no pequenas (escamacelular, adenocarcinoma y carcinoma de células grandes) en estados I (T1,2;N0) y II (T1,2:N1). La recurencia a distancia es una causa importante de muerte luego de resección quirúrgica completa, lo cual ocurre en 30–60% de los casos. La quimioterapia postoperatoria coadyuvante ha sido valorada por más de tres decenios en ensayos clínicos randomizados, y no se ha considerado una modalidad terapéutica estándar para este grupo de pacientes. El uso de regímenes con múltiples drogas, incluyendo el cisplatino, ha resultado en prolongación de la supervivencia libre de enfermedad, pero hasta hace poco tiempo no se había demostrado un beneficio sobre la supervivencia global. Se requiere una nueva generación de estudios clínicos empleando las combinaciones de drogas más activas identificadas en los años 1980s, o incorporando uno de los numerosos promisorios nuevos agentes que están siendo ensayados en el cáncer pulmonar de células no pequeñas (NSCLC). El uso de los mejores métodos de soporte, tales como los nuevos agentes antieméticos antagonistas de los receptores de serotinina, está indicado a fin de mejorar la tolerancia a la quimioterapia en este grupo de pacientes. Con tal aproche es posible que se logre el propósito real de la quimioterapia sistémica coadyuvante: incrementar el número de pacientes con cáncer de células no pequeñas en estado inicial verdaderamente curados.

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Résumé La résection chirurgicale est le traitement de choix chez le patient atteint de cancer bronchopulmonaire (qu'il s'agisse de cancer épithélial, glandulaire ou à grandes cellules à l'exclusion des cancers à petites cellules) aux stades I et II. Les récidives à distance, dont la fréquence se situe entre 30 et 60%, sont la cause principale de décès lorsque la résection a été complète. La chimiothérapie adjuvante postopératoire, évaluée maintenent depuis plus de trois décennies par des études randomisées, n'est pourtant pas encore appliquée de façon systématique chez ces patients. L'utilisation de chimiothérapies combinées comprenant le cisplatine peut laisser espérer une prolongation de survie sans maladie, mais jusqu'à une époque encore récente, aucune bénéfice de survie globale n'a été démontré. D'autres études sont nécessaires à présent, en utilisant des combinaisons plus puissantes, identifiées dans les années 1990, ou en incluant une des nouvelles drogues actuellement étudiées dans les cancers pulmonaires (en dehors des cancers à petites cellules). L'utilisation de médicaments de soutien, tels les antiémétiques, antogonistes des récepteurs de la sérotonine, est nécessaire pour augmenter la compliance de la chimiothérapie chez ce groupe de patients. Avec cette approche thérapeutique, le vrai but de la chimiothérapie adjuvantec'est-à-dire augmenter le nombre de patients guéris de leur cancer-peut être obtenu à un stade précoce.

     

全胸腔镜下肺叶切除治疗早期非小细胞肺癌

目的 探讨全胸腔镜下肺叶切除在早期非小细胞肺癌治疗中的安全性、有效性及适应证.方法 2006年11月至2007年11月共施行全胸腔镜下肺叶切除治疗早期非小细胞肺癌44例,其中男2,4例,女20例;平均年龄61.5岁.手术全部通过3个胸腔镜切口完成,肺叶解剖性切除和系统性淋巴结清扫的操作顺序与常规开胸手术基本相同.结果 全部手术顺利,未发生严重并发症及围手术期死亡,中转开胸1例.平均手术202.6 min,平均出血216.8 ml,无输血病例.术后平均带胸管7.4 d.术后病理:腺癌30例,鳞癌10例,肺泡细胞癌3例,肉瘤样癌1例.随访平均7.7个月,1例Ⅲa期腺癌病人术后3个月发生转移,其余无复发.结论 全胸腔镜下肺叶切除在有效性、彻底性方面可以达到开胸手术相同的效果,对于早期非小细胞肺癌是一种安全、有效的手术方式.     

Neoadjuvant and adjuvant therapy in the management of locally advanced non-small-cell lung cancer

The role of adjuvant therapy in non-small-cell lung cancer continues to be defined. We review the most recent major reports of adjuvant trials. Three large randomized trials of postoperative chemotherapy and/or radiation therapy for stage I and II patients have noted improvement trends in median and long-term survival. Two large preoperative phase II trials for stage III A patients have reported high response and surgical resectability rates for preoperative combinations of radiation and chemotherapy, but without significant improvement in survival. In general, most of these protocols require months to complete, and not all patients are able to withstand the associated toxicity. The field of adjuvant therapy is continuing to develop; some of the strategies of ongoing protocols are reviewed.

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Resumen El papel de la terapia adyuvante en el manejo del cáncer de células no pequeñas continúa en proceso de definición. Muchos de los ensayos terapéuticos han demostrado tendencias sin significación estadística en cuanto a mejor sobrevida. Con el propósito de valorar si la nueva terapia experimental es superior al tratamiento estándar, si los efectos secundarios son tolerables por los pacientes y cuales son los costos en términos de tiempo y toxicidad para la prolongation de la sobrevida, nos propusimos revisar los más recientes informes emanados de ensayos con terapia adyuvante. Tres grandes estudios randomizados de quimio y/o radioterapia postoperatoria en estados I y II han señalado mejoría en la sobrevida a mediano y a largo plazo. Dos ensayos preoperatorios de fase II para pacientes en estado IIIa han informado altas tasas de respuesta y de resecabilidad quirúrgica con la combinación preoperatoria de irradiación y quimioterapia, pero sin mejoría significativa en la sobrevida. En general la mayor parte de estos protocolos requieren meses para ser implementados y no todos los pacientes son capaces de tolerar la toxicidad asociada. El campo de la terapia adyuvante continúa en desarrollo; se revisan las estrategias de algunos de los protocolos en progreso.

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Résumé Le rôle de la thérapeutique adjuvante des cancers bronchopulmonaires en dehors des cancers à petites cellules reste à définir. Trois études randomisées importantes ont noté une tendance vers une meilleure survie à moyen et à long terme avec une chimiothérapie et/ou radiothérapie postopératoires pour les cancers stades I et II. Deux études prospectives de phase II ont rapporté une bonne résponse et une amélioration de la résecabilité pour les cancers du stade IIIA avec une combinaison de chimiothérapie et de radiothérapie, mais sans amélioration significative de la survie. En général, la plupart des protocoles nécessitent des mois pour être menées à bon terme et tous les patients ne sont pas capables de tolérer la toxicité. Le domaine de thérapie adjuvante continue à se déveloper: les protocoles actuellement en cours sont passés en revue.

     

Short-course induction chemoradiotherapy with paclitaxel for stage III non-small-cell lung cancer

Background. This study assessed toxicity, tumor response, disease control, and survival after short-course induction chemoradiotherapy and surgical resection in patients with stage III non-small-cell lung carcinoma.

Methods. Forty-five patients with stage III non-small-cell lung carcinoma received 12-day induction therapy of a 96-hour continuous infusion of cisplatin (20 mg/m² per day), 24-hour infusion of paclitaxel (175 mg/m²), and concurrent accelerated fractionation radiation therapy (1.5 Gy twice daily) to a dose of 30 Gy. Surgical resection was scheduled for 4 weeks later. Postoperatively, a second identical course of chemotherapy and concurrent radiation therapy (30 to 33 Gy) was given.

Results. Induction toxicity resulted in hospitalization of 18 (40%) patients for neutropenic fever. No induction deaths occurred. Of 40 (89%) patients who underwent thoracotomy, resection for cure was possible in 32 (71%) patients. Pathologic response was noted in 21 (47%) patients, and 14 (31%) were downstaged to mediastinal node negative (stage 0, I, or II). At a median follow-up of 19 months, 24 patients were alive, 10 with recurrent disease. Of 21 deaths, 16 were from recurrent disease, three were from treatment, and two were unrelated. Recurrent disease was distant in 21 patients, distant and locoregional in 2, and locoregional in 3. The Kaplan-Meier projected 24-month survival is 49%. Projected 24-month survival is 61% for stage IIIA, 17% for stage IIIB (p = 0.035); 84% for pathologic responders, 22% for nonresponders (p < 0.001); 83% for downstaged patients (stage 0, I, or II), 33% for those not downstaged (p = 0.005); and 63% for resectable patients, 14% for unresectable patients (p = 0.007).

Conclusions. We conclude that short-course neoadjuvant therapy with paclitaxel (1) has manageable toxicity and a low treatment mortality, (2) results in good tumor response and downstaging, (3) provides excellent locoregional control with most recurrences being distant, and (4) has improved the median survival compared with historical controls. Survival was better in stage IIIA patients, resectable patients, pathologic responders, and patients downstaged to mediastinal node negative disease (stage 0, I, or II).     

Postoperative complications in relation with induction therapy for lung cancer.

OBJECTIVES: The purpose of this study was to evaluate the risk of lung cancer surgery following induction chemotherapy and/or radiotherapy. METHODS: This retrospective study included 69 patients treated from January 1990 to January 1998 for a primary lung cancer in whom surgery had been performed after induction treatment. Surgery had not been considered initially for the following reasons: N2 disease (IIIA, n = 25); temporary functional impairment (two stages IB and two stages IIIA (N2), n = 4); and doubtful resectability (stage IIIB (T4), n = 40). The medical regimen resulted in combined radio-chemotherapy in 43 patients who received two to four cycles of chemotherapy (average 2.9 +/- 0.8 cycles) and 43 +/- 8 Gy (range 20--60 Gy), or chemotherapy alone in 26 patients (3 +/- 0.7 cycles). RESULTS: Exploratory thoracotomy was performed in four patients (6%). The in-hospital mortality was 9% (n = 6) from respiratory origin in all cases. There were four re-operations (6%): three for bronchial fistula and one for bleeding. Thirty-five patients (51%) required blood transfusion (4.5 +/- 3.8 cell packs). The incidence of early and delayed bronchial fistula after pneumonectomy was 15%. Thirteen patients had a postoperative pneumonia (19%). CONCLUSIONS: Surgery for lung cancer after induction chemotherapy and/or radiotherapy is associated with an increased risk. If the mortality seems 'acceptable', the morbidity rate, however, is high.     

Eight-year follow-up of adjuvant therapy for stage II breast cancer

The 8-year results of a prospective, randomized, clinical trial of 3 treatment regimens in 311 women with stage II breast cancer are reported. Cyclophosphamide, methotrexate, and 5-fluorouracil (C) were compared with C plus the anti-estrogen drug tamoxifen citrate (Nolvadex^®) (CT) and CT plus Bacillus Calmette-Guérin vaccinations (CTBCG) as adjuvant therapy postmastectomy. Estrogen receptors (ER) were measured in all primary tumors. The addition of Nolvadex^® to chemotherapy significantly decreased the number of recurrences at 8 years. This decrease in recurrence was more pronounced in estrogen receptor-positive patients as follows: (a) those with 4 positive lymph nodes; (b) those with tumor diameters 3 cm; and (c) postmenopausal women.Addition of Nolvadex^® to C had no effect on disease-free survival in patients with ER-negative tumors. Immunotherapy with BCG vaccinations had no discernible effect on disease-free survival. Estrogen receptor measurements in the primary tumor provide important prognostic information regardless of treatment. Estrogen receptor-positive patients have a lower recurrence rate and lower mortality after 8 years. Both estrogen and progesterone receptor measurements have predictive value for response to endocrine therapy and should be determined in all patients with breast cancer.

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Resumen Se informan los resultados a 8 años de un estudio clínico prospectivo y aleatorizado con 3 regímenes terapéuticos en 311 mujeres con cáncer de seno estado II, en quienes se comparó ciclofosfamida, metotrexato 5-fluoruracido (Ci) con C más la droga antiestrógeno citrato de tamoxifen (Nolvadex^®) (CT) y CT más vacunaciones con bacilo Calmette-Guérin (CTBCG) como terapia adyuvante postmastectomía. Se determinaron receptores de estrógeno (RE) en todos los tumores primarios. La adición de Nolvadex^® a la quimioterapia redujo en forma significativa el número de recurrencias a 8 años. Esta reducción en la recurrencia fué más notoria en las pacientes con tumores RE positivos, así: (a) en aquellas con 4 ganglios positivos; (b) en aquellas con tumores con diámetros 3 cm; (c) en mujeres postmenopáusicas.La adición de Nolvadex^® al regimen C no exhibió efectos sobre la supervivencia libre de enfermedad en pacientes con tumores RE negativos. La inmunoterapia con vacunaciones BCG no exhibió efecto demostrable sobre la supervivencia libre de enfermedad. La determinación de RE en el tumor primario provee una información pronóstica importante, no importa cual sea el tratamiento. Los pacientes RE positivos exhiben más bajas tasas de recurrencia y de mortalidad a los 8 años. Tanto las mediciones de receptores de estrógeno como las de receptores de progesterona tienen valor en la predicción de la respuesta a la terapia endocrina y deben ser realizadas en toda paciente con cáncer de seno.

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Résumé Les résultats à 8 ans d'une étude clinique prospective randomisée concernant trois méthodes thérapeutiques appliquées chez 311 femmes atteintes d'un cancer du sein au stade II sont rapportés par les auteurs. L'action après mastectomie de la combinaison cyclosphamide, méthotrexate et 5-fluouracil (C) a été comparée à celle associant d'une part C à un agent anti-oestrogénique: le citrate de tamoxifène (CT) et d'autre part CT à la vaccination par le BCG (CTBCG). Les récepteurs oestrogéniques (ER) ont été dosés systématiquement. L'adjonction de l'agent anti-oestrogénique (CT) a diminué significativement le taux des récidives à 8 ans. Cette diminution a été plus marquée chez les malades ER positifs qui présentaient: (a) 4 ganglions positifs; (b) diamètre tumoral 3 cm; (c) période suivant la ménopause. En revanche, l'adjonction de cet agent anti-oestrogénique n'a eu aucune influence chez les malades qui présentaient un dosage ER négatif. L'immunothérapie à l'aide de la vaccination par le BCG n'a eu aucun effet probant. La mesure du récepteur oestrogénique de la tumeur représente un facteur de pronostic de valeur considérable. Les malades à ER positif ont un taux de récidive et un taux de décès à 8 ans plus faibles. Les dosages de l'oestrogène et de la progestérone sont des facteurs essentiels du choix du traitement endocrinien. Ils doivent être pratiqués chez tous les malades atteints de cancer du sein.

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Supported by Public Service contracts, CB-23922 and CB-23862 from the National Cancer Institute, National Institutes of Health, Bethesda, Maryland, U.S.A.     

Induction chemoradiotherapy and surgical resection for selected stage IIIB non-small-cell lung cancer

BACKGROUND: Combination chemotherapy using an oral combination of uracil and tegafur (UFT) plus cisplatin and concurrent thoracic radiotherapy is reported to have a high response rate and less toxicity for locally advanced non-small-cell lung cancer (NSCLC) patients. We performed a phase II trial using this chemoradiotherapy as an induction treatment. METHODS: Patients with marginally resectable stage IIIB NSCLC, an age younger than 70 years, a performance status of 0 or 1, and good organ function were eligible. The UFT (400 mg/m(2)) was administered orally on days 1 through 14 and 22 through 35 and cisplatin (80 mg/m(2)) was injected intravenously on days 8 and 29. Radiotherapy with a total dose of 40 Gy was delivered in 20 fractions from day 1. A surgical resection was performed from 3 to 6 weeks after completing the induction treatment. RESULTS: Twenty-seven patients, 18 male and 9 female with a median age of 56 years and ranging from 36 to 69 years, were entered into the phase II trial. Clinical T4 and N3 cancers were observed in 22 and 7 patients, respectively. Twenty-five (93%) achieved a partial response. The most frequently observed adverse event was grade 3 leukopenia in 26%. Of 25 patients who underwent a thoracotomy, 22 had a tumor resection. In all 22 patients a complex resection including a resection of the superior vena cava, carina, and vertebrae was required. Operative morbidity and mortality rates were 36% and 4% respectively. The calculated 1-year and 3-year survival rates of all 27 patients were 73% and 56% respectively. CONCLUSIONS: Chemotherapy using UFT plus cisplatin and concurrent radiotherapy as induction treatment and a surgical resection for patients with marginally resectable stage IIIB NSCLC is feasible and promising. However it is difficult to conduct multi-institutional trials even for selected stage IIIB disease as a complex resection in almost all patients is necessary.     

Surgical results and surgical adjuvant therapy for lung cancer

Careful intraoperative surgical staging should be considered routine for all patients undergoing thoracotomy for lung cancer. In addition, conservative resection is indicated for T₁N₀ lesions. Surgical adjuvant immunotherapy has not proved as effective as originally hoped. However, the advent of more effective combination chemotherapy for advanced lung cancer has led to the evolution of these agents as adjuncts to surgery. The preliminary results are promising.     

Postoperative complications after induction chemoradiotherapy in patients with non-small-cell lung cancer

Objective: This study evaluates the risks of postoperative complications in 124 patients with non-small-cell lung cancer who received pre-operative induction chemoradiotherapy and surgery. Methods: All patients with non-small-cell lung cancer who underwent surgery after induction therapy between January 1990 and December 2003 were reviewed. We adopted univariate and multiple logistic regression models to identify predictors that increased the incidence of postoperative complications. Results: Of 124 patients, 59 received carboplatin and docetaxel, 53 received cisplatin and etoposide, and 12 received other platinum-based combinations. Pre-operative thoracic radiotherapy was performed concurrently with chemotherapy. The median dose to the primary tumor was 40 Gy, and 29 patients (23.4%) received radiotherapy of more than 45 Gy before surgery. There were 25 pneumonectomies (20.2%). The overall postoperative mortality was 9 of 124 patients (7.3%), and complications developed in 54 patients (43.5%). Multivariate analysis demonstrated that only thoracic radiotherapy of more than 45 Gy predicted postoperative complications (P = 0.021; odds ratio, 3.620; 95% confidence interval, 1.214–10.797). Conclusions: Thoracic radiotherapy of more than 45 Gy, in combination with chemotherapy, was a significant risk factor for postoperative complications.     

Postoperative adjuvant treatment for pancreatic cancer

To improve surgical results after resection of pancreatic cancer, clinical trials of postoperative adjuvant treatment have been aggressively performed worldwide. In the USA, postoperative chemoradiation therapy is supported on the basis of the results of the Gastrointestinal Tumor Study Group (GITSG) trial published in 1985. In Europe, chemotherapy was approved as postoperative adjuvant therapy based on the results of the European Study Group for Pancreatic Cancer-1 (ESPAC-1) trial published in 2004 and Charité Onkologie (CONKO)-001 study published in 2007. As in Europe, postoperative chemotherapy is recommended in Japan based on the results of the Japanese Study Group of Adjuvant Therapy for Pancreatic Cancer-02 (JSAP-02) trial published in 2009. In recent years, gemcitabine has been recognized as the first choice for adjuvant chemotherapy after surgery. Clinical trials with gemcitabine, fluorouracil, and molecular targeting agents are currently under way.     

Postoperative adjuvant treatments for biliary tract cancer

Surgery currently remains the only potentially curative treatment for biliary tract cancer, and most patients develop recurrence. Thus, effective adjuvant therapy is required to increase the curability of surgery and to prolong the survival in these patients. However, to date, no standard postoperative adjuvant therapy regimen has been established for patients with biliary tract cancer. Based on favorable results reported from phase II trials, gemcitabine and S-1 are currently available as promising agents for the treatment of unresectable biliary tract cancer in Japan. Both agents are also expected to be effective in the postoperative adjuvant therapy setting for biliary tract cancer, and well-designed randomized controlled trials (phase III trials) to determine the efficacy of these agents in the postoperative adjuvant setting should be pursued vigorously. In phase III trials, appropriate stratification of patients is important, and the primary disease (gallbladder cancer versus nongallbladder cancers), curability (R0 or R1), and presence/absence of lymph node metastasis should be taken into account.     

Postoperative airway stenosis and stent therapy in carinal reconstruction for lung cancer.

A 48-year-old male had adenocarcinoma of the right upper lung lobe that invaded the lower trachea. The right upper lobe, the carina, and 5 rings of the lower trachea were resected. The carina was reconstructed using end-to-end anastomosis between the trachea and right intermediate bronchus, with the left main bronchus anastomosed to the side wall of the intermediate bronchus. Two months after surgery, the right intermediate bronchus developed bronchomalacia and the tracheal anastomosis granulatory stenosis. Bronchomalacia was treated with 2 expandable metallic stents, and granulatory stenosis with a Dumon stent. Although the silicone stent successfully dilated the granulatory stenosis, the metallic stents caused delayed glanulatory stenosis. We concluded that a metallic stent is not desirable for treating postreconstructive airway stenosis including bronchomalacia, whereas a Dumon stent may be effective.     

Comparative prognostic features of stage IIIAN2 and IIIB non-small-cell lung cancer patients treated with surgery after induction therapy.

OBJECTIVE: Induction Therapy (IT) before surgery emerged as a widely used strategy for IIIAN2 and selected IIIB NSCLC patients. However, IT is associated with a possible increase in postoperative complications. Consequently, selection of patients with the best chances to benefit from combined treatment is mandatory. METHODS: Study recorded demographics, treatment and outcome of consecutive patients treated with IT plus surgery for IIIAN2 or IIIB NSCLC. Survival was analysed by Kaplan-Meier and prognostic factors were analysed by log-rank and Cox regression. RESULTS: From 1993 to 2003, 155 patients (IIIAN2=95/IIIB=60) were treated. Complete resection was associated with a significant prolonged median survival both for IIIAN2 (20 vs 16 months, P=0.05) and IIIB (20 vs 15 months, P=0.02) patients. A lower risk of death for IIIAN2 patients was independently associated with postoperative mediastinal lymph node clearance (HR=0.45, 95%CI [0.25-0.81], P=0.009) and absence of postoperative complication (HR=0.54, 95%CI [0.31-0.93], P=0.02). Absence of blood vessel invasion only was identified as an independent predictor of a lower risk of death (HR=0.27, 95%CI [0.12-0.59], P=0.01) for stage IIIB patients. CONCLUSIONS: Besides similarities as the role of a complete R0 resection, treatment-related factors influence outcome of IIIAN2 patients while disease-related factors prevail on survival of IIIB patients, in whom the benefit of IT is unclear.     

Overview of adjuvant systemic therapy in early stage breast cancer

The benefits of adjuvant systemic therapy in reducing risk of distant relapse from breast cancer have been recognized for several decades. The intent of adjuvant therapy is to eliminate the occult micrometastatic breast cancer burden before it progresses into clinically apparent disease. Successful delivery of effective adjuvant systemic therapy as a complement to surgical management of breast cancer has contributed to the steady declines in breast cancer mortality observed internationally over the past 2 decades. Ongoing clinical and translational research in breast cancer seeks to improve the efficacy of systemic agents for use in the conventional postoperative (adjuvant) setting.     

Chemotherapy for metastatic non-small-cell lung cancer. A case report

The role of chemotherapy for patients with metastatic non-small-cell lung carcinoma (NSCCL) is controversial. A patient with intrathoracic metastatic NSCCL, who was treated by moderate dose cisplatin combination chemotherapy and who remained clinically free of disease more than 5 years after presentation, is described. This treatment has not previously been reported. A trial of moderate-dose cisplatin combination chemotherapy in selected patients with good performance status seems justified.     

Nodal stage after induction therapy for stage IIIA lung cancer determines patient survival

Background. This study was undertaken to determine the predictive value of nodal status at resection in regards to long-term outcome of patients undergoing neo-adjuvant therapy and resection for stage IIIA N2-positive non-small cell lung cancer (NSCLC).

Methods. We reviewed the medical records of all patients found on surgical staging to have N2-positive NSCLC and who underwent induction therapy followed by resection between 1988 and 1996 at our hospital. Complete follow-up information was examined utilizing Kaplan-Meier survival analysis and Cox proportional hazards multivariate analysis.

Results. One hundred three patients (59 men) with stage IIIA N2-positive NSCLC received neoadjuvant therapy before surgical resection. Preoperative therapy consisted of platinum-based chemotherapy (76), radiotherapy (18), or chemoradiation (9). Operations included pneumonectomy (38), bilobectomy (6), and lobectomy (59). There were four deaths and seven major complications. Eighty-five patients were followed until death. Median survival among 18 living patients is 60.9 months (range 29 to 121 months). Twenty-nine patients were downstaged to N0 and had 5-year survival of 35.8% (median survival 21.3 months). Seventy-four patients with persistent tumor in their lymph nodes (25 N1 and 49 N2) had significantly worse, 9%, 5-year survival, p = 0.023 (median survival 15.9 months). Other negative prognostic factors were adenocarcinoma and pneumonectomy.

Conclusions. Patients with N2-positive NSCLC whose nodal disease is eradicated after neoadjuvant therapy and surgery enjoy significantly improved cancer-free survival. These data support surgical resection for patients downstaged by induction therapy; however, patients who are not downstaged do not benefit from surgical resection. Direct effort should be made to improve the accuracy of restaging before resection.     

Surgical outcome for small-sized non-small-cell lung cancer

We reviewed surgical outcome for small-sized non-small-cell lung cancer. From 2004 to 2007, 109 patients with complete resected non-small-cell lung cancer of 2 cm or less in diameter were examined retrospectively. Sixty-five were male and 44 were female. Ages ranged 41~87 (median 68) years.Overall 5-year survival rate(OS) was 89%, and 5-year disease free survival rate(DFS) was 82%.Ground-glass opacity( GGO) dominant group[ GGO ratio ≥ 50% in high resolution computed tomography(CT)] and lymph node (LN) negative group were showed favorable DFS significantly. Other parameters,such as histology, tumor diameter, serum carcinoembryonic antigen (CEA) level, pleural invasion,vascular permeation, operative procedure, were showed no significant difference about DFS. All GGO dominant group patients(n=23) had no LN involvement and survived in disease free. Cases with LN involvement [n=10 (9%)] were all in solid group(GGO<50%) and their tumor diameter were over 10 mm. Sublober resections were performed in 28 cases( segmentectomy in 12, wedge resection in 16). Among these cases, intentional limited resections were done in 13 patients with GGO dominant group (tumor diameter ranged 7 to 20 mm), and they had no local recurrence. Prognosis of small-sized GGO dominant lung cancer is very favorable, so limited resection will be appropriate. But solid lesions, especially over 10 mm in tumor diameter, have possibility of LN involvement, lobectomy should be considered.