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Results of combined modality treatment in patients with non-small-cell lung cancer of the superior sulcus and the rationale for surgical resection

^a Department of Surgical Oncology, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
^b Department of Thoracic Oncology, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
^c Department of Radiation Oncology, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands

Received 17 November 2008; received in revised form 13 April 2009; accepted 20 April 2009.

^_* Corresponding author. Address: The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Department of Surgical Oncology, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands. Tel.: +31 20 5122551; fax: +31 20 5122554. (Email: i.kappers{at}nki.nl; h.klomp{at}nki.nl).

Objective: Superior sulcus tumours (SSTs) or Pancoast tumours are preferably treated with chemoradiotherapy (CRT) followed by surgical resection. However, when followed by surgery, it is associated with an increased complication rate. This study aims to evaluate the efficacy and safety of a concurrent induction protocol of 66 Gy radiotherapy with cisplatinum and evaluate the rationale for subsequent surgery. Methods: Patients with SST treated in our institute from 1994 to 2006 were identified. The preferred induction treatment consisted of accelerated radiation (66 Gy in fractions of 2.75 Gy) with concurrent daily cisplatinum 6 mg m^–2. Surgical resection was planned 4–6 weeks thereafter. Performance status, co-morbidity, clinical and pathological tumour stage, (response to) treatment and survival were reviewed. Survival analysis was performed using the Kaplan–Meier method. Results: Over these 12 years, 85 patients with Pancoast tumours, 57 men and 28 women, were referred. Mean follow-up was 42 months (range: 2–120 months). Twenty-five patients had stage IIB (29%), seven had stage IIIA (8%), 32 had stage IIIB (38%) and 21 had stage IV (25%). Of the 64 patients presenting with stage II or III disease, 38 medically operable patients with potentially resectable tumours received induction therapy. After restaging, 22 patients underwent resection. All resections were complete and local recurrences were not observed. In 13 patients (62%) a pathologic complete response was found. In most cases, pathologic response was not evident from radiological imaging. The morbidity of surgery after induction treatment was acceptable. There was no fatal toxicity or treatment-related mortality. The 2- and 5-year overall survival of this selected group was 70% and 37%, respectively. Conclusion: This schedule of induction therapy with high-dose radiation and concurrent cisplatinum was safe and highly effective in fit patients. At this time, pathologic complete response cannot be reliably recognised preoperatively, and better tools for response assessment are critical for more tailored treatment of patients with SST.

Key Words: Non-small-cell lung carcinoma • Superior sulcus tumours • Surgery • Combined modality treatment • Pancoast tumours • Chemoradiation therapy