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Induction Chemoradiotherapy for Superior Sulcus Non–Small-Cell Lung Cancer: An Answer for Few

Department of Thoracic Surgery, European Institute of Oncology, Milan, Italy

Gianpiero Catalano

Department of Radiotherapy, European Institute of Oncology, Milan, Italy

Tommaso De Pas

Department of Oncology, European Institute of Oncology, Milan, Italy

Francesco Petrella, Lorenzo Spaggiari

Department of Thoracic Surgery, European Institute of Oncology, Milan, Italy

To the Editor:

We read with interest the article recently published by Dr Rusch et al on long-term results of the Southwest Oncology Group trial 9416.¹ From 1995 to 1999, 110 patients with superior sulcus tumors received induction chemoradiotherapy, and 88 of them subsequently underwent thoracotomy. Given a 30% complete pathologic response and a 44% 5-year survival, the authors concluded that local control and overall survival seem markedly improved relative to previous studies of radiation plus resection.

In our opinion, there are three areas of concern that limit this conclusion.

First of all, the entity of the benefit. This population is represented by patients judged fit for the protocol. From a theoretical point of view, it is logical to assume that they were selected based on their performance status, which per se is a predictor of survival in advanced lung cancer.² It is possible that their performance status was better as compared with performance status from the entire series from Memorial Sloan-Kettering (New York, NY),³ in which all patients who underwent surgery (20% after chemotherapy, 35% of them without any induction treatment) were analyzed. This element by itself could justify a significant difference in term of overall survival.

The second concern is regarding treatment toxicity, which was not negligible. Mortality due to induction chemoradiotherapy was 3%, 33 episodes of grade 4 toxicity were recorded, and the planned treatment was completed in less than 50% of cases (49 of 110). Keeping this aspect in mind, it would probably be interesting to reserve this type of induction to specific subgroups of patients. In the article, the adverse role of mediastinal nodal disease is not mentioned but has been previously reported.³ Does induction chemoradiotherapy reduce the risk of early treatment failure in these patients?

Our last concern is regarding the risk of local recurrence. Even if a complete response was obtained in one third of patients, almost 20% of them (17 of 88) developed local recurrence, showing that improvements are needed for superior sulcus tumors in terms of local control. Why should we limit the beneficial contribution of radiotherapy to 45 Gy? It probably would be better to use radiotherapy in an adjuvant context, in which higher dose can be reached and the target is better defined based on surgical exploration findings.

Given the complexity of superior sulcus tumors, the use of induction treatment should permit exclusion of patients with rapidly evolving disease from surgery. This target is obtained by neoadjuvant chemotherapy. We believe that induction chemoradiotherapy for these patients should be administered in the context of controlled trials until more evidence is available.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The authors indicated no potential conflicts of interest.

REFERENCES

1. Rusch VW, Giroux DJ, Kraut M, et al: Induction chemoradiation and surgical resection for superior sulcus non–small-cell lung carcinomas: Long-term results of Southwest Oncology Group trial 9416 (Intergroup Trial 0160). J Clin Oncol 25: 313-318, 2007[Abstract/Free Full Text]

2. Albain KS, Crowley JJ, LeBlanc M, et al: Survival determinants in extensive-stage non-small-cell lung cancer: The Southwest Oncology Group experience. J Clin Oncol 9: 1618-1626, 1991[Abstract]

3. Rusch VW, Parekh KR, Leon L, et al: Factors determining outcome after surgical resection of T3 and T4 lung cancers of the superior sulcus. J Thorac Cardiovasc Surg 119: 1147-1153, 2000[Abstract/Free Full Text]

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