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A Journal on Internal Medicine and Pharmacology

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Gazzetta Medica Italiana Archivio per le Scienze Mediche 2003 February;162(1):19-28

language: Italian

Chemotherapy and radiotherapy associated or not to surgery in bronchogenic cancer in non small cell lung cancer at stage III (A e B)

Lyberis P.

Dipartimento di Fisiopatologia Clinica, Università degli Studi di Torino, Torino


At the ­time of in­itial di­ag­no­sis, ap­prox­i­mate­ly 50% of pa­tients ­with non-­small ­cell ­lung can­cer (­NSCLC) ­have clin­i­cal­ly de­tect­able met­a­stat­ic ­spread out­side the ­chest, and lo­cal­ly ad­vanced un­re­sect­able tho­rac­ic tu­mors are ­found in a fur­ther 10-15% of pa­tients. Furthermore, ­more ­than 50% of the re­main­ing pa­tients re­cur ei­ther lo­cal­ly or at dis­tant met­a­stat­ic ­sites af­ter sur­gery. This ­means ­that ­more ­than ­three-quar­ters of pa­tients ­with ­NSCLC are po­ten­tial can­di­dates for system­ic chem­o­ther­a­py ­alone or ­with ra­dio­ther­a­py at ­some ­time dur­ing the ­course of ­their dis­ease. Following over­all chem­o­the­rap­ic treat­ment, com­plete re­sponse ­rates are strong­ly cor­re­lat­ed ­with ­stage (­stage III, 39% ­stage IV, 25%). Response ­rates ­were sig­nif­i­cant­ly high­er for com­bi­na­tion chem­o­ther­a­py ­than for sin­gle-­agent treat­ment. Response ­rates in ­NSCLC are high­er ­when com­bi­na­tion chem­o­ther­a­py is ­used com­pared ­with sin­gle-­agent treat­ment. Comparing sin­gle-­agent ther­a­py to com­bined ther­a­py we ­find a con­sis­tent im­prove­ment in sur­vi­val ­when poly­chem­o­ther­a­py is em­ployed. As far as ad­ju­vant chem­o­ther­a­py af­ter sur­gi­cal re­sec­tion is con­cerned, the ­most ac­tive reg­i­mens in use to­day re­sult at ­best, in re­sponse in on­ly 35-50% of pa­tients ­with ad­vanced dis­ease, and com­plete clin­i­cal re­spons­es are ­rare. Several ­trials ­were per­formed in the ear­ly 1980s and 1990s to de­ter­mine wheth­er the se­quen­tial ad­min­is­tra­tion of com­bi­na­tion chem­o­ther­a­py fol­lowed by tho­rac­ic ra­dio­ther­a­py ­could pro­long sur­vi­val for pa­tients ­with lo­cal­ly ad­vanced ­NSCLC. No or min­i­mal sur­vi­val ben­e­fit was ­seen at ­three ­years and ­five ­years in ­most of the stud­ies. The val­ue of add­ing chem­o­ther­a­py to tho­rac­ic ir­ra­di­a­tion is ­still con­tro­ver­sial to­day. All the stud­ies ­showed im­prove­ments in ­both me­dian and two ­years sur­vi­vals, but ­this was not al­ways ac­com­pa­nied by pro­lon­ga­tion of ­long-­term sur­vi­val or in­creased ­cure ­rates. Although ra­di­a­tion ­with or with­out chem­o­ther­a­py is stan­dard ther­a­py for pa­tients ­with un­re­sect­able lo­cal­ly ad­vanced tu­mors, ­there has ­been re­cent inter­est in treat­ment pro­grams of chem­o­ther­a­py fol­lowed by sur­gery. Response to chem­o­ther­a­py may al­low an oth­er­wise-un­re­sect­able tu­mor to be sur­gi­cal­ly re­sect­ed. However, ­this ­should not be ­viewed as the pri­mary ­goal of treat­ment, ­since oth­er treat­ment mo­dal­ities can ­achieve lo­cal con­trol and ­most pa­tients die of dis­tant fail­ure. The in­di­ca­tions for ex­ter­nal-­beam ra­di­a­tion in­clude med­i­cal­ly in­op­er­able ­lung can­cer, re­gion­al­ly ad­vanced ­lung can­cer ­where sur­gi­cal re­sec­tion is not fea­sible, and as a pal­li­a­tive ­tool in pa­tients ­with ad­vanced dis­ease. Combination chem­o­ther­a­py and ra­di­a­tion ther­a­py has ­been uti­lized as a meth­od to in­crease ag­gres­sive non-sur­gi­cal treat­ment in re­gion­al­ly ad­vanced ­lung can­cer. It re­mains un­clear as to ­which chem­o­ther­a­peu­tic ­agents are ­best and as to the ­most ap­pro­pri­ate tim­ing of ir­ra­di­a­tion and chem­o­ther­a­py.

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