title: Results of combined modality treatment in patients with non-small-cell lung cancer of the superior sulcus and the rationale for surgical resection.
abstract: 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 66Gy 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 mgm(-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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands. i.kappers@nki.nl
authors.forename: Ingrid
authors.initials: I
authors.lastname: Kappers
authors.forename: Johanna W
authors.initials: JW
authors.lastname: van Sandick
authors.forename: Jacques A
authors.initials: JA
authors.lastname: Burgers
authors.forename: José S A
authors.initials: JS
authors.lastname: Belderbos
authors.forename: Michel W
authors.initials: MW
authors.lastname: Wouters
authors.forename: Nico
authors.initials: N
authors.lastname: van Zandwijk
authors.forename: Houke M
authors.initials: HM
authors.lastname: Klomp
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D002945:Cisplatin / Q000627:therapeutic use; D003131:Combined Modality Therapy / Q000379:methods; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D010178:Pancoast Syndrome / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D011013:Pneumonectomy / Q000379:methods; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents; D002945:Cisplatin