الفهرس 
Introduction and aim of the workOnly 14 pages are availabe for public view
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Abstract
This study was carried out at clinical oncology department, Assuit University Hospital in the period between 2008 to 2011. All patients included in the study had a previously untreated unresectable stage III non-small cell lung cancer. Diagnoses were confirmed either histologically or cytologically. All patients had a performance status of 0-2 according to the ECOG scale, with adequate hepatic, renal cardiopulmonary functions. A written consent was given by each patient.
A total of 35 patients were enrolled in this prospective phase II study aimed at evaluation of the efficacy and feasibility of a unique schedule of combined chemo radiation.
This regimen consists of induction chemotherapy with cisplatin and etoposide followed by concurrent chemo radiation with hyper fractionated split-course radiotherapy (60 Gy over 40 fractions with two weeks break after 42Gy) and concurrent cisplatin and etoposide followed by 1-2 cycles of consolidation cisplatin and etoposide.
At the end of the study, only 30 patients were evaluated, the ORR was 76.6%, complete response in 13.3%, partial response in 36.7%, stable disease in 26.7% and disease progression in 23.3%. The MST was 17 months, the estimated one year PFS was 73.9% and the OS at 1and 2 years were 95.7% and 21.7% respectively. The regimen was well-tolerated with no serious toxicity.
The toxicity was evaluated according to common terminology criteria for adverse events, v.3.0.
Our results may be inferior to some of the combination trials but reasonable with comparable MST and toxicity to that reported by many trials.
Conclusion and Recommendation
Lung cancer is the leading cause of cancer-related mortality all over the world. Patients with clinical stage IIIA-N2 disease have a 5-year overall survival rate of 10% to 15%; however, patients with bulky mediastinal involvement (i.e., visible on chest radiography) have a 5-year survival rate of 2% to 5%. The anticipated 5-year survival for the vast majority of patients who present with clinical stage IIIB NSCLC is 3% to 7%.
The addition of sequential and concurrent chemotherapy to radiation therapy has been evaluated in prospective randomized trials and meta-analyses. Overall, concurrent treatment may provide the greatest benefit with increased toxicity.
In medically fit patients with locally advanced non-small-cell lung cancer (NSCLC), concurrent chemo radiotherapy improves survival compared with radiotherapy alone or sequential chemotherapy followed by radiotherapy. However, chemo radiotherapy is also associated with significantly higher rates of grade ≥3 toxic effects.
The optimal chemotherapy regimen to be used concurrently with thoracic radiation for locally advanced non-small-cell lung cancer remains uncertain. Studies investigating this question are ongoing.
The uses of new technologies (3-D conformal RT and IMRT) allow dose escalation, and enhance local tumor control and subsequently improve treatment outcome
Definitive-dose thoracic radiotherapy should be no less than the biological equivalent of 60 Gy, in 1.8- to 2.0-Gy fractions to the planning target volume (PTV). Ideally, this requires 3-dimensional (3D) conformal radiotherapy.
Lung cancer patients treated with curative intent in good performance status, surveillance with physical examination and CT scan is recommended every 6 months for 2 years and then annually, coordinated by a multidisciplinary team.
Despite some reports of better sensitivity, specificity and accuracy of PET/CT for earlier diagnosis of recurrence, this methodology is not yet recommended, mainly because there is no correlation between earlier detection of recurrence and survival benefit and an intensive surveillance programme is certainly more expensive.
Treatment complications related to chemotherapy or radiotherapy should be carefully evaluated for a frame time of 3–6 months.
Patients treated with curative intent should be encouraged and sustained in programmes to quit smoking.
Considering our protocol:
• It is feasible and tolerable with reduced toxicity
• Down staging can occur after induction chemotherapy phase or chemo radiation and the patients may be considered for surgery
• Based on the lower toxicity , dose >60 Gy can be delivered with improved local control
• Split course RT may compromise local control as local failure rate was 67.7%.
• Long-term follow up of surviving patients in order to determine 5-year overall survival is advised.
• Our protocol was promising with comparable results to that reported by many trials but it did not add any survival advantage over that reported for concurrent chemo radiation.
• Patients with brain metastasis as a pattern of distant failure were found to have adenocarcinoma which was known to have the highest incidence of brain metastasis.