Randomized Phase 2 Evaluation of Preoperative Radiation Therapy and Preoperative Chemotherapy with Mitomycin, Vinblastine, and Cisplatin in Patients With Technically Unresectable Stage IIIA and IIIB Non-small Cell Cancer of the Lung

LCSG 881

¹ From the Department of Radiation Oncology, Albany Medical College, Albany NY
² From the Department of Medical Oncology, Veterans Administration; West Side Medical Center, Chicago
³ From the Oncology Center, The Johns Hopkins Hospital, Baltimore
⁴ From the Department of Medical Oncology, Albany Medical College, Albany NY

Between June 1988 and January 1980, 67 patients with pathologic stage III non-small cell lung cancer were randomized to receive either preoperative mitomycin, vinblastine, and cisplatin (MVP) chemotherapy (cisplatin 120 mg/m², and mitomycin, 8 mg/m² day 1+29, and vinblastine, 4.5 mg/m² on day 1, 15, 22, and 29 and 2.0 mg/m² day 8), or preoperative radiotherapy (44 Gy in 22 fractions to the primary tumor and mediastinum). The purpose of this study was to identify a treatment approach that showed sufficient effectiveness and acceptable toxicity to warrant testing by prospective randomized trial against "standard" nonsurgical treatment. All patients had surgical staging of the mediastinum and had either unresectable N2 disease or T4 disease with proximal extension of disease along the pulmonary artery. Response to preoperative therapy was evaluated 8 weeks after beginning treatment and patients with complete or partial radiographic response were to undergo surgical exploration and resection if possible. Fifty-seven patients were eligible and evaluable for response. Of the 67 total patients, 3 were unavailable for follow-up, 4 were ineligible, 1 was canceled, and 2 refused all treatment after having been randomized. Of the eligible and evaluable patients, 49 had stage IIIA and 8 had stage IIIB disease. Randomization was to MVP in 26 cases and to radiotherapy (XRT) in 31. Radiographic response to treatment was virtually identical for the two approaches, with 29 of the 57 evaluable patients achieving objective responses. In patients achieving radiographic response, 24 underwent surgical exploration and 20 underwent resection, of which 18 were complete. The mediastinum was free of tumor in seven patients but only two pathologic complete responses were seen (one each to XRT and MVP). In addition, ten nonresponders underwent surgery; seven underwent resection. Median survival for the entire group is 12 months, with a 27% actuarial survival at 4 years. Two patients died of treatment toxicity during preoperative therapy. Overall toxicity included 2 preoperative toxic deaths and 6 postoperative deaths in 34 patients who underwent surgical exploration (3 each with XRT and MVP) due to adult respiratory distress syndrome (3), myocardial infarction (1), pulmonary edema (1), and esophageal fistula (1), for an overall death rate 8 of 57 (14%) and a perioperative death rate in surgically explored patients of 6/34 (18%). These preoperative regimens, in the population studied herein, were of modest efficacy and substantial toxicity. While these data do not exclude possible gain in long-term survival for these preoperative treatments compared with the best nonsurgical therapy, until such benefits are documented in prospective trials, their use should be considered investigational.