Chest ACCP Education Calendar
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (6)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Milleron, B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Milleron, B.
(Chest. 2005;128:1442-1447.)
© 2005 American College of Chest Physicians

Complete Response Following Preoperative Chemotherapy for Resectable Non-Small Cell Lung Cancer*

Accuracy of Clinical Assessment Using the French Trial Database

Bernard Milleron, MD, FCCP; Virginie Westeel, MD, PhD; Elisabeth Quoix, MD; Denis Moro-Sibilot, MD; Denis Braun, MD; Bernard Lebeau, MD; Alain Depierre; for the French Thoracic Cooperative Group

* From Tenon University Hospital (Dr. Milleron), CancerEst, Paris; J Minjoz University Hospital (Dr. Westeel), Besançon; University Hospital (Dr. Quoix), Strasbourg; Michalon University Hospital (Dr. Moro-Sibilot), Grenoble; General Hospital (Dr. Braun), Briey; Saint Antoine University Hospital (Dr. Lebeau), CancerEst, Paris; and J Minjoz University Hospital (Mr. Depierre), Besançon, France.

Correspondence to: Bernard Milleron, MD, Service de Pneumologie, Hôpital Tenon, 4, Rue de la Chine, 75020 Paris, France; e-mail: bernard.milleron{at}tnn.ap-hop-paris.fr


   Abstract
TOP
 Abstract
Introduction
 Methods and Materials
 Results
 Discussion
 Conclusion
 References
 
Background: Pathologic complete response (CR) to preoperative chemotherapy has been shown to be a strong prognostic factor in resected non-small cell lung cancer (NSCLC). This preoperative setting offers the opportunity to evaluate the clinical prediction of CR by investigators and an evaluation committee (EC) using the "gold standard" pathologic examination as the reference. The only published large randomized trial of preoperative chemotherapy (to our knowledge), the French neoadjuvant study, constitutes an interesting database to evaluate CT scan-based CR assessment.

Study objectives and design: The French trial compared mitomycin-ifosfamide-cisplatin followed by surgery with surgery alone in stage I (except T1N0) to IIIa resectable NSCLC. Response was prospectively assessed in all patients receiving preoperative chemotherapy by the investigator in charge of the patient and by an EC, and was compared with pathologic postoperative data.

Results: In the preoperative chemotherapy study, 167 patients were operated on. Nineteen patients were found to have a pathologic CR. Only seven patients were classified as having a CR by investigators and five patients by the EC. Evaluation of CR was correct in six of these seven cases and in three of these five cases, respectively. Sensitivity of the CR diagnosis was 31.6% for investigators and 15.8% for the EC. Specificities of the CR diagnosis were 99.4% and 98.8%, respectively. Positive predictive values were 85.7% and 60%, respectively. Negative predictive values were 91.9% and 90.1%, respectively. Accuracies were 91.6% and 89.2%, respectively.

Conclusion: Investigator assessment of CR was highly predictive of pathologic CR. However, this study showed that clinical CT scan-based assessment, whether performed by investigators or the EC, underestimated the frequency of CR after preoperative chemotherapy in resectable NSCLC.

Key Words: complete response • lung cancer • non-small cell lung cancer • preoperative chemotherapy • response to chemotherapy


   Introduction
TOP
 Abstract
 Introduction
Methods and Materials
 Results
 Discussion
 Conclusion
 References
 
Overall survival and response are usual end points used for clinical trials in oncology. In contrast to the straightforward survival end point, assessment of response is highly dependent on the accuracy of successive tumor measurements. Response evaluation is in most cases based on imaging procedures, mainly CT scan. In lung cancer, thoracic CT scan has been shown to be superior to chest radiography.12 However, technical quality and especially reproducibility of CT slices at the level of the target lesions impact on measurements. Furthermore, intraobserver and interobserver variability introduces the most important level of uncertainty.34 Comparisons between the investigator assessment and evaluation by an external evaluation committee (EC), the latter being considered as the reference, found differences in the rates of tumor response.5 Reasons for disagreements included errors in tumor measurements and in the choice of targets, and technical radiologic problems.6 With the increasing number of preoperative chemotherapy studies in non-small cell lung cancer (NSCLC), clinical prediction of response to chemotherapy can now be compared to the examination of resected specimens. For the evaluation of complete response (CR), pathologic reference is considered as the "gold standard."

Pathologic CR after preoperative chemotherapy for stage IIIA NSCLC has been shown to be associated with better outcome.7 Therefore, identification of CR is an important issue. Response evaluation remains in most patients based on thoracic CT scan. A small series8 of preoperative chemotherapy suggested that chest CT scan underestimated the effect of induction treatment. To our knowledge, the French neoadjuvant study9 is the only large published randomized trial comparing chemotherapy followed by surgery to surgery alone in stage I to IIIa NSCLC. This study provides a large database that can be used to better evaluate CT scan-based CR evaluation, and not only in stage IIIa disease but also in stage I and II NSCLC. Therefore, we evaluated the ability of both investigators and an EC to predict pathologic CR in patients treated with preoperative chemotherapy for NSCLC within the French neoadjuvant randomized trial.


   Methods and Materials
TOP
 Abstract
 Introduction
 Methods and Materials
Results
 Discussion
 Conclusion
 References
 
Study Population
Eligibility criteria, treatment allocation, and schedule have been extensively described in the publication of the French trial.9 Briefly, eligibility criteria were as follows: (1) pathologically proven NSCLC, (2) resectable tumor (clinical stage I except T1N0, stage II and IIIA), (3) operable patients, (4) age ≤ 75 years, and (5) World Health Organization performance status ≤ 2. Pretreatment investigations included chest radiography, thoracic CT scan, brain CT scan or MRI, adrenal CT scan and/or abdominal ultrasound, fiberoptic bronchoscopy, pulmonary function tests, cardiovascular evaluation, total blood cell count and differential, and biochemistry. Patients were randomly assigned to surgery alone or to receive preoperative chemotherapy followed by surgery. The treatment plan is illustrated in Figure 1 . Preoperative chemotherapy consisted of two cycles at a 3-week interval of mitomycin (6 mg/m2 at day 1), ifosfamide (1.5 g/m2 at day 1 to day 3), and cisplatin (30 mg/m2 at day 1 to day 3). Surgery was planned during the seventh week. In responders, two additional chemotherapy cycles were to be delivered after surgery. Only patients included in the preoperative chemotherapy arm who underwent surgery were considered for the present analysis.



View larger version (13K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1.. The French prospective neoadjuvant trial: mitomycin (6 mg/m2 day 1), ifosfamide (1.5 g/m2 day 1 to day 3), and cisplatin (30 mg/m2 day 1 to day 3). NC = no change; P = progression.

 
Response Evaluation
Response to chemotherapy was prospectively evaluated in all patients of the preoperative chemotherapy arm by the investigator in charge of the patient 1 week before surgery, with thoracic CT scan and fiberoptic bronchoscopy plus bronchial biopsies. All data were subsequently reviewed by an EC constituted of all other investigators. A total of 38 centers participated in this multicenter study. This evaluation by the EC was blinded with regard to both the investigator assessment and the postoperative pathologic findings.

CR assessment used the World Health Organization criteria.10 CR was defined as the complete disappearance of all target lesions without any residual lesion. The absence of cancer cells in bronchial biopsy specimens was required for clinical CR. Partial response (PR) was defined as a > 50% decrease in tumor mass, without progression in any target lesion or appearance of a new lesion. Stable disease was defined as either a < 50% decrease or a < 25% increase of tumor mass without appearance of a new lesion. Progressive disease (PD) was defined as a > 25% increase in tumor mass or the appearance of a new lesion.

Pathologic response was determined after examination of all resected histopathologic materials, and classified as CR or others. Patients whose specimens contained no cancer cells were considered as having a pathologic CR. All other possibilities were called "others."

Statistical Analysis
The ability of both investigators and the EC to predict pathologic CR was measured using the calculation of sensitivity, specificity, accuracy, and positive and negative predictive values. Pathologic assessment was considered as the reference. The degree of agreement between investigators and the EC was provided for all categories of response (CR, PR, stable disease, progression, and nonevaluable) using a {kappa} coefficient.


   Results
TOP
 Abstract
 Introduction
 Methods and Materials
 Results
Discussion
 Conclusion
 References
 
Study Population
From June 1991 to July 1997, 373 NSCLC patients were included in the French neoadjuvant study (187 patients enrolled in the preoperative chemotherapy arm and 186 in the primary surgery arm). Among the 187 patients of the preoperative chemotherapy arm, 179 were eligible. Clinical staging resulted in 62 stage IB, 25 stage II, and 92 stage IIIA NSCLCs. Pathologic type was squamous cell carcinoma in 129 patients, adenocarcinoma in 30 patients, and large cell carcinoma in 20 patients. Among these 179 patients, 167 were operated on and constituted the database of this analysis.

Response Evaluation
Nineteen patients were found to have a pathologic CR after thoracotomy. Of these 19 patients, 7 patients had stage I, 7 patients had stage II, and 5 patients had stage IIIA NSCLC. Pathologic type was squamous cell carcinoma in 13 patients, adenocarcinoma in 3 patients, and large cell carcinoma in 3 patients.

Investigator and EC response assessments and pathologic responses are displayed in Table 1 . Only seven patients were identified as having a CR by their investigator and five patients by the EC. Thus, 13 of the 107 operated-on patients (14%) classified by investigators as PRs and 15 patients (16.1%) of the 93 PRs defined by the EC had in fact a CR. The results of investigators and the EC compared with those of pathologic assessment are detailed in Table 2 . Evaluation of CR was correct in six of the seven cases defined by investigators and in three of the five cases of the EC. All the patients with a pathologic CR not identified by investigators had been considered as having a PR. Among the 16 cases of pathologic CR missed by the EC, 15 cases had been classified as PRs but 1 case had been evaluated as stable disease. Four (three in stage IIIaN2) of the six CRs identified by investigators and one of the three CRs predicted by the EC occurred in stage IIIa disease. Sensitivity of the CR diagnosis was 31.6% for investigators and 15.8% for the EC. Specificities of the CR diagnosis were 99.4% and 98.8%, respectively. Positive predictive values were 85.7% and 60%, respectively. Negative predictive values were 91.9% and 90.1%, respectively. Accuracies were 91.6% and 89.2%, respectively.


View this table:
[in this window]
[in a new window]

  		Table 1.. Investigator, EC, and Pathologic CR in the 167 Patients Operated on After Chemotherapy*

 

View this table:
[in this window]
[in a new window]

  		Table 2.. Investigator Response vs Pathologic CR and EC Response vs Pathologic CR in the 167 Patients Operated on After Chemotherapy

 
Comparisons between investigator and EC response evaluations are presented in Table 3 . Only 2 of the 19 pathologic CRs were correctly predicted by both investigators and the EC. Few patients were classified as responders by investigators and PD by the EC or vice versa. The {kappa} coefficient was 0.59 ± 0.113 (mean ± SD). Disagreements were more frequent in stage I ({kappa} = 0.46 ± 0.37) and stage IIIA ({kappa} = 0.46 ± 0.17) than in stage II NSCLC ({kappa} = 0.85 ± 0.11).


View this table:
[in this window]
[in a new window]

  		Table 3.. Comparison of Response Evaluation Between Investigators and EC in the 167 Patients Operated on After Chemotherapy

 

   Discussion
TOP
 Abstract
 Introduction
 Methods and Materials
 Results
 Discussion
Conclusion
 References
 
This study showed on a large database that pathologic CR was largely underestimated by both investigators and the EC, with only 6 and 3 of the 19 pathologic CRs predicted, respectively. All CRs missed by investigators and all but one of the CRs not identified by the EC were considered as clinical PRs. However, investigator assessment of CR was highly predictive of a pathologic CR. As most published studies of preoperative chemotherapy have focused on stage III disease, it is interesting to notice in this series, including half stages I and II, that clinical prediction of pathologic CR was easier in early stages.

In a phase II study11 by the Swiss Group for Clinical Cancer Research, a similar analysis was performed in a smaller group of patients. Among the 75 patients who underwent tumor resection after three cycles of docetaxel-cisplatin for operable stage IIIA pathologic N2 NSCLC, 14 pathologic CRs (19%) were observed. Definition of pathologic CR was different from that used in the present analysis, also including patients with a few persistent viable tumor cells. All tumors containing ≥ 95% necrosis and fibrosis were considered as pathologic CRs. Of the 14 pathologic CRs, clinical staging assessed by medical panels resulted in 6 CRs, 5 PRs, and 3 stabilizations. In an Italian retrospective analysis12 conducted in 76 patients operated-on for a stage III NSCLC after chemoradiation, none of the eight pathologic CRs were clinically predicted. Hope for better clinical CR evaluation could be awaited from an EC. Indeed, review of all presumed responses by an EC, which assesses compliance with evaluation guidelines and verifies consistency of tumor measurements, has been reported to produce more reliable overall response evaluation.6 The present study, with pathologic reference available, allows evaluation of an EC for the specific situation of pathologic CR. Our data did not confirm the superiority of EC over investigators in the assessment of pathologic CR, with an even worse sensitivity than that of investigators (15.8% for the EC and 31.5% for investigators). Clinical assessment of a CR defined as disappearance of all targets without any residual lesions is very difficult. Most CT scan presentations consist of residual masses impossible to distinguish between fibrosis and necrosis only and a mixed pattern of fibrosis, necrosis, and viable cancer cells, as they present no specific features. For CR, a too-rigorous review of response assessment as provided by an EC did not seem to be helpful.

Pathologic CR after preoperative chemotherapy is significantly correlated with improved survival.7 It requires clearance of both the primary tumor and lymph nodes, and especially mediastinal lymph nodes usually referred to as mediastinal downstaging. Emphasis is often placed on mediastinal lymph node CR, which has also been shown to be a strong prognostic factor.111314 Among the 75 patients who underwent tumor resection in the Swiss study,11 23 patients (31%) downstaged to N0 and 22 patients (21%) downstaged to N1. Downstaging to N0–1 was associated with highly significantly improved survival (61% vs 11% at 3 years, p = 0.0001). In multivariate analysis, CR and mediastinal lymph node downstaging were the only significant prognostic factors, with mediastinal downstaging being the most powerful (hazard ratio, 0.22; 95% confidence interval, 0.10 to 0.49; p = 0.0003). However, assessment of overall CR should not be neglected, as nodal downstaging is significantly more frequent in patients with pathologic CR in the primary tumor. In the Swiss study,11 mediastinal downstaging was observed in 93% of pathologic CRs in the primary tumor, and in only 57% of patients with less activity in the primary tumor (p = 0.013). Standard treatment still needs to be defined for stage III disease, and identification of mediastinal lymph node clearance and of complete responders might become crucial to optimize the indications of combined modality therapy. In the Intergroup Trial 0139,14 whose preliminary results were first presented at the 2003 meeting of the American Society of Clinical Oncology, patients with a pIIIaN2 NSCLC were randomized between induction concomitant chemoradiation followed by surgery and chemotherapy, or further radiotherapy and consolidation chemotherapy. Three-year survival was not improved in the trimodality arm (38% vs 33%) but was approximately 50% for operated-on patients who had achieved a mediastinal pathologic CR.

Clinical evaluation of response being insufficient, other procedures are being tested and particularly positron emission tomography (PET) scanning. In patients with aggressive non-Hodgkin lymphoma, F-18 fluorodeoxyglucose (FDG)-PET scan appears to be useful for the diagnosis of CR.15 In a prospective study of 70 patients, none of the 33 patients who showed persistent abnormal FDG uptake achieved a durable complete remission, whereas 31 of 37 patients with normal scan findings remained in complete remission with a median follow-up of 1,107 days. In solid tumors, it is uncertain whether FDG uptake may predict a CR. In breast cancer, 10 patients underwent FDG-PET scanning before definitive breast surgery.16 No abnormal uptake at the primary tumor site was visualized in any patient, whereas 9 of the 10 patients had residual invasive carcinoma at operation, ranging from 2 to 20 mm in maximum dimension. Similarly, sensitivity of PET for evaluating a CR in patients with ovarian or peritoneal carcinoma is very low.17 Several studies1819 evaluating PET scan restaging after preoperative chemotherapy or chemoradiation in NSCLC showed a high sensitivity (97 to 100%) but limited specificity (58 to 67%) for detecting residual primary tumors, and good specificity (75 to 99%) but poor sensitivity (50 to 61%) for lymph nodes. One of these studies19 compared PET and CT scan restaging in 34 patients treated with chemotherapy or chemoradiotherapy for NSCLC. PET scanning was shown to be more specific (67% vs 0) for detecting residual tumor and more sensitive (50% vs 30%) for N2 disease than CT scan.19 The same authors20 stated that there was a tight correlation between maximum standardized uptake value (SUV) and pathologic CR with a sensitivity of 90%, a specificity of 100%, and an accuracy of 96% in predicting histopathologic CR when maximum SUV is decreased by ≥ 80%. However, Port et al21 with a cut-off value of 50% decrease in SUV, showed that positive and negative predictive values were rather low as well in tumor and in nodes. Reproducibility of SUV from one center to another may also account for some of the discrepancies in the interpretation of the results. Although better response evaluation can be obtained with PET scanning, remediastinoscopy remains the most accurate procedure for the evaluation of mediastinal response, as it provides histologic evidence. However, clinical response evaluation cannot be neglected, as remediastinoscopy remains an invasive procedure and gives no information on the primary tumor, which can be of great importance in some cases of marginally resectable tumors.


   Conclusion
TOP
 Abstract
 Introduction
 Methods and Materials
 Results
 Discussion
 Conclusion
References
 
This study showed that investigator assessment of CR was highly predictive of pathologic CR. However, this study showed that clinical CT scan-based assessment, whether performed by investigators or the EC, underestimated the frequency of CR after preoperative chemotherapy in resectable NSCLC. If selection of patients for any treatment should depend on CR evaluation, clinical assessment either by the investigator in charge of the patient or by an EC could not be relied on.


   Footnotes
 
Abbreviations: CR = complete response; EC = evaluation committee; FDG = F-18 fluorodeoxyglucose; NSCLC = non-small cell lung cancer; PD = progressive disease; PET = positron emission tomography; PR = partial response; SUV = standardized uptake value

Received for publication November 23, 2004. Accepted for publication January 6, 2005.


   References
TOP
 Abstract
 Introduction
 Methods and Materials
 Results
 Discussion
 Conclusion
 References
 

  1. Dajczman, E, Hanley, J, Lisbona, A, et al (1994) Comparison of response evaluation in small cell lung cancer using computerized tomography and chest radiography. Lung Cancer 11,51-60[ISI][Medline]
  2. Pujol, JL, Demoly, P, Daures, JP, et al Chest tumor response measurement during lung cancer chemotherapy: comparison between computed tomography and standard roentgenography. Am Rev Respir Dis 1992;145,1149-1154[ISI][Medline]
  3. Herschorn, S, Hanley, J, Wolkove, N, et al Measurability of non-small-cell lung cancer on chest radiographs. J Clin Oncol 1986;4,1184-1190[Abstract/Free Full Text]
  4. Quoix, E, Wolkove, N, Hanley, J, et al Problems in radiographic estimation of response to chemotherapy and radiotherapy in small cell lung cancer. Cancer 1988;62,489-493[CrossRef][ISI][Medline]
  5. Gwyther, SJ, Aapro, MS, Hatty, SR, et al Results of an independent oncology review board of pivotal clinical trials of gemcitabine in non-small cell lung cancer. Anticancer Drugs 1999;10,693-698[Medline]
  6. Thiesse, P, Ollivier, L, Di Stefano-Louineau, D, et al Response rate accuracy in oncology trials: reasons for interobserver variability. Groupe Francais d’Immunotherapie of the Federation Nationale des Centres de Lutte Contre le Cancer. J Clin Oncol 1997;15,3507-3514[Abstract/Free Full Text]
  7. Pisters, KM, Kris, MG, Gralla, RJ, et al Pathologic complete response in advanced non-small-cell lung cancer following preoperative chemotherapy: implications for the design of future non-small-cell lung cancer combined modality trials. J Clin Oncol 1993;11,1757-1762[Abstract/Free Full Text]
  8. Schaefer-Prokop, C, Prokop, M New imaging techniques in the treatment guidelines for lung cancer. Eur Respir J Suppl 2002;35,71s-83s[CrossRef][Medline]
  9. Depierre, A, Milleron, B, Moro-Sibilot, D, et al Preoperative chemotherapy followed by surgery compared with primary surgery in resectable stage I (except T1N0), II, and IIIa non-small-cell lung cancer. J Clin Oncol 2002;20,247-253[Abstract/Free Full Text]
  10. Miller, AA, Hargis, JB, Lilenbaum, RC, et al Phase I study of topotecan and cisplatin in patients with advanced solid tumors: a cancer and leukemia group B study. J Clin Oncol 1994;12,2743-2750[Abstract/Free Full Text]
  11. Betticher, DC, Hsu Schmitz, SF, Totsch, M, et al Mediastinal lymph node clearance after docetaxel-cisplatin neoadjuvant chemotherapy is prognostic of survival in patients with stage IIIA pN2 non-small-cell lung cancer: a multicenter phase II trial. J Clin Oncol 2003;21,1752-1759[Abstract/Free Full Text]
  12. Margaritora, S, Cesario, A, Galetta, D, et al Ten year experience with induction therapy in locally advanced non-small cell lung cancer (NSCLC): is clinical re-staging predictive of pathological staging? Eur J Cardiothorac Surg 2001;19,894-898[Abstract/Free Full Text]
  13. Bueno, R, Richards, WG, Swanson, SJ, et al Nodal stage after induction therapy for stage IIIA lung cancer determines patient survival. Ann Thorac Surg 2000;70,1826-1831[Abstract/Free Full Text]
  14. Albain, KCS, Rush, VR, Turrisi, AT, et al Phase III comparison of concurrent chemotherapy plus radiotherapy (CT/RT) and CTRT followed by surgical resection for stage IIIA(pN2) non-small cell lung cancer (NSCLC): initial results from Intergroup Trial 0139 (RTOG 93–09) [abstract]. Proc Am Soc Clin Oncol 2003;22,2497
  15. Spaepen, K, Stroobants, S, Dupont, P, et al Early restaging positron emission tomography with (18)F-fluorodeoxyglucose predicts outcome in patients with aggressive non-Hodgkin’s lymphoma. Ann Oncol 2002;13,1356-1363[Abstract/Free Full Text]
  16. Burcombe, RJ, Makris, A, Pittam, M, et al Evaluation of good clinical response to neoadjuvant chemotherapy in primary breast cancer using [18F]-fluorodeoxyglucose positron emission tomography. Eur J Cancer 2002;38,375-379[CrossRef][ISI][Medline]
  17. Rose, PG, Faulhaber, P, Miraldi, F, et al Positive emission tomography for evaluating a complete clinical response in patients with ovarian or peritoneal carcinoma: correlation with second-look laparotomy. Gynecol Oncol 2001;82,17-21[CrossRef][ISI][Medline]
  18. Ryu, JS, Choi, NC, Fischman, AJ, et al FDG-PET in staging and restaging non-small cell lung cancer after neoadjuvant chemoradiotherapy: correlation with histopathology. Lung Cancer 2002;35,179-187[CrossRef][ISI][Medline]
  19. Cerfolio, RJ, Ojha, B, Mukherjee, S, et al Positron emission tomography scanning with 2-fluoro-2-deoxy-d-glucose as a predictor of response of neoadjuvant treatment for non-small cell carcinoma. J Thorac Cardiovasc Surg 2003;125,938-944[Abstract/Free Full Text]
  20. Cerfolio, R, Bryant, A, Winokur, T, et al Repeat FDG-PET after neoadjuvant therapy is a predictor of pathologic response in patients with non-small cell lung cancer. Ann Thorac Surg 2004;78,1903-1909[Abstract/Free Full Text]
  21. Port, JL, Kent, MS, Korst, RJ, et al Positron emission tomography scanning poorly predicts response to preoperative chemotherapy in non-small cell lung cancer. Ann Thorac Surg 2004;77,254-259,discussion 259[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 ChestHome page
M. Serra, L. Occhionero, and D. Galetta
Complete Response Following Preoperative Chemotherapy for Resectable Non-small Cell Lung Cancer.
Chest, October 1, 2006; 130(4): 1284 - 1285.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (6)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Milleron, B.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Milleron, B.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS