Hongxing Zhang

Postoperative Radiotherapy for Resected Pathological Stage IIIA–N2 Non-Small Cell Lung Cancer: A Retrospective Study of 221 Cases from a Single Institution

BACKGROUND For patients with resected pathological stage IIIA-N2 non-small cell lung cancer (NSCLC), the role of postoperative radiotherapy (PORT) is not well defined. In this single-institutional study, we re-evaluated the effect of PORT on overall survival (OS) as well as tumor control in this subgroup of patients. METHODS In 2003-2005, 221 consecutive patients with resected pathological stage IIIA-N2 NSCLC at our institution were retrospectively analyzed in an institutional review board-approved study. The effect of PORT on OS, cancer-specific survival (CSS), and disease-free survival (DFS) was evaluated using the Kaplan-Meier method and log-rank tests. The impact of PORT on locoregional control and distant metastasis was also analyzed. Results. Compared with the control, patients treated with PORT had a significantly longer OS time (χ2, 3.966; p = .046) and DFS interval (χ2, 6.891; p = .009), as well as a trend toward a longer CSS duration (χ2, 3.486; p = .062). Patients treated with PORT also had a significantly higher locoregional recurrence-free survival rate (χ2, 5.048; p = .025) as well as distant metastasis-free survival rate (χ2, 11.248; p = .001). Multivariate analyses showed that PORT was significantly associated with a longer OS duration (p = .000). CONCLUSIONS PORT can significantly improve the survival of patients with resected pathological stage IIIA-N2 NSCLC. A prospective randomized multicenter clinical trial is ongoing.

Role of Adjuvant Radiotherapy for Stage II Thymoma After Complete Tumor Resection

PURPOSE To determine whether patients with Masaoka stage II thymoma benefit from adjuvant radiation therapy after complete tumor resection. METHODS AND MATERIALS A total of 107 patients with stage II thymoma who underwent complete resection of their tumors between September 1964 and October 2006 were retrospectively analyzed. Sixty-six patients were treated with adjuvant radiotherapy, and 41 patients received surgery alone. RESULTS Eight patients (7.5%) had a relapse of their disease, including two patients (4.5%) who had surgery alone, and 6 patients (9.5%) who had adjuvant radiation therapy. Disease-free survival rates at 5 and 10 years were 92.3% and 82.6%, respectively, for the surgery-plus-radiation group, and 97.6% and 93.1%, respectively, for the group that underwent surgery alone (p = 0.265). Disease-specific survival rates at 5 and 10 years were 96.4% and 89.3%, respectively, for the surgery-plus-radiation group and 97.5% and 97.5% for the surgery group (p = 0.973). On univariate analysis, patients with type B3 thymomas had the lowest disease-free survival rates among all subtypes (p = 0.001), and patients with large thymomas (>7 cm) had lower disease-specific survival rates than those with small tumors (<7 cm) (p = 0.017). On multivariate analysis, histological type (type B3) thymoma was a significant independent prognostic factor. CONCLUSIONS Adjuvant radiotherapy after complete tumor resection for patients with stage II thymoma did not significantly reduce recurrence rates or improve survival rates. Histological type (type B3) thymoma was a significant independent prognostic factor. Further investigation should be carried out using a multicenter randomized or controlled study.

Etoposide and cisplatin versus paclitaxel and carboplatin with concurrent thoracic radiotherapy in unresectable stage III non-small cell lung cancer: a multicenter randomized phase III trial

Background The optimal chemotherapy regimen administered currently with radiation in patients with stage III non-small cell lung cancer (NSCLC) remains unclear. A multicenter phase III trial was conducted to compare the efficacy of concurrent thoracic radiation therapy with either etoposide/cisplatin (EP) or carboplatin/paclitaxel (PC) in patients with stage III NSCLC. Patients and methods Patients were randomly received 60–66 Gy of thoracic radiation therapy concurrent with either etoposide 50 mg/m2 on days 1–5 and cisplatin 50 mg/m2 on days 1 and 8 every 4 weeks for two cycles (EP arm), or paclitaxel 45 mg/m2 and carboplatin (AUC 2) on day 1 weekly (PC arm). The primary end point was overall survival (OS). The study was designed with 80% power to detect a 17% superiority in 3-year OS with a type I error rate of 0.05. Results A total of 200 patients were randomized and 191 patients were treated (95 in the EP arm and 96 in the PC arm). With a median follow-up time of 73 months, the 3-year OS was significantly higher in the EP arm than that of the PC arm. The estimated difference was 15.0% (95% CI 2.0%–28.0%) and P value of 0.024. Median survival times were 23.3 months in the EP arm and 20.7 months in the PC arm (log-rank test P = 0.095, HR 0.76, 95%CI 0.55–1.05). The incidence of Grade ≥2 radiation pneumonitis was higher in the PC arm (33.3% versus 18.9%, P = 0.036), while the incidence of Grade ≥3 esophagitis was higher in the EP arm (20.0% versus 6.3%, P = 0.009). Conclusion EP might be superior to weekly PC in terms of OS in the setting of concurrent chemoradiation for unresectable stage III NSCLC. Trial registration ID NCT01494558.

Selection of proper candidates with resected pathological stage IIIA-N2 non-small cell lung cancer for postoperative radiotherapy

To establish a prediction model in selecting fit patients with resected pIIIA‐N2 non‐small cell lung cancer (NSCLC) for postoperative radiotherapy (PORT), and evaluate the model in clinical practice.

Patterns and predictors of recurrence after radical resection of thymoma

BACKGROUND Recurrence of thymomas even after complete resection is common, but the relapse patterns remain controversial. This study aimed to define the patterns and predictors of relapse after complete resection of thymoma. METHODS A single-institution retrospective study was performed with 331 patients who underwent radical resection of thymoma between 1991 and 2012. RESULTS After a median follow-up of 59 months, the recurrence rate was 6.9% (23/331). Relapse occurred in 23 patients with the pleura (14) and tumor bed (6) as the most common sites of recurrence. According to the definitions of the International Thymic Malignancy Interest Group, 10 (43.5%) patients had local relapse, 15 (65.2%) had regional relapse, 10 (43.5%) had distant relapse. The difference in survival following relapse between lung and regional relapse was statistically significant (P=0.027) but that between lung and distant relapse was not (P=0.808). The recurrence rates correlated with the initial Masaoka stage. Further, recurrence also correlated with World Health Organization (WHO) tumor type. The recurrence-free survival rates in patients with tumor size ⩾8 cm were worse than those of patients with tumor size <8 cm (P=0.007). Tumor size was also correlated with stage (r=0.110). As tumor becomes larger, the stage is more advanced (P=0.023). Multivariate analysis showed that Masaoka stage (P=0.005), tumor size (P=0.033), and WHO histological type (P=0.046) were predictive factors of relapse. CONCLUSION Regional recurrence is the most common relapse pattern but local and distant relapse are also common. Advanced Masaoka stage, larger tumor size, and type B3 are risk factors of recurrence. Lung relapse should be considered distant relapse. Further, tumor size was correlated with Masaoka stage and therefore should be considered in the staging system.

A prognostic nomogram for overall survival after neoadjuvant radiotherapy or chemoradiotherapy in thoracic esophageal squamous cell carcinoma: a retrospective analysis

Background Currently, the AJCC staging system or pathological complete response (pCR) are considered not sufficiently accurate to evaluate the survival of patients with esophageal squamous cell carcinoma after neoadjuvant radiotherapy or chemoradiotherapy. This study aimed to establish a nomogram and a recursive partitioning analysis (RPA) model to estimate prognosis and to provide advice for subsequent treatments. Methods We analyzed retrospectively 407 patients that were diagnosed with thoracic esophageal squamous cell carcinoma (TESCC) and received neoadjuvant radiotherapy or chemoradiotherapy. Hazard ratios and 95% confidence intervals of categorical clinicopathological characteristics with overall survival (OS) were calculated using the Cox proportional hazard model. The nomogram and RPA model were then established and total scores according to each variable were calculated and stratified to predict OS. Results Patients were followed-up over a median 49.9 months. AJCC did not perform well in distinguishing OS among each stage except for IIB and IIIA. Patients were divided into 4 groups according to the total scores based on nomogram (low risk: ≤180; intermediate risk: 180-270; high risk: 270-340; very high risk: >340). The 5-year OS was 57.3%, 40.7%, 18.3%, 6.1% respectively (p<0.05). RPA model also divide the patients into 4 groups, though group2 and group3 were not statistically significant (p=0.574). Conclusion The nomogram is a good evaluation model for estimating the prognosis of patients with TESCC after neoadjuvant radiotherapy or chemoradiotherapy compared with the AJCC and RPA. The results of this study also suggested that the high-risk subgroups need further treatments.

Role of radiotherapy in treating patients with primary malignant mediastinal non-seminomatous germ cell tumor: A 21-year experience at a single institution.

The aim of this study was to investigate the clinical characteristics and outcomes of patients with primary malignant mediastinal non‐seminomatous germ cell tumor (MMNSGCT) by comparing the efficacies of different treatment modalities.

Efficacy of intensity-modulated radiotherapy for resected thoracic esophageal squamous cell carcinoma

Little is known about the clinical use of intensity‐modulated radiotherapy (IMRT) in postoperative radiotherapy (PORT) of esophageal cancer; therefore, we retrospectively investigated the clinical value of postoperative IMRT among resected thoracic esophageal squamous cell carcinoma (TESCC) patients.

Factors predicting radiation toxicity in the treatment of three-dimensional conformal radiotherapy for lung cancer

BACKGROUND The lung and esophagus are always damaged during radiation on thoracic tumors to a certain extent. This study is to report the incidence of radiation pneumonitis and radiation esophagitis and to analyze the factors as predictors of radiation toxicity in the treatment of three-dimensional conformal radiotherapy (3DCRT) for lung cancer. METHODS Between March 1999 and September 2003, 112 lung cancer patients treated with 3DCRT were reviewed at this Hospital. This population consisted of 87 men and 25 women, including 97 cases of non-small cell lung cancer and 15 of small cell lung cancer. The median age was 64 years old. Radiotherapy was delivered at 2Gy fraction, 5 fractions per week. The median total dose was 60Gy. RESULTS Grade 2 or more acute radiation pneumonitis developed in 7.1% (8/112) of patients while grade 2 or more late radiation pneumonitis appeared in 1.8% (2/112) of patients. Acute radiation esophagitis was observed in 8.9% (10/112) of patients with grade 2. No clinical and physical factor was relative to acute radiation pneumonitis by univariate and multivariate analysis. In the entire population, the univariate analysis revealed that many parameters (pre-treatment weight loss more than 5%, chemotherapy and concurrent chemotherapy) were significantly associated with acute radiation esophagitis. Multivariate analysis revealed that pre-treatment weight loss more than 5% was the most important risk factor for acute radiation esophagitis (P= 0.016). CONCLUSIONS No clinical and physical factor is relative to acute radiation pneumonitis and pre-treatment weight loss more than 5% is the most important risk factor for acute radiation esophagitis in this study.

A Proposal for Combination of Lymph Node Ratio and Anatomic Location of Involved Lymph Nodes for Nodal Classification in Non–Small Cell Lung Cancer

Introduction: The current pathologic nodal classification (pN) based on anatomic location of involved lymph nodes (LNs) is unsatisfactory in distinguishing heterogeneous pN1 or pN2 non–small cell lung cancer (NSCLC). For the first time we comprehensively compared the prognostic significance of the number of positive LNs (nN), the ratio of the number of positive to removed LNs (LN ratio [LNR]), the combination of pN and nN (pN‐nN), the combination of pN and LNR (pN‐LNR), and pN to identify a superior classification. Methods: We identified 700 patients with pN1 (n = 203) or pN2 (n = 497) NSCLC. We classified the patients into four nN categories (nN1, nN2, nN3–6, and nN≥7), four pN‐nN categories (pN1–nN1–2, pN1–nN≥3, pN2–nN1–6, and pN2–nN≥7); four LNR categories (LNR≤0.05, 0.1≥LNR>0.05, 0.4≥LNR>0.1, and LNR>0.4), and four pN‐LNR categories (pN1–LNR<0.1, pN1–LNR≥0.1, pN2–LNR<0.4, and pN2–LNR≥0.4). The log‐rank test was used to analyze differences among groups, and Cox regression was used to evaluate relationships between each classification and survival. Results: In adjusted analyses, pN‐LNR was an independent prognostic factor for patients with pN1 or pN2 NSCLC, as were pN‐nN, LNR, nN, and pN. pN‐LNR was prognostically superior to the other four classifications. Postoperative radiotherapy (PORT) was an independent prognostic factor for pN2 NSCLC. Analyses stratified by LNR showed that PORT did not improve survival in patients with pN2–LNR<0.14 NSCLC, whereas significantly improved survival times in pN2–LNR≥0.14 NSCLC. Conclusions: We propose a potential revised nodal classification, pN‐LNR, to further stratify patients with pN1 or pN2 NSCLC into subgroups so as to more precisely predict survival and help tailor individualized postoperative treatment.