Trimodality Treatment of Superior Sulcus Non-Small Cell Lung Cancer: An Institutional Series of 47 Consecutive Patients

Abstract

Objectives: Treatment of superior sulcus tumors (SST) using concurrent chemoradiation followed by surgery is a current standard. However, due to the rarity of this entity, clinical experience in its treatment remains scarce. Here, we present the results of a large consecutive series of patients treated with concurrent chemoradiation followed by surgery at a single academic institution.

Materials and methods: The study group included 48 patients with pathologically confirmed SST. The treatment schedule consisted of preoperative 6-MV photon-beam radiotherapy (45-66 Gy delivered in 25-33 fractions over 5-6.5 weeks) and concurrent two cycles of platinum-based chemotherapy. Five weeks after completion of chemoradiation, pulmonary and chest wall resection was performed.

Results: From 2006 to 2018, 47 of 48 consecutive patients meeting protocol criteria underwent two cycles of cisplatin-based chemotherapy and concurrent radiotherapy (45-66 Gy) followed by pulmonary resection. One patient did not undergo surgery due to brain metastases that occurred during induction therapy. The median follow-up was 64.7 months. Chemoradiation was well tolerated, with no toxicity-related deaths. Twenty-one patients (44%) developed grade 3-4 side effects, of which the most common was neutropenia (17 patients; 35.4%). Seventeen patients (36.2%) had postoperative complications, and 90-day mortality was 2.1%. Three- and five-year overall survival (OS) were 43.6% and 33.5%, respectively, and three- and five-year recurrence-free survival were 42.1% and 32.4%, respectively. Thirteen (27.7%) and 22 (46.8%) patients had a complete and major pathological response, respectively. Five-year OS in patients with complete tumor regression was 52.7% (95% CI 29.4-94.5). Predictive factors of long-term survival included age below 70 years, complete resection, pathological stage, and response to induction treatment.

Conclusions: Chemoradiation followed by surgery is a relatively safe method with satisfactory outcomes.

Keywords: multimodality treatment; neoadjuvant chemoradiation; superior sulcus tumors; surgery; survival.

Figure 1

The swimmer plot shows patients’ survival in years. Every patient is marked with a color according to pathological response to neoadjuvant treatment: Junker 2A—orange, Junker 2B—green, Junker 3—blue. The id is a unique number assigned to a patient. The black line is indicating the recurrence of the disease. The black cross—the death of a patient. OSY—overall survival in years.

Figure 2

The Kaplan-Meier survival curves for overall survival (OS) are represented by a red line versus recurrence-free survival (RFS) represented by a blue line, with corresponding 95% confidence intervals illustrated with light-red and light-blue zones.

Figure 3

Multivariate analysis with forest plot of risk of death according to Cox proportional hazard ratio (HR).

Figure 4

Estimated survival is presented with Kaplan-Meier survival curves. Plot (A)—Comparison of overall survival in a group of patients aged 70 years or older (blue line) versus a group of patients under 70 years of age (red line). Plot (B)—Comparison of overall survival in a group of patients with positive resection margin—R1 (blue line) versus a group of patients with negative resection margin—R0 (red line). Plot (C)—Comparison of overall survival in a group of patients with complete pathological regression according to JUNKER scale 3 (blue line) versus a group of patients without complete pathological regression—JUNKER 2a or 2b (red line). Plot (D)—Comparison of overall survival in a group of patients with recurrence of lung cancer (blue line) versus a group of patients without recurrence (red line). Figure legend: a red and blue line: estimated survival, light red and blue zone: 95% confidence intervals.