Definitive Chemoradiotherapy vs. Surgery After Induction for Stage III Lung Cancer

Stage III non–small-cell lung cancer (NSCLC) is highly variable in its presentation and is usually treated with multimodality therapy tailored to each patient. To compare surgery versus definitive concurrent chemoradiotherapy boost after induction in this setting, investigators conducted a multicenter, phase III trial (ESPATUE) involving good-performance patients (status, 0–1) with medically operable, pathologically proven stage IIIA (N2) or IIIB (N3 contralateral mediastinal nodes or T4) disease. Because the trial was closed due to slow accrual after only 246 of the planned 500 patients were enrolled, it was underpowered for the primary endpoint of overall survival (OS).

Patients received three cycles of neoadjuvant cisplatin-paclitaxel chemotherapy followed by concurrent chemoradiation (45 Gy) using weekly cisplatin and vinorelbine. During the last week of concurrent chemoradiation, the 161 patients who were still resectable were randomized to a chemoradiotherapy boost (65 to 71 Gy) or surgery.

Five-year OS was similar with a chemoradiotherapy boost or surgery (40% and 44%, respectively), as was 5-year progression-free survival (PFS; 35% and 32%). Among patients who received a chemoradiotherapy boost, two died from pneumonia. Among patients who underwent surgery, three died from lung bleeding and two died from pneumonia and empyema.