Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center at the University of North Carolina, Chapel Hill, North Carolina 27599-7305, USA.
Oncologist. 2012;17(5):682-93. doi: 10.1634/theoncologist.2012-0020. Epub 2012 Apr 24.
Approximately one third of patients with non-small cell lung cancer have unresectable stage IIIA or stage IIIB disease, and appropriate patients are candidates for chemoradiotherapy with curative intent. The optimal treatment paradigm is currently undefined. Concurrent chemoradiotherapy, compared with sequential chemotherapy and thoracic radiation therapy (TRT), results in superior overall survival outcomes as a result of better locoregional control. Recent trials have revealed efficacy for newer chemotherapy combinations similar to that of older chemotherapy combinations with concurrent TRT and a lower rate of some toxicities. Ongoing phase III trials will determine the roles of cisplatin and pemetrexed concurrent with TRT in patients with nonsquamous histology, cetuximab, and the L-BLP25 vaccine. It is unlikely that bevacizumab will have a role in stage III disease because of its toxicity. Erlotinib, gefitinib, and crizotinib have not been evaluated in stage III patients selected based on molecular characteristics. The preliminary results of a phase III trial that compared conventionally fractionated standard-dose TRT (60 Gy) with high-dose TRT (74 Gy) revealed an inferior survival outcome among patients assigned to the high-dose arm. Hyperfractionation was investigated previously with promising results, but adoption has been limited because of logistical considerations. More recent trials have investigated hypofractionated TRT in chemoradiotherapy. Advances in tumor targeting and radiation treatment planning have made this approach more feasible and reduced the risk for normal tissue toxicity. Adaptive radiotherapy uses changes in tumor volume to adjust the TRT treatment plan during therapy, and trials using this strategy are ongoing. Ongoing trials with proton therapy will provide initial efficacy and safety data.
约三分之一的非小细胞肺癌患者患有不可切除的 IIIA 期或 IIIB 期疾病，适当的患者是有治愈意图的放化疗候选者。目前还没有确定最佳的治疗模式。与序贯化疗和胸部放射治疗（TRT）相比，同步放化疗可通过更好的局部区域控制来提高总生存结果。最近的试验表明，与使用 TRT 的旧化疗联合方案相比，新型化疗联合方案具有相似的疗效，且某些毒性的发生率更低。正在进行的 III 期试验将确定顺铂和培美曲塞联合 TRT 在非鳞状组织学患者、西妥昔单抗和 L-BLP25 疫苗中的作用。由于其毒性，贝伐单抗在 III 期疾病中不太可能发挥作用。厄洛替尼、吉非替尼和克唑替尼尚未在基于分子特征选择的 III 期患者中进行评估。一项比较常规分割标准剂量 TRT（60Gy）与高剂量 TRT（74Gy）的 III 期试验的初步结果显示，高剂量组患者的生存结果较差。以前曾对超分割进行过研究，结果有一定希望，但由于后勤方面的考虑，应用受到限制。最近的试验研究了放化疗中的低分割 TRT。肿瘤靶向和放射治疗计划的进步使这种方法更可行，并降低了正常组织毒性的风险。适应性放射治疗利用肿瘤体积的变化在治疗过程中调整 TRT 治疗计划，并且正在使用这种策略进行试验。正在进行的质子治疗试验将提供初步的疗效和安全性数据。
