Survival Results and Prognostic Factors in T4 N0-3 Non-small Cell Lung Cancer Patients According to the AJCC 7th Edition Staging System

Background: The American Joint Committee on Cancer (AJCC) published a new staging system (7th edition)in 2009. In our study, we evaluated the survival results and prognostic factors among T4 local advanced nonsmallcell lung cancer (LA-NSCLC) patients in a large heterogeneous group, in accordance with this new system.Materials and
Methods: We retrospectively evaluated the files of 122 T4 N0-3 M0 LA-NSCLC patients, identifiedaccording to the new staging system, treated at two centers between November 2003 and June 2012. Variablescorrelating with univariate survival at p<0.20 were later included in multivariate Cox regression analysis. Here,selection of relevant predictors of survival was carried out in accordance with the likelihood ratio formulawith p<0.05 regarded as significant.
Results: The median age was 60 and the median follow-up period was 17.4months. Median overall survival (OS) was 18.3 months, the 1 year overall survival (OS) rate was 72%, andthe 5 year OS rate was 28%. Statistically significant predictors of survival were (p<0.20) ECOG-PS (EasternCooperative Oncology Group Performance Status), age, T4 factor subgroup, stage and primary treatment inOS univariate analysis. On multivariate analysis for OS ECOG-PS (p=0.001), diagnostic stage (p=0.021), andprimary treatment (p=0.004) were significant. In the group receiving non-curative treatment, the median OSwas 11.0 months, while it was 19.0 months in the definitive RT group and 26.6 months in the curative treatmentgroup. There was a significant difference between the non-curative group and the groups which had definitiveRT and curative operations (respectively p<0.001 and p=0.001) in terms of OS, but not between the groupswhich had definitive RT and curative operations. The median event free survival (EFS) rate was 9.9 months,with rates of 46% and 19% at 3 and 5 years, respectively. On univariate analysis of EFS rate with ECOG-PS,weight loss and staging, statistical significance was found only for thorax computerized tomography (CT)+18Ffluorodeoxy-glucose positron emission tomography-CT (PET-CT) use, stage and primary treatment (p<0.20). Inmultivariate analysis with EFS, only the primary treatment was statistically significant (p=0.001). In the groupreceiving non-curative treatment, the median EFS was 10.5 months while in the curative operation group it was14.7 months. When all the primary treatment groups were taken into consideration, grade III/IV side effectswas observed in 57 patients (46.6%). Esophagitis was most prominent among those that received definitiveradiotherapy.
Conclusions: Independent prognostic factors among these 122 heterogeneous LA-NSCLC T4 N0-3M0 patients were age at diagnosis, ECOG-PS, stage and primary treatment, the last also being a significantprognostic indicator of EFS. Our findings point to the importance of appropriate staging and a multidisciplinaryapproach with modern imaging methods in this patient group. In those with T4 lesions, treatment selection andthe effective use of curative potential should be the most important goal of clinical care.