RATIONALE: Drugs used in chemotherapy use different ways to stop tumor cells from dividing
so they stop growing or die. Radiation therapy uses high-energy x-rays to damage tumor
cells. Biological therapies such as gefitinib may interfere with the growth of the tumor
cells and slow the growth of the tumor. Combining chemotherapy and radiation therapy with
gefitinib before surgery may shrink the tumor so that it can be removed during surgery.
PURPOSE: Phase I/II trial to compare the effectiveness of neoadjuvant chemoradiotherapy with
or without gefitinib in treating patients who are undergoing surgery for stage III non-small
cell lung cancer.
OBJECTIVES: Phase I:
- Determine the tolerability and toxicity of gefitinib in combination with chest
radiotherapy in patients with stage IIIA or stage IIIB non-small cell lung cancer.
- Compare the pathologic response (complete response and rate of downstaging) in patients
treated with neoadjuvant chemoradiotherapy with vs without gefitinib.
- Compare the feasibility and toxicity profile of these regimens in these patients.
- Compare the resection rates, time to progression, and overall survival of patients
treated with these regimens.
- Correlate the percent decline in the fludeoxyglucose F 18 standardized uptake value as
measured by position emission tomography with pathologic response at resection, time to
progression, and overall survival in patients treated with these regimens.
- Phase I: This is an open-label, nonrandomized study.
- Induction: Patients receive cisplatin IV over 60 minutes on day 1 and gemcitabine
IV over 30 minutes on days 1 and 8. Treatment repeats every 3 weeks for a total of
2 courses in the absence of disease progression or unacceptable toxicity.
- Consolidation: Within 3-4 weeks after the completion of induction therapy,
patients undergo radiotherapy once daily 5 days a week for 5 weeks and receive
oral gefitinib once daily concurrently.
A cohort of 3-6 patients receives consolidation chemoradiotherapy. If 2 of 6 patients
experience dose-limiting toxicity, gefitinib is deleted from consolidation therapy in phase
II arm II.
- Surgery: Patients without disease progression after consolidation therapy undergo
thoracotomy within 3-5 weeks after consolidation.
- Maintenance: Beginning 2-4 weeks after surgery, patients receive oral gefitinib once
daily for 6 months in the absence of disease progression.
- Phase II: This is a randomized study. Patients are randomized to 1 of 2 treatment
- Arm I: Patients receive induction and consolidation therapy (with the exception of
gefitinib) as in phase I. Patients also receive docetaxel IV over 60 minutes
concurrently with radiotherapy during consolidation. Patients undergo surgery as in
- Arm II: Patients receive therapy (including gefitinib) as in phase I. Patients also
receive docetaxel IV over 60 minutes concurrently with radiotherapy during
Patients are followed every 6-8 weeks for the first 12 months and then every 4-6 months
PROJECTED ACCRUAL: A total of 43-80 patients (3-6 patients for phase I and 40-74 patients
[20-37 per treatment arm] for phase II) will be accrued for this study.
- Histologically or cytologically confirmed non-small cell lung cancer
- Stage IIIA (T1-3, N2)
- Positive (pathological) ipsilateral mediastinal node
- Selective stage IIIB meeting all of the following criteria:
- No pleural/pericardial effusion or superior vena cava syndrome
- T4 due to invasion of carina, trachea, or mediastinal structures
- Mediastinal N3 nodes (without supraclavicular or cervical adenopathy)
- Proof of N2 or N3 status requires surgical staging of the mediastinum
(mediastinoscopy, mediastinotomy, or exploration)
- Expression of epidermal growth factor receptor (at least 1+) by immunohistochemistry
- Measurable disease by contrast CT scan allowed
- No bronchoalveolar cell carcinoma
- No prior diagnosis of lung cancer
- 19 and over
- ECOG 0-1 (0-2 if albumin is at least 0.85 times lower limit of normal and weight loss
within 3 months before diagnosis is no greater than 10%)
- Not specified
- Absolute neutrophil count at least 1,500/mm^3
- Platelet count at least 150,000/mm^3
- Hemoglobin at least 10 g/dL
- Bilirubin normal
- AST and ALT no greater than 2.5 times upper limit of normal (ULN)
- Alkaline phosphatase no greater than 2 times ULN
- Alkaline phosphatase between 1.5-2 times ULN requires a negative bone scan for
metastatic bone disease
- Creatinine no greater than 1.4 mg/dL OR
- Creatinine clearance at least 60 mL/min
- No myocardial infarction within the past 3 months
- No active angina
- No unstable heart rhythms
- No congestive heart failure
- Post-resection predicted FEV_1% greater than 35%
- Predicted FEV_1% is defined as FEV_1% times percent perfusion to uninvolved lung
from quantitative lung V/Q scan report
- Not pregnant or nursing
- Negative pregnancy test
- Fertile patients must use effective contraception during and for at least 6 weeks
after study treatment
- No other uncontrolled medical illness
- No other malignancy within the past 5 years except basal cell skin cancer or
carcinoma in situ of the cervix
- No grade 2 or greater peripheral neuropathy
- No concurrent ocular inflammation or infection
- No prior severe hypersensitivity reaction to docetaxel or other drugs formulated with
- No known severe hypersensitivity reaction to gefitinib or any of its excipients
- No prior severe allergic reaction to platinum-containing compounds or mannitol
PRIOR CONCURRENT THERAPY:
- No concurrent growth factors (e.g., filgrastim [G-CSF] or sargramostim [GM-CSF])
- No prior chemotherapy for lung cancer
- Not specified
- No prior radiotherapy for lung cancer
- Recovered from prior major surgery
- No concurrent ophthalmic surgery
- More than 30 days since prior unapproved or investigational drugs
- No concurrent use of the following drugs:
- Hypericum perforatum (St. John's Wort)
- No concurrent retinoids