Outcomes after stereotactic lung radiotherapy or wedge resection for stage I non-small-cell lung cancer.
ABSTRACT PURPOSE To compare outcomes between lung stereotactic radiotherapy (SBRT) and wedge resection for stage I non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS One hundred twenty-four patients with T1-2N0 NSCLC underwent wedge resection (n = 69) or image-guided lung SBRT (n = 58) from February 2003 through August 2008. All were ineligible for anatomic lobectomy; of those receiving SBRT, 95% were medically inoperable, with 5% refusing surgery. Mean forced expiratory volume in 1 second and diffusing capacity of lung for carbon monoxide were 1.39 L and 12.0 mL/min/mmHg for wedge versus 1.31 L and 10.14 mL/min/mmHg for SBRT (P = not significant). Mean Charlson comorbidity index and median age were 3 and 74 years for wedge versus 4 and 78 years for SBRT (P < .01, P = .04). SBRT was volumetrically prescribed as 48 (T1) or 60 (T2) Gy in four to five fractions. Results Median potential follow-up is 2.5 years. At 30 months, no significant differences were identified in regional recurrence (RR), locoregional recurrence (LRR), distant metastasis (DM), or freedom from any failure (FFF) between the two groups (P > .16). SBRT reduced the risk of local recurrence (LR), 4% versus 20% for wedge (P = .07). Overall survival (OS) was higher with wedge but cause-specific survival (CSS) was identical. Results excluding synchronous primaries, nonbiopsied tumors, or pathologic T4 disease (wedge satellite lesion) showed reduced LR (5% v 24%, P = .05), RR (0% v 18%, P = .07), and LRR (5% v 29%, P = .03) with SBRT. There were no differences in DM, FFF, or CSS, but OS was higher with wedge. CONCLUSION Both lung SBRT and wedge resection are reasonable treatment options for stage I NSCLC patients ineligible for anatomic lobectomy. SBRT reduced LR, RR, and LRR. In this nonrandomized population of patients selected for surgery versus SBRT (medically inoperable) at physician discretion, OS was higher in surgical patients. SBRT and surgery, however, had identical CSS.
- SourceAvailable from: Jean-Pierre Bissonnette[Show abstract] [Hide abstract]
ABSTRACT: To examine potential dose-response relationships with various non-small-cell lung cancer (NSCLC) SBRT fractionation regimens delivered with online CT-based image guidance. 505 tumors in 483 patients with clinical stage T1-T2N0 NSCLC were treated with SBRT using on-line cone-beam-CT-based image guidance at 5 institutions (1998-2010). Median maximum tumor dimension was 2.6cm (range 0.9-8.5cm). Dose fractionation prescription was according to each institution's protocol with the most common schedules of 18-20GyX3, 12GyX4, 12GyX5, 12.5GyX3, 7.5GyX8 (median=54Gy, 3 fractions). Median prescription (Rx) BED10=132Gy (50.4-180). Median values (Gy) of 3D planned doses for BED10 were GTVmin=164.1, GTVmean=188.4, GTVmax=205.9, PTVmin=113.9, PTV D99=123.9, PTVmean=164.7, PTV D1=197.3, PTVmax=210.7. Mean follow-up=1.6years. 26 cases (5%) had local recurrence (LR) for a 2-year rate of 6% and 3-year rate of 9%. All BED10 GTV&PTV endpoints were associated with LR as continuous variables on univariate analysis (p<0.05). Rx and PTVmean dose appeared to have the highest correlation with LR with area under ROC curve of 0.69 and 0.65 respectively and optimal cut points of 105 and 125Gy, respectively. 2-year LR was 4% for PTVmean>125 vs 17% for <125Gy (p<0.01) with sensitivity=84% and specificity=57% for predicting LR. 2-year LR for Rx BED10>105 was 4% vs 15% for <105Gy (p<0.01). Longer treatment duration (⩾11 elapsed days) demonstrated a 2-year LR of 14% vs 4% for ⩽10days (p<0.01). GTV size was associated with LR on univariate analysis as a continuous variable (p=0.02) with 2-year LR=3% for <2.7cm vs 9% for ⩾2.7cm (p=0.03). BED10 (p=0.01) and elapsed days during RT (p=0.05) were independent predictors on multivariate analysis as continuous variables. There is a substantial dose-response relationship for local control of NSCLC following image-guided SBRT with optimal PTVmean BED10>125Gy. Shorter treatment duration was also associated with better local control in this dataset.Radiotherapy and Oncology 03/2014; · 4.52 Impact Factor
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ABSTRACT: Stereotactic body radiation therapy (SBRT) and accelerated hypofractionated radiation therapy (AHRT) have favorable local control (LC) relative to conventional fractionation in the treatment of stage I non-small cell lung cancer (NSCLC). We report the results of our single institution experience with the treatment of early stage NSCLC with SBRT or AHRT in cases where SBRT was felt to be suboptimal. One hundred and sixty patients with Stage 1 and node negative Stage 2 NSCLC were treated with SBRT or AHRT from 2003 to 2011. Median follow-up was 29.4 and 19 months (mo), respectively. The median dose was 54Gy in 3 fractions (fx) (SBRT) and 70.2Gy in 26 fx (AHRT). Acute and late toxicities (tox) were graded (G) per CTCAE v4. Time to local (LF), regional (RF) and distant (DF) failure were estimated using the Kaplan-Meier method. The impact of patient and tumor related factors on LF were estimated by multivariate Cox proportional hazard model. Three-year LC rates were 87.7% (SBRT) and 71.7% (AHRT). The 3-year freedom from DF was 73.3% and 68.1%. Median OS was 38.4 (95% CI 29.7-51.6) and 35 (95% CI 22-48.3) mo. No G3 or 4 tox were observed. At 1 year, 30% and 50% of complications resolved, while (5-6%) had persistent chest wall pain. Multivariate analysis demonstrated that increasing dose per fraction and tumor size (>5.5 vs. 4cm) in the AHRT and SBRT group were found to be associated with a reduced (HR 0.33 95% CI 0.13-0.84, p=0.021) and increased (HR: 6.372 95% CI 1.23-32.92, p=0.027) hazard for local failure respectively. Our results compare favorably with other reports of treatment for early stage NSCLC. AHRT patients had comparable LC despite increased size and central disease. Toxicity was limited and overall survival, regional and distant recurrences were similar between groups.Lung cancer (Amsterdam, Netherlands) 04/2014; · 3.14 Impact Factor
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ABSTRACT: There are limited treatment options for patients with prior pneumonectomy and a new lung malignancy. The safety and efficacy of stereotactic body radiotherapy in this subpopulation has not been well defined. Postpneumonectomy patients treated with lung SBRT were identified from a prospective single institution database. Treatment toxicity was recorded prospectively using the Common Terminology Criteria for Adverse Events version 3.0. Disease recurrences were categorized as local, regional, or distant metastatic disease. Overall survival was calculated using the Kaplan-Meier method. Of 406 patients, 13 postpneumonectomy patients were identified and 14 tumors were treated with SBRT. Median age was 69 years. Three lesions were biopsy confirmed. The SBRT doses were 60 Gy/3 (n = 1), 54 Gy/3 (n = 1), 48 Gy/4 (n = 7), 60 Gy/8 (n = 2), and 50 Gy/10 (n = 3). Median follow-up was 24 months. Two patients had grade 3 radiation pneumonitis 3 and 4 months post-SBRT; they died 3 and 1 months later, respectively, one of myocardial infarction and the other of progressive dyspnea thought to be related to congestive heart failure. There were no local failures, one regional failure, and three distant failures. Median survival was 29 months, 1 and 2 year overall survival were 69% (95% confidence interval: 48-100%) and 61% (95% confidence interval: 39-95%), respectively. SBRT in patients with prior pneumonectomy poses challenges because of limited lung reserve. However, local control and long-term survival can be achieved using SBRT in this inoperable population. Careful consideration must be given to radiation planning to minimize the risk of radiation pneumonitis.Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 06/2014; 9(6):843-7. · 4.55 Impact Factor