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Exclusion of elective nodal irradiation is associated with minimal elective nodal failure in non-small cell lung cancer.

Sulman EP, Komaki R, Klopp AH, Cox JD, Chang JY - Radiat Oncol (2009)

Bottom Line: For 88 patients with stage IIIA/B, the frequencies of IFF, any ENF, isolated ENF, and DM were 23 (26%), 3 (9%), 1 (1.1%) and 36 (40.9%), respectively.The comparable rates for the 22 patients with early stage node-negative disease (stage IA/IB) were 3 (13.6%), 1(4.5%), 0 (0%), and 5 (22.7%), respectively.Thus, distant metastasis and IFF remain the primary causes of treatment failure and cancer death in such patients, suggesting little value of ENI in this cohort.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Radiation Oncology, the University of Texas M, D, Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, USA. epsulman@mdanderson.org

ABSTRACT

Background: Controversy still exists regarding the long-term outcome of patients whose uninvolved lymph node stations are not prophylactically irradiated for non-small cell lung cancer (NSCLC) treated with definitive radiotherapy. To determine the frequency of elective nodal failure (ENF) and in-field failure (IFF), we examined a large cohort of patients with NSCLC staged with positron emission tomography (PET)/computed tomography (CT) and treated with 3-dimensional conformal radiotherapy (3D-CRT) that excluded uninvolved lymph node stations.

Methods: We retrospectively reviewed the records of 115 patients with non-small cell lung cancer treated at our institution with definitive radiation therapy with or without concurrent chemotherapy (CHT). All patients were treated with 3D-CRT, including nodal regions determined by CT or PET to be disease involved. Concurrent platinum-based CHT was administered for locally advanced disease. Patients were analyzed in follow-up for survival, local regional recurrence, and distant metastases (DM).

Results: The median follow-up time was 18 months (3 to 44 months) among all patients and 27 months (6 to 44 months) among survivors. The median overall survival, 2-year actuarial overall survival and disease-free survival were 19 months, 38%, and 28%, respectively. The majority of patients died from DM, the overall rate of which was 36%. Of the 31 patients with local regional failure, 26 (22.6%) had IFF, 5 (4.3%) had ENF and 2 (1.7%) had isolated ENF. For 88 patients with stage IIIA/B, the frequencies of IFF, any ENF, isolated ENF, and DM were 23 (26%), 3 (9%), 1 (1.1%) and 36 (40.9%), respectively. The comparable rates for the 22 patients with early stage node-negative disease (stage IA/IB) were 3 (13.6%), 1(4.5%), 0 (0%), and 5 (22.7%), respectively.

Conclusion: We observed only a 4.3% recurrence of any ENF and a 1.7% recurrence of isolated ENF in patients with NSCLC treated with definitive 3D-CRT without prophylactic irradiation of uninvolved lymph node stations. Thus, distant metastasis and IFF remain the primary causes of treatment failure and cancer death in such patients, suggesting little value of ENI in this cohort.

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Representative coronal reconstructions from planning CT images demonstrating locations of ENF. The green contour represents ENF. The approximate location of the recurrences based on diagnostic CT imaging performed at the time of the recurrence is indicated (shaded area). A. Patient #4, isolated ENF. B. Patient #5, not isolated ENF. Refer to Table 4 for details regarding the sites of primary disease and recurrences.
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Figure 2: Representative coronal reconstructions from planning CT images demonstrating locations of ENF. The green contour represents ENF. The approximate location of the recurrences based on diagnostic CT imaging performed at the time of the recurrence is indicated (shaded area). A. Patient #4, isolated ENF. B. Patient #5, not isolated ENF. Refer to Table 4 for details regarding the sites of primary disease and recurrences.

Mentions: The leading cause of death among the patients was DM and the overall rate of DM was 36%. Of the 31 patients with local regional failure, 26 (22% of patients overall) had IFF. The other 5 patients (4.3% of all patients) developed ENF (Tables 3, 4 and Figure 2). Two of the 5 patients (1.7% of the overall group) developed isolated ENF as the first site of failure, whereas the other 3 patients developed in-field recurrence followed by out-of-field recurrence (any ENF). All of the elective nodal failures occurred in regions that did not receive a therapeutic dose of incidental radiation (> 45 Gy, Table 4). The Representative cases of ENF were shown in Figure 2. The locations of recurrence were mixed and not clearly predictable on the basis of the location of the primary tumor. For all 88 patients with stage IIIA/B, the frequency of IFF, ENF, isolated ENF, and DM were 23 (26%), 3 (3.4%), 1 (1.1%), and 36 (40.9%), respectively. Of the 27 patients with early-stage node-negative disease (stage IA/IB), 3 had IFF (11.1%), 1 had ENF (3.7%), 0 had isolated ENF (0%), and 5 had DM (18.5%). All 5 patients with ENF underwent PET for staging, and 1 of these patients was alive at the last follow-up (at 44 months).


Exclusion of elective nodal irradiation is associated with minimal elective nodal failure in non-small cell lung cancer.

Sulman EP, Komaki R, Klopp AH, Cox JD, Chang JY - Radiat Oncol (2009)

Representative coronal reconstructions from planning CT images demonstrating locations of ENF. The green contour represents ENF. The approximate location of the recurrences based on diagnostic CT imaging performed at the time of the recurrence is indicated (shaded area). A. Patient #4, isolated ENF. B. Patient #5, not isolated ENF. Refer to Table 4 for details regarding the sites of primary disease and recurrences.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2651897&req=5

Figure 2: Representative coronal reconstructions from planning CT images demonstrating locations of ENF. The green contour represents ENF. The approximate location of the recurrences based on diagnostic CT imaging performed at the time of the recurrence is indicated (shaded area). A. Patient #4, isolated ENF. B. Patient #5, not isolated ENF. Refer to Table 4 for details regarding the sites of primary disease and recurrences.
Mentions: The leading cause of death among the patients was DM and the overall rate of DM was 36%. Of the 31 patients with local regional failure, 26 (22% of patients overall) had IFF. The other 5 patients (4.3% of all patients) developed ENF (Tables 3, 4 and Figure 2). Two of the 5 patients (1.7% of the overall group) developed isolated ENF as the first site of failure, whereas the other 3 patients developed in-field recurrence followed by out-of-field recurrence (any ENF). All of the elective nodal failures occurred in regions that did not receive a therapeutic dose of incidental radiation (> 45 Gy, Table 4). The Representative cases of ENF were shown in Figure 2. The locations of recurrence were mixed and not clearly predictable on the basis of the location of the primary tumor. For all 88 patients with stage IIIA/B, the frequency of IFF, ENF, isolated ENF, and DM were 23 (26%), 3 (3.4%), 1 (1.1%), and 36 (40.9%), respectively. Of the 27 patients with early-stage node-negative disease (stage IA/IB), 3 had IFF (11.1%), 1 had ENF (3.7%), 0 had isolated ENF (0%), and 5 had DM (18.5%). All 5 patients with ENF underwent PET for staging, and 1 of these patients was alive at the last follow-up (at 44 months).

Bottom Line: For 88 patients with stage IIIA/B, the frequencies of IFF, any ENF, isolated ENF, and DM were 23 (26%), 3 (9%), 1 (1.1%) and 36 (40.9%), respectively.The comparable rates for the 22 patients with early stage node-negative disease (stage IA/IB) were 3 (13.6%), 1(4.5%), 0 (0%), and 5 (22.7%), respectively.Thus, distant metastasis and IFF remain the primary causes of treatment failure and cancer death in such patients, suggesting little value of ENI in this cohort.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Radiation Oncology, the University of Texas M, D, Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, USA. epsulman@mdanderson.org

ABSTRACT

Background: Controversy still exists regarding the long-term outcome of patients whose uninvolved lymph node stations are not prophylactically irradiated for non-small cell lung cancer (NSCLC) treated with definitive radiotherapy. To determine the frequency of elective nodal failure (ENF) and in-field failure (IFF), we examined a large cohort of patients with NSCLC staged with positron emission tomography (PET)/computed tomography (CT) and treated with 3-dimensional conformal radiotherapy (3D-CRT) that excluded uninvolved lymph node stations.

Methods: We retrospectively reviewed the records of 115 patients with non-small cell lung cancer treated at our institution with definitive radiation therapy with or without concurrent chemotherapy (CHT). All patients were treated with 3D-CRT, including nodal regions determined by CT or PET to be disease involved. Concurrent platinum-based CHT was administered for locally advanced disease. Patients were analyzed in follow-up for survival, local regional recurrence, and distant metastases (DM).

Results: The median follow-up time was 18 months (3 to 44 months) among all patients and 27 months (6 to 44 months) among survivors. The median overall survival, 2-year actuarial overall survival and disease-free survival were 19 months, 38%, and 28%, respectively. The majority of patients died from DM, the overall rate of which was 36%. Of the 31 patients with local regional failure, 26 (22.6%) had IFF, 5 (4.3%) had ENF and 2 (1.7%) had isolated ENF. For 88 patients with stage IIIA/B, the frequencies of IFF, any ENF, isolated ENF, and DM were 23 (26%), 3 (9%), 1 (1.1%) and 36 (40.9%), respectively. The comparable rates for the 22 patients with early stage node-negative disease (stage IA/IB) were 3 (13.6%), 1(4.5%), 0 (0%), and 5 (22.7%), respectively.

Conclusion: We observed only a 4.3% recurrence of any ENF and a 1.7% recurrence of isolated ENF in patients with NSCLC treated with definitive 3D-CRT without prophylactic irradiation of uninvolved lymph node stations. Thus, distant metastasis and IFF remain the primary causes of treatment failure and cancer death in such patients, suggesting little value of ENI in this cohort.

Show MeSH
Related in: MedlinePlus