Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois.
Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois.
Pract Radiat Oncol. 2013 Oct-Dec;3(4):287-93. doi: 10.1016/j.prro.2012.09.002. Epub 2012 Oct 10.
Treatment of locally advanced non-small cell lung cancer (LA-NSCLC) involves definitive chemoradiation therapy (CRT) or neoadjuvant CRT and resection, but radiation treatment volumes remain in question. With CRT, involved-field radiation therapy (IFRT) is replacing elective nodal irradiation, reducing toxicity, and allowing dose escalation. However, prior reports of IFRT describe failures only after radical CRT; with improved local control after resection, IFRT may lead to more regional recurrences. Our objective is to evaluate pattern-of-failure in patients with LA-NSCLC treated with split-course IFRT, chemotherapy, and subsequent surgery.
Patients treated between December 2004 and 2010 were included. Imaging scans demonstrating failure were fused into the radiation therapy planning computed tomography, and recurrent nodes were contoured to determine pattern-of-failure (involved versus elective nodal failure [INF vs ENF]). Locoregional progression-free survival and distant metastasis-free survival were calculated using Kaplan-Meier methodology. The cumulative incidence of regional recurrence (CIRR) was determined with death as a competing risk.
Forty-five patients met inclusion criteria, and patients with RR had a lower rate of pN0 than those without RR (20% vs 60%, P = .02). With a median follow-up of 2.9 years, median survival was not reached, and 3-year locoregional progression-free survival and distant metastasis-free survival were 53% and 35%, respectively. Two and 3-year CIRR were 25% and 33%, respectively. There were no local failures. Thirteen (29%) patients had RR, 8 with INF only and 5 with ENF alone or both, totaling 27 recurrences. Only 2 (4%) ENF occurred without INF, both with distant metastasis, and no elective node was the first and only site of failure.
Our data suggest that IFRT does not compromise regional control in the neoadjuvant management of LA-NSCLC. Tailoring nodal volumes may improve treatment-related morbidity and allow for dose intensification of involved nodes. Further research is necessary to improve regional and distant control.
局部晚期非小细胞肺癌（LA-NSCLC）的治疗包括明确的放化疗（CRT）或新辅助 CRT 加切除术，但放射治疗范围仍存在疑问。在 CRT 中，累及野放疗（IFRT）正在取代选择性淋巴结照射，降低毒性并允许提高剂量。然而，先前 IFRT 描述的失败仅在根治性 CRT 后出现；切除后局部控制得到改善，IFRT 可能导致更多的区域性复发。我们的目的是评估接受分段 IFRT、化疗和随后手术治疗的 LA-NSCLC 患者的失败模式。
纳入 2004 年 12 月至 2010 年期间治疗的患者。显示失败的影像学扫描与放射治疗计划 CT 融合，并对复发性淋巴结进行轮廓勾画以确定失败模式（累及性与选择性淋巴结失败[INF 与 ENF]）。采用 Kaplan-Meier 方法计算局部无进展生存率和远处无转移生存率。采用竞争风险法确定区域复发累积发生率（CIRR）。
45 例患者符合纳入标准，RR 患者的 pN0 率低于无 RR 患者（20% vs. 60%，P =.02）。中位随访 2.9 年后，中位生存期未达到，3 年局部无进展生存率和远处无转移生存率分别为 53%和 35%。2 年和 3 年 CIRR 分别为 25%和 33%。无局部失败。13 例（29%）患者发生 RR，8 例仅 INF，5 例仅 ENF 或两者兼有，共 27 例复发。仅 2 例（4%）ENF 无 INF，均伴远处转移，无选择性淋巴结是唯一的初始和失败部位。
我们的数据表明，IFRT 不会影响 LA-NSCLC 新辅助治疗的区域性控制。调整淋巴结体积可能会降低治疗相关的发病率，并允许提高受累淋巴结的剂量。需要进一步研究以提高区域性和远处控制率。
