Chun Stephen G, Hu Chen, Choy Hak, Komaki Ritsuko U, Timmerman Robert D, Schild Steven E, Bogart Jeffrey A, Dobelbower Michael C, Bosch Walter, Galvin James M, Kavadi Vivek S, Narayan Samir, Iyengar Puneeth, Robinson Clifford G, Wynn Raymond B, Raben Adam, Augspurger Mark E, MacRae Robert M, Paulus Rebecca, Bradley Jeffrey D
Stephen G. Chun and Ritsuko U. Komaki, University of Texas MD Anderson Cancer Center, Houston; Hak Choy, Robert D. Timmerman, and Puneeth Iyengar, University of Texas Southwestern Medical Center, Dallas; Vivek S. Kavadi, Texas Oncology-Sugar Land, Sugar Land, TX; Chen Hu and Rebecca Paulus, NRG Oncology Statistics and Data Management Center; James M. Galvin, Imaging and Radiation Oncology Core, Philadelphia; Raymond B. Wynn, UPMC Cancer Center, Pittsburg, PA; Chen Hu, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Steven E. Schild, Mayo Clinic, Scottsdale, AZ; Jeffrey A. Bogart, State University of New York Upstate Medical University, Syracuse, NY; Michael C. Dobelbower, University of Alabama at Birmingham, Birmingham, AL; Walter Bosch, Clifford G. Robinson, and Jeffrey D. Bradley, Washington University in Saint Louis, St Louis, MO; Samir Narayan, Michigan Cancer Research Consortium Community Clinical Oncology Program, Ann Arbor, MI; Adam Raben, Christiana Care Health Services Community Clinical Oncology Program, Newark, DE; Mark E. Augspurger, Florida Radiation Oncology Group; Baptist Health, Jacksonville, FL; and Robert M. MacRae, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada.
J Clin Oncol. 2017 Jan;35(1):56-62. doi: 10.1200/JCO.2016.69.1378. Epub 2016 Oct 31.
Purpose Although intensity-modulated radiation therapy (IMRT) is increasingly used to treat locally advanced non-small-cell lung cancer (NSCLC), IMRT and three-dimensional conformal external beam radiation therapy (3D-CRT) have not been compared prospectively. This study compares 3D-CRT and IMRT outcomes for locally advanced NSCLC in a large prospective clinical trial. Patients and Methods A secondary analysis was performed to compare IMRT with 3D-CRT in NRG Oncology clinical trial RTOG 0617, in which patients received concurrent chemotherapy of carboplatin and paclitaxel with or without cetuximab, and 60- versus 74-Gy radiation doses. Comparisons included 2-year overall survival (OS), progression-free survival, local failure, distant metastasis, and selected Common Terminology Criteria for Adverse Events (version 3) ≥ grade 3 toxicities. Results The median follow-up was 21.3 months. Of 482 patients, 53% were treated with 3D-CRT and 47% with IMRT. The IMRT group had larger planning treatment volumes (median, 427 v 486 mL; P = .005); a larger planning treatment volume/volume of lung ratio (median, 0.13 v 0.15; P = .013); and more stage IIIB disease (30.3% v 38.6%, P = .056). Two-year OS, progression-free survival, local failure, and distant metastasis-free survival were not different between IMRT and 3D-CRT. IMRT was associated with less ≥ grade 3 pneumonitis (7.9% v 3.5%, P = .039) and a reduced risk in adjusted analyses (odds ratio, 0.41; 95% CI, 0.171 to 0.986; P = .046). IMRT also produced lower heart doses ( P < .05), and the volume of heart receiving 40 Gy (V40) was significantly associated with OS on adjusted analysis ( P < .05). The lung V5 was not associated with any ≥ grade 3 toxicity, whereas the lung V20 was associated with increased ≥ grade 3 pneumonitis risk on multivariable analysis ( P = .026). Conclusion IMRT was associated with lower rates of severe pneumonitis and cardiac doses in NRG Oncology clinical trial RTOG 0617, which supports routine use of IMRT for locally advanced NSCLC.
目的 尽管调强放射治疗（IMRT）越来越多地用于治疗局部晚期非小细胞肺癌（NSCLC），但IMRT与三维适形外照射放疗（3D-CRT）尚未进行前瞻性比较。本研究在一项大型前瞻性临床试验中比较了3D-CRT和IMRT治疗局部晚期NSCLC的疗效。
患者与方法 在NRG肿瘤学临床试验RTOG 0617中进行了一项二次分析，以比较IMRT与3D-CRT，该试验中患者接受卡铂和紫杉醇同步化疗，联合或不联合西妥昔单抗，以及60 Gy与74 Gy的放射剂量。比较内容包括2年总生存期（OS）、无进展生存期、局部复发、远处转移，以及选定的不良事件通用术语标准（第3版）≥3级毒性反应。
结果 中位随访时间为21.3个月。482例患者中，53%接受3D-CRT治疗，47%接受IMRT治疗。IMRT组的计划靶体积更大（中位值，427 vs 486 mL；P = 0.005）；计划靶体积/肺体积比值更大（中位值，0.13 vs 0.15；P = 0.013）；且ⅢB期疾病更多（30.3% vs 38.6%，P = 0.056）。IMRT与3D-CRT在2年OS、无进展生存期、局部复发和无远处转移生存期方面无差异。IMRT与≥3级肺炎发生率较低相关（7.9% vs 3.5%，P = 0.039），在调整分析中风险降低（比值比，0.41；95%置信区间，0.171至0.986；P = 0.046）。IMRT还使心脏受量更低（P < 0.05），在调整分析中，接受40 Gy照射的心脏体积（V40）与OS显著相关（P < 0.05）。肺V5与任何≥3级毒性反应均无关联，而在多变量分析中，肺V20与≥3级肺炎风险增加相关（P = 0.026）。
结论 在NRG肿瘤学临床试验RTOG 0617中，IMRT与严重肺炎发生率和心脏受量较低相关，这支持将IMRT常规用于局部晚期NSCLC的治疗。
