Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio.
Department of Cardiothoracic Surgery, New York University, New York, New York.
Pract Radiat Oncol. 2017 Sep-Oct;7(5):295-301. doi: 10.1016/j.prro.2017.04.014. Epub 2017 Jun 5.
This guideline presents evidence-based recommendations for stereotactic body radiation therapy (SBRT) in challenging clinical scenarios in early-stage non-small cell lung cancer (NSCLC).
The American Society for Radiation Oncology convened a task force to perform a systematic literature review on 4 key questions addressing: (1) application of SBRT to operable patients; (2) appropriate use of SBRT in tumors that are centrally located, large, multifocal, or unbiopsied; (3) individual tailoring of SBRT in "high-risk" clinical scenarios; and (4) SBRT as salvage therapy after recurrence. Guideline recommendations were created using a predefined consensus-building methodology supported by American Society for Radiation Oncology-approved tools for grading evidence quality and recommendation strength.
Although few randomized trials have been completed for SBRT, strong consensus recommendations based on extensive, consistent publications were generated for several questions, including recommendations for fractionation for central tumors and surgery versus SBRT in standard-risk medically operable patients with early-stage NSCLC. Lower quality evidence led to conditional recommendations on use of SBRT for tumors >5 cm, patients with prior pneumonectomy, T3 tumors with chest wall invasion, synchronous multiple primary lung cancer, and as a salvage therapy after prior radiation therapy. These areas of moderate- and low-quality evidence highlight the importance of clinical trial enrollment as well as the role of prospective data registries.
SBRT has an important role to play in treating early-stage NSCLC, particularly for medically inoperable patients with limited other treatment options. Shared decision-making with patients should be performed in all cases to ensure the patient understands the risks related to SBRT, the side effects, and the alternative treatments available.
本指南针对早期非小细胞肺癌（NSCLC）的挑战性临床情况，提出了立体定向体部放射治疗（SBRT）的循证推荐。
美国放射肿瘤学会召集了一个工作组，对 4 个关键问题进行了系统的文献回顾，这些问题涉及：（1）SBRT 在可手术患者中的应用；（2）在中央、大、多灶或未经活检的肿瘤中合理应用 SBRT；（3）在“高危”临床情况下个体化定制 SBRT；（4）SBRT 作为复发后的挽救性治疗。指南建议的制定采用了一种预先确定的共识制定方法，该方法得到了美国放射肿瘤学会批准的证据质量和推荐强度分级工具的支持。
尽管完成了几项 SBRT 的随机试验，但根据广泛、一致的文献，针对几个问题，包括中央肿瘤的分割和标准风险的医学上可手术的早期 NSCLC 患者中手术与 SBRT 的比较，产生了强烈的共识推荐。较低质量的证据导致对 SBRT 在>5cm 的肿瘤、有既往肺切除术史的患者、有胸壁侵犯的 T3 肿瘤、同步多原发肺癌以及作为既往放射治疗后挽救性治疗的应用提出了有条件的推荐。这些中等到低质量证据的领域突出了临床试验入组的重要性以及前瞻性数据登记的作用。
SBRT 在治疗早期 NSCLC 方面具有重要作用，特别是对于有有限其他治疗选择的不能手术的医学患者。在所有情况下都应与患者进行共同决策，以确保患者了解与 SBRT 相关的风险、副作用和可用的替代治疗方法。
