Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston.
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston.
JAMA Netw Open. 2018 Aug 3;1(4):e181390. doi: 10.1001/jamanetworkopen.2018.1390.
Stereotactic ablative radiotherapy (SABR) is first-line treatment for patients with early-stage non-small cell lung cancer (NSCLC) who cannot undergo surgery. However, up to 1 in 6 such patients will develop isolated local recurrence (iLR) or isolated regional recurrence (iRR). Little is known about outcomes when disease recurs after SABR, or about optimal management strategies for such recurrences.
To characterize long-term outcomes for patients with iLR or iRR after SABR for early-stage NSCLC with the aim of informing treatment decision making for these patients with potentially curable disease.
DESIGN, SETTING, AND PARTICIPANTS: In this cohort study, a retrospective review was conducted of 912 patients prospectively enrolled in an institutional database at a tertiary cancer center from January 1, 2004, through December 31, 2014.
Overall survival, progression-free survival, recurrence patterns, demographics, salvage techniques, patterns of salvage failure, and toxic effects.
Of the 912 patients in the study (456 women and 456 men; median age, 72 years [range, 46-91 years]), 756 (82.9%) had T1 tumors at initial diagnosis; 502 tumors (55.0%) were adenocarcinomas and 309 tumors (33.9%) were squamous cell carcinomas. Of 912 patients with early-stage I to II NSCLC who received definitive SABR (50 Gy in 4 fractions or 70 Gy in 10 fractions), 102 developed isolated recurrence (49 with iLR and 53 with iRR), and 658 had no recurrence. Median times to recurrence after SABR were 14.5 months (range, 1.5-60.8 months) for iLR and 9.0 months (range, 1.9-70.7 months) for iRR; 39 of 49 patients (79.6%) with iLR and 48 of 53 patients (90.6%) with iRR underwent salvage with reirradiation, surgery, thermal ablation, or chemotherapy. Median follow-up times for patients with iLR or iRR were 57.2 months (interquartile range, 37.7-87.6 months) from initial SABR and 38.5 months (interquartile range, 19.9-69.3 months) from recurrence. Rates of overall survival at 5 years from initial SABR were no different between patients with iLR and salvage treatment (57.9%) and patients with no recurrence (54.9%; hazard ratio, 0.89; 95% CI, 0.56-1.43; P = .65) but were lower for patients with iRR and salvage treatment (31.1%; hazard ratio, 1.43; 95% CI, 1.00-2.34; P = .049). Patients receiving salvage treatment had longer overall survival than patients who did not (median, 37 vs 7 months after recurrence; hazard ratio, 0.40; 95% CI, 0.09-0.66; P = .006). Twenty-four of 87 patients (27.6%) who received salvage treatment for iLR or iRR subsequently developed distant metastases. No patient experienced grade 5 toxic effects after salvage treatment.
Life expectancy after salvage treatment for iLR was similar to that for patients without recurrence, but survival after salvage treatment for iRR was similar to that of patients with stage III NSCLC. Patients who received salvage treatment had significantly improved survival. Because salvage treatment for iLR or iRR was based on a consistent multidisciplinary approach, this may help in clinical decision making.
立体定向消融放疗 (SABR) 是不能进行手术的早期非小细胞肺癌 (NSCLC) 患者的一线治疗方法。然而，多达 1/6 的此类患者会出现孤立性局部复发 (iLR) 或孤立性区域复发 (iRR)。对于 SABR 后疾病复发的患者，或对于此类复发的最佳治疗策略，人们知之甚少。
描述 SABR 治疗早期 NSCLC 后 iLR 或 iRR 患者的长期结果，旨在为这些具有潜在治愈性疾病的患者提供治疗决策。
设计、地点和参与者：在这项队列研究中，对 2004 年 1 月 1 日至 2014 年 12 月 31 日期间，在一家三级癌症中心的一个机构数据库中前瞻性纳入的 912 名患者进行了回顾性审查。
总生存、无进展生存、复发模式、人口统计学、挽救技术、挽救失败模式和毒性作用。
在研究的 912 名患者中（456 名女性和 456 名男性；中位年龄 72 岁[范围 46-91 岁]），756 名（82.9%）患者在初始诊断时为 T1 肿瘤；502 个肿瘤（55.0%）为腺癌，309 个肿瘤（33.9%）为鳞状细胞癌。在 912 名接受确定性 SABR（50 Gy 分 4 次或 70 Gy 分 10 次）治疗的早期 I 至 II 期 NSCLC 患者中，102 例发生孤立性复发（49 例 iLR 和 53 例 iRR），658 例无复发。SABR 后复发的中位时间分别为 iLR 14.5 个月（范围 1.5-60.8 个月）和 iRR 9.0 个月（范围 1.9-70.7 个月）；49 例 iLR 患者中有 39 例（79.6%）和 53 例 iRR 患者中有 48 例（90.6%）接受了挽救性再放疗、手术、热消融或化疗。iLR 或 iRR 患者的中位随访时间分别为初始 SABR 后 57.2 个月（四分位距 37.7-87.6 个月）和复发后 38.5 个月（四分位距 19.9-69.3 个月）。初始 SABR 后 5 年的总生存率在 iLR 伴挽救治疗（57.9%）和无复发（54.9%）的患者之间没有差异（危险比，0.89；95%CI，0.56-1.43；P = .65），但在 iRR 伴挽救治疗（31.1%）的患者中较低（危险比，1.43；95%CI，1.00-2.34；P = .049）。接受挽救治疗的患者的总生存时间长于未接受挽救治疗的患者（复发后 37 个月与 7 个月；危险比，0.40；95%CI，0.09-0.66；P = .006）。87 例 iLR 或 iRR 接受挽救治疗的患者中，有 24 例随后发生远处转移。没有患者在挽救治疗后出现 5 级毒性作用。
iLR 挽救治疗后的预期寿命与无复发患者相似，但 iRR 挽救治疗后的生存率与 III 期 NSCLC 患者相似。接受挽救治疗的患者的生存明显改善。由于 iLR 或 iRR 的挽救治疗是基于一致的多学科方法，这可能有助于临床决策。
