Komaki R, Scott C B, Byhardt R, Emami B, Asbell S O, Russell A H, Roach M, Parliament M B, Gaspar L E
The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
Int J Radiat Oncol Biol Phys. 1998 Sep 1;42(2):263-7. doi: 10.1016/s0360-3016(98)00213-2.
To identify groups of patients who might benefit from more aggressive systemic or local treatment, based on failure patterns when unresectable NSCLC was treated by radiation therapy (RT) alone.
From 4 RTOG trials, 1547 patients treated by RT alone were analyzed for patterns of first failure by RPA class defined by prognostic factors, including KPS, weight loss, nodal stage, pleural effusion, age and radiation therapy dose. All patients had NSCLC AJCC Stage II, IIIA, or IIIB, KPS > 50, with no previous RT or chemotherapy. Progressions in the primary (within irradiated fields), thorax (outside irradiated area, but within thorax), brain and distant metastasis other than brain were compared (2-sided) for each failure category by RPA.
The RPA classes were 4 distinct subgroups that had significantly different median survivals of 12.6, 8.3, 6.3 and 3.3 months for Classes I, II, III and IV, respectively, (all groups, p = 0.0002). There were 583, 667, 249 and 48 patients in Classes I, II, III and IV, respectively. Primary failure was seen in 27%, 25%, 21% and 10% for Classes I, II, III, and IV, respectively (I vs. IV, p = 0.014; II vs. IV, p = 0.022). Distant metastasis, including brain metastasis, occurred at significantly higher rates among Classes I and II (58% and 54%) than in Classes III and IV (42% and 27%). A higher rate (58%) of death without an identifiable site of failure was found in Class IV than in Classes I, II and III (27%, 28% and 36%, respectively).
The data suggest that physiologic compromise from the intrathoracic disease in Class IV patients is sufficient to cause death before specific sites of failure became evident. Clinical investigations using treatments directed at specific sites of failure could lead to improved outcome for Class I, II and, possibly, Class III patients. Inclusion of Class IV patients in clinical trials may obscure outcomes.
基于单纯放射治疗（RT）不可切除非小细胞肺癌（NSCLC）时的失败模式，识别可能从更积极的全身或局部治疗中获益的患者群体。
从4项放射肿瘤学组（RTOG）试验中，分析了1547例单纯接受RT治疗的患者按由预后因素定义的递归分区分析（RPA）类别划分的首次失败模式，这些预后因素包括 Karnofsky 功能状态评分（KPS）、体重减轻、淋巴结分期、胸腔积液、年龄和放射治疗剂量。所有患者均为NSCLC美国癌症联合委员会（AJCC）II期、IIIA期或IIIB期，KPS>50，既往未接受过RT或化疗。按RPA对每个失败类别比较原发灶（在照射野内）、胸部（在照射区域外但在胸部内）、脑和脑外远处转移的进展情况（双侧）。
RPA类别为4个不同亚组，I、II、III和IV类的中位生存期分别为12.6、8.3、6.3和3.3个月，差异有统计学意义（所有组，p = 0.0002）。I、II、III和IV类分别有583、667、249和48例患者。I、II、III和IV类患者的原发灶失败率分别为27%、25%、21%和10%（I类与IV类比较，p = 0.014；II类与IV类比较，p = 0.022）。I类和II类患者远处转移（包括脑转移）的发生率显著高于III类和IV类（分别为58%和54% 比42%和27%）。IV类患者中无明确失败部位的死亡率（58%）高于I、II和III类（分别为27%、28%和36%）。
数据表明，IV类患者胸腔内疾病导致的生理功能损害足以在特定失败部位明显之前导致死亡。针对特定失败部位进行治疗的临床研究可能会改善I、II类以及可能III类患者的预后。将IV类患者纳入临床试验可能会掩盖结果。
