Abstract
BackgroundImage-guided (IG) intensity-modulated radiotherapy (IMRT) enables maximal tumor margin reduction for the sparing of organs at risk (OARs) when used to treat locally advanced non-small cell lung cancer (NSCLC) with definitive chemo-radiation. It also allows for the incorporation of stereotactic ablative radiotherapy (SABR) into the treatment regimen. Here, we describe our initial experience in combining definitive upfront SABR to the primary lesion with chemo-radiation delivered with conventionally fractionated IG-IMRT to the remaining regional disease; along with clinical outcome following chemo-radiation with conventionally fractionated IG-IMRT alone in the treatment of locally advanced NSCLC.MethodsThe clinical outcome of 29 patients with locally advanced NSCLC who underwent conventionally fractionated IG-IMRT, or definitive upfront SABR followed by IG-IMRT combined with chemotherapy (induction, concurrent, or both) was retrospectively reviewed.ResultsAfter a median follow up of 23.7 months, the median overall survival (OS) and progression-free survival (PFS) were 19.8 and 11.3 months, respectively. The 2 year local, regional, and distant control was 60%, 62%, and 38%, respectively. No local failure was observed in 3 patients following SABR + IG-IMRT while 6/26 patients failed locally following IG-IMRT alone. SABR + IG-IMRT was well tolerated. No ≥ grade 3 radiation-related toxicity was observed.ConclusionDefinitive upfront SABR followed by IG-IMRT in selected patients with locally advanced NSCLC warrants further investigation in future clinical trials, while chemo-radiation with IG-IMRT alone was well tolerated.
Highlights
In recent years, advances in technology such as 4DCT and intensity modulated radiotherapy (IMRT) led to lower incidence of radiation-related toxicities and better short-term survival in the treatment of locally advanced non-small cell lung cancer (NSCLC) with chemo-radiation when compared to 3D techniques [1, 2]
Definitive upfront stereotactic ablative radiotherapy (SABR) followed by IG-intensity-modulated radiotherapy (IMRT) in selected patients with locally advanced nonsmall cell lung cancer (NSCLC) warrants further investigation in future clinical trials, while chemo-radiation with IGIMRT alone was well tolerated
Given the negative results obtained from RTOG 0617, a phase III randomized study assessing the benefit of moderate dose escalation with 3D conformal radiotherapy (3D-CRT) or IMRT in the patients receiving chemo-radiation for unresectable stage III NSCLC, similar strategies of dose escalation with IG-IMRT has not been actively pursued
Summary
Advances in technology such as 4DCT and intensity modulated radiotherapy (IMRT) led to lower incidence of radiation-related toxicities and better short-term survival in the treatment of locally advanced non-small cell lung cancer (NSCLC) with chemo-radiation when compared to 3D techniques [1, 2]. Local control may be significantly decreased by delayed tumor cell repopulation associated with prolonged overall treatment time, which may be one reason for the lack of clinical benefit observed with moderate, conventionally-fractionated dose escalation [8] This problem may be solved by adopting alternative dose escalation strategies, such as stereotactic ablative radiotherapy (SABR), to deliver a high dose to the tumor over a shorter overall treatment time course. Image-guided (IG) intensity-modulated radiotherapy (IMRT) enables maximal tumor margin reduction for the sparing of organs at risk (OARs) when used to treat locally advanced nonsmall cell lung cancer (NSCLC) with definitive chemo-radiation. It allows for the incorporation of stereotactic ablative radiotherapy (SABR) into the treatment regimen. We describe our initial experience in combining definitive upfront SABR to the primary lesion with chemo-radiation delivered with conventionally fractionated IG-IMRT to the remaining regional disease; along with clinical outcome following chemo-radiation with conventionally fractionated IG-IMRT alone in the treatment of locally advanced NSCLC
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