Abstract
ObjectiveCurative surgery is not an option for many patients with clinical stage I non-small-cell lung carcinoma (NSCLC), but radical radiosurgery may be effective.MethodsInoperable patients with small peripheral clinical stage I NSCLC were enrolled in this study. Three-to-five fiducial markers were implanted in or near tumors under CT guidance. Gross tumor volumes (GTVs) were contoured using lung windows. The GTV margin was expanded by 5 mm to establish the planning treatment volume (PTV). A dose of 42–60 Gy was delivered to the PTV in 3 equal fractions in less than 2 weeks using the CyberKnife radiosurgery system. The 30-Gy isodose contour extended at least 1 cm from the GTV. Physical examination, CT imaging and pulmonary function testing were completed at 6 months intervals for three years following treatment.ResultsTwenty patients with an average maximum tumor diameter of 2.2 cm (range, 1.1 – 3.5 cm) and a mean FEV1 of 1.08 liters (range, 0.53 – 1.71 L) were treated. Pneumothorax requiring tube thoracostomy occurred following CT-guided fiducial placement in 25% of the patients. All patients completed treatment with few acute side effects and no procedure-related mortality. Transient chest wall discomfort developed in 8 of the 12 patients with lesions within 5 mm of the pleura. The mean percentage of the total lung volume receiving a minimum of 15 Gy was 7.3% (range, 2.4% to 11.3%). One patient who received concurrent gefitinib developed short-lived, grade III radiation pneumonitis. The mean percent predicted DLCO decreased by 9% and 11% at 6 and 12 months, respectively. There were no local failures, regional lymph node recurrences or distant metastases. With a median follow-up of 25 months for the surviving patients, Kaplan-Meier overall survival estimate at 2 years was 87%, with deaths due to COPD progression.ConclusionRadical CyberKnife radiosurgery is a well-tolerated treatment option for inoperable patients with small, peripheral stage I NSCLC. Effective doses and adequate margins are likely to have contributed to the optimal early local control seen in this study.
Highlights
Standard therapy for operable clinical stage I non-small cell lung cancer (NSCLC) is lobectomy, a radical surgery requiring complete removal of the involved lobe plus ipsilateral hilar and mediastinal lymph node dissection.[1]
We report preliminary outcomes from 20 consecutive inoperable patients with small, peripheral, clinical stage I NSCLC treated using this novel treatment approach
Patient and Tumor Characteristics Twenty consecutive patients (5 men and 15 women) with inoperable clinical stage I NSCLC and an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or less were treated over a 30-month period extending from October 2004 to April 2007 (Table 2)
Summary
Standard therapy for operable clinical stage I non-small cell lung cancer (NSCLC) is lobectomy, a radical surgery requiring complete removal of the involved lobe plus ipsilateral hilar and mediastinal lymph node dissection.[1] Tumor recurrence is infrequent following lobectomy and limited to the regional lymph nodes or distant sites. Despite recent improvements,[2] lobectomy remains a major operation associated with early mortality,[3] a decline in pulmonary function[1] and multiple postoperative morbidities.[4] Recently, sublobar resection with adequate margins (> 1 cm) has been advocated for marginally operable patients with small peripheral lesions.[5] Such treatment in appropriately selected patients provides excellent local control without the early mortality and significant decline in lung function associated with lobectomy. Completed trials suggest that extremely high biologically effective doses may be delivered safely and rapidly to small peripheral lung tumors with this enhanced accuracy. [10,11,12] As anticipated, such treatment has resulted in improved early local control rates.[13]
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