Omission Of Elective Nodal Irradiation Research Articles

Twice-daily chemoradiotherapy in limited-stage small-cell lung cancer

Acute radiation-induced oesophagitis has been associated with adverse events such as weight loss, substantial effect on quality of life, and reduced survival.1 Concurrent chemotherapy given with hyperfractionated radiation therapy has been associated with an increased incidence of acute oesophageal toxicity.2 Several dosimetric parameters and high doses have been associated with an increased risk of acute oesophagitis.1 However, radiotherapy technical developments (eg, use of intensity-modulated radiotherapy and omission of elective nodal irradiation) allow a reduced dose to the organs at risk, including the oesophagus.

Elective Nodal Irradiation for Limited-stage Small-cell Lung Cancer: Survey of US Radiation Oncologists on Practice Patterns

BackgroundTraditionally, elective nodal irradiation (ENI) has been used in clinical trials that have established thoracic radiotherapy as instrumental in improving survival for patients with limited-stage small-cell lung cancer (LS-SCLC). However, several reports have suggested that the omission of ENI might be appropriate. Current US practice patterns are unknown regarding ENI for patients with LS-SCLC. Materials and MethodsWe surveyed US radiation oncologists via an institutional review board-approved questionnaire. The questions covered demographics, treatment recommendations, and self-assessed knowledge of key clinical trials. χ2 and Cochran-Armitage tests were used to evaluate for statistically significant correlations between responses. ResultsWe received 309 responses. Of the respondents, 21% recommended ENI for N0 LS-SCLC, 29% for N1, and 30% for N2; 64% did not recommend ENI for any of these clinical scenarios. The respondents who recommended ENI were more likely to have been practicing for > 10 years (P < .001), more likely to be in private practice (P = .04), and less likely to be familiar with the ongoing Cancer and Leukemia Group B 30610 trial (P = .04). Almost all respondents (93%) prescribed the same radiation dose to the primary disease and involved lymph nodes. When delivering ENI, 36% prescribed the same dose to the involved and elective nodes, and 64% prescribed a lower dose to the elective nodes. ConclusionNearly two thirds of respondents did not recommend ENI, which represents a shift in practice. A recent large clinical trial that omitted ENI reported greater overall survival than previously reported and lower-than-expected radiation toxicities, lending further evidence that omitting ENI should be considered a standard treatment strategy.

Cancer du poumon et irradiation ganglionnaire prophylactique : un débat clos ?

Lung cancer treatment is a heavy workload for radiation oncologist and that field showed many evolutions over the last two decades. The issue about target volume was raised when treatment delivery became more precise with the development of three-dimensional conformal radiotherapy. Initially based upon surgical series, numerous retrospective and prospective studies aimed to evaluate the risk of elective nodal failure of involved-field radiotherapy compared to standard large field elective nodal irradiation. In every setting, locally advanced non-small cell lung cancer, localized non-small cell lung cancer, localized small cell lung cancer, exclusive chemoradiation or postoperative radiotherapy, most of the studies showed no significant difference between involved-field radiotherapy or elective nodal irradiation with elective nodal failure rate under 5% at 2 years, provided staging had been done with modern imaging and diagnostic techniques (positron emission tomography scan, endoscopy, etc.). Moreover, if reducing irradiated volumes are safe regarding recurrences, involved-field radiotherapy allowed dose escalation while reducing acute and late oesophageal, cardiac and pulmonary toxicities. Consequently, major clinical trials involving radiotherapy initiated in the last two decades and international clinical guidelines recommended omission of elective nodal irradiation in favour of in-field radiotherapy.

Incidence and predictors of severe acute esophagitis and subsequent esophageal stricture in patients treated with accelerated hyperfractionated chemoradiation for limited-stage small cell lung cancer

PurposeClinical and dosimetric predictors of severe (grade 3 or greater) acute esophageal toxicity and subsequent esophageal dilation were explored in patients with limited-stage small cell lung cancer treated with accelerated hyperfractionated chemoradiation. Methods and materialsA total of 130 patients were identified who were treated to 45 Gy in 1.5-Gy twice-daily fractions with concurrent platinum-based chemotherapy between 2000 and 2009. Data on clinical, disease-related, and treatment-related variables were collected. Patients with percutaneous endoscopic gastrostomy tube insertion or intravenous hydration because of poor oral intake were designated as having acute grade 3 esophagitis. Univariate and multivariate analyses that associated treatment characteristics with esophagitis were assessed via logistic regression, and optimal cut points were identified with recursive partitioning analysis. ResultsTwenty-five patients developed severe acute esophagitis, at a rate of 26% (18/69) in patients treated with earlier 3-dimensional conformal radiation therapy techniques and 11.5% (7/61) in patients treated with intensity modulated radiation therapy techniques and omission of elective nodal irradiation. The incidence of esophageal stricture was 6% overall (8 of 128 eligible) but 26% (6/23) among those who experienced prior grade 3 acute esophagitis and 2% (2/105) among those with acute esophagitis less than or equal to grade 2. Significant multivariate predictors of acute esophagitis were mean dose and volume of esophagus receiving at least 5% to 35% of the prescribed dose (V5 to V40). Patients with V5 ≥ 74% had a 44.4% risk of severe acute esophagitis (12/27) versus 12.6% (13/103) among those with V5 < 74%. V45 was the only dosimetric predictor for esophageal stricture, with 13.7% of patients in whom V45 was ≥37.5% requiring subsequent dilation. ConclusionsModern radiation techniques are associated with a lower frequency of severe acute esophagitis than previous paradigms. The proportion of esophagus receiving low- to moderate-range doses (mean, V5 through V40) predicts acute esophagitis, whereas the proportion of esophagus that receives high doses (V45) predicts the development of esophageal stricture that requires dilation. Patients who develop grade 3 acute esophagitis are at significant risk for subsequent esophageal stricture, whereas those with acute esophagitis of grade 2 or less display minimal risk.

Patterns of failure after postoperative radiotherapy for incompletely resected (R1) non-small cell lung cancer: Implications for radiation target volume design

ObjectiveOverall survival (OS) and pattern of failure in R1-resected non-small cell lung cancer (NSCLC) patients treated with 3D-planned postoperative radiotherapy (PORT) was retrospectively evaluated. The outcomes and patterns of failure in patients with (+) and without (−) extracapsular nodal extension (ECE) were compared and analyzed with respect to the radiation target volume design. Materials and methodsEighty R1-resected (37 ECE+ and 43 ECE−) patients received PORT (60Gy, 2Gy daily) between 2002 and 2011. Patients with N2 disease received limited elective nodal irradiation (ENI); for pN0-1 disease the use of ENI was optional. Among ECE− (extranodal-R1) patients there were 35 pN0-1 and eight pN2 cases; in pN0-1 patients, patterns of failure and outcomes were analyzed with respect to the use of ENI. Loco-regional failure (LRF) was defined as in-field relapse; isolated nodal failure (INF) was defined as out-of-field regional nodal recurrence occurring without LRF, irrespective of distant metastases. ResultsThe actuarial 3-year OS rate was 36.3% (median: 30 months). Three-year OS rates in the ECE− and ECE+ group were 40.4% and 31.4%, with median OS of 31 and 24 months, respectively (p=0.43). In multivariate analysis, the presence of ECE was correlated with OS (HR=3.02; 95% CI: 1.00–9.16; p=0.05). Three-year cumulative incidence of LRF (CILRF) was 14.5% and 15.5% in the ECE− and ECE+ groups, respectively (p=0.98). Three-year cumulative incidence of INF (CIINF) was 14.1% in the ECE− group and 11.1% in the ECE+ group (p=0.76). For pN0-1 patients treated with and without ENI (13 and 22 patients) 3-year CILRF rates were 7.7% and 20.8%, respectively (p=0.20); 3-year CIINF rates were 9.1% and 16.3%, respectively (p=0.65). ConclusionPORT resulted in a relatively good survival of R1-resected NSCLC patients. Relatively high incidence of INF was found in both ECE+ and ECE− patients. For ECE+ patients, treated with limited ENI, distant failure remains a major concern, so the design of ENI fields seems of lesser importance. Omission of ENI in pN0-1 (extranodal-R1) patients resulted in an unacceptably high incidence of INF. We postulate the use of some form of ENI in this setting.

Impact of omission of elective nodal irradiation on treatment outcomes in locally advanced pancreatic adenocarcinoma patients treated with definitive concurrent chemoradiotherapy

BackgroundWe evaluated influence of limited-field radiotherapy with no elective nodal irradiation (ENI) on outcomes and toxicity profile in patients with locally advanced pancreatic adenocarcinoma (LAPAC), treated with definitive concurrent chemoradiotherapy (C-CRT). MethodsThirty-five patients with histological proof of LAPAC underwent 50.4Gy of C-CRT with 5-FU followed by maintenance gemcitabine. Target volume included primary tumor and lymph nodes that appeared to be involved on either contrast-enhanced computerized tomography or 18F-fluoro-deoxyglucose positron emission tomography. ResultsNo grade 4/5 acute/late toxicity was reported at median 15.7 months. Acute hematologic plus non-hematologic grade 3 toxicity was noted in 10 (28.6%) patients. At long-term, 2 patients (5.7%) experienced grade 3 gastric outlet obstructions at 8.7 and 10.9 months, respectively. No isolated regional relapses were noted. Median overall-survival (OS), progression-free survival (PFS), and locoregional-PFS (LRPFS) were 15.2, 9.1 and 7.3 months, respectively. Corresponding 1- and 2-year survival estimates were 60.0% and 20.0% for OS, 41.9% and 17.4% for LRPFS, and 34.0% and 12.7% for PFS, respectively. ConclusionsCompared to ENI literature, first report of a limited-field C-CRT study carried out in Turkey showed that omission of ENI was relatively well tolerated without compromising survival and locoregional control rates in patients with LAPAC.

Comparison of Treatment Outcomes Between Involved-field and Elective Nodal Irradiation in Limited-stage Small Cell Lung Cancer

The present study was performed to assess the usefulness of involved-field irradiation and the impact of (18)F-fluorodeoxyglucose-positron emission tomography-based staging on treatment outcomes in limited-stage small cell lung cancer. Eighty patients who received definitive chemoradiotherapy for limited-stage small cell lung cancer were retrospectively analyzed. Fifty patients were treated with involved-field irradiation, which means that the radiotherapy portal includes only clinically identifiable tumors. The other 30 patients were irradiated with a comprehensive portal, including uninvolved mediastinal and/or supraclavicular lymph nodes, so-called elective nodal irradiation. No significant difference was seen in clinical factors between the two groups. At a median follow-up of 27 months (range, 5-75 months), no significant differences were observed in 3 year overall survival (44.6 vs. 54.1%, P= 0.220) and 3 year progression-free survival (24.4 vs. 42.8%, P= 0.133) between the involved-field irradiation group and the elective nodal irradiation group, respectively. For patients who did not undergo positron emission tomography scans, 3 year overall survival (29.3 vs. 56.3%, P= 0.022) and 3 year progression-free survival (11.0 vs. 50.0%, P= 0.040) were significantly longer in the elective nodal irradiation group. Crude incidences of isolated nodal failure were 6.0% in the involved-field irradiation group and 0% in the elective nodal irradiation group, respectively. All isolated nodal failures were developed in patients who had not undergone positron emission tomography scans in their initial work-ups. If patients did not undergo positron emission tomography-based staging, the omission of elective nodal irradiation resulted in impaired survival outcomes and raised the risk of isolated nodal failure. Therefore, involved-field irradiation for limited-stage small cell lung cancer might be reasonable only with positron emission tomography scan implementation.

The Omission of Elective Nodal Irradiation is Reasonable Approach in Definitive Radiotherapy for Limited-stage Small Cell Lung Cancer with the Implementation of FDG-PET/CT

The Omission of Elective Nodal Irradiation is Reasonable Approach in Definitive Radiotherapy for Limited-stage Small Cell Lung Cancer with the Implementation of FDG-PET/CT

Three-Dimensional Conformal Radiation Therapy for Esophageal Squamous Cell Carcinoma: Is Elective Nodal Irradiation Necessary?

To evaluate the local control, survival, and toxicity associated with three-dimensional conformal radiotherapy (3D-CRT) for squamous cell carcinoma (SCC) of the esophagus, to determine the appropriate target volumes, and to determine whether elective nodal irradiation is necessary in these patients. A prospective study of 3D-CRT was undertaken in patients with esophageal SCC without distant metastases. Patients received 68.4 Gy in 41 fractions over 44 days using late-course accelerated hyperfractionated 3D-CRT. Only the primary tumor and positive lymph nodes were irradiated. Isolated out-of-field regional nodal recurrence was defined as a recurrence in an initially uninvolved regional lymph node. All 53 patients who made up the study population tolerated the irradiation well. No acute or late Grade 4 or 5 toxicity was observed. The median survival time was 30 months (95% confidence interval, 17.7-41.8). The overall survival rate at 1, 2, and 3 years was 77%, 56%, and 41%, respectively. The local control rate at 1, 2, and 3 years was 83%, 74%, and 62%, respectively. Thirty-nine of the 53 patients (74%) showed treatment failure. Seventeen of the 39 (44%) developed an in-field recurrence, 18 (46%) distant metastasis with or without regional failure, and 3 (8%) an isolated out-of-field nodal recurrence only. One patient died of disease in an unknown location. In patients treated with 3D-CRT for esophageal SCC, the omission of elective nodal irradiation was not associated with a significant amount of failure in lymph node regions not included in the planning target volume. Local failure and distant metastases remained the predominant problems.

Reply: Patterns of nodal recurrence after omission of elective nodal irradiation for limited-stage small-cell lung cancer

Reply: Patterns of nodal recurrence after omission of elective nodal irradiation for limited-stage small-cell lung cancer

Involved-field radiotherapy in limited-stage small-cell lung cancer

Sir, Elective nodal irradiation (ENI) was used in conventional radiotherapy (RT) target volume for limited-stage small-cell lung cancer (LS-SCLC) in contrast to involved-field RT only in some recent studies (Erridge and Murray, 2003). In contrast to non-small-cell lung cancer (NSCLC), where ENI was now less favoured (Senan et al, 2004), whether ENI could be safely omitted or not was less clear for LS-SCLC. To our knowledge, your article by Baas et al (2006) was the first prospective report regarding involved-field RT (i.e., omission of ENI). However, we felt that the data and conclusion reported in this study were not complete. The authors reported that local recurrences (within the target area) were seen in six patients (16%). It was concluded that combination chemotherapy with concurrent involved-field RT is an effective treatment for LS-SCLC. However, the number of nodal failures (within omitted ENI) was not reported. De Ruysscher et al (2006) reported that three patients (crude rate 11%, 95% CI 2.4–29%) developed an isolated nodal failure in a phase II study employing ENI. They concluded that the safety of selective nodal irradiation in NSCLC should not be extrapolated to patients with LS-SCLC until more data are available. We believe that the detail recurrence pattern in the study by Baas et al (2006) would be of great value in the issue of ENI in RT for LS-SCLC if this was reported formally in your journal, unless it was planned to be published elsewhere.

A Randomized Study of Involved-Field Irradiation Versus Elective Nodal Irradiation in Combination With Concurrent Chemotherapy for Inoperable Stage III Nonsmall Cell Lung Cancer

Radiation dose escalation is limited by the high incidence of pulmonary and esophageal toxicity, leading to calls for the omission of elective nodal irradiation (ENI) and the willingness to use involved-field irradiation (IFI) in patients with nonsmall cell lung cancer (NSCLC). A total of 200 eligible patients with inoperable stage III NSCLC were treated with concurrent chemoradiotherapy and randomized into either an IFI or ENI arm. A total of 4 to 6 cycles of cisplatin-based chemotherapy were delivered, and concurrent radiotherapy was started after the second cycle of chemotherapy. Three-dimensional conformal radiotherapy was delivered in once-daily fractions of 1.8 to 2 Gy to 68 to 74 Gy for IFI or 60 to 64 Gy for ENI. Patients in the IFI arm achieved better overall response rate (90% vs. 79%, P = 0.032) and better 5-years local control rate (51% vs.36%, P = 0.032) than those in the ENI arm. The radiation pneumonitis rate in patients with IFI was lower than in patients with ENI (17% vs. 29%, P = 0.044), and similar trends appeared in the radiation esophagitis, myelosuppression, and radiation pericarditis between 2 study arms, although not significantly. The 1-, 2-, and 5-year survival rates were 60.4%, 25.6%, and 18.3% for the ENI arm and 69.9%, 39.4%, and 25.1% for the IFI arm, respectively. Only the 2-year survival rates were statistically significant (P = 0.048). IFI arm achieved better overall response and local control than ENI arm, and it allowed a dose of 68 to 74 Gy to be safely administered to patients with inoperable stage III NSCLC. Outcome improvement can be expected by conformal IFI combined with chemotherapy for stage III NSCLC.

Omission of elective node irradiation on basis of CT-scans in patients with limited disease small cell lung cancer: A phase II trial

Purpose To evaluate the patterns of recurrence when elective node irradiation was omitted in patients with limited disease small cell lung cancer (LD-SCLC). Methods A prospective phase II study was undertaken in 27 patients with LD-SCLC without detectable distant metastases on CT scan. Chest radiotherapy to a dose of 45 Gy in 30 fractions in 3 weeks (1.5 Gy BID with 6–8 h interval) was delivered concurrently with carboplatin and etoposide chemotherapy. Chest radiation started after a mean time of 17.7 days ± 9.7 days (SD) (range: 0–33 days) after the beginning of chemotherapy. Only the primary tumour and the positive nodal areas on the pre-treatment CT scan were irradiated. A total of five chemotherapy cycles were administered, followed by prophylactic cranial irradiation (PCI) in patients without disease progression. Isolated nodal failure was defined as recurrence in the regional nodes outside of the clinical target volume, in the absence of in-field failure. Results After a median time of 18 months post-radiotherapy, 7 patients (26%, 95% CI 19.5–42.5%) developed a local recurrence. Three patients (crude rate 11%, 95% CI 2.4–29%), developed an isolated nodal failure, all of them in the ipsilateral supraclavicular fossa. The median actuarial overall survival was 21 months (95% CI 15.3–26.7), and the median actuarial progression free survival was 16 months (95% CI 6.5–25.5). Eight patients developed an acute, reversible grade 3 (CTC 3.0) radiation oesophagitis (30%, 95% CI 14–50%). Conclusions Because of the small sample size, no definitive conclusions can be drawn. However, the omission of elective nodal irradiation on the basis of CT scans in patients with LD-SCLC resulted in a higher than expected rate of isolated nodal failures in the ipsilateral supraclavicular fossa. The incidence of acute, reversible oesophagitis was in the same range as reported with elective nodal fields. The safety of selective nodal irradiation in NSCLC should not be extrapolated to patients with LD-SCLC until more data are available. In the mean time, elective nodal irradiation should only be omitted in clinical trials.

Three-dimensional conformal involved-field radiotherapy for stage III non-small cell lung cancer

7044 Background: Radiation dose escalation is limited by the high incidence of pulmonary and esophageal toxicity, leading to calls for the omission of elective nodal irradiation (ENI) and the willingness to use involved-field radiotherapy (IFRT) in patients with stage III non-small cell lung cancer (NSCLC). Methods and Materials: Patients with inoperable stage III NSCLC were enrolled and patients with previous treatment were ineligible, as were those with supraclavicular nodal metastases, pleural effusion, the Karnofsky performance status of &lt;80 or a weight loss exceeding 10% of baseline in the preceding 3 months. Two-hundred patients were treated with concurrent chemo-radiotherapy and randomized into IFRT group or ENI group. Two cycles of cisplatin-based chemotherapy (CHT) were delivered before radiotherapy, and another 2–3 cycles were followed after radiotherapy by the same or changed regime according to different response to the first 2 cycles of CHT. Radiotherapy was delivered using 3D treatment planning in once-daily fractions of 2 Gy to 68–74 Gy for IFRT or 60–64 Gy for ENI. The involved field consisted of the pre-CHT (or greatest) tumor volume, and any mediastinal nodes confirmed by biopsy or with a short-axis diameter of ≥1 cm on CT. Results: 193 patients had complete follow-up data. Radiation pneumonitis rate of patients with ENI was higher than patients with IFRT (29% vs. 17%, P = 0.044 ).The main cause of failure was local failure in 49% patients with ENI group and 41% with IFRT within 2 years. Only 7% of patients with IFRT developed a failure in an elective nodal region. Patients in IFRT group achieved a better overall response than ENI group (90% vs. 79%, P = 0.032). The overall survival at 1, 2, and 3 years was 59.7%, 25.6%, and 19.2% for ENI group vs. 67.2%, 38.7, and 27.3%for IFRT (P = 0.048). Conclusions: Local and distant failures remain the overwhelming modes of failure for stage III NSCLC patients. The omission of ENI did not result in any increase in isolated nodal failures, and it allowed a dose of 68–74 Gy to be safely administered to a substantial proportion of patients with inoperable Stage III NSCLC. Dose-escalation by conformal IFRT combined with CHT may improve the outcome for stage III NSCLC. No significant financial relationships to disclose.

Radiation pneumonitis following treatment of non–small-cell lung cancer with continuous hyperfractionated accelerated radiotherapy (CHART)

Purpose To determine whether partial volume lung irradiation influences the risk of developing acute radiation pneumonitis after the treatment of non–small-cell lung cancer with continuous hyperfractionated accelerated radiotherapy (CHART). Methods and materials We conducted an analysis of 32 patients treated with CHART at the Gloucestershire Oncology Center. Twelve patients were treated using conventional two-dimensional treatment techniques and received elective nodal irradiation (ENI). Their treatment plans were subsequently recapitulated using a three-dimensional treatment planning system. Twenty patients were planned using this system from the outset. For these patients, elective nodal irradiation was omitted. Dose–volume histograms (DVH) were constructed and several parameters analyzed for their ability to predict for the development of pneumonitis. Results Univariate analysis revealed that the percentage lung volume receiving more than 20 Gy (V 20) and the mean lung dose are of predictive value for the development of pneumonitis after CHART. There is a strong correlation between these two parameters. Importantly, partial volume lung irradiation using CHART appears to be better tolerated than conventionally fractionated radiotherapy. The omission of ENI considerably reduces V 20. Using a commonly employed 3-beam technique it was also noted that the shape of the planning target volume (PTV) in the transverse plane (expressed as an elliptical index) affects the conformity of the V 20 isodose to the PTV. This influences the scope for dose escalation with irregularly shaped tumors. Conclusions In relation to acute radiation pneumonitis, CHART appears to have a superior therapeutic index than conventionally fractionated radiotherapy. V 20 and mean lung dose are useful factors for predicting the risk of this complication. The use of these parameters will aid the selection of optimal treatment plans and provides a basis for future dose escalation studies.

Can elective nodal irradiation be omitted in stage III non-small cell lung cancer? An analysis of recurrences after sequential chemotherapy and “involved-field” radiotherapy to 70 gy

Purpose: In stage III non-small cell lung cancer (NSCLC), both local failure and distant metastases are common after sequential chemo-radiotherapy. Elective mediastinal nodal irradiation is commonly performed in these patients, resulting in substantial radiation doses to the esophagus and the normal lung. Both radiation dose escalation and/or concurrent chemo-radiotherapy are limited by the high incidence of pulmonary and esophageal toxicity, leading to calls for the omission of elective nodal irradiation. However, concerns about recurrences in the nodal regions which are not included in the gross target volume (GTV) have limited the willingness to use “involved-field” radiotherapy (IFRT). A study was performed in order to study the recurrence patterns after IFRT using 3-dimensional (3D) treatment planning.

Point: The potential importance of elective nodal irradiation in the treatment of non-small cell lung cancer

Patients who receive radiation therapy for non-small cell lung cancer (NSCLC) will require accurate targeting of the grossly involved primary and nodal disease. However, the treatment of grossly uninvolved elective nodal sites that may harbor microscopic occult disease is controversial. In simple terms, physicians are guided by 1 of 2 paradigms when they decide about the use of elective nodal irradiation in NSCLC. First, one may consider that high doses of radiation therapy for the primary and grossly involved lymph nodes represents the most important aspect of treatment and that elective irradiation of potential occult micrometastasis is not necessary because it may limit the doses that can be given to the gross disease. Additionally, this line of thought often includes the belief that most or all patients with occult micrometastasis are not curable. Alternatively, one may consider that the evidence for a dose response, for grossly involved NSCLC, beyond 60 Gy is very limited and that the omission of elective nodal irradiation obviates the chance for cure in many patients. These small deposits of tumor in regional nodes are common, are amenable to low doses of radiation (50 Gy), and treatment of these lesions does result in cures. This review focuses on this latter paradigm and the available evidence to support it.

Dose escalation of chart in non-small cell lung cancer: is three-dimensional conformal radiation therapy really necessary?

Purpose: To evaluate, preclinically, the potential for dose escalation of continuous, hyperfractionated, accelerated radiation therapy (CHART) for non small-cell lung cancer (NSCLC), we examined the strategy of omission of elective nodal irradiation with and without the application of three-dimensional conformal radiation technology (3DCRT).Methods and Materials: 2D, conventional therapy plans were designed according to the specifications of CHART for 18 patients with NSCLC (Stages Ib, IIb, IIIa, and IIIb). Further plans were generated with the omission of elective nodal irradiation (ENI) from the treatment portals (2D minus ENI plans [2D-ENI plans]). Both sets were inserted in the patient’s planning computed tomographies (CTs). These reconstructed plans were then compared to alternative, three-dimensional treatment plans which had been generated de novo, with the omission of ENI: 3D minus elective nodal irradiation (3D-ENI plans). Dose delivery to the planning target volumes (PTVs) and to the organs at risk were compared between the 3 sets of corresponding plans. The potential for dose escalation of each patient’s 2D-ENI and 3D-ENI plan beyond 54 Gy, standard to CHART, was also determined.Results: PTV coverage was suboptimal in the 2D CHART and the 2D-ENI plans. Only in the 3D-ENI plans did 100% of the PTV get ≥95% of the dose prescribed (i.e., 51.5 Gy [51.3–52.2]). Using 3D-ENI plans significantly reduced the dose received by the spinal cord, the mean and median doses to the esophagus and the heart. It did not significantly reduce the lung dose when compared to 2D-ENI plans. Escalation of the dose (minimum ≥1 Gy) with optimal PTV coverage was possible in 55.5% of patients using 3D-ENI, but was possible only in 16.6% when using the 2D-ENI planning strategy.Conclusions: 3DCRT is fundamental to achieving optimal PTV coverage in NSCLC. A policy of omission of elective nodal irradiation alone (and using 2D technology) will not achieve optimal PTV coverage or dose escalation. 3DCRT with omission of ENI can achieve true escalation of CHART in 55.5% of tumors, depending on their site and N-stage.

Dose escalation for non-small cell lung cancer by omission of elective nodal irradiation may be dangerous without 3-dimensional conformal radiation therapy

Dose escalation for non-small cell lung cancer by omission of elective nodal irradiation may be dangerous without 3-dimensional conformal radiation therapy