National guidelines recommend surgery, ideally lobectomy, as the preferred treatment for stage I NSCLC. For patients who cannot tolerate lobectomy, sublobar resection can be considered but is known to be associated with a higher risk of disease recurrence. We sought to compare our institutional experience with SBRT and sublobar resection in stage I NSCLC. We also evaluated pre-treatment factors that may be associated with a higher risk of local failure after SBRT. As part of an IRB-approved retrospective study, data was collected on patients treated at our institution for stage I NSCLC between 2007 and 2014. SBRT was delivered using 3-5 fractions to a total dose of 48-60 Gy. All surgical patients underwent a wedge resection or segmentectomy, typically with hilar and mediastinal lymph node sampling/dissection. Patients undergoing lobectomy or pneumonectomy were excluded. Clinical data including patterns of failure were collected. The primary endpoint of interest was progression-free survival, defined as date of treatment to date of disease recurrence or death from any cause, with patients censored at the time of last follow-up, estimated using the Kaplan-Meier method. Freedom from local recurrence and overall survival were also assessed. 85 patients undergoing SBRT and 53 patients undergoing sublobar resection (surgery) were compared. The SBRT cohort was older (72 vs 67 years, p=0.008), had worse pulmonary function (FEV1 50% vs. 64%, p=0.001; DLCO 50% vs. 60%, p=0.037), and had larger tumors (2.4 vs 2 cm, p=0.003) with higher SUVmax values (10.4 vs 6.8, p=0.005). The median Charleson co-morbidity index was 3 with SBRT and 1 with surgery (p<0.05). With a median follow-up of 2 years, progression-free survival at 2 years for SBRT and surgery cohorts was 72% versus 78%, (p=0.23). On multivariate analysis, the only factor that was significantly associated with inferior progression-free survival was Charleson comorbidity index (HR 1.28, 95%CI 1.09-1.51, p=0.003), with SUVmax trending toward significance (HR 1.04, 95%CI 0.99-1.09, p=0.06). Treatment approach (SBRT versus surgery) was not significant on multivariate analysis (p=0.228). Local control (89% at 2 years in both, p=0.31) and overall survival (88% surgery vs 97% SBRT, p=0.18) were comparable. Within the SBRT subgroup, SUVmax and tumor size were associated with a higher risk of local failure after SBRT on univariate analysis. However, on multivariate analysis the only factor that remained significant was SUVmax (HR 1.12, 95% CI 1.01-1.24, p=0.035) assessed as a continuous variable. Comparing SBRT and surgery is challenging given differences in known prognostic factors between cohorts. Progression-free survival appears to be comparable between both approaches. With far less morbidity than surgery, SBRT is an attractive alternative to sublobar resection in patients not eligible for lobectomy. SUVmax may be an important metric predicting for a higher risk of local failure after SBRT.
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