NSCLC EARLY STAGE (I/II)

Survival

  • All comers
    • Stage I: 5-year survival 50%
    • Stage II: 5-year survival 35%
  • Completely resected
    • T1N0 tumors, 5-OS 70% to 80%

Local Control

  • Lung Cancer Study Group (LCSG) study
  • locoregional recurrence rate
    • wedge of segment 15%
    • lobectomy 5%
  • mortality rate
    • wedge of segment 1.4%
    • lobectomy 2.9% (p = N.S.)
  • If T3 or N2 noted intra-operatively then LR is about 20%.

Distant failures

  • 30%

Radiation

Conventional Radiation

  • Meta-analysis of 17 non-randomized trials by Rowell for stage I/II NSCLC
    • 22-40% 2-yr OS

Dose and Field

  • 22 patients with <61Gy to tumor and 5 year survival was 27% and 36% for those receiving 69 Gy. (Hong Radiation Oncology 1989)
  • 3D-CRT to a median isocenter dose of 70 Gy (range 59.94-83.85) +/- elective nodal radiation[1] (Mallinckrodt)
  • LC-1 88%, LC-2 69%, LC-3 63%
  • OS-1 73%, OS-2 51%, OS-3 34%
  • cause-specific survival rate 82%, 67%, and 51%
  • metastasis-free survival rate was 90%, 85%, and 81%
  • "postage stamp" field using hypofractionated radiotherapy (48 Gy in 12 fractions) with OS-3 and DFS-3 of 42% and 76% respectively.[2]
  • The "standard" involves 45-66 Gy in 1.8 to 2.0 Gy fractions.

Elective nodal radiation

  • Elective nodal failures do occur, but are rare (2-7%)[1]

SBRT

  • RTOG 0236
    • 20 Gy x 3
    • upto 5 cm tumor
    • > 2 cm from proximal bronchius
    • GTV and CTV are the same
    • PTV 0.5 axially and 1cm CC
Bronch
  • Kyoto University
    • 12 x 4 = 48 Gy

Adjuvant Chemotherapy

  • Adjuvant chemotherapy has shown to be beneficial in completely resected stage II or IIIA
  • Newer studies have shown some benefit in stage I patients but remains controversial.
Bibliography
1. Bradley JD, Wahab S, Lockett MA, Perez CA, Purdy JA. Elective nodal failures are uncommon in medically inoperable patients with Stage I non-small-cell lung carcinoma treated with limited radiotherapy fields. Int J Radiat Oncol Biol Phys. 2003 Jun 1;56(2):342-7.
2. Slotman BJ, Antonisse IE, Njo KH. Limited field irradiation in early stage (T1-2N0) non-small cell lung cancer. Radiother Oncol. 1996 Oct;41(1):41-4.
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