PET in lung cancer RT
Incidence of isolated nodal failure in non-small cell lung cancer patients included in a prospective study of the value of PET–CT

https://doi.org/10.1016/j.radonc.2012.04.012Get rights and content

Abstract

Purpose

Elective nodal irradiation (ENI) is not recommended in PET–CT-based radiotherapy for NSCLC despite a low level of evidence to support such guidelines. The aim of this investigation is to find out whether omitting ENI is safe.

Materials and methods

Sixty-seven patients treated within a frame of a previously published prospective trial of the value of PET–CT were included in the analysis. Seventeen (25%) patients received ENI due to higher initial nodal involvement and in the remaining 50 patients (75%) with N0-N1 or single N2 disease ENI was omitted. Isolated nodal failure (INF) was recorded if relapse occurred in the initially uninvolved regional lymph node without previous or simultaneous local recurrence regardless of the status of distant metastases.

Results

With a median follow-up of 32 months, the estimated 3-year overall survival was 42%, local progression-free interval was 55%, and distant metastases-free interval was 62%. Three patients developed INF; all had ENI omitted from treatment, giving a final result of three INFs in 50 (6%) patients treated without ENI. In this group of patients, the 3-year cause-specific cumulative incidence of INF was 6.4% (95% confidence interval: 0–17%).

Conclusions

The omission of ENI appears to be not as safe as suggested by current recommendations.

Section snippets

Material and methods

The details of the material and methods, and the impact of PET–CT on therapeutic decisions and radiotherapy plans, in the studied group have been reported previously [1]. In short, 100 consecutive NSCLC stages I–III patients referred for radical radiotherapy underwent conventional imaging (CT) planning and then PET–CT based planning. The patients for whom the decision about curative radiotherapy was maintained after PET–CT were treated according to the PET-based plan. Patients with stage III

Results

Sixty-seven (89%) of the 75 patients for whom the decision to include radical radiotherapy was maintained after PET–CT were treated and followed up in our center and are included in the analysis of the pattern of failure. The characteristics of this subgroup are shown in Table 1. Patients who were excluded did not complete radical radiotherapy in our center for following reasons: two early (during and before radiotherapy) disclosures of brain metastases, two cardiac deaths before radiotherapy,

Discussion

In our series, INF was observed in three of 50 (6%) patients for whom ENI was omitted. The 3-year cause-specific cumulative incidence of INF was 6.4% for patients treated without ENI. None of our 17 patients for whom ENI was used experienced an INF. Despite the widespread abandoning of ENI for NSCLC patients, in our institution we still take a conservative approach and use some form of ENI in patients with advanced nodal disease. This is based on our previous findings that bulky mediastinal

Conflicts of interest

There were no financial and/or personal relationships with other people and organizations that could inappropriately influence (bias) this work.

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