Naomi E. Verstegen

Stage I–II non-small-cell lung cancer treated using either stereotactic ablative radiotherapy (SABR) or lobectomy by video-assisted thoracoscopic surgery (VATS): outcomes of a propensity score-matched analysis

BACKGROUND Video-assisted thoracoscopic surgery (VATS) lobectomy and stereotactic ablative radiotherapy (SABR) are both used for early-stage non-small-cell lung cancer. We carried out a propensity score-matched analysis to compare locoregional control (LRC). PATIENTS AND METHODS VATS lobectomy data from six hospitals were retrospectively accessed; SABR data were obtained from a single institution database. Patients were matched using propensity scores based on cTNM stage, age, gender, Charlson comorbidity score, lung function and performance score. Eighty-six VATS and 527 SABR patients were matched blinded to outcome (1:1 ratio, caliper distance 0.025). Locoregional failure was defined as recurrence in/adjacent to the planning target volume/surgical margins, ipsilateral hilum or mediastinum. Recurrences were either biopsy-confirmed or had to be PET-positive and reviewed by a tumor board. RESULTS The matched cohort consisted of 64 SABR and 64 VATS patients with the median follow-up of 30 and 16 months, respectively. Post-SABR LRC rates were superior at 1 and 3 years (96.8% and 93.3% versus 86.9% and 82.6%, respectively, P = 0.04). Distant recurrences and overall survival (OS) were not significantly different. CONCLUSION This retrospective analysis found a superior LRC after SABR compared with VATS lobectomy, but OS did not differ. Our findings support the need to compare both treatments in a randomized, controlled trial.

Outcomes of stereotactic ablative radiotherapy following a clinical diagnosis of stage I NSCLC: comparison with a contemporaneous cohort with pathologically proven disease.

INTRODUCTION As a finding of benign disease is uncommon in Dutch patients undergoing surgery after a clinical diagnosis of stage I NSCLC, patients are also accepted for stereotactic ablative radiotherapy (SABR) without pathology. We studied outcomes in patients who underwent SABR after either a pathological (n=209) or clinical diagnosis (N=382). MATERIALS AND METHODS Five hundred and ninety-one patients with a single pulmonary lesion underwent SABR after either a pathological- or a clinical diagnosis of stage I NSCLC based on a (18)FDG-PET positive lesion with CT features of malignancy. SABR was delivered to a total dose of 60Gy in 3, 5 or 8 fractions, and outcomes were compared between groups with and without pathological diagnosis. RESULTS Patients with pathology had significantly larger tumor diameters (p<.001) and higher predicted FEV1% values (p=.025). No significant differences were observed between both groups in overall survival (p=.99) or local control (p=.98). Regional and distant recurrence rates were also similar. CONCLUSIONS In a population with a low incidence of benign (18)FDG-PET positive lung nodules, clinical SABR outcomes were similar in large groups of patients with or without pathology. The survival benefits reported after the introduction of SABR are unlikely to be biased by inclusion of benign lesions.

Comparison of clinical outcome of stage I non-small cell lung cancer treated surgically or with stereotactic radiotherapy: Results from propensity score analysis

OBJECTIVES Guideline-specified curative therapies for a clinical stage I non-small cell lung cancer (NSCLC) are either lobectomy or Stereotactic Ablative Radiotherapy (SABR). As outcomes of prospective randomized clinical trials comparing these modalities are unavailable, we performed a propensity-score matched analysis to create two similar groups in order to compare clinical outcomes. METHODS We selected 577 patients, 96 VATS or open lobectomy were treated at Erasmus University Medical Center Rotterdam and 481 SABR patients were treated at VU University Medical Center Amsterdam with clinical stage I NSCLC. RESULTS Matching of patients according to propensity score resulted in a cohort that consisted of 73 patients in the surgery group and of 73 patients in the SABR group. Median follow-up in the surgery and SABR group was 49 months and 28 months, respectively. Overall survival of patients who underwent surgery was 95% and 80% at 12 and 60 months, respectively. For the SABR group this was 94% at 12 months and 53% at 60 months. No statistical significant difference (p=0.089) in survival was found between these groups. CONCLUSIONS In this study we found no significant differences in overall survival in propensity matched patients diagnosed with stage I NSCLC treated either surgically or with SABR. After 3 years there seems to be a trend toward improved survival in patients who were treated surgically.

Patterns of Disease Recurrence after SABR for Early Stage Non-Small-Cell Lung Cancer: Optimizing Follow-Up Schedules for Salvage Therapy.

Introduction: Stereotactic ablative radiotherapy is a guideline-recommended treatment for early stage non–small-cell lung cancer. We report on incidence and salvage of local recurrences (LR) and second primary lung cancers (SPLC) in a large series of patients with long-term follow-up, to generate data for evidence-based follow-up regimens. Methods: We excluded all patients with double tumors, TNM-stages other than T1-T2N0M0, biologically effective dose less than 100 Gy10 and previous treatment for the index tumor from our institutional database. LR was defined as recurrence in/adjacent to the planning target volume. A diagnosis of SPLC was determined using criteria described by Martini et al. Results: The 855 patients included had a median follow-up of 52 months. Forty-six patients developed LR after a median of 22 months (range 7–87 months). Actuarial local control rates at 3 and 5 years were 92.4% and 90.9%, respectively. Fifty-four percent had isolated LR and 13% had LR in combination with regional recurrences. Ten patients underwent radical salvage treatment; surgery (N = 6), high-dose radiotherapy (N = 3), or chemoradiation (N = 1). Median overall survival following LR was 13 months, but it was 36 months in patients who underwent radical salvage. A SPLC was diagnosed in 79 patients, after a median interval of 34 months. Actuarial cumulative incidences of SPLC at 3 and 5 years were 11.7% and 16.7%, respectively. Radical salvage for SPLC was performed in 63 patients (80%). Conclusions: Both the timing of LR and persistent risk of SPLC serve as rationale for long-term follow-up using computed tomography scans in patients fit enough to undergo any radical treatment.

Curative Radiotherapy in Patients Inoperable for Medical Reasons

Due to changing demographics, increasing numbers of elderly patients are being diagnosed with an early-stage non-small cell lung cancer. These patients may be difficult to treat due to coexistent illnesses and poor performance. Stereotactic radiotherapy is a new and promising treatment option, particularly in the frail elderly. However, the high local control rates and favorable toxicity profile make it also an increasingly attractive treatment for patients who are at increased risk for operative mortality.

Treatment of Peripheral Lung Tumors Arising After a Prior Pneumonectomy

(December 2011) on the use of percutaneous cryoablation to manage lung tumors arising in the contralateral lung postpneumonectomy. The authors indicated they were unaware of reported outcomes for the use of stereotactic radiotherapy (SRT) in this group of patients. In 2009, we reported such out-comes for 15 patients presenting with a new primary lung cancer after prior pneumonectomy.