Has 3-D conformal radiotherapy (3D CRT) improved the local tumour control for stage I non-small cell lung cancer?
Introduction
Curative external beam radiotherapy offers an alternative for patients with stage I non-small cell lung carcinoma (NSCLC) who are medically inoperable or refuse surgery. The overall 5-year survival rates in these patients range from 6 to 32%, and cause-specific survival (CSS) rates at 3 years of between 22 and 42% have been reported [26]. As local recurrence is the most common pattern of failure, improved radiation techniques and/or radiation dose escalation are warranted for such patients. 3-Dimensional conformal radiotherapy (3D CRT) has gained wide acceptance as a more effective means of achieving improved tumour coverage without increasing doses to critical normal structures. The advantages of 3D technology include a more realistic appreciation of the gross tumour volume (GTV), a better assessment of the doses to critical structures, improved geometric coverage by external beams, as well as tools to compare and judge rival plans [6], [18].
Much of the published literature refers to series in which 3D CRT was not uniformly used. Our institution implemented beams eye view (BEV) treatment planning for all patients with stage I NSCLC in 1991. The aim of the present study was to establish the local and distant tumour control, and overall survival (OS) and CSS for our patients who were treated using 3D CRT.
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Patient characteristics
The medical records of 113 patients with stage I NSCLC who were treated with curative 3D CRT during the period from 1991 to 1999 were evaluated. Patients who received endobronchial brachytherapy as part of their treatment, as well as patients with a previous pneumonectomy were excluded. Most patients were considered ineligible for thoracic surgery, usually as a result of poor pulmonary or cardiac function, but 10% had refused surgery (Table 1). In addition, patients were only accepted for
OS
OS, CSS, LPFS and DFFS are shown in Fig. 1. The median actuarial survival of the 113 patients was 20 months, with 1-, 3- and 5-year survivals of 71, 25 and 12%, respectively (Fig. 1a). Eighty-one patients died and the cause of death was known in 67 patients. Local progression was the cause of death in 24/81 patients (29.6%), and 18/81 (22.2%) patients died from distant metastases. The percentage of non-cancer related deaths was 27%.
The results of univariate and multivariate analyses of
Discussion
The present study differs from previous large series in that 3D CRT was consistently used for the treatment of all patients with stage I NSCLC [1], [5], [7], [8], [12], [14], [17], [23], [27], [29]. Disappointingly, however, the use of 3D CRT resulted in comparable OS and CSS rates to those reported in the literature (Table 4). As the operative mortality in patients aged 70 or more in our region is 6% after pneumonectomy and 1% after more limited surgery [4], we pursue a policy which strongly
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