A randomized study of split-course radiotheray of lung cancer: long term results

Reirradiation for locoregionally recurrent lung cancer: outcomes in small cell and non-small cell lung carcinoma

OBJECTIVES

To our knowledge this is the largest report analyzing outcomes for re-irradiation (reRT) for locoregionally recurrent lung cancer, and the first to assess thoracic reRT outcomes in patients with small cell lung cancer (SCLC).

METHODS

Forty-eight patients (11 SCLC, 37 non-small cell lung cancer [NSCLC]) receiving reRT to the thorax were identified; 44 (92%) received reRT by intensity-modulated radiotherapy. Palliative responses, survival outcomes, and prognostic factors were analyzed.

RESULTS

NSCLC patients received a median of 30 Gy in a median of 10 fractions, whereas SCLC patients received a median of 37.5 Gy in a median of 15 fractions. Median survival for the entire cohort from reRT was 4.2 months. Median survival for NSCLC patients was 5.1 months, versus 3.1 months for the SCLC patients (P=0.15). In NSCLC patients, multivariate analysis demonstrated that Karnofsky performance status≥80 and higher radiation dose were associated with improved survival following reRT, and 75% of patients with symptoms experienced palliative benefit. In SCLC, 4 patients treated with the intent of life prolongation for radiographic recurrence had a median survival of 11.7 months. However, acute toxicities and new disease symptoms limited the duration of palliative benefit in the 7 symptomatic SCLC patients to 0.5 months.

CONCLUSIONS

ReRT to the thorax for locoregionally recurrent NSCLC can provide palliative benefit, and a small subset of patients may experience long-term survival. Select SCLC patients may experience meaningful survival prolongation after reRT, but reRT for patients with symptomatic recurrence and/or extrathoracic disease did not offer meaningful survival or durable symptom benefit.

Radiation therapy

RT is an indispensable part of current treatment approaches of locally advanced and metastatic NSCLC. It can be used alone or in combination with surgery or CHT. Because RT can potentially cure some patients, prolong the life of others, and reduce symptoms in the majority of them, it is a unique treatment modality in this disease. Radiation oncologists have learned how to deal with RT-induced toxicities and how to improve quality of life of lung cancer patients. Although recent technologic advances made sophisticated RT somewhat more expensive than before (demanding more manpower and being more time-consuming), it is still an inexpensive treatment modality, which is important in the era of focusing on cost-effectiveness. Although newer RT technologies are used to enable effective dose-escalation-a clear must for the community of radiation oncologists--optimization of RT must also include clear identification of various pretreatment, patient, and tumor-related characteristics that may influence treatment outcome. Regardless of the current therapeutic/technologic potential, we still lack some basic knowledge to better understand the process of, for example, combining RT and CHT. There is recognized need for better translational research that ultimately should be seen as a "two-way road," from laboratory to clinic and vice versa, preferably in a continuous way. The National Cancer Institute in the United States recently organized a workshop on translational research in radiation oncology, which has identified RT-CHT interactions as one of its major areas of research. Research topics include development of the methods of imaging the results of RT/ CHT interactions (confirmed by biopsy), development of new radiation modifiers, and identification of factors other than genetic ones that may influence the response of tumors to RT/CHT interactions. Tumor microenvironment was also clearly addressed as one of the targets for research, indicating as special tasks the development of new, microenvironmentally activated cytotoxic or cytostatic drugs, development and validation of more user-friendly methods for determining tumor oxygenation, and answering whether hypoxia predicts for radioresistance to CHT in treatment and whether it causes increased tumor aggression and metastasis. The future may, therefore, be quite simple: technology meets biology.

Hypofractionated irradiation for non-small cell lung cancer

Large radiation fractions are an effective way of killing tumour cells but have generally been avoided in curative treatment of patients because of concerns of a disproportionate increase in late normal tissue toxicity. Radiobiological modelling of the effect of radiation on lung tumours and late-reacting normal tissues, which are more sensitive to large radiation fractions, has been undertaken. The biological effect of radiation on tumours is increased as the overall treatment time is shortened but this is not true for late-reacting normal tissue. Sample data are shown in which the relative increases in radiation effect on the tumour and late-reacting normal tissues are similar after hypofractionation. A favourable therapeutic ratio can be achieved because the bulk of normal tissue will receive a lower dose of radiation at a lower dose per fraction than the tumour, especially with current techniques where the volume of normal tissue irradiated can be sharply reduced. The clinical evidence confirms that lung toxicity is volume-dependent. It is the small Stage I and II tumours which are most likely to benefit from hypofractionated regimens, as the volumes to be treated are smaller and they have a lower incidence of distant metastases. Patients with Stage III tumours with favourable prognostic factors are nowadays treated with combined chemotherapy and radiotherapy and so for this group more conservative hypofractionation regimens are being explored. However, more advanced tumours may be treated with hypofractionation to lower total doses to achieve palliation and a modest degree of survival benefit.

Therapy for stage IIIB and stage IV non-small cell lung cancer

The treatment options for unresectable stage III NSCLC include definitive RT, chemotherapy, combined chemoradiotherapy, or supportive care. Compared with radiation alone or chemotherapy alone, the combination of chemotherapy and standard RT confers a modest survival benefit at the cost of increased toxicity for patients with an excellent performance status. For metastatic disease, combination chemotherapy--in particular, platinum-based regimens--improves symptom control and survival. Newer chemotherapeutic agents with higher response rates and favorable toxicity profiles are improving outcome even for the elderly and debilitated patients and those refractory to first-line chemotherapy. Evolving understanding of the molecular events in tumorigenesis is uncovering a host of promising targets for mechanism-based therapy. Many of these novel target modulators likely will require combination with conventional chemotherapy for optimal results.

Fluorine-18 FDG dual-head gamma camera coincidence imaging of radiation pneumonitis

A 69-year-old man with inoperable stage I squamous cell carcinoma of the lung underwent a radical course of radiotherapy combined with platinum-based chemotherapy. Fluorine-18 fluorodeoxyglucose (FDG) imaging with a dual-head coincidence gamma camera system (Co-PET) diagnosed radiation pneumonitis 1 month after completion of radiotherapy, when the clinical and radiographic signs were atypical and more suggestive of carcinomatous lymphangitis. Treatment with oral steroids was begun based on FDG scan findings, with prompt clinical benefit as would be expected for radiation pneumonitis.

Phase I/II study of weekly irinotecan and concurrent radiation therapy for locally advanced non-small cell lung cancer

A study was undertaken to determine the maximum tolerated dose, the dose-limiting toxicities, and the response rate of irinotecan administered weekly with concurrent thoracic radiation therapy in patients with locally advanced non-small-cell lung cancer. In a phase I/II clinical trial, patients with histologically documented, surgically unresectable stage IIIA or IIIB non-small cell lung cancer (NSCLC) were enrolled. Irinotecan was administered as a 90 min intravenous infusion once weekly for 6 weeks. The starting dose was 30 mg m(-2) and dose escalation was done in 15 mg m(-2) increments. Dose-limiting toxicity was defined as grade 3 nonhaematologic toxicity (excluding nausea, vomiting and alopecia) or grade 4 haematologic toxicity according to the WHO criteria. Radiation was delivered to the primary tumour and regional lymph nodes (40 Gy), followed by a boost to the primary tumour (20 Gy). Twenty-seven patients were entered into this study at three irinotecan dose levels (30, 45 and 60 mg m(-2)). Twenty-six eligible patients were evaluated for toxic effects and clinical outcome. Severe oesophagitis, pneumonitis, and diarrhoea occurred at 45 and 60 mg m(-2). Three of the five patients given 60 mg m(-2) developed grade 3 or 4 oesophagitis and pneumonitis. In addition, one patient died of pneumonitis after completing therapy at 45 mg m(-2) in the phase II study. The objective response rate was 76.9% (95% CI, 53.0-88.9%). Oesophagitis, pneumonitis, and diarrhoea are the dose-limiting toxicities of weekly irinotecan combined with thoracic irradiation. The maximum tolerated dose and the dose for the phase II study were 60 and 45 mg m(-2) wk(-1), respectively. This combined therapy for locally advanced non-small cell lung cancer is promising and shows acceptable toxicity.

A phase I study of daily carboplatin and simultaneous accelerated, hyperfractionated chest irradiation in patients with regionally inoperable non-small cell lung cancer

PURPOSE

This Phase I study was designed to determine the maximally tolerated dose (MTD) of daily low dose carboplatin with concurrent accelerated hyperfractionated radiotherapy (AHFX) in patients with locally advanced non-small-cell lung cancer. Patients also received consolidation chemotherapy with carboplatin. Secondary objectives were to determine the response rate, response duration, sites of first relapse, and survival.

METHODS AND MATERIALS

Thirty patients received daily carboplatin at doses of 25 or 30 mg/m2. Concurrent radiotherapy was given in 1.5 Gy fractions twice daily for a total dose of 60 Gy. Following chemoradiotherapy, patients received four cycles of carboplatin at 350 mg/m2.

RESULTS

Grade 4 esophagitis developed in 2 of 6 (33%) patients receiving 30 mg/m2 of daily carboplatin and was dose limiting. The remaining 24 patients received carboplatin at 25 mg/m2, with 3 patients developing Grade 4 esophagitis (13%). One of 22 patients who received consolidation carboplatin developed Grade 4 thrombocytopenia. An objective response was observed in 70% of patients (2 complete and 17 partial). Sites of failure were local (7 patients), distant (7 patients), and both (3 patients). The median time to progression was 8.3 months, with a median survival time of 18.3 months. The 1- and 2-year survival rates were 63 and 49%, respectively.

CONCLUSIONS

Esophagitis was dose limiting when 30 mg/m2 of daily carboplatin was administered with AHFX. At the MTD of 25 mg/m2 of daily carboplatin plus AHFX followed by four cycles of carboplatin, the regimen was shown to be safe and as active or more active than other regimens. Thus, further studies with this regimen are warranted.

Current strategies for radiation therapy in non-small cell lung cancer

Thoracic radiotherapy is widely used in patients with non-small cell lung cancer. Its role as adjuvant treatment before or after surgery has not been established clearly. In patients with locally advanced disease, the main cause of failure is the absence of local control. Recently, three treatment approaches have shown a beneficial effect on overall survival in randomized trials conducted in this group of patients: sequential combination of thoracic radiotherapy and cisplatin-based chemotherapy, concomitant use of radiation and daily low-dose cisplatin therapy, and hyperfractionated accelerated radiotherapy. Another area that merits further investigation is the role of adjuvant surgery.

Optimizing chemotherapy and radiotherapy in locally advanced non-small cell lung cancer

In recent years, three treatment methods have been shown to improve overall survival of patients with locally advanced non-small cell lung cancer. These are: sequential combined radiotherapy and cisplatin-based chemotherapy, concurrent administration of cisplatin and thoracic radiotherapy, and accelerated hyper fractionated radiotherapy. Optimization of results can be attained by integrating these three treatment approaches.

A phase II trial of radiochemotherapy with daily carboplatin, after induction chemotherapy (carboplatin and etoposide), in locally advanced nonsmall-cell lung cancer: final analysis

PURPOSE

To evaluate feasibility and efficacy of concomitant radiochemotherapy (CRCT) in Stage IIIB nonsmall-cell lung cancer (NSCLC), two induction chemotherapy cycles combining etoposide and carboplatin were first delivered, followed by CRCT with daily radiation fraction in association with carboplatin.

METHODS AND MATERIALS

Forty patients with biopsy-proven, locally advanced unresectable nonmetastatic NSCLC were enrolled. Induction chemotherapy consisted of two cycles (day 1 and day 28) of etoposide (VP16:100 mg/m2, days 1 to 3) and carboplatin (CBDCA:350 mg/m2, day 1). Irradiation starting at day 56, delivered 66 Gy in 2 Gy daily fraction, 5 days a week, along with a daily dose of CBDCA (15 mg/m2) given intravenously 2 to 4 h before radiation. In nonprogressive patients under induction chemotherapy, two additional cycles of VP16-CBDCA were administered 4 weeks after the completion of CRCT.

RESULTS

Out of the 40 patients enrolled (38 males, 2 females), 37 (93%) received induction chemotherapy as scheduled, with 38% Grade 3-4 hematological toxicity. Response rate to induction chemotherapy was 11% (4/37). No tumor became resectable. CRCT was delivered to 32 of these 37 patients, with full doses given to 91% of them. Clinical and hematological Grade 3-4 toxicity rates were 21 and 13%, respectively. Additional chemotherapy was delivered in 12 of 26 nonprogressive patients. At final evaluation, performed 3 months after the end of CRCT, 38% of 26 evaluable patients were responders (4 complete and 6 partial), leading to a 25% (10 of 40) overall objective response rate. Of these 10 responders, 8 became responders after CRCT only. Overall, the 1-year local control rate was 28% (11 of 40). The median survival time was 9 months and the 1-year and 2-year overall survival rates were 38 and 15%, respectively. Thirty-six patients died from local progression (25 patients), distant metastasis (9 patients), or pulmonary fibrosis (2 patients).

CONCLUSION

Concomitant CRCT with CBDCA is feasible with acceptable induction chemotherapy-related toxicity and a 1-year local control rate of 28%. Response rate to induction chemotherapy was low and better chemotherapy combination should be used to reduce distant failure probability and to improve local response rate before CRCT.

[Radiotherapy in locoregional treatment of inoperable non-small cell lung cancer: results from a series of 381 patients]

PURPOSE

The prognosis of inoperable non-small cell lung cancer (NSCLC) is poor and thoracic radiation therapy is usually the main step of the therapeutic approach. The results of a retrospective analysis of a series of 381 patients treated from 1977 to 1990 for an inoperable NSCLC are reported.

PATIENTS AND METHODS

Three hundred and twenty two men and 59 women were included into the study. Their mean age was 66 years. A squamous cell carcinoma was observed in 276 cases (72%). A superior vena cava syndrome or a Pancoast's syndrome were present in 21 and 26 patients, respectively. Fifty-two per cent of the patients had a WHO performance status > or = 2. According to the TNM classification, the tumor distribution was as follows: 11 T1, 153 T2, 175 T3, and 42 T4. The mediastinum was involved in 174 patients. All patients were treated by external radiation therapy with a total dose of 60-65 Gy. Classical fractionation of the irradiation dose was done in 217 patients and hypofractionation was used for 164 patients.

RESULTS

After treatment, improvement of the superior vena and Pancoast's syndromes was observed in 90% of the patients. Radiological complete response was obtained in 177 patients (47%). The 5-year overall survival rate was 6.2%. No significant differences in survival according to the initial tumor size, the mediastinum status or the fractionation scheme were noted. The 5-year survival rate was 13% in patients with a tumor that completely responded to irradiation. Death was mainly due to local failure (231 patients, 69%) and metastatic disease (107 patients, 32%). The radiotherapy tolerance was acceptable.

CONCLUSION

Although irradiation provides good palliation and a 10%-survival rate at 3 years, the results relating to radiation therapy were disappointing.

Altered fractionation of hemithorax irradiation for pleural mesothelioma and failure patterns after treatment

Malignant pleural mesothelioma is a rare malignancy with a bleak prognosis. The role of radiotherapy has not yet been clarified. Our aim was to study the effect of altered fractionation on mesothelioma. We have treated 57 patients, 41 males and 16 females, with hemithorax irradiation with six different fractionation schedules. All the patients have been included in a combined modality program consisting of surgery followed by chemotherapy and finally by hemithorax irradiation. The radiotherapy schedules used were: I. Conventional fractionation of 20 Gy in 10 fractions over 12 days. II. Split-course radiotherapy 55 Gy in 25 fractions of 2.2 Gy over 7 weeks (a two weeks rest halfways) followed by a boost dose of 15 Gy over 8 days to the major tumour area. III. Hyperfractionation of 70 Gy over 7 weeks, 1.25 Gy BID with a 6-h interval and a 10-day rest halfways. IV. Combined hyperfractionation and hypofractionation, 35 Gy hyperfractionation in 28 fractions (1.25 Gy BID with a 6-h interval) over three weeks followed by 36 Gy hypofractionation 9 fractions of 4 Gy given every other day over 3 weeks to the major tumour areas only. V. Hypofractionation of 38.5 Gy over 15 days (9 x 3.5 Gy). VI. Combined conventional radiotherapy and hypofractionation with 20 Gy given conventionally in 10 fractions followed by 10 fractions of 3 Gy over two weeks, overall time 4 weeks. The 2-year survival rate of all patients was 21% and the 5-year survival rate 9%. Two patients are still alive more than 6 and 9 years after radiotherapy. Progression occurred after surgery in four patients, during and after chemotherapy in 22 patients and after completed radiotherapy in 29 patients. The pattern of progression was similar in each treatment group.

Local irradiation alone for peripheral stage I lung cancer: could we omit the elective regional nodal irradiation?

PURPOSE

The results of local irradiation only for patients with Stage I lung cancer were analyzed to see whether the treatment of regional lymph nodes could be omitted.

METHODS AND MATERIALS

One hundred and eight medically inoperable patients with nonsmall cell lung cancer (T1 and peripheral T2) were treated with 60 Gy split course or 65 Gy continuous treatment. The target volume included the primary tumor only, without regional lymph nodes. Response, survival, and patterns of failure were analyzed.

RESULTS

The overall response rate was 85% with 50 (46%) complete responses (CRs). Overall survival at 3 and 5 years was 31 and 15%, and cancer-specific survival was 42 and 31% at 3 and 5 years, respectively. The actuarial 5 years local relapse free survival in patients with a CR was 52%. Tumor size (< or = 4 cm) was strongly correlated with the chance of complete remission and better survival. Of patients in complete remission, only two had a regional recurrence as the only site of relapse; an additional two patients had a locoregional recurrence.

CONCLUSION

High-dose local radiotherapy on the primary tumor only is justified for medically inoperable patients with peripherally located nonsmall lung cancer. The low regional relapse rate does not support the need for the use of large fields encompassing regional lymph nodes. Using small target volumes, higher doses can be given and better local control rates can be expected.

Non-uniform dose/time fractionated radiation therapy and chemotherapy for non-small cell lung cancer

PURPOSE

A Non-uniform Fractionation schedule of large priming doses combined with concurrent chemotherapy and protracted RT was undertaken for the treatment of NSCLC. With several 5-year survivors, this study is reviewed with regard to local control, toxicity, and survival of patients.

METHODS AND MATERIALS

Forty-two patients with unresectable NSCLC were treated prospectively with initial priming doses followed by large field irradiation to the tumor and regional nodes to 3500 cGy. Patients were given a 1-week break and the treatment was repeated. A total dose of 7000 cGy was delivered over 9 weeks. Thirteen patients (Group A) were treated with RT alone. Twenty-nine patients (Group B) received concurrent chemotherapy; Cisplatin, 100 mg/m2, and 5-FU, 1 g/m2 for 24 h times 5 days. Sixteen patients also received Vinblastine, 3 mg/m2 on a weekly schedule. All patients have been followed more than 5 years.

RESULTS

Overall complete response rate was 36% and partial response rate was 57%. Absolute survival at 2 years was 26% and at 5 years was 14%. Local failure occurred in 28/42 (67%) patients. Late complications included pulmonary fibrosis (3), and osteochondritis (2).

CONCLUSION

This approach of high-dose Non-uniform fractionated radiation therapy has yielded an absolute 5-year survival of 14%, which appears better than the long-term results often seen in treatment of NSCL cancer.

Review of the curative role of radiotherapy in the treatment of non-small cell lung cancer

The present paper is a comprehensive review of available data concerning the role of radiotherapy as an intended curative treatment in patients with non-small cell lung cancer (NSCL). The following issues are reviewed (1) optimal dose, (2) optimal fractionation, (3) optimal treatment planning, (4) clinical results in terms of single treatment and combined treatment with either surgery or chemotherapy. In resectable NSCLC high dose radiotherapy to small localized tumours gives a 5-year survival rate of 7-38%. It is concluded that this treatment modality is appropriate for certain selected patients who refuse to have surgery, who have medical contradications for surgery, or who are of old age. It is discussed whether the treatment should be split course, continuous, hypo-og hyperfraction. A total dose of 55 Gy must be given. CT scanning should be mandatory for optimal planning and therapy. The literature does not give a conclusive answer to whether preoperative or postoperative radiotherapy is indicated. The data indicate that patients with Stage III NSCLC will benefit from a combined treatment modality in terms of chemotherapy based on high dose cisplatinum and radiotherapy. The main conclusion of the review is that many areas with randomized controlled trials are needed in order to answer the critical issue of the role of radiotherapy in the treatment of NSCLS.

Planned and unplanned gaps in radiotherapy: the importance of gap position and gap duration

Local tumour control in 971 patients with squamous carcinoma of the supraglottic larynx has been examined in relation to the occurrence of gaps in radiation therapy. The minimum follow-up time was 3 years. The reasons for a gap in radiotherapy fell into four categories: independent of the patient (national holidays, machine break-down, etc.), planned gaps (split-course therapy), severe normal-tissue reactions, and intercurrent disease. Only 11.7% of patients had no gap at all, 75.5% a single gap, and 2.1% had more than four gaps. The probability of tumour control increased with dose in all patient sub-groups; the average percentage increase for a 1% increase in dose was 4.3. The data were subjected to multivariate analysis, leading to the following conclusions. Patients in whom there was a single gap showed a remarkable trend of local control: if the gap began before day 19 after the start of therapy, the local tumour control was considerably below that in patients who did not suffer a gap in treatment. The local tumour control in patients whose gap began at day 20-29 was indistinguishable from that in patients who had no gap in treatment. A gap further towards the end of treatment was again associated with a severe drop in local control. This trend was independent of the recorded cause of the gap. The mechanism of this phenomenon is not clear. The effect of the timing of a treatment gap appears in this data set to have had a considerable impact on outcome and our observations should stimulate further study of this phenomenon in other clinical settings.

Use of Veff and iso-NTCP in the implementation of dose escalation protocols

PURPOSE

This report investigates the use of a normal tissue complication probability (NTCP) model, 3-D dose distributions, and a dose volume histogram reduction scheme in the design and implementation of dose escalation protocols for irradiation of sites that are primarily limited by the dose to a normal tissue which exhibits a strong volume effect (e.g., lung, liver).

METHODS AND MATERIALS

Plots containing iso-NTCP contours are generated as a function of dose and partial volume using a parameterization of a NTCP description. Single step dose volume histograms are generated from 3-D dose distributions using the effective-volume (Veff) reduction scheme. In this scheme, the value of Veff for each dose volume histogram is independent of dose units (Gy, %). Thus, relative dose distributions (%) may be used to segregate patients by Veff into bins containing different ranges of Veff values before the assignment of prescription doses (Gy). The doses for each bin of Veff values can then be independently escalated between estimated complication levels (iso-NTCP contours).

RESULTS AND CONCLUSION

Given that for the site under study, an investigator believes that the NTCP parameterization and the Veff methodology at least describe the general trend of clinical expectations, the concepts discussed allow the use of patient specific 3-D dose/volume information in the design and implementation of dose escalation studies. The result is a scheme with which useful prospective tolerance data may be systematically obtained for testing the different NTCP parameterizations and models.

Results of high-dose thoracic irradiation incorporating beam's eye view display in non-small cell lung cancer: a retrospective multivariate analysis

PURPOSE

To review the University of Michigan clinical experience in nonsmall cell lung cancer using high-dose thoracic irradiation (> or = 60 Gy) so that a starting dose for our prospective dose-escalation study could be determined.

METHODS AND MATERIALS

Eighty-eight consecutive patients diagnosed with medically inoperable or locally advanced, unresectable nonsmall cell lung cancer were identified who were treated with thoracic irradiation alone to a minimum total dose of 60 Gy (uncorrected for lung density). All patients except four (95%) underwent computed tomography scanning for treatment planning that included beam's eye view display for tumor and critical structure localization. All patients were treated with standard fractionation in a continuous course to uncorrected total doses ranging from 60 to 74 Gy (median, 67.6 Gy).

RESULTS

The median follow-up exceeds 24 months for all surviving patients (range, 12 to 78 months). The median survival time was 15 months, and the 2- and 3-year overall actuarial survival rates were 37% and 15%, respectively. Survival was significantly different between stage of disease (p = .004) and N-stage (p = .002) by univariate analysis. In a multivariate analysis, stage becomes the only characteristic significantly associated with outcome. The median time to local progression for 86 evaluable patients was 29 months. Stage (p = .0003), T-stage (p = .0095) and N-stage (p = .027) were significantly different with respect to local progression-free survival by univariate analysis. However, only stage was prognostic for local progression-free survival by multivariate analysis. There was no difference between large volume treatment (inclusion of the contralateral hilar and supraclavicular lymph nodes) and small volume treatment (exclusion of these elective nodal sites) with respect to local progression-free survival (p = .507) or survival (p = .520). With regard to dose, there was no significant difference between patients who received > 67.6 Gy and patients who received < or = 67.6 Gy with respect to local progression-free survival (p = .094) or survival (p = .142). Within the Stage III subgroup, local progression-free survival (p = .018) and survival (p = .061) were longer favoring the high-dose group of patients. Despite these doses, disease progression within the irradiated field was the predominant first site of treatment failure.

CONCLUSION

This retrospective study has shown that it is feasible to deliver uncorrected tumor doses as high as 70 Gy using standard fractionation in NSCLC with acceptable morbidity. Local control remains a significant problem. These data indicate justification for a starting dose in a prospective radiation dose-escalation study.

Hypofractionated radiation therapy in unresectable stage III non-small cell lung cancer

BACKGROUND

Hypofractionation is the current choice for radiation therapy for patients with unresectable non-small cell lung cancer (NSCLC) at the authors' institute.

METHODS

In this nonrandomized study, three hypofractionated radiation schedules (40-Gy split course; 30-32 Gy in 6 fractions and 24 Gy in 3 fractions) are evaluated in 301 patients with unresectable Stage III NSCLC:

RESULTS

Patients with Stage IIIA disease treated with a 40-Gy split course had longer survival (P < 0.005) and a lower local relapse rate (P < 0.01), but a higher distant failure rate (P < 0.01) than those receiving 24-32 Gy. Survival for patients with Stage IIIA disease treated with 40 Gy at 1, 2, and 5 years was 47%, 22%, and 7%, respectively. For patients with Stage IIIB disease, the radiation scheme used did not correlate with survival and relapse rates. Survival at 1, 2, and 5 years was 30%, 9%, and 2%, respectively. The hypofractionated radiation schemes were well tolerated, and no severe complications were recorded.

CONCLUSIONS

In patients with Stage IIIA disease, 40-Gy split-course radiation therapy yields survival rates comparable to those achieved with conventional radiation therapy. In patients with Stages IIIB and IV NSCLC, 24 Gy in 3 weekly fractions yields survival rates comparable to those achieved with higher total doses given in more fractions.

Role of radiation therapy in the management of lung cancer

Most patients who have lung cancer will receive radiation therapy at some point during the course of their disease. For patients with non-small-cell lung cancer, radiation therapy is sometimes used after complete resection, particularly in patients with lymph node involvement. In addition, irradiation is commonly used after incomplete resection. In patients with unresectable non-small-cell lung cancer, radiation therapy alone is typically used, although recent studies of a combination of chemotherapy and radiation therapy, or radiation therapy given in twice-daily fractions, have yielded promising results. For patients with small-cell lung cancer who have limited (that is, nonmetastatic) disease, the addition of thoracic radiation therapy to chemotherapy has improved survival over that with chemotherapy only. The role of prophylactic cranial irradiation in small-cell lung cancer remains controversial. Radiation therapy has a major role in the management of locally recurrent and metastatic lung cancer. Both the bones and the brain are common metastatic sites in patients with lung cancer. Radiation therapy provides effective palliation of symptoms from these and other metastatic lesions.

Hyperfractionated radiation therapy with and without concurrent chemotherapy for advanced non-small cell lung cancer

BACKGROUND

Locally advanced non-small cell lung cancer (NSCLC) continues to be a frustrating challenge for oncologists. In this group of patients, the overall 5-year survival rates have been 3-6% in prospective randomized trials with radiation therapy (RT) alone.

METHODS

One hundred sixty-nine patients, 18 years of age or older, with histologically or cytologically proven, advanced, nonresectable NSCLC; a Karnofsky performance status score of 50 or greater; and no previous therapy were treated as follows: treatment arm 1: hyperfractionated radiation therapy (HFX RT) to a total tumor dose of 64.80 Gy (61 patients); treatment arm 2: HFX RT to the same tumor dose with chemotherapy (CT) consisting of 100 mg of carboplatin, days 1 and 2, and 100 mg of etoposide (VP-16), days 1-3, given every week during the RT course (52 patients); and treatment arm 3: HFX RT to the same tumor dose with CT consisting of 200 mg of CBCDA, days 1 and 2, and 100 mg of VP-16, days 1-5, during the first, third, and fifth weeks of the RT course (56 patients). Acute and late toxic effects were scored from 0 (none) to 5 (fatal), according to the Radiation Therapy Oncology Group classification.

RESULTS

The authors observed acute overall Grade 3 toxic effects in 11.5% of patients in treatment arm 1, 13.4% of patients in treatment arm 2, and 16.1% of patients in treatment arm 3. Acute overall Grade 4 toxic effects were observed in 1.6% of patients in treatment arm 1, 3.8% of patients in treatment arm 2, and 10.7% of patients in treatment arm 3. Regarding late toxic effects, we observed late overall Grade 3 toxic effects in 3.3% of patients in treatment arm 1, 11.6% of patients in treatment arm 2, and 15.4% of patients in treatment arm 3. Late overall Grade 4 toxic effects were observed in treatment arms 2 and 3 only: 3.8% in treatment arm 2 and 8.9% in treatment arm 3. No Grade 5 toxic effects were observed during this study.

CONCLUSIONS

The acute toxic effects observed during this study in treatment arms 1 and 2 are at least comparable to those previously published in other studies of this type, but a high incidence of acute overall toxic effects was observed in treatment arm 3. Regarding late toxic effects, the authors observed a higher incidence of Grade 3 overall late toxic effects in treatment arm 2 and a high incidence of Grade 4 overall late toxic effects in treatment arm 3. Results of this study show that the addition of CT to HFX RT carries a risk of increased high-grade toxic effects, both acute and late.

Simultaneous chemoradiation in advanced non-small cell lung cancer

We designed our study to evaluate the safety and efficacy of simultaneous chemoradiation therapy in an accelerated, twice-a-day schedule to improve local control and survival in advanced lung cancer patients. Forty-one patients were entered into the study. Twenty-three had stage IIIB and 18 had stage IIIA disease. They received cisplatin 30 mg/m2, VP-16 80 mg/m2, and 5-Fluorouracil (5-FU) 900 mg/m2 in iv infusion. Radiation therapy consisted of 2G twice a day for 5 days, followed by a 2-week rest. This cycle was repeated 3 times. Patients were evaluated for surgical resection after the second cycle. Acute toxicity was acceptable: 3 patients expired (1 congestive heart failure, 1 sepsis, 1 pulmonary embolism). The 1-year actuarial survival was 60.3%; the 2-year actuarial survival was 55.3%. Our results show that this regimen is well tolerated and that the 2-year actuarial survival appears to be comparable to that reported in the literature.

Low-versus high-energy photon beams in radiotherapy for lung cancer

This retrospective study analyzed the outcome of lung cancer patients who were treated with either 4-MV or 10-MV photons. From October 1979 through December 1982, 126 patients with locally advanced, unresectable or medically inoperable, nonmetastatic non-small cell lung cancer were treated in a prospective trial in which they were randomly assigned to one of three chemotherapy combinations and thoracic radiotherapy. The patients were stratified by cell type, extent of operation, age, sex, and status of supraclavicular lymph nodes. All patients were followed until death or for a minimum of 4.8 years. Of the 102 evaluable patients, 98 were treated with either 4-MV or 10-MV photons (49 patients in each group). Outcomes examined included best primary tumor response, time to first local (in-field) recurrence, disease-free survival, and overall survival. No significant differences were detected between the patients treated with 4-MV or 10-MV photons for several important prognostic and treatment factors or for any of the study outcomes, including first local (in-field) recurrence, disease-free survival, and overall survival. For the group of 98 patients treated with either 4-MV or 10-MV photons, the estimated 2-year freedom from first local (in-field) recurrence was 47.7%. The estimated 2-year disease-free and overall survivals were 21.6% and 28.6%, respectively.

Effects of concomitant cisplatin and radiotherapy on inoperable non-small-cell lung cancer

BACKGROUND AND METHODS

Cisplatin (cis-diamminedichloroplatinum) has been reported to enhance the cell-killing effect of radiation, an effect whose intensity varies with the schedule of administration. We randomly assigned 331 patients with nonmetastatic inoperable non-small-cell lung cancer to one of three treatments: radiotherapy for two weeks (3 Gy given 10 times, in five fractions a week), followed by a three-week rest period and then radiotherapy for two more weeks (2.5 Gy given 10 times, five fractions a week); radiotherapy on the same schedule, combined with 30 mg of cisplatin per square meter of body-surface area, given on the first day of each treatment week; or radiotherapy on the same schedule, combined with 6 mg of cisplatin per square meter, given daily before radiotherapy.

RESULTS

Survival was significantly improved in the radiotherapy-daily-cisplatin group as compared with the radiotherapy group (P = 0.009): survival in the radiotherapy-daily-cisplatin group was 54 percent at one year, 26 percent at two years, and 16 percent at three years, as compared with 46 percent, 13 percent, and 2 percent, respectively, in the radiotherapy group. Survival in the radiotherapy-weekly-cisplatin group was intermediate (44 percent, 19 percent, and 13 percent) and not significantly different from survival in either of the other two groups. The survival benefit of daily combined treatment was due to improved control of local disease (P = 0.003). Survival without local recurrence was 59 percent at one year and 31 percent at two years in the radiotherapy-daily-cisplatin group; 42 percent and 30 percent, respectively, in the radiotherapy-weekly-cisplatin group; and 41 percent and 19 percent, respectively, in the radiotherapy group. Cisplatin induced nausea and vomiting in 86 percent of the patients given it weekly and in 78 percent of those given it daily; these effects were severe in 26 percent and 28 percent, respectively.

CONCLUSIONS

Cisplatin, given daily in combination with the radiotherapy described here to patients with nonmetastatic but inoperable non-small-cell lung cancer, improved rates of survival and control of local disease at the price of substantial side effects.

Multimodality treatment programs for malignant pleural mesothelioma using high-dose hemithorax irradiation

The characteristic of malignant pleural mesothelioma is a tumor that grows by plate-like extension over the pleura, and invades adjacent tissues and organs. Radical surgical removal of the tumor is generally not possible, and most treatment regimens involve combined chemotherapy and radiotherapy, as well as debulking surgery. We have prospectively evaluated five locally-aggressive multi-modality treatment programs, using different hemithorax irradiation schedules and chemotherapy regimens. One hundred patients with confirmed malignant pleural mesothelioma entered the study between 1977 and 1989. The treatment programs, which can consecutively, were: I, 20 Gy (10 x 2 Gy) to the hemithorax + CYVADIC (cyclophosphamide 500 mg/m2 d 1, vincristine 1 mg/m2 d 1 and 5, adriamycin 40 mg/m2 d 1 and dacarbazine 200 mg/m2 d 1 and 5, several cycles before and after irradiation); II, 55 Gy (25 x 2.2 Gy) to the hemithorax + 15 Gy (6 x 2.5 Gy) to the tumor + CYVADIC (2 cycles before, 1 cycle during, and 2 cycles after irradiation); III, Mitoxantrone (14 mg/m2 q 28 d, < or = 6 cycles) followed by 70 Gy (56 x 1.25 Gy, twice a day); IV, 4-Epirubicin (110-130 mg/m2 q 28 d, < or = 6 cycles) followed by 35 Gy (28 x 1.25 Gy twice a day) to the hemithorax + 36 Gy (9 x 4 Gy every 2 days) to the tumor; V, Etoposide (150 mg/m2 1, 3, 5 q 28 d) followed by 38.5 Gy (11 x 3.5 Gy) to the hemithorax. A new system for evaluating tumor response in pleural mesothelioma was applied. None of the combined treatment programs prevented local invasive growth or the spread of mesothelioma outside the hemithorax. The median survival time was slightly increased from 8 to 12 months for those patients who completed the protocol treatments, but progressive disease was the invariable outcome. Radiation pneumonitis and fibrosis were severe and compatible with results of total loss of lung function on the irradiated side. We conclude that data relating to therapeutic responses and treatment programs in malignant mesothelioma should be better correlated internationally, if the problems associated with the evaluation of treatment and the management of patients with mesothelioma are to be improved.

Radical radiotherapy of inoperable non-small cell lung cancer. Irradiation techniques and tumor characteristics in relation to local control and survival

The relation between tumor characteristics, irradiation technique, local tumor control and survival was retrospectively studied in 323 patients with non-small cell lung cancer who started radical radiotherapy in 1974-1981. At that time three non-randomized different fractionation schedules were used: 16 x 3.25 Gy, total dose 52 Gy, 3 fractions/week (schedule 1), 11 x 4 Gy, total dose 44 Gy, 2 fractions/week (schedule 2) and 25 x 2 Gy, total dose 50 Gy, 5 fractions/week (schedule 3). The highest survival rates were observed in the patient group treated according to schedule 2. The 2-year survival rate was 30% compared with 18% and 6% in the patients treated according to schedule 1 and 3 respectively. However, this can at least partly be explained by patient selection. A correlation between size of the tumor, target volume and survival was observed: the larger the tumor, the poorer the survival. Pleural effusion showed to be an unfavorable prognostic factor. The prognosis of inoperable lung cancer on the whole remained poor: the 1-year survival rate was 43% and 2-year survival rate 16%. Only 3% of the patients lived at least five years.

Optimization of radical radiotherapy with beam's eye view techniques for non-small cell lung cancer

The presence of vital and sensitive organs such as the spinal cord, heart, and lungs makes curative radiotherapy of non-small cell lung cancer difficult to implement and necessitates use of oblique portals. Defining the target volumes in oblique portals is very difficult. We now show, for non-small cell lung cancer, how beam's eye view-based radiotherapy can be used for accurate delineation of treatment volumes and for avoidance of real or dosimetric geographic misses. Furthermore, the beam's eye view-based method enables one to project accurately a 2-dimensional image of 3-dimensional disease extension, especially in oblique fields, thus facilitating the design of accurate customized blocking and avoiding inadvertent blocking of the tumor or unnecessary irradiation of normal tissues. Beam's eye view volumetric analysis is helpful for devising a customized treatment plan for each patient. Such customization may minimize local failure, which is one cause of poor results of radiotherapy in this site. Beam's eye view-based radiotherapy has the potential of improving local control and hence may improve the survival of patients with non-small-cell lung cancer.

Non-small cell lung cancer. Part II: Treatment

Squamous, large cell, and adenocarcinoma, collectively termed non-small cell lung cancer (NSCLC), are diagnosed in approximately 75% of patients with lung cancer in the United States. The treatment of these three tumor cell types is approached in virtually identical fashion because, in contrast to small cell carcinoma of the lung, NSCLC more frequently presents with localized disease at the time of diagnosis and is thus more often amenable to surgical resection but less frequently responds to chemotherapy and irradiation. Cigarette smoking is etiologically related to the development of NSCLC in the great majority of cases. Genetic mutations in dominant oncogenes such as K-ras, loss of genetic material on chromosomes 3p, 11p, and 17p, and deletions or mutations in tumor suppressor genes such as rb and p53 have been documented in NSCLC tumors and tumor cell lines. NSCLC is diagnosed because of symptoms related to the primary tumor or regional or distant metastases, as an incidental finding on chest radiograph, or rarely because of a paraneoplastic syndrome such as hypercalcemia or hypertrophic pulmonary osteoarthropathy. Screening smokers with periodic chest radiographs and sputum cytologic examination has not been shown to reduce mortality. The diagnosis of NSCLC is usually established by fiberoptic bronchoscopy or percutaneous fine-needle aspiration, by biopsy of a regional or distant metastatic site, or at the time of thoracotomy. Pathologically, NSCLC arises in a setting of bronchial mucosal metaplasia and dysplasia that progressively increase over time. Squamous carcinoma more often presents as a central endobronchial lesion, while large cell and adenocarcinoma have a tendency to arise in the lung periphery and invade the pleura. Once the diagnosis is made, the extent of tumor dissemination is determined. Since most NSCLC patients who survive 5 years or longer have undergone surgical resection of their cancers, the focus of the staging process is to determine whether the patient is a candidate for thoracotomy with curative intent. The dominant prognostic factors in NSCLC are extent of tumor dissemination, ambulatory or performance status, and degree of weight loss. Stages I and II NSCLC, which are confined within the pleural reflection, are managed by surgical resection whenever possible, with approximate 5-year survival of 45% and 25%, respectively. Patients with stage IIIa cancers, in which the primary tumor has extended through the pleura or metastasized to ipsilateral or subcarinal lymph nodes, can occasionally be surgically resected but are often managed with definitive thoracic irradiation and have 5-year survival of approximately 15%.(ABSTRACT TRUNCATED AT 400 WORDS)

Results of combination chemotherapy and thoracic radiation therapy for unresectable non-small cell carcinoma of the lung

From October 1979 to December 1982, 126 patients with locally advanced unresectable or inoperable Stage II (7 patients), Stage IIIA (81 patients), and Stage IIIB (38 patients) non-small cell carcinoma of the lung were treated in a prospective randomized trial using five cycles of CAP (Cytoxan, Adriamycin, and cisplatin), T-CAP (triazinate plus CAP), or V-CAP (VP-16 plus CAP) chemotherapy with thoracic radiation therapy (TRT). TRT consisted of 40 Gy in 10 fractions (split-course) with cycles 3 and 4 of chemotherapy. The treatment field included the primary tumor, ipsilateral hilum, mediastinum, and ipsilateral supraclavicular fossa. All patients were followed until death or for a minimum of 5 years for survivors. The evaluable subgroup consisted of 102 patients who completed TRT. Median and 5-year survivals for the entire group were 14.0 months and 10%, respectively; for the evaluable subgroup, they were 14.8 months and 12%, respectively. There was a trend toward better survival with V-CAP plus TRT than with CAP plus TRT (p = 0.08). Median and 5-year survivals were 16.2 months and 18%, respectively, with V-CAP plus TRT. Of eight prognostic variables analyzed for their association with survival, only Eastern Cooperative Oncology Group performance status (0,1 versus 2) (p = 0.02) and weight loss (less than or equal to 10% versus greater than 10%) (p = 0.05) were significant. Sex, age, T stage, N stage, overall stage, and histologic type were not significantly associated with survival. Failure analysis revealed 83 patients (81%) with identifiable first failures. The median time to first failure was 9.8 months, and the median survival after first failure was 4.7 months. Failure patterns included local failure alone (19%), local and distant (20%), and distant alone (43%). Nineteen percent of patients had no documented progression. Total failure patterns were local in 39% and distant in 63%. Twenty-three patients (23%) had failure in the brain; they accounted for 31% of all distant failures. In 20 of these patients (20% of all patients), this was the only site of failure. There were eight (8%) initial nodal failures in 96 untreated contralateral supraclavicular fossae. No initial failures were seen in any of 101 untreated contralateral hila. The data suggest the following: (a) Combined treatment with V-CAP and TRT yielded excellent results (median survival, 16.2 months; 5-year survival, 18%).(ABSTRACT TRUNCATED AT 400 WORDS)

A comparison of cis-platinum-vindesine and cis-platinum-etoposide combined with radiotherapy for previously untreated localized inoperable non-small cell lung cancer

Seventy-two previously untreated patients with localized inoperable non-small cell lung cancer were randomized to a study comparing the efficacy of cis-platinum-vindesine (P-VDS) and of cis-platinum-VP16 (P-VP16), both combined with split-course radiotherapy. Fifty-nine patients were evaluable for response after the minimum requirement of two chemotherapy cycles. Both arms were further randomized to two split intervals, 3 or 5 weeks. The response rate to chemotherapy only (three cycles) was 66% for P-VDS and 50% for P-VP16. Radiotherapy increased the response rates to 83 and 67%, respectively. A Karnofsky score of 80% or more and the 3-week split interval were significant positive prognostic factors. Of all patients, 66% had local or combined recurrences and 17% relapsed at a distant site only. Since the 2-year survival rates are not strikingly better than those obtained by radiotherapy alone, we feel that these regimens should be restricted to further investigations of the role of chemotherapy in the treatment of different clinical presentations of NSCLC.

Results of radical radiation therapy in clinical stage I, technically operable non-small cell lung cancer

From 1970 to 1983, 1,646 lung cancer patients were referred for treatment to the Hunter Radiation Therapy Center, Yale-New Haven Hospital. Forty-three patients had clinical Stage I non-small cell lung cancer felt to be surgically resectable but were treated with radical radiation therapy either for medical reasons (37 patients) or because the patient refused surgery (six patients). This group of clinical Stage I lung cancer patients is understaged by modern criteria since the majority of patients did not have thoracic CT scans and staging was based on fairly limited clinical and radiographic studies. The histological diagnosis was squamous cell carcinoma in 53% of the Stage I patients, adenocarcinoma in 25%, and other non-small cell histologies in 22%. All patients were treated with megavoltage irradiation and the mediastinum was treated in 88% of the patients. Eleven patients were treated with a continuous course (CC) and 32 patients received split course (SC) therapy based on physician preference. The CC consisted of a median fraction size of 200 cGy to a total median dose of 5900 cGy in 6-7 weeks. The SC used a median fraction site of 275 cGy to a total median dose of 5400 cGy over a 6-week period with a 2-week rest in the middle of treatment. The actuarial survival rate of the 43 clinical Stage I patients was 36% at 3 years and 21% at 5 years. Intrathoracic failures occurred in 39% of the patients. Despite the fact that the CC group was similar to the SC group in terms of age, histology, and tumor extent, the CC patients had a lower thoracic failure rate (2/11) versus 15/32), a longer median survival (51.6 months versus 27 months), and a better actuarial 5-year survival rate (45% versus 12%) when compared to the SC patients. Using Cox regression analysis to compare survival curves, the CC group had a significantly better survival compared to the SC group (p = .04).

Inoperable non-small cell lung cancer: radiation with or without chemotherapy

We report a randomized multicentre study of split-course radiotherapy (RT), with or without combination chemotherapy (CT), in 238 patients with inoperable non-small cell lung cancer (NSCLC), previously untreated, confined to one hemithorax and the mediastinal nodes. In both treatment groups RT consisted of 55 Gy in 20 F given over 7 weeks with a 3-week rest interval. CT consisted of the 3-drug regimen CAP: C = cyclophosphamide 400 mg/m2, A = adriamycin 40 mg/m2, P = cisplatin 40 mg/m2; 2 cycles of CAP given before RT, one during the rest interval and six after RT. Seventy per cent in the RT arm and 67% in the RT-CT arm had epidermoid carcinoma. No significant difference was apparent between the RT and the RT-CT arms with respect to objective response rates (CR + PR) (44 and 49%, respectively), median duration of response (278 and 320 days), local failure (31 and 20%), distant progression (23 and 20%) or median survival (311 and 322 days). The survival figures showed an almost significant (P = 0.05) therapeutic advantage of the combined regimen with stage IIIM0 disease. Progressive disease was the cause of death in 92% and 88%. We conclude that chemotherapy did not contribute significantly to either local control or survival as compared to radiotherapy alone.

Split-course versus continuous radiotherapy. Analysis of a randomized trial from 1964 to 1967

A randomized clinical trial was performed from 1964 to 1967 to compare the therapeutic results of split-course external beam radiotherapy with those of continuously fractionated treatment. Altogether 439 consecutive patients with carcinoma of larynx, nasopharynx, hypopharynx, oropharynx, oral cavity, oesophagus and urinary bladder were included in the series. 227 patients received split-course treatment and 212 were treated by the continuous-course method. In the split-course treatment there was a 2-3 weeks' interruption after 25-30 Gy. This break was compensated by a 10% increase in the total dose. For each tumour site local control and failure rates for the 2 treatment techniques were similar. No significant differences in 5- and 10-year survival were noted. Acute side effects were milder in all patients treated with split-course. The occurrence of late reactions was similar in both treatment groups. However, severe late reactions in the urinary bladder were somewhat more frequent in patients treated with split-course technique; the difference was not statistically significant. We conclude that there were no significant differences in local control, long-term survival and late normal tissue reactions between the treatment groups. The acute normal tissue reactions were milder in the split-course treated groups. We still regard split-course as a useful treatment modality provided the interruption is compensated with about 10% increase in total dose. However, more studies are needed to show which tumours proliferate during prolonged radiotherapy.

The effect of resection on local failure in irradiated non-oat cell carcinoma of the lung

From January 1969 through December 1979, 171 patients completed a course of high dose definitive radiotherapy alone for non-oat cell carcinoma of the lung. During the same period, 53 patients completed a course of definitive postoperative radiotherapy after undergoing resection of the primary tumor. The two groups were otherwise very similar with regard to patient related and tumor related variables. A detailed analysis of the incidence of clinically documented local (in-field) failure on the basis of clinical T and N stages was performed. A comparison of the incidence of local failure as the first site of failure for patients with T1-2 tumors demonstrated a statistically significant decrease in local failure in patients whose primary tumors were resected. This was true for all patients with T1-2 tumors whose failure status was known (p less than .001), for all patients known to have failed (p less than .001), and for patients whose clinical node status was other than gross mediastinal (N2) lymphadenopathy (p less than .05). Local failure was decreased in patients with clinical T3 tumors who underwent resection, but the difference was not significant (p greater than .1). Histology (epidermoid vs. non-epidermoid) had no apparent effect on the frequency of local failure, either with or without resection. A review of past experience indicates that local failure is common after definitive irradiation alone, and is due to a low rate of sterilization of the primary tumor, even with tolerance doses of irradiation. Data are presented to support a reappraisal of the role of combined resection and irradiation in future clinical trials, to reduce the present unacceptably high rate of local failure in potentially curable patients treated by irradiation alone.

Prognostic factors of inoperable localized lung cancer treated by high dose radiotherapy

A retrospective study was made of the results of high dose radiotherapy (greater than or equal to 50 Gy) given to 171 patients with inoperable, intrathoracic non small cell lung cancer from January 1971-April 1973. Local control was dependent on the total tumor dose: after one year local control was 63% for patients treated with greater than 65 Gy, the two year local control was 35%. If treated with less than 65 Gy the one year local control was less than or equal to 40%. Tumor doses correlated with the size of the booster field. If the size of the booster field was less than 100 cm2, the one year local control was 72%; the two year local control was 44%. Local control was also influenced by the performance status, by the localization of the primary tumor in the left upper lobe and in the periphery of the lung. Local control for tumors in the left upper lobe and in the periphery of the lung was about 70% after one year, and about 40% after two years. The one and two years survival results were correlated with the factors influencing local control. The dose factor, the localization factors and the performance influenced local control independently. Tumors localized in the left upper lobe did metastasize less than tumors in the lower lobe, or in a combination of the two. This was not true for the right upper lobe. No correlation between the TNM system, pathology and the prognosis were found.