Omission of elective node irradiation on basis of CT-scans in patients with limited disease small cell lung cancer: a phase II trial.
OBJECTIVE
To evaluate the patterns of recurrence when elective node irradiation was omitted in patients with limited disease small cell lung cancer (LD-SCLC).


METHODS
A prospective phase II study was undertaken in 27 patients with LD-SCLC without detectable distant metastases on CT scan. Chest radiotherapy to a dose of 45 Gy in 30 fractions in 3 weeks (1.5 Gy BID with 6 - 8 h interval) was delivered concurrently with carboplatin and etoposide chemotherapy. Chest radiation started after a mean time of 17.7 days +/- 9.7 days (SD) (range: 0-33 days) after the beginning of chemotherapy. Only the primary tumour and the positive nodal areas on the pre-treatment CT scan were irradiated. A total of five chemotherapy cycles were administered, followed by prophylactic cranial irradiation (PCI) in patients without disease progression. Isolated nodal failure was defined as recurrence in the regional nodes outside of the clinical target volume, in the absence of in-field failure.


RESULTS
After a median time of 18 months post-radiotherapy, 7 patients (26%, 95% CI 19.5-42.5%) developed a local recurrence. Three patients (crude rate 11%, 95% CI 2.4-29%), developed an isolated nodal failure, all of them in the ipsilateral supraclavicular fossa. The median actuarial overall survival was 21 months (95% CI 15.3-26.7), and the median actuarial progression free survival was 16 months (95% CI 6.5-25.5). Eight patients developed an acute, reversible grade 3 (CTC 3.0) radiation oesophagitis (30%, 95% CI 14-50%).


CONCLUSIONS
Because of the small sample size, no definitive conclusions can be drawn. However, the omission of elective nodal irradiation on the basis of CT scans in patients with LD-SCLC resulted in a higher than expected rate of isolated nodal failures in the ipsilateral supraclavicular fossa. The incidence of acute, reversible oesophagitis was in the same range as reported with elective nodal fields. The safety of selective nodal irradiation in NSCLC should not be extrapolated to patients with LD-SCLC until more data are available. In the mean time, elective nodal irradiation should only be omitted in clinical trials.
De Ruysscher
Dirk
D
MAASTRO Clinic, Maastricht, The Netherlands. dirk.deruysscher@maastro.nl
Bremer
Robert-Harm
RH
Koppe
Friederike
F
Wanders
Stofferinus
S
van Haren
Erik
E
Hochstenbag
Monique
M
Geeraedts
Wiel
W
Pitz
Cordula
C
Simons
Jean
J
ten Velde
Guul
G
Dohmen
Jo
J
Snoep
Gabriel
G
Boersma
Liesbeth
L
Verschueren
Tom
T
van Baardwijk
Angela
A
Dehing
Cary
C
Pijls
Madelon
M
Minken
Andre
A
Lambin
Philippe
P
D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy / Q000532:radiotherapy*; D018288:Carcinoma, Small Cell / Q000188:drug therapy / Q000532:radiotherapy*; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000188:drug therapy / Q000532:radiotherapy*; D008198:Lymph Nodes / Q000528:radiation effects*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000175:diagnosis*; D009367:Neoplasm Staging; D017564:Radiation Pneumonitis / Q000209:etiology; D014057:Tomography, X-Ray Computed