title: Patterns of regional failure in stage III non-small cell lung cancer treated with neoadjuvant chemoradiation therapy and resection.
abstract: OBJECTIVE
  Treatment of locally advanced non-small cell lung cancer (LA-NSCLC) involves definitive chemoradiation therapy (CRT) or neoadjuvant CRT and resection, but radiation treatment volumes remain in question. With CRT, involved-field radiation therapy (IFRT) is replacing elective nodal irradiation, reducing toxicity, and allowing dose escalation. However, prior reports of IFRT describe failures only after radical CRT; with improved local control after resection, IFRT may lead to more regional recurrences. Our objective is to evaluate pattern-of-failure in patients with LA-NSCLC treated with split-course IFRT, chemotherapy, and subsequent surgery.
  
  
  METHODS
  Patients treated between December 2004 and 2010 were included. Imaging scans demonstrating failure were fused into the radiation therapy planning computed tomography, and recurrent nodes were contoured to determine pattern-of-failure (involved versus elective nodal failure [INF vs ENF]). Locoregional progression-free survival and distant metastasis-free survival were calculated using Kaplan-Meier methodology. The cumulative incidence of regional recurrence (CIRR) was determined with death as a competing risk.
  
  
  RESULTS
  Forty-five patients met inclusion criteria, and patients with RR had a lower rate of pN0 than those without RR (20% vs 60%, P = .02). With a median follow-up of 2.9 years, median survival was not reached, and 3-year locoregional progression-free survival and distant metastasis-free survival were 53% and 35%, respectively. Two and 3-year CIRR were 25% and 33%, respectively. There were no local failures. Thirteen (29%) patients had RR, 8 with INF only and 5 with ENF alone or both, totaling 27 recurrences. Only 2 (4%) ENF occurred without INF, both with distant metastasis, and no elective node was the first and only site of failure.
  
  
  CONCLUSIONS
  Our data suggest that IFRT does not compromise regional control in the neoadjuvant management of LA-NSCLC. Tailoring nodal volumes may improve treatment-related morbidity and allow for dose intensification of involved nodes. Further research is necessary to improve regional and distant control.
authors.affiliation: Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois. Electronic address: shalini_garg@rush.edu.
authors.forename: Shalini
authors.initials: S
authors.lastname: Garg
authors.affiliation: Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois.
authors.forename: Benjamin T
authors.initials: BT
authors.lastname: Gielda
authors.affiliation: Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois.
authors.forename: Julius V
authors.initials: JV
authors.lastname: Turian
authors.affiliation: Department of Cardiothoracic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Michael
authors.initials: M
authors.lastname: Liptay
authors.affiliation: Department of Cardiothoracic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: William H
authors.initials: WH
authors.lastname: Warren
authors.affiliation: Section of Medical Oncology, Rush University Medical Center, Chicago, Illinois.
authors.forename: Philip
authors.initials: P
authors.lastname: Bonomi
authors.affiliation: Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois.
authors.forename: David J
authors.initials: DJ
authors.lastname: Sher