title: Medically inoperable peripheral lung cancer treated with stereotactic body radiation therapy.
abstract: BACKGROUND
  Lung cancer is the most frequent cause of cancer-related death in North America. There is wide variation between patients who are medically inoperable and those managed surgically. The use of stereotactic body radiotherapy (SBRT) has narrowed the gap in survival rates between operative and non-operative management for those with early stage disease. This retrospective study reports outcomes for the treatment of peripheral non-small cell lung carcinoma (NSCLC) with SBRT from a single community practice.
  
  
  METHODS
  Sixty-seven consecutive patients (pts) with inoperable, untreated peripheral lung tumors were treated from 2010 through 2012 and included in this study. Stereotactic targeting was facilitated by either spine or lung-based image guidance, either with or without fiducial marker tracking with a frameless robotic radiosurgery system. Peripheral tumors received a median biological effective dose (BED) of 105.6 Gy10 or in terms of a median physical dose, 48 Gy delivered over 4 daily fractions. Survival was measured using the Kaplan-Meier method to determine rates of local control, progression of disease and overall survival. The Cox proportional hazards regression model was used to study the effects of tumor size, stage, histology, patient age, tumor location (lobe), tracking method, and BED on the survival distributions.
  
  
  RESULTS
  The median follow-up for this cohort was 24.5 months (range: 2.4-50.3) with an overall (OS) 3-year survival of 62.4 % (95 % CI: 74.3-47.3). The median progression-free survival was 28.5 months (95 % CI: 15.8 months to not reached). Local control (LC), defined as a lack of FDG uptake on PET/CT or the absence of tumor growth was achieved in 60 patients (90.9 %) at the time of first follow-up (median 3 months, range: 1-6). Local control at one year for the entire cohort was 81.8 % (95 % CI, 67.3-90.3). The one-year OS probability among those who achieved local control at first follow-up was 86.2 % (95 % CI, 74.3-92.9) but no patients who did not achieve LC at first follow-up survived one year. Of the 60 pts that achieved initial LC, 16 have died. The rates of local control, progression-free survival and overall survival were not statistically different for patients treated using a fiducial target tracking system versus non-invasive guidance. (p = 0.44, p = 0.97 and p = 0.66, respectively). No National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE-4) grade 3 or greater toxicity was observed.
  
  
  CONCLUSIONS
  SBRT is an effective treatment for medically inoperable NSCLC patients with peripherally located tumors. This therapy appears to be well tolerated with low toxicity, and patient outcomes when using non-invasive tumor tracking systems are not inferior to traditional fiducial-based techniques.
authors.affiliation: The Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Lake Success, NY, USA. kkelley1@nshs.edu.
authors.forename: K D
authors.initials: KD
authors.lastname: Kelley
authors.affiliation: The Department of Radiation Medicine, North Shore-LIJ Health System, Huntington, NY, USA. benningln@aol.com.
authors.forename: D L
authors.initials: DL
authors.lastname: Benninghoff
authors.affiliation: The Department of Biostatistics, Feinstein Institute for Medical Research, North Shore-LIJ Health System, Manhasset, NY, USA. jstein4@nshs.edu.
authors.forename: J S
authors.initials: JS
authors.lastname: Stein
authors.affiliation: The Department of Radiation Medicine, North Shore-LIJ Health System, Huntington, NY, USA. jennyl@cancer-radiation.com.
authors.forename: J Z
authors.initials: JZ
authors.lastname: Li
authors.affiliation: The Department of Radiation Medicine, North Shore-LIJ Health System, Huntington, NY, USA. rbyrnes@nshs.edu.
authors.forename: R T
authors.initials: RT
authors.lastname: Byrnes
authors.affiliation: The Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Lake Success, NY, USA. lpotters@nshs.edu.
authors.forename: L
authors.initials: L
authors.lastname: Potters
authors.affiliation: The Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Lake Success, NY, USA. jknisely@nshs.edu.
authors.forename: J P S
authors.initials: JP
authors.lastname: Knisely
authors.affiliation: The Department of Radiation Medicine, North Shore-LIJ Health System, Huntington, NY, USA. hzinkin@nshs.edu.|, 989W Jericho Turnpike, Smithtown, NY, 11787, USA. hzinkin@nshs.edu.
authors.forename: H D
authors.initials: HD
authors.lastname: Zinkin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000601:surgery*; D000075202:Contraindications; D018572:Disease-Free Survival; D004307:Dose-Response Relationship, Radiation; D005221:Fatigue / Q000209:etiology; D005260:Female; D057918:Fiducial Markers; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000401:mortality / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D058958:Organs at Risk; D011013:Pneumonectomy; D016016:Proportional Hazards Models; D016634:Radiosurgery / Q000009:adverse effects; D011879:Radiotherapy Dosage; D012189:Retrospective Studies; D025321:Surgery, Computer-Assisted; D016896:Treatment Outcome