The treatment of Stage III nonsmall cell lung cancer using high dose conformal radiotherapy

Purpose: To review our experience using conformal treatment planning and high-dose radiotherapy for Stage IIIa and IIIb nonsmall cell lung cancer (NSCLC),and to identify a subset of patients best suited for this approach by analyzing multiple pretreatment patient and tumor characteristics. Methods and Materials: Between December 1987 and June 1992,37 patients with Stage III III NSCLC treated with high-dose radiotherapy using conformal radiotherapy were reviewed. The patient characteristics were as follows: Stage IIIa (18 patients), IIIb [19]; T1-2 [13], T3-4 [24]; NO-1 [8], N2-3 [29]; and median age 63. All patients were treated with 1.8-2.0 Gy fractions to a median dose of 66 Gy (range 60-70 Gy). Outcome was analyzed by multiple pretreatment variables including age, sex, Karnofsky performance score, pretreatment symptoms, stage group, T and N stage, tumor volume (calculated from computed tomography (CT) contours), presence of atelectasis, and tumor histology. Outcome was also analyzed by total radiotherapy dose. Results: The median, 1-year and 2-year survival rates for the entire group were 19.5 months, 75 and 37%, respectively. The median, 1-year, and 2-year local progression-free survival rates are 15.6 months, 23%. There was no difference in survival by stage group (IIIa vs. IIIb) or by T or N stage. Tumor volumes ranged from 47-511 cc in the patients without atelectasis and were not a significant prognostic factor. Histology was found to be a significant prognostic factor, with squamous cell carcinoma having a better overall survival and local progression-free survival than other histologies. No other patient characteristic was found to be significant by either univariate or multivariate analysis. When outcome was analyzed by radiotherapy dose, no dose response was evident in the narrow dose range studied (60-70 Gy). Toxicity included two cases of pneumonitis, which resolved with conservative therapy. Conclusion: High-dose conformal radiotherapy, in our experience, results in overall survival rates that compare favorably with trials of chemoradiotherapy or conventional radiotherapy with a low treatment-associated morbidity. However, local progression remains a significant problem despite median radiotherapy doses of 66 Gy. Future trials using escalating radiotherapy doses with conformal radiotherapy are therefore, indicated.