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Stereotactic radiotherapy, wedge resection options for borderline operable NSCLC
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Outcomes including recurrence and distant metastasis were similar between patients with “borderline operable” non–small cell lung cancer treated with stereotactic body radiation or wedge resection. Both may be reasonable treatment options for patients with stage I non–small cell lung cancer ineligible for lobectomy, according to the results of a study published in The Journal of Clinical Oncology.
“These patients, considered to be medically inoperable, cannot tolerate the physical setbacks associated with chest surgery because of coexisting serious medical problems like severe emphysema, heart disease, or diabetes,” Robert D. Timmerman, MD, professor in the department of radiation oncology at the University of Texas Southwestern Medical Center, Dallas, wrote in an accompanying editorial.
“Results from prospective reports from centers across several continents have consistently shown that stereotactic body radiation is both highly effective at controlling the primary tumor while avoiding serious toxicity, even in this most vulnerable population,” he wrote.
The researchers hypothesized that if stereotactic body radiation could replace surgery it would be in patients who were borderline surgical candidates where a wedge resection might be performed in place of a full lobectomy.
To compare the two therapies, the researchers examined data from 69 patients treated with wedge resection and 58 patients treated with stereotactic body radiation therapy.
No difference in outcome
There were no statistically significant differences between groups for 30-month regional recurrence, locoregional recurrence, distant metastasis or freedom from any failure.
Researchers found a trend toward reduced local recurrence in the stereotactic body radiation group vs. the wedge resection group (4% vs. 20%; P=.07).
OS was longer in the wedge resection group compared with the stereotactic body radiation group (87% vs. 72%, P=.01). However, cause-specific survival was similar with wedge resection and stereotactic body radiation (94% vs. 93%; P=.53).
Excluding all cases of pathologic T4 disease, nonbiopsied tumors and patients with presumed synchronous primary tumors, an analysis indicated that differences in local recurrence, locoregional recurrence and regional recurrence were statistically significant — with better outcomes noted for stereotactic body radiation.
In this group, local recurrence was 5% with radiation vs. 24% with resection (P=.05); locoregional recurrence was 5% with radiation vs. 29% with resection (P=.03); and regional recurrence was 0% with radiation vs. 18% (P=.07) with resection.
Practice changing?
“As unlikely as it might have seemed even 10 years ago, it seems that surgery indeed has a potential rival as the gold-standard therapy for early stage lung cancer,” Timmerman wrote.
However, in a second editorial Nasser K. Altorki, MD, professor of thoracic surgery at New York-Presbyterian Hospital/Weill Cornell Medical Center, wrote, “While this report adds to the burgeoning body of literature supporting the safety and efficacy of stereotactic body radiation, it does not accomplish its primary objective of adequately comparing outcomes of the two modalities in question. …The challenge will not only be the comparative analysis of efficacy of these two modalities, but tailoring treatment to the individual patients along the same lines of personalizing drug therapy in patients with advanced disease.”
Timmerman agreed, “Our job then as thoracic oncologists is neither to valiantly protect turf nor aggressively unseat the champion but rather to carry out valid clinical scientific experiments to appropriately characterize the best role for each therapy.”
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