186 Incidental dose to clinically negative nodes from conformal treatment fields for nonsmall cell lung cancer

Martel, Mary K.; Sahijdak, Walter M.; Hayman, James A.; Ball, D.

doi:10.1016/s0360-3016(99)90204-3

Cited by 43 publications

(11 citation statements)

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“…Martel et al [14] confirmed meaningful doses of incidental irradiation in the treatment of the omitted LNS in ten stage III patients. The doses 50 Gy were given to 100% of the volume of the ipsilateral hilum and to 96% of subcarinal region.…”

Section: Discussionmentioning

confidence: 87%

“…In our study, a substantial percentage of patients had too low doses delivered for particular LNS (B40 Gy), because of a discrepancy between initial CTV delineation and a new definition of the borders of LNS according to the recommendations (data not shown). Other reports on incidental irradiation have also failed to solve this problem, reporting on doses for poorly defined regions of the mediastinum [8,14].…”

Section: Discussionmentioning

confidence: 99%

“…Published data on incidental irradiation in radiotherapy for lung cancer are scarce, based on small patient groups and with no deep consideration of either dosimetric/technical aspects of radiotherapy, or the tumor characteristics [8,13,14] the borders of mediastinal and hilar LNS in the CT has produced an opportunity for detailed reporting on the intended and non-intended doses received by particular LNS. Information about an amount of incidental irradiation in different clinical and technical settings may help clinicians construct the ENI volumes which would be smaller than ones traditionally utilized in view of the improvement of the therapeutic ratio.…”

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Incidental irradiation of mediastinal and hilar lymph node stations during 3D-conformal radiotherapy for non-small cell lung cancer

et al. 2008

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To estimate the doses of incidental irradiation in particular lymph node stations (LNS) in different extents of elective nodal irradiation (ENI) in 3D-conformal radiotherapy (3D-CRT) for non-small cell lung cancer (NSCLC). Methods. Doses of radiotherapy were estimated for particular LNS delineated according to the recommendations of the University of Michigan in 220 patients treated using 3D-CRT with different (extended, limited and omitted) extents of ENI. Minimum doses and volumes of LNS receiving 40 Gy or more (V 40 ) were compared for omitted vs. limited' extended ENI and limited vs. extended ENI. Results. For omission of the ENI the minimum doses and V 40 for particular LNS were significantly lower than for patients treated with ENI. For the limited ENI group, the minimum doses for LNS 5, 6 lower parts of 3A and 3P (not included in the elective area) did not differ significantly from doses given to respective LNS for extended ENI group. When the V 40 values for extended and limited ENI were compared, no significant differences were seen for any LNS, except for group 1/2R, 1/2L. Conclusions. Incidental irradiation of untreated LNS seems play a part in case of limited ENI, but not in cases without ENI. For subclinical disease the delineation of uninvolved LNS 5, 6, and lower parts of 3A, 3P may be not necessary, because these stations receive the substantial part of irradiation incidentally, if LNS 4R, 4L, 7, and ipsilateral hilum are included in the elective area while this is not case for stations 1 and 2.There is increasing evidence, derived especially from dose escalation studies that the omission of elective nodal irradiation (ENI) in radiotherapy of non-small cell lung cancer (NSCLC) results in a low incidence of isolated nodal failures (INF) [1Á 10]. The prerequisite for reporting on the incidence of INF after radiotherapy with the omission of ENI is an evaluation of incidental irradiation received by omitted nodal stations. In some cases the incidental irradiation may be enough to eradicate subclinical nodal disease [11]. Thus, although regional nodes are not purposefully included into the clinical target volume, they might actually receive elective irradiation. In the previous analysis of our data [12], the two-year cumulative incidence of INF for 185 patients treated with 3-dimensional conformal radiotherapy (3D-CRT) and different (limited or extended) extents of ENI was 12%.INF was defined as a regional failure occurring outside gross tumor volume (GTV) without previous or synchronous local progression regardless of the distant metastases status. There was no difference in the cumulative incidence of INF for patients treated with extended and limited mediastinal ENI. One of the possible explanations of this finding is that the incidental irradiation may play a role in the limited ENI.The low incidence of INF reported in the dose escalation studies may be related to the unintended dose received by lymph node stations (LNS) at risk. Published data on incidental irradiation in radiotherapy for lung c...

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Section: Discussionmentioning

confidence: 87%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Incidental irradiation of mediastinal and hilar lymph node stations during 3D-conformal radiotherapy for non-small cell lung cancer

et al. 2008

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“…The main arguments for omitting ENI are as follows: when routine broncoscopy is performed after radiotherapy in locally advanced NSCLC, <20% of patients are controlled at 1 year [15]; the incidence of nodal progression in untreated mediastinal nodes is <6% [10][11][12][13]; in a combined chemotherapy-radiotherapy strategy, if chemotherapy is effective as a systemic therapy, it is reasonably to hypothesize that it may also control occult microscopical nodal disease [14]; mediastinal areas located in the proximity of the PTV often receive sufficient radiation doses for the treatment of occult metastases [16].…”

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Multimodality treatment in locally advanced non-small cell lung cancer

Trodella

D’Angelillo²,

Ramella³

et al. 2006

Annals of Oncology

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Prognosis in patients with locally advanced non-small cell lung cancer (NSCLC) is poor (five year survival rate of 5% [1]). Radiotherapy (RT), chemotherapy (CT) and surgery (S), as single modality therapeutical approaches are unable to eradicate locoregional disease and to control systemic microscopic disease.Concurrent chemoradiation (CTRT) is at present time deemed to be the standard of care for inoperable locally advanced NSCLC [2]. In randomized trials this modality treatment has increased median survival from fourteen months of sequential approach to 17 months [3][4][5][6][7].Nowadays, new evidences underline the role of a mixed approach with concurrent radio-chemotherapy followed by consolidation chemotherapy [3,8].In SWOG 9504, mixed approach using concurrent radiochemotherapy followed by consolidation docetaxel showed a median survival of 26 months with a 3-year survival of 37%, better than the results of previous SWOG 9014 [7] where the concurrent approach was the only performed.Using carboplatin-paclitaxel chemotherapy, the LAMP study [3] confirmed a better survival of consolidation chemotherapy (16.3 months) vs. induction chemotherapy (12.7 months), but pointed out two major problems in treating these kinds of patients: non-haematological toxicity registered during radiochemotherapy (28% of grade 3+ oesophageal toxicity), and subsequently, compliance to planned treatment (only 67% of patients completed the concurrent CTRT and among these 75% received the full chemotherapy dose).Higher rates of non-haematological toxicity have reported in the CALGB 9431 [9], where in the concurrent radiochemotherapy grade 3+ toxicity ranged from 25 to 52% for oesophageal toxicity and 14-24% for the pulmonary one.In the light of these results, toxicity, particularly nonhemathological toxicity, remains a major obstacle in treating patients with radio-chemotherapy.A better toxicity profile could be reasonably achieved reducing the irradiating volume.Besides, several authors underlines that despite the high risk of nodal spread in lung cancer, the value of inclusion of ENI is not proven and very little is known about its effectiveness. [10][11][12][13][14].The main arguments for omitting ENI are as follows: when routine broncoscopy is performed after radiotherapy in locally advanced NSCLC, <20% of patients are controlled at 1 year [15]; the incidence of nodal progression in untreated mediastinal nodes is <6% [10][11][12][13]; in a combined chemotherapy-radiotherapy strategy, if chemotherapy is effective as a systemic therapy, it is reasonably to hypothesize that it may also control occult microscopical nodal disease [14]; mediastinal areas located in the proximity of the PTV often receive sufficient radiation doses for the treatment of occult metastases [16].An emerging role of concurrent radio-chemotherapy is in the neoadjuvant setting.Recently, results of the Intergroup Phase III trial 0139 (RTOG 93-09) [17], have been presented at ASCO in 2005. 396 patients with mediastinoscopy-proven IIIAN2 NSCLC, were randomized to re...

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Radiation therapy alone in early stage non‐small cell lung cancer

Zimmermann

Bamberg

Molls

et al. 2003

Seminars in Surgical Oncology

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Among the patients with early stage (I/II) non-small cell lung cancer (NSCLC), there are those who, due to medical comorbidities, advanced age, or refusal, never undergo surgery. For them, exclusive radiation therapy (RT) has been the treatment of choice, achieving median survival times of 30 months and 5-year survival of up to 42%. Doses of > or =65 Gy with standard fractionation (or its radiobiological equivalent when altered fractionation is used) are necessary for long-lasting local control of the disease, with smaller tumors having a more favorable prognosis. The issue of elective nodal irradiation (ENI) remains controversial, since failure patterns identified local failure as the predominant pattern. None of the potential pretreatment patient- and tumor-related prognostic factors has been shown to clearly influence survival. Toxicity is generally mild to moderate, although high doses (e.g., 80 Gy) may carry a risk for an excessive rate of side effects. Conformal treatment and consideration of comorbidities such as altered lung function may be essential, since simultaneous supportive treatment of acute sequelae (mainly acute esophagitis) is necessary. RT is an effective treatment modality in technically operable, but medically inoperable patients with early stage NSCLC and offers a long-lasting cure.

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186 Incidental dose to clinically negative nodes from conformal treatment fields for nonsmall cell lung cancer

Cited by 43 publications

References 0 publications

Incidental irradiation of mediastinal and hilar lymph node stations during 3D-conformal radiotherapy for non-small cell lung cancer

Incidental irradiation of mediastinal and hilar lymph node stations during 3D-conformal radiotherapy for non-small cell lung cancer

Multimodality treatment in locally advanced non-small cell lung cancer

Radiation therapy alone in early stage non‐small cell lung cancer

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