Fractionated palliative thoracic radiotherapy in non-small cell lung cancer – futile or worth-while?

Abstract

BackgroundPalliative thoracic radiotherapy (PTR) can relieve symptoms originating from intra-thoracic disease. The optimal timing and fractionation of PTR is unknown. Time to effect is 2 months. The primary aim of this retrospective study was to investigate survival after PTR, hypothesizing that a significant number of patients received futile fractionated PTR. The secondary aim was to find prognostic factors to guide treatment decisions.MethodsPatients with non-small-cell lung cancer (NSCLC) planned for PTR in the period of 2010-2011 at the University Hospital of Copenhagen were included. We noted pathology, tumor, node and metastasis (TNM) classification of malignant tumors, stage, indication, start date, schedule for PTR, completed y/n, performance status (PS) and time of death. Analyses were performed as an intention-to-treat using Cox regression, Fishers exact test and Kaplan Meier.ResultsA total of 159 patients were included. Median overall survival (OS) was 4.2 months. Sixteen patients (10%) did either not begin or finish PTR. Of these, eight (5%) died prior to or during PTR. Of the 151 patients receiving PTR, sixteen patients (11%) died within 14 days, thirty-three (22%) within 30 days and fifty (33%) within 2 months. PS 0-1 and squamous cell carcinoma were correlated with a better survival.ConclusionsOur study show that a significant number of patients who received PTR died before they could achieve optimal effect of the treatment. PS and histology were significant prognostic factors favoring PS 0-1 and squamous cell carcinoma. Based on our study, we suggest that patients with PS 0-1 should be considered for fractionated PTR whereas patients with PS ≥ 2 should be considered for high dose single fraction only or supportive palliative care.Electronic supplementary materialThe online version of this article (10.1186/s12904-017-0270-4) contains supplementary material, which is available to authorized users.

Palliative Lung Radiotherapy: Higher Dose Leads to Improved Survival?

“…The finding that performance status is significantly correlated with survival is in concordance with other survival analyses [ 12 , 15 , 17 ]. There has been less clarity as to the optimal fractionation scheme in order to increase survival in palliative lung radiotherapy.…”

“…Frank et al. [ 17 ] defined radiotherapy as futile if the patient dies less than 30 days after treatment, as the patient has not yet benefitted fully from the treatment but has still been exposed to the risks of radiotherapy-related acute toxicity [ 17 ]. This issue has been debated at RCR forums and a consensus agreed that there should be a target of under 20% of patients that die within 30 days of palliative radiotherapy [ 18 ].…”

“…There are predictive factors that have been investigated to guide the treatment decisions and give prognostic information in the context of palliative radiotherapy. From the literature, the following factors have been found to be significantly correlated with survival during multivariable analysis: T and N status, extrathoracic disease status, lactate dehydrogenase levels, completion of planned treatment, leukocyte count and C-reactive protein levels [ 10 , 12 , 13 , 17 , 19 , 20 ]. These factors have not been consistently examined through the literature and when included they are not always reproducibly significant and as such they are not incorporated in commonly used guidelines [ 14 , 15 , 21 ].…”

Long-term survival in patients with NSCLC treated with single fraction vs multi-fraction palliative radiotherapy in the case of lung tumor, brain metastases, and bone metastases.

“…In the investigated subgroup of patients with irradiation of bone metastases, no significant differences in OS were found. The choice of a single irradiation with a dose of 8 Gy in 1 fraction for bone metastases not only offers a similar OS, but also allows for further sessions of radiation therapy for the treatment of recurrent osteoarticular pain or improvement of neurological signs in cases of spinal cord compression, as well as for an effective reduction of symptoms caused by compression of neighboring organs by the tumor, bleeding or infiltration [12][13][14][15][16].…”

Gingival Metastasis of ALK Rearranged Non-Small Cell Lung Cancer

“…In our case, we introduced alectinib expecting longer survival and possibility of higher response rate than palliative radiotherapy, which is one of the treatment. Median OS of Palliative thoracic radiotherapy in NSCLC is known to be approximately 4–12 months [15]. The patient was able to undergo alectinib and showed good response to primary tumor and gingival metastasis, however intestinal metastasis showed progression causing bowel obstruction.…”