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Reirradiation of recurrent node-positive non-small cell lung cancer after previous stereotactic radiotherapy for stage I disease

A multi-institutional treatment recommendation

Rebestrahlung von wiederkehrendem lymphknotenpositiven nicht-kleinzelligem Bronchialkarzinom nach vorangegangener stereotaktischer Strahlentherapie im Stadium I

Eine multiinstitutionelle Behandlungsempfehlung

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Abstract

Background

Practice guidelines have been developed for early-stage and locally advanced non-small cell lung cancer (NSCLC). However, many common clinical scenarios still require individualized decision making. This is true for locoregional relapse after initial stereotactic radiotherapy (stereotactic body radiation therapy or stereotactic ablative radiotherapy; SBRT or SABR), an increasingly utilized curative treatment option for stage I NSCLC.

Methods

A consortium of expert radiation oncologists was established with the aim of providing treatment recommendations. In this scenario, a case was distributed to six radiation oncologists who provided their institutions’ treatment recommendations. In this case, a patient developed local and mediastinal relapse after SABR (45 Gy, 3 fractions), comparable to the tumor burden in de novo stage IIIA NSCLC. Treatment recommendations were tabulated and a consensus conclusion was developed.

Results

Three institutions recommended evaluation for surgery. If the patient was not a surgical candidate, and/or refused surgery, definitive chemoradiation was recommended, including retreating the primary to full dose. European participants were more in favor of a non-surgical approach. None of the participants were reluctant to prescribe reirradiation, but two institutions prescribed doses lower than 60 Gy. Platinum-based doublets together with intensity-modulated radiotherapy were preferred.

Conclusion

The institutional recommendations reflect the questions and uncertainties discussed in current stage III guidelines. All institutions agreed that previous SABR is not a contraindication for salvage chemoradiation. In the absence of high-quality prospective trials for recurrent NSCLC, all treatment options recommended in current guidelines for stage III disease can be considered in clinical scenarios such as this.

Zusammenfassung

Hintergrund

Für frühe und lokal fortgeschrittene Stadien des nicht-kleinzelligen Bronchialkarzinoms (NSCLC) wurden Behandlungsleitlinien publiziert. Dennoch erfordern einige klinische Situationen individuelle Entscheidungen. Dazu gehört ein lokoregionales Rezidiv nach stereotaktischer Strahlentherapie (SABR), einer Modalität, die immer öfter im Stadium I angewandt wird.

Methoden

Eine Expertengruppe wurde etabliert, um Empfehlungen zur Rezidivbehandlung zu erarbeiten. Insgesamt 6 Radioonkologen brachten die Behandlungsempfehlungen ihrer Institution ein. In dem Fall entwickelte ein Patient ein Lokal- und Mediastinalrezidiv nach SABR (45 Gy, 3 Fraktionen), vergleichbar mit der Ausbreitung beim De-novo-NSCLC im Stadium IIIA. Empfehlungen wurden in Tabellen verglichen und ein Konsensus wurde ausgearbeitet.

Ergebnisse

Drei Institutionen empfahlen eine chirurgische Konsultation. Kam eine Operation nicht infrage oder wurde vom Patienten abgelehnt, empfahlen sie eine definitive Radiochemotherapie, einschließlich einer erneuten Behandlung des Primärtumors mit der vollen Dosis. Europäische Teilnehmer bevorzugten eine konservative Therapie. Keiner der Teilnehmer war zurückhaltend, eine Rebestrahlung zu verschreiben, aber zwei Institutionen wählten Gesamtdosen <60 Gy. Platinbasierte Kombinationen mit intensitätsmodulierter Strahlentherapie wurden bevorzugt.

Schlussfolgerung

Die Empfehlungen der beteiligten Zentren reflektieren die Kontroversen und Unsicherheiten der aktuellen Leitlinien für das Stadium III. Alle Institutionen waren einig, dass eine initiale SABR keine Kontraindikation für eine Salvage-Radiochemotherapie darstellt. Solange keine prospektiven Daten für rezidivierte NSCLC vorliegen, können in klinischen Szenarien, wie dem hier geschilderten, alle Behandlungsoptionen der Leitlinien für das Stadium III erwogen werden.

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Authors and Affiliations

  1. Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway

    Carsten Nieder MD

  2. Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway

    Carsten Nieder MD

  3. Department of Radiation Oncology, MAASTRO Clinic, Maastricht, The Netherlands

    Dirk De Ruysscher MD

  4. Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA

    Laurie E. Gaspar MD

  5. Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland

    Matthias Guckenberger MD

  6. Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA

    Minesh P. Mehta MD

  7. Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada

    Patrick Cheung MD & Arjun Sahgal MD

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  1. Carsten Nieder MD
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  3. Laurie E. Gaspar MD
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Correspondence to Carsten Nieder MD.

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Conflict of interest

C. Nieder, D. De Ruysscher, L.E. Gaspar, M. Guckenberger, M.P. Mehta, P. Cheung, and A. Sahgal declare that they have no competing interests.

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Nieder, C., De Ruysscher, D., Gaspar, L.E. et al. Reirradiation of recurrent node-positive non-small cell lung cancer after previous stereotactic radiotherapy for stage I disease. Strahlenther Onkol 193, 515–524 (2017). https://doi.org/10.1007/s00066-017-1130-0

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