DART-bid for loco-regionally advanced NSCLC: Summary of acute and late toxicity with long-term follow-up; experiences with pulmonary dose constraints

• Published in: Strahlentherapie und Onkologie 2017-04, Vol.193 (4), p.315-323
• Main Authors: Wurstbauer, Karl, Zehentmayr, Franz, Deutschmann, Heinz, Dagn, Karin, Exeli, Ann-Katrin, Kopp, Peter, Porsch, Peter, Maurer, Birgit, Studnicka, Michael, Sedlmayer, Felix
• Format: Article
• Language: English
• Subjects: Acute Disease; Adult; Aged; Aged, 80 and over; Austria - epidemiology; Carcinoma, Non-Small-Cell Lung - mortality; Carcinoma, Non-Small-Cell Lung - pathology; Carcinoma, Non-Small-Cell Lung - radiotherapy; Disease-Free Survival; Dose Hypofractionation; Dose-Response Relationship, Radiation; Female; Humans; Lung Neoplasms - mortality; Lung Neoplasms - pathology; Lung Neoplasms - radiotherapy; Male; Medicine; Medicine & Public Health; Middle Aged; Neoplasm Recurrence, Local - mortality; Neoplasm Recurrence, Local - pathology; Neoplasm Recurrence, Local - prevention & control; Neoplasm Staging; Oncology; Organ Sparing Treatments - mortality; Original; Original Article; Prevalence; Prognosis; Radiation Injuries - mortality; Radiation Injuries - prevention & control; Radiation Protection - methods; Radiotherapy; Radiotherapy Dosage; Risk Assessment; Survival Rate; Treatment Outcome
• ISSN: 0179-7158; 1439-099X
• DOI: 10.1007/s00066-016-1095-4

Background To report acute and late toxicity with long-term follow-up, and to describe our experiences with pulmonary dose constraints. Methods Between 2002 and 2009, 150 patients with 155 histologically/cytologically proven non-small cell lung cancer (NSCLC; tumor stages II, IIIA, IIIB in 6, 55 and 39%, respectively) received the following median doses: primary tumors 79.2 Gy (range 72.0–90.0 Gy), lymph node metastases 59.4 Gy (54.0–73.8 Gy), nodes electively 45 Gy; with fractional doses of 1.8 Gy twice daily (bid). In all, 86% of patients received 2 cycles of chemotherapy previously. Results Five treatment-related deaths occurred: pneumonitis, n  = 1; progressive pulmonary fibrosis in patients with pre-existing pulmonary fibrosis, n  = 2; haemorrhage, n  = 2. In all, 8% of patients experienced grade 3 and 1.3% grade 4 pneumonitis; 11% showed late fibrotic alterations grade 2 in lung parenchyma. Clinically relevant acute esophagitis (grade 2 and 3) was seen in 33.3% of patients, 2 patients developed late esophageal stenosis (G3). Patients with upper lobe, middle lobe and central lower lobe tumours ( n  = 130) were treated with V20 (total lung) up to 50% and patients with peripheral lower lobe tumours ( n  = 14, basal lateral tumours excluded) up to 42%, without observing acute or late pulmonary toxicity >grade 3. Only patients with basal lateral lower lobe tumours ( n  = 5) experienced grade 4/5 pulmonary toxicity; V20 for this latter group ranged between 30 and 53%. The mean lung dose was below the QUANTEC recommendation of 20–23 Gy in all patients. The median follow-up time of all patients is 26.3 months (range 2.9–149.4) and of patients alive 80.2 months (range 63.9–149.4.). The median overall survival time of all patients is 26.3 months; the 2-, 5- and 8‑year survival rates of 54, 21 and 15%, respectively. The local tumour control rate at 2 and 5 years is 70 and 64%, the regional control rate 90 and 88%, respectively. Discussion and conclusion Grade 4 or 5 toxicity occurred in 7/150 patients (4.7%), which can be partially avoided in the future (e.g. by excluding patients with pre-existing pulmonary fibrosis). Tolerance and oncologic outcome compare favourably to concomitant chemoradiation also in long-term follow-up.