International Journal of Radiation Oncology*Biology*Physics
Clinical investigationLungSelective mediastinal node irradiation based on FDG-PET scan data in patients with non–small-cell lung cancer: A prospective clinical study
Introduction
In recent years, the prognosis of patients with non-small-cell lung cancer (NSCLC) has significantly improved (1, 2, 3, 4). This has mainly been because of a better integration of chemotherapy and radiotherapy, more effective drugs, and improvements in radiotherapy schedules. Local tumor failure still occurs in the overwhelming majority of patients, but radiation-induced esophagitis and pneumonitis are common dose-limiting toxicities. Thus, dose escalation or intensification, which might be needed to improve the prognosis, is not straightforward, and approaches to decrease toxicity are therefore of great clinical interest.
An obvious way to reduce toxicity due to radiotherapy is to reduce the volume of dose-limiting organs, such as the lungs and esophagus, included in the planning target volume (PTV). Previous studies have shown that it is safe to irradiate only mediastinal lymph nodes enlarged on the CT scan, hence omitting elective nodal irradiation, with <5% of patients experiencing an isolated nodal failure (5, 6, 7, 8, 9, 10). Because the diagnostic accuracy of the mediastinal staging is better with 18F-deoxy-D-glucose (FDG) positron emission tomography (PET) than with CT scan, we hypothesized that irradiating only the FDG-positive mediastinal areas in patients suffering from NSCLC would not result in a higher incidence of isolated nodal failure (11, 12, 13, 14, 15). Moreover, in a previous theoretical modeling study (16), we showed that selective irradiation of FDG-PET-positive mediastinal areas would result in smaller radiation fields than those based on CT scan data, leading to less morbidity and hence allowing dose escalation. We therefore initiated a prospective clinical Phase I/II study to investigate whether selective irradiation of the FDG-PET-positive mediastinal areas would be safe and whether radiation dose escalation in a short overall treatment would be feasible.
Section snippets
Patient population
The entry criteria were as follows: cytologically or histologically proved NSCLC, with the exclusion of mixed pathology between NSCLC and small-cell cancer and bronchioloalveolar carcinoma; Union Internationale Contre Cancer Stages I–III, with the exclusion of T4 lesions because of a malignant pleural effusion; World Health Organization performance status 0–1; measurable disease; age ≥18 years; adequate pulmonary function (forced expiratory volume in 1 s > 1 L); no severe recent cardiac disease
Patient characteristics
From November 2001 to December 2003, 44 patients were entered in the study. Their characteristics are summarized in Table 1. The median age was 68 years (range, 51–89 years). All patients were in a good general condition (100% World Health Organization performance status 0 or 1), with a preponderance of men (61%). All patients had to have no detectable distant metastases both on CT and on FDG-PET scan, but because of the latter the mediastinal staging changed in 11 of 44 patients (25%; 95% CI,
Discussion
To the best of our knowledge, this is the first clinical study reporting on selective mediastinal irradiation based on FDG-PET scan data in patients with NSCLC. The rationale is obvious: The diagnostic accuracy for the staging of the mediastinum with the FDG-PET scan is higher than with the CT scan; thus, it is more logical to delineate the mediastinal lymph node areas for radiotherapy based on FDG-PET rather than on CT scan data (11, 12, 13, 14, 15). With a follow-up time sufficient to detect
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