Elective nodal irradiation (ENI) vs. involved field radiotherapy (IFRT) for locally advanced non-small cell lung cancer (NSCLC): A comparative analysis of toxicities and clinical outcomes

Fernandes, Annemarie T.; Shen, Jason; Finlay, Jarod; Mitra, Nandita; Evans, Tracey; Stevenson, James; Langer, Corey; Lin, Lilie; Hahn, Stephen; Glatstein, Eli; Rengan, Ramesh

doi:10.1016/j.radonc.2010.02.007

« Previous Next »Radiotherapy & Oncology
Volume 95, Issue 2 , Pages 178-184, May 2010

Elective nodal irradiation (ENI) vs. involved field radiotherapy (IFRT) for locally advanced non-small cell lung cancer (NSCLC): A comparative analysis of toxicities and clinical outcomes

Annemarie T. Fernandes
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
- Corresponding author. Address: University of Pennsylvania, 3400 Spruce Street, 2 Donner, PA 19104, USA.
Jason Shen
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
Jarod Finlay
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
Nandita Mitra
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
Tracey Evans
- Department of Medical Oncology, University of Pennsylvania, Philadelphia, PA, USA
James Stevenson
- Department of Medical Oncology, University of Pennsylvania, Philadelphia, PA, USA
Corey Langer
- Department of Medical Oncology, University of Pennsylvania, Philadelphia, PA, USA
Lilie Lin
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
Stephen Hahn
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
Eli Glatstein
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
Ramesh Rengan
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA

Received 16 October 2009; received in revised form 3 February 2010; accepted 7 February 2010. published online 31 March 2010.

Abstract

Background

Elective nodal irradiation (ENI) and involved field radiotherapy (IFRT) are definitive radiotherapeutic approaches used to treat patients with locally advanced non-small cell lung cancer (NSCLC). ENI delivers prophylactic radiation to clinically uninvolved lymph nodes, while IFRT only targets identifiable gross nodal disease. Because clinically uninvolved nodal stations may harbor microscopic disease, IFRT raises concerns for increased nodal failures. This retrospective cohort analysis evaluates failure rates and treatment-related toxicities in patients treated at a single institution with ENI and IFRT.

Methods

We assessed all patients with stage III locally advanced or stage IV oligometastatic NSCLC treated with definitive radiotherapy from 2003 to 2008. Each physician consistently treated with either ENI or IFRT, based on their treatment philosophy.

Results

Of the 108 consecutive patients assessed (60 ENI vs. 48 IFRT), 10 patients had stage IV disease and 95 patients received chemotherapy. The median follow-up time for survivors was 18.9months. On multivariable logistic regression analysis, patients treated with IFRT demonstrated a significantly lower risk of high grade esophagitis (Odds ratio: 0.31, p=0.036). The differences in 2-year local control (39.2% vs. 59.6%), elective nodal control (84.3% vs. 84.3%), distant control (47.7% vs. 52.7%) and overall survival (40.1% vs. 43.7%) rates were not statistically significant between ENI vs. IFRT.

Conclusions

Nodal failure rates in clinically uninvolved nodal stations were not increased with IFRT when compared to ENI. IFRT also resulted in significantly decreased esophageal toxicity, suggesting that IFRT may allow for integration of concurrent systemic chemotherapy in a greater proportion of patients.

Keywords: Involved field radiotherapy, Elective nodal irradiation, Non-small cell lung cancer, Definitive radiotherapy, Mediastinal lymph nodes