Association of Long-term Outcomes and Survival With Multidisciplinary Salvage Treatment for Local and Regional Recurrence After Stereotactic Ablative Radiotherapy for Early-Stage Lung Cancer

Abstract

Importance Stereotactic ablative radiotherapy (SABR) is first-line treatment for patients with early-stage non–small cell lung cancer (NSCLC) who cannot undergo surgery. However, up to 1 in 6 such patients will develop isolated local recurrence (iLR) or isolated regional recurrence (iRR). Little is known about outcomes when disease recurs after SABR, or about optimal management strategies for such recurrences. Objective To characterize long-term outcomes for patients with iLR or iRR after SABR for early-stage NSCLC with the aim of informing treatment decision making for these patients with potentially curable disease. Design, Setting, and Participants In this cohort study, a retrospective review was conducted of 912 patients prospectively enrolled in an institutional database at a tertiary cancer center from January 1, 2004, through December 31, 2014. Main Outcomes and Measures Overall survival, progression-free survival, recurrence patterns, demographics, salvage techniques, patterns of salvage failure, and toxic effects. Results Of the 912 patients in the study (456 women and 456 men; median age, 72 years [range, 46-91 years]), 756 (82.9%) had T1 tumors at initial diagnosis; 502 tumors (55.0%) were adenocarcinomas and 309 tumors (33.9%) were squamous cell carcinomas. Of 912 patients with early-stage I to II NSCLC who received definitive SABR (50 Gy in 4 fractions or 70 Gy in 10 fractions), 102 developed isolated recurrence (49 with iLR and 53 with iRR), and 658 had no recurrence. Median times to recurrence after SABR were 14.5 months (range, 1.5-60.8 months) for iLR and 9.0 months (range, 1.9-70.7 months) for iRR; 39 of 49 patients (79.6%) with iLR and 48 of 53 patients (90.6%) with iRR underwent salvage with reirradiation, surgery, thermal ablation, or chemotherapy. Median follow-up times for patients with iLR or iRR were 57.2 months (interquartile range, 37.7-87.6 months) from initial SABR and 38.5 months (interquartile range, 19.9-69.3 months) from recurrence. Rates of overall survival at 5 years from initial SABR were no different between patients with iLR and salvage treatment (57.9%) and patients with no recurrence (54.9%; hazard ratio, 0.89; 95% CI, 0.56-1.43; P = .65) but were lower for patients with iRR and salvage treatment (31.1%; hazard ratio, 1.43; 95% CI, 1.00-2.34; P = .049). Patients receiving salvage treatment had longer overall survival than patients who did not (median, 37 vs 7 months after recurrence; hazard ratio, 0.40; 95% CI, 0.09-0.66; P = .006). Twenty-four of 87 patients (27.6%) who received salvage treatment for iLR or iRR subsequently developed distant metastases. No patient experienced grade 5 toxic effects after salvage treatment. Conclusions and Relevance Life expectancy after salvage treatment for iLR was similar to that for patients without ...

Stereotactic Body Radiation Therapy Versus Nonradiotherapeutic Ablative Procedures (Laser/Cryoablation and Electrocautery) for Early-Stage Non–Small Cell Lung Cancer

“…However, despite the flawed methodologies in other such studies, we posit that TAPs can be excellent alternatives to SBRT in the re-irradiation setting for post-SBRT isolated local recurrences. 27 Overall, limitations in this work are varied. Foremost, despite use of multivariate analyses and propensity matching, the retrospective design of this study never entirely eliminates the presence of potential bias that cannot be accounted for.…”

Predicting 5-Year Progression and Survival Outcomes for Early Stage Non-small Cell Lung Cancer Treated with Stereotactic Ablative Radiation Therapy: Development and Validation of Robust Prognostic Nomograms

“…Given that 30% of patients with ES-NSCLC can experience regional or distant progression after SABR, there is likely utility for integrating additional systemic therapy alongside SABR alone. 2,4 At the same time, previous studies 21 have demonstrated that widespread utilization of adjuvant chemotherapy, in the absence of appropriate candidate selection, can detrimentally affect patient outcomes. Therefore, the ability to select patients at high risk of recurrence (who would benefit most from combining systemic therapy with SABR) is essential.…”

“…1 However, clinical outcomes after SABR for ES-NSCLC vary significantly between different studies: 3year overall survival (OS) ranges from 37% to 72%, and recurrence rates vary between 18% and 29%. [2][3][4] Yet as we transit further into the era of personalized medicine, the ability to accurately predict the prognosis of these patients is essential to guide individualized clinical decision making.…”

Microwave Ablation in Primary Lung Malignancies

“…50 Studies have highlighted the usefulness of percutaneous ablation in addressing local recurrence of NSCLC within a radiation field, 51 with a newer study showing that percutaneous ablation is useful in addressing local recurrence following SBRT. 52 In this retrospective study, the authors concluded that patients who received salvage treatment for local recurrence (which included percutaneous ablation) showed similar life expectancy to patients who did not show local recurrence, which again questions the significance of local recurrence if the treatment can be repeated. 52 Percutaneous ablation has also been recently proven to be useful in patients with epidermal growth factor receptor mutant NSCLC who experience oligoprogression while on tyrosine kinase inhibitors (TKIs).…”

“…52 In this retrospective study, the authors concluded that patients who received salvage treatment for local recurrence (which included percutaneous ablation) showed similar life expectancy to patients who did not show local recurrence, which again questions the significance of local recurrence if the treatment can be repeated. 52 Percutaneous ablation has also been recently proven to be useful in patients with epidermal growth factor receptor mutant NSCLC who experience oligoprogression while on tyrosine kinase inhibitors (TKIs). 53 These patients typically progress through the development of acquired resistance in one or few distant sites from the original tumor, and a study on 71 of these patients showed that percutaneous ablation provided an additional 10 months of disease control when combined with continuous TKI treatment.…”