Outcomes of invasive mediastinal nodal staging versus positron emission tomography staging alone for early-stage non-small cell lung cancer treated with stereotactic body radiation therapy

Caitlin A Schonewolf; Vivek Verma; Carl M Post; Abigail T Berman; Melissa A Frick; Anil Vachani; Chi Lin; Charles B Simone 2nd

doi:10.1016/j.lungcan.2017.07.005

Outcomes of invasive mediastinal nodal staging versus positron emission tomography staging alone for early-stage non-small cell lung cancer treated with stereotactic body radiation therapy

Lung Cancer. 2018 Mar:117:53-59. doi: 10.1016/j.lungcan.2017.07.005. Epub 2017 Jul 14.

Authors

Caitlin A Schonewolf¹, Vivek Verma², Carl M Post², Abigail T Berman¹, Melissa A Frick¹, Anil Vachani³, Chi Lin², Charles B Simone 2nd⁴

Affiliations

¹ Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
² Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA.
³ Department of Medicine, Division of Pulmonology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
⁴ Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA. Electronic address: charlessimone@umm.edu.

PMID: 28800837
DOI: 10.1016/j.lungcan.2017.07.005

Abstract

Background: The benefit of invasive mediastinal nodal staging (IMNS) in addition to positron emission tomography-computed tomography (PET/CT) is undefined for early stage non-small cell lung cancer (NSCLC). This multi-institutional investigation aimed to evaluate outcomes and patterns of failure in patients staged with PET/CT with or without additional IMNS.

Methods: Two academic centers assessed all consecutive patients staged with PET/CT for early-stage, primary lung NSCLC (cT1-2aN0M0) treated with SBRT. Local recurrence-free survival (LRFS), nodal recurrence-free survival (NRFS), distant metastasis-free survival (DMFS), and overall survival (OS) were calculated using Kaplan-Meier methodology. Univariate and multivariate Cox proportional hazards modeling addressed factors associated with outcomes.

Results: Overall, 180 patients (199 lesions) were staged with PET/CT alone and 56 patients (58 lesions) underwent additional IMNS. Among patients receiving IMNS, 52 (93%) underwent EBUS and 4 (7%) underwent mediastinoscopy. At a median follow-up of 33.5 months (range, 1.9-80.9 months), there was no significant difference in LRFS (37 vs. 47 months, p=0.309), NRFS (34 vs. 42 months p=0.370), DMFS (36 vs. 47 months, p=0.234) or OS (37 vs. 47 months, p=0.236) between patients undergoing PET/CT-only versus PET/CT+IMNS staging, respectively. Receipt of IMNS did not correlate with any outcome on either univariate or multivariate analysis (p>0.05). Patterns of failure in both groups were similar, including crude isolated nodal failure rates (8% PET/CT-only versus 14% PET+IMNS group, p=0.202).

Conclusions: Patients undergoing IMNS had similar survival and patterns of recurrence as those receiving PET/CT alone. Further study, ideally prospectively, is needed to determine which subgroups might benefit from IMNS.

Keywords: Endobronchial ultrasound; Mediastinoscopy; Non-small cell lung cancer; Positron emission tomography; Stereotactic ablative radiotherapy; Stereotactic body radiation therapy.

MeSH terms

Aged
Aged, 80 and over
Carcinoma, Non-Small-Cell Lung / diagnosis*
Carcinoma, Non-Small-Cell Lung / mortality
Carcinoma, Non-Small-Cell Lung / radiotherapy
Early Diagnosis
Female
Follow-Up Studies
Humans
Lung / diagnostic imaging*
Lung Neoplasms / diagnosis*
Lung Neoplasms / mortality
Lung Neoplasms / radiotherapy
Lymph Nodes / pathology*
Lymph Nodes / surgery
Male
Mediastinum / pathology*
Mediastinum / surgery
Middle Aged
Neoplasm Staging
Positron Emission Tomography Computed Tomography / methods*
Radiosurgery
Survival Analysis
Treatment Outcome