Stereotactic body radiation therapy (SBRT) for patients with stage I non-small cell lung cancer is applicable to more tumors than sublobar resection

Andrew J Song; Nathaniel Evans; Scott Cowan; Jenny Guo; Tingting Zhan; Bo Lu; Maria Werner-Wasik

doi:10.21037/jtd-20-2001

Stereotactic body radiation therapy (SBRT) for patients with stage I non-small cell lung cancer is applicable to more tumors than sublobar resection

J Thorac Dis. 2021 Mar;13(3):1576-1583. doi: 10.21037/jtd-20-2001.

Authors

Andrew J Song¹, Nathaniel Evans², Scott Cowan², Jenny Guo³, Tingting Zhan⁴, Bo Lu¹, Maria Werner-Wasik¹

Affiliations

¹ Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA.
² Department of Surgery, Division of Thoracic Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
³ Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA.
⁴ Department of Pharmacology & Experimental Therapeutics, Division of Biostatistics, Thomas Jefferson University, Philadelphia, PA, USA.

Abstract

Background: Virtually all patients with medically inoperable stage I non-small cell lung cancer (NSCLC) can receive stereotactic body radiation therapy. However, the percentage of such patients in whom sublobar resection is technically feasible is unknown. This discrepancy can confound clinical trial eligibility and designs comparing stereotactic body radiation therapy vs. sublobar resection.

Methods: A total of 137 patients treated with stereotactic body radiation therapy for lung lesions (3/2013-11/2017) underwent retrospective review. Diagnostic CT chest and PET/CT images, stereotactic body radiation therapy dates, and demographic data were collected on 100 of 137 patients. Two experienced board-certified thoracic surgeons independently reviewed anonymized patients' pre-stereotactic body radiation therapy diagnostic imaging and completed a custom survey about the technical feasibility of sublobar resection for each patient. Interrater agreement was measured using Cohen's kappa coefficient by bootstrap methodology. Summary statistics were performed for baseline demographics and tumor characteristics.

Results: Of the 100 patients, 57% were female, with median age of 75 years (range, 52-95 years) and Karnofsky Performance Status of 80 (range, 40-100). Most patients (61%) had Stage IA1, T1a tumors. For interrater agreement analysis, one patient was removed from each cohort due to inability to locate tumor on images, leaving 98 patients analyzed. Comparing Surgeon #1 vs. Surgeon #2, 64 (65.3%) vs. 69 (70.3%) of tumors were thought eligible for sublobar resection, respectively (κ=0.414).

Conclusions: Stereotactic body radiation therapy for stage I NSCLC is applicable to more tumors than sublobar resection, with ~30-35% of stereotactic body radiation therapy patients unable to undergo sublobar resection assessed by pretreatment diagnostic imaging based on technical grounds. This study illustrates that clinical trials comparing stereotactic body radiation therapy vs. sublobar resection are limited to only a subpopulation of patients with stage I NSCLC.

Keywords: Stereotactic body radiation therapy (SBRT); early stage non-small cell lung cancer (early stage NSCLC); segmentectomy; stereotactic ablative radiotherapy (SAbR); sublobar resection; wedge resection.