SBRT vs Wedge resection (retrospective)

This weeks JCO:

A retrospective comparison of wedge resection and SBRT for stage I NSCLC is reported by Beaumont. They find improved local and regional recurrence rates with SBRT, similar cause specific survival, and worse OS in with SBRT. They explain the worse OS by patient selection (i.e. the healthier patients were taken for wedge).

I think from this, you see a signal that SBRT seems at least equivalent to wedge and potentially less toxic. I think it is hard to say that it is superior for local control, because if one is censoring out the patients who die (as one does in with the local control endpoint), the more patients die from other causes, the less events are possible for local failure. Thus the LRC may have been higher with SBRT due to the lower OS. In addition the followup was not as long for SBRT patients.

Regardless, this is an interesting paper, and supports the use of SBRT in medically inoperable patients.

Link and Abstract:

Outcomes After Stereotactic Lung Radiotherapy or Wedge Resection for Stage I Non-Small-Cell Lung Cancer [Thoracic Oncology]: "Purpose

To compare outcomes between lung stereotactic radiotherapy (SBRT) and wedge resection for stage I non–small-cell lung cancer (NSCLC).

Patients and Methods

One hundred twenty-four patients with T1-2N0 NSCLC underwent wedge resection (n = 69) or image-guided lung SBRT (n = 58) from February 2003 through August 2008. All were ineligible for anatomic lobectomy; of those receiving SBRT, 95% were medically inoperable, with 5% refusing surgery. Mean forced expiratory volume in 1 second and diffusing capacity of lung for carbon monoxide were 1.39 L and 12.0 mL/min/mmHg for wedge versus 1.31 L and 10.14 mL/min/mmHg for SBRT (P = not significant). Mean Charlson comorbidity index and median age were 3 and 74 years for wedge versus 4 and 78 years for SBRT (P < .01, P = .04). SBRT was volumetrically prescribed as 48 (T1) or 60 (T2) Gy in four to five fractions.

Results

Median potential follow-up is 2.5 years. At 30 months, no significant differences were identified in regional recurrence (RR), locoregional recurrence (LRR), distant metastasis (DM), or freedom from any failure (FFF) between the two groups (P > .16). SBRT reduced the risk of local recurrence (LR), 4% versus 20% for wedge (P = .07). Overall survival (OS) was higher with wedge but cause-specific survival (CSS) was identical. Results excluding synchronous primaries, nonbiopsied tumors, or pathologic T4 disease (wedge satellite lesion) showed reduced LR (5% v 24%, P = .05), RR (0% v 18%, P = .07), and LRR (5% v 29%, P = .03) with SBRT. There were no differences in DM, FFF, or CSS, but OS was higher with wedge.

Conclusion

Both lung SBRT and wedge resection are reasonable treatment options for stage I NSCLC patients ineligible for anatomic lobectomy. SBRT reduced LR, RR, and LRR. In this nonrandomized population of patients selected for surgery versus SBRT (medically inoperable) at physician discretion, OS was higher in surgical patients. SBRT and surgery, however, had identical CSS.

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