[Radiochemotherapy of non-small-cell bronchial carcinoma. A report of experience]. / Radiochemotherapie des nichtkleinzelligen Bronchialkarzinoms. Ein Erfahrungsbericht.

PURPOSE: To investigate the survival of patients with inoperable non-small-cell lung cancer treated with combined radiochemotherapy. Frequency of local progression versus systemic dissemination after radiotherapy respectively radiochemotherapy. Extend of the toxicity of a combined modality treatment. PATIENTS AND METHODS: 60 inoperable patients (42 M0- and 18 M1-stage) with non-small-cell lung cancer who had received combined radiochemotherapy (RT+CT) were examined retrospectively. Different drugs or drug combinations were used. The sequence of radiotherapy and chemotherapy also differed. The survival was compared to that of another group of patients who had received at least 50 Gy with definitive radiotherapy at the same period of time (RT: N = 135). The Karnofsky performance index (KPI) was on an average of 80% in both groups. The primary of patients with systemic disease was treated by radiation when it became symptomatic or when it showed an evident progression. RESULTS: The two investigated treatment groups were comparable regarding KPI, histology, stage, tumor dose and age. The survival was significantly better when chemotherapy was added to radiotherapy. The median survival times in months were as follows: M0: RT 10.6/RT+CT 14.7; M1: RT 6.0/ RT+CT 9.3. Local tumor control was the major problem with or without chemotherapy (local progression of about 70% in both groups). The toxicity of radiochemotherapy was acceptable (bone marrow toxicity WHO-grade 4: 10.5%: nausea WHO-grade 4: 3%). CONCLUSION: In the absence of medical contraindications and with a KPI of at least 70% a combined radiochemotherapy in patients with inoperable non-small-cell lung cancer seems to be possible even if high radiation doses are used. Randomized studies are necessary to prove the impact on survival of an additional chemotherapy.

[Usefulness of prophylactic whole brain irradiation in small-cell bronchial carcinoma]. / Der Nutzen der prophylaktischen Ganzhirnbestrahlung (PCI) beim kleinzelligen Bronchialkarzinom.

PURPOSE: An analysis of the incidence of brain metastases in small cell lung cancer, time of occurring during the course of disease, and the prognosis of these patients depending on the use of prophylactic cranial irradiation for three well defined patient groups. MATERIAL AND METHODS: A retrospective study included 133 unselected patients with histologically proven SCLC who were treated from 1985-1990 in our department. From these, 118 patients without CNS metastases at primary diagnosis were divided into three well defined patient groups: group I consisted of 23 patients who achieved a complete remission after primary therapy and who were subsequently treated with PCI, group II consisted of 23 patients in complete remission without PCI. Group III consisted of 72 patients without CNS metastases at the primary diagnosis and without PCI treatment since they did not achieve a complete response after primary therapy. The primary therapy consisted of combined radiochemotherapy or only chemotherapy. Sixteen patients were treated only by irradiation. RESULTS: The overall incidence of CNS metastases for all 133 patients was 33.1%. The incidence of new CNS metastases in group I was 21.7% in group II 26.1%, and in group III 22.2%. The average time to development of CNS metastases after primary diagnosis was different for the three groups: in group I 15.4 months, in group II 9.5 months and in group III 8.4 months. No statistical significance was noted. Median survival time for group I was 16.1 months, for group II 13.8 months and 8.4 months for the group III. No statistical significance was achieved between group I and II (P > 0.05). CONCLUSIONS: These data suggest that treatment with PCI appears to be ineffective in reducing the incidence of subsequently CNS metastases or to improve survival of SCLC patients. We recommend the use of PCI only in well defined clinical studies.

[Radiation pneumonitis and pulmonary fibrosis after the CT-planned radiotherapy of bronchial carcinoma]. / Strahlenpneumonitis und Lungenfibrose nach CT-geplanter Radiotherapie des Bronchialkarzinoms.

PURPOSE: Examination of the influence of total tumor dose, additional therapy and age on the development of radiation pneumonitis and lung fibrosis. PATIENTS AND METHODS: Two hundred and sixteen patients with squamous cell carcinoma of the lung were examined retrospectively. Hundred and eighty-three of them received a percutaneous radiation therapy of the primary tumor and the mediastinal and ipsilateral hilar lymph nodes. The majority of 130 patients was given radiotherapy as only treatment, 27 were irradiated after resection and 26 received chemo- and radiotherapy. Treatment volume was determined by three-dimensional planning using chest CT-scan. The irradiation was administered in a first series of 56 Gy and a following boost to the primary and involved lymph nodes to a total dose of 70 Gy. There was one daily irradiation with 2 Gy 5 days a week. Post-resectional radiation encompassed the bronchus stump and the mediastinum with a total dose of about 60 Gy. RESULTS: Sixty-eight of the 183 irradiated patients developed a pneumonitis (37.2%) and 60 a lung fibrosis (32.8%). The most important factor was the administered total irradiation dose (p < 0.001). There was no pneumonitis documented below 36 Gy and no fibrosis below 40 Gy. An additional chemotherapy did not increase the incidence (pneumonitis after radiotherapy 35.4%, after radio- and chemotherapy 34.6%; fibrosis after radiotherapy 33.9%, after radio- and chemotherapy 38.5%). Particularly high was the incidence of pneumonitis when radiotherapy followed resection (48.2%) while the rate of fibrosis in this group of patients was relatively low (22.2%). Age of patients did not affect the frequency of pneumonitis while fibrosis significantly occurred more often with increasing age (p = 0.037). CONCLUSION: The total dose affecting the normal lung tissue is the most important factor for the development of radiation pneumonitis and lung fibrosis. It is recommended to keep the treatment volume appropriate to the individual extend of tumor. Good results are achieved with a computer supported CT-planning which helps to gain minimal burdening of normal tissue.

The lymphatic pathways of non-small cell lung cancer and their implication in curative irradiation treatment.

Using the pre-therapy CT scans of 266 node positive non-small cell lung cancer patients, we analysed the lymphatic pathways and the incidence of lymph node metastases in regional lymph nodes (as described by CT criteria corresponding to the modified mapping scheme of the American Thoracic Society), in order to develop the target volume for curative irradiation treatment. Among the 105 patients with node positive left sided primaries, the incidence of involvement of the ipsilateral supraclavicular lymph nodes was 9.5%, and the incidence of involvement of the contralateral lymph nodes was 3.8%. The incidence of involvement of the contralateral hilar lymph nodes was 4.8%. Among the 161 patients with nodal positive right sided primaries, the incidence of involvement of the ipsilateral supraclavicular lymph nodes was 8.7% and the incidence of involvement of the contralateral lymph nodes was 1.8%. For this group of patients, the incidence of involvement of the contralateral hilar lymph nodes was 3.7%. All patients with involvement of the contralateral hilar lymph nodes died within 2.5 years of diagnosis. In the cases where there was involvement of the supraclavicular lymph nodes, the patients died within 1.6 years. Involvement of the ipsilateral and/or contralateral supraclavicular lymph nodes, and/or the contralateral hilar lymph nodes, is defined as N3 disease, and is included in Stage IIIb. No curative surgery is indicated for these patients. Why therefore should this group of patients be treated with curative intent by irradiation of the primary, ipsilateral and contralateral hilar lymph nodes, as well as mediastinal, ipsilateral and contralateral supraclavicular lymph nodes? The curative radiation treatment volume for lung cancer has to include the primary tumor and the ipsilateral hilar, and the low and high mediastinal lymph nodes, as is indicated for Stage I, II and IIIa disease.