Outcomes following definitive stereotactic body radiotherapy for patients with Child-Pugh B or C hepatocellular carcinoma. Stage I-II non-small-cell lung cancer treated using either stereotactic ablative radiotherapy (SABR) or lobectomy by video-assisted thoracoscopic surgery (VATS): outcomes of a propensity score-matched analysis. Patterns of Failure after Stereotactic Body Radiation Therapy or Lobar Resection for Clinical Stage I Non–Small-Cell Lung Cancer Methods for combining randomized clinical trials: strengths and limitations. Comparative effectiveness of 5 treatment strategies for early-stage non-small cell lung cancer in the elderly. Outcomes after stereotactic lung radiotherapy or wedge resection for stage I non-small-cell lung cancer. Stereotactic body radiation therapy for inoperable early stage lung cancer. American College of Surgeons Oncology Group Z4099/Radiation Therapy Oncology Group 1021: a randomized study of sublobar resection compared with stereotactic body radiotherapy for high-risk stage I non-small cell lung cancer.
PURPOSE To report outcomes in patients with Child-Pugh B or C ( CP B/C ) hepatocellular carcinoma ( HCC ) treated with stereotactic body radiotherapy ( SBRT ) . METHODS AND MATERIAL S A prospect i ve study of SBRT was developed for patients with CP B7 or B8 unresectable HCC , < 10 cm . Selected ineligible patients ( e.g. CP > B8 , > 10 cm ) treated off- study from 2004 to July 2012 were also review ed . Patients were excluded if they were treated as a bridge-to-liver-transplant . RESULTS 29 patients with CP B/C HCC were treated with SBRT ( median dose 30 Gy in 6 fractions ) from 2004 to December 2012 . The majority had CP B7 liver function ( 69 % ) and portal vein tumor thrombosis ( 76 % ) . The median survival was 7.9 months ( 95 % CI : 2.8 - 15.1 ) . Survival was significantly better in patients with CP = B7 and AFP≤4491 ng/mL. Of 16 evaluable patients , 63 % had a decline in CP score by ≥2 points at 3 months . CONCLUSION SBRT is a treatment option for selected HCC patients with small HCCs and modestly impaired ( CP B7 ) liver function BACKGROUND Video-assisted thoracoscopic surgery ( VATS ) lobectomy and stereotactic ablative radiotherapy ( SABR ) are both used for early-stage non-small-cell lung cancer . We carried out a propensity score-matched analysis to compare locoregional control ( LRC ) . PATIENTS AND METHODS  VATS lobectomy data from six hospitals were retrospectively accessed ; SABR data were obtained from a single institution data base . Patients were matched using propensity scores based on cTNM stage , age , gender , Charlson comorbidity score , lung function and performance score . Eighty-six VATS and 527 SABR patients were matched blinded to outcome ( 1:1 ratio , caliper distance 0.025 ) . Locoregional failure was defined as recurrence in/adjacent to the planning target volume/surgical margins , ipsilateral hilum or mediastinum . Recurrences were either biopsy-confirmed or had to be PET-positive and review ed by a tumor board . RESULTS The matched cohort consisted of 64 SABR and 64 VATS patients with the median follow-up of 30 and 16 months , respectively . Post-SABR LRC rates were superior at 1 and 3 years ( 96.8 % and 93.3 % versus 86.9 % and 82.6 % , respectively , P = 0.04 ) . Distant recurrences and overall survival ( OS ) were not significantly different . CONCLUSION This retrospective analysis found a superior LRC after SABR compared with VATS lobectomy , but OS did not differ . Our findings support the need to compare both treatments in a r and omized , controlled trial Introduction : The purpose of this study was to compare patterns of failure between lobar resection ( lobectomy or pneumonectomy ) and stereotactic body radiation therapy ( SBRT ) for patients with clinical stage I non – small-cell lung cancer ( NSCLC ) . Methods : From January 2004 to January 2008 , 338 patients underwent definitive treatment for pathologically confirmed clinical stage I NSCLC with lobar resection ( n = 260 ) or SBRT ( n = 78 ) . Most surgical patients underwent  lobectomy ( n = 237 ) . SBRT patients received a biologically effective dose of at least 100 Gy10 . Lobar resection patients were younger , healthier , and had superior pulmonary function , whereas most of the patients in the SBRT group had T1 tumors . Final pathology upstaged 32.7 % of surgery patients , and 20.0 % received adjuvant chemotherapy . No SBRT patients received adjuvant chemotherapy . Results : In an unmatched comparison , 4-year lobar local control ( 98.7 % versus 93.6 % , p = 0.015 ) was greater for lobar resection versus SBRT , respectively , though primary tumor ( 98.7 % versus 95.3 % , p = 0.088 ) , regional ( 82.9 % versus 78.1 % , p = 0.912 ) , and distant control ( 76.1 % versus 54.0 % , p = 0.152 ) were similar . Overall survival ( OS , 63.5 % versus 29.6 % , p < 0.0001 ) was greater for lobar resection , though cause-specific survival ( CSS , 81.3 % versus 75.3 % , p = 0.923 ) was similar . In a T-stage matched comparison of 152 patients , there was no significant difference in patterns of failure or CSS , whereas OS favored surgery . Conclusion : Lobectomy/pneumonectomy or SBRT results in comparable patterns of failure for clinical stage I NSCLC . In this retrospective comparison , OS was superior for surgery , though CSS was similar . R and omized trials are necessary to control for fundamental differences in comorbidity , which impact interpretation of both tumor control and survival Methods for combining data from several studies exist and appear to be quite useful . None satisfactorily addresses the question of what studies should be combined . This issue is the most serious method ological limitation . Even studies with statistically significant interaction might still be combined if the effect were in the same direction . Thus , substantial scientific input is required as to what criteria must be met by each potential study . Much can be learned from combining or pooling data but it must be done cautiously . Pooling exercises do not replace well design ed prospect i ve clinical trials . Efforts for establishing basic design criteria to allow for multicentre and multicountry trials to be more easily combined might be useful . PURPOSE The incidence of early-stage non-small cell lung cancer ( NSCLC ) among older adults is expected to increase because of demographic trends and computed tomography-based screening ; yet , optimal treatment in the elderly remains controversial . Using the Surveillance , Epidemiology , and End Results (SEER)-Medicare cohort spanning 2001 - 2007 , we compared survival outcomes associated with 5 strategies used in contemporary practice : lobectomy , sublobar resection , conventional radiation therapy , stereotactic ablative radiation therapy ( SABR ) , and observation . METHODS AND MATERIAL S Treatment strategy and covariates were determined in 10,923 patients aged ≥ 66 years with stage IA-IB NSCLC . Cox regression , adjusted for patient and tumor factors , compared overall and disease-specific survival for the 5 strategies . In a second exploratory analysis , propensity-score matching was used for comparison of SABR with other options . RESULTS The median age was 75 years , and 29 % had moderate to severe comorbidities . Treatment distribution was lobectomy ( 59 % ) , sublobar resection ( 11.7 % ) , conventional radiation ( 14.8 % ) , observation ( 12.6 % ) , and SABR ( 1.1 % ) . In Cox regression analysis with a median follow-up time of 3.2 years , SABR was associated with the lowest risk of death within 6 months of diagnosis ( hazard ratio [ HR ] 0.48 ; 95 % confidence interval [ CI ] 0.38 - 0.63 ; referent is lobectomy ) . After 6 months , lobectomy was associated with the best overall and disease-specific survival . In the propensity-score matched analysis , survival after SABR was similar to that after lobectomy ( HR 0.71 ; 95 % CI 0.45 - 1.12 ; referent is SABR ) . Conventional radiation and observation were associated with poor outcomes in all analyses . CONCLUSIONS In this population -based experience , lobectomy was associated with the best long-term outcomes in fit elderly patients with early-stage NSCLC . Exploratory analysis of SABR early adopters suggests efficacy comparable with that of surgery in select population s. Evaluation of these therapies in r and omized trials is urgently needed 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 nonr and omized 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 CONTEXT Patients with early stage but medically inoperable lung cancer have a poor rate of primary tumor control ( 30%-40 % ) and a high rate of mortality ( 3-year survival , 20%-35 % ) with current management . OBJECTIVE To evaluate the toxicity and efficacy of stereotactic body radiation therapy in a high-risk population of patients with early stage but medically inoperable lung cancer . DESIGN , SETTING , AND PATIENTS Phase 2 North American multicenter study of patients aged 18 years or older with biopsy-proven peripheral T1-T2N0M0 non-small cell tumors ( measuring < 5 cm in diameter ) and medical conditions precluding surgical treatment . The prescription dose was 18 Gy per fraction x 3 fractions ( 54 Gy total ) with entire treatment lasting between 1(1/2 ) and 2 weeks . The study opened May 26 , 2004 , and closed October 13 , 2006 ; data were analyzed through August 31 , 2009 . MAIN OUTCOME MEASURES The primary end point was 2-year actuarial primary tumor control ; secondary end points were disease-free survival ( ie , primary tumor , involved lobe , regional , and disseminated recurrence ) , treatment-related toxicity , and overall survival . RESULTS A total of 59 patients accrued , of which 55 were evaluable ( 44 patients with T1 tumors and 11 patients with T2 tumors ) with a median follow-up of 34.4 months ( range , 4.8 - 49.9 months ) . Only 1 patient had a primary tumor failure ; the estimated 3-year primary tumor control rate was 97.6 % ( 95 % confidence interval [ CI ] , 84.3%-99.7 % ) . Three patients had recurrence within the involved lobe ; the 3-year primary tumor and involved lobe ( local ) control rate was 90.6 % ( 95 % CI , 76.0%-96.5 % ) . Two patients experienced regional failure ; the local-regional control rate was 87.2 % ( 95 % CI , 71.0%-94.7 % ) . Eleven patients experienced disseminated recurrence ; the 3-year rate of disseminated failure was 22.1 % ( 95 % CI , 12.3%-37.8 % ) . The rates for disease-free survival and overall survival at 3 years were 48.3 % ( 95 % CI , 34.4%-60.8 % ) and 55.8 % ( 95 % CI , 41.6%-67.9 % ) , respectively . The median overall survival was 48.1 months ( 95 % CI , 29.6 months to not reached ) . Protocol -specified treatment-related grade 3 adverse events were reported in 7 patients ( 12.7 % ; 95 % CI , 9.6%-15.8 % ) ; grade 4 adverse events were reported in 2 patients ( 3.6 % ; 95 % CI , 2.7%-4.5 % ) . No grade 5 adverse events were reported . CONCLUSION Patients with inoperable non-small cell lung cancer who received stereotactic body radiation therapy had a survival rate of 55.8 % at 3 years , high rates of local tumor control , and moderate treatment-related morbidity During the past decade , tremendous interest has arisen in the use of nonoperative therapies for patients with non-small cell lung cancer . Of these therapies , stereotactic body radiotherapy has become established as an effective modality for treating peripheral cancer in medically inoperable patients .  Toxicity is low , and the treatment is effective , with excellent local control rates . Several investigators have suggested that stereotactic body radiotherapy could be effective for high-risk operable patients ( usually treated with sublobar resection ) and even perhaps for st and ard-risk operable patients ( usually treated with lobectomy ) ; however , this is less accepted . A direct comparison of stereotactic body radiotherapy and sublobar resection is difficult for a number of reasons . These include different definitions of recurrence , different population s of patients in these studies ( with those undergoing stereotactic body radiotherapy tending to be the medically inoperable group ) , and different methods of classifying morbidity in the surgical and radiation oncology studies . Imaging follow-up has also not been st and ardized among the studies . Thus , a r and omized study is necessary and timely . Investigators from the American College of Surgeons Oncology Group and the Radiation Therapy and Oncology Group have collaborated to develop a phase III r and omized study comparing stereotactic body radiotherapy and sublobar resection ( with or without brachytherapy ) for high-risk operable patients with non-small cell lung cancer . This study ( American College of Surgeons Oncology Group Z4099/Radiation Therapy Oncology Group 1021 ) has recently opened for accrual . It is hoped that this will help to better define the role of these therapies for patients with non-small cell lung cancer
PURPOSE A population -based matched-pair comparison was performed to compare the efficacy of stereotactic body radiotherapy ( SBRT ) versus surgery for early-stage non-small cell lung cancer ( NSCLC ) .