Rate Of Lobar Collapse And/Or Urgent Thoracic Rt Following Initial Chemotherapy For Advanced Non-Small Cell Carcinoma (Nsclc): Implications For Selecting Patients For Early Intervention With Thoracic Rt

Initial management of advanced NSCLC is typically systemic chemotherapy; thoracic radiation (RT) is usually reserved for palliation of focal symptoms. The rate of progressive intrathoracic disease leading to lobar collapse and/or urgent thoracic RT (events), and clinical factors associated with such progression, are not well described. We report a secondary analysis of a prospective clinical trial using first-line chemotherapy in advanced NSCLC. From 1997-2001, 67 patients with advanced IIIB (malignant pleural effusion or advanced supraclavicular adenopathy) or stage IV NSCLC were enrolled onto a phase III randomized trial comparing four cycles vs. continuous carboplatin/paclitaxel chemotherapy. The overall survival, response rates, and quality of life were not significantly different in the two arms. We retrospectively reviewed clinical and radiographic data, including lung imaging studies (CXR and CT) from enrollment until death to assess for new lobar collapse, and clinical records to identify receipt of urgent RT. For patients with atelectasis of a lobe at presentation (16 patients), collapse of a different lobe was required to score as an event. Univariate analyses using Fisher's exact test were used to assess the impact of various clinical factors on the rate of new lobar collapse and/or urgent RT. Sixty-seven pts were analyzed; 84% were Stage IV and 16% advanced Stage IIIB. Fifty-eight had subsequent chest imaging available for review. The median survival for all patients was 6.2 months. Twenty events were recorded (8 patients developed new lobar collapse, 6 patients received RT, and 6 patients had both). The fourteen new collapses were single lobe in 7 and whole lung in 7. Urgent RT was delivered for symptoms of dyspnea (9), dysphagia (2), hemoptysis (2), and pain (3). The median time from enrollment to event was 3.9 months. Amongst all 67 patients, those with hilar nodes at diagnosis had a 39% incidence of a subsequent thoracic event vs. 19% for patients without hilar nodes (p = .055). Approximately one third of patients receiving first line chemotherapy for NSCLC subsequently experienced a radiologically confirmed new lobar collapse or required urgent thoracic RT. Patients with hilar nodes were particularly at risk of a subsequent thoracic event. These results suggest that “early” thoracic RT may be helpful in preventing/delaying progressive intrathoracic disease in selected patients. Additional study is needed to better define the utility of “early” RT in this setting.