Stephanie T Peeters1, Christophe Dooms2, Angela Van Baardwijk3, Anne-Marie C Dingemans4, Hanneke Martinussen4, Johan Vansteenkiste2, Herbert Decaluwé5, Paul De Leyn5, Jonas Yserbyt2, Kristiaan Nackaerts2, Walter De Wever6, Christophe M Deroose7, Dirk De Ruysscher8. 1. Radiation Oncology, University Hospitals Leuven/KU Leuven, Belgium. 2. Respiratory Oncology (Pneumology), University Hospitals Leuven/KU Leuven, Belgium. 3. Radiation Oncology (MAASTRO Clinic), GROW, Maastricht University Medical Center, The Netherlands. 4. Pulmonology, Maastricht University Medical Center, The Netherlands. 5. Thoracic Surgery, University Hospitals Leuven/KU Leuven, Belgium. 6. Radiology, University Hospitals Leuven/KU Leuven, Belgium. 7. Nuclear Medicine, University Hospitals Leuven/KU Leuven, Belgium. 8. Radiation Oncology, University Hospitals Leuven/KU Leuven, Belgium; Radiation Oncology (MAASTRO Clinic), GROW, Maastricht University Medical Center, The Netherlands. Electronic address: dirk.deruysscher@maastro.nl.
Abstract
BACKGROUND: FDG-PET-CT-based selective lymph node (LN) irradiation is standard using 3D-conformal techniques for locally advanced NSCLC. With newer techniques (intensity-modulated/volumetric-arc therapy (IMRT/VMAT)), the dose to non-involved adjacent LN decreases, which raises the question whether FDG-PET-CT-delineation is still safe. We therefore evaluated the impact of adding linear endosonography with needle aspiration (E(B)US-NA) to FDG-PET-CT in selective nodal irradiation. METHODS: Based on literature data on sensitivity and specificity of E(B)US-NA in FDG-PET-CT-staged NSCLC, false negative (FN) rates for different constellations of CT, PET and E(B)US-NA were calculated. The algorithm was tested on consecutive patients with N2/N3 disease referred for radiotherapy in Leuven and Maastricht. RESULTS: An algorithm determining when to include LN in the GTV is proposed, based on data from 5 meta-analyses. Adding E(B)US-NA to FDG-PET-CT decreases the FN-rate, but for PET-positive and E(B)US-negative LN, FN rates are still 14-16%. In Leuven 520 LN were analyzed, in Maastricht 364 LN; with E(B)US-NA a geographical miss was avoided in 2 (2/40=5%) and 1 (1/28=4%) patients, respectively. CONCLUSIONS: E(B)US-NA in addition to FDG-PET-CT for mediastinal staging decreases the risk of a geographical miss with 4-5%. The impact of this small decrease on survival is unknown. The proposed algorithm may guide the radiation oncologist when to include LN in the nodal GTV.
BACKGROUND:FDG-PET-CT-based selective lymph node (LN) irradiation is standard using 3D-conformal techniques for locally advanced NSCLC. With newer techniques (intensity-modulated/volumetric-arc therapy (IMRT/VMAT)), the dose to non-involved adjacent LN decreases, which raises the question whether FDG-PET-CT-delineation is still safe. We therefore evaluated the impact of adding linear endosonography with needle aspiration (E(B)US-NA) to FDG-PET-CT in selective nodal irradiation. METHODS: Based on literature data on sensitivity and specificity of E(B)US-NA in FDG-PET-CT-staged NSCLC, false negative (FN) rates for different constellations of CT, PET and E(B)US-NA were calculated. The algorithm was tested on consecutive patients with N2/N3 disease referred for radiotherapy in Leuven and Maastricht. RESULTS: An algorithm determining when to include LN in the GTV is proposed, based on data from 5 meta-analyses. Adding E(B)US-NA to FDG-PET-CT decreases the FN-rate, but for PET-positive and E(B)US-negative LN, FN rates are still 14-16%. In Leuven 520 LN were analyzed, in Maastricht 364 LN; with E(B)US-NA a geographical miss was avoided in 2 (2/40=5%) and 1 (1/28=4%) patients, respectively. CONCLUSIONS: E(B)US-NA in addition to FDG-PET-CT for mediastinal staging decreases the risk of a geographical miss with 4-5%. The impact of this small decrease on survival is unknown. The proposed algorithm may guide the radiation oncologist when to include LN in the nodal GTV.
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