Management of cN2 NSCLC patients treated with radical radiotherapy: Relapse with or without brain metastases
Authors: F. McKay, S. Ansel, C. Lowrie, P. McLoone, N. Mohammed
Journal: Annals of Oncology (2019)

Background: The management and treatment of brain metastases (BM) is debated in NSCLC. SIGN guidelines state all cN2 patients should receive brain imaging prior to curative treatment. Furthermore NICE guidelines state those with a PS 0-1 should be offered palliative whole brain radiotherapy (RT) whilst the QUARTZ study recommends none. More recent advances in radiotherapy, surgery and chemotherapy may change this treatment paradigm. Therefore the aim of this study was to investigate the management of BM in a cN2 cohort of NSCLC patients treated with radical RT. Methods: Patients with NSCLC stage cN2 diagnosed from April 2013 to December 2016 treated with radical radiotherapy in the West of Scotland were identified. Electronic patient data was audited. Results: In total 87 patients were identified to have received radical RT. The demographics are recorded in the table. Median Follow-up was 34 months from end of radiotherapy and overall survival was 14.4 months (95%CI 11.4-18.6 months). Overall 56 patients experienced relapse, 11 patients had brain relapse and median survival for this group was 4.0 m (2.0-upper bound not reached). For patients with other distant site of relapse median survival was 5.5 m (2.7-8.8 m). Regardless of site of relapse, there was a trend in survival by performance status when diagnosed with distant relapse (p = 0.012) – PS 1=8.8m, PS2=3.9m, and PS3=1.8m.Table193P Demographic information of NSCLC patients treated with radical radiotherapyVariablesTotal Population (n = 87)% / rangeAge (median)75(54-91)GenderMale4349Female4451Performance Status013151475422529300Unknown22PathologySquamous5058Adenocarcinoma3035Non-small Cell56Unknown22EGFR StatusPositive67Negative2326Not undertaken5867TNM (6-7) StagingT1/T223/3126/36T3/T417/1620/18N287100M0/M186/198/2Radical radiotherapy dose schedule54 Gy/36 fractions434955 Gy/20 fractions4451Pre-Treatment Brain imaging performedYes1720No7080PET imaging performedYes8598Unknown22CT imaging performedYes87100No00Total relapsed patientsLocal only1730Distant only1730Local and Distant2240Total56Performance score at relapse023115272285031120Treatment given at relapseSurgery12Chemotherapy1221Radiotherapy1018Best Supportive Care2850Patient Refused24Died before treatment given35 Open table in a new tab Conclusions: This study of cN2 NSCLC demonstrates that pre-treatment brain imaging was not performed as recommended for 80% of patients. The survival outcome for NSCLC cN2 patients treated with radical radiotherapy is poor compared with chemo-radiation. In this study, 69% of patients were of PS0-1, and hence it is not clear why chemotherapy was not given. Overall 64% of patients relapsed, of which 20% were diagnosed with BM, with median survival being no different to other sites of relapse. However, performance status at time of relapse was associated with better survival outcome. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.