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In Reply

Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY

The letter from Drs Lima and Cordova highlights several interesting points. Their concerns regarding the heterogeneity in treatment of the patients in this study is appropriate.¹ However, the time frame of the study (1991 to 2005) spans several eras in the treatment of lung cancer, such as the incorporation of sequential and (subsequently, concurrent) chemotherapy into the treatment of patients with locally advanced disease;^2,3 the use of positron emission tomography (PET) scanning in the staging and radiation therapy treatment planning of patients;⁴ and the implementation of intensity-modulated radiation therapy.⁵ The range in radiation dose is not important in the analysis because by definition, elective nodal failure (ENF) occurs outside of the treatment field, and therefore receives limited radiation dose. As we reported, in patients with local control, the ENF rate was 9%. In patients with local control, the dose of radiation required to obtain this control will not have any effect on future ENF.

As Drs Lima and Cordova point out, the relative small number of treatment failures (n = 32) does make statistical analysis difficult. We reported that the patients who received chemotherapy and patients who had pretreatment PET scanning counter-intuitively had higher rates of ENF, although this was not statistically significant. This suggests that even if the patient sample size had been greater, it is unlikely that a significant difference would have been found.

Finally, with regard to the incorporation of PET scanning in the treatment planning process, as we have previously reported,⁶ we prefer the use of software or hardware registration that allows the determination of the target volume directly on the PET images, using a threshold method set at 42% of the maximum value of the standard uptake value. However, due to the technological constraints at the time these patients were treated, the vast majority of patients’ tumors were defined using visual fusion.

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Rosenzweig KE, Sura S, Jackson A, et al: Involved-field radiation therapy for non–small-cell lung cancer. J Clin Oncol 13:5557-5561, 2007

2. Dillman RO, Herndon J, Seagren SL, et al: Improved survival in stage III non–small-cell lung cancer: Seven-year follow-up of cancer and leukemia group B (CALGB) 8433 trial. J Natl Cancer Inst 88:1210-1215, 1996[Abstract/Free Full Text]

3. Furuse K, Fukuoka M, Kawahara M, et al: Phase III study of consurrent versus sequential thoracic radiotherapy in combination with mitomycin, vindesine, and cisplatin in unresectable stage III non-small cell lung cancer. J Clin Oncol 17:2692-2699, 1999[Abstract/Free Full Text]

4. Mac Manus MP, Hicks RJ, Ball DL, et al: F-18 fluorodeoxyglucose positron emission tomography staging in radical radiotherapy candidates with nonsmall cell lung carcinoma: Powerful correlation with survival and high impact on treatment. Cancer 92:886-895, 2001[CrossRef][Medline]

5. Sura S, Gupta V, Yorke E, et al: Intensity-modulated radiation therapy (IMRT) for inoperable non–small-cell lung cancer: The Memorial Sloan-Kettering Cancer Center (MSKCC) experience. Radiother Oncol (in press)

6. Fox JL, Rengan R, O'Meara W, et al: Does the registration of PET and planning CT images decrease inter- and intra-observer variation in delineating tumor volumes for non-small cell lung cancer (NSCLC)? Int J Radiat Oncol Biol Phys 62:70-75, 2005[CrossRef][Medline]

Related Correspondence

• Is There a Definitive Answer to the Question of Involved-Field Radiotherapy for Inoperable Non–Small-Cell Lung Cancer?
  Carlos Genesio Bezerra Lima, Jr and Arno Lotar Cordova, Jr
  JCO 2008 26: 2235 [Full Text]

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