Lung cancer--hopelessness in inoperability? A 10-year follow-up

BACKGROUND: According to reports of Durrant et al. 19] and Berry et al. 5] it was concluded that non-operable non-small cell lung tumors cannot be cured. In this consequence initiation of radiotherapy was fixed at the beginning of symptoms. However, long-time survivors in our follow-up lead us to analyse not only quality of life and secondary therapeutic effects but also this special group with the results of the whole collective treated in the same period of interest. PATIENTS AND METHODS: Between 1.1. 1981 and 31. 12. 1983 a number of 169 patients had been recommended for locoregional radiotherapy treatment of lung cancer; 145 patients received at least 50 Gy, 134 out of them 60 Gy or more. Men/female ratio was 137:8, median age was 65 (36 to 88) years. Classified according to the TN-stage there were 59 patients in T1-4 N0 and 86 patients in T1-4 N1-3 M0. Histologically: 98 squamous cell carcinomas, 23 adenocarcinomas, 9 large cell carcinomas and 15 specimens mixed from the named subgroup or rare histologies. Treatment concept including repetition of bronchoscopic evaluation after 60 Gy was prospectively discussed and fixed with our pneumologist. Radiation dose was given with a shrinking-field technique to mediastinum and primary. In case of macroscopically or microscopically persistence of tumor we continued radiation dose up to 80 Gy. Radiotherapy was not followed by chemotherapy. A telecobalt unit has been used for treatment due to the lack of high-voltage linear accelerators. In absence of a computer assisted planning system-a problem in most of the radiotherapeutic centers in this time-dose calculation was done by central beam planning of ICRU-point in the middle of the tumor respectively the center of target volume on the base of a cross section. Usually there was used a 3-field plan ap/pa opposite and an oblique field with an angle of 30 degrees from the ipsilateral back or ventral side, depending on the position of the tumor. Spinal cord was shielded to avoid a dose-more than 36 to 42 Gy. The longer distance and higher weightiness of the oblique fields had as consequence lung fibrosis in the irradiated lung area and a considerable higher maximal dose situated in the soft tissue and skin often followed by strong indurations in this area 1 to 3 years after radiation therapy without further limitations of quality of life. RESULTS: From 145 patients with non-small cell lung cancer 64.1% (93/145) survived 6 months, 42.8% (62/145) 1 year, 19.3% (28/145) 2 years and 7.6% (11/145) 5 and 4.8 (7/145) more than 10 years. According to TN-stages T1-4 N0 collective had a survival rate of 67.8% (40/59) after half a year, 50.8% (30/59) after 1 year, 23.7% (14/59) after 2 and 11.9% (7/59) after 5 years. Treatment results by patients with positive lymph nodes T1-4 N1-3 after the same intervals are: 61.6% (53/86), 37.2% (32/86), 16.2% (14/86) respectively 4.7% (4/86). In the period 5 to 10 years after irradiation 4 patients died, 1 with local relapse, 2 with contralateral lung cancer-ipsilateral region was endoscopically and histologically free of tumor- and 1 patient in consequence of heart insufficiency of several years. Seven patients are still alive after 13 to 16 years. There is no sign of tumor in this group or any effects limitating their quality of life. Twenty-four patients received less than 50 Gy. All patients but 2 did not survive 6 months. One patient survived half a year and 1 patient 2 years. CONCLUSIONS: The reported treatment results in a period with modest technological possibilities, a telecobalt unit, should encourage to a curative intention, when dissemination cannot be proved. If lung cancer is limited to the primary region with or without lymph node metastases the possibility of tumor elimination is small but feasible. If inoperable lung cancer is not curable, this mostly is not due to inability of locoregional radiotherapy, but rather can be seen as a lack of reliable and permanent elimination or prevention of