Treatment of non-small cell lung cancer: advances following the introduction of PET-CT and IMRT/VMAT.

Purpose: In definitive radiotherapy/radiochemotherapy (RT/RCT) for localized non-small cell lung cancer (NSCLC), the introduction of positron-emission tomography (PET)-CT-based staging/RT planning and dynamic RT techniques (intensity-modulated radiotherapy, IMRT/volumetric modulated arc therapy, VMAT) were important innovations.

Methods: We performed a retrospective study and compared clinical outcomes (1) in patients with PET-CT-based staging (n = 170) vs. conventional staging (n = 103) and (2) in patients with dynamic RT techniques (IMRT/VMAT; n = 99) vs. three-dimensional conformal radiotherapy (3D-CRT; n = 64).

Results: We found improved survival with PET-CT vs. conventional staging. PET-CT patients vs. conventionally staged patients had higher applied RT doses, higher RT completion rates, and a higher rate of patients who received RCT vs. RT only. Additionally, we found higher rates of leukopenia and lung infections in PET-CT patients. When comparing RT techniques (IMRT/VMAT vs. 3D-CRT), there were no differences in survival. IMRT/VMAT patients had higher RT doses and higher rates of intensified concomitant chemotherapy (cisplatin/vinorelbine vs. low-dose cisplatin). IMRT/VMAT was associated with a reduction in pneumonitis and dermatitis.

Conclusion: In summary, refined RT/RCT strategies with PET-CT and IMRT/VMAT enable the intensification of multimodal treatment. Reduction of toxicities with IMRT/VMAT widens the therapeutic window. The coincidence of intensified treatment, improved outcomes, and higher toxicity rates in PET-CT-staged patients emphasizes the need for a detailed risk-benefit assessment during planning and application of treatment modalities.