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EP-1234: Prophylactic Cranial Irradiation (PCI) in Small-Cell Lung Cancer: a single-institution experience
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Widder1 1 University Medical Center Groningen, Radiation Oncology, Groningen, The Netherlands
differ between BID and OD CRT. Treatment allocation could be further improved by dose-volume-fractionation modelling for esophagitis.
Purpose or Objective Survival results for limited-stage-SCLC are more favourable for accelerated BID compared with OD chemoradiotherapy (CRT) to nominally equal doses (Turrisi et al. NEJM 1999), but were not further improved by escalating once-daily doses from 45 Gy to 66 Gy (CONVERT-trial). However, concerns regarding acute toxicity with BID CRT do exist. We report prospectively assessed patient-reported outcome measures (PROMs) on dysphagia and dyspnea from an institutional cohort where patients receive BID CRT as preferred treatment, and OD in case of adverse patient- or tumour-related baseline factors suggesting they would not tolerate the accelerated schedule. Material and Methods All consecutive patients with LS-SCLC treated with VMAT/IMRT or 3D-CRT between 2013 and 2016 within our prospective data registration program (clinicaltrials.gov) were included. The BID schedule was given in 3 weeks to 45 Gy (30*1.5 Gy), OD CRT was given in 5 weeks to 45–50 Gy (25*1.8–2.0 Gy), concurrent or sequential cisplatinetoposide was scheduled with both regimens. The primary endpoint was PROM-dysphagia within (acute) and after 3 months of inclusion (late). Secondary endpoints were PROM-dyspnea, physician-rated dysphagia, radiation pneumonitis, and survival. Toxicities were related with esophageal and pulmonary DVH-parameters, respectively. Results Out of 74 patients, 38 received BID and 36 received OD CRT with no difference in number of cisplatin-etoposide cycles between groups. In line with the institutional policy, the BID cohort was younger (62 versus 68 years, p=0.017), had smaller tumour volumes at planning CT (79 cc versus 127 cc, p=0.056), and tended to be in a better general WHO performance status (PS) (45% versus 25% at PS 0, p=0.075). At median follow-up of 9.4 months for surviving patients, unadjusted as well as adjusted survival (adjusted for age, WHO PS, stage and GTV) was not significantly better for BID (HR=0.60, 95%CI 0.3–1.4 and HR=0.70, 95%CI 0.3–1.8, respectively). PROMs regarding dysphagia and dyspnea as well as physician-rated toxicities and radiation pneumonitis were not different between groups (figure). Mean esophageal V35 and mean pulmonary V20 were different between BID and OD cohorts (30 Gy versus 41 Gy; p=0.027, and 20 Gy versus 23 Gy; p=0.061, respectively), in line with GTV differences between groups.
EP-1233 Early results of SBRT as a salvage treatment after thoracic radiotherapy. A. Navarro-Martin1, I. Guix1, J. Mases1, M. Mutto2, E. Nadal3, F. Guedea1 1 Institut Català d'Oncologia, Radiation Oncology, L'Hospitalet de Llobregat, Spain 2 European Oncology Institue, Radiation Oncology, Milano, Italy 3 Institut Català d'Oncologia, Medical Oncology, L'Hospitalet de Llobregat, Spain
Conclusion Treatment selection based on tumour volume and patient condition effectively limited PROMs and physician-rated acute and late dysphagia in BID CRT. This can be explained by the significantly lower esophageal V35 due to smaller GTVs in patients receiving BID treatment. Also, acute and late PROM-dyspnea and radiation pneumonitis did not
EP-1234 Prophylactic Cranial Irradiation (PCI) in SmallCell Lung Cancer: a single-institution experience. M. Konkol1, M. Matecka-Nowak1, M. Trojanowski2, A. Kubiak2, P. Milecki1 1 Greater Poland Cancer Centre, I Radiotherapy Dept., Poznan, Poland
Purpose or Objective Isolated intrathoracic relapse is common across distinct tumors and especially in lung cancer. Patients who received previous radiotherapy treatment (PRT) are not suitable for salvage surgery and chemotherapy provides poor local control. This study aimed to assess the toxicity and outcome of SBRT re-irradiation (reRT) in patients with solid tumors who developed an intrathoracic relapse. Material and Methods 35p treated with PRT who received salvage SBRT were identified in our database and their medical records were retrospectively reviewed. All patients underwent complete pulmonary function tests (cPFTs) (including DLCO, FEV1 and FVC) and PET-CT scan was performed before and after receiving lung reRT. Treatment planning was based on image fusion with the previous treatment plan and calculating the cumulative total nominal dose. Survival estimations were performed using Kaplan-Meier and differences between PFTs prior and post-reRT were analyzed using Student T-Test. Early toxicity was defined when it occurred up to 6 months. Results Median age: 68 (r53-81); 29p (83%) were male The previous treatments SBRT in 17p (49%), 3D-RT 4p (11%) and CT+RT 14p (40%) Mean RT dose 60,4Gy (r34-74). Primary tumors: lung 24 (69%), colorectal 9 (25%), oesophagus 2 (6%). For lung cancer p, the stage distribution was: IA 8 (23%), IB 2 (6%), IIA 2 (5.7%), IIB 1 (3%), IIIA 5 (4%), IIIb 4 (11%), IV 2 (6%). For other primaries, 8p (23%) were non metastatic at diagnosis and developed oligoprogressive disease in thorax which was treated with SBRT and 3 (8.5%) were oligometastatic. The location of reRT site: same lobe 17 (48%), ipsilateral different lobe 7 (20%), contralateral lobes 11 (32%). Median delivered dose of salvage SBRT was 50Gy (50-60) in 10 fractions (r3-10). Median accumulated dose in the lung was 81Gy (r60.10Gy-176Gy). With a median follow-up of 10m local control rate was 74% (IC95%; 0.59-0.9) and 1-year OS was 84% (IC 95%;0.67-1). The metabolic complete response rate was 23%. No differences in the baseline and post re-irradiation PFTs were observed: FEV1, FVC and DLCO difference and CI95% were 2.41 (-1.79-6.62); 65 (-125-257) and 12.5 (-95 - 121). Asthenia GII in 12p (31%) was the most frequent acute toxicity, no long-term toxicities were detected. Conclusion Salvage SBRT for treating isolated intrathoracic relapses achieved an outstanding local control and overall survival in selected p . This treatment did not impair postreirradiation PFT and long-term toxicities were not observed.
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2
Greater Poland Cancer Centre, Greater Poland Cancer Register, Poznan, Poland Purpose or Objective In 2013 1.963 (ASR 33,6/105) new lung cancer cases and 1.855 (ASR 31,1/105) lung cancer deaths were reported in Greater Poland. Compared to 1999 the number of new cases rose by 21% and the number of deaths rose by 16%. In the group of lung cancer patients from the Greater Poland population, diagnosed during 2009-2011, 80% were microscopically verified, among them 79,9% were NSCLC and 20,1% were SCLC. Prophylactic Cranial Irradiation (PCI) in SCLC patients remains an important part of the treatment process associated with a reduction of brain metastases and better survival. This paper is a retrospective review of 146 patients irradiated in Greater Poland Cancer Center, Poznan, Poland. Material and Methods Eighty limited SCLC (LSCLC) and sixty six extensive SCLC (ESCLC) patients irradiated in Greater Poland Cancer Center between 2007-2010 received a standard scheme of 25Gy/10fx with 6MV photons. The qualification based on X-ray post-chemotherapy assessment described as significant partial response or complete response. Mean time from the diagnosis date to the end of treatment was 6 months. The survival data were collected from the national and regional cancer registers. Results Mean observed survival in our patients was 16,8 months (13,6 months for ESCLC and 19,5 months for LSCLC). The 1-, 3- and 5-year observed survival rates were 74,12%, 9,52%, 4,70% for LSCLC and 48,48%, 1,49% 1,49% for ESCLC. For our group as a whole respectively: 65%, 8,6%, 3,3%. After radiotherapy, LSCLC and ESLCL patients survived 7,4 and 12,7 months on average. Grade 3 or 4 toxicity has not been noticed. Conclusion The Concord-2 study results show, that the 5-year net survival rates among lung cancer patients diagnosed during 2005-2009 in Poland (13,4%) and Greater Poland (13,2%) were on the average European level. Similarly, presented SCLC group meets 5-year survival rates of that time. Comparing to other authors, we have noticed slightly better results in 1- year survival - Schild et al: 56% (PCI arm, LSCLC&ESCLC), Slotman et. al: 27,1% (PCI arm, ESCLC). Nevertheless, in spite of good results shown above, the prospective analysis shoud be done. Contemporary salvage treatments for intracranial relapse may be underestimated especially if provided before patients become symptomatic. EP-1235 Stereotactic body radiotherapy for lung metastases: retrospective analysis of a single-center H. Herrmann1, C. Proksch1, K. Dieckmann1 1 Universitätsklinik für Strahlentherapie Medizinische Universität Wien, Wien, Austria Purpose or Objective A significant number of cancer patients with initially localized disease develop distant metastases at follow up. A subset of patients with successful treatment of the primary tumor develop oligometastatic disease months to years after initial treatment. Other patients with metastatic disease present with long-lasting stable disease or remission during systemic treatment and develop progression in single lesions in later course of disease. For these patients with low tumor burden, a semi-curative treatment strategy might be an option. In recent years, stereotactic body radiotherapy (SBRT) of the lung has been shown to provide an alternative to surgical resection of lung metastases. Typically, SBRT in the lung is performed with high single-doses per fraction. High
radiation doses to the lung could result in severe fibrosis, which might especially be relevant for patients with impaired lung function. Material and Methods We retrospectively analyzed 95 metastatic patients (male, n=64; female, n=31) who underwent SBRT in the lung at our institution from 2005-2015 with a total of 166 lung metastases. The median age was 65 years (range 38-84 years) at initial SBRT treatment. Primary tumors were colorectal cancer (n=35), renal cell carcinoma (n=15), head and neck cancer (n=12), melanoma (n=8), and other malignancies (n=25). Parameters assessed were: local control, survival, lung function test before start of treatment and during follow up, PTV volume, extent of fibrosis on CT scans. Results The treatment regimen most often used was 12.5 Gy x 3 fractions prescribed to the 65% isodose (n=100; EQD2 for α/β=10 Gy: 70.3 Gy at prescribed isodose, 140.5 Gy at 100% isodose) and 15 Gy x 3 fractions prescribed to the 65% isodose (n=33; EQD2 for α/β=10 Gy: 93.8 Gy at prescribed isodose, 190.8 Gy at 100% isodose). The median PTV volume was 15.9 ccm (range: 3.6 – 404.5 ccm). Median follow up was 20 months (range 1 – 136 months). The overall survival at 1 and 2 years was 85% and 68%, respectively. We achieved high local control after SBRT treatment at 1 and 2 years which was 95% and 88%, respectively. Signs of morphologically dense radiation induced fibrotic changes (hounsfield units > 10 as evaluated on CT scans) 4-6 months after treatment was seen in 40 % of all treated lesions. The median diameter of these fibrotic changes were 6.0 cm (range: 2.0 – 10.4 cm). Before SBRT treatment the median baseline FEV1 value of lung function test was 2.5 L (range: 0.96 – 3.96 L). FEV1 values at 1 years after treatment (expressed as mean percentage of baseline FEV1 ±SD) decreased to 95% (±8%) which was significant (p<0.05) in a paired t-test. Conclusion SBRT treatment for lung metastases results in high local control rates and can be safely applied. The impact on lung function test at one year after treatment was minimal although high biological doses were delivered. We conclude, that SBRT to the lung can be recommended to oligometastatic patients as an effective alternative treatment to surgical resection. EP-1236 Validation of the clinical diagnostic method for solitary pulmonary nodules before SBRT in Navarra M. Campo1, I. Visus1, S. Flamarique1, M. Barrado1, A. Martin1, M. Rico1, E. Martinez1 1 Hospital of Navarra, Oncología radioterapia, Pamplona, Spain Purpose or Objective In the general practice of the Hospital of Navarra, solitary pulmonary nodules (SPN) are frequently treated with SBRT without cytological confirmation due to patients´ comorbidities that heighten the risks associated with transthoracic biopsy. In this analysis we study the reliability of our clinical diagnostic system to better know the accuracy and quality of our protocols. Material and Methods We analyze retrospectively the pathological results of SPN treated surgically under suspicion of being stage I nonsmall-cell lung cancer (NSCLC) during 2012 and 2013. The suspicion was based on the criteria of an expert board composed by pneumologists, radiation oncologists, medical oncologists, thoracic surgeons, radiologists and pathologists. The decision of treating was taken according to the FDG-PET features, the morphological characteristics on CT and the growing pattern of the SPN.
Widder1 1 University Medical Center Groningen, Radiation Oncology, Groningen, The Netherlands
differ between BID and OD CRT. Treatment allocation could be further improved by dose-volume-fractionation modelling for esophagitis.
Purpose or Objective Survival results for limited-stage-SCLC are more favourable for accelerated BID compared with OD chemoradiotherapy (CRT) to nominally equal doses (Turrisi et al. NEJM 1999), but were not further improved by escalating once-daily doses from 45 Gy to 66 Gy (CONVERT-trial). However, concerns regarding acute toxicity with BID CRT do exist. We report prospectively assessed patient-reported outcome measures (PROMs) on dysphagia and dyspnea from an institutional cohort where patients receive BID CRT as preferred treatment, and OD in case of adverse patient- or tumour-related baseline factors suggesting they would not tolerate the accelerated schedule. Material and Methods All consecutive patients with LS-SCLC treated with VMAT/IMRT or 3D-CRT between 2013 and 2016 within our prospective data registration program (clinicaltrials.gov) were included. The BID schedule was given in 3 weeks to 45 Gy (30*1.5 Gy), OD CRT was given in 5 weeks to 45–50 Gy (25*1.8–2.0 Gy), concurrent or sequential cisplatinetoposide was scheduled with both regimens. The primary endpoint was PROM-dysphagia within (acute) and after 3 months of inclusion (late). Secondary endpoints were PROM-dyspnea, physician-rated dysphagia, radiation pneumonitis, and survival. Toxicities were related with esophageal and pulmonary DVH-parameters, respectively. Results Out of 74 patients, 38 received BID and 36 received OD CRT with no difference in number of cisplatin-etoposide cycles between groups. In line with the institutional policy, the BID cohort was younger (62 versus 68 years, p=0.017), had smaller tumour volumes at planning CT (79 cc versus 127 cc, p=0.056), and tended to be in a better general WHO performance status (PS) (45% versus 25% at PS 0, p=0.075). At median follow-up of 9.4 months for surviving patients, unadjusted as well as adjusted survival (adjusted for age, WHO PS, stage and GTV) was not significantly better for BID (HR=0.60, 95%CI 0.3–1.4 and HR=0.70, 95%CI 0.3–1.8, respectively). PROMs regarding dysphagia and dyspnea as well as physician-rated toxicities and radiation pneumonitis were not different between groups (figure). Mean esophageal V35 and mean pulmonary V20 were different between BID and OD cohorts (30 Gy versus 41 Gy; p=0.027, and 20 Gy versus 23 Gy; p=0.061, respectively), in line with GTV differences between groups.
EP-1233 Early results of SBRT as a salvage treatment after thoracic radiotherapy. A. Navarro-Martin1, I. Guix1, J. Mases1, M. Mutto2, E. Nadal3, F. Guedea1 1 Institut Català d'Oncologia, Radiation Oncology, L'Hospitalet de Llobregat, Spain 2 European Oncology Institue, Radiation Oncology, Milano, Italy 3 Institut Català d'Oncologia, Medical Oncology, L'Hospitalet de Llobregat, Spain
Conclusion Treatment selection based on tumour volume and patient condition effectively limited PROMs and physician-rated acute and late dysphagia in BID CRT. This can be explained by the significantly lower esophageal V35 due to smaller GTVs in patients receiving BID treatment. Also, acute and late PROM-dyspnea and radiation pneumonitis did not
EP-1234 Prophylactic Cranial Irradiation (PCI) in SmallCell Lung Cancer: a single-institution experience. M. Konkol1, M. Matecka-Nowak1, M. Trojanowski2, A. Kubiak2, P. Milecki1 1 Greater Poland Cancer Centre, I Radiotherapy Dept., Poznan, Poland
Purpose or Objective Isolated intrathoracic relapse is common across distinct tumors and especially in lung cancer. Patients who received previous radiotherapy treatment (PRT) are not suitable for salvage surgery and chemotherapy provides poor local control. This study aimed to assess the toxicity and outcome of SBRT re-irradiation (reRT) in patients with solid tumors who developed an intrathoracic relapse. Material and Methods 35p treated with PRT who received salvage SBRT were identified in our database and their medical records were retrospectively reviewed. All patients underwent complete pulmonary function tests (cPFTs) (including DLCO, FEV1 and FVC) and PET-CT scan was performed before and after receiving lung reRT. Treatment planning was based on image fusion with the previous treatment plan and calculating the cumulative total nominal dose. Survival estimations were performed using Kaplan-Meier and differences between PFTs prior and post-reRT were analyzed using Student T-Test. Early toxicity was defined when it occurred up to 6 months. Results Median age: 68 (r53-81); 29p (83%) were male The previous treatments SBRT in 17p (49%), 3D-RT 4p (11%) and CT+RT 14p (40%) Mean RT dose 60,4Gy (r34-74). Primary tumors: lung 24 (69%), colorectal 9 (25%), oesophagus 2 (6%). For lung cancer p, the stage distribution was: IA 8 (23%), IB 2 (6%), IIA 2 (5.7%), IIB 1 (3%), IIIA 5 (4%), IIIb 4 (11%), IV 2 (6%). For other primaries, 8p (23%) were non metastatic at diagnosis and developed oligoprogressive disease in thorax which was treated with SBRT and 3 (8.5%) were oligometastatic. The location of reRT site: same lobe 17 (48%), ipsilateral different lobe 7 (20%), contralateral lobes 11 (32%). Median delivered dose of salvage SBRT was 50Gy (50-60) in 10 fractions (r3-10). Median accumulated dose in the lung was 81Gy (r60.10Gy-176Gy). With a median follow-up of 10m local control rate was 74% (IC95%; 0.59-0.9) and 1-year OS was 84% (IC 95%;0.67-1). The metabolic complete response rate was 23%. No differences in the baseline and post re-irradiation PFTs were observed: FEV1, FVC and DLCO difference and CI95% were 2.41 (-1.79-6.62); 65 (-125-257) and 12.5 (-95 - 121). Asthenia GII in 12p (31%) was the most frequent acute toxicity, no long-term toxicities were detected. Conclusion Salvage SBRT for treating isolated intrathoracic relapses achieved an outstanding local control and overall survival in selected p . This treatment did not impair postreirradiation PFT and long-term toxicities were not observed.
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2
Greater Poland Cancer Centre, Greater Poland Cancer Register, Poznan, Poland Purpose or Objective In 2013 1.963 (ASR 33,6/105) new lung cancer cases and 1.855 (ASR 31,1/105) lung cancer deaths were reported in Greater Poland. Compared to 1999 the number of new cases rose by 21% and the number of deaths rose by 16%. In the group of lung cancer patients from the Greater Poland population, diagnosed during 2009-2011, 80% were microscopically verified, among them 79,9% were NSCLC and 20,1% were SCLC. Prophylactic Cranial Irradiation (PCI) in SCLC patients remains an important part of the treatment process associated with a reduction of brain metastases and better survival. This paper is a retrospective review of 146 patients irradiated in Greater Poland Cancer Center, Poznan, Poland. Material and Methods Eighty limited SCLC (LSCLC) and sixty six extensive SCLC (ESCLC) patients irradiated in Greater Poland Cancer Center between 2007-2010 received a standard scheme of 25Gy/10fx with 6MV photons. The qualification based on X-ray post-chemotherapy assessment described as significant partial response or complete response. Mean time from the diagnosis date to the end of treatment was 6 months. The survival data were collected from the national and regional cancer registers. Results Mean observed survival in our patients was 16,8 months (13,6 months for ESCLC and 19,5 months for LSCLC). The 1-, 3- and 5-year observed survival rates were 74,12%, 9,52%, 4,70% for LSCLC and 48,48%, 1,49% 1,49% for ESCLC. For our group as a whole respectively: 65%, 8,6%, 3,3%. After radiotherapy, LSCLC and ESLCL patients survived 7,4 and 12,7 months on average. Grade 3 or 4 toxicity has not been noticed. Conclusion The Concord-2 study results show, that the 5-year net survival rates among lung cancer patients diagnosed during 2005-2009 in Poland (13,4%) and Greater Poland (13,2%) were on the average European level. Similarly, presented SCLC group meets 5-year survival rates of that time. Comparing to other authors, we have noticed slightly better results in 1- year survival - Schild et al: 56% (PCI arm, LSCLC&ESCLC), Slotman et. al: 27,1% (PCI arm, ESCLC). Nevertheless, in spite of good results shown above, the prospective analysis shoud be done. Contemporary salvage treatments for intracranial relapse may be underestimated especially if provided before patients become symptomatic. EP-1235 Stereotactic body radiotherapy for lung metastases: retrospective analysis of a single-center H. Herrmann1, C. Proksch1, K. Dieckmann1 1 Universitätsklinik für Strahlentherapie Medizinische Universität Wien, Wien, Austria Purpose or Objective A significant number of cancer patients with initially localized disease develop distant metastases at follow up. A subset of patients with successful treatment of the primary tumor develop oligometastatic disease months to years after initial treatment. Other patients with metastatic disease present with long-lasting stable disease or remission during systemic treatment and develop progression in single lesions in later course of disease. For these patients with low tumor burden, a semi-curative treatment strategy might be an option. In recent years, stereotactic body radiotherapy (SBRT) of the lung has been shown to provide an alternative to surgical resection of lung metastases. Typically, SBRT in the lung is performed with high single-doses per fraction. High
radiation doses to the lung could result in severe fibrosis, which might especially be relevant for patients with impaired lung function. Material and Methods We retrospectively analyzed 95 metastatic patients (male, n=64; female, n=31) who underwent SBRT in the lung at our institution from 2005-2015 with a total of 166 lung metastases. The median age was 65 years (range 38-84 years) at initial SBRT treatment. Primary tumors were colorectal cancer (n=35), renal cell carcinoma (n=15), head and neck cancer (n=12), melanoma (n=8), and other malignancies (n=25). Parameters assessed were: local control, survival, lung function test before start of treatment and during follow up, PTV volume, extent of fibrosis on CT scans. Results The treatment regimen most often used was 12.5 Gy x 3 fractions prescribed to the 65% isodose (n=100; EQD2 for α/β=10 Gy: 70.3 Gy at prescribed isodose, 140.5 Gy at 100% isodose) and 15 Gy x 3 fractions prescribed to the 65% isodose (n=33; EQD2 for α/β=10 Gy: 93.8 Gy at prescribed isodose, 190.8 Gy at 100% isodose). The median PTV volume was 15.9 ccm (range: 3.6 – 404.5 ccm). Median follow up was 20 months (range 1 – 136 months). The overall survival at 1 and 2 years was 85% and 68%, respectively. We achieved high local control after SBRT treatment at 1 and 2 years which was 95% and 88%, respectively. Signs of morphologically dense radiation induced fibrotic changes (hounsfield units > 10 as evaluated on CT scans) 4-6 months after treatment was seen in 40 % of all treated lesions. The median diameter of these fibrotic changes were 6.0 cm (range: 2.0 – 10.4 cm). Before SBRT treatment the median baseline FEV1 value of lung function test was 2.5 L (range: 0.96 – 3.96 L). FEV1 values at 1 years after treatment (expressed as mean percentage of baseline FEV1 ±SD) decreased to 95% (±8%) which was significant (p<0.05) in a paired t-test. Conclusion SBRT treatment for lung metastases results in high local control rates and can be safely applied. The impact on lung function test at one year after treatment was minimal although high biological doses were delivered. We conclude, that SBRT to the lung can be recommended to oligometastatic patients as an effective alternative treatment to surgical resection. EP-1236 Validation of the clinical diagnostic method for solitary pulmonary nodules before SBRT in Navarra M. Campo1, I. Visus1, S. Flamarique1, M. Barrado1, A. Martin1, M. Rico1, E. Martinez1 1 Hospital of Navarra, Oncología radioterapia, Pamplona, Spain Purpose or Objective In the general practice of the Hospital of Navarra, solitary pulmonary nodules (SPN) are frequently treated with SBRT without cytological confirmation due to patients´ comorbidities that heighten the risks associated with transthoracic biopsy. In this analysis we study the reliability of our clinical diagnostic system to better know the accuracy and quality of our protocols. Material and Methods We analyze retrospectively the pathological results of SPN treated surgically under suspicion of being stage I nonsmall-cell lung cancer (NSCLC) during 2012 and 2013. The suspicion was based on the criteria of an expert board composed by pneumologists, radiation oncologists, medical oncologists, thoracic surgeons, radiologists and pathologists. The decision of treating was taken according to the FDG-PET features, the morphological characteristics on CT and the growing pattern of the SPN.