Outcomes of stereotactic ablative radiotherapy or surgery for early-stage lung cancer in patients with interstitial lung disease

PURPOSE: /objective(s): The ASPIRE-ILD (n = 39) and WJOG-6711 L (n = 39) studies suggest both stereotactic ablative radiotherapy (SABR) and surgery might be feasible and safe for selected patients with early-stage NSCLC and interstitial lung disease (ILD). Real-world data on patient outcomes is limited. We analyzed outcomes of SABR and surgery in ILD-lung cancer patients managed at a referral center. MATERIALS: /Methods: We retrospectively studied ILD patients with stage I-II lung cancer treated with SABR or surgery (2006-2024) after routine pre-treatment review by an ILD panel. Primary outcomes were progression-free survival (PFS) and overall survival (OS), analyzed both using unadjusted and inverse probability for treatment weighting (IPTW) analyses. Secondary endpoints included prognostic factors and pulmonary adverse events. RESULTS: A total of 67 ILD-lung cancer patients with stage I-II disease underwent surgery (n = 33) or SABR (n = 34). Surgical patients were generally younger with better WHO performance status. Two-year PFS after surgery was 54% and 53% after SABR; two-year OS was 68% and 56%, respectively. After IPTW adjustment, no significant differences were observed between surgery and SABR for PFS (HR 1.18, 95%CI: 0.48-2.90; p = 0.710) or OS (HR 0.94, 95%CI: 0.38-2.31; p = 0.890). Sixteen pulmonary adverse events occurred in 21% (n = 14) of all patients, including ILD exacerbations (n = 3), surgical complications (n = 6), and radiation pneumonitis (n = 7), with no significant differences between treatments. Progressive pulmonary fibrosis was independently associated with worse PFS and OS. CONCLUSION: SABR and surgery are feasible curative options for ILD patients with early-stage lung cancer. As potential toxicity risks appear acceptable, the diagnosis should not preclude curative treatments in this population.