One advantage of this approach is a shortened steroid course, and there are many reported long-term survivals beyond 2 years. These patients should undergo magnetic resonance imaging prior to surgery to rule out occult sites of metastasis not seen on computed tomographic scans. Patients with femoral metastases should be evaluated for prophylactic orthopedic pinning prior to radiation therapy, especially if more than 60% of the bone cross section or more than 50% of the cortex circumference is involved. Pathologic fractures should be considered for orthopedic stabilization prior to radiation. In general, at least a 2-week interval should be allowed between surgery and the institution of radiation therapy in order to allow for callus formation.
Primary Radiation Therapy
Resectable but Medically Inoperable Lung Cancer
Smart and Hilton reported in 1956 a 32% 5-year survival in a series of 33 patients with early-stage lung cancer treated with primary radiation therapy. They were encouraged to utilize radiation therapy because of favorable anecdotal results in patients who were inoperable or who refused surgery. These results were comparable to those in contemporary surgical reports. Noordijk et al reported in 1988 on a group of elderly patients (mean age, 74 years) with stage 1 or 2 cancers irradiated because of poor medical condition or refusal of surgery. The median survival of this group was 27 months, comparable to that of a group of similarly elderly patients with stage 1 or 2 disease who were treated operatively during the same time period (median survival, 23 months).