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Chang JY, Jabbour SK, De Ruysscher D, Schild SE, Simone CB, Rengan R, Feigenberg S, Khan AJ, Choi NC, Bradley JD, Zhu XR, Lomax AJ, Hoppe BS. Consensus Statement on Proton Therapy in Early-Stage and Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2016; 95:505-516. [PMID: 27084663 PMCID: PMC10868643 DOI: 10.1016/j.ijrobp.2016.01.036] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/08/2015] [Accepted: 01/19/2016] [Indexed: 12/25/2022]
Abstract
Radiation dose escalation has been shown to improve local control and survival in patients with non-small cell lung cancer in some studies, but randomized data have not supported this premise, possibly owing to adverse effects. Because of the physical characteristics of the Bragg peak, proton therapy (PT) delivers minimal exit dose distal to the target volume, resulting in better sparing of normal tissues in comparison to photon-based radiation therapy. This is particularly important for lung cancer given the proximity of the lung, heart, esophagus, major airways, large blood vessels, and spinal cord. However, PT is associated with more uncertainty because of the finite range of the proton beam and motion for thoracic cancers. PT is more costly than traditional photon therapy but may reduce side effects and toxicity-related hospitalization, which has its own associated cost. The cost of PT is decreasing over time because of reduced prices for the building, machine, maintenance, and overhead, as well as newer, shorter treatment programs. PT is improving rapidly as more research is performed particularly with the implementation of 4-dimensional computed tomography-based motion management and intensity modulated PT. Given these controversies, there is much debate in the oncology community about which patients with lung cancer benefit significantly from PT. The Particle Therapy Co-operative Group (PTCOG) Thoracic Subcommittee task group intends to address the issues of PT indications, advantages and limitations, cost-effectiveness, technology improvement, clinical trials, and future research directions. This consensus report can be used to guide clinical practice and indications for PT, insurance approval, and clinical or translational research directions.
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Affiliation(s)
- Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey Rutgers, Robert Wood Johnson Medical School, The State University of New Jersey, New Brunswick, New Jersey
| | | | | | - Charles B Simone
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramesh Rengan
- University of Washington Medical Center, Seattle, Washington
| | | | - Atif J Khan
- Rutgers Cancer Institute of New Jersey Rutgers, Robert Wood Johnson Medical School, The State University of New Jersey, New Brunswick, New Jersey
| | - Noah C Choi
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Xiaorong R Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Bradford S Hoppe
- University of Florida Proton Therapy Institute, Jacksonville, Florida
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Pöttgen C, Abu Jawad J, Gkika E, Freitag L, Lübcke W, Welter S, Gauler T, Schuler M, Eberhardt WEE, Stamatis G, Stuschke M. Accelerated radiotherapy and concurrent chemotherapy for patients with contralateral central or mediastinal lung cancer relapse after pneumonectomy. J Thorac Dis 2015; 7:264-72. [PMID: 25922702 DOI: 10.3978/j.issn.2072-1439.2015.01.59] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 01/13/2015] [Indexed: 12/25/2022]
Abstract
BACKGROUND Treatment options are very limited for patients with lung cancer who experience contralateral central or mediastinal relapse following pneumonectomy. We present results of an accelerated salvage chemoradiotherapy regimen. METHODS Patients with localized contralateral central intrapulmonary or mediastinal relapse after pneumonectomy were offered combined chemoradiotherapy including concurrent weekly cisplatin (25 mg/m(2)) and accelerated radiotherapy [accelerated fractionated (AF), 60 Gy, 8×2 Gy per week] to reduce time for repopulation. Based on 4D-CT-planning, patients were irradiated using multifield intensity-modulated radiotherapy (IMRT) or helical tomotherapy. RESULTS Between 10/2011 and 12/2012, seven patients were treated. Initial stages were IIB/IIIA/IIIB: 3/1/3; histopathological subtypes scc/adeno/large cell: 4/1/2. Tumour relapses were located in mediastinal nodal stations in five patients with endobronchial tumour in three patients. The remaining patients had contralateral central tumour relapses. All patients received 60 Gy (AF), six patients received concurrent chemotherapy. Median dose to the remaining contralateral lung, esophagus, and spinal cord was 6.8 (3.3-11.4), 8.0 (5.1-15.5), and 7.6 (2.8-31.2) Gy, respectively. With a median follow-up of 29 [17-32] months, no esophageal or pulmonary toxicity exceeding grade 2 [Common terminology criteria for adverse events (CTC-AE) v. 3] was observed. Median survival was 17.2 months, local in-field control at 12 months 80%. Only two local recurrences were observed, both in combination with out-field metastases. CONCLUSIONS This intensified accelerated chemoradiotherapy schedule was safely applicable and offers a curative chance in these pretreated frail lung cancer patients.
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Affiliation(s)
- Christoph Pöttgen
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Jehad Abu Jawad
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Eleni Gkika
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Lutz Freitag
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Wolfgang Lübcke
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Stefan Welter
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Thomas Gauler
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Martin Schuler
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Wilfried Ernst Erich Eberhardt
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Georgios Stamatis
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Martin Stuschke
- 1 Department of Radiotherapy; West German Cancer Center, University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 2 Division of Interventional Pneumology, 3 Division of Thoracic Surgery, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 4 Department of Medical Oncology, West German Cancer Center; University of Duisburg-Essen, Hufelandstr, 55, D-45122 Essen, Germany ; 5 Division of Thoracic Oncology, Ruhrlandklinik, West German Lung Center, University of Duisburg-Essen, Tüschener Weg 40, D-45239 Essen, Germany ; 6 German Cancer Consortium (DKTK), Heidelberg, Germany
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