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Liu W, Feng H, Taylor PA, Kang M, Shen J, Saini J, Zhou J, Giap HB, Yu NY, Sio TS, Mohindra P, Chang JY, Bradley JD, Xiao Y, Simone CB, Lin L. NRG Oncology and Particle Therapy Co-Operative Group Patterns of Practice Survey and Consensus Recommendations on Pencil-Beam Scanning Proton Stereotactic Body Radiation Therapy and Hypofractionated Radiation Therapy for Thoracic Malignancies. Int J Radiat Oncol Biol Phys 2024; 119:1208-1221. [PMID: 38395086 PMCID: PMC11209785 DOI: 10.1016/j.ijrobp.2024.01.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 11/25/2023] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Stereotactic body radiation therapy (SBRT) and hypofractionation using pencil-beam scanning (PBS) proton therapy (PBSPT) is an attractive option for thoracic malignancies. Combining the advantages of target coverage conformity and critical organ sparing from both PBSPT and SBRT, this new delivery technique has great potential to improve the therapeutic ratio, particularly for tumors near critical organs. Safe and effective implementation of PBSPT SBRT/hypofractionation to treat thoracic malignancies is more challenging than the conventionally fractionated PBSPT because of concerns of amplified uncertainties at the larger dose per fraction. The NRG Oncology and Particle Therapy Cooperative Group Thoracic Subcommittee surveyed proton centers in the United States to identify practice patterns of thoracic PBSPT SBRT/hypofractionation. From these patterns, we present recommendations for future technical development of proton SBRT/hypofractionation for thoracic treatment. Among other points, the recommendations highlight the need for volumetric image guidance and multiple computed tomography-based robust optimization and robustness tools to minimize further the effect of uncertainties associated with respiratory motion. Advances in direct motion analysis techniques are urgently needed to supplement current motion management techniques.
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Affiliation(s)
- Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Hongying Feng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona; College of Mechanical and Power Engineering, China Three Gorges University, Yichang, Hubei, China; Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, Guangdong, China
| | - Paige A Taylor
- Imaging and Radiation Oncology Core Houston Quality Assurance Center, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jatinder Saini
- Seattle Cancer Care Alliance Proton Therapy Center and Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Huan B Giap
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence S Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Pranshu Mohindra
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey D Bradley
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
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Valdes G, Scholey J, Nano TF, Gennatas ED, Mohindra P, Mohammed N, Zeng J, Kotecha R, Rosen LR, Chang J, Tsai HK, Urbanic JJ, Vargas CE, Yu NY, Ungar LH, Eaton E, Simone CB. Predicting the Effect of Proton Beam Therapy Technology on Pulmonary Toxicities for Patients With Locally Advanced Lung Cancer Enrolled in the Proton Collaborative Group Prospective Clinical Trial. Int J Radiat Oncol Biol Phys 2024; 119:66-77. [PMID: 38000701 DOI: 10.1016/j.ijrobp.2023.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023]
Abstract
PURPOSE This study aimed to predict the probability of grade ≥2 pneumonitis or dyspnea within 12 months of receiving conventionally fractionated or mildly hypofractionated proton beam therapy for locally advanced lung cancer using machine learning. METHODS AND MATERIALS Demographic and treatment characteristics were analyzed for 965 consecutive patients treated for lung cancer with conventionally fractionated or mildly hypofractionated (2.2-3 Gy/fraction) proton beam therapy across 12 institutions. Three machine learning models (gradient boosting, additive tree, and logistic regression with lasso regularization) were implemented to predict Common Terminology Criteria for Adverse Events version 4 grade ≥2 pulmonary toxicities using double 10-fold cross-validation for parameter hyper-tuning without leak of information. Balanced accuracy and area under the curve were calculated, and 95% confidence intervals were obtained using bootstrap sampling. RESULTS The median age of the patients was 70 years (range, 20-97), and they had predominantly stage IIIA or IIIB disease. They received a median dose of 60 Gy in 2 Gy/fraction, and 46.4% received concurrent chemotherapy. In total, 250 (25.9%) had grade ≥2 pulmonary toxicity. The probability of pulmonary toxicity was 0.08 for patients treated with pencil beam scanning and 0.34 for those treated with other techniques (P = 8.97e-13). Use of abdominal compression and breath hold were highly significant predictors of less toxicity (P = 2.88e-08). Higher total radiation delivered dose (P = .0182) and higher average dose to the ipsilateral lung (P = .0035) increased the likelihood of pulmonary toxicities. The gradient boosting model performed the best of the models tested, and when demographic and dosimetric features were combined, the area under the curve and balanced accuracy were 0.75 ± 0.02 and 0.67 ± 0.02, respectively. After analyzing performance versus the number of data points used for training, we observed that accuracy was limited by the number of observations. CONCLUSIONS In the largest analysis of prospectively enrolled patients with lung cancer assessing pulmonary toxicities from proton therapy to date, advanced machine learning methods revealed that pencil beam scanning, abdominal compression, and lower normal lung doses can lead to significantly lower probability of developing grade ≥2 pneumonitis or dyspnea.
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Affiliation(s)
- Gilmer Valdes
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Jessica Scholey
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Tomi F Nano
- Department of Radiation Oncology, University of California, San Francisco, California.
| | - Efstathios D Gennatas
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Pranshu Mohindra
- University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | - Nasir Mohammed
- Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Jing Zeng
- University of Washington and Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Lane R Rosen
- Willis-Knighton Medical Center, Shreveport, Louisiana
| | - John Chang
- Oklahoma Proton Center, Oklahoma City, Oklahoma
| | - Henry K Tsai
- New Jersey Procure Proton Therapy Center, Somerset, New Jersey
| | - James J Urbanic
- Department of Radiation Oncology, California Protons Therapy Center, San Diego, California
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic Proton Center, Phoenix, Arizona
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic Proton Center, Phoenix, Arizona
| | - Lyle H Ungar
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric Eaton
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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Ming X, Mao J, Ma N, Chen J, Wang W, Sheng Y, Wu K. Intensity-modulated proton and carbon-ion radiotherapy using a fixed-beam system for locally advanced lung cancer: dosimetric comparison with x-ray radiotherapy and normal tissue complication probability (NTCP) evaluation. Phys Med Biol 2024; 69:015025. [PMID: 38064747 DOI: 10.1088/1361-6560/ad13d1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024]
Abstract
Objective. To assess the dosimetric consequences and the normal tissue complication probability (NTCP) for the organs at risk (OARs) in intensity-modulated particle radiotherapy of proton (IMPT) and carbon-ion (IMCT) using a fixed-beam delivery system when compared with intensity-modulated photon radiotherapy (IMRT) for locally advanced small-cell lung cancer.Approach. The plans were all designed under the same total relative biological effectiveness (RBE)-weighted prescription dose, in which the planning target volume (PTV) of the internal gross target volume(IGTV) and the PTV of the clinical target volume was irradiated with 69.3 Gy (RBE) and 63 Gy (RBE), respectively, using a simultaneously integrated boosting (SIB) technique. NTCPs were estimated for heart, lung, esophagus and spinal cord by Lyman-Kutcher-Burman (LKB) and logistic models. Dose escalation was simulated under the desired NTCP values (0.05, 0.10 and 0.50) of the three radiation techniques.Main results. Under the similar target coverage, almost all OARs were significantly better spared (p< 0.05) when using the particle radiotherapy except for D1cc (the dose to 1 cm3of the volume) of the proximal bronchial tree (p> 0.05). At least 57.6% of mean heart dose, 28.8% of mean lung dose and 19.1% of mean esophageal dose were reduced compared with IMRT. The mean NTCP of radiation-induced pneumonitis (RP) in the ipsilateral lung was 0.39 ± 0.33 (0.39 ± 0.31) in IMPT plans and 0.36 ± 0.32 (0.35 ± 0.30) in IMCT plans compared with 0.66 ± 0.30 (0.64 ± 0.28) in IMRT plans by LKB (logistic) models. The target dose could be escalated to 78.3/76.9 Gy (RBE) in IMPT/IMCT plans compared with 61.7 Gy (RBE) in IMRT plans when 0.50 of NTCP in terms of RP in the ipsilateral lung was applied.Significance. This study presents the potential of better control of the side effects and improvement of local control originating from the dosimetric advantage with the application of IMPT and IMCT with the SIB technique for locally advanced lung cancer, even with limited beam directions.
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Affiliation(s)
- Xue Ming
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People's Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China
| | - Jingfang Mao
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People's Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China
| | - Ningyi Ma
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People's Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China
| | - Jian Chen
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People's Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China
| | - Weiwei Wang
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People's Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China
| | - Yinxiangzi Sheng
- Department of Medical Physics, Shanghai Proton and Heavy Ion Center, Shanghai, Fudan University Cancer Hospital, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People's Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China
| | - Kailiang Wu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, People's Republic of China
- Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, People's Republic of China
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Seo SH, Pyo H, Ahn YC, Oh D, Yang K, Kim N, Sun JM, Park S, Jung HA, Lee SH, Ahn JS, Ahn MJ, Noh JM. Pulmonary function and toxicities of proton versus photon for limited-stage small cell lung cancer. Radiat Oncol J 2023; 41:274-282. [PMID: 38185932 PMCID: PMC10772597 DOI: 10.3857/roj.2023.00773] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/26/2023] [Accepted: 10/10/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE We aimed to compare the oncological outcomes and toxicities of definitive proton beam therapy (PBT) and photon beam therapy in patients with limited-stage small cell lung cancer (LS-SCLC). MATERIALS AND METHODS We retrospectively reviewed 262 patients with newly diagnosed LS-SCLC who underwent definitive PBT (n = 20; proton group) or photon beam therapy (n = 242; photon group) with concurrent chemotherapy between January 2016 and February 2021 and compared overall survival (OS), progression-free survival (PFS), dose-volume parameters, and toxicities between the groups. RESULTS The median follow-up duration was 24.5 months (range, 3.7 to 78.7). Baseline lung function was significantly worse and clinical target volume (CTV) was larger in the proton group (CTV: 296.6 vs. 215.3 mL; p = 0.080). The mean lung V10 was 37.7% ± 16.8% and 51.6% ± 24.5% in the proton and photon groups, respectively (p = 0.002). Two-year OS and PFS rates were 57.2% and 35.7% in the proton group and 65.3% and 40.8% in the photon group, respectively (p = 0.542 and 0.748, respectively). Grade ≥2 radiation pneumonitis and esophagitis occurred in 5 (25.0%) and 7 (35.0%) PBT-treated patients and 66 (27.3%) and 40 (16.5%) photon beam therapy-treated patients, respectively (p = 0.826 and 0.062, respectively). CONCLUSION Although the proton group had poorer lung function and a larger CTV than that in the photon group, both groups exhibited comparable treatment outcomes and radiation-related toxicities in LS-SCLC. PBT may be a valuable therapeutic modality in patients with poor pulmonary function or extensive disease burden owing to its lung-sparing ability.
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Affiliation(s)
- Sang Hoon Seo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hongryull Pyo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dongryul Oh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyungmi Yang
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Mu Sun
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sehhoon Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Ae Jung
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Se-Hoon Lee
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Seok Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myung-Ju Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Choi JI, Prabhu K, Hartsell WF, DeWees T, Sinesi C, Vargas C, Benda RK, Cahlon O, Chang AL. Outcomes and toxicities after proton partial breast radiotherapy for early stage, hormone receptor positive breast cancer: 3-Year results of a phase II multi-center trial. Clin Transl Radiat Oncol 2022; 37:71-77. [PMID: 36093343 PMCID: PMC9450061 DOI: 10.1016/j.ctro.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Proton therapy (PT) for partial breast irradiation (PBI) in early-stage breast cancer can decrease morbidity versus photon PBI with superior organs-at-risk sparing. We report 3-year outcomes of the first prospective, multicenter, phase II trial of proton PBI. Methods and Materials This Proton Collaborative Group phase II trial (PCG BRE007-12) recruited women ≥ 50 years with node-negative, estrogen receptor (ER)-positive, ≤3cm, invasive ductal carcinoma (IDC) or ductal carcinoma in situ undergoing breast conserving surgery followed by proton PBI (40 Gy(RBE), 10 daily fractions). Primary endpoint was freedom from ipsilateral breast cancer recurrence. Adverse events were prospectively graded using CTCAEv4.0. Breast Cancer Treatment Outcome Scale (BCTOS) assessed patient-reported quality of life (PRQOL). Results Thirty-eight evaluable patients enrolled between 2/2013-11/2016. Median age was 67 years (range 50-79); 55 % had left-sided disease, and median tumor size was 0.9 cm. Treatment was delivered in ≥ 2 fields predominantly with uniform scanning PT (n = 37). At 35-month median follow-up (12-62), all patients were alive, and none had local, regional or distant disease progression. One patient developed an ER-negative contralateral IDC. Seven grade 2 adverse events occurred; no radiotherapy-related grade ≥ 3 toxicities occurred. Changes in BCTOS subdomain mean scores were maximum 0.36, indicating no meaningful change in PRQOL. Median heart volume receiving 5 Gy (V5Gy), lung V20Gy, and lung V10Gy were 0 %, 0 % and 0.19 %, respectively. Conclusion At 3 years, proton PBI provided 100 % cancer control for early-stage, ER-positive breast cancer. Toxicities are minimal, and PRQOL remains acceptable with continued follow-up. These findings support PT as a safe and effective PBI delivery option.
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Affiliation(s)
- J. Isabelle Choi
- New York Proton Center, 225 East 126th Street, New York, NY 10035, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Kiran Prabhu
- Integris Health, 5911 W. Memorial, Oklahoma City, OK 73142, USA
| | - William F. Hartsell
- Northwestern Medicine, Chicago Proton Center, 4455 Weaver Pkwy, Warrenville, IL 60555, USA
| | - Todd DeWees
- Department of Quantitative Health Sciences, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | - Christopher Sinesi
- Hampton University Proton Therapy Institute, 40 Enterprise Pkwy, Hampton, VA 23666, USA
| | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic, 5777 E Mayo Blvd, Scottsdale, AZ 85054, USA
| | - Rashmi K. Benda
- Lynn Cancer Institute, Boca Raton Regional Hospital, 701 NW 13 St, Boca Raton, FL 33486, USA
| | - Oren Cahlon
- New York Proton Center, 225 East 126th Street, New York, NY 10035, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Andrew L. Chang
- California Protons Cancer Therapy Center, 9730 Summers Ridge Rd, San Diego, CA 92121, USA
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Wei S, Lin H, Isabelle Choi J, Shi C, Simone CB, Kang M. Advanced pencil beam scanning Bragg peak FLASH-RT delivery technique can enhance lung cancer planning treatment outcomes compared to conventional multiple-energy proton PBS techniques. Radiother Oncol 2022; 175:238-247. [PMID: 35961583 DOI: 10.1016/j.radonc.2022.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/01/2022] [Accepted: 08/01/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate the dosimetric characteristics between an advanced proton pencil beam scanning (PBS) Bragg peak FLASH technique and conventional PBS planning technique in lung tumors. To evaluate the "FLASHness" of single-field in a multiple-field delivery scheme for a hypofractionation regimen and move a step forward to clinical application. METHODS Single-energy PBS Bragg peak FLASH treatment plans were optimized based on a novel Bragg peak tracking technique to enable Bragg peaks to stop at the distal edge of the target. Inverse treatment planning using multiple-field optimization (MFO) can achieve sufficient FLASH dose rate and intensity-modulated proton therapy (IMPT)-equivalent dosimetric quality. The dose rate of organs-at-risk (OARs) and the target were calculated under FLASH machine parameters. A group of 10 consecutive lung SBRT patients was optimized to 34 Gy/fraction using a standard treatment of PBS technique with multiple energy layers as references to the Bragg peak plans. The dosimetric quality was compared between Bragg peak FLASH and conventional plans based on RTOG0915 dose metrics. FLASH dose rate ratios (V40Gy/s) were calculated as a metric of the FLASH-sparing effect. RESULTS For higher dose thresholds, the Bragg peak plans achieved greater V40Gy/s FLASH coverage for all major OARs. The V40Gy/s was close to 100% for all OARs when the dose thresholds were > 5 Gy for full plan and single beam evaluations. The less "FLASHness" region was associated with a low dose distribution, mainly occurring in the PBS field penumbra region. The conventional IMPT treatment plans yielded slightly superior target dose uniformity with a D2%(%) of 108.02% versus that of Bragg peak 300 MU plans of 111.81% (p < 0.01) and that of Bragg peak 1200 MU plans of 115.95% (p < 0.01). No significant difference in dose metrics was found between Bragg peak and IMPT treatment plans for the spinal cord, esophagus, heart, or lung-GTV (all p > 0.05). CONCLUSION Hypofractionated lung Bragg peak plans can maintain comparable plan quality to conventional PBS while achieving sufficient FLASH dose rate coverage for major OARs for each field under the multiple-field delivery scheme. The novel Bragg peak FLASH technique has the potential to enhance lung cancer planning treatment outcomes compared to standard PBS treatment techniques.
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Affiliation(s)
- Shouyi Wei
- New York Proton Center, New York, NY 10035, USA
| | - Haibo Lin
- New York Proton Center, New York, NY 10035, USA.
| | | | - Chengyu Shi
- City of Hope, Orange County, Irvine, CA 92618, USA
| | | | - Minglei Kang
- New York Proton Center, New York, NY 10035, USA.
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Pangua C, Rogado J, Serrano-Montero G, Belda-Sanchís J, Álvarez Rodríguez B, Torrado L, Rodríguez De Dios N, Mielgo-Rubio X, Trujillo JC, Couñago F. New perspectives in the management of small cell lung cancer. World J Clin Oncol 2022; 13:429-447. [PMID: 35949427 PMCID: PMC9244973 DOI: 10.5306/wjco.v13.i6.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 09/05/2021] [Accepted: 05/22/2022] [Indexed: 02/06/2023] Open
Abstract
The treatment of small cell lung cancer (SCLC) is a challenge for all specialists involved. New treatments have been added to the therapeutic armamentarium in recent months, but efforts must continue to improve both survival and quality of life. Advances in surgery and radiotherapy have resulted in prolonged survival times and fewer complications, while more careful patient selection has led to increased staging accuracy. Developments in the field of systemic therapy have resulted in changes to clinical guidelines and the management of patients with advanced disease, mainly with the introduction of immunotherapy. In this article, we describe recent improvements in the management of patients with SCLC, review current treatments, and discuss future lines of research.
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Affiliation(s)
- Cristina Pangua
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid 28031, Spain
| | - Jacobo Rogado
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid 28031, Spain
| | - Gloria Serrano-Montero
- Department of Medical Oncology, Hospital Universitario Infanta Leonor, Madrid 28031, Spain
| | - José Belda-Sanchís
- Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau & Hospital de Mar, Universitat Autònoma de Barcelona, Barcelona 08041, Catalonia, Spain
| | - Beatriz Álvarez Rodríguez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, HM CIOCC Centro Integral Oncológico Clara Campal, Madrid 28050, Spain
| | - Laura Torrado
- Department of Radiation Oncology, Hospital Universitario Lucus Augusti & Instituto de Investigación Sanitaria Santiago de Compostela (IDIS), Lugo 27003, Spain
| | - Nuria Rodríguez De Dios
- Department of Radiation Oncology, Hospital Del Mar & Hospital Del Mar Medical Research Institute (IMIM) & Pompeu Fabra University, Barcelona 08003, Catalonia, Spain
| | - Xabier Mielgo-Rubio
- Department of Medical Oncology, Alcorcón Foundation University Hospital, Alcorcón 28922, Madrid, Spain
| | - Juan Carlos Trujillo
- Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona 08029, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Hospital La Luz, Universidad Europea de Madrid, Madrid 28223, Spain
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Miyasaka Y, Sato H, Okano N, Kubo N, Kawamura H, Ohno T. A Promising Treatment Strategy for Lung Cancer: A Combination of Radiotherapy and Immunotherapy. Cancers (Basel) 2021; 14:203. [PMID: 35008367 PMCID: PMC8750493 DOI: 10.3390/cancers14010203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/26/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022] Open
Abstract
Lung cancer is a leading cause of cancer-related deaths worldwide despite advances in treatment. In the past few decades, radiotherapy has achieved outstanding technical advances and is being widely used as a definitive, prophylactic, or palliative treatment of patients with lung cancer. The anti-tumor effects of radiotherapy are considered to result in DNA damage in cancer cells. Moreover, recent evidence has demonstrated another advantage of radiotherapy: the induction of anti-tumor immune responses, which play an essential role in cancer control. In contrast, radiotherapy induces an immunosuppressive response. These conflicting reactions after radiotherapy suggest that maximizing immune response to radiotherapy by combining immunotherapy has potential to achieve more effective anti-tumor response than using each alone. Immune checkpoint molecules, such as cytotoxic T-lymphocyte-associated protein 4, programmed cell death-1/programmed death-ligand 1, and their inhibitors, have attracted significant attention for overcoming the immunosuppressive conditions in patients with cancer. Therefore, the combination of immune checkpoint inhibitors and radiotherapy is promising. Emerging preclinical and clinical studies have demonstrated the rationale for these combination strategies. In this review, we outlined evidence suggesting that combination of radiotherapy, including particle therapy using protons and carbon ions, with immunotherapy in lung cancer treatment could be a promising treatment strategy.
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Affiliation(s)
- Yuhei Miyasaka
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Hiro Sato
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Naoko Okano
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Nobuteru Kubo
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Hidemasa Kawamura
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
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9
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Limited-Stage Small-Cell Lung Cancer: Current Progress and the Next Frontier. RADIATION 2021. [DOI: 10.3390/radiation1040026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Limited-stage (LS) small-cell lung cancer (SCLC) is defined as disease confined to a tolerable radiation portal without extrathoracic metastases. Despite clinical research over two decades, the prognosis of LS-SCLC patients remains poor. The current standard of care for LS-SCLC patients is concurrent platinum-based chemotherapy with thoracic radiotherapy (RT). Widespread heterogeneity on the optimal radiation dose and fractionation regimen among physicians highlights the logistical challenges of administering BID regimens. Prophylactic cranial irradiation (PCI) is recommended to patients following a good initial response to chemoradiation due to improved overall survival from historical trials and the propensity for LS-SCLC to recur with brain metastases. However, PCI utilization is being debated due to the greater availability of magnetic resonance imaging (MRI) and data in extensive-stage SCLC regarding close MRI surveillance in lieu of PCI while spurring novel RT techniques, such as hippocampal-avoidance PCI. Additionally, novel treatment combinations incorporating targeted small molecule therapies and immunotherapies with or following radiation for LS-SCLC have seen recent interest and some concepts are being investigated in clinical trials. Here, we review the landscape of progress, limitations, and challenges for LS-SCLC including current standard of care, novel radiation techniques, and the integration of novel therapeutic strategies for LS-SCLC.
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10
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Ma NY, Chen J, Ming X, Jiang GL, Lu JJ, Wu KL, Mao J. Preliminary Safety and Efficacy of Proton Plus Carbon-Ion Radiotherapy With Concurrent Chemotherapy in Limited-Stage Small Cell Lung Cancer. Front Oncol 2021; 11:766822. [PMID: 34858845 PMCID: PMC8631778 DOI: 10.3389/fonc.2021.766822] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/11/2021] [Indexed: 01/08/2023] Open
Abstract
Objectives This study aimed to investigate the tolerance and effect of proton plus carbon-ion radiotherapy with concurrent chemotherapy in limited-stage small cell lung cancer using the pencil beam scanning technique. Materials and Methods From March 2017 to April 2020, 25 patients with limited-stage small cell lung cancer treated with combined proton and carbon-ion radiotherapy were analyzed. The primary lesions and involved lymph nodes were irradiated using 2-4 portals. Proton and sequential carbon-ion beams were delivered with a median dose of 67.1 (range, 63-74.8) GyE as fraction doses of 2.0-2.2 GyE with proton beams in 20-23 fractions and 3.0-3.8 GyE with carbon ions in 5-8 fractions. Chemotherapy was delivered concurrently with radiotherapy in all patients. Results At the last follow-up, the 2-year overall and locoregional progression-free survival rates were 81.7% and 66.7%, respectively. Radiochemotherapy was well tolerated, with grade 1, 2, and 3 acute toxicities occurring in 12.0%, 68.0%, and 20.0% of patients, respectively. All grade 3 acute toxicities were hematologically related changes. One patient experienced grade 3 acute non-hematological toxicity in the esophagus, and one other patient had grade 3 bronchial obstruction accompanied by obstructive atelectasis as a late side effect. Conclusion Proton plus carbon-ion radiotherapy using pencil beam scanning yielded promising survival rates and tolerability in patients with limited-stage small cell lung cancer. A prospective clinical study is warranted to validate the therapeutic efficacy of particle radiotherapy in combination with chemotherapy in limited-stage small cell lung cancer.
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Affiliation(s)
- Ning-Yi Ma
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Department of Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Jian Chen
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Department of Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Xue Ming
- Department of Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Radiation Physics, Shanghai Proton and Heavy Ion Center, Shanghai, China
| | - Guo-Liang Jiang
- Department of Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Fudan University, Shanghai, China
| | - Jiade J Lu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Shanghai, China.,Department of Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China
| | - Kai-Liang Wu
- Department of Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Fudan University, Shanghai, China
| | - Jingfang Mao
- Department of Radiation Oncology, Shanghai Key Laboratory of Radiation Oncology (20dz2261000), Shanghai, China.,Department of Radiation Oncology, Shanghai Engineering Research Center of Proton and Heavy Ion Radiation Therapy, Shanghai, China.,Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Fudan University, Shanghai, China
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11
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Levy A, Botticella A, Le Péchoux C, Faivre-Finn C. Thoracic radiotherapy in small cell lung cancer-a narrative review. Transl Lung Cancer Res 2021; 10:2059-2070. [PMID: 34012814 PMCID: PMC8107758 DOI: 10.21037/tlcr-20-305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Small-cell lung cancer (SCLC) represents 10–15% of all lung cancers and has a poor prognosis. Thoracic radiotherapy plays a central role in current SCLC management. Concurrent chemoradiotherapy (CTRT) is the standard of care for localised disease (stage I−III, limited-stage, LS). Definitive thoracic radiotherapy may be offered in metastatic patients (stage IV, extensive stage, ES-SCLC) after chemotherapy. For LS-SCLC, the gold standard is early accelerated hyperfractionated twice-daily CTRT (4 cycles of cisplatin etoposide, starting with the first or second chemotherapy cycle). Modern radiation techniques should be used with involved-field radiotherapy based on baseline CT and PET/CT scans. In ES-SCLC, thoracic radiotherapy should be discussed in cases of initial bulky mediastinal disease/residual thoracic disease not progressing after induction chemotherapy. This strategy was however not assessed in recent trials establishing chemo-immunotherapy as the standard first line treatment in ES-SCLC. Future developments include technical radiotherapy advances and the incorporation of new drugs. Thoracic irradiation is delivered more precisely given technical developments (IMRT, image-guided radiotherapy, stereotactic radiotherapy), reducing the risks of severe adverse events. Stereotactic ablative radiotherapy may be discussed in rare early stage (T1 to 2, N0) inoperable patients. A number of current clinical trials are investigating immunoradiotherapy. In this review, we highlight the current role of thoracic radiotherapy and describe ongoing research in the integration of biological surrogate markers, advanced radiotherapy technologies and novel drugs in SCLC patients.
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Affiliation(s)
- Antonin Levy
- Department of Radiation Oncology, Institut d'Oncologie Thoracique (IOT), Gustave Roussy, Villejuif, France.,Univ Paris Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM U1030, Molecular Radiotherapy, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Angela Botticella
- Department of Radiation Oncology, Institut d'Oncologie Thoracique (IOT), Gustave Roussy, Villejuif, France
| | - Cécile Le Péchoux
- Department of Radiation Oncology, Institut d'Oncologie Thoracique (IOT), Gustave Roussy, Villejuif, France
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,The Christie NHS Foundation Trust and Division of Cancer Sciences, University of Manchester, Manchester, UK
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12
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Couñago F, de la Pinta C, Gonzalo S, Fernández C, Almendros P, Calvo P, Taboada B, Gómez-Caamaño A, Guerra JLL, Chust M, González Ferreira JA, Álvarez González A, Casas F. GOECP/SEOR radiotherapy guidelines for small-cell lung cancer. World J Clin Oncol 2021; 12:115-143. [PMID: 33767969 PMCID: PMC7968106 DOI: 10.5306/wjco.v12.i3.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/25/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
Small cell lung cancer (SCLC) accounts for approximately 20% of all lung cancers. The main treatment is chemotherapy (Ch). However, the addition of radiotherapy significantly improves overall survival (OS) in patients with non-metastatic SCLC and in those with metastatic SCLC who respond to Ch. Prophylactic cranial irradiation reduces the risk of brain metastases and improves OS in both metastatic and non-metastatic patients. The 5-year OS rate in patients with limited-stage disease (non-metastatic) is slightly higher than 30%, but less than 5% in patients with extensive-stage disease (metastatic). The present clinical guidelines were developed by Spanish radiation oncologists on behalf of the Oncologic Group for the Study of Lung Cancer/Spanish Society of Radiation Oncology to provide a current review of the diagnosis, planning, and treatment of SCLC. These guidelines emphasise treatment fields, radiation techniques, fractionation, concomitant treatment, and the optimal timing of Ch and radiotherapy. Finally, we discuss the main indications for reirradiation in local recurrence.
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Affiliation(s)
- Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Hospital La Luz, Universidad Europea de Madrid, Madrid 28223, Madrid, Spain
| | - Carolina de la Pinta
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Susana Gonzalo
- Department of Radiation Oncology, Hospital Universitario La Princesa, Madrid 28006, Spain
| | - Castalia Fernández
- Department of Radiation Oncology, GenesisCare Madrid, Madrid 28043, Spain
| | - Piedad Almendros
- Department of Radiation Oncology, Hospital General Universitario, Valencia 46014, Spain
| | - Patricia Calvo
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - Begoña Taboada
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - Antonio Gómez-Caamaño
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - José Luis López Guerra
- Department of Radiation Oncology, Hospital Universitario Virgen del Rocío, Sevilla 41013, Spain
| | - Marisa Chust
- Department of Radiation Oncology, Fundación Instituto Valenciano de Oncología, Valencia 46009, Spain
| | | | | | - Francesc Casas
- Department of Radiation Oncology, Thoracic Unit, Hospital Clinic, Barcelona 08036, Spain
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13
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Chiang JS, Yu NY, Daniels TB, Liu W, Schild SE, Sio TT. Proton beam radiotherapy for patients with early-stage and advanced lung cancer: a narrative review with contemporary clinical recommendations. J Thorac Dis 2021; 13:1270-1285. [PMID: 33717598 PMCID: PMC7947490 DOI: 10.21037/jtd-20-2501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although lung cancer rates are decreasing nationally, lung cancer remains the leading cause of cancer related death. Despite advancements in treatment and technology, overall survival (OS) for lung cancer remains poor. Proton beam therapy (PBT) is an advanced radiation therapy (RT) modality for treatment of lung cancer with the potential to achieve dose escalation to tumor while sparing critical structures due to higher target conformality. In early and late-stage non-small cell lung cancer (NSCLC), dosimetric studies demonstrated reduced doses to organs at risk (OARs) such as the lung, spinal cord, and heart, and clinical studies report limited toxicities with PBT, including hypofractionated regimens. In limited-stage SCLC, studies showed that regimens chemo RT including PBT were well tolerated, which may help optimize clinical outcomes. Improved toxicity profiles may be beneficial in post-operative radiotherapy, for which initial dosimetric and clinical data are encouraging. Sparing of OARs may also increase the proportion of patients able to complete reirradiation for recurrent disease. However, there are various challenges of using PBT including a higher financial burden on healthcare and limited data supporting its cost-effectiveness. Further studies are needed to identify subgroups that benefit from PBT based on prognostic factors, and to evaluate PBT combined with immunotherapy, in order to elucidate the benefit that PBT may offer future lung cancer patients.
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Affiliation(s)
- Jennifer S Chiang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Thomas B Daniels
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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14
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Chun SG, Simone CB, Amini A, Chetty IJ, Donington J, Edelman MJ, Higgins KA, Kestin LL, Movsas B, Rodrigues GB, Rosenzweig KE, Slotman BJ, Rybkin II, Wolf A, Chang JY. American Radium Society Appropriate Use Criteria: Radiation Therapy for Limited-Stage SCLC 2020. J Thorac Oncol 2020; 16:66-75. [PMID: 33166720 DOI: 10.1016/j.jtho.2020.10.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/30/2020] [Accepted: 10/09/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Combined modality therapy with concurrent chemotherapy and radiation has long been the standard of care for limited-stage SCLC (LS-SCLC). However, there is controversy over best combined modality practices for LS-SCLC. To address these controversies, the American Radium Society (ARS) Thoracic Appropriate Use Criteria (AUC) Committee have developed updated consensus guidelines for the treatment of LS-SCLC. METHODS The ARS AUC are evidence-based guidelines for specific clinical conditions that are reviewed by a multidisciplinary expert panel. The guidelines include a review and analysis of current evidence with application of consensus methodology (modified Delphi) to rate the appropriateness of treatments recommended by the panel for LS-SCLC. Agreement or consensus was defined as less than or equal to 3 rating points from the panel median. The consensus ratings and recommendations were then vetted by the ARS Executive Committee and subject to public comment before finalization. RESULTS The ARS Thoracic AUC committee developed multiple consensus recommendations for LS-SCLC. There was strong consensus that patients with unresectable LS-SCLC should receive concurrent chemotherapy with radiation delivered either once or twice daily. For medically inoperable T1-T2N0 LS-SCLC, either concurrent chemoradiation or stereotactic body radiation followed by adjuvant chemotherapy is a reasonable treatment option. The panel continues to recommend whole-brain prophylactic cranial irradiation after response to chemoradiation for LS-SCLC. There was panel agreement that prophylactic cranial irradiation with hippocampal avoidance and programmed cell death protein-1/programmed death-ligand 1-directed immune therapy should not be routinely administered outside the context of clinical trials at this time. CONCLUSIONS The ARS Thoracic AUC Committee provide consensus recommendations for LS-SCLC that aim to provide a groundwork for multidisciplinary care and clinical trials.
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Affiliation(s)
- Stephen G Chun
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas.
| | | | - Arya Amini
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Indrin J Chetty
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | | | - Martin J Edelman
- Department of Hematology and Oncology, Fox Chase Comprehensive Cancer Center, Philadelphia, Pennsylvania
| | - Kristin A Higgins
- Department of Radiation Oncology, Emory University Winship Cancer Institute, Atlanta, Georgia
| | - Larry L Kestin
- MHP Radiation Oncology Institute/GenesisCare USA, Farmington Hills, Michigan
| | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - George B Rodrigues
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Kenneth E Rosenzweig
- Department of Radiation Oncology, Mount Sinai School of Medicine, New York, New York
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Igor I Rybkin
- Department of Hematology and Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Andrea Wolf
- Department of Thoracic Surgery, Mount Sinai School of Medicine, New York, New York
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
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15
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Zhang Y, Ho MW, Li Z. A Beam-Angle-Selection Method to Improve Inter-Fraction Motion Robustness for Lung Tumor Irradiation With Passive Proton Scattering. Technol Cancer Res Treat 2020; 19:1533033820948052. [PMID: 32844716 PMCID: PMC7453456 DOI: 10.1177/1533033820948052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
In terms of dose distribution, protons are more sensitive to range variations than photons due to their unique properties. The aim of this study was to develop a method to identify patient-specific robust proton beam angles for lung tumor irradiation by investigating the association between water equivalent thickness (WET) variation and inter-fraction motion-induced target dose degradation. Using 3-dimensional computed tomography (3D-CT) images, the impact of WET variations on the target dose coverage of a series of coplanar proton beams was evaluated for 4 patients with lung cancer. Using ray tracing, WET maps, or WET baseline, were estimated for the internal target volume (ITV) at every 5° gantry interval in the axial plane. After calculating the WET baseline, the planning CT was shifted 5 mm in each anterior-posterior (AP), superior-inferior (SI), and left-right (LR) direction, yielding a total of 6 shifted CTs, and differential WET maps between the planning CT and each shifted CT were calculated. Target dose differences were associated with the average WET change between the original planning CT and the shifted CTs for all 360° gantry rotation beams. Target and OAR dose metrics in the ΔWET-guided plans were compared with those of the clinical plans. The WET variation maps showed areas of both high and low WET variations, with overall similar patterns yet individual differences reflecting tumor position differences. For all 4 patients investigated in this study, the coplanar plans demonstrated a strong correlation between WET changes and ITV dose reductions. Target dose coverage was more stable with the ΔWET-guided plan while OAR doses were comparable to the clinical plan. The WET variation maps have been used in this pilot study to identify proton beam angles that are either sensitive or robust to WET changes in proton passive scattering. This work demonstrates the feasibility of using WET variation maps to assist the planner in inter-fraction motion-robust proton beam angle selection.
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Affiliation(s)
- Yawei Zhang
- 90618University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA.,Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Meng Wei Ho
- 90618University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA.,Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Zuofeng Li
- 90618University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA.,Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
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16
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Simone CB, Bogart JA, Cabrera AR, Daly ME, DeNunzio NJ, Detterbeck F, Faivre-Finn C, Gatschet N, Gore E, Jabbour SK, Kruser TJ, Schneider BJ, Slotman B, Turrisi A, Wu AJ, Zeng J, Rosenzweig KE. Radiation Therapy for Small Cell Lung Cancer: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2020; 10:158-173. [PMID: 32222430 PMCID: PMC10915746 DOI: 10.1016/j.prro.2020.02.009] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/15/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Several sentinel phase III randomized trials have recently been published challenging traditional radiation therapy (RT) practices for small cell lung cancer (SCLC). This American Society for Radiation Oncology guideline reviews the evidence for thoracic RT and prophylactic cranial irradiation (PCI) for both limited-stage (LS) and extensive-stage (ES) SCLC. METHODS The American Society for Radiation Oncology convened a task force to address 4 key questions focused on indications, dose fractionation, techniques and timing of thoracic RT for LS-SCLC, the role of stereotactic body radiation therapy (SBRT) compared with conventional RT in stage I or II node negative SCLC, PCI for LS-SCLC and ES-SCLC, and thoracic consolidation for ES-SCLC. Recommendations were based on a systematic literature review and created using a consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS The task force strongly recommends definitive thoracic RT administered once or twice daily early in the course of treatment for LS-SCLC. Adjuvant RT is conditionally recommended in surgically resected patients with positive margins or nodal metastases. Involved field RT delivered using conformal advanced treatment modalities to postchemotherapy volumes is also strongly recommended. For patients with stage I or II node negative disease, SBRT or conventional fractionation is strongly recommended, and chemotherapy should be delivered before or after SBRT. In LS-SCLC, PCI is strongly recommended for stage II or III patients who responded to chemoradiation, conditionally not recommended for stage I patients, and should be a shared decision for patients at higher risk of neurocognitive toxicities. In ES-SCLC, radiation oncologist consultation for consideration of PCI versus magnetic resonance surveillance is strongly recommended. Lastly, the use of thoracic RT is strongly recommended in select patients with ES-SCLC after chemotherapy treatment, including a conditional recommendation in those responding to chemotherapy and immunotherapy. CONCLUSIONS RT plays a vital role in both LS-SCLC and ES-SCLC. These guidelines inform best clinical practices for local therapy in SCLC.
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Affiliation(s)
| | - Jeffrey A Bogart
- Department of Radiation Oncology, SUNY Upstate Medical University, Syracuse, NY
| | - Alvin R Cabrera
- Department of Radiation Oncology, Kaiser Permanente, Seattle, WA
| | - Megan E Daly
- Department of Radiation Oncology, University of California Davis, Sacramento, CA
| | - Nicholas J DeNunzio
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Frank Detterbeck
- Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT
| | - Corinne Faivre-Finn
- Division of Cancer Science, University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Elizabeth Gore
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers University, New Brunswick, NJ
| | - Tim J Kruser
- Department of Radiation Oncology, Northwestern Memorial Hospital, Chicago, IL
| | - Bryan J Schneider
- Department of Medical Oncology, University of Michigan, Ann Arbor, MI
| | - Ben Slotman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, Netherlands
| | - Andrew Turrisi
- Department of Radiation Oncology, James H. Quillen VA Medical Center, Mountain Home, TN
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering, New York, NY
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington, Seattle, WA
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17
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Luna JM, Chao HH, Shinohara RT, Ungar LH, Cengel KA, Pryma DA, Chinniah C, Berman AT, Katz SI, Kontos D, Simone CB, Diffenderfer ES. Machine learning highlights the deficiency of conventional dosimetric constraints for prevention of high-grade radiation esophagitis in non-small cell lung cancer treated with chemoradiation. Clin Transl Radiat Oncol 2020; 22:69-75. [PMID: 32274426 PMCID: PMC7132156 DOI: 10.1016/j.ctro.2020.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/17/2020] [Accepted: 03/21/2020] [Indexed: 12/23/2022] Open
Abstract
A large cohort to predict radiation esophagitis in lung cancer patients was used. Modern machine learning models were implemented to predict radiation esophagitis. Previously published predictors of grade ≥ 3 radiation esophagitis may be unreliable.
Background and Purpose Radiation esophagitis is a clinically important toxicity seen with treatment for locally-advanced non-small cell lung cancer. There is considerable disagreement among prior studies in identifying predictors of radiation esophagitis. We apply machine learning algorithms to identify factors contributing to the development of radiation esophagitis to uncover previously unidentified criteria and more robust dosimetric factors. Materials and Methods We used machine learning approaches to identify predictors of grade ≥ 3 radiation esophagitis in a cohort of 202 consecutive locally-advanced non-small cell lung cancer patients treated with definitive chemoradiation from 2008 to 2016. We evaluated 35 clinical features per patient grouped into risk factors, comorbidities, imaging, stage, histology, radiotherapy, chemotherapy and dosimetry. Univariate and multivariate analyses were performed using a panel of 11 machine learning algorithms combined with predictive power assessments. Results All patients were treated to a median dose of 66.6 Gy at 1.8 Gy per fraction using photon (89.6%) and proton (10.4%) beam therapy, most often with concurrent chemotherapy (86.6%). 11.4% of patients developed grade ≥ 3 radiation esophagitis. On univariate analysis, no individual feature was found to predict radiation esophagitis (AUC range 0.45–0.55, p ≥ 0.07). In multivariate analysis, all machine learning algorithms exhibited poor predictive performance (AUC range 0.46–0.56, p ≥ 0.07). Conclusions Contemporary machine learning algorithms applied to our modern, relatively large institutional cohort could not identify any reliable predictors of grade ≥ 3 radiation esophagitis. Additional patients are needed, and novel patient-specific and treatment characteristics should be investigated to develop clinically meaningful methods to mitigate this survival altering toxicity.
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Affiliation(s)
- José Marcio Luna
- Department of Radiation Oncology, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Hann-Hsiang Chao
- Department of Radiation Oncology, Hunter Holmes McGuire Veterans Affairs Medical Center, 1201 Broad Rock Blvd, Richmond, VA 23249, United States
| | - Russel T Shinohara
- Department of Biostatistics and Epidemiology, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, United States
| | - Lyle H Ungar
- Department of Computer and Information Science, University of Pennsylvania, 3330 Walnut St, Philadelphia, PA 19104, United States
| | - Keith A Cengel
- Department of Radiation Oncology, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Daniel A Pryma
- Department of Radiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, United States
| | | | - Abigail T Berman
- Department of Radiation Oncology, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Sharyn I Katz
- Department of Radiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, United States
| | - Despina Kontos
- Department of Radiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, United States
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, 225 East 126 St, New York, NY 10035, United States
| | - Eric S Diffenderfer
- Department of Radiation Oncology, University of Pennsylvania, Perelman Center for Advanced Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
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Barsky AR, Reddy VK, Plastaras JP, Ben-Josef E, Metz JM, Wojcieszynski AP. Proton beam re-irradiation for gastrointestinal malignancies: a systematic review. J Gastrointest Oncol 2020; 11:187-202. [PMID: 32175122 DOI: 10.21037/jgo.2019.09.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Radiotherapy (RT) is part of the standard of care management of most gastrointestinal (GI) cancers. Even with advanced RT, systemic therapy, and surgical techniques, locoregional recurrences or second primary cancers can still occur within previously irradiated fields, which can present challenges in delivering effective and safe treatment. Options for reirradiation are often limited, but given the favorable dosimetric aspects of proton-beam RT, it may provide an effective and safe re-irradiation option for patients with recurrent or second primary GI cancers. Methods We conducted a systematic review as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement protocol, assessing for reports of proton-beam reirradiation for recurrent or second primary GI cancers, primarily via PubMed. From the initial 373 articles identified, 7 articles were ultimately included in the analysis. Results The 7 included studies reported on proton-beam re-irradiation for the following disease sites: esophageal (n=2), pancreas (n=1), liver (n=2), rectal (n=1), and anal (n=1). Study sizes varied from as few as 1 to as many as 83 patients. Across studies, in patients who presented with tumor-related symptoms, palliation (stability/improvement) was achieved in 80-100% of the cases. Local control rates, with variable follow-up, ranged from 36-100%. All median overall survival values, when reported, were greater than 1 year. Across both liver studies, there were no cases of radiation-induced liver disease (RILD) from proton-beam re-irradiation. Across all studies, there were 2 acute (esophagopleural fistula in esophageal cancer, small bowel perforation in pancreatic cancer) and 1 late (esophageal ulcer in esophageal cancer) grade 5 toxicities, all favored to be due to progressive disease, rather than proton-beam re-irradiation. Two studies (1 esophageal, 1 rectal) generated comparison photon plans. One found that proton therapy reduced mean heart and lung doses, spinal cord dose, and lung V5Gy as compared to photon treatment, while resulting in higher lung V20Gy and V30Gy. The other found that protons decreased bowel V10Gy, V20Gy, and the dose to 200 and 150 cc of bowel, as compared to photons. Conclusions Based upon the published experiences, proton-beam re-irradiation for recurrent or second primary GI cancers appears effective for palliation, with good disease-control, limited toxicity, favorable dosimetry, and overall compares well with published non-proton-beam experiences. Given short follow-up, additional studies are warranted to determine if dosimetric advantages from proton therapy will translate into comparative toxicity benefits.
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Affiliation(s)
- Andrew R Barsky
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - Vishruth K Reddy
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - Edgar Ben-Josef
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - James M Metz
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
| | - Andrzej P Wojcieszynski
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, PA, USA
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Wu Q, Xiong Y, Zhang S, Chen X, Yi F, Wei Y, Zhang W. A Meta-Analysis of the Efficacy and Toxicity of Twice-Daily vs. Once-Daily Concurrent Chemoradiotherapy for Limited-Stage Small Cell Lung Cancer Based on Randomized Controlled Trials. Front Oncol 2020; 9:1460. [PMID: 31970086 PMCID: PMC6960125 DOI: 10.3389/fonc.2019.01460] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Currently, the accepted standard management of limited-stage small cell lung cancer (SCLC) is concurrent chemoradiotherapy (CCRT), but the frequency of radiotherapy is controversial. Therefore, this meta-analysis, which compared the efficacy and toxicity between twice-daily (BID) and once-daily (OD) CCRT, was performed to help clinicians make better decisions. Methods: Relevant randomized controlled trials (RCTs) were collected by searching the PubMed, Ovid MEDLINE, Embase, ScienceDirect, Web of Science, the Cochrane Library, Scopus and Google Scholar databases to assess antitumor effects (overall survival, OS; progression-free survival, PFS; overall response rate, ORR) and toxicity (adverse effects, AEs). Results: We screened 1499 articles and included 5 RCTs including 1421 patients. We found that BID CCRT improved OS (hazard ratio, HR = 0.88, 95% confidence interval, CI 0.78-0.99, p = 0.03), the 1-year OS rate (OSR-1y, risk ratio, RR = 1.07, 95%CI 1.01-1.13, p = 0.03), and OSR-4y (RR = 1.22, 95%CI 1.03-1.43, p = 0.02), with better trends in OSR-2y, OSR-3y, and OSR-5y, compared to OD CCRT. In addition, BID CCRT had a higher complete response (CR, RR = 1.31, 95%CI 1.01-1.70, p = 0.04) than OD CCRT. PFS (HR = 0.92, 95%CI 0.79-1.07, p = 0.29), annual PFS rate, ORR (RR = 0.99, 95%CI 0.93-1.05, p = 0.72), and AEs for all grades (RR = 1.00, 95%CI 0.98-1.01, p = 0.57), and grades 3-5 (RR = 1.02, 95%CI 0.95-1.09, p = 0.60) were similar between the two arms. Conclusions: BID CCRT appears to be better than OD CCRT for limited-stage SCLC, with better antitumor effects (OS, OSR, and CR) and similar AEs. However, the high levels of AEs in both arms should be taken as a sign of caution. More large sample and high-quality RCTs need to be conducted to confirm our conclusions.
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Affiliation(s)
- Qian Wu
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yiting Xiong
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Shujuan Zhang
- Jiangxi Medical College, Nanchang University, Nanchang, China
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xinling Chen
- Jiangxi Medical College, Nanchang University, Nanchang, China
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fengming Yi
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yiping Wei
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenxiong Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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Patterns of Care and Outcomes of Elderly Esophageal Cancer Patients Not Meeting Age-based Criteria of the CROSS Trial. Am J Clin Oncol 2019; 42:67-74. [PMID: 30216194 DOI: 10.1097/coc.0000000000000481] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The CROSS trial established neoadjuvant chemoradiation followed by surgery (nCRT-S) as superior to surgery alone (S) for locally advanced esophageal cancer (EC). However, because patients above 75 years of age were excluded, this comparison cannot be extrapolated to older patients. This study of a large, contemporary national database evaluated practice patterns in elderly patients ineligible for CROSS, and analyzed overall survival (OS) between nCRT+S, S, and definitive CRT (dCRT). MATERIALS AND METHODS The National Cancer Data Base was queried for EC patients with cT1N1M0/T2-3N0-1M0 EC (per the CROSS trial) but 76 years and above of age. Multivariable logistic regression ascertained factors associated with nCRT+S (vs. S). Kaplan-Meier analysis evaluated OS; Cox multivariate analysis determined variables associated with OS. Propensity matching aimed to address group imbalances and indication biases. RESULTS Of 4099 total patients, 594 (14%) underwent nCRT+S, 494 (12%) underwent S, and 3011 (73%) underwent dCRT. Since 2010, trimodality management has risen, corresponding to declines in S and dCRT. Median OS in the respective groups were 26.7, 20.3, and 17.8 months (P<0.05). Following propensity matching, there was a trend towards higher OS with nCRT-S over S (P=0.077); dCRT showed poorer OS than nCRT-S (P<0.001) but was equivalent to S (P=0.669). Before and following matching, nCRT-S experienced equivalent 30- and 90-day mortality as S (P>0.05), with lower 30-day readmission and postoperative hospital stay (P<0.05). CONCLUSIONS Although most older patients not meeting CROSS criteria undergo dCRT, utilization of trimodality therapy is rising. Despite the trend towards higher OS with trimodality therapy without poorer postoperative outcomes, careful patient selection continues to be essential in this population.
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Dreyfuss AD, Jahangiri P, Simone CB, Alavi A. Evolving Role of Novel Quantitative PET Techniques to Detect Radiation-Induced Complications. PET Clin 2019; 15:89-100. [PMID: 31735305 DOI: 10.1016/j.cpet.2019.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Radiation-induced normal tissue toxicities vary in terms of pathophysiologic determinants and timing of disease development, and they are influenced by the dose and radiation volume the critical organs receive, and the radiosensitivity of normal tissues and their baseline rate of cell turnover. Radiation-induced lung injury is dose limiting for the treatment of lung and thoracic cancers and can lead to fibrosis and potentially fatal pneumonitis. This article focuses on pulmonary and cardiovascular complications of radiation therapy and discusses how PET-based novel quantitative techniques can be used to detect these events earlier than current imaging modalities or clinical presentation allow.
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Affiliation(s)
- Alexandra D Dreyfuss
- Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Pegah Jahangiri
- Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, 225 East 126th Street, New York, NY 10035, USA.
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Gomez DR, Rimner A, Simone CB, Cho BCJ, de Perrot M, Adjei AA, Bueno R, Gill RR, Harpole DH, Hesdorffer M, Hirsch FR, Jackson AA, Pass HI, Rice DC, Rusch VW, Tsao AS, Yorke E, Rosenzweig K. The Use of Radiation Therapy for the Treatment of Malignant Pleural Mesothelioma: Expert Opinion from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation. J Thorac Oncol 2019; 14:1172-1183. [PMID: 31125736 DOI: 10.1016/j.jtho.2019.03.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/28/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Detailed guidelines regarding the use of radiation therapy for malignant pleural mesothelioma (MPM) are currently lacking because of the rarity of the disease, the wide spectrum of clinical presentations, and the paucity of high-level data on individual treatment approaches. METHODS In March 2017, a multidisciplinary meeting of mesothelioma experts was cosponsored by the U.S. National Cancer Institute, International Association for the Study of Lung Cancer Research, and Mesothelioma Applied Research Foundation. Among the outcomes of this conference was the foundation of detailed, multidisciplinary consensus guidelines. RESULTS Here we present consensus recommendations on the use of radiation therapy for MPM in three discrete scenarios: (1) hemithoracic radiation therapy to be used before or after extrapleural pneumonectomy; (2) hemithoracic radiation to be used as an adjuvant to lung-sparing procedures (i.e., without pneumonectomy); and (3) palliative radiation therapy for focal symptoms caused by the disease. We discuss appropriate simulation techniques, treatment volumes, dose fractionation regimens, and normal tissue constraints. We also assess the role of particle beam therapy, specifically, proton beam therapy, for MPM. CONCLUSION The recommendations provided in this consensus statement should serve as important guidelines for developing future clinical trials of treatment approaches for MPM.
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Affiliation(s)
- Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - B C John Cho
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Marc de Perrot
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Alex A Adjei
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ritu R Gill
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David H Harpole
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | | | - Fred R Hirsch
- Department of Medicine, University of Colorado, Denver, Colorado; Department of Pathology, University of Colorado, Denver, Colorado
| | | | - Harvey I Pass
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Valerie W Rusch
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S Tsao
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kenneth Rosenzweig
- Department of Radiation Oncology, Mount Sinai School of Medicine, New York, New York
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Quantification of global lung inflammation using volumetric 18F-FDG PET/CT parameters in locally advanced non-small-cell lung cancer patients treated with concurrent chemoradiotherapy: a comparison of photon and proton radiation therapy. Nucl Med Commun 2019; 40:618-625. [PMID: 31095527 DOI: 10.1097/mnm.0000000000000997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Radiation pneumonitis is a major dose-limiting complication in thoracic radiation therapy (RT) and presents clinically in the first few months after RT. We evaluated the feasibility of quantifying pulmonary parenchymal glycolysis (PG) as a surrogate of global lung inflammation and radiation-induced pulmonary toxicity using a novel semiautomatic lung segmentation technique in non-small-cell lung cancer (NSCLC) patients and compared PG in patients treated with photon or proton RT. PATIENTS AND METHODS We evaluated 18 consecutive locally advanced NSCLC patients who underwent pretreatment and post-treatment F-FDG PET/CT treated with definitive (median: 66.6 Gy; 1.8 Gy fractions) photon or proton RT between 2010 and 2014. Lung volume segmentation was conducted using 3D Slicer by performing simple thresholding. Pulmonary PG was calculated by summing F-FDG uptake in the whole lung. RESULTS In nine patients treated with photon RT, significant increases in PG in both ipsilateral (mean difference: 1400±510; P=0.02) and contralateral (mean difference: 1200±450; P=0.03) lungs were noted. In nine patients treated with proton therapy, no increase in pulmonary PG was observed in either the ipsilateral (P=0.30) or contralateral lung (P=0.98). CONCLUSION We observed a significant increase in global lung inflammation bilaterally as measured by quantification of PG. However, no significant change in global lung inflammation was noted after proton therapy. Future larger studies are needed to determine whether this difference correlates with lower risks of radiation pneumonitis in NSCLC patients treated with proton therapy.
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Braunstein S, Wang L, Newhauser W, Tenenholz T, Rong Y, van der Kogel A, Dominello M, Joiner MC, Burmeister J. Three discipline collaborative radiation therapy (3DCRT) special debate: The United States should build additional proton therapy facilities. J Appl Clin Med Phys 2019; 20:7-12. [PMID: 30735613 PMCID: PMC6370982 DOI: 10.1002/acm2.12537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 12/31/2022] Open
Affiliation(s)
- Steve Braunstein
- Department of Radiation Oncology, University of California - San Francisco, San Francisco, CA, USA
| | - Li Wang
- Department of Radiation Oncology, University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Wayne Newhauser
- Department of Physics and Astronomy, Louisiana State University, Baton Rouge, LA, USA
| | - Todd Tenenholz
- Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Yi Rong
- Department of Radiation Oncology, University of California - Davis Cancer Center, Sacramento, CA, USA
| | | | - Michael Dominello
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Michael C Joiner
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Jay Burmeister
- Department of Oncology, Wayne State University School of Medicine, Detroit, MI, USA.,Gershenson Radiation Oncology Center, Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA
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Ryckman JM, Ganesan V, Kusi Appiah A, Zhang C, Verma V. National practice patterns of proton versus photon therapy in the treatment of adult patients with primary brain tumors in the United States. Acta Oncol 2019; 58:66-73. [PMID: 30280620 DOI: 10.1080/0284186x.2018.1512755] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To examine patterns of care associated with the administration of proton versus photon therapy for adult patients with primary brain tumors in a large national cohort from the United States. METHODS The National Cancer Database (NCDB) was queried for newly diagnosed primary brain tumors (2004-2014) in adult patients aged 18 and older receiving proton or photon radiotherapy. Clinical features, patient demographics and treatment parameters were extracted. Differences between groups were assessed using multivariable logistic regression analysis. RESULTS In total, 73,073 patients were analyzed (n = 72,635 [99.4%] photon therapy, n = 438 [0.6%] proton therapy). On multivariable analysis of photon versus proton therapy, several factors predicted for receipt of proton therapy, including younger age (p = .041), highest income quartile (p = .007), treatment at academic institutions (p < .001), in regional facilities outside the Midwest/South (p < .001), diagnosis in more recent years (p = .003), fewer comorbidities (p < .001) and non-glioblastoma histology (p < .001). CONCLUSIONS There are several significant socioeconomic variables that influence receipt of proton therapy for primary brain tumors. Although not implying causation, the socioeconomic findings discovered herein should be taken into account when delivering cancer care to all patients.
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Affiliation(s)
- Jeffrey M. Ryckman
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vaishnavi Ganesan
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Adams Kusi Appiah
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Chi Zhang
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
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Rice SR, Li YR, Busch TM, Kim MM, McNulty S, Dimofte A, Zhu TC, Cengel KA, Simone CB. A Novel Prospective Study Assessing the Combination of Photodynamic Therapy and Proton Radiation Therapy: Safety and Outcomes When Treating Malignant Pleural Mesothelioma. Photochem Photobiol 2019; 95:411-418. [PMID: 30485442 PMCID: PMC6778401 DOI: 10.1111/php.13065] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/20/2018] [Indexed: 12/11/2022]
Abstract
Malignant pleural mesothelioma remains difficult to treat, with high failure rates despite optimal therapy. We present a novel prospective trial combining proton therapy (PT) and photodynamic therapy (PDT) and the largest-ever mesothelioma PT experience (n = 10). PDT photosensitizers included porfimer sodium (2 mg·kg-1 ; 24 h drug-light interval) or 2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide-a (HPPH) (4 mg·m-2 ;48 h) with wavelengths of 630 nm to 60J·cm-2 and 665 nm to 15-45J·cm-2 , respectively. With a median age of 69 years, patients were predominantly male (90%) with epithelioid histology (100%) and stage III-IV disease (100%). PT was delivered to a median of 55.0 CGE/1.8-2.0 CGE (range 50-75 CGE) adjuvantly (n = 8) or as salvage therapy (n = 2) following extended pleurectomy/decortication (ePD)/PDT. Two-year local control was 90%, with distant and regional failure rates of 50% and 30%, respectively. All patients received chemotherapy, and four received immunotherapy. Surgical complications included atrial fibrillation (n = 3), pneumonia (n = 2), and deep vein thrombosis (n = 2). Median survival from PT completion was 19.5 months (30.3 months from diagnosis), and 1- and 2-year survival rates were 58% and 29%. No patient experienced CTCAEv4 grade ≥2 acute or late toxicity. Our prolonged survival in very advanced-stage patients compares favorably to survival for PT without PDT and photon therapy with PDT, suggesting possible spatial or systemic cooperativity and immune effect.
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Affiliation(s)
- Stephanie R. Rice
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Yun R. Li
- Helen Diller Family Comprehensive Cancer Center, Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Theresa M. Busch
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michele M. Kim
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sally McNulty
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrea Dimofte
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Timothy C. Zhu
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Keith A. Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Charles B. Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
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Verma V, Ahern CA, Berlind CG, Lindsay WD, Shabason J, Sharma S, Culligan MJ, Grover S, Friedberg JS, Simone CB. Survival by Histologic Subtype of Malignant Pleural Mesothelioma and the Impact of Surgical Resection on Overall Survival. Clin Lung Cancer 2018; 19:e901-e912. [PMID: 30224273 DOI: 10.1016/j.cllc.2018.08.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/23/2018] [Accepted: 08/11/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION For the 3 histologic subtypes of malignant pleural mesothelioma (MPM)-epithelioid, sarcomatoid, and biphasic-the magnitude of benefit with surgical management remains underdefined. MATERIALS AND METHODS The National Cancer Data Base was queried for newly diagnosed nonmetastatic MPM with known histology. Patients in each histologic group were dichotomized into those receiving gross macroscopic resection versus lack thereof/no surgery. Kaplan-Meier analysis evaluated overall survival (OS) between cohorts; multivariable Cox proportional hazards modeling assessed factors associated with OS. After propensity matching, survival was evaluated for each histologic subtype with and without surgery. RESULTS Overall, 4207 patients (68% epithelioid, 18% sarcomatoid, 13% biphasic) met the study criteria. Before propensity matching, patients with epithelioid disease experienced the highest median OS (14.4 months), followed by biphasic (9.5 months) and sarcomatoid (5.3 months) disease; this also persisted after propensity matching (P < .001). After propensity matching, surgery was associated with significantly improved OS for epithelioid (20.9 vs. 14.7 months, P < .001) and biphasic (14.5 vs. 8.8 months, P = .013) but not sarcomatoid (11.2 vs. 6.5 months, P = .140) disease. On multivariable analysis, factors predictive of poorer OS included advanced age, male gender, uninsured status, urban residence, treatment at community centers, and T4/N2 disease (all P < .05). Chemotherapy and surgery were independently associated with improved OS, as was histology (all P < .001). CONCLUSION This large investigation evaluated surgical practice patterns and survival by histology for MPM and found that histology independently affects survival. Gross macroscopic resection is associated with significantly increased survival in epithelioid and biphasic, but not sarcomatoid, disease. However, the decision to perform surgery should continue to be individualized in light of available randomized data.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA
| | | | | | | | - Jacob Shabason
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Sonam Sharma
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Melissa J Culligan
- Department of Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Joseph S Friedberg
- Department of Surgery, Division of Thoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD.
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Mishra MV, Louie AV, Gondi V, Slotman B. The evolving role of radiotherapy in the management of small cell lung cancer. J Thorac Dis 2018; 10:S2545-S2554. [PMID: 30206498 DOI: 10.21037/jtd.2018.06.98] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Small cell lung cancer (SCLC) represents a small but significant subset of newly diagnosed lung cancers. In spite of being both chemo- and radiation-sensitive, SCLC has a high-propensity for recurrence after treatment. Although systemic therapy plays a central role in the management of patients with SCLC, many of the advances in overall survival for patients with SCLC have directly related to the use of radiation therapy. The objective of this review is to discuss the key radiation therapy clinical trials that have defined the current standard-of-care treatment for SCLC, and to review ongoing advances in radiation therapy that may further advance outcomes for patients with SCLC.
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Affiliation(s)
- Mark V Mishra
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Vinai Gondi
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ben Slotman
- VU University Medical Center, Amsterdam, The Netherlands
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Verma V, Fakhreddine MH, Haque W, Butler EB, Teh BS, Simone CB. Cardiac mortality in limited-stage small cell lung cancer. Radiother Oncol 2018; 128:492-497. [PMID: 29934110 DOI: 10.1016/j.radonc.2018.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 06/05/2018] [Accepted: 06/05/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Life expectancy of patients with limited-stage small cell lung cancer (LS-SCLC) continues to rise; thus, characterization of long-term toxicities is essential. Although there are emerging data linking cardiac irradiation doses with survival for non-small cell lung cancer, there are currently minimal data on cardiac-specific mortality (CSM) in LS-SCLC. The goal of this investigation was to evaluate CSM between left- and right-sided cases. METHODS The Surveillance, Epidemiology, and End Results database was queried for stage I-III primary SCLC patients receiving radiotherapy; CSM was compared between left- and right-sided diseases. Accounting for mortality from other causes, Gray's test compared cumulative incidences of CSM between both groups. Multiple multivariate models examined the independent effect of laterality on CSM, including the Fine and Gray competing risk model and the Cox proportional hazards model. RESULTS Of 19,692 patients, 7991 (41%) were left-sided and 11,701 (59%) were right-sided. Left-sided patients experienced significantly higher CSM overall (3.3% vs. 2.6%, p = 0.004). Laterality was an independent predictor of CSM in the overall population in the Fine and Gray competing risk model (p = 0.006) as well as the Cox proportional hazards model (p = 0.007). The overall hazard ratio for CSM by disease laterality was 1.27 (95% confidence interval, 1.08-1.50). Laterality had no statistical association with non-cardiac mortality in the Fine and Gray competing risk model (p = 0.130). CONCLUSIONS Although causation between radiotherapy and CSM in LS-SCLC cannot be stated based on these data, we encourage clinical attentiveness to cardiac-sparing radiotherapy for LS-SCLC, along with further investigation evaluating dosimetric correlates for cardiotoxicity.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, United States
| | | | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, United States
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, United States
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, United States
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, United States.
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Shaaban SG, Verma V, Choi JI, Shabason J, Sharma S, Glass E, Grover S, Badiyan SN, Simone CB. Utilization of Intensity-Modulated Radiation Therapy for Malignant Pleural Mesothelioma in the United States. Clin Lung Cancer 2018; 19:e685-e692. [PMID: 29803576 DOI: 10.1016/j.cllc.2018.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/04/2018] [Accepted: 04/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although postoperative radiotherapy (RT) for malignant pleural mesothelioma (MPM) has historically been delivered using 3-dimensional conformal RT (3DCRT) techniques, multiple reports show noteworthy safety and efficacy of the more advanced intensity-modulated RT (IMRT). To our knowledge, this is the only known study to evaluate national practice patterns of IMRT utilization for MPM. MATERIALS AND METHODS The National Cancer Data Base was queried for newly-diagnosed MPM patients who underwent definitive surgery (extrapleural pneumonectomy [EPP] or extended pleurectomy/decortication [P/D]) followed by adjuvant RT. Patients with metastatic disease, non-EPP or P/D surgical techniques, and lack of RT receipt (or without specified RT technique) were excluded. Statistics included multivariable logistic regression, Kaplan-Meier overall survival (OS) analysis, and Cox proportional hazards modeling. RESULTS Overall, 286 patients met criteria (181 [63%] IMRT and 105 [37%] 3DCRT). Temporal trends revealed that although 3DCRT was more common at initial time periods, IMRT utilization rose from 2004 to 2007 and stayed as a relatively constant majority thereafter. This was also present when substratifying the cohort according to EPP versus P/D approaches. IMRT was more often delivered at academic centers, along with institutions in the Southern United States, whereas 3DCRT was more frequently utilized in community facilities and in the Northeast (P ≤ .05 for all). RT technique did not affect OS (P > .05 for all comparisons). CONCLUSION In the United States, IMRT is now the most commonly utilized adjuvant RT technique for MPM. Facility and regional differences might associate with IMRT delivery. The findings of this investigation have implications for insurance coverage, clinical referral patterns, and ongoing and future prospective trial design.
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Affiliation(s)
- Sherif G Shaaban
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE
| | - J Isabelle Choi
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD
| | - Jacob Shabason
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Sonam Sharma
- Department of Radiation Oncology, The Mount Sinai Hospital, New York, NY
| | - Erica Glass
- California Protons Cancer Therapy Center, San Diego, CA
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
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Verma V, Cushman TR, Selek U, Tang C, Welsh JW. Safety of Combined Immunotherapy and Thoracic Radiation Therapy: Analysis of 3 Single-Institutional Phase I/II Trials. Int J Radiat Oncol Biol Phys 2018; 101:1141-1148. [PMID: 30012526 DOI: 10.1016/j.ijrobp.2018.04.054] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/11/2018] [Accepted: 04/18/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE The safety of combined immunotherapy and thoracic radiation therapy (iRT) has been understudied. We evaluated toxicities in patients receiving iRT from 3 single-institutional phase 1/2 trials. METHODS AND MATERIALS Clinical/treatment characteristics and toxicities (per the Common Toxicity Criteria for Adverse Events, version 4.0) were extracted. For purposes of this analysis, groupings were made into (1) patients receiving immunotherapy plus stereotactic body radiation therapy (50 Gy/4 fractions or 60 Gy/10 fractions), (2) immunotherapy plus 45 Gy/15 fractions, and (3) twice-daily chemoimmunoradiotherapy (45 Gy in twice-daily fractions). RESULTS None of the 60 patients undergoing immunotherapy plus stereotactic body radiation therapy (50 Gy, n = 49; 60 Gy, n = 11) experienced grade ≥4 events. There were 34 instances of any grade 3 event (in 15 total patients), with 9 pulmonary specific grade 3 events (in 4 patients). In the patients receiving 45 Gy/15 fractions (small cell lung cancers, n = 26; non-small cell lung cancers, n = 27), there were 2 grade 4 events (in the same patient), along with 17 grade 3 toxicities experienced by 10 total patients (2 pulmonary specific). Lastly, in the twice-daily cohort (n = 22), there were 5 grade 4 events (3 of which occurred in 1 patient) and 16 grade 3 toxicities occurring in 8 total patients (half of which were hematologic). CONCLUSIONS Administration of combined iRT is safe in the short term. Toxicities did not appreciably associate with demographics or dosimetry.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Taylor R Cushman
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Ugur Selek
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, School of Medicine, Koc University, Istanbul, Turkey
| | - Chad Tang
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - James W Welsh
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas.
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Badiyan SN, Molitoris JK, Zhu M, Glass E, Diwanji T, Simone CB. Proton beam therapy for malignant pleural mesothelioma. Transl Lung Cancer Res 2018; 7:189-198. [PMID: 29876318 DOI: 10.21037/tlcr.2018.04.07] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Malignant pleural mesothelioma (MPM) is a rare disease with a poor prognosis. Surgical techniques have made incremental improvements over the last few decades while new systemic therapies, including immunotherapies, show promise as potentially effective novel therapies. Radiation therapy has historically been used only in the palliative setting or as adjuvant therapy after extrapleural pneumonectomy, but recent advances in treatment planning and delivery techniques utilizing intensity-modulated radiation therapy and more recently pencil-beam scanning (PBS) proton therapy, have enabled the delivery of radiation therapy as neoadjuvant or adjuvant therapy after an extended pleurectomy and decortication or as definitive therapy for patients with recurrent or unresectable disease. In particular, PBS proton therapy has the potential to deliver high doses of irradiation to the entire effected pleura while significantly reducing doses to nearby organs at risk. This article describes the evolution of radiation therapy for MPM and details how whole-pleural PBS proton therapy is delivered to patients at the Maryland Proton Treatment Center.
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Affiliation(s)
| | | | - Mingyao Zhu
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Erica Glass
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tejan Diwanji
- University of Maryland School of Medicine, Baltimore, MD, USA
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Cushman TR, Verma V, Rwigema JCM. Comparison of proton therapy and intensity modulated photon radiotherapy for locally advanced non-small cell lung cancer: considerations for optimal trial design. J Thorac Dis 2018; 10:S988-S990. [PMID: 29849214 DOI: 10.21037/jtd.2018.04.59] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Taylor R Cushman
- The University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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Verma V, Choi JI, Simone CB. Proton therapy for small cell lung cancer. Transl Lung Cancer Res 2018; 7:134-140. [PMID: 29876312 PMCID: PMC5960657 DOI: 10.21037/tlcr.2018.04.02] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/28/2018] [Indexed: 12/15/2022]
Abstract
The prognosis of limited-stage small cell lung cancer (LS-SCLC) continues to improve and is now roughly comparable to that of locally advanced non-small cell lung cancer (NSCLC). This shift, taken together with the decreased toxicities of modern radiotherapy (RT) for LS-SCLC compared with those reported in historical trials, necessitates further evaluation of whether proton beam therapy (PBT) could further reduce both acute and late toxicities for patients receiving concurrent chemoradiotherapy for LS-SCLC. These notions are discussed theoretically, with an emphasis on cardiac events. This is followed by a review of the published evidence to date demonstrating improved dosimetry with PBT over intensity-modulated RT and encouraging safety and efficacy profiles seen in early clinical reports. In addition to covering technical aspects of PBT for LS-SCLC such as intensity-modulated PBT, image-guidance for PBT, and adaptive planning, this review also discusses the need for increased data on intensity-modulated PBT for LS-SCLC, economic and quality of life analyses for future PBT SCLC studies, careful categorization of cardiac events in these patients, and the role for immunotherapy combined with photon- or proton-based RT for LS-SCLC.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - J. Isabelle Choi
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Charles B. Simone
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland, USA
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Verma V, Simone CB, Mishra MV. Quality of Life and Patient-Reported Outcomes Following Proton Radiation Therapy: A Systematic Review. J Natl Cancer Inst 2018; 110:4430583. [PMID: 29028221 DOI: 10.1093/jnci/djx208] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/05/2017] [Indexed: 09/19/2023] Open
Abstract
Background As costs of cancer care rise, the importance of documenting value in oncology increases. Proton beam radiotherapy (PBT) has the potential to reduce toxicities in cancer patients, but is relatively expensive and unproven. Evaluating quality of life (QOL) and patient-reported outcomes (PROs) is essential to establishing PBT's "value" in oncologic therapy. The goal of this systematic review was to assess QOL and PROs in patients treated with PBT. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic searches were conducted. The PubMed search engine was the primary data source, along with publications found from references of selected articles, and articles known to the authors published through 2017. Seventeen original investigations were found to have sufficient focus and relevance to be incorporated into the systematic review. Results Studies of skull base (n = 1), brain (n = 1), head/neck (n = 1), lung (n = 1), breast (n = 2), prostate (n = 8), and pediatric (n = 3) malignancies treated with PBT that met eligibility criteria were included. QOL did not deteriorate during PBT for skull base and after PBT for brain tumors, respectively. PROs were higher for PBT than photon-based radiotherapy for both head/neck and lung cancer. Patient-reported breast cosmesis was appropriate after PBT and comparable to photon modalities. PBT in various settings of prostate cancer displayed an expected post-therapy decline; one study showed improved PROs (rectal urgency, bowel frequency) for PBT, and two others showed PROs/QOL comparable with other modalities. Pediatric studies demonstrated improvements in QOL during therapy, with additional increases thereafter. Conclusions Based on limited data, PBT provides favorable QOL/PRO profiles for select brain, head/neck, lung, and pediatric cancers; measures for prostate and breast cancers were more modest. These results have implications for cost-effective cancer care and prudently designed QOL evaluation in ongoing trials, which are discussed. Future data could substantially change the conclusions of this review.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE; Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Charles B Simone
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE; Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Mark V Mishra
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE; Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
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Haque W, Verma V, Butler EB, Teh BS. Utilization of neoadjuvant intensity-modulated radiation therapy and proton beam therapy for esophageal cancer in the United States. J Gastrointest Oncol 2018; 9:282-294. [PMID: 29755767 DOI: 10.21037/jgo.2017.11.14] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Randomized esophageal cancer (EC) trials have utilized two- or three-dimensional conformal radiotherapy (3DCRT). Advanced radiotherapy (RT) techniques [(ARTs): intensity-modulated radiotherapy (IMRT) and proton beam therapy (PBT)] may have benefits, but are relatively unproven. This is the first study to date evaluating utilization of ARTs versus 3DCRT in the trimodality setting in the United States. Methods The National Cancer Data Base (NCDB) was queried (2004-2013) for newly-diagnosed cT1b-T4bN0/N+M0 EC receiving neoadjuvant CRT followed by esophagectomy. The primary objective was to assess temporal trends, with multivariable logistic regression analysis assessing factors predictive of receiving ARTs. Secondarily, Kaplan-Meier analysis evaluated overall survival (OS), Cox proportional hazards modeling determined variables associated with OS, and postoperative complications were compared between cohorts. Results Altogether, 3,138 patients met criteria; 1,398 (45%) received 3DCRT, and 1,740 (55%) received ARTs (99% IMRT, 1% PBT). Temporally, utilization of ARTs is steadily rising in the United States, from 20% in 2004 to 69% in 2013, corresponding with a progressive decrease in utilization of 3DCRT. ARTs were more often delivered with advancing age, squamous cell histology, N2+ disease, and at academic centers (P<0.05 for all). Centers in the Southwest were more likely to use ARTs, and those in the Midwest least likely (P<0.05 for both). As expected, there were no OS differences (P=0.8477); there were also no differences in postoperative events (P>0.05 for all). Treatment at an academic center independently correlated with improved OS (P<0.001). Conclusions Utilization of ARTs (IMRT in the vast majority) is steadily rising in the United States; 3DCRT is now used in a minority of patients. This has implications for payers and insurance coverage. ART use is impacted by not only age and disease factors, but also regional and facility differences. Treatment at an academic facility independently correlated with higher survival, which has implications for patient counseling.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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Synthetic Secoisolariciresinol Diglucoside (LGM2605) Protects Human Lung in an Ex Vivo Model of Proton Radiation Damage. Int J Mol Sci 2017; 18:ijms18122525. [PMID: 29186841 PMCID: PMC5751128 DOI: 10.3390/ijms18122525] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 11/14/2017] [Accepted: 11/16/2017] [Indexed: 01/22/2023] Open
Abstract
Radiation therapy for the treatment of thoracic malignancies has improved significantly by directing of the proton beam in higher doses on the targeted tumor while normal tissues around the tumor receive much lower doses. Nevertheless, exposure of normal tissues to protons is known to pose a substantial risk in long-term survivors, as confirmed by our work in space-relevant exposures of murine lungs to proton radiation. Thus, radioprotective strategies are being sought. We established that LGM2605 is a potent protector from radiation-induced lung toxicity and aimed in the current study to extend the initial findings of space-relevant, proton radiation-associated late lung damage in mice by looking at acute changes in human lung. We used an ex vivo model of organ culture where tissue slices of donor living human lung were kept in culture and exposed to proton radiation. We exposed donor human lung precision-cut lung sections (huPCLS), pretreated with LGM2605, to 4 Gy proton radiation and evaluated them 30 min and 24 h later for gene expression changes relevant to inflammation, oxidative stress, and cell cycle arrest, and determined radiation-induced senescence, inflammation, and oxidative tissue damage. We identified an LGM2605-mediated reduction of proton radiation-induced cellular senescence and associated cell cycle changes, an associated proinflammatory phenotype, and associated oxidative tissue damage. This is a first report on the effects of proton radiation and of the radioprotective properties of LGM2605 on human lung.
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Haque W, Verma V, Fakhreddine M, Butler EB, Teh BS, Simone CB. Trends in Cardiac Mortality in Patients With Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 100:470-477. [PMID: 29353659 DOI: 10.1016/j.ijrobp.2017.10.031] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 10/03/2017] [Accepted: 10/17/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE To use the Surveillance, Epidemiology, and End Results (SEER) database to compare cardiac-specific mortality (CSM) between left- and right-sided locally advanced non-small cell lung cancer (LA-NSCLC) patients treated with definitive radiation therapy; and to stratify these patients over fixed time intervals to assess for differences in events by treatment era. METHODS AND MATERIALS The SEER database was queried for patients with stage III NSCLC who received radiation therapy to compare CSM between left- and right-sided primary cases at 5 time intervals: 1988-1992, 1993-1997, 1998-2002, 2003-2007, and 2008-2012. Cumulative incidence of CSM was compared between left- and right-sided patients using Gray's test. The multivariate Fine and Gray competing risk model was used to compare CSM while accounting for other-cause mortality. RESULTS Of 884,610 lung cancer patients, 52,624 met inclusion criteria; of these, 31,549 (60%) were right-sided and 21,075 (40%) were left-sided. When evaluating CSM in each of the 5 time periods, the overall incidence of CSM decreased over time. There was a statistically significant (P<.05) difference based on laterality in all time periods except 1988-1992 (P=.14). The subdistribution hazard ratio for CSM based on disease laterality in all time periods was 1.30 (95% confidence interval 1.18-1.42) and did not discernibly differ by time interval. On multivariate analysis using the Fine and Gray competing risk model, left-sided laterality independently predicted for CSS from 1993 to 2007 (P<.05). CONCLUSIONS Cardiac-specific mortality has decreased over time, and left-sided disease independently predicted for CSS during 1993-2007 but not 2008-2012. The time course of cardiac mortality seems to be early, consistent with other studies. These findings underscore the importance of minimizing cardiac irradiation during radiation treatment planning.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas.
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Mohamad Fakhreddine
- Department of Radiation Oncology, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
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Systematic assessment of clinical outcomes and toxicities of proton radiotherapy for reirradiation. Radiother Oncol 2017; 125:21-30. [DOI: 10.1016/j.radonc.2017.08.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 08/06/2017] [Accepted: 08/06/2017] [Indexed: 12/25/2022]
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Verma V, Simone CB, Werner-Wasik M. Acute and Late Toxicities of Concurrent Chemoradiotherapy for Locally-Advanced Non-Small Cell Lung Cancer. Cancers (Basel) 2017; 9:cancers9090120. [PMID: 28885561 PMCID: PMC5615335 DOI: 10.3390/cancers9090120] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 12/25/2022] Open
Abstract
For patients with unresectable locally-advanced non-small cell lung cancer (LA-NSCLC), concurrent chemoradiotherapy improves overall survival as compared to sequential chemotherapy and radiation therapy, but is associated with higher rates of toxicities. Acute, clinically significant esophagitis or pneumonitis can occur in one in five patients. The risks of esophagitis and pneumonitis can impact the decision to deliver concurrent therapy and limit the total dose of radiation therapy that is delivered. Hematologic toxicities and emesis are common toxicities from systemic therapies for LA-NSCLC and can result in delaying chemotherapy dosing or chemotherapy dose reductions. Late treatment morbidities, including pulmonary fibrosis and cardiac toxicities, can also significantly impact quality of life and potentially even survival. Recent advances in radiation therapy treatment delivery, better knowledge of normal tissue radiotherapy tolerances and more widespread and improved uses of supportive care and medical management of systemic therapy toxicities have improved the therapeutic ratio and reduced the rates of chemoradiotherapy-induced toxicities. This review details the acute and late toxicities associated with definitive chemoradiotherapy for LA-NSCLC and discusses toxicity management and strategies to mitigate the risks of treatment-related toxicities.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE 68106, USA.
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD 21201, USA.
| | - Maria Werner-Wasik
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
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