1
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Chandra RA, Keane FK, Voncken FEM, Thomas CR. Contemporary radiotherapy: present and future. Lancet 2021; 398:171-184. [PMID: 34166607 DOI: 10.1016/s0140-6736(21)00233-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 12/18/2020] [Accepted: 01/08/2021] [Indexed: 02/06/2023]
Abstract
Oncology care is increasingly a multidisciplinary endeavour, and radiation therapy continues to have a key role across the disease spectrum in nearly every cancer. However, the field of radiation oncology is still one of the most poorly understood of the cancer disciplines. In this Review, we attempt to summarise and contextualise developments within the field of radiation oncology for the non-radiation oncologist. We discuss advancements in treatment technologies and imaging, followed by an overview of the interplay with advancements in systemic therapy and surgical techniques. Finally, we review new frontiers in radiation oncology, including advances within the metastatic disease continuum, reirradiation, and emerging types of radiation therapy.
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Affiliation(s)
- Ravi A Chandra
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Florence K Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Francine E M Voncken
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Charles R Thomas
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR, USA
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2
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Provider decision regret-a useful method for analysis of palliative thoracic re-irradiation for lung cancer? Strahlenther Onkol 2020; 196:315-324. [PMID: 32002566 DOI: 10.1007/s00066-020-01577-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The overall usefulness of palliative thoracic re-irradiation depends on the balance between efficacy, survival, and toxicity, and is difficult to judge from previous studies. In the absence of patient-reported data, we developed a method for provider decision regret that addresses the question "would we re-irradiate this patient again in light of the known outcome?" Furthermore, we analyzed different reasons for decision regret and defined a subgroup at increased risk. PATIENTS AND METHODS A retrospective analysis of 33 patients with lung cancer re-irradiated with 17-45 Gy was performed. Reasons for decision regret included re-irradiation within the last 30 days of life, immediate radiological progression after re-irradiation (as opposed to stable disease or objective response), radiation myelopathy, any grade 4-5 toxicity, grade 3 pneumonitis, and other grade 3 toxicity in the absence of a symptomatic benefit or a time period of at least 3 months without worsening of the treated tumor. RESULTS Median survival time was 5.2 months (95% confidence interval 3.4-7.0 months). Symptomatic and radiological responses were observed. Provider decision regret was declared in 12 patients (36%): 2 patients with grade 3 pneumonitis, 3 patients with a short survival (radiotherapy during the last 30 days of life), and 7 patients with progression. Decision regret was declared only in patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS) 2 or 3 and was associated with a time interval to re-irradiation <6 months. CONCLUSION Our data support the usefulness and acceptable side effects profile of palliative re-irradiation for lung cancer. Patients with reduced PS are at increased risk of futile treatment. Future research should aim at prediction of immediate disease progression (the prevailing cause of decision regret). Evaluation of provider decision regret has the potential to improve the way we learn from retrospective databases and should also be considered for other scenarios where high-quality prospective outcome data are lacking.
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3
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Kumar SS, McGarry RC. Management of local recurrences and regional failure in early stage non-small cell lung cancer after stereotactic body radiation therapy. Transl Lung Cancer Res 2019; 8:S213-S221. [PMID: 31673526 DOI: 10.21037/tlcr.2019.09.06] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Stereotactic body radiation therapy (SBRT) is a very effective way to treat early stage non-small cell lung cancer (NSCLC) and small oligometastatic lung lesions with consistently high rates of local control, but both local and regional/distant recurrences still occur. The management of recurrences remains unsettled and may entail repeat SBRT, conventionally fractionated external beam RT (EF-EBRT), chemotherapy or surgery. Most patients with local recurrences [within the initial planning target volume (PTV)] can be salvaged successfully with good cancer specific survival. Nonetheless, proximity of the initial SBRT delivery to organs at risk (ribs, blood vessels, airways) may make retreatment more difficult. With attention to detail and careful patient selection, both surgery and reirradiation can be performed safely and effectively. Strategies for management of regional (nodal) recurrences may require conventional therapies tailored to the patterns of failure. The role of immunotherapy in salvage has not been elucidated as yet. We review here data on the available literature concerning salvage of SBRT lung patients.
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Affiliation(s)
- Sameera S Kumar
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Ronald C McGarry
- Department of Radiation Oncology, University of Kentucky, Lexington, KY, USA
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4
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Li F, Li Z, Jin X, Liu Y, Zhang P, Li P, Shen Z, Wu A, Chen W, Li Q. Ultra-small gadolinium oxide nanocrystal sensitization of non-small-cell lung cancer cells toward X-ray irradiation by promoting cytostatic autophagy. Int J Nanomedicine 2019; 14:2415-2431. [PMID: 31040665 PMCID: PMC6455003 DOI: 10.2147/ijn.s193676] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Gadolinium-based nanoparticles (GdNPs) have been used as theranostic sensitizers in clinical radiotherapy studies; however, the biomechanisms underlying the radio-sensitizing effects of GdNPs have yet to be determined. In this study, ultra-small gadolinium oxide nanocrystals (GONs) were employed to investigate their radiosensitizing effects and biological mechanisms in non-small-cell lung cancer (NSCLC) cells under X-ray irradiation. METHOD AND MATERIALS GONs were synthesized using polyol method. Hydroxyl radical production, oxidative stress, and clonogenic survival after X-ray irradiation were used to evaluate the radiosensitizing effects of GONs. DNA double-strand breakage, cell cycle phase, and apoptosis and autophagy incidences were investigated in vitro to determine the radiosensitizing biomechanism of GONs under X-ray irradiation. RESULTS GONs induced hydroxyl radical production and oxidative stress in a dose- and concentration-dependent manner in NSCLC cells after X-ray irradiation. The sensitizer enhancement ratios of GONs ranged between 19.3% and 26.3% for the NSCLC cells under investigation with a 10% survival rate compared with that of the cells treated with irradiation alone. Addition of 3-methyladenine to the cell medium decreased the incidence rate of autophagy and increased cell survival, supporting the idea that the GONs promoted cytostatic autophagy in NSCLC cells under X-ray irradiation. CONCLUSION This study examined the biological mechanisms underlying the radiosensitizing effects of GONs on NSCLC cells and presented the first evidence for the radiosensitizing effects of GONs via activation of cytostatic autophagy pathway following X-ray irradiation.
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Affiliation(s)
- Feifei Li
- Institute of Modern Physics, Chinese Academy of Sciences, Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences, Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine, Gansu Province, Lanzhou 730000, China, ;
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zihou Li
- University of Chinese Academy of Sciences, Beijing 100049, China
- Key Laboratory of Magnetic Materials and Devices, Chinese Academy of Sciences, Division of Functional Materials and Nano Devices, Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang 315201, China
| | - Xiaodong Jin
- Institute of Modern Physics, Chinese Academy of Sciences, Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences, Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine, Gansu Province, Lanzhou 730000, China, ;
| | - Yan Liu
- Institute of Modern Physics, Chinese Academy of Sciences, Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences, Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine, Gansu Province, Lanzhou 730000, China, ;
| | - Pengcheng Zhang
- Institute of Modern Physics, Chinese Academy of Sciences, Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences, Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine, Gansu Province, Lanzhou 730000, China, ;
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Ping Li
- Institute of Modern Physics, Chinese Academy of Sciences, Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences, Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine, Gansu Province, Lanzhou 730000, China, ;
| | - Zheyu Shen
- Key Laboratory of Magnetic Materials and Devices, Chinese Academy of Sciences, Division of Functional Materials and Nano Devices, Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang 315201, China
| | - Aiguo Wu
- Key Laboratory of Magnetic Materials and Devices, Chinese Academy of Sciences, Division of Functional Materials and Nano Devices, Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, Zhejiang 315201, China
| | - Weiqiang Chen
- Institute of Modern Physics, Chinese Academy of Sciences, Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences, Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine, Gansu Province, Lanzhou 730000, China, ;
| | - Qiang Li
- Institute of Modern Physics, Chinese Academy of Sciences, Key Laboratory of Heavy Ion Radiation Biology and Medicine of Chinese Academy of Sciences, Key Laboratory of Basic Research on Heavy Ion Radiation Application in Medicine, Gansu Province, Lanzhou 730000, China, ;
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5
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Nieder C, Guckenberger M, Gaspar LE, Rusthoven CG, De Ruysscher D, Sahgal A, Nguyen T, Grosu AL, Mehta MP. Management of patients with brain metastases from non-small cell lung cancer and adverse prognostic features: multi-national radiation treatment recommendations are heterogeneous. Radiat Oncol 2019; 14:33. [PMID: 30770745 PMCID: PMC6377775 DOI: 10.1186/s13014-019-1237-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/08/2019] [Indexed: 12/25/2022] Open
Abstract
Background Different management options exist for patients with brain metastases from non-small cell lung cancer (NSCLC), patients whose treatment with whole brain radiotherapy (WBRT) has become more controversial over the last decade. It is not trivial to find the optimal balance of over- versus undertreatment in these patients. Several recent trials, including the randomized QUARTZ trial now influence the decision to recommend or withhold WBRT for patients with unfavorable prognosis, and similarly, for favorable prognosis patients, the balance between radiosurgery alone or WBRT has become a nuanced decision. Additionally, the availability of intracranially active targeted agent for some subsets of these patients has added another layer of complexity to the decision-making. Methods A multinational consortium of expert radiation oncologists was established with the aim of compiling treatment recommendations for challenging scenarios, in this case the choice between optimal supportive care (SC), WBRT and other types of radiation therapy (RT). We distributed 17 cases to 7 radiation oncologists who were allowed to involve coworkers to provide their treatment recommendations. The cases differed in extra- and intracranial disease extent, histology, age and other prognostic factors. Expert recommendations were tabulated with the aim of providing guidance. Results Regarding willingness to include the 17 patients in the QUARTZ trial, the rates of trial inclusion were low (range 0/7 to 3/7). Experts not recommending trial inclusion provided their treatment recommendations. These suggestions differed widely for most of the patients. It was not uncommon to see 3 or 4 different recommendations. In general, few (0–2) recommended SC. Some kind of local treatment was suggested by the majority of experts for all 17 patients. Commonly, stereotactic single-fraction radiosurgery (SRS) or stereotactic fractionated radiotherapy (SFRT) were recommended by many experts, also for patients with 5–7 lesions. The highest proportion of recommendations towards WBRT in any patient was 3/7. It was also quite common for patients with multiple metastases of varying size that experts suggested combinations of resection, post-operative SRS/SFRT and SRS/SFRT to intact lesions. Despite recommending active treatment, experts were often willing to include the patients in a hypothetical protocol investigating radiotherapy utilization in the last 30 days of life (assessment of factors predicting early death). Conclusions WBRT was infrequently recommended. Even in patients with adverse prognostic features that raised the experts’ awareness of an increased risk for futile treatment near the end of life, SRS/SFRT were more often recommended than optimal supportive care, unless a patient decided to forego active treatment. Electronic supplementary material The online version of this article (10.1186/s13014-019-1237-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital, 8092, Bodø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO Clinic), Maastricht University Medical Center, GROW, Maastricht, The Netherlands
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Timothy Nguyen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
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6
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Nieder C. Second re-irradiation: A delicate balance between safety and efficacy. Phys Med 2019; 58:155-158. [DOI: 10.1016/j.ejmp.2019.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/20/2018] [Accepted: 01/04/2019] [Indexed: 12/16/2022] Open
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7
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Matsuo Y. A Systematic Literature Review on Salvage Radiotherapy for Local or Regional Recurrence After Previous Stereotactic Body Radiotherapy for Lung Cancer. Technol Cancer Res Treat 2019; 17:1533033818798633. [PMID: 30198413 PMCID: PMC6131295 DOI: 10.1177/1533033818798633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose: The purpose of this review article was to summarize available data on the efficacy and safety of salvage radiotherapy for isolated local or regional recurrence after prior stereotactic body radiotherapy for lung cancer. Methods: Studies were systematically searched on PubMed, following which suitable papers were selected. Reported outcomes and toxicities were qualitatively reviewed. Results: Nineteen papers, which were retrospective studies based on single institution experiences, were selected. Sixteen papers were on salvage radiotherapy for local tumor recurrence, and the remaining 3 papers evaluated radiotherapy for regional failures after stereotactic body radiotherapy for lung cancer. Patient cohorts in the selected papers seemed very frail with 2-year survival of 30% to 40% after the salvage. Local control was reported to be approximately 60% to 70%, which is worse than that after primary stereotactic body radiotherapy. Reported rates of toxicity grade 3 or worse were considered acceptable. Larger target volume and central tumor localization were suggested as risk factors for severe toxicities. Dosimetric data on patients having toxicities were found to help with considering dose constraints for organs at risk. Conclusion: Based on data from a limited number of articles, salvage radiotherapy is a reasonable treatment option for select patients with local or regional tumor recurrence after prior stereotactic body radiotherapy for lung cancer. Optimal patient selection and dose prescription can be clarified with a larger study that include more data on experiences with salvage radiotherapy.
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Affiliation(s)
- Yukinori Matsuo
- 1 Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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8
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Hong L, Huang YX, Zhuang QY, Zhang XQ, Tang LR, Du KX, Lin XY, Zheng BH, Cai SL, Wu JX, Li JL. Survival benefit of re-irradiation in esophageal Cancer patients with Locoregional recurrence: a propensity score-matched analysis. Radiat Oncol 2018; 13:171. [PMID: 30201005 PMCID: PMC6131819 DOI: 10.1186/s13014-018-1122-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 08/30/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To investigate the treatment failure pattern and factors influencing locoregional recurrence of esophageal squamous cell carcinoma (ESCC) and examine patient survival with re-irradiation (re-RT) after primary radiotherapy. METHODS We retrospectively analyzed 87 ESCC patients treated initially with radiotherapy. Failure patterns were classified into regional lymph node recurrence only (LN) and primary failure with/without regional lymph node recurrence (PF). Patients received either re-RT or other treatments (non-re-RT group). Baseline covariates were balanced by a propensity score model. Overall survival (OS) and toxicities were assessed as outcomes. RESULTS The median follow-up time was 87 months. Thirty-nine patients received re-RT. Failure pattern and re-RT were independent prognostic factors for OS (P = 0.040 and 0.015) by Cox multivariate analysis. Re-RT with concomitant chemotherapy showed no survival benefit over re-RT alone (P = 0.70). No differences in characteristics were found between the groups by Chi-square tests after propensity score matching. The Cox model showed that failure pattern and re-RT were prognostic factors with hazard ratios (HR) of 0.319 (P = 0.025) and 0.375 (P = 0.002), respectively, in the matched cohort. Significant differences in OS were observed according to failure pattern (P = 0.004) and re-RT (P < 0.001). In the re-RT and non-re-RT groups, 9.09% and 3.03% of patients experienced tracheoesophageal fistulas, and 15.15% and 3.03% of patients developed pericardial/pleural effusion, respectively (P > 0.05). The incidence of radiation pneumonitis was higher in the re-RT group (24.24% vs. 6.06%, P = 0.039), but no cases of pneumonia-related death occurred. CONCLUSIONS Re-RT improved long-term survival in patients with locoregional recurrent ESCC. Despite a high incidence of radiation pneumonitis, toxicities were tolerable.
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Affiliation(s)
- Liang Hong
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Yun-Xia Huang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Qing-Yang Zhuang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Xue-Qing Zhang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Li-Rui Tang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Kai-Xin Du
- Department of Radiation Oncology, Xiamen Humanity Hospital, Xiamen, China
| | - Xiao-Yi Lin
- Department of Radiation Oncology, Xiamen Humanity Hospital, Xiamen, China
| | - Bu-Hong Zheng
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Shao-Li Cai
- Biomedical Research Center of South China, Fujian Normal University, Fuzhou, China
| | - Jun-Xin Wu
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, China
| | - Jin-Luan Li
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, China.
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9
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Verma V, Schonewolf CA, Cushman TR, Post CM, Doms A, Berman AT, DeVries M, Katz SI, Simone CB. Impact of Enlarged Nonhypermetabolic Lymph Nodes on Outcomes After Stereotactic Body Radiotherapy for Early-Stage Non-Small-Cell Lung Cancer. Clin Lung Cancer 2018; 19:502-510. [PMID: 30111509 DOI: 10.1016/j.cllc.2018.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/04/2018] [Accepted: 07/16/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Up to 15% of patients undergoing positron emission tomography (PET)/computed tomography (CT) before stereotactic body radiotherapy (SBRT) harbor occult nodal disease. In the absence of invasive mediastinal staging, the clinical significance of enlarged nonhypermetabolic lymph nodes (LNs) remains unclear. We performed what is to our knowledge the first study to address whether enlarged nonhypermetabolic LNs were associated with higher post-SBRT failure rates. PATIENTS AND METHODS Two academic centers assessed 157 consecutive patients treated with SBRT for cT1-2aN0M0 non-small-cell lung cancer who underwent PET/CT without pathologic nodal staging. The cutoff of an enlarged node was ≥ 1.0 cm, although a 7 mm threshold was also evaluated. Local recurrence-free survival (RFS), regional RFS, distant metastasis-free survival, RFS, and overall survival (OS) were calculated by Kaplan-Meier methodology. Multivariate Cox modeling addressed factors associated with RFS and OS. RESULTS There were 120 patients (76%) with LNs < 1 cm and 37 (24%) with nodes ≥ 1 cm. Most patients had peripheral and/or T1 tumors. Median follow-up was 25.5 months. There were no differences between cohorts in actuarial local RFS, regional RFS, distant metastasis-free survival, RFS, or OS (P > .05 for all). Thirteen percent of patients experienced any nodal relapse, 15% of which occurred in the same station as that of the largest pre-SBRT LN. Stratification by largest LN location in an N1 versus N2 station showed no differences in RFS or OS (P > .05 for both). A 7 mm cutoff also showed no differences in outcomes (P > .05 for all). LN size was not correlated with RFS/OS on multivariable analysis (P > .05 for both). CONCLUSION The presence of enlarged nonhypermetabolic LNs on PET/CT is not associated with increased post-SBRT failure rates.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA
| | - Caitlin A Schonewolf
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Carl M Post
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA
| | - Alexandra Doms
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Abigail T Berman
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Matthew DeVries
- Department of Radiology, University of Nebraska Medical Center, Omaha, NE
| | - Sharyn I Katz
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD.
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10
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Baumann R, Chan MKH, Pyschny F, Stera S, Malzkuhn B, Wurster S, Huttenlocher S, Szücs M, Imhoff D, Keller C, Balermpas P, Rades D, Rödel C, Dunst J, Hildebrandt G, Blanck O. Clinical Results of Mean GTV Dose Optimized Robotic-Guided Stereotactic Body Radiation Therapy for Lung Tumors. Front Oncol 2018; 8:171. [PMID: 29868486 PMCID: PMC5966546 DOI: 10.3389/fonc.2018.00171] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/01/2018] [Indexed: 12/24/2022] Open
Abstract
Introduction We retrospectively evaluated the efficacy and toxicity of gross tumor volume (GTV) mean dose optimized stereotactic body radiation therapy (SBRT) for primary and secondary lung tumors with and without robotic real-time motion compensation. Materials and methods Between 2011 and 2017, 208 patients were treated with SBRT for 111 primary lung tumors and 163 lung metastases with a median GTV of 8.2 cc (0.3–174.0 cc). Monte Carlo dose optimization was performed prioritizing GTV mean dose at the potential cost of planning target volume (PTV) coverage reduction while adhering to safe normal tissue constraints. The median GTV mean biological effective dose (BED)10 was 162.0 Gy10 (34.2–253.6 Gy10) and the prescribed PTV BED10 ranged 23.6–151.2 Gy10 (median, 100.8 Gy10). Motion compensation was realized through direct tracking (44.9%), fiducial tracking (4.4%), and internal target volume (ITV) concepts with small (≤5 mm, 33.2%) or large (>5 mm, 17.5%) motion. The local control (LC), progression-free survival (PFS), overall survival (OS), and toxicity were analyzed. Results Median follow-up was 14.5 months (1–72 months). The 2-year actuarial LC, PFS, and OS rates were 93.1, 43.2, and 62.4%, and the median PFS and OS were 18.0 and 39.8 months, respectively. In univariate analysis, prior local irradiation (hazard ratio (HR) 0.18, confidence interval (CI) 0.05–0.63, p = 0.01), GTV/PTV (HR 1.01–1.02, CI 1.01–1.04, p < 0.02), and PTV prescription, mean GTV, and maximum plan BED10 (HR 0.97–0.99, CI 0.96–0.99, p < 0.01) were predictive for LC while the tracking method was not (p = 0.97). For PFS and OS, multivariate analysis showed Karnofsky Index (p < 0.01) and tumor stage (p ≤ 0.02) to be significant factors for outcome prediction. Late radiation pneumonitis or chronic rip fractures grade 1–2 were observed in 5.3% of the patients. Grade ≥3 side effects did not occur. Conclusion Robotic SBRT is a safe and effective treatment for lung tumors. Reducing the PTV prescription and keeping high GTV mean doses allowed the reduction of toxicity while maintaining high local tumor control. The use of real-time motion compensation is strongly advised, however, well-performed ITV motion compensation may be used alternatively when direct tracking is not feasible.
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Affiliation(s)
- Rene Baumann
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Florian Pyschny
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Susanne Stera
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Bettina Malzkuhn
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Stefan Wurster
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany.,Department of Radiation Oncology, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Stefan Huttenlocher
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany
| | - Marcella Szücs
- Department of Radiation Oncology, Universitätsmedizin Rostock, Rostock, Germany
| | - Detlef Imhoff
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Christian Keller
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany.,Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Panagiotis Balermpas
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany.,Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Dirk Rades
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Claus Rödel
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Department of Radiation Oncology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Guido Hildebrandt
- Department of Radiation Oncology, Universitätsmedizin Rostock, Rostock, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany
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11
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Repeat reirradiation of the spinal cord: multi-national expert treatment recommendations. Strahlenther Onkol 2018; 194:365-374. [PMID: 29362835 DOI: 10.1007/s00066-018-1266-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/10/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Improved survival of patients with spinal bone metastases has resulted in an increased number of referrals for retreatment and repeat reirradiation. METHODS A consortium of expert radiation oncologists (RO) has been established with the aim of providing treatment recommendations for challenging clinical scenarios for which there are no established guidelines. In this case, a patient developed local progression of a T5 vertebral lesion after two prior courses of palliative radiotherapy (time interval >12 months, assumed cumulative biologically equivalent dose in 2‑Gy fractions [EQD2] for spinal cord [alpha/beta 2 Gy] 75 Gy). Expert recommendations were tabulated with the aim of providing guidance. RESULTS Five of seven RO would offer a third course of radiotherapy, preferably with advanced techniques such as stereotactic radiotherapy. However, the dose-fractionation concepts were heterogeneous (3-20 fractions) and sometimes adjusted to different options for systemic treatment. All five RO would compromise target volume coverage to reduce the dose to the spinal cord. Definition of the spinal cord planning-organ-at-risk volume was heterogeneous. All five RO limited the EQD2 for spinal cord. Two were willing to accept more than 12.5 Gy and the highest EQD2 was 19 Gy. CONCLUSIONS The increasing body of literature about bone metastases and spinal cord reirradiation has encouraged some expert RO to offer palliative reirradiation with cumulative cord doses above 75 Gy EQD2; however, no consensus was achieved. Strategies for harmonization of clinical practice and development of evidence-based dose constraints are discussed.
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Stera S, Balermpas P, Chan MKH, Huttenlocher S, Wurster S, Keller C, Imhoff D, Rades D, Dunst J, Rödel C, Hildebrandt G, Blanck O. Breathing-motion-compensated robotic guided stereotactic body radiation therapy : Patterns of failure analysis. Strahlenther Onkol 2017; 194:143-155. [PMID: 28875297 DOI: 10.1007/s00066-017-1204-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/16/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE We retrospectively evaluated the patterns of failure for robotic guided real-time breathing-motion-compensated (BMC) stereotactic body radiation therapy (SBRT) in the treatment of tumors in moving organs. PATIENTS AND METHODS Between 2011 and 2016, a total of 198 patients with 280 lung, liver, and abdominal tumors were treated with BMC-SBRT. The median gross tumor volume (GTV) was 12.3 cc (0.1-372.0 cc). Medians of mean GTV BEDα/β =10 Gy (BED = biological effective dose) was 148.5 Gy10 (31.5-233.3 Gy10) and prescribed planning target volume (PTV) BEDα/β =10 Gy was 89.7 Gy10 (28.8-151.2 Gy10), respectively. We analyzed overall survival (OS) and local control (LC) based on various factors, including BEDs with α/β ratios of 15 Gy (lung metastases), 21 Gy (primary lung tumors), and 27 Gy (liver metastases). RESULTS Median follow-up was 10.4 months (2.0-59.0 months). The 2‑year actuarial LC was 100 and 86.4% for primary early and advanced stage lung tumors, respectively, 100% for lung metastases, 82.2% for liver metastases, and 90% for extrapulmonary extrahepatic metastases. The 2‑year OS rate was 47.9% for all patients. In uni- and multivariate analysis, comparatively lower PTV prescription dose (equivalence of 3 × 12-13 Gy) and higher average GTV dose (equivalence of 3 × 18 Gy) to current practice were significantly associated with LC. For OS, Karnofsky performance score (100%), gender (female), and SBRT without simultaneous chemotherapy were significant prognostic factors. Grade 3 side effects were rare (0.5%). CONCLUSIONS Robotic guided BMC-SBRT can be considered a safe and effective treatment for solid tumors in moving organs. To reach sufficient local control rates, high average GTV doses are necessary. Further prospective studies are warranted to evaluate these points.
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Affiliation(s)
- Susanne Stera
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Saphir Radiosurgery Center, Frankfurt, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Stefan Wurster
- Saphir Radiosurgery Center, Güstrow, Germany.,Department of Radiation Oncology, University Medicine Greifswald, Greifswald, Germany
| | - Christian Keller
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Saphir Radiosurgery Center, Frankfurt, Germany
| | - Detlef Imhoff
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Dirk Rades
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany.,Department of Radiation Oncology, University Hospital Copenhagen, Copenhagen, Denmark
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Medicine Rostock, Rostock, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center, Frankfurt, Germany.,Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany.,Saphir Radiosurgery Center, Güstrow, Germany
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