1
|
Jairam V, Soulos PR, K.C. M, Gross CP, Slotman BJ, Chiang AC, Park HS. Differential Effect of Consolidative Thoracic Radiation Therapy in Extensive-Stage Small Cell Lung Cancer Based on Sex. Adv Radiat Oncol 2024; 9:101413. [PMID: 38778819 PMCID: PMC11110031 DOI: 10.1016/j.adro.2023.101413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/19/2023] [Indexed: 05/25/2024] Open
Abstract
Purpose The landmark randomized trial on chest irradiation in extensive disease small cell lung cancer (CREST) demonstrated that consolidative thoracic radiation therapy (cTRT) improved overall (OS) and progression-free survival (PFS) after initial chemotherapy (chemo) in extensive-stage small cell lung cancer, with potentially increased benefit in women compared with men. It is unknown whether similar findings would apply after chemoimmunotherapy became the standard first-line treatment. In this analysis, we report national practice patterns and survival outcomes of cTRT according to patient sex. Methods and Materials We included patients from de-identified electronic health record-derived database diagnosed with stage IV small cell lung cancer (2014-2021) who completed 4 to 6 cycles of first-line systemic therapy (platinum-doublet chemotherapy or chemoimmunotherapy). We evaluated OS and PFS using multivariable Cox proportional hazards regression with receipt of cTRT as an independent variable and stratified by sex. As a sensitivity analysis, we weighted the models by the inverse probability of receiving cTRT. Results A total of 1227 patients were included (850 chemotherapy, 377 chemoimmunotherapy). There were no statistically significant differences in baseline characteristics between patients who did and did not receive cTRT. Among women, cTRT was associated with superior OS (adjusted hazard ratio [HR], 0.67; 95% CI, 0.52-0.87) and PFS (HR, 0.63; 95% CI, 0.49-0.82) compared with those not receiving cTRT. Conversely, no OS or PFS benefit with cTRT was observed in men (OS HR, 1.03; 95% CI, 0.80-1.31; PFS HR, 1.12; 95% CI, 0.85-1.47). Findings were similar in weighted analyses. Conclusions The survival efficacy of cTRT may be moderated by sex, with female patients appearing more likely to benefit than male patients. These findings reflect sex-based survival trends with similar effect sizes to those observed in the CREST trial. Although the underpinnings of this association need to be elucidated, stratification by sex should be considered for randomized-controlled trials studying cTRT in extensive-stage small cell lung cancer.
Collapse
Affiliation(s)
- Vikram Jairam
- Department of Radiation Oncology, Sutter Medical Group, Sacramento, California
| | - Pamela R. Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
| | - Madhav K.C.
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
| | - Cary P. Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ben J. Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, De Boelelaan, Amsterdam, The Netherlands
| | - Anne C. Chiang
- Section of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Henry S. Park
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
2
|
Thor M, Lee C, Sun L, Patel P, Apte A, Grkovski M, Shepherd AF, Gelblum DY, Wu AJ, Simone CB, Chaft JE, Rimner A, Gomez DR, Deasy JO, Shaverdian N. An 18F-FDG PET/CT and Mean Lung Dose Model to Predict Early Radiation Pneumonitis in Stage III Non-Small Cell Lung Cancer Patients Treated with Chemoradiation and Immunotherapy. J Nucl Med 2024; 65:520-526. [PMID: 38485270 PMCID: PMC10995528 DOI: 10.2967/jnumed.123.266965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/11/2024] [Indexed: 04/04/2024] Open
Abstract
Radiation pneumonitis (RP) that develops early (i.e., within 3 mo) (RPEarly) after completion of concurrent chemoradiation (cCRT) leads to treatment discontinuation and poorer survival for patients with stage III non-small cell lung cancer. Since no RPEarly risk model exists, we explored whether published RP models and pretreatment 18F-FDG PET/CT-derived features predict RPEarly Methods: One hundred sixty patients with stage III non-small cell lung cancer treated with cCRT and consolidative immunotherapy were analyzed for RPEarly Three published RP models that included the mean lung dose (MLD) and patient characteristics were examined. Pretreatment 18F-FDG PET/CT normal-lung SUV featured included the following: 10th percentile of SUV (SUVP10), 90th percentile of SUV (SUVP90), SUVmax, SUVmean, minimum SUV, and SD. Associations between models/features and RPEarly were assessed using area under the receiver-operating characteristic curve (AUC), P values, and the Hosmer-Lemeshow test (pHL). The cohort was randomly split, with similar RPEarly rates, into a 70%/30% derivation/internal validation subset. Results: Twenty (13%) patients developed RPEarly Predictors for RPEarly were MLD alone (AUC, 0.72; P = 0.02; pHL, 0.87), SUVP10, SUVP90, and SUVmean (AUC, 0.70-0.74; P = 0.003-0.006; pHL, 0.67-0.70). The combined MLD and SUVP90 model generalized in the validation subset and was deemed the final RPEarly model (RPEarly risk = 1/[1+e(- x )]; x = -6.08 + [0.17 × MLD] + [1.63 × SUVP90]). The final model refitted in the 160 patients indicated improvement over the published MLD-alone model (AUC, 0.77 vs. 0.72; P = 0.0001 vs. 0.02; pHL, 0.65 vs. 0.87). Conclusion: Patients at risk for RPEarly can be detected with high certainty by combining the normal lung's MLD and pretreatment 18F-FDG PET/CT SUVP90 This refined model can be used to identify patients at an elevated risk for premature immunotherapy discontinuation due to RPEarly and could allow for interventions to improve treatment outcomes.
Collapse
Affiliation(s)
- Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York;
| | - Chen Lee
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lian Sun
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Purvi Patel
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Milan Grkovski
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annemarie F Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Daphna Y Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Jamie E Chaft
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Narek Shaverdian
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York; and
| |
Collapse
|
3
|
Zhang X, Cai X, Yan C. Opportunities and challenges in combining immunotherapy and radiotherapy in esophageal cancer. J Cancer Res Clin Oncol 2023; 149:18253-18270. [PMID: 37985502 PMCID: PMC10725359 DOI: 10.1007/s00432-023-05499-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Immunotherapy has shown promise in the treatment of esophageal cancer, but using it alone only benefits a small number of patients. Most patients either do not have a significant response or develop secondary drug resistance. The combination of radiotherapy and immunotherapy appears to be a promising approach to treating esophageal cancer. PURPOSE We reviewed milestone clinical trials of radiotherapy combined with immunotherapy for esophageal cancer. We then discussed potential biomarkers for radiotherapy combined with immunotherapy, including programmed cell death-ligand 1 (PD-L1) status, tumor mutation burden (TMB), tumor-infiltrating lymphocytes, ct-DNA, imaging biomarkers, and clinical factors. Furthermore, we emphasize the key mechanisms of radiation therapy-induced immune stimulation and immune suppression in order to propose strategies for overcoming immune resistance in radiation therapy (RT). Lastly, we discussed the emerging role of low-dose radiotherapy (LDRT) , which has become a promising approach to overcome the limitations of high-dose radiotherapy. CONCLUSION Radiotherapy can be considered a triggering factor for systemic anti-tumor immune response and, with the assistance of immunotherapy, can serve as a systemic treatment option and potentially become the standard treatment for cancer patients.
Collapse
Affiliation(s)
- Xinyu Zhang
- Weifang Hospital of Traditional Chinese Medicine, 666 Weizhou Road, Weifang, 261000, Shandong, China
- Shandong University of Traditional Chinese Medicine, Jinan, 250000, Shandong, China
| | - Xinsheng Cai
- Weifang Hospital of Traditional Chinese Medicine, 666 Weizhou Road, Weifang, 261000, Shandong, China
| | - Chaoguang Yan
- Weifang Hospital of Traditional Chinese Medicine, 666 Weizhou Road, Weifang, 261000, Shandong, China.
| |
Collapse
|
4
|
Guan S, Zhang S, Ren K, Li X, Li X, Zhao L. Induction chemoimmunotherapy may improve outcomes of chemoradiotherapy in patients with unresectable stage III NSCLC. Front Immunol 2023; 14:1289207. [PMID: 38090575 PMCID: PMC10711043 DOI: 10.3389/fimmu.2023.1289207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
Background Currently, the value of induction chemoimmunotherapy before chemoradiotherapy (CRT) in unresectable stage III non-small cell lung cancer (NSCLC) has not been explored. This study was designed to explore the efficacy and safety of induction chemoimmunotherapy in patients with unresectable stage III NSCLC. Methods Unresectable stage III NSCLC patients who received CRT with or without induction chemoimmunotherapy between August 2014 and December 2021 were retrospectively enrolled. Progression-free survival (PFS) and overall survival (OS) were assessed from the initiation of treatment and estimated by the Kaplan-Meier method. The potential factors affecting PFS and OS were analyzed by univariate and multivariate Cox regression models. One-to-one propensity score matching (PSM) was used to further minimize confounding. Results A total of 279 consecutive patients were enrolled, with 53 (19.0%) receiving induction chemoimmunotherapy followed by CRT (I-CRT group), and the remaining 226 (81.0%) receiving CRT alone (CRT group). After PSM, the median PFS was 24.8 months in the I-CRT group vs. 13.3 months in the CRT group (P=0.035). The median OS was not reached (NR) vs. 36.6 months ((P=0.142). The incidence of treatment-related adverse events (TRAEs) was similar in both groups, except that the incidence of hematological toxicity was higher in the I-CRT group (77.1% vs. 58.3%, P=0.049). Compared to induction chemotherapy, induction chemoimmunotherapy demonstrated a superior objective response rate (60.4% vs. 22.2%, P<0.001) and further prolonged PFS (median NR vs. 13.2 months, P=0.009) and OS (median NR vs. 25.9 months, P=0.106) without increasing the incidence of TRAEs in patients receiving concurrent chemoradiotherapy. Conclusion Induction chemoimmunotherapy is safe and may improve outcomes of CRT in patients with unresectable stage III NSCLC. Moreover, induction chemoimmunotherapy may further improve treatment response and survival outcomes compared to induction chemotherapy before cCRT.
Collapse
Affiliation(s)
- Song Guan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Shufeng Zhang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Kai Ren
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Xingyue Li
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Xue Li
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Lujun Zhao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| |
Collapse
|
5
|
Kang Y, Zhen H, Ma N, Zhao H, Cao B. Encephalitis in a patient with hypopharynx cancer treated with immune checkpoint inhibitors and radiotherapy: a case report and review of the literature. J Cancer Res Clin Oncol 2023; 149:16239-16246. [PMID: 37676267 PMCID: PMC10620264 DOI: 10.1007/s00432-023-05328-3] [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: 07/15/2023] [Accepted: 08/21/2023] [Indexed: 09/08/2023]
Abstract
Hypopharyngeal cancer (HPC) has one of the most unfavorable prognoses among head and neck squamous cell carcinomas. Immunotherapy in combination with chemotherapy, the same as conventional induction chemotherapy, has emerged as a vital part of the induction therapy protocol for HPC. Meanwhile, the incidence of immune-related adverse events is increasing. In this light, we present the first reported case of immune-associated encephalitis in a patient with hypopharyngeal cancer treated with Camrelizumab (a PD-1 inhibitor). After receiving immunotherapy combined with chemotherapy as induction therapy, along with concurrent chemoradiotherapy, the patient presented with symptoms of fatigue, tremors, drowsiness, and an abnormal signal in the right temporal lobe as shown on a brain magnetic resonance imaging (MRI). Despite the minor elevation in protein and IgG index observed in the lumbar puncture, there is no evidence of abnormal autoantibodies or evidence of pathogenic infection. Following a thorough multidisciplinary consultation, the patient is suspected to be afflicted with immune-related autoimmune encephalitis. Intravenous methylprednisolone was prescribed as an empirical treatment at an initial dosage of 120 mg/day for 3 days, followed by steroid tapering. Finally, the patient experienced complete neurologic and radiographic (brain MRI) recovery. This case serves as a critical reminder that encephalitis is a potential diagnosis that should never be overlooked in patients undergoing immunotherapy who present with abnormal signs of the brain. The timely diagnosis and initiation of immunosuppressive therapy are key components of treating ICI-associated encephalitis.
Collapse
Affiliation(s)
- Yan Kang
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Hongchao Zhen
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Nina Ma
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Hong Zhao
- Department of Radiotherapy, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Bangwei Cao
- Department of Oncology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong An Road, Xicheng District, Beijing, 100050, People's Republic of China.
| |
Collapse
|
6
|
Guan S, Ren K, Zhang X, Yan M, Li X, Zhao L. Concurrent chemoradiotherapy versus radiotherapy alone after induction chemoimmunotherapy for stage III NSCLC patients who did not undergo surgery: a single institution retrospective study. Radiat Oncol 2023; 18:122. [PMID: 37491257 PMCID: PMC10367242 DOI: 10.1186/s13014-023-02305-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/21/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND With remarkable success and few side effects, induction chemoimmunotherapy has been used to improve the prognosis of patients with resectable or potentially resectable non-small cell lung cancer (NSCLC), even in stage III disease. However, for patients who are medically inoperable, unresectable or refuse surgery after induction chemoimmunotherapy, it is unclear whether patients should be treated with concurrent chemoradiotherapy (cCRT) or radiotherapy (RT) alone considering patient safety and tolerability. This study aimed to determine whether cCRT is safe and superior to RT alone after chemoimmunotherapy for stage III NSCLC. METHODS Patients diagnosed with stage III NSCLC who received chemoimmunotherapy followed by cCRT/RT alone without surgery at Tianjin Cancer Hospital between November 2018 to December 2021 were retrospectively collected. Patients were divided into two groups: induction chemoimmunotherapy followed by cCRT (cCRT cohort) or RT alone (RT alone cohort). Kaplan-Meier method was used to estimate survival. Univariate and multivariate Cox regression models were adopted to estimate risk factors for PFS. RESULTS Sixty-five patients were included, with 44 (67.7%) received RT alone and 21 (32.3%) received cCRT. Patients in the cCRT group had significantly prolonged PFS (HR = 0.155, p = 0.004), LPFS (HR = 0.225, p = 0.029) and DMFS (HR = 0.028, p = 0.006) than those in the RT alone group. Albeit nonsignificant, a trend toward improved OS (HR = 0.030, p = 0.069) was also observed in the cCRT group. The multivariate analysis further confirmed that cCRT (HR = 0.141, p = 0.008) was the independent factor for promoting a favorable PFS. Treatment-related adverse events were similar between groups (p > 0.05). Patients with consolidation immunotherapy exhibited a trend of improved PFS (HR = 0.398, p = 0.274) and numerically better OS (HR = 0.018, p = 0.209) compared with those without. CONCLUSIONS For patients with unresectable stage III NSCLC, cCRT following chemoimmunotherapy appears to be safe and may prolong survival compared with radiotherapy alone. Further investigations on the combination of chemoimmunotherapy and CRT are warranted.
Collapse
Affiliation(s)
- Song Guan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Kai Ren
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Xuyu Zhang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Meng Yan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Xue Li
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Lujun Zhao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China.
- Tianjin's Clinical Research Center for Cancer, Tianjin, China.
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.
| |
Collapse
|
7
|
Jiang M, Hu Y, Lin G, Chen C, Li H. Radiotherapy combined with immune checkpoint inhibitors in locally advanced/metastatic esophageal squamous cell carcinoma: clinical trials, efficacy and future directions. Front Immunol 2023; 14:1177085. [PMID: 37325652 PMCID: PMC10261849 DOI: 10.3389/fimmu.2023.1177085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/22/2023] [Indexed: 06/17/2023] Open
Abstract
Esophageal squamous cell carcinoma (ESCC) is a common malignancy worldwide and often diagnosed at advanced stages with poor prognosis. Combination of radiotherapy and immunotherapy seems to be a promising approach for treating ESCC. This comprehensive review article summarizes the current state of combination of radiotherapy and immunotherapy in locally advanced/metastatic ESCC, delineates the clinical trials that merit attention, and outlines unresolved issues and future research directions in this field. The clinical trial findings suggest that radio-immunotherapy combination may improve tumor response and overall survival with manageable side effects, highlighting the importance of patient selection and the necessity for further research to optimize treatment strategies. Issues such as irradiation dosage, fractionation regimen, irradiation site and technique of radiotherapy, as well as the timing, sequence and duration of combination therapy will all affect treatment outcomes, justifying further in-depth investigation.
Collapse
Affiliation(s)
- Mengjie Jiang
- Department of Radiotherapy, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | | | | | | | | |
Collapse
|
8
|
Wu L, Zhang Z, Bai M, Yan Y, Yu J, Xu Y. Radiation combined with immune checkpoint inhibitors for unresectable locally advanced non-small cell lung cancer: synergistic mechanisms, current state, challenges, and orientations. Cell Commun Signal 2023; 21:119. [PMID: 37221584 DOI: 10.1186/s12964-023-01139-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/22/2023] [Indexed: 05/25/2023] Open
Abstract
Until the advent of immune checkpoint inhibitors (ICIs), definitive radiotherapy (RT) concurrently with chemotherapy was recommended for unresectable, locally advanced non-small cell lung cancer (LA-NSCLC). The trimodality paradigm with consolidation ICIs following definitive concurrent chemoradiotherapy has been the standard of care since the PACIFIC trial. Preclinical evidence has demonstrated the role of RT in the cancer-immune cycle and the synergistic effect of RT combined with ICIs (iRT). However, RT exerts a double-edged effect on immunity and the combination strategy still could be optimized in many areas. In the context of LA-NSCLC, optimized RT modality, choice, timing, and duration of ICIs, care for oncogenic addicted tumors, patient selection, and novel combination strategies require further investigation. Targeting these blind spots, novel approaches are being investigated to cross the borders of PACIFIC. We discussed the development history of iRT and summarized the updated rationale for the synergistic effect. We then summarized the available research data on the efficacy and toxicity of iRT in LA-NSCLC for cross-trial comparisons to eliminate barriers. Progression during and after ICIs consolidation therapy has been regarded as a distinct resistance scenario from primary or secondary resistance to ICIs, the subsequent management of which has also been discussed. Finally, based on unmet needs, we probed into the challenges, strategies, and auspicious orientations to optimize iRT in LA-NSCLC. In this review, we focus on the underlying mechanisms and recent advances of iRT with an emphasis on future challenges and directions that warrant further investigation. Taken together, iRT is a proven and potential strategy in LA-NSCLC, with multiple promising approaches to further improve the efficacy. Video Abstract.
Collapse
Affiliation(s)
- Leilei Wu
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Zhenshan Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Cancer Hospital, Shanghai, China
| | - Menglin Bai
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yujie Yan
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jinming Yu
- Department of Radiation Oncology and Shandong Provincial Key Laboratory of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.
| | - Yaping Xu
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.
| |
Collapse
|
9
|
Kępka L. Palliative extracranial radiotherapy in patients receiving immunotherapy for non-small cell lung cancer: a narrative review. Transl Cancer Res 2023; 12:163-176. [PMID: 36760380 PMCID: PMC9906063 DOI: 10.21037/tcr-22-1969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
Background and Objective Role of radiotherapy (RT) in the era of immuno-oncology (IO) in advanced non-small cell lung cancer (NSCLC) is rapidly changing. RT is not only intended for addressing palliation symptoms but also is considered as a potential tool potentializing an immunogenic effect of given drugs. However, the best timing, techniques, doses, volumes, and its use for asymptomatic patients is a subject of research. We performed a review on the role of palliative RT schedules in combination with IO for advanced NSCLC. Indications in symptomatic and asymptomatic patients, outcomes, toxicity, and possible developments are discussed. Methods A literature search was conducted in MEDLINE and PubMed databases and clinicaltrials.gov using the keywords 'lung cancer' AND "immunotherapy" AND 'radiotherapy' OR "palliative radiotherapy". Key Content and Findings Body of evidence indicate that palliative RT used in combination with IO is effective in terms of symptom management and safe; does not increase the risk of serious side effects, including serious pulmonary toxicity. We have limited data evidencing improvement of survival by addition of short ablative RT dose to one site of the disease to IO in oligometastatic NSCLC. Some data indicate that short ablative doses of stereotactic body radiation therapy (SBRT) are more effective with regard to treatment response and survival than protracted RT schedule with lower fractional doses. However, this may be a selection bias of better prognostic patients who underwent SBRT. The use of steroids being a potential concern during IO should not be prohibited if clinically indicated during palliative RT. Its detrimental effect shown in some studies may also be a result of selection bias, because steroids given for not cancer-related causes during IO did not decrease survival. Conclusions RT for symptom management may be used during, directly before or after IO. This has a potential to ease symptom burdens and improve performance status (PS). However, still more studies are needed to establish optimal guidelines in asymptomatic patients for appropriate timing, volumes, dose, and fractionation schedules of palliative RT use in combination with IO.
Collapse
|
10
|
Guo XJ, Cai XT, Rong ZX, Zhang YP, Wen YX, Bai X, Wang J, Fu QJ, Guo ZQ, Long LL, Ma SC, Tang XR, Liu L, Guan J, Dong ZY, Wu DH. Interstitial pneumonitis associated with combined regimen of immunotherapy and conventional therapies-pharmacovigilance database analysis with real-world data validation. BMC Med 2023; 21:6. [PMID: 36600276 PMCID: PMC9814324 DOI: 10.1186/s12916-022-02713-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI) therapy combined with conventional therapies is being broadly applied in non-small cell lung cancer (NSCLC) patients. However, the risk of interstitial pneumonitis (IP) following a combined regimen is incompletely characterized. METHODS A total of 46,127 NSCLC patients were extracted for disproportionality analyses of IP from the Food and Drug Administration's Adverse Event Reporting System (FAERS) database. A total of 1108 NSCLC patients who received ICI treatment at Nanfang Hospital of Southern Medical University were collected and utilized for real-world validation. RESULTS Of the 46,127 patients with NSCLC, 3830 cases (8.3%; 95% confidence interval [CI], 8.05-8.56) developed IP. Multivariable logistic regression analyses revealed that the adjusted ROR of ICI combined with radiation (RT) was the highest (121.69; 95% CI, 83.60-184.96; P < 0.0001) among all therapies, while that of ICI combined with chemotherapy (CHEMO) or targeted therapy (TARGET) was 0.90 (95% CI, 0.78-1.04; P = 0.160) and 1.49 (95% CI, 0.95-2.23; P = 0.065), respectively, using ICI monotherapy as reference. Furthermore, analyses from our validation cohort of 1108 cases showed that the adjusted odds ratio of ICI combined with RT was the highest (12.25; 95% CI, 3.34-50.22; P < 0.01) among all the therapies, while that of ICI combined with CHEMO or TARGET was 2.32 (95% CI, 0.89-7.92; P = 0.12) and 0.66 (95% CI, 0.03-4.55; P = 0.71), respectively, using ICI monotherapy as reference. CONCLUSIONS Compared with ICI monotherapy, ICI combined with RT, rather than with CHEMO or TARGET, is associated with a higher risk of IP in NSCLC patients. Hence, patients receiving these treatments should be carefully monitored for IP.
Collapse
Affiliation(s)
- Xue-Jun Guo
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Xiao-Ting Cai
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Zi-Xuan Rong
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Yan-Pei Zhang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Yu-Xiang Wen
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Xue Bai
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Jian Wang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Qiang John Fu
- Department of Community Health, School of Arts and Sciences, Tufts University, Medford, MA, USA
| | - Ze-Qin Guo
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Li-Li Long
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Si-Cong Ma
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Xin-Ran Tang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China
| | - Li Liu
- Information Management and Big Data Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jian Guan
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| | - Zhong-Yi Dong
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| | - De-Hua Wu
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, 510515, China.
| |
Collapse
|
11
|
Aldea M, Belkhir R, Colomba E, Blanchard P, Danlos FX, Botticella A, Terlizzi M, Deutsch E, Le Péchoux C, Planchard D, Michot JM, Besse B, Levy A. Immune-related arthritis following pelvic radiation therapy in a patient with lung cancer receiving long-term immune checkpoint blocker treatment: Case report. Front Immunol 2022; 13:920130. [PMID: 36353627 PMCID: PMC9637658 DOI: 10.3389/fimmu.2022.920130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 10/05/2022] [Indexed: 11/27/2022] Open
Abstract
Radiotherapy can trigger immune-related out-of-field “abscopal” response. We report a patient with advanced NSCLC (non-small cell lung cancer) receiving long-term anti-PD1 (programmed cell death protein 1) who have developed out-of-field immune-related arthritis following pelvic irradiation.
Collapse
Affiliation(s)
- Mihaela Aldea
- Department of Medical Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
- *Correspondence: Mihaela Aldea, ; Antonin Levy,
| | - Rakiba Belkhir
- Rheumatology, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, FHU CARE, Le Kremlin-Bicêtre, France
| | - Emeline Colomba
- Department of Medical Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Pierre Blanchard
- Department of Radiation Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Francois-Xavier Danlos
- Department of Medical Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Angela Botticella
- Department of Radiation Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Mario Terlizzi
- Department of Radiation Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Eric Deutsch
- Department of Radiation Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Université Paris-Saclay, Villejuif, France
| | - Cecile Le Péchoux
- Department of Radiation Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - David Planchard
- Department of Medical Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Jean-Marie Michot
- DITEP (Département des Innovations Thérapeutiques et Essais Précoces), Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Benjamin Besse
- Department of Medical Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
| | - Antonin Levy
- Department of Radiation Oncology, International Center for Thoracic Cancers (CICT), Université Paris-Saclay, Gustave Roussy, Villejuif, France
- INSERM U1030, Molecular Radiotherapy, Université Paris-Saclay, Villejuif, France
- *Correspondence: Mihaela Aldea, ; Antonin Levy,
| |
Collapse
|
12
|
Zhang A, Yang F, Gao L, Shi X, Yang J. Research Progress on Radiotherapy Combined with Immunotherapy for Associated Pneumonitis During Treatment of Non-Small Cell Lung Cancer. Cancer Manag Res 2022; 14:2469-2483. [PMID: 35991677 PMCID: PMC9386171 DOI: 10.2147/cmar.s374648] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/07/2022] [Indexed: 12/24/2022] Open
Abstract
Radiation pneumonitis is a common and serious complication of radiotherapy for thoracic tumours. Although radiotherapy technology is constantly improving, the incidence of radiation pneumonitis is still not low, and severe cases can be life-threatening. Once radiation pneumonitis develops into radiation fibrosis (RF), it will have irreversible consequences, so it is particularly important to prevent the occurrence and development of radiation pneumonitis. Immune checkpoint inhibitors (ICIs) have rapidly altered the treatment landscape for multiple tumour types, providing unprecedented survival in some patients, especially for the treatment of non-small cell lung cancer (NSCLC). However, in addition to its remarkable curative effect, ICls may cause immune-related adverse events. The incidence of checkpoint inhibitor pneumonitis (CIP) is 3% to 5%, and its mortality rate is 10% to 17%. In addition, the incidence of CIP in NSCLC is higher than in other tumour types, reaching 7%–13%. With the increasing use of immune checkpoint inhibitors (ICls) and thoracic radiotherapy in the treatment of patients with NSCLC, ICIs may induce delayed radiation pneumonitis in patients previously treated with radiation therapy, or radiation activation of the systemic immune system increases the toxicity of adverse reactions, which may lead to increased pulmonary toxicity and the incidence of pneumonitis. In this paper, the data about the occurrence of radiation pneumonitis, immune pneumonitis, and combined treatment and the latest related research results will be reviewed.
Collapse
Affiliation(s)
- Anqi Zhang
- Department of Oncology, First Affiliated Hospital of Yangtze University, Jingzhou, People's Republic of China
| | - Fuyuan Yang
- School of Basic Medicine, Health Science Center, Yangtze University, Jingzhou, People's Republic of China
| | - Lei Gao
- Department of Oncology, First Affiliated Hospital of Yangtze University, Jingzhou, People's Republic of China
| | - Xiaoyan Shi
- Department of Gynaecology and Obstetrics, First Affiliated Hospital of Yangtze University, Jingzhou, People's Republic of China
| | - Jiyuan Yang
- Department of Oncology, First Affiliated Hospital of Yangtze University, Jingzhou, People's Republic of China
| |
Collapse
|
13
|
Hao Y, Zhang X, Yu L. Immune checkpoint inhibitor-related pneumonitis in non-small cell lung cancer: A review. Front Oncol 2022; 12:911906. [PMID: 36052257 PMCID: PMC9424849 DOI: 10.3389/fonc.2022.911906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have shown definite therapeutic effects in various types of cancers, especially non-small cell lung cancer (NSCLC). However, ICIs have unique side effects, called immune-related adverse events (irAEs), which can occur in various systems throughout the body. Among such irAEs, immune checkpoint inhibitor-related pneumonitis (ICI-P) is a fatal adverse reaction. In this review, we discussed the risk factors, pathogenesis, clinical characteristics, radiological manifestations, pathological features, diagnosis, grading, and management of ICI-P in NSCLC and the relationship between ICI-P and the efficacy of ICI therapy. In addition, we discussed the predictive factors for ICI-P. This review will play a crucial role in the prediction, evaluation, and management of ICI-P for widespread application of immunotherapy.
Collapse
|
14
|
Lu X, Wang J, Zhang T, Zhou Z, Deng L, Wang X, Wang W, Liu W, Tang W, Wang Z, Wang J, Jiang W, Bi N, Wang L. Comprehensive Pneumonitis Profile of Thoracic Radiotherapy Followed by Immune Checkpoint Inhibitor and Risk Factors for Radiation Recall Pneumonitis in Lung Cancer. Front Immunol 2022; 13:918787. [PMID: 35795657 PMCID: PMC9251068 DOI: 10.3389/fimmu.2022.918787] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/19/2022] [Indexed: 01/21/2023] Open
Abstract
Purpose Whilst survival benefits of thoracic radiotherapy (TRT) followed by immune checkpoint inhibitor (ICI) have been reported in patients with lung cancer, the potential high risk of treatment-related pneumonitis remains a concern. Asians may be more sensitive to lung toxicity than other races. This retrospective study intended to provide a comprehensive pneumonitis profile of TRT followed by ICI and investigate the risk factors from a Chinese cohort of lung cancer. Methods and Materials From January 2016 to July 2021, 196 patients with lung cancer who received TRT prior to ICI were retrospectively analyzed. Treatment-related pneumonitis, including checkpoint inhibitor pneumonitis (CIP), radiation pneumonitis (RP), and radiation recall pneumonitis (RRP), were recorded and graded through medical records and chest computed tomography. Characteristics predictive of pneumonitis were assessed using logistic regression models, and the receiver operating characteristic analyses were performed to identify optimal cut points for quantitative variables. Results With a median follow-up of 18 months, a total of 108 patients (55.1%) developed treatment-related pneumonitis during ICI therapy, with an incidence of 25.5% for grade 2 or higher (G2+) and 4.1% for G3+. The overall rates of CIP, RP and RRP were 8.2% (n=16), 46.9% (n=92) and 7.1% (n=14), respectively. With a total mortality rate of 1.5%, vast majority of the patients recovered from pneumonitis or remained stable. No patients died of RRP. Half of the patients with G2+ RP who withheld ICI therapy restarted ICI safely after resolution of RP. The history of chronic pulmonary diseases (P=0.05), mean lung dose (MLD, P=0.038), percent volume of lung receiving ≥5 Gy (V5, P=0.012) and percent volume of lung receiving ≥20 Gy (V20, P=0.030) predicted the occurrence of RRP in univariate analyses. Interval between TRT and ICI less than 3 months was an independent predictor for G2+ treatment-related pneumonitis in a multivariate model (Odds ratio OR=2.787, P=0.004). Conclusions Treatment-related pneumonitis, especially RRP, is acceptable and manageable in the setting of TRT followed by ICI in this Asian population. Dosimetric parameters MLD, V5 and V20 may improve the predictions of RRP in clinical practice.
Collapse
Affiliation(s)
- Xiaotong Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianyang Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zongmei Zhou
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Deng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenqing Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenyang Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Tang
- Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhijie Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Jiang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Nan Bi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Nan Bi, ; Luhua Wang,
| | - Luhua Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
- *Correspondence: Nan Bi, ; Luhua Wang,
| |
Collapse
|
15
|
Pneumonitis after Stereotactic Thoracic Radioimmunotherapy with Checkpoint Inhibitors: Exploration of the Dose-Volume-Effect Correlation. Cancers (Basel) 2022; 14:cancers14122948. [PMID: 35740613 PMCID: PMC9221463 DOI: 10.3390/cancers14122948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Stereotactic body radiation therapy (SBRT) is widely applied for treatment of early stage lung cancer and pulmonary metastases. Modern immune checkpoint blockade (ICB) is progressively used in cancer treatment. Pneumonitis is a relevant side effect of both thoracic SBRT and ICB. Currently, it remains unclear whether we can presume the same radiation dose–volume–effect correlations and dose constraints for safe application of SBRT + ICB. We present a dose–volume–effect correlation analysis method using pneumonitis contours and dose–volume histograms (DVH). We showed dosimetric differences for pneumonitis volumes between SBRT + ICB and SBRT alone. We found a large extent of pneumonitis, even bilateral and apart from the radiation field for combined SBRT + ICB. We noticed a shift in pneumonitis DVHs towards lower doses and a trend towards decreased areas under the curve (AUC) for SBRT + ICB. This provides a direction for re-evaluation and potential adaptation of lung dose constraints for combined SBRT and ICB. Abstract Thoracic stereotactic body radiation therapy (SBRT) is extensively used in combination with immune checkpoint blockade (ICB). While current evidence suggests that the occurrence of pneumonitis as a side effect of both treatments is not enhanced for the combination, the dose–volume correlation remains unclear. We investigate dose–volume–effect correlations for pneumonitis after combined SBRT + ICB. We analyzed patient clinical characteristics and dosimetric data for 42 data sets for thoracic SBRT with ICB treatment (13) and without (29). Dose volumes were converted into 2 Gy equivalent doses (EQD2), allowing for dosimetric comparison of different fractionation regimes. Pneumonitis volumes were delineated and corresponding DVHs were analyzed. We noticed a shift towards lower doses for combined SBRT + ICB treatment, supported by a trend of smaller areas under the curve (AUC) for SBRT+ ICB (median AUC 1337.37 vs. 5799.10, p = 0.317). We present a DVH-based dose–volume–effect correlation method and observed large pneumonitis volumes, even with bilateral extent in the SBRT + ICB group. We conclude that further studies using this method with enhanced statistical power are needed to clarify whether adjustments of the radiation dose constraints are required to better estimate risks of pneumonitis after the combination of SBRT and ICB.
Collapse
|
16
|
Skribek M, Rounis K, Tsakonas G, Ekman S. Complications following novel therapies for non-small cell lung cancer. J Intern Med 2022; 291:732-754. [PMID: 35032058 DOI: 10.1111/joim.13445] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The emergence of tyrosine kinase inhibitors and immune checkpoint inhibitors has paved a new era for the management of non-small cell lung cancer, which has for many years lacked major clinical breakthroughs. Historically, 5-year overall survival remained below 5% in individuals with metastatic disease. These novel treatments have led to significant prolongation of survival in the locally advanced and metastatic setting, exceeding 25% in selected populations. However, they present new challenges to clinicians due to their inherently different spectrum of toxicity unique to each specific drug's pharmacodynamic profile. Internists commonly come across these side effects in their daily clinical practice. Their optimal recognition and management are of utmost importance, because it is associated with significant improvements in patient survival outcomes and their quality of life. The aim of this review is to summarize the complications following these novel treatments for non-small cell lung cancer.
Collapse
Affiliation(s)
- Marcus Skribek
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Thoracic Oncology Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Konstantinos Rounis
- Thoracic Oncology Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Tsakonas
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Thoracic Oncology Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Simon Ekman
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Thoracic Oncology Center, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
17
|
Simon Davis DA, Atmosukarto II, Garrett J, Gosling K, Syed FM, Quah BJ. Irradiation immunity interactions. J Med Imaging Radiat Oncol 2022; 66:519-535. [PMID: 35261190 PMCID: PMC9314628 DOI: 10.1111/1754-9485.13399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/18/2022] [Accepted: 02/21/2022] [Indexed: 12/17/2022]
Abstract
The immune system can influence cancer development by both impeding and/or facilitating tumour growth and spread. A better understanding of this complex relationship is fundamental to optimise current and future cancer therapeutic strategies. Although typically regarded as a localised and immunosuppressive anti‐cancer treatment modality, radiation therapy has been associated with generating profound systemic effects beyond the intended target volume. These systemic effects are immune‐driven suggesting radiation therapy can enhance anti‐tumour immunosurveillance in some instances. In this review, we summarise how radiation therapy can positively and negatively affect local and systemic anti‐tumour immune responses, how co‐administration of immunotherapy with radiation therapy may help promote anti‐tumour immunity, and how the use of immune biomarkers may help steer radiation therapy‐immunotherapy personalisation to optimise clinical outcomes.
Collapse
Affiliation(s)
- David A Simon Davis
- Irradiation Immunity Interaction Laboratory, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia.,Division of Genome Sciences & Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Ines I Atmosukarto
- Irradiation Immunity Interaction Laboratory, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia.,Division of Genome Sciences & Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Jessica Garrett
- Division of Genome Sciences & Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Katharine Gosling
- Division of Genome Sciences & Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Farhan M Syed
- Irradiation Immunity Interaction Laboratory, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia.,Division of Genome Sciences & Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia.,Radiation Oncology Department, Canberra Hospital, Canberra Health Services, Canberra, Australian Capital Territory, Australia
| | - Ben Jc Quah
- Irradiation Immunity Interaction Laboratory, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia.,Division of Genome Sciences & Cancer, John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia.,Radiation Oncology Department, Canberra Hospital, Canberra Health Services, Canberra, Australian Capital Territory, Australia
| |
Collapse
|
18
|
Duriseti S, Kavanaugh JA, Szymanski J, Huang Y, Basarabescu F, Chaudhuri A, Henke L, Samson P, Lin A, Robinson C, Spraker MB. LITE SABR M1: A phase I trial of Lattice stereotactic body radiotherapy for large tumors. Radiother Oncol 2022; 167:317-322. [PMID: 34875286 DOI: 10.1016/j.radonc.2021.11.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/09/2021] [Accepted: 11/22/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) is an attractive treatment option for patients with metastatic and/or unresectable tumors, however its use is limited to smaller tumors. Lattice is a form of spatially fractionated radiotherapy that may allow safe delivery of ablative doses to bulky tumors. We previously described Lattice SBRT, which delivers 20 Gy in 5 fractions with a simultaneous integrated boost to 66.7 Gy in a defined geometric arrangement (Lattice boost). The goal of this study was to prospectively evaluate the acute toxicity and quality of life (QoL) of patients with large tumors (>5 cm) treated with Lattice SBRT. METHODS This was a single-arm phase I trial conducted between October 2019 and August 2020. Patients with tumors > 4.5 cm were eligible. Lattice SBRT was delivered every other day. The primary outcome was the rate of 90-day treatment-associated (probably or definitely attributable) grade 3 + acute toxicity by Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 criteria. Other outcomes included changes in patient reported toxicity and QoL inventories, GTV, and peripheral blood cytokines. RESULTS Twenty patients (22 tumors) were enrolled. Median GTV was 579.2 cc (range: 54.2-3713.5 cc) in volume and 11.1 cm (range: 5.6-21.4 cm) in greatest axial diameter. Fifty percent of tumors were in the thorax, 45% abdomen/pelvis, and 5% extremity. There was no likely treatment-associated grade 3 + toxicity in the 90-day period (acute and sub-acute). There was one case of grade 4 toxicity possibly associated with Lattice SBRT. CONCLUSIONS This phase I study met its primary endpoint of physician reported short-term safety. An ongoing phase II clinical trial of Lattice SBRT will evaluate late safety and efficacy of this novel technique.
Collapse
Affiliation(s)
- Sai Duriseti
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - James A Kavanaugh
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Jeff Szymanski
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Yi Huang
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Franco Basarabescu
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Aadel Chaudhuri
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Lauren Henke
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Pamela Samson
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Alexander Lin
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St. Louis, United States
| | - Matthew B Spraker
- Department of Radiation Oncology, Washington University in St. Louis, United States.
| |
Collapse
|
19
|
Bernstein MB, Walker K, Gillespie E, Mueller B, Cuaron J, Xu A, McCormick B, Khan A, Cahlon O, Powell S, Braunstein LZ. Bilateral Regional Nodal Irradiation using Volumetric Modulated Arc Therapy (VMAT): Dosimetric analysis and feasibility. Pract Radiat Oncol 2022; 12:189-194. [PMID: 35045364 PMCID: PMC9081150 DOI: 10.1016/j.prro.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/16/2021] [Accepted: 11/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE/OBJECTIVES Dosimetric and technical challenges often limit radiotherapy (RT) target coverage for breast cancer patients who require bilateral breast/chest wall and regional nodal irradiation (RNI). We evaluated the feasibility of using volumetric modulated arc therapy (VMAT) to administer bilateral comprehensive RNI including the internal mammary nodes. MATERIALS/METHODS We analyzed all patients treated at our institution with bilateral RNI using VMAT from 2017-2020. Medical records were reviewed to ascertain clinicopathologic features, radiotherapeutic parameters and treatment-related adverse events. RESULTS The cohort comprised 12 patients who underwent VMAT for bilateral RNI, with a median follow-up of 14.5 months. Median V5Gy for bilateral lungs was 96.1% (range: 84.5%-99.8%). Median V20Gy for each lung was 27.5% (range: 14.9-38.1%). Cardiac mean dose was a median of 699 cGy (range: 527-1117 cGy). Five patients (41%) developed grade 1 cough/dyspnea, with one patient developing grade 3 dyspnea. Of note, three of these (60%) were current or former smokers. No patient received glucocorticoid therapy or required respiratory intervention and none developed longer term pulmonary complaints. Decline in ejection fraction occurred in one patient with a pre-existing cardiac condition who also received anthracycline-based chemotherapy and trastuzumab. Only one patient experienced locoregional recurrence with synchronous distant progression and subsequently succumbed to her disease. No secondary cancers have been noted to date. CONCLUSION VMAT appears to be a feasible and tolerable RT modality for breast cancer patients who require bilateral comprehensive adjuvant RT with RNI obtaining excellent target coverage. No patients required medical intervention for pulmonary complaints despite a median bilateral V5 approaching 100%, providing further evidence that V5 is not predictive for complications.
Collapse
Affiliation(s)
- Michael B Bernstein
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Katherine Walker
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erin Gillespie
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Boris Mueller
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John Cuaron
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Amy Xu
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Beryl McCormick
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Atif Khan
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Oren Cahlon
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Simon Powell
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lior Z Braunstein
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.
| |
Collapse
|
20
|
Bardoscia L, Pasinetti N, Triggiani L, Cozzi S, Sardaro A. Biological Bases of Immune-Related Adverse Events and Potential Crosslinks With Immunogenic Effects of Radiation. Front Pharmacol 2021; 12:746853. [PMID: 34790123 PMCID: PMC8591245 DOI: 10.3389/fphar.2021.746853] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/19/2021] [Indexed: 01/03/2023] Open
Abstract
Immune checkpoint inhibitors have gained an established role in the treatment of different tumors. Indeed, their use has dramatically changed the landscape of cancer care, especially for tumor types traditionally known to have poor outcomes. However, stimulating anticancer immune responses may also elicit an unusual pattern of immune-related adverse events (irAEs), different from those of conventional chemotherapy, likely due to a self-tolerance impairment featuring the production of autoreactive lymphocytes and autoantibodies, or a non-specific autoinflammatory reaction. Ionizing radiation has proven to promote both positive pro-inflammatory and immunostimolatory activities, and negative anti-inflammatory and immunosuppressive mechanisms, as a result of cross-linked interactions among radiation dose, the tumor microenvironment and the host genetic predisposition. Several publications argue in favor of combining immunotherapy and a broad range of radiation schedules, based on the recent evidence of superior treatment responses and patient survival. The synergistic modulation of the immune response by radiation therapy and immunotherapeutics, particularly those manipulating T-cell activation, may also affect the type and severity of irAEs, suggesting a relationship between the positive antitumor and adverse autoimmune effects of these agents. As yet, information on factors that may help to predict immune toxicity is still lacking. The aim of our work is to provide an overview of the biological mechanisms underlying irAEs and possible crosslinks with radiation-induced anticancer immune responses. We believe such an overview may support the optimization of immunotherapy and radiotherapy as essential components of multimodal anticancer therapeutic approaches. Challenges in translating these to clinical practice are discussed.
Collapse
Affiliation(s)
- Lilia Bardoscia
- Radiation Oncology Unit, S. Luca Hospital, Healthcare Company Tuscany Nord Ovest, Lucca, Italy
| | - Nadia Pasinetti
- Radiation Oncology Department, ASST Valcamonica Esine and University of Brescia, Brescia, Italy
| | - Luca Triggiani
- Department of Radiation Oncology, University and Spedali Civili Hospital, Brescia, Italy
| | - Salvatore Cozzi
- Radiotherapy Unit, Clinical Cancer Centre, AUSL-IRCCS, Reggio Emilia, Italy
| | - Angela Sardaro
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari "Aldo Moro", Bari, Italy
| |
Collapse
|
21
|
Chen Y, Liu X, Huang Z, Zhao K, Wang Y, Ren F, Yu J, Meng X. Safety of thoracic radiotherapy after PD-(L)1 inhibitor treatment in patients with lung cancer. Cancer Med 2021; 10:8518-8529. [PMID: 34664788 PMCID: PMC8633221 DOI: 10.1002/cam4.4363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 12/25/2022] Open
Abstract
Background The safety of thoracic radiotherapy (TRT) after programmed death 1/programmed death ligand 1 (PD‐(L)1) inhibitor treatment in patients with lung cancer was scarcely reported. This retrospective study was conducted to evaluate the incidence, severity, and risk factors of symptomatic treatment‐related pneumonitis in patients with lung cancer who received this sequential combination. Methods We conducted a retrospective study of a cohort of patients with lung cancer who received TRT after at least two cycles of PD‐(L)1 inhibitor treatment between January 2018 and August 2020. Treatment‐related pneumonitis was evaluated and analyzed to illustrate the safety profile of this sequential combination. Potential risk factors were explored by univariate and multivariate logistic regression analyses. Results Among the 828 patients with prior PD‐(L)1 inhibitor treatment, 96 patients receiving subsequent TRT were included in the analysis. Of these, 49 patients (51%) received radical TRT while 47 patients (49%) received palliative TRT. The median total dose was 52 Gy (IQR 50–60 Gy). The median time from the initiation of PD‐(L)1 inhibitor treatment to TRT was 4.8 months (1.6–14.1 months) with most of the patients (74%) administering no less than four cycles of PD‐(L)1 inhibitor. During follow‐up, 47 patients (48.96%) developed symptomatic treatment‐related pneumonitis (grade 2 n = 28, grade ≥3 n = 19) while six patients (6.25%) suffered from fatal toxicity. The median time of pneumonitis onset after completion of TRT was 35 days (0–177 days) with six patients developing during TRT. Pulmonary emphysema and lung V20 were demonstrated to be independent risk factors of symptomatic pneumonitis (OR: 5.67, 95% CI: 1.66–19.37, p = 0.006; OR: 3.49, 95% CI: 1.41–8.66, p = 0.007, respectively). Conclusion TRT after PD‐(L)1 inhibitor treatment resulted in significantly increased incidence and severity of treatment‐related pneumonitis in patients with lung cancer. Intensive attention should be emphasized to the safety of this sequential combination in clinical practice.
Collapse
Affiliation(s)
- Yu Chen
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Xinchao Liu
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Zhaoqin Huang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Kaikai Zhao
- Department of Radiation Oncology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China
| | - Yao Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Fei Ren
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jinming Yu
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Xiangjiao Meng
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| |
Collapse
|
22
|
van Hoorn JE, Dahele M, Daniels JMA. Late Central Airway Toxicity after High-Dose Radiotherapy: Clinical Outcomes and a Proposed Bronchoscopic Classification. Cancers (Basel) 2021; 13:cancers13061313. [PMID: 33804058 PMCID: PMC7999982 DOI: 10.3390/cancers13061313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/08/2021] [Accepted: 03/12/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary High-dose radiotherapy is frequently used to treat lung cancer, however, it can cause serious central airway toxicity. Although radiation toxicity of the lung parenchyma has been studied extensively, relatively little has been published on bronchoscopic findings in the central airways and no standard classification/reporting system exists. With the growing use of high-dose (chemo)radiotherapy and high-dose hypo-fractionated radiotherapy in close proximity to central airways, as well as potential interactions with new systemic therapies, the risks and incidence of central airway toxicity may increase. In this retrospective study, we analyzed patient characteristics and clinical outcomes of 70 patients with central airway toxicity after high-dose radiotherapy. Furthermore, we analyzed the post-radiotherapy bronchoscopic images to identify main patterns of airway toxicity. We identified luminal stenosis and vascular changes as the two main patterns and have proposed a classification system. Preliminary analysis suggests that the pattern and severity of radiation toxicity may be of prognostic value. Abstract The study’s purpose was to identify the bronchoscopic patterns of central airway toxicity following high-dose radiotherapy or chemoradiotherapy, and to look at the consequences of these findings. Our institutional bronchoscopy database was accessed to identify main patterns of airway toxicity observed in a seven-year period. A total of 70 patients were identified with central airway toxicity, and the findings of bronchoscopy were used to derive a classification system. Patient characteristics, time from radiotherapy to toxicity, follow-up and survival were retrospectively analyzed. Results: The main bronchoscopic patterns of airway toxicity were vascular changes (telangiectasia, loss of vascularity, necrosis) and stenosis of the lumen (moderate, severe). Indications for bronchoscopy were airway symptoms (n = 28), assessment post-CRT/surgery (n = 12), (suspected) recurrence (n = 21) or assessment of radiological findings (n = 9). Stenosis was revealed by bronchoscopy at a median time of 10.0 months (IQR: 4–23.5) after radiotherapy and subsequent follow-up after identification was 23 months (IQR: 1.5–55). The corresponding findings for vascular changes were 29 months (IQR: 10.5–48.5), and follow-up after identification was nine months (IQR: 2.5–19.5). There was a statistically significant difference in survival rates between patients with necrosis and telangiectasia (p = 0.002) and loss of vascularity (p = 0.001). Eight out of 10 deceased patients with telangiectasia died of other causes and 4/8 patients with necrosis died of other causes. We identified two main patterns of central airway toxicity visualized with bronchoscopy after high-dose radiotherapy or chemoradiotherapy, and propose a bronchoscopic classification system based on these findings. Preliminary analysis suggests that the pattern and severity of radiation damage might be of prognostic value. Prospective data are required to confirm our findings.
Collapse
Affiliation(s)
- Juliët E. van Hoorn
- Department of Pulmonary Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
- Correspondence:
| | - Max Dahele
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Johannes M. A. Daniels
- Department of Pulmonary Medicine, Cancer Center Amsterdam, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| |
Collapse
|
23
|
Senan S, Bahce I. Pulmonary toxicity in patients treated with immune checkpoint inhibitors and radiation. Ann Oncol 2020; 31:1597-1598. [PMID: 33091560 DOI: 10.1016/j.annonc.2020.10.476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- S Senan
- Department of Radiation Oncology, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
| | - I Bahce
- Department of Pulmonary Diseases, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| |
Collapse
|