Role of gross tumor volume in the prognosis of non-small cell lung cancer treated with 3D conformal radiotherapy: a meta-analysis

Prognostic Role of Biologically Active Volume of Disease in Patients With Metastatic Lung Adenocarcinoma

BACKGROUND

Number of metastatic sites can identify patient populations with non-small cell lung cancer (NSCLC) that benefit from aggressive therapy. Total volume of disease is also relevant. We evaluated the prognostic impact of biologically active volume of disease (BaVD) on patients with metastatic lung adenocarcinoma.

MATERIALS AND METHODS

Positron emission tomography/computerized tomography (PET/CT) scans from patients with newly diagnosed lung adenocarcinoma prior to starting any therapy were identified. SUV thresholds of 3 and 4 were used to auto-contour all FDG avid areas. Kaplan-Meier analysis and Cox regression were performed to examine influence on OS.

RESULTS

One hundred forty-eight patients were included in the analysis. The median BaVD when using an SUV threshold of 3 was 122.8 mL. The median BaVD when using an SUV threshold of 4 was 46.2 mL When stratified by median BaVD using an SUV of 3, median OS was higher for patients with <=122.8 mL (2.12 years) compared to patients with >122.8 mL (1.46 years) (log-rank P = .001). Similarly, when stratified by median BaVD using an SUV of 4, median OS was higher for patients with <=46.2 mL (1.91 years; 95% CI: 1.65-3.22 years) compared to patients with >46.2 mL (1.48 years; 95% CI: 1.07-1.80 years) (log-rank P = .007). On multivariable analysis, BaVD was significantly associated with OS when using an SUV threshold of 3 (HR: 20.169, P < .001) and 4 (HR: 4.117, P < .001).

CONCLUSION

BaVD is an important prognostic factor in metastatic lung adenocarcinoma and may aid identification of patients with limited disease who may be candidates for more aggressive therapies.

A comparison of machine learning methods for predicting recurrence and death after curative-intent radiotherapy for non-small cell lung cancer: Development and validation of multivariable clinical prediction models

BACKGROUND

Surveillance is universally recommended for non-small cell lung cancer (NSCLC) patients treated with curative-intent radiotherapy. High-quality evidence to inform optimal surveillance strategies is lacking. Machine learning demonstrates promise in accurate outcome prediction for a variety of health conditions. The purpose of this study was to utilise readily available patient, tumour, and treatment data to develop, validate and externally test machine learning models for predicting recurrence, recurrence-free survival (RFS) and overall survival (OS) at 2 years from treatment.

METHODS

A retrospective, multicentre study of patients receiving curative-intent radiotherapy for NSCLC was undertaken. A total of 657 patients from 5 hospitals were eligible for inclusion. Data pre-processing derived 34 features for predictive modelling. Combinations of 8 feature reduction methods and 10 machine learning classification algorithms were compared, producing risk-stratification models for predicting recurrence, RFS and OS. Models were compared with 10-fold cross validation and an external test set and benchmarked against TNM-stage and performance status. Youden Index was derived from validation set ROC curves to distinguish high and low risk groups and Kaplan-Meier analyses performed.

FINDINGS

Median follow-up time was 852 days. Parameters were well matched across training-validation and external test sets: Mean age was 73 and 71 respectively, and recurrence, RFS and OS rates at 2 years were 43% vs 34%, 54% vs 47% and 54% vs 47% respectively. The respective validation and test set AUCs were as follows: 1) RFS: 0·682 (0·575-0·788) and 0·681 (0·597-0·766), 2) Recurrence: 0·687 (0·582-0·793) and 0·722 (0·635-0·81), and 3) OS: 0·759 (0·663-0·855) and 0·717 (0·634-0·8). Our models were superior to TNM stage and performance status in predicting recurrence and OS.

INTERPRETATION

This robust and ready to use machine learning method, validated and externally tested, sets the stage for future clinical trials entailing quantitative personalised risk-stratification and surveillance following curative-intent radiotherapy for NSCLC.

FUNDING

A full list of funding bodies that contributed to this study can be found in the Acknowledgements section.

Role of T0 status in overall survival for unresectable stage III non-small cell lung cancer: A NCDB analysis

OBJECTIVES

Occult primary non-small cell lung cancer (NSCLC) with mediastinal involvement is a known but rare clinical condition. Very limited retrospective data are available in the literature. Its prognosis and response to systemic chemotherapy have not been investigated with large scale data.

MATERIALS AND METHODS

Using National Cancer Database (NCDB), cases that had undergone radiation therapy without surgery for N2-3M0 NSCLC were selected. Demographics and survival data were compared between T0 and T1-4 groups. Survival analyses were conducted with Kaplan-Meier and log-rank tests. Cox proportional hazard models were used for univariate and multivariate analyses.

RESULTS

Between 2004 and 2016, 84,263 and 458 cases met criteria for unresectable stage III NSCLC with T1-4 and T0 stage, respectively. T0 status was associated with younger age, recent diagnosis (year 2010-2016), adenocarcinoma histology, N3 stage, and use of chemotherapy. Survival analysis demonstrated that those with T0 status had prolonged overall survival as compared to T1-4 counterparts in both overall and chemotherapy groups (p < 0.0001 for each). Five-year overall survival rates for T0 and T1-4 groups were 30.5% and 12.7% in all groups, and 33.6% and 14.6% in chemotherapy groups, respectively. Propensity score matching also demonstrated a statistically significant difference in overall survival (p < 0.0001). These findings are confirmed by independent analysis using Surveillance, Epidemiology, and End Results Program (SEER).

CONCLUSION

This large hospital-based study demonstrates the favorable prognosis for T0 status in the setting of unresectable stage III NSCLC. Researchers may consider it as distinct stage (e.g., stage IIC) for future studies.

Total Tumor Volume Should be Considered as an Important Prognostic Factor for Synchronous Multiple Gastric Cancer Patients with Curative Gastrectomy

Synchronous multiple gastric cancer (SMGC) was a special type of gastric cancer with relatively low incidence. This article was designed to demonstrate that the total tumor volume (TTV) should be treated as an important prognostic factor in SMGC patients with curative gastrectomy. This study retrospective analyzed 140 SMGC patients who received curative gastrectomy between December 2004 and December 2014 in our hospital. Clinicopathological features, preoperative evaluation, surgical treatment, and outcome parameters were reviewed and analyzed. This study applied univariate and multivariate analyses to identify the most significant prognostic factors. In the univariate analysis, the TTV, pT_TVNM, pN stage, pT of main tumor were all significant prognostic factors in SMGC patients (all P < 0.05). In the multivariate analysis, pN stage, TTV and pT_TVNM were confirmed to be independent prognostic factors (all P < 0.05). In the comparison of survival analysis, the pT_TVNM stage system (P < 0.05) was superior to the pTNM stage system (P > 0.05) in SMGC patients. In conclusion, the TTV should be considered as an independent prognostic factor in overall survival in SMGC patients who received curative gastrectomy. The pT_TVNM stage should be recommended as a suitable staging system for SMGC patients.

Imaging-based target volume reduction in chemoradiotherapy for locally advanced non-small-cell lung cancer (PET-Plan): a multicentre, open-label, randomised, controlled trial

BACKGROUND

With increasingly precise radiotherapy and advanced medical imaging, the concept of radiotherapy target volume planning might be redefined with the aim of improving outcomes. We aimed to investigate whether target volume reduction is feasible and effective compared with conventional planning in the context of radical chemoradiotherapy for patients with locally advanced non-small-cell lung cancer.

METHODS

We did a multicentre, open-label, randomised, controlled trial (PET-Plan; ARO-2009-09) in 24 centres in Austria, Germany, and Switzerland. Previously untreated patients (aged older than 18 years) with inoperable locally advanced non-small-cell lung cancer suitable for chemoradiotherapy and an Eastern Cooperative Oncology Group performance status of less than 3 were included. Undergoing ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET and CT for treatment planning, patients were randomly assigned (1:1) using a random number generator and block sizes between four and six to target volume delineation informed by ¹⁸F-FDG PET and CT plus elective nodal irradiation (conventional target group) or target volumes informed by PET alone (¹⁸F-FDG PET-based target group). Randomisation was stratified by centre and Union for International Cancer Control stage. In both groups, dose-escalated radiotherapy (60-74 Gy, 2 Gy per fraction) was planned to the respective target volumes and applied with concurrent platinum-based chemotherapy. The primary endpoint was time to locoregional progression from randomisation with the objective to test non-inferiority of ¹⁸F-FDG PET-based planning with a prespecified hazard ratio (HR) margin of 1·25. The per-protocol set was included in the primary analysis. The safety set included all patients receiving any study-specific treatment. Patients and study staff were not masked to treatment assignment. This study is registered with ClinicalTrials.gov, NCT00697333.

FINDINGS

From May 13, 2009, to Dec 5, 2016, 205 of 311 recruited patients were randomly assigned to the conventional target group (n=99) or the ¹⁸F-FDG PET-based target group (n=106; the intention-to-treat set), and 172 patients were treated per protocol (84 patients in the conventional target group and 88 in the ¹⁸F-FDG PET-based target group). At a median follow-up of 29 months (IQR 9-54), the risk of locoregional progression in the ¹⁸F-FDG PET-based target group was non-inferior to, and in fact lower than, that in the conventional target group in the per-protocol set (14% [95% CI 5-21] vs 29% [17-38] at 1 year; HR 0·57 [95% CI 0·30-1·06]). The risk of locoregional progression in the ¹⁸F-FDG PET-based target group was also non-inferior to that in the conventional target group in the intention-to-treat set (17% [95% CI 9-24] vs 30% [20-39] at 1 year; HR 0·64 [95% CI 0·37-1·10]). The most common acute grade 3 or worse toxicity was oesophagitis or dysphagia (16 [16%] of 99 patients in the conventional target group vs 17 [16%] of 105 patients in the ¹⁸F-FDG PET-based target group); the most common late toxicities were lung-related (12 [12%] vs 11 [10%]). 20 deaths potentially related to study treatment were reported (seven vs 13).

INTERPRETATION

¹⁸F-FDG PET-based planning could potentially improve local control and does not seem to increase toxicity in patients with chemoradiotherapy-treated locally advanced non-small-cell lung cancer. Imaging-based target volume reduction in this setting is, therefore, feasible, and could potentially be considered standard of care. The procedures established might also support imaging-based target volume reduction concepts for other tumours.

FUNDING

German Cancer Aid (Deutsche Krebshilfe).

Long non‑coding RNA CCAT1 enhances human non‑small cell lung cancer growth through downregulation of microRNA‑218

Long non-coding RNAs (lncRNAs) have critical functions in non-small cell lung cancer (NSCLC) growth. In the present study, we showed that lncRNA-CCAT1 was upregulated in NSCLC tissues. High expression of lncRNA-CCAT1 was related to tumor growth and reduced survival rate. We used short hairpin RNAs (shRNAs) to inhibit the expression of lncRNA-CCAT1 in NSCLC cells. In vitro and in vivo results demonstrated that lncRNA-CCAT1 knockdown suppressed tumor proliferation and induced apoptosis. Furthermore, microRNA-218 (miR-218) was confirmed as an effective target of lncRNA-CCAT1 in NSCLC. B lymphoma Mo-MLV insertion region 1 homolog (BMI-1), which served as a downstream target of miR-218, was also inhibited by lncRNA-CCAT1 knockdown. In conclusion, the present study indicated that upregulation of lncRNA-CCAT1 in NSCLC is associated with tumor malignant potential. lncRNA-CCAT1 enhances tumor growth in NSCLC by directly inhibiting miR-218 and indirectly increasing BMI-1 expression.

Tumor Volume Index as a Prognostic Factor in Patients after Curative Esophageal Cancer Resection

BACKGROUND

The tumor, node, metastasis classification system for staging esophageal cancer does not include tumor volume although it may be an important prognostic factor. We evaluated the prognostic value of tumor volume in esophageal cancer.

METHODS

We performed a retrospective study in patients with histologically confirmed primary esophageal cancer who underwent curative esophagectomy at our facility between April 1992 and December 2013. The Tumor Depth Parameter (TDP) was defined as mucosa = 1, submucosa = 2, muscularis propria = 3, adventitia = 4, and invasion into adjacent organs = 5. The pathological Tumor Volume Index (TVI) was defined as the major axis × the minor axis × TDP. The appropriate tumor diameter and TVI cutoff values were determined by the Youden index obtained from the receiver operating characteristic curve. Prognostic factors for overall survival were evaluated by univariate analysis and Cox proportional hazards regression models.

RESULTS

We enrolled 302 patients. In the univariate analysis, patient age and sex, thoracoscopic surgery, tumor depth of invasion and diameter, lymph node metastasis, and the TVI were significantly associated with overall survival. In our multivariate analysis, patient age and sex, thoracoscopic surgery, lymph node metastasis, and the TVI were independently associated with overall survival.

CONCLUSIONS

The pathological TVI was an independent prognostic factor in patients with esophageal carcinoma and could be included in the staging system of esophageal cancer.

The role of tumour volume as a prognostic factor in non-small cell lung cancer (NSCLC) patients treated with definitive radiotherapy

Background

It has been shown that patients with a greater tumour volume have poorer outcomes following definitive radiotherapy but its exact role remains unclear. The purpose of this study is to investigate the role of tumour volume as a prognostic indicator in non-small cell lung cancer (NSCLC) patients treated with definitive radiotherapy in a single institution over 10 years.

Methods

In total, 167 patients with NSCLC treated by definitive (chemo)radiotherapy were retrospectively reviewed between 2006 and 2015. Patient demographics, disease characteristics and tumour volume parameters were collected. Univariate analyses were carried out using Kaplan–Meier survival curves to assess the association of potential prognostic factors with the primary endpoints of overall survival (OS) rates and locoregional recurrence rates. Multivariate analyses were carried out using a Cox regression method.

Results

The median total tumour volume (TTV), defined as the gross tumour volume plus the volume of involved nodes, was 103 cm3. Patients were divided into small and large tumour groups based on this median. OS rates at 1, 3 and 5 years for smaller volumes were 69%, 24% and 13% and for larger volumes 48%, 14% and 8%, respectively. On univariate survival analyses larger TTV was significantly associated with poorer OS (p= 0·019). The concurrent use of chemotherapy significantly improved survival (p= 0·026). Nodal involvement (p= 0·03) and Eastern Cooperative Oncology Group performance status (p&lt; 0·001) were also significant independent prognostic factors of OS. On multivariate analysis TTV was strongly predictive of survival (p= 0·03; hazard ratio 1·702, 95% confidence interval 1·198–2·415). There was no association between nodal volume, tumour stages, overall stage, age, histology and radiation dose with any of the primary endpoints.

Conclusion

TTV is a significant prognostic factor in patients with advanced NSCLC treated by radical radiotherapy. In this cohort of patients TTV is more reliable at predicting survival than T stage and overall stage.

Greater reduction in mid-treatment FDG-PET volume may be associated with worse survival in non-small cell lung cancer

BACKGROUND AND PURPOSE

This study tested the hypotheses that 1) changes in mid-treatment fluorodeoxyglucose (FDG)-positron emission tomography (PET) parameters are predictive of overall survival (OS) and 2) mid-treatment FDG-PET-adapted treatment has the potential to improve survival in patients with non-small cell lung cancer (NSCLC).

MATERIAL AND METHODS

Patients with stage I-III NSCLC requiring daily fractionated radiation were eligible. FDG-PET-CT scans were obtained prior to and mid-treatment with radiotherapy at 40-50 Gy. The normalized maximum standardized uptake value (NSUVmax), normalized mean SUV (NSUVmean), PET-metabolic tumor volume (MTV), total lesion glycolysis (TLG), and computed tomography-based gross tumor volume (CT-GTV) were consistently measured for all patients. The primary study endpoint was OS.

RESULTS

The study is comprised of 102 patients who received 3-dimensional conformal radiotherapy, among whom 30 patients who received mid-treatment PET-adapted dose escalation radiotherapy. All PET-CT parameters decreased significantly (P < 0.001) mid-treatment, with greater reductions in FDG-volumetric parameters compared to FDG-activity factors. Mid-treatment changes in MTV (P = 0.053) and TLG (P = 0.021) were associated with OS, while changes in NSUVmax, NSUVmean, and CT-GTV were not (all Ps>0.1). Patients receiving conventional radiation (60-70 Gy) with MTV reductions greater than the mean had a median survival of 14 months, compared to those with MTV reductions less than the mean who had a median survival of 22 months. By contrast, patients receiving mid-treatment PET-adapted radiation with MTV reductions greater than the mean had a median survival of 33 months, compared to those with MTV reductions less than the mean who had a median survival of 19 months. Overall, PET-adapted treatment resulted in a 19% better 5-year survival than conventional radiation.

CONCLUSION

Changes in mid-treatment PET-volumetric parameters were significantly associated with survival in NSCLC. A greater reduction in the mid-treatment MTV was associated with worse survival in patients treated with standard radiation, but with better survival in patients who received mid-treatment PET-adapted treatment.

A retrospective study of shrinking field radiation therapy during chemoradiotherapy in stage III non-small cell lung cancer

Background

and purpose: This retrospective study aimed to investigate the feasibility of shrinking field radiotherapy during chemoradiotherapy in non-small cell lung cancer (NSCLC).

Patients and methods

Ninety-seven patients with stage III NSCLC who achieved a good response to chemoradiation were analyzed. Computed tomography was performed after 40-50 Gy dose radiation to evaluate curative effect. Patients in the shrinking field group underwent resimulation CT scans and shrinking field radiotherapy. Acute symptomatic irradiation-induced pneumonia (ASIP), progression patterns and survival were assessed.

Results

Of the 97 patients who achieved response after a median total dose of 60 Gy, fifty patients received shrinking field radiotherapy. The incidence of acute symptomatic irradiation-induced pneumonia tended to be lower for the shrinking field group (18.0% vs. 23.4%, P = 0.51). The rate of disease progression was significantly higher in the non-shrinking than shrinking field group (95.7% vs. 66.0%, P < 0.001). Compared to the non-shrinking field group, the shrinking field group had similar overall survival (30.0 vs. 30.0 months, P = 0.58) but significantly better median progression-free survival (14.0 vs. 11.0 months, P = 0.006).

Conclusions

Shrinking field radiotherapy during chemoradiotherapy in stage III non-small cell lung cancer seems safe with acceptable toxicities and relapse, and potentially spares normal tissues and enables dose escalation. Prospective trials are warranted.