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Zhang Q, Fan S, Xu X, Du S, Zhu G, Jiang C, Xia SA, Li Q, Wang Q, Qian D, Zhang M, Xiao H, Chen G, Zeng Z, He J. Efficacy and Toxicity of Moderately Hypofractionated Radiation Therapy with Helical TomoTherapy Versus Conventional Radiation Therapy in Patients with Unresectable Stage III Non-Small Cell Lung Cancer Receiving Concurrent Chemotherapy: A Multicenter, Randomized Phase 3 Trial. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00450-4. [PMID: 38631536 DOI: 10.1016/j.ijrobp.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 03/08/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE The standard treatment schedule for unresectable stage III non-small cell lung cancer (NSCLC) is chemotherapy with concurrent radiation therapy (60 Gy delivered in 30 fractions), although moderately hypofractionated radiation therapy (Hypo-RT) has also been considered as an alternative strategy. This study aimed to compare the efficacy and toxicity of moderately Hypo-RT with helical TomoTherapy versus conventionally fractionated radiation therapy (Con-RT) in patients with unresectable stage III NSCLC receiving concurrent chemotherapy. METHODS AND MATERIALS In this randomized, multicenter, nonblinded phase 3 clinical trial, eligible patients were randomised at a 1:1 ratio to either the Hypo-RT group (60 Gy in 20 fractions) or Con-RT group (60 Gy in 30 fractions). All patients received 2 cycles of concurrent platinum-based chemotherapy plus 2 cycles of consolidation therapy. The primary endpoint was 3-year overall survival (OS) in the intention-to-treat population. The secondary endpoints were progression-free survival and treatment-related adverse events. RESULTS A total of 146 patients were enrolled from July 27, 2018, to November 1, 2021. The median follow-up was 46 months. The 3-year OS rates in the Hypo-RT and Con-RT groups were 58.4% and 38.4%, respectively (P = .02). The median OS from randomisation was 41 months in the Hypo-RT group and 30 months in the Con-RT group (hazard ratio, 0.61; 95% confidence interval, 0.40-0.94; P = .02). There was no significant difference in the rates of grade ≥2 treatment-related adverse events between the 2 groups. CONCLUSIONS Moderately Hypo-RT using helical TomoTherapy may improve OS in patients with unresectable stage III NSCLC, while maintaining toxicity rates.
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Affiliation(s)
- Qi Zhang
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shaonan Fan
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaohong Xu
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shisuo Du
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guangying Zhu
- Department of Radiation Oncology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Chaoyang Jiang
- Department of Oncology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Shi-An Xia
- Department of Oncology, Xinhua Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qiwen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qifeng Wang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Dong Qian
- Department of Radiation Oncology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Ming Zhang
- Department of Radiation Oncology, Yunnan Cancer Hospital & the Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Han Xiao
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Gang Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Jian He
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
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Zhou R, Qiu B, Xiong M, Liu Y, Peng K, Luo Y, Wang D, Liu F, Chen N, Guo J, Zhang J, Huang X, Rong Y, Liu H. Hypofractionated Radiotherapy followed by Hypofractionated Boost with weekly concurrent chemotherapy for Unresectable Stage III Non-Small Cell Lung Cancer: Results of A Prospective Phase II Study (GASTO-1049). Int J Radiat Oncol Biol Phys 2023; 117:387-399. [PMID: 37100160 DOI: 10.1016/j.ijrobp.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 03/31/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE We launched a prospective phase 2 clinical trial to explore the safety and efficacy of hypofractionated radiation therapy (hypo-RT) followed by hypofractionated boost (hypo-boost) combined with concurrent weekly chemotherapy in patients with unresectable locally advanced non-small cell lung cancer (LA-NSCLC). METHODS AND MATERIALS Patients with newly diagnosed LA-NSCLC with unresectable stage III disease were recruited between June 2018 and June 2020. Patients were treated with hypo-RT (40 Gy in 10 fractions) followed by hypo-boost (24-28 Gy in 6-7 fractions) combined with concurrent weekly chemotherapy (docetaxel 25 mg/m2 and nedaplatin 25 mg/m2). The primary endpoint of the study was progression-free survival (PFS), and the secondary endpoints included overall survival (OS), locoregional failure-free survival (LRFS), distant metastasis-free survival (DMFS), objective response rate (ORR), and toxicities. RESULTS From June 2018 to June 2020, 75 patients were enrolled with a median follow-up duration of 28.0 months. The ORR of the whole cohort was 94.7%. Disease progression or death was recorded in 44 (58.7%) patients, with a median PFS of 21.6 months (95% confidence interval [CI], 15.6-27.6 months). The 1- and 2-year PFS rates were 81.3% (95% CI, 72.5%-90.1%) and 43.3% (95% CI, 31.5%-55.1%), respectively. The median OS, DMFS, and LRFS had not been reached at the time of the last follow-up. The 1- and 2-year OS rates were 94.7% (95% CI, 89.6%-99.8%) and 72.4% (95% CI, 62.0%-82.8%), respectively. The most frequent acute nonhematologic toxicity was radiation esophagitis. Grade (G) 2 and G3 acute radiation esophagitis were observed in 20 (26.7%) and 4 (5.3%) patients, respectively. Thirteen patients (13/75, 17.3%) had G2 pneumonitis and no G3-G5 acute pneumonitis occurred during follow-up. CONCLUSIONS Hypo-RT followed by hypo-boost combined with concurrent weekly chemotherapy could yield satisfactory local control and survival outcomes with moderate radiation-induced toxicity in patients with LA-NSCLC. The new potent hypo-CCRT regimen significantly shortened treatment time and provided the potential opportunity for the combination of consolidative immunotherapy.
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Affiliation(s)
- Rui Zhou
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Bo Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Mai Xiong
- Department of Cardiac Surgery, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - YiMei Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - KangQiang Peng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Department of Medical Imaging, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - YiFeng Luo
- Pulmonary and Critical Care Medicine, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - DaQuan Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - FangJie Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - NaiBin Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - JinYu Guo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Jun Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - XiaoYan Huang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - YuMing Rong
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Department of VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Hui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangzhou, China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China.
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Huo L, Chu C, Jiang X, Zheng S, Zhang P, Zhou R, Chen N, Guo J, Qiu B, Liu H. A pilot trial of consolidation bevacizumab after hypo-fractionated concurrent chemoradiotherapy in patients with unresectable locally advanced non-squamous non-small-cell lung cancer. Cancer Med 2023; 12:17638-17647. [PMID: 37537968 PMCID: PMC10523965 DOI: 10.1002/cam4.6381] [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: 04/20/2023] [Revised: 07/10/2023] [Accepted: 07/16/2023] [Indexed: 08/05/2023] Open
Abstract
PURPOSE To determine the feasibility of incorporating bevacizumab consolidation into hypo-fractionated concurrent chemoradiotherapy (hypo-CCRT) for patients with unresectable locally advanced non-squamous non-small-cell lung cancer (LA-NS-NSCLC). PATIENTS AND METHODS Eligible patients were treated with hypo-RT (40Gy in 10 fractions) followed by hypo-boost (24-28Gy in 6-7 fractions), along with concurrent weekly chemotherapy. Patients who completed the hypo-CCRT without experiencing ≥G2 toxicities received consolidation bevacizumab every 3 weeks for up to 1 year, until disease progression or unacceptable treatment-related toxicities. The primary endpoint was the risk of G4 or higher hemorrhage. Secondary endpoints included progression-free survival (PFS), overall survival (OS), locoregional failure-free survival (LRFS), distant metastasis-free survival (DMFS), and objective response rate (ORR). All time-to-event endpoints (OS, PFS, LRFS, and DMFS) were measured from the start of radiotherapy. RESULTS Between December 2017 and July 2020, a total of 27 patients were included in the analysis, with a median follow-up duration of 28.0 months. One patient (3.7%) developed G5 hemorrhage during bevacizumab consolidation. Additionally, seven patients (25.9%) had G3 cough and three patients (11.1%) experienced G3 pneumonitis. The ORR for the entire cohort was 92.6%. The median OS was 37.0 months (95% confidence interval, 8.9-65.1 months), the median PFS was 16.0 months (95% confidence interval, 14.0-18.0 months), the median LRFS was not reached, and the median DMFS was 18.0 months. CONCLUSIONS This pilot study met its goal of demonstrating the tolerability of consolidation bevacizumab after hypo-CCRT. Further investigation of antiangiogenic and immunotherapy combinations in LA-NSCLC is warranted, while the potential for grade 3 respiratory toxicities should be taken into consideration.
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Affiliation(s)
- LanQing Huo
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - Chu Chu
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - XiaoBo Jiang
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - ShiYang Zheng
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - PengXin Zhang
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - Rui Zhou
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - NaiBin Chen
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - JinYu Guo
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
| | - Bo Qiu
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
- Lung Cancer Institute of Sun Yat‐sen UniversityGuangzhouChina
- Guangdong Association Study of Thoracic OncologyGuangzhouChina
| | - Hui Liu
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouChina
- State Key Laboratory of Oncology in South ChinaSun Yat‐sen University Cancer CenterGuangzhouChina
- Collaborative Innovation Center for Cancer MedicineSun Yat‐sen University Cancer CenterGuangzhouChina
- Lung Cancer Institute of Sun Yat‐sen UniversityGuangzhouChina
- Guangdong Association Study of Thoracic OncologyGuangzhouChina
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Jia Z, Fang F, Cao Y, Zhu X, Yang X, Guo X, Zhang H. Efficacy and toxicity of stereotactic body radiotherapy for un-resectable stage III non-small cell lung cancer patients unfit for concurrent chemoradiation therapy: a retrospective study. Radiat Oncol 2023; 18:140. [PMID: 37620952 PMCID: PMC10463766 DOI: 10.1186/s13014-023-02333-1] [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: 05/04/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND In this study, we evaluated the efficacy and toxicity of stereotactic body radiotherapy (SBRT) as replacement strategy of conventionally fractionated radiation therapy in stage III non-small cell lung cancer (NSCLC) patients unfit for concurrent chemoradiation therapy (CRT). METHODS We analyzed the clinical outcomes in patients with unresectable stage III NSCLC who received SBRT from January 1, 2013 to December 31, 2018. Both induction and consolidation chemotherapy were allowed. The survival rates and toxicities were calculated using the Kaplan-Meier method, and potential risk factors were investigated by multivariate Cox regression. RESULTS A total of 213 consecutive patients who had received SBRT were enrolled. The median overall survival (OS) and progression-free survival (PFS) were 36.5 months and 16.1 months respectively. The estimated 1-, 2- and 3-year OS rates were 90.6%, 73.7% and 52.0%, respectively and the corresponding PFS rates were 69.5%, 25.4% and 15.0%, respectively. Treatment failures were largely (n = 151, 70.9%) distant metastases, with low rates of local (n = 74, 34.74%) and regional (n = 76, 35.68%) recurrences. In 13.1% patients (n = 28), ≥ grade (G) 3 toxicities were identified, including radiation pneumonia (n = 20, 9.4%) and bronchopulmonary hemorrhage (n = 8, 3.8%). None of the patients suffered from ≥ G 3 late toxic effects. Compared with patients with peripheral tumors, patients with central tumors had lower median OS (P<0.001) and the biological effective dose (BED) was not a predictor for OS. CONCLUSIONS SBRT combined with chemotherapy for stage III NSCLC produced favorable treatment outcomes with acceptable toxicity. For patients with central tumors, an appropriate BED reduction can be considered. Further studies are warranted. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Zhen Jia
- Department of Radiation Oncology, Shanghai Changhai Hospital Affiliated to Navy Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Fang Fang
- Department of Radiation Oncology, Shanghai Changhai Hospital Affiliated to Navy Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Yangsen Cao
- Department of Radiation Oncology, Shanghai Changhai Hospital Affiliated to Navy Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xiaofei Zhu
- Department of Radiation Oncology, Shanghai Changhai Hospital Affiliated to Navy Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - XiaoYu Yang
- Department of hepatic surgery, Shanghai Eastern Hepatobiliary Surgery Hospital, 255 Changhai Road, Shanghai, 200433, China
| | - Xueling Guo
- Department of Radiation Oncology, Shanghai Changhai Hospital Affiliated to Navy Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Huojun Zhang
- Department of Radiation Oncology, Shanghai Changhai Hospital Affiliated to Navy Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Arcidiacono F, Anselmo P, Casale M, Trippa F. 18F-FDG-PET guided vs whole tumour radiotherapy dose escalation in patients with locally advanced non-small cell lung cancer (PET-Boost): Results from a randomised clinical trial: Should dose intensification be discontinued or should accelerated schemes remain an important area of clinical research? Radiother Oncol 2023; 185:109688. [PMID: 37164107 DOI: 10.1016/j.radonc.2023.109688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/26/2023] [Accepted: 04/24/2023] [Indexed: 05/12/2023]
Affiliation(s)
| | - Paola Anselmo
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy.
| | | | - Fabio Trippa
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
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6
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Chen Y, Luo H, Liu R, Tan M, Wang Q, Wu X, Du T, Liu Z, Sun S, Zhang Q, Wang X. Efficacy and safety of particle therapy for inoperable stage II-III non-small cell lung cancer: a systematic review and meta-analysis. Radiat Oncol 2023; 18:86. [PMID: 37217970 DOI: 10.1186/s13014-023-02264-x] [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: 03/21/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND AND PURPOSE Particle therapy, mainly including carbon-ion radiotherapy (CIRT) and proton beam therapy (PBT), has dose distribution advantages compared to photon radiotherapy. It has been widely reported as a promising treatment method for early non-small cell lung cancer (NSCLC). However, its application in locally advanced non-small cell lung cancer (LA-NSCLC) is relatively rare, and its efficacy and safety are inconclusive. This study aimed to provide systematic evidence for evaluating the efficacy and safety of particle therapy for inoperable LA-NSCLC. METHODS To retrieve published literature, a systematic search was conducted in PubMed, Web of Science, Embase, and Cochrane Library until September 4, 2022. The primary endpoints were local control (LC) rate, overall survival (OS) rate, and progression-free survival (PFS) rate at 2 and 5 years. The secondary endpoint was treatment-related toxicity. The pooled clinical outcomes and 95% confidence intervals (CIs) were calculated by using STATA 15.1. RESULTS Nineteen eligible studies with a total sample size of 851 patients were included. The pooled data demonstrated that the OS, PFS, and LC rates at 2 years of LA-NSCLC treated by particle therapy were 61.3% (95% CI = 54.7-68.7%), 37.9% (95% CI = 33.8-42.6%) and 82.2% (95% CI = 78.7-85.9%), respectively. The pooled 5-year OS, PFS, and LC rates were 41.3% (95% CI = 27.1-63.1%), 25.3% (95% CI = 16.3-39.4%), and 61.5% (95% CI = 50.7-74.6%), respectively. Subgroup analysis stratified by treatment type showed that the concurrent chemoradiotherapy (CCRT, PBT combined with concurrent chemotherapy) group had better survival benefits than the PBT and CIRT groups. The incidence rates of grade 3/4 esophagitis, dermatitis, and pneumonia in LA-NSCLC patients after particle therapy were 2.6% (95% CI = 0.4-6.0%), 2.6% (95% CI = 0.5-5.7%) and 3.4% (95% CI = 1.4-6.0%), respectively. CONCLUSIONS Particle therapy demonstrated promising efficacy and acceptable toxicity in LA-NSCLC patients.
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Affiliation(s)
- Yanliang Chen
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Hongtao Luo
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Ruifeng Liu
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Mingyu Tan
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Qian Wang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Xun Wu
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Tianqi Du
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Zhiqiang Liu
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Shilong Sun
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China
| | - Qiuning Zhang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China.
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China.
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China.
| | - Xiaohu Wang
- Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, 730000, Gansu Province, China.
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China.
- Department of Postgraduate, University of Chinese Academy of Sciences, Beijing, China.
- Heavy Ion Therapy Center, Lanzhou Heavy Ions Hospital, Lanzhou, China.
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7
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Arcidiacono F, Anselmo P, Casale M, Zannori C, Ragusa M, Mancioli F, Marchetti G, Loreti F, Italiani M, Bracarda S, Maranzano E, Trippa F. STereotactic Ablative RadioTherapy in NEWly Diagnosed and Recurrent Locally Advanced Non-Small Cell Lung Cancer Patients Unfit for ConcurrEnt RAdio-Chemotherapy: Early Analysis of the START-NEW-ERA Non-Randomised Phase II Trial. Int J Radiat Oncol Biol Phys 2023; 115:886-896. [PMID: 36288758 DOI: 10.1016/j.ijrobp.2022.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/06/2022] [Accepted: 10/13/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE This is a single arm phase 2 trial (Clinical trials.gov NCT05291780) to assess local control (LC) and safety of SAbR in patients with unresectable locally advanced non-small cell lung cancer (LA-NSCLC) unfit for concurrent chemo-radiation therapy (ChT-RT). METHODS Neoadjuvant ChT was prescribed in fit patients. The tumor volume included primary tumor and any regionally positive node/s. The coprimary study endpoints were LC and safety. RESULTS Between December 31, 2015, and December 31, 2020, 50 patients with LA-NSCLC were enrolled. Histology was squamous cell carcinoma and adenocarcinoma (ADC) in 52% and 48%, respectively. Forty (80%) patients had ultracentral tumor. Twenty-seven (54%) received neoadjuvant ChT and 7 (14%) adjuvant durvalumab. Median prescribed dose was 45 Gy (range, 35-55) and 40 Gy (35-45) in 5 daily fractions to tumor and node/s, respectively. After a median follow-up of 38 months (range, 12-80), 19 (38%) patients had experienced local recurrence (LR) at a median time of 13 months (range, 7-34). The median LR-free survival (FS) was not reached (95% confidence interval [CI], 28 to not reached). The 1-, 2-, and 3-year LR-FS rates were 86% ± 5%, 66% ± 7%, and 56% ± 8%, respectively. At last follow-up, 33 (66%) patients were alive. Median overall survival (OS) was 55 months (95% CI, 43-55 months). The 1-, 2-, and 3-year OS rates were 94% ± 3%, 79% ± 6%, and 72% ± 7%, respectively. No patients developed ≥ grade (G) 3 toxicity. ADC (hazard ratio [HR], 3.61; 95% CI, 1.15-11.35) was a significant predictor of better LC, while OS was significantly conditioned by smaller planning target volumes (HR, 1.004; 95% CI, 1.001-1.010) and tumor, node, and metastasis stage (HR, 4.8; 95% CI, 1.34-17). CONCLUSIONS Patients with LA-NSCLC treated with SABR had optimal LC and promising OS in absence of ≥G3 toxicity. Our early outcomes would suggest the feasibility of using this approach in patients with LA-NSCLC unfit for concurrent ChT-RT.
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Affiliation(s)
| | | | | | | | | | | | | | - Fabio Loreti
- Nuclear Medicine Service, "S. Maria" Hospital, Terni, Italy
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8
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Massaro M, Franceschini D, Spoto R, Dominici L, Franzese C, Baldaccini D, Marini B, di Cristina L, Marzo MA, lo Faro L, Paganini L, Reggiori G, Galdieri C, Testori A, Scorsetti M. Locally Advanced Non-Small Cell Lung Cancer: Clinical Outcome, Toxicity and Predictive Factors in Patients Treated with Hypofractionated Sequential or Exclusive Radiotherapy. Curr Oncol 2022; 29:4893-4901. [PMID: 35877248 PMCID: PMC9325151 DOI: 10.3390/curroncol29070388] [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: 05/20/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This study evaluated the outcome, toxicity and predictive factors in patients unfit for concurrent chemo-radiotherapy (CT-RT) treated with hypofractionated sequential CT-RT or exclusive radiotherapy (RT) for locally advanced non-small cell lung cancer (LA-NSCLC). Methods: We included patients affected by LA-NSCLC (stage IIA-IVA) treated with a total dose of 50–60 Gy in 20 fractions. The primary outcomes were local control (LC), distant metastasis-free survival (DMFS), progression-free survival (PFS) and overall survival (OS). Univariate analysis was used to correlate outcomes with prognostic factors. Results: Between 2011 and 2019, 210 patients were treated, 113 (53.8%) with sequential CT-RT and 97 (46.2%) with exclusive RT. After a median follow-up of 15.3 months, 74 patients (35.2%) had a local progression and 133 (63.3%) had a distant progression. The one-, two- and five-year LC were 73.6%, 55.3% and 47.9%, respectively. At the time of analysis, 167 patients (79.5%) died. The one-, two- and five-year OS were 64.7%, 36% and 20%, respectively. PTV volume correlated with PFS (p = 0.001) and LC (p = 0.005). Acute and late toxicity occurred in 82% and 26% of patients. Conclusions: Albeit with the known limitations of a retrospective and heterogeneous study, our work shows that hypofractionated sequential CT-RT or exclusive RT offer a good local control and toxicity profile and a promising survival rate in LA-NSCLC patients unfit for the concurrent CT-RT scheme.
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Affiliation(s)
- Maria Massaro
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
- Correspondence:
| | - Ruggero Spoto
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
| | - Luca Dominici
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
| | - Ciro Franzese
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Davide Baldaccini
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
| | - Beatrice Marini
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Luciana di Cristina
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Marco A. Marzo
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Lorenzo lo Faro
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
| | - Lucia Paganini
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
| | - Giacomo Reggiori
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
| | - Carmela Galdieri
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
| | - Alberto Testori
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (M.M.); (R.S.); (L.D.); (C.F.); (D.B.); (B.M.); (L.d.C.); (M.A.M.); (L.l.F.); (L.P.); (G.R.); (C.G.); (M.S.)
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy
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Wass R, Hochmair M, Kaiser B, Grambozov B, Feurstein P, Weiß G, Moosbrugger R, Sedlmayer F, Lamprecht B, Studnicka M, Zehentmayr F. Durvalumab after Sequential High Dose Chemoradiotherapy versus Standard of Care (SoC) for Stage III NSCLC: A Bi-Centric Trospective Comparison Focusing on Pulmonary Toxicity. Cancers (Basel) 2022; 14:3226. [PMID: 35804997 PMCID: PMC9265119 DOI: 10.3390/cancers14133226] [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: 05/25/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 01/09/2023] Open
Abstract
Introduction: The standard of care (SoC) for unresectable stage III non-small-cell lung cancer (NSCLC) is durvalumab maintenance therapy after concurrent chemoradiation in patients with PD-L1 > 1%. However, the concurrent approach is only amenable for about one-third of patients due to co-morbidities. Although sequential regimens are usually not regarded as curative, these schedules applied in a dose-escalated manner may be similarly radical as SoC. As combining high-dose radiation and durvalumab remains a question of debate this retrospective bi-center study aims to evaluate pulmonary toxicity after high-dose chemoradiotherapy beyond 70 Gy compared to SoC. Patients and Methods: Patients with NSCLC stage III received durvalumab after either sequential high-dose chemoradiation or concomitant SoC. Chemotherapy consisted of platinum combined with either pemetrexed, taxotere, vinorelbine, or gemcitabine. The primary endpoint was short-term pulmonary toxicity occurring within six months after the end of radiotherapy (RT). Results: A total of 78 patients were eligible for this analysis. 18F-FDG-PET-CT, cranial MRT, and histological/cytological verification were mandatory in the diagnostic work-up. The high-dose and SoC group included 42/78 (53.8%) and 36/78 (46.2%) patients, respectively, which were matched according to baseline clinical variables. While the interval between the end of RT and the start of durvalumab was equal in both groups (p = 0.841), more courses were administered in the high-dose cohort (p = 0.031). Pulmonary toxicity was similar in both groups (p = 0.599), whereas intrathoracic disease control was better in the high-dose group (local control p = 0.081, regional control p = 0.184). Conclusion: The data of this hypothesis-generating study suggest that sequential high-dose chemoradiation followed by durvalumab might be similar to SoC in terms of pulmonary toxicity and potentially more effective with respect to intra-thoracic disease control. Larger trials with a prospective design are warranted to validate these results.
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Affiliation(s)
- Romana Wass
- Department of Pulmonology, Paracelsus Medical University, A-5020 Salzburg, Austria; (R.W.); (G.W.); (R.M.); (M.S.)
- Department of Pulmonology, Kepler University Hospital, A-4020 Linz, Austria; (B.K.); (B.L.)
| | - Maximilian Hochmair
- Department of Respiratory and Critical Care Medicine, Karl Landsteiner Institute of Lung Cancer Research and Pulmonary Oncology, Klinik Floridsdorf, A-1210 Vienna, Austria;
| | - Bernhard Kaiser
- Department of Pulmonology, Kepler University Hospital, A-4020 Linz, Austria; (B.K.); (B.L.)
| | - Brane Grambozov
- Department of Radiation Oncology, Paracelsus Medical University, A-5020 Salzburg, Austria; (B.G.); (F.S.)
| | - Petra Feurstein
- Department of Radiation Oncology, Klinik Ottakring, A-1160 Vienna, Austria;
| | - Gertraud Weiß
- Department of Pulmonology, Paracelsus Medical University, A-5020 Salzburg, Austria; (R.W.); (G.W.); (R.M.); (M.S.)
| | - Raphaela Moosbrugger
- Department of Pulmonology, Paracelsus Medical University, A-5020 Salzburg, Austria; (R.W.); (G.W.); (R.M.); (M.S.)
| | - Felix Sedlmayer
- Department of Radiation Oncology, Paracelsus Medical University, A-5020 Salzburg, Austria; (B.G.); (F.S.)
- radART—Institute for Research and Development on Advanced Radiation Technologies, Paracelsus Medical University, A-5020 Salzburg, Austria
| | - Bernd Lamprecht
- Department of Pulmonology, Kepler University Hospital, A-4020 Linz, Austria; (B.K.); (B.L.)
| | - Michael Studnicka
- Department of Pulmonology, Paracelsus Medical University, A-5020 Salzburg, Austria; (R.W.); (G.W.); (R.M.); (M.S.)
| | - Franz Zehentmayr
- Department of Radiation Oncology, Paracelsus Medical University, A-5020 Salzburg, Austria; (B.G.); (F.S.)
- radART—Institute for Research and Development on Advanced Radiation Technologies, Paracelsus Medical University, A-5020 Salzburg, Austria
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10
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Rodríguez De Dios N, Navarro-Martin A, Cigarral C, Chicas-Sett R, García R, Garcia V, Gonzalez JA, Gonzalo S, Murcia-Mejía M, Robaina R, Sotoca A, Vallejo C, Valtueña G, Couñago F. GOECP/SEOR radiotheraphy guidelines for non-small-cell lung cancer. World J Clin Oncol 2022; 13:237-266. [PMID: 35582651 PMCID: PMC9052073 DOI: 10.5306/wjco.v13.i4.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/27/2021] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is a heterogeneous disease accounting for approximately 85% of all lung cancers. Only 17% of patients are diagnosed at an early stage. Treatment is multidisciplinary and radiotherapy plays a key role in all stages of the disease. More than 50% of patients with NSCLC are treated with radiotherapy (curative-intent or palliative). Technological advances-including highly conformal radiotherapy techniques, new immobilization and respiratory control systems, and precision image verification systems-allow clinicians to individualize treatment to maximize tumor control while minimizing treatment-related toxicity. Novel therapeutic regimens such as moderate hypofractionation and advanced techniques such as stereotactic body radiotherapy (SBRT) have reduced the number of radiotherapy sessions. The integration of SBRT into routine clinical practice has radically altered treatment of early-stage disease. SBRT also plays an increasingly important role in oligometastatic disease. The aim of the present guidelines is to review the role of radiotherapy in the treatment of localized, locally-advanced, and metastatic NSCLC. We review the main radiotherapy techniques and clarify the role of radiotherapy in routine clinical practice. These guidelines are based on the best available evidence. The level and grade of evidence supporting each recommendation is provided.
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Affiliation(s)
- Núria Rodríguez De Dios
- Department of Radiation Oncology, Hospital del Mar, Barcelona 08003, Spain
- Radiation Oncology Research Group, Hospital Del Mar Medical Research Institution, Barcelona 08003, Spain
- Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona 08003, Spain
| | - Arturo Navarro-Martin
- Department of Radiation Oncology, Thoracic Malignancies Unit, Hospital Duran i Reynals. ICO, L´Hospitalet de L, Lobregat 08908, Spain
| | - Cristina Cigarral
- Department of Radiation Oncology, Hospital Clínico de Salamanca, Salamanca 37007, Spain
| | - Rodolfo Chicas-Sett
- Department of Radiation Oncology, ASCIRES Grupo Biomédico, Valencia 46004, Spain
| | - Rafael García
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Virginia Garcia
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | | | - Susana Gonzalo
- Department of Radiation Oncology, Hospital Universitario La Princesa, Madrid 28006, Spain
| | - Mauricio Murcia-Mejía
- Department of Radiation Oncology, Hospital Universitario Sant Joan de Reus, Reus 43204, Tarragona, Spain
| | - Rogelio Robaina
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | - Amalia Sotoca
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Carmen Vallejo
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - German Valtueña
- Department of Radiation Oncology, Hospital Clínico Universitario Lozano Blesa, Zaragoza 50009, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid 28223, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Department of Clinical, Universidad Europea, Madrid 28670, Spain
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11
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Hoppe BS, Nichols RC, Flampouri S, Pankuch M, Morris CG, Pham DC, Mohindra P, Hartsell WF, Mohammed N, Chon BH, Kestin LL, Simone CB. Chemoradiation with Hypofractionated Proton Therapy in Stage II-III Non-Small Cell Lung Cancer: A YYY Phase 1/2 Trial. Int J Radiat Oncol Biol Phys 2022; 113:732-741. [PMID: 35306151 DOI: 10.1016/j.ijrobp.2022.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hypofractionated radiotherapy has been safely implemented into the treatment of early-stage non-small cell lung cancer (NSCLC), but not locally advanced (LA-) NSCLC due to prohibitive toxicities with photon therapy. Proton therapy, however, may allow for safe delivery of hypofractionated radiotherapy. We sought to determine whether hypofractionated proton therapy with concurrent chemotherapy improves overall survival. METHODS & MATERIALS The YYY conducted a phase 1/2 single-arm nonrandomized prospective multicenter trial from 2013 through 2018. Thirty-two patients were consented; 28 were eligible for on-study treatment. Patients had AJCCv7 stage II or III unresectable NSCLC and received hypofractionated proton therapy at 2.5-4 Gy per fraction to a total 60 Gy with concurrent platin-based doublet chemotherapy. The primary outcome was 1-year overall survival comparable to that reported for RTOG 9410 of 62%. RESULTS The trial closed early due to slow accrual, in part, from a competing trial, NRG 1308. Median patient age was 70 (range, 50-86) years. Patients were predominantly male (N=20), white (N=23), and prior smokers (N=27). Most had stage III NSCLC (N=22), 50% of whom had adenocarcinoma. After a median follow-up of 31 months, the 1- and 3-year overall survival rates were 89% and 49%, and progression-free survival rates were 58% and 32%, respectively. No acute grade 3 or higher esophagitis occurred. Only 14% developed a grade 3 or higher radiation-related pulmonary toxicity. CONCLUSION Hypofractionated proton therapy delivered at 2.5-3.53 Gy per fraction to a total 60 Gy with concurrent chemotherapy provides promising survival and additional examination through larger studies may be warranted.
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Affiliation(s)
- Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida.
| | - Romaine C Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Mark Pankuch
- Northwestern Medicine Proton Center, Warrenville, Illinois
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Dat C Pham
- Baptist MD Anderson Cancer Center, Jacksonville, Florida
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | | | | | - Brian H Chon
- ProCure Proton Therapy Center, Somerset, New Jersey
| | - Larry L Kestin
- MHP Radiation Oncology Institute/GenesisCare USA, Farmington Hills, Michigan
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center and New York Proton Center, New York, New York
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Contreras J, Srivastava A, Samson P, DeWees T, Govindan R, Baggstrom MQ, Morgensztern D, Roach M, Badiyan SN, Bradley J, Waqar S, Robinson C. Phase I Study of Accelerated Hypofractionated Proton Therapy and Chemotherapy for Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2022; 113:742-748. [PMID: 35074432 DOI: 10.1016/j.ijrobp.2022.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/28/2021] [Accepted: 01/11/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the maximum tolerated dose (MTD) of hypofractionated proton beam radiation therapy (PBT) with concurrent weekly carboplatin/paclitaxel in patients with stage II-III non-small cell lung cancer (NSCLC). MATERIALS/METHODS A phase I trial was designed using the Time to Event-Continuous Reassessment Method (TITE-CRM). MTD was defined as the dose associated with a 20% probability of CTCAE protocol-specified serious adverse events (SAEs). Starting dose was 3.5 Gy/fx for 15 fractions with 2 potential escalation and de-escalation levels in 0.25 Gy/fx increments. Chemotherapy was weekly concurrent carboplatin/paclitaxel with 2 cycles of optional consolidation carboplatin/paclitaxel. RESULTS From 5/2015-9/2016, 23 patients enrolled at a single institution. Of 20 evaluable, median age was 66.5 years (range, 54-89) and 12 (60%) were male. Fourteen had squamous cell (70%), and 15 (75%) were stage IIIA. Nineteen (95%) completed all 3 cycles of concurrent chemotherapy, and 16 (80%) received at least one cycle of consolidation chemotherapy. Within the 6-month TITE-CRM assessment window, no SAEs were reported, and most patients were treated at the highest dose-level. Dose-level assignment was 52.5 Gy (n=2), 56.25 Gy (n=4), and 60 Gy (n=14). The posterior probability of dose limiting toxicity (DLT) for 60 Gy was 5.3% (95% CI, 1-18.1%). Acute, non-serious AEs included grade 2 esophagitis in 7 patients (35%) and grade 2 pneumonitis in 1 patient (5%). At a median follow-up of 20.3 months for all and 44.9 months for living patients, there were no grade 4 or 5 AEs, though there were three (21% at 24 months) SAEs outside of the dose-escalation window. The 2-year overall survival, local, regional, and distant control rates were 48%, 84%, 77%, and 79%, respectively. CONCLUSIONS Hypofractionated PBT and chemotherapy up to 60 Gy in 15 fractions is acutely well tolerated, with high rates of locoregional control and overall survival, though late SAEs were noted.
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Affiliation(s)
| | | | - Pamela Samson
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | | | | | - Saiama Waqar
- Washington University School of Medicine, St. Louis, Missouri
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13
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Khalifa J, Lerouge D, Le Péchoux C, Pourel N, Darréon J, Mornex F, Giraud P. Radiotherapy for primary lung cancer. Cancer Radiother 2021; 26:231-243. [PMID: 34953709 DOI: 10.1016/j.canrad.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Herein are presented the recommendations from the Société française de radiothérapie oncologique regarding indications and modalities of lung cancer radiotherapy. The recommendations for delineation of the target volumes and organs at risk are detailed.
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Affiliation(s)
- J Khalifa
- Département de radiothérapie, Institut universitaire du cancer de Toulouse - Oncopole, 1, avenue Irène-Joliot-Curie, 31100 Toulouse, France.
| | - D Lerouge
- Département de radiothérapie, centre François-Baclesse, 3, avenue du General-Harris, 14076 Caen, France
| | - C Le Péchoux
- Département de radiothérapie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - N Pourel
- Département de radiothérapie, institut Sainte-Catherine, 250, chemin de Baigne-Pieds, CS80005, 84918 Avignon cedex 9, France
| | - J Darréon
- Service de physique médicale, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - F Mornex
- Service de radiothérapie, CHU Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France
| | - P Giraud
- Service d'oncologie radiothérapie, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, Paris, France; Université de Paris, 85, boulevard Saint-Germain, 75006 Paris, France
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14
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Outcomes of Image-Guided Moderately Hypofractionated Radiotherapy for Stage III Non-Small-Cell Lung Cancer. JOURNAL OF ONCOLOGY 2021; 2021:2721261. [PMID: 34887921 PMCID: PMC8651380 DOI: 10.1155/2021/2721261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/07/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022]
Abstract
Objective To evaluate the efficacy and toxicity of hypofractionated radiotherapy (hypo-RT) for stage III non-small-cell lung cancer (NSCLC) in the Chinese population. Methods Eighty-six stage III NSCLC patients who received hypo-RT (60 Gy/20 fractions, BED = 78.00 Gy: 73 patients; 62.5 Gy/25 fractions, BED = 78.13 Gy: 13 patients) were recruited. Fifty-seven patients who received conventional radiotherapy (60 Gy/30 fractions, BED = 72.00 Gy) during the same period were enrolled as the control group. All hypo-RT treatments were conducted using image-guided technology. The efficacy and toxicity of the treatment were compared between the two groups. Results The median duration of follow-up was 23.0 months (range: 4.0–82.0 months). Univariate and multivariate analyses of all 143 stage III NSCLC patients revealed that hypo-RT was an independent factor for progression-free survival (PFS) and overall survival (OS). The median PFS and OS of hypo-RT were significantly higher than in the conventional RT group (PFS: 14.30, 11.00 months, p=0.035; OS: 43.30, 31.50 months, p=0.045). The incidence rates of symptomatic radiation pneumonitis and radiation esophagitis (≥grade 2) were 17.77% and 27.91%, respectively, in the hypo-RT group. Compared to the conventional radiation therapy group (22.81% and 19.30%, respectively), no significant differences were found between the two common side effects (p=0.662 and p=0.241, respectively). Conclusion For Chinese stage III NSCLC patients, image-guided hypo-RT offers favorable prognosis, and the treatment toxicity was totally acceptable. This radiation modality deserves further prospective clinical trials.
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15
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Martel-Lafay I, Monnet I, Lardy-Cleaud A, Danhier S, Salem N, Gallocher O, Fournel P, Chouaid C, Bylicki O. Feasibility of Stereotactic Body Radiation Therapy on Unresectable Stage III NSCLC with Peripheral Primary Tumor: A Prospective Study (GFPC 01-14). Curr Oncol 2021; 28:3804-3811. [PMID: 34677242 PMCID: PMC8534340 DOI: 10.3390/curroncol28050324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 09/25/2021] [Accepted: 09/26/2021] [Indexed: 11/16/2022] Open
Abstract
Concomitant radiochemotherapy (RTCT) is the standard treatment for unresectable stage III non-small cell lung cancer (NSCLC). However, in patients with a peripheral primary tumor, the irradiated volume may include a large portion of normal lung and RT-CT is not possible. This multicenter phase II trial in unresectable stage III NSCLC with peripheral primary tumor evaluated the feasibility of stereotactic body radiation therapy (SBRT) in peripheral tumor after concomitant radio-chemotherapy (RT-CT). Nineteen patients were included and analyzed (median age, 60.9 years; male, 78%; adenocarcinoma, 74%; median size of peripheral primary tumor, 19 mm). At 6 months, the disease control rate was 79% (15/19). SBRT toxicity was generally mild with one (5%) patient having grade 3 lung toxicity. Recruitment for this study was stopped prior to completion, firstly due to the approval of adjuvant durvalumab after RT-CT, which was not anticipated in the design, and secondly due to the small number of stage III NSCLC patients with a peripheral tumor that was accessible to SBRT. Nevertheless, the combination of RT-CT and SBRT appeared to be feasible and safe.
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Affiliation(s)
| | | | - Audrey Lardy-Cleaud
- Centre Léon Bérard, Direction de la Recherche Clinique et de l′Innovation, 69008 Lyon, France;
| | | | - Naji Salem
- Institute Paoli Calmettes, 13009 Marseille, France;
| | | | | | - Christos Chouaid
- Inserm U955, UPEC, IMRB, équipe CEpiA, Créteil, CHI Créteil, 94010 Créteil, France
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16
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Socha J, Wasilewska-Teśluk E, Stando R, Kuncman L, Kepka L. Duration of acute esophageal toxicity in concomitant radio-chemotherapy for non-small cell lung cancer with different fractionation schedules. Br J Radiol 2021; 94:20210776. [PMID: 34538071 DOI: 10.1259/bjr.20210776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES In our previous prospective trial on accelerated hypofractionated concomitant radiochemotherapy (AHRT-CHT) for non-small-cell lung cancer (NSCLC), the incidence of grade ≥3 acute esophageal toxicity (AET) was similar to that reported for conventionally fractionated concomitant radiochemotherapy (CFRT-CHT), but its duration was prolonged. Thus, we aimed to compare the duration of grade ≥3 AET between AHRT-CHT and CFRT-CHT. METHODS Clinical data of 76 NSCLC patients treated with CFRT-CHT (60-66 Gy/2 Gy) during 2015-2020 were retrospectively compared with the data of 92 patients treated with AHRT-CHT (58.8 Gy/2.8 Gy) in the prospective trial. The maximum grade of AET, incidence, and duration of grade ≥3 AET were the end points. Univariate and multivariate analyses were applied to correlate clinical and treatment variables with these end points. RESULTS Neither the maximum grade of AET (p = 0.71), nor the incidence of grade ≥3 AET (p = 0.87) differed between the two groups. The number of CHT cycles delivered (2 vs 1, p = 0.005) and higher esophagus mean BED (p = 0.009) were significant predictors for a higher maximum grade of AET; older age was a significant predictor for higher incidence of grade ≥3 AET (p = 0.03). The median duration of grade ≥3 AET in AHRT-CHT and CFRT-CHT group was 30 days (range 5-150) vs 7 days (range 3-20), respectively, p = 0.0005. In multivariate analysis, only the AHRT-CHT schedule (p=0.003) was a significant predictor for a longer duration of grade ≥3 AET. CONCLUSION Despite similar incidence of grade ≥3 AET, its duration is significantly prolonged in NSCLC patients treated with AHRT-CHT compared to CFRT-CHT. ADVANCES IN KNOWLEDGE Reporting only the rate of grade ≥3 AET in clinical trials may underestimate the real extent of the esophageal toxicity; its duration should also be routinely reported.
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Affiliation(s)
- Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland.,Department of Radiotherapy, Regional Oncology Centre, Czestochowa, Poland
| | - Ewa Wasilewska-Teśluk
- Independent Public Health Care Facility of the Ministry of the Interior and Warmian & Mazurian Oncology Centre, Olsztyn, Poland.,Department of Oncology, Faculty of Medicine, University of Warmia & Mazury, Olsztyn, Poland
| | - Rafal Stando
- Department of Radiotherapy, Holy Cross Cancer Center, Kielce, Poland
| | - Lukasz Kuncman
- Department of Radiotherapy, Medical University of Lodz, Lodz, Poland
| | - Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
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17
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Farooqi A, Ludmir EB, Mitchell KG, Antonoff MB, Tang C, Lee P, Chang J, Elamin Y, Gomez DR, Gandhi SJ. Increased biologically effective dose (BED) to the primary tumor is associated with improved survival in patients with oligometastatic NSCLC. Radiother Oncol 2021; 163:114-118. [PMID: 34419505 DOI: 10.1016/j.radonc.2021.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Local consolidative therapy (LCT) for oligometastatic non-small cell lung cancer (NSCLC) is an evolving treatment paradigm. We investigated whether the biologically effective dose (BED) of consolidative radiation therapy (RT) to the primary tumor predicted for improved local control, progression-free survival (PFS), and overall survival (OS) among NSCLC patients presenting with oligometastatic disease. MATERIALS AND METHODS Patients presenting to a single institution (2000-2017) with stage IV NSCLC, ≤3 synchronous metastatic lesions at diagnosis, and treated with RT to the primary tumor were identified. Univariate and multivariable Cox proportional-hazards regression modeling were performed to identify factors associated with local recurrence-free survival (LRFS), PFS, and OS. RESULTS One hundred twenty-four patients were identified meeting our inclusion criteria. With a median follow-up of 55.1 months, median PFS and OS for the entire cohort were 11.0 months and 25.3 months, respectively. The median BED (α/β = 10) of RT to the primary tumor was 74.3 Gy. On univariate analysis, increased BED to the primary tumor predicted for improved PFS (p < 0.001) and LRFS (p = 0.01), with a median PFS of 8.5 vs 12.8 months and median LRFS of 23.4 vs 58.4 months between patients treated with BED < 75 Gy and ≥75 Gy, respectively. Increased BED to the primary tumor was also associated with significantly improved OS (p = 0.02); patients treated with a BED of <75 Gy demonstrated a median OS of 22.9 months vs 27.5 months if treated with BED ≥ 75 Gy. On multivariable analysis, primary site BED remained a significant predictor of OS (p = 0.02) and PFS (p = 0.002). CONCLUSIONS We found that delivery of >75 Gy BED RT regimens to the primary lesion in patients with synchronous oligometastatic NSCLC is associated with improved local control, PFS, and OS. These data support results of recent prospective trials and other ongoing prospective efforts to characterize therapeutic benefits associated with this management strategy.
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Affiliation(s)
- Ahsan Farooqi
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, United States.
| | - Ethan B Ludmir
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, United States
| | - Kyle G Mitchell
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, United States
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, United States
| | - Chad Tang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, United States
| | - Percy Lee
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, United States
| | - Joe Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, United States
| | - Yasir Elamin
- Department of Thoracic and Head & Neck Medical Oncology, University of Texas MD Anderson Cancer Center, United States
| | - Daniel R Gomez
- Deptartment of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, United States
| | - Saumil J Gandhi
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, United States
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Eze C, Taugner J, Schmidt-Hegemann NS, Käsmann L, Guggenberger JE, Roengvoraphoj O, Dantes M, Gjika A, Li M, Belka C, Manapov F. Feasibility of hypofractionated radiotherapy in inoperable node-positive NSCLC patients with poor prognostic factors and limited pulmonary reserve: a prospective observational study. Acta Oncol 2021; 60:1074-1078. [PMID: 34155956 DOI: 10.1080/0284186x.2021.1941244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Chukwuka Eze
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Julian Taugner
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | | | - Lukas Käsmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), Munich, Germany
- German Cancer Consortium (DKTK), Munich, Germany
| | | | - Olarn Roengvoraphoj
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maurice Dantes
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Arteda Gjika
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Minglun Li
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), Munich, Germany
- German Cancer Consortium (DKTK), Munich, Germany
| | - Farkhad Manapov
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Pneumology Center Munich (CPC-M), Munich, Germany
- German Cancer Consortium (DKTK), Munich, Germany
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19
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Parisi E, Arpa D, Ghigi G, Micheletti S, Neri E, Tontini L, Pieri M, Romeo A. Complete pathological response in locally advanced non-small-cell lung cancer patient: A case report. World J Clin Cases 2021; 9:5540-5546. [PMID: 34307607 PMCID: PMC8281427 DOI: 10.12998/wjcc.v9.i20.5540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/22/2021] [Accepted: 04/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chemotherapy and radiotherapy followed by durvalumab is currently the standard treatment for locally advanced node-positive non-small-cell lung cancer (NSCLC). We describe the case of a patient with locally advanced node-positive NSCLC (LA-NSCLC) treated in a phase II prospective protocol with chemotherapy, accelerated hypofractionated radiotherapy (AHRT) and surgery in the pre-immunotherapy era.
CASE SUMMARY A 69-year-old male, ex-smoker (20 PY), with a Karnofsky performance status of 90, was diagnosed with locally advanced squamous cell lung carcinoma. He was staged by total body computed tomography (CT) scanning, and integrated 18F-fluorodeoxyglucose positron emission tomography/CT scan [cT4 cN3 cM0, stage IIIC according to TNM (tumor-node-metastasis) 8th edition] and received AHRT between chemotherapy cycles, in accordance with the study protocol (EudractCT registration 2008-006525-14). At the end of the study the patient underwent surgery, which was not part of the protocol, and showed a complete pathological response.
CONCLUSION This case report confirms that AHRT can be used successfully to treat primary LA-NSCLC with bilateral mediastinal lymph node involvement. Our case is of particular interest because of the pathological response after AHRT and the lack of surgical complications. We hypothesize that this radiotherapeutic approach, with its proven efficacy, could be delivered as a short course reducing treatment costs, increasing patient compliance and reducing toxicity. We are currently investigating the possibility of combining hypofractionation, chemotherapy and immunotherapy for patients with LA-NSCLC.
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Affiliation(s)
- Elisabetta Parisi
- Radiotherapy Unit, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola 47014, Italy
| | - Donatella Arpa
- Radiotherapy Unit, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola 47014, Italy
| | | | - Simona Micheletti
- Radiotherapy Unit, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola 47014, Italy
| | - Elisa Neri
- Radiotherapy Unit, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola 47014, Italy
| | - Luca Tontini
- Radiotherapy Unit, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola 47014, Italy
| | - Martina Pieri
- Radiotherapy Unit, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola 47014, Italy
| | - Antonino Romeo
- Radiotherapy Unit, IRCCS Istituto Scientifico Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola 47014, Italy
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20
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Kepka L, Socha J. Dose and fractionation schedules in radiotherapy for non-small cell lung cancer. Transl Lung Cancer Res 2021; 10:1969-1982. [PMID: 34012807 PMCID: PMC8107746 DOI: 10.21037/tlcr-20-253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the field of radiotherapy (RT), the issues of total dose, fractionation, and overall treatment time for non-small cell lung cancer (NSCLC) have been extensively investigated. There is some evidence to suggest that higher treatment intensity of RT, when given alone or sequentially with chemotherapy (CHT), is associated with improved survival. However, there is no evidence that the outcome is improved by RT at a higher dose and/or higher intensity when it is used concurrently with CHT. Moreover, some reports on the combination of full dose CHT with a higher biological dose of RT warn of the significant risk posed by such intensification. Stereotactic body radiotherapy (SBRT) provides a high rate of local control in the management of early-stage NSCLC through the use of high ablative doses. However, in centrally located tumors the use of SBRT may carry a risk of serious damage to the great vessels, bronchi, and esophagus, owing to the high ablative doses needed for optimal tumor control. There is a similar problem with moderate hypofractionation in radical RT for locally advanced NSCLC, and more evidence needs to be gathered regarding the safety of such schedules, especially when used in combination with CHT. In this article, we review the current evidence and questions related to RT dose/fractionation in NSCLC.
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Affiliation(s)
- Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
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21
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Prasad RN, Williams TM. A narrative review of toxicity of chemoradiation and immunotherapy for unresectable, locally advanced non-small cell lung cancer. Transl Lung Cancer Res 2020; 9:2040-2050. [PMID: 33209624 PMCID: PMC7653152 DOI: 10.21037/tlcr-20-638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Despite declining smoking rates, lung cancer remains the second most common malignancy in the United States and the leading cause of cancer-related mortality. Non-small cell lung cancer (NSCLC) comprises roughly 85% of cases, and patients tend to present with advanced disease. Historically, concurrent chemoradiotherapy (CRT) has been the standard of care for stage III unresectable NSCLC but outcomes even with multimodal therapy have remained relatively poor. Efforts to improve outcomes through radiation dose escalation with conventional dose fractionation were unsuccessful with RTOG 0617, demonstrating significantly decreased overall survival (OS) with high dose radiation with respect to standard therapy. The recent PACIFIC trial established a new role for consolidative immune checkpoint blockade therapy after CRT using the programmed death ligand 1 (PD-L1) inhibitor durvalumab, by demonstrating significantly improved progression free survival and OS. Although promising, the addition of immunotherapy to multimodal therapy has generated debate regarding the most effective immune pathways to target, appropriate sequencing of therapy, most effective radiation techniques, and toxicity-related concerns. This review will highlight recent and ongoing trials in unresectable, locally advanced NSCLC that incorporate chemotherapy, radiation, and immunotherapy with an emphasis on analysis of treatment-related toxicities and implications for future study design.
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Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
| | - Terence M Williams
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
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22
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Katsuta T, Matsuura K, Kashiwado K, Kagemoto M. Phase II Study: The Outcome of Hypofractionated Involved-Field Radiation Therapy With Concurrent Chemotherapy for the Treatment of Locally Advanced Non-small Cell Lung Cancer. Pract Radiat Oncol 2020; 11:35-43. [PMID: 32949771 DOI: 10.1016/j.prro.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/24/2020] [Accepted: 09/05/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE This phase II study aimed to evaluate the efficacy and safety of hypofractionated involved-field radiation therapy (HypoFx-IFRT) in 2.5 Gy fractions and concurrent chemotherapy for locally advanced stage IIIA and B nonsmall cell lung cancer (LA-NSCLC) without prolonging treatment delivery time beyond 6 weeks. We analyzed the overall survival (OS), progression-free survival, and safety of the treatment. METHODS AND MATERIALS This prospective, single center, single-arm trial was initiated in 2010. All LA-NSCLC patients were treated with HypoFx-IFRT using 3-dimensional conformal radiation therapy. The median total dose of HypoFx-IFRT was 67.5 Gy (range, 60-70). RESULTS From December 2010 to October 2016, 36 patients were ultimately enrolled and evaluated. The trial closed early owing to slow accrual. The median follow-up duration was 50 months in all patients and 65 months in surviving patients. The 1-, 3-, and 5-year OS rates were 88.9% (95% confidence interval [CI], 78.6%-99.2%), 61.1% (95% CI, 45.2%-77.0%), and 54.1% (95% CI, 37.3%-70.9%), respectively. The median time for OS was not reached. The median time for progression-free survival was 10.7 months. The incidence rates of grade 3 radiation pneumonitis, esophagitis and esophageal stenosis were 8.3%, 2.8%, and 2.8%, respectively, and no acute or late toxicities of grade 4 or 5 were observed. CONCLUSIONS This study indicated that HypoFx-IFRT with concurrent chemotherapy yielded an acceptable safety profile and might be beneficial in the survival outcomes of patients with LA-NSCLC.
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Affiliation(s)
- Tsuyoshi Katsuta
- Department of Radiation Oncology, Hiroshima City Hospital Organization, Hiroshima City Hiroshima Citizens Hospital, Hiroshima City, Hiroshima, Japan; Department of Radiation Oncology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, 1ku, Hiroshima City, Hiroshima, Japan.
| | - Kanji Matsuura
- Department of Radiation Oncology, Hiroshima City Hospital Organization, Hiroshima City Hiroshima Citizens Hospital, Hiroshima City, Hiroshima, Japan
| | - Kozo Kashiwado
- Department of Radiation Oncology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, 1ku, Hiroshima City, Hiroshima, Japan
| | - Masayuki Kagemoto
- Department of Radiation Oncology, Hiroshima City Hospital Organization, Hiroshima City Hiroshima Citizens Hospital, Hiroshima City, Hiroshima, Japan
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Investigating the loco-regional control of simultaneous integrated boost intensity-modulated radiotherapy with different radiation fraction sizes for locally advanced non-small-cell lung cancer: clinical outcomes and the application of an extended LQ/TCP model. Radiat Oncol 2020; 15:124. [PMID: 32460796 PMCID: PMC7251706 DOI: 10.1186/s13014-020-01555-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/27/2020] [Indexed: 12/25/2022] Open
Abstract
Background To investigate the loco-regional progression-free survival (LPFS) of intensity-modulated radiotherapy (IMRT) with different fraction sizes for locally advanced non-small-cell lung cancer (LANSCLC), and to apply a new radiobiological model for tumor control probability (TCP). Methods One hundred and three LANSCLC patients treated with concurrent radiochemotherapy were retrospectively analyzed. Factors potentially predictive of LPFS were assessed in the univariate and multivariate analysis. Patients were divided into group A (2.0 ≤ fraction size<2.2Gy), B (2.2 ≤ fraction size<2.5Gy), and C (2.5 ≤ fraction size≤3.1Gy) according to the tertiles of fraction size. A novel LQRG/TCP model, incorporating four “R”s of radiobiology and Gompertzian tumor growth, was developed to predict LPFS and compared with the classical LQ/TCP model. Results With a median follow-up of 22.1 months, the median LPFS was 23.8 months. Fraction size was independently prognostic of LPFS. The median LPFS of group A, B and C was 13.8, 35.7 months and not reached, respectively. Using the new LQRG/TCP model, the average absolute and relative fitting errors for LPFS were 6.9 and 19.6% for group A, 5.5 and 8.8% for group B, 6.6 and 9.5% for group C, compared with 9.5 and 29.4% for group A, 16.6 and 36.7% for group B, 24.8 and 39.1% for group C using the conventional LQ/TCP model. Conclusions Hypo-fractionated IMRT could be an effective approach for dose intensification in LANSCLC. Compared with conventional LQ model, the LQRG model showed a better performance in predicting follow-up time dependent LPFS.
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24
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Kumar S, Chmura S, Robinson C, Lin SH, Gadgeel SM, Donington J, Feliciano J, Stinchcombe TE, Werner-Wasik M, Edelman MJ, Moghanaki D. Alternative Multidisciplinary Management Options for Locally Advanced NSCLC During the Coronavirus Disease 2019 Global Pandemic. J Thorac Oncol 2020; 15:1137-1146. [PMID: 32360578 PMCID: PMC7194660 DOI: 10.1016/j.jtho.2020.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is currently accelerating. Patients with locally advanced NSCLC (LA-NSCLC) may require treatment in locations where resources are limited, and the prevalence of infection is high. Patients with LA-NSCLC frequently present with comorbidities that increase the risk of severe morbidity and mortality from COVID-19. These risks may be further increased by treatments for LA-NSCLC. Although guiding data is scarce, we present an expert thoracic oncology multidisciplinary (radiation oncology, medical oncology, surgical oncology) consensus of alternative strategies for the treatment of LA-NSCLC during a pandemic. The overarching goals of these approaches are the following: (1) reduce the number of visits to a health care facility, (2) reduce the risk of exposure to severe acute respiratory syndrome–coronavirus-2, (3) attenuate the immunocompromising effects of lung cancer therapies, and (4) provide effective oncologic therapy. Patients with resectable disease can be treated with definitive nonoperative management if surgical resources are limited or the risks of perioperative care are high. Nonoperative options include chemotherapy, chemoimmunotherapy, and radiation therapy with sequential schedules that may or may not affect long-term outcomes in an era in which immunotherapy is available. The order of treatments may be on the basis of patient factors and clinical resources. Whenever radiation therapy is delivered without concurrent chemotherapy, hypofractionated schedules are appropriate. For patients who are confirmed to have COVID-19, usually, cancer therapies may be withheld until symptoms have resolved with negative viral test results. The risk of severe treatment-related morbidity and mortality is increased for patients undergoing treatment for LA-NSCLC during the COVID-19 pandemic. Adapting alternative treatment strategies as quickly as possible may save lives and should be implemented through communication with the multidisciplinary cancer team.
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Affiliation(s)
- Sameera Kumar
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
| | - Steven Chmura
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Steven H Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Shirish M Gadgeel
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Josephine Feliciano
- Department of Medical Oncology, Johns Hopkins University, Baltimore, Maryland
| | | | - Maria Werner-Wasik
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Martin J Edelman
- Department of Hematology and Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Drew Moghanaki
- Department of Radiation Oncology, Emory University, Atlanta Veterans Affairs Health Care System, Atlanta, Georgia
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Glinski K, Socha J, Wasilewska-Tesluk E, Komosinska K, Kepka L. Accelerated hypofractionated radiotherapy with concurrent full dose chemotherapy for locally advanced non-small cell lung cancer: A phase I/II study. Radiother Oncol 2020; 148:174-180. [PMID: 32388152 DOI: 10.1016/j.radonc.2020.04.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION We report the results of toxicity and survival in stage III NSCLC patients treated with concurrent accelerated hypofractionated AHRT-CHT within a prospective study. METHODS 92 patients received 3D-CRT or IMRT-planned RT: 58.8 Gy /21 fractions (2.8 Gy/fraction, 4 weeks) with 2 cycles of CHT (Cisplatin 80 mg/m2 D1 and D22; and Vinorelbine 25 mg/m2, D1, D8, D22, and D29) started with D1 of RT. Non-hematological toxicity was evaluated using RTOG-EORTC criteria, every week during treatment, one month after treatment completion, and every three months thereafter. RESULTS Two patients did not receive the prescribed RT dose; 22 (24%) received only one CHT cycle. Median follow-up was 21.5 months (range: 1-65) for all patients and 32 months (range: 8-65) for living patients. There were: 13 (14%) cases of grade ≥III acute esophageal toxicity; 3 grade III acute pneumonitis, and 2 grade III late pulmonary toxicities. Two toxic deaths occurred within 3 months after treatment: fatal hemoptysis (1) and complications of esophageal toxicity (1). Five other deaths that occurred within one year after treatment were probably treatment-related: lung abscess (1), fatal hemoptysis (2), death from undetermined cause (2). Median overall survival was 38 months (95%CI:27-49), median progression free survival was 25 months (95%CI:14-36). CONCLUSIONS Survival rates are encouraging, but the observed rate of toxic and probably toxic deaths is of potential concern. We proceed with the use of AHRT with concomitant full dose CHT, but patients with large PTV and major vascular abutment are excluded due to potentially increased risk of toxic death.
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Affiliation(s)
- Krzysztof Glinski
- Independent Public Health Care Facility of the Ministry of the Interior and Warmian & Mazurian Oncology Centre, Olsztyn, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Ewa Wasilewska-Tesluk
- Independent Public Health Care Facility of the Ministry of the Interior and Warmian & Mazurian Oncology Centre, Olsztyn, Poland; Department of Oncology, University of Warmia & Mazury, Olsztyn, Poland
| | | | - Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland.
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Zehentmayr F, Grambozov B, Kaiser J, Fastner G, Sedlmayer F. Radiation dose escalation with modified fractionation schedules for locally advanced NSCLC: A systematic review. Thorac Cancer 2020; 11:1375-1385. [PMID: 32323484 PMCID: PMC7262927 DOI: 10.1111/1759-7714.13451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/04/2020] [Accepted: 04/05/2020] [Indexed: 12/25/2022] Open
Abstract
Concomitant chemo‐radiotherapy (cCRT) with 60 Gy in 30 fractions is the standard of care for stage 111 non‐small cell lung cancer (NSCLC). With a median overall survival of 28.7 months at best and maximum locoregional control rates of 70% at two years, the prognosis for these patients is still dismal. This systematic review summarizes data on dose escalation by alternative fractionation, which has been explored as a primary strategy to improve both local control and overall survival over the past three decades. A Pubmed literature search was performed according to the PRISMA guidelines. Because of the large variety of radiation regimens total doses were converted to EQD2,T. Only studies using an EQD2,T of at least 49.5 Gy, which corresponds to the conventional 60 Gy in six weeks, were included. In a total of 3256 patients, the median OS was 17 months (range 7.4–30 months). While OS was better for patients treated after the year 2000 (P = 0.003) or with a mandatory 18F‐FDG‐PET‐CT in the diagnostic work‐up (P = 0.001), treatment sequence did not make a difference (P = 0.106). The most commonly reported toxicity was acute esophagitis (AE) with a median rate of 24% (range 0%–84%). AE increased at a rate of 0.5% per Gy increment in EQD2,T (P = 0.016). Dose escalation above the conventional 60 Gy using modified radiation fractionation schedules and shortened OTT yield similar mOS and LRC regardless of treatment sequence with a significant EQD2,T dependent increase in AE. Key points Significant findingsModified radiation dose escalation sequentially combined with chemotherapy yields similar outcome as concomitant treatment. OS is better with the mandatory inclusion of FDG‐PET‐CT in the diagnostic work‐up. The risk of acute esophagitis increases with higher EQD2,T.
What this study addsChemo‐radiotherapy (CRT) with modified dose escalation regimens yields OS and LC rates in the range of standard therapy regardless of treatment sequence. This broadens the database of curative options in patients who are not eligible concomitant CRT.
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Affiliation(s)
- Franz Zehentmayr
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia.,Institute for Research and Development on Advanced Radiation Technologies (radART), Paracelsus Medical University, Salzburg, Australia
| | - Brane Grambozov
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia
| | - Julia Kaiser
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia
| | - Gerd Fastner
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia
| | - Felix Sedlmayer
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia.,Institute for Research and Development on Advanced Radiation Technologies (radART), Paracelsus Medical University, Salzburg, Australia
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Kong C, Zhu X, Shi M, Wang L, Chen C, Tao H, Jiang N, Yan P, Zhao L, Song X, He X. Survival and Toxicity of Hypofractionated Intensity Modulated Radiation Therapy in 4 Gy Fractions for Unresectable Stage III Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2020; 107:710-719. [PMID: 32275994 DOI: 10.1016/j.ijrobp.2020.03.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 03/24/2020] [Accepted: 03/28/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To assess the survival, local and distant control, and toxicity in patients with unresectable locally advanced non-small cell lung cancer treated with radical-intent hypofractionated radiation therapy delivering approximately 60 Gy in 4-Gy fractions. METHODS AND MATERIALS Consecutive patients with unresectable stage III non-small cell lung cancer (n = 42) who received hypofractionated intensity modulated radiation therapy were retrospectively analyzed (2012-2016). Treatments consisted of first-line platinum-based doublet induction chemotherapy followed by an intended dose of 60 Gy in 15 fractions. RESULTS During a median follow-up period of 46 months (95% confidence interval, 41-59) the median overall survival was 47 months (95% confidence interval, 31 to not reached). The 1-, 2-, 3-, and 5-year overall survival rates were 81%, 69%, 64%, and 32%, respectively. The 1-, 2-, 3-, and 5-year progression-free survival rates were 58%, 35%, 25%, and 25%, respectively. An isolated locoregional recurrence was seen in 12% of the patients (n = 5). The incidence of grade (G) 3 or higher treatment-related lung toxicity was 14% (n = 6), among which G3 toxicity was 9.5% (n = 4) and G5 toxicity was 4.8% (n = 2). Twelve percent of patients (n = 5) experienced G3 radiation esophagitis, and 2% (n = 1) had G4 esophageal toxicity. CONCLUSIONS Patients with unresectable locally advanced non-small cell lung cancer treated with hypofractionated intensity modulated radiation therapy in doses up to 60 Gy at 4 Gy per fraction had promising survival, although high-grade esophageal and lung toxicities were seen. Our findings deserve further evaluation in prospective studies.
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Affiliation(s)
- Cheng Kong
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Xiangzhi Zhu
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China.
| | - Meiqi Shi
- Department of Medical Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Li Wang
- Department of Medical Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Cheng Chen
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Hua Tao
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Ning Jiang
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Pengwei Yan
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Lijun Zhao
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Xue Song
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Xia He
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
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Hoppe BS, Nichols RC, Flampouri S, Li Z, Morris CG, Pham DC, Mohindra P, Hartsell W, Mohammed N, Chon BH, Simone CB. Hypofractionated Proton Therapy with Concurrent Chemotherapy for Locally Advanced Non-Small Cell Lung Cancer: A Phase 1 Trial from the University of Florida and Proton Collaborative Group. Int J Radiat Oncol Biol Phys 2020; 107:455-461. [PMID: 32251754 DOI: 10.1016/j.ijrobp.2020.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/12/2020] [Accepted: 03/16/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE We report the safety data from the first multicenter phase 1 trial investigating the use of hypofractionated proton therapy with concurrent chemotherapy for patients with stage II or III non-small cell lung cancer. METHODS AND MATERIALS From 2013 through 2018, patients with newly diagnosed stage II or III non-small cell lung cancer were enrolled in a multicenter phase 1 clinical trial evaluating concurrent chemotherapy with increasing dose-per-fraction proton therapy. This was a stepwise 5 + 2 dose-intensification protocol with the following dose arms: (1) 2.5 GyRBE per fraction to 60 GyRBE; (2) 3.0 GyRBE per fraction to 60 GyRBE; (3) 3.53 GyRBE per fraction to 60.01 GyRBE; and (4) 4.0 GyRBE per fraction to 60 GyRBE. A dose arm was considered tolerable if no radiation therapy-attributable severe adverse event (SAE) occurred within 90 days of treatment among 5 patients enrolled on the arm or if 1 SAE occurred among 7 patients enrolled. Dose constraints to the heart, brachial plexus, and spinal cord were more conservative at higher doses per fraction. RESULTS The study closed early because of slow accrual and competing enrollment in NRG 1308 before accrual was met, with no maximum tolerated dose identified. Eighteen patients were treated, including 5 patients on arms 1 and 2, 7 patients on arm 3, and 1 patient on arm 4. Two SAEs occurred among 7 patients treated at 3.53 GyRBE per fraction; however, per outside expert review, both were attributed to chemotherapy and unrelated to radiation therapy. CONCLUSIONS Hypofractionated proton therapy delivered at 2.5 to 3.53 GyRBE per fraction to a dose of 60 GyRBE with concurrent chemotherapy has an acceptable toxicity profile. Further exploration of this regimen is warranted on a phase 2 clinical trial.
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Affiliation(s)
- Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida.
| | - Romaine C Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Stella Flampouri
- Department of Radiation Oncology, Emory Winship Cancer Institute, Atlanta, Georgia
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Dat C Pham
- Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - William Hartsell
- Department of Radiation Oncology, Northwestern Medicine, Chicago, Illinois
| | | | - Brian H Chon
- ProCure Proton Therapy Center, New Jersey, Somerset, New Jersey
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Kwint MH, Walraven I, Verheij M, Sonke JJ, Belderbos JSA, Janssen TM. The use of real-world evidence to audit normal tissue complication probability models for acute esophageal toxicity in non-small cell lung cancer patients. Radiother Oncol 2020; 146:52-57. [PMID: 32114266 DOI: 10.1016/j.radonc.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/28/2020] [Accepted: 02/11/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The aim of this work is to assess the validity of real world data (RWD) derived from an electronic toxicity registration (ETR). As a showcase, the NTCP-models of acute esophageal toxicity (AET) for concurrent chemoradiation (CCRT) for NSCLC patients were used to validate the ETR of AET before/after dose de-escalation to the mediastinal lymph nodes. MATERIAL AND METHODS One hundred and one patients received 24 × 2.75 Gy and 116 patients received de-escalated dose of 24 × 2.42 Gy to the mediastinal lymph nodes. The validity and completeness of the ETR was analyzed. The grade ≥2 AET probability was defined according the V50 Gy and V60 Gy NTCP-models from literature. Validity of the models was assessed by calibration and discrimination. Furthermore, sensitivity and specificity for different cut-off points were determined. RESULTS The compliance of ETR was 73-80%, with sensitivity and specificity rates of 83% and 86% for grade ≥2 AET, respectively. Discrimination of both NTCP-models demonstrated a moderate accuracy (V50 model, AUC 0.71; V60-model, AUC 0.69). Dose de-escalation did not influence the accuracy of the V50-model; AUC before: 0.69, and AUC after: 0.71. For the V60-model the model-accuracy decreased after dose de-escalation; AUC before: 0.72 and AUC after: 0.62, respectively. CONCLUSION RWD is a useful method to audit NTCP models in clinical practice. The NTCP models to predict AET in NSCLC patients showed moderate predictive accuracy. For clinical practice, the V50Gy seems to be most stable for dose de-escalation without compromising safety and efficacy.
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Affiliation(s)
- Margriet H Kwint
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Iris Walraven
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marcel Verheij
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - José S A Belderbos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Tomas M Janssen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Safety and efficacy of reduced dose and margins to involved lymph node metastases in locally advanced NSCLC patients. Radiother Oncol 2020; 143:66-72. [DOI: 10.1016/j.radonc.2019.07.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/12/2019] [Accepted: 07/22/2019] [Indexed: 12/25/2022]
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31
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Iocolano M, Wild AT, Hannum M, Zhang Z, Simone CB, Gelblum D, Wu AJ, Rimner A, Shepherd AF. Hypofractionated vs. conventional radiation therapy for stage III non-small cell lung cancer treated without chemotherapy. Acta Oncol 2020; 59:164-170. [PMID: 31608751 DOI: 10.1080/0284186x.2019.1675907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Patients with unresectable locally advanced NSCLC who refuse or are not candidates for chemotherapy often receive radiation therapy (RT) alone. Hypofractionated RT (HFRT) regimens are becoming increasingly common. An analysis of the National Cancer Database (NCDB) was performed to evaluate the practice patterns and outcomes of HFRT vs. conventionally fractionated RT (CFRT) in patients with stage III NSCLC undergoing definitive RT alone.Material and methods: The NCDB was queried for all patients with stage III NSCLC diagnosed between 2004 and 2014 who received RT alone. CFRT was defined as patients treated to a total dose of 60-80 Gy in 1.8-2 Gy daily fractions. HFRT was defined as patients treated to a total dose of 50-80 Gy in 2.25-4 Gy fractions. Logistic regression, univariable and multivariable analyses (MVAs) for overall survival (OS) and propensity score matched analyses (PSMAs) were performed.Results: A total of 6490 patients were evaluated: 5378 received CFRT and 1112 received HFRT. Median CFRT dose was 66 Gy in 2 Gy fractions vs. 58.5 Gy in 2.5 Gy fractions for HFRT. HFRT was associated with older age, lower biological effective dose (BED10), academic facility type, higher T-stage and lower N-stage. On initial analysis, HFRT was associated with inferior OS (median 9.9 vs. 11.1 months, p<.001), but after adjusting for the imbalance in covariates such as age, BED10, T-stage and N-stage using PSMA, the difference in survival was no longer significant (p=.1).Conclusions: In the appropriate clinical context, HFRT can be an option for patients with locally advanced NSCLC who are not candidates for chemotherapy or surgical resection. HFRT needs to be further studied in prospective trials to evaluate toxicity and tumor control.
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Affiliation(s)
| | - Aaron T. Wild
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Margaret Hannum
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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WITHDRAWN: Patterns of care for patients with non-operable T1-4 N+ M0 non-small cell lung cancer in the US and outcomes with radiation or chemotherapy monotherapies. Lung Cancer 2020. [DOI: 10.1016/j.lungcan.2020.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Robinson SD, Tahir BA, Absalom KAR, Lankathilake A, Das T, Lee C, Fisher PM, Bates E, Hatton MQF. Radical accelerated radiotherapy for non-small cell lung cancer (NSCLC): A 5-year retrospective review of two dose fractionation schedules. Radiother Oncol 2019; 143:37-43. [PMID: 31563408 DOI: 10.1016/j.radonc.2019.08.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/22/2019] [Accepted: 08/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Numerous fractionation regimes are used for inoperable NSCLC patients not suitable for stereotactic ablative radiotherapy. Continuous hyperfractionated accelerated radiotherapy (CHART, 54 Gy, 36 fractions over 12 days) and hypofractionated accelerated radiotherapy (55 Gy, 20 fractions over 4 weeks) are recommended UK schedules. In this single-centre retrospective analysis, we compare both fractionation schemes for patients treated at our institution from 2010 to 15. MATERIALS AND METHODS Clinical demographic, tumour and survival data were collected alongside radiotherapy dosimetric data from the Varian Eclipse Scripting application programming interface. Differences were assessed using independent samples t-tests. Multivariate survival analysis was performed using Cox regression. RESULTS We identified 563 eligible patients; 43% received CHART and 57% hypofractionated radiotherapy. Median age was 71 years, 56% were male, 95% PET staged with 53% WHO performance status 0-1. 30%, 14%, 50% and 6% were stage I, II, III and IV, respectively. 38% of patients underwent induction chemotherapy. 99% completed their prescribed radiotherapy treatment. Overall response rate was 50% with a 6.5% 90-day mortality rate. Median disease-free survival was 19 months, 50% recurred locally. Median overall survival was 22.5 months with 48% alive at 2 years. Multivariate analysis identified histology, stage, performance status, chemotherapy and radiotherapy response as independent predictors of survival; no significant differences between radiotherapy regimes were observed. CONCLUSION In our centre, CHART and hypofractionated accelerated radiotherapy produce similar outcomes. Dose escalation studies are in progress to develop these schedules to match outcomes reported in concurrent chemo-radiation studies.
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Affiliation(s)
- Stephen D Robinson
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, Weston Park Hospital, University of Sheffield, United Kingdom
| | - Bilal A Tahir
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, Weston Park Hospital, University of Sheffield, United Kingdom
| | - Katherine A R Absalom
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, Weston Park Hospital, University of Sheffield, United Kingdom
| | - Amila Lankathilake
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, Weston Park Hospital, University of Sheffield, United Kingdom
| | - Tathagata Das
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, Weston Park Hospital, University of Sheffield, United Kingdom
| | - Caroline Lee
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, Weston Park Hospital, University of Sheffield, United Kingdom
| | - Patricia M Fisher
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, Weston Park Hospital, University of Sheffield, United Kingdom
| | - Emma Bates
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, Weston Park Hospital, University of Sheffield, United Kingdom
| | - Matthew Q F Hatton
- Academic Unit of Clinical Oncology, Department of Oncology and Metabolism, Weston Park Hospital, University of Sheffield, United Kingdom.
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Eze C, Taugner J, Roengvoraphoj O, Schmidt-Hegemann NS, Käsmann L, Wijaya C, Belka C, Manapov F. Initial report on feasibility of PET/CT-based image-guided moderate hypofractionated thoracic irradiation in node-positive non-small cell lung Cancer patients with poor prognostic factors and strongly diminished lung function: a retrospective analysis. Radiat Oncol 2019; 14:163. [PMID: 31484542 PMCID: PMC6727570 DOI: 10.1186/s13014-019-1304-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/22/2019] [Indexed: 12/25/2022] Open
Abstract
Background To determine the feasibility of PET/CT-based image-guided moderate hypofractionated thoracic irradiation (Hypo-IGRT) in locally advanced node-positive non-small cell lung cancer patients with highly compromised pulmonary function. Method Eight highly-selected and closely monitored patients with highly diminished pulmonary function (FEV1 ≤ 1.0 L and/or DLCO-SB ≤ 40% and/or on long-term oxygen therapy) were treated with Hypo-IGRT. Planning was based on 18F-FDG-PET/CT and 4D-CT in the treatment position. Hypo-IGRT was delivered to a total dose of 45 Gy (ICRU) in 15 daily fractions under strict image-guidance. Vital capacity (VC), forced expiratory volume in 1 s (FEV1), and single-breath diffusing capacity of the lung for CO (DLCO-SB) were analyzed prior to, 3 and 6 months after Hypo-IGRT. Result Eight patients with stage IIIA-C NSCLC (8th TNM Ed.) completed Hypo-IGRT. The median follow-up was 29.4 months. The median age was 64 years. Four, three and one patient(s) presented with COPD GOLD IV, III and II, respectively and 5 patients (63%) were on long-term oxygen therapy. The median PTV was 226.9 cc (range: 100.17–379.80 cc). Median PFS and OS were 19 and 34.3 months. The 6 months and 1-year OS rates were 100, 87.5%, respectively. The 6- and 12- months PFS rates were 87.5 and 52.5%. Three patients developed local failure. Median initial VC, FEV1 and DLCO-SB was 1.69 L/64.8% predicted (range: 1.36–2.66 L/33–80%), 1 L/39.4% predicted (range:0.78–1.26 L/28–60% predicted) and 33.3% (range: 13.3–54%) predicted, respectively. Median values for VC, FEV1, DLCO-SB 3 and 6 months after Hypo-IGRT were 2.05 L/56.35% predicted (range: 1.34–2.33 L/47–81.5%), 1.08 L/47.5% predicted (range: 0.74–1.60 L/30.8–59.59%), 38.55% (range: 24–68%) and 1.64 L/66% predicted (range: 1.41–2.79/35.5–75.5%), 1.0 L/47% predicted (range: 0.65–1.28 L/24.5–54.10%), 31% (range: 27–43%), respectively. Mean lung dose was 9.4 Gy (range: 5.3–11.6 Gy) and V20 for both lungs was 15% (range: 6–19%). Mean esophageal dose was 12.76 Gy (range: 2.1–26.7 Gy). There was no case of grade 2 or higher radiation pneumonitis. Four patients developed grade 2 radiation esophagitis. Conclusion Hypo-IGRT can be considered for individual and closely monitored patients with locally advanced node-positive NSCLC with highly compromised pulmonary function. No severe pulmonary toxicity and significant decline of pulmonary function parameters was observed in our cohort. Currently, this protocol is being assessed in an ongoing single-centre prospective study.
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Affiliation(s)
- Chukwuka Eze
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Julian Taugner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Olarn Roengvoraphoj
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Nina-Sophie Schmidt-Hegemann
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Lukas Käsmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.,Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany.,German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
| | - Cherylina Wijaya
- Department of Pulmonology, Asklepios-Fachkliniken München-Gauting, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.,Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany.,German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
| | - Farkhad Manapov
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.,Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany.,German Cancer Consortium (DKTK), partner site Munich, Munich, Germany
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Valeriani M, Marinelli L, Nicosia L, Reverberi C, De Sanctis V, Mollo D, Osti MF. Locally advanced inoperable primary or recurrent non-small cell lung cancer treated with 4-week hypofractionated radiation therapy (3 Gy/fraction). Radiol Med 2019; 124:1324-1332. [PMID: 31317381 DOI: 10.1007/s11547-019-01064-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/07/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND The prognosis of locally advanced non-small cell lung cancer (NSCLC) treated with conventional radiotherapy remains poor. Hypofractionation reduces overall treatment time increasing biological effect in patients not suitable for concurrent chemo-radiotherapy. METHOD From January 2009 to October 2016, 76 inoperable locally advanced primary or recurrent NSCLC patients were treated with 60 Gy in 20 fractions of 3 Gy/each for 4 weeks as exclusive or post-chemotherapy treatment. Fifty-eight patients (76.3%) had stage III and 18 (23.7%) stage IV (≤ 2 metastases) disease: 63 primary (82.9%) and 13 recurrent (17.1%). RESULTS Median and 2-year overall survival were 17 months and 38.9%, respectively. Median and 2-year loco-regional progression free survival were 27 months and 55.3%, respectively. Univariate and multivariate analyses demonstrated that patients with complete response presented better outcomes, whereas no statistically relevant difference was evidenced in terms of previous chemotherapy, recurrent vs primary disease, volume and stage. Thirty patients (39.5%) presented acute esophagitis (1-grade 3) and 19 (25.0%) acute pneumonitis (2-grade 3). Six patients (7.9%) developed grade 2-3 late pneumonitis and 3 patients (3.9%) grade 1 late esophagitis. CONCLUSION In patients not suitable of concurrent radio-chemotherapy, exclusive or sequential hypofractionated schedule using 60 Gy in 20 fractions was well tolerated and presented promising results. Complete local response was a predictor of better outcomes, and any efforts will be made to perform prospective clinical trials to further evaluate hypofractionated regimens with increased lesional BED.
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Affiliation(s)
- Maurizio Valeriani
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Luca Marinelli
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Luca Nicosia
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Chiara Reverberi
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Vitaliana De Sanctis
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Davide Mollo
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Mattia Falchetto Osti
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
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Accelerated hypofractionated radiotherapy plus chemotherapy for inoperable locally advanced non-small-cell lung cancer: final results of a prospective phase-II trial with a long-term follow-up. Radiat Oncol 2019; 14:112. [PMID: 31234868 PMCID: PMC6591967 DOI: 10.1186/s13014-019-1317-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 06/06/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Concurrent chemotherapy and radiation using conventional fractionation is the standard treatment for inoperable, locally advanced non-small-cell lung cancer (NSCLC). We tested accelerated hypofractionated radiotherapy (AHR) and chemotherapy for the treatment of locally advanced NSCLC. METHODS Eligible patients with locally advanced NSCLC were treated with induction chemotherapy (cisplatin and docetaxel), followed by AHR using tomotherapy and consolidation chemotherapy. The prescribed doses were 30 Gy/5 daily fractions at the reference isodose (60-70%) to the tumor, and 25 Gy/5 daily fractions to the clinically involved lymph nodes. The primary end-point was response rate (RR); the secondary end-points were acute and late side-effects, local progression-free survival (PFS), metastasis-free survival (MFS) and overall survival (OS). This trial closed before the first planned interim analysis due to poor accrual. RESULTS From January 2009 to January 2012, 17 of the 23 enrolled patients were evaluable. Treatment yielded an overall RR of 82%. Median follow-up was 87 months (range: 6-87), local PFS was 19.8 months (95% CI 9.7 - not reached), MFS was 9.7 months (95% CI 5.8-46.0) and OS was 23 months (95% CI 8.4-48.4). 70% of patients experienced acute G4 neutropenia, 24% G4 leukopenia, 24% G3 paresthesia, 4% G3 cardiac arrythmia, 4% underwent death after chemotherapy. Late toxicity was represented by 24% dyspnea G3. CONCLUSIONS AHR combined with chemotherapy is feasible with no severe side-effects, and it appears highly acceptable by patients. TRIAL REGISTRATION This study is registered with the EudractCT registration 2008-006525-14 . Registered on 9 December 2008.
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Hughes RT, Helis CA, Soike MH, Levine BJ, Farris M, Blackstock AW. Moderately Hypofractionated Radiotherapy Alone for Stage I-IIB Non-small Cell Lung Cancer. Cureus 2019; 11:e4969. [PMID: 31453041 PMCID: PMC6701921 DOI: 10.7759/cureus.4969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/22/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The optimal management of patients with early non-small cell lung cancer (NSCLC) not amenable to surgical resection or stereotactic body radiotherapy (SBRT) or those with hilar nodal involvement ineligible for surgery or concurrent chemoradiotherapy is unclear. This report describes survival outcomes and toxicity profiles of patients treated with hypofractionated radiotherapy (HRT) alone. METHODS A total of 52 patients with Stage I-IIB NSCLC treated with HRT alone between 2010-2018 were reviewed. Patients were categorized as having ultracentral tumors if the planning target volume contacted or overlapped the proximal bronchial tree, esophagus, pulmonary vein or artery. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method and the competing risk cumulative incidence of locoregional failure (LRF) and distant failure (DF) were estimated using death without failure as a competing risk. Pneumonitis and esophagitis rates were evaluated as per Acute Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. RESULTS Of the 52 patients analyzed, 50 patients were treated with radiotherapy alone to a dose of 70.2 Gy in 26 fractions, one patient was treated with 68 Gy in 25 fractions and one patient was treated with 65 Gy in 26 fractions. The median age was 72 (range 48-89), 42% of patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 2-3, 46% were stage I and 54% were stage II. Hilar nodal involvement was present in 21% of patients and 74% of node-negative patients had ultracentral primary tumors. Median OS was 39.6 months and the median PFS was 21.0 months. Overall three-year cumulative incidence of LRF and DF were 32% and 34%, respectively. Grade 3 pneumonitis occurred in two (4%) patients. No grade 3+ acute esophagitis or grade 4-5 toxicities were observed. CONCLUSION Hypofractionated thoracic radiotherapy consisting of 70.2 Gy is well-tolerated and results in favorable locoregional control for stage I-IIB patients who are not candidates for SBRT, surgery, or concurrent chemoradiotherapy.
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Affiliation(s)
- Ryan T Hughes
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Corbin A Helis
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Michael H Soike
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Beverly J Levine
- Epidemiology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Michael Farris
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
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Zhao Q, Chen G, Ye L, Shi S, Du S, Zeng Z, He J. Treatment-duration is related to changes in peripheral lymphocyte counts during definitive radiotherapy for unresectable stage III NSCLC. Radiat Oncol 2019; 14:86. [PMID: 31133034 PMCID: PMC6537222 DOI: 10.1186/s13014-019-1287-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To investigate the potential impact of fractionation regimes and overall treatment time (OTT) on lymphopenia during definitive radiotherapy (RT) and its associations with patient outcomes in non-small cell lung cancer (NSCLC). METHODS Subjects consisted of 115 patients who had received definitive chemoradiation therapy (CRT) with different doses and fractions for unresectable stage III NSCLC. Clinical and laboratory records were reviewed to assess the changes in total lymphocyte counts (TLCs) during definitive RT. The associations of the TLCs with the clinical and treatment features, and outcomes were analyzed. RESULTS The median reduction of TLCs in the entire cohort was 1300 cells/μL (interquartile range [IQR], 950-1510 cells/μL). Of all patients, 63 (54.8%) experienced severe lymphopenia (SL) (TLC nadir < 500 cells/μL), which occurred at a median of the 5th week following RT initiation, not at the completion of RT or upon treatment with maximal doses. SL risk was increased over the first 5 weeks (odds ratio [OR] = 3.455, P = 0.007), after which, no increased risk was observed (OR = 0.562, P = 0.216). The median TLCs remained low and failed to recover to the initial normal values of their pre-RT level after 2 months of RT completion. Patients without SL exhibited significantly improved progression-free survival (hazard ratio [HR] = 0.544, P = 0.010) and overall survival (HR = 0.463, P = 0.011) after controlling for confounding variables in multivariate analyses. The incidence of SL was significantly lower (71.1% reduction in risk (OR = 0.289, P = 0.007)) in patients who received hypofractionated RT with an OTT within 4 weeks, compared to those who had an OTT of more than 4 weeks (32.1% vs 62.1%, P = 0.006). Multivariate analyses revealed that OTT within 4 weeks (OR = 0.322, P = 0.032) was significantly associated with a decreased risk of developing SL after controlling for confounding factors. CONCLUSIONS Hypofractionated RT was significantly associated with a decreased risk of SL and improved survival during definitive radiotherapy for unresectable stage III NSCLC.
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Affiliation(s)
- Qianqian Zhao
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Gang Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Luxi Ye
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shiming Shi
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shisuo Du
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Jian He
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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Ma L, Men Y, Feng L, Kang J, Sun X, Yuan M, Jiang W, Hui Z. A current review of dose-escalated radiotherapy in locally advanced non-small cell lung cancer. Radiol Oncol 2019; 53:6-14. [PMID: 30840594 PMCID: PMC6411023 DOI: 10.2478/raon-2019-0006] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 01/05/2019] [Indexed: 12/14/2022] Open
Abstract
Background The mainstay therapy for locally advanced non-small cell lung cancer is concurrent chemoradiotherapy. Loco-regional recurrence constitutes the predominant failure patterns. Previous studies confirmed the relationship between increased biological equivalent doses and improved overall survival. However, the large randomized phase III study, RTOG 0617, failed to demonstrate the benefit of dose-escalation to 74 Gy compared with 60 Gy by simply increasing fraction numbers. Conclusions Though effective dose-escalation methods have been explored, including altered fractionation, adapting individualized increments for different patients, and adopting new technologies and new equipment such as new radiation therapy, no consensus has been achieved yet.
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Affiliation(s)
- Li Ma
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Yu Men
- Department of VIP Medical Services, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100021, China
| | - Lingling Feng
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Jingjing Kang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100021, China
| | - Xin Sun
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100021, China
| | - Meng Yuan
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100021, China
| | - Wei Jiang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, 518116, China
| | - Zhouguang Hui
- Department of VIP Medical Services, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100021, China
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100021, China
- Zhouguang Hui, M.D., Department of VIP Medical Services & Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Panjiayuan Nanli 17, Chaoyang District, Beijing 100021, China. Phone: + 861087787656
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Hypofractionated Concomitant Chemoradiation in Inoperable Locally Advanced Non-small Cell Lung Cancer: A Report on 100 Patients and a Systematic Review. Clin Oncol (R Coll Radiol) 2018; 31:e1-e10. [PMID: 30415784 DOI: 10.1016/j.clon.2018.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/25/2018] [Indexed: 01/14/2023]
Abstract
AIMS Concomitant chemoradiation is the standard of care in patients with inoperable non-small cell lung cancer. The purpose of this study was to analyse the survival outcome and toxicity data of using hypofractionated chemoradiation. MATERIALS AND METHODS One hundred patients were treated from June 2011 to November 2016. Treatment consisted of 55 Gy in 20 daily fractions concurrently with split-dose cisplatin vinorelbine chemotherapy over 4 weeks followed by two cycles of cisplatin vinorelbine only. Survival was estimated using Kaplan-Meier and Cox regression was carried out for known prognostic factors. A systematic search of literature was conducted using Medline, Embase and Cochrane databases and relevant references included. RESULTS In total, 97% of patients completed radiotherapy and 73% of patients completed all four cycles of chemotherapy. One patient died of a cardiac event during consolidative chemotherapy. There were two cases of grade 4 toxicities (one sepsis, one renal impairment). Grade 3 toxicities included nausea/vomiting (17%), oesophagitis (15%), infection with neutropenia (12%) and pneumonitis (4%). Clinical benefit was seen in 86%. Two-year progression-free survival and overall survival rates were 49% and 58%, respectively. The median progression-free survival and overall survival were 23.4 and 43.4 months, respectively. The only significant prognostic factor was the number of chemotherapy cycles received (P = 0.02). The systematic review identified 13 relevant studies; a variety of regimens were assessed with variable reporting of outcomes and toxicity but with overall an improvement in survival over time. CONCLUSION Our experience compared with the original phase II trial showed improved treatment completion rates and survival with acceptable morbidity. With appropriate patient selection this regimen is an effective treatment option for locally advanced non-small cell lung cancer. This study helps to benchmark efficacy and toxicity rates while considering the addition of new agents to hypofractionated concurrent chemoradiotherapy. The agreement of a standard regimen for assessment in future trials would be beneficial.
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Concurrent Daily Cisplatin and High-Dose Radiation Therapy in Patients With Stage III Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2018; 102:543-551. [DOI: 10.1016/j.ijrobp.2018.07.188] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 06/14/2018] [Accepted: 07/04/2018] [Indexed: 12/25/2022]
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Jaksic N, Chajon E, Bellec J, Corre R, Ricordel C, de Latour B, Lena H, Schick U, de Crevoisier R, Castelli J. Optimized radiotherapy to improve clinical outcomes for locally advanced lung cancer. Radiat Oncol 2018; 13:147. [PMID: 30103774 PMCID: PMC6090773 DOI: 10.1186/s13014-018-1094-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/03/2018] [Indexed: 12/25/2022] Open
Abstract
Background We aimed to evaluate the toxicity, loco-regional control (LRC) and overall survival (OS) associated with accelerated intensity-modulated radiotherapy (IMRT) for locally advanced lung cancer. Methods Seventy-three patients were consecutively treated with IMRT from November 2011 to August 2016. A total dose of 66 Gy was delivered using two different schedules of radiotherapy: simultaneous modulated accelerated radiotherapy (SMART) (30 × 2.2 Gy, across 6 weeks) with or without chemotherapy, or moderate hypofractionated radiotherapy (HRT) (24 × 2.75 Gy, across 4 weeks) in patients unfit to receive concomitant chemotherapy. Data on esophageal and pulmonary toxicities, LRC and OS were prospectively collected. Results The median follow-up duration was 44 months. Severe pneumonitis and esophagitis (grade 3–4) were observed in 7% and 1% of patients respectively, with only one case of grade 4 (pneumonitis). Overall, the 1-year and 2-year LRCs were 76% [95 confidence interval (CI)%: 66–87%] and 62% [95 CI%: 49–77%] respectively. The 1 and 2-year OS rates were 72% [95% CI: 63–83%] and 54% [95 CI%: 43–68%] respectively. None parameters were correlated with LRC or OS. In particular, no difference was observed between patients treated with SMART and H-RT (p = 0.26 and 0.6 respectively), with a 1-year LRC of 74% [95 CI%: 62–86%] for SMART and 91% [95 CI%: 74–100%] for H-RT. No significant differences were observed in the toxicity rates associated with each of the RT schedules. Conclusions Accelerated IMRT for locally advanced lung cancer is associated with low toxicities and high LRC. Moderate hypofractionated RT, by decreasing the total treatment time, may be promising in improving clinical outcomes.
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Affiliation(s)
- Nicolas Jaksic
- Département de Radiothérapie, Centre Eugène Marquis, Rue de la Bataille Flandres Dunkerque, Rennes, France. .,Université de Rennes 1, Rennes, France.
| | - Enrique Chajon
- Département de Radiothérapie, Centre Eugène Marquis, Rue de la Bataille Flandres Dunkerque, Rennes, France
| | - Julien Bellec
- Département de Radiothérapie, Centre Eugène Marquis, Rue de la Bataille Flandres Dunkerque, Rennes, France
| | - Romain Corre
- Service de pneumologie CHU Pontchaillou, Rennes, France
| | | | | | - Hervé Lena
- Service de pneumologie CHU Pontchaillou, Rennes, France
| | - Ulrike Schick
- Département de Radiothérapie, CHRU Brest, Brest, France
| | - Renaud de Crevoisier
- Département de Radiothérapie, Centre Eugène Marquis, Rue de la Bataille Flandres Dunkerque, Rennes, France.,Université de Rennes 1, Rennes, France
| | - Joël Castelli
- Département de Radiothérapie, Centre Eugène Marquis, Rue de la Bataille Flandres Dunkerque, Rennes, France.,Université de Rennes 1, Rennes, France
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Roach MC, Bradley JD, Robinson CG. Optimizing radiation dose and fractionation for the definitive treatment of locally advanced non-small cell lung cancer. J Thorac Dis 2018; 10:S2465-S2473. [PMID: 30206492 DOI: 10.21037/jtd.2018.01.153] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Radiation therapy is the foundation for treatment of locally advanced non-small cell lung cancer (NSCLC), a disease that is often inoperable and has limited long term survival. Local control of disease is strongly linked to patient survival and continues to be problematic despite continued attempts at changing the dose and fractionation of radiation delivered. Technological advancements such as 4-dimensional computed tomography (CT) based planning, positron emission tomography (PET) based target delineation, and daily image guidance have allowed for ever more accurate and conformal treatments. A limit to dose escalation with conventional fractions of 2 Gy once per day appears to have been reached at 60 Gy in the randomized trial Radiation Therapy Oncology Group (RTOG) 0617. Higher doses were surprisingly associated with worse overall survival. Approaches other than conventional dose escalation have been explored to better control disease including accelerating treatment to limit tumor repopulation both with hyperfractionation and its multiple small (<2 Gy) fractions each day and with hypofractionation and its single larger (>2 Gy) fraction each day. These accelerated regimens are increasingly being used with concurrent chemotherapy, and multiple institutions have reported it as tolerable. Tailoring treatment to individual patient disease and normal anatomic characteristics has been explored with isotoxic dose escalation up to the tolerance of organs at risk, with both hyperfractionation and hypofractionation. Metabolic imaging during and after treatment is increasingly being used to boost doses to residual disease. Boost doses have included moderate hypofractionation of 2-4 Gy, and more recently extreme hypofractionation with stereotactic body radiation therapy (SBRT). In spite of all these changes in dose and fractionation, lung and cardiovascular toxicity remain obstacles that limit disease control and patient survival.
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Affiliation(s)
- Michael C Roach
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
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Ma L, Qiu B, Li Q, Chen L, Wang B, Hu Y, Liu M, Zhang L, Huang Y, Deng X, Xia Y, Lin M, Liu H. An esophagus-sparing technique to limit radiation esophagitis in locally advanced non-small cell lung cancer treated by simultaneous integrated boost intensity-modulated radiotherapy and concurrent chemotherapy. Radiat Oncol 2018; 13:130. [PMID: 30016978 PMCID: PMC6050724 DOI: 10.1186/s13014-018-1073-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 07/05/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND To investigate the incidence of radiation esophagitis (RE) and tumor local control using esophagus sparing technique in locally advanced non-small cell lung cancer (LANSCLC) treated by simultaneous integrated boost intensity-modulated radiation therapy (SIB-IMRT) and concurrent chemotherapy. METHODS Eighty-seven patients with stage IIIA/B NSCLC who received definitive SIB-IMRT and concurrent chemotherapy had been divided into two groups: 1.with esophagus sparing technique; 2.without esophagus sparing technique. Chi-square test was performed to compare sex, clinical stage, histology, concurrent chemotherapy, RE and nutrition status between two groups. T-test was used to compare the dosimetric parameters. Overall survival (OS) and loco-regional failure free survival (LRFS) were calculated by the Kaplan-Meier method and compared by a log-rank test. RESULTS There were 44 patients in the esophagus sparing group and 43 in the non-sparing group. The incidence of severe RE (Grade 3) was significantly lower in patients with esophagus sparing technique (p = 0.002). Patients in esophagus sparing group had better nutrition status (p = 0.045). With a median follow-up of 18 months (range 1-51 months), the 1-year, 2-year and 3-year OS of all the patients was 86.6, 65.4 and 43.7%. The 1-year, 2-year LRFS was 78.4, 65.9%. OS time (p = 0.301) and LRFS (p = 0.871) was comparable between two groups. CONCLUSIONS Esophagus-sparing technique is an effective and essential method to limit RE in LANSCLC treated by SIB-IMRT and concurrent chemotherapy without compromising local control.
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Affiliation(s)
- Li Ma
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Bo Qiu
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
| | - QiWen Li
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Li Chen
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Bin Wang
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
| | - YongHong Hu
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
| | - MengZhong Liu
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Li Zhang
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| | - Yan Huang
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China
| | - XiaoWu Deng
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
| | - YunFei Xia
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China
| | - MaoSheng Lin
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China. .,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China. .,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China.
| | - Hui Liu
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China. .,Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, People's Republic of China. .,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, Guangdong, 510060, People's Republic of China.
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Fang P, Swanick CW, Pezzi TA, Liao Z, Welsh J, Lin SH, Gomez DR. Outcomes and toxicity following high-dose radiation therapy in 15 fractions for non-small cell lung cancer. Pract Radiat Oncol 2017; 7:433-441. [PMID: 28428017 DOI: 10.1016/j.prro.2017.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/08/2017] [Accepted: 03/06/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Accelerated hypofractionated radiation therapy (AHRT) is increasingly used for select lung cancer patients. We evaluated clinical outcomes and predictors of pulmonary/esophageal toxicity in patients treated with ≥52.5 Gy in 15 fractions. METHODS AND MATERIALS We evaluated 229 patients treated with radiation therapy doses ≥52.5 Gy in 15 fractions for non-small cell lung cancer from January 2009 through January 2016. Toxicity was scored using Common Terminology Criteria for Adverse Events, v4.0. Univariate and multivariate logistic regression was used to identify predictors of toxicity. Overall survival, progression-free survival, and local control were estimated using the Kaplan-Meier method. Predictors of clinical outcome were modeled using Cox proportional hazards regression. RESULTS Median follow-up was 7 months. Forty-two patients (19%) developed grade ≥2 pneumonitis, and 9 (4%) developed grade ≥3 esophagitis. In multivariate analysis, age >75 years (odds ratio [OR], 2.56; 95% confidence interval [CI], 1.24-5.25; P = .01) and percentage of lung volume receiving doses of >10 Gy higher than 32% were associated with grade ≥2 pneumonitis (OR, 2.79; 95% CI, 1.39-5.79; P = .005). On univariate analysis, esophagus mean dose ≥17 Gy (OR, 10.14; 95% CI, 1.82-189.8; P = .006), gross tumor volume size ≥71 cm3 (P = .002), and planning target volume size ≥409 cm3 (P = .02) were associated with development of grade ≥3 esophagitis. In patients with stage II/III disease (n = 73), median local control was not reached, median overall survival was 14 months, and median progression-free survival was 6 months. CONCLUSIONS AHRT in 15 fractions can be safe and effective. Consideration for using AHRT with immunotherapy and sequential chemotherapy for improved out-of-radiation field and distant control is warranted.
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Affiliation(s)
- Penny Fang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - Cameron W Swanick
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - Todd A Pezzi
- Baylor College of Medicine, One Baylor Plaza, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - James Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas.
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
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Matched-Pair Analysis of High Dose Versus Standard Dose Definitive Chemoradiation for Locally Advanced Non–Small-Cell Lung Cancer. Clin Lung Cancer 2017; 18:149-155. [DOI: 10.1016/j.cllc.2016.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/14/2016] [Accepted: 06/14/2016] [Indexed: 12/25/2022]
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47
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Radical hypo-fractionated radiotherapy with volumetric modulated arc therapy in lung cancer : A retrospective study of elderly patients with stage III disease. Strahlenther Onkol 2017; 193:385-391. [PMID: 28168322 DOI: 10.1007/s00066-017-1103-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 01/06/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study aimed to analyse the feasibility and acute toxicity of radical hypo-fractionated radiotherapy (RT) for elderly patients with non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS We conducted a retrospective evaluation of treatment with volumetric modulated arc therapy (VMAT) of elderly patients affected by stage III inoperable NSCLC. The dose prescription was 56 Gy in 20 fractions, 55 Gy in 22 fractions, or 50 Gy in 20 fractions. Target volume included only the primary lesion and the infiltrated lymph nodes. The primary end point was acute and late toxicity, while secondary end points were progression-free survival (PFS), and overall survival (OS). RESULTS In all, 41 patients were included in this analysis. The mean age of the patients was 78.6 years, and 22 patients had staged IIIA while 19 patients had stage IIIB disease. All but one patient had pathological nodal involvement; 15 patients received chemotherapy before RT. Acute grade 1-2 toxicity was recorded in 25 (61%) patients. Late toxicity was recorded in 13 (32%) patients. No cases of G3 or G4 toxicity were recorded. Complete response was obtained in two (5%) patients, 26 (63%) showed a partial response, and two (5%) experience disease progression. At a mean follow-up of 9.9 months (range, 1.1-25.4), 17 patients had died from disease progression, one died from other causes, and 23 were alive. Median OS was 13.7 ± 1.5 months (95% CI: 10.7-16.7), OS at 12 and 18 months was 51.3 ± 9.5% and 35.1 ± 10.1%, respectively. Median PFS was 13.7 ± 2.3 months (95% CI: 9.1-18.2), and PFS at 12 and 18 months was 50.1 ± 9.9% and 38.9 ± 10.4%, respectively. CONCLUSION Radical hypo-fractionated VMAT is a promising treatment for locally advanced NSCLC in the elderly. The use of hypo-fractionated radiotherapy for lung cancer in older patients can be considered a valuable approach, particularly for patients with poor performance status or refusing other treatment approaches.
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Nieder C, Tollåli T, Haukland E, Reigstad A, Flatøy LR, Dalhaug A. External Validation of a Prognostic Score for Patients Receiving Palliative Thoracic Radiotherapy for Lung Cancer. Clin Lung Cancer 2017; 18:e297-e301. [PMID: 28189593 DOI: 10.1016/j.cllc.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/06/2017] [Accepted: 01/10/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Palliative thoracic radiotherapy is a common treatment for patients with incurable lung cancer. A recent study suggested that a prognostic score based on performance status and N and M stage predicts survival and might support decision-making (eg, when deciding about fractionation). Our aim was to perform a validation study in an independent, larger dataset. PATIENTS AND METHODS This was a retrospective single-institution study of 232 patients with small- or non-small-cell lung cancer, with methodology comparable with that of the original study. Three subgroups were created, based on the point sum resulting from assessment of performance status and N and M stage (10-11, 12-14, 15-17 points). RESULTS Performance status and N and M stage were significantly associated with overall survival after palliative radiotherapy in uni- and multivariate analyses. An unfavorable prognosis (10-11 points) was predicted in 56 patients (24%). Their median survival was 1.2 months. The intermediate group consisted of 137 patients (59%) with a median survival of 5.3 months. A favorable prognosis (15-17 points) was predicted in 39 patients (17%), whose median survival was 8.2 months. The difference between the intermediate and favorable subgroups did not reach statistical significance (P = .1, as compared with P = .0001 for the remaining 2 comparisons). CONCLUSION In the original study, the median survival of patients in the 3 different prognostic strata was 2, 6, and 38 months. Except for the favorable subgroup, the validation study confirmed these results. Given the large, clinically highly relevant discrepancy (8 vs. 38 months), additional studies are needed in order to inform therapeutic decisions in patients with favorable point sum of 15 to 17.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital Trust, Bodø, Norway; Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.
| | - Terje Tollåli
- Department of Pulmonology, Nordland Hospital Trust, Bodø, Norway
| | - Ellinor Haukland
- Department of Oncology and Palliative Medicine, Nordland Hospital Trust, Bodø, Norway; Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Anne Reigstad
- Department of Pulmonology, Nordland Hospital Trust, Bodø, Norway
| | - Liv Randi Flatøy
- Department of Pulmonology, Nordland Hospital Trust, Bodø, Norway
| | - Astrid Dalhaug
- Department of Oncology and Palliative Medicine, Nordland Hospital Trust, Bodø, Norway; Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
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Swanick CW, Allen PK, Tao R, Olanrewaju AM, Sutton JR, Lin SH, Welsh J, Das P, Chang JY, Crane CH, Gomez DR. Incidence and predictors of chest wall toxicity after high-dose radiation therapy in 15 fractions. Pract Radiat Oncol 2016; 7:63-71. [PMID: 27637136 DOI: 10.1016/j.prro.2016.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/23/2016] [Accepted: 05/31/2016] [Indexed: 12/24/2022]
Abstract
PURPOSE Fifteen fraction treatment schedules are increasingly used to deliver high doses of radiation therapy (RT) to both lung and hepatobiliary malignancies. The purpose of our study was to examine the incidence and predictors of chest wall (CW) toxicity in patients treated with this regimen. METHODS AND MATERIALS We evaluated 135 patients treated with RT to doses ≥52.5 Gy in 15 fractions for thoracic and hepatobiliary malignancies between January 2009 and December 2012. We documented patient characteristics and CW dosimetric parameters for each case. Toxicity was scored using the Common Terminology Criteria for Adverse Events, version 4.0, criteria for radiation dermatitis and CW pain. Patient characteristics and CW dosimetric parameters were evaluated for their association with CW toxicity using proportional hazards regression. RESULTS Median follow-up was 9 months from the start of RT. Forty-eight patients (36%) developed dermatitis at a median time of 18 days. In multivariable analysis, the absolute volume of CW (in cm3) receiving 40 Gy (V40) ≥120 cm3 was associated with the occurrence of dermatitis (hazard ratio, 3.12; 95% confidence interval, 1.74-5.60; P < .001). Twenty-one patients (16%) developed CW pain (20 grade 1, 1 grade 2) at a median time of 3 months. In multivariable analysis, CW V40 ≥150 cm3 was associated with the occurrence of CW pain (hazard ratio, 2.65; 95% confidence interval, 1.12-6.24; P = .03). The absolute rate of CW pain in patients with V40 <150 cm3 was 11% versus 26% in patients with V40 ≥150 cm3 (P = .03). CONCLUSIONS Hypofractionated RT with 15 fraction regimens results in an acceptable incidence of CW toxicity, specifically CW pain. We recommend a dose constraint of V40 <150 cm3 to minimize this adverse event.
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Affiliation(s)
- Cameron W Swanick
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Randa Tao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adenike M Olanrewaju
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jordan R Sutton
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - James Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher H Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Roy S, Pathy S, Mohanti BK, Raina V, Jaiswal A, Kumar R, Kalaivani M. Accelerated hypofractionated radiotherapy with concomitant chemotherapy in locally advanced squamous cell carcinoma of lung: evaluation of response, survival, toxicity and quality of life from a Phase II randomized study. Br J Radiol 2016; 89:20150966. [PMID: 26986459 DOI: 10.1259/bjr.20150966] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility and efficacy of accelerated hypofractionated radiation with concomitant chemotherapy (AHFx-RT-CT) in locally advanced squamous cell carcinoma (SCC) of the lung. METHODS 36 patients were enrolled in this study (CTRI/2013/11/004143). Patients in Arm A (n = 18) received neoadjuvant chemotherapy (NACT) (paclitaxel 200 mg m(-2) and carboplatin area under the curve 5) followed by external radiotherapy (60 Gy/30 fractions/6 weeks). Patients in Arm B (n = 18) received NACT as in Arm A followed by AHFx-RT (48 Gy/20 fractions/4 weeks) with concomitant chemotherapy (cisplatin 30 mg m(-2) weekly). Primary end points included comparative evaluation of overall locoregional response rates (ORRs) and progression-free survival (PFS). Secondary end points included toxicity, quality of life (QOL) and overall survival (OS). RESULTS The median follow-up duration was 15 months. The ORR at first follow-up (72.2% vs 44%, p = 0.06) and at 1 year after treatment completion (61% vs 5.5%, p = 0.04) were superior in Arm B. The median PFS (17 vs 5.36 months; p = 0.053) and OS (24.73 vs 12.33 months; p = 0.007) were also superior in Arm B. Grade ≥3 acute pharyngitis/oesophagitis was less in Arm B (p = 0.05). Improvement of emotional function, cognitive function and chest pain was observed in Arm B. CONCLUSION The study suggests that AHFx-RT-CT is feasible for locally advanced SCC of the lung with improved response rate, survival, QOL and favourable toxicity. ADVANCES IN KNOWLEDGE To the best of our knowledge, this is the first study comparing conventionally fractionated radiation with AHFx-RT-CT. Addition of low-dose weekly cisplatin as radiosensitizer may be the potential factor responsible for improved response rate, survival and favourable toxicity in the study arm despite lower biological effective dose.
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Affiliation(s)
- Soumyajit Roy
- 1 Department of Radiation Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sushmita Pathy
- 1 Department of Radiation Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Bidhu K Mohanti
- 1 Department of Radiation Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Vinod Raina
- 2 Department of Medical Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Anand Jaiswal
- 3 Department of Pulmonary Medicine, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Rakesh Kumar
- 4 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Mani Kalaivani
- 5 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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