Use of simultaneous radiation boost achieves high control rates in patients with non-small-cell lung cancer who are not candidates for surgery or conventional chemoradiation

Clinical implementation and evaluation of deep learning-assisted automatic radiotherapy treatment planning for lung cancer

PURPOSE

The purpose of the study is to investigate the clinical application of deep learning (DL)-assisted automatic radiotherapy planning for lung cancer.

METHODS

A DL model was developed for predicting patient-specific doses, trained and validated on a dataset of 235 patients with diverse target volumes and prescriptions. The model was integrated into clinical workflow with DL-predicted objective functions. The automatic plans were retrospectively designed for additional 50 treated manual volumetric modulated arc therapy (VMAT) plans. A comparison was made between automatic and manual plans in terms of dosimetric indexes, monitor units (MUs) and planning time. Plan quality metric (PQM) encompassing these indexes was evaluated, with higher PQM values indicating superior plan quality. Qualitative evaluations of two plans were conducted by four reviewers.

RESULTS

The PQM score was 40.7 ± 13.1 for manual plans and 40.8 ± 13.5 for automatic plans (P = 0.75). Compared to manual plans, the targets coverage and homogeneity of automatic plans demonstrated no significant difference. Manual plans exhibited better sparing for lung in V5 (difference: 1.8 ± 4.2 %, P = 0.02), whereas automatic plans showed enhanced sparing for heart in V30 (difference: 1.4 ± 4.7 %, P = 0.02) and for spinal cord in Dmax (difference: 0.7 ± 4.7 Gy, P = 0.04). The planning time and MUs of automatic plans were significantly reduced by 70.5 ± 20.0 min and 97.4 ± 82.1. Automatic plans were deemed acceptable in 88 % of the reviews (176/200).

CONCLUSIONS

The DL-assisted approach for lung cancer notably decreased planning time and MUs, while demonstrating comparable or superior quality relative to manual plans. It has the potential to provide benefit to lung cancer patients.

Evidence-based clinical recommendations for hypofractionated radiotherapy: exploring efficacy and safety - Part 2. Lung (non-small cell lung cancer)

Several recent studies have investigated the use of hypofractionated radiotherapy (HFRT) for various cancers. However, HFRT for non-small cell lung cancer (NSCLC) with or without concurrent chemotherapy is not yet widely used because of concerns about serious side effects and the lack of evidence for improved treatment results. Investigations of HFRT with concurrent chemotherapy in NSCLC have usually been performed in single-arm studies and with a small number of patients, so there are not yet sufficient data. Therefore, the Korean Society for Radiation Oncology Practice Guidelines Committee planned this review article to summarize the evidence on HFRT so far and provide it to radiation oncology clinicians. In summary, HFRT has demonstrated promising results, and the reviewed data support its feasibility and comparable efficacy for the treatment of locally advanced NSCLC. The incidence and severity of esophageal toxicity have been identified as major concerns, particularly when treating large fraction sizes. Strategies, such as esophagus-sparing techniques, image guidance, and dose constraints, may help mitigate this problem and improve treatment tolerability. Continued research and clinical trials are essential to refine treatment strategies, identify optimal patient selection criteria, and enhance therapeutic outcomes.

Persisting Gaps in Optimal Care of Stage III Non-small Cell Lung Cancer: An Australian Patterns of Care Analysis

BACKGROUND

Wide variation exists globally in the treatment and outcomes of stage III patients with non-small cell lung cancer (NSCLC). We conducted an up-to-date patterns of care analysis in the state of Victoria, Australia, with a particular focus on the proportion of patients receiving treatment with radical intent, treatment trends over time, and survival.

MATERIALS AND METHODS

Stage III patients with NSCLC were identified in the Victorian Lung Cancer Registry and categorized by treatment received and treatment intent. Logistic regression was used to explore factors predictive of receipt of radical treatment and the treatment trends over time. Cox regression was used to explore variables associated with overall survival (OS). Covariates evaluated included age, sex, ECOG performance status, smoking status, year of diagnosis, Australian born, Aboriginal or Torres Strait Islander status, socioeconomic status, rurality, public/private status of notifying institution, and multidisciplinary meeting discussion.

RESULTS

A total of 1396 patients were diagnosed between 2012 and 2019 and received treatment with radical intent 67%, palliative intent 23%, unknown intent 5% and no treatment 5%. Radical intent treatment was less likely if patients were >75 years, ECOG ≥1, had T3-4 or N3 disease or resided rurally. Surgery use decreased over time, while concurrent chemoradiotherapy and immunotherapy use increased. Median OS was 38.0, 11.1, and 4.4 months following radical treatment, palliative treatment or no treatment, respectively.

CONCLUSION

Almost a third of stage III patients with NSCLC still do not receive radical treatment. Strategies to facilitate radical treatment and better support decision making between increasing multimodality options are required.

Dose-escalation by hypofractionated simultaneous integrated boost IMRT in unresectable stage III non-small-cell lung cancer

Background

To explore the maximum tolerated dose (MTD) and evaluate the safety of dose escalation using hypofractionated simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) concurrent with chemotherapy for unresectable stage III non-small cell lung cancer (NSCLC).

Methods

Four escalating radiation dose levels were used. This study included 25 patients with previously untreated NSCLC who received six concurrent weekly chemotherapy cycles comprising cisplatin and docetaxel. Dose-limiting toxicity (DLT) was defined as any acute toxicity that interrupted radiotherapy for more than 1 week. MTD was defined as the highest dose level that didn’t induce DLT or grade 5 toxicity in two patients.

Results

All 25 patients received the prescribed escalating radiation dose from the start dose up to LEVEL 4. Two patients experienced DLT at dose LEVEL 4. One patient died because of upper gastrointestinal hemorrhage within 6 months after radiotherapy, whereas another patient among the additional five patients died because of grade 5 radiation pneumonitis within 2 months after radiotherapy. Dose LEVEL 3 was defined as MTD. The 1- and 2-year local controls were 82.8 and 67.8%, respectively. The median progression-free survival was 15.4 months, whereas the median overall survival was 27.3 months.

Conclusions

Dose escalation was safely achieved up to LEVEL 3 [the planning gross target volume (PTVG) 60.5 Gy/22 Fx, 2.75 Gy/Fx; the planning clinical target volume (PTVC) 49.5 Gy/22 Fx] using SIB-IMRT concurrently with chemotherapy for unresectable stage III NSCLC, and the acute toxicities were generally well tolerated. Further prospective studies on long-term outcomes and late toxicities are warranted.

Trial registration

Retrospective registration, ChiCTR1900027290(08/11/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-09099-3.

Effect of Intensity Modulated Radiotherapy (IMRT) on the immunity, physical status and clinical effect of locally advanced NSCLC patients

Objectives:

To evaluate the clinical value of radiotherapy combined with Camrelizumab in treating locally advanced non-small cell lung cancer (NSCLC) patients.

Methods:

80 locally advanced NSCLC patients were randomly divided into two groups (n=40). The control group was administered with intensity modulated radiation therapy (IMRT), whereas the experimental group with Camrelizumab in addition to IMRT. All the patients underwent clinical efficacy evaluation in terms of adverse drug reaction (ADR), physical status improvement after the treatment, and changes in T lymphocyte subpopulations (incl. CD3⁺, CD4⁺, CD8⁺, CD4⁺/CD8⁺).

Results:

The efficacy was found to be 70% and 47.5 in experimental group and control group, respectively, with the former being significantly better than the latter (p=0.03). The ADR rates were 50% and 37.5% in the experimental group and control group, respectively; but the difference remained insignificant (p=0.26). As for physical status improvement, experimental group evidently excelled the control group (p=0.04). The post-treatment indicators such as CD3⁺, CD4⁺, CD8⁺, CD4⁺/CD8⁺ were significantly more improved in the experimental group than the control group (CD3⁺, p=0.02; CD4⁺, p=0.00; and CD4⁺/CD8⁺, p=0.01). However, the changes in CD8+ were not significant at all (p=0.46).

Conclusions:

The combined therapy of IMRT with Camrelizumab appeared effective in dealing with the locally advanced NSCLC patients, as such patients presented significantly better immune state and physical status improvement but not increased ADR. The therapy is both safe and effective.

Hypofractionated Volumetric-Modulated Arc Radiotherapy for Patients With Non-Small-Cell Lung Cancer Not Suitable for Surgery or Conventional Chemoradiotherapy or SBRT

Background

Hypofractionated radiotherapy (HypoRT) has been used to pursue an alternative treatment regimen for patients with non-small-cell lung cancer (NSCLC) who are not eligible for stereotactic ablative radiotherapy (SABR), surgery or concurrent chemoradiotherapy (CCRT) and has shown good local control and safety. We analyzed the feasibility of using volumetric-modulated arc radiotherapy (VMAT) with the simultaneous integrated boost (SIB) technique to achieve high local control with few treatment-related toxicities.

Patients and Methods

A total of 55 patients with stage I-IV NSCLC who were not candidates for SABR, surgery or CCRT were included in the present study. All patients received a prescribed dose of 60 to 66 Gy in 15 fractions. Local progression-free survival (LPFS), PFS, overall survival (OS), and toxicities were retrospectively analyzed.

Results

Thirty-three patients (60.0%) had stage IV or recurrent disease in this study. The median follow-up time was 8 months (interquartile range: 5.0-16.3 months). The 1-year and 2-year OS rates were 84.3% and 69.9%, and the 1-year and 2-year LPFS rates were 91.0% and 63.0%. The median OS (mOS) and median LPFS (mLPFS) were not reached, and median PFS (mPFS) was 15 months. Twenty-eight (51.9%) patients had disease progression at the time of analysis. Of these, 7 (13.0%), 7 (13.0%) and 21 (38.9%) had local recurrence, locoregional failure and distant metastasis, respectively. All cases of local recurrence were found within the SIB region. Four patients had grade 2-3 pneumonitis, and 8 patients had grade 2-3 esophagitis. Patients with grade 2-3 esophagitis had significantly higher maximum dose and dose to 5 cm³ volume to esophagus than those with grade 0-1 esophagitis. No grade 4 or higher toxicity was observed.

Conclusion

The 60 to 66 Gy in 15 fractions RT regimen provides favorable local control and survival with well-tolerated toxicities. Hypofractionated VMAT+SIB is an alternative treatment option for patients with NSCLC who cannot tolerate standard definitive therapy.

Adaptive intensity-modulated radiotherapy with simultaneous integrated boost for stage III non-small cell lung cancer: Is a routine adaptation beneficial?

PURPOSE

Tumor and anatomical changes during radiotherapy have been observed in stage III non-small cell lung cancer (NSCLC) from many previous studies. We hypothesized that a routinely scheduled adaptive radiotherapy would have clinical important dose benefits to lower the risk of toxicities, without increasing the tumor recurrences.

METHODS

We retrospectively reviewed 92 consecutive patients with inoperable stage III NSCLC between November 2017 and March 2019. All eligible patients should received simultaneously integrated boost (SIB) using intensity-modulated radiation therapy (IMRT). A mid-treatment CT simulation and a new adapted plan were routinely given after the first 20 fractions. The organs at risk (OARs) were delineated per RTOG 1106 atlas. Dose-volume histograms were quantitatively compared between the initial and composite adaptive plans. Logistic regression was applied to analyze the dose-response relationship. Clinical endpoints included acute symptomatic radiation pneumonitis (RP2) and esophagitis (RE2), local and regional tumor control, and progression-free survival (PFS).

RESULTS

Sixty-four eligible patients received adaptive SIB-IMRT were consecutively included. The GTVs reduced by a median of -38.2% after 42 to 44 Gy in 20 fractions of radiotherapy. By adapting to tumor and anatomical changes, dosimetric parameters of OARs decreased significantly. The mean lung dose decreased by an average of -74.8 cGy, and mean esophagus dose was lower by 183.1 cGy. We found grade 2 or higher acute RP in 11 patients (17.2%), and RE2 in 28 patients (43.8%). Commonly used lung and esophagus dose metrics were significantly associated with RP2 and RE2. The adaptation could reduce RP2 probability by 3%, and RE2 risk by 5%. Subgroups with higher OARs dose or larger tumor shrinkage may get more dose and toxicities benefits. The estimated median PFS was 12.5 months from the start of radiotherapy.

CONCLUSIONS

We demonstrated that the routinely adaptive SIB-IMRT strategy could significantly reduce the dose to surrounding normal tissues, potentially lower the associated acute RP and RE, without increasing the risk of tumor recurrences.

Alternative Multidisciplinary Management Options for Locally Advanced NSCLC During the Coronavirus Disease 2019 Global Pandemic

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.

[Application of Simultaneous Integrated Boost Intensity Modulated Radiotherapy in Locally Advanced Non-small Cell Lung Cancer]

背景与目的

局部晚期非小细胞肺癌（non-small cell lung cancer, NSCLC）的标准治疗方案为放疗联合化疗，但其生存仍不令人满意。随着调强放疗技术的发展，同步推量（simultaneous integrated boost, SIB）技术成为局部晚期NSCLC的研究方向。本研究拟探讨局部晚期NSCLC采用SIB调强放疗技术的有效性和安全性。

方法

回顾性分析北京大学肿瘤医院2015年6月-2018年12月采用SIB技术进行放疗的局部晚期NSCLC患者资料，采用Kaplan-Meier方法进行统计分析，分析其疗效、生存及治疗相关毒性。

结果

研究纳入93例患者，中位随访时间34.23个月，3年生存率、无进展生存率、无局部区域复发生存率和无远处转移生存率分别为53.0%、37.0%、50.5%和50.5%。3级放射性食管炎发生率为5.4%，≥3级放射性肺炎发生率为2.2%。

结论

局部晚期NSCLC采用SIB调强放疗技术安全有效。

Survival score to characterize prognosis in inoperable stage III NSCLC after chemoradiotherapy

Background

Stage III non-small cell lung cancer (NSCLC) represents a heterogeneous disease regarding principal patient- and tumor characteristics. A simple score may aid in personalizing multimodal therapy.

Methods

The data of 99 consecutive patients with performance status ECOG 0-1 treated until the end of 2016 with multimodal approach for inoperable NSCLC (UICC 7^th edition stage IIIA/B) were evaluated. Patient- and tumor-related factors were examined for their impact on overall survival. Factors showing a negative association with prognosis were then included in the score. Three subgroups with low, intermediate and high-risk score were defined. The results were then validated in the prospective cohort, which includes 45 patients.

Results

Most Patients were treated with concurrent (78%) or sequential (11%) chemoradiotherapy. 53% received induction chemotherapy. Median survival for the entire cohort was 20.8 (range: 15.3-26.3) months. Age (P=0.020), gender (P=0.007), pack years (P=0.015), tumor-associated atelectasis (P=0.004) and histology (P=0.004) had a significant impact on overall survival and were scored with one point each. Twelve, 59 and 28 patients were defined to have a low (0-1 points), intermediate (2-3 points) and high-risk (4-5 points) score. Median survival, 1-, 2- and 3-year survival rates were not reached, 100%, 83% and 67% in the low, 22.9 months, 80%, 47% and 24% intermediate and 13.7 months, 57%, 25% and 18% high-risk patients, respectively (P<0.001). Median survival was not reached in prospective cohort; analysis has revealed a trend for the 1-year survival rates with 100% for the low, 93% intermediate and 69% high-risk patients (P=0.100).

Conclusions

The score demonstrated remarkable survival differences in inoperable stage III NSCLC patients with good performance status receiving multimodal therapy.

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

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.

Locally advanced inoperable primary or recurrent non-small cell lung cancer treated with 4-week hypofractionated radiation therapy (3 Gy/fraction)

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.

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

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.

Optimized radiotherapy to improve clinical outcomes for locally advanced lung cancer

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.

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

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.

The potential for increased tumor control probability in non-small cell lung cancer with a hypofractionated integrated boost to the gross tumor volume

Treatment outcomes in locally advanced non-small cell lung cancer (NSCLC) to date have been poor, with normal tissue toxicity often limiting the dose that can be delivered to the tumor. Treatment intensification in NSCLC via targeted dose escalation with modern delivery techniques may offer the potential for a significant increase in tumor control probability (TCP) without a clinically significant increase in organ-at-risk (OAR) toxicity. In this planning study, 20 patients were re-planned with a volumetric modulated arc therapy (VMAT) and an inhomogeneous dose distribution with iteratively escalated doses to the gross tumor volume (iGTV) (composite GTV across multiple 4-dimensional computed tomography [4DCT] phases) in a series of 20 fraction regimes. For each plan OAR doses, target coverage and predicted TCPs were collected and compared with homogenous 3-dimensional (3D) and VMAT plans, as well as with each other. In 70% of patients, it was possible to escalate to 75 Gy in 20 fractions within OAR tolerances, opening the possibility of treating these patients to a biological effective dose (BED) of 103.1 Gy₁₀. This planning study forms the basis of a clinical trial INTENSE (Inhomogeneous Targeted Dose Escalation in Non-Small CEll Lung Cancer), CTRIAL 15-47.

Simultaneous Integrated Boost for Radiation Dose Escalation to the Gross Tumor Volume With Intensity Modulated (Photon) Radiation Therapy or Intensity Modulated Proton Therapy and Concurrent Chemotherapy for Stage II to III Non-Small Cell Lung Cancer: A Phase 1 Study

PURPOSE

To establish, in the phase 1 portion of a prospective phase 1/2 study, the maximum tolerated dose of image guided intensity modulated radiation therapy (IMRT) or proton therapy (IMPT), both with a simultaneous integrated boost (SIB), for patients with stage II to IIIB non-small cell lung cancer receiving concurrent chemoradiation therapy.

METHODS AND MATERIALS

Patients had pathologically proven non-small cell lung cancer, either unresectable stage II to IIIB disease or recurrent disease after surgical resection, and could tolerate concurrent chemoradiation. Radiation doses were selectively escalated to the SIB volume (internal gross tumor volume + 5-mm margin), and the dose to the planning target volume (internal gross tumor volume + 8-mm margin for clinical target volume + 5 mm) was kept at 60 Gy [cobalt gray equivalent (CGE)] over 30 fractions. Patients were randomized between the IMRT and IMPT groups if slots were available on the treatment machines for both groups. Otherwise, patients were allocated to IMRT or IMPT, whichever had an open treatment slot on the machine without randomization.

RESULTS

Fifteen patients (6 IMRT, 9 IMPT) were enrolled. The highest doses to the SIB were 72 Gy in the IMRT group and 78 Gy(CGE) in the IMPT group. Nine patients (6 IMRT, 3 IMPT) received an SIB dose of 72 Gy(CGE) [biologically effective dose = 89.3 Gy(CGE)], and 6 patients (IMPT) received an SIB dose of 78 Gy(CGE) [biologically effective dose = 98.3 Gy(CGE)]. Dose-limiting (grade ≥3) toxicity (esophagitis) developed in 1 of the 9 patients given 72 Gy(CGE) SIB. Grade ≥3 pneumonitis developed in 2 of the 6 patients treated to 78 Gy(CGE) IMPT SIB: 1 (grade 3) at 3 months after treatment and the other (grade 5, possibly related to treatment) at 2 months after treatment. Only 1 patient developed a marginal tumor recurrence with a median follow-up of 25 months (range, 4.3-47.4 months).

CONCLUSIONS

We recommend that an SIB dose of 72 Gy(CGE) be used as the highest SIB dose for the planned randomized phase 2 study.

Outcome and toxicity of intensity modulated radiotherapy with simultaneous integrated boost in locally advanced non-small cell lung cancer patients

PURPOSE

The aim of this study was to assess the feasibility and treatment outcome of intensity modulated radiation therapy with simultaneous integrated boost (SIB-IMRT) in locally advanced non-small cell lung cancer (NSCLC) patients.

MATERIALS AND METHODS

A total of 64 NSCLC patients with stage IIB (3%), IIIA (36%), and IIIB (61%) were treated with concomitant (N = 47; 73%) or sequential (N = 9; 14%) chemotherapy between February 2009 and January 2014. Eight patients (13%) received RT alone. All patients received the same irradiation scheme using IMRT: prophylactic dose for mediastinum was 56 Gy at 1.65 Gy/fraction and SIB to macroscopic disease up to 68 Gy at 2 Gy/fraction.

RESULTS

The median follow-up was 16 months (range, 1-70 months). The overall survival rate for all patients was 79% after 1 year and 46% after 2 years. Disease-free survival (DFS) was 81 and 45% after 1 and 2 years, respectively, resulting in a median DFS of 16 months. Multivariate analysis showed a statistically significant association between stage IIIB patients and a higher risk of mortality (HR 2.11; P = 0.019). In addition, T4 stage associated with higher risk of recurrence (HR 2.23; P = 0.024) while concomitant chemoradiation was associated with lower risk of any recurrence (HR 0.34; P = 0.004) No patient experienced grade ≥3 esophagitis and only 6 cases (9%) had grade 3 pneumonitis. Only having a higher lung volume was associated with higher risk of pneumonitis in the multivariate analysis (HR 16.21; P = 0.022).

CONCLUSION

This study in advanced NSCLC patients shows that SIB-IMRT is an effective technique with acceptable toxicity, also when combined with chemotherapy.

A Dosimetric Comparison of Dose Escalation with Simultaneous Integrated Boost for Locally Advanced Non-Small-Cell Lung Cancer

Background

Many studies have demonstrated that a higher radiotherapy dose is associated with improved outcomes in non-small-cell lung cancer (NSCLC). We performed a dosimetric planning study to assess the dosimetric feasibility of intensity-modulated radiation therapy (IMRT) with a simultaneous integrated boost (SIB) in locally advanced NSCLC.

Methods

We enrolled twenty patients. Five different dose plans were generated for each patient. All plans were prescribed a dose of 60 Gy to the planning tumor volume (PTV). In the three SIB groups, the prescribed dose was 69 Gy, 75 Gy, and 81 Gy in 30 fractions to the internal gross tumor volume (iGTV).

Results

The SIB-IMRT plans were associated with a significant increase in the iGTV dose (P < 0.05), without increased normal tissue exposure or prolonged overall treatment time. Significant differences were not observed in the dose to the normal lung in terms of the V5 and V20 among the four IMRT plans. The maximum dose (Dmax) in the esophagus moderately increased along with the prescribed dose (P < 0.05).

Conclusions

Our results indicated that escalating the dose by SIB-IMRT is dosimetrically feasible; however, systematic evaluations via clinical trials are still warranted. We have designed a further clinical study (which is registered with ClinicalTrials.gov, number NCT02841228).

Local Control and Toxicity of Adaptive Radiotherapy Using Weekly CT Imaging: Results from the LARTIA Trial in Stage III NSCLC

INTRODUCTION

Anatomical change of tumor during radiotherapy contributes to target missing. However, in the case of tumor shrinkage, adaptation of volume could result in an increased incidence of recurrence in the area of target reduction. This study aims to investigate the incidence of failure of the adaptive approach and, in particular, the risk for local recurrence in the area excluded after replanning.

METHODS

In this prospective study, patients with locally advanced NSCLC treated with concomitant chemoradiation underwent weekly chest computed tomography simulation during treatment. In the case of tumor shrinkage, a new tumor volume was delineated and a new treatment plan outlined (replanning). Toxicity was evaluated with the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer scale. Patterns of failures were classified as in field (dimensional and/or metabolic progression within the replanning planning target volume [PTV]), marginal (recurrence in initial the PTV excluded from the replanning PTV), and out of field (recurrence outside the initial PTV).

RESULTS

Replanning was outlined in 50 patients selected from a total of 217 patients subjected to weekly simulation computed tomography in our center from 2012 to 2014. With a median follow-up of 20.5 months, acute grade 3 or higher pulmonary and esophageal toxicity were reported in 2% and 4% of cases and late toxicity in 4% and 2%, respectively. Marginal relapse was recorded in 6% of patients, and 20% and 4% of patients experienced in-field and out-of-field local failure, respectively.

CONCLUSIONS

The reduced toxicity and the documented low rate of marginal failures make the adaptive approach a modern option for future randomized studies. The best scenario to confirm its application is probably in neoadjuvant chemoradiation trials.

Outcomes and toxicity following high-dose radiation therapy in 15 fractions for non-small cell lung cancer

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.

Stereotactic ablative radiotherapy for adrenal gland metastases: Factors influencing outcomes, patterns of failure, and dosimetric thresholds for toxicity

PURPOSE

We report our single-institution experience with stereotactic ablative radiotherapy (SABR) for adrenal metastasis and identify factors influencing outcomes, patterns of failure, and dosimetric thresholds for toxicity.

METHODS AND MATERIALS

We identified patients with adrenal metastases treated with SABR from 2009 to 2015. Toxicity was evaluated with Common Terminology Criteria for Adverse Events v4.0. Local failures were categorized as in-field, marginal, or out-of-field. New or progressive disease outside the treated adrenal gland was considered distant failure. Survival and time to local and distant failure were estimated by the Kaplan-Meier method. Prognostic factors were evaluated with a Cox proportional hazards model. Fisher's exact tests were used to compare toxicity between dosimetric thresholds.

RESULTS

Forty-three patients with 49 adrenal metastases (84% from lung) were treated with SABR to a median prescribed dose of 60 Gy in 10 fractions. Median overall survival time was 19 months, and 1- and 2-year rates were 65% and 42%, respectively. Bilateral adrenal metastases were associated with worse overall survival (P = .01). Median progression-free survival (PFS) time was 6 months, with most progressions being distant failure (most often to brain or bone). PFS was better in patients with a solitary adrenal metastasis (P = .03). Median time to local failure was not reached; the 1-year freedom from local failure rate was 74%. Nine failures were in field and 1 was marginal; no local failures occurred in lesions treated with biologically equivalent doses of >100 Gy. No patient experienced grade 3-5 toxicity. Low-grade gastrointestinal toxicity was common, but grade 2 toxicity was avoided in patients with a maximum stomach-bowel point dose of ≤50 Gy (P = .03). Low-grade adrenal insufficiency was common with bilateral treatment.

CONCLUSION

SABR was well tolerated and resulted in good 1-year local control; PFS was promising for patients with solitary metastases. Low-grade toxicity was common, but can be minimized with strict dosimetric constraints.

Incidence and predictors of chest wall toxicity after high-dose radiation therapy in 15 fractions

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.

Superior sulcus non-small cell lung carcinoma: A comparison of IMRT and 3D-RT dosimetry

AIM

A dosimetric study comparing intensity modulated radiotherapy (IMRT) by TomoTherapy to conformational 3D radiotherapy (3D-RT) in patients with superior sulcus non-small cell lung cancer (NSCLC).

BACKGROUND

IMRT became the main technique in modern radiotherapy. However it was not currently used for lung cancers. Because of the need to increase the dose to control lung cancers but because of the critical organs surrounding the tumors, the gains obtainable with IMRT is not still demonstrated.

MATERIAL AND METHODS

A dosimetric comparison of the planned target and organs at risk parameters between IMRT and 3D-RT in eight patients who received preoperative or curative intent irradiation.

RESULTS

In the patients who received at least 66 Gy, the mean V95% was significantly better with IMRT than 3D-RT (p = 0.043). IMRT delivered a lower D2% compared to 3D-RT (p = 0.043). The IH was significantly better with IMRT (p = 0.043). The lung V 5 Gy and V 13 Gy were significantly higher in IMRT than 3D-RT (p = 0.043), while the maximal dose (D max) to the spinal cord was significantly lower in IMRT (p = 0.043). The brachial plexus D max was significantly lower in IMRT than 3D-RT (p = 0.048). For patients treated with 46 Gy, no significant differences were found.

CONCLUSION

Our study showed that IMRT is relevant for SS-NSCLC. In patients treated with a curative dose, it led to a reduction of the exposure of critical organs, allowing a better dose distribution in the tumor. For the patients treated with a preoperative schedule, our results provide a basis for future controlled trials to improve the histological complete response by increasing the radiation dose.

Normal tissue considerations and dose-volume constraints in the moderately hypofractionated treatment of non-small cell lung cancer

Hypofractionated radiation therapy (RT) regimes in non-small cell lung cancer (NSCLC) have become increasingly popular with a number of international trials currently underway. The majority of the dose-volume-constraints (DVCs) published in the literature refer to conventional 2Gy per fraction deliveries. Here relevant organs-at-risk (OARs) are identified and available dose-volume constraint data discussed and summarised for moderately hypofractionated NSCLC regimes. The OARs examined include lung, brachial plexus, heart, oesophagus, airway and spinal cord. Where available the toxicity rates are also reported with all data summarised tabulated to aid its use in the clinic.

Definitive chemotherapy and radiotherapy in patients with stage II non-small cell lung cancer: A population-based outcomes study

OBJECTIVES

There is a paucity of data on non-surgical outcomes specific to stage II non-small cell lung cancer (NSCLC) patients receiving definitive chemotherapy and radiation therapy (CRT). This study reports population-based outcomes for this subgroup, and investigates a radiation dose-response for overall survival.

MATERIALS AND METHODS

The National Oncology Data Alliance (NODA), a merging of multiple tumor registries maintained by Elekta(®) medical systems, was queried for stage II patients and CRT. Only curative cases (RT doses ≥59 Gy) were included. Both sequential and concurrent CRT were allowed. Univariate and Cox multivariate techniques were used to assess factors significant for overall survival. These factors included: gender, age, race, radiation dose, radiation total treatment time, stage, histology, tumor size, and chemotherapy sequence.

RESULTS

A total of 568 patients were included in the analysis, with a median follow-up of 12.9 months for surviving patients. Patients were treated between 2004 and 2014. Median survival was 20.5 months (95% confidence interval (CI) 18-23 months), with 16% patients alive at 5 years. Only gender was found to be significantly associated with survival in the Cox model. Although median survival was higher in patients receiving greater than 60 Gy (21 months, 95% CI 18-24 moths) compared to 59-60 Gy (16.5 months 95% CI 10-23 months), this was not statistically significant (p=0.6).

CONCLUSIONS

This is the first report on outcomes for stage II NSCLC patients receiving CRT as definitive therapy. Survival approximates stage III CRT patients from historical phase III trials. As an increasing aging population may parallel a rise in medically inoperable stage II patients, this study can provide useful information when reviewing treatment options.