Hypofractionated Concomitant Chemoradiation in Inoperable Locally Advanced Non-small Cell Lung Cancer: A Report on 100 Patients and a Systematic Review

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.

Randomized, Multicenter, Phase 3 Study of Accelerated Fraction Radiation Therapy With Concomitant Boost to the Gross Tumor Volume Compared With Conventional Fractionation in Concurrent Chemoradiation in Patients With Unresectable Stage III Non-Small Cell Lung Cancer: The Korean Radiation Oncology Group 09-03 Trial

PURPOSE

We designed the Korean Radiation Oncology Group 09-03 phase III clinical trial to compare accelerated hypofractionated radiation therapy (RT) using a concomitant boost to the gross tumor volume (GTV) with conventionally fractionated 60-Gy RT in patients with stage III unresectable non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

A conventionally fractionated RT group (arm 1; 124 patients) received a 2-Gy daily dose to a total cumulative dose of 44 Gy to the planning target volume (PTV) in 22 fractions and 60 Gy to the GTV in 30 fractions over 6 weeks. A hypofractionated RT group (arm 2; 142 patients) received a 1.8-Gy daily dose to the PTV with a synchronous boost of 0.6 Gy to the GTV, for total cumulative doses of 45 Gy to the PTV and 60 Gy to the GTV in 25 fractions over 5 weeks. All patients received concurrent weekly chemotherapy consisting of paclitaxel and cisplatin.

RESULTS

The objective response rate of all patients was 86.5% (arm 1, 84.6%; arm 2, 88.1%; P = .612). The median overall survival was 26 months (arm 1, 26 months; arm 2, 27 months; P = .508). The median progression-free survival was 11 months (arm 1, 10 months; arm 2, 13 months; P = .295). The local tumor control rates at 2 and 5 years were 58.3% and 50.7%, respectively (arm 1, 62.4% and 51.0%, respectively; arm 2, 54.0% and 48.6%, respectively; P = .615). There were no significant between-group differences in the cumulative incidence of grade ≥3 radiation pneumonitis (P = .134) or radiation esophagitis (P = .539).

CONCLUSIONS

This clinical trial did not confirm the superiority of accelerated 2.4-Gy hypofractionated RT compared with conventional 2-Gy fractionation in patients with unresectable stage III NSCLC undergoing concurrent chemoradiation therapy.

Excessive esophageal toxicity in patients with locally advanced non-small cell lung cancer treated with concurrent hypofractionated chemoradiotherapy and 3-weekly platinum doublet chemotherapy

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Concurrent full dose chemoradiotherapy (24x2.75 Gy) is toxic in multiple N2 disease.

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Toxicity after platinum doublet chemoradiation (24x2.75 Gy) is mainly esophageal.

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Fatal toxicity may be increased in patients with bulky centrally located tumors.

Introduction

Concurrent chemoradiation followed by immunotherapy is the standard of care for patients with stage III non-small cell lung cancer (NSCLC). Prior to the introduction of adjuvant immunotherapy, we treated patients with stage III NSCLC with concurrent platinum doublet chemotherapy and 66 Gy in 24 fractions. We determined the toxicity of this treatment.

Methods

A retrospective observational study was performed in a cohort of patients with stage III NSCLC, <70 years old, and WHO performance score 0–1. Patients were treated with concurrent platinum doublet chemotherapy and 66 Gy in 24 fractions. All patients were staged with a PET-scan and brain MRI-scan. Toxicity was scored using the common criteria for adverse events (CTCAE v4.03).

Results

Between 2012 and 2017, 41 patients were treated with mildly hypofractionated radiotherapy and platinum doublet chemotherapy. The median follow-up was 4.7 years. The median age was 57 and 58% of patients were male. The majority of patients had stage IIIB disease (68%). The median total Gross Tumor Volume (GTV) was 104 cc (range: 15–367 cc). The median lymph node GTV was 59 cc (10–341 cc). Five patients died: four due to an esophagus perforation or fistula, and one due to pulmonary bleeding. Grade ≥ 3 esophageal toxicity occurred in 16 patients. Five patients had late grade ≥ 3 esophageal toxicity (12%). The median overall survival was 19 months.

Conclusion

Toxicity was unexpectedly high in patients with stage III NSCLC (WHO 0–1) after concurrent platinum doublet chemotherapy and 66 Gy in 24 fractions.

GOECP/SEOR radiotheraphy guidelines for non-small-cell lung cancer

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.

Unmet needs in the management of unresectable stage III non-small cell lung cancer: a review after the 'Radio Talk' webinars

INTRODUCTION

Stage III non-small cell lung cancer (NSCLC) is a variable entity, encompassing bulky primary tumors, nodal involvement or both. Multidisciplinary evaluation is essential to discuss multiple treatment options, to outline optimal management and to examine the main debated topics and critical issues not addressed by current trials and guidelines that influence daily clinical practice.

AREAS COVERED

From March to May 2021, 5 meetings were scheduled in a webinar format titled 'Radio Talk' due to the COVID-19 pandemic; the faculty was composed of 6 radiation oncologists from 6 different Institutions of Italy, all of them were the referring radiation oncologist for lung cancer treatment at their respective departments and were or had been members of AIRO (Italian Association of Radiation Oncology) Thoracic Oncology Study Group. The topics covered included: pulmonary toxicity, cardiac toxicity, radiotherapy dose, fractionation and volumes, unfit/elderly patients, multidisciplinary management.

EXPERT OPINION

The debate was focused on the unmet needs triggered by case reports, personal experiences and questions; the answers were often not univocal, however, the exchange of opinion and the contribution of different centers confirmed the role of multidisciplinary management and the necessity that the most critical issues should be investigated in clinical trials.

Improving Outcomes in NSCLC: Optimum Dose Fractionation in Radical Radiotherapy Matters

INTRODUCTION

We analyzed a comprehensive national radiotherapy data set to compare outcomes of the most frequently used moderate hypofractionation regimen (55 Gy in 20 fractions) and conventional fractionation regimen (60-66 Gy in 30-33 fractions).

METHODS

A total of 169,863 cases of NSCLC registered in England from January 2012 to December 2016 obtained from the Public Health England were divided into cohort 1 (training set) diagnosed in 2012 to 2013 and cohort 2 (validation set) diagnosed in 2014 to 2016. Radiotherapy data were obtained from the National Radiotherapy Dataset and linked by National Health Service number to survival data from the Office of National Statistics and Hospital Episode Statistics, from which surgical data and Charlson comorbidity index were obtained. Of 73,186 patients with stages I to III NSCLC, 12,898 received radical fractionated radiotherapy (cohort 1-4894; cohort 2-8004). The proportional hazards model was used to investigate overall survival from time of diagnosis. Survival was adjusted for the prognostic factors of age, sex, stage of disease, comorbidity, other radical treatments, and adjuvant chemotherapy, and the difference between the treatment schedules was summarized by hazard ratio (HR) and 95% confidence interval. The significance of any difference was evaluated by the log likelihood test.

RESULTS

Of patients with stages I to III NSCLC, 17% to 18% received radical fractionated radiotherapy. After adjustment for independent prognostic factors of age, stage, comorbidity, and other radical and adjuvant treatments, patients in cohort 1 treated with the 2.75 Gy per fraction regimen had a median survival of 25 months compared with 29 months for patients treated with the 2 Gy per fraction regimen (HR = 1.16, p = 0.001). Similarly, in cohort 2, the respective median survival values were 25 and 28 months (HR = 1.10, p = 0.02).

CONCLUSIONS

Big data analysis of a comprehensive national cohort of patients with NSCLC treated in England suggests that compared with a 4-week regimen of 55 Gy in 20 fractions, a 6-week regimen of conventional daily fractionation to a dose of 60 to 66 Gy at 2 Gy per fraction is associated with a survival benefit. Within the limitations of the retrospective big data analysis with potential selection bias and in the absence of randomized trials, the results suggest that conventional fractionation regimens should remain the standard of care.

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

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.

Reduced Fractionation in Lung Cancer Patients Treated with Curative-intent Radiotherapy during the COVID-19 Pandemic

Patients treated with curative-intent lung radiotherapy are in the group at highest risk of severe complications and death from COVID-19. There is therefore an urgent need to reduce the risks associated with multiple hospital visits and their anti-cancer treatment. One recommendation is to consider alternative dose-fractionation schedules or radiotherapy techniques. This would also increase radiotherapy service capacity for operable patients with stage I-III lung cancer, who might be unable to have surgery during the pandemic. Here we identify reduced-fractionation for curative-intent radiotherapy regimes in lung cancer, from a literature search carried out between 20/03/2020 and 30/03/2020 as well as published and unpublished audits of hypofractionated regimes from UK centres. Evidence, practical considerations and limitations are discussed for early-stage NSCLC, stage III NSCLC, early-stage and locally advanced SCLC. We recommend discussion of this guidance document with other specialist lung MDT members to disseminate the potential changes to radiotherapy practices that could be made to reduce pressure on other departments such as thoracic surgery. It is also a crucial part of the consent process to ensure that the risks and benefits of undergoing cancer treatment during the COVID-19 pandemic and the uncertainties surrounding toxicity from reduced fractionation have been adequately discussed with patients. Furthermore, centres should document all deviations from standard protocols, and we urge all colleagues, where possible, to join national/international data collection initiatives (such as COVID-RT Lung) aimed at recording the impact of the COVID-19 pandemic on lung cancer treatment and outcomes.

Treatment Guidance for Patients With Lung Cancer During the Coronavirus 2019 Pandemic

The global coronavirus disease 2019 pandemic continues to escalate at a rapid pace inundating medical facilities and creating substantial challenges globally. The risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients with cancer seems to be higher, especially as they are more likely to present with an immunocompromised condition, either from cancer itself or from the treatments they receive. A major consideration in the delivery of cancer care during the pandemic is to balance the risk of patient exposure and infection with the need to provide effective cancer treatment. Many aspects of the SARS-CoV-2 infection currently remain poorly characterized and even less is known about the course of infection in the context of a patient with cancer. As SARS-CoV-2 is highly contagious, the risk of infection directly affects the cancer patient being treated, other cancer patients in close proximity, and health care providers. Infection at any level for patients or providers can cause considerable disruption to even the most effective treatment plans. Lung cancer patients, especially those with reduced lung function and cardiopulmonary comorbidities are more likely to have increased risk and mortality from coronavirus disease 2019 as one of its common manifestations is as an acute respiratory illness. The purpose of this manuscript is to present a practical multidisciplinary and international overview to assist in treatment for lung cancer patients during this pandemic, with the caveat that evidence is lacking in many areas. It is expected that firmer recommendations can be developed as more evidence becomes available.

COVID-19: Global radiation oncology's targeted response for pandemic preparedness

As the global COVID-19 pandemic escalates there is a need within radiation oncology to work to support our patients in the best way possible. Measures are required to reduce infection spread between patients and within the workforce. Departments need contingency planning to create capacity and continue essential treatments despite a reduced workforce. The #radonc community held an urgent online journal club on Twitter in March 2020 to discuss these issues and create some consensus on crucial next steps. There were 121 global contributors. This document summarises these discussions around themes of infection prevention, rationalisation of workload and working practice in the presence of infection.

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.