ACR Appropriateness Criteria® Nonsurgical Treatment for Non-Small-Cell Lung Cancer: Good Performance Status/Definitive Intent

American Radium Society Appropriate Use Criteria for Unresectable Locally Advanced Non-Small Cell Lung Cancer

Importance

The treatment of locally advanced non-small cell lung cancer (LA-NSCLC) has been informed by more than 5 decades of clinical trials and other relevant literature. However, controversies remain regarding the application of various radiation and systemic therapies in commonly encountered clinical scenarios.

Objective

To develop case-referenced consensus and evidence-based guidelines to inform clinical practice in unresectable LA-NSCLC.

Evidence Review

The American Radium Society (ARS) Appropriate Use Criteria (AUC) Thoracic Committee guideline is an evidence-based consensus document assessing various clinical scenarios associated with LA-NSCLC. A systematic review of the literature with evidence ratings was conducted to inform the appropriateness of treatment recommendations by the ARS AUC Thoracic Committee for the management of unresectable LA-NSCLC.

Findings

Treatment appropriateness of a variety of LA-NSCLC scenarios was assessed by a consensus-based modified Delphi approach using a range of 3 points to 9 points to denote consensus agreement. Committee recommendations were vetted by the ARS AUC Executive Committee and a 2-week public comment period before official approval and adoption. Standard of care management of good prognosis LA-NSCLC consists of combined concurrent radical (60-70 Gy) platinum-based chemoradiation followed by consolidation durvalumab immunotherapy (for patients without progression). Planning and delivery of locally advanced lung cancer radiotherapy usually should be performed using intensity-modulated radiotherapy techniques. A variety of palliative and radical fractionation schedules are available to treat patients with poor performance and/or pulmonary status. The salvage therapy for a local recurrence after successful primary management is complex and likely requires both multidisciplinary input and shared decision-making with the patient.

Conclusions and Relevance

Evidence-based guidance on the management of various unresectable LA-NSCLC scenarios is provided by the ARS AUC to optimize multidisciplinary patient care for this challenging patient population.

Stereotactic Body Radiation Therapy (SBRT) Using CyberKnife in Oligometastatic Cancer Patients; Retrospective Evaluation, Single Institution Experience

OBJECTIVES

We retrospectively evaluate local control rate at 6 months and 1 year in oligometastatic cancer patients treated with SBRT using CyberKnife.

METHODS

Total of 21 patients with 24 treatment sites from February 2014 till June 2017 who were treated with SBRT in our institution were included in this study.

RESULTS

Eleven patients were males, 10 patients were females, median age at diagnosis was 63 years, and colorectal cancer is the most commonly diagnosed cancer in 18 patients. The abdomino-pelvic lymph nodes were the commonest treatment site in 11 (45.8%), average PTV volume of 46.4 cc. All the patients received SBRT with average (BED) of 97 GY, 7 treatment sites received BED of < 100GYgroup 1, and 17 received BED ≥ 100GY group 2. No reported G3 or G4 acute or chronic toxicity. The 6 months and 1 year local control (LC) were 95.8 and 88.2%, respectively. After a median follow-up of 16.8 months, 19(90.5%) patients were alive; among them, local progression was observed in 1 (4.1%) treatment site, while systemic progression in 4 (16.6%), and two (9.5%) patients died; they had both local and systemic failures. The 1-year local PFS rate was 82%. In univariate analysis, PTV volume was significantly correlated with LC rate at 6 months (p = 0.001), while the site of metastasis appeared to significantly correlate with PFS (p = 0.03).

CONCLUSION

SBRT using CyberKnife is feasible, safe, and effective treatment for oligometastatic sites. Six months and 1 year local control rate is 95.8 and 88.2% respectively in our patients cohort, treatment regimens with higher BED resulting in better 1-year local PFS, although it was not statistically significant. A larger cohort of patients and longer follow up is required for better evaluation.

Predictive factors for survival and correlation to toxicity in advanced Stage III non-small cell lung cancer patients with concurrent chemoradiation

OBJECTIVE

Concurrent chemoradiotherapy is the standard treatment for locally advanced Stage III non-small cell lung cancer in patients with a good performance status and minimal weight loss. This study aimed to define subgroups with different survival outcomes and identify correlations with the radiation-related toxicities.

METHODS

We retrospectively reviewed 381 locally advanced Stage III non-small cell lung cancer patients with a good performance status or weight loss of <10% who received concurrent chemoradiotherapy between 2004 and 2011. Three-dimensional conformal radiotherapy was administered once daily, combined with weekly chemotherapy. The Kaplan-Meier method was used for survival comparison and Cox regression for multivariate analysis. Multivariate analysis was performed using all variables with P values <0.1 from the univariate analysis.

RESULTS

Median survival of all patients was 24 months. Age > 75 years, the diffusion lung capacity for carbon monoxide ≤80%, gross tumor volume ≥100 cm(3) and subcarinal nodal involvement were the statistically significant predictive factors for poor overall survival both in univariate and multivariate analyses. Patients were classified into four groups according to these four predictive factors. The median survival times were 36, 29, 18 and 14 months in Groups I, II, III and IV, respectively (P < 0.001). Rates of esophageal or lung toxicity ≥Grade 3 were 5.9, 14.1, 12.5 and 22.2%, respectively. The radiotherapy interruption rate differed significantly between the prognostic subgroups; 8.8, 15.4, 22.7 and 30.6%, respectively (P = 0.017).

CONCLUSION

Severe toxicity and interruption of radiotherapy were more frequent in patients with multiple adverse predictive factors. To maintain the survival benefit in patients with concurrent chemoradiotherapy, strategies to reduce treatment-related toxicities need to be deeply considered.

Management of normal tissue toxicity associated with chemoradiation (primary skin, esophagus, and lung)

Nearly one quarter of patients with lung cancer present with locally advanced disease where concurrent chemoradiotherapy is the current standard of care for patients with good performance status. Cisplatin-based concurrent chemoradiotherapy consistently showed an improvement in survival compared with sequential chemoradiotherapy, at the expense of an increase in the toxicity profile. Over the past decades, several encouraging biomarkers such as transforming growth factor-beta and radioprotective agents such as amifostine were studied but without reaching approval for patient care. We reviewed the prevalence and risk factors for different adverse effects associated with the combined chemoradiotherapy modality, especially dermatitis, mucositis, esophagitis, and pneumonitis. These adverse effects can further be divided into acute, subacute, and chronic. Dermatitis is usually rare and responds well to topical steroids and usual skin care. Acute esophagitis occurs in 30% of patients and is treated with proton pump inhibitors, promotility agents, local anesthetic, and dietary changes. Radiation pneumonitis is a subacute complication seen in 15% of patients and is usually managed with steroids. Chronic adverse effects such as radiation fibrosis and esophageal stricture occur approximately 6 months after completion of radiation therapy and are usually permanent. In this review, complications of chemoradiotherapy for patients with locally advanced lung cancer are delineated, and approaches to their management are described. Given that treatment interruption is associated with a worse outcome, patients are aggressively treated with a curative intent. Therefore, planning for treatment adverse effects improves patient tolerance, compliance, and outcome.

Use of new treatment modalities for non-small cell lung cancer care in the Medicare population

BACKGROUND

Many older patients with early stage non-small cell lung cancer (NSCLC) do not receive curative therapy. New surgical techniques and radiation therapy modalities, such as video-assisted thoracoscopic surgery (VATS), potentially allow more patients to receive treatment. The adoption of these techniques and their impact on access to cancer care among Medicare beneficiaries with stage I NSCLC are unknown.

METHODS

We used the Surveillance, Epidemiology and End Results-Medicare database to identify patients with stage I NSCLC diagnosed between 1998 and 2007. We assessed temporal trends and created hierarchical generalized linear models of the relationship between patient, clinical, and regional factors and type of treatment.

RESULTS

The sample comprised 13,458 patients with a mean age of 75.7 years. The proportion of patients not receiving any local treatment increased from 14.6% in 1998 to 18.3% in 2007. The overall use of surgical resection declined from 75.2% to 67.3% ( P , .001), although the proportion of patients undergoing VATS increased from 11.3% to 32.0%. Similarly, although the use of new radiation modalities increased from 0% to 5.2%, the overall use of radiation remained stable. The oldest patients were less likely to receive surgical vs no treatment (OR, 0.12; 95% CI, 0.09-0.16) and more likely to receive radiation vs surgery (OR, 13.61; 95% CI, 9.75-19.0).

CONCLUSION

From 1998 to 2007, the overall proportion of older patients with stage I NSCLC receiving curative local therapy decreased, despite the dissemination of newer, less-invasive forms of surgery and radiation.

A decade of advances in treatment of early-stage lung cancer

Emerging from the past decade, there has been a diversification of options for the treatment of early-stage lung cancer. Video-assisted thoracoscopic surgery is now more widely performed, with oncologic outcomes equivalent to those with open thoracotomy. Although lobectomy remains the standard approach to surgical resection, lesser resections, such as segmentectomy and wedge resection, are considerations for some patients. Advances in surgical, radiation, and medical therapies continue to evolve. Future research questions will focus on comparing long-term outcomes with these modalities, including survival, as well as patient-centered endpoints, such as quality of life.

Non-small cell lung carcinoma in an adolescent manifested by acute paraplegia due to spinal metastases: a case report

Introduction

Bronchial carcinomas in childhood and adolescence are extremely rare; only individual cases have been reported previously.

Case presentation

We report on a 16-year-old Caucasian German boy with non-small cell lung carcinoma (squamous cell non-small cell lung carcinoma) stage IV, T4N2M1, without epidermal growth factor receptor overexpression and/or mutation or k-ras mutation. He presented with paraplegia due to spinal metastases of the bronchial carcinoma. No familial predisposition or toxin exposure was identified. Treatment following adult protocols consisted of surgical intervention for spinal metastases, first-line cisplatinum and gemcitabine, irradiation and second-line docetaxel. After a transient response our patient experienced disease progression and died about 10 months later.

Conclusion

Response and survival in our 16-year-old patient were similar to adult patients with stage IV non-small cell lung carcinoma.