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Knap MM, Khan S, Khalil AA, Møller DS, Hoffmann L. Outcome of conventional radiotherapy in small centrally located tumours or lymph nodes: minimal toxicity, remarkable survival but challenging loco-regional control. Acta Oncol 2023; 62:1433-1439. [PMID: 37707506 DOI: 10.1080/0284186x.2023.2257872] [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: 05/22/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND In peripheral lung tumours, stereotactic body radiotherapy (SBRT) is superior to conventional RT. SBRT has also shown high loco-regional control (LC) in centrally located tumours, but there is a high risk of severe toxicity. The STRICTSTARLung trial (NCT05354596) examines if risk-adapted SBRT for central tumours is feasible. In this study, we examined overall survival (OS), Disease-free survival (DSF), LC, and toxicity in patients with central tumours that could have been candidates for SBRT but received conventional RT. MATERIAL AND METHODS Retrospectively, we evaluated 49 lung cancer patients that between 2008 and 2021 received RT (60-70Gy in 2 Gy fractions) for a solitary tumour or lymph node with a diameter <5cm located <2cm from the bronchial tree, oesophagus, aorta or heart. All tumours were pathologically verified; 30 were primary lung tumours (T1b-T4) and 19 were solitary lymph nodes (T0N1-N2). Chemotherapy was administered as concomitant (29) or sequential (4). OS and LC were analysed using Kaplan Meier. Cox proportional hazards model for OS and disease-free survival (DFS) was performed including tumour volume, histology, sex, T- vs N-site and chemotherapy. Toxicity was scored. RESULTS In 42 patients, the tumour was located <1 cm to mediastinum. Median follow-up time was 44 months (range: 7-123). The median OS was 51 months. OS at 1-, 3- and 5-year was 88% (SE:5), 59% (SE:7) and 50% (SE:8). Loco-regional recurrences occurred in 16 patients resulting in 1-, and 3-year LC rates of 77% (SE:6) and 64% (SE:8). The majority occurred within 3 years after RT. Only stage showed significant impact on OS and DFS. No patients experienced grade 4-5 toxicity. Seven patients developed grade 3 toxicity (5 oesophageal stenosis, 2 pneumonitis). CONCLUSION Conventional RT for patients with small central lung tumours or solitary lymph nodes is feasible. Median OS was 51 months, and toxicity was low with no grade 4-5 events.
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Affiliation(s)
- M M Knap
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - S Khan
- Department of Respiratory Diseases and Allergology, Aarhus University Hospital, Aarhus N, Denmark
| | - A A Khalil
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - D S Møller
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - L Hoffmann
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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2
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Eisenberg M, Deboever N, Antonoff MB. Salvage surgery in lung cancer following definitive therapies. J Surg Oncol 2023; 127:319-328. [PMID: 36630094 DOI: 10.1002/jso.27155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/10/2022] [Accepted: 11/11/2022] [Indexed: 01/12/2023]
Abstract
Salvage surgery refers to operative resection of persistent or recurrent disease in patients initially treated with intention-to-cure nonoperative management. In non-small-cell lung cancer, salvage surgery may be effective in treating selected patients with locally progressive tumors, recurrent local or locoregional disease, or local complications after nonoperative therapy. Importantly, those patients who may be candidates for salvage surgery are evolving, in terms of disease stage as well as the types of attempted definitive therapy received.
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Affiliation(s)
- Michael Eisenberg
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nathaniel Deboever
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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3
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Zhang Q, Cai XW, Feng W, Yu W, Fu XL. Dose-escalation by hypofractionated simultaneous integrated boost IMRT in unresectable stage III non-small-cell lung cancer. BMC Cancer 2022; 22:96. [PMID: 35065627 PMCID: PMC8783483 DOI: 10.1186/s12885-021-09099-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 11/24/2021] [Indexed: 12/25/2022] Open
Abstract
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.
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4
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Lee P, Loo BW, Biswas T, Ding GX, El Naqa IM, Jackson A, Kong FM, LaCouture T, Miften M, Solberg T, Tome WA, Tai A, Yorke E, Li XA. Local Control After Stereotactic Body Radiation Therapy for Stage I Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2021; 110:160-171. [PMID: 30954520 PMCID: PMC9446070 DOI: 10.1016/j.ijrobp.2019.03.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/06/2019] [Accepted: 03/27/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Numerous dose and fractionation schedules have been used to treat medically inoperable stage I non-small cell lung cancer (NSCLC) with stereotactic body radiation therapy (SBRT) or stereotactic ablative radiation therapy. We evaluated published experiences with SBRT to determine local control (LC) rates as a function of SBRT dose. METHODS AND MATERIALS One hundred sixty published articles reporting LC rates after SBRT for stage I NSCLC were identified. Quality of the series was assessed by evaluating the number of patients in the study, homogeneity of the dose regimen, length of follow-up time, and reporting of LC. Clinical data including 1, 2, 3, and 5-year tumor control probabilities for stages T1, T2, and combined T1 and T2 as a function of the biological effective dose were fitted to the linear quadratic, universal survival curve, and regrowth models. RESULTS Forty-six studies met inclusion criteria. As measured by the goodness of fit χ2/ndf, with ndf as the number of degrees of freedom, none of the models were ideal fits for the data. Of the 3 models, the regrowth model provides the best fit to the clinical data. For the regrowth model, the fitting yielded an α-to-β ratio of approximately 25 Gy for T1 tumors, 19 Gy for T2 tumors, and 21 Gy for T1 and T2 combined. To achieve the maximal LC rate, the predicted physical dose schemes when prescribed at the periphery of the planning target volume are 43 ± 1 Gy in 3 fractions, 47 ± 1 Gy in 4 fractions, and 50 ± 1 Gy in 5 fractions for combined T1 and T2 tumors. CONCLUSIONS Early-stage NSCLC is radioresponsive when treated with SBRT or stereotactic ablative radiation therapy. A steep dose-response relationship exists with high rates of durable LC when physical doses of 43-50 Gy are delivered in 3 to 5 fractions.
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Affiliation(s)
- Percy Lee
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California.
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Tithi Biswas
- Department of Radiation Oncology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - George X Ding
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Issam M El Naqa
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Andrew Jackson
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Feng-Ming Kong
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Tamara LaCouture
- Department of Radiation Oncology, Jefferson Health New Jersey, Sewell, New Jersey
| | - Moyed Miften
- Department of Radiation Oncology, Colorado University School of Medicine, Aurora, Colorado
| | - Timothy Solberg
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - Wolfgang A Tome
- Department of Radiation Oncology, Albert Einstein College of Medicine, New York, New York
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ellen Yorke
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
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5
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Agarwal JP, Pilar A, Mummudi N, Gupta M, Laskar SG, Pathak RS, Tibdewal AR, Kinhikar R, Ghadi Y, Tandon S, Purandare N, Prabhash K, Patil V. Stereotactic body radiation therapy for medically inoperable early-stage lung cancer: Tata Memorial Hospital perspective and practice recommendations. Indian J Cancer 2020; 57:18-24. [PMID: 31929233 DOI: 10.4103/ijc.ijc_216_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Stereotactic body radiotherapy (SBRT) is now considered the standard treatment for medically inoperable early-stage non-small lung cell cancer (ES-NSCLC). Purpose There is a paucity of data related to outcomes with SBRT in ES-NSCLC from the developing countries. We report the early outcomes of ES-NSCLC patients treated with SBRT at our institute. Materials and Methods Between 2007 and 2015, 40 consecutive patients with histologically proven ES-NSCLC were treated with SBRT. Median age was 71 years (range: 46-88 years) and median Charlson comorbidity index (CCI) was 3. The majority had stage I (70%) and 45% of the tumors were centrally located. The median tumor diameter was 3.8 cm (range: 2-7.6 cm). The mean gross tumor volume was 41 cc (range: 4-139 cc) and the mean planning target volume (PTV) was 141 cc (range: 27-251 cc). Varying dose and fraction (fr) sizes were used depending on tumor location, tumor size, and treatment period. The median biologically effective dose (BED) was 77 Gy10 (range: 77-105 Gy10) for the initial cohort (2007-2012) and 105 Gy10 (range: 77-132 Gy10) for the subsequent cohort (2013-2015). Results After a median follow-up of 16 months (range: 3-99 months), the 2-year local control (LC), overall survival, and cancer-specific survival (CSS) rates were 94%, 41%, and 62%, respectively. The univariate and multivariate analysis determined CCI >3 and PTV >80.6 cc as significant predictors of worse OS and CSS (P< 0.01). The clinical stage, tumor location, BED, and treatment period (2007-2012 vs. 2013-2015) did not significantly predict any of the outcomes. The most common acute toxicities were skin erythema (10%), grade 1 esophagitis (8%), and exacerbation of previous chronic obstructive pulmonary disease (10%). Grade ≥2 late radiation pneumonitis was seen in 17.5%. One patient developed a rib fracture. No neurological or vascular complications were seen. Conclusions SBRT results in excellent local control (LC) and acceptable survival in medically inoperable ES-NSCLC with minimal adverse effects. Charlson comorbidity index and target volume are important prognostic factors and may aid in patient selection.
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Affiliation(s)
- Jai Prakash Agarwal
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Avinash Pilar
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Naveen Mummudi
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Meetakshi Gupta
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rima S Pathak
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Anil R Tibdewal
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rajesh Kinhikar
- Department of Medical Physics, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Yogesh Ghadi
- Department of Medical Physics, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sandeep Tandon
- Department of General Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nilendu Purandare
- Department of Nuclear Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vijay Patil
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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6
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Ijsseldijk MA, Shoni M, Siegert C, Wiering B, van Engelenburg AKC, Tsai TC, Ten Broek RPG, Lebenthal A. Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis. Clin Lung Cancer 2020; 22:e235-e292. [PMID: 32912754 DOI: 10.1016/j.cllc.2020.04.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/21/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT). METHODS A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates. RESULTS A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses. CONCLUSION Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.
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Affiliation(s)
- Michiel A Ijsseldijk
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, The Netherlands; Division of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Melina Shoni
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Charles Siegert
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA; Division of Thoracic Surgery, West Roxbury Veterans Administration, West Roxbury, MA
| | - Bastiaan Wiering
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, The Netherlands
| | | | - Thomas C Tsai
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Richard P G Ten Broek
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, The Netherlands; Division of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Abraham Lebenthal
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA; Division of Thoracic Surgery, West Roxbury Veterans Administration, West Roxbury, MA; Harvard Medical School, Boston, MA
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7
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Castle KD, Kirsch DG. Establishing the Impact of Vascular Damage on Tumor Response to High-Dose Radiation Therapy. Cancer Res 2019; 79:5685-5692. [PMID: 31427377 PMCID: PMC6948140 DOI: 10.1158/0008-5472.can-19-1323] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/17/2019] [Accepted: 08/07/2019] [Indexed: 12/26/2022]
Abstract
Approximately half of all patients with cancer receive radiotherapy, which is conventionally delivered in relatively small doses (1.8-2 Gy) per daily fraction over one to two months. Stereotactic body radiation therapy (SBRT), in which a high daily radiation dose is delivered in 1 to 5 fractions, has improved local control rates for several cancers. However, despite the widespread adoption of SBRT in the clinic, controversy surrounds the mechanism by which SBRT enhances local control. Some studies suggest that high doses of radiation (≥10 Gy) trigger tumor endothelial cell death, resulting in indirect killing of tumor cells through nutrient depletion. On the other hand, mathematical models predict that the high radiation dose per fraction used in SBRT increases direct tumor cell killing, suggesting that disruption of the tumor vasculature is not a critical mediator of tumor cure. Here, we review the application of genetically engineered mouse models to radiosensitize tumor cells or endothelial cells to dissect the role of these cellular targets in mediating the response of primary tumors to high-dose radiotherapy in vivo These studies demonstrate a role for endothelial cell death in mediating tumor growth delay, but not local control following SBRT.
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Affiliation(s)
- Katherine D Castle
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - David G Kirsch
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, North Carolina
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8
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Kaiss H, Mornex F. [Stereotactic radiotherapy of stage I non-small cell lung cancer. State of the art in 2019 and recommendations: Stereotaxy as an alternative to surgery?]. Cancer Radiother 2019; 23:720-731. [PMID: 31471255 DOI: 10.1016/j.canrad.2019.07.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/24/2022]
Abstract
Stereotactic radiotherapy (or Stereotactic body radiotherapy [SBRT]) is a technique currently well established in the therapeutic arsenal for the management of bronchial cancers. It represents the standard treatment for inoperable patients or who refuses surgery. It is well tolerated, especially in elderly and frail patients, and the current issue is to define its indications in operated patients, based on retrospective and randomized trials comparing stereotactic radiotherapy and surgery, with results equivalents. This work analyzes in detail the different aspects of pulmonary stereotactic radiotherapy and suggests arguments that help in the therapeutic choice between surgery and stereotaxic irradiation. In all cases, the therapeutic decision must be discussed in a multidisciplinary consultation meeting, while informing the patient of the possible therapeutic options.
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Affiliation(s)
- H Kaiss
- Département de radiothérapie oncologie, centre hospitalier Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France.
| | - F Mornex
- Département de radiothérapie oncologie, centre hospitalier Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France.
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9
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Menoux I, Antoni D, Truntzer P, Keller A, Massard G, Noël G. Stereotactic body radiation therapy for stage I non-small cell lung carcinomas: Moderate hypofractionation optimizes outcome. Lung Cancer 2018; 126:201-207. [PMID: 30527188 DOI: 10.1016/j.lungcan.2018.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/04/2018] [Accepted: 11/09/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES In case of inoperability or refusal of surgery, stereotactic body radiation therapy (SBRT) is the most effective treatment for a stage I non-small cell lung carcinoma (NSCLC). The results obtained by this irradiation technique are considerably superior to those observed in the time of conventional 3D irradiation and its toxicities are much less important, which makes it possible in elderly patients, or those presenting cardio-pulmonary comorbidities and a poor perfomance status. MATERIALS AND METHODS This study is a retrospective analysis of 90 patients who underwent SBRT for a stage I NSCLC between 2010 and 2015. Its purpose is to describe its effectiveness in term of overall survival (OS), specific survival (SS), local control (LC), regional control (RC) and metastatic control (MC) as well as their prognostic factors, and its tolerance. RESULTS LC, RC, MC as well as OS and SS rate at 4 years were comparable to the main prospective studies, respectively 89%, 92%, 70%, 33% and 66%. No LC prognostic factor could be identified. Radiation pneumonitis was observed with a rate of 61.5%, of which 56% were asymptomatic, and 4% of the patients had a rib fracture. CONCLUSIONS SBRT is an efficient and well-tolerated treatment for stage I non-small cell lung carcinomas.
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Affiliation(s)
- I Menoux
- Department of Radiotherapy, Centre Paul Strauss, 3, rue de la porte de l'hôpital, BP 42, 67065, Strasbourg cedex, France.
| | - D Antoni
- Department of Radiotherapy, Centre Paul Strauss, 3, rue de la porte de l'hôpital, BP 42, 67065, Strasbourg cedex, France; Laboratory of Radiobiology, EA 3430, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg University, Strasbourg, France.
| | - P Truntzer
- Department of Radiotherapy, Centre Paul Strauss, 3, rue de la porte de l'hôpital, BP 42, 67065, Strasbourg cedex, France.
| | - A Keller
- Department of Radiotherapy, Centre Paul Strauss, 3, rue de la porte de l'hôpital, BP 42, 67065, Strasbourg cedex, France.
| | - G Massard
- Department of Thoracic surgery, Nouvel hôpital Civil, 1, place de l'hôpital, 67000, Strasbourg, France.
| | - G Noël
- Department of Radiotherapy, Centre Paul Strauss, 3, rue de la porte de l'hôpital, BP 42, 67065, Strasbourg cedex, France; Laboratory of Radiobiology, EA 3430, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg University, Strasbourg, France.
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10
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Tandberg DJ, Tong BC, Ackerson BG, Kelsey CR. Surgery versus stereotactic body radiation therapy for stage I non-small cell lung cancer: A comprehensive review. Cancer 2017; 124:667-678. [PMID: 29266226 DOI: 10.1002/cncr.31196] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/10/2017] [Accepted: 11/18/2017] [Indexed: 12/14/2022]
Abstract
Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related death in the United States. With the implementation of lung cancer screening, the number and proportion of patients diagnosed with early-stage disease are anticipated to increase. Surgery is currently the standard of care for patients with operable stage I NSCLC. However, promising outcomes with stereotactic body radiation therapy (SBRT) in patients with inoperable disease has led to interest in directly comparing SBRT and surgery in operable patients. Unfortunately, early randomized trials comparing surgery and SBRT closed early because of poor accrual. In this article, the nuances of surgery and SBRT for early-stage NSCLC are reviewed. Furthermore, retrospective and prospective analyses of SBRT in early-stage NSCLC are discussed, and active randomized trials comparing these 2 approaches are described. Cancer 2018;124:667-78. © 2017 American Cancer Society.
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Affiliation(s)
- Daniel J Tandberg
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Betty C Tong
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Bradley G Ackerson
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
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11
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Patrini D, Panagiotopoulos N, Lawrence D, Scarci M. Surgical management of lung metastases. Br J Hosp Med (Lond) 2017; 78:192-198. [PMID: 28398890 DOI: 10.12968/hmed.2017.78.4.192] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Management of pulmonary metastases has evolved considerably over the last few decades but is still controversial. The surgical management of lung metastases is outlined, discussing the preoperative management, indications for surgery, the surgical approach and outcomes according to the primary histology.
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Affiliation(s)
- Davide Patrini
- Senior Registrar in Thoracic Surgery, Thoracic Surgery Department, University College London Hospitals, London W1G 8PH
| | - Nikolaos Panagiotopoulos
- Consultant Thoracic Surgeon, Thoracic Surgery Department, University College London Hospitals, London
| | - David Lawrence
- Consultant Cardiothoracic Surgeon, Thoracic Surgery Department, University College London Hospitals, London
| | - Marco Scarci
- Consultant Thoracic Surgeon, Thoracic Surgery Department, University College London Hospitals, London
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12
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Fundowicz M, Adamczyk M, Kołodziej-Dybaś A. Stereotactic body radiation therapy for liver metastasis - The linac-based Greater Poland Cancer Centre practice. Rep Pract Oncol Radiother 2017; 22:158-162. [PMID: 28490987 DOI: 10.1016/j.rpor.2017.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 01/18/2017] [Accepted: 02/25/2017] [Indexed: 01/10/2023] Open
Abstract
AIM The main purpose of this work is to give a technical description and present the properties of the liver SBRT protocol implemented in the Greater Poland Cancer Centre (GPCC) in Poznan, Poland. BACKGROUND Stereotactic body radiation therapy (SBRT) for liver metastasis is a non-invasive therapeutic option which enables irradiation of a small target in the body with a high dose. MATERIALS AND METHODS This study presents details of our linac-based liver SBRT protocol. Special emphasis has been placed on fiducial implantation, patient preparation (CT scanning, immobilization), treatment planning, and its implementation. RESULTS The liver SBRT treatment course implemented in the GPCC consists of three fractions to deliver a total of 45 Gy. Fraction delivery details with description of patient positioning (localization of liver metastasis) are presented below. CONCLUSIONS The literature validation of the assumptions concerning the steps of the GPCC linac-based liver SBRT procedure show their potential for an effective and patient friendly implementation.
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Affiliation(s)
| | - Marta Adamczyk
- Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
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Murray P, Franks K, Hanna GG. A systematic review of outcomes following stereotactic ablative radiotherapy in the treatment of early-stage primary lung cancer. Br J Radiol 2017; 90:20160732. [PMID: 27885858 PMCID: PMC5601509 DOI: 10.1259/bjr.20160732] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 12/25/2022] Open
Abstract
Stereotactic ablative body radiotherapy (SABR) describes a radiotherapy (RT) technique where high doses of radiation are precisely delivered to an extracranial target within the body, using either a single fraction of RT or using multiple small numbers of fractions. SABR has now become the standard of care treatment for patients with early-stage non-small-cell lung cancer (NSCLC) for whom surgery is not appropriate. This systematic review considers the evidence supporting the use of SABR in early-stage NSCLC, reported toxicity rates, the use of SABR in centrally located NSCLC, the use of SABR as salvage therapy following surgery or RT, and future potential drug combinations with SABR.
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Affiliation(s)
- Patrick Murray
- Leeds Cancer Centre, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kevin Franks
- Leeds Cancer Centre, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gerard G Hanna
- Centre for Cancer Research and Cell Biology, Queen's University of Belfast, Belfast, Northern Ireland, UK
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Ricardi U, Badellino S, Filippi AR. What do radiation oncologists require for future advancements in lung SBRT? Phys Med 2016; 44:150-156. [PMID: 27914779 DOI: 10.1016/j.ejmp.2016.11.114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 11/11/2016] [Accepted: 11/17/2016] [Indexed: 12/25/2022] Open
Abstract
Stereotactic Body Radiotherapy (SBRT) is a well established therapeutic option for patients affected with peripheral early stage non-small cell lung cancer (NSCLC), given the positive clinical evidence accumulated so far on its efficacy and safety. SBRT is regarded as the best choice for inoperable patients, and could also be offered as an alternative to surgery to selected operable patients. More recently, its use for lung metastases progressively increased, and SBRT is now regarded as a low toxic and highly effective local therapy for lung oligometastases from different primary tumors, especially colorectal cancer. Improved planning and delivery techniques have facilitated over the years its use on large and/or centrally located primary tumors, and multiple nodules. Given the successful applications and the current wide dissemination of this technique, clinicians are now faced with an increasingly complex and multi-variable decision process. Some clinically relevant factors are still uncertain, and strategies are needed to reduce the risk of both local and distant failures. Secondly, aspects related to target delineation, dose prescription, image guidance and treatment planning still need to be fully addressed; this may hamper, at least for now, the standardization of SBRT procedures through different Institutions making any kind of direct outcomes comparison difficult. We here aim to provide a perspective on the current role of lung SBRT and its critical aspects, highlighting the potential future developments.
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Liu F, Tai A, Lee P, Biswas T, Ding GX, El Naqa I, Grimm J, Jackson A, Kong FMS, LaCouture T, Loo B, Miften M, Solberg T, Li XA. Tumor control probability modeling for stereotactic body radiation therapy of early-stage lung cancer using multiple bio-physical models. Radiother Oncol 2016; 122:286-294. [PMID: 27871671 DOI: 10.1016/j.radonc.2016.11.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 10/13/2016] [Accepted: 11/04/2016] [Indexed: 12/25/2022]
Abstract
This work is to analyze pooled clinical data using different radiobiological models and to understand the relationship between biologically effective dose (BED) and tumor control probability (TCP) for stereotactic body radiotherapy (SBRT) of early-stage non-small cell lung cancer (NSCLC). The clinical data of 1-, 2-, 3-, and 5-year actuarial or Kaplan-Meier TCP from 46 selected studies were collected for SBRT of NSCLC in the literature. The TCP data were separated for Stage T1 and T2 tumors if possible, otherwise collected for combined stages. BED was calculated at isocenters using six radiobiological models. For each model, the independent model parameters were determined from a fit to the TCP data using the least chi-square (χ2) method with either one set of parameters regardless of tumor stages or two sets for T1 and T2 tumors separately. The fits to the clinic data yield consistent results of large α/β ratios of about 20Gy for all models investigated. The regrowth model that accounts for the tumor repopulation and heterogeneity leads to a better fit to the data, compared to other 5 models where the fits were indistinguishable between the models. The models based on the fitting parameters predict that the T2 tumors require about additional 1Gy physical dose at isocenters per fraction (⩽5 fractions) to achieve the optimal TCP when compared to the T1 tumors. In conclusion, this systematic analysis of a large set of published clinical data using different radiobiological models shows that local TCP for SBRT of early-stage NSCLC has strong dependence on BED with large α/β ratios of about 20Gy. The six models predict that a BED (calculated with α/β of 20) of 90Gy is sufficient to achieve TCP⩾95%. Among the models considered, the regrowth model leads to a better fit to the clinical data.
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Affiliation(s)
- Feng Liu
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, United States
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, United States
| | - Percy Lee
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, United States
| | - Tithi Biswas
- Department of Radiation Oncology, University Hospitals at Case Western Reserve University, Cleveland, United States
| | - George X Ding
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, United States
| | - Isaam El Naqa
- Department of Radiation Oncology, McGill University, Montreal, Canada
| | - Jimm Grimm
- Holy Redeemer Hospital, Philadelphia, United States
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Feng-Ming Spring Kong
- Department of Radiation Oncology, GRU Cancer Center and Medical School of Georgia, Augusta, United States
| | - Tamara LaCouture
- Department of Radiation Oncology, Cooper University Hospital, Camden, United States
| | - Billy Loo
- Department of Radiation Oncology, Stanford Cancer Center, Stanford, United States
| | - Moyed Miften
- Department of Radiation Oncology, University of Colorado at Denver, Aurora, United States
| | - Timothy Solberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, United States
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, United States.
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Abstract
Pulmonary metastases are common in patients with cancer for which surgery is considered a standard approach in appropriately selected patients. A number of patients are not candidates for surgery due to a medical comorbidities or the extent of surgery required. For these patients, noninvasive or minimally invasive approaches to ablate pulmonary metastases are potential treatment strategies. This article summarizes the rationale and outcomes for non-surgical treatment approaches, including radiotherapy, radiofrequency and microwave ablation, for pulmonary metastases.
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Affiliation(s)
- Matthew J Boyer
- Department of Radiation Oncology, Duke University, Box 3085 DUMC, Durham, NC 27710, USA
| | - Umberto Ricardi
- Department of Oncology, University of Turin, Regione Gonzole 10, 10043 Orbassano, Turin, Italy
| | - David Ball
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, 2 St Andrews Pl, Melbourne, Victoria 3002, Australia; The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria 3010, Australia
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University, Box 3085 DUMC, Durham, NC 27710, USA.
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Ricardi U, Badellino S, Filippi AR. Stereotactic body radiotherapy for early stage lung cancer: History and updated role. Lung Cancer 2015; 90:388-96. [DOI: 10.1016/j.lungcan.2015.10.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 10/12/2015] [Indexed: 12/21/2022]
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Ricardi U, Badellino S, Filippi AR. Stereotactic radiotherapy for early stage non-small cell lung cancer. Radiat Oncol J 2015; 33:57-65. [PMID: 26157674 PMCID: PMC4493429 DOI: 10.3857/roj.2015.33.2.57] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 06/16/2015] [Accepted: 06/17/2015] [Indexed: 12/11/2022] Open
Abstract
Stereotactic body radiotherapy (SBRT) represents a consolidated treatment option for patients with medically inoperable early stage non-small cell lung cancer (NSCLC). The clinical evidence accumulated in the past decade supports its use as an alternative to surgery with comparable survival outcomes. Due to its limited toxicity, SBRT is also applicable to elderly patients with very poor baseline pulmonary function or other severe comorbidities. Recent comparative studies in operable patients raised the issue of the possible use of SBRT also for this subgroup, with quite promising results that still should be fully confirmed by prospective trials with long-term follow-up. Aim of this review is to summarize and discuss the major studies conducted over the years on SBRT and to provide data on the efficacy and toxicity of this radiotherapy technique for stage I NSCLC. Technical aspects and quality of life related issues are also discussed, with the goal to provide information on the current role and limitations of SBRT in clinical practice.
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Affiliation(s)
- Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Torino, Torino, Italy
| | - Serena Badellino
- Department of Oncology, Radiation Oncology, University of Torino, Torino, Italy
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Stereotactic Ablative Radiation Therapy for the Treatment of Early-stage Non–Small-Cell Lung Cancer: CEPO Review and Recommendations. J Thorac Oncol 2015; 10:872-82. [DOI: 10.1097/jto.0000000000000524] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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20
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Abstract
Extracranial stereotactic body radiotherapy (SBRT) has been developed and refined over the last 25 years as a means to precisely deliver ablative doses of hypofractionated radiotherapy to small targets located outside of the cranial vault. SBRT has armed the radiation oncologist with a therapeutic approach that allows for intensification of both dose delivered and fractionation regimen employed. As a consequence, tumor control rates have improved to levels that previously have been associated only with surgical resection. Several prospective phase I and II studies have evaluated the use of SBRT for non-small cell lung cancer (NSCLC), liver tumors, and spinal metastases. This article will give an overview of SBRT and evidence for its use in the most common sites of disease for which it is employed today.
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Affiliation(s)
- Laura Kollar
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA.
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA; SCCA Proton Therapy, a ProCure Center, Seattle, WA
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Nakagawa T, Negoro Y, Matsuoka T, Okumura N, Dodo Y. Comparison of the outcomes of stereotactic body radiotherapy and surgery in elderly patients with cT1-2N0M0 non-small cell lung cancer. Respir Investig 2014; 52:221-6. [PMID: 24998368 DOI: 10.1016/j.resinv.2014.01.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 01/16/2014] [Accepted: 01/21/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND This study aimed to compare the outcomes of stereotactic body radiotherapy (SBRT) and surgery in elderly patients with cT1-2N0M0 non-small cell lung cancer (NSCLC). METHODS Elderly patients (≥75 years) with cT1-2 (≤5 cm) N0M0 NSCLC who were treated with SBRT (n=35) or surgery (n=183) between January 2001 and December 2011 were analyzed. RESULTS The following radiation doses were administered: 48 Gy/4-6 fractions in 12 patients; 50 Gy/4-5 fractions in 20; and 60 Gy/8 fractions in 3. The following surgical methods were performed: pneumonectomy in 2 patients, lobectomy in 154, segmentectomy in 23, and wedge resection in 4. Patients in the SBRT group had a higher mean age, a worse performance status, and a lower percentage of forced expiratory volume in 1.0 s than those in the surgery group. The overall 5-year survival rates were 43.8% and 67.6% for the SBRT and surgery groups, respectively (p=0.057, log-rank test). Regarding tumor diameter, patients in the surgery group survived significantly longer than did those in the SBRT group (>20-mm tumors, p=0.027; >30-mm tumors p=0.043), whereas survival did not differ significantly between the groups for ≤20-mm tumors (p=0.982). Multivariate analysis confirmed the improved survival in the surgery group compared to the SBRT group for all tumors (p=0.034) and for >20-mm tumors (p=0.016). CONCLUSIONS Post-therapeutic survival among elderly patients might be better with surgery than with SBRT in NSCLC patients with tumors >20 mm.
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Affiliation(s)
- Tatsuo Nakagawa
- Department of Thoracic Surgery, Tenri Hospital, 200, Mishima, Tenri, Nara 632-8552, Japan.
| | - Yoshiharu Negoro
- Department of Radiology, Tenri Hospital, 200, Mishima, Tenri, Nara 632-8552, Japan.
| | - Tomoaki Matsuoka
- Department of Thoracic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan.
| | - Norihito Okumura
- Department of Thoracic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan.
| | - Yoshihiro Dodo
- Department of Radiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan.
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22
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Kong C, Guo WJ, Zha WW, Zhu XZ, Huang SF, Zhang YW, Xu JH, He X. A new index comparable to BED for evaluating the biological efficacy of hypofractionated radiotherapy schemes on early stage non-small cell lung cancer: analysis of data from the literature. Lung Cancer 2014; 84:7-12. [PMID: 24548340 DOI: 10.1016/j.lungcan.2014.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 01/18/2014] [Accepted: 01/20/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Hypofractionated radiotherapy has been the principal curative treatment option for early stage NSCLC patients who are medically inoperable or those who refuse surgery and achieved favorable clinical outcomes. Evidence demonstrated that the linear quadratic model widely used in normally fractionated radiotherapy cannot work well to fit outcome data by use of BED to predict the effect of hypofractionation schemes. New models and the related metrics need to be developed to quantify the effect of high-dose ablative regimens for early stage NSCLC. PATIENTS AND METHODS Trials using hypofractionated radiotherapy without chemotherapy to treat early stage (T1 or T2N0M0) primary NSCLC and providing information on patient numbers, age, T stage and local control rates were eligible. The endpoint was local relapse and the covariates analyzed were total radiotherapy dose, dose per fraction or combinations of the two parameters, treatment duration, T stage and median age of patients within the trial. The model used was a multivariate logistic regression. RESULTS 19 trials were included (767 patients) in which 90 patients suffered local relapse. Only total dose × dose per fraction (D × d) and stage T had statistically significant effect on local control. Smaller T stage (p=0.000) and increasing D × d (p=0.006) were associated with improved probability of local control. In contrast, BED10 had no significant impact on local control, which probably indicated that D × d might be a more effective metric than BED10 to predict tumor control rate and assess the efficacy of the large dose fractionation schemes for early stage NSCLC. CONCLUSIONS BED was not an ideal metric to estimate the effect of the schemes of high-dose ablative radiotherapy for early stage NSCLC, and total dose × fraction dose could be considered as a comparable index, though the result need to be further validated.
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Affiliation(s)
- Cheng Kong
- Department of Radiation Oncology, Affiliated Hospital of Nanjing Medical University, and Cancer Center of Jiangsu Province, Nanjing, People's Republic of China
| | - Wen-jie Guo
- Department of Radiation Oncology, Affiliated Hospital of Nanjing Medical University, and Cancer Center of Jiangsu Province, Nanjing, People's Republic of China
| | - Wen-wu Zha
- Department of Radiation Oncology, Affiliated Hospital of Nanjing Medical University, and Cancer Center of Jiangsu Province, Nanjing, People's Republic of China
| | - Xiang-zhi Zhu
- Department of Radiation Oncology, Affiliated Hospital of Nanjing Medical University, and Cancer Center of Jiangsu Province, Nanjing, People's Republic of China
| | - Sheng-fu Huang
- Department of Radiation Oncology, Affiliated Hospital of Nanjing Medical University, and Cancer Center of Jiangsu Province, Nanjing, People's Republic of China
| | - Ye-wei Zhang
- Department of Radiation Oncology, Affiliated Hospital of Nanjing Medical University, and Cancer Center of Jiangsu Province, Nanjing, People's Republic of China
| | - Jian-hua Xu
- Department of Radiation Oncology, Affiliated Hospital of Nanjing Medical University, and Cancer Center of Jiangsu Province, Nanjing, People's Republic of China
| | - Xia He
- Department of Radiation Oncology, Affiliated Hospital of Nanjing Medical University, and Cancer Center of Jiangsu Province, Nanjing, People's Republic of China.
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Chmura SJ, Salama JK, Weichselbaum RR. Stereotactic radiotherapy for pulmonary metastases. Semin Thorac Cardiovasc Surg 2014; 25:292-9. [PMID: 24673958 DOI: 10.1053/j.semtcvs.2014.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2014] [Indexed: 11/11/2022]
Abstract
The most common treatment of pulmonary metastasis for solid tumors employs systemic chemotherapy, hormonal therapy, or biologic agents. Some series have suggested that aggressive surgical resection of pulmonary metastasis may improve patient outcomes in terms of quality of life and overall survival. Recently, data from clinical trials and retrospective series support the use of aggressive local control with high conformal dose radiotherapy (stereotactic body radiation therapy) in patients with limited metastases or oligometastases. Further evidence suggests that these patients represent a distinct clinical and biological class of patients. This review focuses on the role of ablative doses of radiotherapy in the treatment of pulmonary metastases. Specifically we discuss the rationale, treatment delivery, and local control that have led to the ongoing randomized clinical trials attempting to demonstrate a benefit over the current palliative standard of care.
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Affiliation(s)
- Steven J Chmura
- Ludwig Center for Metastasis Research, University of Chicago, Chicago, Illinois.
| | - Joseph K Salama
- Department of Radiation Oncology, Duke Cancer Institute, Durham, North Carolina
| | - Ralph R Weichselbaum
- Department of Radiation Oncology, University of Chicago, Chicago, Illinois; Ludwig Center for Metastasis Research, University of Chicago, Chicago, Illinois
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Lo SS, Fakiris AJ, Papiez L, Abdulrahman R, McGarry RC, Henderson MA, Forquer JA, Hoopes D, Timmerman RD. Stereotactic body radiation therapy for early-stage non-small-cell lung cancer. Expert Rev Anticancer Ther 2014; 8:87-98. [DOI: 10.1586/14737140.8.1.87] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kelsey CR, Vujaskovic Z, Jackson IL, Riedel RF, Marks LB. Lung. ALERT • ADVERSE LATE EFFECTS OF CANCER TREATMENT 2014. [PMCID: PMC7121399 DOI: 10.1007/978-3-540-75863-1_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The lungs are particularly sensitive to RT, and are often the primary dose-limiting structure during thoracic therapy. The alveolar/capillary units and pneumocytes within the alveoli appear to be particularly sensitive to RT. Hypoxia may be important in the underlying physiology of RT-associated lung injury. The cytokine transforming growth factor-beta (TGF-β), plays an important role in the development of RT-induced fibrosis. The histopathological changes observed in the lung after RT are broadly characterized as diffuse alveolar damage. The interaction between pre-treatment PFTs and the risk of symptomatic lung injury is complex. Similarly, the link between changes in PFTs and the development of symptoms is uncertain. The incidence of symptomatic lung injury increases with increase in most dosimetric parameters. The mean lung dose (MLD) and V20 have been the most-often considered parameters. MLD might be a preferable metric since it considers the entire 3D dose distribution. Radiation to the lower lobes appears to be more often associated with clinical symptoms than is radiation to the upper lobes. This might be related to incidental cardiac irradiation. In pre-clinical models, there appears to be a complex interaction between lung and heart irradiation. TGF-β has been suggested in several studies to predict for RT-induced lung injury, but the data are still somewhat inconsistent. Oral prednisone (Salinas and Winterbauer 1995), typically 40–60 mg daily for 1–2 weeks with a slow taper, is usually effective in treating pneumonitis. There are no widely accepted treatments for fibrosis. A number of chemotherapeutic agents have been suggested to be associated with a range of pulmonary toxicities.
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Kirkpatrick JP, Kelsey CR, Palta M, Cabrera AR, Salama JK, Patel P, Perez BA, Lee J, Yin FF. Stereotactic body radiotherapy: a critical review for nonradiation oncologists. Cancer 2013; 120:942-54. [PMID: 24382744 DOI: 10.1002/cncr.28515] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/11/2013] [Accepted: 11/12/2013] [Indexed: 12/25/2022]
Abstract
Stereotactic body radiotherapy (SBRT) involves the treatment of extracranial primary tumors or metastases with a few, high doses of ionizing radiation. In SBRT, tumor kill is maximized and dose to surrounding tissue is minimized, by precise and accurate delivery of multiple radiation beams to the target. This is particularly challenging, because extracranial lesions often move with respiration and are irregular in shape, requiring careful treatment planning and continual management of this motion and patient position during irradiation. This review presents the rationale, process workflow, and technology for the safe and effective administration of SBRT, as well as the indications, outcome, and limitations for this technique in the treatment of lung cancer, liver cancer, and metastatic disease.
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Affiliation(s)
- John P Kirkpatrick
- Department of Radiation Oncology, Duke Cancer Institute, and the Durham VA Medical Center, Durham, North Carolina
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What would be the most appropriate α/β ratio in the setting of stereotactic body radiation therapy for early stage non-small cell lung cancer. BIOMED RESEARCH INTERNATIONAL 2013; 2013:391021. [PMID: 24350266 PMCID: PMC3853037 DOI: 10.1155/2013/391021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 09/25/2013] [Indexed: 12/25/2022]
Abstract
We hypothesize that the correlation between the radiation dose expressed as the biologically effective dose (BED) and the clinical endpoints will correlate better as the value of the α/β ratio is increased to >10 Gy, which theoretically minimizes the overestimation of the dose potency associated with the linear quadratic (LQ) formula in the setting of stereotactic body radiation therapy (SBRT) for early stage non-small cell lung cancer (NSCLC). A search was conducted in the PubMed electronic databases in August 2011. In the studies analyzed, increasing the α/β ratio is associated with an increase in the strength of the correlation between isocenter BED and local control, especially in the studies with median followup of ≥24 months, for which Spearman's correlation coefficients of 0.74-0.76 were achieved for α/β of 20 Gy, 30 Gy, and 50 Gy (P = 0.007-0.008). A trend toward statistical significance was observed for the correlation of isocenter BED and the 2-year overall survival when an α/β of 20 Gy was used approached statistical significance (P = 0.073). Our results suggest that an α/β > 10 Gy may be more appropriate for the prediction of dose response in the setting of lung SBRT.
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28
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Kelsey CR, Salama JK. Stereotactic Body Radiation Therapy for Treatment of Primary and Metastatic Pulmonary Malignancies. Surg Oncol Clin N Am 2013; 22:463-81. [DOI: 10.1016/j.soc.2013.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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29
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Nakajima N, Sugawara Y, Kataoka M, Hamamoto Y, Ochi T, Sakai S, Takahashi T, Kajihara M, Teramoto N, Yamashita M, Mochizuki T. Differentiation of tumor recurrence from radiation-induced pulmonary fibrosis after stereotactic ablative radiotherapy for lung cancer: characterization of 18F-FDG PET/CT findings. Ann Nucl Med 2013; 27:261-70. [PMID: 23299492 DOI: 10.1007/s12149-012-0682-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 12/26/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Stereotactic ablative radiotherapy (SABR), also known as stereotactic body radiotherapy (SBRT), is now a standard treatment option for patients with stage I non-small cell lung cancer or oligometastatic lung tumor who are medically inoperable or medically operable but refuse surgery. When mass-like consolidation is observed on follow-up CT after SABR, it is sometimes difficult to differentiate tumor recurrence from SABR-induced pulmonary fibrosis. In this study, we evaluated the role of (18)F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) in differentiating tumor recurrence from radiation fibrosis after SABR. METHODS Between June 2006 and June 2009, 130 patients received SABR for stage I non-small cell lung cancer or metastatic lung cancer at our institution. Fifty-nine patients of them were imaged with FDG-PET/CT after SABR. There were a total of 137 FDG-PET/CT scans for retrospective analysis. The FDG uptake in the pulmonary region was assessed qualitatively using a 3-point scale (0, none or faint; 1, mild; or 2, moderate to intense), and the shape (mass-like or non mass-like) was evaluated. For semi-quantitative analysis, the maximum standardized uptake value (SUV(max)) was calculated. RESULTS Sixteen of 59 patients had local failure. In recurrent tumor, the combination of intensity grade 2 and mass-like shape was most common (21/23; 91%). By contrast, in cases of radiation fibrosis, the combination of intensity grade 0 or 1 and non mass-like shape was most common (48/59; 81%). The SUV(max) of tumor recurrence after 12 months was significantly higher than that of radiation fibrosis (8.0 ± 3.2 vs. 2.1 ± 0.9, p < 0.001), and all tumor recurrence showed the SUV(max) > 4.5 at diagnosis of local failure. At ≥12 months after SABR, these two variables, the combination of intensity 2 and mass-like FDG uptake or SUV(max) > 4.5 acquired a significant high predictive value of local recurrence, finding sensitivity 100% and specificity 100% for both of them. CONCLUSIONS The combination of FDG uptake patterns and SUV(max) was useful for distinguishing tumor recurrence from radiation fibrosis after SABR.
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Affiliation(s)
- Naomi Nakajima
- Department of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minamiumemoto-machi, Matsuyama, Ehime 791-0280, Japan.
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A retrospective study of SBRT of metastases in patients with primary sarcoma. Med Oncol 2012; 29:3431-9. [PMID: 22815154 PMCID: PMC3505552 DOI: 10.1007/s12032-012-0256-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 05/11/2012] [Indexed: 12/18/2022]
Abstract
We retrospectively reviewed the results of stereotactic body radiotherapy (SBRT) in 46 patients with a total of 136 metastases from primary sarcoma. The purpose of this study was to evaluate the overall response rate and side effects of SBRT in metastatic sarcoma. The patients were treated at Karolinska University Hospital between 1994 and 2005, using 3D conformal multifield technique and a stereotactic body-frame. Prescribed doses ranged from 4 to 20 Gy per fraction in 1–5 fractions, with total doses of 10–48 Gy. All 46 patients were diagnosed with a primary sarcoma. The treated metastases were localized mainly in the lungs. A total number of 136 metastases were treated (1–14 per patient). Overall response rate (local control = CR, PR and SD) for each tumour was 88 % (119/135). Median follow-up was 21.8 months (range 2.7–112.8 months). Thirteen patients (31 %) were long-term survivors (>36 months), and 5 patients are still alive after last follow-up. Two cases of serious non-lethal side effects were seen, one patient had a colon perforation and another patient had contracture of the hip region. SBRT is a safe, convenient and effective non-invasive treatment with high local control for patients with metastatic sarcoma.
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Nakagawa T, Saito M, Tokunaga Y, Kondo T, Negoro Y. Comparison of Outcome Between Stereotactic Body Radiotherapy (SBRT) and Surgery in cN0 Non-small Cell Carcinoma of the Lung. ACTA ACUST UNITED AC 2012. [DOI: 10.2482/haigan.52.209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mehta N, King CR, Agazaryan N, Steinberg M, Hua A, Lee P. Stereotactic body radiation therapy and 3-dimensional conformal radiotherapy for stage I non-small cell lung cancer: A pooled analysis of biological equivalent dose and local control. Pract Radiat Oncol 2011; 2:288-295. [PMID: 24674167 DOI: 10.1016/j.prro.2011.10.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 10/20/2011] [Accepted: 10/24/2011] [Indexed: 12/25/2022]
Abstract
PURPOSE To determine the relationship between tumor control probability (TCP) and biological effective dose (BED) for radiation therapy in medically inoperable stage I non-small cell lung cancer (NSCLC). METHODS AND MATERIALS Forty-two studies on 3-dimensional conformal radiation therapy (3D-CRT) and SBRT for stage I NSCLC were reviewed for tumor control (TC), defined as crude local control ≥ 2 years, as a function of BED. For each dose-fractionation schedule, BED was calculated at isocenter using the linear quadratic (LQ) and universal survival curve (USC) models. A scatter plot of TC versus BED was generated and fitted to the standard TCP equation for both models. RESULTS A total of 2696 patients were included in this study (SBRT: 1640; 3D-CRT: 1056). Daily fraction size was 1.2-4 Gy (total dose: 48-102.9) with 3D-CRT and 6-26 (total dose: 20-66) with SBRT. Median BED was 118.6 Gy (range, 68.5-320.3) and 95.6 Gy (range, 46.1-178.1) for the LQ and USC models, respectively. According to the LQ model, BED to achieve 50% TC (TCD50) was 61 Gy (95% confidence interval, 50.2-71.1). TCP as a function of BED was sigmoidal, with TCP ≥ 90% achieved with BED ≥ 159 Gy and 124 Gy for the LQ and USC models, respectively. CONCLUSIONS Dose-escalation beyond a BED 159 by LQ model likely translates into clinically insignificant gain in TCP but may result in clinically significant toxicity. When delivered with SBRT, BED of 159 Gy corresponds to a total dose of 53 Gy in 3 fractions at the isocenter.
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Affiliation(s)
- Niraj Mehta
- Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Christopher R King
- Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Nzhde Agazaryan
- Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Michael Steinberg
- Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Amanda Hua
- Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Percy Lee
- Department of Radiation Oncology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.
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Stereotactic radiosurgery-radiotherapy: Should Monte Carlo treatment planning be used for all sites? Pract Radiat Oncol 2011; 1:251-60. [DOI: 10.1016/j.prro.2011.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 02/28/2011] [Accepted: 03/01/2011] [Indexed: 12/25/2022]
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Stereotactic body radiation therapy in non-small-cell lung cancer: linking radiobiological modeling and clinical outcome. Am J Clin Oncol 2011; 34:432-41. [PMID: 20539207 DOI: 10.1097/coc.0b013e3181df4b3f] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For patients with peripheral, early-stage non-small-cell lung cancer, it has been found feasible to deliver 5 or fewer fractions of large doses through stereotactic body radiation therapy (SBRT) without causing severe early or late injury and with impressive tumor control. In this review, we employ radiobiological modeling with the linear quadratic formulation to explore the adequacy of various dose schedules used for tumor control in the lung as supported by clinical evidence, the influence of dose distribution and delivery time on local control, and how to decrease the likelihood of severe toxicity following SBRT. Furthermore, the validity of the linear quadratic formalism in the high dose range of SBRT for lung cancer is explored.
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Radiothérapie en conditions stéréotaxiques dans les cancers bronchiques de stades I et II : résultats d’une série de 33 patients. Cancer Radiother 2011; 15:192-6. [DOI: 10.1016/j.canrad.2010.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 09/24/2010] [Accepted: 10/12/2010] [Indexed: 12/25/2022]
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Wennberg BM, Baumann P, Gagliardi G, Nyman J, Drugge N, Hoyer M, Traberg A, Nilsson K, Morhed E, Ekberg L, Wittgren L, Lund JÅ, Levin N, Sederholm C, Lewensohn R, Lax I. NTCP modelling of lung toxicity after SBRT comparing the universal survival curve and the linear quadratic model for fractionation correction. Acta Oncol 2011; 50:518-27. [PMID: 21198416 DOI: 10.3109/0284186x.2010.543695] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In SBRT of lung tumours no established relationship between dose-volume parameters and the incidence of lung toxicity is found. The aim of this study is to compare the LQ model and the universal survival curve (USC) to calculate biologically equivalent doses in SBRT to see if this will improve knowledge on this relationship. MATERIAL AND METHODS Toxicity data on radiation pneumonitis grade 2 or more (RP2+) from 57 patients were used, 10.5% were diagnosed with RP2+. The lung DVHs were corrected for fractionation (LQ and USC) and analysed with the Lyman- Kutcher-Burman (LKB) model. In the LQ-correction α/β = 3 Gy was used and the USC parameters used were: α/β = 3 Gy, D(0) = 1.0 Gy, [Formula: see text] = 10, α = 0.206 Gy(-1) and d(T) = 5.8 Gy. In order to understand the relative contribution of different dose levels to the calculated NTCP the concept of fractional NTCP was used. This might give an insight to the questions of whether "high doses to small volumes" or "low doses to large volumes" are most important for lung toxicity. RESULTS AND DISCUSSION NTCP analysis with the LKB-model using parameters m = 0.4, D(50) = 30 Gy resulted for the volume dependence parameter (n) with LQ correction n = 0.87 and with USC correction n = 0.71. Using parameters m = 0.3, D(50) = 20 Gy n = 0.93 with LQ correction and n = 0.83 with USC correction. In SBRT of lung tumours, NTCP modelling of lung toxicity comparing models (LQ,USC) for fractionation correction, shows that low dose contribute less and high dose more to the NTCP when using the USC-model. Comparing NTCP modelling of SBRT data and data from breast cancer, lung cancer and whole lung irradiation implies that the response of the lung is treatment specific. More data are however needed in order to have a more reliable modelling.
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Affiliation(s)
- Berit M Wennberg
- Department of Medical Physics, Karolinska University Hospital and the Karolinska Institute, Stockholm, Sweden.
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Matsuo Y, Shibuya K, Nagata Y, Takayama K, Norihisa Y, Mizowaki T, Narabayashi M, Sakanaka K, Hiraoka M. Prognostic Factors in Stereotactic Body Radiotherapy for Non–Small-Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2011; 79:1104-11. [DOI: 10.1016/j.ijrobp.2009.12.022] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 10/30/2009] [Accepted: 12/08/2009] [Indexed: 12/25/2022]
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Extra-cranial Stereotactic Radiation Therapy (ESRT) in the treatment of inoperable stage 1 & 2 non-small-cell lung cancer patients with highly mobile tumours: a literature review. JOURNAL OF RADIOTHERAPY IN PRACTICE 2010. [DOI: 10.1017/s1460396910000105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AbstractObjective: Extra-cranial Stereotactic Radiation Therapy (ESRT) techniques and equipment utilised in the treatment of Stage 1 or 2 inoperable non-small-cell lung cancer (NSCLC); accounting for Respiratory Induced Tumour Motion (RITM).Methods: A narrative review of current world literature.Results: Four main strategies are employed to address RITM: (1) tumour movement minimisation/immobilisation; (2) integration of respiratory movements into planning; (3) respiratory-gating techniques; and (iv) tumour-tracking techniques.Discussion: Analysis of data gathered suggests that due to inherent difficulties with respiratory function, combined with co-morbidities and the level of dose escalation facilitated by ESRT: techniques that do not require patient ability to comply are more likely to be effective with a wider range of patients. Similarly, treatment planning must incorporate accurate four-dimensional (4D) data to ensure target coverage, although setup and verification should be controlled to smaller margins for error.Conclusion: The disparate nature of reporting methods restricts statistical comparison. However, this paper suggests that the ESRT technique using abdominal compression (AC), free-breathing respiratory-gating (FBRG), 4D computed tomography (4DCT) planning, combined with daily on board kV cone beam computed tomography (CBCT) imaging for setup and target verification, is a possible candidate for further treatment regime assessments in large multi-centre trials.
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Matsuo Y, Nakamoto Y, Nagata Y, Shibuya K, Takayama K, Norihisa Y, Narabayashi M, Mizowaki T, Saga T, Higashi T, Togashi K, Hiraoka M. Characterization of FDG-PET images after stereotactic body radiation therapy for lung cancer. Radiother Oncol 2010; 97:200-4. [PMID: 20430463 DOI: 10.1016/j.radonc.2010.04.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 03/16/2010] [Accepted: 04/05/2010] [Indexed: 11/19/2022]
Affiliation(s)
- Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University, Sakyo-ku, Kyoto, Japan.
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Unger K, Ju A, Oermann E, Suy S, Yu X, Vahdat S, Subramaniam D, Harter KW, Collins SP, Dritschilo A, Anderson E, Collins BT. CyberKnife for hilar lung tumors: report of clinical response and toxicity. J Hematol Oncol 2010; 3:39. [PMID: 20969774 PMCID: PMC2987864 DOI: 10.1186/1756-8722-3-39] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Accepted: 10/22/2010] [Indexed: 12/25/2022] Open
Abstract
Objective To report clinical efficacy and toxicity of fractionated CyberKnife radiosurgery for the treatment of hilar lung tumors. Methods Patients presenting with primary and metastatic hilar lung tumors, treated using the CyberKnife system with Synchrony fiducial tracking technology, were retrospectively reviewed. Hilar location was defined as abutting or invading a mainstem bronchus. Fiducial markers were implanted by conventional bronchoscopy within or adjacent to tumors to serve as targeting references. A prescribed dose of 30 to 40 Gy to the gross tumor volume (GTV) was delivered in 5 fractions. Clinical examination and PET/CT imaging were performed at 3 to 6-month follow-up intervals. Results Twenty patients were accrued over a 4 year period. Three had primary hilar lung tumors and 17 had hilar lung metastases. The median GTV was 73 cc (range 23-324 cc). The median dose to the GTV was 35 Gy (range, 30 - 40 Gy), delivered in 5 fractions over 5 to 8 days (median, 6 days). The resulting mean maximum point doses delivered to the esophagus and mainstem bronchus were 25 Gy (range, 11 - 39 Gy) and 42 Gy (range, 30 - 49 Gy), respectively. Of the 17 evaluable patients with 3 - 6 month follow-up, 4 patients had a partial response and 13 patients had stable disease. AAT t a median follow-up of 10 months, the 1-year Kaplan-Meier local control and overall survival estimates were 63% and 54%, respectively. Toxicities included one patient experiencing grade II radiation esophagitis and one patient experiencing grade III radiation pneumonitis. One patient with gross endobronchial tumor within the mainstem bronchus developed a bronchial fistula and died after receiving a maximum bronchus dose of 49 Gy. Conclusion CyberKnife radiosurgery is an effective palliative treatment option for hilar lung tumors, but local control is poor at one year. Maximum point doses to critical structures may be used as a guide for limiting toxicities. Preliminary results suggest that dose escalation alone is unlikely to enhance the therapeutic ratio of hilar lung tumors and novel approaches, such as further defining the patient population or employing the use of radiation sensitizers, should be investigated.
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Affiliation(s)
- Keith Unger
- Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA.
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Bral S, Gevaert T, Linthout N, Versmessen H, Collen C, Engels B, Verdries D, Everaert H, Christian N, De Ridder M, Storme G. Prospective, risk-adapted strategy of stereotactic body radiotherapy for early-stage non-small-cell lung cancer: results of a Phase II trial. Int J Radiat Oncol Biol Phys 2010; 80:1343-9. [PMID: 20708849 DOI: 10.1016/j.ijrobp.2010.04.056] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 04/13/2010] [Indexed: 12/23/2022]
Abstract
PURPOSE Validation of a prospective, risk-adapted strategy for early-stage non-small-cell lung cancer (NSCLC) patients treated with stereotactic body radiotherapy (SBRT). METHODS AND MATERIALS Patients with a T1-3N0M0 (American Joint Committee on Cancer 6th edition) NSCLC were accrued. Using the Radiation Therapy Oncology Group definition, patients were treated to a total dose of 60,Gy in three fractions for peripherally located lesions and four fractions for centrally located lesions. The primary endpoint was toxicity, graded according to the Radiation Therapy Oncology Group acute and late morbidity scoring system, and the National Cancer Institute Common Terminology Criteria for Adverse Events Version 3.0. Secondary endpoints were local control and survival. RESULTS A total of 40 patients were included, 17 with a centrally located lesion. The lung toxicity-free survival estimate at 2 years was 74% and was related to the location (central vs. peripheral) and the size of the target volume. No dose volumetric parameters could predict the occurrence of lung toxicity. One patient died because of treatment-related toxicity. The 1-year and 2-year local progression-free survival estimates were 97% and 84%, respectively, and were related to stage (T1 vs. T2) related (p = 0.006). Local failure was not more frequent for patients treated in four fractions. The 1-year local progression-free survival estimate dropped below 80% for lesions with a diameter of more than 4 cm. CONCLUSION The proposed risk-adapted strategy for both centrally and peripherally located lesions showed an acceptable toxicity profile while maintaining excellent local control rates. The correlation between local control and tumor diameter calls for the inclusion of tumor stage as a variable in future study design.
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Affiliation(s)
- Samuel Bral
- Department of Radiotherapy, University Hospital Brussels, Brussels, Belgium.
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Wilcox EE, Daskalov GM, Lincoln H, Shumway RC, Kaplan BM, Colasanto JM. Comparison of Planned Dose Distributions Calculated by Monte Carlo and Ray-Trace Algorithms for the Treatment of Lung Tumors With CyberKnife: A Preliminary Study in 33 Patients. Int J Radiat Oncol Biol Phys 2010; 77:277-84. [DOI: 10.1016/j.ijrobp.2009.08.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 08/12/2009] [Accepted: 08/13/2009] [Indexed: 12/25/2022]
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Grutters JP, Kessels AG, Pijls-Johannesma M, De Ruysscher D, Joore MA, Lambin P. Comparison of the effectiveness of radiotherapy with photons, protons and carbon-ions for non-small cell lung cancer: A meta-analysis. Radiother Oncol 2010; 95:32-40. [DOI: 10.1016/j.radonc.2009.08.003] [Citation(s) in RCA: 249] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 07/08/2009] [Accepted: 08/01/2009] [Indexed: 01/20/2023]
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Suit H, DeLaney T, Goldberg S, Paganetti H, Clasie B, Gerweck L, Niemierko A, Hall E, Flanz J, Hallman J, Trofimov A. Proton vs carbon ion beams in the definitive radiation treatment of cancer patients. Radiother Oncol 2010; 95:3-22. [DOI: 10.1016/j.radonc.2010.01.015] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 01/22/2010] [Accepted: 01/23/2010] [Indexed: 02/03/2023]
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Chi A, Liao Z, Nguyen NP, Xu J, Stea B, Komaki R. Systemic review of the patterns of failure following stereotactic body radiation therapy in early-stage non-small-cell lung cancer: clinical implications. Radiother Oncol 2010; 94:1-11. [PMID: 20074823 DOI: 10.1016/j.radonc.2009.12.008] [Citation(s) in RCA: 265] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Revised: 11/23/2009] [Accepted: 12/17/2009] [Indexed: 12/22/2022]
Abstract
PURPOSE To analyze the patterns of failure, the toxicity profile, and the factors influencing efficacy of stereotactic body radiation (SBRT) for early-stage non-small-cell lung cancer (NSCLC). METHODS AND MATERIALS A search was based on PubMed electronic databases. All searches were conducted in May, 2009. RESULTS The local control ranged from 80% to 100% in most studies with adequate isocentric or peripheral biologically effective dose (BED). Recurrences were associated with increased tumor size. The main pattern of failure after SBRT was distant metastasis. Grades 3-5 toxicity occurred mostly in centrally located tumors, and adjuvant chemotherapy may further decrease all recurrences; possibly translating to a survival benefit in large or centrally located tumors where high BED cannot be safely reached. CONCLUSION SBRT is an excellent treatment option for early-stage, and mostly medically inoperable, NSCLC. BED at both the isocenter and the tumor periphery is very important for optimal tumor control; higher doses are required for large (T2) lesions; SBRT for centrally located tumors can be feasible with a much less aggressive dose regimen than 60-66Gy/3 fractions and adjacent critical structures excluded from the target volume; chemotherapy may optimize the clinical outcome in large or centrally located lesions.
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Affiliation(s)
- Alexander Chi
- Department of Radiation Oncology, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85724, USA.
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Co-morbidity index predicts for mortality after stereotactic body radiotherapy for medically inoperable early-stage non-small cell lung cancer. Radiother Oncol 2009; 93:402-7. [DOI: 10.1016/j.radonc.2009.06.002] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 05/22/2009] [Accepted: 06/01/2009] [Indexed: 12/26/2022]
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Fritz P, Kraus HJ, Mühlnickel W, Sassmann V, Hering W, Strauch K. High-frequency jet ventilation for complete target immobilization and reduction of planning target volume in stereotactic high single-dose irradiation of stage I non-small cell lung cancer and lung metastases. Int J Radiat Oncol Biol Phys 2009; 78:136-42. [PMID: 19910142 DOI: 10.1016/j.ijrobp.2009.07.1678] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 05/26/2009] [Accepted: 07/06/2009] [Indexed: 12/26/2022]
Abstract
PURPOSE To demonstrate the feasibility of complete target immobilization by means of high-frequency jet ventilation (HFJV); and to show that the saving of planning target volume (PTV) on the stereotactic body radiation therapy (SBRT) under HFJV, compared with SBRT with respiratory motion, can be predicted with reliable accuracy by computed tomography (CT) scans at peak inspiration phase. METHODS AND MATERIALS A comparison regarding different methods for defining the PTV was carried out in 22 patients with tumors that clearly moved with respiration. A movement span of the gross tumor volume (GTV) was defined by fusing respiration-correlated CT scans. The PTV enclosed the GTV positions with a safety margin throughout the breathing cycle. To create a PTV from CT scans acquired under HFJV, the same margins were drawn around the immobilized target. In addition, peak inspiration phase CT images (PIP-CTs) were used to approximate a target immobilized by HFJV. RESULTS The resulting HFJV-PTVs were between 11.6% and 45.4% smaller than the baseline values calculated as respiration-correlated CT-PTVs (median volume reduction, 25.4%). Tentative planning by means of PIP-CT PTVs predicted that in 19 of 22 patients, use of HFJV would lead to a reduction in volume of >or=20%. Using this threshold yielded a positive predictive value of 0.89, as well as a sensitivity of 0.94 and a specificity of 0.5. CONCLUSIONS In all patients, SBRT under HFJV provided a reliable immobilization of the GTVs and achieved a reduction in PTVs, regardless of patient compliance. Tentative planning facilitated the selection of patients who could better undergo radiation in respiratory standstill, both with greater accuracy and lung protection.
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Affiliation(s)
- Peter Fritz
- Department of Radiotherapy, St Marien-Krankenhaus, Siegen, Germany.
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Lim DH, Yi BY, Mirmiran A, Dhople A, Suntharalingam M, D'Souza WD. Optimal beam arrangement for stereotactic body radiation therapy delivery in lung tumors. Acta Oncol 2009; 49:219-24. [PMID: 19888895 DOI: 10.3109/02841860903302897] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE To compare the different beam arrangement and delivery techniques for stereotactic body radiation therapy (SBRT) of lung lesions using the criteria of Radiation Therapy Oncology Group (RTOG) 0236 protocol. MATERIAL AND METHODS Thirty-seven medically inoperable lung cancers were evaluated with various planning techniques including multiple coplanar multiple static beams, multiple non-coplanar static beams and arc delivery. Twelve plans were evaluated for each case, including five plans using coplanar fixed beams, six plans using non-coplanar fixed beams and one plan using arc therapy. These plans were compared using the target prescription isodose coverage, high and low dose volumes, and critical organ dose-volume limits. RESULTS The prescription isodose coverage, high dose evaluation criteria and dose to critical organs were similar among treatment delivery techniques. However, there were differences in low dose criteria, especially in the ratio of the volume of 50% isodose of the prescription dose to the volume of planning treatment volume (R(50%)). The R(50%) in plans using non-coplanar static beams was lower than other plans in 30 of 37 cases (81%). CONCLUSION Based on the dosimetric criteria outlined in RTOG 0236, the treatment technique using non-coplanar static beams showed the most preferable results for SBRT of lung lesions.
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Affiliation(s)
- Do Hoon Lim
- Department of Radiation Oncology, University of Maryland Medical System, Baltimore, Maryland, USA.
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Hodge CW, Tomé WA, Fain SB, Bentzen SM, Mehta MP. On the use of hyperpolarized helium MRI for conformal avoidance lung radiotherapy. Med Dosim 2009; 35:297-303. [PMID: 19944585 DOI: 10.1016/j.meddos.2009.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 09/04/2009] [Accepted: 09/23/2009] [Indexed: 12/25/2022]
Abstract
We wanted to illustrate the feasibility of using hyperpolarized helium magnetic resonance imaging (HPH-MRI) to obtain functional information that may assist in improving conformal avoidance of ventilating lung tissue during thoracic radiotherapy. HPH-MRI images were obtained from a volunteer patient and were first fused with a proton density-weighted (PD(w)) MRI to provide corresponding anatomic detail; they were then fused with the treatment planning computed tomography scan of a patient from our treatment planning database who possessed equivalent thoracic dimensions. An optimized treatment plan was then generated using the TomoTherapy treatment planning system, designating the HPH-enhancing regions as ventilation volume (VV). A dose-volume histogram compares the dosimetry of the lungs as a paired organ, the VV, and the lungs minus the VV. The clinical consequences of these changes was estimated using a bio-effect model, the parallel architecture model, or the local damage (f(dam)) model. Model parameters were chosen from published studies linking the incidence of grade 3+ pneumonitis, with the dose and volume irradiated. For two hypothetical treatment plans of 60 Gy in 30 fractions delivered to a right upper-lobe lung mass, one using and one ignoring the VV as an avoidance structure, the mean normalized total dose (NTD(mean)) values for the lung subvolumes were: lungs = 12.5 Gy₃ vs. 13.52 Gy₃, VV = 9.94 Gy₃ vs. 13.95 Gy₃, and lungs minus VV = 16.69 Gy₃ vs. 19.16 Gy₃. Using the f(dam) values generated from these plans, one would predict a reduction of the incidence of grade 3+ radiation pneumonitis from 12%-4% when compared with a conventionally optimized plan. The use of HPH-MRI to identify ventilated lung subvolumes is feasible and has the potential to be incorporated into conformal avoidance treatment planning paradigms. A prospective clinical study evaluating this imaging technique is being developed.
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Affiliation(s)
- C W Hodge
- Department of Human Oncology, University of Wisconsin, Madison, 53792, USA
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Jin JY, Kong FM, Chetty IJ, Ajlouni M, Ryu S, Ten Haken R, Movsas B. Impact of fraction size on lung radiation toxicity: hypofractionation may be beneficial in dose escalation of radiotherapy for lung cancers. Int J Radiat Oncol Biol Phys 2009; 76:782-8. [PMID: 19577855 DOI: 10.1016/j.ijrobp.2009.02.079] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 02/24/2009] [Indexed: 12/25/2022]
Abstract
PURPOSE To assess how fraction size impacts lung radiation toxicity and therapeutic ratio in treatment of lung cancers. METHODS AND MATERIALS The relative damaged volume (RDV) of lung was used as the endpoint in the comparison of various fractionation schemes with the same normalized total dose (NTD) to the tumor. The RDV was computed from the biologically corrected lung dose-volume histogram (DVH), with an alpha/beta ratio of 3 and 10 for lung and tumor, respectively. Two different (linear and S-shaped) local dose-effect models that incorporated the concept of a threshold dose effect with a single parameter D(L50) (dose at 50% local dose effect) were used to convert the DVH into the RDV. The comparison was conducted using four representative DVHs at different NTD and D(L50) values. RESULTS The RDV decreased with increasing dose/fraction when the NTD was larger than a critical dose (D(CR)) and increased when the NTD was less than D(CR). The D(CR) was 32-50 Gy and 58-87 Gy for a small tumor (11 cm(3)) for the linear and S-shaped local dose-effect models, respectively, when D(L50) was 20-30 Gy. The D(CR) was 66-97 Gy and 66-99 Gy, respectively, for a large tumor (266 cm(3)). Hypofractionation was preferred for small tumors and higher NTDs, and conventional fractionation was better for large tumors and lower NTDs. Hypofractionation might be beneficial for intermediate-sized tumors when NTD = 80-90 Gy, especially if the D(L50) is small (20 Gy). CONCLUSION This computational study demonstrated that hypofractionated stereotactic body radiotherapy is a better regimen than conventional fractionation in lung cancer patients with small tumors and high doses, because it generates lower RDV when the tumor NTD is kept unchanged.
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Affiliation(s)
- Jin-Yue Jin
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, MI 48202, USA.
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