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Rodríguez De Dios N, Navarro-Martin A, Cigarral C, Chicas-Sett R, García R, Garcia V, Gonzalez JA, Gonzalo S, Murcia-Mejía M, Robaina R, Sotoca A, Vallejo C, Valtueña G, Couñago F. GOECP/SEOR radiotheraphy guidelines for non-small-cell lung cancer. World J Clin Oncol 2022; 13:237-266. [PMID: 35582651 PMCID: PMC9052073 DOI: 10.5306/wjco.v13.i4.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/27/2021] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is a heterogeneous disease accounting for approximately 85% of all lung cancers. Only 17% of patients are diagnosed at an early stage. Treatment is multidisciplinary and radiotherapy plays a key role in all stages of the disease. More than 50% of patients with NSCLC are treated with radiotherapy (curative-intent or palliative). Technological advances-including highly conformal radiotherapy techniques, new immobilization and respiratory control systems, and precision image verification systems-allow clinicians to individualize treatment to maximize tumor control while minimizing treatment-related toxicity. Novel therapeutic regimens such as moderate hypofractionation and advanced techniques such as stereotactic body radiotherapy (SBRT) have reduced the number of radiotherapy sessions. The integration of SBRT into routine clinical practice has radically altered treatment of early-stage disease. SBRT also plays an increasingly important role in oligometastatic disease. The aim of the present guidelines is to review the role of radiotherapy in the treatment of localized, locally-advanced, and metastatic NSCLC. We review the main radiotherapy techniques and clarify the role of radiotherapy in routine clinical practice. These guidelines are based on the best available evidence. The level and grade of evidence supporting each recommendation is provided.
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Affiliation(s)
- Núria Rodríguez De Dios
- Department of Radiation Oncology, Hospital del Mar, Barcelona 08003, Spain
- Radiation Oncology Research Group, Hospital Del Mar Medical Research Institution, Barcelona 08003, Spain
- Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona 08003, Spain
| | - Arturo Navarro-Martin
- Department of Radiation Oncology, Thoracic Malignancies Unit, Hospital Duran i Reynals. ICO, L´Hospitalet de L, Lobregat 08908, Spain
| | - Cristina Cigarral
- Department of Radiation Oncology, Hospital Clínico de Salamanca, Salamanca 37007, Spain
| | - Rodolfo Chicas-Sett
- Department of Radiation Oncology, ASCIRES Grupo Biomédico, Valencia 46004, Spain
| | - Rafael García
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Virginia Garcia
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | | | - Susana Gonzalo
- Department of Radiation Oncology, Hospital Universitario La Princesa, Madrid 28006, Spain
| | - Mauricio Murcia-Mejía
- Department of Radiation Oncology, Hospital Universitario Sant Joan de Reus, Reus 43204, Tarragona, Spain
| | - Rogelio Robaina
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | - Amalia Sotoca
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Carmen Vallejo
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - German Valtueña
- Department of Radiation Oncology, Hospital Clínico Universitario Lozano Blesa, Zaragoza 50009, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid 28223, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Department of Clinical, Universidad Europea, Madrid 28670, Spain
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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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Outcomes of Image-Guided Moderately Hypofractionated Radiotherapy for Stage III Non-Small-Cell Lung Cancer. JOURNAL OF ONCOLOGY 2021; 2021:2721261. [PMID: 34887921 PMCID: PMC8651380 DOI: 10.1155/2021/2721261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/07/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022]
Abstract
Objective To evaluate the efficacy and toxicity of hypofractionated radiotherapy (hypo-RT) for stage III non-small-cell lung cancer (NSCLC) in the Chinese population. Methods Eighty-six stage III NSCLC patients who received hypo-RT (60 Gy/20 fractions, BED = 78.00 Gy: 73 patients; 62.5 Gy/25 fractions, BED = 78.13 Gy: 13 patients) were recruited. Fifty-seven patients who received conventional radiotherapy (60 Gy/30 fractions, BED = 72.00 Gy) during the same period were enrolled as the control group. All hypo-RT treatments were conducted using image-guided technology. The efficacy and toxicity of the treatment were compared between the two groups. Results The median duration of follow-up was 23.0 months (range: 4.0–82.0 months). Univariate and multivariate analyses of all 143 stage III NSCLC patients revealed that hypo-RT was an independent factor for progression-free survival (PFS) and overall survival (OS). The median PFS and OS of hypo-RT were significantly higher than in the conventional RT group (PFS: 14.30, 11.00 months, p=0.035; OS: 43.30, 31.50 months, p=0.045). The incidence rates of symptomatic radiation pneumonitis and radiation esophagitis (≥grade 2) were 17.77% and 27.91%, respectively, in the hypo-RT group. Compared to the conventional radiation therapy group (22.81% and 19.30%, respectively), no significant differences were found between the two common side effects (p=0.662 and p=0.241, respectively). Conclusion For Chinese stage III NSCLC patients, image-guided hypo-RT offers favorable prognosis, and the treatment toxicity was totally acceptable. This radiation modality deserves further prospective clinical trials.
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Aye SM, Kyi LL, Hlaing M, Myint AA, Win KC. Short term clinical outcomes of accelerated hypofractionated radiotherapy in inoperable non-small cell lung cancer patients. Rep Pract Oncol Radiother 2021; 26:747-755. [PMID: 34760309 DOI: 10.5603/rpor.a2021.0095] [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: 03/03/2021] [Accepted: 06/27/2021] [Indexed: 11/25/2022] Open
Abstract
Background This study aimed to evaluate short term clinical outcomes of accelerated hypofractionated radiotherapy (AHR T) regarding locoregional response (LRR), symptoms relief and acute toxicities in non-small cell lung cancer (NSCLC) patients. The radical treatment for inoperable NSCLC is intolerable for some patients. An alternative RT regime should be considered for them. Materials and methods Inoperable NSCLC patients who could not tolerate radical treatment were treated with AHRT (45 Gy in 15 fractions over three weeks) by using the 3-dimensional conformal (RT) technique. The LRR was assessed by chest computed tomography (CT) performed before and 6 weeks after RT. Relief of symptoms such as cough, dyspnoea and chest pain was evaluated during RT and 6 and 12 weeks after RT, compared with the status before RT. Treatment-related acute toxicities such as dysphagia and radiation dermatitis were observed during and 6 and 12 weeks after RT. Results Total 65 patients (seven patients of stage II and fifty-eight patients of stage III) were included. Partial response was seen in 70.8% of patients, and stable disease was seen in 29.2% while there was neither complete response nor progressive disease after RT. Statistically significant associations were found between tumour response vs. pre-treatment tumour size and tumour response vs. performance status of the patients. Satisfactory symptom relief was found after RT, but severe acute dysphagia and radiation dermatitis (more than grade 3) were not observed. Conclusion Satisfactory LRR, symptom relief and acute toxicities were achieved by this regime. Long term studies are recommended to evaluate late toxicities and survival outcome further. Trial registration no TCTR20200110001.
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Affiliation(s)
- Shoon Mya Aye
- Radiotherapy Department, Yangon General Hospital, Yangon, Myanmar
| | - Lin Lin Kyi
- Radiotherapy Department, Yangon General Hospital, Yangon, Myanmar
| | - Moe Hlaing
- Radiotherapy Department, Yangon General Hospital, Yangon, Myanmar
| | - Aye Aye Myint
- Radiotherapy Department, Yangon General Hospital, Yangon, Myanmar
| | - Khin Cho Win
- Radiotherapy Department, Yangon General Hospital, Yangon, Myanmar
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Shen J, Yang D, Chen M, Jiang L, Dong X, Li D, Yu R, Yu H, Shi A. Hypofractionated Volumetric-Modulated Arc Radiotherapy for Patients With Non-Small-Cell Lung Cancer Not Suitable for Surgery or Conventional Chemoradiotherapy or SBRT. Front Oncol 2021; 11:644852. [PMID: 34221967 PMCID: PMC8244290 DOI: 10.3389/fonc.2021.644852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/20/2021] [Indexed: 12/25/2022] Open
Abstract
Background Hypofractionated radiotherapy (HypoRT) has been used to pursue an alternative treatment regimen for patients with non-small-cell lung cancer (NSCLC) who are not eligible for stereotactic ablative radiotherapy (SABR), surgery or concurrent chemoradiotherapy (CCRT) and has shown good local control and safety. We analyzed the feasibility of using volumetric-modulated arc radiotherapy (VMAT) with the simultaneous integrated boost (SIB) technique to achieve high local control with few treatment-related toxicities. Patients and Methods A total of 55 patients with stage I-IV NSCLC who were not candidates for SABR, surgery or CCRT were included in the present study. All patients received a prescribed dose of 60 to 66 Gy in 15 fractions. Local progression-free survival (LPFS), PFS, overall survival (OS), and toxicities were retrospectively analyzed. Results Thirty-three patients (60.0%) had stage IV or recurrent disease in this study. The median follow-up time was 8 months (interquartile range: 5.0-16.3 months). The 1-year and 2-year OS rates were 84.3% and 69.9%, and the 1-year and 2-year LPFS rates were 91.0% and 63.0%. The median OS (mOS) and median LPFS (mLPFS) were not reached, and median PFS (mPFS) was 15 months. Twenty-eight (51.9%) patients had disease progression at the time of analysis. Of these, 7 (13.0%), 7 (13.0%) and 21 (38.9%) had local recurrence, locoregional failure and distant metastasis, respectively. All cases of local recurrence were found within the SIB region. Four patients had grade 2-3 pneumonitis, and 8 patients had grade 2-3 esophagitis. Patients with grade 2-3 esophagitis had significantly higher maximum dose and dose to 5 cm3 volume to esophagus than those with grade 0-1 esophagitis. No grade 4 or higher toxicity was observed. Conclusion The 60 to 66 Gy in 15 fractions RT regimen provides favorable local control and survival with well-tolerated toxicities. Hypofractionated VMAT+SIB is an alternative treatment option for patients with NSCLC who cannot tolerate standard definitive therapy.
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Affiliation(s)
- Junyue Shen
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Dan Yang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Mailin Chen
- Departments of Radiology, Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University Cancer Hospital and Institute, Beijing, China
| | - Leilei Jiang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Xin Dong
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Dongming Li
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Rong Yu
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Huiming Yu
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Anhui Shi
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
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Wang B, Wang DQ, Lin MS, Lu SP, Zhang J, Chen L, Li QW, Cheng ZK, Liu FJ, Guo JY, Liu H, Qiu B. Accumulation of the delivered dose based on cone-beam CT and deformable image registration for non-small cell lung cancer treated with hypofractionated radiotherapy. BMC Cancer 2020; 20:1112. [PMID: 33198676 PMCID: PMC7670776 DOI: 10.1186/s12885-020-07617-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022] Open
Abstract
Background This study aimed to quantify the dosimetric differences between the planned and delivered dose to tumor and normal organs in locally advanced non-small cell lung cancer (LANSCLC) treated with hypofractionated radiotherapy (HRT), and to explore the necessity and identify optimal candidates for adaptive radiotherapy (ART). Methods Twenty-seven patients with stage III NSCLC were enrolled. Planned radiation dose was 51Gy in 17 fractions with cone-beam CT (CBCT) acquired at each fraction. Virtual CT was generated by deformable image registration (DIR) of the planning CT to CBCT for dose calculation and accumulation. Dosimetric parameters were compared between original and accumulated plans using Wilcoxon signed rank test. Correlations between dosimetric differences and clinical variables were analyzed using Mann-Whitney U test or Chi-square test. Results Patients had varied gross tumor volume (GTV) reduction by HRT (median reduction rate 11.1%, range − 2.9-44.0%). The V51 of planning target volume for GTV (PTV-GTV) was similar between original and accumulated plans (mean, 88.2% vs. 87.6%, p = 0.452). Only 11.1% of patients had above 5% relative decrease in V51 of PTV-GTV in accumulated plans. Compared to the original plan, limited increase (median relative increase < 5%) was observed in doses of total lung (mean dose, V20 and V30), esophagus (mean dose, maximum dose) and heart (mean dose, V30 and V40) in accumulated plans. Less than 30% of patients had above 5% relative increase of lung or heart doses. Patients with quick tumor regression or baseline obstructive pneumonitis showed more notable increase in doses to normal structures. Patients with baseline obstructive atelectasis showed notable decrease (10.3%) in dose coverage of PTV-GTV. Conclusions LANSCLC patients treated with HRT had sufficient tumor dose coverage and acceptable normal tissue dose deviation. ART should be applied in patients with quick tumor regression and baseline obstructive pneumonitis/atelectasis to spare more normal structures. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12885-020-07617-3.
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Affiliation(s)
- Bin Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Da Quan Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Mao Sheng Lin
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Shi Pei Lu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jun Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Li Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Qi Wen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Zhang Kai Cheng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Fang Jie Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jin Yu Guo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Hui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
| | - Bo Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
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Liu YE, Xue XY, Zhang R, Chen XJ, Ding YX, Liu CX, Qin YL, Li WQ, Ren XC, Lin Q. Study protocol: a multicentre, prospective, phase II trial of isotoxic hypofractionated concurrent chemoradiotherapy for non-small cell lung cancer. BMJ Open 2020; 10:e036295. [PMID: 33099491 PMCID: PMC7590348 DOI: 10.1136/bmjopen-2019-036295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Concurrent chemoradiotherapy with conventional fractionation has been acknowledged as one of the standard treatments for locally advanced non-small cell lung cancer (NSCLC). The radiotherapy dose of 60 Gy is far from enough for local tumour control. Due to this fact, hypofractionated radiotherapy can shorten the total treatment duration, partially counteract the accelerated repopulation of tumour cells and deliver a higher biological effective dose, it has been increasingly used for NSCLC. In theory, concurrent hypofractionated chemoradiotherapy can result in an enhanced curative effect. To date, the vast majority of radiotherapy prescriptions assign a uniform radiotherapy dose to all patients. However this kind of uniform radiotherapy prescription may lead to two consequences: excess damage to normal tissues for large tumours and insufficient dose for small tumours. Our study aims to evaluate whether delivering individualised radiotherapy dose is feasible using intensity-modulated radiotherapy. METHODS AND ANALYSIS Our study of individualised radiotherapy is a multicenter phase II trial. From April 2019, a total of 30 patients from three Chinese centres, with a proven histological or cytological diagnosis of inoperable NSCLC, will be recruited. The dose of radiation will be increased until one or more of the organs at risk tolerance or the maximum dose of 69 Gy is reached. The primary end point is feasibility, with response rates, progression-free survival and overall survival as secondary end points. The concurrent chemotherapy regimen will be docetaxel plus lobaplatin. ETHICS AND DISSEMINATION The study has been approved by medical ethics committees from three research centres. The trial is conducted in accordance with the Declaration of Helsinki.The trial results will be disseminated through academic conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03606239.
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Affiliation(s)
- Yue-E Liu
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Xiao-Ying Xue
- Department of Radiotherapy, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Rui Zhang
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Xue-Ji Chen
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Yu-Xia Ding
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Chao-Xing Liu
- Department of Oncology, No.1 Hospital of Shijiazhuang City, Shijiazhuang, Hebei, China
| | - Yue-Liang Qin
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Wei-Qian Li
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Xiao-Cang Ren
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Qiang Lin
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
- Hebei Medical University, Shijiazhuang, Hebei, China
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Practice Recommendations for Lung Cancer Radiotherapy During the COVID-19 Pandemic: An ESTRO-ASTRO Consensus Statement. Int J Radiat Oncol Biol Phys 2020; 107:631-640. [PMID: 32589990 PMCID: PMC7836268 DOI: 10.1016/j.ijrobp.2020.05.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 01/08/2023]
Abstract
Background The COVID-19 pandemic has caused radiotherapy resource pressures and led to increased risks for lung cancer patients and healthcare staff. An international group of experts in lung cancer radiotherapy established this practice recommendation pertaining to whether and how to adapt radiotherapy for lung cancer in the COVID-19 pandemic. Methods For this ESTRO & ASTRO endorsed project, 32 experts in lung cancer radiotherapy contributed to a modified Delphi consensus process. We assessed potential adaptations of radiotherapy in two pandemic scenarios. The first, an early pandemic scenario of risk mitigation, is characterized by an altered risk–benefit ratio of radiotherapy for lung cancer patients due to their increased susceptibility for severe COVID-19 infection, and minimization of patient travelling and exposure of radiotherapy staff. The second, a later pandemic scenario, is characterized by reduced radiotherapy resources requiring patient triage. Six common lung cancer cases were assessed for both scenarios: peripherally located stage I NSCLC, locally advanced NSCLC, postoperative radiotherapy after resection of pN2 NSCLC, thoracic radiotherapy and prophylactic cranial irradiation for limited stage SCLC and palliative thoracic radiotherapy for stage IV NSCLC. Results In a risk-mitigation pandemic scenario, efforts should be made not to compromise the prognosis of lung cancer patients by departing from guideline-recommended radiotherapy practice. In that same scenario, postponement or interruption of radiotherapy treatment of COVID-19 positive patients is generally recommended to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection. In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors for triage include potential for cure, relative benefit of radiation, life expectancy, and performance status. Case-specific consensus recommendations regarding multimodality treatment strategies and fractionation of radiotherapy are provided. Conclusion This joint ESTRO-ASTRO practice recommendation established pragmatic and balanced consensus recommendations in common clinical scenarios of radiotherapy for lung cancer in order to address the challenges of the COVID-19 pandemic.
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Kumar S, Chmura S, Robinson C, Lin SH, Gadgeel SM, Donington J, Feliciano J, Stinchcombe TE, Werner-Wasik M, Edelman MJ, Moghanaki D. Alternative Multidisciplinary Management Options for Locally Advanced NSCLC During the Coronavirus Disease 2019 Global Pandemic. J Thorac Oncol 2020; 15:1137-1146. [PMID: 32360578 PMCID: PMC7194660 DOI: 10.1016/j.jtho.2020.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is currently accelerating. Patients with locally advanced NSCLC (LA-NSCLC) may require treatment in locations where resources are limited, and the prevalence of infection is high. Patients with LA-NSCLC frequently present with comorbidities that increase the risk of severe morbidity and mortality from COVID-19. These risks may be further increased by treatments for LA-NSCLC. Although guiding data is scarce, we present an expert thoracic oncology multidisciplinary (radiation oncology, medical oncology, surgical oncology) consensus of alternative strategies for the treatment of LA-NSCLC during a pandemic. The overarching goals of these approaches are the following: (1) reduce the number of visits to a health care facility, (2) reduce the risk of exposure to severe acute respiratory syndrome–coronavirus-2, (3) attenuate the immunocompromising effects of lung cancer therapies, and (4) provide effective oncologic therapy. Patients with resectable disease can be treated with definitive nonoperative management if surgical resources are limited or the risks of perioperative care are high. Nonoperative options include chemotherapy, chemoimmunotherapy, and radiation therapy with sequential schedules that may or may not affect long-term outcomes in an era in which immunotherapy is available. The order of treatments may be on the basis of patient factors and clinical resources. Whenever radiation therapy is delivered without concurrent chemotherapy, hypofractionated schedules are appropriate. For patients who are confirmed to have COVID-19, usually, cancer therapies may be withheld until symptoms have resolved with negative viral test results. The risk of severe treatment-related morbidity and mortality is increased for patients undergoing treatment for LA-NSCLC during the COVID-19 pandemic. Adapting alternative treatment strategies as quickly as possible may save lives and should be implemented through communication with the multidisciplinary cancer team.
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Affiliation(s)
- Sameera Kumar
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
| | - Steven Chmura
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Steven H Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Shirish M Gadgeel
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Josephine Feliciano
- Department of Medical Oncology, Johns Hopkins University, Baltimore, Maryland
| | | | - Maria Werner-Wasik
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Martin J Edelman
- Department of Hematology and Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Drew Moghanaki
- Department of Radiation Oncology, Emory University, Atlanta Veterans Affairs Health Care System, Atlanta, Georgia
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Kong C, Zhu X, Shi M, Wang L, Chen C, Tao H, Jiang N, Yan P, Zhao L, Song X, He X. Survival and Toxicity of Hypofractionated Intensity Modulated Radiation Therapy in 4 Gy Fractions for Unresectable Stage III Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2020; 107:710-719. [PMID: 32275994 DOI: 10.1016/j.ijrobp.2020.03.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 03/24/2020] [Accepted: 03/28/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To assess the survival, local and distant control, and toxicity in patients with unresectable locally advanced non-small cell lung cancer treated with radical-intent hypofractionated radiation therapy delivering approximately 60 Gy in 4-Gy fractions. METHODS AND MATERIALS Consecutive patients with unresectable stage III non-small cell lung cancer (n = 42) who received hypofractionated intensity modulated radiation therapy were retrospectively analyzed (2012-2016). Treatments consisted of first-line platinum-based doublet induction chemotherapy followed by an intended dose of 60 Gy in 15 fractions. RESULTS During a median follow-up period of 46 months (95% confidence interval, 41-59) the median overall survival was 47 months (95% confidence interval, 31 to not reached). The 1-, 2-, 3-, and 5-year overall survival rates were 81%, 69%, 64%, and 32%, respectively. The 1-, 2-, 3-, and 5-year progression-free survival rates were 58%, 35%, 25%, and 25%, respectively. An isolated locoregional recurrence was seen in 12% of the patients (n = 5). The incidence of grade (G) 3 or higher treatment-related lung toxicity was 14% (n = 6), among which G3 toxicity was 9.5% (n = 4) and G5 toxicity was 4.8% (n = 2). Twelve percent of patients (n = 5) experienced G3 radiation esophagitis, and 2% (n = 1) had G4 esophageal toxicity. CONCLUSIONS Patients with unresectable locally advanced non-small cell lung cancer treated with hypofractionated intensity modulated radiation therapy in doses up to 60 Gy at 4 Gy per fraction had promising survival, although high-grade esophageal and lung toxicities were seen. Our findings deserve further evaluation in prospective studies.
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Affiliation(s)
- Cheng Kong
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Xiangzhi Zhu
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China.
| | - Meiqi Shi
- Department of Medical Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Li Wang
- Department of Medical Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Cheng Chen
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Hua Tao
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Ning Jiang
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Pengwei Yan
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Lijun Zhao
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Xue Song
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Xia He
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
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11
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Guckenberger M, Belka C, Bezjak A, Bradley J, Daly ME, DeRuysscher D, Dziadziuszko R, Faivre-Finn C, Flentje M, Gore E, Higgins KA, Iyengar P, Kavanagh BD, Kumar S, Le Pechoux C, Lievens Y, Lindberg K, McDonald F, Ramella S, Rengan R, Ricardi U, Rimner A, Rodrigues GB, Schild SE, Senan S, Simone CB, Slotman BJ, Stuschke M, Videtic G, Widder J, Yom SS, Palma D. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. Radiother Oncol 2020; 146:223-229. [PMID: 32342863 PMCID: PMC7252074 DOI: 10.1016/j.radonc.2020.04.001] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 01/08/2023]
Abstract
Background The COVID-19 pandemic has caused radiotherapy resource pressures and led to increased risks for lung cancer patients and healthcare staff. An international group of experts in lung cancer radiotherapy established this practice recommendation pertaining to whether and how to adapt radiotherapy for lung cancer in the COVID-19 pandemic. Methods For this ESTRO & ASTRO endorsed project, 32 experts in lung cancer radiotherapy contributed to a modified Delphi consensus process. We assessed potential adaptations of radiotherapy in two pandemic scenarios. The first, an early pandemic scenario of risk mitigation, is characterized by an altered risk–benefit ratio of radiotherapy for lung cancer patients due to their increased susceptibility for severe COVID-19 infection, and minimization of patient travelling and exposure of radiotherapy staff. The second, a later pandemic scenario, is characterized by reduced radiotherapy resources requiring patient triage. Six common lung cancer cases were assessed for both scenarios: peripherally located stage I NSCLC, locally advanced NSCLC, postoperative radiotherapy after resection of pN2 NSCLC, thoracic radiotherapy and prophylactic cranial irradiation for limited stage SCLC and palliative thoracic radiotherapy for stage IV NSCLC. Results In a risk-mitigation pandemic scenario, efforts should be made not to compromise the prognosis of lung cancer patients by departing from guideline-recommended radiotherapy practice. In that same scenario, postponement or interruption of radiotherapy treatment of COVID-19 positive patients is generally recommended to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection. In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors for triage include potential for cure, relative benefit of radiation, life expectancy, and performance status. Case-specific consensus recommendations regarding multimodality treatment strategies and fractionation of radiotherapy are provided. Conclusion This joint ESTRO-ASTRO practice recommendation established pragmatic and balanced consensus recommendations in common clinical scenarios of radiotherapy for lung cancer in order to address the challenges of the COVID-19 pandemic.
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland.
| | - Claus Belka
- Department of Radiation Oncology, LMU Klinikum, LMU Munich, Germany
| | - Andrea Bezjak
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Canada
| | - Jeffrey Bradley
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, USA
| | - Megan E Daly
- Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, USA
| | - Dirk DeRuysscher
- Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Center(+), GROW Research Institute, The Netherlands
| | - Rafal Dziadziuszko
- Dept. of Oncology and Radiotherapy, Medical University of Gdansk, Poland
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - Michael Flentje
- Department of Radiation Oncology, University Hospital Würzburg, JMU Würzburg, Germany
| | - Elizabeth Gore
- Department of Radiation Oncology, Medical College of Wisconsin and Zablocki VAMC, Milwaukee, USA
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, USA
| | - Puneeth Iyengar
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado, Aurora, USA
| | - Sameera Kumar
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - Cecile Le Pechoux
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, Belgium
| | - Karin Lindberg
- Department of Head, Neck, Lung and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | | | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University of Rome, Italy
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | | | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | - Suresh Senan
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, USA
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands
| | - Martin Stuschke
- Department of Radiotherapy, University Duisburg-Essen, Germany
| | - Greg Videtic
- Department of Radiation Oncology, Cleveland Clinic Lerner College of Medicine of Case Western University, USA
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Sue S Yom
- Department of Radiation Oncology, University of California San Francisco, USA
| | - David Palma
- Division of Radiation Oncology, Western University, London, Canada
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12
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Iocolano M, Wild AT, Hannum M, Zhang Z, Simone CB, Gelblum D, Wu AJ, Rimner A, Shepherd AF. Hypofractionated vs. conventional radiation therapy for stage III non-small cell lung cancer treated without chemotherapy. Acta Oncol 2020; 59:164-170. [PMID: 31608751 DOI: 10.1080/0284186x.2019.1675907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Patients with unresectable locally advanced NSCLC who refuse or are not candidates for chemotherapy often receive radiation therapy (RT) alone. Hypofractionated RT (HFRT) regimens are becoming increasingly common. An analysis of the National Cancer Database (NCDB) was performed to evaluate the practice patterns and outcomes of HFRT vs. conventionally fractionated RT (CFRT) in patients with stage III NSCLC undergoing definitive RT alone.Material and methods: The NCDB was queried for all patients with stage III NSCLC diagnosed between 2004 and 2014 who received RT alone. CFRT was defined as patients treated to a total dose of 60-80 Gy in 1.8-2 Gy daily fractions. HFRT was defined as patients treated to a total dose of 50-80 Gy in 2.25-4 Gy fractions. Logistic regression, univariable and multivariable analyses (MVAs) for overall survival (OS) and propensity score matched analyses (PSMAs) were performed.Results: A total of 6490 patients were evaluated: 5378 received CFRT and 1112 received HFRT. Median CFRT dose was 66 Gy in 2 Gy fractions vs. 58.5 Gy in 2.5 Gy fractions for HFRT. HFRT was associated with older age, lower biological effective dose (BED10), academic facility type, higher T-stage and lower N-stage. On initial analysis, HFRT was associated with inferior OS (median 9.9 vs. 11.1 months, p<.001), but after adjusting for the imbalance in covariates such as age, BED10, T-stage and N-stage using PSMA, the difference in survival was no longer significant (p=.1).Conclusions: In the appropriate clinical context, HFRT can be an option for patients with locally advanced NSCLC who are not candidates for chemotherapy or surgical resection. HFRT needs to be further studied in prospective trials to evaluate toxicity and tumor control.
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Affiliation(s)
| | - Aaron T. Wild
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Margaret Hannum
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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13
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Valeriani M, Marinelli L, Nicosia L, Reverberi C, De Sanctis V, Mollo D, Osti MF. Locally advanced inoperable primary or recurrent non-small cell lung cancer treated with 4-week hypofractionated radiation therapy (3 Gy/fraction). Radiol Med 2019; 124:1324-1332. [PMID: 31317381 DOI: 10.1007/s11547-019-01064-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/07/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND The prognosis of locally advanced non-small cell lung cancer (NSCLC) treated with conventional radiotherapy remains poor. Hypofractionation reduces overall treatment time increasing biological effect in patients not suitable for concurrent chemo-radiotherapy. METHOD From January 2009 to October 2016, 76 inoperable locally advanced primary or recurrent NSCLC patients were treated with 60 Gy in 20 fractions of 3 Gy/each for 4 weeks as exclusive or post-chemotherapy treatment. Fifty-eight patients (76.3%) had stage III and 18 (23.7%) stage IV (≤ 2 metastases) disease: 63 primary (82.9%) and 13 recurrent (17.1%). RESULTS Median and 2-year overall survival were 17 months and 38.9%, respectively. Median and 2-year loco-regional progression free survival were 27 months and 55.3%, respectively. Univariate and multivariate analyses demonstrated that patients with complete response presented better outcomes, whereas no statistically relevant difference was evidenced in terms of previous chemotherapy, recurrent vs primary disease, volume and stage. Thirty patients (39.5%) presented acute esophagitis (1-grade 3) and 19 (25.0%) acute pneumonitis (2-grade 3). Six patients (7.9%) developed grade 2-3 late pneumonitis and 3 patients (3.9%) grade 1 late esophagitis. CONCLUSION In patients not suitable of concurrent radio-chemotherapy, exclusive or sequential hypofractionated schedule using 60 Gy in 20 fractions was well tolerated and presented promising results. Complete local response was a predictor of better outcomes, and any efforts will be made to perform prospective clinical trials to further evaluate hypofractionated regimens with increased lesional BED.
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Affiliation(s)
- Maurizio Valeriani
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Luca Marinelli
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Luca Nicosia
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Chiara Reverberi
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Vitaliana De Sanctis
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Davide Mollo
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Mattia Falchetto Osti
- Department of Radiation Oncology, Sant' Andrea Hospital, "Sapienza" University, Via di Grottarossa 1035-1039, 00189, Rome, Italy
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14
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Zhao Q, Chen G, Ye L, Shi S, Du S, Zeng Z, He J. Treatment-duration is related to changes in peripheral lymphocyte counts during definitive radiotherapy for unresectable stage III NSCLC. Radiat Oncol 2019; 14:86. [PMID: 31133034 PMCID: PMC6537222 DOI: 10.1186/s13014-019-1287-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To investigate the potential impact of fractionation regimes and overall treatment time (OTT) on lymphopenia during definitive radiotherapy (RT) and its associations with patient outcomes in non-small cell lung cancer (NSCLC). METHODS Subjects consisted of 115 patients who had received definitive chemoradiation therapy (CRT) with different doses and fractions for unresectable stage III NSCLC. Clinical and laboratory records were reviewed to assess the changes in total lymphocyte counts (TLCs) during definitive RT. The associations of the TLCs with the clinical and treatment features, and outcomes were analyzed. RESULTS The median reduction of TLCs in the entire cohort was 1300 cells/μL (interquartile range [IQR], 950-1510 cells/μL). Of all patients, 63 (54.8%) experienced severe lymphopenia (SL) (TLC nadir < 500 cells/μL), which occurred at a median of the 5th week following RT initiation, not at the completion of RT or upon treatment with maximal doses. SL risk was increased over the first 5 weeks (odds ratio [OR] = 3.455, P = 0.007), after which, no increased risk was observed (OR = 0.562, P = 0.216). The median TLCs remained low and failed to recover to the initial normal values of their pre-RT level after 2 months of RT completion. Patients without SL exhibited significantly improved progression-free survival (hazard ratio [HR] = 0.544, P = 0.010) and overall survival (HR = 0.463, P = 0.011) after controlling for confounding variables in multivariate analyses. The incidence of SL was significantly lower (71.1% reduction in risk (OR = 0.289, P = 0.007)) in patients who received hypofractionated RT with an OTT within 4 weeks, compared to those who had an OTT of more than 4 weeks (32.1% vs 62.1%, P = 0.006). Multivariate analyses revealed that OTT within 4 weeks (OR = 0.322, P = 0.032) was significantly associated with a decreased risk of developing SL after controlling for confounding factors. CONCLUSIONS Hypofractionated RT was significantly associated with a decreased risk of SL and improved survival during definitive radiotherapy for unresectable stage III NSCLC.
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Affiliation(s)
- Qianqian Zhao
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Gang Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Luxi Ye
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shiming Shi
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shisuo Du
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Jian He
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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15
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Parisi G, Mazzola R, Ciammella P, Timon G, Fozza A, Franceschini D, Navarria F, Bruni A, Perna M, Giaj-Levra N, Alongi F, Scotti V, Trovo M. Hypofractionated radiation therapy in the management of locally advanced NSCLC: a narrative review of the literature on behalf of the Italian Association of Radiation Oncology (AIRO)-Lung Working Group. Radiol Med 2018; 124:136-144. [PMID: 30368721 DOI: 10.1007/s11547-018-0950-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022]
Abstract
A systematic literature was performed to assess the benefit in terms of effectiveness and feasibility of hypofractionated radiotherapy (HypoRT), with or without chemotherapy (CT), in the treatment of locally advanced non-small cell lung cancer (NSCLC). We have identified all studies, published from 2007 onwards, on patients with locally advanced NSCLC treated with HypoRT with radical intent, with a minimal dose per fraction of 2.4 Gy, with or without concurrent chemotherapy. Twenty-nine studies were identified, for a total of 2614 patients. Patients were divided in the concurrent chemo-radiation therapy group (CT-RT) and radiotherapy alone (RT). In RT group, the delivered dose ranged from 45 to 85.5 Gy, with a dose/fraction from 2.4 to 4 Gy. Actuarial 2-year PFS ranged from 13 to 57.8%, and 1, 2- and 3-year overall survival (OS) ranged from 51.3 to 95%, from 22 to 68.7%, and from 7 to 32%, respectively. Acute Grade ≥ 3 esophagitis occurred in 0-15%, while late esophageal toxicity was 0-16%. Acute pneumonitis occured in 0-44%, whereas late pneumonitis occured in 0-47%, most commonly grade ≤ G3. In CT-RT group, the delivered dose ranged from 52.5 to 75 Gy, with a dose/fraction ranging from 2.4 to 3.5 Gy. Actuarial 2-year PFS ranged from 19 to 57.8%, and OS at 1, 2 and 3 years ranged from 28 to 95%, 38.6 to 68.7%, and 31 to 44%, respectively. Acute Grade 2 and 3 esophagitis occurred in 3-41.7%, while late esophageal toxicity occurred in 0-8.3%. Acute pneumonitis ranged from 0 to 23%, whereas late pneumonitis occured 0-47%. HypoRT seems to be safe in patients with locally advanced NSCLC. The encouraging survival results of several studies analyzed suggest that hypofractionated radiation schemes should be further investigated in the future.
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Affiliation(s)
- Giuseppe Parisi
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata UD, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy.
| | - Rosario Mazzola
- Department of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Patrizia Ciammella
- Department of Oncology and Advanced Technology, Arcispedale S Maria Nuova-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Giorgia Timon
- Department of Oncology and Advanced Technology, Arcispedale S Maria Nuova-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Alessandra Fozza
- Department of Radiation Oncology, SS.Antonio e Biagio e C.Arrigo Hospital Alessandria, Alessandria, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, Humanitas Cancer Center and Research Hospital, Rozzano, Milan, Italy
| | | | - Alessio Bruni
- Radiotherapy Unit - Department of Oncology and Hematology, University Hospital of Modena Italy, Modena, Italy
| | - Marco Perna
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
| | - Niccolò Giaj-Levra
- Department of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Filippo Alongi
- Department of Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Vieri Scotti
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
| | - Marco Trovo
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata UD, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy
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16
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Spałek M, Wyrwicz L. Hematological Toxicity of Hypofractionated Radiotherapy: A Review of the Available Evidence. Oncol Res Treat 2018; 41:713-718. [DOI: 10.1159/000492342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 07/23/2018] [Indexed: 12/25/2022]
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17
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Valeriani M, Marinelli L, Reverberi C, De Sanctis V, Mollo D, Nicosia L, Osti MF. Inoperable early-stage primary and early recurrent non-small cell lung cancer: outcomes of a mono-institutional experience using a moderate hypofractionated schedule. Radiol Med 2018; 124:58-64. [PMID: 30178173 DOI: 10.1007/s11547-018-0934-z] [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: 06/26/2018] [Accepted: 08/20/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with medically inoperable early-stage non-small cell lung cancer (NSCLC) may beneficiate of a hypofractionated radiation therapy in order to intensificate the treatment and to reduce the number of hospital access. METHODS From 2007 to 2015, 27 patients with early-stage primary or limited loco-regional recurrent (T2a > 4 cm, T2b N0 or T1-2 N1M0) NSCLC were treated. All patients were medically inoperable or refused surgery and were treated with 60 Gy in 20 fractions, 5 times per week. Thirteen (48.1%) presented limited recurrence after surgery and 14 (51.9%) primary disease. RESULTS Median follow-up was 34 months. Twelve patients achieved a CR (44.4%) and 8 a PR (29.6%) with a tumour response rate of 74%. Median overall survival (OS) and 2-year OS were 34 months and 63.0%, respectively. Median and 2-year loco-regional progression-free survival (LR-PFS) were 31 months and 51.4%, respectively. Survival outcomes were statistically favourable in patients with partial or complete response with respect to patients with stable or progressive disease, whereas stage (N0 vs N1) and primary or relapse/recurrent disease not. No cases of acute toxicity > grade 2 were observed. Seven patients (25.9%) presented grade 2 late toxicities. CONCLUSION Sixty Gy in 20 fractions is well tolerated and achieves good clinical outcomes in early primary or recurrent NSCLC patients. A greater number of patients and a longer follow-up are necessary to confirm the results obtained with our treatment.
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Affiliation(s)
- Maurizio Valeriani
- Department of Radiation Oncology, Facoltà di Medicina e Psicologia, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
| | - Luca Marinelli
- Department of Radiation Oncology, Facoltà di Medicina e Psicologia, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Chiara Reverberi
- Department of Radiation Oncology, Facoltà di Medicina e Psicologia, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Vitaliana De Sanctis
- Department of Radiation Oncology, Facoltà di Medicina e Psicologia, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Davide Mollo
- Department of Radiation Oncology, Facoltà di Medicina e Psicologia, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Luca Nicosia
- Department of Radiation Oncology, Facoltà di Medicina e Psicologia, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Via di Grottarossa 1035-1039, 00189, Rome, Italy
| | - Mattia Falchetto Osti
- Department of Radiation Oncology, Facoltà di Medicina e Psicologia, Sant'Andrea Hospital, Università degli Studi di Roma La Sapienza, Via di Grottarossa 1035-1039, 00189, Rome, Italy
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18
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Urbanic JJ, Wang X, Bogart JA, Stinchcombe TE, Hodgson L, Schild SE, Bazhenova L, Hahn O, Salgia R, Vokes EE. Phase 1 Study of Accelerated Hypofractionated Radiation Therapy With Concurrent Chemotherapy for Stage III Non-Small Cell Lung Cancer: CALGB 31102 (Alliance). Int J Radiat Oncol Biol Phys 2018; 101:177-185. [PMID: 29487024 DOI: 10.1016/j.ijrobp.2018.01.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 01/07/2018] [Accepted: 01/10/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE To investigate the safety of accelerated hypofractionated radiation therapy (AHRT) with concurrent chemotherapy (CT) for inoperable stage III non-small cell lung cancer (NSCLC). PATIENTS AND METHODS The primary objectives were to define the maximally tolerable course of accelerated radiation therapy and to describe toxicities of therapy. Total radiation therapy remained at 60 Gy. The number of once-daily fractions in each successive cohort was reduced as follows: cohort 1, 60 Gy in 27 fractions; cohort 2, 60 Gy in 24 fractions; cohort 3, 60 Gy in 22 fractions; and cohort 4, 60 Gy in 20 fractions. Concurrent treatment consisted of weekly carboplatin area under the curve (AUC) 2 and paclitaxel 45 mg/m2. Consolidation treatment consisted of carboplatin AUC 6 and paclitaxel 200 mg/m2 every weeks × 2 cycles. Maximum tolerated dose: Of 6 patients/cohort, ≤2 patients experienced grade ≥3 toxicity, and ≤1 patient experienced grade ≥4 toxicity. RESULTS 22 patients were accrued; of those, 21 patients were evaluable between July 2012 and May 2014. Grade 5 toxicity occurred in 3 patients: 1 patient in cohort 2 (hemoptysis), 2 patients in cohort 3 (hemoptysis, pneumonitis). The maximum tolerated dose (MTD) was defined by cohort 2 (60 Gy in 2.5 Gy/fraction). Time to grade 5 toxicity was 9 months, 6 months, and 9 months after the start of treatment. The median follow-up time was 23.0 months (range, 7.6-30.6 months) in living patients, the median overall survival was 19.3 months (95% confidence interval [CI] 9.3-34.0 months), and the median progression-free survival was 12.2 months (95% CI 6.1-22.5 months). CONCLUSIONS Only modest hypofractionation was achievable as a result of long-term toxicities. Nevertheless, the MTD of 60 Gy given at 2.5 Gy/fraction allows completion of RT in 20% fewer treatments than conventional therapy. Further investigation of AHRT may help to better define the therapeutic index.
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Affiliation(s)
- James J Urbanic
- Department of Radiation Medicine and Applied Sciences, University of California at San Diego, Moores Cancer Center, La Jolla, California.
| | - Xiaofei Wang
- Alliance Statistics and Data Center, Duke University, Durham, North Carolina
| | - Jeffrey A Bogart
- Department of Radiation Oncology, State University of New York Upstate Medical University, Syracuse, New York
| | - Thomas E Stinchcombe
- Division of Hematology Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lydia Hodgson
- Alliance Statistics and Data Center, Duke University, Durham, North Carolina
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Lyudmila Bazhenova
- Division of Hematology Oncology, University of California at San Diego, Moores Cancer Center, La Jolla, California
| | - Olwen Hahn
- Division of Hematology Oncology, Alliance Protocol Office, University of Chicago, Chicago, Illinois
| | - Ravi Salgia
- Division of Hematology Oncology, University of Chicago Comprehensive Cancer Center, Chicago, Illinois
| | - Everett E Vokes
- Department of Medicine, University of Chicago Comprehensive Cancer Center, Chicago, Illinois
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Zhang J, Zhou L, Nan Z, Yuan Q, Wen J, Xu M, Li Y, Li B, Wang P, Liu C, Ma Y, Chen S, Xie S. Knockdown of c‑Myc activates Fas-mediated apoptosis and sensitizes A549 cells to radiation. Oncol Rep 2017; 38:2471-2479. [PMID: 28849062 DOI: 10.3892/or.2017.5897] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/31/2017] [Indexed: 11/06/2022] Open
Abstract
Several studies have demonstrated that cancer radiosensitivity is associated with the deregulation of c‑Myc, but the relationship between c‑Myc and Fas in radioresistance of lung adenocarcinoma remains unclear. In this study, we established radiation-resistant A549 cell model (A549/R), and investigated the roles of c‑Myc and Fas in radiation-induced cytotoxicity of A549 cells. Apoptosis detection showed that there were fewer apoptotic cells in A549/R cells treated with radiation than in A549 cells. Western blotting results demonstrated the inverse expression pattern of c‑Myc and Fas in A549 and A549/R cells. Suppression of c‑Myc expression by small interfering RNA (siRNA) displayed enhancement of Fas-mediated apoptosis in A549/R cells, accompanying a significant decrease of Bid, Bcl‑2, pro‑caspase‑8, -9 and -3 and increase of Bax. In contrast, Fas-mediated apoptosis was attenuated while Fas expression was suppressed by ectopic expression of c‑Myc in A549 cells. Moreover, decreased cell viability and increased induction of apoptosis were observed in A549/R cells followed by combinational treatment of c‑Myc siRNA and irradiation, whereas, upregulation of c‑Myc reduced the sensitivity of A549 cells to irradiation. These results indicated that c‑Myc and Fas regulated the sensitivity of A549 cells to irradiation by regulating caspase‑8-mediated Bid activation and the subsequent association with the mitochondrial pathway of apoptosis.
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Affiliation(s)
- Jing Zhang
- Key Laboratory of Tumor Molecular Biology in Binzhou Medical University, Department of Biochemistry and Molecular Biology, Binzhou Medical University, Yantai, Shandong 264003, P.R. China
| | - Ling Zhou
- Key Laboratory of Tumor Molecular Biology in Binzhou Medical University, Department of Biochemistry and Molecular Biology, Binzhou Medical University, Yantai, Shandong 264003, P.R. China
| | - Zhaodi Nan
- Department of Oncology, Affiliated Hospital to Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Qing Yuan
- Department of Oncology, Affiliated Hospital to Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Jie Wen
- Department of Oncology, Affiliated Hospital to Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Maolei Xu
- The Key Laboratory of Traditional Chinese Medicine Prescription Effect and Clinical Evaluation of State Administration of Traditional Chinese Medicine, School of Pharmacy, Binzhou Medical University, Yantai, Shandong 264003, P.R. China
| | - Youjie Li
- Key Laboratory of Tumor Molecular Biology in Binzhou Medical University, Department of Biochemistry and Molecular Biology, Binzhou Medical University, Yantai, Shandong 264003, P.R. China
| | - Baosheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital, Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Pingyu Wang
- Key Laboratory of Tumor Molecular Biology in Binzhou Medical University, Department of Biochemistry and Molecular Biology, Binzhou Medical University, Yantai, Shandong 264003, P.R. China
| | - Changmin Liu
- Department of Oncology, Affiliated Hospital to Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Ying Ma
- Key Laboratory of Tumor Molecular Biology in Binzhou Medical University, Department of Biochemistry and Molecular Biology, Binzhou Medical University, Yantai, Shandong 264003, P.R. China
| | - Shaoshui Chen
- Department of Oncology, Affiliated Hospital to Binzhou Medical University, Binzhou, Shandong 256603, P.R. China
| | - Shuyang Xie
- Key Laboratory of Tumor Molecular Biology in Binzhou Medical University, Department of Biochemistry and Molecular Biology, Binzhou Medical University, Yantai, Shandong 264003, P.R. China
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20
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Fang P, Swanick CW, Pezzi TA, Liao Z, Welsh J, Lin SH, Gomez DR. Outcomes and toxicity following high-dose radiation therapy in 15 fractions for non-small cell lung cancer. Pract Radiat Oncol 2017; 7:433-441. [PMID: 28428017 DOI: 10.1016/j.prro.2017.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/08/2017] [Accepted: 03/06/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Accelerated hypofractionated radiation therapy (AHRT) is increasingly used for select lung cancer patients. We evaluated clinical outcomes and predictors of pulmonary/esophageal toxicity in patients treated with ≥52.5 Gy in 15 fractions. METHODS AND MATERIALS We evaluated 229 patients treated with radiation therapy doses ≥52.5 Gy in 15 fractions for non-small cell lung cancer from January 2009 through January 2016. Toxicity was scored using Common Terminology Criteria for Adverse Events, v4.0. Univariate and multivariate logistic regression was used to identify predictors of toxicity. Overall survival, progression-free survival, and local control were estimated using the Kaplan-Meier method. Predictors of clinical outcome were modeled using Cox proportional hazards regression. RESULTS Median follow-up was 7 months. Forty-two patients (19%) developed grade ≥2 pneumonitis, and 9 (4%) developed grade ≥3 esophagitis. In multivariate analysis, age >75 years (odds ratio [OR], 2.56; 95% confidence interval [CI], 1.24-5.25; P = .01) and percentage of lung volume receiving doses of >10 Gy higher than 32% were associated with grade ≥2 pneumonitis (OR, 2.79; 95% CI, 1.39-5.79; P = .005). On univariate analysis, esophagus mean dose ≥17 Gy (OR, 10.14; 95% CI, 1.82-189.8; P = .006), gross tumor volume size ≥71 cm3 (P = .002), and planning target volume size ≥409 cm3 (P = .02) were associated with development of grade ≥3 esophagitis. In patients with stage II/III disease (n = 73), median local control was not reached, median overall survival was 14 months, and median progression-free survival was 6 months. CONCLUSIONS AHRT in 15 fractions can be safe and effective. Consideration for using AHRT with immunotherapy and sequential chemotherapy for improved out-of-radiation field and distant control is warranted.
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Affiliation(s)
- Penny Fang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - Cameron W Swanick
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - Todd A Pezzi
- Baylor College of Medicine, One Baylor Plaza, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - James Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas.
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
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Pollom EL, Qian Y, Durkee BY, von Eyben R, Maxim PG, Shultz DB, Gensheimer M, Diehn M, Loo BW. Hypofractionated Intensity-Modulated Radiotherapy for Patients With Non-Small-Cell Lung Cancer. Clin Lung Cancer 2016; 17:588-594. [PMID: 27378172 DOI: 10.1016/j.cllc.2016.05.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/29/2016] [Accepted: 05/31/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Alternative treatment regimens are needed for patients with non-small cell lung cancer (NSCLC) who cannot receive definitive treatment with concurrent chemoradiotherapy, surgery, or stereotactic ablative radiotherapy (SABR). PATIENTS AND METHODS We report survival, patterns of failure and toxicity outcomes for patients with NSCLC who were not eligible for surgical resection, concurrent chemoradiotherapy, or SABR and underwent hypofractionated intensity-modulated radiotherapy (IMRT). Kaplan-Meier survival analysis was used to evaluate the progression-free and overall survival. Competing risk analysis was used to evaluate in-field, locoregional, and distant failure. RESULTS A total of 42 patients treated to 52.5 to 60 Gy in 15 fractions were included. Most of the patients had metastatic or recurrent disease (64%) and a relatively large, centrally located tumor burden (74%). The median follow-up period was 13 months (interquartile range, 6-18 months). All patients received the total prescribed dose. The median survival was 15.1 months. The overall and progression-free survival rates at 1 year were 63% and 22.5%, respectively. The pattern of failure was predominantly distant, with only 2% of patients experiencing isolated in-field recurrence. The cumulative incidence of in-field failure at 6 and 12 months was 2.5% (95% confidence interval, 0.4%-15.6%) and 16.1% (95% confidence interval, 7.5%-34.7%), respectively. The risk of esophageal toxicity was associated with the esophageal mean dose, maximal point dose, and dose to the 5 cm3 volume. The risk of pneumonitis was associated with the lung mean dose and volume receiving 18 Gy. CONCLUSION Hypofractionated IMRT without concurrent chemotherapy provides favorable rates of local control and survival for well-selected patients with NSCLC who cannot tolerate standard definitive therapy.
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Affiliation(s)
- Erqi L Pollom
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Yushen Qian
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Ben Y Durkee
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Rie von Eyben
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Peter G Maxim
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - David B Shultz
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA; Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Michael Gensheimer
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Maximilian Diehn
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA.
| | - Billy W Loo
- Department of Radiation Oncology and Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA.
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22
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He J, Huang Y, Chen Y, Shi S, Ye L, Hu Y, Zhang J, Zeng Z. Feasibility and efficacy of helical intensity-modulated radiotherapy for stage III non-small cell lung cancer in comparison with conventionally fractionated 3D-CRT. J Thorac Dis 2016; 8:862-71. [PMID: 27162660 DOI: 10.21037/jtd.2016.03.46] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The standard treatment for stage III non-small-cell lung cancer (NSCLC) is still 60 Gy in conventional fractions combined with concurrent chemotherapy; however, the resulting local controls are disappointing. The aim of this study was to compare and assess the feasibility and efficacy of hypofractionated chemoradiotherapy using helical tomotherapy (HT) with conventional fractionation as opposed to using three-dimensional conformal radiotherapy (3D-CRT) for stage III NSCLC. METHODS Sixty-nine patients with stage III (AJCC 7th edition) NSCLC who underwent definitive radiation treatment at our institution between July 2011 and November 2013 were reviewed and analyzed retrospectively. A dose of 60 Gy in 20 fractions was delivered in the HT group (n=34), whereas 60 Gy in 30 fractions in the 3D-CRT group (n=35). Primary endpoints were toxicity, overall response rate, overall survival (OS) and progression-free survival (PFS). RESULTS The median follow-up period was 26.4 months. V20 (P=0.005), V30 (P=0.001), V40 (P=0.004), mean lung dose (P=0.000) and max dose of spinal cord (P=0.005) were significantly lower in the HT group than in the 3D-CRT group. There was no significant difference in the incidences of acute radiation pneumonitis (RP) ≥ grade 2 between the two groups, whereas the incidences of acute radiation esophagitis ≥ grade 2 were significantly lower in the HT group than in the 3D-CRT group (P=0.027). Two-year overall response rate was significantly higher in the HT group than in the 3D-CRT group (P=0.015). One- and 2-year OS rates were significantly higher in the HT group (95.0% and 68.7%, respectively) than in the 3D-CRT group (85.5% and 47.6%, respectively; P=0.0236). One- and 2-year PFS rates were significantly higher in the HT group (57.8% and 26.3%, respectively) than in the 3D-CRT group (32.7% and 11.4%, respectively; P=0.0351). Univariate analysis indicated that performance status (PS), T stage and radiotherapy technique were significant prognostic factors for both OS and PFS. Multivariate analysis indicated that PS and radiotherapy technique were independent prognostic factors of OS and PS was independent prognostic factor of PFS. CONCLUSIONS Hypofractionated chemoradiotherapy via HT can shorten the radiotherapy time without increasing treatment-related toxicity. The preliminary findings are that OS and PFS can be improved by hypofractionated chemoradiotherapy via HT for patients with stage III NSCLC.
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Affiliation(s)
- Jian He
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yan Huang
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yixing Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Shiming Shi
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Luxi Ye
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yong Hu
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jianying Zhang
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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23
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Normal tissue considerations and dose-volume constraints in the moderately hypofractionated treatment of non-small cell lung cancer. Radiother Oncol 2016; 119:423-31. [PMID: 27084120 DOI: 10.1016/j.radonc.2016.03.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 02/15/2016] [Accepted: 03/11/2016] [Indexed: 12/25/2022]
Abstract
Hypofractionated radiation therapy (RT) regimes in non-small cell lung cancer (NSCLC) have become increasingly popular with a number of international trials currently underway. The majority of the dose-volume-constraints (DVCs) published in the literature refer to conventional 2Gy per fraction deliveries. Here relevant organs-at-risk (OARs) are identified and available dose-volume constraint data discussed and summarised for moderately hypofractionated NSCLC regimes. The OARs examined include lung, brachial plexus, heart, oesophagus, airway and spinal cord. Where available the toxicity rates are also reported with all data summarised tabulated to aid its use in the clinic.
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Roy S, Pathy S, Mohanti BK, Raina V, Jaiswal A, Kumar R, Kalaivani M. Accelerated hypofractionated radiotherapy with concomitant chemotherapy in locally advanced squamous cell carcinoma of lung: evaluation of response, survival, toxicity and quality of life from a Phase II randomized study. Br J Radiol 2016; 89:20150966. [PMID: 26986459 DOI: 10.1259/bjr.20150966] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To evaluate the feasibility and efficacy of accelerated hypofractionated radiation with concomitant chemotherapy (AHFx-RT-CT) in locally advanced squamous cell carcinoma (SCC) of the lung. METHODS 36 patients were enrolled in this study (CTRI/2013/11/004143). Patients in Arm A (n = 18) received neoadjuvant chemotherapy (NACT) (paclitaxel 200 mg m(-2) and carboplatin area under the curve 5) followed by external radiotherapy (60 Gy/30 fractions/6 weeks). Patients in Arm B (n = 18) received NACT as in Arm A followed by AHFx-RT (48 Gy/20 fractions/4 weeks) with concomitant chemotherapy (cisplatin 30 mg m(-2) weekly). Primary end points included comparative evaluation of overall locoregional response rates (ORRs) and progression-free survival (PFS). Secondary end points included toxicity, quality of life (QOL) and overall survival (OS). RESULTS The median follow-up duration was 15 months. The ORR at first follow-up (72.2% vs 44%, p = 0.06) and at 1 year after treatment completion (61% vs 5.5%, p = 0.04) were superior in Arm B. The median PFS (17 vs 5.36 months; p = 0.053) and OS (24.73 vs 12.33 months; p = 0.007) were also superior in Arm B. Grade ≥3 acute pharyngitis/oesophagitis was less in Arm B (p = 0.05). Improvement of emotional function, cognitive function and chest pain was observed in Arm B. CONCLUSION The study suggests that AHFx-RT-CT is feasible for locally advanced SCC of the lung with improved response rate, survival, QOL and favourable toxicity. ADVANCES IN KNOWLEDGE To the best of our knowledge, this is the first study comparing conventionally fractionated radiation with AHFx-RT-CT. Addition of low-dose weekly cisplatin as radiosensitizer may be the potential factor responsible for improved response rate, survival and favourable toxicity in the study arm despite lower biological effective dose.
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Affiliation(s)
- Soumyajit Roy
- 1 Department of Radiation Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sushmita Pathy
- 1 Department of Radiation Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Bidhu K Mohanti
- 1 Department of Radiation Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Vinod Raina
- 2 Department of Medical Oncology, Dr BR Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Anand Jaiswal
- 3 Department of Pulmonary Medicine, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Rakesh Kumar
- 4 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Mani Kalaivani
- 5 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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Hong JC, Salama JK. Dose escalation for unresectable locally advanced non-small cell lung cancer: end of the line? Transl Lung Cancer Res 2016; 5:126-33. [PMID: 26958507 DOI: 10.3978/j.issn.2218-6751.2016.01.07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Radiation Therapy Oncology Group (RTOG) 0617 was a randomized trial that investigated both the impact of radiation dose-escalation and the addition of cetuximab on the treatment of non-small cell lung cancer (NSCLC). The results of RTOG 0617 were surprising, with the dose escalation randomization being closed prematurely due to futility stopping rules, and cetuximab ultimately showing no overall survival benefit. Locally advanced unresectable NSCLC has conventionally been treated with concurrent chemoradiation. Though advances in treatment technology have improved the ability to deliver adequate treatment dose, the foundation for radiotherapy (RT) has remained the same since the 1980s. Since then, progressive studies have sought to establish the safety and efficacy of escalating radiation dose to loco-regional disease. Though RTOG 0617 did not produce the anticipated result, much interest remains in dose escalation and establishing an explanation for the findings of this study. Cetuximab was also not found to provide a survival benefit when applied to an unselected population. However, planned retrospective analysis suggests that those patients with high epidermal growth factor receptor (EGFR) expression may benefit, suggesting that cetuximab should be applied in a targeted fashion. We discuss the results of RTOG 0617 and additional findings from post-hoc analysis that suggest that dose escalation may be limited by normal tissue toxicity. We also present ongoing studies that aim to address potential causes for mortality in the dose escalation arm through adaptive or proton therapy, and are also leveraging additional concurrent systemic agents such as tyrosine kinase inhibitors (TKIs) for EGFR-activating mutations or EML4-ALK rearrangements, and poly (ADP-ribose) polymerase (PARP) inhibitors.
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Affiliation(s)
- Julian C Hong
- Department of Radiation Oncology, Duke University, Durham, NC, USA
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University, Durham, NC, USA
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26
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Westover KD, Loo BW, Gerber DE, Iyengar P, Choy H, Diehn M, Hughes R, Schiller J, Dowell J, Wardak Z, Sher D, Christie A, Xie XJ, Corona I, Sharma A, Wadsworth ME, Timmerman R. Precision Hypofractionated Radiation Therapy in Poor Performing Patients With Non-Small Cell Lung Cancer: Phase 1 Dose Escalation Trial. Int J Radiat Oncol Biol Phys 2015; 93:72-81. [PMID: 26279026 DOI: 10.1016/j.ijrobp.2015.05.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/29/2015] [Accepted: 05/04/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Treatment regimens for locally advanced non-small cell lung cancer (NSCLC) give suboptimal clinical outcomes. Technological advancements such as radiation therapy, the backbone of most treatment regimens, may enable more potent and effective therapies. The objective of this study was to escalate radiation therapy to a tumoricidal hypofractionated dose without exceeding the maximally tolerated dose (MTD) in patients with locally advanced NSCLC. METHODS AND MATERIALS Patients with stage II to IV or recurrent NSCLC and Eastern Cooperative Oncology Group performance status of 2 or greater and not candidates for surgical resection, stereotactic radiation, or concurrent chemoradiation were eligible. Highly conformal radiation therapy was given to treat intrathoracic disease in 15 fractions to a total of 50, 55, or 60 Gy. RESULTS Fifty-five patients were enrolled: 15 at the 50-Gy, 21 at the 55-Gy, and 19 at the 60-Gy dose levels. A 90-day follow-up was completed in each group without exceeding the MTD. With a median follow-up of 12.5 months, there were 93 grade ≥ 3 adverse events (AEs), including 39 deaths, although most AEs were considered related to factors other than radiation therapy. One patient from the 55- and 60-Gy dose groups developed grade ≥ 3 esophagitis, and 5, 4, and 4 patients in the respective dose groups experienced grade ≥ 3 dyspnea, but only 2 of these AEs were considered likely related to therapy. There was no association between fraction size and toxicity (P = .24). The median overall survival was 6 months with no significant differences between dose levels (P = .59). CONCLUSIONS Precision hypofractionated radiation therapy consisting of 60 Gy in 15 fractions for locally advanced NSCLC is generally well tolerated. This treatment regimen could provide patients with poor performance status a potent alternative to chemoradiation. This study has implications for the cost effectiveness of lung cancer therapy. Additional studies of long-term safety and efficacy of this therapy are warranted.
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Affiliation(s)
- Kenneth D Westover
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - David E Gerber
- Division of Hematology-Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Puneeth Iyengar
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hak Choy
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Randy Hughes
- Division of Hematology-Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joan Schiller
- Division of Hematology-Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan Dowell
- Division of Hematology-Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Zabi Wardak
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David Sher
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Alana Christie
- Department of Clinical Science, Southwestern Medical Center, Dallas, Texas
| | - Xian-Jin Xie
- Department of Clinical Science, Southwestern Medical Center, Dallas, Texas
| | - Irma Corona
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Akanksha Sharma
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas.
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27
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Involved field irradiation for the treatment of esophageal cancer: Is it better than elective nodal irradiation? Cancer Lett 2015; 357:69-74. [DOI: 10.1016/j.canlet.2014.11.045] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 11/19/2014] [Accepted: 11/19/2014] [Indexed: 12/25/2022]
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Harris JP, Chang-Halpenny CN, Maxim PG, Quon A, Graves EE, Diehn M, Loo BW. Outcomes of Modestly Hypofractionated Radiation for Lung Tumors: Pre- and Mid-Treatment Positron Emission Tomography-Computed Tomography Metrics as Prognostic Factors. Clin Lung Cancer 2015; 16:475-85. [PMID: 25770888 DOI: 10.1016/j.cllc.2015.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 01/20/2015] [Accepted: 01/23/2015] [Indexed: 12/25/2022]
Abstract
UNLABELLED Many patients with lung tumors have tumors too large for stereotactic ablative radiotherapy and comorbidities precluding concurrent chemotherapy. We report the outcomes of 29 patients treated with hypofractionated radiotherapy (RT) to 60 to 66 Gy in 3-Gy fractions. We also report an exploratory analysis of the prognostic value of the pre- and mid-RT positron emission tomography-computed tomography. INTRODUCTION Modestly hypofractionated radiation therapy (HypoRT; 60-66 Gy in 3-Gy fractions) allows patients with locally advanced thoracic tumors and poor performance status to complete treatment within a shorter period without concurrent chemotherapy. We evaluated the outcomes and imaging prognostic factors of HypoRT. MATERIALS AND METHODS We retrospectively reviewed the data from all patients with primary and metastatic intrathoracic tumors treated with HypoRT from 2006 to 2012. We analyzed the survival and toxicity outcomes, including overall survival (OS), progression-free survival (PFS), local recurrence (LR), and distant metastasis. We also evaluated the following tumor metrics in an exploratory analysis: gross tumor volume (GTV), maximum standardized uptake value (SUVMax), and metabolic tumor volume using a threshold of ≥ 50% of the SUVMax (MTV50%) or the maximum gradient of fluorine-18 fluorodeoxyglucose uptake (MTVEdge). We assessed the association of these metrics and their changes from before to mid-RT using positron emission tomography-computed tomography (PET-CT) with OS and PFS. RESULTS We identified 29 patients, all with pre-RT and 20 with mid-RT PET-CT scans. The median follow-up period was 15 months. The 2-year overall and non-small-cell lung cancer-only rate for OS, PFS, and LR, was 59% and 59%, 52% and 41%, and 27% and 32%, respectively. No grade ≥ 3 toxicities developed. The median decrease in GTV, SUVMax, and MTVEdge was 11%, 24%, and 18%, respectively. Inferior OS was associated with a larger pre-RT MTVEdge (P = .005) and pre-RT MTV50% (P = .007). Inferior PFS was associated with a larger mid-RT SUVMax (P = .003). CONCLUSION These findings add to the growing body of data demonstrating promising outcomes and limited toxicity with HypoRT. The pre- and mid-RT PET-CT metrics could be useful for prognostic stratification in future clinical trials.
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Affiliation(s)
- Jeremy P Harris
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA
| | - Christine N Chang-Halpenny
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA; Department of Radiation Oncology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Peter G Maxim
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Andrew Quon
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA; Division of Nuclear Medicine, Department of Radiology, Stanford University School of Medicine, Stanford, CA
| | - Edward E Graves
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA.
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Swanick CW, Lin SH, Sutton J, Naik NS, Allen PK, Levy LB, Liao Z, Welsh JW, Komaki R, Chang JY, Gomez DR. Use of simultaneous radiation boost achieves high control rates in patients with non-small-cell lung cancer who are not candidates for surgery or conventional chemoradiation. Clin Lung Cancer 2014; 16:156-63. [PMID: 25467928 DOI: 10.1016/j.cllc.2014.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/20/2014] [Accepted: 10/21/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Intensity-modulated radiation therapy (IMRT) with a simultaneous integrated boost (SIB) has improved the local disease control at a variety of anatomic sites. However, little is known about its use in lung cancer, especially in the context of shorter treatment schedules (hypofractionation). We analyzed the feasibility, toxicity, and patterns of failure of this approach for patients with non-small-cell lung cancer (NSCLC) who were not candidates for surgery or standard concurrent chemoradiation therapy. PATIENTS AND METHODS We retrospectively identified 71 patients with NSCLC who received IMRT+SIB in 15 fractions to ≥ 52.5 Gy from January 2007 to February 2013. Toxicity and local control were evaluated for all patients. RESULTS Of the 71 patients, 11 (16%) had stage I to II NSCLC, 15 (21%) stage III, and 45 (63%) stage IV. The esophagitis rate was grade 0 to 1 in 55%, grade 2 in 39%, and grade ≥ 3 in 6%. One patient developed a bronchoesophageal fistula 6 months after radiation. The pneumonitis rate was grade 0 to 1 in 93%, grade 2 in 6%, and grade 3 in 1%. At the time of analysis, 17 (24%) patients had local failure at a median of 5.2 months (range, < 1-16.1) after treatment. All but 1 failure occurred within the higher dose region. CONCLUSION Hypofractionated IMRT+SIB is a viable option for some patients with NSCLC, with little high-grade toxicity overall. Nearly all local failures occurred within the higher dose region, implying strong radioresistance or some other mechanism for recurrence in a subgroup of patients.
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Affiliation(s)
- Cameron W Swanick
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven H Lin
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jordan Sutton
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nilan S Naik
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pamela K Allen
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lawrence B Levy
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zhongxing Liao
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - James W Welsh
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ritsuko Komaki
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel R Gomez
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
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Karam SD, Horne ZD, Hong RL, McRae D, Duhamel D, Nasr NM. Hypofractionated stereotactic body radiation therapy for elderly patients with stage IIB-IV nonsmall cell lung cancer who are ineligible for or refuse other treatment modalities. LUNG CANCER-TARGETS AND THERAPY 2014; 5:59-66. [PMID: 28210143 PMCID: PMC5217745 DOI: 10.2147/lctt.s66395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective In elderly patients with stage IIB–IV nonsmall cell lung cancer who cannot tolerate chemotherapy, conventionally fractionated radiotherapy is the treatment of choice. We present our experience with hypofractionated stereotactic body radiation therapy (SBRT) in the treatment of this patient population. Methods Thirty-three patients with a median age of 80 years treated with fractionated SBRT were retrospectively analyzed. Most patients were smokers and had preexisting lung disease and either refused treatment or were ineligible. A median prescribed dose of 40 Gy was delivered to the prescription isodose line over a median of five treatments. The majority of patients (70%) did not receive chemotherapy. Results With a median follow-up of 9 months (range: 4–40 months), the actuarial median overall survival (OS) and progression-free survival were 12 months for both. One year actuarial survival outcomes were 75%, 58%, 44%, and 48% for local control, regional control, progression-free survival, and OS, respectively. Increased volume of disease was a statistically significant predictor of worse OS. Three patients developed a grade 1 cough that peaked 3 weeks after treatment and resolved within 1 month. One patient developed grade 1 tracheal mucositis and three patients developed grade 1 pneumonitis. Both resolved 6 weeks after treatment. Three patients died within the first month of treatment, but the cause of death did not appear to be related to the treatment. Conclusion Hypofractionated SBRT is a relatively safe and convenient treatment option for elderly patients with inoperable stage IIB–IV nonsmall cell lung cancer. However, given the small sample size and the heterogeneity of the patient population, larger studies are needed before adopting this treatment option into clinical practice.
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Affiliation(s)
- Sana D Karam
- Department of Radiation Oncology, University of Colorado, Denver, CO, USA
| | | | | | | | - David Duhamel
- Department of Pulmonary/Critical Care Medicine, Virginia Hospital Center, Arlington, VA, USA
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Kaster TS, Yaremko B, Palma DA, Rodrigues GB. Radical-intent hypofractionated radiotherapy for locally advanced non-small-cell lung cancer: a systematic review of the literature. Clin Lung Cancer 2014; 16:71-9. [PMID: 25450876 DOI: 10.1016/j.cllc.2014.08.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 08/14/2014] [Accepted: 08/26/2014] [Indexed: 02/08/2023]
Abstract
PURPOSE To identify survival and toxicity characteristics associated with radical-intent hypofractionated radiotherapy for the treatment of stage III non-small-cell lung cancer (NSCLC). MATERIALS AND METHODS Relevant studies were identified from a systematic PubMed search of articles published between January 1990 and January 2014. All studies were peer reviewed and included both retrospective and prospective studies of NSCLC patients being treated with radical hypofractionated radiotherapy. Data on overall survival (OS) and toxicity were extracted from each of the studies where available. RESULTS Of 685 studies initially identified by the search, a total of 33 studies were found to be relevant and were included in this systematic review. The number of fractions ranged from 15 to 35, the dose per fraction ranged from 2.3 to 3.5 Gy, and the delivered dose ranged from 45.0 to 85.5 Gy. Fifteen of the studies included concurrent chemotherapy, while 18 did not. OS was found to be associated with tumor biological effective dose, with the Pearson correlation coefficient ranging from 0.34 to 0.48. For both concurrent and nonconcurrent chemoradiotherapy acute pulmonary, late esophageal and late pulmonary incidences of toxicity ranged from 1.2% to 12.2%, but had 95% confidence intervals that included zero. The greatest incidence of toxicity was acute esophageal toxicity at 14.9% (95% confidence interval, 0.7%, 29.1%). CONCLUSIONS There is a moderate linear relationship between biological effective dose and OS, and greater acute esophageal toxicity with concurrent chemotherapy. Improving outcomes in stage III NSCLC may involve some form of hypofractionation in the context of systemic concurrent therapy.
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Affiliation(s)
- Tyler S Kaster
- Department of Radiation Oncology, Western University, London, Ontario; Faculty of Medicine, University of Ottawa, Ottawa, Ontario
| | - Brian Yaremko
- Department of Radiation Oncology, Western University, London, Ontario
| | - David A Palma
- Department of Radiation Oncology, Western University, London, Ontario
| | - George B Rodrigues
- Department of Radiation Oncology, Western University, London, Ontario; Department of Epidemiology and Biostatistics, Western University, London, Ontario.
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Chi A, Nguyen NP, Welsh JS, Tse W, Monga M, Oduntan O, Almubarak M, Rogers J, Remick SC, Gius D. Strategies of dose escalation in the treatment of locally advanced non-small cell lung cancer: image guidance and beyond. Front Oncol 2014; 4:156. [PMID: 24999451 PMCID: PMC4064255 DOI: 10.3389/fonc.2014.00156] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/04/2014] [Indexed: 12/25/2022] Open
Abstract
Radiation dose in the setting of chemo-radiation for locally advanced non-small cell lung cancer (NSCLC) has been historically limited by the risk of normal tissue toxicity and this has been hypothesized to correlate with the poor results in regard to local tumor recurrences. Dose escalation, as a means to improve local control, with concurrent chemotherapy has been shown to be feasible with three-dimensional conformal radiotherapy in early phase studies with good clinical outcome. However, the potential superiority of moderate dose escalation to 74 Gy has not been shown in phase III randomized studies. In this review, the limitations in target volume definition in previous studies; and the factors that may be critical to safe dose escalation in the treatment of locally advanced NSCLC, such as respiratory motion management, image guidance, intensity modulation, FDG-positron emission tomography incorporation in the treatment planning process, and adaptive radiotherapy, are discussed. These factors, along with novel treatment approaches that have emerged in recent years, are proposed to warrant further investigation in future trials in a more comprehensive and integrated fashion.
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Affiliation(s)
- Alexander Chi
- Department of Radiation Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA
| | - Nam Phong Nguyen
- The International Geriatric Radiotherapy Group , Tucson, AZ , USA
| | - James S Welsh
- Northern Illinois University Institute for Neutron Therapy at Fermilab , Batavia, IL , USA
| | - William Tse
- Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA
| | - Manish Monga
- Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA
| | - Olusola Oduntan
- Thoracic Surgery, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA
| | - Mohammed Almubarak
- Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA
| | - John Rogers
- Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA
| | - Scot C Remick
- Division of Hematology and Oncology, Mary Babb Randolph Cancer Center of West Virginia University , Morgantown, WV , USA
| | - David Gius
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago, IL , USA
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Kong FM(S, Zhao J, Wang J, Faivre-Finn C. Radiation dose effect in locally advanced non-small cell lung cancer. J Thorac Dis 2014; 6:336-47. [PMID: 24688778 PMCID: PMC3968556 DOI: 10.3978/j.issn.2072-1439.2014.01.23] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 01/20/2014] [Indexed: 11/14/2022]
Abstract
Radiation is the foundation of treatment for locally advanced non-small cell lung cancer (NSCLC), and as such, optimal radiation dose is essential for successful treatment. This article will briefly review biological considerations of radiation dose and their effect in the context of three-dimensional conformal radiation therapy (3D-CRT) including intensity modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) for NSCLC. It will focus on literature review and discussions regarding radiation dose effect in locally advanced NSCLC including potential severe and lethal toxicities of high dose radiation given with concurrent chemotherapy. Potential new approaches for delivering safe and effective doses by individualizing treatment based on functional imaging are being applied in studies such as the PET boost trial and RTOG1106. The RTOG concept of delivering high dose radiation to the more resistant tumors with the use of isotoxic dose prescription and adaptive planning will also be discussed in detail.
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Oncology scan--promising strategies for the treatment of locally-advanced non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2013; 87:1-4. [PMID: 23920382 DOI: 10.1016/j.ijrobp.2013.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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35
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Liu YE, Lin Q, Meng FJ, Chen XJ, Ren XC, Cao B, Wang N, Zong J, Peng Y, Ku YJ, Chen Y. High-dose accelerated hypofractionated three-dimensional conformal radiotherapy (at 3 Gy/fraction) with concurrent vinorelbine and carboplatin chemotherapy in locally advanced non-small-cell lung cancer: a feasibility study. Radiat Oncol 2013; 8:198. [PMID: 23937855 PMCID: PMC3751137 DOI: 10.1186/1748-717x-8-198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Accepted: 08/02/2013] [Indexed: 12/25/2022] Open
Abstract
Background Increasing the radiotherapy dose can result in improved local control for non-small-cell lung cancer (NSCLC) and can thereby improve survival. Accelerated hypofractionated radiotherapy can expose tumors to a high dose of radiation in a short period of time, but the optimal treatment regimen remains unclear. The purpose of this study was to evaluate the feasibility of utilizing high-dose accelerated hypofractionated three-dimensional conformal radiotherapy (at 3 Gy/fraction) with concurrent vinorelbine (NVB) and carboplatin (CBP) chemotherapy for the treatment of local advanced NSCLC. Methods Untreated patients with unresectable stage IIIA/IIIB NSCLC or patients with a recurrence of NSCLC received accelerated hypofractionated three-dimensional conformal radiotherapy. The total dose was greater than or equal to 60 Gy. The accelerated hypofractionated radiotherapy was conducted once daily at 3 Gy/fraction with 5 fractions per week, and the radiotherapy was completed in 5 weeks. In addition to radiotherapy, the patients also received at least 1 cycle of a concurrent two-drug chemotherapy regimen of NVB and CBP. Results A total of 26 patients (19 previously untreated cases and 7 cases of recurrent disease) received 60Gy-75Gy radiotherapy with concurrent chemotherapy. All of the patients underwent evaluations for toxicity and preliminary therapeutic efficacy. There were no treatment-related deaths within the entire patient group. The major acute adverse reactions were radiation esophagitis (88.5%) and radiation pneumonitis (42.3%). The percentages of grade III acute radiation esophagitis and grade III radiation pneumonitis were 15.4% and 7.7%, respectively. Hematological toxicities were common and did not significantly affect the implementation of chemoradiotherapy after supportive treatment. Two patients received high dose of 75 Gy had grade III late esophageal toxicity, and none had grade IV and above. Grade III and above late lung toxicity did not occur. Conclusion High-dose accelerated hypofractionated three-dimensional conformal radiotherapy with a dose of 60 Gy or greater with concurrent NVB and CBP chemotherapy might be feasible. However esophagus toxicity needs special attention. A phase I trial is recommended to obtain the maximum tolerated radiation dose of accelerated hypofractionated radiotherapy with concurrent chemotherapy.
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Affiliation(s)
- Yue-E Liu
- Department of Oncology, North China Petroleum Bureau General Hospital of Hebei Medical University, 8 Huizhan Avenue, Renqiu, Hebei Province 062552, PR China
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Gomez DR, Gillin M, Liao Z, Wei C, Lin SH, Swanick C, Alvarado T, Komaki R, Cox JD, Chang JY. Phase 1 study of dose escalation in hypofractionated proton beam therapy for non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2013; 86:665-70. [PMID: 23688815 DOI: 10.1016/j.ijrobp.2013.03.035] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 03/26/2013] [Accepted: 03/30/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Many patients with locally advanced non-small cell lung cancer (NSCLC) cannot undergo concurrent chemotherapy because of comorbidities or poor performance status. Hypofractionated radiation regimens, if tolerable, may provide an option to these patients for effective local control. METHODS AND MATERIALS Twenty-five patients were enrolled in a phase 1 dose-escalation trial of proton beam therapy (PBT) from September 2010 through July 2012. Eligible patients had histologically documented lung cancer, thymic tumors, carcinoid tumors, or metastatic thyroid tumors. Concurrent chemotherapy was not allowed, but concurrent treatment with biologic agents was. The dose-escalation schema comprised 15 fractions of 3 Gy(relative biological effectiveness [RBE])/fraction, 3.5 Gy(RBE)/fraction, or 4 Gy(RBE)/fraction. Dose constraints were derived from biologically equivalent doses of standard fractionated treatment. RESULTS The median follow-up time for patients alive at the time of analysis was 13 months (range, 8-28 months). Fifteen patients received treatment to hilar or mediastinal lymph nodes. Two patients experienced dose-limiting toxicity possibly related to treatment; 1 received 3.5-Gy(RBE) fractions and experienced an in-field tracheoesophageal fistula 9 months after PBT and 1 month after bevacizumab. The other patient received 4-Gy(RBE) fractions and was hospitalized for bacterial pneumonia/radiation pneumonitis 4 months after PBT. CONCLUSION Hypofractionated PBT to the thorax delivered over 3 weeks was well tolerated even with significant doses to the lungs and mediastinal structures. Phase 2/3 trials are needed to compare the efficacy of this technique with standard treatment for locally advanced NSCLC.
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Affiliation(s)
- Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77054, USA.
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