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Berber T, Yıldırım BA, Kandemir Gürsel Ö. Stereotactic Body Radiotherapy Reirradiation Is Safe in Patients With Lung Cancer With In-Field Enlarged Tumor Recurrence. Technol Cancer Res Treat 2024; 23:15330338231208616. [PMID: 38860536 PMCID: PMC11168055 DOI: 10.1177/15330338231208616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 06/12/2024] Open
Abstract
Introduction: Recurrence after stage III lung cancer treatment usually appears with a poor prognosis, and salvage therapy for these patients is challenging, with limited data for reirradiation. Materials and Methods: Fifteen patients with recurrent stage III lung cancer treated with stereotactic body radiotherapy (SABR) between October 2013 and December 2017 were retrospectively evaluated for local control as a first endpoint; overall survival, disease-free survival, and treatment-related toxicity were secondary endpoints. Results: The median age was 68 (IQR: 50-71) years, and the median tumor size was 3.3 cm (IQR: 3.0-4.5). The radiation field was all within the previous radiation (previous 80%-90% isodose line), and the median dose was 66 Gy/(2 Gy × 33 standard fractionation). For SABR, the median biologically effective dose at an α/β ratio of 10 (BED10) was 60.0 Gy (IQR: 39.38-85.0) and given in 3 to 5 fractions. Three patients experienced grade 3 or 4 toxicity but none experienced grade 5. The median follow-up period was 14 (IQR: 10-23) months. The local control rate was found as 86.7% in the first year, 80% in the second year, and 80% in the third year. The median disease-free survival was 8 (IQR: 6-20) months and the median overall survival was 14 (IQR: 10-23) months. The rate of overall survival was 66.6% for the first year and 33.3% for the second and third years. The disease-free survival rate was 46.6% for the first year and 40% for the second and third years. Nine patients who received doses of BED10 ≥ 50 Gy developed no local recurrence (P = .044). Discussion: In local local-regional recurrence of lung cancer, radiosurgery as reirradiation can be used at doses of BED10 ≥ 50 Gy and above to provide local control for radical or palliative purposes. SABR is an important and relatively safe treatment option in such recurrences.
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Affiliation(s)
- Tanju Berber
- Department of Radiation Oncology, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Berna Akkuş Yıldırım
- Department of Radiation Oncology, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Özge Kandemir Gürsel
- Department of Radiation Oncology, Okmeydani Training and Research Hospital, Istanbul, Turkey
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Catania C, Filippi AR, Sangalli C, Piperno G, Russano M, Greco C, Scotti V, Proto C, Bennati C, Di Pietro Paolo M, Platania A, Olmetto E, Agustoni F, Teodorani N, Agbaje V, Russo A. New options and open issues in the management of unresectable stage III and in early-stage NSCLC: A report from an expert panel of Italian medical and radiation oncologists - INTERACTION group. Crit Rev Oncol Hematol 2023; 190:104108. [PMID: 37633350 DOI: 10.1016/j.critrevonc.2023.104108] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/22/2023] [Indexed: 08/28/2023] Open
Abstract
IMPORTANCE After the PACIFIC trial, concurrent chemo-radiotherapy followed by consolidation therapy with durvalumab for 1 year (limited to PD-L1 tumour proportion score ≥ 1% in the EMA region) is the firmly established standard of care treatment for unresectable NSCLC patients. Several relevant questions are emerging with the growing use of this approach, posing novel challenges in clinical practice. Treatment of oncogene-addicted NSCLCs, management of mediastinal disease recurrence after surgery and the optimal management of patients progressing during or after durvalumab are now some of the most clinically relevant issues. OBSERVATIONS Patients with unresectable NSCLC harbouring EGFR and HER2 mutations or ALK/ROS1/RET /NTRK1,2,3 rearrangements are unresponsive to immunotherapy. Importance of knowing the tumour genotyping (NGS, preferable DNA and RNA) from the earliest stages of NSCLC, also for the possible use of immunotherapy both in the adjuvant and perioperative setting. In case of mediastinal disease recurrence after surgery, re-biopsy is essential to re-determine the histological and biological characteristics of the disease and the distinction of recurrence in curable and non-curable disease is of pivotal important for the optimal management of subsequent treatments. CONCLUSIONS AND RELEVANCE Treatment of stage III NSCLC has always been controversial and challenging: Multidisciplinary approach is mandatory and defining resectability is a critical issue. Chemo-radiotherapy followed by maintenance Durvalumab is now the standard of treatment. Herein, we provide a comprehensive overview of the key challenges and open questions that we are currently facing in clinical practice, in unresectable stage III and in early-stage NSCLC, identifying the knowledge gaps and the possible solutions.
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Affiliation(s)
- Chiara Catania
- Unit of Thoracic Oncology, Gavazzeni Humanitas Bergamo, Via Gavazzeni 21, Bergamo, Milan, Italy.
| | - Andrea Riccardo Filippi
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Claudia Sangalli
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gaia Piperno
- Division of Radiotherapy, IEO, European Institute of Oncology, IRCCS, Via Ripamonti 435, Milan, Italy
| | - Marco Russano
- Medical Oncology Radiation, Campus Bio-Medico University, Rome
| | - Carlo Greco
- Radiation Oncology, Campus Bio-Medico University, Rome
| | - Vieri Scotti
- Radiation Therapy Unit, Department of Oncology, Careggi University Hospital, Firenze, Italy
| | - Claudia Proto
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Chiara Bennati
- Oncology Unit, Ausl Romagna Ravenna, Emilia Romagna, Oncologia Medica Ravenna, Emilia Romagna, Italy
| | - Marzia Di Pietro Paolo
- Medical Oncology Unit, Università Politecnica delle Marche, Azienda Ospedaliero-Universitaria Ospedali Riuniti Umberto I, GM Lancisi, G Salesi, Ancona, Italy
| | | | - Emanuela Olmetto
- Department of Radiation-Oncology, University of Florence, Firenze, Italy
| | - Francesco Agustoni
- Medical Oncology Department, Fondazione IRCCS Policlinico "San Matteo", Pavia, Italy
| | - Nazario Teodorani
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Vincenzo Agbaje
- Radiotherapy Università Politecnica delle Marche, Azienda Ospedaliero-Universitaria Ospedali Riuniti Umberto I, GM Lancisi, G Salesi, Ancona, Italy
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Tonneau M, Richard C, Routy B, Campeau MP, Vu T, Filion E, Roberge D, Mathieu D, Doucet R, Beliveau-Nadeau D, Bahig H. A competing risk analysis of the patterns and risk factors of recurrence in early-stage non-small cell lung cancer treated with stereotactic ablative radiotherapy. Radiother Oncol 2023; 185:109697. [PMID: 37169303 DOI: 10.1016/j.radonc.2023.109697] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION To assess patterns of recurrence after stereotactic ablative radiotherapy (SABR) in patient ineligible to surgery with early-stage non-small cell lung cancer (ES-NSCLC), report survival and treatment after first recurrence. METHODS We performed a retrospective analysis on 1068 patients with ES-NSCLC and 1143 lesions. Between group differences were estimated using competing risk analysis and cause-specific hazard ratios were calculated. Overall survival (OS) after first recurrence was calculated. RESULTS Median follow-up was 37.6 months. Univariate analysis demonstrated that ultra-central location was associated with higher risk of regional recurrence (RR) and distant metastasis (DM) (p = 0.004 and 0.01). Central lesions were associated with higher risk of local recurrence (LR) and RR (p < 0.001). Ultra-central lesions were associated with shorter OS (p = 0.002) compared to peripheral lesions. In multivariate analysis, central location was the only factor associated with increased LR and RR risks (p = 0.016 and 0.005). Median OS after first recurrence was 14.8 months. There was no difference in OS after first recurrence between ultra-central, central, and peripheral lesions (p = 0.83). Patients who received a second SABR course had an OS of 51.3 months, compared to 19.5 months with systemic therapy and 8.1 months with supportive care (p < 0.0001). DISCUSSION The main prognostic factor for LR and RR risks was central location. Ultra-central and central tumors might benefit from treatment intensification strategies such as dose escalation and/or addition of systemic therapy to improve radiotherapy outcomes. After a first recurrence post SABR, patients with contralateral lung recurrences and those who were eligible to receive a second course of SABR had improved OS.
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Affiliation(s)
- Marion Tonneau
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada; Université de Médecine Henri Warembourg, Lille, France
| | - Corentin Richard
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Bertrand Routy
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Marie-Pierre Campeau
- Radiation Oncology Department, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Toni Vu
- Radiation Oncology Department, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Edith Filion
- Radiation Oncology Department, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - David Roberge
- Radiation Oncology Department, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Dominique Mathieu
- Radiation Oncology Department, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Robert Doucet
- Radiation Oncology Department, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Dominic Beliveau-Nadeau
- Radiation Oncology Department, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Houda Bahig
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, QC, Canada; Radiation Oncology Department, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada.
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Janopaul-Naylor JR, Cao Y, McCall NS, Switchenko JM, Tian S, Chen H, Stokes WA, Kesarwala AH, McDonald MW, Shelton JW, Bradley JD, Higgins KA. Definitive intensity modulated proton re-irradiation for lung cancer in the immunotherapy era. Front Oncol 2023; 12:1074675. [PMID: 36733369 PMCID: PMC9888533 DOI: 10.3389/fonc.2022.1074675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/29/2022] [Indexed: 01/18/2023] Open
Abstract
Introduction As immunotherapy has improved distant metastasis-free survival (DMFS) in Non-Small Cell Lung Cancer (NSCLC), isolated locoregional recurrences have increased. However, management of locoregional recurrences can be challenging. We report our institutional experience with definitive intent re-irradiation using Intensity Modulated Proton Therapy (IMPT). Method Retrospective cohort study of recurrent or second primary NSCLC or LS-SCLC treated with IMPT. Kaplan-Meier method and log-rank test were used for time-to-event analyses. Results 22 patients were treated from 2019 to 2021. After first course of radiation (median 60 Gy, range 45-70 Gy), 45% received adjuvant immunotherapy. IMPT re-irradiation began a median of 28.2 months (8.8-172.9 months) after initial radiotherapy. The median IMPT dose was 60 GyE (44-60 GyE). 36% received concurrent chemotherapy with IMPT and 18% received immunotherapy after IMPT. The median patient's IMPT lung mean dose was 5.3 GyE (0.9-13.9 GyE) and 5 patients had cumulative esophagus max dose >100 GyE with 1-year overall survival (OS) 68%, 1-year local control 80%, 1-year progression free survival 45%, and 1-year DMFS 60%. Higher IMPT (HR 1.4; 95% CI 1.1-1.7, p=0.01) and initial radiotherapy mean lung doses (HR 1.3; 95% CI 1.0-1.6, p=0.04) were associated with worse OS. Two patients developed Grade 3 pneumonitis or dermatitis, one patient developed Grade 2 pneumonitis, and seven patients developed Grade 1 toxicity. There were no Grade 4 or 5 toxicities. Discussion Definitive IMPT re-irradiation for lung cancer can prolong disease control with limited toxicity, particularly in the immunotherapy era.
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Affiliation(s)
- James R. Janopaul-Naylor
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Yichun Cao
- Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Neal S. McCall
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Jeffrey M. Switchenko
- Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, United States
| | - Sibo Tian
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Haijian Chen
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - William A. Stokes
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Aparna H. Kesarwala
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Mark W. McDonald
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Joseph W. Shelton
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Jeffrey D. Bradley
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Kristin A. Higgins
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
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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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Beddok A, Calugaru V, de Marzi L, Graff P, Dumas JL, Goudjil F, Dendale R, Minsat M, Verrelle P, Buvat I, Créhange G. Clinical and technical challenges of cancer reirradiation: Words of wisdom. Crit Rev Oncol Hematol 2022; 174:103655. [PMID: 35398521 DOI: 10.1016/j.critrevonc.2022.103655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 03/13/2022] [Accepted: 03/15/2022] [Indexed: 12/25/2022] Open
Abstract
Since the development of new radiotherapy techniques that have improved healthy tissue sparing, reirradiation (reRT) has become possible. The selection of patients eligible for reRT is complex given that it can induce severe or even fatal side effects. The first step should therefore be to assess, in the context of multidisciplinary staff meeting, the patient's physical status, the presence of sequelae resulting from the first irradiation and the best treatment option available. ReRT can be performed either curatively or palliatively to treat a cancer-related symptom that is detrimental to the patient's quality of life. The selected techniques for reRT should provide the best protection of healthy tissue. The construction of target volumes and the evaluation of constraints regarding the doses that can be used in this context have not yet been fully codified. These points raised in the literature suggest that randomized studies should be undertaken to answer pending questions.
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Affiliation(s)
- Arnaud Beddok
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France; Laboratoire d'Imagerie Translationnelle en Oncologie (LITO), U1288 Université Paris Saclay/Inserm/Institut Curie. Orsay. France; Proton Therapy Center. Institut Curie, PSL Research University, Orsay. France.
| | - Valentin Calugaru
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France; Proton Therapy Center. Institut Curie, PSL Research University, Orsay. France
| | - Ludovic de Marzi
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France; Laboratoire d'Imagerie Translationnelle en Oncologie (LITO), U1288 Université Paris Saclay/Inserm/Institut Curie. Orsay. France; Proton Therapy Center. Institut Curie, PSL Research University, Orsay. France
| | - Pierre Graff
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France
| | - Jean-Luc Dumas
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France
| | - Farid Goudjil
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France; Proton Therapy Center. Institut Curie, PSL Research University, Orsay. France
| | - Rémi Dendale
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France; Proton Therapy Center. Institut Curie, PSL Research University, Orsay. France
| | - Mathieu Minsat
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France
| | - Pierre Verrelle
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France
| | - Irène Buvat
- Laboratoire d'Imagerie Translationnelle en Oncologie (LITO), U1288 Université Paris Saclay/Inserm/Institut Curie. Orsay. France
| | - Gilles Créhange
- Department of Radiation Oncology. Institut Curie, PSL Research University, Paris - Saint Cloud-Orsay. France; Laboratoire d'Imagerie Translationnelle en Oncologie (LITO), U1288 Université Paris Saclay/Inserm/Institut Curie. Orsay. France; Proton Therapy Center. Institut Curie, PSL Research University, Orsay. France
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Gabrys D, Kulik R, Namysł-Kaletka A. Re-irradiation for intra-thoracic tumours and extra-thoracic breast cancer: dose accumulation, evaluation of efficacy and toxicity based on a literature review. Br J Radiol 2022; 95:20201292. [PMID: 34826226 PMCID: PMC9153724 DOI: 10.1259/bjr.20201292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The improvement seen in the diagnostic procedures and treatment of thoracic tumours means that patients have an increased chance of longer overall survival. Nevertheless, we can still find those who have had a recurrence or developed a secondary cancer in the previously treated area. These patients require retreatment including re-irradiation. We have reviewed the published data on thoracic re-irradiation, which shows that some specific healthy tissues can tolerate a significant dose of irradiation and these patients benefit from aggressive treatment; however, there is a risk of damage to normal tissue under these circumstances. We analysed the literature data on re-irradiation in the areas of vertebral bodies, spinal cord, breast, lung and oesophagus. We evaluated the doses of primary and secondary radiotherapy, the treatment techniques, as well as the local control and median or overall survival in patients treated with re-radiation. The longest OS is reported in the case of re-irradiation after second breast-conserving therapy where the 5-year OS range is 81 to 100% and is shorter in patients with loco-reginal re-irradiation where the 5-y OS range is 18 to 60%. 2-year OS in patients re-irradiated for lung cancer and oesophagus cancer range from 13 to 74% and 18 to 42%, respectively. Majority grade ≥3 toxicity after second breast-conserving therapy was fibrosis up to 35%. For loco-regional breast cancer recurrences, early toxicity occurred in up to 33% of patients resulting in mostly desquamation, while late toxicity was recorded in up to 23% of patients and were mostly ulcerations. Early grade ≥3 lung toxicity developed in up to 39% of patients and up to 20% of Grade 5 hemoptysis. The most frequently observed early toxicity grade ≥3 in oesophageal cancer was oesophagitis recorded in up to 57% of patients, followed by hematological complications which was recorded in up to 50% of patients. The most common late complications included dysphagia, recorded in up to 16.7% of patients. We have shown that thoracic re-irradiation is feasible and effective in achieving local control in some patients. Re-irradiation should be performed with maximum accuracy and care using the best available treatment methods with a highly conformal, image-guided approach. Due to tremendous technological progress in the field of radiotherapy, we can deliver radiation precisely, shorten the overall treatment time and potentially reduce treatment-related toxicities.
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Affiliation(s)
- Dorota Gabrys
- Radiotherapy Department, Maria Sklodowska-Curie National Research and Institute of Oncology, Gliwice, Poland
| | - Roland Kulik
- Radiotherapy Planning Department, Maria Sklodowska-Curie National Research and Institute of Oncology, Gliwice, Poland
| | - Agnieszka Namysł-Kaletka
- Radiotherapy Department, Maria Sklodowska-Curie National Research and Institute of Oncology, Gliwice, Poland
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Toxicity of Proton Therapy versus Photon Therapy on Salvage Re-Irradiation for Non-Small Cell Lung Cancer. Life (Basel) 2022; 12:life12020292. [PMID: 35207579 PMCID: PMC8876714 DOI: 10.3390/life12020292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/10/2022] [Accepted: 02/13/2022] [Indexed: 12/24/2022] Open
Abstract
This study evaluated the toxicity associated with radiation techniques on curative re-irradiation (re-RT) in patients with thoracic recurrence of non-small cell lung cancer (NSCLC). From 2011 to 2019, we retrospectively reviewed the data of 63 patients with salvage re-RT for in-field or marginal recurrence of NSCLC at two independent institutions. Re-RT techniques using X-ray beams and proton beam therapy (PBT) were also included. Re-RT had a 2-year overall survival (OS) and local progression-free survival of 48.0% and 52.0%, respectively. Fifteen patients experienced grade 3 or higher toxicity after re-RT. The complication rates were 18.2% (4/22) and 26.8% (11/41) in PBT patients and X-ray patients, respectively. Airway or esophageal fistulas occurred in seven patients (11.1%). Fistulas or severe airway obstruction occurred in patients with tumors adjacent to the proximal bronchial tree and esophagus, who underwent hypofractionated radiotherapy (RT) or concurrent chemotherapy, and with a higher dose exposure to the esophagus. In conclusion, salvage re-RT was feasible even in patients with local recurrence within the previous RT field. PBT showed similar survival outcomes and toxicity to those of other techniques. However, thoracic re-RT should be performed carefully considering tumor location and RT regimens such as the fraction size and concurrent chemotherapy.
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High Dose Thoracic Re-Irradiation and Chemo-Immunotherapy for Centrally Recurrent NSCLC. Cancers (Basel) 2022; 14:cancers14030573. [PMID: 35158841 PMCID: PMC8833516 DOI: 10.3390/cancers14030573] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Since the early 1980s, there has been a trend towards escalating radiation doses in pulmonary tumor recurrences with the aim of improving survival. In this context, we performed a literature search in order to summarize the evidence of curative thoracic re-irradiation for centrally recurrent lung cancer. Tumor relapse in this specific situation poses a major problem because of the proximity to mediastinal organs. Of the initial 227 studies, 11 fulfilled the inclusion criteria for this analysis. The median overall survival (mOS) was 18.1 months (range 9.3–25.1), the median progression-free survival (mPFS) was nine months (range 4.5–16), and the median locoregional control (mLRC) was 12.1 months (range 6.5–20). The total re-irradiation dose correlated with both mLRC (p-value = 0.012) and mOS (p-value = 0.007). As large-scale prospective trials in the field are missing, this literature review is primarily based on retrospective data. In today’s age of enhanced long-term survival rates after chemoradiotherapy followed by immune checkpoint inhibition, the current analysis provides valuable insights into radiation treatment options for patients with loco-regional lung cancer recurrence. Abstract Introduction: Thoracic re-irradiation for recurrent lung cancer dates back four decades, when the first small series on 29 patients receiving palliative doses was published. With 5-year overall survival rates of 57% in PDL-1 positive patients after primary chemo-radio-immunotherapy, the number of patients who experience loco-regional relapse will increase in the near future. In this context, centrally recurring lung tumors pose a major treatment challenge. Hence, the aim of the current review is to compile the available evidence on curatively intended thoracic re-irradiation for this special clinical situation. Methods: A systematic literature search according to the PRISMA guidelines was performed. A study was included when the following criteria were met: (1) 66% of the patients had NSCLC, (2) a total dose of 50 Gy in the second course and/or a biologically effective dose of at least 100 Gy in both treatment courses was administered, (3) re-irradiation was administered with modern radiation techniques, (4) 50% or more of the patients had a centrally located relapse, (5) the minimum cohort size was 30 patients. Results: Of the initial 227 studies, 11 were analyzed, 1 of which was prospective. Median overall survival (OS) was 18.1 months (range 9.3–25.1), median progression free survival (PFS) was nine months (range 4.5–16), and median loco-regional control (LRC) was 12.1 months (range 6.5–20). Treatment-related mortality rates ranged from 2% to 14%. The total dose at re-irradiation correlated with both LRC (p-value = 0.012) and OS (p-value = 0.007) with a close relation between these two clinical endpoints (p-value = 0.006). The occurrence of acute toxicity grade 1 to 4 depended on the PTV size at re-irradiation (p-value = 0.033). Conclusion: The evidence regarding curative re-irradiation for centrally recurrent NSCLC is primarily based on scarce retrospective data, which are characterized by a high degree of heterogeneity. The OS in this clinically challenging situation is expected to be around 1.5 years after re-treatment. Patients with a good performance score, younger age, small tumors, and a longer interval to recurrence potentially benefit most from re-irradiation. In this context, prospective trials are warranted to achieve substantial advances in the field.
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An algorithm for thoracic re-irradiation using biologically effective dose: a common language on how to treat in a "no-treat zone". Radiat Oncol 2022; 17:4. [PMID: 34991637 PMCID: PMC8739721 DOI: 10.1186/s13014-021-01977-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background Re-irradiation (re-RT) is a technically challenging task for which few standardized approaches exist. This is in part due to the lack of a common platform to assess dose tolerance in relation to toxicity in the re-RT setting. To better address this knowledge gap and provide new tools for studying and developing thresholds for re-RT, we developed a novel algorithm that allows for anatomically accurate three-dimensional mapping of composite biological effective dose (BED) distributions from nominal doses (Gy). Methods The algorithm was designed to automatically convert nominal dose from prior treatment plans to corresponding BED value maps (voxel size 2.5 mm3 and α/β of 3 for normal tissue, BED3). Following the conversion of each plan to a BED3 dose distribution, deformable registration was used to create a summed composite re-irradiation BED3 plan for each patient who received two treatments. A proof-of-principle analysis was performed on 38 re-irradiation cases of initial stereotactic ablative radiotherapy (SABR) followed by either re-SABR or chemoradiation for isolated locoregional recurrence of early-stage non-small cell lung cancer. Results Evaluation of the algorithm-generated maps revealed appropriate conversion of physical dose to BED at each voxel. Of 14 patients receiving repeat SABR, there was one case each of grade 3 chest wall pain (7%), pneumonitis (7%), and dyspnea (7%). Of 24 patients undergoing repeat fractionated radiotherapy, grade 3 events were limited to two cases each of pneumonitis and dyspnea (8%). Composite BED3 dosimetry for each patient who experienced grade 2–3 events is provided and may help guide development of precise cumulative dose thresholds for organs at risk in the re-RT setting. Conclusions This novel algorithm successfully created a voxel-by-voxel composite treatment plan using BED values. This approach may be used to more precisely examine dosimetric predictors of toxicities and to establish more accurate normal tissue constraints for re-irradiation.
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11
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Maddalo M, D'Angelo E, Fiorica F, Argenone A, Scricciolo M, Cozzi S, Nardangeli A, Dionisi F, Costantino G, Vagge S, Pontoriero A, Donato V, Massaccesi M. Thoracic re-irradiation with 3D-conformal or more advanced techniques: A systematic review of treatment safety by the Re-irradiation Study Group of the Italian Association of Radiation and Oncology AIRO. Crit Rev Oncol Hematol 2021; 167:103500. [PMID: 34688894 DOI: 10.1016/j.critrevonc.2021.103500] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/20/2021] [Accepted: 10/10/2021] [Indexed: 12/25/2022] Open
Abstract
Re-irradiation (re-RT) is a treatment modality that has been actively investigated in recurrent lung cancer or in lung metastases appeared in previously irradiated areas. A literature search, according PRISMA recommendations and a meta-analysis technique were performed with the aims to identify possible factors related to the toxicity incidence and severity of ≥ G3 acute toxicity. 1243 patients and 36 studies, met inclusion criteria. Our results, showed that there was no difference in ≥ G3 acute (10,5%) toxicity rate with respect to different radiation techniques, cumulative dose and re-irradiation total dose and fractionation. Factors eventually related to severe toxicity were described. The frequent lack of a sufficient description of the treatment's intent, the heterogeneity in technique and radiotherapy regimen, makes balancing risk and benefit of re-RT based on published data even more difficult.
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Affiliation(s)
- Marta Maddalo
- Department of Radiation Oncology, ASST Spedali Civili of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy.
| | - Elisa D'Angelo
- Department of Radiotherapy, University Hospital of Modena, L. del Pozzo 71, 41121, Modena, Italy.
| | - Francesco Fiorica
- Department of Radiation Oncology and Nuclear Medicine, State Hospital Mater Salutis AULSS 9, 37045, Legnago (VR), Italy.
| | - Angela Argenone
- Radiotherapy Unit, AORN San PIO, Via dell'Angelo, 82100, Benevento, Italy.
| | - Melissa Scricciolo
- Radiation Therapy Unit, Ospedale dell'Angelo, Via Paccagnella 11, 30174, Venezia, Italy.
| | - Salvatore Cozzi
- Radiation Therapy Unit, Azienda USL-IRCCS di Reggio Emilia, 42122, Reggio Emilia, Italy.
| | - Alessia Nardangeli
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, L. Gemelli 1, 00168, Roma, Italy.
| | - Francesco Dionisi
- Department of Research and Advanced Technology, Radiation Oncology Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi, 53, 00144, Roma, Italy.
| | - Gianluca Costantino
- Department of Radiation Oncology, ASST Spedali Civili of Brescia, P.le Spedali Civili 1, 25123, Brescia, Italy
| | - Stefano Vagge
- Department of Radiation Oncology, Azienda Ospedaliera Universitaria San Martino di Genova-IST, Istituto Nazionale Ricerca sul Cancro, Genoa, Italy.
| | - Antonio Pontoriero
- Dept. of Radiation Oncology, University of Messina, 98125, Messina, Italy.
| | - Vittorio Donato
- Radiation Oncology Division, Oncology and Speciality Medicine Department, San Camillo-Forlanini Hospital, 00152, Roma, Italy.
| | - Mariangela Massaccesi
- Radiation Oncology Department, Gemelli-ART, Università Cattolica S. Cuore, L. Gemelli 1, 00168, Roma, Italy.
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Kinj R, Casutt A, Bennassi A, Bouchaab H, Vallet V, Lovis A, Ozsahin M. Stereotactic lung reirradiation for local relapse: A case series. Clin Transl Radiat Oncol 2021; 28:85-87. [PMID: 33912693 PMCID: PMC8065183 DOI: 10.1016/j.ctro.2021.03.007] [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: 02/18/2021] [Revised: 03/17/2021] [Accepted: 03/28/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction Local recurrence after lung SBRT for early stage NSCLC is rare but its treatment remains a challenge due to limited surgical options. We report a case series of 5 patients treated by stereotactic lung salvage reirradiation for local relapse after a previous lung SBRT. Material and methods Included patients presented an isolated primary lung relapse within at least the 50% isodose of the previous SBRT treatment. Typical reirradiation schedule was 60 Gy in 8 fractions at isodose 80% and was delivered by Cyberknife® using Synchrony® fiducial tracking system. Dose summations were performed to evaluate the safety of the reirradiation. Results We identified 5 patients presenting peripheral lesions. All reirradiated lesions were locally controlled after a median follow-up of 11.1 months (6,7-12,2), while PFS at 6 months was 60% (n = 3). We did not notice any Grade 3 or more acute or late adverse event. Conclusion We observed encouraging short-term outcome of lung SBRT reirradiation in patients presenting isolated local relapse of an early-stage NSCLC. Further studies are necessary to confirm the safety and efficiency of this salvage treatment approach.
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Affiliation(s)
- Rémy Kinj
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Corresponding author.
| | - Alessio Casutt
- Department of Pulmonology, Lausanne University Hospital, Lausanne, Switzerland
| | - Alexander Bennassi
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Hasna Bouchaab
- Department of Medical Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Véronique Vallet
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alban Lovis
- Department of Pulmonology, Lausanne University Hospital, Lausanne, Switzerland
| | - Mahmut Ozsahin
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Rico M, Flamarique S, Casares C, García T, López M, Martínez M, Serrano J, Blanco M, Hernanz R, de Ingunza-Barón L, Marcos FJ, Couñago F. GOECP/SEOR radiotherapy guidelines for thymic epithelial tumours. World J Clin Oncol 2021; 12:195-216. [PMID: 33959475 PMCID: PMC8085511 DOI: 10.5306/wjco.v12.i4.195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/23/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023] Open
Abstract
Thymic epithelial tumours (TET) are rare, heterogeneous neoplasms that range from resectable indolent tumours to aggressive thymic carcinomas with a strong tendency to metastasize. The pathological diagnosis is complex, in part due to the existence of several different classification systems. The evidence base for the management of TETs is scant and mainly based on non-randomised studies and retrospective series. Consequently, the clinical management of TETs tends to be highly heterogenous, which makes it difficult to improve the evidence level. The role of technological advances in the field of radiotherapy and new systemic therapies in the treatment of TETs has received little attention to date. In the present clinical guidelines, developed by the GOECP/SEOR, we review recent developments in the diagnosis and classification of TETs. We also present a consensus-based therapeutic strategy for each disease stage that takes into consideration the best available evidence. These guidelines focus primarily on the role of radiotherapy, including recent advances, in the management of TETs. The main aim of this document is to promote the standardisation of clinical practice and lay the foundations for future studies to clarify the main unresolved questions related to the optimal management of TET.
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Affiliation(s)
- Mikel Rico
- Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona 31008, Navarra, Spain
- Health Research Institute of Navarre (IdiSNA), Navarra Biomed, Pamplona 31008, Navarra, Spain
| | - Sonia Flamarique
- Department of Radiation Oncology, University Hospital Miguel Servet, Zaragoza 50009, Aragón, Spain
| | - Cristina Casares
- Department of Radiation Oncology, University Hospital of Caceres, Cáceres 10004, Extremadura, Spain
| | - Tamara García
- Department of Radiation Oncology, Hospital Universitario de Fuenlabrada, Fuenlabrada 28942, Madrid, Spain
| | - Miriam López
- Department of Radiation Oncology, Hospital Clínico Universitario Lozano Blesa, Zaragoza 50009, Aragón, Spain
| | - Maribel Martínez
- Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona 31008, Navarra, Spain
| | - Javier Serrano
- Department of Radiation Oncology, Clínica Universidad de Navarra, Madrid 28027, Spain
| | - Manuel Blanco
- Department of Radiation Oncology, Hospital Universitario Torrecárdenas, Almería 04009, Andalucía, Spain
| | - Raúl Hernanz
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Lourdes de Ingunza-Barón
- Department of Radiation Oncology, Hospital Universitario Puerta del Mar, Cádiz 11009, Andalucía, Spain
| | - Francisco José Marcos
- Department of Radiation Oncology, University Hospital of Caceres, Cáceres 10004, Extremadura, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Hospital La Luz, Universidad Europea de Madrid, Madrid 28223, Spain
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14
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Andruska N, Stowe HB, Crockett C, Liu W, Palma D, Faivre-Finn C, Badiyan SN. Stereotactic Radiation for Lung Cancer: A Practical Approach to Challenging Scenarios. J Thorac Oncol 2021; 16:1075-1085. [PMID: 33901637 DOI: 10.1016/j.jtho.2021.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/02/2021] [Accepted: 04/07/2021] [Indexed: 12/18/2022]
Abstract
Stereotactic body radiation therapy (SBRT) is an effective and well-tolerated treatment for medically inoperable patients with early stage NSCLC. SBRT is a noninvasive treatment involving the delivery of ablative radiation doses with high precision in the course of a few treatments. Relative to conventionally fractionated radiation, SBRT achieves superior local control and survival. SBRT use has increased dramatically in the past 15 years and is currently considered the standard of care in cases of inoperable early stage NSCLC. It is being increasingly applied to more complex patient populations at higher risk of treatment-related toxicity. In these more complex patients, there is an increasing need to balance patient and treatment factors in selecting the optimal patients for SBRT. Here, we review several challenging clinical scenarios often encountered in thoracic multidisciplinary tumor boards.
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Affiliation(s)
- Neal Andruska
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Hayley B Stowe
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Cathryn Crockett
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Wei Liu
- Division of Radiation Oncology, Western University, London, Ontario, Canada
| | - David Palma
- Division of Radiation Oncology, Western University, London, Ontario, Canada; Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St Louis, Missouri.
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15
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Hunter B, Crockett C, Faivre-Finn C, Hiley C, Salem A. Re-Irradiation of Recurrent Non-Small Cell Lung Cancer. Semin Radiat Oncol 2021; 31:124-132. [PMID: 33610269 DOI: 10.1016/j.semradonc.2020.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Locoregional recurrence occurs in 10%-30% of non-small cell lung cancer (NSCLC) after treatment with definitive (chemo)radiotherapy. Re-irradiation is the main curative-intent treatment option for these patients; however, it represents a therapeutic challenge for thoracic radiation oncologists. Re-irradiation practices are variable worldwide with lack of agreement on the optimal dose or the cumulative maximum dose acceptable for critical organs. The role of re-irradiation in NSCLC is also not clearly defined in the era of immunotherapy. In this review, we will present published and on-going re-irradiation studies for recurrent NSCLC. We will appraise available evidence for critical organ dose constraints and provide a framework for future therapeutic approaches and trials.
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Affiliation(s)
| | - Cathryn Crockett
- Division of Cancer Sciences, University of Manchester, The Christie NHS Foundation Trust, Manchester, UK
| | - Corrinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester, The Christie NHS Foundation Trust, Manchester, UK
| | - Crispin Hiley
- CRUK Lung Cancer Centre of Excellence, UCL Cancer Institute, Faculty of Medical Sciences, University College London, University College London Hospital, London, UK
| | - Ahmed Salem
- Division of Cancer Sciences, University of Manchester, The Christie NHS Foundation Trust, Manchester, UK.
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16
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Shin H, Noh JM, Pyo H, Ahn YC, Oh D. Salvage proton beam therapy for locoregional recurrence of non-small cell lung cancer. Radiat Oncol J 2021; 39:24-32. [PMID: 33794571 PMCID: PMC8024187 DOI: 10.3857/roj.2020.01074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/12/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose This study aimed to evaluate the clinical outcomes and toxicities of salvage proton beam therapy (PBT) in patients with locoregional recurrent non-small cell lung cancer (NSCLC). Materials and Methods We retrospectively reviewed 53 patients who received salvage PBT for locoregionally recurrent NSCLC between January 2016 and December 2019. The median clinical target volume (CTV) was 71.2 cm3 (range, 13.3 to 1,200.7 cm3). The median prescribed dose was 64.0 cobalt gray equivalent (CGE) (range, 45.0 to 70.0 CGE). One-third of the patients (32.1%) received concurrent chemoradiotherapy (CCRT). Results The patients’ median age was 67 years (range, 44 to 86 years). The initial treatments were surgery in 31 (58.5%), definitive CCRT in 12 (22.6%), and definitive radiotherapy in 10 (18.9%) patients. The median disease-free interval (DFI) was 14 months (range, 3 to 112 months). Thirty-seven patients (69.8%) had a previous radiotherapy history. Among them, 18 patients (48.7%) had in-field recurrence. The median follow-up time after salvage PBT was 15.0 months (range, 3.5 to 49.3 months). During the follow-up period, 26 patients (49.1%) experienced disease progression: local in 13 (24.5%), regional in 14 (26.5%), and distant metastases in 15 (26.5%). The 2-year overall survival (OS) rate, local control rate, and progression-free survival rate were 79.2%, 68.2%, and 37.1%, respectively. Shorter DFI (≤12 months; p = 0.015) and larger CTV (>80 mL; p = 0.014) were associated with poor OS. Grade 3 toxicities occurred in 8 patients (15.1%): esophagitis in 2, dermatitis in 3, and pulmonary toxicities in 4. Conclusion Salvage PBT for locoregionally recurrent NSCLC was effective, and treatment-related toxicities were tolerable.
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Affiliation(s)
- Hyunju Shin
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hongryull Pyo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dongryul Oh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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17
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Chiang JS, Yu NY, Daniels TB, Liu W, Schild SE, Sio TT. Proton beam radiotherapy for patients with early-stage and advanced lung cancer: a narrative review with contemporary clinical recommendations. J Thorac Dis 2021; 13:1270-1285. [PMID: 33717598 PMCID: PMC7947490 DOI: 10.21037/jtd-20-2501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although lung cancer rates are decreasing nationally, lung cancer remains the leading cause of cancer related death. Despite advancements in treatment and technology, overall survival (OS) for lung cancer remains poor. Proton beam therapy (PBT) is an advanced radiation therapy (RT) modality for treatment of lung cancer with the potential to achieve dose escalation to tumor while sparing critical structures due to higher target conformality. In early and late-stage non-small cell lung cancer (NSCLC), dosimetric studies demonstrated reduced doses to organs at risk (OARs) such as the lung, spinal cord, and heart, and clinical studies report limited toxicities with PBT, including hypofractionated regimens. In limited-stage SCLC, studies showed that regimens chemo RT including PBT were well tolerated, which may help optimize clinical outcomes. Improved toxicity profiles may be beneficial in post-operative radiotherapy, for which initial dosimetric and clinical data are encouraging. Sparing of OARs may also increase the proportion of patients able to complete reirradiation for recurrent disease. However, there are various challenges of using PBT including a higher financial burden on healthcare and limited data supporting its cost-effectiveness. Further studies are needed to identify subgroups that benefit from PBT based on prognostic factors, and to evaluate PBT combined with immunotherapy, in order to elucidate the benefit that PBT may offer future lung cancer patients.
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Affiliation(s)
- Jennifer S Chiang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Thomas B Daniels
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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Hamada A, Soh J, Mitsudomi T. Salvage surgery after definitive chemoradiotherapy for patients with non-small cell lung cancer. Transl Lung Cancer Res 2021; 10:555-562. [PMID: 33569336 PMCID: PMC7867739 DOI: 10.21037/tlcr-20-453] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Definitive chemoradiotherapy (CRT) has been a standard of care for patients with unresectable stage III non-small cell lung cancer (NSCLC). However, locoregional recurrence occurs in about 30% of patients after definitive CRT. Recently, the addition of durvalumab as maintenance therapy has shown to improve the outcome of these patients. However, locoregional recurrence will still remain. “Salvage surgery” has been performed to achieve local control in clinical practice, although its clinical significance is unclear. In this review, we define salvage surgery as lung resection for local control of the tumor which was not planned initially, after failure or insufficient treatment effect of the initial CRT for locally advanced cancer and evaluated nine studies to gain some insights on its role in the treatment of lung cancer. The time from radiotherapy (RT) to salvage surgery varied considerably (range, 3 to 282 weeks). Salvage surgery was performed for persistent disease (47%) and locoregional recurrence (52%). Lobectomy (63%) and mediastinal lymph node dissections (90%) were the most common procedures. However, the rate of pneumonectomy was higher in salvage surgery (28%) compared to that in lung resection in general. The median morbidity was 41% (range, 15% to 62%) and the mortality was 4% (range, 0 to 11%) which appeared acceptable. The median recurrence-free survival and overall survival (OS) after salvage surgery ranged from 10 to 22 months and 13 to 76 months, respectively. Favorable prognostic factors of salvage surgery were longer period from RT to salvage surgery and radiological downstaging. The pathological response was also prognostic, although this information cannot be obtained preoperatively. We conclude that salvage surgery can be considered especially for those with late local recurrence or those with the metabolic response. Given the condition where phase III trials are difficult, the accumulation of real-world evidence in a prospective fashion will be necessary.
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Affiliation(s)
- Akira Hamada
- Division of Thoracic Surgery, Department of Surgery, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Junichi Soh
- Division of Thoracic Surgery, Department of Surgery, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Tetsuya Mitsudomi
- Division of Thoracic Surgery, Department of Surgery, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
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Barsky AR, Lin H, Mendes A, Dreyfuss A, Wright C, Anstadt EJ, Berman AT, Levin WP, Cengel KA, Anderson N, Dong L, Metz JM, Li T, Feigenberg S. Initial Clinical Experience Treating Patients With Lung Cancer on a 6MV-Flattening-Filter-Free O-Ring Linear Accelerator. Cureus 2020; 12:e10325. [PMID: 33052286 PMCID: PMC7546605 DOI: 10.7759/cureus.10325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/08/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction Modern technologies, like intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT), have improved the therapeutic ratio of thoracic radiotherapy (TRT) for lung cancer (LC). Halcyon™ (Varian Medical Systems, Palo Alto, CA, USA), a novel 6MV-flattening-filter-free O-ring linear accelerator (6X-FFF ORL), was designed to deliver IMRT and VMAT with greater speed than a C-arm linac. Herein, we report our initial clinical experience treating patients with LC on this linac. Methods All patients who received TRT for LC on the 6X-FFF ORL at our institution were retrospectively identified. Patients' clinicopathologic data, radiotherapy details, early disease-control and toxicity outcomes, dosimetric data, couch corrections, and treatment times are reported. Results Between 10/2018-12/2019, 30 consecutive patients (median age 66 years, range 54-94 years) received definitive or post-operative TRT for LC (median 66 Gy/33 fractions; range 5-70 Gy/2-37 fractions) following four-dimensional computed tomography (CT) simulation (97%) using daily kilovoltage KV cone-beam CT (CBCT) (100%) on a 6X-FFF ORL for non-small cell LC (84%) or small cell LC (16%), with 53% receiving VMAT, 43% receiving static-field IMRT, and 77% receiving concurrent systemic therapy. All plans were approved through institutional peer review. The average three-dimensional vector couch correction based on CBCT guidance was 0.90 ± 0.50 cm. The average beam-on and beam on plus CBCT times were 1.7 ± 1.1 min, and 5.0 ± 3.2 min, respectively. Grade 3 dyspnea and fatigue occurred in 3% and 3% of patients, respectively. There were no grade ≥4 toxicities. Conclusion In this first clinical report of TRT for LC on a 6X-FFF ORL, daily CBCT-guided treatment was fast and safe with respect to dosimetry and clinical outcomes. Thus, use of this linac for TRT may increase LC patient throughput without a detriment in radiotherapy quality.
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Affiliation(s)
- Andrew R Barsky
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Hui Lin
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Amberly Mendes
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Alexandra Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Christopher Wright
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Emily J Anstadt
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Abigail T Berman
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - William P Levin
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Keith A Cengel
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Nathan Anderson
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Lei Dong
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - James M Metz
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Taoran Li
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Steven Feigenberg
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
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20
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Nicosia L, Di Muzio J, Agolli L, Alongi F, Mazzola R, Valeriani M, Badellino S, Osti MF, Ricardi U. What is the role of reirradiation in the management of locoregionally relapsed non small-cell lung cancer? Lung Cancer 2020; 146:263-275. [PMID: 32593916 DOI: 10.1016/j.lungcan.2020.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/06/2020] [Accepted: 06/13/2020] [Indexed: 12/25/2022]
Abstract
The prognosis of lung cancer patients has improved in the last few years. Despite definitive therapy, local recurrence or a second primary tumour can occur in many patients within previously irradiated areas. Recent developement of more accurate techniques in radiation oncology allows delivery of high radiation dose to the tumor with the aim of improving local control, delaying disease progression and in some cases even curing. Nevertheless, the use of high dose in the reirradiation setting is not without risks, especially when treatment volumes overlap with previously irradiated tissues. The risk of adverse effects must be balanced with the choice of an effective treatment by selecting suitable candidates and the best radiation technique. In this systemic review efficacy and toxicity of reirradiation in locoregionally recurrent non-small-cell lung cancer is extensively discussed. Results indicate that reirradiation might be beneficial in well-selected patients. Prospective and high quality studies are necessary in this field.
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Affiliation(s)
- Luca Nicosia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, Italy.
| | - Jacopo Di Muzio
- Radiation Oncology Department AO Città della Salute e della Scienza - Molinette, University of Turin, Turin, Italy
| | - Linda Agolli
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, Italy; University of Brescia, Italy
| | - Rosario Mazzola
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Cancer Care Center, Italy
| | - Maurizio Valeriani
- Department of Radiation Oncology, Sant'Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Serena Badellino
- Radiation Oncology Department AO Città della Salute e della Scienza - Molinette, University of Turin, Turin, Italy
| | - Mattia F Osti
- Department of Radiation Oncology, Sant'Andrea Hospital, "Sapienza" University of Rome, Italy
| | - Umberto Ricardi
- Radiation Oncology Department AO Città della Salute e della Scienza - Molinette, University of Turin, Turin, Italy
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21
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Simone CB, Plastaras JP, Jabbour SK, Lee A, Lee NY, Choi JI, Frank SJ, Chang JY, Bradley J. Proton Reirradiation: Expert Recommendations for Reducing Toxicities and Offering New Chances of Cure in Patients With Challenging Recurrence Malignancies. Semin Radiat Oncol 2020; 30:253-261. [PMID: 32503791 PMCID: PMC10870390 DOI: 10.1016/j.semradonc.2020.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Local and regional recurrences are common following an initial course of radiotherapy, yet management of these recurrences remains a challenge. Reirradiation may be an optimal treatment approach for providing durable tumor control and even offering select patients with locoregional recurrences or new primary tumors a chance of cure, but photon reirradiation can be associated with considerable risks of high grade acute and late toxicities. The high conformality and lack of exit dose with proton therapy offer significant advantages for reirradiation. By decreasing dose to adjacent normal tissues, proton therapy can more safely deliver definitive instead of palliative doses of reirradiation, more safely dose escalate reirradiation treatment, and more safely allow for concurrent systemic therapy in the reirradiation setting. In this case-based analysis, renowned experts in the fields of proton therapy and of reirradiation present cases for which they recently employed proton reirradiation. This manuscript focuses on case studies in patients with lung cancer, head and neck malignancies, and pelvic malignancies. Considerations for when to deliver proton therapy in the reirradiation setting and the pros and cons of proton therapy are discussed, and the existing literature supporting the use of proton reirradiation for these disease sites is assessed.
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Affiliation(s)
- Charles B Simone
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY.
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Anna Lee
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy Y Lee
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey Bradley
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA
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22
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Fischer-Valuck BW, Robinson CG, Simone CB, Gomez DR, Bradley JD. Challenges in Re-Irradiation in the Thorax: Managing Patients with Locally Recurrent Non-Small Cell Lung Cancer. Semin Radiat Oncol 2020; 30:223-231. [PMID: 32503787 DOI: 10.1016/j.semradonc.2020.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Treatment of locally recurrent non-small lung cancer (NSCLC) after definitive chemoradiation therapy is challenging as patients are often inoperable and systemic therapy alone frequently results in suboptimal outcomes. Re-irradiation of NSCLC may be the best strategy for treating locoregional failures with the goal of durable long-term control and potentially cure. Repeat irradiation is technically challenging for fear of life-threatening toxicities to previously irradiated organs at risk while also delivering definitive doses of radiation to recurrent disease. No standard guidelines exist with regards to re-irradiation technique and re-treatment dose constraints to organs at risks. We herein describe a case of locoregional recurrence after definitive chemoradiation therapy for NSCLC with expert opinions for subsequent management. As described and guided by our experts, we review the various techniques for repeat radiation therapy, treatment planning goals, and reported toxicities and outcomes in the re-irradiation setting.
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Affiliation(s)
| | - Clifford G Robinson
- Department of Radiation Oncology, Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO
| | - Charles B Simone
- New York Proton Center, New York City, NY; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Daniel R Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
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23
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Assessing Outcomes of Patients Treated With Re-Irradiation Utilizing Proton Pencil-Beam Scanning for Primary or Recurrent Malignancies of the Esophagus and Gastroesophageal Junction. J Thorac Oncol 2020; 15:1054-1064. [DOI: 10.1016/j.jtho.2020.01.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/10/2020] [Accepted: 01/25/2020] [Indexed: 12/25/2022]
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24
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Yang WC, Hsu FM, Chen YH, Shih JY, Yu CJ, Lin ZZ, Lu SH, Yang JCH, Cheng AL, Kuo SH. Clinical outcomes and toxicity predictors of thoracic re-irradiation for locoregionally recurrent lung cancer. Clin Transl Radiat Oncol 2020; 22:76-82. [PMID: 32280792 PMCID: PMC7139144 DOI: 10.1016/j.ctro.2020.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/15/2020] [Accepted: 03/21/2020] [Indexed: 12/25/2022] Open
Abstract
Background and purpose Thoracic re-irradiation may be an alternative treatment for lung cancer patients who develop intrathoracic locoregional recurrence without systemic progression. This study aimed to retrospectively assess locoregional control, clinical outcomes, and toxicities in lung cancer patients who received thoracic re-irradiation. Materials and methods We retrospectively reviewed 50 lung cancer patients who received thoracic re-irradiation using conventional photon radiotherapy (RT) and stereotactic body radiotherapy (SBRT) between 2009 and 2017. The correlations of clinicopathologic factors, treatment factors, and dosimetric factors of RT with time to local progression (TTLP), progression-free survival (PFS), and overall survival (OS) after starting thoracic re-irradiation were calculated using log-rank tests and Cox regression models. Results The median re-irradiation dose in equivalent dose in 2-Gy fractions was 51.1 Gy, and the mean re-irradiation planning target volume was 201.58 ml. The median mean lung dose (MLD) was 4.18 Gy, and the total lung volumes receiving a dose of 5 Gy (lung V5) and of 20 Gy (V20) were 19.8% and 5.85%, respectively. The TTLP, PFS, and OS were 18.0, 5.9, and 25.1 months, respectively. Lung V5 (p < 0.001), V20 (p = 0.011), and MLD (p = 0.002) were significantly associated with grade ≥2 lung toxicity. Seven (14%) patients developed lethal lung events. Subsequent chemotherapy following thoracic re-irradiation was significantly correlated with lethal lung events (p = 0.009). Conclusion Promising local control can be achieved with thoracic re-irradiation in lung cancer patients with locoregional recurrence. However, unexpected lethal lung events may occur, especially in patients receiving systemic therapy following thoracic re-irradiation.
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Affiliation(s)
- Wen-Chi Yang
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Feng-Ming Hsu
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Hsuan Chen
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jin-Yuan Shih
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Zhong-Zhe Lin
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Oncology, National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Szu-Huai Lu
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - James Chih-Hsin Yang
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan.,Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ann-Lii Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Oncology, National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sung-Hsin Kuo
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan.,Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan
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25
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Käsmann L, Janssen S, Baschnagel AM, Kruser TJ, Harada H, Aktan M, Rades D. Prognostic factors and outcome of reirradiation for locally recurrent small cell lung cancer-a multicenter study. Transl Lung Cancer Res 2020; 9:232-238. [PMID: 32420062 PMCID: PMC7225148 DOI: 10.21037/tlcr.2020.01.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background The prognosis of patients with recurrent small cell lung cancer (SCLC) remains poor and treatment options are limited. We performed a multi-institution retrospective cohort study to evaluate the outcome of thoracic reirradiation, identify prognostic factors and assess treatment-related toxicity. Methods Data of 33 patients re-irradiated for recurrent SCLC at 4 international university hospitals, were analysed. Overall survival (OS) acute and late toxicities were evaluated and prognostic factors for reirradiation were identified. Results Reirradiation (Re-RT) was performed at a median interval time of 24 months after the first thoracic radiotherapy series. Median survival after reirradiation was 7 months (range, 1-54 months). The Re-RT dose in EQD2 ranged from 20 to 87.50 Gy with a median of 32.50 Gy. The 1- and 2-year OS were 33% and 17%, respectively. Patients with a good performance status (KPS >70%), absence of extrathoracic disease, reirradiation dose (EQD2) of >40 Gy and a cumulative dose of first plus second series of radiotherapy (EQD2) >90 Gy were associated with improved OS. Acute pulmonary Grade 1-2 toxicity from re-irradiation was recorded in 11 patients (33%) and grade 3 acute toxicity was encountered 1 patient (3%). Conclusions Reirradiation for locoregionally recurrent SCLC is safe and shows promising outcomes. Patients reirradiated with doses >40 Gy experienced more favourable survival rates. In contrast, patients with a poor performance status or extrathoracic disease have a poor prognosis and Re-RT should be considered only for symptom control in this group.
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Affiliation(s)
- Lukas Käsmann
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany.,Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany.,German Cancer Consortium (DKTK), Partner Site Munich, Germany
| | - Stefan Janssen
- Medical Practice for Radiotherapy and Radiation Oncology, Hannover, Germany.,Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - Andrew M Baschnagel
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Tim J Kruser
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hideyuki Harada
- Division of Radiation Therapy, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, Japan
| | - Meryem Aktan
- Department of Radiation Oncology, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
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26
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Ng C, Pircher A, Augustin F, Kocher F. Evidence-based follow-up in lung cancer? MEMO - MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2020. [DOI: 10.1007/s12254-020-00575-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
SummaryIn 2012 approximately 410,000 patients were diagnosed with lung cancer and about 353,000 lung cancer deaths were registered in the European Union. Although lung cancer is still the leading cause of cancer-related death worldwide, advances in detection and treatment have increased the likelihood of long-term survival. In patients receiving definitive curative treatment for lung cancer guidelines suggest follow-up of patients using clinical and radiological examinations over a certain period of time. However, standards differ and there are no generally accepted follow-up recommendations. Aim of this short review is to summarize the currently available knowledge and guidelines regarding surveillance of patients receiving definitive lung cancer treatment.
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27
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Kennedy WR, Gabani P, Nikitas J, Robinson CG, Bradley JD, Roach MC. Repeat stereotactic body radiation therapy (SBRT) for salvage of isolated local recurrence after definitive lung SBRT. Radiother Oncol 2020; 142:230-235. [PMID: 31481272 PMCID: PMC7655115 DOI: 10.1016/j.radonc.2019.08.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 08/14/2019] [Accepted: 08/14/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Optimal management of isolated local recurrences after stereotactic body radiation therapy (SBRT) for early non-small cell lung cancer (NSCLC) is unknown and literature describing repeat SBRT for in-field recurrences after initial SBRT are sparse. We investigate the safety and efficacy of salvage SBRT for isolated local failures after initial SBRT for NSCLC. METHODS/MATERIALS Patients receiving SBRT for isolated local recurrence after initial SBRT for early NSCLC were identified using a prospective registry. Both courses were 3-5 fractions with a biologically effective dose (BED10) of ≥100 Gy. Local failure was defined as within 1 cm of the initial planning target volume (PTV) or an overlap of the ≥25% isodose lines of the first and second treatments. Failures >1 cm beyond the PTV and without ≥25% overlap, or with additional recurrence sites were excluded. Kaplan-Meier analysis was used to estimate survival. RESULTS A total 21 patients receiving salvage SBRT from 2008 to 2017 were identified. Median interval from initial SBRT to salvage SBRT was 23 months (7-52). Six patients (29%) had central tumors. Median follow-up time from salvage SBRT was 24 months (3-60). Median overall survival after salvage was 39 months. After reirradiation, two-year primary tumor control was 81%, regional nodal control was 89%, distant control was 75% and overall survival was 68%. Grade 2 pneumonitis occurred in 2 patients (10%) and grade 2 chest wall toxicity in 4 patients (19%). No grade 3+ toxicity was observed. CONCLUSIONS Salvage SBRT for isolated local failures after initial SBRT appears safe, with low treatment-related toxicity and encouraging rates of tumor control.
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Affiliation(s)
- William R Kennedy
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Prashant Gabani
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - John Nikitas
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States
| | - Michael C Roach
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, United States.
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Yu NY, DeWees TA, Liu C, Daniels TB, Ashman JB, Beamer SE, Jaroszewski DE, Ross HJ, Paripati HR, Rwigema JCM, Ding JX, Shan J, Liu W, Schild SE, Sio TT. Early Outcomes of Patients With Locally Advanced Non-small Cell Lung Cancer Treated With Intensity-Modulated Proton Therapy Versus Intensity-Modulated Radiation Therapy: The Mayo Clinic Experience. Adv Radiat Oncol 2019; 5:450-458. [PMID: 32529140 PMCID: PMC7276663 DOI: 10.1016/j.adro.2019.08.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/20/2019] [Accepted: 08/06/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose There are very little data available comparing outcomes of intensity-modulated proton therapy (IMPT) to intensity-modulated radiation therapy (IMRT) in patients with locally advanced NSCLC (LA-NSCLC). Methods Seventy-nine consecutively treated patients with LA-NSCLC underwent definitive IMPT (n = 33 [42%]) or IMRT (n = 46 [58%]) from 2016 to 2018 at our institution. Survival rates were calculated using the Kaplan-Meier method and compared with the log-rank test. Acute and subacute toxicities were graded based on Common Terminology Criteria for Adverse Events, version 4.03. Results Median follow-up was 10.5 months (range, 1-27) for all surviving patients. Most were stage III (80%), received median radiation therapy (RT) dose of 60 Gy (range, 45-72), and had concurrent chemotherapy (65%). At baseline, the IMPT cohort was older (76 vs 69 years, P < .01), were more likely to be oxygen-dependent (18 vs 2%, P = .02), and more often received reirradiation (27 vs 9%, P = .04) than their IMRT counterparts. At 1 year, the IMPT and IMRT cohorts had similar overall survival (68 vs 65%, P = .87), freedom from distant metastasis (71 vs 68%, P = .58), and freedom from locoregional recurrence (86 vs 69%, P = .11), respectively. On multivariate analyses, poorer pulmonary function and older age were associated with grade +3 toxicities during and 3 months after RT, respectively (both P ≤ .02). Only 5 (15%) IMPT and 4 (9%) IMRT patients experienced grade 3 or 4 toxicities 3 months after RT (P = .47). There was 1 treatment-related death from radiation pneumonitis 6 months after IMRT in a patient with idiopathic pulmonary fibrosis. Conclusions Compared with IMRT, our early experience suggests that IMPT resulted in similar outcomes in a frailer population of LA-NSCLC who were more often being reirradiated. The role of IMPT remains to be defined prospectively.
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Affiliation(s)
- Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Todd A DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Chenbin Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | | | - Staci E Beamer
- Department of Cardiothoracic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Helen J Ross
- Department of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
| | - Harshita R Paripati
- Department of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Julia X Ding
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jie Shan
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Poel R, Stuessi Lobmaier A, Andratschke N, Unkelbach J, Tanadini-Lang S, Guckenberger M, Foerster R. Dosimetric comparison of protons vs photons in re-irradiation of intracranial meningioma. Br J Radiol 2019; 92:20190113. [PMID: 31264474 DOI: 10.1259/bjr.20190113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Re-irradiation of recurrent intracranial meningiomas represents a major challenge due to dose limits of critical structures and the necessity of sufficient dose coverage of the recurrent tumor for local control. The aim of this study was to investigate dosimetric differences between pencil beam scanning protons (PBS) and volumetric modulated arc therapy (VMAT) photons for intracranial re-irradiation of meningiomas. METHODS Nine patients who received an initial dose >50 Gy for intracranial meningioma and who were re-irradiated for recurrence were selected for plan comparison. A volumetric modulated arc therapy photon and a pencil beam scanning proton plan were generated (prescription dose: 15 × 3 Gy) based on the targets used in the re-irradiation treatment. RESULTS In all cases, where the cumulative dose exceeded 100 or 90 Gy, these high dose volumes were larger for the proton plans. The integral doses were significantly higher in all photon plans (reduction with protons: 48.6%, p < 0.01). In two cases (22.2%), organ at risk (OAR) sparing was superior with the proton plan. In one case (11.1%), the photon plan showed a dosimetric advantage. In the remaining six cases (66.7%), we found no clinically relevant differences in dose to the OARs. CONCLUSIONS The dosimetric results of the accumulated dose for a re-irradiation with protons and with photons were very similar. The photon plans had a steeper dose falloff directly outside the target and were superior in minimizing the high dose volumes. The proton plans achieved a lower integral dose. Clinically relevant OAR sparing was extremely case specific. The optimal treatment modality should be assessed individually. ADVANCES IN KNOWLEDGE Dose sparing in re-irradiation of intracranial meningiomas with protons or photons is highly case specific and the optimal treatment modality needs to be assessed on an individual basis.
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Affiliation(s)
- Robert Poel
- 1 Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland.,2 Center for Proton Therapy, Paul Scherer Institute (PSI), Villingen, Switzerland
| | | | - Nicolaus Andratschke
- 1 Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Jan Unkelbach
- 1 Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | | | | | - Robert Foerster
- 1 Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
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Mercado CE, Hartsell WF, Simone CB, Tsai HK, Vargas CE, Zhu HJ, Henderson RH, Zeng J, Larson GL, Hoppe BS. Proton therapy for thymic malignancies: multi-institutional patterns-of-care and early clinical outcomes from the proton collaborative group and the university of Florida prospective registries. Acta Oncol 2019; 58:1036-1040. [PMID: 30784340 DOI: 10.1080/0284186x.2019.1575981] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective: Thymic malignancies (TM) are rare tumors with long-term survivorship, causing concerns for radiotherapy-related late side effects. Proton therapy (PT) reduces the radiation dose to organs at risk, potentially decreasing long-term toxicities while preserving disease control. We report patterns-of-care and early clinical outcomes after PT for thymoma and thymic carcinoma. Methods: Between January 2008 and March 2017, 30 patients with TMs enrolled on one of two IRB-approved prospective protocols and received postoperative or definitive PT. Clinical outcomes, pathology, treatment dose, toxicities, and follow-up information were analyzed. Results: Twenty-two thymoma patients with a median age of 52.1 years (range, 23-72) received a median RT dose of 54 Gy (RBE) (range, 45-70) either postoperatively (91%) or definitively (9%); 23% received adjuvant chemotherapy. Among eight thymic carcinoma patients, the median age was 65.5 years (range, 38-88) and median RT dose was 60 Gy (RBE) (range, 42-70) delivered postoperatively (75%) or definitively (25%); 50% received chemotherapy. Median follow-up for all patients was 13 months (range, 2-59 months). Five patients relapsed, one locally (3%). Three patients died of disease progression, including two thymomas and one thymic carcinoma patient; a fourth died of intercurrent disease. One patient with thymic carcinoma and 1 with thymoma are alive with disease. No patients treated with PT for their initial disease (de novo) experienced grade ≥3 toxicities. The most common grade 2 toxicities were dermatitis (37%), cough (13%), and esophagitis (10%). Conclusion: Adjuvant and definitive PT are being used in the treatment of TMs. Early results of the largest such cohort reported to date demonstrates an acceptable rate of recurrence with a favorable toxicity profile. Longer follow-up and a larger patient cohort are needed to confirm these findings.
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Affiliation(s)
| | | | - Charles B. Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Henry K. Tsai
- New Jersey Procure Proton Therapy Center, Oklahoma City, OK, USA
| | | | - He J. Zhu
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Randal H. Henderson
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Gary L. Larson
- Oklahoma City Procure Proton Therapy Center, Oklahoma City, OK, USA
| | - Bradford S. Hoppe
- University of Florida Health Proton Therapy Institute, Jacksonville, FL, USA
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Shirai K, Ohno T, Saitoh JI, Okamoto M, Katoh H, Murata K, Kawamura H, Musha A, Abe T, Mizukami T, Akahane K, Nakano T. Prospective Study of Isolated Recurrent Tumor Re-irradiation With Carbon-Ion Beams. Front Oncol 2019; 9:181. [PMID: 30972294 PMCID: PMC6445888 DOI: 10.3389/fonc.2019.00181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 03/04/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose: To perform a prospective study to evaluate the efficacy and safety of isolated recurrent tumor re-irradiation with carbon-ion radiotherapy (RT). Methods and Materials: The inclusion criteria were clinically proven recurrent tumors, measurable by computed tomography or magnetic resonance imaging, patients ≥ 16 years old, performance status scores between 0 and 2, isolated tumor at a previously irradiated site, and a life expectancy > 6 months. The exclusion criteria were tumor invasion into the gastrointestinal tract or a major blood vessel, uncontrolled infection, early recurrence (<3 months), and severe concomitant diseases. The primary end-point was the local control rate, the secondary end-points including the overall survival rate, and adverse events. Results: Between December 2013 and March 2016, 22 patients were enrolled in this prospective study. All patients were re-irradiated with carbon-ion RT with radical intent. Five patients had rectal cancer, 4 had sarcoma, 4 had lung cancer, 3 had hepatic cell carcinoma, and 6 had other tumors. The median follow-up time was 26 months. Eight patients developed local recurrence, and the 1- and 2-year local control rates were 71 and 60%, respectively. Eight patients died of their cancers and 2 died of other diseases. The 1- and 2-year overall survival rates were 76 and 67%, respectively. There were no grade 2 or higher acute adverse events and 4 patients (18%) developed grade 3 late adverse events. The group with the longer interval (>16 months) between the first RT and re-irradiation had significantly better outcomes than the shorter interval group (≤ 16 months). Conclusions: Re-irradiation, using carbon-ion RT with radical intent, had favorable local control and overall survival rates without severe toxicities for selected patients. Re-irradiation has the potential to improve clinical outcomes for isolated, local, recurrent tumors; further investigations are required to confirm the therapeutic efficacy.
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Affiliation(s)
- Katsuyuki Shirai
- Department of Radiology, Saitama Medical Center, Jichi Medical University, Omiya-ku, Japan.,Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | - Tatsuya Ohno
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | | | | | - Hiroyuki Katoh
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | | | | | - Atsushi Musha
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | - Takanori Abe
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
| | | | - Keiko Akahane
- Department of Radiology, Saitama Medical Center, Jichi Medical University, Omiya-ku, Japan
| | - Takashi Nakano
- Gunma University Heavy Ion Medical Center, Maebashi, Japan
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Badiyan SN, Rutenberg MS, Hoppe BS, Mohindra P, Larson G, Hartsell WF, Tsai H, Zeng J, Rengan R, Glass E, Katz S, Vargas C, Feigenberg SJ, Simone CB. Clinical Outcomes of Patients With Recurrent Lung Cancer Reirradiated With Proton Therapy on the Proton Collaborative Group and University of Florida Proton Therapy Institute Prospective Registry Studies. Pract Radiat Oncol 2019; 9:280-288. [PMID: 30802618 DOI: 10.1016/j.prro.2019.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 02/07/2019] [Accepted: 02/14/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE We sought to assess clinical outcomes and toxicities of patients with recurrent lung cancer reirradiated with proton beam therapy (PBT) who were enrolled in 2 prospective registry trials. METHODS AND MATERIALS Seventy-nine consecutive patients were reirradiated with PBT at 8 institutions. Conventionally fractionated radiation therapy was used to treat the previous lung cancer in 68% of patients (median equivalent dose in 2 Gy fractions [EQD2], 60.2 Gy) and hypofractionated/stereotactic body radiation therapy in 32% (median EQD2, 83.3 Gy). Nine patients (11%) received ≥2 courses of thoracic irradiation before PBT. Eastern Cooperative Oncology Group (ECOG) performance status was 2 to 3 in 13%. Median time from prior radiation therapy to PBT was 19.9 months. PBT was delivered with conventional fractionation in 58% (median EQD2, 60 Gy), hyperfractionation in 3% (median EQD2, 62.7 Gy), and hypofractionation in 39% (median EQD2, 60.4 Gy). Twenty-four patients (30%) received chemotherapy concurrently with PBT. RESULTS All patients completed PBT as planned. At a median follow-up of 10.7 months after PBT, median overall survival (OS) and progression-free survival (PFS) were 15.2 months and 10.5 months, respectively. Acute and late grade 3 toxicities occurred in 6% and 1%, respectively. Three patients died after PBT from possible radiation toxicity. On multivariate analysis, ECOG performance status ≤1 was associated with OS (hazard ratio, 0.35; 95% confidence interval, 0.15-0.80; P = .014) and PFS (hazard ratio, 0.32; 95% confidence interval, 0.14-0.73; P = .007). CONCLUSIONS This is the largest series to date of PBT reirradiation for recurrent lung cancer and indicates that reirradiation with PBT is well tolerated with acceptable toxicity and encouraging efficacy. ECOG performance status was associated with OS and PFS.
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Affiliation(s)
- Shahed N Badiyan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Bradford S Hoppe
- University of Florida Proton Therapy Institute, Jacksonville, Florida
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gary Larson
- Oklahoma Procure Proton Therapy Center, Oklahoma City, Oklahoma
| | | | - Henry Tsai
- New Jersey Procure Proton Therapy Center, Somerset, New Jersey
| | - Jing Zeng
- University of Washington and Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Ramesh Rengan
- University of Washington and Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Erica Glass
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sanford Katz
- Willis-Knighton Proton Therapy Center, Shreveport, Louisiana
| | - Carlos Vargas
- Mayo Clinic Arizona Proton Therapy Program, Rochester, Minnesota
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Charles B Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland.
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Hong JH, Kim YS, Lee SW, Lee SJ, Kang JH, Hong SH, Hong JY, Cheon G. High-Dose Thoracic Re-irradiation of Lung Cancer Using Highly Conformal Radiotherapy Is Effective with Acceptable Toxicity. Cancer Res Treat 2018; 51:1156-1166. [PMID: 30514067 PMCID: PMC6639224 DOI: 10.4143/crt.2018.472] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/28/2018] [Indexed: 12/25/2022] Open
Abstract
Purpose Thoracic re-irradiation (re-RT) of lung cancer has been challenged by the tolerance doses of normal tissues. We retrospectively analyzed local control, overall survival (OS) and toxicity after thoracic re-RT using highly conformal radiotherapy, such as intensity modulated radiotherapy and stereotactic body radiotherapy. Materials and Methods Thirty-one patients who received high-dose thoracic re-RT were analyzed. Doses were recalculated to determine biologically equivalent doses. The median interval to re-RT was 15.1 months (range, 4.4 to 56.3 months), the median initial dose was 79.2 Gy10 (range, 51.75 to 150 Gy10), and the median re-RT dose was 68.8 Gy10 (range, 43.2 to 132 Gy10). Results Eighteen (58.1%) and eleven (35.5%) patients showed loco-regional recurrence and distant metastasis, respectively, after 17.4 months of median follow-up. The 1-year and 2-year local control rates were 60.2% and 43.7%, respectively. The median loco-regional recurrence-free-survival (LRFS) was 15.4 months, and the median OS was 20.4 months. The cumulative and re-RT biologically equivalent dose for α/β=10 (BED10) doses were the most significant prognostic factors. Cumulative BED10 ≥145 Gy10 and re-RT BED10≥68.7 Gy10 were significantly associated with longer OS (p=0.029 and p=0.012, respectively) and LRFS (p=0.003 and p=0.000, respectively). The most frequent acute toxicity was grade 1-2 pulmonary toxicity (41.9%). No acute grade 3 or higher toxicities occurred. Conclusion Our results show that high-dose thoracic re-RT of lung cancer can be safely delivered using highly conformal radiotherapy with favorable survival and acceptable toxicity. An optimal strategy to select patients who would benefit from re-RT is crucial in extending the indications and improving the efficacy with a sufficiently high dose.
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Affiliation(s)
- Ji Hyun Hong
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yeon-Sil Kim
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sea-Won Lee
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - So Jung Lee
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin Hyung Kang
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Suk Hee Hong
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ju-Young Hong
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - GeumSeong Cheon
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
OPINION STATEMENT Non-small cell lung cancer (NSCLC) accounts for 85% of new lung cancer cases and has 5-year survival rates ranging from 92% in early-stage disease to as low as 13% in locally advanced cases. Radiation therapy is a key component in the treatment repertoire for NSCLC, where it is currently used alone or in combinations with chemotherapy and surgery. Despite the broad use of modern photon radiation techniques, as many as 25% of patients experience isolated locoregional recurrences, and toxicity has been proven to be a limiting factor in many cases. Proton beam therapy (PBT) has emerged as a potential solution to improve upon clinical outcomes in both early-stage and locally advanced disease. The proton beam allows for a sharp dose build-up and drop-off, which is particularly important in lung cancer where nearby structures include the heart, spinal cord, esophagus, and uninvolved lung. There are now numerous studies showing dosimetric advantages of PBT in early and locally advanced NSCLC, particularly in the heart and lung doses. Randomized data comparing clinical outcomes between proton and photon radiation are limited to a small number of studies. Despite early results suggesting improvements or at least comparable outcomes with PBT, the most recent randomized comparisons have failed to show significant differences in toxicity and local control between photon and proton therapy. As newer PBT techniques (e.g., intensity-modulated proton therapy) are increasingly utilized, more dramatic improvements in tumor control and toxicity may be demonstrated. It is also important to recognize that there may be certain subpopulations in which the benefits of proton therapy are greater, such as central early-stage tumors, previously irradiated tumors, and locally advanced tumors, while others may best be treated with traditional photon techniques. As immunotherapy becomes more prevalent in the treatment of NSCLC, improving local control and limiting the toxicity contributed by radiation will be increasingly important. The unique dosimetric advantages of PBT may allow for tumor dose escalation while maintaining normal tissue doses to improve local control, or treating the tumor to the standard dose while decreasing normal tissue doses to improve toxicity. Finally, given the high costs of proton therapy, where low insurance approval rates have limited trial enrollment, it will be important to determine the overall cost-benefit ratio.
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Affiliation(s)
- Shane Mesko
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Daniel Gomez
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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McVicar N, Thomas S, Liu M, Carolan H, Bergman A. Re-irradiation volumetric modulated arc therapy optimization based on cumulative biologically effective dose objectives. J Appl Clin Med Phys 2018; 19:341-345. [PMID: 30371001 PMCID: PMC6236857 DOI: 10.1002/acm2.12481] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 12/25/2022] Open
Abstract
The objective of this note is to introduce a clinical tool that generates ideal base plan dose distributions to enable re‐irradiation volumetric modulated arc therapy (VMAT) optimization based on cumulative biological effective dose objectives for specific organs at risk (OARs). The tool is demonstrated with a lung cancer case that required re‐irradiation at our clinic. First, previous treatment dose is deformed onto the retreatment computed tomography (CT) using commercial software. Then, the in‐house Matlab tool alters the deformed previous dose using radiobiological concepts on a voxel‐by‐voxel manner to generate an ideal base plan dose distribution. Ideal base plans that were generated using the in‐house Matlab tool were compatible with the Varian Eclipse™ treatment planning system. The tool enabled optimization of VMAT re‐irradiation plans using cumulative dose limits for OARs and all OAR cumulative dose objectives were met on the first optimization for the recurrent lung cancer case tested.
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Affiliation(s)
- Nevin McVicar
- Department of Medical Physics, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada
| | - Steven Thomas
- Department of Medical Physics, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada
| | - Mitchell Liu
- Department of Radiation Oncology, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada
| | - Hannah Carolan
- Department of Radiation Oncology, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada
| | - Alanah Bergman
- Department of Medical Physics, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada
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Brooks ED, Sun B, Feng L, Verma V, Zhao L, Gomez DR, Liao Z, Jeter M, O’Reilly M, Welsh JW, Nguyen QN, Erasmus JJ, Eapen G, Ahrar K, Antonoff MB, Hahn SM, Heymach JV, Rice DC, Chang JY. Association of Long-term Outcomes and Survival With Multidisciplinary Salvage Treatment for Local and Regional Recurrence After Stereotactic Ablative Radiotherapy for Early-Stage Lung Cancer. JAMA Netw Open 2018; 1:e181390. [PMID: 30646121 PMCID: PMC6324276 DOI: 10.1001/jamanetworkopen.2018.1390] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 05/26/2018] [Indexed: 12/19/2022] Open
Abstract
Importance Stereotactic ablative radiotherapy (SABR) is first-line treatment for patients with early-stage non-small cell lung cancer (NSCLC) who cannot undergo surgery. However, up to 1 in 6 such patients will develop isolated local recurrence (iLR) or isolated regional recurrence (iRR). Little is known about outcomes when disease recurs after SABR, or about optimal management strategies for such recurrences. Objective To characterize long-term outcomes for patients with iLR or iRR after SABR for early-stage NSCLC with the aim of informing treatment decision making for these patients with potentially curable disease. Design, Setting, and Participants In this cohort study, a retrospective review was conducted of 912 patients prospectively enrolled in an institutional database at a tertiary cancer center from January 1, 2004, through December 31, 2014. Main Outcomes and Measures Overall survival, progression-free survival, recurrence patterns, demographics, salvage techniques, patterns of salvage failure, and toxic effects. Results Of the 912 patients in the study (456 women and 456 men; median age, 72 years [range, 46-91 years]), 756 (82.9%) had T1 tumors at initial diagnosis; 502 tumors (55.0%) were adenocarcinomas and 309 tumors (33.9%) were squamous cell carcinomas. Of 912 patients with early-stage I to II NSCLC who received definitive SABR (50 Gy in 4 fractions or 70 Gy in 10 fractions), 102 developed isolated recurrence (49 with iLR and 53 with iRR), and 658 had no recurrence. Median times to recurrence after SABR were 14.5 months (range, 1.5-60.8 months) for iLR and 9.0 months (range, 1.9-70.7 months) for iRR; 39 of 49 patients (79.6%) with iLR and 48 of 53 patients (90.6%) with iRR underwent salvage with reirradiation, surgery, thermal ablation, or chemotherapy. Median follow-up times for patients with iLR or iRR were 57.2 months (interquartile range, 37.7-87.6 months) from initial SABR and 38.5 months (interquartile range, 19.9-69.3 months) from recurrence. Rates of overall survival at 5 years from initial SABR were no different between patients with iLR and salvage treatment (57.9%) and patients with no recurrence (54.9%; hazard ratio, 0.89; 95% CI, 0.56-1.43; P = .65) but were lower for patients with iRR and salvage treatment (31.1%; hazard ratio, 1.43; 95% CI, 1.00-2.34; P = .049). Patients receiving salvage treatment had longer overall survival than patients who did not (median, 37 vs 7 months after recurrence; hazard ratio, 0.40; 95% CI, 0.09-0.66; P = .006). Twenty-four of 87 patients (27.6%) who received salvage treatment for iLR or iRR subsequently developed distant metastases. No patient experienced grade 5 toxic effects after salvage treatment. Conclusions and Relevance Life expectancy after salvage treatment for iLR was similar to that for patients without recurrence, but survival after salvage treatment for iRR was similar to that of patients with stage III NSCLC. Patients who received salvage treatment had significantly improved survival. Because salvage treatment for iLR or iRR was based on a consistent multidisciplinary approach, this may help in clinical decision making.
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Affiliation(s)
- Eric D. Brooks
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Bing Sun
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Lei Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha
| | - Lina Zhao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Daniel R. Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Melenda Jeter
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Michael O’Reilly
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - James W. Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Jeremy J. Erasmus
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston
| | - George Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Kamran Ahrar
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mara B. Antonoff
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Stephen M. Hahn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - John V. Heymach
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - David C. Rice
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Joe Y. Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
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Vyfhuis MAL, Rice S, Remick J, Mossahebi S, Badiyan S, Mohindra P, Simone CB. Reirradiation for locoregionally recurrent non-small cell lung cancer. J Thorac Dis 2018; 10:S2522-S2536. [PMID: 30206496 PMCID: PMC6123190 DOI: 10.21037/jtd.2017.12.50] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 12/14/2022]
Abstract
Locoregional failure in non-small cell lung cancer (NSCLC) remains high, and the management for recurrent disease in the setting of prior radiotherapy is difficult. Retreatment options such as surgery or systemic therapy are typically limited or frequently result in suboptimal outcomes. Reirradiation (reRT) of thoracic malignancies may be an optimal strategy for providing definitive local control and offering a new chance of cure. Yet, retreatment with radiation therapy can be challenging for fear of excessive toxicities and the inability to safely deliver definitive (≥60 Gy) doses of reRT. However, with recent improvements in radiation delivery techniques and image-guidance, dose-escalation with reRT is possible and outcomes are encouraging. Here, we present a review of various radiation techniques, clinical outcomes and associated toxicities in patients with locoregionally recurrent NSCLC treated primarily with reRT.
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Affiliation(s)
- Melissa A L Vyfhuis
- Maryland Proton Treatment Center, Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Stephanie Rice
- Maryland Proton Treatment Center, Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jill Remick
- Maryland Proton Treatment Center, Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Sina Mossahebi
- Maryland Proton Treatment Center, Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Shahed Badiyan
- Maryland Proton Treatment Center, Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Pranshu Mohindra
- Maryland Proton Treatment Center, Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Charles B Simone
- Maryland Proton Treatment Center, Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
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Chaaya G, Abdelghani R, Kheir F, Komiya T, Vander Velde N. NSCLC: State of the Art Diagnosis, Treatment, and Outcomes. CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0198-z] [Citation(s) in RCA: 1] [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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Hayashi K, Yamamoto N, Karube M, Nakajima M, Tsuji H, Ogawa K, Kamada T. Feasibility of carbon-ion radiotherapy for re-irradiation of locoregionally recurrent, metastatic, or secondary lung tumors. Cancer Sci 2018; 109:1562-1569. [PMID: 29498145 PMCID: PMC5980300 DOI: 10.1111/cas.13555] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/15/2018] [Accepted: 02/22/2018] [Indexed: 12/25/2022] Open
Abstract
Intrathoracic recurrence after carbon‐ion radiotherapy for primary or metastatic lung tumors remains a major cause of cancer‐related deaths. However, treatment options are limited. Herein, we report on the toxicity and efficacy of re‐irradiation with carbon‐ion radiotherapy for locoregionally recurrent, metastatic, or secondary lung tumors. Data of 95 patients with prior intrathoracic carbon‐ion radiotherapy who were treated with re‐irradiation with carbon‐ion radiotherapy at our institution between 2006 and 2016 were retrospectively analyzed. Seventy‐three patients (76.8%) had primary lung tumors and 22 patients (23.2%) had metastatic lung tumors. The median dose of initial carbon‐ion radiotherapy was 52.8 Gy (relative biological effectiveness) and the median dose of re‐irradiation was 66.0 Gy (relative biological effectiveness). None of the patients received concurrent chemotherapy. The median follow‐up period after re‐irradiation was 18 months. In terms of grade ≥3 toxicities, one patient experienced each of the following: grade 5 bronchopleural fistula, grade 4 radiation pneumonitis, grade 3 chest pain, and grade 3 radiation pneumonitis. The 2‐year local control and overall survival rates were 54.0% and 61.9%, respectively. In conclusion, re‐irradiation with carbon‐ion radiotherapy was associated with relatively low toxicity and moderate efficacy. Re‐irradiation with carbon‐ion radiotherapy might be an effective treatment option for patients with locoregionally recurrent, metastatic, or secondary lung tumors.
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Affiliation(s)
- Kazuhiko Hayashi
- Hospital of the National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Sciences and Technology, Chiba City, Chiba, Japan
| | - Naoyoshi Yamamoto
- Hospital of the National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Sciences and Technology, Chiba City, Chiba, Japan
| | | | - Mio Nakajima
- Hospital of the National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Sciences and Technology, Chiba City, Chiba, Japan
| | - Hiroshi Tsuji
- Hospital of the National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Sciences and Technology, Chiba City, Chiba, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tadashi Kamada
- Hospital of the National Institute of Radiological Sciences, National Institutes for Quantum and Radiological Sciences and Technology, Chiba City, Chiba, Japan
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40
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Chao HH, Berman AT. Proton therapy for thoracic reirradiation of non-small cell lung cancer. Transl Lung Cancer Res 2018; 7:153-159. [PMID: 29876314 DOI: 10.21037/tlcr.2018.03.22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Lung cancer is a leading cause of cancer death with frequent local failures after initial curative-intent treatment. Locally recurrent non-small cell lung cancer represents a challenging clinical scenario as patients have often received prior radiation as part of a definitive treatment regimen. Proton beam therapy, through its characteristic Bragg peak and lack of exit dose is a potential means of minimizing the toxicity to previously irradiated organs and improving the therapeutic ratio. This article aims to review the rationale for the use of proton beam therapy for treatment of locally recurrent non-small cell lung cancer, highlight the current published experience on the feasibility, efficacy, and limitations of proton beam reirradiation, and discuss future avenues for improved patient selection and treatment delivery.
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Affiliation(s)
- Hann-Hsiang Chao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Abigail T Berman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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Vyfhuis MA, Onyeuku N, Diwanji T, Mossahebi S, Amin NP, Badiyan SN, Mohindra P, Simone CB. Advances in proton therapy in lung cancer. Ther Adv Respir Dis 2018; 12:1753466618783878. [PMID: 30014783 PMCID: PMC6050808 DOI: 10.1177/1753466618783878] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 05/29/2018] [Indexed: 12/18/2022] Open
Abstract
Lung cancer remains the leading cause of cancer deaths in the United States (US) and worldwide. Radiation therapy is a mainstay in the treatment of locally advanced non-small cell lung cancer (NSCLC) and serves as an excellent alternative for early stage patients who are medically inoperable or who decline surgery. Proton therapy has been shown to offer a significant dosimetric advantage in NSCLC patients over photon therapy, with a decrease in dose to vital organs at risk (OARs) including the heart, lungs and esophagus. This in turn, can lead to a decrease in acute and late toxicities in a population already predisposed to lung and cardiac injury. Here, we present a review on proton treatment techniques, studies, clinical outcomes and toxicities associated with treating both early stage and locally advanced NSCLC.
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Affiliation(s)
- Melissa A.L. Vyfhuis
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Nasarachi Onyeuku
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Tejan Diwanji
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Sina Mossahebi
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Neha P. Amin
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Shahed N. Badiyan
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, Baltimore, MD, USA
| | - Charles B. Simone
- Maryland Proton Treatment Center, University of
Maryland School of Medicine, 850 West Baltimore Street, Baltimore, MD 21201,
USA
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Five-fraction SBRT for ultra-central NSCLC in-field recurrences following high-dose conventional radiation. Radiat Oncol 2017; 12:162. [PMID: 29052514 PMCID: PMC5649069 DOI: 10.1186/s13014-017-0897-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/03/2017] [Indexed: 12/25/2022] Open
Abstract
Purpose/objective Local treatment options for patients with in-field non-small cell lung cancer (NSCLC) recurrence following conventionally fractionated external beam radiation therapy (CF-EBRT) are limited. Stereotactic body radiation therapy (SBRT) is a promising modality to achieve reasonable local control, although toxicity remains a concern. Materials/methods Patients previously treated with high-dose CF-EBRT (≥59.4 Gy, ≤3 Gy/fraction) for non-metastatic NSCLC who underwent salvage SBRT for localized ultra-central in-field recurrence were included in this analysis. Ultra-central recurrences were defined as those abutting the trachea, mainstem bronchus, or esophagus and included both parenchymal and nodal recurrences. The Kaplan-Meier method was used to estimate local control and overall survival. Durable local control was defined as ≥12 months. Toxicity was scored per the CTC-AE v4.0. Results Twenty patients were treated with five-fraction robotic SBRT for ultra-central in-field recurrence following CF-EBRT. Fifty percent of recurrences were adenocarcinoma, while 35% of tumors were classified as squamous cell carcinoma. The median interval between the end of CF-EBRT and SBRT was 23.3 months (range: 2.6 – 93.6 months). The median CF-EBRT dose was 63 Gy (range: 59.4 – 75 Gy), the median SBRT dose was 35 Gy (range: 25 – 45 Gy), and the median total equivalent dose in 2 Gy fractions (EQD2) was 116 Gy (range: 91.3 – 136.7 Gy). At a median follow-up of 12 months for all patients and 37.5 months in surviving patients, the majority of patients (90%) have died. High-dose SBRT was associated with improved local control (p < .01), and the one-year overall survival and local control were 77.8% and 66.7% respectively in this sub-group. No late esophageal toxicity was noted, although a patient who received an SBRT dose of 45 Gy (total EQD2: 129.7 Gy) experienced grade 5 hemoptysis 35 months following treatment. Conclusions Although the overall prognosis for patients with in-field ultra-central NSCLC recurrences following CF-EBRT remains grim, five-fraction SBRT was well tolerated with an acceptable toxicity profile. Dose escalation above 35 Gy may offer improved local control, however caution is warranted when treating high-risk recurrences with aggressive regimens.
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Re-irradiation for oligo-recurrence from esophageal cancer with radiotherapy history: a multi-institutional study. Radiat Oncol 2017; 12:146. [PMID: 28870211 PMCID: PMC5583760 DOI: 10.1186/s13014-017-0882-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 08/25/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy following surgery has recently become a standard therapy. The purpose of the present study was to determine the effectiveness and toxicity of re-irradiation for oligo-recurrence in lymph nodes from esophageal cancer treated by definitive radiotherapy or by surgery with additional radiotherapy. METHODS We reviewed retrospectively 248 patients treated with (chemo)radiotherapy for oligo-recurrence in lymph nodes from esophageal cancer in five Japanese high-volume centers between 2000 and 2015. Thirty-three patients in whom re-irradiation was performed were enrolled in this study, and the results for patients in whom re-irradiation was performed were compared with the results for other patients. RESULTS Median maximum lymph node diameter was 22 mm. Median total radiation dose was 60 Gy. The median calculated biological effective dose using the LQ model with α/β = 10 Gy (BED10) in patients in whom re-irradiation was performed was significantly lower than the median BED10 in others. There was no different factor except for BED10, histology and irradiation field between patients with a past irradiation history and patients without a past irradiation history. The median observation period in surviving patients in whom re-irradiation was performed was 21.7 months. The 3-year overall survival rate in the 33 patients with a past irradiation history was 17.9%, with a median survival period of 16.0 months. Overall survival rate and local control rate in patients with a past irradiation history were significantly worse than those in patients without a past irradiation history (log-rank test, p = 0.016 and p = 0.0007, respectively). One patient in whom re-irradiation was performed died from treatment-related gastric hemorrhage. CONCLUSIONS Results in the present study suggested that re-irradiation for oligo-recurrence in lymph nodes from esophageal cancer treated by definitive radiotherapy or by surgery with additional radiotherapy might be acceptable but unsatisfactory.
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Pastina P, Nardone V, Botta C, Croci S, Tini P, Battaglia G, Ricci V, Cusi MG, Gandolfo C, Misso G, Zappavigna S, Caraglia M, Giordano A, Aldinucci D, Tassone P, Tagliaferri P, Pirtoli L, Correale P. Radiotherapy prolongs the survival of advanced non-small-cell lung cancer patients undergone to an immune-modulating treatment with dose-fractioned cisplatin and metronomic etoposide and bevacizumab (mPEBev). Oncotarget 2017; 8:75904-75913. [PMID: 29100279 PMCID: PMC5652673 DOI: 10.18632/oncotarget.20411] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/20/2017] [Indexed: 12/25/2022] Open
Abstract
Radiotherapy (RT), together with a direct cytolytic effect on tumor tissue, also elicits systemic immunological events, which sometimes result in the regression of distant metastases (abscopal effect). We have shown the safety and anti-tumor activity of a novel metronomic chemotherapy (mCH) regimen with dose-fractioned cisplatin, oral etoposide and bevacizumab, a mAb against the vasculo-endothelial-growth-factor (mPEBev regimen), in metastatic non-small-cell-lung cancer (mNSCLC). This regimen, designed on the results of translational studies, showed immune-modulating effects that could trigger and empower the immunological effects associated with tumor irradiation. In order to assess this, we carried out a retrospective analysis in a subset of 69 consecutive patients who received the mPEBev regimen within the BEVA2007 trial. Forty-five of these patients, also received palliative RT of one or more metastatic sites. Statistical analysis (a Log-rank test) revealed a much longer median survival in the group of patients who received RT [mCH vs mCH + RT: 12.1 +/-2.5 (95%CI 3.35-8.6) vs 22.12 +/-4.3 (95%CI 11.9-26.087) months; P=0.015] with no difference in progression-free survival. In particular, their survival correlated with the mPEBev regimen ability to induce the percentage of activated dendritic cells (DCs) (CD3-CD11b+CD15-CD83+CD80+) [Fold to baseline value (FBV) ≤1 vs >1: 4+/-5.389 (95%CI,0- 14.56) vs 56+/-23.05 (95%CI,10.8-101.2) months; P:0.049)] and central-memory- T-cells (CD3+CD8+CD45RA-CCR7+) [FBV ≤ 1 vs >1: 8+/-5.96 (95%CI,0-19.68) vs 31+/-12.3 (95%CI,6.94-55.1) months; P:0.045]. These results suggest that tumor irradiation may prolong the survival of NSCLC patients undergone mPEBev regimen presumably by eliciting an immune-mediated effect and provide the rationale for further perspective clinical studies.
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Affiliation(s)
- Pierpaolo Pastina
- Radiotherapy Unit, Department of Medicine, Surgery, and Neuroscience, Siena University Hospital, Siena, Italy
| | - Valerio Nardone
- Radiotherapy Unit, Department of Medicine, Surgery, and Neuroscience, Siena University Hospital, Siena, Italy
| | - Cirino Botta
- Medical Oncology Unit, AUO "Mater Domini", "Magna Graecia" University, Catanzaro, Italy
| | - Stefania Croci
- Radiotherapy Unit, Department of Medicine, Surgery, and Neuroscience, Siena University Hospital, Siena, Italy
| | - Paolo Tini
- Radiotherapy Unit, Department of Medicine, Surgery, and Neuroscience, Siena University Hospital, Siena, Italy
| | - Giuseppe Battaglia
- Radiotherapy Unit, Department of Medicine, Surgery, and Neuroscience, Siena University Hospital, Siena, Italy
| | - Veronica Ricci
- Radiology Unit,Department of Medicine, Surgery, and Neuroscience, Siena University Hospital, Siena, Italy
| | - Maria Grazia Cusi
- Department of Medical Biotechnology, Microbiology and Virology Unit, University of Siena, Siena, Italy
| | - Claudia Gandolfo
- Department of Medical Biotechnology, Microbiology and Virology Unit, University of Siena, Siena, Italy
| | - Gabriella Misso
- Department of Biochemistry, Biophysics and General Pathology, University of Campania "L. Vanvitelli", Naples, Italy
| | - Silvia Zappavigna
- Department of Biochemistry, Biophysics and General Pathology, University of Campania "L. Vanvitelli", Naples, Italy
| | - Michele Caraglia
- Department of Biochemistry, Biophysics and General Pathology, University of Campania "L. Vanvitelli", Naples, Italy.,Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, Temple University, Philadelphia, PA, USA
| | - Antonio Giordano
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, Temple University, Philadelphia, PA, USA.,Department of Medicine, Surgery, and Neuroscience, University of Siena and Istituto Toscano Tumori (ITT), Siena, Italy
| | - Donatella Aldinucci
- Department of Experimental Oncology 2, CRO Aviano National Cancer Institute, Aviano, Italy
| | - Pierfrancesco Tassone
- Medical Oncology Unit, AUO "Mater Domini", "Magna Graecia" University, Catanzaro, Italy.,Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, Temple University, Philadelphia, PA, USA
| | | | - Luigi Pirtoli
- Radiotherapy Unit, Department of Medicine, Surgery, and Neuroscience, Siena University Hospital, Siena, Italy
| | - Pierpaolo Correale
- Radiotherapy Unit, Department of Medicine, Surgery, and Neuroscience, Siena University Hospital, Siena, Italy.,Medical Oncology Unit, Metropolitan Hospital "Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
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Harada H, Murayama S. Proton beam therapy in non-small cell lung cancer: state of the art. LUNG CANCER-TARGETS AND THERAPY 2017; 8:141-145. [PMID: 28883747 PMCID: PMC5574682 DOI: 10.2147/lctt.s117647] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This review summarizes the past and present status of proton beam therapy (PBT) for lung cancer. PBT has a unique characteristic called the Bragg peak that enables a reduction in the dose of normal tissue around the tumor, but is sensitive to the uncertainties of density changes. The heterogeneity in electron density for thoracic lesions, such as those in the lung and mediastinum, and tumor movement according to respiration necessitates respiratory management for PBT to be applied in lung cancer patients. There are two types of PBT - a passively scattered approach and a scanning approach. Typically, a passively scattered approach is more robust for respiratory movement and a scanning approach could result in a more conformal dose distribution even when the tumor shape is complex. Large tumors of centrally located lung cancer may be more suitably irradiated than with intensity-modulated radiotherapy (IMRT) or stereotactic body radiotherapy (SBRT). For a locally advanced lung cancer, PBT can spare the lung and heart more than photon IMRT. However, no randomized controlled trial has reported differences between PBT and IMRT or SBRT for early-stage and locally advanced lung cancers. Therefore, a well-designed controlled trial is warranted.
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Affiliation(s)
- Hideyuki Harada
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
| | - Shigeyuki Murayama
- Radiation and Proton Therapy Center, Shizuoka Cancer Center Hospital, Nagaizumi, Shizuoka, Japan
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Ho JC, Nguyen QN, Li H, Allen PK, Zhang X, Liao Z, Zhu XR, Gomez D, Lin SH, Gillin M, Komaki R, Hahn S, Chang JY. Reirradiation of thoracic cancers with intensity modulated proton therapy. Pract Radiat Oncol 2017; 8:58-65. [PMID: 28867546 DOI: 10.1016/j.prro.2017.07.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE Reirradiation of thoracic malignancies is a treatment challenge, with concerns for toxicity and the inability to deliver definitive doses. Intensity modulated proton therapy (IMPT) may allow safe delivery of a higher dose of radiation to the tumor while minimizing toxicities. METHODS AND MATERIALS Between 2011 and 2016, 27 patients who received IMPT for reirradiation of thoracic malignancies with definitive intent were retrospectively analyzed. Patients were included if they received a prior thoracic radiation course. All doses were recalculated to an equivalent dose in 2-Gy fractions (EQD2). Patients received IMPT to a median dose of 66 EQD2 Gy (range, 43.2-84 Gy) for recurrence of thoracic cancer (93%) or sequentially after a course of thoracic stereotactic ablative radiation therapy (7%). RESULTS Twenty-two patients (81%) were treated for non-small cell lung cancer. The median time to reirradiation was 29.5 months. At a median follow-up for all patients of 11.2 months (25.9 surviving patients), the median overall survival was 18.0 months, with a 1-year overall survival of 54%. Four patients (15%) experienced an in-field local failure (LF), with a 1-year freedom from LF rate of 78%. The 1-year freedom from locoregional failure and 1-year progression-free survival rates were 61% and 51%, respectively. Patients who received 66 EQD2 Gy or higher had improved 1-year freedom from LF (100% vs 49%; P = .013), 1-year freedom from locoregional failure (84% vs 23%; P = .035), and 1-year progression-free survival (76% vs 14%; P = .050). Reirradiation was well tolerated, with only 2 patients (7%) experiencing late grade 3 pulmonary toxicity, and none with grade 3 or higher esophagitis. There were no grade 4-5 toxicities. CONCLUSIONS These data represent the largest series of patients treated with IMPT for definitive reirradiation of thoracic cancers. They demonstrate that IMPT provided durable local control with minimal toxicity and suggest that higher doses may improve outcomes.
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Affiliation(s)
- Jennifer C Ho
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heng Li
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xiaodong Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - X Ronald Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Gillin
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ritsuko Komaki
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stephen Hahn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Murray TA, Thall PF, Yuan Y, McAvoy S, Gomez DR. Robust treatment comparison based on utilities of semi-competing risks in non-small-cell lung cancer. J Am Stat Assoc 2017; 112:11-23. [PMID: 28943681 PMCID: PMC5607962 DOI: 10.1080/01621459.2016.1176926] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 01/01/2016] [Indexed: 12/25/2022]
Abstract
A design is presented for a randomized clinical trial comparing two second-line treatments, chemotherapy versus chemotherapy plus reirradiation, for treatment of recurrent non-small-cell lung cancer. The central research question is whether the potential efficacy benefit that adding reirradiation to chemotherapy may provide justifies its potential for increasing the risk of toxicity. The design uses two co-primary outcomes: time to disease progression or death, and time to severe toxicity. Because patients may be given an active third-line treatment at disease progression that confounds second-line treatment effects on toxicity and survival following disease progression, for the purpose of this comparative study follow-up ends at disease progression or death. In contrast, follow-up for disease progression or death continues after severe toxicity, so these are semi-competing risks. A conditionally conjugate Bayesian model that is robust to misspecification is formulated using piecewise exponential distributions. A numerical utility function is elicited from the physicians that characterizes desirabilities of the possible co-primary outcome realizations. A comparative test based on posterior mean utilities is proposed. A simulation study is presented to evaluate test performance for a variety of treatment differences, and a sensitivity assessment to the elicited utility function is performed. General guidelines are given for constructing a design in similar settings, and a computer program for simulation and trial conduct is provided.
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Affiliation(s)
| | - Peter F Thall
- Department of Biostatistics, MD Anderson Cancer Center
| | - Ying Yuan
- Department of Biostatistics, MD Anderson Cancer Center
| | - Sarah McAvoy
- Department of Radiation Oncology, MD Anderson Cancer Center
| | - Daniel R Gomez
- Department of Radiation Oncology, MD Anderson Cancer Center
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48
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Multi-Institutional Prospective Study of Reirradiation with Proton Beam Radiotherapy for Locoregionally Recurrent Non–Small Cell Lung Cancer. J Thorac Oncol 2017; 12:281-292. [DOI: 10.1016/j.jtho.2016.10.018] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/17/2016] [Accepted: 10/18/2016] [Indexed: 12/15/2022]
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Radiothérapie et traitements combinés des cancers bronchiques non à petites cellules localement avancés. ONCOLOGIE 2016. [DOI: 10.1007/s10269-016-2640-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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50
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Chang JY, Jabbour SK, De Ruysscher D, Schild SE, Simone CB, Rengan R, Feigenberg S, Khan AJ, Choi NC, Bradley JD, Zhu XR, Lomax AJ, Hoppe BS. Consensus Statement on Proton Therapy in Early-Stage and Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2016; 95:505-516. [PMID: 27084663 PMCID: PMC10868643 DOI: 10.1016/j.ijrobp.2016.01.036] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/08/2015] [Accepted: 01/19/2016] [Indexed: 12/25/2022]
Abstract
Radiation dose escalation has been shown to improve local control and survival in patients with non-small cell lung cancer in some studies, but randomized data have not supported this premise, possibly owing to adverse effects. Because of the physical characteristics of the Bragg peak, proton therapy (PT) delivers minimal exit dose distal to the target volume, resulting in better sparing of normal tissues in comparison to photon-based radiation therapy. This is particularly important for lung cancer given the proximity of the lung, heart, esophagus, major airways, large blood vessels, and spinal cord. However, PT is associated with more uncertainty because of the finite range of the proton beam and motion for thoracic cancers. PT is more costly than traditional photon therapy but may reduce side effects and toxicity-related hospitalization, which has its own associated cost. The cost of PT is decreasing over time because of reduced prices for the building, machine, maintenance, and overhead, as well as newer, shorter treatment programs. PT is improving rapidly as more research is performed particularly with the implementation of 4-dimensional computed tomography-based motion management and intensity modulated PT. Given these controversies, there is much debate in the oncology community about which patients with lung cancer benefit significantly from PT. The Particle Therapy Co-operative Group (PTCOG) Thoracic Subcommittee task group intends to address the issues of PT indications, advantages and limitations, cost-effectiveness, technology improvement, clinical trials, and future research directions. This consensus report can be used to guide clinical practice and indications for PT, insurance approval, and clinical or translational research directions.
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Affiliation(s)
- Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Salma K Jabbour
- Rutgers Cancer Institute of New Jersey Rutgers, Robert Wood Johnson Medical School, The State University of New Jersey, New Brunswick, New Jersey
| | | | | | - Charles B Simone
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ramesh Rengan
- University of Washington Medical Center, Seattle, Washington
| | | | - Atif J Khan
- Rutgers Cancer Institute of New Jersey Rutgers, Robert Wood Johnson Medical School, The State University of New Jersey, New Brunswick, New Jersey
| | - Noah C Choi
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Xiaorong R Zhu
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Bradford S Hoppe
- University of Florida Proton Therapy Institute, Jacksonville, Florida
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