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Han C, Qiu J, Bai L, Liu T, Chen J, Wang H, Dang J. Pneumonitis Risk After Chemoradiotherapy With and Without Immunotherapy in Patients With Locally Advanced Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2024; 119:1179-1207. [PMID: 38360117 DOI: 10.1016/j.ijrobp.2024.01.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 12/28/2023] [Accepted: 01/28/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE Chemoradiotherapy (CRT) combined with immune checkpoint inhibitors (ICIs) is the standard of care for patients with unresectable and locally advanced non-small cell lung cancer. This study aimed to determine whether the addition of ICIs to CRT is associated with an increased risk of pneumonitis. METHODS AND MATERIALS The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for eligible studies published between January 1, 2015, and July 31, 2023. The outcome of interest was the incidence rate of pneumonitis. A random-effects model was used for statistical analysis. RESULTS A total of 185 studies with 24,527 patients were included. The pooled rate of grade ≥2 pneumonitis for CRT plus ICIs was significantly higher than that for CRT alone (29.6%; 95% CI, 25.7%-33.6% vs 20.2%; 95% CI, 17.7%-22.8%; P < .0001) but not that of grade ≥3 (5.7%; 95% CI, 4.8%-6.6% vs 5.6%; 95% CI, 4.7%-6.5%; P = .64) or grade 5 (0.1%; 95% CI, 0.0%-0.2% vs 0.3%; 95% CI, 0.1%-0.4%; P = .68). The results from the subgroup analyses of prospective studies, retrospective studies, Asian and non-Asian studies, concurrent CRT (cCRT), and durvalumab consolidation were comparable to the overall results. However, CRT or cCRT plus PD-1 inhibitors not only significantly increased the incidence of grade ≥2 but also that of grade ≥3 pneumonitis compared to CRT alone or cCRT plus PD-L1 inhibitors. CONCLUSIONS Compared with CRT alone, durvalumab consolidation after CRT appears to be associated with a higher incidence of moderate pneumonitis and CRT plus PD-1 inhibitors with an increased risk of severe pneumonitis. Nevertheless, these findings are based on observational studies and need to be validated in future large head-to-head studies.
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Affiliation(s)
- Chong Han
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China
| | - Jingping Qiu
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China
| | - Lu Bai
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China
| | - Tingting Liu
- Department of Radiation Oncology, Anshan Cancer Hospital, Anshan, China
| | - Jun Chen
- Department of Radiation Oncology, Shenyang Tenth People's Hospital, Shenyang, China
| | - He Wang
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China
| | - Jun Dang
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China.
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Liu T, Li S, Ding S, Qiu J, Ren C, Chen J, Wang H, Wang X, Li G, He Z, Dang J. Comparison of post-chemoradiotherapy pneumonitis between Asian and non-Asian patients with locally advanced non-small cell lung cancer: a systematic review and meta-analysis. EClinicalMedicine 2023; 64:102246. [PMID: 37781162 PMCID: PMC10539643 DOI: 10.1016/j.eclinm.2023.102246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023] Open
Abstract
Background Pneumonitis is a common complication for patients with locally advanced non-small cell lung cancer undergoing definitive chemoradiotherapy (CRT). It remains unclear whether there is ethnic difference in the incidence of post-CRT pneumonitis. Methods PubMed, Embase, Cochrane Library, and Web of Science were searched for eligible studies from January 1, 2000 to April 30, 2023. The outcomes of interest were incidence rates of pneumonitis. The random-effect model was used for statistical analysis. This meta-analysis was registered with PROSPERO (CRD42023416490). Findings A total of 248 studies involving 28,267 patients were included. Among studies of CRT without immunotherapy, the pooled rates of pneumonitis for Asian patients were significantly higher than that for non-Asian patients (all grade: 66.8%, 95% CI: 59.2%-73.9% vs. 28.1%, 95% CI: 20.4%-36.4%; P < 0.0001; grade ≥2: 25.1%, 95% CI: 22.9%-27.3% vs. 14.9%, 95% CI: 12.0%-18.0%; P < 0.0001; grade ≥3: 6.5%, 95% CI: 5.6%-7.3% vs. 4.6%, 95% CI: 3.4%-5.9%; P = 0.015; grade 5: 0.6%, 95% CI: 0.3%-0.9% vs. 0.1%, 95% CI: 0.0%-0.2%; P < 0.0001). Regarding studies of CRT plus immunotherapy, Asian patients had higher rates of all-grade (74.8%, 95% CI: 63.7%-84.5% vs. 34.3%, 95% CI: 28.7%-40.2%; P < 0.0001) and grade ≥2 (34.0%, 95% CI: 30.7%-37.3% vs. 24.6%, 95% CI: 19.9%-29.3%; P = 0.001) pneumonitis than non-Asian patients, but with no significant differences in the rates of grade ≥3 and grade 5 pneumonitis. Results from subgroup analyses were generally similar to that from the all studies. In addition, the pooled median/mean of lung volume receiving ≥20 Gy and mean lung dose were relatively low in Asian studies compared to that in non-Asian studies. Interpretation Asian patients are likely to have a higher incidence of pneumonitis than non-Asian patients, which appears to be due to the poor tolerance of lung to radiation. Nevertheless, these findings are based on observational studies and with significant heterogeneity, and need to be validated in future large prospective studies focusing on the subject. Funding None.
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Affiliation(s)
- Tingting Liu
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
- Department of Radiation Oncology, Anshan Cancer Hospital, Anshan, China
| | - Sihan Li
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Silu Ding
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Jingping Qiu
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Chengbo Ren
- Department of Radiation Oncology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, China
| | - Jun Chen
- Department of Radiation Oncology, Shenyang Tenth People's Hospital, Shenyang, China
| | - He Wang
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Xiaoling Wang
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Guang Li
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Zheng He
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Jun Dang
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
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Xiang L, Ren PR, Li HX, Ye H, Pang HW, Wen QL, Zhang JW, He LJH, Shang CL, Yang BY, Lin SL, Wu JBW. Effect of 3-Dimensional Interstitial High-Dose-Rate Brachytherapy With Regional Metastatic Lymph Node Intensity-Modulated Radiation Therapy in Locally Advanced Peripheral Non-Small Cell Lung Cancer: 5-Year Follow-up of a Phase 2 Clinical Trial. Int J Radiat Oncol Biol Phys 2023; 115:347-355. [PMID: 35901979 DOI: 10.1016/j.ijrobp.2022.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/29/2022] [Accepted: 07/16/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE We aimed to reveal the 5-year clinical outcomes of 3-dimensional (3D) interstitial high-dose-rate (HDR) brachytherapy with regional metastatic lymph node intensity modulated radiation therapy (IMRT) for locally advanced peripheral non-small cell lung cancer (NSCLC), which has been shown to have low toxicity and improved 2-year survival rates in patients with this disease. METHODS AND MATERIALS In this phase 2, single-arm, open-label clinical trial, 83 patients with locally advanced peripheral NSCLC were enrolled (median follow-up [range], 53.7 [4.3-120.4] months). All eligible patients received 3D interstitial HDR brachytherapy with regional metastatic lymph node IMRT. The primary endpoint was overall survival (OS). Secondary endpoints were local recurrence-free survival, regional recurrence-free survival, progression-free survival, distant metastasis-free survival, toxicities, and quality of life. RESULTS The final analysis included 75 patients (19 [25.3%] females, 56 [74.7%] males; median [range] age, 64 [44-80] years; stage IIIA, 34 [45.3%]; stage IIIB, 41 [54.7%]). At the latest follow-up, 32 (42.7%) patients had survived. The median OS was 38.0 months (5-year OS, 44.5%; 95% confidence interval [CI], 33.8%-58.6%). Local recurrence-free survival, recurrence-free survival, and distant metastasis-free survival at 5 years were 79.2% (95% CI, 68.5%-91.5%), 73.6% (95% CI, 61.5%-88.1%), and 50.3% (95% CI, 38.3%-66.1%), respectively. The dominant failure pattern was distant disease, corresponding to 40% (30 of 75) of patients and 65.2% (30 of 46) of all failures. Two (2.7%) patients developed grade 1 acute pneumonitis. Grade 2 and 3 acute esophagitis occurred in 11 (14.7%) and 4 (5.3%) patients, respectively. No late radiation-related grade ≥2 late adverse events were observed. CONCLUSIONS 3D interstitial HDR brachytherapy with regional metastatic lymph node IMRT for locally advanced peripheral NSCLC shows significant OS and has a low toxicity rate. Additional evaluation in a phase 3 trial is recommended to substantiate these findings.
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Affiliation(s)
- Li Xiang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Pei-Rong Ren
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hong-Xia Li
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hua Ye
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hao-Wen Pang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Qing-Lian Wen
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jian-Wen Zhang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Li-Jia He He
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chang-Ling Shang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bo Yang Yang
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Sheng Lin Lin
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China.
| | - Jing-Bo Wu Wu
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, China.
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Wiedemann J, Coppes RP, van Luijk P. Radiation-induced cardiac side-effects: The lung as target for interacting damage and intervention. Front Oncol 2022; 12:931023. [PMID: 35936724 PMCID: PMC9354542 DOI: 10.3389/fonc.2022.931023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
Radiotherapy is part of the treatment for many thoracic cancers. During this treatment heart and lung tissue can often receive considerable doses of radiation. Doses to the heart can potentially lead to cardiac effects such as pericarditis and myocardial fibrosis. Common side effects after lung irradiation are pneumonitis and pulmonary fibrosis. It has also been shown that lung irradiation has effects on cardiac function. In a rat model lung irradiation caused remodeling of the pulmonary vasculature increasing resistance of the pulmonary vascular bed, leading to enhanced pulmonary artery pressure, right ventricle hypertrophy and reduced right ventricle performance. Even more pronounced effects are observed when both, lung and heart are irradiated. The effects observed after lung irradiation show striking similarities with symptoms of pulmonary arterial hypertension. In particular, the vascular remodeling in lung tissue seems to have similar underlying features. Here, we discuss the similarities and differences of vascular remodeling observed after thoracic irradiation compared to those in pulmonary arterial hypertension patients and research models. We will also assess how this knowledge of similarities could potentially be translated into interventions which would be beneficial for patients treated for thoracic tumors, where dose to lung tissue is often unavoidable.
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Affiliation(s)
- Julia Wiedemann
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Robert P. Coppes
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Peter van Luijk
- Department of Biomedical Sciences of Cells and Systems, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- *Correspondence: Peter van Luijk,
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Fakir H, Chen J, Sachs RK. Hypo-fractionated boost in locally advanced non-small cell lung cancer: temporal distribution of boost fractions. Phys Med Biol 2018; 63:235018. [PMID: 30484435 DOI: 10.1088/1361-6560/aaee24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
To propose new schemas for radiation boosting of primary tumors, in locally advanced non-small cell lung cancers (NSCLC), in conjunction with standard chemoradiotherapy. To investigate the effect of temporal distributions of the boost fractions on tumor control. NSCLC cases, previously treated with 60 Gy in 30 fractions, were retrospectively planned by adding a radiation boost (25 Gy in 5 fractions) to the primary tumor. Several integrated and sequential boosting schedules were considered. Biological doses were calculated for targets and organs at risk (OAR). Tumor control probabilities (TCP) were calculated using an empirical model and a stochastic model that accounts more systematically for tumor growth kinetics and cell kill. For heterogeneous patient populations, the TCPs for different boost schedules ranged from 82% to 84% and from 73% to 74% for integrated and sequential boosting respectively. For individual tumors with specific growth parameters, the TCP varied by up to 19% between the different schedules. The TCP for sequential boosting was expected to be up to 67% lower than front integrated boosting. The gap in TCP between schedules was higher for tumors with higher clonogenic cell numbers, lower radio-sensitivity, shorter doubling times and lower cell loss. The proposed boosting schemas are dosimetrically feasible and biologically effective. We suggest that the boosts are most effective when given during the first week of treatment and least effective when given sequentially after the end of treatment. The effect of boost scheduling and the effectiveness of front boosting are expected to be most significant for tumors with high clonogenic cell numbers, fast growing rates, low cell loss and low radio-sensitivity. Ultimately, animal studies and clinical trials, guided by biology modeling as presented in the present work, will be needed to verify the effectiveness of fine tuning temporal distributions of radiotherapy fractions.
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Affiliation(s)
- H Fakir
- Department of Physics and Engineering, London Health Sciences Centre, London, Ontario, Canada. Department of Medical Biophysics, Western University, London, Ontario, Canada. Author to whom any correspondence should be addressed
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Farr KP, Khalil AA, Møller DS, Bluhme H, Kramer S, Morsing A, Grau C. Time and dose-related changes in lung perfusion after definitive radiotherapy for NSCLC. Radiother Oncol 2017; 126:307-311. [PMID: 29203289 DOI: 10.1016/j.radonc.2017.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/04/2017] [Accepted: 11/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE To examine radiation-induced changes in regional lung perfusion per dose level in 58 non-small-cell lung cancer (NSCLC) patients treated with intensity-modulated radiotherapy (IMRT). MATERIAL AND METHODS NSCLC patients receiving chemo-radiotherapy (RT) of minimum 60 Gy were included prospectively in the study. Lung perfusion single-photon emission computed tomography (SPECT/CT) was performed before and serially after RT. Changes (relative to baseline, %) in regional lung perfusion were correlated with regional dose. Toxicity outcome was radiation pneumonitis (RP) CTC grades 2-5. RESULTS Perfusion changes were associated with dose. Dose-dependent reduction in regional perfusion was observed at 3, 6 and 12 months of follow-up. Relative perfusion loss per dose bin was 4% at 1 month, 14% at 3 months, 13% at 6 months and 21% at 12 months after RT. In patients with RP, perfusion reduction was larger in high dose lung regions, compared to those without RP. Low dose regions, on the contrary, revealed perfusion gain in the patients with RP. CONCLUSION Progressive dose dependent perfusion loss is manifested on SPECT up to 12 months following IMRT. These findings suggest that the dynamic change in perfusion may have prognostic value in predicting radiation pneumonitis in NSCLC patients treated with IMRT.
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Affiliation(s)
| | - Azza A Khalil
- Department of Oncology, Aarhus University Hospital, Denmark
| | - Ditte S Møller
- Department of Medical Physics, Aarhus University Hospital, Denmark
| | - Henrik Bluhme
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Denmark
| | - Stine Kramer
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Denmark
| | - Anni Morsing
- Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Denmark
| | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Denmark
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Concurrent Neoadjuvant Chemotherapy and Radiation Therapy in Locally Advanced Breast Cancer. Int J Radiat Oncol Biol Phys 2017; 99:769-776. [DOI: 10.1016/j.ijrobp.2017.06.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 06/03/2017] [Accepted: 06/07/2017] [Indexed: 01/23/2023]
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Christodouleas JP, Hall MD, van der Pas MA, Guo W, Schultheiss TE, Gabriel P. The use of dose-escalated radiation for locally advanced non-small cell lung cancer in the U.S., 2004-2013. Radiat Oncol 2017; 12:19. [PMID: 28095882 PMCID: PMC5240383 DOI: 10.1186/s13014-016-0755-y] [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: 09/15/2016] [Accepted: 12/21/2016] [Indexed: 11/11/2022] Open
Abstract
Purpose/Objectives The clinical effects of radiation dose-intensification in locally advanced non-small cell lung (NSCLCa) and other cancers are challenging to predict and are ideally studied in randomized trials. The purpose of this study was to assess the use of dose-escalated radiation for locally advanced NSCLCa in the U.S., 2004–2013, a period in which there were no published level 1 studies on dose-escalation. Materials/Methods We performed analyses on two cancer registry databases with complementary strengths and weaknesses: the National Oncology Data Alliance (NODA) 2004–2013 and the National Cancer Database (NCDB) 2004–2012. We classified locally advanced patients according to the use of dose-escalation (>70 Gy). We used adjusted logistic regression to assess the association of year of treatment with dose-escalated radiation use in two periods representing time before and after the closure of a cooperative group trial (RTOG 0617) on dose-escalation: 2004–2010 and 2010–2013. To determine the year in which a significant change in dose could have been detected had dose been prospectively monitored within the NODA network, we compared the average annual radiation dose per year with the forecasted dose (average of the prior 3 years) adjusted for patient age and comorbidities. Results Within both the NODA and NCDB, use of dose-escalation increased from 2004 to 2010 (p < 0.0001) and decreased from 2010 to 2013 (p = 0.0018), even after controlling for potential confounders. Had the NODA network been monitoring radiation dose in this cohort, significant changes in average annual dose would have been detected at the end of 2008 and 2012. Conclusions Patterns of radiation dosing in locally advanced NSCLCa changed in the U.S. in the absence of level 1 evidence. Monitoring radiation dose is feasible using an existing national cancer registry data collection infrastructure.
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Affiliation(s)
- John P Christodouleas
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, 3400, Civic Center Blvd, Philadelphia, 19104, PA, USA.,Elekta Inc., Atlanta, GA, USA
| | - Matthew D Hall
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Wensheng Guo
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Timothy E Schultheiss
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Peter Gabriel
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, 3400, Civic Center Blvd, Philadelphia, 19104, PA, USA
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Agrawal S, Kumar S, Maurya AK. Potential for adaptive dose escalation in radiotherapy for patients with locally advanced non-small-cell lung cancer in a low mid income setting. Br J Radiol 2017; 90:20140234. [PMID: 27897060 DOI: 10.1259/bjr.20140234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate the effect of tumour volume regression on adaptive treatment planning, reduction in doses to organs at risk (OARs) and dose escalation. METHODS 20 patients undergoing radical chemoradiotherapy were imaged in the fifth week of radiotherapy (CT_45) to evaluate differences in tumour volume regression between concurrent and sequential chemoradiotherapy. Replanning was carried out in the CT_45 in those with >20% regression (n = 10) and evaluated for change in target coverage indices (the coverage index and external volume index) and doses to the OAR [mean lung dose, V20 and V5 of whole and ipsilateral lung (MLDWL, V20WL, V5WL, MLDIL, V20IL, V5IL); mean oesophagus dose, V50oesophagus; and maximum spinal cord doses]. The feasibility of maximum dose escalation was explored keeping the limit of the OAR below their tolerance limits. RESULTS Tumour regression was higher with concurrent chemoradiotherapy as compared with sequential chemoradiotherapy (p = 0.02). With the adaptive plan, the mean coverage index improved from 0.96 (±0.14) to 1.29 (±0.36), the mean external volume index changed from 1.39(±0.60) to 1.41(±0.56) and the reduction in doses to the OARs were MLDWL 10.6%, V20WL 1.3%, V5WL 1.2%, MLDIL 6.6%, V20IL 1.5%, V5IL 2.3%, mean oesophagus dose 7%, V50oesophagus 31% and maximum cord dose 0.35%. Dose escalation was possible in four patients in CT_45. CONCLUSION There is 35% reduction in tumour volume with chemoradiotherapy at 45 Gy which allows improvement in conformality, reduction in doses to the OARs and dose escalation in 40% of patients. Advances in knowledge: This article emphasizes that adaptive planning with a single diagnostic scan at 45 Gy has the potential for improvement of radiotherapy planning indices, dose escalation while respecting the dose to the OAR. This simple strategy can be helpful in radiotherapy planning upto 60 Gy in 40% of the patients of locally advanced non-small-cell lung cancer in countries with limited resources.
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Affiliation(s)
- Sushma Agrawal
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sunil Kumar
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anil K Maurya
- Department of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Brower JV, Amini A, Chen S, Hullett CR, Kimple RJ, Wojcieszynski AP, Bassetti M, Witek ME, Yu M, Harari PM, Baschnagel AM. Improved survival with dose-escalated radiotherapy in stage III non-small-cell lung cancer: analysis of the National Cancer Database. Ann Oncol 2016; 27:1887-94. [PMID: 27502703 DOI: 10.1093/annonc/mdw276] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/02/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Concurrent chemoradiation is the standard of care in non-operable stage III non-small-cell lung cancer (NSCLC). Data have suggested a benefit of dose escalation; however, results from the randomized dose-escalation trial RTOG 0617 revealed a lower survival rate with high-dose radiation. To evaluate the impact of dose escalation on overall survival (OS) in stage III NSCLC treated with chemoradiotherapy outside the controlled setting of a randomized trial, we carried out an observational, population-based investigation of the National Cancer Database (NCDB). PATIENTS AND METHODS A total of 33 566 patients with stage III NSCLC treated with chemoradiation from 2004 to 2012 and radiation doses between 59.4 and 85 Gy were included. The primary end point was OS, with median survival calculated via Kaplan-Meier. Univariate, multivariable and propensity-score matching analyses were carried out. RESULTS Patients were stratified by dose with median OS of: 18.8, 19.8 and 21.6 months for cohorts receiving 59.4-60, 61-69 and ≥70 Gy, respectively (P < 0.001). Granular dose analyses were carried out demonstrating increased OS with increasing radiation dose: median survival of 18.8, 21.1, 22.0 and 21.0 months for 59.4-60, 66, 70 and ≥71 Gy, respectively. While 66, 70 and ≥71 Gy resulted in increased OS in comparison with 59.4-60 Gy, no significant difference in OS was observed when comparing 66 with ≥71 Gy (P = 0.38). CONCLUSIONS Dose escalation above 60 Gy was associated with improved OS in this cohort of stage III NSCLC patients treated with chemoradiotherapy. A plateau of benefit was observed, with no additional improvement in OS with increased dose (≥71 Gy) compared with 66-70 Gy. With evidence suggesting worse OS and quality of life with increased dose, these data support investigation of the role of intermediate-dose radiation, and in the absence of randomized evidence, may be leveraged to justify utilization of intermediate-dose radiation.
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Affiliation(s)
- J V Brower
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison
| | - A Amini
- Department of Radiation Oncology, University of Colorado, Anschutz Medical Campus, Aurora
| | - S Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, USA
| | - C R Hullett
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison
| | - R J Kimple
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison
| | - A P Wojcieszynski
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison
| | - M Bassetti
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison
| | - M E Witek
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison
| | - M Yu
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, USA
| | - P M Harari
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison
| | - A M Baschnagel
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison
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Kim YJ, Song SY, Jeong SY, Kim SW, Lee JS, Kim SS, Choi W, Choi EK. Definitive radiotherapy with or without chemotherapy for clinical stage T4N0-1 non-small cell lung cancer. Radiat Oncol J 2015; 33:284-93. [PMID: 26756028 PMCID: PMC4707211 DOI: 10.3857/roj.2015.33.4.284] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/01/2015] [Accepted: 12/09/2015] [Indexed: 12/25/2022] Open
Abstract
Purpose To determine failure patterns and survival outcomes of T4N0-1 non-small cell lung cancer (NSCLC) treated with definitive radiotherapy. Materials and Methods Ninety-five patients with T4N0-1 NSCLC who received definitive radiotherapy with or without chemotherapy from May 2003 to October 2014 were retrospectively reviewed. The standard radiotherapy scheme was 66 Gy in 30 fractions. The main concurrent chemotherapy regimen was 50 mg/m2 weekly paclitaxel combined with 20 mg/m2 cisplatin or AUC 2 carboplatin. The primary outcome was overall survival (OS). Secondary outcomes were failure patterns and toxicities. Results The median age was 64 years (range, 34 to 90 years). Eighty-eight percent of patients (n = 84) had an Eastern Cooperative Oncology Group performance status of 0-1, and 42% (n = 40) experienced pretreatment weight loss. Sixty percent of patients (n = 57) had no metastatic regional lymph nodes. The median radiation dose was EQD2 67.1 Gy (range, 56.9 to 83.3 Gy). Seventy-one patients (75%) were treated with concurrent chemotherapy; of these, 13 were also administered neoadjuvant chemotherapy. At a median follow-up of 21 months (range, 1 to 102 months), 3-year OS was 44%. The 3-year cumulative incidences of local recurrence and distant recurrence were 48.8% and 36.3%, respectively. Pretreatment weight loss and combined chemotherapy were significant factors for OS. Acute esophagitis over grade 3 occurred in three patients and grade 3 chronic esophagitis occurred in one patient. There was no grade 3-4 radiation pneumonitis. Conclusion Definitive radiotherapy for T4N0-1 NSCLC results in favorable survival with acceptable toxicity rates. Local recurrence is the major recurrence pattern. Intensity modulated radiotherapy and radio-sensitizing agents would be needed to improve local tumor control.
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Affiliation(s)
- Yeon Joo Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Si Yeol Song
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Yun Jeong
- Institute of Innovative Science, Asan Medical Center, Seoul, Korea
| | - Sang We Kim
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Shin Lee
- Department of Medical Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonsik Choi
- Department of Radiation Oncology, Gangneung Asan Hospital, Gangneung, Korea
| | - Eun Kyung Choi
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Tao H, Yang JJ, Zhou X, Deng ZY, Shi KH, Li J. Emerging role of long noncoding RNAs in lung cancer: Current status and future prospects. Respir Med 2015; 110:12-9. [PMID: 26603340 DOI: 10.1016/j.rmed.2015.10.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/08/2015] [Accepted: 10/09/2015] [Indexed: 01/01/2023]
Abstract
Lung cancer is the leading cause of cancer-related death worldwide with a 5-year survival rate of less than 15%, despite significant advances in both diagnostic and therapeutic approaches. Combined genomic and transcriptomic sequencing studies have identified numerous genetic driver mutations that are responsible for the development of lung cancer. Importantly, these approaches have also uncovered the widespread expression of "noncoding RNAs" including long noncoding RNAs (LncRNAs), which impact biologic responses through the regulation of mRNA transcription or translation. To date, most studies of the role of noncoding RNAs have focused on LncRNAs, which regulate mRNA translation via the RNA interference pathway. Although many of their attributes, such as patterns of expression, remain largely unknown, LncRNAs have key functions in transcriptional, post-transcriptional, and epigenetic gene regulation. Recent research showed that LncRNAs regulate flowering time in the lung cancer. In this review, we discuss these investigations into long noncoding RNAs were performed almost exclusively in lung cancer. Future work will need to extend these into lung cancer and to analyze how LncRNAs interact to regulate mRNA expression. From a clinical perspective, the targeting of LncRNAs as a novel therapeutic approach will require a deeper understanding of their function and mechanism of action.
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Affiliation(s)
- Hui Tao
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei 230601, China
| | - Jing-Jing Yang
- Department of Pharmacology, The Second Hospital of Anhui Medical University, Hefei 230601, China
| | - Xiao Zhou
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei 230601, China.
| | - Zi-Yu Deng
- Department of Scientific and Educational, The Second Hospital of Anhui Medical University, China
| | - Kai-Hu Shi
- Department of Cardiothoracic Surgery, The Second Hospital of Anhui Medical University, Hefei 230601, China.
| | - Jun Li
- School of Pharmacy, Anhui Medical University, Hefei 230032, China
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13
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Inclusion of functional information from perfusion SPECT improves predictive value of dose–volume parameters in lung toxicity outcome after radiotherapy for non-small cell lung cancer: A prospective study. Radiother Oncol 2015; 117:9-16. [DOI: 10.1016/j.radonc.2015.08.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/27/2015] [Accepted: 08/02/2015] [Indexed: 12/25/2022]
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14
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Oberije C, De Ruysscher D, Houben R, van de Heuvel M, Uyterlinde W, Deasy JO, Belderbos J, Dingemans AMC, Rimner A, Din S, Lambin P. A Validated Prediction Model for Overall Survival From Stage III Non-Small Cell Lung Cancer: Toward Survival Prediction for Individual Patients. Int J Radiat Oncol Biol Phys 2015; 92:935-44. [PMID: 25936599 PMCID: PMC4786012 DOI: 10.1016/j.ijrobp.2015.02.048] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 02/18/2015] [Accepted: 02/26/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE Although patients with stage III non-small cell lung cancer (NSCLC) are homogeneous according to the TNM staging system, they form a heterogeneous group, which is reflected in the survival outcome. The increasing amount of information for an individual patient and the growing number of treatment options facilitate personalized treatment, but they also complicate treatment decision making. Decision support systems (DSS), which provide individualized prognostic information, can overcome this but are currently lacking. A DSS for stage III NSCLC requires the development and integration of multiple models. The current study takes the first step in this process by developing and validating a model that can provide physicians with a survival probability for an individual NSCLC patient. METHODS AND MATERIALS Data from 548 patients with stage III NSCLC were available to enable the development of a prediction model, using stratified Cox regression. Variables were selected by using a bootstrap procedure. Performance of the model was expressed as the c statistic, assessed internally and on 2 external data sets (n=174 and n=130). RESULTS The final multivariate model, stratified for treatment, consisted of age, gender, World Health Organization performance status, overall treatment time, equivalent radiation dose, number of positive lymph node stations, and gross tumor volume. The bootstrapped c statistic was 0.62. The model could identify risk groups in external data sets. Nomograms were constructed to predict an individual patient's survival probability (www.predictcancer.org). The data set can be downloaded at https://www.cancerdata.org/10.1016/j.ijrobp.2015.02.048. CONCLUSIONS The prediction model for overall survival of patients with stage III NSCLC highlights the importance of combining patient, clinical, and treatment variables. Nomograms were developed and validated. This tool could be used as a first building block for a decision support system.
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Affiliation(s)
- Cary Oberije
- Radiation Oncology, Research Institute GROW of Oncology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Dirk De Ruysscher
- Radiation Oncology, Research Institute GROW of Oncology, Maastricht University Medical Center, Maastricht, The Netherlands; Universitaire Ziekenhuizen Leuven, KU Leuven, Belgium
| | - Ruud Houben
- Radiation Oncology, Research Institute GROW of Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michel van de Heuvel
- Department of Thoracic Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wilma Uyterlinde
- Department of Thoracic Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Jose Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Anne-Marie C Dingemans
- Department of Pulmonology, University Hospital Maastricht, Research Institute GROW of Oncology, Maastricht, The Netherlands
| | | | - Shaun Din
- Memorial Sloan Kettering Cancer Center, New York
| | - Philippe Lambin
- Radiation Oncology, Research Institute GROW of Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
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15
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Cobben DCP, Jager PL. In Regard to Rodrigues et al. Int J Radiat Oncol Biol Phys 2015; 92:699-700. [PMID: 26068496 DOI: 10.1016/j.ijrobp.2015.02.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 02/23/2015] [Indexed: 10/23/2022]
Affiliation(s)
| | - P L Jager
- Isala Clinics, Zwolle, The Netherlands
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16
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In Reply to Cobben and Jager. Int J Radiat Oncol Biol Phys 2015; 92:700-1. [PMID: 26068498 DOI: 10.1016/j.ijrobp.2015.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 02/23/2015] [Indexed: 11/24/2022]
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