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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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2
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Woodford K, Panettieri V, Ruben JD, Davis S, Tran Le T, Miller S, Senthi S. Oesophageal IGRT considerations for SBRT of LA-NSCLC: barium-enhanced CBCT and interfraction motion. Radiat Oncol 2021; 16:218. [PMID: 34775990 PMCID: PMC8591953 DOI: 10.1186/s13014-021-01946-8] [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: 06/23/2021] [Accepted: 11/03/2021] [Indexed: 12/25/2022] Open
Abstract
Background To determine the optimal volume of barium for oesophageal localisation on cone-beam CT (CBCT) for locally-advanced non-small cell lung cancers (NSCLC) and quantify the interfraction oesophageal movement relative to tumour. Methods Twenty NSCLC patients with mediastinal and/or hilar disease receiving radical radiotherapy were recruited. The first five patients received 25 ml of barium prior to their planning CT and alternate CBCTs during treatment. Subsequent five patient cohorts, received 15 ml, 10 ml and 5 ml. Six observers contoured the oesophagus on each of the 107 datasets and consensus contours were created. Overall 642 observer contours were generated and interobserver contouring reproducibility was assessed. The kappa statistic, dice coefficient and Hausdorff Distance (HD) were used to compare barium-enhanced CBCTs and non-enhanced CBCTs. Oesophageal displacement was assessed using the HD between consensus contours of barium-enhanced CBCTs and planning CTs. Results Interobserver contouring reproducibility was significantly improved in barium-enhanced CBCTs compared to non-contrast CBCTs with minimal difference between barium dose levels. Only 10 mL produced a significantly higher kappa (0.814, p = 0.008) and dice (0.895, p = 0.001). The poorer the reproducibility without barium, the greater the improvement barium provided. The median interfraction HD between consensus contours was 4 mm, with 95% of the oesophageal displacement within 15 mm. Conclusions 10 mL of barium significantly improves oesophageal localisation on CBCT with minimal image artifact. The oesophagus moves substantially and unpredictably over a course of treatment, requiring close daily monitoring in the context of hypofractionation. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01946-8.
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Affiliation(s)
- Katrina Woodford
- Alfred Health Radiation Oncology, The Alfred, 55 Commercial Road, Melbourne, VIC, 3004, Australia. .,Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Vanessa Panettieri
- Alfred Health Radiation Oncology, The Alfred, 55 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, VIC, Australia
| | - Jeremy D Ruben
- Alfred Health Radiation Oncology, The Alfred, 55 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Sidney Davis
- Alfred Health Radiation Oncology, The Alfred, 55 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Trieumy Tran Le
- Alfred Health Radiation Oncology, The Alfred, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Stephanie Miller
- Alfred Health Radiation Oncology, The Alfred, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Sashendra Senthi
- Alfred Health Radiation Oncology, The Alfred, 55 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia
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3
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Shen J, Yang D, Chen M, Jiang L, Dong X, Li D, Yu R, Yu H, Shi A. Hypofractionated Volumetric-Modulated Arc Radiotherapy for Patients With Non-Small-Cell Lung Cancer Not Suitable for Surgery or Conventional Chemoradiotherapy or SBRT. Front Oncol 2021; 11:644852. [PMID: 34221967 PMCID: PMC8244290 DOI: 10.3389/fonc.2021.644852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/20/2021] [Indexed: 12/25/2022] Open
Abstract
Background Hypofractionated radiotherapy (HypoRT) has been used to pursue an alternative treatment regimen for patients with non-small-cell lung cancer (NSCLC) who are not eligible for stereotactic ablative radiotherapy (SABR), surgery or concurrent chemoradiotherapy (CCRT) and has shown good local control and safety. We analyzed the feasibility of using volumetric-modulated arc radiotherapy (VMAT) with the simultaneous integrated boost (SIB) technique to achieve high local control with few treatment-related toxicities. Patients and Methods A total of 55 patients with stage I-IV NSCLC who were not candidates for SABR, surgery or CCRT were included in the present study. All patients received a prescribed dose of 60 to 66 Gy in 15 fractions. Local progression-free survival (LPFS), PFS, overall survival (OS), and toxicities were retrospectively analyzed. Results Thirty-three patients (60.0%) had stage IV or recurrent disease in this study. The median follow-up time was 8 months (interquartile range: 5.0-16.3 months). The 1-year and 2-year OS rates were 84.3% and 69.9%, and the 1-year and 2-year LPFS rates were 91.0% and 63.0%. The median OS (mOS) and median LPFS (mLPFS) were not reached, and median PFS (mPFS) was 15 months. Twenty-eight (51.9%) patients had disease progression at the time of analysis. Of these, 7 (13.0%), 7 (13.0%) and 21 (38.9%) had local recurrence, locoregional failure and distant metastasis, respectively. All cases of local recurrence were found within the SIB region. Four patients had grade 2-3 pneumonitis, and 8 patients had grade 2-3 esophagitis. Patients with grade 2-3 esophagitis had significantly higher maximum dose and dose to 5 cm3 volume to esophagus than those with grade 0-1 esophagitis. No grade 4 or higher toxicity was observed. Conclusion The 60 to 66 Gy in 15 fractions RT regimen provides favorable local control and survival with well-tolerated toxicities. Hypofractionated VMAT+SIB is an alternative treatment option for patients with NSCLC who cannot tolerate standard definitive therapy.
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Affiliation(s)
- Junyue Shen
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Dan Yang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Mailin Chen
- Departments of Radiology, Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University Cancer Hospital and Institute, Beijing, China
| | - Leilei Jiang
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Xin Dong
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Dongming Li
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Rong Yu
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Huiming Yu
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
| | - Anhui Shi
- Department of Radiation Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China
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4
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Efficacy and toxicity hypofractionated radiotherapy for centrally located non-small cell lung cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396921000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Aim:
Centrally located early-stage non-small cell lung cancer in patients who are unfit for surgery are treated with fractionated radiotherapy. We present the outcomes of a moderately hypofractionated accelerated dose regimen of 50 Gy in 15 fractions from a single centre in the UK.
Materials and methods:
Electronic case notes and radiotherapy records of lung cancer patients treated between January 2014 and December 2016 were retrospectively reviewed. Adult Comorbidity Evaluation-27 score was used to evaluate comorbidities. Mean lung doses and percentage of lung receiving more than 20 Gy were calculated for all patients. Survival outcomes were estimated using Kaplan–Meier curves.
Results:
Fifty-three patients were included in the study; the median follow-up was 20.2 months. 87% of patients had stage I disease. There was no 30-day post-treatment mortality. Ninety-day mortality rate after radiotherapy was 3.8%. Grade 2 pneumonitis was seen in five patients while no grade 3 or 4 pneumonitis was observed. The median progression-free survival (PFS) and overall survival (OS) were 18.5 months and 28.2 months, respectively. The estimated 1 and 2 years PFS were 62.3% and 41.3%, respectively, and OS were 77.4% and 56.6%, respectively. Worsening performance status was associated with worse survival on cox regression analysis. Disease relapsed in 36% of patients. 7.5% of patients with relapsed disease had infield recurrence.
Findings:
50 Gy in 15 fractions radiotherapy for central early-stage lung cancer is a feasible choice that requires further randomised trials.
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5
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Couñago F, Navarro-Martin A, Luna J, Rodríguez de Dios N, Rodríguez A, Casas F, García R, Gómez-Caamaño A, Contreras J, Serrano J. GOECP/SEOR clinical recommendations for lung cancer radiotherapy during the COVID-19 pandemic. World J Clin Oncol 2020; 11:510-527. [PMID: 32879841 PMCID: PMC7443829 DOI: 10.5306/wjco.v11.i8.510] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/07/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease 2019 crisis has had a major and highly complex impact on the clinical practice of radiation oncology worldwide. Spain is one of the countries hardest hit by the virus, with devastating consequences. There is an urgent need to share experiences and offer guidance on decision-making with regard to the indications and standards for radiation therapy in the treatment of lung cancer. In the present article, the Oncological Group for the Study of Lung Cancer of the Spanish Society of Radiation Oncology reviews the literature and establishes a series of consensus-based recommendations for the treatment of patients with lung cancer in different clinical scenarios during the present pandemic.
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Affiliation(s)
- Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Pozuelo de Alarcón, Madrid 28223, Spain
- Clinical Department, Hospital La Luz, Madrid, Faculty of Biomedicine, Universidad Europea, Madrid 28223, Spain
| | - Arturo Navarro-Martin
- Department of Radiation Oncology, Institut Catalá d’Oncologia, L’Hospitalet de Llobregat, Barcelona 08908, Spain
| | - Javier Luna
- Department of Radiation Oncology, Hospital Fundación Jiménez Díaz, Madrid 28040, Spain
| | | | - Aurora Rodríguez
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Francesc Casas
- Department of Radiation Oncology, Thoracic Unit, Hospital Clínic, Barcelona 08036, Spain
| | - Rafael García
- Department of Radiaiton Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Antonio Gómez-Caamaño
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, A Coruña 15706, Spain
| | - Jorge Contreras
- Department of Radiation Oncology, Hospital Regional Universitario de Málaga, 29010, Spain
| | - Javier Serrano
- Department of Radiation Oncology, Clínica Universidad de Navarra, Madrid 28027, Spain
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6
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Faivre-Finn C, Fenwick JD, Franks KN, Harrow S, Hatton MQF, Hiley C, McAleese JJ, McDonald F, O'Hare J, Peedell C, Pope T, Powell C, Rulach R, Toy E. Reduced Fractionation in Lung Cancer Patients Treated with Curative-intent Radiotherapy during the COVID-19 Pandemic. Clin Oncol (R Coll Radiol) 2020; 32:481-489. [PMID: 32405158 PMCID: PMC7218369 DOI: 10.1016/j.clon.2020.05.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 12/14/2022]
Abstract
Patients treated with curative-intent lung radiotherapy are in the group at highest risk of severe complications and death from COVID-19. There is therefore an urgent need to reduce the risks associated with multiple hospital visits and their anti-cancer treatment. One recommendation is to consider alternative dose-fractionation schedules or radiotherapy techniques. This would also increase radiotherapy service capacity for operable patients with stage I-III lung cancer, who might be unable to have surgery during the pandemic. Here we identify reduced-fractionation for curative-intent radiotherapy regimes in lung cancer, from a literature search carried out between 20/03/2020 and 30/03/2020 as well as published and unpublished audits of hypofractionated regimes from UK centres. Evidence, practical considerations and limitations are discussed for early-stage NSCLC, stage III NSCLC, early-stage and locally advanced SCLC. We recommend discussion of this guidance document with other specialist lung MDT members to disseminate the potential changes to radiotherapy practices that could be made to reduce pressure on other departments such as thoracic surgery. It is also a crucial part of the consent process to ensure that the risks and benefits of undergoing cancer treatment during the COVID-19 pandemic and the uncertainties surrounding toxicity from reduced fractionation have been adequately discussed with patients. Furthermore, centres should document all deviations from standard protocols, and we urge all colleagues, where possible, to join national/international data collection initiatives (such as COVID-RT Lung) aimed at recording the impact of the COVID-19 pandemic on lung cancer treatment and outcomes.
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Affiliation(s)
- C Faivre-Finn
- The Christie NHS Foundation Trust, Manchester, UK; The University of Manchester, Manchester, UK.
| | - J D Fenwick
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Department of Physics, Clatterbridge Cancer Centre, Bebington, Wirral, UK
| | - K N Franks
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK; University of Leeds, Leeds, UK
| | - S Harrow
- Beatson West of Scotland Cancer Centre, Glasgow, UK; University of Glasgow, Glasgow, UK
| | | | - C Hiley
- CRUK Lung Cancer Centre of Excellence, University College London, London, UK; Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J J McAleese
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK
| | - F McDonald
- The Royal Marsden NHS Foundation Trust, London, UK
| | - J O'Hare
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK
| | - C Peedell
- James Cook University Hospital, Middlesbrough, UK
| | - T Pope
- Clatterbridge Cancer Centre, Bebington, Wirral, UK
| | - C Powell
- South West Wales Cancer Centre, Singleton Hospital, Swansea, UK; Velindre Cancer Centre, Cardiff, UK
| | - R Rulach
- Beatson West of Scotland Cancer Centre, Glasgow, UK; University of Glasgow, Glasgow, UK
| | - E Toy
- Royal Devon and Exeter NHS Foundation Trust, Exeter Hospital, Exeter, UK
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7
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Practice Recommendations for Lung Cancer Radiotherapy During the COVID-19 Pandemic: An ESTRO-ASTRO Consensus Statement. Int J Radiat Oncol Biol Phys 2020; 107:631-640. [PMID: 32589990 PMCID: PMC7836268 DOI: 10.1016/j.ijrobp.2020.05.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 01/08/2023]
Abstract
Background The COVID-19 pandemic has caused radiotherapy resource pressures and led to increased risks for lung cancer patients and healthcare staff. An international group of experts in lung cancer radiotherapy established this practice recommendation pertaining to whether and how to adapt radiotherapy for lung cancer in the COVID-19 pandemic. Methods For this ESTRO & ASTRO endorsed project, 32 experts in lung cancer radiotherapy contributed to a modified Delphi consensus process. We assessed potential adaptations of radiotherapy in two pandemic scenarios. The first, an early pandemic scenario of risk mitigation, is characterized by an altered risk–benefit ratio of radiotherapy for lung cancer patients due to their increased susceptibility for severe COVID-19 infection, and minimization of patient travelling and exposure of radiotherapy staff. The second, a later pandemic scenario, is characterized by reduced radiotherapy resources requiring patient triage. Six common lung cancer cases were assessed for both scenarios: peripherally located stage I NSCLC, locally advanced NSCLC, postoperative radiotherapy after resection of pN2 NSCLC, thoracic radiotherapy and prophylactic cranial irradiation for limited stage SCLC and palliative thoracic radiotherapy for stage IV NSCLC. Results In a risk-mitigation pandemic scenario, efforts should be made not to compromise the prognosis of lung cancer patients by departing from guideline-recommended radiotherapy practice. In that same scenario, postponement or interruption of radiotherapy treatment of COVID-19 positive patients is generally recommended to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection. In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors for triage include potential for cure, relative benefit of radiation, life expectancy, and performance status. Case-specific consensus recommendations regarding multimodality treatment strategies and fractionation of radiotherapy are provided. Conclusion This joint ESTRO-ASTRO practice recommendation established pragmatic and balanced consensus recommendations in common clinical scenarios of radiotherapy for lung cancer in order to address the challenges of the COVID-19 pandemic.
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8
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Kumar S, Chmura S, Robinson C, Lin SH, Gadgeel SM, Donington J, Feliciano J, Stinchcombe TE, Werner-Wasik M, Edelman MJ, Moghanaki D. Alternative Multidisciplinary Management Options for Locally Advanced NSCLC During the Coronavirus Disease 2019 Global Pandemic. J Thorac Oncol 2020; 15:1137-1146. [PMID: 32360578 PMCID: PMC7194660 DOI: 10.1016/j.jtho.2020.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is currently accelerating. Patients with locally advanced NSCLC (LA-NSCLC) may require treatment in locations where resources are limited, and the prevalence of infection is high. Patients with LA-NSCLC frequently present with comorbidities that increase the risk of severe morbidity and mortality from COVID-19. These risks may be further increased by treatments for LA-NSCLC. Although guiding data is scarce, we present an expert thoracic oncology multidisciplinary (radiation oncology, medical oncology, surgical oncology) consensus of alternative strategies for the treatment of LA-NSCLC during a pandemic. The overarching goals of these approaches are the following: (1) reduce the number of visits to a health care facility, (2) reduce the risk of exposure to severe acute respiratory syndrome–coronavirus-2, (3) attenuate the immunocompromising effects of lung cancer therapies, and (4) provide effective oncologic therapy. Patients with resectable disease can be treated with definitive nonoperative management if surgical resources are limited or the risks of perioperative care are high. Nonoperative options include chemotherapy, chemoimmunotherapy, and radiation therapy with sequential schedules that may or may not affect long-term outcomes in an era in which immunotherapy is available. The order of treatments may be on the basis of patient factors and clinical resources. Whenever radiation therapy is delivered without concurrent chemotherapy, hypofractionated schedules are appropriate. For patients who are confirmed to have COVID-19, usually, cancer therapies may be withheld until symptoms have resolved with negative viral test results. The risk of severe treatment-related morbidity and mortality is increased for patients undergoing treatment for LA-NSCLC during the COVID-19 pandemic. Adapting alternative treatment strategies as quickly as possible may save lives and should be implemented through communication with the multidisciplinary cancer team.
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Affiliation(s)
- Sameera Kumar
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
| | - Steven Chmura
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Steven H Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Shirish M Gadgeel
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Josephine Feliciano
- Department of Medical Oncology, Johns Hopkins University, Baltimore, Maryland
| | | | - Maria Werner-Wasik
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Martin J Edelman
- Department of Hematology and Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Drew Moghanaki
- Department of Radiation Oncology, Emory University, Atlanta Veterans Affairs Health Care System, Atlanta, Georgia
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9
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Kong C, Zhu X, Shi M, Wang L, Chen C, Tao H, Jiang N, Yan P, Zhao L, Song X, He X. Survival and Toxicity of Hypofractionated Intensity Modulated Radiation Therapy in 4 Gy Fractions for Unresectable Stage III Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2020; 107:710-719. [PMID: 32275994 DOI: 10.1016/j.ijrobp.2020.03.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 03/24/2020] [Accepted: 03/28/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To assess the survival, local and distant control, and toxicity in patients with unresectable locally advanced non-small cell lung cancer treated with radical-intent hypofractionated radiation therapy delivering approximately 60 Gy in 4-Gy fractions. METHODS AND MATERIALS Consecutive patients with unresectable stage III non-small cell lung cancer (n = 42) who received hypofractionated intensity modulated radiation therapy were retrospectively analyzed (2012-2016). Treatments consisted of first-line platinum-based doublet induction chemotherapy followed by an intended dose of 60 Gy in 15 fractions. RESULTS During a median follow-up period of 46 months (95% confidence interval, 41-59) the median overall survival was 47 months (95% confidence interval, 31 to not reached). The 1-, 2-, 3-, and 5-year overall survival rates were 81%, 69%, 64%, and 32%, respectively. The 1-, 2-, 3-, and 5-year progression-free survival rates were 58%, 35%, 25%, and 25%, respectively. An isolated locoregional recurrence was seen in 12% of the patients (n = 5). The incidence of grade (G) 3 or higher treatment-related lung toxicity was 14% (n = 6), among which G3 toxicity was 9.5% (n = 4) and G5 toxicity was 4.8% (n = 2). Twelve percent of patients (n = 5) experienced G3 radiation esophagitis, and 2% (n = 1) had G4 esophageal toxicity. CONCLUSIONS Patients with unresectable locally advanced non-small cell lung cancer treated with hypofractionated intensity modulated radiation therapy in doses up to 60 Gy at 4 Gy per fraction had promising survival, although high-grade esophageal and lung toxicities were seen. Our findings deserve further evaluation in prospective studies.
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Affiliation(s)
- Cheng Kong
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Xiangzhi Zhu
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China.
| | - Meiqi Shi
- Department of Medical Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Li Wang
- Department of Medical Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Cheng Chen
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Hua Tao
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Ning Jiang
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Pengwei Yan
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Lijun Zhao
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Xue Song
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
| | - Xia He
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing Medical University Affiliated Cancer Hospital, Nanjing, People's Republic of China
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Guckenberger M, Belka C, Bezjak A, Bradley J, Daly ME, DeRuysscher D, Dziadziuszko R, Faivre-Finn C, Flentje M, Gore E, Higgins KA, Iyengar P, Kavanagh BD, Kumar S, Le Pechoux C, Lievens Y, Lindberg K, McDonald F, Ramella S, Rengan R, Ricardi U, Rimner A, Rodrigues GB, Schild SE, Senan S, Simone CB, Slotman BJ, Stuschke M, Videtic G, Widder J, Yom SS, Palma D. Practice recommendations for lung cancer radiotherapy during the COVID-19 pandemic: An ESTRO-ASTRO consensus statement. Radiother Oncol 2020; 146:223-229. [PMID: 32342863 PMCID: PMC7252074 DOI: 10.1016/j.radonc.2020.04.001] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 01/08/2023]
Abstract
Background The COVID-19 pandemic has caused radiotherapy resource pressures and led to increased risks for lung cancer patients and healthcare staff. An international group of experts in lung cancer radiotherapy established this practice recommendation pertaining to whether and how to adapt radiotherapy for lung cancer in the COVID-19 pandemic. Methods For this ESTRO & ASTRO endorsed project, 32 experts in lung cancer radiotherapy contributed to a modified Delphi consensus process. We assessed potential adaptations of radiotherapy in two pandemic scenarios. The first, an early pandemic scenario of risk mitigation, is characterized by an altered risk–benefit ratio of radiotherapy for lung cancer patients due to their increased susceptibility for severe COVID-19 infection, and minimization of patient travelling and exposure of radiotherapy staff. The second, a later pandemic scenario, is characterized by reduced radiotherapy resources requiring patient triage. Six common lung cancer cases were assessed for both scenarios: peripherally located stage I NSCLC, locally advanced NSCLC, postoperative radiotherapy after resection of pN2 NSCLC, thoracic radiotherapy and prophylactic cranial irradiation for limited stage SCLC and palliative thoracic radiotherapy for stage IV NSCLC. Results In a risk-mitigation pandemic scenario, efforts should be made not to compromise the prognosis of lung cancer patients by departing from guideline-recommended radiotherapy practice. In that same scenario, postponement or interruption of radiotherapy treatment of COVID-19 positive patients is generally recommended to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection. In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors for triage include potential for cure, relative benefit of radiation, life expectancy, and performance status. Case-specific consensus recommendations regarding multimodality treatment strategies and fractionation of radiotherapy are provided. Conclusion This joint ESTRO-ASTRO practice recommendation established pragmatic and balanced consensus recommendations in common clinical scenarios of radiotherapy for lung cancer in order to address the challenges of the COVID-19 pandemic.
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Affiliation(s)
- Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland.
| | - Claus Belka
- Department of Radiation Oncology, LMU Klinikum, LMU Munich, Germany
| | - Andrea Bezjak
- Department of Radiation Oncology, Princess Margaret Cancer Center, University of Toronto, Canada
| | - Jeffrey Bradley
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, USA
| | - Megan E Daly
- Department of Radiation Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, USA
| | - Dirk DeRuysscher
- Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Center(+), GROW Research Institute, The Netherlands
| | - Rafal Dziadziuszko
- Dept. of Oncology and Radiotherapy, Medical University of Gdansk, Poland
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - Michael Flentje
- Department of Radiation Oncology, University Hospital Würzburg, JMU Würzburg, Germany
| | - Elizabeth Gore
- Department of Radiation Oncology, Medical College of Wisconsin and Zablocki VAMC, Milwaukee, USA
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, USA
| | - Puneeth Iyengar
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado, Aurora, USA
| | - Sameera Kumar
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, USA
| | - Cecile Le Pechoux
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, Belgium
| | - Karin Lindberg
- Department of Head, Neck, Lung and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | | | - Sara Ramella
- Radiation Oncology, Campus Bio-Medico University of Rome, Italy
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, USA
| | | | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | - Suresh Senan
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, USA
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands
| | - Martin Stuschke
- Department of Radiotherapy, University Duisburg-Essen, Germany
| | - Greg Videtic
- Department of Radiation Oncology, Cleveland Clinic Lerner College of Medicine of Case Western University, USA
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria
| | - Sue S Yom
- Department of Radiation Oncology, University of California San Francisco, USA
| | - David Palma
- Division of Radiation Oncology, Western University, London, Canada
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The safety and effectiveness of stereotactic body radiotherapy for central versus ultracentral lung tumors. Radiother Oncol 2018; 129:277-283. [PMID: 30049454 DOI: 10.1016/j.radonc.2018.07.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 06/22/2018] [Accepted: 07/02/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Recent studies have postulated that patients undergoing lung stereotactic body radiotherapy (SBRT) for ultracentral tumors have higher toxicity and mortality rates than those with central tumors. Our aim was to compare the outcomes after lung SBRT for central versus ultracentral tumors in our own series. MATERIAL AND METHODS This was a retrospective review of patients with primary and metastatic lung tumors treated with SBRT from 1 September 2009 to 30 June 2015. Patients were included if they were treated with five-fraction SBRT to central or ultracentral tumors. Central tumors were defined as tumors where the closest point was within 2 cm of (but not abutting) the proximal bronchial tree, or within 2 cm of (whether abutting or not) mediastinal structures. Ultracentral tumors were defined as tumors abutting the proximal bronchial tree. The 2-year overall survival (OS), 2-year local failure (LF), and 2-year grade ≥3 toxicity rates were compared between patients with central and ultracentral tumors. RESULTS A total of 107 patients were included in this study. There were no significant differences in 2-year OS between the two groups, with 2-year OS 57.7% for central tumors, and 50.4% for ultracentral tumors (p = 0.10). There were no significant differences in 2-year LF between the two groups, with 2-year LF 3.4% for central tumors and 4.3% for ultracentral tumors (p = 0.92). There were no significant differences in 2-year grade ≥3 toxicity rate for the two groups, with 3.5% with central tumors and 8.7% with ultracentral tumors (p = 0.23). CONCLUSIONS There were no significant differences in OS, LF, or grade ≥3 toxicity between patients with central and ultracentral lung tumors. Although these results indicate that SBRT for ultracentral tumors may be safe, caution should be applied in selecting and treating these patients until the completion of large prospective trials.
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Dudani S, Zhu X, Yokom DW, Yamada A, Ho C, Pantarotto JR, Leighl NB, Zhang T, Wheatley-Price P. Radical Treatment of Stage II Non-small-cell Lung Cancer With Nonsurgical Approaches: A Multi-institution Report of Outcomes. Clin Lung Cancer 2017; 19:e11-e18. [PMID: 28711384 DOI: 10.1016/j.cllc.2017.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/02/2017] [Accepted: 06/13/2017] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Standard management of stage II non-small-cell lung cancer (NSCLC) is surgery, often followed by adjuvant chemotherapy. However, some patients do not undergo surgery for various reasons. We examined outcomes in this defined patient group. METHODS We reviewed the records of patients with stage II NSCLC treated nonsurgically with curative intent from 2002 to 2012 across 3 academic cancer centers. Data collected included demographics, comorbidities, staging, treatments, and survival. The primary endpoint was overall survival (OS). We assessed factors associated with treatment choice and OS. RESULTS A total of 158 patients were included: the median age was 74 years (range, 50-91 years), 44% were female, and 68% had a performance status of 0 to 1. The stage II groupings of the patients were T2b-T3 N0 in 55% and N1 in 45%. The most common reasons for inoperability were inadequate pulmonary reserve (27%) and medical comorbidities (24%). All patients received radical radiotherapy (RT) (median, 60 Gy [range, 48-75 Gy]). Seventy-three percent received RT alone; 24% received concurrent and 3% sequential chemoradiotherapy (CRT). In multivariate analyses, CRT was less likely in older patients (≥ 70 years) (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.11-0.70; P = .006) and in patients with higher (> 5) Charlson comorbidity scores (OR, 0.34; 95% CI, 0.13-0.90; P = .03) or normal (< 10 × 109/L) white blood cell counts (OR, 0.26; 95% CI, 0.09-0.73; P = .01). At the time of our analysis, 74% have died. The median OS was 22.9 months (range, 17.1-26.6 months). Patients who had undergone CRT had a significantly longer median OS than those receiving RT alone (39.1 vs. 20.5 months; P = .0019), confirmed in multivariate analysis (hazard ratio, 0.38; 95% CI, 0.21-0.69; P = .001). CONCLUSION Nonsurgical approaches to management of stage II NSCLC are varied. Treatment with CRT was associated with significantly longer survival compared with RT alone. A randomized trial may be warranted.
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Affiliation(s)
- Shaan Dudani
- Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Xiaofu Zhu
- Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel W Yokom
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Yamada
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Cheryl Ho
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Jason R Pantarotto
- Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Natasha B Leighl
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Tinghua Zhang
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul Wheatley-Price
- Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
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Affiliation(s)
- Stephen G Chun
- Stephen G. Chun, University of Texas MD Anderson Cancer Center, Houston, TX; Chen Hu, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, and NRG Oncology Statistics and Data Management Center, Philadelphia, PA; and Jeffrey D. Bradley, Siteman Comprehensive Cancer Center, Washington University in Saint Louis, Saint Louis, MO
| | - Chen Hu
- Stephen G. Chun, University of Texas MD Anderson Cancer Center, Houston, TX; Chen Hu, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, and NRG Oncology Statistics and Data Management Center, Philadelphia, PA; and Jeffrey D. Bradley, Siteman Comprehensive Cancer Center, Washington University in Saint Louis, Saint Louis, MO
| | - Jeffrey D Bradley
- Stephen G. Chun, University of Texas MD Anderson Cancer Center, Houston, TX; Chen Hu, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, and NRG Oncology Statistics and Data Management Center, Philadelphia, PA; and Jeffrey D. Bradley, Siteman Comprehensive Cancer Center, Washington University in Saint Louis, Saint Louis, MO
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Fang P, Swanick CW, Pezzi TA, Liao Z, Welsh J, Lin SH, Gomez DR. Outcomes and toxicity following high-dose radiation therapy in 15 fractions for non-small cell lung cancer. Pract Radiat Oncol 2017; 7:433-441. [PMID: 28428017 DOI: 10.1016/j.prro.2017.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/08/2017] [Accepted: 03/06/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Accelerated hypofractionated radiation therapy (AHRT) is increasingly used for select lung cancer patients. We evaluated clinical outcomes and predictors of pulmonary/esophageal toxicity in patients treated with ≥52.5 Gy in 15 fractions. METHODS AND MATERIALS We evaluated 229 patients treated with radiation therapy doses ≥52.5 Gy in 15 fractions for non-small cell lung cancer from January 2009 through January 2016. Toxicity was scored using Common Terminology Criteria for Adverse Events, v4.0. Univariate and multivariate logistic regression was used to identify predictors of toxicity. Overall survival, progression-free survival, and local control were estimated using the Kaplan-Meier method. Predictors of clinical outcome were modeled using Cox proportional hazards regression. RESULTS Median follow-up was 7 months. Forty-two patients (19%) developed grade ≥2 pneumonitis, and 9 (4%) developed grade ≥3 esophagitis. In multivariate analysis, age >75 years (odds ratio [OR], 2.56; 95% confidence interval [CI], 1.24-5.25; P = .01) and percentage of lung volume receiving doses of >10 Gy higher than 32% were associated with grade ≥2 pneumonitis (OR, 2.79; 95% CI, 1.39-5.79; P = .005). On univariate analysis, esophagus mean dose ≥17 Gy (OR, 10.14; 95% CI, 1.82-189.8; P = .006), gross tumor volume size ≥71 cm3 (P = .002), and planning target volume size ≥409 cm3 (P = .02) were associated with development of grade ≥3 esophagitis. In patients with stage II/III disease (n = 73), median local control was not reached, median overall survival was 14 months, and median progression-free survival was 6 months. CONCLUSIONS AHRT in 15 fractions can be safe and effective. Consideration for using AHRT with immunotherapy and sequential chemotherapy for improved out-of-radiation field and distant control is warranted.
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Affiliation(s)
- Penny Fang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - Cameron W Swanick
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - Todd A Pezzi
- Baylor College of Medicine, One Baylor Plaza, Houston, Texas
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - James Welsh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas.
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas
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