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Zhang Q, Fan S, Xu X, Du S, Zhu G, Jiang C, Xia SA, Li Q, Wang Q, Qian D, Zhang M, Xiao H, Chen G, Zeng Z, He J. Efficacy and Toxicity of Moderately Hypofractionated Radiation Therapy with Helical TomoTherapy Versus Conventional Radiation Therapy in Patients with Unresectable Stage III Non-Small Cell Lung Cancer Receiving Concurrent Chemotherapy: A Multicenter, Randomized Phase 3 Trial. Int J Radiat Oncol Biol Phys 2024; 120:422-431. [PMID: 38631536 DOI: 10.1016/j.ijrobp.2024.03.030] [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: 06/21/2023] [Revised: 03/08/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE The standard treatment schedule for unresectable stage III non-small cell lung cancer (NSCLC) is chemotherapy with concurrent radiation therapy (60 Gy delivered in 30 fractions), although moderately hypofractionated radiation therapy (Hypo-RT) has also been considered as an alternative strategy. This study aimed to compare the efficacy and toxicity of moderately Hypo-RT with helical TomoTherapy versus conventionally fractionated radiation therapy (Con-RT) in patients with unresectable stage III NSCLC receiving concurrent chemotherapy. METHODS AND MATERIALS In this randomized, multicenter, nonblinded phase 3 clinical trial, eligible patients were randomised at a 1:1 ratio to either the Hypo-RT group (60 Gy in 20 fractions) or Con-RT group (60 Gy in 30 fractions). All patients received 2 cycles of concurrent platinum-based chemotherapy plus 2 cycles of consolidation therapy. The primary endpoint was 3-year overall survival (OS) in the intention-to-treat population. The secondary endpoints were progression-free survival and treatment-related adverse events. RESULTS A total of 146 patients were enrolled from July 27, 2018, to November 1, 2021. The median follow-up was 46 months. The 3-year OS rates in the Hypo-RT and Con-RT groups were 58.4% and 38.4%, respectively (P = .02). The median OS from randomisation was 41 months in the Hypo-RT group and 30 months in the Con-RT group (hazard ratio, 0.61; 95% confidence interval, 0.40-0.94; P = .02). There was no significant difference in the rates of grade ≥2 treatment-related adverse events between the 2 groups. CONCLUSIONS Moderately Hypo-RT using helical TomoTherapy may improve OS in patients with unresectable stage III NSCLC, while maintaining toxicity rates.
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Affiliation(s)
- Qi Zhang
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shaonan Fan
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaohong Xu
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shisuo Du
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guangying Zhu
- Department of Radiation Oncology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Chaoyang Jiang
- Department of Oncology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Shi-An Xia
- Department of Oncology, Xinhua Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qiwen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qifeng Wang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Dong Qian
- Department of Radiation Oncology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Ming Zhang
- Department of Radiation Oncology, Yunnan Cancer Hospital & the Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Han Xiao
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Gang Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Jian He
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
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Emadi Torghabeh A, Aledavood SA, Soltani E, Akbari Oryani M, Akhlaghi S, Hosseini S, Fani Pakdel A, Taghizadeh Kermani A, Anvari K, Shahidsales S, Bahadorian S, Mashreghi Moghaddam S. Pathologic response evaluation of localized or locally advanced esophageal carcinoma to induction chemotherapy followed by preoperative concurrent chemotherapy and hypofractionated radiotherapy: a clinical trial. Front Oncol 2024; 14:1439730. [PMID: 39224811 PMCID: PMC11366607 DOI: 10.3389/fonc.2024.1439730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
Objective Esophageal cancer is a therapeutic challenge in most healthcare systems. Most patients present with locally advanced disease at diagnosis. Concurrent chemoradiotherapy (CRT) is the standard treatment for locally advanced esophageal carcinoma. Since achieving a complete pathological response in postoperative specimens following neoadjuvant therapy is associated with improved patient survival, this study was designed to evaluate the pathologic response of localized or locally advanced esophageal carcinoma to induction chemotherapy followed by preoperative concurrent chemotherapy and hypofractionated radiotherapy (HFR). Methods This single-arm clinical trial (IRCT20210623051676N1) evaluated patients with squamous cell carcinoma or adenocarcinoma of the esophagus, stage cT2-T4a N0 M0 or cT1-T4a N+ M0. Patients received 3-5 cycles of weekly induction chemotherapy with the paclitaxel (50 mg/m2) and carboplatin (AUC=2) regimen, followed by weekly concurrent CRT with the same chemotherapy regimen. The radiation dose was 40 Gy, delivered over 16 fractions, 5 days per week (2.5 Gray/fraction). Patients underwent surgery 4-6 weeks after completion of CRT. The surgical specimens were evaluated for pathological response. A p-value of < 0.05 was considered significant in all analyses. Results Out of 54 patients enrolled in this study, 45 completed the neoadjuvant protocol. Of these 45 patients, 32 underwent surgery and were finally analyzed. The mean age of the patients was 59.9 ± 8.6 years (range, 37-75 years). The location of the tumor was in the mid-thoracic esophagus in most patients (21, 65.6%) and the most common histological type was SCC (29, 90.6%). The median number of induction and concurrent chemotherapy cycles was 5 (4.8 ± 1.3 course, range, 1-10) and 3 (2.6 ± 0.8 course, range, 0-4), respectively. Among 45 patients who completed the neoadjuvant protocol, the most common toxicities were grade 3 neutropenia (15.6%), acute renal failure (4.4%), and odynophagia (37.8%). Nearly two-thirds of the patients experienced complete or near-complete responses (71.9%, 23 patients). Partial response was reported in 6 patients (18.8%) and poor response in 3 patients (9.4%). Conclusion Preoperative induction chemotherapy followed by HFR with concurrent chemotherapy has low toxicity and side effects, good tolerance, and significant efficacy in the treatment of patients with esophageal cancer. Clinical trial registration https://irct.behdasht.gov.ir/trial/59930, identifier NCT05745545.
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Affiliation(s)
- Ali Emadi Torghabeh
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Ehsan Soltani
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahsa Akbari Oryani
- Department of Pathology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeed Akhlaghi
- Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sare Hosseini
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Azar Fani Pakdel
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Kazem Anvari
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Shahrzad Bahadorian
- Department of Pathology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Zhou R, Liu F, Zhang H, Wang D, Zhang P, Zheng S, Liu Y, Chen L, Guo J, Zou Y, Rong YM, Liu H, Qiu B. Fraction Dose Escalation of Hypofractionated Radiotherapy with Concurrent Chemotherapy and Subsequent Consolidation Immunotherapy in Locally Advanced Non-Small Cell Lung Cancer: A Phase I Study. Clin Cancer Res 2024; 30:2719-2728. [PMID: 38652815 DOI: 10.1158/1078-0432.ccr-23-3600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/20/2024] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE This phase I trial aimed to determine the maximum tolerated fraction dose (MTFD) of hypofractionated radiotherapy (hypo-RT) combined with concurrent chemotherapy and subsequent consolidation immune checkpoint inhibitors (cICI) for patients with locally advanced non-small cell lung cancer. PATIENTS AND METHODS Split-course hypo-RT and hypoboost combined with concurrent chemotherapy was administered at three dose levels (DL), using a stepwise dose-escalation protocol. The sophisticated esophagus-sparing technique was implemented to restrict the dose to the esophagus. Patients who did not experience disease progression or unresolved ≥grade 2 (G2+) toxicities after RT received cICI. Each DL aimed to treat six patients. The MTFD was defined as the highest DL at which ≤2 patients of the six who were treated experienced treatment-related G3+ toxicity and ≤1 patient experienced G4+ toxicity within 12 months post-RT. RESULTS Eighteen patients were enrolled, with six patients in each DL. All patients completed hypo-RT and concurrent chemotherapy, and 16 (88.9%) received at least one infusion of cICI, with a median of 10 infusions. Within the 12-month assessment period, one patient in DL1 experienced G3 pneumonitis, and one patient in DL3 developed G3 tracheobronchitis. The MTFD was not reached. The objective response rate was 100%. With a median follow-up of 20.9 months, the 1-year overall survival and progression-free survival rates were 94.4% and 83.3%, respectively. CONCLUSIONS Utilizing the split-course hypo-RT and hypoboost approach, a fraction dose of 5 Gy to a total dose of 60 Gy, combined with concurrent chemotherapy and subsequent cICI, was well tolerated and yielded a promising objective response rate and survival outcomes.
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Affiliation(s)
- Rui Zhou
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China
- Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - FangJie Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China
- Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - HongMei Zhang
- Air Force Hospital of Southern Theater Command of the People's Liberation Army, Guangzhou, China
| | - DaQuan Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China
- Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - PengXin Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China
- Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - ShiYang Zheng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China
- Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - YiMei Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - Li Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
| | - JinYu Guo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China
- Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - YingYi Zou
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China
- Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Yu-Ming Rong
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of VIP Region, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Hui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China
- Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Bo Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in South China, Guangzhou, China
- Guangdong Provincial Clinical Research Center for Cancer, Guangzhou, China
- Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China
- Guangdong Association Study of Thoracic Oncology, Guangzhou, China
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Kwak YK, Kim KS, Yoo GS, Byun HK, Kim YJ, Kim YS, Sung SY, Song JH, Kim BH. Evidence-based clinical recommendations for hypofractionated radiotherapy: exploring efficacy and safety - Part 2. Lung (non-small cell lung cancer). Radiat Oncol J 2024; 42:104-115. [PMID: 38946072 PMCID: PMC11215506 DOI: 10.3857/roj.2023.00955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/26/2023] [Accepted: 12/26/2023] [Indexed: 07/02/2024] Open
Abstract
Several recent studies have investigated the use of hypofractionated radiotherapy (HFRT) for various cancers. However, HFRT for non-small cell lung cancer (NSCLC) with or without concurrent chemotherapy is not yet widely used because of concerns about serious side effects and the lack of evidence for improved treatment results. Investigations of HFRT with concurrent chemotherapy in NSCLC have usually been performed in single-arm studies and with a small number of patients, so there are not yet sufficient data. Therefore, the Korean Society for Radiation Oncology Practice Guidelines Committee planned this review article to summarize the evidence on HFRT so far and provide it to radiation oncology clinicians. In summary, HFRT has demonstrated promising results, and the reviewed data support its feasibility and comparable efficacy for the treatment of locally advanced NSCLC. The incidence and severity of esophageal toxicity have been identified as major concerns, particularly when treating large fraction sizes. Strategies, such as esophagus-sparing techniques, image guidance, and dose constraints, may help mitigate this problem and improve treatment tolerability. Continued research and clinical trials are essential to refine treatment strategies, identify optimal patient selection criteria, and enhance therapeutic outcomes.
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Affiliation(s)
- Yoo-Kang Kwak
- Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung Su Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gyu Sang Yoo
- Department of Radiation Oncology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yeon Joo Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon-Sil Kim
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo-Yoon Sung
- Department of Radiation Oncology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Ho Song
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byoung Hyuck Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul Metropolitan Government–Seoul National University Boramae Medical Center, Seoul, Republic of Korea
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Lester-Coll NH, Park HS. Stereotactic Body Radiotherapy in Locally Advanced Non-Small Cell Lung Cancer-Is This the Future? JAMA Oncol 2024; 10:360-361. [PMID: 38206616 DOI: 10.1001/jamaoncol.2023.5856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Affiliation(s)
- Nataniel H Lester-Coll
- Division of Radiation Oncology, University of Vermont Larner College of Medicine, Burlington
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
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Hui C, Brown E, Wong S, Das M, Wakelee H, Neal J, Ramchandran K, Myall NJ, Pham D, Xing L, Yang Y, Kovalchuk N, Yuan Y, Lu Y, Xiang M, Chin A, Diehn M, Loo BW, Vitzthum LK. Personalized Accelerated ChEmoRadiation (PACER) for Lung Cancer: Protocol for a Bayesian Optimal Phase I/II Trial. Clin Lung Cancer 2024; 25:186-189. [PMID: 38040540 PMCID: PMC11334968 DOI: 10.1016/j.cllc.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/07/2023] [Indexed: 12/03/2023]
Abstract
INTRODUCTION Prior attempts to escalate radiation dose for non-small cell lung cancer (NSCLC) have not improved survival. Given the high risk for cardiopulmonary toxicity with treatment and heterogenous presentation of locally advanced NSCLC, it is unlikely that a single dose regimen is optimal for all patients. This phase I/II trial aims to evaluate a novel treatment approach where the level of accelerated hypofractionation is determined by the predicted toxicity from dose to organs at risk (OARs). METHODS Patients ≥ 18 years old with lung cancer planned for fractionated radiotherapy to the lung with concurrent chemotherapy will be eligible. Radiation therapy (RT) will be delivered to a total dose of 60 to 66 Gy in 30, 25, or 20 fractions depending on the ability to meet constraints to key organs at risk including the lungs, heart, and esophagus. The primary endpoint is high grade pulmonary, esophageal, or cardiac toxicity. A Bayesian optimized design is used to determine stopping boundaries and evaluate the primary endpoint. CONCLUSION PACER will evaluate the safety and feasibility of personalized accelerated chemoradiotherapy for lung cancer.
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Affiliation(s)
- Caressa Hui
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Eleanor Brown
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Samantha Wong
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Millie Das
- Department of Medical Oncology, Stanford University, Stanford, CA
| | - Heather Wakelee
- Department of Medical Oncology, Stanford University, Stanford, CA
| | - Joel Neal
- Department of Medical Oncology, Stanford University, Stanford, CA
| | | | | | - Daniel Pham
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Lei Xing
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Yong Yang
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | | | - Ying Yuan
- Department of Biostatistics, Stanford University, Stanford, CA
| | - Ying Lu
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Stanford, CA
| | - Michael Xiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Alex Chin
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, CA.
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Wu TC, Luterstein E, Neilsen BK, Goldman JW, Garon EB, Lee JM, Felix C, Cao M, Tenn SE, Low DA, Kupelian PA, Steinberg ML, Lee P. Accelerated Hypofractionated Chemoradiation Followed by Stereotactic Ablative Radiotherapy Boost for Locally Advanced, Unresectable Non-Small Cell Lung Cancer: A Nonrandomized Controlled Trial. JAMA Oncol 2024; 10:352-359. [PMID: 38206614 PMCID: PMC10784998 DOI: 10.1001/jamaoncol.2023.6033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/15/2023] [Indexed: 01/12/2024]
Abstract
Importance Intrathoracic progression remains the predominant pattern of failure in patients treated with concurrent chemoradiation followed by a consolidation immune checkpoint inhibitor for locally advanced, unresectable non-small cell lung cancer (NSCLC). Objective To determine the maximum tolerated dose (MTD) and use of hypofractionated concurrent chemoradiation with an adaptive stereotactic ablative radiotherapy (SABR) boost. Design, Setting, and Participants This was an early-phase, single-institution, radiation dose-escalation nonrandomized controlled trial with concurrent chemotherapy among patients with clinical stage II (inoperable/patient refusal of surgery) or III NSCLC (American Joint Committee on Cancer Staging Manual, seventh edition). Patients were enrolled and treated from May 2011 to May 2018, with a median patient follow-up of 18.2 months. Patients advanced to a higher SABR boost dose if dose-limiting toxic effects (any grade 3 or higher pulmonary, gastrointestinal, or cardiac toxic effects, or any nonhematologic grade 4 or higher toxic effects) occurred in fewer than 33% of the boost cohort within 90 days of follow-up. The current analyses were conducted from January to September 2023. Intervention All patients first received 4 Gy × 10 fractions followed by an adaptive SABR boost to residual metabolically active disease, consisting of an additional 25 Gy (low, 5 Gy × 5 fractions), 30 Gy (intermediate, 6 Gy × 5 fractions), or 35 Gy (high, 7 Gy × 5 fractions) with concurrent weekly carboplatin/paclitaxel. Main Outcome and Measure The primary outcome was to determine the MTD. Results Data from 28 patients (median [range] age, 70 [51-88] years; 16 [57%] male; 24 [86%] with stage III disease) enrolled across the low- (n = 10), intermediate- (n = 9), and high- (n = 9) dose cohorts were evaluated. The protocol-specified MTD was not exceeded. The incidences of nonhematologic acute and late (>90 days) grade 3 or higher toxic effects were 11% and 7%, respectively. No grade 3 toxic effects were observed in the intermediate-dose boost cohort. Two deaths occurred in the high-dose cohort. Two-year local control was 74.1%, 85.7%, and 100.0% for the low-, intermediate-, and high-dose cohorts, respectively. Two-year overall survival was 30.0%, 76.2%, and 55.6% for the low-, intermediate-, and high-dose cohorts, respectively. Conclusions and Relevance This early-phase, dose-escalation nonrandomized controlled trial showed that concurrent chemoradiation with an adaptive SABR boost to 70 Gy in 15 fractions with concurrent chemotherapy is a safe and effective regimen for patients with locally advanced, unresectable NSCLC. Trial Registration ClinicalTrials.gov Identifier: NCT01345851.
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Affiliation(s)
- Trudy C. Wu
- Department of Radiation Oncology, University of California, Los Angeles
| | | | - Beth K. Neilsen
- Department of Radiation Oncology, University of California, Los Angeles
| | | | - Edward B. Garon
- Department of Medicine, University of California, Los Angeles
| | - Jay M. Lee
- Division of Thoracic Surgery, Department of Surgery, University of California, Los Angeles
| | - Carol Felix
- Department of Radiation Oncology, University of California, Los Angeles
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles
| | - Stephen E. Tenn
- Department of Radiation Oncology, University of California, Los Angeles
| | - Daniel A. Low
- Department of Radiation Oncology, University of California, Los Angeles
| | | | | | - Percy Lee
- Department of Radiation Oncology, University of California, Los Angeles
- Now with Department of Radiation Oncology, City of Hope Orange County, Lennar Foundation Cancer Center, Irvine, California
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Hui C, Marquez C, Lau B, Das M, Myall NJ, Roy M, Wakelee HA, Neal JW, Kovalchuk N, Chin A, Diehn M, Loo BW, Xiang M, Vitzthum LK. Patient Selection and Outcomes for Hypofractionated Accelerated Radiation and Concurrent Chemotherapy for Non-Small-Cell Lung Cancer. Clin Lung Cancer 2024; 25:e92-e100.e4. [PMID: 38065707 DOI: 10.1016/j.cllc.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 03/01/2024]
Abstract
PURPOSE/OBJECTIVES Adoption of hypofractionated accelerated radiation therapy (HART) with concurrent chemotherapy has been limited by toxicity concerns. We aimed to describe outcomes of patients treated with HART and concurrent chemotherapy and to evaluate dosimetry to organs at risk to guide patient selection. MATERIALS/METHODS We evaluated a retrospective cohort of NSCLC patients treated with concurrent chemotherapy with HART (>2.2 Gy per fraction) or standard fractionated radiation therapy (SFRT; 2-2.2 Gy fractions). Dosimetric parameters to key organs at risk were compared, and toxicity, patterns of recurrence and survival were calculated for the cohorts. RESULTS Fifty-three patients treated with HART were compared with 100 patients treated with SFRT. Median dose per fraction for the HART cohort was 2.75 Gy (range 2.4-3 Gy). HART patients had significantly lower doses to the lung, heart, and esophagus due to patient selection. The HART group and had rates of grade 2+ pneumonitis (9.4 vs. 19%, P = .16) and grade 2+ esophagitis (20.8 vs. 45%, P < .01) that compared favorably to SFRT. Cumulative incidence of in-field recurrence trended lower in the HART cohort (7.6% vs. 23.1%, P = .058). Among the HART group, 88.7% (47/53) met the newly proposed lung constraints based on the degree of hypofractionation CONCLUSION: In select patients with favorable dosimetry to organs at risk, definitive HART with concurrent chemotherapy achieved excellent local control with low toxicity. These results are being used to inform a prospective study on the safety and efficacy of HART with concurrent chemotherapy for select NSCLC patients.
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Affiliation(s)
- Caressa Hui
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Cesar Marquez
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Brianna Lau
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Millie Das
- Department of Medical Oncology, Stanford University, Stanford, CA
| | | | - Mohana Roy
- Department of Medical Oncology, Stanford University, Stanford, CA
| | | | - Joel W Neal
- Department of Medical Oncology, Stanford University, Stanford, CA
| | | | - Alex Chin
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Michael Xiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, CA.
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9
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Regnery S, de Colle C, Eze C, Corradini S, Thieke C, Sedlaczek O, Schlemmer HP, Dinkel J, Seith F, Kopp-Schneider A, Gillmann C, Renkamp CK, Landry G, Thorwarth D, Zips D, Belka C, Jäkel O, Debus J, Hörner-Rieber J. Pulmonary magnetic resonance-guided online adaptive radiotherapy of locally advanced: the PUMA trial. Radiat Oncol 2023; 18:74. [PMID: 37143154 PMCID: PMC10161406 DOI: 10.1186/s13014-023-02258-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Patients with locally-advanced non-small-cell lung cancer (LA-NSCLC) are often ineligible for surgery, so that definitive chemoradiotherapy (CRT) represents the treatment of choice. Nevertheless, long-term tumor control is often not achieved. Intensification of radiotherapy (RT) to improve locoregional tumor control is limited by the detrimental effect of higher radiation exposure of thoracic organs-at-risk (OAR). This narrow therapeutic ratio may be expanded by exploiting the advantages of magnetic resonance (MR) linear accelerators, mainly the online adaptation of the treatment plan to the current anatomy based on daily acquired MR images. However, MR-guidance is both labor-intensive and increases treatment times, which raises the question of its clinical feasibility to treat LA-NSCLC. Therefore, the PUMA trial was designed as a prospective, multicenter phase I trial to demonstrate the clinical feasibility of MR-guided online adaptive RT in LA-NSCLC. METHODS Thirty patients with LA-NSCLC in stage III A-C will be accrued at three German university hospitals to receive MR-guided online adaptive RT at two different MR-linac systems (MRIdian Linac®, View Ray Inc. and Elekta Unity®, Elekta AB) with concurrent chemotherapy. Conventionally fractioned RT with isotoxic dose escalation up to 70 Gy is applied. Online plan adaptation is performed once weekly or in case of major anatomical changes. Patients are followed-up by thoracic CT- and MR-imaging for 24 months after treatment. The primary endpoint is twofold: (1) successfully completed online adapted fractions, (2) on-table time. Main secondary endpoints include adaptation frequency, toxicity, local tumor control, progression-free and overall survival. DISCUSSION PUMA aims to demonstrate the clinical feasibility of MR-guided online adaptive RT of LA-NSCLC. If successful, PUMA will be followed by a clinical phase II trial that further investigates the clinical benefits of this approach. Moreover, PUMA is part of a large multidisciplinary project to develop MR-guidance techniques. TRIAL REGISTRATION ClinicalTrials.gov: NCT05237453 .
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Affiliation(s)
- Sebastian Regnery
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Chiara de Colle
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Chukwuka Eze
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Thieke
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Sedlaczek
- Division of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Julien Dinkel
- Department of Radiology, LMU Munich, Munich, Germany
| | - Ferdinand Seith
- Department of Radiology, University Hospital Tübingen, Tübingen, Germany
| | | | - Clarissa Gillmann
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - C Katharina Renkamp
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Jäkel
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
- Division of Medical Physics in Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- National Center for Radiation Oncology (NCRO), Heidelberg Institute for Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, Heidelberg, Germany.
- National Center for Tumor diseases (NCT), Heidelberg, Germany.
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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10
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Randomized, Multicenter, Phase 3 Study of Accelerated Fraction Radiation Therapy With Concomitant Boost to the Gross Tumor Volume Compared With Conventional Fractionation in Concurrent Chemoradiation in Patients With Unresectable Stage III Non-Small Cell Lung Cancer: The Korean Radiation Oncology Group 09-03 Trial. Int J Radiat Oncol Biol Phys 2023; 115:873-885. [PMID: 36280151 DOI: 10.1016/j.ijrobp.2022.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE We designed the Korean Radiation Oncology Group 09-03 phase III clinical trial to compare accelerated hypofractionated radiation therapy (RT) using a concomitant boost to the gross tumor volume (GTV) with conventionally fractionated 60-Gy RT in patients with stage III unresectable non-small cell lung cancer (NSCLC). METHODS AND MATERIALS A conventionally fractionated RT group (arm 1; 124 patients) received a 2-Gy daily dose to a total cumulative dose of 44 Gy to the planning target volume (PTV) in 22 fractions and 60 Gy to the GTV in 30 fractions over 6 weeks. A hypofractionated RT group (arm 2; 142 patients) received a 1.8-Gy daily dose to the PTV with a synchronous boost of 0.6 Gy to the GTV, for total cumulative doses of 45 Gy to the PTV and 60 Gy to the GTV in 25 fractions over 5 weeks. All patients received concurrent weekly chemotherapy consisting of paclitaxel and cisplatin. RESULTS The objective response rate of all patients was 86.5% (arm 1, 84.6%; arm 2, 88.1%; P = .612). The median overall survival was 26 months (arm 1, 26 months; arm 2, 27 months; P = .508). The median progression-free survival was 11 months (arm 1, 10 months; arm 2, 13 months; P = .295). The local tumor control rates at 2 and 5 years were 58.3% and 50.7%, respectively (arm 1, 62.4% and 51.0%, respectively; arm 2, 54.0% and 48.6%, respectively; P = .615). There were no significant between-group differences in the cumulative incidence of grade ≥3 radiation pneumonitis (P = .134) or radiation esophagitis (P = .539). CONCLUSIONS This clinical trial did not confirm the superiority of accelerated 2.4-Gy hypofractionated RT compared with conventional 2-Gy fractionation in patients with unresectable stage III NSCLC undergoing concurrent chemoradiation therapy.
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11
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Kraus RD, Weil CR, Abdel-Wahab M. Benefits of Adopting Hypofractionated Radiotherapy as a Standard of Care in Low-and Middle-Income Countries. JCO Glob Oncol 2022; 8:e2200215. [PMID: 36525619 PMCID: PMC10166538 DOI: 10.1200/go.22.00215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Ryan D Kraus
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Christopher R Weil
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - May Abdel-Wahab
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
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12
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Moderately Hypofractionated Proton Beam Therapy for Locally Advanced Non-Small Cell Lung Cancer: A New Way Forward for Dose Escalation? Int J Radiat Oncol Biol Phys 2022; 113:749-751. [PMID: 35772442 DOI: 10.1016/j.ijrobp.2022.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 11/20/2022]
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13
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Bucknell NW, Belderbos J, Palma DA, Iyengar P, Samson P, Chua K, Gomez D, McDonald F, Louie AV, Faivre-Finn C, Hanna GG, Siva S. Avoiding toxicity with lung radiation therapy: An IASLC perspective. J Thorac Oncol 2022; 17:961-973. [DOI: 10.1016/j.jtho.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/25/2022]
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14
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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: 6] [Impact Index Per Article: 3.0] [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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15
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Borghetti P, Guerini AE, Sangalli C, Piperno G, Franceschini D, La Mattina S, Arcangeli S, Filippi AR. Unmet needs in the management of unresectable stage III non-small cell lung cancer: a review after the 'Radio Talk' webinars. Expert Rev Anticancer Ther 2022; 22:549-559. [PMID: 35450510 DOI: 10.1080/14737140.2022.2069098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Stage III non-small cell lung cancer (NSCLC) is a variable entity, encompassing bulky primary tumors, nodal involvement or both. Multidisciplinary evaluation is essential to discuss multiple treatment options, to outline optimal management and to examine the main debated topics and critical issues not addressed by current trials and guidelines that influence daily clinical practice. AREAS COVERED From March to May 2021, 5 meetings were scheduled in a webinar format titled 'Radio Talk' due to the COVID-19 pandemic; the faculty was composed of 6 radiation oncologists from 6 different Institutions of Italy, all of them were the referring radiation oncologist for lung cancer treatment at their respective departments and were or had been members of AIRO (Italian Association of Radiation Oncology) Thoracic Oncology Study Group. The topics covered included: pulmonary toxicity, cardiac toxicity, radiotherapy dose, fractionation and volumes, unfit/elderly patients, multidisciplinary management. EXPERT OPINION The debate was focused on the unmet needs triggered by case reports, personal experiences and questions; the answers were often not univocal, however, the exchange of opinion and the contribution of different centers confirmed the role of multidisciplinary management and the necessity that the most critical issues should be investigated in clinical trials.
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Affiliation(s)
- Paolo Borghetti
- Department of Radiation Oncology, University and Spedali Civili Hospital, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Andrea Emanuele Guerini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Claudia Sangalli
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gaia Piperno
- Division of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Salvatore La Mattina
- Department of Radiation Oncology, University and Spedali Civili Hospital, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Stefano Arcangeli
- Department of Radiation Oncology, School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Andrea Riccardo Filippi
- Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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16
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Carbon ion radiotherapy in the management of non‐small cell lung cancer. PRECISION RADIATION ONCOLOGY 2022. [DOI: 10.1002/pro6.1146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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17
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Hoppe BS, Nichols RC, Flampouri S, Pankuch M, Morris CG, Pham DC, Mohindra P, Hartsell WF, Mohammed N, Chon BH, Kestin LL, Simone CB. Chemoradiation with Hypofractionated Proton Therapy in Stage II-III Non-Small Cell Lung Cancer: A YYY Phase 1/2 Trial. Int J Radiat Oncol Biol Phys 2022; 113:732-741. [PMID: 35306151 DOI: 10.1016/j.ijrobp.2022.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hypofractionated radiotherapy has been safely implemented into the treatment of early-stage non-small cell lung cancer (NSCLC), but not locally advanced (LA-) NSCLC due to prohibitive toxicities with photon therapy. Proton therapy, however, may allow for safe delivery of hypofractionated radiotherapy. We sought to determine whether hypofractionated proton therapy with concurrent chemotherapy improves overall survival. METHODS & MATERIALS The YYY conducted a phase 1/2 single-arm nonrandomized prospective multicenter trial from 2013 through 2018. Thirty-two patients were consented; 28 were eligible for on-study treatment. Patients had AJCCv7 stage II or III unresectable NSCLC and received hypofractionated proton therapy at 2.5-4 Gy per fraction to a total 60 Gy with concurrent platin-based doublet chemotherapy. The primary outcome was 1-year overall survival comparable to that reported for RTOG 9410 of 62%. RESULTS The trial closed early due to slow accrual, in part, from a competing trial, NRG 1308. Median patient age was 70 (range, 50-86) years. Patients were predominantly male (N=20), white (N=23), and prior smokers (N=27). Most had stage III NSCLC (N=22), 50% of whom had adenocarcinoma. After a median follow-up of 31 months, the 1- and 3-year overall survival rates were 89% and 49%, and progression-free survival rates were 58% and 32%, respectively. No acute grade 3 or higher esophagitis occurred. Only 14% developed a grade 3 or higher radiation-related pulmonary toxicity. CONCLUSION Hypofractionated proton therapy delivered at 2.5-3.53 Gy per fraction to a total 60 Gy with concurrent chemotherapy provides promising survival and additional examination through larger studies may be warranted.
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Affiliation(s)
- Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida.
| | - Romaine C Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia
| | - Mark Pankuch
- Northwestern Medicine Proton Center, Warrenville, Illinois
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Dat C Pham
- Baptist MD Anderson Cancer Center, Jacksonville, Florida
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | | | | | - Brian H Chon
- ProCure Proton Therapy Center, Somerset, New Jersey
| | - Larry L Kestin
- MHP Radiation Oncology Institute/GenesisCare USA, Farmington Hills, Michigan
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center and New York Proton Center, New York, New York
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18
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Contreras J, Srivastava A, Samson P, DeWees T, Govindan R, Baggstrom MQ, Morgensztern D, Roach M, Badiyan SN, Bradley J, Waqar S, Robinson C. Phase I Study of Accelerated Hypofractionated Proton Therapy and Chemotherapy for Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2022; 113:742-748. [PMID: 35074432 DOI: 10.1016/j.ijrobp.2022.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/28/2021] [Accepted: 01/11/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the maximum tolerated dose (MTD) of hypofractionated proton beam radiation therapy (PBT) with concurrent weekly carboplatin/paclitaxel in patients with stage II-III non-small cell lung cancer (NSCLC). MATERIALS/METHODS A phase I trial was designed using the Time to Event-Continuous Reassessment Method (TITE-CRM). MTD was defined as the dose associated with a 20% probability of CTCAE protocol-specified serious adverse events (SAEs). Starting dose was 3.5 Gy/fx for 15 fractions with 2 potential escalation and de-escalation levels in 0.25 Gy/fx increments. Chemotherapy was weekly concurrent carboplatin/paclitaxel with 2 cycles of optional consolidation carboplatin/paclitaxel. RESULTS From 5/2015-9/2016, 23 patients enrolled at a single institution. Of 20 evaluable, median age was 66.5 years (range, 54-89) and 12 (60%) were male. Fourteen had squamous cell (70%), and 15 (75%) were stage IIIA. Nineteen (95%) completed all 3 cycles of concurrent chemotherapy, and 16 (80%) received at least one cycle of consolidation chemotherapy. Within the 6-month TITE-CRM assessment window, no SAEs were reported, and most patients were treated at the highest dose-level. Dose-level assignment was 52.5 Gy (n=2), 56.25 Gy (n=4), and 60 Gy (n=14). The posterior probability of dose limiting toxicity (DLT) for 60 Gy was 5.3% (95% CI, 1-18.1%). Acute, non-serious AEs included grade 2 esophagitis in 7 patients (35%) and grade 2 pneumonitis in 1 patient (5%). At a median follow-up of 20.3 months for all and 44.9 months for living patients, there were no grade 4 or 5 AEs, though there were three (21% at 24 months) SAEs outside of the dose-escalation window. The 2-year overall survival, local, regional, and distant control rates were 48%, 84%, 77%, and 79%, respectively. CONCLUSIONS Hypofractionated PBT and chemotherapy up to 60 Gy in 15 fractions is acutely well tolerated, with high rates of locoregional control and overall survival, though late SAEs were noted.
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Affiliation(s)
| | | | - Pamela Samson
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | | | | | - Saiama Waqar
- Washington University School of Medicine, St. Louis, Missouri
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Qiu B, Xiong M, Luo Y, Li Q, Chen N, Chen L, Guo S, Wang B, Huang X, Lin M, Hu N, Guo J, Liang Y, Fang Y, Li J, Yang Y, Huang Y, Zhang L, Wang S, Liu H. Hypofractionated Intensity Modulated Radiation Therapy With Concurrent Chemotherapy in Locally Advanced Non-Small Cell Lung Cancer: A Phase II Prospective Clinical Trial (GASTO1011). Pract Radiat Oncol 2021; 11:374-383. [PMID: 34157448 DOI: 10.1016/j.prro.2021.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE We aimed to explore the efficacy and toxicity of split-course hypofractionated radiotherapy with concurrent chemotherapy (HRT-CHT) in patients with locally advanced non-small cell lung cancer (LANSCLC) in this single-arm, phase II study. METHODS LANSCLC patients were considered eligible if their forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC%) and carbon monoxide diffusing capacity (DLCO%) were ≥40% and ≥45%, respectively. HRT-CHT using the IMRT technique was administered with 51 Gy in 17 fractions as the first course followed by a break. Patients without disease progression or persistent ≥grade 2 toxicities had an HRT-CHT of 15-18 Gy in 5-6 fractions as a boost. The primary endpoint was progression-free survival (PFS), and the secondary endpoint was overall survival (OS). RESULTS Eighty-nine patients were enrolled and analyzed. The median follow-up was 29.5 months for all patients and 35.3 months for the survivors. The objective response rate was 97.8%; the median PFS and OS were 11.0 months and 27.0 months, respectively. Grade 3 acute esophagitis/pneumonitis occurred in 15 (16.9%)/7 (7.9%) patients. Grade 3/5 late pneumonitis occurred in 2 (2.2%)/1 (1.1%) patients. Of the 78 (87.6%) who completed the split-course HRT-CHT per protocol, patients with better FEV1/FVC% and DLCO% after the break had significantly better OS (for the FEV/FVC1%≥80% vs 60-79% vs 41-59% groups, 2-year OS values were 57.2% vs 56.9% vs 0%, respectively, p=0.024; for the DLCO%≥80% vs 60-79% vs 45-59% groups, 2-year OS values were 70.4% vs 48.4% vs 37.5%, respectively, p=0.049). CONCLUSIONS Split-course HRT-CHT achieved a promising response rate and survival with tolerable toxicity in LANSCLC. Pulmonary function tests are necessary indicators for radiation treatment planning and dose escalation.
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Affiliation(s)
- Bo Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Mai Xiong
- Department of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - YiFeng Luo
- Pulmonary and Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - QiWen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - NaiBin Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Li Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - SuPing Guo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Bin Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - XiaoYan Huang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - MaoSheng Lin
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Nan Hu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - JinYu Guo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Ying Liang
- Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Yi Fang
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou
| | - JiBin Li
- Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou.
| | - YunPeng Yang
- Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou
| | - Yan Huang
- Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou
| | - Li Zhang
- Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou
| | - SiYu Wang
- Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Hui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou.
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20
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Lung Cancer Radiotherapy: Simulation and Analysis Based on a Multicomponent Mathematical Model. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:6640051. [PMID: 34012477 PMCID: PMC8105103 DOI: 10.1155/2021/6640051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/15/2021] [Indexed: 12/25/2022]
Abstract
Background Lung cancer has been one of the most deadly illnesses all over the world, and radiotherapy can be an effective approach for treating lung cancer. Now, mathematical model has been extended to many biomedical fields to give a hand for analysis, evaluation, prediction, and optimization. Methods In this paper, we propose a multicomponent mathematical model for simulating the lung cancer growth as well as radiotherapy treatment for lung cancer. The model is digitalized and coded for computer simulation, and the model parameters are fitted with many research and clinical data to provide accordant results along with the growth of lung cancer cells in vitro. Results Some typical radiotherapy plans such as stereotactic body radiotherapy, conventional fractional radiotherapy, and accelerated hypofractionated radiotherapy are simulated, analyzed, and discussed. The results show that our mathematical model can perform the basic work for analysis and evaluation of the radiotherapy plan. Conclusion It will be expected that in the near future, mathematical model will be a valuable tool for optimization in personalized medical treatment.
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21
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Chen N, Li Q, Wang S, Xiong M, Luo Y, Wang B, Chen L, Lin M, Jiang X, Fang J, Guo S, Guo J, Hu N, Ai X, Wang D, Chu C, Liu F, Long H, Wang J, Qiu B, Liu H. Hypo-fractionated radiotherapy with concurrent chemotherapy for locoregional recurrence of non-small cell lung cancer after complete resection: A prospective, single-arm, phase II study (GASTO-1017). Lung Cancer 2021; 156:82-90. [PMID: 33933895 DOI: 10.1016/j.lungcan.2021.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/25/2021] [Accepted: 04/22/2021] [Indexed: 09/30/2022]
Abstract
OBJECTIVES To explore the efficacy and toxicities of split-course hypo-fractionated radiotherapy with concurrent chemotherapy (HFRT-CHT) with intensity modulated radiotherapy (IMRT) technique in non-small cell lung cancer (NSCLC) patients with postoperative locoregional recurrence (LRR). MATERIALS AND METHODS NSCLC patients were eligible if confirmed as LRR disease without distant metastasis after complete resection. HFRT-CHT using IMRT technique was administered with 51 Gy in 17 fractions or 40 Gy in 10 fractions as the first course followed by a break. Patients with no disease progression and no persistent Grade ≥2 toxicities had the second course of 15 Gy in 5 fractions or 28 Gy in 7 fractions as a boost. The primary endpoint was progression-free survival (PFS). RESULTS Fifty-eight patients were enrolled and analyzed. With a median follow-up of 23.9 months for all, the 2-year and 3-year PFS rate was 59.7 % and 46.4 %, the 2-year and 3-year OS rate was 72.5 % and 52.2 %, respectively, and a favorable objective response rate of 95.9 % was obtained after the whole courses protocol. Grade 3 acute pneumonitis and esophagitis occurred in 2 (3.4 %) and 7 (12.1 %) patients, and fatal pneumonitis was reported in one case (1.7 %). Exploratory subgroup analysis showed that performance status (PS) (PS 0 vs. 1: 2-year PFS, 88.1 % vs. 46.9 %,P = 0.001; 2-year OS, 100 % vs. 59.4 %, P < 0.001), recurrence site (single vs. multiple: 2-year PFS, 93.8 % vs. 47.4 %, P = 0.008; 2-year OS, 100 % vs. 63.0 %, P = 0.001), and gross tumor volume (GTV) (<50cm3 vs. ≥ 50cm3: 2-year PFS, 70.6 % vs. 46.2 %, P = 0.024; 2-year OS, 85.6 % vs. 57.4 %, P = 0.034) were significantly associated with PFS and OS. CONCLUSION Split-course HFRT-CHT with IMRT technique achieved promising disease control and satisfactory survival with moderate toxicities in postoperative LRR of NSCLC. Good PS, a single recurrence site and GTV<50cm3 tended to have prolonged PFS and OS. Early detection of LRR may improve the efficacy of HFRT-CHT.
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Affiliation(s)
- NaiBin Chen
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - QiWen Li
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - SiYu Wang
- Department of Thoracic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Mai Xiong
- Department of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - YiFeng Luo
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bin Wang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Li Chen
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - MaoSheng Lin
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - XiaoBo Jiang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - JianLan Fang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - SuPing Guo
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - JinYu Guo
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Nan Hu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - XinLei Ai
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - DaQuan Wang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Chu Chu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - FangJie Liu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Hao Long
- Department of Thoracic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - JunYe Wang
- Department of Thoracic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Bo Qiu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China.
| | - Hui Liu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China.
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22
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Rico M, Martínez M, Rodríguez M, Rosas L, Barco A, Martínez E. Hypofractionation and Stereotactic Body Radiation Therapy in Inoperable Locally Advanced Non-small Cell Lung Cancer. J Clin Transl Res 2021; 7:199-208. [PMID: 34104822 PMCID: PMC8177839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/24/2021] [Accepted: 03/29/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND AND AIM Radiotherapy (RT) plays a key role in the control of locally advanced non-small cell lung cancer (LA-NSCLC). Throughout the years, different doses and fractionations of RT have been used in an attempt to optimize the results. Recently, special interest has been given to hypofractionation (hypoRT) and stereotactic body radiation therapy (SBRT). HypoRT is a relatively widespread treatment, although the accompanying level of evidence is limited. For its part, SBRT has been used specially to overdose specific areas of the disease as a boost after radiochemotherapy. In both cases, the study of how to integrate these RT tools with chemotherapy and immunotherapy is fundamental. In addition, the 2020 COVID-19 pandemic situation has sparked increased interest in hypofractionated treatments. In this review, we analyze the role of SBRT and hypoRT in the management of LA-NSCLC in accordance with current scientific evidence. RELEVANCE FOR PATIENTS The objective of this article is to introduce professionals to the role that hypoRT and SBRT can play in the treatment of LA-NSCLC to offer the best treatment to their patients.
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Affiliation(s)
- Mikel Rico
- 1Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona 31008, Navarra, Spain,2Health Research Institute of Navarre (IdiSNA), Navarra Biomed, Pamplona 31008, Navarra, Spain,
Corresponding author Mikel Rico Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona 31008, Navarra, Spain/Health Research Institute of Navarre (IdiSNA), Navarra Biomed, Pamplona 31008, Navarra, Spain E-mail:
| | - Maribel Martínez
- 1Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona 31008, Navarra, Spain
| | - Maitane Rodríguez
- 1Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona 31008, Navarra, Spain
| | - Lombardo Rosas
- 1Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona 31008, Navarra, Spain
| | - Andrea Barco
- 1Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona 31008, Navarra, Spain
| | - Enrique Martínez
- 1Department of Radiation Oncology, Complejo Hospitalario de Navarra, Pamplona 31008, Navarra, Spain
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23
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Kepka L, Socha J. Dose and fractionation schedules in radiotherapy for non-small cell lung cancer. Transl Lung Cancer Res 2021; 10:1969-1982. [PMID: 34012807 PMCID: PMC8107746 DOI: 10.21037/tlcr-20-253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the field of radiotherapy (RT), the issues of total dose, fractionation, and overall treatment time for non-small cell lung cancer (NSCLC) have been extensively investigated. There is some evidence to suggest that higher treatment intensity of RT, when given alone or sequentially with chemotherapy (CHT), is associated with improved survival. However, there is no evidence that the outcome is improved by RT at a higher dose and/or higher intensity when it is used concurrently with CHT. Moreover, some reports on the combination of full dose CHT with a higher biological dose of RT warn of the significant risk posed by such intensification. Stereotactic body radiotherapy (SBRT) provides a high rate of local control in the management of early-stage NSCLC through the use of high ablative doses. However, in centrally located tumors the use of SBRT may carry a risk of serious damage to the great vessels, bronchi, and esophagus, owing to the high ablative doses needed for optimal tumor control. There is a similar problem with moderate hypofractionation in radical RT for locally advanced NSCLC, and more evidence needs to be gathered regarding the safety of such schedules, especially when used in combination with CHT. In this article, we review the current evidence and questions related to RT dose/fractionation in NSCLC.
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Affiliation(s)
- Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
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24
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Wang B, Wang DQ, Lin MS, Lu SP, Zhang J, Chen L, Li QW, Cheng ZK, Liu FJ, Guo JY, Liu H, Qiu B. Accumulation of the delivered dose based on cone-beam CT and deformable image registration for non-small cell lung cancer treated with hypofractionated radiotherapy. BMC Cancer 2020; 20:1112. [PMID: 33198676 PMCID: PMC7670776 DOI: 10.1186/s12885-020-07617-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022] Open
Abstract
Background This study aimed to quantify the dosimetric differences between the planned and delivered dose to tumor and normal organs in locally advanced non-small cell lung cancer (LANSCLC) treated with hypofractionated radiotherapy (HRT), and to explore the necessity and identify optimal candidates for adaptive radiotherapy (ART). Methods Twenty-seven patients with stage III NSCLC were enrolled. Planned radiation dose was 51Gy in 17 fractions with cone-beam CT (CBCT) acquired at each fraction. Virtual CT was generated by deformable image registration (DIR) of the planning CT to CBCT for dose calculation and accumulation. Dosimetric parameters were compared between original and accumulated plans using Wilcoxon signed rank test. Correlations between dosimetric differences and clinical variables were analyzed using Mann-Whitney U test or Chi-square test. Results Patients had varied gross tumor volume (GTV) reduction by HRT (median reduction rate 11.1%, range − 2.9-44.0%). The V51 of planning target volume for GTV (PTV-GTV) was similar between original and accumulated plans (mean, 88.2% vs. 87.6%, p = 0.452). Only 11.1% of patients had above 5% relative decrease in V51 of PTV-GTV in accumulated plans. Compared to the original plan, limited increase (median relative increase < 5%) was observed in doses of total lung (mean dose, V20 and V30), esophagus (mean dose, maximum dose) and heart (mean dose, V30 and V40) in accumulated plans. Less than 30% of patients had above 5% relative increase of lung or heart doses. Patients with quick tumor regression or baseline obstructive pneumonitis showed more notable increase in doses to normal structures. Patients with baseline obstructive atelectasis showed notable decrease (10.3%) in dose coverage of PTV-GTV. Conclusions LANSCLC patients treated with HRT had sufficient tumor dose coverage and acceptable normal tissue dose deviation. ART should be applied in patients with quick tumor regression and baseline obstructive pneumonitis/atelectasis to spare more normal structures. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12885-020-07617-3.
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Affiliation(s)
- Bin Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Da Quan Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Mao Sheng Lin
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Shi Pei Lu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jun Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Li Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Qi Wen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Zhang Kai Cheng
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Fang Jie Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jin Yu Guo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Hui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
| | - Bo Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
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25
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Singh AP, Berman AT, Marmarelis ME, Haas AR, Feigenberg SJ, Braun J, Ciunci CA, Bauml JM, Cohen RB, Kucharczuk JC, Shulman LN, Langer CJ, Aggarwal C. Management of Lung Cancer During the COVID-19 Pandemic. JCO Oncol Pract 2020; 16:579-586. [PMID: 32453656 DOI: 10.1200/op.20.00286] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has had a devastating impact around the world. With high rates of transmission and no curative therapies or vaccine yet available, the current cornerstone of management focuses on prevention by social distancing. This includes decreased health care contact for patients. Patients with lung cancer are a particularly vulnerable population, where the risk of mortality from cancer must now be balanced by the potential risk of a life-threatening infection. In these unprecedented times, a collaborative and multidisciplinary approach is required to streamline but not compromise care. We have developed guidelines at our academic cancer center to standardize management of patients with lung cancer across our health care system and provide guidance to the larger oncology community. We recommend that general principles of lung cancer treatment continue to be followed in most cases where delays could result in rapid cancer progression. We recognize that our recommendations may change over time based on clinical resources and the evolving nature of the COVID-19 pandemic. In principle, however, treatment paradigms must continue to be individualized, with careful consideration of risks and benefits of continuing or altering lung cancer-directed therapy.
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Affiliation(s)
- Aditi P Singh
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Philadelphia, PA
| | - Abigail T Berman
- Abramson Cancer Center, Philadelphia, PA.,Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Melina E Marmarelis
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Philadelphia, PA
| | - Andrew R Haas
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steven J Feigenberg
- Abramson Cancer Center, Philadelphia, PA.,Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | | | - Christine A Ciunci
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Philadelphia, PA
| | - Joshua M Bauml
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Philadelphia, PA
| | - Roger B Cohen
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Philadelphia, PA
| | | | - Lawrence N Shulman
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Philadelphia, PA
| | - Corey J Langer
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Philadelphia, PA
| | - Charu Aggarwal
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA.,Abramson Cancer Center, Philadelphia, PA
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26
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Glinski K, Socha J, Wasilewska-Tesluk E, Komosinska K, Kepka L. Accelerated hypofractionated radiotherapy with concurrent full dose chemotherapy for locally advanced non-small cell lung cancer: A phase I/II study. Radiother Oncol 2020; 148:174-180. [PMID: 32388152 DOI: 10.1016/j.radonc.2020.04.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/25/2020] [Accepted: 04/21/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION We report the results of toxicity and survival in stage III NSCLC patients treated with concurrent accelerated hypofractionated AHRT-CHT within a prospective study. METHODS 92 patients received 3D-CRT or IMRT-planned RT: 58.8 Gy /21 fractions (2.8 Gy/fraction, 4 weeks) with 2 cycles of CHT (Cisplatin 80 mg/m2 D1 and D22; and Vinorelbine 25 mg/m2, D1, D8, D22, and D29) started with D1 of RT. Non-hematological toxicity was evaluated using RTOG-EORTC criteria, every week during treatment, one month after treatment completion, and every three months thereafter. RESULTS Two patients did not receive the prescribed RT dose; 22 (24%) received only one CHT cycle. Median follow-up was 21.5 months (range: 1-65) for all patients and 32 months (range: 8-65) for living patients. There were: 13 (14%) cases of grade ≥III acute esophageal toxicity; 3 grade III acute pneumonitis, and 2 grade III late pulmonary toxicities. Two toxic deaths occurred within 3 months after treatment: fatal hemoptysis (1) and complications of esophageal toxicity (1). Five other deaths that occurred within one year after treatment were probably treatment-related: lung abscess (1), fatal hemoptysis (2), death from undetermined cause (2). Median overall survival was 38 months (95%CI:27-49), median progression free survival was 25 months (95%CI:14-36). CONCLUSIONS Survival rates are encouraging, but the observed rate of toxic and probably toxic deaths is of potential concern. We proceed with the use of AHRT with concomitant full dose CHT, but patients with large PTV and major vascular abutment are excluded due to potentially increased risk of toxic death.
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Affiliation(s)
- Krzysztof Glinski
- Independent Public Health Care Facility of the Ministry of the Interior and Warmian & Mazurian Oncology Centre, Olsztyn, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Ewa Wasilewska-Tesluk
- Independent Public Health Care Facility of the Ministry of the Interior and Warmian & Mazurian Oncology Centre, Olsztyn, Poland; Department of Oncology, University of Warmia & Mazury, Olsztyn, Poland
| | | | - Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland.
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Hoppe BS, Nichols RC, Flampouri S, Li Z, Morris CG, Pham DC, Mohindra P, Hartsell W, Mohammed N, Chon BH, Simone CB. Hypofractionated Proton Therapy with Concurrent Chemotherapy for Locally Advanced Non-Small Cell Lung Cancer: A Phase 1 Trial from the University of Florida and Proton Collaborative Group. Int J Radiat Oncol Biol Phys 2020; 107:455-461. [PMID: 32251754 DOI: 10.1016/j.ijrobp.2020.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/12/2020] [Accepted: 03/16/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE We report the safety data from the first multicenter phase 1 trial investigating the use of hypofractionated proton therapy with concurrent chemotherapy for patients with stage II or III non-small cell lung cancer. METHODS AND MATERIALS From 2013 through 2018, patients with newly diagnosed stage II or III non-small cell lung cancer were enrolled in a multicenter phase 1 clinical trial evaluating concurrent chemotherapy with increasing dose-per-fraction proton therapy. This was a stepwise 5 + 2 dose-intensification protocol with the following dose arms: (1) 2.5 GyRBE per fraction to 60 GyRBE; (2) 3.0 GyRBE per fraction to 60 GyRBE; (3) 3.53 GyRBE per fraction to 60.01 GyRBE; and (4) 4.0 GyRBE per fraction to 60 GyRBE. A dose arm was considered tolerable if no radiation therapy-attributable severe adverse event (SAE) occurred within 90 days of treatment among 5 patients enrolled on the arm or if 1 SAE occurred among 7 patients enrolled. Dose constraints to the heart, brachial plexus, and spinal cord were more conservative at higher doses per fraction. RESULTS The study closed early because of slow accrual and competing enrollment in NRG 1308 before accrual was met, with no maximum tolerated dose identified. Eighteen patients were treated, including 5 patients on arms 1 and 2, 7 patients on arm 3, and 1 patient on arm 4. Two SAEs occurred among 7 patients treated at 3.53 GyRBE per fraction; however, per outside expert review, both were attributed to chemotherapy and unrelated to radiation therapy. CONCLUSIONS Hypofractionated proton therapy delivered at 2.5 to 3.53 GyRBE per fraction to a dose of 60 GyRBE with concurrent chemotherapy has an acceptable toxicity profile. Further exploration of this regimen is warranted on a phase 2 clinical trial.
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Affiliation(s)
- Bradford S Hoppe
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida.
| | - Romaine C Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Stella Flampouri
- Department of Radiation Oncology, Emory Winship Cancer Institute, Atlanta, Georgia
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Dat C Pham
- Department of Medical Oncology, University of Florida College of Medicine, Jacksonville, Florida
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - William Hartsell
- Department of Radiation Oncology, Northwestern Medicine, Chicago, Illinois
| | | | - Brian H Chon
- ProCure Proton Therapy Center, New Jersey, Somerset, New Jersey
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Iocolano M, Wild AT, Hannum M, Zhang Z, Simone CB, Gelblum D, Wu AJ, Rimner A, Shepherd AF. Hypofractionated vs. conventional radiation therapy for stage III non-small cell lung cancer treated without chemotherapy. Acta Oncol 2020; 59:164-170. [PMID: 31608751 DOI: 10.1080/0284186x.2019.1675907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: Patients with unresectable locally advanced NSCLC who refuse or are not candidates for chemotherapy often receive radiation therapy (RT) alone. Hypofractionated RT (HFRT) regimens are becoming increasingly common. An analysis of the National Cancer Database (NCDB) was performed to evaluate the practice patterns and outcomes of HFRT vs. conventionally fractionated RT (CFRT) in patients with stage III NSCLC undergoing definitive RT alone.Material and methods: The NCDB was queried for all patients with stage III NSCLC diagnosed between 2004 and 2014 who received RT alone. CFRT was defined as patients treated to a total dose of 60-80 Gy in 1.8-2 Gy daily fractions. HFRT was defined as patients treated to a total dose of 50-80 Gy in 2.25-4 Gy fractions. Logistic regression, univariable and multivariable analyses (MVAs) for overall survival (OS) and propensity score matched analyses (PSMAs) were performed.Results: A total of 6490 patients were evaluated: 5378 received CFRT and 1112 received HFRT. Median CFRT dose was 66 Gy in 2 Gy fractions vs. 58.5 Gy in 2.5 Gy fractions for HFRT. HFRT was associated with older age, lower biological effective dose (BED10), academic facility type, higher T-stage and lower N-stage. On initial analysis, HFRT was associated with inferior OS (median 9.9 vs. 11.1 months, p<.001), but after adjusting for the imbalance in covariates such as age, BED10, T-stage and N-stage using PSMA, the difference in survival was no longer significant (p=.1).Conclusions: In the appropriate clinical context, HFRT can be an option for patients with locally advanced NSCLC who are not candidates for chemotherapy or surgical resection. HFRT needs to be further studied in prospective trials to evaluate toxicity and tumor control.
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Affiliation(s)
| | - Aaron T. Wild
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Margaret Hannum
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B. Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphna Gelblum
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Annemarie F. Shepherd
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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29
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Hughes RT, Helis CA, Soike MH, Levine BJ, Farris M, Blackstock AW. Moderately Hypofractionated Radiotherapy Alone for Stage I-IIB Non-small Cell Lung Cancer. Cureus 2019; 11:e4969. [PMID: 31453041 PMCID: PMC6701921 DOI: 10.7759/cureus.4969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/22/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The optimal management of patients with early non-small cell lung cancer (NSCLC) not amenable to surgical resection or stereotactic body radiotherapy (SBRT) or those with hilar nodal involvement ineligible for surgery or concurrent chemoradiotherapy is unclear. This report describes survival outcomes and toxicity profiles of patients treated with hypofractionated radiotherapy (HRT) alone. METHODS A total of 52 patients with Stage I-IIB NSCLC treated with HRT alone between 2010-2018 were reviewed. Patients were categorized as having ultracentral tumors if the planning target volume contacted or overlapped the proximal bronchial tree, esophagus, pulmonary vein or artery. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method and the competing risk cumulative incidence of locoregional failure (LRF) and distant failure (DF) were estimated using death without failure as a competing risk. Pneumonitis and esophagitis rates were evaluated as per Acute Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. RESULTS Of the 52 patients analyzed, 50 patients were treated with radiotherapy alone to a dose of 70.2 Gy in 26 fractions, one patient was treated with 68 Gy in 25 fractions and one patient was treated with 65 Gy in 26 fractions. The median age was 72 (range 48-89), 42% of patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 2-3, 46% were stage I and 54% were stage II. Hilar nodal involvement was present in 21% of patients and 74% of node-negative patients had ultracentral primary tumors. Median OS was 39.6 months and the median PFS was 21.0 months. Overall three-year cumulative incidence of LRF and DF were 32% and 34%, respectively. Grade 3 pneumonitis occurred in two (4%) patients. No grade 3+ acute esophagitis or grade 4-5 toxicities were observed. CONCLUSION Hypofractionated thoracic radiotherapy consisting of 70.2 Gy is well-tolerated and results in favorable locoregional control for stage I-IIB patients who are not candidates for SBRT, surgery, or concurrent chemoradiotherapy.
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Affiliation(s)
- Ryan T Hughes
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Corbin A Helis
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Michael H Soike
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Beverly J Levine
- Epidemiology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Michael Farris
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
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Lyu J, Liu T, Li T, Li F, Wang Q, Wang J, Han Y, Wang J, Zhang J, Peng L, Lang J. Comparison of efficacy, safety, and costs between neoadjuvant hypofractionated radiotherapy and conventionally fractionated radiotherapy for esophageal carcinoma. Cancer Med 2019; 8:3710-3718. [PMID: 31119872 PMCID: PMC6639169 DOI: 10.1002/cam4.2250] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 12/17/2022] Open
Abstract
Background We compared the efficacy, safety, and costs of hypofractionated radiotherapy (HFRT) and conventional fractionated radiotherapy (CFRT) for the neoadjuvant treatment of esophageal cancer. Materials and Methods Overall, 110 patients with esophageal cancer treated with neoadjuvant chemoradiotherapy from October 2002 to July 2017 were retrospectively included and divided into a HFRT group (42 patients received 30 Gray [Gy]/10 fractions for 2 weeks) and a CFRT group [68 patients received 40 Gy/20 fractions for 4 weeks]. Concurrent chemotherapy comprised cisplatin combined with either 5‐FU or taxane. Surgery was performed 3‐8 weeks after radiotherapy. We compared the outcomes, adverse events, and costs between the two groups. Results Pathological downstaging was achieved in 78.6% of the HFRT group and 83.8% of the CFRT group (P = 0.612). Compared with the CFRT group, the HFRT group had similar pathological complete response (pCR) (33.3% vs 35.3%; P = 0.834), median overall survival (OS) (40.8 months vs 44.9 months; P = 0.772) and progression free survival (32.7 months vs 35.4 months; P = 0.785). The perioperative complication rates were also similar between the groups, but the treatment time and costs were significantly reduced in the HFRT group (P < 0.05). Finally, multivariate analysis identified cN0 stage, pathological downstaging and pCR as independent predictors of better OS. Conclusion Preoperative HFRT is effective and safe for esophageal cancer. Moreover, it is similar to CFRT in terms of overall survival and toxicity and is cost effective and less time consuming.
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Affiliation(s)
- Jiahua Lyu
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Tao Liu
- Ya'an people's hospital, Ya'an, China
| | - Tao Li
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Fang Li
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qifeng Wang
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jie Wang
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yongtao Han
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Junchao Wang
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jun Zhang
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lin Peng
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jinyi Lang
- Sichuan Cancer Hospital and Institute, Chengdu, China.,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Hypofractionated Concomitant Chemoradiation in Inoperable Locally Advanced Non-small Cell Lung Cancer: A Report on 100 Patients and a Systematic Review. Clin Oncol (R Coll Radiol) 2018; 31:e1-e10. [PMID: 30415784 DOI: 10.1016/j.clon.2018.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/25/2018] [Indexed: 01/14/2023]
Abstract
AIMS Concomitant chemoradiation is the standard of care in patients with inoperable non-small cell lung cancer. The purpose of this study was to analyse the survival outcome and toxicity data of using hypofractionated chemoradiation. MATERIALS AND METHODS One hundred patients were treated from June 2011 to November 2016. Treatment consisted of 55 Gy in 20 daily fractions concurrently with split-dose cisplatin vinorelbine chemotherapy over 4 weeks followed by two cycles of cisplatin vinorelbine only. Survival was estimated using Kaplan-Meier and Cox regression was carried out for known prognostic factors. A systematic search of literature was conducted using Medline, Embase and Cochrane databases and relevant references included. RESULTS In total, 97% of patients completed radiotherapy and 73% of patients completed all four cycles of chemotherapy. One patient died of a cardiac event during consolidative chemotherapy. There were two cases of grade 4 toxicities (one sepsis, one renal impairment). Grade 3 toxicities included nausea/vomiting (17%), oesophagitis (15%), infection with neutropenia (12%) and pneumonitis (4%). Clinical benefit was seen in 86%. Two-year progression-free survival and overall survival rates were 49% and 58%, respectively. The median progression-free survival and overall survival were 23.4 and 43.4 months, respectively. The only significant prognostic factor was the number of chemotherapy cycles received (P = 0.02). The systematic review identified 13 relevant studies; a variety of regimens were assessed with variable reporting of outcomes and toxicity but with overall an improvement in survival over time. CONCLUSION Our experience compared with the original phase II trial showed improved treatment completion rates and survival with acceptable morbidity. With appropriate patient selection this regimen is an effective treatment option for locally advanced non-small cell lung cancer. This study helps to benchmark efficacy and toxicity rates while considering the addition of new agents to hypofractionated concurrent chemoradiotherapy. The agreement of a standard regimen for assessment in future trials would be beneficial.
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32
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Amin NP, Mohindra P, Jabbour SK. Serum microRNA guiding personalized radiation therapy in non-small cell lung cancer. J Thorac Dis 2018; 10:S4108-S4112. [PMID: 30631568 DOI: 10.21037/jtd.2018.09.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Neha P Amin
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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van Diessen J, De Ruysscher D, Sonke JJ, Damen E, Sikorska K, Reymen B, van Elmpt W, Westman G, Fredberg Persson G, Dieleman E, Bjorkestrand H, Faivre-Finn C, Belderbos J. The acute and late toxicity results of a randomized phase II dose-escalation trial in non-small cell lung cancer (PET-boost trial). Radiother Oncol 2018; 131:166-173. [PMID: 30327236 DOI: 10.1016/j.radonc.2018.09.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE The PET-boost randomized phase II trial (NCT01024829) investigated dose-escalation to the entire primary tumour or redistributed to regions of high pre-treatment FDG-uptake in inoperable non-small cell lung cancer (NSCLC) patients. We present a toxicity analysis of the 107 patients randomized in the study. MATERIALS AND METHODS Patients with stage II-III NSCLC were treated with an isotoxic integrated boost of ≥72 Gy in 24 fractions, with/without chemotherapy and strict dose limits. Toxicity was scored until death according to the CTCAEv3.0. RESULTS 77 (72%) patients were treated with concurrent chemoradiotherapy. Acute and late ≥G3 occurred in 41% and 25%. For concurrent (C) and sequential or radiotherapy alone (S), the most common acute ≥G3 toxicities were: dysphagia in 14.3% (C) and 3.3% (S), dyspnoea in 2.6% (C) and 6.7% (S), pneumonitis in 0% (C) and 6.7% (S), cardiac toxicity in 6.5% (C) and 3.3% (S). Seventeen patients died of which in 13 patients a possible relation to treatment could not be excluded. In 10 of these 13 patients progressive disease was scored. Fatal pulmonary haemorrhages and oesophageal fistulae were observed in 9 patients. CONCLUSION Personalized dose-escalation in inoperable NSCLC patients results in higher acute and late toxicity compared to conventional chemoradiotherapy. The toxicity, however, was within the boundaries of the pre-defined stopping rules.
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Affiliation(s)
- Judi van Diessen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dirk De Ruysscher
- Department of Radiation Oncology (MAASTRO Clinic), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Eugène Damen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Karolina Sikorska
- Department of Biometrics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Bart Reymen
- Department of Radiation Oncology (MAASTRO Clinic), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO Clinic), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, The Netherlands
| | - Gunnar Westman
- Department of Oncology, Rigshospitalet Copenhagen University Hospital, Denmark
| | | | - Edith Dieleman
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Corinne Faivre-Finn
- The University of Manchester, Division of Cancer Sciences, The Christie NHS Foundation Trust, United Kingdom
| | - José Belderbos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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34
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Ohri N, Bodner WR, Kabarriti R, Shankar V, Cheng H, Abraham T, Halmos B, Gucalp R, Perez-Soler R, Kalnicki S, Garg M. Positron Emission Tomography-Adjusted Intensity Modulated Radiation Therapy for Locally Advanced Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 102:709-715. [PMID: 29249527 DOI: 10.1016/j.ijrobp.2017.10.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/18/2017] [Accepted: 10/17/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE To perform a prospective trial examining positron emission tomography (PET)-based, dose-painted intensity modulated radiation therapy (IMRT) in the setting of locally advanced non-small cell lung cancer (NSCLC). METHODS AND MATERIALS Patients with stage IIB-III NSCLC were treated with 25 fractions of dose-painted IMRT. Tumors or lymph nodes with metabolic tumor volume exceeding 25 cm3 were deemed "high risk" and received 65 Gy. Smaller lesions were treated with 57 Gy or 52.5 Gy (after November 2014). Patients received concurrent weekly carboplatin (area under the curve = 2) and paclitaxel (45 mg/m2). The primary study endpoint was the absence of high residual metabolic activity (maximum standardized uptake value > 6) in treated lesions on PET 12 to 16 weeks after completion of IMRT. RESULTS Thirty-five subjects with 116 hypermetabolic lesions were eligible for analysis. The primary endpoint was met for 24 of 30 patients (80%) who underwent posttreatment PET, satisfying our efficacy objective. With a median follow-up duration of 23.8 months for living patients, progression in a lesion targeted with radiation therapy has been observed in 5 patients (14%). Treating progression in other sites and death without progression as competing risks, 2-year cumulative incidence rates of local disease progression in high-risk lesions (n=24) and low-risk lesions (n=92) are 9% and 3%, respectively. The actuarial rate of overall survival at 2 years is 52%. CONCLUSIONS Dose-painted IMRT based on pretreatment PET metrics with concurrent chemotherapy yields high rates of metabolic response and local disease control for locally advanced NSCLC. Future trials should test this approach to maximize the therapeutic ratio of thoracic radiation therapy.
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Affiliation(s)
- Nitin Ohri
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | - William R Bodner
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Rafi Kabarriti
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Viswanathan Shankar
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Haiying Cheng
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Tony Abraham
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Balazs Halmos
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Rasim Gucalp
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Roman Perez-Soler
- Department of Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Shalom Kalnicki
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Madhur Garg
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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