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Fenwick JD, Mayhew C, Jolly S, Amos RA, Hawkins MA. Navigating the straits: realizing the potential of proton FLASH through physics advances and further pre-clinical characterization. Front Oncol 2024; 14:1420337. [PMID: 39022584 PMCID: PMC11252699 DOI: 10.3389/fonc.2024.1420337] [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: 04/19/2024] [Accepted: 06/11/2024] [Indexed: 07/20/2024] Open
Abstract
Ultra-high dose-rate 'FLASH' radiotherapy may be a pivotal step forward for cancer treatment, widening the therapeutic window between radiation tumour killing and damage to neighbouring normal tissues. The extent of normal tissue sparing reported in pre-clinical FLASH studies typically corresponds to an increase in isotoxic dose-levels of 5-20%, though gains are larger at higher doses. Conditions currently thought necessary for FLASH normal tissue sparing are a dose-rate ≥40 Gy s-1, dose-per-fraction ≥5-10 Gy and irradiation duration ≤0.2-0.5 s. Cyclotron proton accelerators are the first clinical systems to be adapted to irradiate deep-seated tumours at FLASH dose-rates, but even using these machines it is challenging to meet the FLASH conditions. In this review we describe the challenges for delivering FLASH proton beam therapy, the compromises that ensue if these challenges are not addressed, and resulting dosimetric losses. Some of these losses are on the same scale as the gains from FLASH found pre-clinically. We therefore conclude that for FLASH to succeed clinically the challenges must be systematically overcome rather than accommodated, and we survey physical and pre-clinical routes for achieving this.
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Affiliation(s)
- John D. Fenwick
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Christopher Mayhew
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Simon Jolly
- Department of Physics and Astronomy, University College London, London, United Kingdom
| | - Richard A. Amos
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Maria A. Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
- Clinical Oncology, Radiotherapy Department, University College London NHS Foundation Trust, London, United Kingdom
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2
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Cooper D, Padilla L, Watson A, Neiderer K, Smith B, Weiss E. Motion-Inclusive Treatment Planning to Assess Normal Tissue Dose for Central Lung Stereotactic Body Radiation Therapy. Adv Radiat Oncol 2024; 9:101525. [PMID: 38948918 PMCID: PMC11214394 DOI: 10.1016/j.adro.2024.101525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/19/2024] [Indexed: 07/02/2024] Open
Abstract
Purpose For lung stereotactic body radiation therapy, 4-dimensional computed tomography is often used to delineate target volumes, whereas organs at risk (OARs) are typically outlined on either average intensity projection (AIP) or midventilation (MidV = 30% phase) images. AIP has been widely adopted as it represents a true average, but image blurring often precludes accurate contouring of critical structures such as central airways. Here, we compare AIP versus MidV planning for centrally located tumors via respiratory motion-inclusive (RMI) plans to better evaluate dose delivered throughout the breathing cycle. Methods and Materials Independently contoured and optimized AIP and MidV plans were created for 16 treatments and rigidly copied to each of the 10 breathing phase-specific computed tomography image sets. Resulting dose distributions were deformably registered back to the MidV image set (used as reference because of clearer depiction of anatomy compared with motion-blurred AIP) and averaged to create RMI plans. Doses to central OARs were compared between plans. Results Mean absolute dose differences were low for all comparisons (range, 0.01-2.87 Gy); however, individual plans exhibited differences >20 Gy. Dose differences >5 Gy were observed most often for plan comparisons involving AIP-based plans (MidV vs AIP 23, AIP RMI vs AIP 12, MidV RMI vs AIP RMI 7, and MidV RMI vs MidV 8 times). Inclusion of respiratory motion reduced large dose differences. Standard OAR thresholds were exceeded up to 5 times for each plan comparison scenario and always involved proximal bronchial tree D4 cc tolerance dose. AIP-based contours were larger by, on average, 3% to 15%. Conclusions Large dose differences were observed when plans with AIP-based contours were compared with MidV-based contours, indicating that observed dose differences were likely due to contoured volume differences rather than the effect of motion. Because of blurring with AIP images, MidV RMI-based planning may offer a more accurate method to determine dose to critical OARs in the presence of respiratory motion.
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Affiliation(s)
| | - Laura Padilla
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Amy Watson
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Keith Neiderer
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Benjamin Smith
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia
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3
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Lynch C, Korpics MC, Katipally RR, Wu T, Bestvina CM, Pitroda S, Chmura SJ, Juloori A. Combined Stereotactic Body Radiation Therapy and Immune Checkpoint Inhibition for Liver Metastases: Safety and Outcomes in a Pooled Analysis of 3 Phase 1 Trials. Int J Radiat Oncol Biol Phys 2024; 118:1519-1530. [PMID: 38199382 DOI: 10.1016/j.ijrobp.2024.01.002] [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: 08/15/2023] [Revised: 01/02/2024] [Accepted: 01/02/2024] [Indexed: 01/12/2024]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) safely and effectively controls liver metastases (LMs), but its safety and efficacy when combined with immune checkpoint inhibitors (ICIs) are not well characterized. This analysis of 3 phase 1 trials of combination SBRT and ICI evaluates whether LM-SBRT increases the risk for hepatotoxicity when combined with ICI and explores efficacy endpoints. METHODS AND MATERIALS Data were analyzed from 3 phase 1 trials of combination SBRT and ICI for patients with metastatic solid tumors conducted between 2016 and 2020. ICI was administered per trial protocol with LM-SBRT delivered to 45 Gy in 3 fractions with mean liver dose <16 Gy and ≥700 cc of normal liver spared 17.1 Gy. Hepatic adverse events (HAEs) were defined as hepatic failure, autoimmune hepatitis, or elevation of aspartate transaminase, alanine transaminase, bilirubin, or alkaline phosphatase using Common Terminology Criteria for Adverse Events version 4.0. Cumulative incidence of HAEs and local failure were modeled with death as a competing risk. Competing risk regression was performed using Fine-Gray modeling. Survival was estimated via the Kaplan-Meier method. RESULTS Two hundred patients were analyzed, including 81 patients with LM, 57 of whom received LM-SBRT. The 12-month rate of any grade ≥2 HAE was 11% and 10% in LM-SBRT and non-LM-SBRT patients, respectively non-significant (NS). Radiographic evidence for liver disease and dual-agent ICI was significantly associated with HAEs on univariable and multivariable analysis, but liver dose metrics were not. Patients with LM had significantly worse progression-free and overall survival compared with those without, and local failure of treated LM was significantly higher than for treated extrahepatic metastases (28% vs 4% at 12 months, P < .001). CONCLUSIONS Combination LM-SBRT and ICI did not significantly increase the risk for HAEs compared with ICI without LM-SBRT, suggesting hepatotoxicity is largely driven by factors other than liver radiation therapy, such as choice of ICI. LM is associated with worse overall survival and local control outcomes.
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Affiliation(s)
- Connor Lynch
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Mark C Korpics
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Rohan R Katipally
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Tianming Wu
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | | | - Sean Pitroda
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Steven J Chmura
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois
| | - Aditya Juloori
- Departments of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois.
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4
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Tekatli H, Giraud N, van Eekelen R, Lagerwaard FJ, Senan S. Ten years outcomes after SABR in central and ultracentral primary lung tumors. Radiother Oncol 2023; 188:109848. [PMID: 37562553 DOI: 10.1016/j.radonc.2023.109848] [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: 04/12/2023] [Revised: 07/04/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE SABR performed for central and ultracentral lung tumors is associated with increased toxicity but limited data is available on late toxicities. We studied toxicity in patients followed-up ≥ 2 years post-SABR at a single-institution. METHODS All patients were treated using VMAT for a primary or recurrent central lung cancer between 2008-2015. 60 Gy was delivered in 8 or 12 fractions. Grade ≥ 3 clinical and radiological bronchial toxicity was scored. Multivariable Cox regression models were used to estimate hazard ratios. RESULTS Of 127 eligible patients, 63% were treated with 8 fractions. Median tumor diameter was 4.4 cm (range 1.3-12.0). Median overall survival was 25.0 months (95% CI 16.5-33.5); 4% developed isolated local recurrences. The actuarial 5-year rate for severe clinical toxicity was 34.1% (95% CI 21.2-44.9). Both clinical toxicity and fatal lung haemorrhage were most observed when tumors were located ≤ 1 cm from the trachea or main bronchi (46% of all cases). The 5-year actuarial rate of radiological bronchial toxicity was 37.5% (95% CI 21.5-50.2). Multivariable analysis revealed that a performance score of 2 or 3 (HR 3.6; 95% CI 1.7-7.8), and tumor location ≤ 1 cm from the trachea or main bronchi (HR 4.3; 95% CI 1.2-14.9) were significant predictors for severe clinical toxicity. CONCLUSION The actuarial rates for both severe clinical and radiological bronchial toxicity after central SABR was approximately 35% in patients surviving 5 years. Patients with tumors located ≤ 1 cm from the trachea or main bronchus were at the highest risk for severe clinical toxicity.
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Affiliation(s)
- Hilâl Tekatli
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands.
| | - Nicolas Giraud
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands
| | | | - Frank J Lagerwaard
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands; Cancer Center Amsterdam, Treatment and quality of life, Amsterdam, The Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands; Cancer Center Amsterdam, Treatment and quality of life, Amsterdam, The Netherlands
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5
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Yan M, Louie AV, Kotecha R, Ashfaq Ahmed M, Zhang Z, Guckenberger M, Kim MS, Lo SS, Scorsetti M, Tree AC, Sahgal A, Slotman BJ. Stereotactic body radiotherapy for Ultra-Central lung Tumors: A systematic review and Meta-Analysis and International Stereotactic Radiosurgery Society practice guidelines. Lung Cancer 2023; 182:107281. [PMID: 37393758 DOI: 10.1016/j.lungcan.2023.107281] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is an effective and safe modality for early-stage lung cancer and lung metastases. However, tumors in an ultra-central location pose unique safety considerations. We performed a systematic review and meta-analysis to summarize the current safety and efficacy data and provide practice recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS). METHODS We performed a systematic review using PubMed and EMBASE databases of patients with ultra-central lung tumors treated with SBRT. Studies reporting local control (LC) and/or toxicity were included. Studies with <5 treated lesions, non-English language, re-irradiation, nodal tumors, or mixed outcomes in which ultra-central tumors could not be discerned were excluded. Random-effects meta-analysis was performed for studies reporting relevant endpoints. Meta-regression was conducted to determine the effect of various covariates on the primary outcomes. RESULTS 602 unique studies were identified of which 27 (one prospective observational, the remainder retrospective) were included, representing 1183 treated targets. All studies defined ultra-central as the planning target volume (PTV) overlapping the proximal bronchial tree (PBT). The most common dose fractionations were 50 Gy/5, 60 Gy/8, and 60 Gy/12 fractions. The pooled 1- and 2-year LC estimates were 92 % and 89 %, respectively. Meta-regression identified biological effective dose (BED10) as a significant predictor of 1-year LC. A total of 109 grade 3-4 toxicity events, with a pooled incidence of 6 %, were reported, most commonly pneumonitis. There were 73 treatment related deaths, with a pooled incidence of 4 %, with the most common being hemoptysis. Anticoagulation, interstitial lung disease, endobronchial tumor, and concomitant targeted therapies were observed risk factors for fatal toxicity events. CONCLUSION SBRT for ultra-central lung tumors results in acceptable rates of local control, albeit with risks of severe toxicity. Caution should be taken for appropriate patient selection, consideration of concomitant therapies, and radiotherapy plan design.
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Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, USA
| | - Md Ashfaq Ahmed
- Center for Advanced Analytics, Baptist Health South Florida, Miami, USA
| | - Zhenwei Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, USA
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mi-Sook Kim
- Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | - Marta Scorsetti
- Radiosurgery and Radiotherapy Department, IRCCS-Humanitas Research Hospital, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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6
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Regnery S, Katsigiannopulos E, Hoegen P, Weykamp F, Sandrini E, Held T, Deng M, Eichkorn T, Buchele C, Rippke C, Renkamp CK, König L, Lang K, Thomas M, Winter H, Adeberg S, Klüter S, Debus J, Hörner-Rieber J. To fly or not to fly: Stereotactic MR-guided adaptive radiotherapy effectively treats ultracentral lung tumors with favorable long-term outcomes. Lung Cancer 2023; 179:107175. [PMID: 36965207 DOI: 10.1016/j.lungcan.2023.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Stereotactic radiotherapy of ultracentral lung tumors (ULT) is challenging as it may cause overdoses to sensitive mediastinal organs with severe complications. We aimed to describe long-term outcomes after stereotactic magnetic resonance (MR)-guided online adaptive radiotherapy (SMART) as an innovative treatment of ULT. PATIENTS & METHODS We analyzed 36 patients that received SMART to 40 tumors between 02/2020 - 08/2021 inside prospective databases. ULT were defined by planning target volume (PTV) overlap with the proximal bronchial tree or esophagus. We calculated Kaplan Meier estimates for overall survival (OS) and progression-free survival (PFS), and competing risk estimates for the incidence of tumor progression and treatment-related toxicities. ULT patients (N = 16) were compared to non-ULT patients (N = 20). RESULTS Baseline characteristics were similar between ULT and non-ULT, but ULT were larger (median PTV: ULT 54.7 cm3, non-ULT 19.2 cm3). Median follow-up was 23.6 months. ULT and non-ULT showed a similar OS (2-years: ULT 67%, non-ULT 60%, p = 0.7) and PFS (2-years: ULT 37%, non-ULT 34%, p = 0.73). Progressions occurred mainly at distant sites (2-year incidence of distant progression: ULT 63%, non-ULT 61%, p = 0.77), while local tumor control was favorable (2-year incidence of local progression: ULT 7%, non-ULT 0%, p = 0.22). Treatment of ULT led to significantly more toxicities ≥ grade (G) 2 (ULT: 9 (56%), non-ULT: 1 (5%), p = 0.002). Most toxicities were moderate (G2). Two ULT patients developed high-grade toxicities: 1) esophagitis G3 and bronchial bleeding G4 after VEGF treatment, 2) bronchial bleeding G3. Estimated incidence of high-grade toxicities was 19% (3-48%) in ULT, and no treatment-related death occurred. CONCLUSION Our small series supports SMART as potentially effective treatment of ULT. SMART with careful fractionation could reduce severe complications, but treatment of ULT remains a high-risk procedure and needs careful benefit-risk-assessment.
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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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Efthimios Katsigiannopulos
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Philipp Hoegen
- 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Fabian Weykamp
- 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Elisabetta Sandrini
- 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Thomas Held
- 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Maximilian Deng
- 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Tanja Eichkorn
- 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Carolin Buchele
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Carolin Rippke
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - C Katharina Renkamp
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Laila König
- 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Kristin Lang
- 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Michael Thomas
- National Center for Tumor Diseases (NCT), Heidelberg, Germany; Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany
| | - Hauke Winter
- National Center for Tumor Diseases (NCT), Heidelberg, Germany; Translational Lung Research Center Heidelberg (TLRC-H), Member of the German Center for Lung Research (DZL), Heidelberg, Germany; Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Roentgenstrasse 1, 69126 Heidelberg, Germany
| | - Sebastian Adeberg
- 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Sebastian Klüter
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 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; 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; National Center for Tumor Diseases (NCT), Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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7
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Korpics MC, Katipally RR, Partouche J, Cutright D, Pointer KB, Bestvina CM, Luke JJ, Pitroda SP, Dignam JJ, Chmura SJ, Juloori A. Predictors of Pneumonitis in Combined Thoracic Stereotactic Body Radiotherapy and Immunotherapy. Int J Radiat Oncol Biol Phys 2022; 114:645-654. [PMID: 35753553 DOI: 10.1016/j.ijrobp.2022.06.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Thoracic stereotactic body radiotherapy (SBRT) is associated with high rates of local control but carries a risk of pneumonitis. Immunotherapy is a standard treatment for patients with metastatic disease but can also cause pneumonitis. To evaluate the feasibility and safety of thoracic SBRT with systemic immunotherapy, clinical outcomes of patients treated with immune checkpoint blockade (ICB) and SBRT on prospective trials were reviewed. METHODS AND MATERIALS Three consecutive phase 1 trials of combination SBRT and ICB conducted between 2016-2020 for widely metastatic solid tumors were reviewed. The protocols mandated adherence to NRG BR001/BR002 OAR constraints, resulting in <100% coverage of some target volumes. ICB was administered either sequentially (within 7 days after completion of SBRT) or concurrently (before or at the start of SBRT), depending on protocol. Endpoints included pneumonitis, dose-volume constraints, local failure, and overall survival (OS). The cumulative incidence estimator and Kaplan-Meier method were used. RESULTS 123 patients met eligibility with 311 metastases irradiated. The most common histologies included non-small cell lung cancer (33%) and colorectal cancer (12%). Median follow up was 12 months. The overall rate of grade 3+ pneumonitis was 8.1%. 1-year local failure was 3.6%. Established dosimetric parameters were significantly associated with the development of pneumonitis (p<0.05). In most patients, the lungs were not challenged with high doses of radiation, defined as receiving ≥75% of the maximum for a given lung dose-volume constraint. Patients who were challenged were not found to have a significantly higher risk of pneumonitis. CONCLUSIONS In the largest series of thoracic SBRT and immunotherapy, local control was excellent with acceptable toxicity and support the conclusion that established dose-volume constraints for the lung are safe. However, these results highlight the potential value in reporting of OARs being challenged with doses approaching protocol specified limits.
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Affiliation(s)
- Mark C Korpics
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Rohan R Katipally
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States; Department of Medicine, Section of Hematology/Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, United States
| | - Julien Partouche
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Dan Cutright
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Kelli B Pointer
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Christine M Bestvina
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Jason J Luke
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Sean P Pitroda
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - James J Dignam
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, United States
| | - Steven J Chmura
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Aditya Juloori
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States.
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8
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Regnery S, Ristau J, Weykamp F, Hoegen P, Sprengel SD, Paul KM, Buchele C, Klüter S, Rippke C, Renkamp CK, Pohl M, Meis J, Welzel T, Adeberg S, Koerber SA, Debus J, Hörner-Rieber J. Magnetic resonance guided adaptive stereotactic body radiotherapy for lung tumors in ultracentral location: the MAGELLAN trial (ARO 2021-3). Radiat Oncol 2022; 17:102. [PMID: 35614486 PMCID: PMC9134672 DOI: 10.1186/s13014-022-02070-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stereotactic Body Radiotherapy (SBRT) is a standard treatment for inoperable primary and secondary lung tumors. In case of ultracentral tumor location, defined as tumor contact with vulnerable mediastinal structures such as the proximal bronchial tree (PBT) or esophagus, SBRT is associated with an increased risk for severe complications. Magnetic resonance (MR)-guided SBRT can mitigate this risk based on gated dose delivery and daily plan adaptation. The MAGELLAN trial aims to find the maximum tolerated dose (MTD) of MR-guided SBRT of ultracentral lung tumors (ULT). PATIENTS AND METHODS MAGELLAN is a prospective phase I dose escalation trial. A maximum of 38 patients with primary and secondary ULT with a tumor size ≤ 5 cm will be enrolled. Ultracentral location is defined as an overlap of the planning target volume (PTV) with the PBT or esophagus. Patients are treated at a 0.35 Tesla MR-linac (MRIdian® Linac, ViewRay Inc. ) employing a gating strategy and daily plan adaptation. Dose escalation starts at 10 × 5.5 Gy (biologically effective dose BED3/10: 155.83 Gy/85.25 Gy), may proceed up to 10 × 6.5 Gy (BED3/10: 205.83 Gy/107.25 Gy) and is guided by a customized time-to-event continual reassessment method (TITE CRM) with backup element, which alternately assigns patients to dose escalation and backup cohorts. DISCUSSION The results of the MAGELLAN trial will guide further research and clinical implementation of MR-guided SBRT as ablative treatment of ULT. Moreover, the combination of MR-guided radiotherapy with TITE-CRM including a backup element may serve as blueprint for future radiation dose escalation studies in critical locations. TRIAL REGISTRATION Registered at ClinicalTrials.gov: NCT04925583 on 14th June 2021.
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Affiliation(s)
- Sebastian Regnery
- Department of Radiation Oncology, University Hospital Heidelberg, 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
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jonas Ristau
- Department of Radiation Oncology, University Hospital Heidelberg, 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
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, University Hospital Heidelberg, 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
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, University Hospital Heidelberg, 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
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Simon David Sprengel
- Department of Radiation Oncology, University Hospital Heidelberg, 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
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Katharina Maria Paul
- Department of Radiation Oncology, University Hospital Heidelberg, 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
| | - Carolin Buchele
- Department of Radiation Oncology, University Hospital Heidelberg, 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
| | - Sebastian Klüter
- Department of Radiation Oncology, University Hospital Heidelberg, 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
| | - Carolin Rippke
- Department of Radiation Oncology, University Hospital Heidelberg, 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
| | - Claudia Katharina Renkamp
- Department of Radiation Oncology, University Hospital Heidelberg, 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
| | - Moritz Pohl
- Institute of Medical Biometry, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Jan Meis
- Institute of Medical Biometry, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Thomas Welzel
- Department of Radiation Oncology, University Hospital Heidelberg, 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
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, University Hospital Heidelberg, 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
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Alexander Koerber
- Department of Radiation Oncology, University Hospital Heidelberg, 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
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, 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
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, 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, University Hospital Heidelberg, 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.
- Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, University Hospital Heidelberg, 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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Rijksen BLT, Rossi MMG, Walraven I, Stam B, Knegjens JL, van Diessen JNA, Lalezari F, Sonke JJ, Belderbos JSA. Bronchial stenosis in central pulmonary tumors treated with Stereotactic Body Radiation Therapy: Bronchial stenosis in central lung tumors after SBRT. Pract Radiat Oncol 2022; 12:e382-e392. [PMID: 35452867 DOI: 10.1016/j.prro.2022.03.016] [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: 09/16/2021] [Revised: 03/01/2022] [Accepted: 03/31/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) in lung tumors has an excellent local control due to the high delivered dose. Proximity of the proximal bronchial tree (PBT) to the high dose area may result in pulmonary toxicity. Bronchial stenosis is an adverse event that can occur after high dose to the PBT. Literature on the risk of developing bronchial stenosis is limited. We therefore evaluated the risk of bronchial stenosis for tumors central to the PBT and correlated the dose to the bronchi. METHODS AND MATERIALS Patients with a planning tumor volume (PTV) ≤2cm from PBT receiving SBRT (8 × 7.5Gy) between 2015-2019 were retrospectively reviewed. Main bronchi and lobar bronchi were manually delineated. Follow-up CT-scans were analyzed for bronchial stenosis and atelectasis. Bronchial stenosis was assessed using CTCAEv4. Patient, tumor, dosimetric factors and survival were evaluated between patients with and without stenosis using uni- and multivariate and Kaplan Meier analysis. RESULTS Fifty-one patients were analyzed with a median age of 70 years and WHO≤1 in 92.2%. Median follow-up was 36 months (IQR 19.6-45.4) and median OS 48 months (IQR 21.5-59.3). In fifteen patients (29.4%) bronchial stenosis was observed on FU-CT-scan. Grade 1 stenosis was seen in 21.6% (n=11), grade 2 in 7.8% (n=4). No grade ≥3 stenosis was observed. Median time to stenosis was 9.6 months (IQR 4.4-19.2). Patients who developed stenosis had significantly larger gross tumor volume (GTV) with a median of 19cc (IQR 7.7-63.2) versus 5.2cc (IQR 1.7-11.3, p<0.01). Prognostic factors in multivariate analysis for stenosis were age (p=0.03; OR 1.1), baseline dyspnea (p=0.02 OR 7.7) and the mean lobar bronchus dose (p=0.01; OR 1.1). CONCLUSION Low grade (≤2) lobar bronchial stenosis is a complication in approximately one third of patients following SBRT for lung tumors with a PTV ≤2cm from PBT. Prognostic risk factors were age, baseline dyspnea and mean dose on a lobar bronchus.
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Affiliation(s)
- Barbara L T Rijksen
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Maddalena M G Rossi
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Iris Walraven
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Barbara Stam
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Joost L Knegjens
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Judi N A van Diessen
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Ferry Lalezari
- Netherlands Cancer Institute, Department of Radiology, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - José S A Belderbos
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands.
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10
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Latrèche A, Bourbonne V, Lucia F. Unrecognized thoracic radiotherapy toxicity: A review of literature. Cancer Radiother 2022; 26:616-621. [DOI: 10.1016/j.canrad.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 10/19/2022]
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11
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Lindberg K, Onjukka E. Medical consequences of radiation exposure of the bronchi-what can we learn from high-dose precision radiation therapy? JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2021; 41:S355-S370. [PMID: 34547741 DOI: 10.1088/1361-6498/ac28ef] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/21/2021] [Indexed: 06/13/2023]
Abstract
The bronchial tolerance to high doses of radiation is not fully understood. However, in the event of a radiological accident with unintended exposure of the central airways to high doses of radiation it would be important to be able to anticipate the clinical consequences given the magnitude of the absorbed dose to different parts of the bronchial tree. Stereotactic body radiation therapy (SBRT) is a radiation treatment technique involving a few large fractions of photon external-beam radiation delivered to a well-defined target in the body. Despite generally favourable results, with high local tumour control and low-toxicity profile, its utility for tumours located close to central thoracic structures has been questioned, considering reports of severe toxic symptoms such as haemoptysis (bleedings from the airways), bronchial necrosis, bronchial stenosis, fistulas and pneumonitis. In conjunction with patient- and tumour-related risk factors, recent studies have analysed the absorbed radiation dose to different thoracic structures of normal tissue to better understand their tolerance to these high doses per fraction. Although the specific mechanisms behind the toxicity are still partly unknown, dose to the proximal bronchial tree has been shown to correlate with high-grade radiation side effects. Still, there is no clear consensus on the tolerance dose of the different bronchial structures. Recent data indicate that a too high dose to a main bronchus may result in more severe clinical side effects as compared to a smaller sized bronchus. This review analyses the current knowledge on the clinical consequences of bronchial exposure to high dose hypofractionated radiation delivered with the SBRT technique, and the tolerance doses of the bronchi. It presents the current literature regarding types of high-grade clinical side effects, data on dose response and comments on other risk factors for high-grade toxic effects.
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Affiliation(s)
- Karin Lindberg
- Section of Head, Neck, Lung and Skin tumours, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Eva Onjukka
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
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12
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Wallat EM, Wuschner AE, Flakus MJ, Christensen GE, Reinhardt JM, Shanmuganayagam D, Bayouth JE. Radiation-induced airway changes and downstream ventilation decline in a swine model. Biomed Phys Eng Express 2021; 7:10.1088/2057-1976/ac3197. [PMID: 34670195 PMCID: PMC8785227 DOI: 10.1088/2057-1976/ac3197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/20/2021] [Indexed: 11/11/2022]
Abstract
Purpose.To investigate indirect radiation-induced changes in airways as precursors to atelectasis post radiation therapy (RT).Methods.Three Wisconsin Miniature Swine (WMSTM) underwent a research course of 60 Gy in 5 fractions delivered to a targeted airway/vessel in the inferior left lung. The right lung received a max point dose <5 Gy. Airway segmentation was performed on the pre- and three months post-RT maximum inhale phase of the four-dimensional (4D) computed tomography (CT) scans. Changes in luminal area (Ai) and square root of wall area (WA) for each airway were investigated. Changes in ventilation were assessed using the Jacobian ratio and were measured in three different regions: the inferior left lung <5 Gy (ILL), the superior left lung <5 Gy (SLL), and the contralateral right lung <5 Gy (RL).Results.Airways (n = 25) in the right lung for all swine showed no significant changes (p = 0.48) in Ai post-RT compared to pre-RT. Airways (n = 28) in the left lung of all swine were found to have a significant decrease (p < 0.001) in Ai post-RT compared to pre-RT, correlated (Pearson R = -0.97) with airway dose. Additionally,WAdecreased significantly (p < 0.001) with airway dose. Lastly, the Jacobian ratio of the ILL (0.883) was lower than that of the SLL (0.932) and the RL (0.955).Conclusions.This work shows that for the swine analyzed, there were significant correlations between Ai andWAchange with radiation dose. Additionally, there was a decrease in lung function in the regions of the lung supplied by the irradiated airways compared to the regions supplied by unirradiated airways. These results support the hypothesis that airway dose should be considered during treatment planning in order to potentially preserve functional lung and reduce lung toxicities.
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Affiliation(s)
- Eric M Wallat
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53705, United States of America
| | - Antonia E Wuschner
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53705, United States of America
| | - Mattison J Flakus
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53705, United States of America
| | - Gary E Christensen
- Department of Electrical and Computer Engineering, University of Iowa, Iowa City, IA 52242, United States of America
- Department of Radiation Oncology, University of Iowa, Iowa City, IA 52242, United States of America
| | - Joseph M Reinhardt
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242, United States of America
- Department of Radiology, University of Iowa, Iowa City, IA 52242, United States of America
| | - Dhanansayan Shanmuganayagam
- Department of Animal and Dairy Sciences, University of Wisconsin-Madison, Madison, WI 53705, United States of America
| | - John E Bayouth
- Department of Human Oncology, University of Wisconsin-Madison, Madison, WI 53705, United States of America
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13
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Exceeding Radiation Dose to Volume Parameters for the Proximal Airways with Stereotactic Body Radiation Therapy Is More Likely for Ultracentral Lung Tumors and Associated with Worse Outcome. Cancers (Basel) 2021; 13:cancers13143463. [PMID: 34298677 PMCID: PMC8305634 DOI: 10.3390/cancers13143463] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/01/2021] [Accepted: 07/07/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary The optimal way to treat central (CLT) and ultracentral (UCLT) lung tumors with curative radiation is unclear. We evaluated 83 patients with CLT and UCLT who underwent a curative radiotherapy technique called stereotactic body radiation therapy (SBRT). On statistical analysis, patients with UCLT had worse overall survival. Using a cohort of patients matched for relevant variables such as gender and performance status, we evaluated radiation doses to critical central structures such as the airway and heart. In this group, patients with UCLT were more likely to exceed dose constraints as compared CLT, particularly constraints regarding the airway. Additionally, patients had worse non-cancer associated survival when radiation doses were higher than 18 Gy to 4cc’s of either the trachea or proximal bronchial tree. Based on these findings, patients with UCLT have worse outcomes which could be secondary to higher radiation doses to the trachea and proximal bronchial tree. Abstract The preferred radiotherapeutic approach for central (CLT) and ultracentral (UCLT) lung tumors is unclear. We assessed the toxicity and outcomes of patients with CLT and UCLT who underwent definitive five-fraction stereotactic body radiation therapy (SBRT). We reviewed the charts of patients with either CLT or UCLT managed with SBRT from June 2010–April 2019. CLT were defined as gross tumor volume (GTV) within 2 cm of either the proximal bronchial tree, trachea, mediastinum, aorta, or spinal cord. UCLT were defined as GTV abutting any of these structures. Propensity score matching was performed for gender, performance status, and history of prior lung cancer. Within this cohort of 83 patients, 43 (51.8%) patients had UCLT. The median patient age was 73.1 years with a median follow up of 29.9 months. The two most common dose fractionation schemes were 5000 cGy (44.6%) and 5500 cGy (42.2%) in five fractions. Multivariate analysis revealed UCLT to be associated with worse overall survival (OS) (HR = 1.9, p = 0.02) but not time to progression (TTP). Using propensity score match pairing, UCLT correlated with reduced non-cancer associated survival (p = 0.049) and OS (p = 0.03), but not TTP. Within the matched cohort, dosimetric study found exceeding a D4cc of 18 Gy to either the proximal bronchus (HR = 3.9, p = 0.007) or trachea (HR = 4.0, p = 0.02) was correlated with worse non-cancer associated survival. In patients undergoing five fraction SBRT, UCLT location was associated with worse non-cancer associated survival and OS, which could be secondary to excessive D4cc dose to the proximal airways.
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