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Brunner TB, Boda-Heggemann J, Bürgy D, Corradini S, Dieckmann UK, Gawish A, Gerum S, Gkika E, Grohmann M, Hörner-Rieber J, Kirste S, Klement RJ, Moustakis C, Nestle U, Niyazi M, Rühle A, Lang ST, Winkler P, Zurl B, Wittig-Sauerwein A, Blanck O. Dose prescription for stereotactic body radiotherapy: general and organ-specific consensus statement from the DEGRO/DGMP Working Group Stereotactic Radiotherapy and Radiosurgery. Strahlenther Onkol 2024; 200:737-750. [PMID: 38997440 PMCID: PMC11343978 DOI: 10.1007/s00066-024-02254-2] [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: 05/29/2024] [Accepted: 06/02/2024] [Indexed: 07/14/2024]
Abstract
PURPOSE AND OBJECTIVE To develop expert consensus statements on multiparametric dose prescriptions for stereotactic body radiotherapy (SBRT) aligning with ICRU report 91. These statements serve as a foundational step towards harmonizing current SBRT practices and refining dose prescription and documentation requirements for clinical trial designs. MATERIALS AND METHODS Based on the results of a literature review by the working group, a two-tier Delphi consensus process was conducted among 24 physicians and physics experts from three European countries. The degree of consensus was predefined for overarching (OA) and organ-specific (OS) statements (≥ 80%, 60-79%, < 60% for high, intermediate, and poor consensus, respectively). Post-first round statements were refined in a live discussion for the second round of the Delphi process. RESULTS Experts consented on a total of 14 OA and 17 OS statements regarding SBRT of primary and secondary lung, liver, pancreatic, adrenal, and kidney tumors regarding dose prescription, target coverage, and organ at risk dose limitations. Degree of consent was ≥ 80% in 79% and 41% of OA and OS statements, respectively, with higher consensus for lung compared to the upper abdomen. In round 2, the degree of consent was ≥ 80 to 100% for OA and 88% in OS statements. No consensus was reached for dose escalation to liver metastases after chemotherapy (47%) or single-fraction SBRT for kidney primaries (13%). In round 2, no statement had 60-79% consensus. CONCLUSION In 29 of 31 statements a high consensus was achieved after a two-tier Delphi process and one statement (kidney) was clearly refused. The Delphi process was able to achieve a high degree of consensus for SBRT dose prescription. In summary, clear recommendations for both OA and OS could be defined. This contributes significantly to harmonization of SBRT practice and facilitates dose prescription and reporting in clinical trials investigating SBRT.
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Affiliation(s)
- Thomas B Brunner
- Department of Radiation Oncology, Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria.
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center, Medical University of Graz, 8036, Graz, Austria.
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medicine Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Bürgy
- Department of Radiation Oncology, University Medicine Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Ute Karin Dieckmann
- Department of Radiation Oncology, Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria
| | - Ahmed Gawish
- Department of Radiotherapy, University Medical Center Giessen-Marburg, Marburg, Germany
| | - Sabine Gerum
- Department of Radiation Oncology, Paracelsus University Salzburg, Salzburg, Austria
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital Bonn, 53127, Bonn, Germany
| | - Maximilian Grohmann
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Simon Kirste
- Department of Radiation Oncology, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Rainer J Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Robert-Koch-Straße 10, 97422, Schweinfurt, Germany
| | - Christos Moustakis
- Department of Radiation Oncology, University Hospital Leipzig, Stephanstraße 9a, 04103, Leipzig, Germany
| | - Ursula Nestle
- Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Alexander Rühle
- Department of Radiation Oncology, University Hospital Leipzig, Stephanstraße 9a, 04103, Leipzig, Germany
| | - Stephanie-Tanadini Lang
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Peter Winkler
- Department of Radiation Oncology, Medical University of Graz, Auenbruggerplatz 32, 8036, Graz, Austria
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center, Medical University of Graz, 8036, Graz, Austria
| | - Brigitte Zurl
- Department of Therapeutic Radiology and Oncology, Comprehensive Cancer Center, Medical University of Graz, 8036, Graz, Austria
| | | | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Arnold-Heller-Straße 3, 24105, Kiel, Germany
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2
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Thomsen SN, Møller DS, Knap MM, Khalil AA, Shcytte T, Hoffmann L. Daily CBCT-based dose calculations for enhancing the safety of dose-escalation in lung cancer radiotherapy. Radiother Oncol 2024; 200:110506. [PMID: 39197502 DOI: 10.1016/j.radonc.2024.110506] [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: 07/01/2024] [Accepted: 08/19/2024] [Indexed: 09/01/2024]
Abstract
PURPOSE Dose-escalation in lung cancer comes with a high risk of severe toxicity. This study aimed to calculate the delivered dose in a Scandinavian phase-III dose-escalation trial. METHODS The delivered dose was evaluated for 21 locally-advanced non-small cell lung cancer (LA-NSCLC) patients treated as part of the NARLAL2 dose-escalation trial. The patients were randomized between standard and escalated heterogeneous dose-delivery. Both treatment plans were created and approved before randomization. Daily cone-beam CT (CBCT) for patient positioning, and adaptive radiotherapy were mandatory. Standard and escalated plans, including adaptive re-plans, were recalculated on each daily CBCT and accumulated on the planning CT for each patient. Dose to the clinical target volume (CTV), organs at risk (OAR), and the effects of plan adaptions were evaluated for the accumulated dose and on each treated fraction scaled to full treatment. RESULTS For the standard treatment, plan adaptations reduced the number of patients with CTV-T underdosage from six to one, and the total number of fractions with CTV-T underdosage from 161 to 56; while for the escalated treatment, the number of patients was reduced from five to zero and number of fractions from 81 to 11. For dose-escalation, three patients had fractions exceeding trial constraints for heart, bronchi, or esophagus, and one had an accumulated heart dose above the constraints. CONCLUSION Dose-escalation for LA-NSCLC patients, using daily image guidance and adaptive radiotherapy, is dosimetrically safe for the majority of patients. Dose calculation on daily CBCTs is an efficient tool to monitor target coverage and OAR doses.
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Affiliation(s)
- S N Thomsen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - D S Møller
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - M M Knap
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - A A Khalil
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - T Shcytte
- Department of Oncology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - L Hoffmann
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Franceschini D, Teriaca MA, Mancosu P, Bertolini A, Lo Faro L, Spoto R, Dominici L, Badalamenti M, Bellu L, Dei D, La Fauci F, Franzese C, Scorsetti M. Prospective phase II trial on ablative stereotactic body radiation therapy (SBRT) for medically inoperable thoracic nodes metastases. Radiother Oncol 2024; 197:110335. [PMID: 38772477 DOI: 10.1016/j.radonc.2024.110335] [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: 11/29/2023] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Oligometastases in mediastinal nodes are increasingly prevalent, posing challenges for treatment with stereotactic body radiotherapy (SBRT) due to proximity to organs at risk (OARs). We report the results of a single prospective observational phase II trial on ablative SBRT for medically inoperable thoracic nodes metastases (NCT02970955). MATERIAL AND METHODS Since 2017, patients with < 3 nodal metastases were evaluated by the tumor board and included if deemed inoperable. SBRT was delivered using risk adaptive approach based on number, site and size of metastatic nodes (50 Gy/5fractions, 60 Gy/8fractions, 70 Gy/10 fractions). Planning target volume (PTV) partial underdosage was allowed. The primary end point was local control (LC) at 12 months. Secondary end points were: acute and late toxicities, overall survival (OS), progression free survival (PFS), and time to next systemic therapy (TTNS). RESULTS Between 03/2017-11/2021, 32 patients (41 nodal metastases) were included. NSCLC (13pts), breast (5pts) and colorectal cancer (4pts) were the most represented primary tumour. In 66 % cases, partial PTV undercoverage was necessary. LC at 1 and 2 years was 93.5 % and 82.3 %, respectively. Treatment was well-tolerated with no acute or late toxicity ≥ G3. Median OS was 59.7 months. OS at 1 and 2 years was 96.9 % and 83.8 % respectively. Median PFS was 12.2 months. PFS at 1 and 2 years was 53.1 % and 31.3 %, respectively. CONCLUSION This trial supported the feasibility and safety of ablative SBRT for thoracic nodes metastases thanks to risk adaptive approach allowing to delay of new systemic therapies. Larger studies are needed to confirm these observations.
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Affiliation(s)
- D Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy.
| | - M A Teriaca
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - P Mancosu
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - A Bertolini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
| | - L Lo Faro
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
| | - R Spoto
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - L Dominici
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - M Badalamenti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - L Bellu
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
| | - D Dei
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - F La Fauci
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - C Franzese
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
| | - M Scorsetti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
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Sarria GR, Wiegreffe S, Gkika E. [New Radiation Therapy Concepts in Non-Metastatic Lung Cancer]. Zentralbl Chir 2024; 149:S52-S61. [PMID: 39137762 DOI: 10.1055/a-2365-8743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Radiotherapy plays a critical role in the management of non-metastatic lung cancer, offering curative potential and symptom relief. It serves as a primary treatment modality or adjuvant therapy post-surgery, enhancing local control and survival rates. Modern techniques like Stereotactic Body Radiotherapy (SBRT) enable precise tumor targeting, minimizing damage to healthy tissue and reducing treatment duration. The synergy between radiotherapy and systemic treatments, including immunotherapy, holds promise in improving outcomes. Immunotherapy augments the immune response against cancer cells, potentially enhancing radiotherapy's efficacy. Furthermore, radiotherapy's ability to modulate the tumor microenvironment complements the immunotherapy's mechanism of action. As a result, the combination of radiotherapy and immunotherapy may offer superior tumor control and survival benefits. Moreover, the integration of radiotherapy with surgery and chemotherapy in multidisciplinary approaches maximizes treatment efficacy while minimizing toxicity. Herein we present an overview on modern radiotherapy and potential developments in the close future.
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Affiliation(s)
- Gustavo R Sarria
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Shari Wiegreffe
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Eleni Gkika
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Bonn, Bonn, Deutschland
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5
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Cheng SH, Lee SY, Lee HH. Harnessing the Power of Radiotherapy for Lung Cancer: A Narrative Review of the Evolving Role of Magnetic Resonance Imaging Guidance. Cancers (Basel) 2024; 16:2710. [PMID: 39123438 PMCID: PMC11311467 DOI: 10.3390/cancers16152710] [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: 06/27/2024] [Revised: 07/22/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
Compared with computed tomography (CT), magnetic resonance imaging (MRI) traditionally plays a very limited role in lung cancer management, although there is plenty of room for improvement in the current CT-based workflow, for example, in structures such as the brachial plexus and chest wall invasion, which are difficult to visualize with CT alone. Furthermore, in the treatment of high-risk tumors such as ultracentral lung cancer, treatment-associated toxicity currently still outweighs its benefits. The advent of MR-Linac, an MRI-guided radiotherapy (RT) that combines MRI with a linear accelerator, could potentially address these limitations. Compared with CT-based technologies, MR-Linac could offer superior soft tissue visualization, daily adaptive capability, real-time target tracking, and an early assessment of treatment response. Clinically, it could be especially advantageous in the treatment of central/ultracentral lung cancer, early-stage lung cancer, and locally advanced lung cancer. Increasing demands for stereotactic body radiotherapy (SBRT) for lung cancer have led to MR-Linac adoption in some cancer centers. In this review, a broad overview of the latest research on imaging-guided radiotherapy (IGRT) with MR-Linac for lung cancer management is provided, and development pertaining to artificial intelligence is also highlighted. New avenues of research are also discussed.
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Affiliation(s)
- Sarah Hsin Cheng
- Department of Clinical Education and Training, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
| | - Shao-Yun Lee
- Department of Medical Education, Taichung Veterans General Hospital, Taichung 407, Taiwan;
| | - Hsin-Hua Lee
- Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Ph.D. Program in Environmental and Occupational Medicine, Kaohsiung Medical University and National Health Research Institutes, Kaohsiung 807, Taiwan
- Department of Radiation Oncology, Faculty of Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Center for Cancer Research, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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6
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Harris JP, Samson P, Owen D, Siva S, Daly ME, Giuliani M. Adapt or Perish: Adaptive RT for NSCLC. Int J Radiat Oncol Biol Phys 2024; 119:1047-1051. [PMID: 38925759 DOI: 10.1016/j.ijrobp.2024.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 02/24/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Jeremy P Harris
- Department of Radiation Oncology, University of California Irvine, Orange, California.
| | - Pamela Samson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Center, Victoria, Australia
| | - Megan E Daly
- Department of Radiation Oncology, University of California, Davis, California
| | - Meredith Giuliani
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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7
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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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Miller SR, Chang DT. Local-Regional Therapy for Oligometastatic Colorectal Cancer. Cancer J 2024; 30:272-279. [PMID: 39042779 DOI: 10.1097/ppo.0000000000000729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
ABSTRACT Colorectal cancer is one of the most common malignancies in the United States as well as a leading cause of cancer-related death. Upward of 30% of patients ultimately develop metastatic disease, most commonly to the liver and lung. Untreated, patients have poor survival. Historically, patients with oligometastatic disease were treated with resection leading to long-term survival; however, there are many patients who are not surgical candidates. Innovations in thermal ablation, hepatic artery infusions, chemoembolization and radioembolization, and stereotactic ablative radiation have led to an expansion of patients eligible for local therapy. This review examines the evidence behind each modality for the most common locations of oligometastatic colorectal cancer.
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Affiliation(s)
- Sean R Miller
- From the Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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Harrison N, Kang M, Liu R, Charyyev S, Wahl N, Liu W, Zhou J, Higgins KA, Simone CB, Bradley JD, Dynan WS, Lin L. A Novel Inverse Algorithm To Solve the Integrated Optimization of Dose, Dose Rate, and Linear Energy Transfer of Proton FLASH Therapy With Sparse Filters. Int J Radiat Oncol Biol Phys 2024; 119:957-967. [PMID: 38104869 DOI: 10.1016/j.ijrobp.2023.11.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 09/27/2023] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE The recently proposed Integrated Physical Optimization Intensity Modulated Proton Therapy (IPO-IMPT) framework allows simultaneous optimization of dose, dose rate, and linear energy transfer (LET) for ultra-high dose rate (FLASH) treatment planning. Finding solutions to IPO-IMPT is difficult because of computational intensiveness. Nevertheless, an inverse solution that simultaneously specifies the geometry of a sparse filter and weights of a proton intensity map is desirable for both clinical and preclinical applications. Such solutions can reduce effective biologic dose to organs at risk in patients with cancer as well as reduce the number of animal irradiations needed to derive extra biologic dose models in preclinical studies. METHODS AND MATERIALS Unlike the initial forward heuristic, this inverse IPO-IMPT solution includes simultaneous optimization of sparse range compensation, sparse range modulation, and spot intensity. The daunting computational tasks vital to this endeavor were resolved iteratively with a distributed computing framework to enable Simultaneous Intensity and Energy Modulation and Compensation (SIEMAC). SIEMAC was demonstrated on a human patient with central lung cancer and a minipig. RESULTS SIEMAC simultaneously improves maps of spot intensities and patient-field-specific sparse range compensators and range modulators. For the patient with lung cancer, at our maximum nozzle current of 300 nA, dose rate coverage above 100 Gy/s increased from 57% to 96% in the lung and from 93% to 100% in the heart, and LET coverage above 4 keV/µm dropped from 68% to 9% in the lung and from 26% to <1% in the heart. For a simple minipig plan, the full-width half-maximum of the dose, dose rate, and LET distributions decreased by 30%, 1.6%, and 57%, respectively, again with similar target dose coverage, thus reducing uncertainty in these quantities for preclinical studies. CONCLUSIONS The inverse solution to IPO-IMPT demonstrated the capability to simultaneously modulate subspot proton energy and intensity distributions for clinical and preclinical studies.
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Affiliation(s)
| | | | - Ruirui Liu
- Emory University, Atlanta, Georgia; University of Nebraska, Omaha, Nebraska
| | | | - Niklas Wahl
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Wei Liu
- Mayo Clinic, Phoenix, Arizona
| | - Jun Zhou
- Emory University, Atlanta, Georgia
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Ivanick NM, Kunadharaju R, Bhura S, Mengiste H, Saeed M, Saradna A, Grover H, Kalvapudi S, Yendamuri S, Yu H, Shafirstein G, Reid M. Epidemiology and Survival of Malignant Central Airway Obstruction in Lung Cancer Identified on Cross-Sectional Imaging. J Bronchology Interv Pulmonol 2024; 31:e0970. [PMID: 38881337 DOI: 10.1097/lbr.0000000000000970] [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: 10/26/2023] [Accepted: 04/17/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND The prevalence of malignant central airway obstruction at diagnosis and its 5-year incidence are largely unknown, as are basic epidemiological data pertaining to this serious condition. To address these data limitations, we retrospectively collected data from the cohort of patients diagnosed with lung cancer at our institution in 2015 and followed cohort patients 5 years forward, until 2020. METHODS We reviewed index PET/CT or CT scans at the time of lung cancer diagnosis to identify the presence, subtype, and severity of malignant central airway obstruction as well as progression/development over the next 5 years. RESULTS The prevalence of malignant central airway obstruction affecting the airway lumen by 25% or greater was 17%, and its 5-year incidence of development was 8.2%. Notable associations from the multivariate analysis included a younger age and a stepwise increase in obstruction with increasing stage of disease. Squamous cell carcinoma and small-cell lung cancer were the 2 histologic subtypes with the strongest association with obstruction. The presence of malignant central airway obstruction either at time of diagnosis or on follow-up imaging was associated with significantly shortened survival (multivariate Cox proportional HR for MCAO=1.702, P<0.001). CONCLUSION This study provides the first systematic characterization of fundamental epidemiological data on malignant central airway obstructions at a tertiary cancer center in the United States. This data is important to inform research directions and funding efforts of this serious complication. It also serves as a baseline value against which to compare for future studies.
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Affiliation(s)
| | - Rajesh Kunadharaju
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY
| | - Sajeer Bhura
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY
| | - Hiwot Mengiste
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY
| | - Musa Saeed
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY
| | - Arjun Saradna
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY
| | - Harshwant Grover
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY
| | | | | | - Han Yu
- Biostatistics and Bioinformatics
| | - Gal Shafirstein
- Department of Cell Stress Biology, Photodynamic Therapy Center
| | - Mary Reid
- Department of Medicine, Cancer Screening and Survivorship Section, Roswell Park Comprehensive Cancer Center
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Miccio JA, Potter NJ, Showkat A, Yao M, Mahase S, Ferenci M, Sisley K, Dailey A, Knipple J, Blakely A, Tuanquin L, Machtay M. Single institution experience of MRI-guided radiotherapy for thoracic tumors and clinical characteristics impacting treatment duty cycle. Front Oncol 2024; 14:1401703. [PMID: 38919525 PMCID: PMC11196615 DOI: 10.3389/fonc.2024.1401703] [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: 03/15/2024] [Accepted: 05/20/2024] [Indexed: 06/27/2024] Open
Abstract
Introduction MRI-guided radiotherapy (MRgRT) allows for direct motion management and real-time radiation treatment plan adaptation. We report our institutional experience using low strength 0.35T MRgRT for thoracic malignancies, and evaluate changes in treatment duty cycle between first and final MRgRT fractions. Methods All patients with intrathoracic tumors treated with MRgRT were included. The primary reason for MRgRT (adjacent organ at risk [OAR] vs. motion management [MM] vs. other) was recorded. Tumor location was classified as central (within 2cm of tracheobronchial tree) vs. non-central, and further classified by the Expanded HILUS grouping. Gross tumor volume (GTV) motion, planning target volume expansions, dose/fractionation, treatment plan time, and total delivery time were extracted from the treatment planning system. Treatment plan time was defined as the time for beam delivery, including multileaf collimator (MLC) motion, and gantry rotation. Treatment delivery time was defined as the time from beam on to completion of treatment, including treatment plan time and patient respiratory breath holds. Duty cycle was calculated as treatment plan time/treatment delivery time. Duty cycles were compared between first and final fraction using a two-sample t-test. Results Twenty-seven patients with thoracic tumors (16 non-small cell lung cancer and 11 thoracic metastases) were treated with MRgRT between 12/2021 and 06/2023. Fifteen patients received MRgRT due to OAR and 11 patients received MRgRT for motion management. 11 patients had central tumors and all were treated with MRgRT due to OAR risk. The median dose/fractionation was 50 Gy/5 fractions. For patients treated due to OAR (n=15), 80% had at least 1 adapted fraction during their course of radiotherapy. There was no plan adaptation for patients treated due to motion management (n=11). Mean GTV motion was significantly higher for patients treated due to motion management compared to OAR (16.1mm vs. 6.5mm, p=0.011). Mean duty cycle for fraction 1 was 54.2% compared to 62.1% with final fraction (p=0.004). Mean fraction 1 duty cycle was higher for patients treated due to OAR compared to patients treated for MM (61% vs. 45.0%, p=0.012). Discussion Duty cycle improved from first fraction to final fraction possibly due to patient familiarity with treatment. Duty cycle was improved for patients treated due to OAR risk, likely due to more central location and thus decreased target motion.
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Affiliation(s)
- Joseph A. Miccio
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Nicholas J. Potter
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Anaum Showkat
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
- Department of Arts and Letters, University of Notre Dame, South Bend, IN, United States
| | - Min Yao
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Sean Mahase
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Michele Ferenci
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Kaitlin Sisley
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Amy Dailey
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Jamie Knipple
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Amy Blakely
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Leonard Tuanquin
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
| | - Mitchell Machtay
- Department of Radiation Oncology, Penn State Cancer Institute, Hershey, PA, United States
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Zhao S, Beckert R, Zhao X, Laugeman E, Robinson CG, Vlacich G, Samson PP, Schiff JP. The First Reported Case of Treating the Ultra-Central Thorax With Cone Beam Computed Tomography-Guided Stereotactic Adaptive Radiotherapy (CT-STAR). Cureus 2024; 16:e62906. [PMID: 39040774 PMCID: PMC11262774 DOI: 10.7759/cureus.62906] [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] [Accepted: 06/22/2024] [Indexed: 07/24/2024] Open
Abstract
Stereotactic body radiotherapy (SBRT) to the central and ultra-central thorax is associated with infrequent but potentially serious adverse events. Adaptive SBRT, which provides more precise treatment planning and inter-fraction motion management, may allow the delivery of ablative doses to ultra-central tumors with effective local control and improved toxicity profiles. Herein, we describe the first reported case of cone beam computed tomography (CBCT)-guided stereotactic adaptive radiotherapy (CT-STAR) in the treatment of ultra-central non-small cell lung cancer (NSCLC) in a prospective clinical trial (NCT05785845). An 80-year-old man with radiographically diagnosed early-stage NSCLC presented for definitive management of an enlarging ultra-central lung nodule. He was prescribed 55 Gy in five fractions with CT-STAR. A simulation was performed using four-dimensional CT, and patients were planned for treatment at end-exhale breath-hold. Treatment plans were generated using a strict isotoxicity approach, which prioritized organ at risk (OAR) constraints over target coverage. During treatment, daily CBCTs were acquired and used to generate adapted contours and treatment plans based on the patient's anatomy-of-the-day, all while the patient was on the treatment table. The initial and adapted plans were compared using dose-volume histograms, and the superior plan was selected for treatment. The adapted plan was deemed superior and used for treatment in three out of five fractions. The adapted plan provided improved target coverage in two fractions and resolved an OAR hard constraint violation in one fraction. We report the successful treatment of a patient with ultra-central NSCLC utilizing CT-STAR. This case report builds on previously published in silico data to support the viability and dosimetric advantages of CT-STAR in the ablative treatment of this challenging tumor location. Further data are needed to confirm the toxicity and efficacy of this technique.
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Affiliation(s)
- Stephanie Zhao
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Robbie Beckert
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Xiaodong Zhao
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Eric Laugeman
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Gregory Vlacich
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Pamela P Samson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
| | - Joshua P Schiff
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, USA
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13
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Bryant JM, Cruz-Chamorro RJ, Gan A, Liveringhouse C, Weygand J, Nguyen A, Keit E, Sandoval ML, Sim AJ, Perez BA, Dilling TJ, Redler G, Andreozzi J, Nardella L, Naghavi AO, Feygelman V, Latifi K, Rosenberg SA. Structure-specific rigid dose accumulation dosimetric analysis of ablative stereotactic MRI-guided adaptive radiation therapy in ultracentral lung lesions. COMMUNICATIONS MEDICINE 2024; 4:96. [PMID: 38778215 PMCID: PMC11111790 DOI: 10.1038/s43856-024-00526-7] [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: 09/05/2023] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Definitive local therapy with stereotactic ablative radiation therapy (SABR) for ultracentral lung lesions is associated with a high risk of toxicity, including treatment related death. Stereotactic MR-guided adaptive radiation therapy (SMART) can overcome many of the challenges associated with SABR treatment of ultracentral lesions. METHODS We retrospectively identified 14 consecutive patients who received SMART to ultracentral lung lesions from 10/2019 to 01/2021. Patients had a median distance from the proximal bronchial tree (PBT) of 0.38 cm. Tumors were most often lung primary (64.3%) and HILUS group A (85.7%). A structure-specific rigid registration approach was used for cumulative dose analysis. Kaplan-Meier log-rank analysis was used for clinical outcome data and the Wilcoxon Signed Rank test was used for dosimetric data. RESULTS Here we show that SMART dosimetric improvements in favor of delivered plans over predicted non-adapted plans for PBT, with improvements in proximal bronchial tree DMax of 5.7 Gy (p = 0.002) and gross tumor 100% prescription coverage of 7.3% (p = 0.002). The mean estimated follow-up is 17.2 months and 2-year local control and local failure free survival rates are 92.9% and 85.7%, respectively. There are no grade ≥ 3 toxicities. CONCLUSIONS SMART has dosimetric advantages and excellent clinical outcomes for ultracentral lung tumors. Daily plan adaptation reliably improves target coverage while simultaneously reducing doses to the proximal airways. These results further characterize the therapeutic window improvements for SMART. Structure-specific rigid dose accumulation dosimetric analysis provides insights that elucidate the dosimetric advantages of SMART more so than per fractional analysis alone.
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Affiliation(s)
- J M Bryant
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
| | - Ruben J Cruz-Chamorro
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Alberic Gan
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Casey Liveringhouse
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Joseph Weygand
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ann Nguyen
- University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Emily Keit
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Maria L Sandoval
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Austin J Sim
- Department of Radiation Oncology; James Cancer Hospital, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Bradford A Perez
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Thomas J Dilling
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Gage Redler
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jacqueline Andreozzi
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Louis Nardella
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Arash O Naghavi
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Vladimir Feygelman
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Kujtim Latifi
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Stephen A Rosenberg
- Department of Radiation Oncology; H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
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14
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Levy A, Adebahr S, Hurkmans C, Ahmed M, Ahmad S, Guckenberger M, Geets X, Lievens Y, Lambrecht M, Pourel N, Lewitzki V, Konopa K, Franks K, Dziadziuszko R, McDonald F, Fortpied C, Clementel E, Fournier B, Rizzo S, Fink C, Riesterer O, Peulen H, Andratschke N, McWilliam A, Gkika E, Schimek-Jasch T, Grosu AL, Le Pechoux C, Faivre-Finn C, Nestle U. Stereotactic Body Radiotherapy for Centrally Located Inoperable Early-Stage NSCLC: EORTC 22113-08113 LungTech Phase II Trial Results. J Thorac Oncol 2024:S1556-0864(24)00577-X. [PMID: 38788924 DOI: 10.1016/j.jtho.2024.05.366] [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: 03/06/2024] [Revised: 05/04/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION The international phase II single-arm LungTech trial 22113-08113 of the European Organization for Research and Treatment of Cancer assessed the safety and efficacy of stereotactic body radiotherapy (SBRT) in patients with centrally located early-stage NSCLC. METHODS Patients with inoperable non-metastatic central NSCLC (T1-T3 N0 M0, ≤7cm) were included. After prospective central imaging review and radiation therapy quality assurance for any eligible patient, SBRT (8 × 7.5 Gy) was delivered. The primary endpoint was freedom from local progression probability three years after the start of SBRT. RESULTS The trial was closed early due to poor accrual related to repeated safety-related pauses in recruitment. Between August 2015 and December 2017, 39 patients from six European countries were included and 31 were treated per protocol and analyzed. Patients were mainly male (58%) with a median age of 75 years. Baseline comorbidities were mainly respiratory (68%) and cardiac (48%). Median tumor size was 2.6 cm (range 1.2-5.5) and most cancers were T1 (51.6%) or T2a (38.7%) N0 M0 and of squamous cell origin (48.4%). Six patients (19.4%) had an ultracentral tumor location. The median follow-up was 3.6 years. The rates of 3-year freedom from local progression and overall survival were 81.5% (90% confidence interval [CI]: 62.7%-91.4%) and 61.1% (90% CI: 44.1%-74.4%), respectively. Cumulative incidence rates of local, regional, and distant progression at three years were 6.7% (90% CI: 1.6%-17.1%), 3.3% (90% CI: 0.4%-12.4%), and 29.8% (90% CI: 16.8%-44.1%), respectively. SBRT-related acute adverse events and late adverse events ≥ G3 were reported in 6.5% (n = 2, including one G5 pneumonitis in a patient with prior interstitial lung disease) and 19.4% (n = 6, including one lethal hemoptysis after a lung biopsy in a patient receiving anticoagulants), respectively. CONCLUSIONS The LungTech trial suggests that SBRT with 8 × 7.5Gy for central lung tumors in inoperable patients is associated with acceptable local control rates. However, late severe adverse events may occur after completion of treatment. This SBRT regimen is a viable treatment option after a thorough risk-benefit discussion with patients. To minimize potentially fatal toxicity, careful management of dose constraints, and post-SBRT interventions is crucial.
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Affiliation(s)
- Antonin Levy
- Department of Radiation Oncology, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Sonja Adebahr
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| | - Coen Hurkmans
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - Merina Ahmed
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust/Institute of Cancer Research, Sutton, United Kingdom
| | - Shahreen Ahmad
- Department of Oncology and Radiotherapy, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Xavier Geets
- Department of Radiation Oncology, Cliniques universitaires Saint-Luc, MIRO - IREC Lab, Brussels, Belgium
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - Maarten Lambrecht
- Department of Radiotherapy-Oncology, UZ Gasthuisberg Leuven, Leuven, Belgium; KU Leuven, Laboratory of Experimental Radiotherapy, Leuven, Belgium
| | - Nicolas Pourel
- Institut Sainte-Catherine, Service de radiothérapie, Avignon, France
| | - Victor Lewitzki
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Krzysztof Konopa
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - Kevin Franks
- Department of Clinical Oncology, St. James's University Hospital, Leeds, United Kingdom
| | - Rafal Dziadziuszko
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
| | - Fiona McDonald
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust/Institute of Cancer Research, Sutton, United Kingdom
| | | | | | | | - Stefania Rizzo
- Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano, Switzerland
| | - Christian Fink
- Allgemeines Krankenhaus, AKH Celle, Celle, Germany; Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Oliver Riesterer
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Kantonsspital Aarau, Radio-Onkologie-Zentrum KSA-KSB, Aarau, Switzerland
| | - Heike Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands; Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Alan McWilliam
- Division of Cancer Sciences, The Christie NHS Foundation Trust, University of Manchester, Manchester, United Kingdom
| | - Eleni Gkika
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany; Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Tanja Schimek-Jasch
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| | - Cécile Le Pechoux
- Department of Radiation Oncology, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, The Christie NHS Foundation Trust, University of Manchester, Manchester, United Kingdom
| | - Ursula Nestle
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany; Department of Radiation Oncology, Kliniken Maria Hilf GmbH Mönchengladbach, Mönchengladbach, Germany.
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15
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Li GJ, Tan H, Nusrat H, Chang J, Chen H, Poon I, Shahi J, Tsao M, Ung Y, Cheung P, Louie AV. Safety and Efficacy of Stereotactic Body Radiation Therapy for Ultra-central Thoracic Tumors: A Single Center Retrospective Review. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00508-X. [PMID: 38621607 DOI: 10.1016/j.ijrobp.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 03/29/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE We sought to evaluate the toxicity and efficacy of stereotactic body radiation therapy (SBRT) for ultracentral thoracic tumors at our institution. METHODS AND MATERIALS Patients with ultracentral lung tumors or nodes, defined as having the planning target volume (PTV) overlapping or abutting the central bronchial tree and/or esophagus, treated at our institution with SBRT between 2009 and 2019 were retrospectively reviewed. All SBRT plans were generated with the goal of creating homogenous dose distributions. The primary endpoint was incidence of SBRT-related grade ≥3 toxicity, defined using the Common Terminology Criteria for Adverse Events (V5.0). Secondary endpoints included local failure (LF), progression-free survival (PFS), and overall survival. Competing risk analysis was used to estimate incidence and identify predictors of severe toxicity and LF, while the Kaplan-Meier method was used to estimate PFS and OS. RESULTS A total of 154 patients receiving 162 ultracentral courses of SBRT were included. The most common prescription was 50 Gy in 5 fractions (42%), with doses ranging from 30 to 55 Gy in 5 fractions (BED10 range, 48-115 Gy). The incidence of severe toxicity was 9.4% at 3 years. The most common severe toxicity was pneumonitis (n = 4). There was 1 possible treatment-related death from pneumonitis/pneumonia. Predictors of severe toxicity included increased PTV size, decreased PTV V95%, lung V5 Gy, and lung V20 Gy. The incidence of LF was 14% at 3 years. Predictors of LF included younger age and greater volume of overlap between the PTV and esophagus. The median PFS was 8.8 months, while the median overall survival was 44.0 months. CONCLUSIONS In the largest case series of ultracentral thoracic SBRT to date, homogenously prescribed SBRT was associated with relatively low rates of severe toxicity and LF. Predictors of toxicity should be interpreted in the context of the heterogeneity in toxicities observed.
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Affiliation(s)
- George J Li
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Hendrick Tan
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Humza Nusrat
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Joe Chang
- Liverpool Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jeevin Shahi
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - May Tsao
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Yee Ung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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16
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Giuliani ME, Filion E, Faria S, Kundapur V, Toni Vu TTT, Lok BH, Raman S, Bahig H, Laba JM, Lang P, Louie AV, Hope A, Rodrigues GB, Bezjak A, Campeau MP, Duclos M, Bratman S, Swaminath A, Salunkhe R, Warner A, Palma DA. Stereotactic Radiation for Ultra-Central Non-Small Cell Lung Cancer: A Safety and Efficacy Trial (SUNSET). Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00480-2. [PMID: 38614279 DOI: 10.1016/j.ijrobp.2024.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/22/2024] [Accepted: 03/30/2024] [Indexed: 04/15/2024]
Abstract
PURPOSE The use of stereotactic body radiation therapy for tumors in close proximity to the central mediastinal structures has been associated with a high risk of toxicity. This study (NCT03306680) aimed to determine the maximally tolerated dose of stereotactic body radiation therapy for ultracentral non-small cell lung carcinoma, using a time-to-event continual reassessment methodology. METHODS AND MATERIALS Patients with T1-3N0M0 (≤6 cm) non-small cell lung carcinoma were eligible. The maximally tolerated dose was defined as the dose of radiation therapy associated with a ≤30% rate of grade (G) 3 to 5 prespecified treatment-related toxicity occurring within 2 years of treatment. The starting dose level was 60 Gy in 8 daily fractions. The dose-maximum hotspot was limited to 120% and within the planning tumor volume; tumors with endobronchial invasion were excluded. This primary analysis occurred 2 years after completion of accrual. RESULTS Between March 2018 and April 2021, 30 patients were enrolled at 5 institutions. The median age was 73 years (range, 65-87) and 17 (57%) were female. Planning tumor volume was abutting proximal bronchial tree in 19 (63%), esophagus 5 (17%), pulmonary vein 1 (3.3%), and pulmonary artery 14 (47%). All patients received 60 Gy in 8 fractions. The median follow-up was 37 months (range, 8.9-51). Two patients (6.7%) experienced G3-5 adverse events related to treatment: 1 patient with G3 dyspnea and 1 G5 pneumonia. The latter had computed tomography findings consistent with a background of interstitial lung disease. Three-year overall survival was 72.5% (95% CI, 52.3%-85.3%), progression-free survival 66.1% (95% CI, 46.1%-80.2%), local control 89.6% (95% CI, 71.2%-96.5%), regional control 96.4% (95% CI, 77.2%-99.5%), and distant control 85.9% (95% CI, 66.7%-94.5%). Quality-of-life scores declined numerically over time, but the decreases were not clinically or statistically significant. CONCLUSIONS Sixty Gy in 8 fractions, planned and delivered with only a moderate hotspot, has a favorable adverse event rate within the prespecified acceptability criteria and results in excellent control for ultracentral tumors.
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Affiliation(s)
| | - Edith Filion
- Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Sergio Faria
- McGill University Health Centre, Montréal, Canada
| | | | | | | | | | - Houda Bahig
- Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Joanna M Laba
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | - Pencilla Lang
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | - Alexander V Louie
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrew Hope
- Princess Margaret Cancer Centre, Toronto, Canada
| | - George B Rodrigues
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | | | | | - Marie Duclos
- McGill University Health Centre, Montréal, Canada
| | | | | | | | - Andrew Warner
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | - David A Palma
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
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17
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Kalvapudi S, Zubair HM, Kunadharaju R, Bhura S, Mengiste H, Saeed M, Saradna A, Grover H, Shafirstein G, Yendamuri S, Ivanick NM. Correlation of Bronchoscopy and CT in Characterizing Malignant Central Airway Obstruction. Cancers (Basel) 2024; 16:1258. [PMID: 38610936 PMCID: PMC11010868 DOI: 10.3390/cancers16071258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Malignant Central Airway Obstruction (MCAO) presents a significant challenge in lung cancer management, with notable morbidity and mortality implications. While bronchoscopy is the established diagnostic standard for confirming MCAO and assessing obstruction subtype (intrinsic, extrinsic, mixed) and severity, Computed Tomography (CT) serves as an initial screening tool. However, the extent of agreement between CT and bronchoscopy findings for MCAO remains unclear. METHODS To assess the correlation between bronchoscopy and CT, we conducted a retrospective review of 108 patients at Roswell Park Comprehensive Cancer Center, analyzing CT and bronchoscopy results to document MCAO presence, severity, and subtype. RESULTS CT correctly identified MCAO in 99% of cases (107/108). Agreement regarding obstruction subtype (80.8%, Cohen's κ = 0.683, p < 0.001), and severity (65%, Quadratic κ = 0.657, p < 0.001) was moderate. CT tended to equally overestimate (7/19) and underestimate (7/19) the degree of obstruction. CT was also poor in identifying mucosal involvement in mixed MCAO. CONCLUSIONS CT demonstrates reasonable agreement with bronchoscopy in detecting obstruction. Nevertheless, when CT indicates a positive finding for MCAO, it is advisable to conduct bronchoscopy. This is because CT lacks reliability in determining the severity of obstruction and identifying the mucosal component of mixed disease.
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Affiliation(s)
- Sukumar Kalvapudi
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (S.K.); (S.Y.)
| | - Hafiz M. Zubair
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY 14203, USA; (H.M.Z.); (R.K.); (S.B.); (H.M.); (M.S.); (A.S.); (H.G.)
| | - Rajesh Kunadharaju
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY 14203, USA; (H.M.Z.); (R.K.); (S.B.); (H.M.); (M.S.); (A.S.); (H.G.)
| | - Sajeer Bhura
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY 14203, USA; (H.M.Z.); (R.K.); (S.B.); (H.M.); (M.S.); (A.S.); (H.G.)
| | - Hiwot Mengiste
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY 14203, USA; (H.M.Z.); (R.K.); (S.B.); (H.M.); (M.S.); (A.S.); (H.G.)
| | - Musa Saeed
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY 14203, USA; (H.M.Z.); (R.K.); (S.B.); (H.M.); (M.S.); (A.S.); (H.G.)
| | - Arjun Saradna
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY 14203, USA; (H.M.Z.); (R.K.); (S.B.); (H.M.); (M.S.); (A.S.); (H.G.)
| | - Harshwant Grover
- Department of Pulmonary and Critical Care, University at Buffalo, Buffalo, NY 14203, USA; (H.M.Z.); (R.K.); (S.B.); (H.M.); (M.S.); (A.S.); (H.G.)
| | - Gal Shafirstein
- Department of Cell Stress Biology, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA;
| | - Sai Yendamuri
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (S.K.); (S.Y.)
| | - Nathaniel M. Ivanick
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (S.K.); (S.Y.)
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Kishi N, Yoneyama M, Inoo H, Inoue M, Iramina H, Nakakura A, Ono T, Hirashima H, Adachi T, Matsushita N, Sasaki M, Fujimoto T, Nakamura M, Matsuo Y, Mizowaki T. Protocol of a phase II study to evaluate the efficacy and safety of deep-inspiration breath-hold daily online adaptive radiotherapy for centrally located lung tumours (PUDDING study). Radiat Oncol 2024; 19:32. [PMID: 38459580 PMCID: PMC10921600 DOI: 10.1186/s13014-024-02427-4] [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: 09/28/2023] [Accepted: 02/29/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Centrally located lung tumours present a challenge because of their tendency to exhibit symptoms such as airway obstruction, atelectasis, and bleeding. Surgical resection of these tumours often requires sacrificing the lungs, making definitive radiotherapy the preferred alternative to avoid pneumonectomy. However, the proximity of these tumours to mediastinal organs at risk increases the potential for severe adverse events. To mitigate this risk, we propose a dual-method approach: deep inspiration breath-hold (DIBH) radiotherapy combined with adaptive radiotherapy. The aim of this single-centre, single-arm phase II study is to investigate the efficacy and safety of DIBH daily online adaptive radiotherapy. METHODS Patients diagnosed with centrally located lung tumours according to the International Association for the Study of Lung Cancer recommendations, are enrolled and subjected to DIBH daily online adaptive radiotherapy. The primary endpoint is the one-year cumulative incidence of grade 3 or more severe adverse events, as classified by the Common Terminology Criteria for Adverse Events (CTCAE v5.0). DISCUSSION Delivering definitive radiotherapy for centrally located lung tumours presents a dilemma between ensuring optimal dose coverage for the planning target volume and the associated increased risk of adverse events. DIBH provides measurable dosimetric benefits by increasing the normal lung volume and distancing the tumour from critical mediastinal organs at risk, leading to reduced toxicity. DIBH adaptive radiotherapy has been proposed as an adjunct treatment option for abdominal and pelvic cancers. If the application of DIBH adaptive radiotherapy to centrally located lung tumours proves successful, this approach could shape future phase III trials and offer novel perspectives in lung tumour radiotherapy. TRIAL REGISTRATION Registered at the Japan Registry of Clinical Trials (jRCT; https://jrct.niph.go.jp/ ); registration number: jRCT1052230085 ( https://jrct.niph.go.jp/en-latest-detail/jRCT1052230085 ).
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Affiliation(s)
- Noriko Kishi
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Masahiro Yoneyama
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Hiroyuki Inoo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Minoru Inoue
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Hiraku Iramina
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Akiyoshi Nakakura
- Department of Biomedical Statistics and Bioinformatics, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Tomohiro Ono
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Hideaki Hirashima
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Takanori Adachi
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | | | - Makoto Sasaki
- Clinical Radiology Service, Kyoto University Hospital, Kyoto, Japan
| | | | - Mitsuhiro Nakamura
- Department of Information Technology and Medical Engineering, Division of Medical Physics, Graduate School of Medicine, Human Health Sciences, Kyoto University, Kyoto, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2, Onohigashi, Osakasayama-Shi, Osaka, 589-8511, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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19
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Singh R. In Reply To: Comment on: Improved local control following dose-escalated stereotactic ablative radiation therapy (SABR) for metastatic sarcomas: An international multi-institutional experience. Radiother Oncol 2024; 192:110058. [PMID: 38122853 DOI: 10.1016/j.radonc.2023.110058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Raj Singh
- The Ohio State University Comprehensive Cancer Center, The James Cancer Hospital and Solove Research Institute, Department of Radiation Oncology, Columbus, OH, USA.
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20
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Sasse A, Oh P, Saeed N, Yang DX, Hayman TJ, Knowlton CA, Peters GW, Campbell A, Laird J, Housri N, Park HS. Dose-Volume Predictors of Radiation Pneumonitis After Thoracic Hypofractionated Radiation Therapy. Pract Radiat Oncol 2024; 14:e97-e104. [PMID: 37984711 DOI: 10.1016/j.prro.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Hypofractionated radiation therapy (HFRT) is a common treatment for thoracic tumors, typically delivered as 60 Gy in 15 fractions. We aimed to identify dosimetric risk factors associated with radiation pneumonitis in patients receiving HFRT at 4 Gy per fraction, focusing on lung V20, mean lung dose (MLD), and lung V5 as potential predictors of grade ≥2 pneumonitis. METHODS AND MATERIALS All patients were treated with thoracic HFRT to 60 Gy in 15 fractions or 72 Gy in 18 fractions at a single health care system from 2013 to 2020. Tumors near critical structures (trachea, proximal tracheobronchial tree, esophagus, spinal cord, or heart) were considered central (within 2 cm), and those closer were classified as ultracentral (within 1 cm). The primary endpoint was grade ≥2 pneumonitis. Logistic regression analyses, adjusting for target size and dosimetric variables, were used to establish a dose threshold associated with <20% risk of grade ≥2 pneumonitis. RESULTS During a median 24.3-month follow-up, 18 patients (16.8%) developed grade ≥2 radiation pneumonitis, with no significant difference between the 2 dose regimens (17.3% vs 16.3%, P = .88). Four patients (3.7%) experienced grade ≥3 pneumonitis, including 2 grade 5 cases. Patients with grade ≥2 pneumonitis had significantly higher lung V20 (mean 23.4% vs 14.5%, P < .001), MLD (mean 13.0 Gy vs 9.5 Gy, P < .001), and lung V5 (mean 49.6% vs 40.6%, P = .01). Dose thresholds for a 20% risk of grade ≥2 pneumonitis were lung V20 <17.7%, MLD <10.6 Gy, and V5 <41.3%. Multivariable analysis revealed a significant association between lung V20 and grade ≥2 pneumonitis (adjusted odds ratio, 1.48, P = .03). CONCLUSIONS To minimize the risk of grade ≥2 radiation pneumonitis when delivering 4 Gy per fraction at either 60 Gy or 72 Gy, it is advisable to maintain lung V20<17.7%. MLD <10.6 Gy and V5<41.3% can also be considered as lower-priority constraints. However, additional validation is necessary before incorporating these constraints into clinical practice or trial planning guidelines.
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Affiliation(s)
- Alexander Sasse
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Patrick Oh
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Nadia Saeed
- Department of Radiation Oncology, Dana Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel X Yang
- Department of Radiation Oncology, UT Southwestern, Dallas, Texas
| | - Thomas J Hayman
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Christin A Knowlton
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Gabrielle W Peters
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Allison Campbell
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - James Laird
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Nadine Housri
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Henry S Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut.
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21
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Csiki E, Simon M, Papp J, Barabás M, Mikáczó J, Gál K, Sipos D, Kovács Á. Stereotactic body radiotherapy in lung cancer: a contemporary review. Pathol Oncol Res 2024; 30:1611709. [PMID: 38476352 PMCID: PMC10928908 DOI: 10.3389/pore.2024.1611709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/15/2024] [Indexed: 03/14/2024]
Abstract
The treatment of early stage non-small cell lung cancer (NSCLC) has improved enormously in the last two decades. Although surgery is not the only choice, lobectomy is still the gold standard treatment type for operable patients. For inoperable patients stereotactic body radiotherapy (SBRT) should be offered, reaching very high local control and overall survival rates. With SBRT we can precisely irradiate small, well-defined lesions with high doses. To select the appropriate fractionation schedule it is important to determine the size, localization and extent of the lung tumor. The introduction of novel and further developed planning (contouring guidelines, diagnostic image application, planning systems) and delivery techniques (motion management, image guided radiotherapy) led to lower rates of side effects and more conformal target volume coverage. The purpose of this study is to summarize the current developments, randomised studies, guidelines about lung SBRT, with emphasis on the possibility of increasing local control and overall rates in "fit," operable patients as well, so SBRT would be eligible in place of surgery.
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Affiliation(s)
- Emese Csiki
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Mihály Simon
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Papp
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Márton Barabás
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Johanna Mikáczó
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Kristóf Gál
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - David Sipos
- Faculty of Health Sciences, University of Pécs, Pecs, Hungary
| | - Árpád Kovács
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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22
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Aoki S, Ishikawa H, Nakajima M, Yamamoto N, Mori S, Wakatsuki M, Okonogi N, Murata K, Tada Y, Mizobuchi T, Yoshino I, Yamada S. Long-Term Outcomes of Ablative Carbon-Ion Radiotherapy for Central Non-Small Cell Lung Cancer: A Single-Center, Retrospective Study. Cancers (Basel) 2024; 16:933. [PMID: 38473295 DOI: 10.3390/cancers16050933] [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: 01/11/2024] [Revised: 02/14/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
The aim of this study is to assess the efficacy and safety of ablative carbon ion radiotherapy (CIRT) for early stage central non-small cell lung cancer (NSCLC). We retrospectively reviewed 30 patients who had received CIRT at 68.4 Gy in 12 fractions for central NSCLC in 2006-2019. The median age was 75 years, and the median Karnofsky Performance Scale score was 90%. All patients had concomitant chronic obstructive pulmonary disease, and 20 patients (67%) were considered inoperable. In DVH analysis, the median lung V5 and V20 were 15.5% and 10.4%, and the median Dmax, D0.5cc, D2cc of proximal bronchial tree was 65.6 Gy, 52.8 Gy, and 10.0 Gy, respectively. At a median follow-up of 43 months, the 3-year overall survival, disease-specific survival, and local control rates were 72.4, 75.8, and 88.7%, respectively. Two patients experienced grade 3 pneumonitis, but no grade ≥3 adverse events involving the mediastinal organs occurred. Ablative CIRT is feasible and effective for central NSCLC and could be considered as a treatment option, especially for patients who are intolerant of other curative treatments.
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Affiliation(s)
- Shuri Aoki
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
- Department of Radiology, University of Tokyo Hospital, 3-7-1 Hongo, Tokyo 113-8655, Japan
| | - Hitoshi Ishikawa
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
| | - Mio Nakajima
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
| | - Naoyoshi Yamamoto
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
| | - Shinichiro Mori
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
| | - Masaru Wakatsuki
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
| | - Noriyuki Okonogi
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Tokyo 113-8421, Japan
| | - Kazutoshi Murata
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
| | - Yuji Tada
- Department of Pulmonary Medicine, International University of Health and Welfare, Narita Hospital, Hatakeda 852, Chiba 286-8520, Japan
| | - Teruaki Mizobuchi
- Department of Respiratory Surgery, Social Welfare Organization Saiseikai Imperial Gift Foundation, Chibaken Saiseikai Narashino Hospital, 1-1-1 Izumi-cho, Chiba 275-8580, Japan
| | - Ichiro Yoshino
- Department of Thoracic Surgery, International University of Health and Welfare, Narita Hospital, Hatakeda 852, Chiba 286-8520, Japan
| | - Shigeru Yamada
- QST Hospital, National Institutes for Quantum Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba 263-8555, Japan
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23
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Bourbonne V, Lévy A, Khalifa J, Antoni D, Blais E, Darréon J, Le Péchoux C, Lerouge D, Giraud P, Marguerit A, Pourel N, Riet FG, Thureau S. Radiotherapy in the management of lung oligometastases. Cancer Radiother 2024; 28:36-48. [PMID: 38228422 DOI: 10.1016/j.canrad.2023.06.030] [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: 02/26/2023] [Revised: 06/07/2023] [Accepted: 06/29/2023] [Indexed: 01/18/2024]
Abstract
In recent years, the development of both medical imaging and new systemic agents (targeted therapy and immunotherapy) have revolutionized the field of oncology, leading to a new entity: oligometastatic disease. Adding local treatment of oligometastases to systemic treatment could lead to prolonged survival with no significant impact on quality of life. Given the high prevalence of lung oligometastases and the new systemic agents coming with increased pulmonary toxicity, this article provides a comprehensive review of the current state-of-art for radiotherapy of lung oligometastases. After reviewing pretreatment workup, the authors define several radiotherapy regimen based on the localization and size of the oligometastases. A comment on the synergistic combination of medical treatment and radiotherapy is also made, projecting on future steps in this specific clinical setting.
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Affiliation(s)
- V Bourbonne
- Radiation Oncology Department, CHU de Brest, Brest, France; LaTim, Inserm, UMR 1101, université de Bretagne occidentale, Brest, France
| | - A Lévy
- Department of Radiation Oncology, Centre international des cancers thoraciques (CICT), Gustave-Roussy, 94805 Villejuif, France; Faculté de médecine, université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France
| | - J Khalifa
- Department of Radiation Oncology, institut Claudius-Regaud, institut universitaire du cancer Toulouse-Oncopôle, Toulouse, France
| | - D Antoni
- Department of Radiation Oncology, Institut de cancérologie Strasbourg Europe, Strasbourg, France
| | - E Blais
- Department of Radiation Oncology, polyclinique Marzet, Pau, France
| | - J Darréon
- Department of Radiation Oncology, institut Paoli-Calmettes, Marseille, France
| | - C Le Péchoux
- Department of Radiation Oncology, Centre international des cancers thoraciques (CICT), Gustave-Roussy, 94805 Villejuif, France; Faculté de médecine, université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France
| | - D Lerouge
- Department of Radiation Oncology, centre François-Baclesse, Caen, France
| | - P Giraud
- Department of Radiation Oncology, hôpital européen Georges-Pompidou, Paris, France; Université Paris Cité, Paris, France
| | - A Marguerit
- Department of Radiation Oncology, Institut de cancérologie de Montpellier, Montpellier, France
| | - N Pourel
- Department of Radiation Oncology, institut Sainte-Catherine, Avignon, France
| | - F-G Riet
- Department of Radiation Oncology, centre hospitalier privé Saint-Grégoire, 35760 Saint-Grégoire, France
| | - S Thureau
- Radiotherapy Department, centre Henri-Becquerel, Rouen, France; QuantIF-Litis EA4108, université de Rouen, Rouen, France.
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24
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La Rosa A, Mittauer KE, Bassiri N, Rzepczynski AE, Chuong MD, Yarlagadda S, Kutuk T, McAllister NC, Hall MD, Gutierrez AN, Tolakanahalli R, Mehta MP, Kotecha R. Accelerated Hypofractionated Magnetic Resonance Guided Adaptive Radiation Therapy for Ultracentral Lung Tumors. Tomography 2024; 10:169-180. [PMID: 38250959 PMCID: PMC10820032 DOI: 10.3390/tomography10010013] [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: 10/05/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
Radiotherapy for ultracentral lung tumors represents a treatment challenge, considering the high rates of high-grade treatment-related toxicities with stereotactic body radiation therapy (SBRT) or hypofractionated schedules. Accelerated hypofractionated magnetic resonance-guided adaptive radiation therapy (MRgART) emerged as a potential game-changer for tumors in these challenging locations, in close proximity to central organs at risk, such as the trachea, proximal bronchial tree, and esophagus. In this series, 13 consecutive patients, predominantly male (n = 9), with a median age of 71 (range (R): 46-85), underwent 195 MRgART fractions (all 60 Gy in 15 fractions) to metastatic (n = 12) or primary ultra-central lung tumors (n = 1). The median gross tumor volumes (GTVs) and planning target volumes (PTVs) were 20.72 cc (R: 0.54-121.65 cc) and 61.53 cc (R: 3.87-211.81 cc), respectively. The median beam-on time per fraction was 14 min. Adapted treatment plans were generated for all fractions, and indications included GTV/PTV undercoverage, OARs exceeding tolerance doses, or both indications in 46%, 18%, and 36% of fractions, respectively. Eight patients received concurrent systemic therapies, including immunotherapy (four), chemotherapy (two), and targeted therapy (two). The crude in-field loco-regional control rate was 92.3%. No CTCAE grade 3+ toxicities were observed. Our results offer promising insights, suggesting that MRgART has the potential to mitigate toxicities, enhance treatment precision, and improve overall patient care in the context of ultracentral lung tumors.
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Affiliation(s)
- Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Kathryn E. Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Nema Bassiri
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Amy E. Rzepczynski
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Sreenija Yarlagadda
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Nicole C. McAllister
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
| | - Matthew D. Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Alonso N. Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL 33176, USA; (K.E.M.); (N.B.); (A.E.R.); (M.D.C.); (S.Y.); (T.K.); (N.C.M.); (M.D.H.); (A.N.G.); (R.T.); (M.P.M.)
- Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
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25
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Habermann FNOJ, Schmitt D, Failing T, Ziegler DA, Fischer J, Fischer LA, Guhlich M, Bendrich S, Knaus O, Overbeck TR, Treiber H, von Hammerstein-Equord A, Koch R, El Shafie R, Rieken S, Leu M, Dröge LH. And Yet It Moves: Clinical Outcomes and Motion Management in Stereotactic Body Radiation Therapy (SBRT) of Centrally Located Non-Small Cell Lung Cancer (NSCLC): Shedding Light on the Internal Organ at Risk Volume (IRV) Concept. Cancers (Basel) 2024; 16:231. [PMID: 38201658 PMCID: PMC10778176 DOI: 10.3390/cancers16010231] [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: 12/04/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
The internal organ at risk volume (IRV) concept might improve toxicity profiles in stereotactic body radiation therapy (SBRT) for non-small cell lung cancer (NSCLC). We studied (1) clinical aspects in central vs. peripheral tumors, (2) the IRV concept in central tumors, (3) organ motion, and (4) associated normal tissue complication probabilities (NTCPs). We analyzed patients who received SBRT for NSCLC (clinical aspects, n = 78; motion management, n = 35). We found lower biologically effective doses, larger planning target volume sizes, higher lung doses, and worse locoregional control for central vs. peripheral tumors. Organ motion was greater in males and tall patients (bronchial tree), whereas volume changes were lower in patients with a high body mass index (BMI) (esophagus). Applying the IRV concept (retrospectively, without new optimization), we found an absolute increase of >10% in NTCPs for the bronchial tree in three patients. This study emphasizes the need to optimize methods to balance dose escalation with toxicities in central tumors. There is evidence that organ motion/volume changes could be more pronounced in males and tall patients, and less pronounced in patients with higher BMI. Since recent studies have made efforts to further subclassify central tumors to refine treatment, the IRV concept should be considered for optimal risk assessment.
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Affiliation(s)
- Felix-Nikolai Oschinka Jegor Habermann
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Daniela Schmitt
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Thomas Failing
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
- Institute of Medical Physics and Radiation Protection (IMPS), University of Applied Sciences, Wiesenstr. 14, 35390 Gießen, Germany
| | - David Alexander Ziegler
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Jann Fischer
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Laura Anna Fischer
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Manuel Guhlich
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Stephanie Bendrich
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Olga Knaus
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Tobias Raphael Overbeck
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
- Department of Hematology and Medical Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Hannes Treiber
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
- Department of Hematology and Medical Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Alexander von Hammerstein-Equord
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
- Department of Cardio-Thoracic and Vascular Surgery, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Raphael Koch
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
- Department of Hematology and Medical Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Rami El Shafie
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Stefan Rieken
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Martin Leu
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
| | - Leif Hendrik Dröge
- Department of Radiotherapy and Radiation Oncology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany; (F.-N.O.J.H.); (D.S.); (D.A.Z.); (J.F.); (L.A.F.); (M.G.); (S.B.); (R.E.S.); (S.R.); (M.L.)
- Göttingen Comprehensive Cancer Center (G-CCC), University Medical Center Göttingen, Von-Bar-Str. 2/4, 37075 Göttingen, Germany; (T.R.O.); (H.T.); (A.v.H.-E.); (R.K.)
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26
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Gouw ZAR, Jeong J, Rimner A, Lee NY, Jackson A, Fu A, Sonke JJ, Deasy JO. "Primer shot" fractionation with an early treatment break is theoretically superior to consecutive weekday fractionation schemes for early-stage non-small cell lung cancer. Radiother Oncol 2024; 190:110006. [PMID: 37972733 DOI: 10.1016/j.radonc.2023.110006] [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: 07/18/2023] [Revised: 10/14/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Radiotherapy is traditionally given in equally spaced weekday fractions. We hypothesize that heterogeneous interfraction intervals can increase radiosensitivity via reoxygenation. Through modeling, we investigate whether this minimizes local failures and toxicity for early-stage non-small cell lung cancer (NSCLC). METHODS Previously, a tumor dose-response model based on resource competition and cell-cycle-dependent radiosensitivity accurately predicted local failure rates for early-stage NSCLC cohorts. Here, the model mathematically determined non-uniform inter-fraction intervals minimizing local failures at similar normal tissue toxicity risk, i.e., iso-BED3 (iso-NTCP) for fractionation schemes 18Gyx3, 12Gyx4, 10Gyx5, 7.5Gyx8, 5Gyx12, 4Gyx15. Next, we used these optimized schedules to reduce toxicity risk (BED3) while maintaining stable local failures (TCP). RESULTS Optimal schedules consistently favored a "primer shot" fraction followed by a 2-week break, allowing tumor reoxygenation. Increasing or decreasing the assumed baseline hypoxia extended or shortened this optimal break by up to one week. Fraction sizes of 7.5 Gy and up required a single primer shot, while smaller fractions needed one or two extra fractions for full reoxygenation. The optimized schedules, versus consecutive weekday fractionation, predicted absolute LF reductions of 4.6%-7.4%, except for the already optimal LF rate seen for 18Gyx3. Primer shot schedules could also reduce BED3 at iso-TCP with the biggest improvements for the shortest schedules (94.6Gy reduction for 18Gyx3). CONCLUSION A validated simulation model clearly supports non-standard "primer shot" fractionation, reducing the impact of hypoxia-induced radioresistance. A limitation of this study is that primer-shot fractionation is outside prior clinical experience and therefore will require clinical studies for definitive testing.
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Affiliation(s)
- Z A R Gouw
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA; The Netherlands Cancer Institute, Amsterdam, Department of Radiation Oncology, the Netherlands.
| | - J Jeong
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
| | - A Rimner
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - N Y Lee
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - A Jackson
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
| | - A Fu
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
| | - J-J Sonke
- The Netherlands Cancer Institute, Amsterdam, Department of Radiation Oncology, the Netherlands
| | - J O Deasy
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
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27
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Lee G, Han Z, Huynh E, Tjong MC, Cagney DN, Huynh MA, Kann BH, Kozono D, Leeman JE, Singer L, Williams CL, Mak RH. Widening the therapeutic window for central and ultra-central thoracic oligometastatic disease with stereotactic MR-guided adaptive radiation therapy (SMART). Radiother Oncol 2024; 190:110034. [PMID: 38030080 DOI: 10.1016/j.radonc.2023.110034] [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: 08/29/2023] [Revised: 10/13/2023] [Accepted: 11/24/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND/PURPOSE Central/ultra-central thoracic tumors are challenging to treat with stereotactic radiotherapy due potential high-grade toxicity. Stereotactic MR-guided adaptive radiation therapy (SMART) may improve the therapeutic window through motion control with breath-hold gating and real-time MR-imaging as well as the option for daily online adaptive replanning to account for changes in target and/or organ-at-risk (OAR) location. MATERIALS/METHODS 26 central (19 ultra-central) thoracic oligoprogressive/oligometastatic tumors treated with isotoxic (OAR constraints-driven) 5-fraction SMART (median 50 Gy, range 35-60) between 10/2019-10/2022 were reviewed. Central tumor was defined as tumor within or touching 2 cm around proximal tracheobronchial tree (PBT) or adjacent to mediastinal/pericardial pleura. Ultra-central was defined as tumor abutting the PBT, esophagus, or great vessel. Hard OAR constraints observed were ≤ 0.03 cc for PBT V40, great vessel V52.5, and esophagus V35. Local failure was defined as tumor progression/recurrence within the planning target volume. RESULTS Tumor abutted the PBT in 31 %, esophagus in 31 %, great vessel in 65 %, and heart in 42 % of cases. 96 % of fractions were treated with reoptimized plan, necessary to meet OAR constraints (80 %) and/or target coverage (20 %). Median follow-up was 19 months (27 months among surviving patients). Local control (LC) was 96 % at 1-year and 90 % at 2-years (total 2/26 local failure). 23 % had G2 acute toxicities (esophagitis, dysphagia, anorexia, nausea) and one (4 %) had G3 acute radiation dermatitis. There were no G4-5 acute toxicities. There was no symptomatic pneumonitis and no G2 + late toxicities. CONCLUSION Isotoxic 5-fraction SMART resulted in high rates of LC and minimal toxicity. This approach may widen the therapeutic window for high-risk oligoprogressive/oligometastatic thoracic tumors.
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Affiliation(s)
- Grace Lee
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Zhaohui Han
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elizabeth Huynh
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Michael C Tjong
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel N Cagney
- Radiotherapy Department, Mater Private Network, Dublin, Ireland
| | - Mai Anh Huynh
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Benjamin H Kann
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David Kozono
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jonathan E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lisa Singer
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Christopher L Williams
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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28
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Lindberg S, Grozman V, Karlsson K, Onjukka E, Lindbäck E, Jirf KA, Lax I, Wersäll P, Persson GF, Josipovic M, Khalil AA, Møller DS, Hoffmann L, Knap MM, Nyman J, Drugge N, Bergström P, Olofsson J, Rogg LV, Hagen RK, Frøland AS, Ramberg C, Kristiansen C, Jeppesen SS, Nielsen TB, Lödén B, Rosenbrand HO, Engelholm S, Haraldsson A, Billiet C, Lewensohn R, Lindberg K. Expanded HILUS Trial: A Pooled Analysis of Risk Factors for Toxicity From Stereotactic Body Radiation Therapy of Central and Ultracentral Lung Tumors. Int J Radiat Oncol Biol Phys 2023; 117:1222-1231. [PMID: 37423292 DOI: 10.1016/j.ijrobp.2023.06.246] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE Stereotactic body radiation therapy for tumors near the central airways implies high-grade toxic effects, as concluded from the HILUS trial. However, the small sample size and relatively few events limited the statistical power of the study. We therefore pooled data from the prospective HILUS trial with retrospective data from patients in the Nordic countries treated outside the prospective study to evaluate toxicity and risk factors for high-grade toxic effects. METHODS AND MATERIALS All patients were treated with 56 Gy in 8 fractions. Tumors within 2 cm of the trachea, the mainstem bronchi, the intermediate bronchus, or the lobar bronchi were included. The primary endpoint was toxicity, and the secondary endpoints were local control and overall survival. Clinical and dosimetric risk factors were analyzed for treatment-related fatal toxicity in univariable and multivariable Cox regression analyses. RESULTS Of 230 patients evaluated, grade 5 toxicity developed in 30 patients (13%), of whom 20 patients had fatal bronchopulmonary bleeding. The multivariable analysis revealed tumor compression of the tracheobronchial tree and maximum dose to the mainstem or intermediate bronchus as significant risk factors for grade 5 bleeding and grade 5 toxicity. The 3-year local control and overall survival rates were 84% (95% CI, 80%-90%) and 40% (95% CI, 34%-47%), respectively. CONCLUSIONS Tumor compression of the tracheobronchial tree and high maximum dose to the mainstem or intermediate bronchus increase the risk of fatal toxicity after stereotactic body radiation therapy in 8 fractions for central lung tumors. Similar dose constraints should be applied to the intermediate bronchus as to the mainstem bronchi.
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Affiliation(s)
- Sara Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden.
| | - Vitali Grozman
- Section of Thoracic Radiology, Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Kristin Karlsson
- 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
| | - 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
| | - Elias Lindbäck
- 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
| | - Karam Al Jirf
- Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden
| | - Ingmar Lax
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Wersäll
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Section of Radiotherapy, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Gitte Fredberg Persson
- Section of Radiotherapy, Department of Oncology, Rigshospitalet, Copenhagen, Denmark; Department of Oncology, Herlev-Gentofte Hospital, Herlev, Denmark; Department of Clinical Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mirjana Josipovic
- Section of Radiotherapy, Department of Oncology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Azza Ahmed Khalil
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark; Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Ditte Sloth Møller
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark; Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Hoffmann
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark; Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Marquard Knap
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Jan Nyman
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ninni Drugge
- Department of Therapeutic Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Bergström
- Department of Oncology, Northern Sweden University Hospital, Umeå, Sweden
| | - Jörgen Olofsson
- Department of Oncology, Northern Sweden University Hospital, Umeå, Sweden
| | | | | | | | - Christina Ramberg
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | - Charlotte Kristiansen
- Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Stefan Starup Jeppesen
- Department of Oncology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tine Bjørn Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Britta Lödén
- Oncology Department, Central Hospital in Karlstad, Karlstad, Sweden
| | | | - Silke Engelholm
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - André Haraldsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Charlotte Billiet
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, University of Antwerp, Antwerp, Belgium
| | - Rolf Lewensohn
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden
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Safavi AH, Palma DA, Giuliani ME. Beyond the HILUS Trial: How Can We Improve the Safety of SABR for Ultracentral Thoracic Tumors? Int J Radiat Oncol Biol Phys 2023; 117:1232-1235. [PMID: 37980143 DOI: 10.1016/j.ijrobp.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Amir H Safavi
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Meredith E Giuliani
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
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Knap MM, Khan S, Khalil AA, Møller DS, Hoffmann L. Outcome of conventional radiotherapy in small centrally located tumours or lymph nodes: minimal toxicity, remarkable survival but challenging loco-regional control. Acta Oncol 2023; 62:1433-1439. [PMID: 37707506 DOI: 10.1080/0284186x.2023.2257872] [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: 05/22/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND In peripheral lung tumours, stereotactic body radiotherapy (SBRT) is superior to conventional RT. SBRT has also shown high loco-regional control (LC) in centrally located tumours, but there is a high risk of severe toxicity. The STRICTSTARLung trial (NCT05354596) examines if risk-adapted SBRT for central tumours is feasible. In this study, we examined overall survival (OS), Disease-free survival (DSF), LC, and toxicity in patients with central tumours that could have been candidates for SBRT but received conventional RT. MATERIAL AND METHODS Retrospectively, we evaluated 49 lung cancer patients that between 2008 and 2021 received RT (60-70Gy in 2 Gy fractions) for a solitary tumour or lymph node with a diameter <5cm located <2cm from the bronchial tree, oesophagus, aorta or heart. All tumours were pathologically verified; 30 were primary lung tumours (T1b-T4) and 19 were solitary lymph nodes (T0N1-N2). Chemotherapy was administered as concomitant (29) or sequential (4). OS and LC were analysed using Kaplan Meier. Cox proportional hazards model for OS and disease-free survival (DFS) was performed including tumour volume, histology, sex, T- vs N-site and chemotherapy. Toxicity was scored. RESULTS In 42 patients, the tumour was located <1 cm to mediastinum. Median follow-up time was 44 months (range: 7-123). The median OS was 51 months. OS at 1-, 3- and 5-year was 88% (SE:5), 59% (SE:7) and 50% (SE:8). Loco-regional recurrences occurred in 16 patients resulting in 1-, and 3-year LC rates of 77% (SE:6) and 64% (SE:8). The majority occurred within 3 years after RT. Only stage showed significant impact on OS and DFS. No patients experienced grade 4-5 toxicity. Seven patients developed grade 3 toxicity (5 oesophageal stenosis, 2 pneumonitis). CONCLUSION Conventional RT for patients with small central lung tumours or solitary lymph nodes is feasible. Median OS was 51 months, and toxicity was low with no grade 4-5 events.
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Affiliation(s)
- M M Knap
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - S Khan
- Department of Respiratory Diseases and Allergology, Aarhus University Hospital, Aarhus N, Denmark
| | - A A Khalil
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - D S Møller
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - L Hoffmann
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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31
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Gensheimer MF, Gee H, Shirato H, Taguchi H, Snyder JM, Chin AL, Vitzthum LK, Maxim PG, Wakelee HA, Neal J, Das M, Chang DT, Kidd E, Hancock SL, Shultz DB, Horst KC, Le QT, Wong S, Brown E, Nguyen N, Liang R, Loo BW, Diehn M. Individualized Stereotactic Ablative Radiotherapy for Lung Tumors: The iSABR Phase 2 Nonrandomized Controlled Trial. JAMA Oncol 2023; 9:1525-1534. [PMID: 37707820 PMCID: PMC10502697 DOI: 10.1001/jamaoncol.2023.3495] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/11/2023] [Indexed: 09/15/2023]
Abstract
Importance Stereotactic ablative radiotherapy (SABR) is used for treating lung tumors but can cause toxic effects, including life-threatening damage to central structures. Retrospective data suggested that small tumors up to 10 cm3 in volume can be well controlled with a biologically effective dose less than 100 Gy. Objective To assess whether individualizing lung SABR dose and fractionation by tumor size, location, and histological characteristics may be associated with local tumor control. Design, Setting, and Participants This nonrandomized controlled trial (the iSABR trial, so named for individualized SABR) was a phase 2 multicenter trial enrolling participants from November 15, 2011, to December 5, 2018, at academic medical centers in the US and Japan. Data were analyzed from December 9, 2020, to May 10, 2023. Patients were enrolled in 3 groups according to cancer type: initial diagnosis of non-small cell lung cancer (NSCLC) with an American Joint Committee on Cancer 7th edition T1-3N0M0 tumor (group 1), a T1-3N0M0 new primary NSCLC with a history of prior NSCLC or multiple NSCLCs (group 2), or lung metastases from NSCLC or another solid tumor (group 3). Intervention Up to 4 tumors were treated with once-daily SABR. The dose ranged from 25 Gy in 1 fraction for peripheral tumors with a volume of 0 to 10 cm3 to 60 Gy in 8 fractions for central tumors with a volume greater than 30 cm3. Main outcome Per-group freedom from local recurrence (same-lobe recurrence) at 1 year, with censoring at time of distant recurrence, death, or loss to follow-up. Results In total, 217 unique patients (median [IQR] age, 72 [64-80] years; 129 [59%] male; 150 [69%] current or former smokers) were enrolled (some multiple times). There were 240 treatment courses: 79 in group 1, 82 in group 2, and 79 in group 3. A total of 285 tumors (211 [74%] peripheral and 74 [26%] central) were treated. The most common dose was 25 Gy in 1 fraction (158 tumors). The median (range) follow-up period was 33 (2-109) months, and the median overall survival was 59 (95% CI, 49-82) months. Freedom from local recurrence at 1 year was 97% (90% CI, 91%-99%) for group 1, 94% (90% CI, 87%-97%) for group 2, and 96% (90% CI, 89%-98%) for group 3. Freedom from local recurrence at 5 years ranged from 83% to 93% in the 3 groups. The proportion of patients with grade 3 to 5 toxic effects was low, at 5% (including a single patient [1%] with grade 5 toxic effects). Conclusions and Relevance The results of this nonrandomized controlled trial suggest that individualized SABR (iSABR) used to treat lung tumors may allow minimization of treatment dose and is associated with excellent local control. Individualized dosing should be considered for use in future trials. Trial Registration ClinicalTrials.gov Identifier: NCT01463423.
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Affiliation(s)
- Michael F. Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Harriet Gee
- Sydney West Radiation Oncology Network, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Hiroki Shirato
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Taguchi
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - John M. Snyder
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Alexander L. Chin
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Lucas K. Vitzthum
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Peter G. Maxim
- Department of Radiation Oncology, University of California Irvine, Irvine, California
| | - Heather A. Wakelee
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Joel Neal
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Millie Das
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Daniel T. Chang
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth Kidd
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Steven L. Hancock
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - David B. Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen C. Horst
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Samantha Wong
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Eleanor Brown
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Ngan Nguyen
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Rachel Liang
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Billy W. Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
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Chen I, Iyer A, Thor M, Wu AJ, Apte A, Rimner A, Gomez D, Deasy JO, Jackson A. Simulating the Potential of Model-Based Individualized Prescriptions for Ultracentral Lung Tumors. Adv Radiat Oncol 2023; 8:101285. [PMID: 38047220 PMCID: PMC10692285 DOI: 10.1016/j.adro.2023.101285] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 05/30/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose The use of stereotactic body radiation therapy for ultracentral lung tumors is limited by increased toxicity. We hypothesized that using published normal tissue complication probability (NTCP) and tumor control probability (TCP) models could improve the therapeutic ratio between tumor control and toxicity. A proposed model-based approach was applied to virtually replan early-stage non-small cell lung cancer (NSCLC) tumors. Methods and Materials The analysis included 63 patients with ultracentral NSCLC tumors treated at our center between 2008 and 2017. Along with current clinical constraints, additional NTCP model-based criteria, including for grade 3+ radiation pneumonitis (RP3+) and grade 2+ esophagitis, were implemented using 4 different fractionation schemes. Scaled dose distributions resulting in the highest TCP without violating constraints were selected (optimal plan [Planopt]). Planopt predictions were compared with the observed local control and toxicities. Results The observed 2-year local control rate was 72% (95% CI, 57%-88%) compared with 87% (range, 6%-93%) for Planopt TCP. Thirty-nine patients had Planopt with TCP > 80%, and 14 patients had Planopt TCP < 50%. The Planopt NTCPs for RP3+ were reduced by nearly half compared with patients' observed RP3+. The RP3+ NTCP was the most frequent reason for TCP of Planopt < 80% (14/24 patients), followed by grade 2+ esophagitis NTCP (5/24 patients) due to larger tumors (>40 cc vs ≤40 cc; P = .002) or a shorter tumor to esophagus distance (≥5 cm vs <5 cm; P < .001). Conclusions We demonstrated the potential for model-based prescriptions to yield higher TCP while respecting NTCP for patients with ultracentral NSCLC. Individualizing treatments based on NTCP- and TCP-driven simulations halved the predicted relative to the observed rates of RP3+. Our simulations also identified patients whose TCP could not be improved without violating NTCP due to larger tumors or a near tumor to esophagus proximity.
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Affiliation(s)
- Ishita Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditi Iyer
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph O. Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Jackson
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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Zarębska I, Harat M. An optimal dose-fractionation for stereotactic body radiotherapy in peripherally, centrally and ultracentrally located early-stage non-small lung cancer. Thorac Cancer 2023; 14:2813-2820. [PMID: 37691151 PMCID: PMC10542466 DOI: 10.1111/1759-7714.15071] [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: 04/06/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT), also known as stereotactic ablative radiotherapy (SABR), is commonly used in inoperable patients with early-stage non-small lung cancer (NSCLC). This treatment has good outcomes and low toxicity in peripherally located tumors. However, in lesions which are located close to structures such as the bronchial tree or mediastinum the risk of severe toxicity increases. This review summarizes the evidence of dose-fractionation in SBRT of NSCLC patients in various locations.
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Affiliation(s)
- Izabela Zarębska
- Department of Neurooncology and RadiosurgeryFranciszek Lukaszczyk Oncology CenterBydgoszczPoland
- Department of RadiotherapyFranciszek Lukaszczyk Oncology CenterBydgoszczPoland
| | - Maciej Harat
- Department of Neurooncology and RadiosurgeryFranciszek Lukaszczyk Oncology CenterBydgoszczPoland
- Center of Medical SciencesUniversity of Science and TechnologyBydgoszczPoland
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34
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Wang HH, Chen Y, Liu X, Zaorsky NG, Mani K, Niu ZM, Zheng BY, Zeng HY, Yan YY, Li YJ, He Y, Ji CZ, Sun BS, Meng MB. Reirradiation with stereotactic body radiotherapy for primary or secondary lung malignancies: Tumor control probability and safety analyses. Radiother Oncol 2023; 187:109817. [PMID: 37480993 DOI: 10.1016/j.radonc.2023.109817] [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: 12/25/2022] [Revised: 07/06/2023] [Accepted: 07/16/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Reirradiation with stereotactic body radiotherapy (SBRT) for patients with primary or secondary lung malignancies represents an appealing definitive approach, but its feasibility and safety are not well defined. The purpose of this study was to investigate the tumor control probability (TCP) and toxicity for patients receiving reirradiation with SBRT. PATIENTS AND METHODS Eligible patients with recurrence of primary or secondary lung malignancies from our hospital were subjected to reirradiation with SBRT, and PubMed- and Embase-indexed articles were reviewed. The patient characteristics, pertinent SBRT dosimetric details, local tumor control, and toxicities were extracted. The logistic dose-response models were compared for TCP and overall survival (OS) in terms of the physical dose and three-, four-, and five-fraction equivalent doses. RESULTS The data of 17 patients from our hospital and 195 patients extracted from 12 articles were summarized. Reirradiation with SBRT yielded 2-year estimates of 80% TCP for doses of 50.10 Gy, 55.85 Gy, and 60.54 Gy in three, four, and five fractions, respectively. The estimated TCP with common fractionation schemes were 50%, 60%, and 70% for 42.04 Gy, 47.44 Gy, and 53.32 Gy in five fractions, respectively. Similarly, the 2-year estimated OS was 50%, 60%, and 70% for 41.62 Gy, 46.88 Gy, and 52.55 Gy in five fractions, respectively. Central tumor localization may be associated with severe toxicity. CONCLUSIONS Reirradiation with SBRT doses of 50-60 Gy in 3-5 fractions is feasible for appropriately selected patients with recurrence of peripheral primary or secondary lung malignancies, but should be carefully considered for centrally-located tumors due to potentially severe toxicity. Further studies are warranted for optimal dose/fractionation schedules and more accurate selection of patients suitable for reirradiation with SBRT.
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Affiliation(s)
- Huan-Huan Wang
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Yuan Chen
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Xin Liu
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Kyle Mani
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Zhi-Min Niu
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Bo-Yu Zheng
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Hong-Yu Zeng
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Yuan-Yuan Yan
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Yan-Jin Li
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Yuan He
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Chao-Zhi Ji
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Bing-Sheng Sun
- Department of Lung Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin 's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China
| | - Mao-Bin Meng
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin's Clinical Research Center for Cancer, National Clinical Research Center for Cancer, Tianjin 300060, PR China.
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Lindberg K. Balancing tumour control probability and toxicity in SBRT of ultra-central lung tumours - One step forward. Lung Cancer 2023; 184:107343. [PMID: 37625912 DOI: 10.1016/j.lungcan.2023.107343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Karin Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Centre of Pulmonary Oncology, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden.
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Bourbonne V, Thureau S, Pradier O, Antoni D, Lucia F. Stereotactic radiotherapy for ultracentral lung tumours. Cancer Radiother 2023; 27:659-665. [PMID: 37516640 DOI: 10.1016/j.canrad.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 07/31/2023]
Abstract
Ultracentral (UC) lung lesions are generally defined by the presence of the tumour or the Planning Target Volume (PTV) abutting proximal bronchial tree (PBT) or the esophagus. Initial reports rose awareness regarding the potential toxicity of stereotactic body radiotherapy (SBRT) when delivered to UC lesions. Major concerns include necrosis, stenosis, and bleeding of the PBT. Technological improvements now enable the delivery of more accurate treatments, possibly redefining the historical "no-fly zone". In this review, studies focusing on the treatment of UC lesions with SBRT are presented. The narrow therapeutic window requires a multidisciplinary approach.
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Affiliation(s)
- V Bourbonne
- Radiation Oncology Department, centre hospitalier universitaire de Brest, Brest, France; Inserm, LaTim UMR 1101, université de Bretagne occidentale, Brest, France.
| | - S Thureau
- Radiation Oncology Department, centre Henri-Becquerel, Rouen, France; QuantIf-Litis EA4108, université de Rouen, Rouen, France
| | - O Pradier
- Radiation Oncology Department, centre hospitalier universitaire de Brest, Brest, France; Inserm, LaTim UMR 1101, université de Bretagne occidentale, Brest, France
| | - D Antoni
- Radiation Oncology Department, institut de cancérologie Strasbourg Europe, Strasbourg, France
| | - F Lucia
- Radiation Oncology Department, centre hospitalier universitaire de Brest, Brest, France; Inserm, LaTim UMR 1101, université de Bretagne occidentale, Brest, France
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37
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Owen D, Siva S, Salama JK, Daly M, Kruser TJ, Giuliani M. Some Like It Hot: The Value of Dose and Hot Spots in Lung Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:1-5. [PMID: 37574234 DOI: 10.1016/j.ijrobp.2023.03.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Center, Victoria, Australia
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Megan Daly
- Department of Radiation Oncology, University of California, Davis, California
| | - Timothy J Kruser
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Meredith Giuliani
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Rock C, Sood S, Cao Y, Shelton S, Chen RC, Wang F. Ten fraction hypofractionated stereotactic body radiotherapy for the management of ultracentral lung tumors: a retrospective analysis of dosimetry, outcomes, and toxicity. Radiat Oncol 2023; 18:128. [PMID: 37533092 PMCID: PMC10394937 DOI: 10.1186/s13014-023-02298-1] [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: 01/05/2023] [Accepted: 06/15/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND The management of ultracentral thoracic tumors with ablative dose of radiotherapy remains challenging given proximity to critical central structures. We report patient outcomes, toxicity, and dosimetry for ultracentrally located tumors with hypofractionated stereotactic body radiotherapy (hfSBRT). METHODS Seventy-eight individuals (50 initial radiotherapy, 28 re-irradiation) undergoing 10 fraction hfSBRT for ultracentrally located thoracic tumors treated between 2009 and 2020 at a single institution were retrospectively reviewed. Overall survival (OS), progression free survival (PFS), and local control (LC) were calculated. Incidence and grade of treatment related toxicity were evaluated. Dosimetric analysis of treatment plans and critical adjacent OARs was performed. RESULTS At a median follow up time of 13 months, 1- and 3-year OS, PFS, and LC were 89%/63%, 37%/18%, and 84%/65%, respectively. Median dose was 65 Gy (BED10 = 107.25 Gy). Median primary bronchial tree maximum dose (Dmax) was 60 Gy (V50 = 0.96 cc). Median esophageal Dmax was 38 Gy (V40 = 0 cc). Median great vessel Dmax was 68 Gy (V50 = 3.53 cc). The most common ≥ grade 2 adverse event was pneumonitis, in 15 individuals (20%). Grade 3 or higher toxicity was observed in 9 individuals (12%): three cases of grade 3 pneumonitis (two re-irradiation, one initial radiotherapy), one grade 3 esophageal stricture following re-irradiation, two grade 3 endobronchial obstructions both following initial radiotherapy, and three grade 5 hemoptysis events (two re-irradiation, one initial radiotherapy). One hemoptysis event was categorized as "possibly" related to treatment, while the remaining two events were categorized as "unlikely" related to treatment in patients with clear evidence of disease progression. CONCLUSIONS hfSBRT to ultracentral lung tumors delivered over 10 fractions is a safe and effective treatment option, with acceptable rates of toxicity and good rates of tumor control. TRIAL REGISTRATION IRB registration number 12573.
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Affiliation(s)
- Crosby Rock
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sumit Sood
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Ying Cao
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Shary Shelton
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Fen Wang
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA.
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Patel VM, Elias R, Asokan A, Sharma A, Christie A, Pedrosa I, Chiu H, Reznik S, Hannan R, Timmerman R, Brugarolas J. Life-threatening hemoptysis in patients with metastatic kidney cancer. Clin Genitourin Cancer 2023; 21:497-506. [PMID: 37045713 PMCID: PMC10510952 DOI: 10.1016/j.clgc.2023.01.011] [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: 06/13/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
Hemoptysis is a complication of intrathoracic tumors, both primary and metastatic, and the risk may be increased by procedural interventions as well as Stereotactic Ablative Radiation (SAbR). The risk of hemoptysis with SAbR for lung cancer is well characterized, but there is a paucity of data about intrathoracic metastases. Here, we sought to evaluate the incidence of life-threatening/fatal hemoptysis (LTH) in patients with renal cell carcinoma (RCC) chest metastases with a focus on SAbR. We systematically evaluated patients with RCC at UT Southwestern Medical Center (UTSW) Kidney Cancer Program (KCP) from July 2005 to March 2020. We queried Kidney Cancer Explorer (KCE), a data portal with clinical, pathological, and experimental genomic data. Patients were included in the study based on mention of "hemoptysis" in clinical documentation, if they had a previous bronchoscopy, or had undergone SAbR to any site within the chest. Two hundred and thirty four patients met query criteria and their records were individually reviewed. We identified 10 patients who developed LTH. Of these, 4 had LTH as an immediate procedural complication whilst the remaining 6 had prior SAbR to ultra-central (UC; abutting the central bronchial tree) metastases. These 6 patients had a total of 10 lung lesions irradiated (UC, 8; central 1, peripheral 1), with a median total cumulative SAbR dose of 38 Gray (Gy/ lesion) (range: 25-50 Gy). Other risk factors included intrathoracic disease progression (n = 4, 67%), concurrent anticoagulant therapy (n = 1, 17%) and concurrent systemic therapy (n = 4, 67%). Median time to LTH from first SAbR was 26 months (range: 8-61 months). Considering that 130 patients received SAbR to a chest lesion during the study period, the overall incidence of LTH following SAbR was 4.6% (6/130). The patient population that received SAbR (n = 130) was at particularly high risk for complications, with 67 (52%) having two or more chest metastaes treated, and 29 (22%) receiving SAbR to three or more lesions. Overall, the risk of LTH following SAbR to a central or UC lesion was 10.5% (6/57). In conclusion, SAbR of RCC metastases located near the central bronchial tree may increase the risk of LTH.
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Affiliation(s)
- Viral M Patel
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Roy Elias
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Annapoorani Asokan
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Akanksha Sharma
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alana Christie
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Biostatistics Shared Resource, Simmons Comprehensive Cancer Center, University of Texas Southwestern, Dallas, TX, USA
| | - Ivan Pedrosa
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hsienchang Chiu
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Pulmonary Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Scott Reznik
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Raquibul Hannan
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Timmerman
- Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Brugarolas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA; Kidney Cancer Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Lau BC, Wu YF, No HJ, Ko RB, Devine MD, Das MS, Neal JW, Wakelee HA, Ramchandran K, Gensheimer MF, Diehn M, Chin AL, Loo BW, Vitzthum LK. Pulmonary Hemorrhage in Patients Treated With Thoracic Stereotactic Ablative Radiotherapy and Antiangiogenic Agents. J Thorac Oncol 2023; 18:922-930. [PMID: 37085030 DOI: 10.1016/j.jtho.2023.04.007] [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: 12/16/2022] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Severe pulmonary hemorrhage can occur in patients treated with thoracic stereotactic ablative radiotherapy (SABR) and vascular endothelial growth factor inhibitors (VEGFis). There is limited understanding of which patients are at risk for toxicity with the combination of thoracic SABR and VEGFis or how the risk differs over either therapy alone. METHODS We evaluated a prospectively maintained cohort of 690 patients with 818 pulmonary tumors treated with highly conformal SABR. Rates of any-grade and grade 3 plus (G3+) pulmonary hemorrhage were compared between patients treated with or without VEGFi therapy across tumor locations. Outcomes were compared between patients treated with SABR plus VEGFi and a propensity-matched cohort of those treated with VEGFi therapy alone. RESULTS Treatment with VEGFi plus SABR was associated with higher rates of G3+ pulmonary hemorrhage compared with those treated with SABR alone for the overall cohort (3-y incidence: 7.9% versus 0.6%, p < 0.01) and those with central tumors (19.1% versus 3.3%, p = 0.04). When further subdivided, there were significantly higher toxicity rates with VEGFi for the ultracentral (9.0% versus 45.0%, p = 0.044), but not central nonabutting tumors (0.0% versus 1.3%, p = 0.69). There was an increased incidence of G3+ hemorrhage in patients treated with VEGFi plus SABR compared with VEGFi alone (9.6% versus 1.3%, p = 0.04). CONCLUSIONS The combination of VEGFi and SABR was associated with an increased risk of high-grade pulmonary hemorrhage over either therapy alone. Low rates of toxicity were observed when excluding patients with SABR to ultracentral tumors and applying highly conformal SABR techniques.
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Affiliation(s)
- Brianna C Lau
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Yufan F Wu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Hyunsoo J No
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Ryan B Ko
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | - Max D Devine
- University of Nebraska College of Medicine, Omaha, Nebraska
| | - Millie S Das
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California; Veteran Affairs (VA) Palo Alto Health Care System, Palo Alto, California
| | - Joel W Neal
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Heather A Wakelee
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Kavitha Ramchandran
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Michael F Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California
| | - Alexander L Chin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California.
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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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La Rosa A, Mittauer KE, Chuong MD, Hall MD, Kutuk T, Bassiri N, McCulloch J, Alvarez D, Herrera R, Gutierrez AN, Tolakanahalli R, Mehta MP, Kotecha R. Accelerated hypofractionated magnetic resonance-guided adaptive radiotherapy for oligoprogressive non-small cell lung cancer. Med Dosim 2023; 48:238-244. [PMID: 37330328 DOI: 10.1016/j.meddos.2023.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/12/2023] [Accepted: 05/08/2023] [Indexed: 06/19/2023]
Abstract
Given the positive results from recent randomized controlled trials in patients with oligometastatic, oligoprogressive, or oligoresidual disease, the role of radiotherapy has expanded in patients with metastatic non-small cell lung cancer (NSCLC). While small metastatic lesions are commonly treated with stereotactic body radiotherapy (SBRT), treatment of the primary tumor and involved regional lymph nodes may require prolonged fractionation schedules to ensure safety especially when treating larger volumes in proximity to critical organs-at-risk (OARs). We have developed an institutional MR-guided adaptive radiotherapy (MRgRT) workflow for these patients. We present a 71-year-old patient with stage IV NSCLC with oligoprogression of the primary tumor and associated regional lymph nodes in which MR-guided, online adaptive radiotherapy was performed, prescribing 60 Gy in 15 fractions. We describe our workflow, dosimetric constraints, and daily dosimetric comparisons for the critical OARs (esophagus, trachea, and proximal bronchial tree [PBT] maximum doses [D0.03cc]), in comparison to the original treatment plan recalculated on the anatomy of the day (i.e., predicted doses). During MRgRT, few fractions met the original dosimetric objectives: 6.6% for esophagus, 6.6% for PBT, and 6.6% for trachea. Online adaptive radiotherapy reduced the cumulative doses to the structures by 11.34%, 4.2%, and 5.62% when comparing predicted plan summations to the final delivered summation. Therefore, this case study presets a workflow and treatment paradigm for accelerated hypofractionated MRgRT due to the significant variations in daily dose to the central thoracic OARs to reduce treatment-related toxicity associated with radiotherapy.
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Affiliation(s)
- Alonso La Rosa
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA.
| | - Kathryn E Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Tugce Kutuk
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Nema Bassiri
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - James McCulloch
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Diane Alvarez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Robert Herrera
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiation Oncology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA; Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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Ladbury C, Amini A, Schwer A, Liu A, Williams T, Lee P. Clinical Applications of Magnetic Resonance-Guided Radiotherapy: A Narrative Review. Cancers (Basel) 2023; 15:cancers15112916. [PMID: 37296879 DOI: 10.3390/cancers15112916] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/20/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Magnetic resonance-guided radiotherapy (MRgRT) represents a promising new image guidance technology for radiation treatment delivery combining an onboard MRI scanner with radiation delivery technology. By enabling real-time low-field or high-field MRI acquisition, it facilitates improved soft tissue delineation, adaptive treatment, and motion management. Now that MRgRT has been available for nearly a decade, research has shown the technology can be used to effectively shrink treatment margins to either decrease toxicity (in breast, prostate cancer, and pancreatic cancer) or facilitate dose-escalation and improved oncologic outcomes (in pancreatic and liver cancer), as well as enabling indications that require clear soft tissue delineation and gating (lung and cardiac ablation). In doing so, the use of MRgRT has the potential to significantly improve the outcomes and quality of life of the patients it treats. The present narrative review aims to describe the rationale for MRgRT, the current and forthcoming state of technology, existing studies, and future directions for the advancement of MRgRT, including associated challenges.
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Affiliation(s)
- Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Amanda Schwer
- Department of Radiation Oncology, City of Hope Orange County Lennar Foundation Cancer Center, Irvine, CA 92618, USA
| | - An Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Terence Williams
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Percy Lee
- Department of Radiation Oncology, City of Hope Orange County Lennar Foundation Cancer Center, Irvine, CA 92618, USA
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Oakley E, Parilov E, Beeson K, Potasek M, Ivanick N, Tworek L, Hutson A, Shafirstein G. Computational Optimization of Irradiance and Fluence for Interstitial Photodynamic Therapy Treatment of Patients with Malignant Central Airway Obstruction. Cancers (Basel) 2023; 15:cancers15092636. [PMID: 37174102 PMCID: PMC10177073 DOI: 10.3390/cancers15092636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
There are no effective treatments for patients with extrinsic malignant central airway obstruction (MCAO). In a recent clinical study, we demonstrated that interstitial photodynamic therapy (I-PDT) is a safe and potentially effective treatment for patients with extrinsic MCAO. In previous preclinical studies, we reported that a minimum light irradiance and fluence should be maintained within a significant volume of the target tumor to obtain an effective PDT response. In this paper, we present a computational approach to personalized treatment planning of light delivery in I-PDT that simultaneously optimizes the delivered irradiance and fluence using finite element method (FEM) solvers of either Comsol Multiphysics® or Dosie™ for light propagation. The FEM simulations were validated with light dosimetry measurements in a solid phantom with tissue-like optical properties. The agreement between the treatment plans generated by two FEMs was tested using typical imaging data from four patients with extrinsic MCAO treated with I-PDT. The concordance correlation coefficient (CCC) and its 95% confidence interval (95% CI) were used to test the agreement between the simulation results and measurements, and between the two FEMs treatment plans. Dosie with CCC = 0.994 (95% CI, 0.953-0.996) and Comsol with CCC = 0.999 (95% CI, 0.985-0.999) showed excellent agreement with light measurements in the phantom. The CCC analysis showed very good agreement between Comsol and Dosie treatment plans for irradiance (95% CI, CCC: 0.996-0.999) and fluence (95% CI, CCC: 0.916-0.987) in using patients' data. In previous preclinical work, we demonstrated that effective I-PDT is associated with a computed light dose of ≥45 J/cm2 when the irradiance is ≥8.6 mW/cm2 (i.e., the effective rate-based light dose). In this paper, we show how to use Comsol and Dosie packages to optimize rate-based light dose, and we present Dosie's newly developed domination sub-maps method to improve the planning of the delivery of the effective rate-based light dose. We conclude that image-based treatment planning using Comsol or Dosie FEM-solvers is a valid approach to guide the light dosimetry in I-PDT of patients with MCAO.
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Affiliation(s)
- Emily Oakley
- Department of Cell Stress Biology, Photodynamic Therapy Center, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | | | - Karl Beeson
- Simphotek, Inc., 211 Warren St., Newark, NJ 07103, USA
| | - Mary Potasek
- Simphotek, Inc., 211 Warren St., Newark, NJ 07103, USA
| | - Nathaniel Ivanick
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Lawrence Tworek
- Department of Cell Stress Biology, Photodynamic Therapy Center, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Alan Hutson
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
| | - Gal Shafirstein
- Department of Cell Stress Biology, Photodynamic Therapy Center, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA
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Chuong MD, Palm RF, Tjong MC, Hyer DE, Kishan AU. Advances in MRI-Guided Radiation Therapy. Surg Oncol Clin N Am 2023; 32:599-615. [PMID: 37182995 DOI: 10.1016/j.soc.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Image guidance for radiation therapy (RT) has evolved over the last few decades and now is routinely performed using cone-beam computerized tomography (CBCT). Conventional linear accelerators (LINACs) that use CBCT have limited soft tissue contrast, are not able to image the patient's internal anatomy during treatment delivery, and most are not capable of online adaptive replanning. RT delivery systems that use MRI have become available within the last several years and address many of the imaging limitations of conventional LINACs. Herein, the authors review the technical characteristics and advantages of MRI-guided RT as well as emerging clinical outcomes.
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Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, 8900 North Kendall Drive, Miami, FL 33176, USA.
| | - Russell F Palm
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Michael C Tjong
- Department of Radiation Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Daniel E Hyer
- Department of Radiation Oncology, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, 1338 S Hope Street, Los Angeles, CA 90015, USA
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Daly ME, Beagen P, Madani MH. Nonsurgical Therapy for Early-Stage Lung Cancer. Hematol Oncol Clin North Am 2023; 37:499-512. [PMID: 37024386 DOI: 10.1016/j.hoc.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Treatment options for medically inoperable, early-stage non-small cell lung cancer (NSCLC) include stereotactic ablative radiotherapy (SABR) and percutaneous image guided thermal ablation. SABR is delivered over 1-5 sessions of highly conformal ablative radiation with excellent tumor control. Toxicity is depending on tumor location and anatomy but is typically mild. Studies evaluating SABR in operable NSCLC are ongoing. Thermal ablation can be delivered via radiofrequency, microwave, or cryoablation, with promising results and modest toxicity. We review the data and outcomes for these approaches and discuss ongoing studies.
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Bryant JM, Weygand J, Keit E, Cruz-Chamorro R, Sandoval ML, Oraiqat IM, Andreozzi J, Redler G, Latifi K, Feygelman V, Rosenberg SA. Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions. Cancers (Basel) 2023; 15:2081. [PMID: 37046741 PMCID: PMC10093051 DOI: 10.3390/cancers15072081] [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: 03/13/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (J.M.B.)
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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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Comparison of Survival Outcomes of Single- and Five-Fraction Schedules of Stereotactic Body Radiation Therapy for Early-Stage Central or Peripheral NSCLC. Cancers (Basel) 2023; 15:cancers15061648. [PMID: 36980533 PMCID: PMC10046844 DOI: 10.3390/cancers15061648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023] Open
Abstract
Background: The treatment of early-stage non-small cell lung cancer (NSCLC) with stereotactic body radiation therapy (SBRT) frequently involves different fractionation schemes for peripheral and central tumors due to concerns with toxicity. We performed an observational cohort study to determine survival outcomes for patients with peripheral and central NSCLC treated with SBRT. Methods: A single-institutional database of patients with early-stage NSCLC treated with SBRT from September 2008 to December 2018 was evaluated. Outcomes were progression-free survival (PFS), overall survival (OS), local failure (LF), nodal failure (NF), and distant failure (DF). Cox multivariable analysis (MVA), Kaplan–Meier plotting, Fine–Gray competing risk MVA, and propensity score matching were performed. Results: A total of 265 patients were included with a median follow-up of 44.2 months. There were 191 (72%) and 74 (28%) patients with peripheral and central tumors treated with single-fraction SBRT to a dose of 27 Gy and five-fraction SBRT to a dose of 50 Gy, respectively. On Cox MVA, there was no difference in OS (adjusted hazards ratio (aHR) of 1.04, 95% CI of 0.74–1.46) or PFS (aHR of 1.05, 95% CI of 0.76–1.45). On Fine–Gray competing risk MVA, there were no differences in LF, NF, or DF. Propensity matching confirmed these findings. Conclusion: The survival outcomes of patients treated with SBRT for early-stage NSCLC were equivalent for central and peripheral tumors.
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50
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Buchberger DS, Videtic GMM. Stereotactic Body Radiotherapy for the Management of Early-Stage Non-Small-Cell Lung Cancer: A Clinical Overview. JCO Oncol Pract 2023; 19:239-249. [PMID: 36800644 DOI: 10.1200/op.22.00475] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Affiliation(s)
- David S Buchberger
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Gregory M M Videtic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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