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Long K, Suresh K. Pulmonary toxicity of systemic lung cancer therapy. Respirology 2020; 25 Suppl 2:72-79. [PMID: 32729207 DOI: 10.1111/resp.13915] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/19/2020] [Accepted: 06/21/2020] [Indexed: 12/11/2022]
Abstract
Lung cancer is the leading cause of cancer-related deaths worldwide. As new therapies are developed, it is important to understand the pulmonary toxicities associated with systemic lung cancer therapies. Cytotoxic chemotherapy regimens for NSCLC often include taxanes. Pulmonary toxicity from taxanes presents as an ILD-type reaction characterized by increasing dyspnoea, dry cough, fever and bilateral pulmonary interstitial infiltrates. The incidence of taxane-induced pneumonitis is rare, and many patients respond to steroid therapy; however, fatal cases have been reported. Patients with NSCLC are routinely tested for the presence of tumour oncogenes to determine their candidacy for targeted therapies, such as TKI. EGFR-TKI can cause pneumonitis characterized by progressive dyspnoea and hypoxia. EGFR-TKI-associated ILD rarely presents as an AIP with rapidly progressive respiratory failure and high mortality rates. The most recent development in lung cancer therapy has been the discovery of immune checkpoint inhibitor (ICI). ICI pneumonitis has been increasingly recognized as a common complication of ICI therapy, with reported incidence as high as 19% in some clinical settings. Early-grade ICI pneumonitis may be asymptomatic; however, high-grade ICI pneumonitis can result in progressive dyspnoea, hypoxia and respiratory failure. ICI pneumonitis is unique in that only half of the patients will improve with steroid treatment, and mortality rates are high. As treatment of NSCLC evolves, providers must be able to recognize and respond to the development of drug-induced pulmonary toxicities.
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Affiliation(s)
- Kathryn Long
- Division of Pulmonary Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karthik Suresh
- Division of Pulmonary Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Russell K, Healy B, Pantarotto J, Laurie SA, MacRae R, Sabri E, Wheatley-Price P. Prognostic factors in the radical nonsurgical treatment of stage IIIB non-small-cell lung cancer. Clin Lung Cancer 2013; 15:237-43. [PMID: 24461300 DOI: 10.1016/j.cllc.2013.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 12/21/2013] [Accepted: 12/23/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many patients diagnosed with stage IIIB (AJCC sixth edition; T4, N3, or both; no pleural effusion) non-small-cell lung cancer (NSCLC) are treated with curative intent, despite a low cure rate. Guidelines are required to help select patients for radical therapy so that the patients with little chance of cure may be spared the toxicities of aggressive treatment. A retrospective analysis was performed to investigate factors influencing outcomes in these patients. MATERIALS AND METHODS From 2002 to 2009, all cases of stage IIIB NSCLC from the authors' institution were identified. Patients treated with radical radiotherapy (minimum dose, 50 Gy), with or without chemotherapy, were included. Charts were reviewed for patient demographic data, baseline blood work, tumor factors, treatment factors, and hospitalizations. The primary outcome was overall survival (OS), measured from time of diagnosis. RESULTS Of 238 patients identified, 184 eligible cases were reviewed. The median follow-up for all patients was 17.2 months (range, 1.7-237.1). The median progression-free survival was 10.8 months (95% CI, 9.6-12.4). Median survival was 17.9 months, and OS was 68%, 42%, and 28% at 1, 2, and 3 years, respectively. In multivariate analysis, female gender (hazard ratio [HR], 0.58; 95% CI, 0.37-0.88; P = .0013), ≤ 5% weight loss (HR, 0.64; 95% CI, 0.43-0.93; P = .01), and absence of N3 disease (HR, 0.64; 95% CI, 0.42-0.96; P = .03) were associated with significantly longer survival. CONCLUSION OS was significantly longer in women, in patients with ≤ 5% weight loss, and in those without N3 disease. Good patient selection remains important in the radical treatment of stage IIIB NSCLC.
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Affiliation(s)
- Kent Russell
- Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Healy
- Division of Medical Oncology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jason Pantarotto
- Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Scott A Laurie
- Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Robert MacRae
- Division of Radiation Oncology, Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Wheatley-Price
- Division of Medical Oncology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.
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Uyterlinde W, Belderbos J, Baas C, van Werkhoven E, Knegjens J, Baas P, Smit A, Rikers C, van den Heuvel M. Prediction of acute toxicity grade ≥ 3 in patients with locally advanced non-small-cell lung cancer receiving intensity modulated radiotherapy and concurrent low-dose Cisplatin. Clin Lung Cancer 2013; 14:541-8. [PMID: 23835165 DOI: 10.1016/j.cllc.2013.04.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Intensity modulated radiotherapy (IMRT) is increasingly used with concurrent chemotherapy but toxicity data are not well investigated. We correlated clinical and dosimetric parameters with acute toxicity grade ≥ 3 in patients with locally advanced NSCLC treated with IMRT and concurrent low-dose cisplatin. PATIENTS AND METHODS We analyzed age, PS, comorbidities, gross tumor volume, and the volume of the esophagus irradiated with 50 Gy (V50oes) in relation with acute toxicity. The mean lung dose (MLD) and pulmonary toxicity was described. Treatment consisted of 24 × 2, 75 Gy, and daily cisplatin 6 mg/m². Patients with an MLD ≥ 20 Gy or a PS > 2 were excluded from CCRT. Toxicity was prospectively scored using the Common Toxicity Criteria for adverse events version 3.0. The Charlson Comorbidity Index (CCI) was applied for scoring comorbidities. Multivariable logistic regressions for toxicity and survival estimates (Kaplan-Meier) were used for evaluation. RESULTS From 2008 to 2011, 188 patients received standard CCRT. In 35% of the patients, acute toxicity grade ≥ 3 was reported. Grade 5 toxicity was scored in 1% of the patients. V50oes (odds ratio [OR], 1.33 per 10% increase; P = .01) and PS ≥ 2 (OR, 3.45; P = .07) were significantly correlated with acute toxicity ≥ grade 3. No differences in toxicity were observed between age groups (< 70 and ≥ 70; P = .26), and those with a CCI score < 5 and ≥ 5, and acute severe toxicity (P = .36). Grade ≥ 3 pulmonary toxicity was seen in 7%. The 1- and 2-year overall survival in stage III disease were 78% and 52%, respectively. Patients with a poor PS or a high CCI score had similar survival outcomes. CONCLUSION Concurrent low-dose cisplatin using IMRT is effective in a large cohort of consecutive patients with NSCLC and life threatening toxicity is rare (1%). PS ≥ 2 and V50oes are correlated with acute toxicity grade ≥ 3.
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Affiliation(s)
- Wilma Uyterlinde
- Department of Thoracic Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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Wang L, Wu S, Ou G, Bi N, Li W, Ren H, Cao J, Liang J, Li J, Zhou Z, Lv J, Zhang X. Randomized phase II study of concurrent cisplatin/etoposide or paclitaxel/carboplatin and thoracic radiotherapy in patients with stage III non-small cell lung cancer. Lung Cancer 2012; 77:89-96. [PMID: 22418243 DOI: 10.1016/j.lungcan.2012.02.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 02/07/2012] [Accepted: 02/14/2012] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the activity and safety of concurrent thoracic radiotherapy (TRT) plus weekly paclitaxel/carboplatin (PC) regimen compared with widely used cisplatin/etoposide (PE) regimen in patients with unresectable stage III non-small cell lung cancer (NSCLC). PATIENTS AND METHODS Patients were randomly assigned to receive the following treatments: PE arm, cisplatin (50mg/m(2)) on days 1, 8, 29, and 36 and etoposide (50 mg/m(2)) on days 1-5 and 29-33 plus 60 Gy of TRT; PC arm, weekly concurrent carboplatin (AUC = 2) and paclitaxel (45 mg/m(2)) plus 60 Gy of TRT. RESULTS A total of 65 patients were randomized (PE arm, n = 33; PC arm, n = 32). The 3-year overall survival (OS) was significantly better in the PE arm than in the PC arm (33.1% vs. 13%, P = .04). The incidence of Grade 3/4 neutropenia was 78.1% in the PE arm and 51.5% in the PC arm (P = .05). The rate of Grade 2 or greater radiation pneumonitis was 25% in the PE arm and 48.5% in the PC arm (P = .09). CONCLUSIONS Compared to PE regimen, weekly PC regimen cannot be recommended since it failed to achieve an improvement in either OS or PFS.
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Affiliation(s)
- Luhua Wang
- Department of Radiation Oncology, Cancer Institute and Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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McAleer MF, Moughan J, Byhardt RW, Cox JD, Sause WT, Komaki R. Does Response to Induction Chemotherapy Predict Survival for Locally Advanced Non–Small-Cell Lung Cancer? Secondary Analysis of RTOG 8804/8808. Int J Radiat Oncol Biol Phys 2010; 76:802-8. [DOI: 10.1016/j.ijrobp.2009.02.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 01/12/2009] [Accepted: 02/18/2009] [Indexed: 11/25/2022]
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A phase II trial of induction gemcitabine and vinorelbine followed by concurrent vinorelbine and radiotherapy in locally advanced non-small cell lung cancer. Lung Cancer 2010; 67:325-9. [DOI: 10.1016/j.lungcan.2009.04.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 04/23/2009] [Accepted: 04/27/2009] [Indexed: 11/19/2022]
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McCurdy M, McAleer MF, Wei W, Ezhil M, Johnson V, Khan M, Baker J, Luo D, Ajani J, Guerrero T. Induction and concurrent taxanes enhance both the pulmonary metabolic radiation response and the radiation pneumonitis response in patients with esophagus cancer. Int J Radiat Oncol Biol Phys 2009; 76:816-23. [PMID: 19525073 DOI: 10.1016/j.ijrobp.2009.02.059] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 02/25/2009] [Accepted: 02/27/2009] [Indexed: 11/16/2022]
Abstract
PURPOSE The primary aim of this study was to assess pulmonary radiation toxicity quantitatively in patients who received thoracic radiotherapy combined with induction and/or concurrent chemotherapy with or without taxanes for esophageal cancer. METHODS AND MATERIALS The study subjects were 139 patients treated at the University of Texas M.D. Anderson Cancer Center for esophageal cancer and who had undergone [(18)F]-fluorodeoxyglucose positron emission tomography/computed tomography between November 1, 2003 and December 15, 2007 for disease restaging after chemoradiotherapy. The patients were grouped into those who had not received taxanes (Group 1), those who had received induction or concurrent taxanes (Group 2), and those who had received both induction and concurrent taxanes (Group 3). Clinical pulmonary toxicity was scored using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 3. Linear regression was applied to the fluorodeoxyglucose uptake vs. radiation dose to determine the pulmonary metabolic radiation response (PMRR) for each case. The clinical toxicity scores and PMRR among the groups were evaluated for significance differences. RESULTS The crude rate of pneumonitis symptoms was 46%, 62%, and 74% for Group 1, 2, and 3, respectively. The analysis of variance test of log(PMRR) by treatment was significant (p = .0046). Group 3 had a 61% greater PMRR compared with Group 1 (p = .002). Group 2 had a 38% greater PMRR compared with Group 1 (p = .015). Finally, Group 3 had a 17% greater PMRR compared with Group 2 (p = .31). A PMRR enhancement ratio of 1.60 (95% confidence interval, 1.19-2.14) was observed for Group 3 vs. Group 1. CONCLUSION Patients given induction and concurrent taxane chemotherapy had a significantly greater PMRR and clinical pneumonitis symptoms compared with the patients whose chemotherapy regimen did not include taxanes.
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Affiliation(s)
- Matthew McCurdy
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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How to improve loco-regional control in stages IIIa-b NSCLC? Results of a three-armed randomized trial from the Swedish Lung Cancer Study Group. Lung Cancer 2008; 65:62-7. [PMID: 19081652 DOI: 10.1016/j.lungcan.2008.10.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 10/13/2008] [Accepted: 10/19/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND A combination of chemotherapy and radiotherapy is the treatment base for locally advanced non-small cell lung cancer (NSCLC). However, both loco-regional and distant failure is frequent. Attempts to improve the loco-regional control were made in three separate phase II studies in Swedish University Hospitals, where accelerated radiotherapy or concurrent daily or weekly chemotherapy with conventional radiotherapy were tested. Comparatively good results from these studies lead to this national randomized phase II study, the RAKET-study, where the different concepts were investigated on a wider basis for further phase III studies. METHODS Inoperable stage III non-small cell lung cancer patients in good performance status (PS<2) were equally randomized to either of three arms in eight institutions. All arms started with two cycles of induction chemotherapy: paclitaxel 200 mg/m2 and carboplatin AUC6. Arm A: a third identical cycle was given concomitant with start of accelerated radiotherapy, 1.7 Gy BID to 64.6 Gy in 4.5 weeks. Arm B consisted of daily concomitant paclitaxel 12 mg/m2 with conventionally fractionated radiotherapy: 2 Gy to 60 Gy in 6 weeks. Arm C: weekly concomitant paclitaxel 60 mg/m2 and identical radiotherapy to 60 Gy. Primary endpoint: TTP. Secondary: OS, toxicity, QL and relapse pattern. RESULTS Between June 2002 and May 2005 152 patients were randomized and of them 151 were evaluable: 78 men and 73 women, median age 62 years (43-78), 55% had performance status 0 and 45% PS 1. Thirty-four percent had stage IIIa and 66% IIIb. HISTOLOGY adenocarcinoma 48%, squamous cell carcinoma 32% and 20% non-small cell carcinoma. The three arms were well balanced. Toxicity was manageable with 12% grades 3-4 esophagitis, 1% grades 3-4 pneumonitis and there was no clear difference between the arms. The QL data did not differ either. Median time to progression was 9.8 (8.3-12.7) months (8.8, 10.3 and 9.3 months for arms A, B and C, respectively). Median survival was 17.8 (14.4-23.7) months (17.7, 17.7 and 20.6 months for A, B and C, respectively). The 1-, 3- and 5-year overall survival was 63, 31 and 24%. Sixty-nine percent of the patients relapsed with distant metastases initially and 31% had loco-regional tumor progression, without significant differences between treatment arms. Thirty-four percent developed brain metastases. CONCLUSIONS Treatment results are quite equal by intensifying the loco-regional treatment either by accelerated fractionated radiotherapy or daily or weekly concomitant chemo-radiotherapy both in terms of survival, toxicity and quality of life. The optimal treatment schedule for patients with locally advanced NSCLC is still to be decided and investigated in future clinical studies. Relapse pattern with distant metastases and especially brain metastases is a great problem and need further research for better therapy options and higher cure rate for this patient group.
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Rodríguez N, Algara M, Foro P, Lacruz M, Reig A, Membrive I, Lozano J, López JL, Quera J, Fernández-Velilla E, Sanz X. Predictors of acute esophagitis in lung cancer patients treated with concurrent three-dimensional conformal radiotherapy and chemotherapy. Int J Radiat Oncol Biol Phys 2008; 73:810-7. [PMID: 18755556 DOI: 10.1016/j.ijrobp.2008.04.064] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 04/30/2008] [Accepted: 04/30/2008] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the risk factors for acute esophagitis (AET) in lung cancer patients treated with concurrent 3D-CRT and chemotherapy. METHODS AND MATERIALS Data from 100 patients treated with concurrent chemoradiotherapy with a mean dose of 62.05 +/- 4.64 Gy were prospectively evaluated. Esophageal toxicity was graded according to criteria of the Radiation Therapy Oncology Group. The following dosimetric parameters were analyzed: length and volume of esophagus in treatment field, percentage of esophagus volume treated to >or=10, >or=20, >or=30, >or=35, >or=40, >or=45, >or=50, >or=55, and >or=60 Gy, and the maximum (D(max)) and mean doses (D(mean)) delivered to the esophagus. Also, we developed an esophagitis index (EI) to account the esophagitis grades over treatment time. RESULTS A total of 59 patients developed AET (Grade 1, 26 patients; Grade 2, 29 patients; and Grade 3, 4 patients). V50 was associated with AET duration (p = 0.017), AET Grade 1 duration (p = 0.016), maximum analgesia (p = 0.019), esophagitis index score (p = 0.024), and AET Grade >or=1 (p = 0.058). If V50 is <30% there is a 47.3% risk of AET Grade >or=1, which increases to 73.3% if V50 is >or=30% (p = 0.008). The predictive abilities of models (sensitivity and specificity) were calculated by receiver operating characeristic curves. CONCLUSIONS According to the receiver operating characeristic curve analysis, the 30% of esophageal volume receiving >or=50 Gy was the most statistically significant factor associated with AET Grade >or=1 and maximum analgesia (A(max)). There was an association with AET Grade >or=2 but it did not achieve statistical significance (p = 0.076).
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Affiliation(s)
- Núria Rodríguez
- Department of Radiation Oncology, Hospital de la Esperanza, IMAS, Barcelona, Spain.
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