Optimal imaging surveillance after stereotactic ablative radiation therapy for early-stage non-small cell lung cancer: Findings of an International Delphi Consensus Study

Refining Surveillance Guidelines after Stereotactic Body Radiation Therapy for Early-Stage Lung Cancer

INTRODUCTION

Stereotactic body radiation therapy (SBRT) is a treatment for patients with early-stage non-small cell lung cancer (ES-NSCLC). Surveillance guidelines vary after treatment. While patients are more likely to locally recur within 2 years of treatment, there remains a paucity of data on the benefit of frequent and long-term surveillance. We evaluated a cohort of NSCLC patients to evaluate surveillance patterns and outcomes.

MATERIALS AND METHODS

Patients with ES-NSCLC treated with SBRT were retrospectively evaluated. Imaging was reviewed after SBRT for evidence of recurrence or new malignancy. The median scan interval (MSI) was calculated as the median number of months between surveillance scans. The MSI between patients with or without new disease was compared by t-test. New disease development and survival between patients with =T2 disease and with or without prior malignancy was compared using χ², Kaplan-Meier analysis, and Gray's test.

RESULTS

A cohort of 168 patients with median follow up of 23.4 months met criteria for review with 50% developing new disease. MSI did not differ between patients with or without new disease. Patients with >=cT2 tumors had worse overall survival and trended towards higher incidence of new disease. New disease continued to occur, even 5 years after treatment.

CONCLUSION

Increased scan frequency did not increase detection of new disease. Patients continued to fail 5 years after treatment. Larger tumors trended toward more frequent failures and those patients experienced worse OS. Surveillance guidelines should be optimized to prevent over surveillance after treatment and to continue long-term surveillance.

Evaluation of chest CT-scans following lung stereotactic ablative radiotherapy: Challenges and new insights

Stereotactic ablative radiotherapy (SABR) is increasingly used for the treatment of early-stage non-small cell lung cancer (ES-NSCLC) and for pulmonary metastases. In patients with ES-NSCLC, SABR is highly successful with reported 5-year local control rates of approximately 90%. However, the assessment of local control following lung SABR can be challenging as radiological changes arising from radiation-induced lung injury (RILI) can be observed in up to 90% of patients. These so-called 'benign' radiological changes evolve with time and are often asymptomatic. Several radiological and metabolic features have been explored to help distinguish RILI from local recurrences (LR). These include the Response Evaluation Criteria for Solid Tumors (RECIST), high-risk features (HRF's) and maximum standardized uptake value (SUVmax) on FDG-PET-CT. However, use of some of these approaches have poor predictive values and low specificity for recurrence. A proposed new workflow for the evaluation of post-lung SABR radiological changes will be reviewed which uses the presence of so-called 'actionable radiological features' to trigger changes to imaging schedules and identifies the need for a multidisciplinary board review. Furthermore, this critical review of post-lung SABR imaging will highlight current challenges, new insights, and unknowns in this field.

Optimal management of radiation pneumonitis: Findings of an international Delphi consensus study

PURPOSE

Radiation pneumonitis (RP) is a dose-limiting toxicity for patients undergoing radiotherapy (RT) for lung cancer, however, the optimal practice for diagnosis, management, and follow-up for RP remains unclear. We thus sought to establish expert consensus recommendations through a Delphi Consensus study.

METHODS

In Round 1, open questions were distributed to 31 expert clinicians treating thoracic malignancies. In Round 2, participants rated agreement/disagreement with statements derived from Round 1 answers using a 5-point Likert scale. Consensus was defined as ≥ 75 % agreement. Statements that did not achieve consensus were modified and re-tested in Round 3.

RESULTS

Response rate was 74 % in Round 1 (n = 23/31; 17 oncologists, 6 pulmonologists); 82 % in Round 2 (n = 19/23; 15 oncologists, 4 pulmonologists); and 100 % in Round 3 (n = 19/19). Thirty-nine of 65 Round 2 statements achieved consensus; a further 10 of 26 statements achieved consensus in Round 3. In Round 2, there was agreement that risk stratification/mitigation includes patient factors; optimal treatment planning; the basis for diagnosis of RP; and that oncologists and pulmonologists should be involved in treatment. For uncomplicated radiation pneumonitis, an equivalent to 60 mg oral prednisone per day, with consideration of gastroprotection, is a typical initial regimen. However, in this study, no consensus was achieved for dosing recommendation. Initial steroid dose should be administered for a duration of 2 weeks, followed by a gradual, weekly taper (equivalent to 10 mg prednisone decrease per week). For severe pneumonitis, IV methylprednisolone is recommended for 3 days prior to initiating oral corticosteroids. Final consensus statements included that the treatment of RP should be multidisciplinary, the uncertainty of whether pneumonitis is drug versus radiation-induced, and the importance risk stratification, especially in the scenario of interstitial lung disease.

CONCLUSIONS

This Delphi study achieved consensus recommendations and provides practical guidance on diagnosis and management of RP.

A Delphi consensus panel about clinical management of early-stage EGFR-mutated non-small cell lung cancer (NSCLC) in Spain: a Delphi consensus panel study

PURPOSE

This Delphi panel study assessed the level of consensus between medical oncologists on the clinical management of patients with early-stage EGFR-mutated non-small cell lung cancer (NSCLC).

METHODS

A modified two-round Delphi approach was used. A scientific committee comprised of medical oncologists developed an online questionnaire. Delphi panel experts rated their level of agreement with each questionnaire statement on a 9-point Likert scale. The questionnaire included 36 statements from 3 domains (clinical management of early-stage NSCLC: 15 statements; role of adjuvant therapy in early-stage NSCLC: 9 statements; and role of adjuvant therapy in early-stage NSCLC with sensitizing EGFR mutation: 12 statements).

RESULTS

In round 1, consensus was reached for 24/36 statements (66.7%). Nine statements that did not achieve consensus after the first round were evaluated in round 2, and none of them reached consensus. Overall, 84.4% of the panelists agreed that EGFR mutation testing should be done after surgery. Consensus was not achieved on whether the implementation of EGFR mutation testing in resected early-stage NSCLC could limit the use of adjuvant osimertinib. The panelists recognized the rationale for the use of osimertinib in the adjuvant scenario (88%) and 72% agreed that it may change the treatment paradigm in stage IB-IIIA EGFR-mutated NSCLC. Consensus was not reached on the inconvenience of prolonged duration of osimertinib.

CONCLUSIONS

This Delphi study provides valuable insights into relevant questions in the management of early-stage EGFR-mutated NSCLC. However, specific issues remain unresolved. The expert consensus emphasizes the role of adjuvant treatment with osimertinib in this scenario.

Local Control With Single-Fraction Lung Stereotactic Body Radiotherapy is not influenced by Non-Small Cell Lung Cancer Histologic Subtype

INTRODUCTION/BACKGROUND

For early stage medically inoperable lung cancer treated with fractionated stereotactic body radiotherapy (SBRT), higher local failure is associated with squamous carcinoma (SqC) compared to adenocarcinoma (AC). This study explored whether histology influences single-fraction SBRT local control.

MATERIALS AND METHODS

We surveyed our prospective data registry from 12/2009 to 12/2019 for SF-SBRT cases with biopsy-proven AC or SqC only. Outcomes of interest included local (LF), nodal (NF), distant (DF) failure rates and overall survival (OS), as well as treatment-related toxicity.

RESULTS

For the 10-year interval surveyed, 113 patients met study criteria. There was no association between histology and dose received (34 Gy or 30 Gy). Median follow up was 22.9 months. Patient characteristics were balanced between histologic cohorts. Median tumor size was 1.9 cm. Comparing total AC vs. SqC cohorts, 2-year LF rates (%) were 7.3 vs. 9.6, respectively (P = .9805). In %, 2-year LF, NF, DF and OS rates for AC for 30 Gy and 34 Gy, respectively, were 10.8 vs. 6.4; 10.5 vs. 16.2; 15.8 vs. 13.0; 77.9 vs.71.2 (all P = non-significant). In %, 2-year LF, NF, DF, and OS rates for SqC for 30 Gy and 34 Gy, respectively, were 11.8 vs. 8.1; 5.9 vs. 18.0; 23.5 vs. 9.7; 70.6 vs. 77.1 (all P = non-significant). When considering toxicities, there were no grade 4/5 toxicities and no significant differences in any other toxicity rate by histology or dose.

CONCLUSION

SF-SBRT local control was not associated with histology, unlike fractionated schedules. This novel finding adds to the evolving understanding of this treatment schedule.

A systematic review into the radiological features predicting local recurrence after stereotactic ablative body radiotherapy (SABR) in patients with non-small cell lung cancer (NSCLC): Local recurrence features of NSCLC post-SABR

BACKGROUND AND PURPOSE

Post-treatment surveillance for local recurrence (LR) following SABR can include both fluorodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT). Radiation-induced lung injury (RILI) shares a similar appearance to LR after treatment making the detection of LR on imaging difficult for clinicians. We aimed to summarise radiological features of CT and FDG-PET predicting LR, and to evaluate radiomics as another tool for detecting LR.

METHODS AND MATERIALS

We searched MEDLINE, EMBASE and PubMed databases for published studies and Web of Science, Wiley Online and Science Direct databases for conference abstracts that had patient populations with NSCLC and reported post-SABR radiological features of FDG-PET or CT and radiomics from either FDG-PET or CT. Studies for inclusion were independently reviewed by two authors.

RESULTS

Across 32 relevant studies, the incidence of LR was 13% (222/1726). On CT, certain gross radiological appearances, and kinetic features of changes in size, diameter, volume or 3 consecutive rises in volume of mass-like consolidation are suggestive of LR. Particular regard should be made for the presence of any ≥3 high-risk features (HRF) on CT or the individual HRF of enlarging opacity at ≥12 month's post-SABR as being highly suspicious of LR. On FDG-PET a relative reduction of <5% of SUV_max from baseline in the first 12 months or cut-offs of SUV_max >5 and SUV_mean >3.44 after 12 months can indicate LR. There is limited evidence available to corroborate radiomic features suggestive of LR.

CONCLUSION

This research has identified common features of LR compared to RILI which may aid in early and accurate detection of LR post-SABR; further research is required to validate these findings.

Ten-Year Experience in Implementing Single-Fraction Lung SBRT for Medically Inoperable Early-Stage Lung Cancer

PURPOSE

To review 10 years of using single-fraction lung stereotactic body radiation therapy (SF-SBRT) for medically inoperable peripheral early-stage lung cancer.

METHODS AND MATERIALS

An institutional review board-approved prospective lung SBRT data registry was surveyed until the end of December 2019 for all patients receiving SF-SBRT with minimum 6-month follow-up. Doses used were either 34 Gy or 30 Gy. Outcomes of interest included rates of local failure and overall survival (OS), as well as treatment-related toxicity graded per Common Terminology Criteria for Adverse Events version 3.0.

RESULTS

A total of 229 patients met the study criteria. Patient characteristics included female sex (55%); median age, 74.6 years (range, 47-94); and median Karnofsky Performance Status 80 (range, 50-100). Tumor characteristics included median diameter, 1.6 cm (range, 0.7-4.1); median positron emission tomography standardized uptake value maximum 6.1 (range, 0.8-24.3); and 63.6% of patients biopsied. SF-SBRT dose was 34 Gy in 72.1% cases and 30 Gy in 27.9%, with patient and tumor characteristics balanced between cohorts. Overall median follow-up times for 30 Gy and 34 Gy were 36.7 and 17.2 months, respectively (P < .0001). At analysis, 55.9% patients were alive. Two (0.9%) patients developed grade 3 toxicities, and none had grade 4/5 toxicities. Grades 1 to 2 pneumonitis and chest wall toxicity were seen in 7% and 12.7% patients, respectively. Median overall survival was 44.1 months. Rates of 2-year local, nodal, and distant failure were 7.3%, 9.4%, and 12.2%, respectively. There were no significant differences in outcomes by dose.

CONCLUSIONS

This is the largest institutional series to date reporting on SF-SBRT outcomes for medically inoperable peripheral early-stage lung cancer and the first to report on a decade's experience in implementing this schedule. Outcomes from this analysis are comparable to published results from 2 randomized trials and validate the use of this schedule in routine practice. In the absence of phase 3 trials, this study should encourage increased use of SF-SBRT for inoperable tumors.

Beyond DNA-targeting in Cancer Chemotherapy. Emerging Frontiers - A Review

Modern anti-cancer drugs target DNA specifically for rapid division of malignant cells. One downside of this approach is that they also target other rapidly dividing healthy cells, such as those involved in hair growth leading to serious toxic side effects and hair loss. Therefore, it would be better to develop novel agents that address cellular signaling mechanisms unique to cancerous cells, and new research is now focussing on such approaches. Although the classical chemotherapy area involving DNA as the set target continues to produce important findings, nevertheless, a distinctly discernible emerging trend is the divergence from the cisplatin operation model that uses the metal as the primary active center of the drug. Many successful anti-cancer drugs present are associated with elevated toxicity levels. Cancers also develop immunity against most therapies and the area of cancer research can, therefore, be seen as an area with a high unaddressed need. Hence, ongoing work into cancer pathogenesis is important to create accurate preclinical tests that can contribute to the development of innovative drugs to manage and treat cancer. Some of the emergent frontiers utilizing different approaches include nanoparticles delivery, use of quantum dots, metal complexes, tumor ablation, magnetic hypothermia and hyperthermia by use of Superparamagnetic Iron oxide Nanostructures, pathomics and radiomics, laser surgery and exosomes. This review summarizes these new approaches in good detail, giving critical views with necessary comparisons. It also delves into what they carry for the future, including their advantages and disadvantages.

Applicability of the PACIFIC trial results in patients not eligible for the PACIFIC trial: Canadian rapid consensus statement and recommendations

BACKGROUND

The PACIFIC study established durvalumab as a standard of care for consolidation therapy in patients treated with radical intent chemoradiation for stage III inoperable non-small cell lung cancer. In clinical practice, many patients are not eligible for trials, yet radical intent chemoradiation may still be used.

METHODS

A virtual anonymous tumour board Delphi-model was used in order to generate consensus on the use of durvalumab in six clinical situations where chemoradiation is used in clinical practice and recommended in guidelines, yet not PACIFIC eligible. Two anonymous iterations were sent and recommendations were circulated for approval and comment. Results are presented using a modified PICOT format (patients, intervention, control, outcomes, and ongoing trials).

RESULTS

In three of the scenarios, consensus was reached and recommendations were for the use of consolidation durvalumab, but being respectful of potentially increased toxicity/reduced benefit in comparison to PACIFIC results (treatment of stage IIB inoperable, recurrent mediastinal disease, and residual gross disease post attempted surgical removal). There was a recommendation against using durvalumab in resected stage III disease with R1 or R0 margins, even if chemoradiation were considered. There was not consensus on the use of consolidation durvalumab in the setting of oligometastatic disease or in the setting of large cell neuroendocrine carcinoma or combined small cell carcinoma.

CONCLUSION

Treatment of 'real-world' lung cancer often involves chemoradiation in settings outside of stage III and eligible for the PACIFIC study. This paper offers recommendations in these scenarios based on a consensus approach.

Timing of fluorodeoxyglucose positron emission tomography maximum standardized uptake value for diagnosis of local recurrence of non-small cell lung cancer after stereotactic body radiation therapy

Introduction

After treatment with stereotactic body radiation therapy (SBRT), local recurrence of non‐small cell cancer (NSCLC) can be difficult to differentiate from radiation‐induced changes. Maximum standardized uptake value (SUVmax), measured with 18‐F‐Fluorodeoxyglucose positron emission tomography (FDG‐PET), can have false positives due to acute radiation inflammation. The primary study objective was to determine the utility of SUVmax > 5 to identify local recurrence later than 9 months after SBRT.

Method

A retrospective review was performed of FDG‐PET scans for suspicious CT findings after SBRT treatment of stage 1 NSCLC. SUVmax was measured including surrounding opacification. Outcome measures were local recurrence, progression free survival, and overall survival. Receiver operator curve analysis, sensitivity, specificity, and Kaplan‐Meier analysis were performed.

Results

Of 118 patients treated, 42 patients had eligible FDG‐PET scans. They received SBRT (48‐60Gy in 3‐8 fractions) for 49 NSCLC and had 101 follow‐up PET scans. The median time to first PET scan was 9.3 months, and the median follow‐up period was 22.4 months. Local recurrence was diagnosed in 12 patients, at a median of 16 months. Due to selection bias, the included patients had poorer outcomes than the entire cohort, with progression free survival (PFS) at 1, 2, and 3 years of 82.7%, 57.8%, and 45.8%; and overall survival of 97.9%, 79.9%, and 59.1%, respectively. Thirty FDG‐PET scans were performed within 9 months, of which 17% were false positives. A total of 71 FDG‐PET scans were performed beyond 9 months, and the median SUVmax was significantly higher for patients with local recurrence (7.48 vs. 2.14, P < .0001). SUVmax > 5 has a sensitivity of 91% (95% CI 62%‐99.8%) and 100% (89.1%‐100%).

Conclusion

For local recurrence of NSCLC, SUVmax > 5 on FDG‐PET scan has good sensitivity and specificity after 6 months, but is highest beyond 9 months after SBRT.

Stereotactic body radiotherapy in patients with lung tumors composed of mainly ground-glass opacity

We retrospectively reviewed the effect of stereotactic body radiation therapy (SBRT) in patients with stage I lung cancer whose lung tumor showed a nodular appearance of ground glass opacity, so-called ground glass nodule (GGN). A total of 84 patients (42 men, 42 women; mean age, 75 years) with stage I lung cancer with GGN accompanying a solid component <50% in diameter of the tumor and no metastases were studied. Concerning histology, 32 tumors were adenocarcinoma, 1 was squamous cell carcinoma, 2 were unclassified carcinoma and 49 cases were histology-unproven but increased in size or had a positive finding in 18F-FDG positron emission tomography (PET) examination. The median tumor size was 20 mm (range, 10-41 mm). All of the patients were treated with SBRT, and the total prescribed dose at the isocenter ranged between 48 Gy in four fractions and 84 Gy in ten fractions. Median follow-up duration was 33 months. No patient had local failure nor regional lymph node failure. The 3-year rate of distant failure was 2.6%. Two patients who experienced distant metastases had a past surgical history of initial lung cancer before SBRT. The rates of cause-specific and overall survival at 3 years were 98.2 and 94.6%, respectively. Treatment-related adverse events of ≥grade 4 were not reported. Although more cases and longer follow-ups are mandatory, SBRT may be one of the radical treatment options for patients with GGN.

Measuring the Integration of Stereotactic Ablative Radiotherapy Plus Surgery for Early-Stage Non-Small Cell Lung Cancer: A Phase 2 Clinical Trial

Importance

Stereotactic ablative radiotherapy (SABR) is a standard treatment option in patients with medically inoperable early-stage non-small cell lung cancer (NSCLC), yet the pathologic complete response (pCR) rate after SABR is unknown. Neoadjuvant SABR in patients with cancer who are fit for resection has been hypothesized to improve local control and induce antitumor immune activity, potentially leading to better outcomes.

Objectives

To determine the pCR rate after SABR and to assess oncologic and toxicity outcomes after a combined approach of neoadjuvant SABR followed by surgery.

Design, Setting, and Participants

A phase 2, single-arm trial, with patient accrual from September 30, 2014, to August 15, 2017 (median follow-up, 19 months), was performed at a tertiary academic cancer center. Patients 18 years or older with T1T2N0M0 NSCLC and good performance status, with adequate pulmonary reserve to undergo surgical resection, were studied.

Interventions

Patients underwent neoadjuvant SABR using a risk-adapted fractionation scheme followed by surgery 10 weeks later.

Main Outcomes and Measures

The pCR rate as determined by hematoxylin-eosin staining.

Results

Forty patients (mean [SD] age, 68 [8] years; 23 [58%] female) were enrolled. Thirty-five patients underwent surgery and were evaluable for the primary end point. The pCR rate was 60% (95% CI, 44%-76%). The 30- and 90-day postoperative mortality rates were both 0%. Grade 3 or 4 toxic effects occurred in 7 patients (18%). In patients receiving surgery, 2-year overall survival was 77% (95% CI, 48%-91%), local control was 100% (95% CI, not defined), regional control was 53% (95% CI, 22%-76%), and distant control was 76% (95% CI, 45%-91%). Quality of life did not decline after treatment, with no significant changes in mean Functional Assessment of Cancer Therapy for Lung-Trial Outcome Index score during the first year of follow-up.

Conclusions and Relevance

The pCR rate after SABR for early-stage NSCLC was 60%, lower than hypothesized. The combined approach had toxic effects comparable to series of surgery alone, and there was no perioperative mortality. Further studies are needed to evaluate this combined approach compared with surgical resection alone.

Trial Registration

ClinicalTrials.gov identifier: NCT02136355.

Response evaluation after stereotactic ablative radiotherapy for localised non-small-cell lung cancer: an equipoise of available resource and accuracy

There is growing evidence supporting the use of stereotactic ablative radiotherapy (SABR) on the treatment of localised stage non-small-cell lung cancer (NSCLC). Distinctive imaging challenges are posed post-SABR treatment. Thus, it is imperative to provide guidance on assessing treatment response, especially for new adopters. This commentary is about filling a gap in response evaluation after SABR for localised NSCLC.

Salvage Therapy for Locoregional Recurrence After Stereotactic Ablative Radiotherapy for Early-Stage NSCLC

Although isolated local (LRs) and regional recurrences (RRs) constitute a minority of post-stereotactic ablative radiotherapy (SABR) relapses, their management is becoming increasingly important as the use of SABR continues to expand. However, few evidence-based strategies are available to guide treatment of these potentially curable recurrences. On behalf of the Advanced Radiation Technology Committee of the International Association for the Study of Lung Cancer, this article was written to address management of recurrent disease. Topics discussed include diagnosis and workup, including the roles of volumetric and functional imaging as well as histopathologic methods; clinical outcomes after salvage therapy; patterns of recurrence after salvage therapy; and management options. Our main conclusions are that survival for patients with adequately salvaged LRs is similar to that for patients after primary SABR without recurrence, and survival for those with salvaged RRs (regardless of nodal burden or location) is similar to that of patients with de novo stage III disease. Although more than half of patients who undergo salvage do not develop a second relapse, the predominant pattern of second failure is distant, especially for RRs. Management requires rigorous multidisciplinary coordination. Isolated LRs can be managed with resection and nodal dissection, repeat SABR, thermal ablation, or systemic therapies. RRs can be treated with combined chemoradiotherapy, radiation or chemotherapy alone, or supportive services. Finally, regular and structured follow-up is recommended after post-SABR salvage therapy.

Surveillance After Treatment of Non-Small-Cell Lung Cancer: A Call for Multidisciplinary Standardization

OBJECTIVE

Though interest in expansion of the use of less-invasive therapies among operable non-small-cell lung cancer (NSCLC) patients is growing, it is not clear that post-treatment surveillance has been comparable between treatment modalities. We sought to characterize institutional surveillance patterns after NSCLC therapy with stereotactic body radiation therapy (SBRT) and lobectomy.

METHODS

NSCLC patients treated with lobectomy or SBRT (2005 to 2016) at a single institution were identified. Natural language processing searched data fields within axial surveillance imaging reports for findings suggestive of recurrence. Duration and patterns of institutional surveillance were compared between the 2 groups.

RESULTS

Three thousand forty-two patients (73.5% lobectomy, 26.5% SBRT) met inclusion criteria. Patients had a longer median duration of surveillance after lobectomy (28.0 months vs SBRT 12.3 months, P < 0.001) and were more likely to undergo histopathological evaluation of clinically suspected relapse (206/274 [75.2%] vs SBRT 54/113 [47.8%], P < 0.001). Patients with clinical suspicion of recurrence had longer durations of institutional surveillance than those who did not among both cohorts (lobectomy 44.4 months vs 25.9, P < 0.001; SBRT 27.9 vs 10.3, P < 0.001). Landmark analyses at 1 and 3 years after therapy identified associations between receipt of lobectomy and ongoing surveillance at each time point (1 year odds ratio [OR] 2.10, P < 0.001; 3 years OR 1.71, P < 0.001) among all patients and those with documented stage I disease.

CONCLUSIONS

We identified potential heterogeneity in institutional surveillance patterns after treatment of NSCLC with 2 therapeutic modalities. As less-invasive treatment options for operable patients expand, it will be critical to implement rigorous surveillance paradigms across all modalities.

Is it safe to irradiate the newest generation of ventricular assist devices? A case report and systematic literature review

An increasing number of mechanical assist devices, especially left ventricular assist devices (VADs), are being implanted for prolonged periods and as destination therapy. Some VAD patients require radiotherapy due to concomitant oncologic morbidities, including thoracic malignancies. This raises the potential of VAD malfunction via radiation-induced damage. So far, only case reports and small case series on radiotherapy have been published, most of them on HeartMate II (HMII, Abbott, North Chicago, IL, USA). Significantly, the effects of irradiation on the HeartMate 3 (HM3, Abbott) remain undefined, despite the presence of controller components engineered within the pump itself. We report the first case of a patient with a HM3 who successfully underwent stereotactic hypofractionated radiotherapy due to an early-stage non-small-cell lung cancer. The patient did not suffer from any complications, including toxicity or VAD malfunction. Based on this case report and on published literature, we think that performing radiotherapy after VAD implantation with the aid of a multidisciplinary team could be performed, but more in vitro studies and cases series are needed to reinforce this statement.

Pathologic response after modern radiotherapy for non-small cell lung cancer

In non-small cell lung cancer (NSCLC), pathologic complete response (pCR) following radiotherapy treatment has been shown to be an independent prognostic factor for long-term survival, progression-free survival and locoregional control. PCR is considered a surrogate to therapeutic efficacy, years before survival data are available, and therefore can be used to guide treatment plans and additional therapeutic interventions post-surgical resection. Given the extensive fibrotic changes induced by radiotherapy in the lung, radiological assessment of response can potentially misrepresent pathologic response. The optimal timing for assessment of pathologic response after conventionally fractionated radiotherapy and stereotactic ablative radiotherapy (SABR) remains poorly understood. In this review, we summarize recent literature on pathologic response after radiotherapy for early stage and locally advanced NSCLC, we discuss current controversies around radiobiological considerations, and we present upcoming trials that will provide insight into current knowledge gaps.

Early-Stage NSCLC: Advances in Thoracic Oncology 2018

2018 was a banner year for all thoracic oncology, but especially for early-stage NSCLC. Three seminal events occurred in the approximately 18 months from mid-2017 to the end of 2018: in June 2017 at the American Society of Clinical Oncology Annual Meeting a small, relatively unheralded study from Max Diehn's group at Stanford University reported on the use of a novel "cancer personalized profiling by deep sequencing" circulating tumor-DNA technology to identify minimal residual disease in patients after curative-intent radiation or surgery for NSCLC; in April 2018 at the American Association for Cancer Research Annual Meeting, Drew Pardoll presented a small pilot study of 21 patients who had received two doses of preoperative nivolumab; in September 2018, at the 19th World Conference on Lung Cancer, Harry J. De Koning presented the long-awaited results of the Dutch-Belgian Lung Cancer Screening Trial (NELSON). These three seminal studies, along with others which are reviewed in this paper, promise to accelerate our progress towards a world in which lung cancer is identified early, more patients undergo curative-intent treatment that achieves the promised cure, and those at risk for failure after treatment are identified early, when the cancer remains most vulnerable. The day is around the corner when lung cancer is defanged and no longer the worldwide terror it currently is. We herein present an overview of the most recent body of work that moves us inexorably towards that day.

Feasibility of radiotherapy in nonagenarian patients: a retrospective study

PURPOSE

Specific information about radiation therapy in nonagenarians is limited. In order to shed more light on the feasibility of radiotherapy in this challenging subgroup, a retrospective study was performed.

METHODS

The data of 93 consecutive patients receiving irradiation treatment at the Department of Radiation Oncology, Ordensklinikum Linz Barmherzige Schwestern between June 2005 and December 2016 were analyzed. Patient- and treatment-related factors were extracted from the patient records. Overall survival (OS) was defined as time from irradiation to death or last follow-up. The survival rates were analyzed using the Kaplan-Meier method and log-rank test.

RESULTS

The study population of 93 patients was between 90 and 99 years old (median 91 years). It included 59 women (63%) and 34 men (37%). Of these, 38 (41%) received definitive radiotherapy, 14 (15%) received neoadjuvant or adjuvant radiotherapy, whereas a palliative regimen was prescribed in 44% of the cases (n = 41). In all, 79 patients (85%) were able to complete their prescribed course of radiotherapy. While 16 (17%) patients reported grade 2 toxicities or higher, 4 had ≥grade 3 side effects (4%). The median survival was significantly higher in patients treated with adjuvant, neoadjuvant or definitive radiotherapy (13.8 months) compared to patients treated with palliative radiotherapy (3.6 months; p < 0.001).

CONCLUSION

Even in patients managed without preradiotherapy comprehensive geriatric assessment, carefully planned fractionated radiotherapy was feasible and resulted in acceptable rates of acute toxicities.

Stereotactic body radiation therapy for lung, spine and oligometastatic disease: current evidence and future directions

Stereotactic body radiation therapy (SBRT) also referred to as stereotactic ablative radiotherapy (SABR), is a technique which has emerged over the past two decades due to improvements in radiation technology. Unlike conventional external beam radiotherapy (cEBRT) which traditionally delivers radiation in small doses [approximately 2 Gray (Gy) per fraction] over several weeks, SBRT, typically delivered in one to eight fractions, is a technique whereby potentially ablative doses of radiotherapy (usually 7.5-20 Gy per fraction) can be delivered with steeper dose gradients and sub millimetre precision, minimising risk to surrounding normal tissues. The potential benefits of excellent tumor control with low toxicity has led to the increasing use of SBRT in a number of clinical situations. Due to compelling evidence, SBRT is now the treatment of choice for medically inoperable patients with peripherally located stage I non-small cell lung cancer (NSCLC). Controversy remains however as to its efficacy and safety for central or ultra-central lung tumors. The evidence base supporting the use of SBRT as a novel treatment for spinal metastases and oligometastases is rapidly expanding but challenges remain in these difficult patient populations. In an era where targeted therapy and improved systemic treatments for stage IV cancer have resulted in increased disease-free survival, and our knowledge of the oligometastatic state is ever expanding, using SBRT to treat metastatic disease and gain durable local control is increasingly desirable. Several randomized trials are currently underway and are sure to provide valuable information on the benefit and utility of SBRT across many tumor sites including early-stage NSCLC, spinal metastases and oligometastatic disease. Recognizing the evolving role of SBRT in clinical practice, this paper provides a critical review of recent developments in each of these areas particularly highlighting the challenges facing clinicians and discusses potential areas for future research.

Consensus minimum data set for lung cancer multidisciplinary teams: Results of a Delphi process

BACKGROUND AND OBJECTIVE

While multidisciplinary team (MDT) care in lung cancer is widely practiced, there are few guidelines for MDT on best data collection strategies. MDT meetings need ready access to information for the provision of optimal treatment recommendations (the primary purpose of the meeting), audit of team performance and benchmarking. This study aimed to develop a practical data set designed for these goals through a recognized consensus process with health professionals who participate in formal MDT settings.

METHODS

A modified Delphi process with three iterations (two surveys and one consensus conference) was carried out involving over 100 Australian lung cancer MDT health professionals.

RESULTS

In total, 122 lung cancer MDT health professionals responded to the Round 1 survey from over 350 invitees. Of the 122, 98 were available for invitation to Round 2. Of 98, 52 (53%) invitees responded to the Round 2 survey. After two rounds, 51 data elements across 8 domains (patient demographics, risk factors, biopsy data, staging, timeliness, treatment, follow-up and patient selection) achieved consensus, defined as 80% agreement. For Round 3, 33 MDT lead clinicians were invited to participate in a consensus conference. Of 33, 14 (42%) invitees distilled the 47 data elements into 23 elements across 8 domains to address the study objectives.

CONCLUSION

A practical data set for lung cancer MDT to use for optimal treatment recommendations and to evaluate team performance was developed through recognized consensus methodology. Access to streamlined, relevant and feasible data collection strategies may improve MDT decision-making, audit of team performance and facilitate benchmarking.

Medically inoperable stage I non-small cell lung cancer: best practices and long-term outcomes

Early-stage non-small cell lung cancer (ES-NSCLC) currently represents a minority of all NSCLC diagnoses but, with ongoing refinement and improvement of treatment approaches, is a group with increasing likelihood of long-term disease control and survival. A significant proportion of this population will not be optimal candidates for definitive surgical resection due to tumor characteristics, patient frailty, or comorbid status. The clinical evidence to support the use of stereotactic body radiation therapy (SBRT) in patients with medically inoperable stage I NSCLC is growing as long-term data are obtained. In this review, initial workup, SBRT delivery considerations, recent trial data, and post-treatment surveillance of this population are discussed.