1
|
Lau B, Wu YF, Cui S, Fu J, Jackson S, Pham D, Dubrowski P, Eswarappa S, Skinner L, Shirato H, Taguchi H, Gensheimer MF, Gee H, Chin AL, Diehn M, Loo BW, Moiseenko V, Vitzthum LK. Chest wall pain after single-fraction thoracic stereotactic ablative Radiotherapy: Dosimetric analysis from the iSABR trial. Radiother Oncol 2024; 196:110317. [PMID: 38679202 DOI: 10.1016/j.radonc.2024.110317] [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: 03/04/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND AND PURPOSE Concerns over chest wall toxicity has led to debates on treating tumors adjacent to the chest wall with single-fraction stereotactic ablative radiotherapy (SABR). We performed a secondary analysis of patients treated on the prospective iSABR trial to determine the incidence and grade of chest wall pain and modeled dose-response to guide radiation planning and estimate risk. MATERIALS AND METHODS This analysis included 99 tumors in 92 patients that were treated with 25 Gy in one fraction on the iSABR trial which individualized dose by tumor size and location. Toxicity events were prospectively collected and graded based on the CTCAE version 4. Dose-response modeling was performed using a logistic model with maximum likelihood method utilized for parameter fitting. RESULTS There were 22 grade 1 or higher chest wall pain events, including five grade 2 events and zero grade 3 or higher events. The volume receiving at least 11 Gy (V11Gy) and the minimum dose to the hottest 2 cc (D2cc) were most highly correlated with toxicity. When dichotomized by an estimated incidence of ≥ 20 % toxicity, the D2cc > 17 Gy (36.6 % vs. 3.7 %, p < 0.01) and V11Gy > 28 cc (40.0 % vs. 8.1 %, p < 0.01) constraints were predictive of chest wall pain, including among a subset of patients with tumors abutting or adjacent to the chest wall. CONCLUSION For small, peripheral tumors, single-fraction SABR is associated with modest rates of low-grade chest wall pain. Proximity to the chest wall may not contraindicate single fractionation when using highly conformal, image-guided techniques with sharp dose gradients.
Collapse
Affiliation(s)
- Brianna Lau
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yufan F Wu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sunan Cui
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Jie Fu
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Scott Jackson
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel Pham
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Piotr Dubrowski
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Shaila Eswarappa
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lawrie Skinner
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Michael F Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA
| | - Harriet Gee
- Department of Radiation Oncology, Westmead Hospital, Sydney, Australia; University of Sydney, Sydney, Australia
| | - Alexander L Chin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of San Diego School of Medicine, San Diego, CA, USA
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford, CA, USA.
| |
Collapse
|
2
|
Liu F, Ververs JD, Farris MK, Blackstock AW, Munley MT. Optimal Radiation Therapy Fractionation Regimens for Early-Stage Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2024; 118:829-838. [PMID: 37734445 DOI: 10.1016/j.ijrobp.2023.09.017] [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: 01/30/2023] [Revised: 08/04/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE A series of radiobiological models were developed to study tumor control probability (TCP) for stereotactic body radiation therapy (SBRT) of early-stage non-small cell lung cancer (NSCLC) per the Hypofractionated Treatment Effects in the Clinic (HyTEC) working group. This study was conducted to further validate 3 representative models with the recent clinical TCP data ranging from conventional radiation therapy to SBRT of early-stage NSCLC and to determine systematic optimal fractionation regimens in 1 to 30 fractions for radiation therapy of early-stage NSCLC that were found to be model-independent. METHODS AND MATERIALS Recent clinical 1-, 2-, 3-, and 5-year actuarial or Kaplan-Meier TCP data of 9808 patients from 56 published papers were collected for radiation therapy of 2 to 4 Gy per fraction and SBRT of early-stage NSCLC. This data set nearly triples the original HyTEC sample, which was used to further validate the HyTEC model parameters determined from a fit to the clinical TCP data. RESULTS TCP data from the expanded data set are well described by the HyTEC models with α/β ratios of about 20 Gy. TCP increases sharply with biologically effective dose and reaches an asymptotic maximal plateau, which allows us to determine optimal fractionation schemes for radiation therapy of early-stage NSCLC. CONCLUSIONS The HyTEC radiobiological models with α/β ratios of about 20 Gy determined from the fits to the clinical TCP data for SBRT of early-stage NSCLC describe the recent TCP data well for both radiation therapy of 2 to 4 Gy per fraction and SBRT dose and fractionation schemes of early-stage NSCLC. A steep dose response exists between TCP and biologically effective dose, and TCP reaches an asymptotic maximum. This feature results in model-independent optimal fractionation regimens determined whenever safe for SBRT and hypofractionated radiation therapy of early-stage NSCLC in 1 to 30 fractions to achieve asymptotic maximal tumor control, and T2 tumors require slightly higher optimal doses than T1 tumors. The proposed optimal fractionation schemes are consistent with clinical practice for SBRT of early-stage NSCLC.
Collapse
Affiliation(s)
- Feng Liu
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.
| | - James D Ververs
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Michael K Farris
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - A William Blackstock
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| |
Collapse
|
3
|
Tekatli H, Palacios MA, Schneiders FL, Haasbeek CJA, Slotman BJ, Lagerwaard FJ, Senan S. Local control and toxicity after magnetic resonance imaging (MR)-guided single fraction lung stereotactic ablative radiotherapy. Radiother Oncol 2023; 187:109823. [PMID: 37516364 DOI: 10.1016/j.radonc.2023.109823] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE Magnetic resonance imaging (MR)-guided radiotherapy permits continuous intrafraction visualization and use of automatic triggered beam delivery, with use of smaller planning target volumes (PTV). We report on long-term clinical outcomes following MR-guided single fraction (SF) lung SABR on a 0.35 T linac. MATERIALS AND METHODS Details of patients treated with SF-SABR for lung tumors were accessed from an ethics approved institutional database. A breath-hold 3D MR simulation scan was performed using a true FISP sequence, followed by a breath-hold 3D CT scan. The gross tumor volume (GTV) was first contoured on the breath-hold CT scan, which was then compared with contours on the 3D MR scan, before the GTV was finalized. SABR plans used step-and-shoot IMRT beams to a PTV derived by adding a 5 mm margin to the breath-hold GTV, and a 3 mm gating window was used. SABR was delivered during repeated breath-holds, using automatic beam gating with continuous visualization of the GTV in a sagittal MR plane. RESULTS Between 2018-2022, 50 consecutive patients were treated, and 69% had a primary non-small cell lung cancer. Median PTV was 11.2 cc (range 3.9-53.5); 80% of GTV's were located ≤2.5 cm from the chest wall. Prescribed doses were 34 Gy (in 58%), 30 Gy (32%), or between 20-28 Gy (10%). After a median follow-up of 18.1 months (95% CI 12.8-23.5), the 2-year survival was 82% (89% for primary NSCLC and 62% for metastases). After a median follow-up of 16.1 months (95% CI 11.2-21.1), local recurrences developed in 2 patients (4%). The 3-year local control rate was 97%, and just 1 patient developed grade ≥3 toxicity (chest wall pain). CONCLUSION MR-guided SF-SABR delivery to lung tumors on a 0.35 T linac, using repeated breath-holds with automatic beam gating, achieves good tumor control and low toxicity.
Collapse
Affiliation(s)
- Hilâl Tekatli
- Amsterdam UMC, location VUmc, Department of Radiation Oncology, Amsterdam, the Netherlands.
| | - Miguel A Palacios
- Amsterdam UMC, location VUmc, Department of Radiation Oncology, Amsterdam, the Netherlands
| | - Famke L Schneiders
- Amsterdam UMC, location VUmc, Department of Radiation Oncology, Amsterdam, the Netherlands
| | - Cornelis J A Haasbeek
- Amsterdam UMC, location VUmc, Department of Radiation Oncology, Amsterdam, the Netherlands
| | - Ben J Slotman
- Amsterdam UMC, location VUmc, Department of Radiation Oncology, Amsterdam, the Netherlands
| | - Frank J Lagerwaard
- Amsterdam UMC, location VUmc, Department of Radiation Oncology, Amsterdam, the Netherlands
| | - Suresh Senan
- Amsterdam UMC, location VUmc, Department of Radiation Oncology, Amsterdam, the Netherlands
| |
Collapse
|
4
|
O'Keeffe S, Higgins MJ, Fleming C, Armstrong J, Thirion P, McClean B, Vintró LL. A strategy to reduce fraction number in peripheral lung stereotactic ablative body radiotherapy. Phys Imaging Radiat Oncol 2023; 26:100429. [PMID: 37007915 PMCID: PMC10060739 DOI: 10.1016/j.phro.2023.100429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Background and purpose Hypo-fractionated lung Stereotactic Ablative Body Radiotherapy (SABR) has often been avoided when tumours are close to the chest wall. Our strategic objective was the reduction of fraction number, while maintaining target biological effective dose coverage without increasing chest wall toxicity (CWT) predictors. Materials and methods Twenty previously treated lung SABR patients were stratified into four cohorts according to distance from PTV to the chest wall, <1 cm, <0.5 cm, overlapping up to 0.5 cm and 1.0 cm. For each patient, four plans were created; a chest wall optimised plan for 54 Gy in 3 fractions, the clinical plan re-prescribed for 55 Gy in 5, 48 Gy in 3 and 45 Gy in 3 fractions. Results For a PTV distance of 0.5-0.0 cm, a reduction of the median (range) Dmax from 55.7 (57.5-54.1) Gy to 40.0 (37.1-42.0 Gy) Gy was observed for the chest wall optimised plans. The median V30Gy decreased from 18.9 (9.7-25.6) cm3 to 3.1 (1.8-4.5) cm3. For a PTV overlap of up to 0.5 cm, the Dmax reduced from 66.5 (64.1-70) Gy to 53.2 (50.6-55.1) Gy. The V30Gy decreased from 21.5 (16.5-29.5) cm3 to 14.9 (11.3-20.2) cm3. For the cohort with up to 1.0 cm overlap, there was a reduction in Dmax values of 9.9 Gy. The V30Gy for clinical plans, at 66.8 (18.7-188.8) cm3, decreased to 55.3 (15.5-149) cm3. Conclusion When PTVs are within 0.5 cm of chest wall, lung SABR dose heterogeneity can be used to reduce fraction number without increasing CWT predictors.
Collapse
|
5
|
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
| |
Collapse
|
6
|
Kang TM, Hardcastle N, Singh AK, Slotman BJ, Videtic GMM, Stephans KL, Couñago F, Louie AV, Guckenberger M, Harden SV, Plumridge NM, Siva S. Practical considerations of single-fraction stereotactic ablative radiotherapy to the lung. Lung Cancer 2022; 170:185-193. [PMID: 35843149 DOI: 10.1016/j.lungcan.2022.06.014] [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: 05/09/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
Stereotactic ablative radiotherapy (SABR) is a well-established treatment for patients with medically inoperable early-stage non-small cell lung cancer (NSCLC) and pulmonary oligometastases. The use of single-fraction SABR in this setting is supported by excellent local control and safety profiles which appear equivalent to multi-fraction SABR based on the available data. The resource efficiency and reduction in hospital outpatient visits associated with single-fraction SABR have been particularly advantageous during the COVID-19 pandemic. Despite the increased interest, single-fraction SABR in subgroups of patients remains controversial, including those with centrally located tumours, synchronous targets, proximity to dose-limiting organs at risk, and concomitant severe respiratory illness. This review provides an overview of the published randomised evidence evaluating single-fraction SABR in primary lung cancer and pulmonary oligometastases, the common clinical challenges faced, immunogenic effect of SABR, as well as technical and cost-utility considerations.
Collapse
Affiliation(s)
- Therese Mj Kang
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum, Department of Oncology, University of Melbourne, Australia; Centre for Medical Radiation Physics, University of Wollongong, New South Wales, Australia
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Gregory M M Videtic
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Kevin L Stephans
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid, Spain
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Susan V Harden
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Nikki M Plumridge
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum, Department of Oncology, University of Melbourne, Australia.
| |
Collapse
|
7
|
Abdelkader H, El-Kassas M. Tailored treatment strategies for cancer patients during COVID-19 pandemic. Rep Pract Oncol Radiother 2022; 27:318-330. [PMID: 36299379 PMCID: PMC9591031 DOI: 10.5603/rpor.a2022.0024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/11/2022] [Indexed: 11/25/2022] Open
Abstract
The global pandemic of respiratory disease caused by the novel human coronavirus (SARS-CoV-2) has caused indefinite global distress, uncertainty, and disturbance. This pandemic has had direct and indirect impacts for the healthcare systems across the world, but certain subgroups of patients have been particularly affected. Among these groups are patients with cancer, who as a result of their immunosuppressed status either from the disease itself or as a consequence of treatment, are at increased risk of severe COVID-19 infection and complications. The pandemic has also led to limited resources as medical services have been primarily directed to emergency care. In this context, physicians and healthcare providers have had to balance the importance of continuing treatment of cancer patients with the risk of virus infection. In this review, we outline the treatment strategies for cancer patients during this pandemic, focusing on tailored treatment in this challenging situation of varying risks and benefits.
Collapse
Affiliation(s)
- Haytham Abdelkader
- Clinical Oncology Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| |
Collapse
|
8
|
Bartl AJ, Mahoney M, Hennon MW, Yendamuri S, Videtic GMM, Stephans KL, Siva S, Farrugia MK, Ma SJ, Singh AK. Systematic Review of Single-Fraction Stereotactic Body Radiation Therapy for Early Stage Non-Small-Cell Lung Cancer and Lung Oligometastases: How to Stop Worrying and Love One and Done. Cancers (Basel) 2022; 14:cancers14030790. [PMID: 35159057 PMCID: PMC8834253 DOI: 10.3390/cancers14030790] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/26/2022] [Accepted: 02/01/2022] [Indexed: 02/06/2023] Open
Abstract
Adoption of single-fraction lung stereotactic body radiation therapy (SBRT) for patients with medically inoperable early stage non-small-cell lung cancer (NSCLC) or oligometastatic lung disease, even during the coronavirus disease 2019 (COVID-19) pandemic, was limited despite encouraging phase II trial results. Barriers to using single-fraction SBRT may include lack of familiarity with the regimen and lack of clarity about the expected toxicity. To address these concerns, we performed a systematic review of prospective literature on single-fraction SBRT for definitive treatment of early stage and oligometastatic lung cancer. A PubMed search of prospective studies in English on single-fraction lung SBRT was conducted. A systematic review was performed of the studies that reported clinical outcomes of single-fraction SBRT in the treatment of early stage non-small-cell lung cancer and lung oligometastases. The current prospective literature including nine trials supports the use of single-fraction SBRT in the definitive treatment of early stage peripheral NSCLC and lung oligometastases. Most studies cite local control rates of >90%, mild toxicity profiles, and favorable survival outcomes. Most toxicities reported were grade 1–2, with grade ≥3 toxicity in 0–17% of patients. Prospective trial results suggest potential consideration of utilizing single-fraction SBRT beyond the COVID-19 pandemic.
Collapse
Affiliation(s)
- Austin J. Bartl
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY 14203, USA;
| | - Mary Mahoney
- College of Medicine, State University of New York Upstate Medical University, Syracuse, NY 13210, USA;
| | - Mark W. Hennon
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.W.H.); (S.Y.)
| | - Sai Yendamuri
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.W.H.); (S.Y.)
| | - Gregory M. M. Videtic
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA; (G.M.M.V.); (K.L.S.)
| | - Kevin L. Stephans
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44195, USA; (G.M.M.V.); (K.L.S.)
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia;
| | - Mark K. Farrugia
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.K.F.); (S.J.M.)
| | - Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.K.F.); (S.J.M.)
| | - Anurag K. Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA; (M.K.F.); (S.J.M.)
- Correspondence: ; Tel.: +1-716-845-5715
| |
Collapse
|
9
|
Tjong M, Louie A, Singh A, Videtic G, Stephans K, Plumridge N, Harden S, Slotman B, Alongi F, Guckenberger M, Siva S. Single-Fraction Stereotactic Ablative Body Radiotherapy to the Lung – The Knockout Punch. Clin Oncol (R Coll Radiol) 2022; 34:e183-e194. [DOI: 10.1016/j.clon.2022.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/19/2022] [Accepted: 02/07/2022] [Indexed: 12/12/2022]
|
10
|
Mou B, Hyde D, Araujo C, Bartha L, Bergman A, Liu M. Implementation of Single-Fraction Lung Stereotactic Ablative Radiotherapy in a Multicenter Provincial Cancer Program During the COVID-19 Pandemic. Cureus 2021; 13:e15598. [PMID: 34277219 PMCID: PMC8270065 DOI: 10.7759/cureus.15598] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 12/26/2022] Open
Abstract
Background During the novel coronavirus disease 2019 (COVID-19) pandemic, cancer centers considered shortened courses of radiotherapy to minimize the risk of infectious exposure of patients and staff members. Amidst a pandemic, the process of implementing new treatment approaches can be particularly challenging in larger institutions with multiple treatment centers. We describe the implementation of single-fraction (SF) lung stereotactic ablative radiotherapy (SABR) in a multicenter provincial cancer program. Materials and Methods British Columbia, Canada has a provincial cancer program with six geographically distributed radiotherapy centers serving a population of 5.1 million, over 944,735 square kilometers. In March 2020, provincial mitigation strategies were developed in case of reduced access to radiotherapy due to the COVID-19 pandemic. SF lung SABR was identified by the provincial lung radiation oncology group as a mitigation measure supported by high-quality randomized evidence that could provide comparable outcomes and toxicity to existing fractionated SABR protocols. A working group consisting of radiation oncologists and medical physicists reviewed the medical literature and drafted consensus guidelines that were reviewed by a group of center representatives as a component of provincial lung radiotherapy mitigation strategic planning. Individual centers were encouraged to implement SF lung SABR as their resources and staffing would allow. Centers were then surveyed about barriers to implementation. Results On March 24, 2020, a working group was created and consensus guidelines for SF lung SABR were drafted. The final version was approved and distributed by the working group on March 26, 2020. The provincial lung radiotherapy mitigation strategy group adopted the guidelines for implementation on April 1, 2020. Implementation was completed at the first center on April 27, 2020. Barriers to implementation were identified at five of six centers. Two centers in regions with disproportionately high COVID-19 cases described inadequate staffing as a barrier to implementation. One center encountered delays due to pre-scheduled commissioning of new treatment techniques. Three centers cited competing priorities as reasons for delay. As of May 2021, two centers had active SF lung SABR programs in place, three centers were in the process of implementation, and one center had no immediate plans for implementation due to ongoing resource issues. Conclusion SF lung SABR was adopted by a provincial cancer program within weeks of conception through rapid communication during the development of COVID-19 pandemic mitigation strategies for radiotherapy. Although consensus guidelines were written and approved in an expedited timeframe, the completion of implementation by individual centers was variable due to differences in resource allocation and staffing among the centers. Strong organizational structures and early identification of potential barriers may improve the efficiency of implementing new treatment initiatives in large multicenter radiotherapy programs.
Collapse
Affiliation(s)
- Benjamin Mou
- Radiation Oncology, BC Cancer Kelowna, Kelowna, CAN
| | - Derek Hyde
- Medical Physics, BC Cancer Kelowna, Kelowna, CAN
| | | | - Leigh Bartha
- Radiation Therapy, BC Cancer Kelowna, Kelowna, CAN
| | | | - Mitchell Liu
- Radiation Oncology, BC Cancer Vancouver, Vancouver, CAN
| |
Collapse
|
11
|
Salama JK, Giuliani ME, Robinson CG, Daly ME. Single-fraction SBRT for Early Stage NSCLC-A Viable Option in "These Uncertain Times"? Int J Radiat Oncol Biol Phys 2021; 109:1-4. [PMID: 33308692 DOI: 10.1016/j.ijrobp.2020.08.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/08/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Joseph K Salama
- Department of Radiation Oncology, Duke University, Durham, North Carolina.
| | - Meredith E Giuliani
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, California
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Megan E Daly
- University of California Davis Comprehensive Cancer, Department of Radiation Oncology, Center, Sacramento, California
| |
Collapse
|
12
|
Strange CD, Shroff GS, Truong MT, Nguyen QN, Vlahos I, Erasmus JJ. Imaging of the post-radiation chest in lung cancer. Clin Radiol 2021; 77:19-30. [PMID: 34090709 DOI: 10.1016/j.crad.2021.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/29/2021] [Indexed: 12/25/2022]
Abstract
Radiation therapy using conventional fractionated external-beam or high-precision dose techniques including three-dimensional conformal radiotherapy, stereotactic body radiation therapy, intensity-modulated radiation therapy, and proton therapy, is a key component in the treatment of patients with lung cancer. Knowledge of the radiation technique used, radiation treatment plan, expected temporal evolution of radiation-induced lung injury and patient-specific parameters, such as previous radiotherapy, concurrent chemoradiotherapy, and/or immunotherapy, is important in imaging interpretation. This review discusses factors that affect the development and severity of radiation-induced lung injury and its radiological manifestations with emphasis on the differences between conventional radiation and high-precision dose radiotherapy techniques.
Collapse
Affiliation(s)
- C D Strange
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - G S Shroff
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - M T Truong
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - Q-N Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - I Vlahos
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - J J Erasmus
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA.
| |
Collapse
|
13
|
Chuong MD, Kotecha R, Mehta MP, Adamson S, Romaguera T, Hall MD, Alvarez D, Gutierrez AN, Mishra V, De Zarraga F, Mittauer KE. Case report of visual biofeedback-driven, magnetic resonance-guided single-fraction SABR in breath hold for early stage non-small-cell lung cancer. Med Dosim 2021; 46:247-252. [PMID: 33648822 DOI: 10.1016/j.meddos.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 10/22/2022]
Abstract
Stereotactic ablative body radiation therapy (SABR) is a well-established alternative to surgery for early stage non-small-cell lung cancer (NSCLC). While SABR is typically delivered in 3 to 5 fractions, randomized trials have shown single-fraction SABR to be a reasonable alternative. We present the case of a 66-year-old male with history of cholangiocarcinoma who was subsequently diagnosed with peripheral early stage NSCLC and treated in mid-inspiration breath hold (BH) to 34 Gy in 1 fraction on a magnetic resonance (MR)-guided linear accelerator, with treatment delivery completed in 17 minutes. Visual biofeedback was utilized to maximize patient compliance with appropriate depth of inspiration BH and improve overall treatment delivery time efficiency. The benefits of single- vs multifraction SABR and unique advantages of MR guidance that are particularly well-suited for single-fraction SABR are reviewed.
Collapse
Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Sonia Adamson
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA
| | - Tino Romaguera
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Matthew D Hall
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Diane Alvarez
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Vivek Mishra
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Fernando De Zarraga
- Department of Medical Oncology, Miami Cancer Institute, Miami, FL 33176, USA
| | - Kathryn E Mittauer
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL 33176, USA; Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| |
Collapse
|
14
|
Conformal Avoidance of Normal Organs at Risk by Perfusion-Modulated Dose Sculpting in Tumor Single-Dose Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 109:288-297. [PMID: 32777335 DOI: 10.1016/j.ijrobp.2020.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/02/2020] [Accepted: 08/03/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Although 24 Gy single-dose radiation therapy (SDRT) renders >90% 5-year local relapse-free survival in human solid tumor lesions, SDRT delivery is not feasible in ∼50% of oligometastatic lesions owing to interference by dose/volume constraints of a serial organ at risk (OAR). Conformal OAR avoidance is based on a hypothetical model positing that the recently described SDRT biology specifically permits volumetric subdivision of the SDRT dose, such that high-intensity vascular drivers of SDRT lethality, generated within a major tumor subvolume exposed to a high 24 Gy dose (high-dose planning target volume [PTVHD]), would equilibrate SDRT signaling intensity throughout the tumor interstitial space, rendering bystander radiosensitization of a minor subvolume (perfusion-modulated dose sculpting PTV [PTVPMDS]), dose-sculpted to meet a serial OAR dose/volume constraint. An engineered PTVPMDS may thus yield tumor ablation despite PMDS dose reduction and conformally avoiding OAR exposure to a toxic dose. METHODS AND MATERIALS Dose fall-off within the PTVPMDS penumbra of oligometastatic lesions was planned and delivered by intensity modulated inverse dose painting. SDRT- and SDRT-PMDS-treated lesions were followed with periodic positron emission tomography/computed tomography imaging to assess local tumor control. RESULTS Cumulative baseline 5-year local relapse rates of oligometastases treated with 24 Gy SDRT alone (8% relapses, n = 292) were similar in moderate PTVPMDS dose-sculpted (23-18 Gy, n = 76, 11% relapses, P = .36) and extreme dose-sculpted (<18 Gy, n = 61, 14% relapses, P = .29) lesions, provided the major 24 Gy PTVHD constituted ≥60% of the total PTV. In contrast, 28% of local relapses occurred in 26 extreme dose-sculpted PTVPMDS lesions when PTVHD constituted <60% of the total PTV (P = .004), suggesting a threshold for the PTVPMDS bystander effect. CONCLUSION The study provides compelling clinical support for the bystander radiosensitization hypothesis, rendering local cure of tumor lesions despite a ≥25% PTVPMDS dose reduction of the 24 Gy PTVHD dose, adapted to conformally meet OAR dose/volume constraints. The SDRT-PMDS approach thus provides a therapeutic resolution to otherwise radioablation-intractable oligometastatic disease.
Collapse
|
15
|
Faivre-Finn C, Fenwick JD, Franks KN, Harrow S, Hatton MQF, Hiley C, McAleese JJ, McDonald F, O'Hare J, Peedell C, Pope T, Powell C, Rulach R, Toy E. Reduced Fractionation in Lung Cancer Patients Treated with Curative-intent Radiotherapy during the COVID-19 Pandemic. Clin Oncol (R Coll Radiol) 2020; 32:481-489. [PMID: 32405158 PMCID: PMC7218369 DOI: 10.1016/j.clon.2020.05.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 12/14/2022]
Abstract
Patients treated with curative-intent lung radiotherapy are in the group at highest risk of severe complications and death from COVID-19. There is therefore an urgent need to reduce the risks associated with multiple hospital visits and their anti-cancer treatment. One recommendation is to consider alternative dose-fractionation schedules or radiotherapy techniques. This would also increase radiotherapy service capacity for operable patients with stage I-III lung cancer, who might be unable to have surgery during the pandemic. Here we identify reduced-fractionation for curative-intent radiotherapy regimes in lung cancer, from a literature search carried out between 20/03/2020 and 30/03/2020 as well as published and unpublished audits of hypofractionated regimes from UK centres. Evidence, practical considerations and limitations are discussed for early-stage NSCLC, stage III NSCLC, early-stage and locally advanced SCLC. We recommend discussion of this guidance document with other specialist lung MDT members to disseminate the potential changes to radiotherapy practices that could be made to reduce pressure on other departments such as thoracic surgery. It is also a crucial part of the consent process to ensure that the risks and benefits of undergoing cancer treatment during the COVID-19 pandemic and the uncertainties surrounding toxicity from reduced fractionation have been adequately discussed with patients. Furthermore, centres should document all deviations from standard protocols, and we urge all colleagues, where possible, to join national/international data collection initiatives (such as COVID-RT Lung) aimed at recording the impact of the COVID-19 pandemic on lung cancer treatment and outcomes.
Collapse
Affiliation(s)
- C Faivre-Finn
- The Christie NHS Foundation Trust, Manchester, UK; The University of Manchester, Manchester, UK.
| | - J D Fenwick
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Department of Physics, Clatterbridge Cancer Centre, Bebington, Wirral, UK
| | - K N Franks
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK; University of Leeds, Leeds, UK
| | - S Harrow
- Beatson West of Scotland Cancer Centre, Glasgow, UK; University of Glasgow, Glasgow, UK
| | | | - C Hiley
- CRUK Lung Cancer Centre of Excellence, University College London, London, UK; Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J J McAleese
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK
| | - F McDonald
- The Royal Marsden NHS Foundation Trust, London, UK
| | - J O'Hare
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK
| | - C Peedell
- James Cook University Hospital, Middlesbrough, UK
| | - T Pope
- Clatterbridge Cancer Centre, Bebington, Wirral, UK
| | - C Powell
- South West Wales Cancer Centre, Singleton Hospital, Swansea, UK; Velindre Cancer Centre, Cardiff, UK
| | - R Rulach
- Beatson West of Scotland Cancer Centre, Glasgow, UK; University of Glasgow, Glasgow, UK
| | - E Toy
- Royal Devon and Exeter NHS Foundation Trust, Exeter Hospital, Exeter, UK
| |
Collapse
|
16
|
Finazzi T, van Sörnsen de Koste JR, Palacios MA, Spoelstra FO, Slotman BJ, Haasbeek CJ, Senan S. Delivery of magnetic resonance-guided single-fraction stereotactic lung radiotherapy. Phys Imaging Radiat Oncol 2020; 14:17-23. [PMID: 33458309 PMCID: PMC7807654 DOI: 10.1016/j.phro.2020.05.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/15/2020] [Accepted: 05/11/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Single-fraction stereotactic ablative radiotherapy (SABR) is an effective treatment for early-stage lung cancer, but concerns remain about the accurate delivery of SABR in a single session. We evaluated the delivery of single-fraction lung SABR using magnetic resonance (MR)-guidance. MATERIALS AND METHODS An MR-simulation was performed in 17 patients, seven of whom were found to be unsuitable, largely due to unreliable tracking of small tumors. Ten patients underwent single-fraction SABR to 34 Gy on a 0.35 T MR-linac system, with online plan adaptation. Gated breath-hold SABR was delivered using a planning target volume (PTV) margin of 5 mm, and a 3 mm gating window. Continuous MR-tracking of the gross tumor volume (GTVt) was performed in sagittal plane, with visual patient feedback provided using an in-room monitor. The real-time MR images were analyzed to determine precision and efficiency of gated delivery. RESULTS All but one patient completed treatment in a single session. The median total in-room procedure was 120 min, with a median SABR delivery session of 39 min. Review of 7.4 h of cine-MR imaging revealed a mean GTVt coverage by the PTV during beam-on of 99.6%. Breath-hold patterns were variable, resulting in a mean duty cycle efficiency of 51%, but GTVt coverage was not influenced due to real-time MR-guidance. On-table adaptation improved PTV coverage, but had limited impact on GTV doses. CONCLUSIONS Single-fraction gated SABR of lung tumors can be performed with high precision using MR-guidance. However, improvements are needed to ensure MR-tracking of small tumors, and to reduce treatment times.
Collapse
Affiliation(s)
- Tobias Finazzi
- Corresponding author at: Amsterdam University Medical Centers, Location VUmc, Postbox 7057, 1007 MB Amsterdam, The Netherlands.
| | | | - Miguel A. Palacios
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location VUmc, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Femke O.B. Spoelstra
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location VUmc, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Berend J. Slotman
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location VUmc, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Cornelis J.A. Haasbeek
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location VUmc, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location VUmc, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| |
Collapse
|
17
|
Balyimez A, Stephans KL, Abazeed ME, Mian OY. The landscape of early carcinogenesis revealed through the lens of integrative genomics, epigenomics, and transcriptomics. J Thorac Dis 2019; 11:2188-2191. [PMID: 31372248 PMCID: PMC6626785 DOI: 10.21037/jtd.2019.06.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/31/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Aysegul Balyimez
- Department of Translational Hematology and Oncology Research, Lerner Research Institute, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kevin L. Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mohamed E. Abazeed
- Department of Translational Hematology and Oncology Research, Lerner Research Institute, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Omar Y. Mian
- Department of Translational Hematology and Oncology Research, Lerner Research Institute, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|