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Zhang Q, Fan S, Xu X, Du S, Zhu G, Jiang C, Xia SA, Li Q, Wang Q, Qian D, Zhang M, Xiao H, Chen G, Zeng Z, He J. Efficacy and Toxicity of Moderately Hypofractionated Radiation Therapy with Helical TomoTherapy Versus Conventional Radiation Therapy in Patients with Unresectable Stage III Non-Small Cell Lung Cancer Receiving Concurrent Chemotherapy: A Multicenter, Randomized Phase 3 Trial. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00450-4. [PMID: 38631536 DOI: 10.1016/j.ijrobp.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 03/08/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE The standard treatment schedule for unresectable stage III non-small cell lung cancer (NSCLC) is chemotherapy with concurrent radiation therapy (60 Gy delivered in 30 fractions), although moderately hypofractionated radiation therapy (Hypo-RT) has also been considered as an alternative strategy. This study aimed to compare the efficacy and toxicity of moderately Hypo-RT with helical TomoTherapy versus conventionally fractionated radiation therapy (Con-RT) in patients with unresectable stage III NSCLC receiving concurrent chemotherapy. METHODS AND MATERIALS In this randomized, multicenter, nonblinded phase 3 clinical trial, eligible patients were randomised at a 1:1 ratio to either the Hypo-RT group (60 Gy in 20 fractions) or Con-RT group (60 Gy in 30 fractions). All patients received 2 cycles of concurrent platinum-based chemotherapy plus 2 cycles of consolidation therapy. The primary endpoint was 3-year overall survival (OS) in the intention-to-treat population. The secondary endpoints were progression-free survival and treatment-related adverse events. RESULTS A total of 146 patients were enrolled from July 27, 2018, to November 1, 2021. The median follow-up was 46 months. The 3-year OS rates in the Hypo-RT and Con-RT groups were 58.4% and 38.4%, respectively (P = .02). The median OS from randomisation was 41 months in the Hypo-RT group and 30 months in the Con-RT group (hazard ratio, 0.61; 95% confidence interval, 0.40-0.94; P = .02). There was no significant difference in the rates of grade ≥2 treatment-related adverse events between the 2 groups. CONCLUSIONS Moderately Hypo-RT using helical TomoTherapy may improve OS in patients with unresectable stage III NSCLC, while maintaining toxicity rates.
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Affiliation(s)
- Qi Zhang
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shaonan Fan
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaohong Xu
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shisuo Du
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guangying Zhu
- Department of Radiation Oncology, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Chaoyang Jiang
- Department of Oncology, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Shi-An Xia
- Department of Oncology, Xinhua Hospital Affiliated to School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qiwen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qifeng Wang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Dong Qian
- Department of Radiation Oncology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Ming Zhang
- Department of Radiation Oncology, Yunnan Cancer Hospital & the Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Han Xiao
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Gang Chen
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Jian He
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
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Yang B, Liu Y, Chen Z, Wang Z, Zhou Q, Qiu J. Tissues margin-based analytical anisotropic algorithm boosting method via deep learning attention mechanism with cervical cancer. Int J Comput Assist Radiol Surg 2023; 18:953-959. [PMID: 36460828 DOI: 10.1007/s11548-022-02801-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 11/19/2022] [Indexed: 12/04/2022]
Abstract
PURPOSE Speed and accuracy are two critical factors in dose calculation for radiotherapy. Analytical Anisotropic Algorithm (AAA) is a rapid dose calculation algorithm but has dose errors in tissue margin area. Acuros XB (AXB) has high accuracy but takes long time to calculate. To improve the dose accuracy on the tissue margin area for AAA, we proposed a novel deep learning-based dose accuracy improvement method using Margin-Net combined with Margin-Loss. METHODS A novel model 'Margin-Net' was designed with a Margin Attention Mechanism to generate special margin-related features. Margin-Loss was introduced to consider the dose errors and dose gradients in tissues margin area. Ninety-five VMAT cervical cancer cases with paired AAA and AXB dose were enrolled in our study: 76 cases for training and 19 cases for testing. Tissues Margin Masks were generated from RT contours with 6 mm extension. Tissues Margin Mask, AAA dose and CTs were input data; AXB dose was used as reference dose for model training and evaluation. Comparison experiments were performed to evaluated effectiveness of Margin-Net and Margin-Loss. RESULTS Compared to AXB dose, the 3D gamma passing rate (1%/1 mm, 10% threshold) for 19 test cases 95.75 ± 1.05% using Margin-Net with Margin-Loss, which was significantly higher than the original AAA dose (73.64 ± 3.46%). The passing rate reduced to 94.07 ± 1.16% without Margin-Loss and 87.3 ± 1.18% if Margin-Net key structure 'MAM' was also removed. CONCLUSION The proposed novel tissues margin-based dose conversion method can significantly improve the dose accuracy of Analytical Anisotropic Algorithm to be comparable to AXB algorithm. It can potentially improve the efficiency of treatment planning process with low demanding of computation resources.
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Affiliation(s)
- Bo Yang
- Peking Union Medical College Hospital, Beijing, 100005, China
| | - Yaoying Liu
- School of Physics, Beihang University, Beijing, 102206, China
- Manteia Technologies Co., Ltd, Xiamen, 361008, China
| | - Zhaocai Chen
- Manteia Technologies Co., Ltd, Xiamen, 361008, China
| | - Zhiqun Wang
- Peking Union Medical College Hospital, Beijing, 100005, China
| | - Qichao Zhou
- Manteia Technologies Co., Ltd, Xiamen, 361008, China.
| | - Jie Qiu
- Peking Union Medical College Hospital, Beijing, 100005, China.
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Guberina N, Pöttgen C, Santiago A, Levegrün S, Qamhiyeh S, Ringbaek TP, Guberina M, Lübcke W, Indenkämpen F, Stuschke M. Machine-learning-based prediction of the effectiveness of the delivered dose by exhale-gated radiotherapy for locally advanced lung cancer: The additional value of geometric over dosimetric parameters alone. Front Oncol 2023; 12:870432. [PMID: 36713497 PMCID: PMC9880443 DOI: 10.3389/fonc.2022.870432] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 12/08/2022] [Indexed: 01/15/2023] Open
Abstract
Purpose This study aimed to assess interfraction stability of the delivered dose distribution by exhale-gated volumetric modulated arc therapy (VMAT) or intensity-modulated arc therapy (IMAT) for lung cancer and to determine dominant prognostic dosimetric and geometric factors. Methods Clinical target volume (CTVPlan) from the planning CT was deformed to the exhale-gated daily CBCT scans to determine CTVi, treated by the respective dose fraction. The equivalent uniform dose of the CTVi was determined by the power law (gEUDi) and cell survival model (EUDiSF) as effectiveness measure for the delivered dose distribution. The following prognostic factors were analyzed: (I) minimum dose within the CTVi (Dmin_i), (II) Hausdorff distance (HDDi) between CTVi and CTVPlan, (III) doses and deformations at the point in CTVPlan at which the global minimum dose over all fractions per patient occurs (PDmin_global_i), and (IV) deformations at the point over all CTVi margins per patient with the largest Hausdorff distance (HDPworst). Prognostic value and generalizability of the prognostic factors were examined using cross-validated random forest or multilayer perceptron neural network (MLP) classifiers. Dose accumulation was performed using back deformation of the dose distribution from CTVi to CTVPlan. Results Altogether, 218 dose fractions (10 patients) were evaluated. There was a significant interpatient heterogeneity between the distributions of the normalized gEUDi values (p<0.0001, Kruskal-Wallis tests). Accumulated gEUD over all fractions per patient was 1.004-1.023 times of the prescribed dose. Accumulation led to tolerance of ~20% of fractions with gEUDi <93% of the prescribed dose. Normalized Dmin >60% was associated with predicted gEUD values above 95%. Dmin had the highest importance for predicting the gEUD over all analyzed prognostic parameters by out-of-bag loss reduction using the random forest procedure. Cross-validated random forest classifier based on Dmin as the sole input had the largest Pearson correlation coefficient (R=0.897) in comparison to classifiers using additional input variables. The neural network performed better than the random forest classifier, and the gEUD values predicted by the MLP classifier with Dmin as the sole input were correlated with the gEUD values characterized by R=0.933 (95% CI, 0.913-0.948). The performance of the full MLP model with all geometric input parameters was slightly better (R=0.952) than that based on Dmin (p=0.0034, Z-test). Conclusion Accumulated dose distributions over the treatment series were robust against interfraction CTV deformations using exhale gating and online image guidance. Dmin was the most important parameter for gEUD prediction for a single fraction. All other parameters did not lead to a markedly improved generalizable prediction. Dosimetric information, especially location and value of Dmin within the CTV i , are vital information for image-guided radiation treatment.
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Affiliation(s)
- Nika Guberina
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany,*Correspondence: Nika Guberina,
| | - Christoph Pöttgen
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Alina Santiago
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sabine Levegrün
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sima Qamhiyeh
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Toke Printz Ringbaek
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Maja Guberina
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Wolfgang Lübcke
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Frank Indenkämpen
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiation Therapy, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
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Colori A, Hiley C. The Interaction of Preexisting Cardiac Dysfunction and Heart Dose From Radical Radiotherapy on All-Cause Mortality in Locally Advanced NSCLC. J Thorac Oncol 2023; 18:14-16. [PMID: 36543430 DOI: 10.1016/j.jtho.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Amy Colori
- Department of Clinical Oncology, University College London Hospital, London, United Kingdom
| | - Crispin Hiley
- Department of Clinical Oncology, University College London Hospital, London, United Kingdom; Cancer Research UK Lung Cancer Centre of Excellence, University College London Cancer Institute, London, United Kingdom.
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Huang HT, Nix MG, Brand DH, Cobben D, Hiley CT, Fenwick JD, Hawkins MA. Dose-Response Analysis Describes Particularly Rapid Repopulation of Non-Small Cell Lung Cancer during Concurrent Chemoradiotherapy. Cancers (Basel) 2022; 14:4869. [PMID: 36230791 PMCID: PMC9563948 DOI: 10.3390/cancers14194869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Purpose: We analysed overall survival (OS) rates following radiotherapy (RT) and chemo-RT of locally-advanced non-small cell lung cancer (LA-NSCLC) to investigate whether tumour repopulation varies with treatment-type, and to further characterise the low α/β ratio found in a previous study. (2) Materials and methods: Our dataset comprised 2-year OS rates for 4866 NSCLC patients (90.5% stage IIIA/B) belonging to 51 cohorts treated with definitive RT, sequential chemo-RT (sCRT) or concurrent chemo-RT (cCRT) given in doses-per-fraction ≤3 Gy over 16-60 days. Progressively more detailed dose-response models were fitted, beginning with a probit model, adding chemotherapy effects and survival-limiting toxicity, and allowing tumour repopulation and α/β to vary with treatment-type and stage. Models were fitted using the maximum-likelihood technique, then assessed via the Akaike information criterion and cross-validation. (3) Results: The most detailed model performed best, with repopulation offsetting 1.47 Gy/day (95% confidence interval, CI: 0.36, 2.57 Gy/day) for cCRT but only 0.30 Gy/day (95% CI: 0.18, 0.47 Gy/day) for RT/sCRT. The overall fitted tumour α/β ratio was 3.0 Gy (95% CI: 1.6, 5.6 Gy). (4) Conclusion: The fitted repopulation rates indicate that cCRT schedule durations should be shortened to the minimum in which prescribed doses can be tolerated. The low α/β ratio suggests hypofractionation should be efficacious.
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Affiliation(s)
- Huei-Tyng Huang
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
| | - Michael G. Nix
- Department of Medical Physics and Engineering, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Foundation Trust, Leeds LS9 7TF, UK
| | - Douglas H. Brand
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
- University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
| | - David Cobben
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool CH63 4JY, UK
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GF, UK
| | - Crispin T. Hiley
- University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
- Cancer Research UK Lung Cancer Centre of Excellence, University College London Cancer Institute, London WC1E 6AG, UK
| | - John D. Fenwick
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool CH63 4JY, UK
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool L69 7BE, UK
| | - Maria A. Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London WC1E 6BT, UK
- University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
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Rodríguez De Dios N, Navarro-Martin A, Cigarral C, Chicas-Sett R, García R, Garcia V, Gonzalez JA, Gonzalo S, Murcia-Mejía M, Robaina R, Sotoca A, Vallejo C, Valtueña G, Couñago F. GOECP/SEOR radiotheraphy guidelines for non-small-cell lung cancer. World J Clin Oncol 2022; 13:237-266. [PMID: 35582651 PMCID: PMC9052073 DOI: 10.5306/wjco.v13.i4.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/27/2021] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is a heterogeneous disease accounting for approximately 85% of all lung cancers. Only 17% of patients are diagnosed at an early stage. Treatment is multidisciplinary and radiotherapy plays a key role in all stages of the disease. More than 50% of patients with NSCLC are treated with radiotherapy (curative-intent or palliative). Technological advances-including highly conformal radiotherapy techniques, new immobilization and respiratory control systems, and precision image verification systems-allow clinicians to individualize treatment to maximize tumor control while minimizing treatment-related toxicity. Novel therapeutic regimens such as moderate hypofractionation and advanced techniques such as stereotactic body radiotherapy (SBRT) have reduced the number of radiotherapy sessions. The integration of SBRT into routine clinical practice has radically altered treatment of early-stage disease. SBRT also plays an increasingly important role in oligometastatic disease. The aim of the present guidelines is to review the role of radiotherapy in the treatment of localized, locally-advanced, and metastatic NSCLC. We review the main radiotherapy techniques and clarify the role of radiotherapy in routine clinical practice. These guidelines are based on the best available evidence. The level and grade of evidence supporting each recommendation is provided.
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Affiliation(s)
- Núria Rodríguez De Dios
- Department of Radiation Oncology, Hospital del Mar, Barcelona 08003, Spain
- Radiation Oncology Research Group, Hospital Del Mar Medical Research Institution, Barcelona 08003, Spain
- Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona 08003, Spain
| | - Arturo Navarro-Martin
- Department of Radiation Oncology, Thoracic Malignancies Unit, Hospital Duran i Reynals. ICO, L´Hospitalet de L, Lobregat 08908, Spain
| | - Cristina Cigarral
- Department of Radiation Oncology, Hospital Clínico de Salamanca, Salamanca 37007, Spain
| | - Rodolfo Chicas-Sett
- Department of Radiation Oncology, ASCIRES Grupo Biomédico, Valencia 46004, Spain
| | - Rafael García
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Virginia Garcia
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | | | - Susana Gonzalo
- Department of Radiation Oncology, Hospital Universitario La Princesa, Madrid 28006, Spain
| | - Mauricio Murcia-Mejía
- Department of Radiation Oncology, Hospital Universitario Sant Joan de Reus, Reus 43204, Tarragona, Spain
| | - Rogelio Robaina
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | - Amalia Sotoca
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Carmen Vallejo
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - German Valtueña
- Department of Radiation Oncology, Hospital Clínico Universitario Lozano Blesa, Zaragoza 50009, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid 28223, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Department of Clinical, Universidad Europea, Madrid 28670, Spain
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Borghetti P, Guerini AE, Sangalli C, Piperno G, Franceschini D, La Mattina S, Arcangeli S, Filippi AR. Unmet needs in the management of unresectable stage III non-small cell lung cancer: a review after the 'Radio Talk' webinars. Expert Rev Anticancer Ther 2022; 22:549-559. [PMID: 35450510 DOI: 10.1080/14737140.2022.2069098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Stage III non-small cell lung cancer (NSCLC) is a variable entity, encompassing bulky primary tumors, nodal involvement or both. Multidisciplinary evaluation is essential to discuss multiple treatment options, to outline optimal management and to examine the main debated topics and critical issues not addressed by current trials and guidelines that influence daily clinical practice. AREAS COVERED From March to May 2021, 5 meetings were scheduled in a webinar format titled 'Radio Talk' due to the COVID-19 pandemic; the faculty was composed of 6 radiation oncologists from 6 different Institutions of Italy, all of them were the referring radiation oncologist for lung cancer treatment at their respective departments and were or had been members of AIRO (Italian Association of Radiation Oncology) Thoracic Oncology Study Group. The topics covered included: pulmonary toxicity, cardiac toxicity, radiotherapy dose, fractionation and volumes, unfit/elderly patients, multidisciplinary management. EXPERT OPINION The debate was focused on the unmet needs triggered by case reports, personal experiences and questions; the answers were often not univocal, however, the exchange of opinion and the contribution of different centers confirmed the role of multidisciplinary management and the necessity that the most critical issues should be investigated in clinical trials.
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Affiliation(s)
- Paolo Borghetti
- Department of Radiation Oncology, University and Spedali Civili Hospital, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Andrea Emanuele Guerini
- Department of Radiation Oncology, University and Spedali Civili Hospital, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Claudia Sangalli
- Department of Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gaia Piperno
- Division of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Salvatore La Mattina
- Department of Radiation Oncology, University and Spedali Civili Hospital, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Stefano Arcangeli
- Department of Radiation Oncology, School of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Andrea Riccardo Filippi
- Department of Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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Brada M, Forbes H, Ashley S, Fenwick J. Improving Outcomes in NSCLC: Optimum Dose Fractionation in Radical Radiotherapy Matters. J Thorac Oncol 2022; 17:532-543. [PMID: 35092841 DOI: 10.1016/j.jtho.2022.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We analyzed a comprehensive national radiotherapy data set to compare outcomes of the most frequently used moderate hypofractionation regimen (55 Gy in 20 fractions) and conventional fractionation regimen (60-66 Gy in 30-33 fractions). METHODS A total of 169,863 cases of NSCLC registered in England from January 2012 to December 2016 obtained from the Public Health England were divided into cohort 1 (training set) diagnosed in 2012 to 2013 and cohort 2 (validation set) diagnosed in 2014 to 2016. Radiotherapy data were obtained from the National Radiotherapy Dataset and linked by National Health Service number to survival data from the Office of National Statistics and Hospital Episode Statistics, from which surgical data and Charlson comorbidity index were obtained. Of 73,186 patients with stages I to III NSCLC, 12,898 received radical fractionated radiotherapy (cohort 1-4894; cohort 2-8004). The proportional hazards model was used to investigate overall survival from time of diagnosis. Survival was adjusted for the prognostic factors of age, sex, stage of disease, comorbidity, other radical treatments, and adjuvant chemotherapy, and the difference between the treatment schedules was summarized by hazard ratio (HR) and 95% confidence interval. The significance of any difference was evaluated by the log likelihood test. RESULTS Of patients with stages I to III NSCLC, 17% to 18% received radical fractionated radiotherapy. After adjustment for independent prognostic factors of age, stage, comorbidity, and other radical and adjuvant treatments, patients in cohort 1 treated with the 2.75 Gy per fraction regimen had a median survival of 25 months compared with 29 months for patients treated with the 2 Gy per fraction regimen (HR = 1.16, p = 0.001). Similarly, in cohort 2, the respective median survival values were 25 and 28 months (HR = 1.10, p = 0.02). CONCLUSIONS Big data analysis of a comprehensive national cohort of patients with NSCLC treated in England suggests that compared with a 4-week regimen of 55 Gy in 20 fractions, a 6-week regimen of conventional daily fractionation to a dose of 60 to 66 Gy at 2 Gy per fraction is associated with a survival benefit. Within the limitations of the retrospective big data analysis with potential selection bias and in the absence of randomized trials, the results suggest that conventional fractionation regimens should remain the standard of care.
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Affiliation(s)
- Michael Brada
- Department of Radiation Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom; Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.
| | - Helen Forbes
- Department of Radiation Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom; National Clinical Analysis and Specialised Applications Team (NATCANSAT), The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - Susan Ashley
- Department of Radiation Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom
| | - John Fenwick
- Department of Radiation Oncology, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, United Kingdom; Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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Muñoz-Guglielmetti D, Sanchez-Lorente D, Reyes R, Martinez D, Lucena C, Boada M, Paredes P, Parera-Roig M, Vollmer I, Mases J, Martin-Deleon R, Castillo S, Benegas M, Muñoz S, Mayoral M, Cases C, Mollà M, Casas F. Pathological response to neoadjuvant therapy with chemotherapy vs chemoradiotherapy in stage III NSCLC-contribution of IASLC recommendations. World J Clin Oncol 2021; 12:1047-1063. [PMID: 34909399 PMCID: PMC8641007 DOI: 10.5306/wjco.v12.i11.1047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/22/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Neoadjuvant treatment (NT) with chemotherapy (Ch) is a standard option for resectable stage III (N2) NSCLC. Several studies have suggested benefits with the addition of radiotherapy (RT) to NT Ch. The International Association for the Study of Lung Cancer (IASLC) published recommendations for the pathological response (PHR) of NSCLC resection specimens after NT.
AIM To contribute to the IASLC recommendations showing our results of PHR to NT Ch vs NT chemoradiotherapy (ChRT).
METHODS We analyzed 67 consecutive patients with resectable stage III NSCLC with positive mediastinal nodes treated with surgery after NT Ch or NT ChRT between 2013 and 2020. After NT, all patients were evaluated for radiological response (RR) according to Response Evaluation Criteria in Solid Tumours criteria and evaluated for surgery by a specialized group of thoracic surgeons. All histological samples were examined by the same two pathologists. PHR was evaluated by the percentage of viable cells in the tumor and the resected lymph nodes.
RESULTS Forty patients underwent NT ChRT and 27 NT Ch. Fifty-six (83.6%) patients underwent surgery (35 ChRT and 21 Ch). The median time from ChRT to surgery was 6 wk (3-19) and 8 wk (3-21) for Ch patients. We observed significant differences in RR, with disease progression in 2.5% and 14.8% of patients with ChRT and Ch, respectively, and partial response in 62.5% ChRT vs 29.6% Ch (P = 0.025). In PHR we observed ≤ 10% viable cells in the tumor in 19 (54.4%) and 2 cases (9.5%), and in the resected lymph nodes (RLN) 30 (85.7%) and 7 (33.3%) in ChRT and Ch, respectively (P = 0.001). Downstaging was greater in the ChRT compared to the Ch group (80% vs 33.3%; P = 0.002). In the univariate analysis, NT ChRT had a significant impact on partial RR [odds ratio (OR) 12.5; 95% confidence interval (CI): 1.21 - 128.61; P = 0.034], a decreased risk of persistence of cancer cells in the tumor and RLN and an 87.5% increased probability for achieving downstaging (OR 8; 95%CI: 2.34-27.32; P = 0.001).
CONCLUSION We found significant benefits in RR and PHR by adding RT to Ch as NT. A longer follow-up is necessary to assess the impact on clinical outcomes.
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Affiliation(s)
| | - David Sanchez-Lorente
- Thoracic Surgery Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Roxana Reyes
- Medical Oncology Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Daniel Martinez
- Pathology Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Carmen Lucena
- Pneumology Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Marc Boada
- Thoracic Surgery Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Pilar Paredes
- Nuclear Medicine Department, Faculty of Medicine of University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Cataluña, Spain
| | - Marta Parera-Roig
- Medical Oncology Department, Hospital Comarcal de Vic, Vic 08500, Cataluña, Spain
| | - Ivan Vollmer
- Radiology Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Joel Mases
- Radiation Oncology Department, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Roberto Martin-Deleon
- Pneumology Department, Hospital Universitario Reina Sofia, Córdoba 14004, Andalucía, Spain
| | - Sergi Castillo
- Medical Oncology Department, Hospital de Mollet, Mollet 08100, Cataluña, Spain
| | - Mariana Benegas
- Radiology Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Silvia Muñoz
- Medical Oncology Department, Hospital General de Granollers, Granollers 08402, Cataluña, Spain
| | - Maria Mayoral
- Nuclear Medicine Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Carla Cases
- Radiation Oncology Department, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Meritxell Mollà
- Radiation Oncology Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
| | - Francesc Casas
- Radiation Oncology Department, Thoracic Unit, Hospital Clínic de Barcelona, Barcelona 08036, Cataluña, Spain
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10
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Witlox WJA, Ramaekers BLT, Lacas B, Pechoux CL, Sun A, Wang SY, Hu C, Redman M, van der Noort V, Li N, Guckenberger M, van Tinteren H, Groen HJM, Joore MA, De Ruysscher DKM. Association of different fractionation schedules for prophylactic cranial irradiation with toxicity and brain metastases-free survival in stage III non-small cell lung cancer: A pooled analysis of individual patient data from three randomized trials. Radiother Oncol 2021; 164:163-166. [PMID: 34619235 DOI: 10.1016/j.radonc.2021.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/07/2021] [Accepted: 09/24/2021] [Indexed: 11/19/2022]
Abstract
We assessed the impact of different PCI fractionation schedules (30 Gy in 10 versus 15 fractions) on brain metastases-free survival (BMFS) and toxicity in stage III NSCLC. Our results suggest that 30 Gy in 10 fractions is associated with increased toxicity, while no conclusive evidence of improving BMFS was seen with this schedule.
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Affiliation(s)
- Willem J A Witlox
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), The Netherlands; Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Centre (MUMC), The Netherlands.
| | - Bram L T Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), The Netherlands
| | - Benjamin Lacas
- Department of Biostatistics and Epidemiology, Gustave Roussy, University Paris-Saclay, Villejuif, France; Oncostat U1018, Inserm, University Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif, France
| | - Cecile Le Pechoux
- Department of Radiation Oncology, Gustave Roussy, Paris-Saclay University, Villejuif, France
| | - Alexander Sun
- Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Canada
| | - Si-Yu Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chen Hu
- NRG Oncology Statistics and Data Management Center, Philadelphia, United States; Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, United States
| | - Mary Redman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Vincent van der Noort
- Department of Biometrics, Netherlands Cancer Institute (NKI), Amsterdam, The Netherlands
| | - Ning Li
- Department of Experimental Research, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Harm van Tinteren
- Trial and Data Center, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Harry J M Groen
- Department of Pulmonary Diseases, University of Groningen and University Medical Center Groningen, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC), The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
| | - Dirk K M De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Centre (MUMC), The Netherlands
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11
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Elamir AM, Stanescu T, Shessel A, Tadic T, Yeung I, Letourneau D, Kim J, Lukovic J, Dawson LA, Wong R, Barry A, Brierley J, Gallinger S, Knox J, O'Kane G, Dhani N, Hosni A, Taylor E. Simulated dose painting of hypoxic sub-volumes in pancreatic cancer stereotactic body radiotherapy. Phys Med Biol 2021; 66. [PMID: 34438383 DOI: 10.1088/1361-6560/ac215c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/26/2021] [Indexed: 12/26/2022]
Abstract
Dose painting of hypoxic tumour sub-volumes using positron-emission tomography (PET) has been shown to improve tumour controlin silicoin several sites, predominantly head and neck and lung cancers. Pancreatic cancer presents a more stringent challenge, given its proximity to critical gastro-intestinal organs-at-risk (OARs), anatomic motion, and impediments to reliable PET hypoxia quantification. A radiobiological model was developed to estimate clonogen survival fraction (SF), using18F-fluoroazomycin arabinoside PET (FAZA PET) images from ten patients with unresectable pancreatic ductal adenocarcinoma to quantify oxygen enhancement effects. For each patient, four simulated five-fraction stereotactic body radiotherapy (SBRT) plans were generated: (1) a standard SBRT plan aiming to cover the planning target volume with 40 Gy, (2) dose painting plans delivering escalated doses to a maximum of three FAZA-avid hypoxic sub-volumes, (3) dose painting plans with simulated spacer separating the duodenum and pancreatic head, and (4), plans with integrated boosts to geometric contractions of the gross tumour volume (GTV). All plans saturated at least one OAR dose limit. SF was calculated for each plan and sensitivity of SF to simulated hypoxia quantification errors was evaluated. Dose painting resulted in a 55% reduction in SF as compared to standard SBRT; 78% with spacer. Integrated boosts to hypoxia-blind geometric contractions resulted in a 41% reduction in SF. The reduction in SF for dose-painting plans persisted for all hypoxia quantification parameters studied, including registration and rigid motion errors that resulted in shifts and rotations of the GTV and hypoxic sub-volumes by as much as 1 cm and 10 degrees. Although proximity to OARs ultimately limited dose escalation, with estimated SFs (∼10-5) well above levels required to completely ablate a ∼10 cm3tumour, dose painting robustly reduced clonogen survival when accounting for expected treatment and imaging uncertainties and thus, may improve local response and associated morbidity.
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Affiliation(s)
- Ahmed M Elamir
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Teodor Stanescu
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Andrea Shessel
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ivan Yeung
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada.,Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Canada
| | - Daniel Letourneau
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - John Kim
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jelena Lukovic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Rebecca Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - James Brierley
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Steven Gallinger
- Ontario Institute for Cancer Research, PanCuRx Translational Research Initiative, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Jennifer Knox
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Grainne O'Kane
- Ontario Institute for Cancer Research, PanCuRx Translational Research Initiative, Toronto, Canada.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Neesha Dhani
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Center, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Edward Taylor
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Canada
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12
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McDermott RL, Mihai A, Dunne M, Keys M, O'Sullivan S, Thirion P, ElBeltagi N, Armstrong JG. Stereotactic Ablative Radiation Therapy for Large (≥5 cm) Non-small Cell Lung Carcinoma. Clin Oncol (R Coll Radiol) 2020; 33:292-299. [PMID: 33309479 DOI: 10.1016/j.clon.2020.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/28/2020] [Accepted: 11/25/2020] [Indexed: 12/25/2022]
Abstract
AIMS Stereotactic ablative radiation therapy (SABR) is a standard of care for medically inoperable early stage non-small cell lung carcinoma. Tumours greater than 5 cm have been excluded from randomised trials using SABR and, hence, it is not used as a standard for larger lung tumours. However, improvements in radiation therapy techniques and the success of SABR in treatment of early stage disease may allow safe delivery of ablative doses to larger tumours. We analysed our experience with tumours ≥5 cm to determine the efficacy and toxicity profile of SABR in this setting. MATERIALS AND METHODS We evaluated survival, control rates, patterns of failure and toxicity in patients with a tumour diameter larger than 5 cm that had no nodal or distant metastases treated with SABR technology. Patients had been treated in two centres since 2009 and were retrospectively analysed. All patients had positron emission tomography staging, were discussed at a tumour board and were documented to have no nodal or distant metastatic disease. Treatment outcomes were analysed using Kaplan-Meier estimates and compared using the Log-rank test. Cox regression was used to investigate the association between the survival outcomes and predictor variables. RESULTS In total, 86 patients were identified. Six patients had no follow-up imaging. Therefore, 80 patients were available for analysis. All patients were reclassified according to the updated AJCC eighth edition. The median follow-up was 19.6 months. No patients received neoadjuvant or concurrent systemic therapy. One patient received adjuvant systemic therapy. The median age at treatment was 77 years (range 58-91). Eighty-four per cent were stage T3N0M0 and 16% were staged T4N0M0. The median tumour diameter was 5.8 cm (range 5.0-9.3 cm). The median gross tumour volume, measured on a single phase of the respiratory cycle, was 45.7 cm3 (range 12.1-203.3 cm3). The median overall survival was 20.9 months (95% confidence interval 12.6-29.1 months). One-, 2- and 3-year overall survival was 71%, 48% and 32%, respectively. The median local failure-free survival was 19.5 months (95% confidence interval 14.4-24.6). The median disease-free survival was 15.1 months (95% confidence interval 9.9-20.4 months). Local control at 1, 2 and 3 years was 85% (95% confidence interval 76-94%), 71% (95% confidence interval 58-84%) and 57% (95% confidence interval 40-74%), respectively. Forty-four patients (55%) had any treatment failure (local, mediastinal, intrapulmonary or distant metastases). Out-of-field intrapulmonary disease progression was the most common mode of failure, occurring in 21 patients (26%). Local failure occurred in 19 patients (24%) - alone or in combination with other progression. Distant metastases occurred in 20 patients (25%). Neither histological subtype, tumour size nor gross tumour volume had a statistically significant effect on local failure-free survival. Two patients experienced grade 3 late dyspnoea. There were no other reported grade 3 or higher acute or late toxicities. CONCLUSION SABR for larger lung tumours ≥5 cm results in high local control and acceptable survival in patients with medically inoperable large non-small cell lung carcinoma treated with radiation alone. Such patients should be considered for SABR owing to fewer treatment fractions and acceptable toxicity. Local control analysis reveals a sustained pattern of local failure emphasising the need for long-term follow-up. Improvements in technical strategies are required to further improve local control.
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Affiliation(s)
- R L McDermott
- St Luke's Institute of Cancer Research, Rathgar, Dublin, Ireland; St Luke's Radiation Oncology Network, St Luke's Hospital, Rathgar, Dublin, Ireland.
| | - A Mihai
- Beacon Hospital, Sandyford, Dublin, Ireland
| | - M Dunne
- St Luke's Radiation Oncology Network, St Luke's Hospital, Rathgar, Dublin, Ireland
| | - M Keys
- St Luke's Radiation Oncology Network, St Luke's Hospital, Rathgar, Dublin, Ireland; St Luke's Radiation Oncology Network, St James' Hospital, Dublin, Ireland
| | - S O'Sullivan
- St Luke's Institute of Cancer Research, Rathgar, Dublin, Ireland; St Luke's Radiation Oncology Network, St Luke's Hospital, Rathgar, Dublin, Ireland
| | - P Thirion
- Beacon Hospital, Sandyford, Dublin, Ireland; St Luke's Radiation Oncology Network, St James' Hospital, Dublin, Ireland
| | - N ElBeltagi
- St Luke's Radiation Oncology Network, St Luke's Hospital, Rathgar, Dublin, Ireland
| | - J G Armstrong
- St Luke's Institute of Cancer Research, Rathgar, Dublin, Ireland; St Luke's Radiation Oncology Network, St Luke's Hospital, Rathgar, Dublin, Ireland; St Luke's Radiation Oncology Network, St James' Hospital, Dublin, Ireland
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13
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Liu YE, Xue XY, Zhang R, Chen XJ, Ding YX, Liu CX, Qin YL, Li WQ, Ren XC, Lin Q. Study protocol: a multicentre, prospective, phase II trial of isotoxic hypofractionated concurrent chemoradiotherapy for non-small cell lung cancer. BMJ Open 2020; 10:e036295. [PMID: 33099491 PMCID: PMC7590348 DOI: 10.1136/bmjopen-2019-036295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Concurrent chemoradiotherapy with conventional fractionation has been acknowledged as one of the standard treatments for locally advanced non-small cell lung cancer (NSCLC). The radiotherapy dose of 60 Gy is far from enough for local tumour control. Due to this fact, hypofractionated radiotherapy can shorten the total treatment duration, partially counteract the accelerated repopulation of tumour cells and deliver a higher biological effective dose, it has been increasingly used for NSCLC. In theory, concurrent hypofractionated chemoradiotherapy can result in an enhanced curative effect. To date, the vast majority of radiotherapy prescriptions assign a uniform radiotherapy dose to all patients. However this kind of uniform radiotherapy prescription may lead to two consequences: excess damage to normal tissues for large tumours and insufficient dose for small tumours. Our study aims to evaluate whether delivering individualised radiotherapy dose is feasible using intensity-modulated radiotherapy. METHODS AND ANALYSIS Our study of individualised radiotherapy is a multicenter phase II trial. From April 2019, a total of 30 patients from three Chinese centres, with a proven histological or cytological diagnosis of inoperable NSCLC, will be recruited. The dose of radiation will be increased until one or more of the organs at risk tolerance or the maximum dose of 69 Gy is reached. The primary end point is feasibility, with response rates, progression-free survival and overall survival as secondary end points. The concurrent chemotherapy regimen will be docetaxel plus lobaplatin. ETHICS AND DISSEMINATION The study has been approved by medical ethics committees from three research centres. The trial is conducted in accordance with the Declaration of Helsinki.The trial results will be disseminated through academic conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03606239.
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Affiliation(s)
- Yue-E Liu
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Xiao-Ying Xue
- Department of Radiotherapy, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Rui Zhang
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Xue-Ji Chen
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Yu-Xia Ding
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Chao-Xing Liu
- Department of Oncology, No.1 Hospital of Shijiazhuang City, Shijiazhuang, Hebei, China
| | - Yue-Liang Qin
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Wei-Qian Li
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Xiao-Cang Ren
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Qiang Lin
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
- Hebei Medical University, Shijiazhuang, Hebei, China
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14
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Xing Y, Zhang Y, Nguyen D, Lin MH, Lu W, Jiang S. Boosting radiotherapy dose calculation accuracy with deep learning. J Appl Clin Med Phys 2020; 21:149-159. [PMID: 32559018 PMCID: PMC7484829 DOI: 10.1002/acm2.12937] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 12/26/2022] Open
Abstract
In radiotherapy, a trade‐off exists between computational workload/speed and dose calculation accuracy. Calculation methods like pencil‐beam convolution can be much faster than Monte‐Carlo methods, but less accurate. The dose difference, mostly caused by inhomogeneities and electronic disequilibrium, is highly correlated with the dose distribution and the underlying anatomical tissue density. We hypothesize that a conversion scheme can be established to boost low‐accuracy doses to high‐accuracy, using intensity information obtained from computed tomography (CT) images. A deep learning‐driven framework was developed to test the hypothesis by converting between two commercially available dose calculation methods: Anisotropic analytic algorithm (AAA) and Acuros XB (AXB). A hierarchically dense U‐Net model was developed to boost the accuracy of AAA dose toward the AXB level. The network contained multiple layers of varying feature sizes to learn their dose differences, in relationship to CT, both locally and globally. Anisotropic analytic algorithm and AXB doses were calculated in pairs for 120 lung radiotherapy plans covering various treatment techniques, beam energies, tumor locations, and dose levels. For each case, the CT and the AAA dose were used as the input and the AXB dose as the “ground‐truth” output, to train and test the model. The mean squared errors (MSEs) and gamma passing rates (2 mm/2% & 1 mm/1%) were calculated between the boosted AAA doses and the “ground‐truth” AXB doses. The boosted AAA doses demonstrated substantially improved match to the “ground‐truth” AXB doses, with average (± s.d.) gamma passing rate (1 mm/1%) 97.6% (±2.4%) compared to 87.8% (±9.0%) of the original AAA doses. The corresponding average MSE was 0.11(±0.05) vs 0.31(±0.21). Deep learning is able to capture the differences between dose calculation algorithms to boost the low‐accuracy algorithms. By combining a less accurate dose calculation algorithm with a trained deep learning model, dose calculation can potentially achieve both high accuracy and efficiency.
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Affiliation(s)
- Yixun Xing
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - You Zhang
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Dan Nguyen
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Mu-Han Lin
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Weiguo Lu
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Steve Jiang
- Medical Artificial Intelligence and Automation (MAIA) Laboratory, Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
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15
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Azria D, Hennequin C, Giraud P. [Practical update of total dose compensation in case of temporary interruption of external radiotherapy in the COVID-19 pandemic context]. Cancer Radiother 2020; 24:182-187. [PMID: 32307313 PMCID: PMC7146696 DOI: 10.1016/j.canrad.2020.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/25/2022]
Abstract
L’étalement est un facteur important de récidive locale et indirectement d’évolution à distance, notamment, en cas de durée de traitement allongée. La pandémie actuelle a un impact sur les patients en cours de radiothérapie qui doivent interrompre leur traitement de manière parfois prolongée du fait de la nécessité de soins respiratoires induits par le COVID-19. Les modèles utilisés de compensation de la dose totale en cas d’interruption prolongée de la radiothérapie sont connus, mais il nous a semblé important de synthétiser afin que chaque oncologue radiothérapeute puisse proposer un traitement le plus optimal possible tant en termes de risque de récidive locale que de protection des tissus sains. L’objectif de ce type de recommandation est d’homogénéiser les pratiques de l’ensemble de la discipline.
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Affiliation(s)
- D Azria
- IRCM, Institut de recherche en cancérologie de Montpellier (U1194), 208, avenue des Apothicaires, 34298 Montpellier cedex 5, France; Inserm, U1194, 208, avenue des Apothicaires, 34298 Montpellier cedex 5, France; Université de Montpellier, centre de recherche U1194, 208, avenue des Apothicaires, 34298 Montpellier cedex 05, France; Fédération universitaire d'oncologie radiothérapie, ICM, institut régional du cancer de Montpellier, rue Croix-Verte, 34298 Montpellier cedex 05, France.
| | - C Hennequin
- Service de cancérologie-radiothérapie, AP-HP, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75475 Paris, France
| | - P Giraud
- Service d'oncologie radiothérapie, AP-HP, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université de Paris, 20, rue Leblanc, 75015 Paris, France
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16
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Fenwick JD, Landau DB, Baker AT, Bates AT, Eswar C, Garcia-Alonso A, Harden SV, Illsley MC, Laurence V, Malik Z, Mayles WPM, Miles E, Mohammed N, Spicer J, Wells P, Vivekanandan S, Mullin AM, Hughes L, Farrelly L, Ngai Y, Counsell N. Long-Term Results from the IDEAL-CRT Phase 1/2 Trial of Isotoxically Dose-Escalated Radiation Therapy and Concurrent Chemotherapy for Stage II/III Non-small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2019; 106:733-742. [PMID: 31809876 PMCID: PMC7049901 DOI: 10.1016/j.ijrobp.2019.11.397] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/30/2019] [Accepted: 11/17/2019] [Indexed: 12/25/2022]
Abstract
Purpose The IDEAL-CRT phase 1/2 multicenter trial of isotoxically dose-escalated concurrent chemoradiation for stage II/III non-small cell lung cancer investigated two 30-fraction schedules of 5 and 6 weeks’ duration. We report toxicity, tumor response, progression-free survival (PFS), and overall survival (OS) for both schedules, with long-term follow-up for the 6-week schedule. Methods and Materials Patients received isotoxically individualized tumor radiation doses of 63 to 71 Gy in 5 weeks or 63 to 73 Gy in 6 weeks, delivered concurrently with 2 cycles of cisplatin and vinorelbine. Eligibility criteria were the same for both schedules. Results One-hundred twenty patients (6% stage IIB, 68% IIIA, 26% IIIB, 1% IV) were recruited from 9 UK centers, 118 starting treatment. Median prescribed doses were 64.5 and 67.6 Gy for the 36 and 82 patients treated using the 5- and 6-week schedules. Grade ≥3 pneumonitis and early esophagitis rates were 3.4% and 5.9% overall and similar for each schedule individually. Late grade 2 esophageal toxicity occurred in 11.1% and 17.1% of 5- and 6-week patients. Grade ≥4 adverse events occurred in 17 (20.7%) 6-week patients but no 5-week patients. Four adverse events were grade 5, with 2 considered radiation therapy related. After median follow-up of 51.8 and 26.4 months for the 6- and 5-week schedules, median OS was 41.2 and 22.1 months, respectively, and median PFS was 21.1 and 8.0 months. In exploratory analyses, OS was significantly associated with schedule (hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.32-0.98; P = .04) and fractional clinical/internal target volume receiving ≥95% of the prescribed dose (HR, 0.88; 95% CI, 0.77-1.00; P = .05). PFS was also significantly associated with schedule (HR, 0.53; 95% CI, 0.33-0.86; P = .01). Conclusions Toxicity in IDEAL-CRT was acceptable. Survival was promising for 6-week patients and significantly longer than for 5-week patients. Survival might be further lengthened by following the 6-week schedule with an immune agent, motivating further study of such combined optimized treatments.
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Affiliation(s)
- John D Fenwick
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - David B Landau
- Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom.
| | | | - Andrew T Bates
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Chinnamani Eswar
- The Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, United Kingdom
| | | | | | - Marianne C Illsley
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | | | - Zafar Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, United Kingdom
| | | | - Elizabeth Miles
- Radiotherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, Middlesex, United Kingdom
| | - Nazia Mohammed
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - James Spicer
- Guy's & St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Paula Wells
- Barts Health NHS Trust, London, United Kingdom
| | | | - Anne-Marie Mullin
- Cancer Research UK & University College London Cancer Trials Centre, London, United Kingdom
| | - Laura Hughes
- Cancer Research UK & University College London Cancer Trials Centre, London, United Kingdom
| | - Laura Farrelly
- Cancer Research UK & University College London Cancer Trials Centre, London, United Kingdom
| | - Yenting Ngai
- Cancer Research UK & University College London Cancer Trials Centre, London, United Kingdom
| | - Nicholas Counsell
- Cancer Research UK & University College London Cancer Trials Centre, London, United Kingdom
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17
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Chen J, Wang K, Jian J, Zhang W. A mathematical model for predicting the changes of non-small cell lung cancer based on tumor mass during radiotherapy. Phys Med Biol 2019; 64:235006. [PMID: 31553960 DOI: 10.1088/1361-6560/ab47c0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This study aims to build a feasible mathematical model to analyze the mass evolution of NSCLC during standard fractionated radiotherapy. Seventy-three cases of NSCLC who were received radiotherapy with prescription dose of 2 Gy × 30 fx were selected retrospectively and divided into adenocarcinoma (ADC) group and squamous cell carcinoma (SCC) group according to the pathological type. A total of six sets of CT/CBCT images were collected. The tumor masses were measured according to each set of images. We build a mathematical model (Linear Quadratic_Repopulation&Reoxygenation& Dissolution model, LQ_RRD model), which was used to fit the first five sets of measured mass into a smooth curve. By adjusting the model parameters (λ, ν and µ), the optimal fitting results can be obtained. In order to verify the accuracy of model prediction, we measured the mass of the review images (MV, measured values), and found out the estimate point of the corresponding time (EV, estimated value) on the fitting curve. The difference and correlation between MV and EV were compared. It was found that the model could substantially simulate the tumor mass changes during radiotherapy, and it had a good fit to the clinical data (%RMSE-Median = 5.52, %RMSE-Range = [3.19, 10.73]). Comparing the differences of model parameters between ADC and SCC group, there was no significant difference in λ (t = 1.622, p = 0.109), but the difference was significant in ν and µ (z = -7.270, p = 0.000 and t = -10.205, p = 0.000). Moreover, linear correlation analysis showed that there was a linear correlation between MV and EV no matter mass or volume (r = 0.960, p = 0.000 versus r = 0.926, p = 0.000). Nevertheless, the deviation between MV and EV of volume was larger than that of mass (z = -1.897, p = 0.058 versus z = -3.387, p = 0.001), and the deviation was more pronounced in larger tumors. We suggest that this mathematical model is more suitable to predict the tumor mass than volume for NSCLC during radiotherapy.
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Affiliation(s)
- Jie Chen
- Department of Radiation Oncology, Tianjin Medical University General Hospital, No. 154, Anshan Road, Heping District, Tianjin 300052, People's Republic of China
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18
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Yuan TZ, Zhan ZJ, Qian CN. New frontiers in proton therapy: applications in cancers. Cancer Commun (Lond) 2019; 39:61. [PMID: 31640788 PMCID: PMC6805548 DOI: 10.1186/s40880-019-0407-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/11/2019] [Indexed: 12/11/2022] Open
Abstract
Proton therapy offers dominant advantages over photon therapy due to the unique depth-dose characteristics of proton, which can cause a dramatic reduction in normal tissue doses both distal and proximal to the tumor target volume. In turn, this feature may allow dose escalation to the tumor target volume while sparing the tumor-neighboring susceptible organs at risk, which has the potential to reduce treatment toxicity and improve local control rate, quality of life and survival. Some dosimetric studies in various cancers have demonstrated the advantages over photon therapy in dose distributions. Further, it has been observed that proton therapy confers to substantial clinical advantage over photon therapy in head and neck, breast, hepatocellular, and non-small cell lung cancers. As such, proton therapy is regarded as the standard modality of radiotherapy in many pediatric cancers from the technical point of view. However, due to the limited clinical evidence, there have been concerns about the high cost of proton therapy from an economic point of view. Considering the treatment expenses for late radiation-induced toxicities, cost-effective analysis in many studies have shown that proton therapy is the most cost-effective option for brain, head and neck and selected breast cancers. Additional studies are warranted to better unveil the cost-effective values of proton therapy and to develop newer ways for better protection of normal tissues. This review aims at reviewing the recent studies on proton therapy to explore its benefits and cost-effectiveness in cancers. We strongly believe that proton therapy will be a common radiotherapy modality for most types of solid cancers in the future.
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Affiliation(s)
- Tai-Ze Yuan
- Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, 510045, Guangdong, P. R. China
| | - Ze-Jiang Zhan
- Department of Radiation Oncology, Cancer Center of Guangzhou Medical University, Guangzhou, 510095, Guangdong, P. R. China
| | - Chao-Nan Qian
- Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, 510045, Guangdong, P. R. China.
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Nix MG, Rowbottom CG, Vivekanandan S, Hawkins MA, Fenwick JD. Chemoradiotherapy of locally-advanced non-small cell lung cancer: Analysis of radiation dose-response, chemotherapy and survival-limiting toxicity effects indicates a low α/β ratio. Radiother Oncol 2019; 143:58-65. [PMID: 31439448 DOI: 10.1016/j.radonc.2019.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/21/2019] [Accepted: 07/22/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To analyse changes in 2-year overall survival (OS2yr) with radiotherapy (RT) dose, dose-per-fraction, treatment duration and chemotherapy use, in data compiled from prospective trials of RT and chemo-RT (CRT) for locally-advanced non-small cell lung cancer (LA-NSCLC). MATERIAL AND METHODS OS2yr data was analysed for 6957 patients treated on 68 trial arms (21 RT-only, 27 sequential CRT, 20 concurrent CRT) delivering doses-per-fraction ≤4.0 Gy. An initial model considering dose, dose-per-fraction and RT duration was fitted using maximum-likelihood techniques. Model extensions describing chemotherapy effects and survival-limiting toxicity at high doses were assessed using likelihood-ratio testing, the Akaike Information Criterion (AIC) and cross-validation. RESULTS A model including chemotherapy effects and survival-limiting toxicity described the data significantly better than simpler models (p < 10-14), and had better AIC and cross-validation scores. The fitted α/β ratio for LA-NSCLC was 4.0 Gy (95%CI: 2.8-6.0 Gy), repopulation negated 0.38 (95%CI: 0.31-0.47) Gy EQD2/day beyond day 12 of RT, and concurrent CRT increased the effective tumour EQD2 by 23% (95%CI: 16-31%). For schedules delivered in 2 Gy fractions over 40 days, maximum modelled OS2yr for RT was 52% and 38% for stages IIIA and IIIB NSCLC respectively, rising to 59% and 42% for CRT. These survival rates required 80 and 87 Gy (RT or sequential CRT) and 67 and 73 Gy (concurrent CRT). Modelled OS2yr rates fell at higher doses. CONCLUSIONS Fitted dose-response curves indicate that gains of ~10% in OS2yr can be made by escalating RT and sequential CRT beyond 64 Gy, with smaller gains for concurrent CRT. Schedule acceleration achieved via hypofractionation potentially offers an additional 5-10% improvement in OS2yr. Further 10-20% OS2yr gains might be made, according to the model fit, if critical normal structures in which survival-limiting toxicities arise can be identified and selectively spared.
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Affiliation(s)
- Michael G Nix
- Department of Medical Physics and Engineering, Leeds Teaching Hospitals NHS Trust, United Kingdom.
| | - Carl G Rowbottom
- Department of Physics, Clatterbridge Cancer Centre, Wirral, United Kingdom; Department of Physics, University of Liverpool, Oliver Lodge Laboratory, Liverpool, United Kingdom
| | - Sindu Vivekanandan
- Guy's Hospital Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Maria A Hawkins
- Department of Oncology, University of Oxford, United Kingdom
| | - John D Fenwick
- Department of Physics, Clatterbridge Cancer Centre, Wirral, United Kingdom; Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, United Kingdom
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20
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Hazell SZ, Hales RK, Hrinivich WT, Ford K, Kang-Hsin Wang K, McNutt TR, Han P, Anderson LJ, Ferro AC, Moore J, Voong KR. Applying Non-Homogeneous Dose Optimization to Improve Conventionally Fractionated Radiation Plan Quality in Patients with Non-Small Cell Lung Cancer. Pract Radiat Oncol 2019; 9:e591-e598. [PMID: 31252089 DOI: 10.1016/j.prro.2019.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/03/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Nonhomogeneous dose optimization (NHDO) is exploited in stereotactic body radiation therapy (SBRT) to increase dose delivery to the tumor and allow rapid dose falloff to surrounding normal tissues. We investigate changes in plan quality when NHDO is applied to inverse-planned conventionally fractionated radiation therapy (CF-RT) plans in patients with non-small cell lung cancer. METHODS AND MATERIALS Patients with near-central non-small cell lung cancer treated with CF-RT in 2018 at a single institution were identified. CF-RT plans were replanned using NHDO techniques, including normalizing to a lower isodose line, while maintaining clinically acceptable normal tissue constraints and target coverage. Tumor control probabilities were calculated. We compared delivered CF-RT plans using homogenous dose optimization (HDO) versus NHDO using Wilcoxon signed-rank tests. Median values are reported. RESULTS Thirteen patients were replanned with NHDO techniques. Planning target volume coverage by the prescription dose was similar (NHDO = 96% vs HDO = 97%, P = .3). All normal-tissue dose constraints were met. NHDO plans were prescribed to a lower-prescription isodose line compared with HDO plans (85% vs 97%, P = .001). NHDO increased mean dose to the planning target volume (73 Gy vs 67 Gy), dose heterogeneity, and dose falloff gradient (P < .03). NHDO decreased mean dose to surrounding lungs, esophagus, and heart (relative reduction of 6%, 14%, and 15%, respectively; P < .05). Other normal tissue objectives improved with NHDO, including total lung V40 and V60, heart V30, and maximum esophageal dose (P < .05). Tumor control probabilities doubled from 31.6% to 65.4% with NHDO (P = .001). CONCLUSIONS In select patients, NHDO principles used in SBRT optimization can be applied to CF-RT. NHDO results in increased tumor dose, reduction in select organ-at-risk dose objectives, and better maintenance of target coverage and normal-tissue constraints compared with HDO. Our data demonstrate that principles of NHDO used in SBRT can also improve plan quality in CF-RT.
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Affiliation(s)
- Sarah Z Hazell
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Russell K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William T Hrinivich
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristy Ford
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ken Kang-Hsin Wang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd R McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peijin Han
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lori J Anderson
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam C Ferro
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph Moore
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Khinh Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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21
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Kjellsson Lindblom E, Ureba A, Dasu A, Wersäll P, Even AJG, van Elmpt W, Lambin P, Toma-Dasu I. Impact of SBRT fractionation in hypoxia dose painting - Accounting for heterogeneous and dynamic tumor oxygenation. Med Phys 2019; 46:2512-2521. [PMID: 30924937 DOI: 10.1002/mp.13514] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 02/18/2019] [Accepted: 03/13/2019] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Tumor hypoxia, often found in nonsmall cell lung cancer (NSCLC), implies an increased resistance to radiotherapy. Pretreatment assessment of tumor oxygenation is, therefore, warranted in these patients, as functional imaging of hypoxia could be used as a basis for dose painting. This study aimed at investigating the feasibility of using a method for calculating the dose required in hypoxic subvolumes segmented on 18 F-HX4 positron emission tomography (PET) imaging of NSCLC. METHODS Positron emission tomography imaging data based on the hypoxia tracer 18 F-HX4 of 19 NSCLC patients were included in the study. Normalized tracer uptake was converted to oxygen partial pressure (pO2 ) and hypoxic target volumes (HTVs) were segmented using a threshold of 10 mmHg. Uniform doses required to overcome the hypoxic resistance in the target volumes were calculated based on a previously proposed method taking into account the effect of interfraction reoxygenation, for fractionation schedules ranging from extremely hypofractionated stereotactic body radiotherapy (SBRT) to conventionally fractionated radiotherapy. RESULTS Gross target volumes ranged between 6.2 and 859.6 cm3 , and the hypoxic fraction < 10 mmHg between 1.2% and 72.4%. The calculated doses for overcoming the resistance of cells in the HTVs were comparable to those currently prescribed in clinical practice as well as those previously tested in feasibility studies on dose escalation in NSCLC. Depending on the size of the HTV and the distribution of pO2 , HTV doses were calculated as 43.6-48.4 Gy for a three-fraction schedule, 51.7-57.6 Gy for five fractions, and 59.5-66.4 Gy for eight fractions. For patients in whom the HTV pO2 distribution was more favorable, a lower dose was required despite a bigger volume. Tumor control probability was lower for single-fraction schedules, while higher levels of tumor control probability were found for schedules employing several fractions. CONCLUSIONS The method to account for heterogeneous and dynamic hypoxia in target volume segmentation and dose prescription based on 18 F-HX4-PET imaging appears feasible in NSCLC patients. The distribution of oxygen partial pressure within HTV could impact the required prescribed dose more than the size of the volume.
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Affiliation(s)
- Emely Kjellsson Lindblom
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, S-17176, Sweden
| | - Ana Ureba
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, S-17176, Sweden
| | | | - Peter Wersäll
- Department of Oncology, Karolinska University Hospital, Stockholm, S-17176, Sweden
| | - Aniek J G Even
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6229, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6229, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6229, The Netherlands
| | - Iuliana Toma-Dasu
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, S-17176, Sweden.,Medical Radiation Physics, Department of Oncology and Pathology, Karolinska Institutet, Stockholm, S-17176, Sweden
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22
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Voong KR, Hazell SZ, Fu W, Hu C, Lin CT, Ding K, Suresh K, Hayman J, Hales RK, Alfaifi S, Marrone KA, Levy B, Hann CL, Ettinger DS, Feliciano JL, Peterson V, Kelly RJ, Brahmer JR, Forde PM, Naidoo J. Relationship Between Prior Radiotherapy and Checkpoint-Inhibitor Pneumonitis in Patients With Advanced Non-Small-Cell Lung Cancer. Clin Lung Cancer 2019; 20:e470-e479. [PMID: 31031204 DOI: 10.1016/j.cllc.2019.02.018] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/04/2019] [Accepted: 02/21/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate the relationship between radiotherapy (RT), in particular chest RT, and development of immune-related (IR) pneumonitis in non-small-cell lung cancer (NSCLC) patients treated with anti-programmed cell death 1 (PD-1)/programmed death ligand 1 (PD-L1). PATIENTS AND METHODS Between June 2011 and July 2017, NSCLC patients treated with anti-PD-1/PD-L1 at a tertiary-care academic cancer center were identified. Patient, treatment, prior RT (intent, technique, timing, courses), and IR pneumonitis details were collected. Treating investigators diagnosed IR pneumonitis clinically. Diagnostic IR pneumonitis scans were overlaid with available chest RT plans to describe IR pneumonitis in relation to prior chest RT. We evaluated associations between patient, treatment, RT details, and development of IR pneumonitis by Fisher exact and Wilcoxon rank-sum tests. RESULTS Of the 188 NSCLC patients we identified, median follow-up was 6.78 (range, 0.30-79.3) months and median age 66 (range, 39-91) years; 54% (n = 102) were male; and 42% (n = 79) had stage I-III NSCLC at initial diagnosis. Patients received anti-PD-1/PD-L1 monotherapy (n = 127, 68%) or PD-1/PD-L1-based combinations (n = 61, 32%). In the entire cohort, 70% (132/188) received any RT, 53% (100/188) chest RT, and 37% (70/188) curative-intent chest RT. Any grade IR pneumonitis occurred in 19% (36/188; 95% confidence interval, 13.8-25.6). Of those who developed IR pneumonitis and received chest RT (n = 19), patients were more likely to have received curative-intent versus palliative-intent chest RT (17/19, 89%, vs. 2/19, 11%; P = .051). Predominant IR pneumonitis appearances were ground-glass opacities outside high-dose chest RT regions. CONCLUSION No RT parameter was significantly associated with IR pneumonitis. On subset analysis of patients who developed IR pneumonitis and who had received prior chest RT, IR pneumonitis was more common in patients who received curative-intent chest RT. Attention should be paid to NSCLC patients receiving curative-intent RT followed by anti-PD-1/PD-L1 agents.
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Affiliation(s)
- Khinh Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD.
| | - Sarah Z Hazell
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD
| | - Wei Fu
- Department of Oncology, Biostatistics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chen Hu
- Department of Oncology, Biostatistics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cheng Ting Lin
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD
| | - Karthik Suresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan Hayman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Russell K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD
| | - Salem Alfaifi
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, MD
| | - Kristen A Marrone
- Department of Oncology, Johns Hopkins University, Baltimore, MD; Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, MD
| | - Benjamin Levy
- Department of Oncology, Johns Hopkins University, Baltimore, MD
| | | | | | | | | | - Ronan J Kelly
- Department of Oncology, Johns Hopkins University, Baltimore, MD
| | - Julie R Brahmer
- Department of Oncology, Johns Hopkins University, Baltimore, MD; Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, MD
| | - Patrick M Forde
- Department of Oncology, Johns Hopkins University, Baltimore, MD; Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, MD
| | - Jarushka Naidoo
- Department of Oncology, Johns Hopkins University, Baltimore, MD; Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University, Baltimore, MD
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23
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Defraene G, La Fontaine M, van Kranen S, Reymen B, Belderbos J, Sonke JJ, De Ruysscher D. Radiation-Induced Lung Density Changes on CT Scan for NSCLC: No Impact of Dose-Escalation Level or Volume. Int J Radiat Oncol Biol Phys 2018; 102:642-650. [PMID: 30244882 DOI: 10.1016/j.ijrobp.2018.06.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/23/2018] [Accepted: 06/20/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Dose-escalation for patients with non-small cell lung cancer (NSCLC) in the positron emission tomography (PET)-boost trial (NCT01024829) exposes portions of normal lung tissue to high radiation doses. The relationship between lung parenchyma dose and density changes on computed tomography (CT) was analyzed. MATERIALS AND METHODS The CT scans of 59 patients with stage IB to III NSCLC, randomized between a boost to the whole primary tumor and an integrated boost to its 50% SUVmax (maximum standardized uptake value) volume. Patients were treated with concurrent or sequential chemoradiation or radiation only. Deformable registration mapped the 3-month follow-up CT to the planning CT. Hounsfield unit differences (ΔHU) were extracted to assess lung parenchyma density changes. Equivalent dose in 2 Gy fractions (EQD2)-ΔHU response was described sigmoidally, and regional response variation was studied by polar analysis. Prognostic factors of ΔHU were obtained through generalized linear modeling. RESULTS Saturation of ΔHU was observed above 60 Gy. No interaction was found between boost dose distribution (D1cc and V70Gy) and ΔHU at lower doses. ΔHU was lowest peripherally from the tumor and peaked posteriorly at 3 cm from the tumor border (3.1 HU/Gy). Right lung location was an independent risk factor for ΔHU (P = .02). CONCLUSIONS No apparent increase of lung density changes at 3-month follow-up was observed above 60 Gy EQD2 for patients with NSCLC treated with (concurrent or sequential chemo) radiation. The mild response observed peripherally in the lung parenchyma might be exploited in plan optimization routines minimizing lung damage.
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Affiliation(s)
- Gilles Defraene
- Department of Oncology, Experimental Radiation Oncology, KU Leuven-University of Leuven, Belgium.
| | - Matthew La Fontaine
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Simon van Kranen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Bart Reymen
- Maastricht University Medical Center, Maastricht, The Netherlands
| | - José Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dirk De Ruysscher
- Department of Oncology, Experimental Radiation Oncology, KU Leuven-University of Leuven, Belgium; Maastricht University Medical Center, Maastricht, The Netherlands; Department of Radiation Oncology (Maastro Clinic), GROW School for Developmental Biology and Oncology, Maastricht, The Netherlands
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24
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Raman S, Bissonnette JP, Warner A, Le L, Bratman S, Leighl N, Bezjak A, Palma D, Schellenberg D, Sun A. Rationale and Protocol for a Canadian Multicenter Phase II Randomized Trial Assessing Selective Metabolically Adaptive Radiation Dose Escalation in Locally Advanced Non-small-cell Lung Cancer (NCT02788461). Clin Lung Cancer 2018; 19:e699-e703. [PMID: 29903551 DOI: 10.1016/j.cllc.2018.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 02/06/2018] [Accepted: 05/01/2018] [Indexed: 12/25/2022]
Abstract
We explain the rationale for metabolically adaptive radiation dose escalation in stage III non-small-cell lung cancer and describe the design of a Canadian phase II randomized trial investigating this approach. In the trial, patients are randomized to either conventional chemoradiation treatment (60 Gy in 30 fractions) or metabolically adaptive chemoradiation, where fluorodeoxyglucose-avid tumor sub-volumes receive an integrated boost dose to a maximum of 85 Gy in 30 fractions. The trial sample size is 78 patients, and the target population is patients with newly diagnosed, inoperable stage III non-small-cell lung cancer treated with radical intent chemoradiation. The primary objective of the trial is to determine if dose escalation to metabolically active sub-volumes will reduce 2-year local-regional failure rate from 42.3% to 22.3%, when compared with standard treatment. The secondary objectives are to determine the effect of dose escalation on overall survival, progression-free survival, quality of life, and rate of grade 3 to 5 toxicities.
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Affiliation(s)
- Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jean-Pierre Bissonnette
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Lisa Le
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Scott Bratman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Natasha Leighl
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Andrea Bezjak
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - David Palma
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Devin Schellenberg
- Department of Radiation Oncology, BC Cancer Agency - Fraser Valley Centre, Surrey, BC, Canada
| | - Alexander Sun
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.
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25
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Yang J, Xu T, Gomez DR, Yuan X, Nguyen QN, Jeter M, Song Y, Hahn S, Liao Z. Polymorphisms in BMP2/BMP4, with estimates of mean lung dose, predict radiation pneumonitis among patients receiving definitive radiotherapy for non-small cell lung cancer. Oncotarget 2018; 8:43080-43090. [PMID: 28574846 PMCID: PMC5522129 DOI: 10.18632/oncotarget.17904] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/07/2017] [Indexed: 12/17/2022] Open
Abstract
Single nucleotide polymorphisms (SNPs) in TGFβ1 can predict the risk of radiation pneumonitis (RP) in patients with non-small cell lung cancer (NSCLC) after definitive radiotherapy. Here we investigated whether SNPs in TGFβ superfamily members BMP2 and BMP4 are associated with RP in such patients. In total, we retrospectively analyzed 663 patients given ≥ 60 Gy for NSCLC. We randomly assigned 323 patients to the training cohort and 340 patients to the validation cohort. Potentially functional and tagging SNPs of BMP2 (rs170986, rs1979855, rs1980499, rs235768, rs3178250) and BMP4 (rs17563, rs4898820, rs762642) were genotyped. The median of mean lung dose (MLD) was 17.9 Gy (range, 0.15–32.74 Gy). Higher MLD was strongly associated with increased risk of grade ≥ 2 RP (hazard ratio [HR]=2.191, 95% confidence interval [CI] = 1.680–2.856, P < 0.001) and grade ≥ 3 RP (HR = 4.253, 95% CI = 2.493–7.257, P < 0.001). In multivariate analyses, BMP2 rs235768 AT/TT was associated with higher risk of grade ≥ 2 RP (HR = 1.866, 95% CI = 1.221–2.820, P = 0.004 vs. AA) both in training cohort and validation cohort. Similar results were observed for BMP2 rs1980499. BMP2 rs3178250 CT/TT was associated with lower risk of grade ≥ 3 RP (HR = 0.406, 95% CI = 0.175–0.942, P = 0.036 vs. CC) in the pooled analysis. Adding the rs235768 and rs1980499 SNPs to a model comprising age, performance status, and MLD raised the Harrell's C for predicting grade ≥ 2 RP from 0.6117 to 0.6235 (P = 0.0105). SNPs in BMP2 can predict grade ≥ 2 or 3 RP after radiotherapy for NSCLC and improve the predictive power of MLD model. Validation is underway through an ongoing prospective trial.
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Affiliation(s)
- Ju Yang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,The Comprehensive Cancer Center of Drum Tower Hospital, Medical School of Nanjing University and Clinical Cancer Institute of Nanjing University, Nanjing, 210008, China
| | - Ting Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Daniel R Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Xianglin Yuan
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Melenda Jeter
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Yipeng Song
- Department of Radiation Oncology, Yuhuangding Hospital, Shandong, 264000, China
| | - Stephen Hahn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
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Nygård L, Vogelius IR, Fischer BM, Kjær A, Langer SW, Aznar MC, Persson GF, Bentzen SM. A Competing Risk Model of First Failure Site after Definitive Chemoradiation Therapy for Locally Advanced Non–Small Cell Lung Cancer. J Thorac Oncol 2018; 13:559-567. [DOI: 10.1016/j.jtho.2017.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/22/2017] [Accepted: 12/24/2017] [Indexed: 12/25/2022]
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Ureba A, Lindblom E, Dasu A, Uhrdin J, Even AJG, van Elmpt W, Lambin P, Wersäll P, Toma-Dasu I. Non-linear conversion of HX4 uptake for automatic segmentation of hypoxic volumes and dose prescription. Acta Oncol 2018; 57:485-490. [PMID: 29141489 DOI: 10.1080/0284186x.2017.1400177] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Tumour hypoxia is associated with increased radioresistance and poor response to radiotherapy. Pre-treatment assessment of tumour oxygenation could therefore give the possibility to tailor the treatment by calculating the required boost dose needed to overcome the increased radioresistance in hypoxic tumours. This study concerned the derivation of a non-linear conversion function between the uptake of the hypoxia-PET tracer 18F-HX4 and oxygen partial pressure (pO2). MATERIAL AND METHODS Building on previous experience with FMISO including experimental data on tracer uptake and pO2, tracer-specific model parameters were derived for converting the normalised HX4-uptake at the optimal imaging time point to pO2. The conversion function was implemented in a Python-based computational platform utilising the scripting and the registration modules of the treatment planning system RayStation. Subsequently, the conversion function was applied to determine the pO2 in eight non-small-cell lung cancer (NSCLC) patients imaged with HX4-PET before the start of radiotherapy. Automatic segmentation of hypoxic target volumes (HTVs) was then performed using thresholds around 10 mmHg. The HTVs were compared to sub-volumes segmented based on a tumour-to-blood ratio (TBR) of 1.4 using the aortic arch as the reference oxygenated region. The boost dose required to achieve 95% local control was then calculated based on the calibrated levels of hypoxia, assuming inter-fraction reoxygenation due to changes in acute hypoxia but no overall improvement of the oxygenation status. RESULTS Using the developed conversion tool, HTVs could be obtained using pO2 a threshold of 10 mmHg which were in agreement with the TBR segmentation. The dose levels required to the HTVs to achieve local control were feasible, being around 70-80 Gy in 24 fractions. CONCLUSIONS Non-linear conversion of tracer uptake to pO2 in NSCLC imaged with HX4-PET allows a quantitative determination of the dose-boost needed to achieve a high probability of local control.
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Affiliation(s)
- Ana Ureba
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
| | - Emely Lindblom
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
| | | | | | - Aniek J. G. Even
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter Wersäll
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Iuliana Toma-Dasu
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
- Medical Radiation Physics, Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
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The potential for increased tumor control probability in non-small cell lung cancer with a hypofractionated integrated boost to the gross tumor volume. Med Dosim 2018; 43:352-357. [PMID: 29289456 DOI: 10.1016/j.meddos.2017.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 11/08/2017] [Accepted: 11/21/2017] [Indexed: 12/25/2022]
Abstract
Treatment outcomes in locally advanced non-small cell lung cancer (NSCLC) to date have been poor, with normal tissue toxicity often limiting the dose that can be delivered to the tumor. Treatment intensification in NSCLC via targeted dose escalation with modern delivery techniques may offer the potential for a significant increase in tumor control probability (TCP) without a clinically significant increase in organ-at-risk (OAR) toxicity. In this planning study, 20 patients were re-planned with a volumetric modulated arc therapy (VMAT) and an inhomogeneous dose distribution with iteratively escalated doses to the gross tumor volume (iGTV) (composite GTV across multiple 4-dimensional computed tomography [4DCT] phases) in a series of 20 fraction regimes. For each plan OAR doses, target coverage and predicted TCPs were collected and compared with homogenous 3-dimensional (3D) and VMAT plans, as well as with each other. In 70% of patients, it was possible to escalate to 75 Gy in 20 fractions within OAR tolerances, opening the possibility of treating these patients to a biological effective dose (BED) of 103.1 Gy10. This planning study forms the basis of a clinical trial INTENSE (Inhomogeneous Targeted Dose Escalation in Non-Small CEll Lung Cancer), CTRIAL 15-47.
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Ruggieri R, Stavrev P, Naccarato S, Stavreva N, Alongi F, Nahum AE. Optimal dose and fraction number in SBRT of lung tumours: A radiobiological analysis. Phys Med 2017; 44:188-195. [DOI: 10.1016/j.ejmp.2016.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/02/2016] [Accepted: 12/14/2016] [Indexed: 12/25/2022] Open
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30
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De Ruysscher D, Lambrecht M, van Baardwijk A, Peeters S, Reymen B, Verhoeven K, Wanders R, Öllers M, van Elmpt W, van Loon J. Standard of care in high-dose radiotherapy for localized non-small cell lung cancer. Acta Oncol 2017; 56:1610-1613. [PMID: 28840754 DOI: 10.1080/0284186x.2017.1349337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
- Radiation Oncology, KU Leuven, Leuven, Belgium
| | - Maarten Lambrecht
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Angela van Baardwijk
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stéphanie Peeters
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bart Reymen
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karolien Verhoeven
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rinus Wanders
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michel Öllers
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Judith van Loon
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
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Pezzi TA, Tang C, Swanick CW, Fang P, Hess K, Xu T, Hahn SM, Chang JY, Liao Z, Gomez D. Patterns and correlates of treatment failure in relation to isodose distribution in non-small cell lung cancer: An analysis of 1522 patients in the modern era. Radiother Oncol 2017; 125:325-330. [PMID: 29054376 DOI: 10.1016/j.radonc.2017.09.018] [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: 01/17/2017] [Revised: 09/09/2017] [Accepted: 09/16/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE To examine the relationship between radiation dose and tumor control in limited stage non-small cell lung cancer (NSCLC). MATERIALS AND METHODS We searched a database of 1552 patients who received radiation therapy for non-metastatic NSCLC between 2000 and 2016. The primary endpoint was freedom from in-field failure. RESULTS Increasing BED correlated with decreasing estimated gross tumor volume-planning target volume expansion, and on multivariable analysis increasing BED was associated with an increased chance of field-edge failures (hazard ratio [HR] 1.032, 95% confidence interval [CI] 1.004-1.062, P = 0.027). Increasing BED also correlated with improved freedom from in-field failure on multivariable analysis (HR 0.978, 95% CI 0.964-0.993, P = 0.003), with the dose-response curve showing a sigmoidal relationship between increasing BED and freedom from in-field failure. CONCLUSION In this large study of patients treated in the modern era with varying dose fractionation regimens, higher BED was associated with improved freedom from in-field failure, and that this relationship appeared to be consistent with the classically described sigmoid shape. We also found that increased BED was associated with higher field-edge failures, implying that margin size may need to be further studied in patients receiving ablative regimens of radiation.
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Affiliation(s)
- Todd A Pezzi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Chad Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cameron W Swanick
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Penny Fang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kenneth Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ting Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Stephen M Hahn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Daniel Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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Vivekanandan S, Landau DB, Counsell N, Warren DR, Khwanda A, Rosen SD, Parsons E, Ngai Y, Farrelly L, Hughes L, Hawkins MA, Fenwick JD. The Impact of Cardiac Radiation Dosimetry on Survival After Radiation Therapy for Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 99:51-60. [PMID: 28816160 PMCID: PMC5554783 DOI: 10.1016/j.ijrobp.2017.04.026] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 04/07/2017] [Accepted: 04/19/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE The heart receives high radiation doses during radiation therapy of advanced-stage lung cancer. We have explored associations between overall survival, cardiac radiation doses, and electrocardiographic (ECG) changes in patients treated in IDEAL-CRT, a trial of isotoxically escalated concurrent chemoradiation delivering tumor doses of 63 to 73 Gy. METHODS AND MATERIALS Dosimetric and survival data were analyzed for 78 patients. The whole heart, pericardium, AV node, and walls of left and right atria (LA/RA-Wall) and ventricles (LV/RV-Wall) were outlined on radiation therapy planning scans, and differential dose-volume histograms (dDVHs) were calculated. For each structure, dDVHs were approximated using the average dDVH and the 10 highest-ranked structure-specific principal components (PCs). ECGs at baseline and 6 months after radiation therapy were analyzed for 53 patients, dichotomizing patients according to presence or absence of "any ECG change" (conduction or ischemic/pericarditis-like change). All-cause death rate (DR) was analyzed from the start of treatment using Cox regression. RESULTS 38% of patients had ECG changes at 6 months. On univariable analysis, higher scores for LA-Wall-PC6, Heart-PC6, "any ECG change," and larger planning target volume (PTV) were significantly associated with higher DR (P=.003, .009, .029, and .037, respectively). Heart-PC6 and LA-Wall-PC6 represent larger volumes of whole heart and left atrial wall receiving 63 to 69 Gy. Cardiac doses ≥63 Gy were concentrated in the LA-Wall, and consequently Heart-PC6 was highly correlated with LA-Wall-PC6. "Any ECG change," LA-Wall-PC6 scores, and PTV size were retained in the multivariable model. CONCLUSIONS We found associations between higher DR and conduction or ischemic/pericarditis-like changes on ECG at 6 months, and between higher DR and higher Heart-PC6 or LA-Wall-PC6 scores, which are closely related to heart or left atrial wall volumes receiving 63 to 69 Gy in this small cohort of patients.
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Affiliation(s)
- S Vivekanandan
- Department of Oncology and CRUK MRC, Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, UK
| | - D B Landau
- Department of Oncology, Guy's & St. Thomas' NHS Trust, King's College London, UK
| | - N Counsell
- Cancer Research UK & UCL Cancer Trials Centre Cancer Institute, University College London, London, UK
| | - D R Warren
- Department of Oncology and CRUK MRC, Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, UK
| | - A Khwanda
- Department of Cardiology, Ealing Hospital and Imperial College London, UK
| | - S D Rosen
- Department of Cardiology, Ealing and Royal Brompton Hospitals & Imperial College, London, UK
| | - E Parsons
- Radiotherapy Trials Quality Assurance, Mount Vernon Hospital, Middlesex, UK
| | - Y Ngai
- Cancer Research UK & UCL Cancer Trials Centre Cancer Institute, University College London, London, UK
| | - L Farrelly
- Cancer Research UK & UCL Cancer Trials Centre Cancer Institute, University College London, London, UK
| | - L Hughes
- Cancer Research UK & UCL Cancer Trials Centre Cancer Institute, University College London, London, UK
| | - M A Hawkins
- Department of Oncology and CRUK MRC, Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, 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, Wirral, UK
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Dose-escalated Hypofractionated Intensity-modulated Radiation Therapy With Concurrent Chemotherapy for Inoperable or Unresectable Non-Small Cell Lung Cancer. Am J Clin Oncol 2017; 40:294-299. [PMID: 25333733 DOI: 10.1097/coc.0000000000000140] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE The local control of inoperable non-small cell lung cancer (NSCLC) using standard radiotherapy (RT) doses is inadequate. Dose escalation is a potential strategy to improve the local control for patients with NSCLC; however, the optimal dose required for local control in this setting is unknown. METHODS AND MATERIALS Patients with unresectable or inoperable stage II/III NSCLC with ECOG≤1 received 48 Gy in 20 daily fractions using intensity-modulated radiotherapy, followed by 1 of 3 boost dose levels: 16.8 Gy/7 (cumulative 2 Gy equivalent dose [EQD2]≅76 Gy/38), 20.0 Gy/7 (EQD2≅84 Gy/42), and 22.7 Gy/7 (EQD2≅92 Gy/46). Two cycles of cisplatin/etoposide chemotherapy were given concurrent with RT. The maximum tolerated dose was defined as the dose at which ≥30% experienced dose-limiting toxicity (any NCIC Common Terminology for Adverse Events V3.0 grade 3 or higher acute toxicity). RESULTS Twelve patients completed treatment with a median follow-up of 22 months (range, 7 to 48). The median age was 72 (range, 54 to 80) and 50% of patients had adenocarcinoma. Five, 3, and 4 patients were treated on dose levels 1, 2, and 3, respectively. No dose-limiting toxicity was observed. One-year local progression-free survival and overall survival estimates were 81% and 58%, respectively. CONCLUSIONS Hypofractionated intensity-modulated radiotherapy was well tolerated and provided meaningful local control for patients with locally advanced inoperable NSCLC. The maximum tolerated dose of RT in this setting lies beyond an EQD2 of 92 Gy/46 and further dose escalation in this setting is warranted.
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Modeling tumor control probability for spatially inhomogeneous risk of failure based on clinical outcome data. Z Med Phys 2017; 27:285-299. [PMID: 28676371 DOI: 10.1016/j.zemedi.2017.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 06/08/2017] [Accepted: 06/09/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Objectives of this work are (1) to derive a general clinically relevant approach to model tumor control probability (TCP) for spatially variable risk of failure and (2) to demonstrate its applicability by estimating TCP for patients planned for photon and proton irradiation. METHODS AND MATERIALS The approach divides the target volume into sub-volumes according to retrospectively observed spatial failure patterns. The product of all sub-volume TCPi values reproduces the observed TCP for the total tumor. The derived formalism provides for each target sub-volume i the tumor control dose (D50,i) and slope (γ50,i) parameters at 50% TCPi. For a simultaneous integrated boost (SIB) prescription for 45 advanced head and neck cancer patients, TCP values for photon and proton irradiation were calculated and compared. The target volume was divided into gross tumor volume (GTV), surrounding clinical target volume (CTV), and elective CTV (CTVE). The risk of a local failure in each of these sub-volumes was taken from the literature. RESULTS Convenient expressions for D50,i and γ50,i were provided for the Poisson and the logistic model. Comparable TCP estimates were obtained for photon and proton plans of the 45 patients using the sub-volume model, despite notably higher dose levels (on average +4.9%) in the low-risk CTVE for photon irradiation. In contrast, assuming a homogeneous dose response in the entire target volume resulted in TCP estimates contradicting clinical experience (the highest failure rate in the low-risk CTVE) and differing substantially between photon and proton irradiation. CONCLUSIONS The presented method is of practical value for three reasons: It (a) is based on empirical clinical outcome data; (b) can be applied to non-uniform dose prescriptions as well as different tumor entities and dose-response models; and (c) is provided in a convenient compact form. The approach may be utilized to target spatial patterns of local failures observed in patient cohorts by prescribing different doses to different target regions. Its predictive power depends on the uncertainty of the employed established TCP parameters D50 and γ50 and to a smaller extent on that of the clinically observed pattern of failure risk.
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Jeong J, Oh JH, Sonke JJ, Belderbos J, Bradley JD, Fontanella AN, Rao SS, Deasy JO. Modeling the Cellular Response of Lung Cancer to Radiation Therapy for a Broad Range of Fractionation Schedules. Clin Cancer Res 2017; 23:5469-5479. [PMID: 28539466 DOI: 10.1158/1078-0432.ccr-16-3277] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/17/2017] [Accepted: 05/16/2017] [Indexed: 12/25/2022]
Abstract
Purpose: To demonstrate that a mathematical model can be used to quantitatively understand tumor cellular dynamics during a course of radiotherapy and to predict the likelihood of local control as a function of dose and treatment fractions.Experimental Design: We model outcomes for early-stage, localized non-small cell lung cancer (NSCLC), by fitting a mechanistic, cellular dynamics-based tumor control probability that assumes a constant local supply of oxygen and glucose. In addition to standard radiobiological effects such as repair of sub-lethal damage and the impact of hypoxia, we also accounted for proliferation as well as radiosensitivity variability within the cell cycle. We applied the model to 36 published and two unpublished early-stage patient cohorts, totaling 2,701 patients.Results: Precise likelihood best-fit values were derived for the radiobiological parameters: α [0.305 Gy-1; 95% confidence interval (CI), 0.120-0.365], the α/β ratio (2.80 Gy; 95% CI, 0.40-4.40), and the oxygen enhancement ratio (OER) value for intermediately hypoxic cells receiving glucose but not oxygen (1.70; 95% CI, 1.55-2.25). All fractionation groups are well fitted by a single dose-response curve with a high χ2 P value, indicating consistency with the fitted model. The analysis was further validated with an additional 23 patient cohorts (n = 1,628). The model indicates that hypofractionation regimens overcome hypoxia (and cell-cycle radiosensitivity variations) by the sheer impact of high doses per fraction, whereas lower dose-per-fraction regimens allow for reoxygenation and corresponding sensitization, but lose effectiveness for prolonged treatments due to proliferation.Conclusions: This proposed mechanistic tumor-response model can accurately predict overtreatment or undertreatment for various treatment regimens. Clin Cancer Res; 23(18); 5469-79. ©2017 AACR.
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Affiliation(s)
- Jeho Jeong
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Postbus, Amsterdam, the Netherlands
| | - Jose Belderbos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Postbus, Amsterdam, the Netherlands
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Andrew N Fontanella
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shyam S Rao
- Department of Radiation Oncology, University of California, Davis Comprehensive Cancer Center, Sacramento, California
| | - Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York.
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Radical hypo-fractionated radiotherapy with volumetric modulated arc therapy in lung cancer : A retrospective study of elderly patients with stage III disease. Strahlenther Onkol 2017; 193:385-391. [PMID: 28168322 DOI: 10.1007/s00066-017-1103-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 01/06/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study aimed to analyse the feasibility and acute toxicity of radical hypo-fractionated radiotherapy (RT) for elderly patients with non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS We conducted a retrospective evaluation of treatment with volumetric modulated arc therapy (VMAT) of elderly patients affected by stage III inoperable NSCLC. The dose prescription was 56 Gy in 20 fractions, 55 Gy in 22 fractions, or 50 Gy in 20 fractions. Target volume included only the primary lesion and the infiltrated lymph nodes. The primary end point was acute and late toxicity, while secondary end points were progression-free survival (PFS), and overall survival (OS). RESULTS In all, 41 patients were included in this analysis. The mean age of the patients was 78.6 years, and 22 patients had staged IIIA while 19 patients had stage IIIB disease. All but one patient had pathological nodal involvement; 15 patients received chemotherapy before RT. Acute grade 1-2 toxicity was recorded in 25 (61%) patients. Late toxicity was recorded in 13 (32%) patients. No cases of G3 or G4 toxicity were recorded. Complete response was obtained in two (5%) patients, 26 (63%) showed a partial response, and two (5%) experience disease progression. At a mean follow-up of 9.9 months (range, 1.1-25.4), 17 patients had died from disease progression, one died from other causes, and 23 were alive. Median OS was 13.7 ± 1.5 months (95% CI: 10.7-16.7), OS at 12 and 18 months was 51.3 ± 9.5% and 35.1 ± 10.1%, respectively. Median PFS was 13.7 ± 2.3 months (95% CI: 9.1-18.2), and PFS at 12 and 18 months was 50.1 ± 9.9% and 38.9 ± 10.4%, respectively. CONCLUSION Radical hypo-fractionated VMAT is a promising treatment for locally advanced NSCLC in the elderly. The use of hypo-fractionated radiotherapy for lung cancer in older patients can be considered a valuable approach, particularly for patients with poor performance status or refusing other treatment approaches.
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Ramroth J, Cutter DJ, Darby SC, Higgins GS, McGale P, Partridge M, Taylor CW. Dose and Fractionation in Radiation Therapy of Curative Intent for Non-Small Cell Lung Cancer: Meta-Analysis of Randomized Trials. Int J Radiat Oncol Biol Phys 2016; 96:736-747. [PMID: 27639294 PMCID: PMC5082441 DOI: 10.1016/j.ijrobp.2016.07.022] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/15/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE The optimum dose and fractionation in radiation therapy of curative intent for non-small cell lung cancer remains uncertain. We undertook a published data meta-analysis of randomized trials to examine whether radiation therapy regimens with higher time-corrected biologically equivalent doses resulted in longer survival, either when given alone or when given with chemotherapy. METHODS AND MATERIALS Eligible studies were randomized comparisons of 2 or more radiation therapy regimens, with other treatments identical. Median survival ratios were calculated for each comparison and pooled. RESULTS 3795 patients in 25 randomized comparisons of radiation therapy dose were studied. The median survival ratio, higher versus lower corrected dose, was 1.13 (95% confidence interval [CI] 1.04-1.22) when radiation therapy was given alone and 0.83 (95% CI 0.71-0.97) when it was given with concurrent chemotherapy (P for difference=.001). In comparisons of radiation therapy given alone, the survival benefit increased with increasing dose difference between randomized treatment arms (P for trend=.004). The benefit increased with increasing dose in the lower-dose arm (P for trend=.01) without reaching a level beyond which no further survival benefit was achieved. The survival benefit did not differ significantly between randomized comparisons where the higher-dose arm was hyperfractionated and those where it was not. There was heterogeneity in the median survival ratio by geographic region (P<.001), average age at randomization (P<.001), and year trial started (P for trend=.004), but not for proportion of patients with squamous cell carcinoma (P=.2). CONCLUSIONS In trials with concurrent chemotherapy, higher radiation therapy doses resulted in poorer survival, possibly caused, at least in part, by high levels of toxicity. Where radiation therapy was given without chemotherapy, progressively higher radiation therapy doses resulted in progressively longer survival, and no upper dose level was found above which there was no further benefit. These findings support the consideration of further radiation therapy dose escalation trials, making use of modern treatment methods to reduce toxicity.
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Affiliation(s)
- Johanna Ramroth
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - David J Cutter
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Sarah C Darby
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Geoff S Higgins
- Department of Oncology, University of Oxford, Oxford, Oxfordshire, UK
| | - Paul McGale
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Mike Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, Oxford, Oxfordshire, UK
| | - Carolyn W Taylor
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK.
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Huang BT, Lin Z, Lin PX, Lu JY, Chen CZ. Radiobiological modeling of two stereotactic body radiotherapy schedules in patients with stage I peripheral non-small cell lung cancer. Oncotarget 2016; 7:40746-40755. [PMID: 27203739 PMCID: PMC5130041 DOI: 10.18632/oncotarget.9442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 04/18/2016] [Indexed: 02/05/2023] Open
Abstract
This study aims to compare the radiobiological response of two stereotactic body radiotherapy (SBRT) schedules for patients with stage I peripheral non-small cell lung cancer (NSCLC) using radiobiological modeling methods. Volumetric modulated arc therapy (VMAT)-based SBRT plans were designed using two dose schedules of 1 × 34 Gy (34 Gy in 1 fraction) and 4 × 12 Gy (48 Gy in 4 fractions) for 19 patients diagnosed with primary stage I NSCLC. Dose to the gross target volume (GTV), planning target volume (PTV), lung and chest wall (CW) were converted to biologically equivalent dose in 2 Gy fraction (EQD2) for comparison. Five different radiobiological models were employed to predict the tumor control probability (TCP) value. Three additional models were utilized to estimate the normal tissue complication probability (NTCP) value for the lung and the modified equivalent uniform dose (mEUD) value to the CW. Our result indicates that the 1 × 34 Gy dose schedule provided a higher EQD2 dose to the tumor, lung and CW. Radiobiological modeling revealed that the TCP value for the tumor, NTCP value for the lung and mEUD value for the CW were 7.4% (in absolute value), 7.2% (in absolute value) and 71.8% (in relative value) higher on average, respectively, using the 1 × 34 Gy dose schedule.
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Affiliation(s)
- Bao-tian Huang
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou 515031, China
| | - Zhu Lin
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou 515031, China
| | - Pei-xian Lin
- Department of Nosocomial Infection Management, The Second Affiliated Hospital of Shantou University Medical College, Shantou 515041, China
| | - Jia-yang Lu
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou 515031, China
| | - Chuang-zhen Chen
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, Shantou 515031, China
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Deasy JO, Mayo CS, Orton CG. Treatment planning evaluation and optimization should be biologically and not dose/volume based. Med Phys 2016; 42:2753-6. [PMID: 26127027 DOI: 10.1118/1.4916670] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Joseph O Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York 10065 (Tel: 212-639-8413; E-mail: )
| | - Charles S Mayo
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota 55905 (Tel: 507-293-4577; E-mail: )
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Grassberger C, Dowdell S, Sharp G, Paganetti H. Motion mitigation for lung cancer patients treated with active scanning proton therapy. Med Phys 2016; 42:2462-9. [PMID: 25979039 DOI: 10.1118/1.4916662] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Motion interplay can affect the tumor dose in scanned proton beam therapy. This study assesses the ability of rescanning and gating to mitigate interplay effects during lung treatments. METHODS The treatments of five lung cancer patients [48 Gy(RBE)/4fx] with varying tumor size (21.1-82.3 cm(3)) and motion amplitude (2.9-30.6 mm) were simulated employing 4D Monte Carlo. The authors investigated two spot sizes (σ ∼ 12 and ∼ 3 mm), three rescanning techniques (layered, volumetric, breath-sampled volumetric) and respiratory gating with a 30% duty cycle. RESULTS For 4/5 patients, layered rescanning 6/2 times (for the small/large spot size) maintains equivalent uniform dose within the target >98% for a single fraction. Breath sampling the timing of rescanning is ∼ 2 times more effective than the same number of continuous rescans. Volumetric rescanning is sensitive to synchronization effects, which was observed in 3/5 patients, though not for layered rescanning. For the large spot size, rescanning compared favorably with gating in terms of time requirements, i.e., 2x-rescanning is on average a factor ∼ 2.6 faster than gating for this scenario. For the small spot size however, 6x-rescanning takes on average 65% longer compared to gating. Rescanning has no effect on normal lung V20 and mean lung dose (MLD), though it reduces the maximum lung dose by on average 6.9 ± 2.4/16.7 ± 12.2 Gy(RBE) for the large and small spot sizes, respectively. Gating leads to a similar reduction in maximum dose and additionally reduces V20 and MLD. Breath-sampled rescanning is most successful in reducing the maximum dose to the normal lung. CONCLUSIONS Both rescanning (2-6 times, depending on the beam size) as well as gating was able to mitigate interplay effects in the target for 4/5 patients studied. Layered rescanning is superior to volumetric rescanning, as the latter suffers from synchronization effects in 3/5 patients studied. Gating minimizes the irradiated volume of normal lung more efficiently, while breath-sampled rescanning is superior in reducing maximum doses to organs at risk.
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Affiliation(s)
- Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114 and Center for Proton Radiotherapy, Paul Scherrer Institute, Villigen-PSI 5232, Switzerland
| | - Stephen Dowdell
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
| | - Greg Sharp
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114
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Doyen J, Falk AT, Floquet V, Hérault J, Hannoun-Lévi JM. Proton beams in cancer treatments: Clinical outcomes and dosimetric comparisons with photon therapy. Cancer Treat Rev 2016; 43:104-12. [PMID: 26827698 DOI: 10.1016/j.ctrv.2015.12.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 12/24/2015] [Accepted: 12/29/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE To review current evidence of the role of proton therapy (PT) in other tumors than skull base, sinusal/parasinusal, spinal and pediatric tumors; to determine medico-economic aspects raised by PT. MATERIAL AND METHODS A systematic review on Medline was performed with the following keywords: proton therapy, proton beam, protontherapy, cancer; publications with comparison between PT and photon-therapy were also selected. RESULTS In silico studies have shown superiority (better dose delivery to the target and/or to organs at risk) of PT toward photon-therapy in most of thoracic and abdominal malignant tumors. Potential benefits of PT could be: reduction of toxicities (including radiation-induced cancer), increase of tumor control through a dose-escalation approach, hypofractionation. Cost of treatment is always cited as an issue which actually can be managed by a precise patient selection making PT a cost-effective procedure. Comparison plan with photon therapy may be useful to determine the dosimetric and clinical advantages of PT (Normal Tissue Complications Probability). CONCLUSION PT may be associated with a great advantage compared to the best photon-therapies in various types of cancers. Accumulation of clinical data is on-going and will challenge the in silico data analysis. Some indications are associated with strong superiority of PT and may be discussed as a new standard within prospective observational studies.
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Affiliation(s)
- Jérôme Doyen
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Alexander Tuan Falk
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Vincent Floquet
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Joël Hérault
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France
| | - Jean-Michel Hannoun-Lévi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, Nice, France.
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Huang BT, Lu JY, Lin PX, Chen JZ, Li DR, Chen CZ. Radiobiological modeling analysis of the optimal fraction scheme in patients with peripheral non-small cell lung cancer undergoing stereotactic body radiotherapy. Sci Rep 2015; 5:18010. [PMID: 26657569 PMCID: PMC4676016 DOI: 10.1038/srep18010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/10/2015] [Indexed: 02/07/2023] Open
Abstract
This study aimed to determine the optimal fraction scheme (FS) in patients with small peripheral non-small cell lung cancer (NSCLC) undergoing stereotactic body radiotherapy (SBRT) with the 4 × 12 Gy scheme as the reference. CT simulation data for sixteen patients diagnosed with primary NSCLC or metastatic tumor with a single peripheral lesion ≤3 cm were used in this study. Volumetric modulated arc therapy (VMAT) plans were designed based on ten different FS of 1 × 25 Gy, 1 × 30 Gy, 1 × 34 Gy, 3 × 15 Gy, 3 × 18 Gy, 3 × 20 Gy, 4 × 12 Gy, 5 × 12 Gy, 6 × 10 Gy and 10 × 7 Gy. Five different radiobiological models were employed to predict the tumor control probability (TCP) value. Three other models were utilized to estimate the normal tissue complication probability (NTCP) value to the lung and the modified equivalent uniform dose (mEUD) value to the chest wall (CW). The 1 × 30 Gy regimen is recommended to achieve 4.2% higher TCP and slightly higher NTCP and mEUD values to the lung and CW compared with the 4 × 12 Gy schedule, respectively. This regimen also greatly shortens the treatment duration. However, the 3 × 15 Gy schedule is suggested in patients where the lung-to-tumor volume ratio is small or where the tumor is adjacent to the CW.
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Affiliation(s)
- Bao-Tian Huang
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, 7 Raoping Road, Shantou 515031, China
| | - Jia-Yang Lu
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, 7 Raoping Road, Shantou 515031, China
| | - Pei-Xian Lin
- Department of Nosocomial Infection Management, The Second Affiliated Hospital of Shantou University Medical College, 69 North Dongsha Road, Shantou 515041, China
| | - Jian-Zhou Chen
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, 7 Raoping Road, Shantou 515031, China
| | - De-Rui Li
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, 7 Raoping Road, Shantou 515031, China
| | - Chuang-Zhen Chen
- Department of Radiation Oncology, Cancer Hospital of Shantou University Medical College, 7 Raoping Road, Shantou 515031, China
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A forward planned treatment planning technique for non-small-cell lung cancer stereotactic ablative body radiotherapy based on a systematic review of literature. JOURNAL OF RADIOTHERAPY IN PRACTICE 2015. [DOI: 10.1017/s1460396915000333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurpose and MethodA systematic literature review of six computerised databases was undertaken in order to review and summarise a forward planned lung stereotactic ablative body radiotherapy (SABR) treatment planning (TP) technique as a starting point for clinical implementation in the author’s department based on current empirical research. The data were abstracted and content analysed to synthesise the findings based upon a SIGN quality checklist tool.FindingsA four-dimensional computed tomography scan should be performed upon which the internal target volume and organs at risk (OAR) are drawn. A set-up margin of 5 mm is applied to account for inter-fraction motion. The field arrangement consists of a combination of 7–13 coplanar and non-coplanar beams all evenly spaced. Beam modifiers are used to assist in the homogeneity of the beam, although a 20% planning target volume dose homogeneity is acceptable. The recommended fractionations by the UK SABR Consortium are 54 Gy in 3 fractions (standard), 55–60 Gy in 5 fractions (conservative) and 50–60 Gy in 8–10 fractions (very conservative). Conformity indices for both the target volume and OAR will be used to assess the planned distribution.ConclusionAn overview of a clinically acceptable forward planned lung SABR TP technique based on current literature as a starting point, with a view to inverse planning with support from the UK SABR Consortium mentoring scheme.
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Inclusion of functional information from perfusion SPECT improves predictive value of dose–volume parameters in lung toxicity outcome after radiotherapy for non-small cell lung cancer: A prospective study. Radiother Oncol 2015; 117:9-16. [DOI: 10.1016/j.radonc.2015.08.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/27/2015] [Accepted: 08/02/2015] [Indexed: 12/25/2022]
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45
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Zhao L, Mi D, Hu B, Sun Y. A generalized target theory and its applications. Sci Rep 2015; 5:14568. [PMID: 26411887 PMCID: PMC4585963 DOI: 10.1038/srep14568] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 09/03/2015] [Indexed: 12/25/2022] Open
Abstract
Different radiobiological models have been proposed to estimate the cell-killing effects, which are very important in radiotherapy and radiation risk assessment. However, most applied models have their own scopes of application. In this work, by generalizing the relationship between "hit" and "survival" in traditional target theory with Yager negation operator in Fuzzy mathematics, we propose a generalized target model of radiation-induced cell inactivation that takes into account both cellular repair effects and indirect effects of radiation. The simulation results of the model and the rethinking of "the number of targets in a cell" and "the number of hits per target" suggest that it is only necessary to investigate the generalized single-hit single-target (GSHST) in the present theoretical frame. Analysis shows that the GSHST model can be reduced to the linear quadratic model and multitarget model in the low-dose and high-dose regions, respectively. The fitting results show that the GSHST model agrees well with the usual experimental observations. In addition, the present model can be used to effectively predict cellular repair capacity, radiosensitivity, target size, especially the biologically effective dose for the treatment planning in clinical applications.
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Affiliation(s)
- Lei Zhao
- College of Environmental Science and Engineering, Dalian Maritime University, Dalian, Liaoning, P.R. China
- Institute of Environmental Systems Biology, Dalian Maritime University, Dalian, Liaoning, P.R. China
| | - Dong Mi
- Department of Physics, Dalian Maritime University, Dalian, Liaoning, P.R. China
| | - Bei Hu
- College of Environmental Science and Engineering, Dalian Maritime University, Dalian, Liaoning, P.R. China
- Institute of Environmental Systems Biology, Dalian Maritime University, Dalian, Liaoning, P.R. China
| | - Yeqing Sun
- College of Environmental Science and Engineering, Dalian Maritime University, Dalian, Liaoning, P.R. China
- Institute of Environmental Systems Biology, Dalian Maritime University, Dalian, Liaoning, P.R. China
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46
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Lindblom E, Dasu A, Toma-Dasu I. Optimal fractionation in radiotherapy for non-small cell lung cancer--a modelling approach. Acta Oncol 2015. [PMID: 26217986 DOI: 10.3109/0284186x.2015.1061207] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Conventionally fractionated radiotherapy (CFRT) has proven ineffective in treating non-small cell lung cancer while more promising results have been obtained with stereotactic body radiotherapy (SBRT). Hypoxic tumours, however, might present a challenge to extremely hypofractionated schedules due to the decreased possibility for inter-fraction fast reoxygenation. A potentially successful compromise might be found in schedules employing several fractions of varying fractional doses. In this modelling study, a wide range of fractionation schedules from single-fraction treatments to heterogeneous, multifraction schedules taking into account repair, repopulation, reoxygenation and radiosensitivity of the tumour cells, has been explored with respect to the probability of controlling lung tumours. MATERIAL AND METHODS The response to radiation of tumours with heterogeneous spatial and temporal oxygenation was simulated including the effects of accelerated repopulation and intra-fraction repair. Various treatments with respect to time, dose and fractionation were considered and the outcome was estimated as Poisson-based tumour control probability for local control. RESULTS For well oxygenated tumours, heterogeneous fractionation could increase local control while hypoxic tumours are not efficiently targeted by such treatments despite reoxygenation. For hypofractionated treatments employing large doses per fraction, a synergistic effect was observed between intra-fraction repair and inter-fraction fast reoxygenation of the hypoxic cells as demonstrated by a reduction in D50 from 53.3 Gy for 2 fractions to 52.7 Gy for 5 fractions. CONCLUSIONS For well oxygenated tumours, heterogeneous fractionation schedules could increase local control rates substantially compared to CFRT. For hypoxic tumours, SBRT-like hypofractionated schedules might be optimal despite the increased risk of intra-fraction repair due to a synergistic effect with inter-fraction reoxygenation.
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Affiliation(s)
- Emely Lindblom
- a Medical Radiation Physics, Department of Physics , Stockholm University , Stockholm , Sweden
| | - Alexandru Dasu
- b Department of Radiation Physics and Department of Medical and Health Sciences , Linköping University , Linköping , Sweden
| | - Iuliana Toma-Dasu
- a Medical Radiation Physics, Department of Physics , Stockholm University , Stockholm , Sweden
- c Medical Radiation Physics, Department of Oncology and Pathology , Karolinska Institutet , Stockholm , Sweden
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Tvilum M, Khalil AA, Møller DS, Hoffmann L, Knap MM. Clinical outcome of image-guided adaptive radiotherapy in the treatment of lung cancer patients. Acta Oncol 2015. [PMID: 26206515 DOI: 10.3109/0284186x.2015.1062544] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Adaptive strategy with daily online tumour match is a treatment option when treating locally advanced lung cancer patients with curative intended radiotherapy (RT). MATERIAL AND METHODS Fifty-two consecutive lung cancer patients treated with soft tissue match, adaptive RT and small planning target volumes (PTV) margins were analysed. A control group of 52 consecutive patients treated with bone match, no adaptive strategy and larger margins was included. Patients were followed with computed tomography (CT) scans every third month. CT-images showing loco-regional recurrences were identified. The recurrence gross tumour volume was delineated and registered with the original radiation treatment plan to identify site of failure. All patients were toxicity-scored using CTCAE 4.03 grading scale. Data were analysed using the Kaplan-Meier analysis. RESULTS The median follow-up time was 16 months (3-35). Within a year, 35% of the patients in the adaptive group (ART-group) and 53% in the control group (No-ART-group) experienced loco-regional failure, showing improved loco-regional control in the ART group (p = 0.05). One patient in the ART-group and four patients in the No-ART-group showed marginal failure. Median overall progression-free survival time for the ART-group was 10 months (95% CI 8-12), and 8 months (95% CI 6-9) for the No-ART-group. Severe pneumonitis (grade 3-5) decreased from 22% in the No-ART-group to 18% in the ART-group (non-significant, p = 0.6). No significant difference in severe dysphagia was found between the two groups. CONCLUSION In the first small cohort of patients investigated, implementation of soft-tissue tumour match and adaptive strategies for locally advanced lung cancer patients increased the loco-regional control rate without increasing treatment-related toxicity.
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Affiliation(s)
- Marie Tvilum
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Azza A Khalil
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Ditte S Møller
- b Department of Medical Physics , Aarhus University Hospital , Aarhus , Denmark
| | - Lone Hoffmann
- b Department of Medical Physics , Aarhus University Hospital , Aarhus , Denmark
| | - Marianne M Knap
- a Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
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Doyen J, Bondiau PY, Bénézéry K, Chand MÈ, Thariat J, Leysalle A, Gérard JP, Habrand JL, Hannoun-Lévi JM. [Current situation and perspectives of proton therapy]. Cancer Radiother 2015; 19:211-9; quiz 231-2, 235. [PMID: 25840776 DOI: 10.1016/j.canrad.2014.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/26/2014] [Indexed: 12/25/2022]
Abstract
Proton beam therapy is indicated as a treatment for some rare tumours and paediatric tumours because the technique allows a good local control with minimal toxicity; the growing number of centres that use proton beam therapy is associated with an increase of dosimetric and clinical data for other malignant tumours as well. This paper reviews potential indications of proton beam therapy. A systematic review on Medline was performed with the following keywords proton beam therapy, cancer, heavy particle, charged particle. No phase III trial has been published using proton beam therapy in comparison with the best photon therapy, but numerous retrospective and dosimetric studies have revealed an advantage of proton beam therapy compared to photons, above all in tumours next to parallel organs at risk (thoracic and abdominal tumours). This could be accompanied with a better safety profile and/or a better tumoural control; numerous phase 0, I, II, III and IV studies are ongoing to examine these hypotheses in more common cancers. Use of proton beam therapy is growing for common cancers within clinical trials but some indications could be applied sooner since in silico analysis showed major advantages with this technique.
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Affiliation(s)
- J Doyen
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - P-Y Bondiau
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - K Bénézéry
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - M-È Chand
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - J Thariat
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - A Leysalle
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - J-P Gérard
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France
| | - J-L Habrand
- Département de radiothérapie, centre François-Baclesse, 3, avenue du Général-Harris, 14076 Caen cedex 05, France
| | - J-M Hannoun-Lévi
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06000 Nice, France.
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Niezink AG, Dollekamp NJ, Elzinga HJ, Borger D, Boer EJ, Ubbels JF, Woltman-van Iersel M, van der Leest AH, Beijert M, Groen HJ, Kraan J, Hiltermann TJ, van der Wekken AJ, van Putten JW, Rutgers SR, Pieterman RM, de Hosson SM, Roenhorst AW, Langendijk JA, Widder J. An instrument dedicated for modelling of pulmonary radiotherapy. Radiother Oncol 2015; 115:3-8. [DOI: 10.1016/j.radonc.2015.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 03/06/2015] [Accepted: 03/15/2015] [Indexed: 12/25/2022]
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50
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Roesch J, Andratschke N, Guckenberger M. SBRT in operable early stage lung cancer patients. Transl Lung Cancer Res 2015; 3:212-24. [PMID: 25806303 DOI: 10.3978/j.issn.2218-6751.2014.08.06] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 08/12/2014] [Indexed: 12/25/2022]
Abstract
Since decades the gold standard for treatment of early stage non-small cell lung cancer (NSCLC) is surgical lobectomy plus mediastinal lymph node dissection. Patients in worse health status are treated with sublobar resection or radiation treatment. With development of stereotactic-body-radiotherapy (SBRT), outcome of patients treated with radiation was substantially improved. Comparison of SBRT and surgical techniques is difficult due to the lack of randomized trials. However, all available evidence in form of case control studies of population based studies show equivalence between sublobar resection and SBRT indicating that SBRT-when performed by a trained and experienced team-should be offered to all high-risk surgical patients. For patients not willing to take the risk of lobectomy and therefore refusing surgery, SBRT is an excellent treatment option.
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Affiliation(s)
- Johannes Roesch
- Department of Radiation Oncology, University Hospital Zurich, Zürich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zürich, Switzerland
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