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Claude L, Schiffler C, Isnardi V, Metzger S, Darnis S, Martel-Lafay I, Baudier T, Rit S, Sarrut D, Ayadi M. "Mid-P strategy" versus "internal target volume strategy in locally advanced non small cell lung cancer: Clinical results from the randomized non-comparative phase II study Mid-P. Radiother Oncol 2024; 199:110435. [PMID: 39004227 DOI: 10.1016/j.radonc.2024.110435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 06/03/2024] [Accepted: 07/10/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Locally advanced non-small cell lung cancer (LA-NSCLC) reported poor 5-year survival rates with frequent local or regional recurrences. Personalized RT may contribute to improve control and clinical outcome. We investigated efficacy and tolerance of "Mid-position" (Mid-P) strategy versus the conventional Internal Target Volume (ITV) strategy in LA-NSCLC patients treated by definitive conformal radiotherapy. METHODS This prospective non-comparative randomized monocentric phase II trial included adult patients with non-resected, non-metastatic, non-previously irradiated proven LA-NSCLC treated with definitive normo-fractionated conformal radiotherapy (+/- chemotherapy). Allocated patients (randomisation 2:1) were treated using Mid-P or ITV strategy. A Fleming single-stage design (1-sided α = 0.1, 80 % power, P0 = 30 %, P1 = 50 %) planned enrolment of 36 patients in the Mid-P group. The ITV group ensured the absence of selection bias. The primary outcome was 1-year progression-free- survival (1y-PFS) rate. RESULTS Among 54 eligible patients included from September 2012 to May 2018, 51 patients were analyzed (Mid-P: N = 34; ITV: 17). The 1y-PFS was 38 % (1-sided 95 %CI 25 %-not reached) with Mid-P strategy, and 47 % (95 %CI [27 %-not reached[) with ITV. Loco-regional failure as first event mainly occurred within radiation-field regardless the strategy. Acute and middle-term radiation toxicities were observed with both strategies. CONCLUSION Local control and survival remain poor using the Mid-P strategy in this prospective randomized non-comparative monocentric study investigating Mid-P strategy versus ITV strategy in LA-NSCLC. Since the Mid-P strategy is not integrated into routine software, and perceived as a time-consuming method, Mid-P strategy cannot be recommended in LA-NSCLCC treated by definitive normo-fractionated conformal radiotherapy outside clinical trials.
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Affiliation(s)
- Line Claude
- Radiotherapy Oncology Department, Léon Bérard Cancer Center, Lyon, France.
| | - Camille Schiffler
- Clinical Research and Innovation Department, Léon Bérard Cancer Center, Lyon, France
| | - Vanina Isnardi
- Nuclear Medicine Department, Léon Bérard Cancer Center, Lyon, France
| | - Séverine Metzger
- Clinical Research and Innovation Department, Léon Bérard Cancer Center, Lyon, France
| | - Sophie Darnis
- Clinical Research and Innovation Department, Léon Bérard Cancer Center, Lyon, France
| | | | - Thomas Baudier
- INSA-Lyon, Université Lyon 1; Centre Léon Bérard; CREATIS CNRS UMR 5220, Inserm U1206, F-69373, Lyon, France
| | - Simon Rit
- INSA-Lyon, Université Lyon 1; Centre Léon Bérard; CREATIS CNRS UMR 5220, Inserm U1206, F-69373, Lyon, France
| | - David Sarrut
- INSA-Lyon, Université Lyon 1; Centre Léon Bérard; CREATIS CNRS UMR 5220, Inserm U1206, F-69373, Lyon, France
| | - Myriam Ayadi
- Radiotherapy Oncology Department, Léon Bérard Cancer Center, Lyon, France
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Roumeliotis M, Thind K, Morrison H, Burke B, Martell K, van Dyke L, Barbera L, Quirk S. The impact of advancing the standard of care in radiotherapy on operational treatment resources. J Appl Clin Med Phys 2024; 25:e14363. [PMID: 38634814 PMCID: PMC11244663 DOI: 10.1002/acm2.14363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/05/2024] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
PURPOSE To demonstrate the impact of implementing hypofractionated prescription regimens and advanced treatment techniques on institutional operational hours and radiotherapy personnel resources in a multi-institutional setting. The study may be used to describe the impact of advancing the standard of care with modern radiotherapy techniques on patient and staff resources. METHODS This study uses radiation therapy data extracted from the radiotherapy information system from two tertiary care, university-affiliated cancer centers from 2012 to 2021. Across all patients in the analysis, the average fraction number for curative and palliative patients was reported each year in the decade. Also, the institutional operational treatment hours are reported for both centers. A sub-analysis for curative intent breast and lung radiotherapy patients was performed to contextualize the impact of changes to imaging, motion management, and treatment technique. RESULTS From 2012 to 2021, Center 1 had 42 214 patient plans and Center 2 had 43 252 patient plans included in the analysis. Averaged over both centers across the decade, the average fraction number per patient decreased from 6.9 to 5.2 (25%) and 21.8 to 17.2 (21%) for palliative and curative patients, respectively. The operational treatment hours for both institutions increased from 8 h 15 min to 9 h 45 min (18%), despite a patient population increase of 45%. CONCLUSION The clinical implementation of hypofractionated treatment regimens has successfully reduced the radiotherapy workload and operational treatment hours required to treat patients. This analysis describes the impact of changes to the standard of care on institutional resources.
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Affiliation(s)
- Michael Roumeliotis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kundan Thind
- Henry Ford Cancer Institute, Detroit, Michigan, USA
| | - Hali Morrison
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Ben Burke
- University of Alberta, Edmonton, Alberta, Canada
| | - Kevin Martell
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | | | - Lisa Barbera
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Sarah Quirk
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, and Harvard Medical School, Boston, Massachusetts, USA
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Le Roy T, Wallet J, Barthoulot M, Leguillette C, Lacornerie T, Pasquier D, Lartigau E, Le Tinier F. IMRT in the treatment of locally advanced or inoperable NSCLC in the pre-durvalumab era: clinical outcomes and pattern of relapses, experience from the Oscar Lambret Center. Front Oncol 2023; 13:1236361. [PMID: 37810972 PMCID: PMC10554937 DOI: 10.3389/fonc.2023.1236361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Background Intensity-modulated conformal radiotherapy (IMRT) has become the technique of choice for the treatment of locally advanced or inoperable non-small cell lung cancer (NSCLC). Nevertheless, this technique presents dosimetric uncertainties, particularly in treating moving targets such as pulmonary neoplasms. Moreover, it theoretically increases the risk of isolated nodal failure (INF) due to reduced incidental irradiation. Objective The objective of this study was to evaluate the efficacy and safety of IMRT in patients with inoperable NSCLC and to describe the pattern of relapses. Methods Patients with locally advanced NSCLC treated with radiotherapy and chemotherapy between 2015 and 2018 at the Oscar Lambret Center were retrospectively included in the study. Overall and progression-free survival were estimated using the Kaplan-Meier method. The cumulative incidence of the different components of relapse was estimated using the Kalbfleisch and Prentice method. Prognostic factors for relapse/death were investigated using the Cox model. A comparison with literature data was performed using a one-sample log-rank test. Results Seventy patients were included, and 65 patients (93%) had stage III disease. All the patients received chemotherapy, most frequently with cisplatin and navelbine. The dose received was 66 Gy administered in 33 fractions. The median follow-up and survival were 49.1 and 39.1 months, respectively. A total of 35 deaths and 43 relapses, including 29 with metastatic components, were reported. The overall survival rates at 1 and 2 years were 80.2% (95% confidence interval 68.3%-88.0%) and 67.2% (95% confidence interval 54.2%-77.3%), respectively. Locoregional relapse was observed in 14 patients, including two INF, one of which was located in the lymph node area adjacent to the clinical target volume. Median relapse-free survival was 15.2 months. No variable was statistically associated with the risk of relapse/death in multivariate analysis. Seven patients (10%) experienced grade 3 or higher toxicity. Conclusion The use of IMRT for locally advanced or inoperable NSCLC led to favorable long-term clinical outcomes. The rate of locoregional relapse, particularly isolated lymph node failure, was low and comparable with that of the three-dimensional radiotherapy series, as was the rate of early and late toxicities.
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Affiliation(s)
- Thomas Le Roy
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
| | - Jennifer Wallet
- Department of Biostatistics, Centre Oscar Lambret, Lille, France
| | - Maël Barthoulot
- Department of Biostatistics, Centre Oscar Lambret, Lille, France
| | | | | | - David Pasquier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
- CRIStAL UMR CNRS 9189, Lille University, Lille, France
| | - Eric Lartigau
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
- CRIStAL UMR CNRS 9189, Lille University, Lille, France
| | - Florence Le Tinier
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
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Liu W, Qiao X, Ge H, Zhang S, Sun X, Li J, Chen W, Gu W, Yuan S. Recurrence patterns are significantly associated with the 18F‑FDG PET/CT radiomic features of patients with locally advanced non‑small cell lung cancer treated with chemoradiotherapy. Oncol Lett 2023; 26:317. [PMID: 37332327 PMCID: PMC10272971 DOI: 10.3892/ol.2023.13903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/22/2023] [Indexed: 06/20/2023] Open
Abstract
A model for predicting the recurrence pattern of patients with locally advanced non-small cell lung cancer (LA-NSCLC) treated with chemoradiotherapy is of great importance for precision treatment. The present study analyzed whether the comprehensive quantitative values (CVs) of the fluorine-18(18F)-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) radiomic features and metastasis tumor volume (MTV) combined with clinical characteristics could predict the recurrence pattern of patients with LA-NSCLC treated with chemoradiotherapy. Patients with LA-NSCLC treated with chemoradiotherapy were divided into training and validation sets. The recurrence profile of each patient, including locoregional recurrence (LR), distant metastasis (DM) and both LR/DM were recorded. In the training set of patients, the primary tumor prior radiotherapy with 18F-FDG PET/CT and both primary tumors and lymph node metastasis were considered as the regions of interest (ROIs). The CVs of ROIs were calculated using principal component analysis. Additionally, MTVs were obtained from ROIs. The CVs, MTVs and the clinical characteristics of patients were subjected to aforementioned analysis. Furthermore, for the validation set of patients, the CVs and clinical characteristics of patients with LA-NSCLC were also subjected to logistic regression analysis and the area under the curve (AUC) values calculated. A total of 86 patients with LA-NSCLC were included in the analysis, including 59 and 27 patients in the training and validation sets of patients, respectively. The analysis revealed 22 and 12 cases with LR, 24 and 6 cases with DM and 13 and 9 cases with LR/DM in the training and validation sets of patients, respectively. Histological subtype, CV2-5 and CV3-4 were identified as independent variables in the logistic regression analysis (P<0.05). In addition, the AUC values for diagnosing LR, DM and LR/DM were 0.873, 0.711 and 0.826, and 0.675, 0.772 and 0.708 in the training and validation sets of patients, respectively. Overall, the results demonstrated that the spatial and metabolic heterogeneity quantitative values from the primary tumor combined with the histological subtype could predict the recurrence pattern of patients with LA-NSCLC treated with chemoradiotherapy.
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Affiliation(s)
- Wenju Liu
- Department of Radiation Oncology, Shandong University Cancer Center, Jinan, Shandong 250117, P.R. China
- Department of Radiation Oncology, Liaocheng People's Hospital, Liaocheng, Shandong 252000, P.R. China
| | - Xu Qiao
- School of Control Science and Engineering, Shandong University, Jinan, Shandong 250117, P.R. China
| | - Hong Ge
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University (Henan Cancer Hospital), Zhengzhou, Henan 450000, P.R. China
| | - Sheng Zhang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Xiaojiang Sun
- Department of Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, P.R. China
| | - Jiancheng Li
- Department of Radiation Oncology, Fujian Cancer Hospital, College of Clinical Medicine for Oncology, Fujian Medical University, Fuzhou, Fujian 350000, P.R. China
| | - Weilin Chen
- Department of Radiation Oncology, Zhangzhou Hospital Affiliated to Fujian Medical University, Zhangzhou, Fujian 363000, P.R. China
| | - Wendong Gu
- Department of Radiation Oncology, The Third Hospital Afiliated to Suzhou University, Changzhou, Jiangsu 213000, P.R. China
| | - Shuanghu Yuan
- Department of Radiation Oncology, Shandong University Cancer Center, Jinan, Shandong 250117, P.R. China
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University (Henan Cancer Hospital), Zhengzhou, Henan 450000, P.R. China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
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Bucknell NW, Belderbos J, Palma DA, Iyengar P, Samson P, Chua K, Gomez D, McDonald F, Louie AV, Faivre-Finn C, Hanna GG, Siva S. Avoiding toxicity with lung radiation therapy: An IASLC perspective. J Thorac Oncol 2022; 17:961-973. [DOI: 10.1016/j.jtho.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/25/2022]
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Chen X, Tong X, Qiu Q, Sun F, Yin Y, Gong G, Xing L, Sun X. Radiomics Nomogram for Predicting Locoregional Failure in Locally Advanced Non-small Cell Lung Cancer Treated with Definitive Chemoradiotherapy. Acad Radiol 2022; 29 Suppl 2:S53-S61. [PMID: 33308945 DOI: 10.1016/j.acra.2020.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/19/2020] [Accepted: 11/25/2020] [Indexed: 02/08/2023]
Abstract
RATIONALE AND OBJECTIVES To develop and validate a computed tomography (CT)-based radiomics nomogram for predicting locoregional failure (LRF) in patients with locally advanced non-small cell lung cancer (NSCLC) treated with definitive chemoradiotherapy (CRT). MATERIALS AND METHODS A total of 141 patients with locally advanced NSCLC treated with definitive CRT from January 2014 to December 2017 were included and divided into testing cohort (n = 100) and validation (n = 41) cohort. Radiomics features were extracted from pretreatment contrast enhanced CT. The least absolute shrinkage and selection operator logistic regression was processed to select predictive features from the testing cohort and constructed a radiomics signature. Clinical characteristics and the radiomics signature were analyzed using univariable and multivariate Cox regression. The radiomics nomogram was established with the radiomics signature and independent clinical factors. Harrell's C-index, calibration curves and decision curves were used to assess the performance of the radiomics nomogram. RESULTS The radiomics signature, which consisted of eight selected features, was an independent factor of LRF. The clinical predictors of LRF were the histologic type and clinical stage. The radiomics nomogram combined with the radiomics signature and clinical prognostic factors showed good performance with C-indexes of 0.796 (95% confidence interval [CI]: 0.709-0.883) and 0.756 (95% CI: 0.674-0.838) in the testing and validation cohorts respectively. Additionally, the combined nomogram resulted in better performance (p < 0.001) for the estimation of LRF than the nomograms with the radiomics signature (C-index: 0.776; 95% CI: 0.686-0.866) or clinical predictors (C-index: 0.641; 95% CI: 0.542-0.740) alone. CONCLUSION The radiomics nomogram provided the best performance for LRF prediction in patients with locally advanced NSCLC, which may help optimize individual treatments.
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Lee TH, Kim DY, Wu HG, Lee JH, Kim HJ. Treatment outcomes of re-irradiation using stereotactic ablative radiotherapy to lung: a propensity score matching analysis. Radiat Oncol 2021; 16:222. [PMID: 34794471 PMCID: PMC8600824 DOI: 10.1186/s13014-021-01948-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 11/04/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The purpose of this study was to compare the treatment efficacy and safety of re-irradiation (re-RT) using stereotactic ablative radiotherapy (SABR) and initial SABR for primary, recurrent lung cancer or metastatic lung tumor. METHODS A retrospective review of the medical records of 336 patients who underwent lung SABR was performed. Re-RT was defined as the overlap of the 70% isodose line of second-course SABR with that of the initial radiotherapy, and 20 patients were classified as the re-RT group. The median dose of re-RT using SABR was 54 Gy (range 48-60 Gy), and the median fraction number was 4 (range 4-6). One-to-three case-matched analysis with propensity score matching was used, and 60 patients were included in the initial SABR group of the matched cohort. RESULTS The 1- and 2-year local control rates for the re-RT group were 73.9% and 63.3% and those for the initial SABR group in the matched cohort were 92.9% and 87.7%, respectively (P = 0.013). There was no difference in distant metastasis-free, progression-free, and overall survival rates. The crude grade ≥ 2 toxicity rates were 40.0% for the re-RT group and 25.0% for the initial SABR group (P = 0.318). Re-RT group had higher acute grade ≥ 2 toxicity rates (25.0% vs 5.0%, P = 0.031). One incident of grade 3 toxicity (pulmonary) was reported in the re-RT group; there was no grade 4‒5 toxicity. CONCLUSIONS The local control rate of the in-field re-RT SABR was lower than that of the initial SABR without compromising the survival rates. The toxicity of re-RT using SABR was acceptable.
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Affiliation(s)
- Tae Hoon Lee
- Department of Radiation Oncology, Seoul National University College of Medicine and Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Dong-Yun Kim
- Department of Radiation Oncology, Seoul National University College of Medicine and Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University College of Medicine and Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Institute of Radiation Medicine, Medical Research Center, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Joo Ho Lee
- Department of Radiation Oncology, Seoul National University College of Medicine and Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hak Jae Kim
- Department of Radiation Oncology, Seoul National University College of Medicine and Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea. .,Institute of Radiation Medicine, Medical Research Center, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Yang Y, Chong Y, Chen M, Dai W, Zhou X, Ji Y, Qiu G, Du X. Targeting lactate dehydrogenase a improves radiotherapy efficacy in non-small cell lung cancer: from bedside to bench. J Transl Med 2021; 19:170. [PMID: 33902615 PMCID: PMC8074241 DOI: 10.1186/s12967-021-02825-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/09/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Lactate dehydrogenase A (LDHA) is overexpressed and associated with poor prognosis in many kinds of cancer. In the current study, we evaluated the prognostic value of LDHA expression in non-small cell lung cancer (NSCLC), and tested whether LDHA inhibition might improve radiotherapy efficacy in NSCLC. METHODS LDHA expression was investigated in NSCLC patients, using online database and further verified by immunohistochemistry. The prognostic value of LDHA was evaluated using Kaplan-Meier plotter database. In vitro, two NSCLC cell lines were pretreated with oxamate, an inhibitor of LDHA, and colony formation method was performed to determine cellular radiosensitivity. Comet assay was used to detect DNA damage after irradiation. Flow cytometry was applied to test cell cycle progression and apoptosis, and monodansylcadaverine (MDC) staining was used to examine cell autophagy. RESULTS Both mRNA and protein levels of LDHA expression were up-regulated in NSCLC tissues. High LDHA expression was a poor prognostic factor and associated with radioresistance in NSCLC patients. LDHA inhibition by oxamate remarkably increased radiosensitivity in both A549 and H1975 cancer cells, and enhanced ionizing radiation (IR)-induced apoptosis and autophagy, accompanied by cell cycle distribution alternations. Furthermore, LDHA inhibition induced reactive oxygen species (ROS) accumulation and cellular ATP depletion, which might increase DNA injury and hinder DNA repair activity. CONCLUSIONS Our study suggests that inhibition of LDHA may be a potential strategy to improve radiotherapy efficacy in NSCLC patients, which needs to be further tested by clinical trials.
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Affiliation(s)
- Yang Yang
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, China. .,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, 310022, China. .,Zhejiang Key Laboratory of Radiation Oncology, No 1, East Banshan Road, Gongshu District, Hangzhou, 310022, People's Republic of China.
| | - Yu Chong
- State Key Laboratory of Radiation Medicine and Protection, School for Radiological and Interdisciplinary Sciences (RAD-X), and Collaborative Innovation Center of Radiation Medicine of Jiangsu Higher Education Institutions, Soochow University, Suzhou, 215123, China
| | - Mengyuan Chen
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, 310022, China
| | - Wumin Dai
- Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, 310022, China.,Department of Clinical Lab, Cancer Hospital of University of Chinese Academy of Sciences, Hangzhou, 310022, China
| | - Xia Zhou
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, 310022, China
| | - Yongling Ji
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, 310022, China
| | - Guoqin Qiu
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, China.,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, 310022, China
| | - Xianghui Du
- Department of Thoracic Radiotherapy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, China. .,Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, 310022, China.
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Katagiri Y, Jingu K, Yamamoto T, Matsushita H, Umezawa R, Ishikawa Y, Takahashi N, Takeda K, Tasaka S, Kadoya N. Differences in patterns of recurrence of squamous cell carcinoma and adenocarcinoma after radiotherapy for stage III non-small cell lung cancer. Jpn J Radiol 2021; 39:611-617. [PMID: 33484424 DOI: 10.1007/s11604-021-01091-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/04/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the differences in patterns of recurrence and treatment results by histology after definitive radiotherapy for stage III non-small cell lung cancer (NSCLC) in Japan. MATERIALS AND METHODS Patients with stage III NSCLC who underwent definitive radiotherapy between 2000 and 2016 in our institution were included. A total of 217 patients were enrolled. Propensity score matching was used to exclude the following confounding factors: (1) age (≥70 years or <70 years), (2) gender, (3) T factor, (4) N factor, (5) Eastern Cooperative Oncology Group performance status score and (6) smoking status (Brinkman index ≥400 or <400). RESULTS The median observation period for survivors was 55.1 months. After propensity score matching, the Sqcc and adenocarcinoma groups each included 62 paired patients. There was no significant difference in OS or PFS between the adenocarcinoma and Sqcc groups. However, rates of recurrence in the GTV-primary site (p = 0.009) and GTV-lymph node site (p = 0.037) were significantly higher in patients with Sqcc than in patients with adenocarcinoma. New metastatic recurrence was more frequent in patients with adenocarcinoma than in patients with Sqcc (p = 0.025). CONCLUSION There were significant differences in patterns of recurrence after definitive (chemo)radiotherapy between patients with Sqcc and patients with adenocarcinoma.
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Affiliation(s)
- Yu Katagiri
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan.
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan
| | - Haruo Matsushita
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan
| | - Rei Umezawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan
| | - Yojiro Ishikawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan
| | - Kazuya Takeda
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan
| | - Shun Tasaka
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan
| | - Noriyuki Kadoya
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-chou, Aoba-ku, Sendai, 980-8574, Japan
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Zou L, Chu L, Xia F, Zhou L, Yang X, Ni J, Chen J, Zhu Z. Is clinical target volume necessary?-a failure pattern analysis in patients with locally advanced non-small cell lung cancer treated with concurrent chemoradiotherapy using intensity-modulated radiotherapy technique. Transl Lung Cancer Res 2020; 9:1986-1995. [PMID: 33209618 PMCID: PMC7653148 DOI: 10.21037/tlcr-20-523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Our previous dosimetric study showed that for locally advanced non-small cell lung cancer (LA-NSCLC), radiotherapy with intensity-modulated radiotherapy (IMRT) technique could deliver sufficient dose coverage to subclinical regions and reduce the dose to normal tissues with the omission of clinical target volume (CTV). To further clinically validate this strategy, we conducted the current study to analyze the failure pattern for patients with LA-NSCLC treated with concurrent chemotherapy and CTV-omitted IMRT. We also investigated the effects of target volumes on lymphopenia during radiotherapy to further test the potential benefits of CTV omission in anti-tumor immunotherapy. Methods A total of 63 patients with LA-NSCLC treated with CTV-omitted IMRT with concurrent chemotherapy were enrolled in this study. Their planning target volume (PTV) (also PTV-g) was expanded directly from gross tumor volume (GTV). A virtual CTV was expanded from GTV, and the PTV generated from virtual CTV was named planning target volume with CTV expansion (PTV-c). Treatment failures were divided into local, regional, and distant failures, and local–regional recurrences were classified into inside PTV-g (IN-PTV-g), between PTV-g and PTV-c (PTV-g-c), and outside PTV-c (OUT-PTV-c). The relationship between lymphopenia during radiotherapy and the target volumes was also evaluated using Spearman’s correlation analysis. Results Among the 60 patients with detailed follow-up data for recurrences, 46 (76.7%) experienced recurrences, with 18 (30.0%) being local recurrence, 5 (8.4%) being regional failure, and 33 (55.0%) being distant failure. For the 21 patients with local–regional recurrences, 16, 6, and 1 were IN-PTV-g, OUT-PTV-c, and PTV-g-c recurrences, respectively. Lymphopenia during radiotherapy was associated with both GTV and PTV, with larger volumes linked to severe lymphopenia. Conclusions CTV omission is feasible for LA-NSCLC treated with concurrent chemoradiotherapy and does not compromise failure inside the subclinical region. The radiation volumes were associated with lymphopenia during radiotherapy, with larger volumes related to severe lymphopenia. This finding supports the further exploration of CTV omission for immunotherapy.
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Affiliation(s)
- Liqing Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Li Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Fan Xia
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Lijun Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Xi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Jianjiao Ni
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Junchao Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, China.,Institute of Thoracic Oncology, Fudan University, Shanghai, China
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11
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Li QS, Liang N, Ouyang WW, Su SF, Ma Z, Geng YC, Yang WG, Hu YX, Li HQ, Lu B. Simultaneous integrated boost of intensity-modulated radiation therapy to Stage II-III non-small cell lung cancer with metastatic lymph nodes. Cancer Med 2020; 9:8364-8372. [PMID: 32902184 PMCID: PMC7666737 DOI: 10.1002/cam4.3446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022] Open
Abstract
Local tumor failure remains a major problem after radiation‐based nonsurgical treatment for unresectable locally advanced nonsmall cell lung cancer (NSCLC)and inoperable stage II NSCLC. The aim of this study was to evaluate the feasibility of simultaneous integrated boost of intensity‐modulated radiation therapy (SIB‐IMRT) to stage II‐III NSCLC with metastatic lymph nodes (ChiCTR 2000029304). Patients were diagnosed by pathology or PET‐CT. PTV was divided into two parts as follows, the PTV of primary tumor (PTVp) and the PTV of metastatic lymph nodes (PTVn). The radiotherapy doses were simultaneously prescripted 78 Gy (BED = 101.48 Gy) for PTVp and 60‐65 Gy (BED = 73.6‐81.25 Gy) for PTVn, 26f/5.2 weeks. Response was scored according to WHO criteria. Radiotherapy toxicity was scored according to RTOG criteria. Hematology and gastrointestinal toxicity were scored according to CTCAE1.0 criteria. A total of 20 patients were enrolled. Seventeen patients were diagnosed by pathology and three patients were diagnosed by PET‐CT. All patients were treated with SIB‐IMRT. The objective response rate (ORR) was 90%, with CR 25%, PR 65%, NC 10%, and PD 0%. Although radiotherapy toxicity was common, there were no grade ≥3, with radiation pneumonitis (10 cases), esophagitis (17 cases), and dermatitis (12 cases). The local control rates at 1, 3, and 5 years were 85%, 75%, and 70%, respectively. The overall survival(OS)and local progression‐free survival (LPFS) rates at 1, 3, and 5 years were 90%, 42.6%, and 35.5% and 84.4%, 35.5%, and 28.4%, respectively. SIB‐IMRT can significantly improve ORR and survival for stage II‐III NSCLC with metastatic lymph nodes, with high safety, and satisfactory efficacy. However, due to the limitation of small sample, these findings are needed to confirm by future trials with a larger sample size.
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Affiliation(s)
- Qing-Song Li
- Department of Thoracic Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Guizhou Cancer Hospital, Guiyang, China
| | - Na Liang
- Department of Thoracic Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Guizhou Cancer Hospital, Guiyang, China
| | - Wei-Wei Ouyang
- Department of Thoracic Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Guizhou Cancer Hospital, Guiyang, China
| | - Sheng-Fa Su
- Department of Thoracic Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Guizhou Cancer Hospital, Guiyang, China
| | - Zhu Ma
- Guizhou Cancer Hospital, Guiyang, China
| | - Yi-Chao Geng
- Department of Thoracic Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Guizhou Cancer Hospital, Guiyang, China
| | - Wen-Gang Yang
- Department of Thoracic Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Guizhou Cancer Hospital, Guiyang, China
| | - Yin-Xiang Hu
- Department of Thoracic Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Guizhou Cancer Hospital, Guiyang, China
| | | | - Bing Lu
- Department of Thoracic Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Guizhou Cancer Hospital, Guiyang, China
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12
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Pattern-of-failure and salvage treatment analysis after chemoradiotherapy for inoperable stage III non-small cell lung cancer. Radiat Oncol 2020; 15:148. [PMID: 32517716 PMCID: PMC7285541 DOI: 10.1186/s13014-020-01590-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 06/03/2020] [Indexed: 12/16/2022] Open
Abstract
Background Loco-regional and distant failure are common in inoperable stage III non small-cell lung cancer (NSCLC) after chemoradiotherapy (CRT). However, there is limited real-world data on failure pattern, patient prognosis and salvage options. Methods We analysed 99 consecutive patients with inoperable stage III NSCLC treated with CRT between 2011 and 2016. Follow up CT scans from date of the first-site failure were matched with the delivered radiation treatment plans. Intra-thoracic loco-regional relapse was defined as in-field (IFR) vs. out-of-field recurrence (OFR) [in- vs. outside 50Gy isodose line in the involved lung], respectively. Extracranial distant (DMs) and brain metastases (BMs) as first site of recurrence were also evaluated. Using the Kaplan-Meier method, impact of salvage surgery (sS), radiotherapy (sRT), chemotherapy (sCT) and immunotherapy (sIO) on patient survival was assessed. Results Median follow-up was 60.0 months. Median PFS from the end of CRT for the entire cohort was 7.5 (95% CI: 6.0–9.0 months) months. Twenty-six (26%) and 25 (25%) patients developed IFR and OFR. Median time to diagnosis of IFR and OFR was 7.2 and 6.2 months. In the entire cohort, onset of IFR and OFR did not influence patient outcome. However, in 73 (74%) patients who survived longer than 12 months after initial diagnosis, IFR was a significant negative prognostic factor with a median survival of 19.3 vs 40.0 months (p < 0.001). No patients with IFR underwent sS and/or sRT. 18 (70%) and 5 (19%) patients with IFR underwent sCT and sIO. Three (12%) patients with OFR underwent sS and are still alive with 3-year survival rate of 100%. 5 (20%) patients with OFR underwent sRT with a median survival of 71.2 vs 19.1 months (p = 0.014). Four (16%) patients with OFR received sIO with a numerical survival benefit (64.6 vs. 26.4 months, p = 0.222). DMs and BMs were detected in 27 (27%) and 16 (16%) patients after median time of 5.8 and 5.13 months. Both had no impact on patient outcome in the entire cohort. However, patients with more than three BMs showed significantly poor OS (9.3 vs 26.0 months; p = 0.012). Conclusions After completion of CRT, IFR was a negative prognostic factor in those patients, who survived longer than 12 months after initial diagnosis. Patients with OFR benefit significantly from salvage local treatment. Patients with more than three BMs as first site of failure had a significantly inferior outcome.
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13
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Impact of positron emission tomography with computed tomography for image-guided radiotherapy. Cancer Radiother 2020; 24:362-367. [PMID: 32284178 DOI: 10.1016/j.canrad.2020.03.006] [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: 12/02/2019] [Revised: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 12/27/2022]
Abstract
Therapeutic effectiveness in radiotherapy is partly related to correct staging of the disease and then precise therapeutic targeting. Positron emission tomography (PET) allows the stage of many cancers to be determined and therefore is essential before deciding on radiation treatment. The definition of the therapeutic target is essential to obtain correct tumour control and limit side effects. The part of adaptive radiotherapy remains to be defined, but PET by its functional nature makes it possible to define the prognosis of many cancers and to consider radiotherapy adapted to the initial response allowing an increase over the entire metabolic volume, or targeted at a subvolume at risk per dose painting, or with a decrease in the dose in case of good response at interim assessment.
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14
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Safety and efficacy of reduced dose and margins to involved lymph node metastases in locally advanced NSCLC patients. Radiother Oncol 2020; 143:66-72. [DOI: 10.1016/j.radonc.2019.07.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/12/2019] [Accepted: 07/22/2019] [Indexed: 12/25/2022]
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15
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« Définition des volumes cibles : quand et comment l’oncologue radiothérapeute peut-il utiliser la TEP ? ». Cancer Radiother 2019; 23:745-752. [DOI: 10.1016/j.canrad.2019.07.133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/28/2019] [Indexed: 12/12/2022]
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16
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Yegya-Raman N, Reyhan M, Kim S, Deek MP, Yue N, Zou W, Malhotra J, Aisner J, Jabbour SK. Association of Target Volume Margins With Locoregional Control and Acute Toxicities for Non-small cell lung cancer Treated With Concurrent Chemoradiation Therapy. Pract Radiat Oncol 2018; 9:e74-e82. [PMID: 30144583 DOI: 10.1016/j.prro.2018.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/23/2018] [Accepted: 08/09/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE This study aimed to investigate the association between target volume margins and clinical outcomes for patients with inoperable non-small cell lung cancer (NSCLC) treated with concurrent chemoradiation therapy. METHODS AND MATERIALS We reviewed the records of 82 patients with inoperable NSCLC treated between 2009 and 2016 with concurrent chemoradiation. All patients received positron emission tomography-based treatment planning, 4-dimensional computed tomography simulation to define an internal target volume, and daily cone beam computed tomography. We quantified variations in target volume margins with a margin deviation index (MDI), calculated as the percentage change in equivalent uniform dose between the original planning target volume (PTV) and a standard reference PTV 10 mm beyond the original gross tumor volume, consistent with the minimum margins mandated by recent NSCLC trials. Greater MDIs equated to smaller effective target volume margins. We dichotomized patients by the upper tercile MDI value (5.8%). Endpoints included time to locoregional progression and time to grade ≥ 3 radiation esophagitis (RE3) or radiation pneumonitis (RP3), modelled with the Fine-Gray method. RESULTS Median follow-up was 37.8 months (range, 5.9-58.1 months). Larger MDIs correlated with smaller clinical target volume (CTV) + PTV margins, larger gross tumor volumes, later treatment year, and intensity modulated radiation therapy use. The risk of locoregional progression did not differ for MDI ≥5.8% versus <5.8% (adjusted hazard ratio: 0.88; P = .76), but the risk of RE3 or RP3 was decreased for MDI ≥5.8% (adjusted hazard ratio: 0.27; P = .027). Patients with MDI ≥5.8% were treated with smaller CTV + PTV margins (median, 5.6 vs 8 mm; P < .0001) and a marginally lower volume of esophagus receiving ≥50 Gy (median, 31.1% vs 35.3%; P = .069). CONCLUSIONS Smaller margins were used for larger tumors but were not associated with an increase in locoregional failures. Additional studies could clarify whether smaller margins, when used alongside modern radiation therapy techniques, decrease treatment-related toxicity for inoperable NSCLC.
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MESH Headings
- Adenocarcinoma/diagnostic imaging
- Adenocarcinoma/pathology
- Adenocarcinoma/therapy
- Adult
- Aged
- Aged, 80 and over
- Carcinoma, Non-Small-Cell Lung/diagnostic imaging
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Non-Small-Cell Lung/therapy
- Chemoradiotherapy/adverse effects
- Cone-Beam Computed Tomography
- Esophagitis/diagnosis
- Esophagitis/etiology
- Female
- Follow-Up Studies
- Four-Dimensional Computed Tomography
- Humans
- Image Processing, Computer-Assisted/methods
- Lung Neoplasms/diagnostic imaging
- Lung Neoplasms/pathology
- Lung Neoplasms/therapy
- Male
- Margins of Excision
- Middle Aged
- Neoplasm Recurrence, Local/diagnosis
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/etiology
- Positron-Emission Tomography
- Prognosis
- Radiation Pneumonitis/diagnosis
- Radiation Pneumonitis/etiology
- Radiotherapy Dosage
- Radiotherapy Planning, Computer-Assisted/methods
- Radiotherapy, Intensity-Modulated/methods
- Retrospective Studies
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Meral Reyhan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Sinae Kim
- Department of Biostatistics, School of Public Health, Rutgers University, Piscataway, New Jersey; Biometrics Division, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Matthew P Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; Department of Radiation Oncology & Molecular Radiation Sciences, the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ning Yue
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Wei Zou
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jyoti Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Joseph Aisner
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey.
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