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Zhang QS, Hayes JP, Gondi V, Pollack SM. Immunotherapy and Radiotherapy Combinations for Sarcoma. Semin Radiat Oncol 2024; 34:229-242. [PMID: 38508787 DOI: 10.1016/j.semradonc.2023.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Sarcomas are a heterogeneous group of bone and soft tissue tumors. Survival outcomes for advanced (unresectable or metastatic) disease remain poor, so therapeutic improvements are needed. Radiotherapy plays an integral role in the neoadjuvant and adjuvant treatment of localized disease as well as in the treatment of metastatic disease. Combining radiotherapy with immunotherapy to potentiate immunotherapy has been used in a variety of cancers other than sarcoma, and there is opportunity to further investigate combining immunotherapy with radiotherapy to try to improve outcomes in sarcoma. In this review, we describe the diversity of the tumor immune microenvironments for sarcomas and describe the immunomodulatory effects of radiotherapy. We discuss studies on the timing of radiotherapy relative to immunotherapy and studies on the radiotherapy dose and fractionation regimen to be used in combination with immunotherapy. We describe the impact of radiotherapy on the tumor immune microenvironment. We review completed and ongoing clinical trials combining radiotherapy with immunotherapy for sarcoma and propose future directions for studies combining immunotherapy with radiotherapy in the treatment of sarcoma.
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Affiliation(s)
- Qian S Zhang
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - John P Hayes
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Seth M Pollack
- Division of Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL..
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Liu F, Ververs JD, Farris MK, Blackstock AW, Munley MT. Optimal Radiation Therapy Fractionation Regimens for Early-Stage Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2024; 118:829-838. [PMID: 37734445 DOI: 10.1016/j.ijrobp.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 08/04/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE A series of radiobiological models were developed to study tumor control probability (TCP) for stereotactic body radiation therapy (SBRT) of early-stage non-small cell lung cancer (NSCLC) per the Hypofractionated Treatment Effects in the Clinic (HyTEC) working group. This study was conducted to further validate 3 representative models with the recent clinical TCP data ranging from conventional radiation therapy to SBRT of early-stage NSCLC and to determine systematic optimal fractionation regimens in 1 to 30 fractions for radiation therapy of early-stage NSCLC that were found to be model-independent. METHODS AND MATERIALS Recent clinical 1-, 2-, 3-, and 5-year actuarial or Kaplan-Meier TCP data of 9808 patients from 56 published papers were collected for radiation therapy of 2 to 4 Gy per fraction and SBRT of early-stage NSCLC. This data set nearly triples the original HyTEC sample, which was used to further validate the HyTEC model parameters determined from a fit to the clinical TCP data. RESULTS TCP data from the expanded data set are well described by the HyTEC models with α/β ratios of about 20 Gy. TCP increases sharply with biologically effective dose and reaches an asymptotic maximal plateau, which allows us to determine optimal fractionation schemes for radiation therapy of early-stage NSCLC. CONCLUSIONS The HyTEC radiobiological models with α/β ratios of about 20 Gy determined from the fits to the clinical TCP data for SBRT of early-stage NSCLC describe the recent TCP data well for both radiation therapy of 2 to 4 Gy per fraction and SBRT dose and fractionation schemes of early-stage NSCLC. A steep dose response exists between TCP and biologically effective dose, and TCP reaches an asymptotic maximum. This feature results in model-independent optimal fractionation regimens determined whenever safe for SBRT and hypofractionated radiation therapy of early-stage NSCLC in 1 to 30 fractions to achieve asymptotic maximal tumor control, and T2 tumors require slightly higher optimal doses than T1 tumors. The proposed optimal fractionation schemes are consistent with clinical practice for SBRT of early-stage NSCLC.
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Affiliation(s)
- Feng Liu
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.
| | - James D Ververs
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Michael K Farris
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - A William Blackstock
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Michael T Munley
- Department of Radiation Oncology, Wake Forest University School of Medicine and Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
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Tjelta J, Fjæra LF, Ytre-Hauge KS, Boer CG, Stokkevåg CH. A systematic approach for calibrating a Monte Carlo code to a treatment planning system for obtaining dose, LET, variable proton RBE and out-of-field dose. Phys Med Biol 2023; 68:225010. [PMID: 37820690 DOI: 10.1088/1361-6560/ad0281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/11/2023] [Indexed: 10/13/2023]
Abstract
Objective. While integration of variable relative biological effectiveness (RBE) has not reached full clinical implementation, the importance of having the ability to recalculate proton treatment plans in a flexible, dedicated Monte Carlo (MC) code cannot be understated . Here we provide a step-wise method for calibrating dose from a MC code to a treatment planning system (TPS), to obtain required parameters for calculating linear energy transfer (LET), variable RBE and in general enabling clinical realistic research studies beyond the capabilities of a TPS.Approach. Initially, Pristine Bragg peaks (PBP) were calculated in both the Eclipse TPS and the FLUKA MC code. A rearranged Bortfeld energy-range relation was applied to the initial energy of the beam to fine-tune the range of the MC code at 80% dose level distal to the PBP. The energy spread was adapted by dividing the TPS range by the MC range for dose level 80%-20% distal to the PBP. Density and relative proton stopping power were adjusted by comparing the TPS and MC for different Hounsfield units. To find the relationship of dose per primary particle from the MC to dose per monitor unit in the TPS, integration was applied to the area of the Bragg curve. The calibration was validated for spread-out Bragg peaks (SOBP) in water and patient treatment plans. Following the validation, variable RBE were calculated using established models.Main results.The PBPs ranges were within ±0.3mm threshold, and a maximum of 5.5% difference for the SOBPs was observed. The patient validation showed excellent dose agreement between the TPS and MC, with the greatest differences for the lung tumor patient.Significance. Aprocedure for calibrating a MC code to a TPS was developed and validated. The procedure enables MC-based calculation of dose, LET, variable RBE, advanced (secondary) particle tracking and more from treatment plans.
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Affiliation(s)
- Johannes Tjelta
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Department of Physics and Technology, University of Bergen, Bergen, Norway
| | - Lars Fredrik Fjæra
- Department of Physics and Technology, University of Bergen, Bergen, Norway
- Department of Oncology and Medical Physics, Oslo University Hospital, Oslo, Norway
| | | | | | - Camilla Hanquist Stokkevåg
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway
- Department of Physics and Technology, University of Bergen, Bergen, Norway
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Le Reun E, Granzotto A, Pêtre A, Bodgi L, Beldjoudi G, Lacornerie T, Vallet V, Bouchet A, Al-Choboq J, Bourguignon M, Thariat J, Bourhis J, Lartigau E, Foray N. Influence of the Hypersensitivity to Low Dose Phenomenon on the Tumor Response to Hypofractionated Stereotactic Body Radiation Therapy. Cancers (Basel) 2023; 15:3979. [PMID: 37568795 PMCID: PMC10416967 DOI: 10.3390/cancers15153979] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/30/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023] Open
Abstract
Stereotactic body radiation therapy (SBRT) has made the hypofractionation of high doses delivered in a few sessions more acceptable. While the benefits of hypofractionated SBRT have been attributed to additional vascular, immune effects, or specific cell deaths, a radiobiological and mechanistic model is still needed. By considering each session of SBRT, the dose is divided into hundreds of minibeams delivering some fractions of Gy. In such a dose range, the hypersensitivity to low dose (HRS) phenomenon can occur. HRS produces a biological effect equivalent to that produced by a dose 5-to-10 times higher. To examine whether HRS could contribute to enhancing radiation effects under SBRT conditions, we exposed tumor cells of different HRS statuses to SBRT. Four human HRS-positive and two HRS-negative tumor cell lines were exposed to different dose delivery modes: a single dose of 0.2 Gy, 2 Gy, 10 × 0.2 Gy, and a single dose of 2 Gy using a non-coplanar isocentric minibeams irradiation mode were delivered. Anti-γH2AX immunofluorescence, assessing DNA double-strand breaks (DSB), was applied. In the HRS-positive cells, the DSB produced by 10 × 0.2 Gy and 2 Gy, delivered by tens of minibeams, appeared to be more severe, and they provided more highly damaged cells than in the HRS-negative cells, suggesting that more severe DSB are induced in the "SBRT modes" conditions when HRS occurs in tumor. Each SBRT session can be viewed as hyperfractionated dose delivery by means of hundreds of low dose minibeams. Under current SBRT conditions (i.e., low dose per minibeam and not using ultra-high dose-rate), the response of HRS-positive tumors to SBRT may be enhanced significantly. Interestingly, similar conclusions were reached with HRS-positive and HRS-negative untransformed fibroblast cell lines, suggesting that the HRS phenomenon may also impact the risk of post-RT tissue overreactions.
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Affiliation(s)
- Eymeric Le Reun
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
- Service de Radio-Oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), 46 Rue du Bugnon, 1011 Lausanne, Switzerland; (V.V.); (J.B.)
| | - Adeline Granzotto
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
| | - Adeline Pêtre
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
- Département de Radiothérapie, Centre Léon-Bérard, 28 Rue Laennec, 69008 Lyon, France;
| | - Larry Bodgi
- Department of Radiation Oncology, American University of Beirut Medical Center, Riad El-Solh, Beirut 1107-2020, Lebanon;
| | - Guillaume Beldjoudi
- Département de Radiothérapie, Centre Léon-Bérard, 28 Rue Laennec, 69008 Lyon, France;
| | - Thomas Lacornerie
- Département de Radiothérapie, Centre Oscar-Lambret, 3 Rue Frédéric Combemale, 59000 Lille, France; (T.L.); (E.L.)
| | - Véronique Vallet
- Service de Radio-Oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), 46 Rue du Bugnon, 1011 Lausanne, Switzerland; (V.V.); (J.B.)
| | - Audrey Bouchet
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
| | - Joëlle Al-Choboq
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
| | - Michel Bourguignon
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
- Département de Biophysique et Médecine Nucléaire, Université Paris Saclay, Versailles St. Quentin en Yvelines, 78035 Versailles, France
| | - Juliette Thariat
- Département de Radiothérapie, Centre François-Baclesse, 3 Avenue du Général Harris, 14076 Caen, France;
| | - Jean Bourhis
- Service de Radio-Oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), 46 Rue du Bugnon, 1011 Lausanne, Switzerland; (V.V.); (J.B.)
| | - Eric Lartigau
- Département de Radiothérapie, Centre Oscar-Lambret, 3 Rue Frédéric Combemale, 59000 Lille, France; (T.L.); (E.L.)
| | - Nicolas Foray
- U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon-Bérard, Inserm, 28 Rue Laennec, 69008 Lyon, France; (E.L.R.); (A.G.); (A.P.); (A.B.); (J.A.-C.); (M.B.)
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Erickson BG, Cui Y, Ackerson BG, Kelsey CR, Yin FF, Niedzwiecki D, Adamson J. Uncertainties in the dosimetric heterogeneity correction and its potential effect on local control in lung SBRT. Biomed Phys Eng Express 2023; 9. [PMID: 36827685 DOI: 10.1088/2057-1976/acbeae] [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: 11/14/2022] [Accepted: 02/24/2023] [Indexed: 02/26/2023]
Abstract
Objective. Dose calculation in lung stereotactic body radiation therapy (SBRT) is challenging due to the low density of the lungs and small volumes. Here we assess uncertainties associated with tissue heterogeneities using different dose calculation algorithms and quantify potential associations with local failure for lung SBRT.Approach. 164 lung SBRT plans were used. The original plans were prepared using Pencil Beam Convolution (PBC, n = 8) or Anisotropic Analytical Algorithm (AAA, n = 156). Each plan was recalculated with AcurosXB (AXB) leaving all plan parameters unchanged. A subset (n = 89) was calculated with Monte Carlo to verify accuracy. Differences were calculated for the planning target volume (PTV) and internal target volume (ITV) Dmean[Gy], D99%[Gy], D95%[Gy], D1%[Gy], and V100%[%]. Dose metrics were converted to biologically effective doses (BED) usingα/β= 10Gy. Regression analysis was performed for AAA plans investigating the effects of various parameters on the extent of the dosimetric differences. Associations between the magnitude of the differences for all plans and outcome were investigated using sub-distribution hazards analysis.Main results. For AAA cases, higher energies increased the magnitude of the difference (ΔDmean of -3.6%, -5.9%, and -9.1% for 6X, 10X, and 15X, respectively), as did lung volume (ΔD99% of -1.6% per 500cc). Regarding outcome, significant hazard ratios (HR) were observed for the change in the PTV and ITV D1% BEDs upon univariate analysis (p = 0.042, 0.023, respectively). When adjusting for PTV volume and prescription, the HRs for the change in the ITV D1% BED remained significant (p = 0.039, 0.037, respectively).Significance. Large differences in dosimetric indices for lung SBRT can occur when transitioning to advanced algorithms. The majority of the differences were not associated with local failure, although differences in PTV and ITV D1% BEDs were associated upon univariate analysis. This shows uncertainty in near maximal tumor dose to potentially be predictive of treatment outcome.
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Affiliation(s)
- Brett G Erickson
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Yunfeng Cui
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Bradley G Ackerson
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Christopher R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, United States of America
| | - Justus Adamson
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, United States of America
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Uchinami Y, Katoh N, Abo D, Morita R, Taguchi H, Fujita Y, Kanehira T, Suzuki R, Miyamoto N, Takao S, Matsuura T, Sho T, Ogawa K, Orimo T, Kakisaka T, Kobashi K, Aoyama H. Study of hepatic toxicity in small liver tumors after photon or proton therapy based on factors predicting the benefits of proton. Br J Radiol 2023; 96:20220720. [PMID: 36633335 PMCID: PMC10078862 DOI: 10.1259/bjr.20220720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES In a previous study of hepatic toxicity, the following three factors were identified to predict the benefits of proton beam therapy (PBT) for hepatocellular carcinomas (HCCs) with a maximum diameter of ≤5 cm and Child-pugh grade A (CP-A): number of tumors (1 vs ≥2), the location of tumors (hepatic hilum or others), and the sum of the diameters of lesions. The aim of this study is to analyze the association between these three factors and hepatic toxicity. METHODS We retrospectively reviewed patients of CP-A treated with PBT or photon stereotactic body radiotherapy (X-ray radiotherapy, XRT) for HCC ≤5 cm. For normal liver dose, the V5, V10, V20 (volumes receiving 5, 10, and 20 Gy at least), and the mean dose was evaluated. The albumin-bilirubin (ALBI) and CP score changes from the baseline were evaluated at 3 and 6 months after treatment. RESULTS In 89 patients (XRT: 48, PBT: 41), those with two or three (2-3) predictive factors were higher normal liver doses than with zero or one (0-1) factor. In the PBT group, the ALBI score worsened more in patients with 2-3 factors than those with 0-1 factor, at 3 months (median: 0.26 vs 0.02, p = 0.032) and at 6 months (median: 0.35 vs 0.10, p = 0.009). The ALBI score change in the XRT group and CP score change in either modality were not significantly different in the number of predictive factors. CONCLUSION The predictive factor numbers predicted the ALBI score change in PBT but not in XRT. ADVANCES IN KNOWLEDGE This study suggest that the number of predictive factors previously identified (0-1 vs 2-3) were significantly associated with dosimetric parameters of the normal liver in both modalities. In the proton group, the number of predictive factors was associated with a worsening ALBI score at 3 and 6 months, but these associations were not found in the photon SBRT group.
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Affiliation(s)
- Yusuke Uchinami
- Department of Radiation Oncology, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Norio Katoh
- Department of Radiation Oncology, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Daisuke Abo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Hokkaido, Japan
| | - Ryo Morita
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Hokkaido, Japan
| | - Hiroshi Taguchi
- Department of Radiation Oncology, Hokkaido University Hospital, Hokkaido, Japan
| | - Yoshihiro Fujita
- Department of Radiation Oncology, Hokkaido University Hospital, Hokkaido, Japan
| | - Takahiro Kanehira
- Department of Medical Physics, Hokkaido University Hospital, Hokkaido, Japan
| | - Ryusuke Suzuki
- Department of Medical Physics, Hokkaido University Hospital, Hokkaido, Japan
| | - Naoki Miyamoto
- Department of Medical Physics, Hokkaido University Hospital, Hokkaido, Japan
| | - Seishin Takao
- Department of Radiation Medical Science and Engineering, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Taeko Matsuura
- Department of Radiation Medical Science and Engineering, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Takuya Sho
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Koji Ogawa
- Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Tatsuya Orimo
- Department of Gastroenterological Surgery I, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Tatsuhiko Kakisaka
- Department of Gastroenterological Surgery I, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Keiji Kobashi
- Global Center for Biomedical Science and Engineering, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Hidefumi Aoyama
- Department of Radiation Oncology, Hokkaido University Faculty of Medicine, Hokkaido, Japan
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Inter- and intrafractional 4D dose accumulation for evaluating ΔNTCP robustness in lung cancer. Radiother Oncol 2023; 182:109488. [PMID: 36706960 DOI: 10.1016/j.radonc.2023.109488] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Model-based selection of proton therapy patients relies on a predefined reduction in normal tissue complication probability (NTCP) with respect to photon therapy. The decision is necessarily made based on the treatment plan, but NTCP can be affected when the delivered treatment deviates from the plan due to delivery inaccuracies. Especially for proton therapy of lung cancer, this can be important because of tissue density changes and, with pencil beam scanning, the interplay effect between the proton beam and breathing motion. MATERIALS AND METHODS In this work, we verified whether the expected benefit of proton therapy is retained despite delivery inaccuracies by reconstructing the delivered treatment using log-file based dose reconstruction and inter- and intrafractional accumulation. Additionally, the importance of two uncertain parameters for treatment reconstruction, namely deformable image registration (DIR) algorithm and α/β ratio, was assessed. RESULTS The expected benefit or proton therapy was confirmed in 97% of all studied cases, despite regular differences up to 2 percent point (p.p.) NTCP between the delivered and planned treatments. The choice of DIR algorithm affected NTCP up to 1.6 p.p., an order of magnitude higher than the effect of α/β ratio. CONCLUSION For the patient population and treatment technique employed, the predicted clinical benefit for patients selected for proton therapy was confirmed for 97.0% percent of all cases, although the NTCP based proton selection was subject to 2 p.p. variations due to delivery inaccuracies.
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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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Watanabe S, Yamazaki H, Kimoto T, Shiomi H, Yamada K, Suzuki G. Potential benefit of dose‐escalated stereotactic body radiation therapy using CyberKnife for early‐stage primary lung cancer. Asia Pac J Clin Oncol 2022; 19:320-326. [DOI: 10.1111/ajco.13842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/14/2022] [Accepted: 08/17/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Shou Watanabe
- Department of Radiology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kamigyo‐ku Japan
| | - Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kamigyo‐ku Japan
- CyberKnife Center Soseikai Clinic Fushimi‐ku Japan
| | - Takuya Kimoto
- Department of Radiology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kamigyo‐ku Japan
| | - Hiroya Shiomi
- Department of Radiology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kamigyo‐ku Japan
| | - Kei Yamada
- Department of Radiology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kamigyo‐ku Japan
| | - Gen Suzuki
- Department of Radiology, Graduate School of Medical Science Kyoto Prefectural University of Medicine Kamigyo‐ku Japan
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Volpe S, Piperno G, Colombo F, Biffi A, Comi S, Mastroleo F, Maria Camarda A, Casbarra A, Cattani F, Corrao G, de Marinis F, Spaggiari L, Guckenberger M, Orecchia R, Alterio D, Alicja Jereczek-Fossa B. Hypofractionated proton therapy for non-small cell lung cancer: Ready for prime time? A systematic review and meta-analysis. Cancer Treat Rev 2022; 110:102464. [DOI: 10.1016/j.ctrv.2022.102464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/02/2022] [Accepted: 09/14/2022] [Indexed: 11/02/2022]
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11
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Pneumonitis after Stereotactic Thoracic Radioimmunotherapy with Checkpoint Inhibitors: Exploration of the Dose-Volume-Effect Correlation. Cancers (Basel) 2022; 14:cancers14122948. [PMID: 35740613 PMCID: PMC9221463 DOI: 10.3390/cancers14122948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Stereotactic body radiation therapy (SBRT) is widely applied for treatment of early stage lung cancer and pulmonary metastases. Modern immune checkpoint blockade (ICB) is progressively used in cancer treatment. Pneumonitis is a relevant side effect of both thoracic SBRT and ICB. Currently, it remains unclear whether we can presume the same radiation dose–volume–effect correlations and dose constraints for safe application of SBRT + ICB. We present a dose–volume–effect correlation analysis method using pneumonitis contours and dose–volume histograms (DVH). We showed dosimetric differences for pneumonitis volumes between SBRT + ICB and SBRT alone. We found a large extent of pneumonitis, even bilateral and apart from the radiation field for combined SBRT + ICB. We noticed a shift in pneumonitis DVHs towards lower doses and a trend towards decreased areas under the curve (AUC) for SBRT + ICB. This provides a direction for re-evaluation and potential adaptation of lung dose constraints for combined SBRT and ICB. Abstract Thoracic stereotactic body radiation therapy (SBRT) is extensively used in combination with immune checkpoint blockade (ICB). While current evidence suggests that the occurrence of pneumonitis as a side effect of both treatments is not enhanced for the combination, the dose–volume correlation remains unclear. We investigate dose–volume–effect correlations for pneumonitis after combined SBRT + ICB. We analyzed patient clinical characteristics and dosimetric data for 42 data sets for thoracic SBRT with ICB treatment (13) and without (29). Dose volumes were converted into 2 Gy equivalent doses (EQD2), allowing for dosimetric comparison of different fractionation regimes. Pneumonitis volumes were delineated and corresponding DVHs were analyzed. We noticed a shift towards lower doses for combined SBRT + ICB treatment, supported by a trend of smaller areas under the curve (AUC) for SBRT+ ICB (median AUC 1337.37 vs. 5799.10, p = 0.317). We present a DVH-based dose–volume–effect correlation method and observed large pneumonitis volumes, even with bilateral extent in the SBRT + ICB group. We conclude that further studies using this method with enhanced statistical power are needed to clarify whether adjustments of the radiation dose constraints are required to better estimate risks of pneumonitis after the combination of SBRT and ICB.
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12
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Nasser NJ. Androgen Flare after LHRH Initiation Is the Side Effect That Makes Most of the Beneficial Effect When It Coincides with Radiation Therapy for Prostate Cancer. Cancers (Basel) 2022; 14:cancers14081959. [PMID: 35454866 PMCID: PMC9029515 DOI: 10.3390/cancers14081959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 01/13/2023] Open
Abstract
Simple Summary Prostate cancer tumor growth is stimulated by androgens. Surgical castration or medical castration using long-acting luteinizing hormone-releasing hormone (LHRH) agonists or antagonists is the backbone of the treatments of metastatic disease. Treatment of locally advanced prostate cancer was accomplished with radiation therapy alone until multiple studies showed that combining radiation therapy with LHRH agonists results in significant survival benefit. While the goal of the use of LHRH agonists was to suppress testosterone levels during radiation, we show, through review of previous studies, that survival benefit was achieved only when LHRH was initiated during the course of radiation, and thus androgen flare during the first 1–3 weeks after the initiation of LHRH is most likely the reason for higher survival. Androgens drive tumor cells into mitosis, and mitotic death is the dominant mechanism of tumor cell kill by radiation. Abstract Treatment of metastatic prostate cancer was historically performed via bilateral orchiectomy to achieve castration. An alternative to surgical castration is the administration of subcutaneous recombinant luteinizing hormone-releasing hormone (LHRH). LHRH causes the pituitary gland to produce luteinizing hormone (LH), which results in synthesis and secretion of testosterone from the testicles. When LHRH levels are continuously high, the pituitary gland stops producing LH, which results in reduced testosterone production by the testicles. Long-acting formulations of LHRH were developed, and its use replaced surgical orchiectomy in the vast majority of patients. Combining LHRH and radiation therapy was shown to increase survival of prostate cancer patients with locally advanced disease. Here, we present a hypothesis, and preliminary evidence based on previous randomized controlled trials, that androgen surge during radiation, rather than its suppression, could be responsible for the enhanced prostate cancer cell kill during radiation. Starting LHRH agonist on the first day of radiation therapy, as in the EORTC 22863 study, should be the standard of care when treating locally advanced prostate cancer. We are developing formulations of short-acting LHRH agonists that induce androgen flare, without subsequent androgen deprivation, which could open the door for an era in which locally advanced prostate cancer could be cured while patients maintain potency.
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Affiliation(s)
- Nicola J. Nasser
- Department of Radiation Oncology, Albany Medical College, Albany, NY 12208, USA; or
- The Umbilicus Inc., Nonprofit Organization for Preserving Sexual Function of Individuals with Cancer Below the Umbilicus, New York, NY 10032, USA
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13
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Bertho A, Dos Santos M, Braga-Cohen S, Buard V, Paget V, Guipaud O, Tarlet G, Milliat F, François A. Preclinical Model of Stereotactic Ablative Lung Irradiation Using Arc Delivery in the Mouse: Is Fractionation Worthwhile? Front Med (Lausanne) 2022; 8:794324. [PMID: 35004768 PMCID: PMC8739220 DOI: 10.3389/fmed.2021.794324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/07/2021] [Indexed: 11/23/2022] Open
Abstract
Lung stereotactic body radiation therapy is characterized by a reduction in target volumes and the use of severely hypofractionated schedules. Preclinical modeling became possible thanks to rodent-dedicated irradiation devices allowing accurate beam collimation and focal lung exposure. Given that a great majority of publications use single dose exposures, the question we asked in this study was as follows: in incremented preclinical models, is it worth using fractionated protocols or should we continue focusing solely on volume limitation? The left lungs of C57BL/6JRj mice were exposed to ionizing radiation using arc therapy and 3 × 3 mm beam collimation. Three-fraction schedules delivered over a period of 1 week were used with 20, 28, 40, and 50 Gy doses per fraction. Lung tissue opacification, global histological damage and the numbers of type II pneumocytes and club cells were assessed 6 months post-exposure, together with the gene expression of several lung cells and inflammation markers. Only the administration of 3 × 40 Gy or 3 × 50 Gy generated focal lung fibrosis after 6 months, with tissue opacification visible by cone beam computed tomography, tissue scarring and consolidation, decreased club cell numbers and a reactive increase in the number of type II pneumocytes. A fractionation schedule using an arc-therapy-delivered three fractions/1 week regimen with 3 × 3 mm beam requires 40 Gy per fraction for lung fibrosis to develop within 6 months, a reasonable time lapse given the mouse lifespan. A comparison with previously published laboratory data suggests that, in this focal lung irradiation configuration, administering a Biological Effective Dose ≥ 1000 Gy should be recommended to obtain lung fibrosis within 6 months. The need for such a high dose per fraction challenges the appropriateness of using preclinical highly focused fractionation schedules in mice.
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Affiliation(s)
- Annaïg Bertho
- Laboratory of Radiobiology of Medical Exposures, Institute for Radioprotection and Nuclear Safety (IRSN), Research Department in Radiobiology and Regenerative Medicine, Fontenay-aux-Roses, France
| | - Morgane Dos Santos
- Laboratory of Radiobiology of Accidental Exposures, Institute for Radioprotection and Nuclear Safety (IRSN), Research Department in Radiobiology and Regenerative Medicine, Fontenay-aux-Roses, France
| | - Sarah Braga-Cohen
- Laboratory of Radiobiology of Medical Exposures, Institute for Radioprotection and Nuclear Safety (IRSN), Research Department in Radiobiology and Regenerative Medicine, Fontenay-aux-Roses, France
| | - Valérie Buard
- Laboratory of Radiobiology of Medical Exposures, Institute for Radioprotection and Nuclear Safety (IRSN), Research Department in Radiobiology and Regenerative Medicine, Fontenay-aux-Roses, France
| | - Vincent Paget
- Laboratory of Radiobiology of Medical Exposures, Institute for Radioprotection and Nuclear Safety (IRSN), Research Department in Radiobiology and Regenerative Medicine, Fontenay-aux-Roses, France
| | - Olivier Guipaud
- Laboratory of Radiobiology of Medical Exposures, Institute for Radioprotection and Nuclear Safety (IRSN), Research Department in Radiobiology and Regenerative Medicine, Fontenay-aux-Roses, France
| | - Georges Tarlet
- Laboratory of Radiobiology of Medical Exposures, Institute for Radioprotection and Nuclear Safety (IRSN), Research Department in Radiobiology and Regenerative Medicine, Fontenay-aux-Roses, France
| | - Fabien Milliat
- Laboratory of Radiobiology of Medical Exposures, Institute for Radioprotection and Nuclear Safety (IRSN), Research Department in Radiobiology and Regenerative Medicine, Fontenay-aux-Roses, France
| | - Agnès François
- Laboratory of Radiobiology of Medical Exposures, Institute for Radioprotection and Nuclear Safety (IRSN), Research Department in Radiobiology and Regenerative Medicine, Fontenay-aux-Roses, France
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14
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Stavrev PV, Stavreva N, Ruggieri R, Nahum AE, Tsonev P, Penev D, Pressyanov D. Theoretical investigation of the impact of different timing schemes in hypofractionated radiotherapy. Med Phys 2021; 48:4085-4098. [PMID: 33905547 DOI: 10.1002/mp.14908] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 03/22/2021] [Accepted: 04/19/2021] [Indexed: 12/26/2022] Open
Abstract
PURPOSE This study compares the effectiveness of three fractionation schemes of equal fraction size, comprising five fractions of SBRT over 5 days, 10 days, or 15 days, respectively. METHOD This comparative study is based on two tumor-control-probability (TCP) models that take into account tumor cell re-sensitization and repopulation during treatment; the Zaider-Minerbo-Stavreva (ZMS) and the Ruggieri-Nahum (RN) models. The ZMS model is further modified to include also re-sensitization according to the β mechanism of the linear-quadratic (LQ) model of cell killing. The modified version of the ZMS model is verified through fitting to the experimental data set of Fisher and Moulder. The study applies an idea used in a plan ranking methodology developed for the case when the specific values of the model parameters are not known. RESULTS The TCPs of the compared regimens are calculated for various values of the model parameters and for two different values of the dose per fraction. The TCPs are presented as 2-D functions of two of the model parameters for each model correspondingly. The differences between the TCPs of each of the prolonged regimens and the TCP of the every week day regimen are also calculated for each model. CONCLUSIONS Both models predict that the prolonged regimens are superior in terms of TCP to the every week-day one for most of the studied cases; however this is shown to exist to a different degree by the two models. It is shown again to a different degree that reversed situations where the every week day schedule is better than the prolonged regimens are also possible. It is concluded that a 30% TCP difference observed in a clinical study in favor of the fifteen-day regimen is theoretically possible. However, the fifteen-day regimen is outperformed in terms of TCP by the every week day regimen in more cases than the regimen lasting ten days. Therefore the choice of a prolongation in time must be made with care.
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Affiliation(s)
- Pavel V Stavrev
- Faculty of Physics, Sofia University "St. Kliment, Ohridski", Sofia, 1164, Bulgaria
| | - Nadejda Stavreva
- Faculty of Physics, Sofia University "St. Kliment, Ohridski", Sofia, 1164, Bulgaria
| | - Ruggero Ruggieri
- Department of Radiation Oncology, IRCCS "Sacro Cuore - don Calabria", Negrar (VR), 37024, Italy
| | - Alan E Nahum
- Formerly at: Physics Department, Clatterbridge Cancer Centre, Bebington, CH63 4JY, United Kingdom
| | - Pavlin Tsonev
- Department of Radiotherapy Specialized Hospital for Active Treatment in Oncology, Sofia, 1756, Bulgaria
| | - Dimitar Penev
- Faculty of Physics, Sofia University "St. Kliment, Ohridski", Sofia, 1164, Bulgaria.,Department of Radiotherapy Specialized Hospital for Active Treatment in Oncology, Sofia, 1756, Bulgaria
| | - Dobromir Pressyanov
- Faculty of Physics, Sofia University "St. Kliment, Ohridski", Sofia, 1164, Bulgaria
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15
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Gago-Arias A, Neira S, Pombar M, Gómez-Caamaño A, Pardo-Montero J. Evaluation of indirect damage and damage saturation effects in dose-response curves of hypofractionated radiotherapy of early-stage NSCLC and brain metastases. Radiother Oncol 2021; 161:1-8. [PMID: 34015386 DOI: 10.1016/j.radonc.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 05/11/2021] [Accepted: 05/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE To investigate the possible contribution of indirect damage and damage saturation to tumour control obtained with SBRT/SRS treatments for early-stage NSCLC and brain metastases. METHODS AND MATERIALS We have constructed a dataset of early-stage NSCLC and brain metastases dose-response. These data were fitted to models based on the linear-quadratic (LQ), the linear-quadratic-linear (LQL), and phenomenological modifications of the LQ-model to account for indirect cell damage. We use the Akaike-Information-Criterion formalism to compare performance, and studied the stability of the results with changes in fitting parameters and perturbations on dose/TCP values. RESULTS In NSCLC, a modified LQ-model with a beta-term increasing with dose yields the best-fits for α/β = 10 Gy. Only the inclusion of very fast accelerated proliferation or low α/β values can eliminate such superiority. In brain, the LQL model yields the best-fits, and the ranking is not affected by variations of fitting parameters or dose/TCP perturbations. CONCLUSIONS For α/β = 10 Gy, a modified LQ-model with a beta-term increasing with dose provides better fits to NSCLC dose-response curves. For brain metastases, the LQL provides the best fit. This might be interpreted as a hint of indirect damage in NSCLC, and damage saturation in brain metastases. The results for NSCLC are strongly dependent on the value of α/β and may require further investigation, while those for brain seem to be clearly significant. Our results can assist in the design of improved radiotherapy for NSCLC and brain metastases, aiming at avoiding over/under-treatment.
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Affiliation(s)
- Araceli Gago-Arias
- Group of Medical Physics and Biomathematics, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain; Department of Medical Physics, Complexo Hospitalario Universitario de Santiago de Compostela, Spain; Institute of Physics, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile.
| | - Sara Neira
- Group of Medical Physics and Biomathematics, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
| | - Miguel Pombar
- Department of Medical Physics, Complexo Hospitalario Universitario de Santiago de Compostela, Spain; Group of Molecular Imaging and Oncology, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
| | - Antonio Gómez-Caamaño
- Group of Molecular Imaging and Oncology, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain; Department of Radiotherapy, Complexo Hospitalario Universitario de Santiago de Compostela, Spain
| | - Juan Pardo-Montero
- Group of Medical Physics and Biomathematics, Instituto de Investigación Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain; Department of Medical Physics, Complexo Hospitalario Universitario de Santiago de Compostela, Spain.
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16
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Lung Cancer Radiotherapy: Simulation and Analysis Based on a Multicomponent Mathematical Model. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:6640051. [PMID: 34012477 PMCID: PMC8105103 DOI: 10.1155/2021/6640051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/15/2021] [Indexed: 12/25/2022]
Abstract
Background Lung cancer has been one of the most deadly illnesses all over the world, and radiotherapy can be an effective approach for treating lung cancer. Now, mathematical model has been extended to many biomedical fields to give a hand for analysis, evaluation, prediction, and optimization. Methods In this paper, we propose a multicomponent mathematical model for simulating the lung cancer growth as well as radiotherapy treatment for lung cancer. The model is digitalized and coded for computer simulation, and the model parameters are fitted with many research and clinical data to provide accordant results along with the growth of lung cancer cells in vitro. Results Some typical radiotherapy plans such as stereotactic body radiotherapy, conventional fractional radiotherapy, and accelerated hypofractionated radiotherapy are simulated, analyzed, and discussed. The results show that our mathematical model can perform the basic work for analysis and evaluation of the radiotherapy plan. Conclusion It will be expected that in the near future, mathematical model will be a valuable tool for optimization in personalized medical treatment.
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17
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Kepka L, Socha J. Dose and fractionation schedules in radiotherapy for non-small cell lung cancer. Transl Lung Cancer Res 2021; 10:1969-1982. [PMID: 34012807 PMCID: PMC8107746 DOI: 10.21037/tlcr-20-253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the field of radiotherapy (RT), the issues of total dose, fractionation, and overall treatment time for non-small cell lung cancer (NSCLC) have been extensively investigated. There is some evidence to suggest that higher treatment intensity of RT, when given alone or sequentially with chemotherapy (CHT), is associated with improved survival. However, there is no evidence that the outcome is improved by RT at a higher dose and/or higher intensity when it is used concurrently with CHT. Moreover, some reports on the combination of full dose CHT with a higher biological dose of RT warn of the significant risk posed by such intensification. Stereotactic body radiotherapy (SBRT) provides a high rate of local control in the management of early-stage NSCLC through the use of high ablative doses. However, in centrally located tumors the use of SBRT may carry a risk of serious damage to the great vessels, bronchi, and esophagus, owing to the high ablative doses needed for optimal tumor control. There is a similar problem with moderate hypofractionation in radical RT for locally advanced NSCLC, and more evidence needs to be gathered regarding the safety of such schedules, especially when used in combination with CHT. In this article, we review the current evidence and questions related to RT dose/fractionation in NSCLC.
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Affiliation(s)
- Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
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18
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Klement RJ, Sonke JJ, Allgäuer M, Andratschke N, Appold S, Belderbos J, Belka C, Blanck O, Dieckmann K, Eich HT, Mantel F, Eble M, Hope A, Grosu AL, Nevinny-Stickel M, Semrau S, Sweeney RA, Hörner-Rieber J, Werner-Wasik M, Engenhart-Cabillic R, Ye H, Grills I, Guckenberger M. Correlating Dose Variables with Local Tumor Control in Stereotactic Body Radiation Therapy for Early-Stage Non-Small Cell Lung Cancer: A Modeling Study on 1500 Individual Treatments. Int J Radiat Oncol Biol Phys 2020; 107:579-586. [PMID: 32188579 DOI: 10.1016/j.ijrobp.2020.03.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/04/2020] [Accepted: 03/02/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Large variation regarding prescription and dose inhomogeneity exists in stereotactic body radiation therapy (SBRT) for early-stage non-small cell lung cancer. The aim of this modeling study was to identify which dose metric correlates best with local tumor control probability to make recommendations regarding SBRT prescription. METHODS AND MATERIALS We combined 2 retrospective databases of patients with non-small cell lung cancer, yielding 1500 SBRT treatments for analysis. Three dose parameters were converted to biologically effective doses (BEDs): (1) the (near-minimum) dose prescribed to the planning target volume (PTV) periphery (yielding BEDmin); (2) the (near-maximum) dose absorbed by 1% of the PTV (yielding BEDmax); and (3) the average between near-minimum and near-maximum doses (yielding BEDave). These BED parameters were then correlated to the risk of local recurrence through Cox regression. Furthermore, BED-based prediction of local recurrence was attempted by logistic regression and fast and frugal trees. Models were compared using the Akaike information criterion. RESULTS There were 1500 treatments in 1434 patients; 117 tumors recurred locally. Actuarial local control rates at 12 and 36 months were 96.8% (95% confidence interval, 95.8%-97.8%) and 89.0% (87.0%-91.1%), respectively. In univariable Cox regression, BEDave was the best predictor of risk of local recurrence, and a model based on BEDmin had substantially less evidential support. In univariable logistic regression, the model based on BEDave also performed best. Multivariable classification using fast and frugal trees revealed BEDmax to be the most important predictor, followed by BEDave. CONCLUSIONS BEDave was generally better correlated with tumor control probability than either BEDmax or BEDmin. Because the average between near-minimum and near-maximum doses was highly correlated to the mean gross tumor volume dose, the latter may be used as a prescription target. More emphasis could be placed on achieving sufficiently high mean doses within the gross tumor volume rather than the PTV covering dose, a concept needing further validation.
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Affiliation(s)
- Rainer J Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany.
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Michael Allgäuer
- Department of Radiotherapy, Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Steffen Appold
- Department of Radiation Oncology, Technische Universität Dresden, Dresden, Germany
| | - José Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Claus Belka
- Department of Radiation Oncology, University Hospital of Ludwig-Maximilians-University Munich, Munich, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Karin Dieckmann
- Department of Radiotherapy, Medical University of Vienna, Vienna, Austria
| | - Hans T Eich
- Department of Radiotherapy, University Hospital Münster, Münster, Germany
| | - Frederick Mantel
- Department of Radiotherapy and Radiation Oncology, University Hospital Wuerzburg, Wuerzberg, Germany
| | - Michael Eble
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
| | - Andrew Hope
- Department of Radiation Oncology, University of Toronto and Princess Margaret Cancer Center, Toronto, Canada
| | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
| | | | - Sabine Semrau
- Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Reinhart A Sweeney
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Maria Werner-Wasik
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Rita Engenhart-Cabillic
- Department of Radiotherapy and Radiation Oncology, Phillips-University Marburg, Marburg, Germany
| | - Hong Ye
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Inga Grills
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
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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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