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Jo NC, Shroff GS, Ahuja J, Agrawal R, Price MC, Wu CC. Radiation Recall Pneumonitis: Imaging Appearance and Differential Considerations. Korean J Radiol 2024; 25:843-850. [PMID: 39197829 PMCID: PMC11361796 DOI: 10.3348/kjr.2024.0334] [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: 04/03/2024] [Revised: 06/22/2024] [Accepted: 07/24/2024] [Indexed: 09/01/2024] Open
Abstract
Radiation recall pneumonitis is an inflammatory reaction of previously radiated lung parenchyma triggered by systemic pharmacological agents (such as chemotherapy and immunotherapy) or vaccination. Patients present with non-specific symptoms such as cough, shortness of breath, or hypoxia soon after the initiation of medication or vaccination. Careful assessment of the patient's history, including the thoracic radiation treatment plan and timing of the initiation of the triggering agent, in conjunction with CT findings, contribute to the diagnosis. Once a diagnosis is established, treatment includes cessation of the causative medication and/or initiation of steroid therapy. Differentiating this relatively rare entity from other common post-therapeutic complications in oncology patients, such as recurrent malignancy, infection, or medication-induced pneumonitis, is essential for guiding downstream clinical management.
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Affiliation(s)
- Nahyun Celina Jo
- Department of Diagnostic Radiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Girish S Shroff
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jitesh Ahuja
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rishi Agrawal
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Melissa C Price
- Department of Radiology, Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Boston, MA, USA
| | - Carol C Wu
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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2
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Shroff GS, Sheshadri A, Altan M, Truong MT, Erasmus LT, Vlahos I. Drug-induced Lung Disease in the Oncology Patient: From Cytotoxic Agents to Immunotherapy. Clin Chest Med 2024; 45:325-337. [PMID: 38816091 DOI: 10.1016/j.ccm.2024.02.006] [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] [Indexed: 06/01/2024]
Abstract
Drug-induced lung disease is commonly encountered, especially in the oncology setting. Diagnosis is challenging because clinical and radiologic findings are nonspecific, often overlapping with other lung pathologies in these patients due to underlying neoplasia, infection, or other treatment effects such as radiotherapy. Furthermore, oncology patients often receive multiple antineoplastic agents concurrently, and virtually every agent has an association with lung injury. In this article, we will review a variety of antineoplastic agents that are associated with drug-induced injury and discuss incidence, their typical timing of onset, and imaging features.
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Affiliation(s)
- Girish S Shroff
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1478, Houston, TX 77030, USA.
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1462, Houston, TX 77030, USA
| | - Mehmet Altan
- Department of Thoracic Head & Neck Medical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 0432, Houston, TX 77030, USA
| | - Mylene T Truong
- Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1478, Houston, TX 77030, USA
| | - Lauren T Erasmus
- McGill University, 845 Sherbrooke Street West, Montreal, Quebec H3A 0G4, Canada
| | - Ioannis Vlahos
- Department of Thoracic Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1478, Houston, TX 77030, USA
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Toussie D, Ginocchio LA, Cooper BT, Azour L, Moore WH, Villasana-Gomez G, Ko JP. Radiation Therapy for Lung Cancer: Imaging Appearances and Pitfalls. Clin Chest Med 2024; 45:339-356. [PMID: 38816092 DOI: 10.1016/j.ccm.2024.02.007] [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] [Indexed: 06/01/2024]
Abstract
Radiation therapy is part of a multimodality treatment approach to lung cancer. The radiologist must be aware of both the expected and the unexpected imaging findings of the post-radiation therapy patient, including the time course for development of post- radiation therapy pneumonitis and fibrosis. In this review, a brief discussion of radiation therapy techniques and indications is presented, followed by an image-heavy differential diagnostic approach. The review focuses on computed tomography imaging examples to help distinguish normal postradiation pneumonitis and fibrosis from alternative complications, such as infection, local recurrence, or radiation-induced malignancy.
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Affiliation(s)
- Danielle Toussie
- Department of Radiology, NYU Langone Health/NYU Grossman School of Medicine, 660 1st Avenue, New York, NY 10016, USA.
| | - Luke A Ginocchio
- Department of Radiology, NYU Langone Health/NYU Grossman School of Medicine, 660 1st Avenue, New York, NY 10016, USA
| | - Benjamin T Cooper
- Department of Radiation Oncology, NYU Langone Health/NYU Grossman School of Medicine, 160 East 34th Street, New York, NY 10016, USA
| | - Lea Azour
- Department of Radiology, David Geffen School of Medicine/UCLA Medical Center, 1250 16th Street, Los Angeles, CA 90404, USA
| | - William H Moore
- Department of Radiology, NYU Langone Health/NYU Grossman School of Medicine, 660 1st Avenue, New York, NY 10016, USA
| | - Geraldine Villasana-Gomez
- Department of Radiology, NYU Langone Health/NYU Grossman School of Medicine, 660 1st Avenue, New York, NY 10016, USA
| | - Jane P Ko
- Department of Radiology, NYU Langone Health/NYU Grossman School of Medicine, 660 1st Avenue, New York, NY 10016, USA
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Zhang GY, Du XZ, Xu R, Chen T, Wu Y, Wu XJ, Liu S. Development and Validation of a Machine Learning-Based Model Using CT Radiomics for Predicting Immune Checkpoint Inhibitor-related Pneumonitis in Patients With NSCLC Receiving Anti-PD1 Immunotherapy: A Multicenter Retrospective CaseControl Study. Acad Radiol 2024; 31:2128-2143. [PMID: 37977890 DOI: 10.1016/j.acra.2023.10.039] [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: 08/24/2023] [Revised: 10/06/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023]
Abstract
RATIONALE AND OBJECTIVES This study aimed to develop and evaluate a radiomics-based model combined with clinical and qualitative radiological (semantic feature [SF]) features to predict immune checkpoint inhibitor-related pneumonitis (CIP) in patients with non-small cell lung cancer (NSCLC) treated with programmed cell death protein 1 inhibitors. MATERIALS AND METHODS This was a multicenter retrospective casecontrol study conducted from January 1, 2018, to December 31, 2022, at three centers. Patients with NSCLC treated with anti-PD1 were enrolled and randomly divided into two groups (7:3): training (n = 95) and validation (n = 39). Logistic regression (LR) and support vector machine (SVM) algorithms were used to transform features into the models. RESULTS The study comprised 134 participants from three independent centers (male, 114/134, 85%; mean [±standard deviation] age, 63.92 [±7.9] years). The radiomics score (RS) models built based on the LR and SVM algorithms could accurately predict CIP (area under the receiver operating characteristics curve [AUC], 0.860 [0.780, 0.939] and 0.861 [0.781, 0.941], respectively). The AUCs for the RS-clinic-SF combined model were 0.903 (0.839, 0.967) and 0.826 (0.688, 0.964) in the training and validation cohorts, respectively. Decision curve analysis showed that the combined models achieved high clinical net benefit across the majority of the range of reasonable threshold probabilities. CONCLUSION This study demonstrated that the combined model constructed by the identified features of RS, clinical features, and SF has the potential to precisely predict CIP. The RS-clinic-SF combined model has the potential to be used more widely as a practical tool for the noninvasive prediction of CIP to support individualized treatment planning.
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Affiliation(s)
- Guo-Yue Zhang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, P.R. China (G.-y.Z., X.-z.D., R.X., Y.W., X.-j.W.).
| | - Xian-Zhi Du
- Department of Respiratory Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, P.R. China (G.-y.Z., X.-z.D., R.X., Y.W., X.-j.W.).
| | - Rui Xu
- Department of Respiratory Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, P.R. China (G.-y.Z., X.-z.D., R.X., Y.W., X.-j.W.).
| | - Ting Chen
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, P.R. China (T.C.).
| | - Yue Wu
- Department of Respiratory Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, P.R. China (G.-y.Z., X.-z.D., R.X., Y.W., X.-j.W.).
| | - Xiao-Juan Wu
- Department of Respiratory Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, P.R. China (G.-y.Z., X.-z.D., R.X., Y.W., X.-j.W.); Department of Respiratory and Critical Care Medicine, Suining Central Hospital, Suining, 629000, Sichuan, P.R. China (X.-j.W.).
| | - Shui Liu
- Department of Respiratory and Critical Care Medicine, People's Hospital of Fengjie, Fengjie, Chongqing, 404600, P.R. China (S.L.).
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5
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Kuipers ME, van Doorn-Wink KCJ, Hiemstra PS, Slats AM. Predicting Radiation-Induced Lung Injury in Patients With Lung Cancer: Challenges and Opportunities. Int J Radiat Oncol Biol Phys 2024; 118:639-649. [PMID: 37924986 DOI: 10.1016/j.ijrobp.2023.10.044] [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: 07/31/2023] [Revised: 10/06/2023] [Accepted: 10/22/2023] [Indexed: 11/06/2023]
Abstract
Radiation-induced lung injury (RILI) is one of the main dose-limiting toxicities in radiation therapy (RT) for lung cancer. Approximately 10% to 20% of patients show signs of RILI of variable severity. The reason for the wide range of RILI severity and the mechanisms underlying its development are only partially understood. A number of clinical risk factors have been identified that can aid in clinical decision making. Technological advancements in RT and the use of strict organ-at-risk dose constraints have helped to reduce RILI. Predicting patients at risk for RILI may be further improved with a combination of cytokine assessments, γH2AX-assays in leukocytes, or epigenetic markers. A complicating factor is the lack of an objective definition of RILI. Tools such as computed tomography densitometry, fluorodeoxyglucose-positron emission tomography uptake, changes in lung function measurements, and exhaled breath analysis can be implemented to better define and quantify RILI. This can aid in the search for new biomarkers, which can be accelerated by omics techniques, single-cell RNA sequencing, mass cytometry, and advances in patient-specific in vitro cell culture models. An objective quantification of RILI combined with these novel techniques can aid in the development of biomarkers to better predict patients at risk and allow personalized treatment decisions.
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Affiliation(s)
- Merian E Kuipers
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands.
| | | | - Pieter S Hiemstra
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annelies M Slats
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
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Bi J, Meng R, Yang D, Li Y, Cai J, Zhang L, Qian J, Xue X, Hu S, Yuan Z, Verma V, Bi N, Han G. Dosimetric predictors of radiation pneumonitis in patients with prior immunotherapy exposure: A multi-institutional analysis. Radiother Oncol 2024; 190:110040. [PMID: 38042497 DOI: 10.1016/j.radonc.2023.110040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/22/2023] [Accepted: 11/25/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND AND PURPOSE Combining immune checkpoint inhibitors (ICIs) and thoracic radiotherapy (TRT) may magnify the radiation pneumonitis (RP) risk. Dosimetric parameters can predict RP, but dosimetric data in context of immunotherapy are very scarce. To address this knowledge gap, we performed a large multicenter investigation to identify dosimetric predictors of RP in this under-studied population. MATERIALS AND METHODS All lung cancer patients from five institutions who underwent conventionally-fractionated thoracic intensity-modulated radiotherapy with prior ICI receipt were retrospectively compiled. RP was defined per CTCAE v5.0. Statistics utilized logistic regression modeling and receiver operating characteristic (ROC) analysis. RESULTS The vast majority of the 192 patients (median follow-up 14.7 months) had non-small cell lung cancer, received PD-1 inhibitors, and did not receive concurrent systemic therapy with TRT. Grades 1-5 RP occurred in 21.9%, 25.0%, 8.3%, 1.6%, and 1.0%, respectively. The mean MLD for patients with grades 1-5 RP was 10.7, 11.6, 12.6, 14.7, and 12.8 Gy, respectively. On multivariable analysis, tumor location and mean lung dose (MLD) significantly predicted for any-grade and grade ≥ 2 pneumonitis. Only MLD significantly predicted for grade ≥ 3 RP. ROC analysis was able to pictorially model RP risk probabilities for a variety of MLD thresholds, which can be an assistive tool during TRT treatment planning. CONCLUSION This study, by far the largest to date of dosimetric predictors of RP in the immunotherapy era, illustrates that MLD is the most critical dose-volume parameter influencing RP risk. These data may provide a basis for revising lung dose constraints in efforts to better prevent RP in this rapidly expanding ICI/TRT population.
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Affiliation(s)
- Jianping Bi
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China; Hubei Key Laboratory of Precision Radiation Oncology, Wuhan 430022, China
| | - Rui Meng
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Dongqin Yang
- Department of Oncology, the Fifth Hospital of Wuhan, Wuhan, Hubei, People's Republic of China
| | - Ying Li
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Jun Cai
- Department of Oncology, First Affiliated Hospital of Yangtze University, Jingzhou, Hubei, People's Republic of China
| | - Li Zhang
- Department of Oncology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jing Qian
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, MA, United States
| | - Xudong Xue
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Shiqi Hu
- Wuhan Tongji Aerospace City Hospital, Longwang Tsui Farm, Yangluo Street, Xinzhou District, Wuhan, Hubei, People's Republic of China
| | - Zilong Yuan
- Department of Radiology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Vivek Verma
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, United States
| | - Nan Bi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China.
| | - Guang Han
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China.
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Yakymenko D, Skougaard K. A retrospective study on immune-related pneumonitis in patients with non-small-cell lung cancer undergoing treatment with PD-1/PD-L1 inhibitors. Eur Clin Respir J 2023; 10:2194162. [PMID: 37025977 PMCID: PMC10071953 DOI: 10.1080/20018525.2023.2194162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Background Lung cancer patients undergoing treatment with immune checkpoint inhibitors (ICIs) are at risk of developing immune-related (ir-)pneumonitis. Since lung cancer patients have competing reasons for respiratory symptoms, this poses a diagnostic challenge. This study aimed to explore diagnosis and management of ir-pneumonitis in this patient group. Materials and Methods Suspected ir-pneumonitis was frequent in this group of patients. The cohort was characterized by high heterogeneity and lack of unequivocal diagnostic conclusions. Treatment of ir-pneumonitis was longer than recommended and involvement of pulmonologist was very infrequent. The result of this study reflects the difficulties in a daily clinical setting to diagnose and manage patients with lung cancer presenting with pulmonary symptoms. Results Suspected ir-pneumonitis was frequent in this group of patients. The cohort was characterized by high heterogeneity and lack of unequivocal diagnostic conclusions. Treatment of ir-pneumonitis was longer than recommended and involvement of pulmonologist was very infrequent. The result of this study reflects the difficulties in a daily clinical setting to diagnose and manage patients with lung cancer presenting with pulmonary symptoms.
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Affiliation(s)
- Dorthe Yakymenko
- Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
- CONTACT Dorthe Yakymenko Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Kristin Skougaard
- Centre for Medicines Licensing & Pharmacovigilance Oncology & Hematology, Danish Medicines Agency, Copenhagen, Denmark
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Guan S, Zhang S, Ren K, Li X, Li X, Zhao L. Induction chemoimmunotherapy may improve outcomes of chemoradiotherapy in patients with unresectable stage III NSCLC. Front Immunol 2023; 14:1289207. [PMID: 38090575 PMCID: PMC10711043 DOI: 10.3389/fimmu.2023.1289207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/13/2023] [Indexed: 12/18/2023] Open
Abstract
Background Currently, the value of induction chemoimmunotherapy before chemoradiotherapy (CRT) in unresectable stage III non-small cell lung cancer (NSCLC) has not been explored. This study was designed to explore the efficacy and safety of induction chemoimmunotherapy in patients with unresectable stage III NSCLC. Methods Unresectable stage III NSCLC patients who received CRT with or without induction chemoimmunotherapy between August 2014 and December 2021 were retrospectively enrolled. Progression-free survival (PFS) and overall survival (OS) were assessed from the initiation of treatment and estimated by the Kaplan-Meier method. The potential factors affecting PFS and OS were analyzed by univariate and multivariate Cox regression models. One-to-one propensity score matching (PSM) was used to further minimize confounding. Results A total of 279 consecutive patients were enrolled, with 53 (19.0%) receiving induction chemoimmunotherapy followed by CRT (I-CRT group), and the remaining 226 (81.0%) receiving CRT alone (CRT group). After PSM, the median PFS was 24.8 months in the I-CRT group vs. 13.3 months in the CRT group (P=0.035). The median OS was not reached (NR) vs. 36.6 months ((P=0.142). The incidence of treatment-related adverse events (TRAEs) was similar in both groups, except that the incidence of hematological toxicity was higher in the I-CRT group (77.1% vs. 58.3%, P=0.049). Compared to induction chemotherapy, induction chemoimmunotherapy demonstrated a superior objective response rate (60.4% vs. 22.2%, P<0.001) and further prolonged PFS (median NR vs. 13.2 months, P=0.009) and OS (median NR vs. 25.9 months, P=0.106) without increasing the incidence of TRAEs in patients receiving concurrent chemoradiotherapy. Conclusion Induction chemoimmunotherapy is safe and may improve outcomes of CRT in patients with unresectable stage III NSCLC. Moreover, induction chemoimmunotherapy may further improve treatment response and survival outcomes compared to induction chemotherapy before cCRT.
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Affiliation(s)
- Song Guan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Shufeng Zhang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Kai Ren
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Xingyue Li
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Xue Li
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Lujun Zhao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
- Tianjin’s Clinical Research Center for Cancer, Tianjin, China
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Sun L, Wang Y, Zhu L, Chen J, Chen Z, Qiu Z, Wu C. Analysis of the risk factors of radiation pneumonitis in patients after radiotherapy for esophageal squamous cell carcinoma. Front Oncol 2023; 13:1198872. [PMID: 38023119 PMCID: PMC10662299 DOI: 10.3389/fonc.2023.1198872] [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: 04/02/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To predict the risk factors of radiation pneumonitis (RP) in patients with esophageal squamous cell carcinoma (ESCC) who received radiotherapy. Methods From January 2015 to October 2021, 477 ESCC patients were enrolled and were assessed retrospectively. All these patients received radiotherapy for primary lesions or mediastinal metastatic lymph nodes. Clinical efficacy and adverse events (AEs) were observed. Univariate analysis identified clinical and dosimetric factors associated with the development of RP, and multivariate logistic regression analysis identified independent potential risk factors associated with the development of RP. Nomograms were constructed to predict RP based on the results of multivariate logistic regression analysis. Results Among the 477 ESCC patients, the incidence of RP was 22.2%, and the incidence of grade 4 or higher RP was 1.5%. Univariate analysis indicated that chronic obstructive pulmonary disease (COPD), pulmonary infection, leucopenia, PTV volume, V5, V20, V30 and MLD affected the occurrence of RP. The multivariate logistic regression analysis indicated that COPD (OR:1.821, 95%CI:1.111-2.985; P=0.017), pulmonary infection (OR:2.528, 95%CI:1.530-4.177; P<0.001), higher V20 (OR: 1.129, 95% CI:1.006-1.266; P=0.029) were significant independent predictors of RP in ESCC patients. COPD, pulmonary infection, V20 have been integrated for the RP nomogram. The rate of RP was significantly reduced in the V20<21.45% group. Further analysis indicated that the old age, diabetes, higher V20, and higher MLD were risk factors for grade 4 or higher RP. The area under the curve (AUC) value for V20 was 0.73 (95% CI, 0.567-0.893, P < 0.05). Conclusion We have determined the risk factors of RP and grade 4 or higher RP in ESCC patients after radiotherapy. MLD, V20, COPD were independent factors for RP. It was necessary to take measures to reduce or avoid the occurrence of RP for patients with these risk factors at the early stage.
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Affiliation(s)
- Lu Sun
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Yan Wang
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Lihua Zhu
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Jun Chen
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Zhifu Chen
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Zhiyuan Qiu
- Department of Oncology, the People’s Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Chaoyang Wu
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
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10
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Kao LE, Stover D. Radiation recall pneumonitis from immune checkpoint inhibitors after extra pulmonary radiation. Respirol Case Rep 2023; 11:e01223. [PMID: 37731586 PMCID: PMC10507574 DOI: 10.1002/rcr2.1223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/11/2023] [Indexed: 09/22/2023] Open
Abstract
Radiation recall is an unpredictable, poorly understood inflammatory reaction within the confines of previously irradiated tissue that occurs following exposure to a systemic agent. In this article, we will focus on a subcategory of radiation recall, called radiation recall pneumonitis (RRP), precipitated by immune checkpoint inhibitors (ICI). Historically, RRP can develop weeks to years after radiation treatment to the lung, most commonly after receiving certain chemotherapeutic agents, but more recently has been recognized in association with immunotherapy agents (ICIs). Up until now, RRP following exposure to ICIs has been described in patients who have received radiation to the lung itself. Here we present three cases of RRP in patients who received radiation to areas adjacent to the lung parenchyma, and developed pulmonary infiltrates in an area adjacent to the radiation field while on ICI therapy. Since ICI induced RRP is treatable and steroid sensitive, early recognition and treatment are important.
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Affiliation(s)
- Leslie E. Kao
- Pulmonary Medicine ServiceMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Diane Stover
- Pulmonary Medicine ServiceMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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11
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Murphy DJ, Mayoral M, Larici AR, Ginsberg MS, Cicchetti G, Fintelmann FJ, Marom EM, Truong MT, Gill RR. Imaging Follow-Up of Nonsurgical Therapies for Lung Cancer: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2023; 221:409-424. [PMID: 37095669 PMCID: PMC11037936 DOI: 10.2214/ajr.23.29104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Lung cancer continues to be the most common cause of cancer-related death worldwide. In the past decade, with the implementation of lung cancer screening programs and advances in surgical and nonsurgical therapies, the survival of patients with lung cancer has increased, as has the number of imaging studies that these patients undergo. However, most patients with lung cancer do not undergo surgical re-section, because they have comorbid disease or lung cancer in an advanced stage at diagnosis. Nonsurgical therapies have continued to evolve with a growing range of systemic and targeted therapies, and there has been an associated evolution in the imaging findings encountered at follow-up examinations after such therapies (e.g., with respect to posttreatment changes, treatment complications, and recurrent tumor). This AJR Expert Panel Narrative Review describes the current status of nonsurgical therapies for lung cancer and their expected and unexpected imaging manifestations. The goal is to provide guidance to radiologists regarding imaging assessment after such therapies, focusing mainly on non-small cell lung cancer. Covered therapies include systemic therapy (conventional chemotherapy, targeted therapy, and immunotherapy), radiotherapy, and thermal ablation.
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Affiliation(s)
- David J. Murphy
- Department of Radiology, St Vincent’s University Hospital and University College Dublin, Dublin, Ireland
| | - Maria Mayoral
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY
- Medical Imaging Department, Hospital Clinic Barcelona, Barcelona, Spain
| | - Anna R. Larici
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
- Department of Radiological and Hematological Sciences, Section of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Giuseppe Cicchetti
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
- Department of Radiological and Hematological Sciences, Section of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Florian J. Fintelmann
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Edith M. Marom
- Chaim Sheba Medical Center, Ramat Gan, and Tel Aviv University, Tel Aviv, Israel
| | - Mylene T. Truong
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ritu R. Gill
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02115. Address correspondence to R. R. Gill ()
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Shu Y, Xu W, Su R, Ran P, Liu L, Zhang Z, Zhao J, Chao Z, Fu G. Clinical applications of radiomics in non-small cell lung cancer patients with immune checkpoint inhibitor-related pneumonitis. Front Immunol 2023; 14:1251645. [PMID: 37799725 PMCID: PMC10547882 DOI: 10.3389/fimmu.2023.1251645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/24/2023] [Indexed: 10/07/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) modulate the body's immune function to treat tumors but may also induce pneumonitis. Immune checkpoint inhibitor-related pneumonitis (ICIP) is a serious immune-related adverse event (irAE). Immunotherapy is currently approved as a first-line treatment for non-small cell lung cancer (NSCLC), and the incidence of ICIP in NSCLC patients can be as high as 5%-19% in clinical practice. ICIP can be severe enough to lead to the death of NSCLC patients, but there is a lack of a gold standard for the diagnosis of ICIP. Radiomics is a method that uses computational techniques to analyze medical images (e.g., CT, MRI, PET) and extract important features from them, which can be used to solve classification and regression problems in the clinic. Radiomics has been applied to predict and identify ICIP in NSCLC patients in the hope of transforming clinical qualitative problems into quantitative ones, thus improving the diagnosis and treatment of ICIP. In this review, we summarize the pathogenesis of ICIP and the process of radiomics feature extraction, review the clinical application of radiomics in ICIP of NSCLC patients, and discuss its future application prospects.
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Affiliation(s)
- Yang Shu
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- The Second Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Wei Xu
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Department of Oncology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Rui Su
- College of Artificial Intelligence and Big Data for Medical Sciences, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Pancen Ran
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- The Second Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Lei Liu
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhizhao Zhang
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jing Zhao
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhen Chao
- College of Artificial Intelligence and Big Data for Medical Sciences, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Guobin Fu
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- The Second Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
- Department of Oncology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
- Department of Oncology, The Third Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China
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Guan S, Ren K, Zhang X, Yan M, Li X, Zhao L. Concurrent chemoradiotherapy versus radiotherapy alone after induction chemoimmunotherapy for stage III NSCLC patients who did not undergo surgery: a single institution retrospective study. Radiat Oncol 2023; 18:122. [PMID: 37491257 PMCID: PMC10367242 DOI: 10.1186/s13014-023-02305-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/21/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND With remarkable success and few side effects, induction chemoimmunotherapy has been used to improve the prognosis of patients with resectable or potentially resectable non-small cell lung cancer (NSCLC), even in stage III disease. However, for patients who are medically inoperable, unresectable or refuse surgery after induction chemoimmunotherapy, it is unclear whether patients should be treated with concurrent chemoradiotherapy (cCRT) or radiotherapy (RT) alone considering patient safety and tolerability. This study aimed to determine whether cCRT is safe and superior to RT alone after chemoimmunotherapy for stage III NSCLC. METHODS Patients diagnosed with stage III NSCLC who received chemoimmunotherapy followed by cCRT/RT alone without surgery at Tianjin Cancer Hospital between November 2018 to December 2021 were retrospectively collected. Patients were divided into two groups: induction chemoimmunotherapy followed by cCRT (cCRT cohort) or RT alone (RT alone cohort). Kaplan-Meier method was used to estimate survival. Univariate and multivariate Cox regression models were adopted to estimate risk factors for PFS. RESULTS Sixty-five patients were included, with 44 (67.7%) received RT alone and 21 (32.3%) received cCRT. Patients in the cCRT group had significantly prolonged PFS (HR = 0.155, p = 0.004), LPFS (HR = 0.225, p = 0.029) and DMFS (HR = 0.028, p = 0.006) than those in the RT alone group. Albeit nonsignificant, a trend toward improved OS (HR = 0.030, p = 0.069) was also observed in the cCRT group. The multivariate analysis further confirmed that cCRT (HR = 0.141, p = 0.008) was the independent factor for promoting a favorable PFS. Treatment-related adverse events were similar between groups (p > 0.05). Patients with consolidation immunotherapy exhibited a trend of improved PFS (HR = 0.398, p = 0.274) and numerically better OS (HR = 0.018, p = 0.209) compared with those without. CONCLUSIONS For patients with unresectable stage III NSCLC, cCRT following chemoimmunotherapy appears to be safe and may prolong survival compared with radiotherapy alone. Further investigations on the combination of chemoimmunotherapy and CRT are warranted.
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Affiliation(s)
- Song Guan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Kai Ren
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Xuyu Zhang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Meng Yan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Xue Li
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China
- Tianjin's Clinical Research Center for Cancer, Tianjin, China
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Lujun Zhao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center for Cancer, Tianjin, China.
- Tianjin's Clinical Research Center for Cancer, Tianjin, China.
- Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.
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Peng J, Zhang L, Wang L, Feng H, Yao D, Meng R, Liu X, Li X, Liu N, Tan B, Huang Z, Li S, Meng X. Real-world outcomes of PD-L1 inhibitors combined with thoracic radiotherapy in the first-line treatment of extensive stage small cell lung cancer. Radiat Oncol 2023; 18:111. [PMID: 37403111 DOI: 10.1186/s13014-023-02308-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND The CREST study showed that the addition of thoracic radiotherapy (TRT) could improve the survival rate in patients with extensive stage small cell lung cancer (ES-SCLC), but whether TRT can bring survival benefit in the era of immunotherapy remains controversial. This study aimed to explore the efficacy and safety of adding TRT to the combination of PD-L1 inhibitors and chemotherapy. METHODS The patients who received durvalumab or atezolizumab combined with chemotherapy as the first-line treatment of ES-SCLC from January 2019 to December 2021 were enrolled. They were divided into two groups, based on whether they received TRT or not. Propensity score matching (PSM) with a 1:1 ratio was performed. The primary endpoints were progression-free survival (PFS), overall survival (OS) and safety. RESULTS A total of 211 patients with ES-SCLC were enrolled, of whom 70 (33.2%) patients received standard therapy plus TRT as first-line treatment, and 141 (66.8%) patients in the control group received PD-L1 inhibitors plus chemotherapy. After PSM, a total of 57 pairs of patients were enrolled in the analysis. In all patients, the median PFS (mPFS) in the TRT and non-TRT group was 9.5 and 7.2 months, respectively, with HR = 0.59 (95%CI 0.39-0.88, p = 0.009). The median OS (mOS) in the TRT group was also significantly longer than that in the non-TRT group (24.1 months vs. 18.5 months, HR = 0.53, 95%CI 0.31-0.89, p = 0.016). Multivariable analysis showed that baseline liver metastasis and the number of metastases ≥ 3 were independent prognostic factors for OS. Addition of TRT increased the incidence of treatment-related pneumonia (p = 0.018), most of which were grade 1-2. CONCLUSIONS Addition of TRT to durvalumab or atezolizumab plus chemotherapy significantly improves survival in ES-SCLC. Although it may leads to increased incidence of treatment-related pneumonia, a majority of the cases can be relieved after symptomatic treatment.
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Affiliation(s)
- Jianfeng Peng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China
| | - Lemeng Zhang
- Department of Thoracic Department, Hunan Cancer Hospital, Changsha, China
| | - Liping Wang
- Department of Medical Oncology, Baotou Cancer Hospital, Baotou, China
| | - Hui Feng
- Department of Clinical Oncolygy, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Dongmei Yao
- Department of Medical Oncology, Chaoyang Second Hospital, Chaoyang, China
| | - Rui Meng
- Department of Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaomei Liu
- Department of Oncology Department, Jinzhou Medical University, Jinzhou, China
| | - Xiaohua Li
- Department of Respiratory and Critical Care, Chifeng Municipal Hospital, Chifeng, Inner Mongolia, China
| | - Ningbo Liu
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital, Tianjin, China
| | - Bingxu Tan
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Zhaoqin Huang
- Department of Radiology, Shandong Provincial Hospital, Jinan, China
| | - Shanshan Li
- Department of Oncology, Zibo Municipal Hospital, Zibo, China
| | - Xiangjiao Meng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China.
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Yang M, You Y, Wang X, Dong W. I-125 seeds brachytherapy combined with immunotherapy for MET amplification in non-small cell lung cancer from clinical application to related lncRNA mechanism explore: a case report. Front Cell Dev Biol 2023; 11:1176083. [PMID: 37389354 PMCID: PMC10300560 DOI: 10.3389/fcell.2023.1176083] [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: 02/28/2023] [Accepted: 05/31/2023] [Indexed: 07/01/2023] Open
Abstract
Advanced non-small cell lung cancer (NSCLC) with MET amplification primarily relies on MET inhibitors for treatment, but once resistance occurs, the available treatment options are limited and the prognosis is typically poor. A 57-year-old man with advanced NSCLC and C-MET amplification was initially treated with crizotinib but developed progressive disease. After the antirotinib treatment, he achieved a partial response for a year. Genetic testing showed high PD-L1 expression, and he was treated with pembrolizumab and chemotherapy for 3 months, with partial response. Maintenance therapy with pembrolizumab and local I-125 seeds brachytherapy (ISB) was given after the lung lesion progressed but other lesions remained stable. The therapy resulted in significant resolution of the right upper lung lesion. It demonstrates the effectiveness of ISB-ICI combination in treating MET amplification advanced NSCLC. Ongoing research and treatment innovation are important in managing advanced NSCLC with complex genetic aberrations. To explore the candidate mechanism of ISB therapy response, we download public genetic data and conduct different expression Lncrnas analysis and pathway analysis to discover radiotherapy related sensitive or resistance lncRNAs and pathways, we found that AL654754.1 is a key lncRNA with radiotherapy response, and it also include in classical p53 and Wnt signaling pathway. Overall, the clinical case reports, combined with the exploration of underlying mechanisms, provide positive guidance for the precise treatment of lung cancer.
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Jacob RA, Bade B, Joffe L, Makkar P, Alfano CM. The Evaluation and Management of Visceral Complications in Radiation Fibrosis Syndrome Part 1. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2023; 11:1-14. [PMID: 37359732 PMCID: PMC10043528 DOI: 10.1007/s40141-023-00391-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 03/30/2023]
Abstract
Abstract External beam ionizing radiation is a fundamental component of cancer treatment and is incorporated into approximately 50% of cancer treatments. Radiation therapy causes cell death directly by apoptosis and indirectly by disruption of mitosis. Purpose of Review This study aims to inform rehabilitation clinicians of the visceral toxicities of radiation fibrosis syndrome and how to detect and diagnose these complications. Recent Findings Latest research indicates that radiation toxicity is primarily related to radiation dose, patient co-morbidity, and concomitant use of chemotherapies and immunotherapies for the treatment of cancer. While cancer cells are the primary target, surrounding normal cells and tissues are also affected. Radiation toxicity is dose dependent, and tissue injury develops from inflammation that may progress to fibrosis. Thus, radiation dosing in cancer therapy is often limited by tissue toxicity. Although newer radiotherapeutic modalities aim to limit delivery of radiation to non-cancerous tissues, many patients continue to experience toxicity. Summary To ensure early recognition of radiation toxicity and fibrosis, it is imperative that all clinicians are aware of the predictors, signs, and symptoms of radiation fibrosis syndrome. Here, we present part 1 of the visceral complications of radiation fibrosis syndrome, addressing radiation-related toxicity in the heart, lungs, and thyroid gland. Graphical abstract
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Kroeze SGC, Pavic M, Stellamans K, Lievens Y, Becherini C, Scorsetti M, Alongi F, Ricardi U, Jereczek-Fossa BA, Westhoff P, But-Hadzic J, Widder J, Geets X, Bral S, Lambrecht M, Billiet C, Sirak I, Ramella S, Giovanni Battista I, Benavente S, Zapatero A, Romero F, Zilli T, Khanfir K, Hemmatazad H, de Bari B, Klass DN, Adnan S, Peulen H, Salinas Ramos J, Strijbos M, Popat S, Ost P, Guckenberger M. Metastases-directed stereotactic body radiotherapy in combination with targeted therapy or immunotherapy: systematic review and consensus recommendations by the EORTC-ESTRO OligoCare consortium. Lancet Oncol 2023; 24:e121-e132. [PMID: 36858728 DOI: 10.1016/s1470-2045(22)00752-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 03/02/2023]
Abstract
Stereotactic body radiotherapy (SBRT) for patients with metastatic cancer, especially when characterised by a low tumour burden (ie, oligometastatic disease), receiving targeted therapy or immunotherapy has become a frequently practised and guideline-supported treatment strategy. Despite the increasing use in routine clinical practice, there is little information on the safety of combining SBRT with modern targeted therapy or immunotherapy and a paucity of high-level evidence to guide clinical management. A systematic literature review was performed to identify the toxicity profiles of combined metastases-directed SBRT and targeted therapy or immunotherapy. These results served as the basis for an international Delphi consensus process among 28 interdisciplinary experts who are members of the European Society for Radiotherapy and Oncology (ESTRO) and European Organisation for Research and Treatment of Cancer (EORTC) OligoCare consortium. Consensus was sought about risk mitigation strategies of metastases-directed SBRT combined with targeted therapy or immunotherapy; a potential need for and length of interruption to targeted therapy or immunotherapy around SBRT delivery; and potential adaptations of radiation dose and fractionation. Results of this systematic review and consensus process compile the best available evidence for safe combination of metastases-directed SBRT and targeted therapy or immunotherapy for patients with metastatic or oligometastatic cancer and aim to guide today's clinical practice and the design of future clinical trials.
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Affiliation(s)
- Stephanie G C Kroeze
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland; Centre for Radiation Oncology KSA-KSB, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Matea Pavic
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Karin Stellamans
- Department of Radiation Oncology, AZ Groeninge Campus Kennedylaan, Kortrijk, Belgium
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, Gent, Belgium
| | - Carlotta Becherini
- Department of Radiation Oncology, Careggi University Hospital, Florence, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology department, IRCCS Sacro Cuore don Calabria Hospital, Negrar di Valpolicella, Italy; Department of Radiation Oncology, University of Brescia, Brescia, Italy
| | | | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Paulien Westhoff
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jasna But-Hadzic
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Joachim Widder
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Xavier Geets
- Department of Radiation Oncology, Cliniques universitaires Saint-Luc, MIRO-IREC Lab, Université catholique de Louvain, Brussels, Belgium
| | - Samuel Bral
- Department of Radiation Oncology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - Maarten Lambrecht
- Department of Radiotherapy-Oncology, Leuvens Kanker Instituut, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | | | - Igor Sirak
- Department of Oncology and Radiotherapy, University Hospital, Hradec Králové, Czech Republic
| | - Sara Ramella
- Department of Radiation Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Sergi Benavente
- Department of Radiation Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Almudena Zapatero
- Department of Radiation Oncology, Hospital Universitario de La Princesa, Health Research Institute, Madrid, Spain
| | - Fabiola Romero
- Department of Radiation Oncology, Hospital Universitario Reina Sofia, Cordoba, Spain
| | - Thomas Zilli
- Department of Radiation Oncology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Kaouthar Khanfir
- Department of Radiation Oncology, Hôpital Valais, Sion, Switzerland
| | - Hossein Hemmatazad
- Department of Radiation Oncology, Inselspital University Hospital, Bern, Switzerland; Department of Radiation Oncology, University of Bern, Bern, Switzerland
| | - Berardino de Bari
- Service Radio-Oncologie Neuchåtel Hôpital Network, La Chaux-de-Fonds, Switzerland
| | - Desiree N Klass
- Institute of Radiation Oncology, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Shaukat Adnan
- Department of Oncology, Aberdeen Royal Infirmary, UK
| | - Heike Peulen
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, Netherlands
| | - Juan Salinas Ramos
- Radiation Oncology Department, Santa Lucia General University Hospital, Cartagena, Spain
| | - Michiel Strijbos
- Department of Oncology, GasthuisZusters Antwerpen, Antwerpen, Belgium
| | | | - Piet Ost
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium
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Frost N, Unger K, Gerriet Blum T, Misch D, Kurz S, Lüders H, Olive E, Raspe M, Hilbrandt M, Koch M, Böhmer D, Senger C, Witzenrath M, Grohé C, Bauer T, Modest DP, Kollmeier J. Management, risk factors and prognostic impact of checkpoint-inhibitor pneumonitis (CIP) in lung cancer – A multicenter observational analysis. Lung Cancer 2023; 179:107184. [PMID: 37040677 DOI: 10.1016/j.lungcan.2023.107184] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Checkpoint-inhibitor pneumonitis (CIP) represents a major immune-related adverse event (irAE) in patients with lung cancer. We aimed for the clinical characterization, diagnostics, risk factors, treatment and outcome in a large cohort of patients from everyday clinical practice. PATIENTS AND METHODS For this retrospective analysis, 1,376 patients having received checkpoint inhibitors (CPI) in any line of therapy from June 2015 until February 2020 from three large-volume lung cancer centers in Berlin, Germany were included and analyzed. RESULTS With a median follow-up of 35 months, all-grade, high-grade (CTCAE ≥ 3) and fatal CIP were observed in 83 (6.0%), 37 (2.7%) and 12 (0.9%) patients, respectively, with a median onset 4 months after initiation of CPI therapy. The most common radiologic patterns were organizing pneumonia (OP) and non-specific interstitial pneumonia (NSIP) (37% and 31%). All except 7 patients with G1-2 CIP interrupted treatment. Corticosteroids were administered to 74 patients with a median starting dose of 0.75 mg/kg. After complete restitution (n = 67), re-exposure to CPI (n = 14) led to additional irAE in 43% of the cases. Thoracic radiotherapy targeting the lung was the only independent risk factor for CIP (odds ratio 2.8, p < 0.001) and pretherapeutic diffusing capacity for carbon monoxide inversely correlated with CIP severity. Compared with patients without CIP and non-CIP irAE, CIP was associated with impaired overall survival (hazard ratios 1.23, p = 0.24 and 2.01, p = 0.005). CONCLUSIONS High-grade CIP accounts for almost half of all CIP cases in an allcomer lung cancer population. A continuous vigilance, rapid diagnostics and adequate treatment are key to prevent disease progression associated with impaired survival.
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Grassi F, Granata V, Fusco R, De Muzio F, Cutolo C, Gabelloni M, Borgheresi A, Danti G, Picone C, Giovagnoni A, Miele V, Gandolfo N, Barile A, Nardone V, Grassi R. Radiation Recall Pneumonitis: The Open Challenge in Differential Diagnosis of Pneumonia Induced by Oncological Treatments. J Clin Med 2023; 12:jcm12041442. [PMID: 36835977 PMCID: PMC9964719 DOI: 10.3390/jcm12041442] [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: 01/08/2023] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023] Open
Abstract
The treatment of primary and secondary lung neoplasms now sees the fundamental role of radiotherapy, associated with surgery and systemic therapies. The improvement in survival outcomes has also increased attention to the quality of life, treatment compliance and the management of side effects. The role of imaging is not only limited to recognizing the efficacy of treatment but also to identifying, as soon as possible, the uncommon effects, especially when more treatments, such as chemotherapy, immunotherapy and radiotherapy, are associated. Radiation recall pneumonitis is an uncommon treatment complication that should be correctly characterized, and it is essential to recognize the mechanisms of radiation recall pneumonitis pathogenesis and diagnostic features in order to promptly identify them and adopt the best therapeutic strategy, with the shortest possible withdrawal of the current oncological drug. In this setting, artificial intelligence could have a critical role, although a larger patient data set is required.
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Affiliation(s)
- Francesca Grassi
- Division of Radiology, Università Degli Studi Della Campania Luigi Vanvitelli, 80127 Naples, Italy
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
| | - Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
- Correspondence:
| | - Roberta Fusco
- Medical Oncology Division, Igea SpA, 80015 Naples, Italy
| | - Federica De Muzio
- Diagnostic Imaging Section, Department of Medical and Surgical Sciences & Neurosciences, University of Molise, 86100 Campobasso, Italy
| | - Carmen Cutolo
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Salerno, Italy
| | - Michela Gabelloni
- Department of Translational Research, Diagnostic and Interventional Radiology, University of Pisa, 56126 Pisa, Italy
| | - Alessandra Borgheresi
- Department of Clinical, Special and Dental Sciences, University Politecnica Delle Marche, Via Conca 71, 60126 Ancona, Italy
- Department of Radiology, University Hospital “Azienda Ospedaliera Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy
| | - Ginevra Danti
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Carmine Picone
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Andrea Giovagnoni
- Department of Clinical, Special and Dental Sciences, University Politecnica Delle Marche, Via Conca 71, 60126 Ancona, Italy
- Department of Radiology, University Hospital “Azienda Ospedaliera Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy
| | - Vittorio Miele
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Nicoletta Gandolfo
- Diagnostic Imaging Department, Villa Scassi Hospital-ASL 3, Corso Scassi 1, 16149 Genoa, Italy
| | - Antonio Barile
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy
| | - Valerio Nardone
- Division of Radiology, Università Degli Studi Della Campania Luigi Vanvitelli, 80127 Naples, Italy
| | - Roberta Grassi
- Division of Radiology, Università Degli Studi Della Campania Luigi Vanvitelli, 80127 Naples, Italy
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20
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Radiation Recall Pneumonitis Anticipates Bilateral Immune-Induced Pneumonitis in Non-Small Cell Lung Cancer. J Clin Med 2023; 12:jcm12041266. [PMID: 36835802 PMCID: PMC9961042 DOI: 10.3390/jcm12041266] [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: 12/22/2022] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023] Open
Abstract
Radiation recall pneumonitis (RRP) is a rare inflammatory reaction that occurs in previously irradiated fields, and it may be caused by various triggering agents. Immunotherapy has been reported to potentially be one of these triggers. However, precise mechanisms and specific treatments have not been explored yet due to a lack of data in this setting. Here, we report a case of a patient who received radiation therapy and immune checkpoint inhibitor therapy for non-small cell lung cancer. He developed first radiation recall pneumonitis and subsequently immune-checkpoint inhibitor-induced pneumonitis (IIP). After presenting the case, we discuss the currently available literature on RRP and the challenges of differential diagnosis between RRP, IIP, and other forms of pneumonitis. We believe that this case is of particular clinical value since it highlights the importance of including RRP in a differential diagnosis of lung consolidation during immunotherapy. Furthermore, it suggests that RRP might anticipate more extensive ICI-induced pneumonitis.
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21
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Shroff GS, Strange CD, Ahuja J, Altan M, Sheshadri A, Unlu E, Truong MT, Vlahos I. Imaging of Immune Checkpoint Inhibitor Immunotherapy for Non-Small Cell Lung Cancer. Radiographics 2022; 42:1956-1974. [PMID: 36240075 DOI: 10.1148/rg.220108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The normal immune system identifies and eliminates precancerous and cancerous cells. However, tumors can develop immune resistance mechanisms, one of which involves the exploitation of pathways, termed immune checkpoints, that normally suppress T-cell function. The goal of immune checkpoint inhibitor (ICI) immunotherapy is to boost T-cell-mediated immunity to mount a more effective attack on cancer cells. ICIs have changed the treatment landscape of advanced non-small cell lung cancer (NSCLC), and numerous ICIs have now been approved as first-line treatments for NSCLC by the U.S. Food and Drug Administration. ICIs can cause atypical response patterns such as pseudoprogression, whereby the tumor burden initially increases but then decreases. Therefore, response criteria have been developed specifically for patients receiving immunotherapy. Because ICIs activate the immune system, they can lead to inflammatory side effects, termed immune-related adverse events (irAEs). Usually occurring within weeks to months after the start of therapy, irAEs range from asymptomatic abnormal laboratory results to life-threatening conditions such as encephalitis, pneumonitis, myocarditis, hepatitis, and colitis. It is important to be aware of the imaging appearances of the various irAEs to avoid misinterpreting them as metastatic disease, progressive disease, or infection. The basic principles of ICI therapy; indications for ICI therapy in the setting of NSCLC; response assessment and atypical response patterns of ICI therapy, as compared with conventional chemotherapy; and the spectrum of irAEs seen at imaging are reviewed. An invited commentary by Nishino is available online. ©RSNA, 2022.
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Affiliation(s)
- Girish S Shroff
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Chad D Strange
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Jitesh Ahuja
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Mehmet Altan
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Ajay Sheshadri
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Ebru Unlu
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Mylene T Truong
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
| | - Ioannis Vlahos
- From the Departments of Thoracic Imaging (G.S.S., C.D.S., J.A., E.U., M.T.T., I.V.), Thoracic/Head and Neck Medical Oncology (M.A.), and Pulmonary Medicine (A.S.), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1478, Houston, TX 77030
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22
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Radiation Recall Pneumonitis: A Rare Syndrome That Should Be Recognized. Cancers (Basel) 2022; 14:cancers14194642. [PMID: 36230564 PMCID: PMC9563843 DOI: 10.3390/cancers14194642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/17/2022] [Accepted: 09/20/2022] [Indexed: 11/29/2022] Open
Abstract
Simple Summary A combination of radiotherapy and systemic antineoplastic agents is a common treatment strategy for lung cancer. However, Radiation recall pneumonitis (RRP) is a rare disease which has been mainly detected in the previously irradiated lung of patients with cancer after the application of triggering agents, including, but not limited to, antineoplastic agents. Physicians should be aware of this rare reaction, as the occurrence of RRP could impact the outcome of anti-cancer treatment. Given that current studies on RRP are primarily case reports and retrospectively reviewed data, the aim of our article was to review the current understanding and evidence on RRP and define the characteristics of RRP. Abstract Radiation recall pneumonitis (RRP) is a rare but severe condition which has been mainly detected in the previously irradiated lung of patients with cancer after administering inciting agents, most commonly antineoplastic regimens including chemotherapy, targeted therapy, or immunotherapy. More recently, coronavirus disease vaccines were found to induce RRP. In addition to typical radiation pneumonitis (RP) or drug-induced interstitial lung disease, the management of RRP requires withholding inciting agents and steroid therapy. Thus, the occurrence of RRP could significantly impact cancer treatment, given that inciting agents are withheld temporarily and even discontinued permanently. In the present review, we discuss the current understanding and evidence on RRP and provide additional insights into this rare but severe disease.
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23
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Zhang Z, Liu X, Chen D, Yu J. Radiotherapy combined with immunotherapy: the dawn of cancer treatment. Signal Transduct Target Ther 2022; 7:258. [PMID: 35906199 PMCID: PMC9338328 DOI: 10.1038/s41392-022-01102-y] [Citation(s) in RCA: 171] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/19/2022] [Accepted: 06/30/2022] [Indexed: 11/09/2022] Open
Abstract
Radiotherapy (RT) is delivered for purposes of local control, but can also exert systemic effect on remote and non-irradiated tumor deposits, which is called abscopal effect. The view of RT as a simple local treatment has dramatically changed in recent years, and it is now widely accepted that RT can provoke a systemic immune response which gives a strong rationale for the combination of RT and immunotherapy (iRT). Nevertheless, several points remain to be addressed such as the interaction of RT and immune system, the identification of the best schedules for combination with immunotherapy (IO), the expansion of abscopal effect and the mechanism to amplify iRT. To answer these crucial questions, we roundly summarize underlying rationale showing the whole immune landscape in RT and clinical trials to attempt to identify the best schedules of iRT. In consideration of the rarity of abscopal effect, we propose that the occurrence of abscopal effect induced by radiation can be promoted to 100% in view of molecular and genetic level. Furthermore, the “radscopal effect” which refers to using low-dose radiation to reprogram the tumor microenvironment may amplify the occurrence of abscopal effect and overcome the resistance of iRT. Taken together, RT could be regarded as a trigger of systemic antitumor immune response, and with the help of IO can be used as a radical and systemic treatment and be added into current standard regimen of patients with metastatic cancer.
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Affiliation(s)
- Zengfu Zhang
- Department of Radiation Oncology, Shandong University Cancer Center, Yantai Road, No. 2999, Jinan, Shandong, China
| | - Xu Liu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road, No. 440, Jinan, Shandong, China
| | - Dawei Chen
- Department of Radiation Oncology, Shandong University Cancer Center, Yantai Road, No. 2999, Jinan, Shandong, China.
| | - Jinming Yu
- Department of Radiation Oncology, Shandong University Cancer Center, Yantai Road, No. 2999, Jinan, Shandong, China.
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24
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Arifin AJ, Palma DA. The changing landscape of pneumonitis in non-small cell lung cancer. Lung Cancer 2022; 171:1-2. [PMID: 35849898 DOI: 10.1016/j.lungcan.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew J Arifin
- Division of Radiation Oncology, Western University, London, Canada.
| | - David A Palma
- Division of Radiation Oncology, Western University, London, Canada.
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25
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Zhang F, Liao L, Wei S, Lu Y. Risk Factors of Acute Radiation-Induced Lung Injury Induced by Radiotherapy for Esophageal Cancer. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:2416196. [PMID: 35872959 PMCID: PMC9300318 DOI: 10.1155/2022/2416196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
Objective To investigate the risk factors of acute radiation-induced lung injury (acute RILI) induced by radiotherapy for esophageal cancer. Methods A total of 206 patients with esophageal cancer who received radiotherapy in our hospital from January 2017 to March 2020 were selected. The general data such as gender, age, and comorbidities of the patients were collected, as well as the levels of cytokines (TNF-α, TNF-β, and IL-6) in peripheral blood before radiotherapy; radiotherapy dose-related parameters were recorded during radiotherapy. Follow-up was 12 months after radiotherapy. The patients with induced acute RILI after radiotherapy were set as the observation group (n = 75). Patients without acute RILI after radiotherapy were set as the control group (n = 131). Univariate and multivariate logistic regression analysis was performed on the risk factors of acute RILI induced by radiotherapy for esophageal cancer. Results Univariate analysis and multivariate logistic regression analysis showed that the combined diabetes, total radiation dose, combined lung disease, physical factors (V30, Dmean), and preradiotherapy cytokine (TNF-α, TNF-β, and IL-6) elevated level was an independent risk factor for radiotherapy-induced acute RILI in esophageal cancer (P < 0.05). Conclusion Concomitant diabetes, total radiation dose, lung disease, physical factors (V30, Dmean), and levels of cytokines (TNF-α, TNF-β, and IL-6) before radiation therapy are risk factors for acute RILI induced by radiation therapy in esophageal cancer. The possibility of acute RILI should be comprehensively assessed according to the patient's condition, and the radiotherapy regimen should be adjusted to reduce and avoid the induction of acute radiation-induced lung injury.
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Affiliation(s)
- Faen Zhang
- Department of Oncology, The People's Hospital of Hechi, Guangxi 547000, China
| | - Lihua Liao
- Department of Oncology, The People's Hospital of Hechi, Guangxi 547000, China
| | - Song Wei
- Department of Oncology, The People's Hospital of Hechi, Guangxi 547000, China
| | - Yuqing Lu
- Department of Oncology, The People's Hospital of Hechi, Guangxi 547000, China
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26
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Lu X, Wang J, Zhang T, Zhou Z, Deng L, Wang X, Wang W, Liu W, Tang W, Wang Z, Wang J, Jiang W, Bi N, Wang L. Comprehensive Pneumonitis Profile of Thoracic Radiotherapy Followed by Immune Checkpoint Inhibitor and Risk Factors for Radiation Recall Pneumonitis in Lung Cancer. Front Immunol 2022; 13:918787. [PMID: 35795657 PMCID: PMC9251068 DOI: 10.3389/fimmu.2022.918787] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/19/2022] [Indexed: 01/21/2023] Open
Abstract
Purpose Whilst survival benefits of thoracic radiotherapy (TRT) followed by immune checkpoint inhibitor (ICI) have been reported in patients with lung cancer, the potential high risk of treatment-related pneumonitis remains a concern. Asians may be more sensitive to lung toxicity than other races. This retrospective study intended to provide a comprehensive pneumonitis profile of TRT followed by ICI and investigate the risk factors from a Chinese cohort of lung cancer. Methods and Materials From January 2016 to July 2021, 196 patients with lung cancer who received TRT prior to ICI were retrospectively analyzed. Treatment-related pneumonitis, including checkpoint inhibitor pneumonitis (CIP), radiation pneumonitis (RP), and radiation recall pneumonitis (RRP), were recorded and graded through medical records and chest computed tomography. Characteristics predictive of pneumonitis were assessed using logistic regression models, and the receiver operating characteristic analyses were performed to identify optimal cut points for quantitative variables. Results With a median follow-up of 18 months, a total of 108 patients (55.1%) developed treatment-related pneumonitis during ICI therapy, with an incidence of 25.5% for grade 2 or higher (G2+) and 4.1% for G3+. The overall rates of CIP, RP and RRP were 8.2% (n=16), 46.9% (n=92) and 7.1% (n=14), respectively. With a total mortality rate of 1.5%, vast majority of the patients recovered from pneumonitis or remained stable. No patients died of RRP. Half of the patients with G2+ RP who withheld ICI therapy restarted ICI safely after resolution of RP. The history of chronic pulmonary diseases (P=0.05), mean lung dose (MLD, P=0.038), percent volume of lung receiving ≥5 Gy (V5, P=0.012) and percent volume of lung receiving ≥20 Gy (V20, P=0.030) predicted the occurrence of RRP in univariate analyses. Interval between TRT and ICI less than 3 months was an independent predictor for G2+ treatment-related pneumonitis in a multivariate model (Odds ratio OR=2.787, P=0.004). Conclusions Treatment-related pneumonitis, especially RRP, is acceptable and manageable in the setting of TRT followed by ICI in this Asian population. Dosimetric parameters MLD, V5 and V20 may improve the predictions of RRP in clinical practice.
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Affiliation(s)
- Xiaotong Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianyang Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zongmei Zhou
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Deng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenqing Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenyang Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Tang
- Department of Diagnostic Radiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhijie Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Jiang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Nan Bi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Luhua Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
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27
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Fusco R, Simonetti I, Ianniello S, Villanacci A, Grassi F, Dell’Aversana F, Grassi R, Cozzi D, Bicci E, Palumbo P, Borgheresi A, Giovagnoni A, Miele V, Barile A, Granata V. Pulmonary Lymphangitis Poses a Major Challenge for Radiologists in an Oncological Setting during the COVID-19 Pandemic. J Pers Med 2022; 12:624. [PMID: 35455740 PMCID: PMC9024504 DOI: 10.3390/jpm12040624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 12/17/2022] Open
Abstract
Due to the increasing number of COVID-19-infected and vaccinated individuals, radiologists continue to see patients with COVID-19 pneumonitis and recall pneumonitis, which could result in additional workups and false-positive results. Moreover, cancer patients undergoing immunotherapy may show therapy-related pneumonitis during imaging management. This is otherwise known as immune checkpoint inhibitor-related pneumonitis. Following on from this background, radiologists should seek to know their patients' COVID-19 infection and vaccination history. Knowing the imaging features related to COVID-19 infection and vaccination is critical to avoiding misleading results and alarmism in patients and clinicians.
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Affiliation(s)
- Roberta Fusco
- Medical Oncology Division, Igea SpA, 80013 Napoli, Italy;
| | - Igino Simonetti
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy;
| | - Stefania Ianniello
- Diagnostica per Immagini nelle Malattie Infettive INMI Spallanzani IRCCS, 00161 Rome, Italy; (S.I.); (A.V.)
| | - Alberta Villanacci
- Diagnostica per Immagini nelle Malattie Infettive INMI Spallanzani IRCCS, 00161 Rome, Italy; (S.I.); (A.V.)
| | - Francesca Grassi
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 80127 Naples, Italy; (F.G.); (F.D.); (R.G.)
| | - Federica Dell’Aversana
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 80127 Naples, Italy; (F.G.); (F.D.); (R.G.)
| | - Roberta Grassi
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 80127 Naples, Italy; (F.G.); (F.D.); (R.G.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy; (D.C.); (E.B.); (A.B.); (A.G.); (V.M.)
| | - Diletta Cozzi
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy; (D.C.); (E.B.); (A.B.); (A.G.); (V.M.)
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
| | - Eleonora Bicci
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy; (D.C.); (E.B.); (A.B.); (A.G.); (V.M.)
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
| | - Pierpaolo Palumbo
- Abruzzo Health Unit 1, Department of Diagnostic Imaging, Area of Cardiovascular and Interventional Imaging, 67100 L’Aquila, Italy;
| | - Alessandra Borgheresi
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy; (D.C.); (E.B.); (A.B.); (A.G.); (V.M.)
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, 60126 Ancona, Italy
| | - Andrea Giovagnoni
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy; (D.C.); (E.B.); (A.B.); (A.G.); (V.M.)
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, 60126 Ancona, Italy
| | - Vittorio Miele
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy; (D.C.); (E.B.); (A.B.); (A.G.); (V.M.)
- Department of Radiology, Azienda Ospedaliero-Universitaria Careggi, 50134 Florence, Italy
| | - Antonio Barile
- Department of Applied Clinical Science and Biotechnology, University of L’Aquila, Via Vetoio 1, 67100 L’Aquila, Italy;
| | - Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy;
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28
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Yin J, Wu Y, Yang X, Gan L, Xue J. Checkpoint Inhibitor Pneumonitis Induced by Anti-PD-1/PD-L1 Therapy in Non-Small-Cell Lung Cancer: Occurrence and Mechanism. Front Immunol 2022; 13:830631. [PMID: 35464480 PMCID: PMC9021596 DOI: 10.3389/fimmu.2022.830631] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/16/2022] [Indexed: 02/05/2023] Open
Abstract
Immune checkpointty inhibitors (ICIs), particularly those targeting programmed death 1 (PD-1) and anti-programmed death ligand 1 (PD-L1), enhance the antitumor effect by restoring the function of the inhibited effector T cells and produce durable responses in a large variety of metastatic and late patients with non-small-cell lung cancer. Although often well tolerated, the activation of the immune system results in side effects known as immune-related adverse events (irAEs), which can affect multiple organ systems, including the lungs. The occurrence of severe pulmonary irAEs, especially checkpoint inhibitor pneumonitis (CIP), is rare but has extremely high mortality and often overlaps with the respiratory symptoms and imaging of primary tumors. The development of CIP may be accompanied by radiation pneumonia and infectious pneumonia, leading to the simultaneous occurrence of a mixture of several types of inflammation in the lungs. However, there is a lack of authoritative diagnosis, grading criteria and clarified mechanisms of CIP. In this article, we review the incidence and median time to onset of CIP in patients with non-small-cell lung cancer treated with PD-1/PD-L1 blockade in clinical studies. We also summarize the clinical features, potential mechanisms, management and predictive biomarkers of CIP caused by PD-1/PD-L1 blockade in non-small-cell lung cancer treatment.
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Affiliation(s)
- Jianqiong Yin
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Yuanjun Wu
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Xue Yang
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Gan
- Research Laboratory of Emergency Medicine, Department of Emergency Medicine, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jianxin Xue
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Clinical Cell Therapy, West China Hospital, Sichuan University, Chengdu, China
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29
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Bi J, Qian J, Yang D, Sun L, Lin S, Li Y, Xue X, Nie T, Verma V, Han G. Dosimetric Risk Factors for Acute Radiation Pneumonitis in Patients With Prior Receipt of Immune Checkpoint Inhibitors. Front Immunol 2022; 12:828858. [PMID: 35095930 PMCID: PMC8792763 DOI: 10.3389/fimmu.2021.828858] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 12/27/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose Dosimetric parameters (e.g., mean lung dose (MLD), V20, and V5) can predict radiation pneumonitis (RP). Constraints thereof were formulated before the era of combined immune checkpoint inhibitors (ICIs) and radiotherapy, which could amplify the RP risk. Dosimetric predictors of acute RP (aRP) in the context of ICIs are urgently needed because no data exist thus far. Methods and Materials All included patients underwent thoracic intensity-modulated radiotherapy, previously received ICIs, and followed-up at least once. Logistic regression models examined predictors of aRP (including a priori evaluation of MLD, V20, and V5), and their discriminative capacity was assessed by receiver operating characteristic analysis. Results Median follow-up of the 40 patients was 5.3 months. Cancers were lung (80%) or esophageal (20%). ICIs were PD-1 (85%) or PD-L1 (15%) inhibitors (median 4 cycles). Patients underwent definitive (n=19), consolidative (n=14), or palliative (n=7) radiotherapy; the median equivalent dose in 2 Gy fractions (EQD2) was 60 Gy (IQR, 51.8-64 Gy). Grades 1-5 aRP occurred in 25%, 17.5%, 15%, 2.5%, and 5%, respectively. The only variables associated with any-grade aRP were V20 (p=0.014) and MLD (p=0.026), and only V20 with grade ≥2 aRP (p=0.035). Neither the number of prior ICI cycles nor the delivery of concurrent systemic therapy significantly associated with aRP risk. Graphs were constructed showing the incrementally increasing risk of aRP based on V20 and MLD (continuous variables). Conclusions This is the first study illustrating that V20 and MLD may impact aRP in the setting of prior ICIs. However, these data should not be extrapolated to patients without pre-radiotherapy receipt of prior ICIs, or to evaluate the risk of chronic pulmonary effects. If these results are validated by larger studies with more homogeneous populations, the commonly accepted V20/MLD dose constraints could require revision if utilized in the setting of ICIs.
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Affiliation(s)
- Jianping Bi
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Qian
- Department of Biostatistics and Epidemiology, University of Massachusetts, Amherst, MA, United States
| | - Dongqin Yang
- Department of Oncology, The Fifth Hospital of Wuhan, Wuhan, China
| | - Lu Sun
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shouyu Lin
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Li
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xudong Xue
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Nie
- Department of Radiology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Vivek Verma
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Guang Han
- Department of Radiation Oncology, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Hughes NM, Hammer MM, Awad MM, Jacene HA. Radiation Recall Pneumonitis on FDG PET/CT Triggered by COVID-19 Vaccination. Clin Nucl Med 2022; 47:e281-e283. [PMID: 34739397 PMCID: PMC8820752 DOI: 10.1097/rlu.0000000000003980] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/28/2021] [Accepted: 09/28/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT A 67-year-old man with metastatic lung adenocarcinoma was initially treated with whole-brain radiotherapy for intracranial metastases, followed by chemotherapy and pembrolizumab. After completing 2 years of systemic therapy, the primary right lung lesion was biopsy-proven to have residual adenocarcinoma, which was then treated with radiation (6000 cGy in 15 fractions). Follow-up serial FDG PET/CT showed radiation fibrosis. Eighteen months after radiotherapy, the patient received 2 doses of an mRNA COVID-19 vaccine. FDG PET/CT performed 4 days following his second vaccine dose showed FDG-avid multistation lymphadenopathy and radiation recall pneumonitis, likely vaccination-induced and mimicking recurrent disease. This resolved spontaneously without therapy.
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Affiliation(s)
| | - Mark M. Hammer
- Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School
| | - Mark M. Awad
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Heather A. Jacene
- From the Department of Imaging, Dana-Farber Cancer Institute
- Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School
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Ye X, Yang J, Stebbing J, Peng L. Radiation recall pneumonitis triggered by an immune checkpoint inhibitor following re-irradiation in a lung cancer patient: a case report. BMC Pulm Med 2022; 22:54. [PMID: 35123465 PMCID: PMC8817644 DOI: 10.1186/s12890-022-01846-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background Radiation recall pneumonitis (RRP) is unpredictable but associated with severe radiation damage in previously irradiated fields. Chemotherapy and targeted drugs have been reported to contribute to RRP. Here we report a case of a patient with non-small cell lung cancer (NSCLC) who developed RRP following administration of immune checkpoint inhibitor (ICI) 18 months after the end of re-irradiation. Case presentation A 69-year-old man received adjuvant chemoradiotherapy post-operatively. He underwent thoracic re-irradiation for oligometastatic NSCLC. On second recurrence, pembrolizumab combined with nab-paclitaxel were administered. After six months, he developed symptoms of persistent cough and dyspnea, with consistent pneumonitis on CT images. The clinical time frame and significant radiographic evidence raised suspicion for RRP. Symptoms resolved after steroids. Conclusions RRP is a rare occurrence. Patients undergoing immunotherapy after prior irradiation may be at increased risk of this rare radiation pneumonitis.
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Latrèche A, Bourbonne V, Lucia F. Unrecognized thoracic radiotherapy toxicity: A review of literature. Cancer Radiother 2022; 26:616-621. [DOI: 10.1016/j.canrad.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 10/19/2022]
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Oligoprogression in Non-Small Cell Lung Cancer. Cancers (Basel) 2021; 13:cancers13225823. [PMID: 34830977 PMCID: PMC8616478 DOI: 10.3390/cancers13225823] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Several retrospective studies present evidence of oligoprogressive disease (OPD) in patients with non-small cell lung cancer (NSCLC) with driver mutations such as EGFR. The strategy of local ablative therapy (LAT) with radiotherapy, followed by the continuation of the same anticancer drug therapy beyond progression disease, is recommended in the current NCCN guideline. Although evidence of the use of this strategy in the treatment of the driver mutation-negative NSCLC is missing, LAT with radiotherapy for OPD after combination therapy of immune checkpoint inhibitor with cytotoxic chemotherapy is expected. Tumors outside of the radiation field may further respond to the immune checkpoint inhibitors due to an abscopal effect. In the future, to achieve long-term survival in advanced NSCLC, it will be important to validate this treatment strategy via prospective comparative studies and to actively implement it in clinical practice. Abstract We reviewed the literature on oligoprogressive disease (OPD) and local ablative therapy (LAT) in patients with advanced non-small cell lung cancer (NSCLC). The frequency of OPD varies depending on its definition and is estimated to be between 15–47%. The implications of the strategy of continuing the same anticancer agents beyond progressive disease after LAT with radiation therapy for OPD are based on the concept of progression in which only a small number of lesions, not more than about four, proliferate after chemotherapy. In the case of OPD harboring driver mutations such as EGFR, prospective studies are underway. However, evidence from retrospective studies support this strategy, which is currently recommended in some guidelines. The prognosis in OPD cases during the administration of an immune checkpoint inhibitor (ICI) is relatively promising. Additionally, LAT with radiation for OPD after the first-line treatment of ICI with cytotoxic chemotherapy may overcome the resistance to the combination drug therapy due to an abscopal effect. To achieve long-term survival in advanced-stage NSCLC, it is important to verify the optimal method and timing of the therapy through prospective comparative studies as well as patient selection based on patient characteristics and biomarker levels.
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Lang JA, Bhalla S, Ganeshan D, Felder GJ, Itani M. Side Effects of Oncologic Treatment in the Chest: Manifestations at FDG PET/CT. Radiographics 2021; 41:2071-2089. [PMID: 34723703 DOI: 10.1148/rg.2021210130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fluorodeoxyglucose (FDG) PET/CT is a vital imaging technique used for staging, assessing treatment response, and restaging following completion of therapy in patients who are undergoing or have completed oncologic treatment. A variety of adverse effects from chemotherapy, targeted therapy, immunotherapy, and radiation therapy are commonly encountered in oncologic patients. It is important to be aware of the manifestations of these adverse effects seen on FDG PET/CT images to avoid misinterpreting these findings as disease progression. Furthermore, early identification of these complications is important, as it may significantly affect patient management and even lead to a change in treatment strategy. The authors focus on the FDG PET/CT manifestations of a broad spectrum of oncologic therapy-related adverse effects in the thorax, as well as some treatment-related changes that may potentially mimic malignancy. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Jordan A Lang
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box #8131, St Louis, MO 63110 (J.A.L., S.B., M.I.); Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (D.G.); and Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.)
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box #8131, St Louis, MO 63110 (J.A.L., S.B., M.I.); Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (D.G.); and Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.)
| | - Dhakshinamoorthy Ganeshan
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box #8131, St Louis, MO 63110 (J.A.L., S.B., M.I.); Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (D.G.); and Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.)
| | - Gabriel J Felder
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box #8131, St Louis, MO 63110 (J.A.L., S.B., M.I.); Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (D.G.); and Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.)
| | - Malak Itani
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box #8131, St Louis, MO 63110 (J.A.L., S.B., M.I.); Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, Tex (D.G.); and Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.)
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Chen X, Sheikh K, Nakajima E, Lin CT, Lee J, Hu C, Hales RK, Forde PM, Naidoo J, Voong KR. Radiation Versus Immune Checkpoint Inhibitor Associated Pneumonitis: Distinct Radiologic Morphologies. Oncologist 2021; 26:e1822-e1832. [PMID: 34251728 PMCID: PMC8488797 DOI: 10.1002/onco.13900] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/07/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients with non-small cell lung cancer may develop pneumonitis after thoracic radiotherapy (RT) and immune checkpoint inhibitors (ICIs). We hypothesized that distinct morphologic features are associated with different pneumonitis etiologies. MATERIALS AND METHODS We systematically compared computed tomography (CT) features of RT- versus ICI-pneumonitis. Clinical and imaging features were tested for association with pneumonitis severity. Lastly, we constructed an exploratory radiomics-based machine learning (ML) model to discern pneumonitis etiology. RESULTS Between 2009 and 2019, 82 patients developed pneumonitis: 29 after thoracic RT, 23 after ICI, and 30 after RT + ICI. Fifty patients had grade 2 pneumonitis, 22 grade 3, and 7 grade 4. ICI-pneumonitis was more likely bilateral (65% vs. 28%; p = .01) and involved more lobes (66% vs. 45% involving at least three lobes) and was less likely to have sharp border (17% vs. 59%; p = .004) compared with RT-pneumonitis. Pneumonitis morphology after RT + ICI was heterogeneous, with 47% bilateral, 37% involving at least three lobes, and 40% sharp borders. Among all patients, risk factors for severe pneumonitis included poor performance status, smoking history, worse lung function, and bilateral and multifocal involvement on CT. An ML model based on seven radiomic features alone could distinguish ICI- from RT-pneumonitis with an area under the receiver-operating curve of 0.76 and identified the predominant etiology after RT + ICI concordant with multidisciplinary consensus. CONCLUSION RT- and ICI-pneumonitis exhibit distinct spatial features on CT. Bilateral and multifocal lung involvement is associated with severe pneumonitis. Integrating these morphologic features in the clinical management of patients who develop pneumonitis after RT and ICIs may improve treatment decision-making. IMPLICATIONS FOR PRACTICE Patients with non-small cell lung cancer often receive thoracic radiation and immune checkpoint inhibitors (ICIs), both of which can cause pneumonitis. This study identified similarities and differences in pneumonitis morphology on computed tomography (CT) scans among pneumonitis due to radiotherapy (RT) alone, ICI alone, and the combination of both. Patients who have bilateral CT changes involving at least three lobes are more likely to have ICI-pneumonitis, whereas those with unilateral CT changes with sharp borders are more likely to have radiation pneumonitis. After RT and/or ICI, severe pneumonitis is associated with bilateral and multifocal CT changes. These results can help guide clinicians in triaging patients who develop pneumonitis after radiation and during ICI treatment.
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Affiliation(s)
- Xuguang Chen
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Khadija Sheikh
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erica Nakajima
- Department of Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Cheng Ting Lin
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland, USA
| | - Junghoon Lee
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chen Hu
- Division of Biostatistics, Department of Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Russell K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Patrick M Forde
- Department of Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jarushka Naidoo
- Department of Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Khinh Ranh Voong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Strange CD, Shroff GS, Truong MT, Nguyen QN, Vlahos I, Erasmus JJ. Imaging of the post-radiation chest in lung cancer. Clin Radiol 2021; 77:19-30. [PMID: 34090709 DOI: 10.1016/j.crad.2021.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/29/2021] [Indexed: 12/25/2022]
Abstract
Radiation therapy using conventional fractionated external-beam or high-precision dose techniques including three-dimensional conformal radiotherapy, stereotactic body radiation therapy, intensity-modulated radiation therapy, and proton therapy, is a key component in the treatment of patients with lung cancer. Knowledge of the radiation technique used, radiation treatment plan, expected temporal evolution of radiation-induced lung injury and patient-specific parameters, such as previous radiotherapy, concurrent chemoradiotherapy, and/or immunotherapy, is important in imaging interpretation. This review discusses factors that affect the development and severity of radiation-induced lung injury and its radiological manifestations with emphasis on the differences between conventional radiation and high-precision dose radiotherapy techniques.
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Affiliation(s)
- C D Strange
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - G S Shroff
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - M T Truong
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - Q-N Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - I Vlahos
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA
| | - J J Erasmus
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030-4009, USA.
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Steber CR, Ponnatapura J, Hughes RT, Farris MK. Rapid Development of Clinically Symptomatic Radiation Recall Pneumonitis Immediately Following COVID-19 Vaccination. Cureus 2021; 13:e14303. [PMID: 33968515 PMCID: PMC8098628 DOI: 10.7759/cureus.14303] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In this report, we present the case of a 66-year-old man who received local consolidation radiotherapy to the right lung and mediastinum for oligometastatic non-small cell lung cancer (NSCLC) following partial response to upfront chemoimmunotherapy. He continued with maintenance immunotherapy and was asymptomatic for eight months after completing radiation therapy. He then developed symptoms consistent with pneumonitis within three to five days of his first administration of the coronavirus disease 2019 (COVID-19) vaccine injection. He reported that these symptoms significantly intensified within three to five days of receiving his second dose of the vaccine. The clinical time frame and radiographic evidence raised suspicion for radiation recall pneumonitis (RRP). Patients undergoing maintenance immunotherapy after prior irradiation may be at increased risk of this phenomenon that may be triggered by the administration of the COVID-19 vaccine.
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Affiliation(s)
- Cole R Steber
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | | | - Ryan T Hughes
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Michael K Farris
- Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, USA
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