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Walls GM, Mitchell JD, Lyon AR, Harbinson M, Hanna GG. Radiation Oncology Opinions and Practice on Cardiotoxicity in Lung Cancer: A Cross-sectional Study by the International Cardio-oncology Society. Clin Oncol (R Coll Radiol) 2024; 36:745-756. [PMID: 39317606 DOI: 10.1016/j.clon.2024.09.001] [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: 02/21/2024] [Revised: 07/31/2024] [Accepted: 09/02/2024] [Indexed: 09/26/2024]
Abstract
AIMS Symptomatic radiation cardiotoxicity affects up to 30% patients with lung cancer and several heart substructure doses are associated with reduced overall survival. A greater focus on minimising cardiotoxicity is now possible due to advancements in radiotherapy technology and the new discipline of cardio-oncology, but uptake of emerging data has not been ascertained. A global cross-sectional analysis of Radiation Oncologists who treat lung cancer was therefore conducted by the International Cardio-Oncology Society in order to establish the impact of recently published literature and guidelines on practice. MATERIALS AND METHODS A bespoke questionnaire was designed following an extensive review of the literature and from recurring relevant themes presented at Radiation Oncology and Cardio-Oncology research meetings. Six question domains were retained following consensus discussions among the investigators, comprising 55 multiple choice stems: guidelines, cardiovascular assessment, cardiology investigations, radiotherapy planning strategies, primary prevention prescribing and local cardio-oncology service access. An invitation was sent to all Radiation Oncologists registered with ICOS and to Radiation Oncology colleagues of the investigators. RESULTS In total 118 participants were recruited and 92% were consultant physicians. The ICOS 2021 expert consensus statement was rated as the most useful position paper, followed by the joint ESC-ESTRO 2022 guideline. The majority (80%) of participants indicated that a detailed cardiovascular history was advisable. Although 69% of respondents deemed the availability of cardiac substructure auto-segmentation to be very/quite important, it was implemented by only a few, with the most common being the left anterior descending coronary artery V15. A distinct cardio-oncology service was available to 39% participants, while the remainder utilised general cardiology services. CONCLUSION The uptake of recent guidelines on cardiovascular optimisation is good, but access to cardiology investigations and consultations, and auto-segmentation, represent barriers to modifying radiotherapy practices in lung cancer to reduce the risk of radiation cardiotoxicity.
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Affiliation(s)
- G M Walls
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Ireland.
| | - J D Mitchell
- Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, Missouri, USA
| | - A R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital, London, UK
| | - M Harbinson
- Department of Cardiology, Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Ireland; Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Jubilee Road, Belfast, Ireland
| | - G G Hanna
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Ireland
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Kong FM(S, Hu C, Pryma DA, Duan F, Matuszak M, Xiao Y, Haken RT, Siegel MJ, Hanna L, Curran WJ, Dunphy M, Gelblum D, Piert M, Jolly S, Robinson CG, Quon A, Loo BW, Srinivas S, Videtic GM, Faria SL, Ferguson C, Dunlap NE, Kundapur V, Paulus R, Siegel BA, Bradley JD, Machtay M. Primary Results of NRG-RTOG1106/ECOG-ACRIN 6697: A Randomized Phase II Trial of Individualized Adaptive (chemo)Radiotherapy Using Midtreatment 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Stage III Non-Small Cell Lung Cancer. J Clin Oncol 2024; 42:3935-3946. [PMID: 39365957 PMCID: PMC11781790 DOI: 10.1200/jco.24.00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/15/2024] [Accepted: 07/17/2024] [Indexed: 10/06/2024] Open
Abstract
PURPOSE NRG-RTOG0617 demonstrated a detrimental effect of uniform high-dose radiation in stage III non-small cell lung cancer. NRG-RTOG1106/ECOG-ACRIN6697 (ClinicalTrials.gov identifier: NCT01507428), a randomized phase II trial, studied whether midtreatment 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) can guide individualized/adaptive dose-intensified radiotherapy (RT) to improve and predict outcomes in patients with this disease. MATERIALS AND METHODS Patients fit for concurrent chemoradiation were randomly assigned (1:2) to standard (60 Gy/30 fractions) or FDG-PET-guided adaptive treatment, stratified by substage, primary tumor size, and histology. All patients had midtreatment FDG-PET/CT; adaptive arm patients had an individualized, intensified boost RT dose to residual metabolically active areas. The primary therapeutic end point was 2-year centrally reviewed freedom from local-regional progression (FFLP), defined as no progression in or near the planning target volume and/or regional nodes. FFLP was analyzed on a modified intent-to-treat population at a one-sided Z-test significance level of 0.15. The primary imaging end point was centrally reviewed change in SUVpeak from baseline to midtreatment; its association with FFLP was assessed using the two-sided Wald test on the basis of Cox regression. RESULTS Of 138 patients enrolled, 127 were eligible. Adaptive-arm patients received a mean 71 Gy in 30 fractions, with mean lung dose 17.9 Gy. There was no significant difference in centrally reviewed 2-year FFLP (59.5% and 54.6% in standard and adaptive arms; P = .66). There were no significant differences in protocol-specified grade 3 toxicities, survival, or progression-free survival (P > .4). Median SUVpeak and metabolic tumor volume (MTV) in the adaptive arm decreased 49% and 54%, from pre-RT to mid-RT PET. However, ΔSUVpeak and ΔMTV were not associated with FFLP (hazard ratios, 0.997; P = .395 and .461). CONCLUSION Midtreatment PET-adapted RT dose escalation as given in this study was safe and feasible but did not improve efficacy outcomes.
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Affiliation(s)
- Feng-Ming (Spring) Kong
- University of Hong Kong Shenzhen Hospital, The University of Hong Kong, Shenzhen/Hong Kong SAR, China
| | - Chen Hu
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, US
- John Hopkins University, Baltimore, MD, US
| | | | - Fenghai Duan
- Brown University, Providence, RI, US and ECOG-ACRIN Biostatistics Center, Providence, RI
| | | | - Ying Xiao
- University of Pennsylvania, Philadelphia, PA, US
| | | | - Marilyn J Siegel
- Mallinckrodt Institute of Radiology and Siteman Cancer Center at Washington University, Saint Louis, MO, US
| | - Lucy Hanna
- Brown University, Providence, RI, US and ECOG-ACRIN Biostatistics Center, Providence, RI
| | | | | | | | | | | | - Clifford G Robinson
- Mallinckrodt Institute of Radiology and Siteman Cancer Center at Washington University, Saint Louis, MO, US
| | - Andrew Quon
- University of California Los Angeles, Los Angeles, CA, US (Accrual for Stanford University)
| | | | - Shyam Srinivas
- University of Pittsburgh Medical Center, Pittsburgh, PA, US (Accruals for CWRU Case Comprehensive Cancer Center)
| | - Gregory M Videtic
- Cleveland Clinic, Cleveland, OH, US (Accrual for CWRU Case Comprehensive Cancer Center)
| | | | - Catherine Ferguson
- Augusta University Medical Center, Augusta, GA, US (Accrual for Georgia Cares Minority Underserved)
| | - Neal E Dunlap
- The James Graham Brown Cancer Center at University of Louisville, Louisville, KY, US
| | | | - Rebecca Paulus
- NRG Oncology Statistics and Data Management Center, Philadelphia, PA, US
- American College of Radiology, Philadelphia, PA, US
| | - Barry A Siegel
- Mallinckrodt Institute of Radiology and Siteman Cancer Center at Washington University, Saint Louis, MO, US
| | | | - Mitchell Machtay
- Penn State University and Cancer Institute, Milton S Hershey Medical Center, Hershey, PA, US
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3
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Gardner LL, Thompson SJ, O'Connor JD, McMahon SJ. Modelling radiobiology. Phys Med Biol 2024; 69:18TR01. [PMID: 39159658 DOI: 10.1088/1361-6560/ad70f0] [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: 04/25/2024] [Accepted: 08/19/2024] [Indexed: 08/21/2024]
Abstract
Radiotherapy has played an essential role in cancer treatment for over a century, and remains one of the best-studied methods of cancer treatment. Because of its close links with the physical sciences, it has been the subject of extensive quantitative mathematical modelling, but a complete understanding of the mechanisms of radiotherapy has remained elusive. In part this is because of the complexity and range of scales involved in radiotherapy-from physical radiation interactions occurring over nanometres to evolution of patient responses over months and years. This review presents the current status and ongoing research in modelling radiotherapy responses across these scales, including basic physical mechanisms of DNA damage, the immediate biological responses this triggers, and genetic- and patient-level determinants of response. Finally, some of the major challenges in this field and potential avenues for future improvements are also discussed.
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Affiliation(s)
- Lydia L Gardner
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
| | - Shannon J Thompson
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
| | - John D O'Connor
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
- Ulster University School of Engineering, York Street, Belfast BT15 1AP, United Kingdom
| | - Stephen J McMahon
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
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4
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Adrian G, Gebre-Medhin M, Nilsson P. Importance of tumor volume, overall treatment time and fractionation sensitivity for p16-positive and p16-negative oropharyngeal tumors. Acta Oncol 2023; 62:1375-1383. [PMID: 37682690 DOI: 10.1080/0284186x.2023.2251084] [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: 05/25/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Analyses of clinical outcomes following radiotherapy (RT) have advanced our understanding of fundamental radiobiological characteristics in head and neck squamous cell carcinoma (HNSCC). Low fractionation sensitivity appears to be a common feature, as well as susceptibility to changes in overall treatment time (OTT). Large tumors should be harder to cure if a successful RT requires the sterilization of all clonogenic cells. Congruently, primary tumor volume has proven to be an important parameter. However, most findings come from an era when p16-negative HNSCC was the dominant tumor type. HPV-associated, p16-positive, oropharyngeal tumors (OPSCC) are more radiosensitive and have better outcome. The current study aims to investigate the role of primary tumor volume, OTT and estimate α/ β -ratio for p16-positive OPSCC, and to quantify the differences in radiosensitivity depending on p16-status. METHODS A cohort of 523 patients treated with RT was studied using a tumor control probability (TCP)-model that incorporates primary tumor volume (V) raised to an exponent c, OTT and α/ β -estimation. The significance of V was also investigated in Cox-regression models. RESULTS In the p16-positive cohort (n = 433), the volume exponent c was 1.44 (95%CI 1.06-1.91), compared to 0.90 (0.54-1.32) for p16-negative tumors (n = 90). Hazard ratios per tumor volume doubling were 2.37 (1.72-3.28) and 1.83 (1.28-2.62) for p16-positive and p16-negative, respectively. The estimated α/ β -ratio was 9.7 Gy (-2.3-21.6), and a non-significant daily loss of 0.30 Gy (-0.17-0.92) was found. An additional dose of 6.8 Gy (interquartile range 4.8-9.1) may theoretically counteract the more radioresistant behavior of p16-negative tumors. CONCLUSION Primary tumor volume plays a crucial role in predicting local tumor response, particularly in p16-positive OPSCC. The estimated α/β-ratio for p16-positive oropharyngeal tumors aligns with previous HNSCC studies, whereas the impact of prolonged OTT was slightly less than previously reported. The differences in radiosensitivity depending on p16-status were quantified. The findings should be validated in independent cohorts.
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Affiliation(s)
- Gabriel Adrian
- Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Division of Oncology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Maria Gebre-Medhin
- Department of Hematology, Oncology, and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Per Nilsson
- Department of Clinical Sciences, Medical Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
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5
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Schütte W, Gütz S, Nehls W, Blum TG, Brückl W, Buttmann-Schweiger N, Büttner R, Christopoulos P, Delis S, Deppermann KM, Dickgreber N, Eberhardt W, Eggeling S, Fleckenstein J, Flentje M, Frost N, Griesinger F, Grohé C, Gröschel A, Guckenberger M, Hecker E, Hoffmann H, Huber RM, Junker K, Kauczor HU, Kollmeier J, Kraywinkel K, Krüger M, Kugler C, Möller M, Nestle U, Passlick B, Pfannschmidt J, Reck M, Reinmuth N, Rübe C, Scheubel R, Schumann C, Sebastian M, Serke M, Stoelben E, Stuschke M, Thomas M, Tufman A, Vordermark D, Waller C, Wolf J, Wolf M, Wormanns D. [Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]. Pneumologie 2023; 77:671-813. [PMID: 37884003 DOI: 10.1055/a-2029-0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.
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Affiliation(s)
- Wolfgang Schütte
- Klinik für Innere Medizin II, Krankenhaus Martha Maria Halle-Dölau, Halle (Saale)
| | - Sylvia Gütz
- St. Elisabeth-Krankenhaus Leipzig, Abteilung für Innere Medizin I, Leipzig
| | - Wiebke Nehls
- Klinik für Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring
| | - Torsten Gerriet Blum
- Helios Klinikum Emil von Behring, Klinik für Pneumologie, Lungenklinik Heckeshorn, Berlin
| | - Wolfgang Brückl
- Klinik für Innere Medizin 3, Schwerpunkt Pneumologie, Klinikum Nürnberg Nord
| | | | - Reinhard Büttner
- Institut für Allgemeine Pathologie und Pathologische Anatomie, Uniklinik Köln, Berlin
| | | | - Sandra Delis
- Helios Klinikum Emil von Behring, Klinik für Pneumologie, Lungenklinik Heckeshorn, Berlin
| | | | - Nikolas Dickgreber
- Klinik für Pneumologie, Thoraxonkologie und Beatmungsmedizin, Klinikum Rheine
| | | | - Stephan Eggeling
- Vivantes Netzwerk für Gesundheit, Klinikum Neukölln, Klinik für Thoraxchirurgie, Berlin
| | - Jochen Fleckenstein
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - Michael Flentje
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Würzburg, Würzburg
| | - Nikolaj Frost
- Medizinische Klinik mit Schwerpunkt Infektiologie/Pneumologie, Charite Universitätsmedizin Berlin, Berlin
| | - Frank Griesinger
- Klinik für Hämatologie und Onkologie, Pius-Hospital Oldenburg, Oldenburg
| | | | - Andreas Gröschel
- Klinik für Pneumologie und Beatmungsmedizin, Clemenshospital, Münster
| | | | | | - Hans Hoffmann
- Klinikum Rechts der Isar, TU München, Sektion für Thoraxchirurgie, München
| | - Rudolf M Huber
- Medizinische Klinik und Poliklinik V, Thorakale Onkologie, LMU Klinikum Munchen
| | - Klaus Junker
- Klinikum Oststadt Bremen, Institut für Pathologie, Bremen
| | - Hans-Ulrich Kauczor
- Klinikum der Universität Heidelberg, Abteilung Diagnostische Radiologie, Heidelberg
| | - Jens Kollmeier
- Helios Klinikum Emil von Behring, Klinik für Pneumologie, Lungenklinik Heckeshorn, Berlin
| | | | - Marcus Krüger
- Klinik für Thoraxchirurgie, Krankenhaus Martha-Maria Halle-Dölau, Halle-Dölau
| | | | - Miriam Möller
- Krankenhaus Martha-Maria Halle-Dölau, Klinik für Innere Medizin II, Halle-Dölau
| | - Ursula Nestle
- Kliniken Maria Hilf, Klinik für Strahlentherapie, Mönchengladbach
| | | | - Joachim Pfannschmidt
- Klinik für Thoraxchirurgie, Lungenklinik Heckeshorn, Helios Klinikum Emil von Behring, Berlin
| | - Martin Reck
- Lungeclinic Grosshansdorf, Pneumologisch-onkologische Abteilung, Grosshansdorf
| | - Niels Reinmuth
- Klinik für Pneumologie, Thorakale Onkologie, Asklepios Lungenklinik Gauting, Gauting
| | - Christian Rübe
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum des Saarlandes, Homburg/Saar, Homburg
| | | | | | - Martin Sebastian
- Medizinische Klinik II, Universitätsklinikum Frankfurt, Frankfurt
| | - Monika Serke
- Zentrum für Pneumologie und Thoraxchirurgie, Lungenklinik Hemer, Hemer
| | | | - Martin Stuschke
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Essen, Essen
| | - Michael Thomas
- Thoraxklinik am Univ.-Klinikum Heidelberg, Thorakale Onkologie, Heidelberg
| | - Amanda Tufman
- Medizinische Klinik und Poliklinik V, Thorakale Onkologie, LMU Klinikum München
| | - Dirk Vordermark
- Universitätsklinik und Poliklinik für Strahlentherapie, Universitätsklinikum Halle, Halle
| | - Cornelius Waller
- Klinik für Innere Medizin I, Universitätsklinikum Freiburg, Freiburg
| | | | - Martin Wolf
- Klinikum Kassel, Klinik für Onkologie und Hämatologie, Kassel
| | - Dag Wormanns
- Evangelische Lungenklinik, Radiologisches Institut, Berlin
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Randomized, Multicenter, Phase 3 Study of Accelerated Fraction Radiation Therapy With Concomitant Boost to the Gross Tumor Volume Compared With Conventional Fractionation in Concurrent Chemoradiation in Patients With Unresectable Stage III Non-Small Cell Lung Cancer: The Korean Radiation Oncology Group 09-03 Trial. Int J Radiat Oncol Biol Phys 2023; 115:873-885. [PMID: 36280151 DOI: 10.1016/j.ijrobp.2022.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE We designed the Korean Radiation Oncology Group 09-03 phase III clinical trial to compare accelerated hypofractionated radiation therapy (RT) using a concomitant boost to the gross tumor volume (GTV) with conventionally fractionated 60-Gy RT in patients with stage III unresectable non-small cell lung cancer (NSCLC). METHODS AND MATERIALS A conventionally fractionated RT group (arm 1; 124 patients) received a 2-Gy daily dose to a total cumulative dose of 44 Gy to the planning target volume (PTV) in 22 fractions and 60 Gy to the GTV in 30 fractions over 6 weeks. A hypofractionated RT group (arm 2; 142 patients) received a 1.8-Gy daily dose to the PTV with a synchronous boost of 0.6 Gy to the GTV, for total cumulative doses of 45 Gy to the PTV and 60 Gy to the GTV in 25 fractions over 5 weeks. All patients received concurrent weekly chemotherapy consisting of paclitaxel and cisplatin. RESULTS The objective response rate of all patients was 86.5% (arm 1, 84.6%; arm 2, 88.1%; P = .612). The median overall survival was 26 months (arm 1, 26 months; arm 2, 27 months; P = .508). The median progression-free survival was 11 months (arm 1, 10 months; arm 2, 13 months; P = .295). The local tumor control rates at 2 and 5 years were 58.3% and 50.7%, respectively (arm 1, 62.4% and 51.0%, respectively; arm 2, 54.0% and 48.6%, respectively; P = .615). There were no significant between-group differences in the cumulative incidence of grade ≥3 radiation pneumonitis (P = .134) or radiation esophagitis (P = .539). CONCLUSIONS This clinical trial did not confirm the superiority of accelerated 2.4-Gy hypofractionated RT compared with conventional 2-Gy fractionation in patients with unresectable stage III NSCLC undergoing concurrent chemoradiation therapy.
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Rodríguez De Dios N, Navarro-Martin A, Cigarral C, Chicas-Sett R, García R, Garcia V, Gonzalez JA, Gonzalo S, Murcia-Mejía M, Robaina R, Sotoca A, Vallejo C, Valtueña G, Couñago F. GOECP/SEOR radiotheraphy guidelines for non-small-cell lung cancer. World J Clin Oncol 2022; 13:237-266. [PMID: 35582651 PMCID: PMC9052073 DOI: 10.5306/wjco.v13.i4.237] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/27/2021] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is a heterogeneous disease accounting for approximately 85% of all lung cancers. Only 17% of patients are diagnosed at an early stage. Treatment is multidisciplinary and radiotherapy plays a key role in all stages of the disease. More than 50% of patients with NSCLC are treated with radiotherapy (curative-intent or palliative). Technological advances-including highly conformal radiotherapy techniques, new immobilization and respiratory control systems, and precision image verification systems-allow clinicians to individualize treatment to maximize tumor control while minimizing treatment-related toxicity. Novel therapeutic regimens such as moderate hypofractionation and advanced techniques such as stereotactic body radiotherapy (SBRT) have reduced the number of radiotherapy sessions. The integration of SBRT into routine clinical practice has radically altered treatment of early-stage disease. SBRT also plays an increasingly important role in oligometastatic disease. The aim of the present guidelines is to review the role of radiotherapy in the treatment of localized, locally-advanced, and metastatic NSCLC. We review the main radiotherapy techniques and clarify the role of radiotherapy in routine clinical practice. These guidelines are based on the best available evidence. The level and grade of evidence supporting each recommendation is provided.
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Affiliation(s)
- Núria Rodríguez De Dios
- Department of Radiation Oncology, Hospital del Mar, Barcelona 08003, Spain
- Radiation Oncology Research Group, Hospital Del Mar Medical Research Institution, Barcelona 08003, Spain
- Department of Experimental and Health Sciences, Pompeu Fabra University, Barcelona 08003, Spain
| | - Arturo Navarro-Martin
- Department of Radiation Oncology, Thoracic Malignancies Unit, Hospital Duran i Reynals. ICO, L´Hospitalet de L, Lobregat 08908, Spain
| | - Cristina Cigarral
- Department of Radiation Oncology, Hospital Clínico de Salamanca, Salamanca 37007, Spain
| | - Rodolfo Chicas-Sett
- Department of Radiation Oncology, ASCIRES Grupo Biomédico, Valencia 46004, Spain
| | - Rafael García
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Virginia Garcia
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | | | - Susana Gonzalo
- Department of Radiation Oncology, Hospital Universitario La Princesa, Madrid 28006, Spain
| | - Mauricio Murcia-Mejía
- Department of Radiation Oncology, Hospital Universitario Sant Joan de Reus, Reus 43204, Tarragona, Spain
| | - Rogelio Robaina
- Department of Radiation Oncology, Hospital Universitario Arnau de Vilanova, Lleida 25198, Spain
| | - Amalia Sotoca
- Department of Radiation Oncology, Hospital Ruber Internacional, Madrid 28034, Spain
| | - Carmen Vallejo
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - German Valtueña
- Department of Radiation Oncology, Hospital Clínico Universitario Lozano Blesa, Zaragoza 50009, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud, Madrid 28223, Spain
- Department of Radiation Oncology, Hospital La Luz, Madrid 28003, Spain
- Department of Clinical, Universidad Europea, Madrid 28670, Spain
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8
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Daly ME, Singh N, Ismaila N, Antonoff MB, Arenberg DA, Bradley J, David E, Detterbeck F, Früh M, Gubens MA, Moore AC, Padda SK, Patel JD, Phillips T, Qin A, Robinson C, Simone CB. Management of Stage III Non-Small-Cell Lung Cancer: ASCO Guideline. J Clin Oncol 2022; 40:1356-1384. [PMID: 34936470 DOI: 10.1200/jco.21.02528] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/12/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To provide evidence-based recommendations to practicing clinicians on management of patients with stage III non-small-cell lung cancer (NSCLC). METHODS An Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary oncology, community oncology, research methodology, and advocacy experts was convened to conduct a literature search, which included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 127 relevant studies to inform the evidence base for this guideline. RECOMMENDATIONS Evidence-based recommendations were developed to address evaluation and staging workup of patients with suspected stage III NSCLC, surgical management, neoadjuvant and adjuvant approaches, and management of patients with unresectable stage III NSCLC.Additional information is available at www.asco.org/thoracic-cancer-guidelines.
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Affiliation(s)
| | - Navneet Singh
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Nofisat Ismaila
- American Society of Clinical Oncology (ASCO), Alexandria, VA
| | | | | | | | | | | | - Martin Früh
- Department of Medical Oncology Cantonal Hospital of St Gallen, St Gallen, Switzerland
- University of Bern, Bern, Switzerland
| | | | | | - Sukhmani K Padda
- Department of Medicine, Division of Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jyoti D Patel
- Northwestern University-Feinberg School of Medicine, Chicago, IL
| | | | - Angel Qin
- University of Michigan, Ann Arbor, MI
| | | | - Charles B Simone
- New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY
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9
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Yamamoto T, Tsukita Y, Katagiri Y, Matsushita H, Umezawa R, Ishikawa Y, Takahashi N, Suzuki Y, Takeda K, Miyauchi E, Saito R, Katsuta Y, Kadoya N, Jingu K. Durvalumab after chemoradiotherapy for locally advanced non-small cell lung cancer prolonged distant metastasis-free survival, progression-free survival and overall survival in clinical practice. BMC Cancer 2022; 22:364. [PMID: 35379201 PMCID: PMC8981776 DOI: 10.1186/s12885-022-09354-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background In clinical practice, the effect of durvalumab and radiation pneumonitis (RP) on survival after intensity-modulated radiotherapy (IMRT) is not fully understood. The purpose of this retrospective study was to investigate factors related to distant metastasis-free survival (DMFS), progression-free survival (PFS) and overall survival (OS) after IMRT for locally advanced non-small cell lung cancer (LA-NSCLC). Methods All patients who were treated with conventional fractionated IMRT for LA-NSCLC between April 2016 and March 2021 were eligible. Time-to-event data were assessed by using the Kaplan–Meier estimator, and the Cox proportional hazards model was used for prognostic factor analyses. Factors that emerged after the start of IMRT, such as durvalumab administration or the development of RP, were analysed as time-dependent covariates. Results A total of 68 consecutive patients treated with conventional fractionated IMRT for LA-NSCLC were analysed. Sixty-six patients completed radiotherapy, 50 patients received concurrent chemotherapy, and 36 patients received adjuvant durvalumab. During the median follow-up period of 14.3 months, 23 patients died, and tumour progression occurred in 37 patients, including 28 patients with distant metastases. The 1-year DMFS rate, PFS rate and OS rate were 59.9%, 48.7% and 84.2%, respectively. Grade 2 RP occurred in 16 patients, grade 3 in 6 patients and grade 5 in 1 patient. The 1-year cumulative incidences of grade 2 or higher RP and grade 3 or higher RP were 33.8% and 10.3%, respectively. The results of multivariate analyses showed that durvalumab had a significantly lower hazard ratio (HR) for DMFS, PFS and OS (HR 0.31, p < 0.01; HR 0.33, p < 0.01 and HR 0.32, p = 0.02), respectively. Grade 2 or higher RP showed significance for DMFS and a nonsignificant trend for OS (HR 2.28, p = 0.04 and HR 2.12, p = 0.13), respectively, whereas a higher percentage of lung volume receiving 20 Gy or higher was significant for PFS (HR 2.25, p = 0.01). Conclusions In clinical practice, durvalumab administration following IMRT with concomitant chemotherapy showed a significant survival benefit. Reducing the risk of grade 2 or higher RP would also be beneficial.
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Affiliation(s)
- Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Yoko Tsukita
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Katagiri
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Haruo Matsushita
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Rei Umezawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yojiro Ishikawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Suzuki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuya Takeda
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Eisaku Miyauchi
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryota Saito
- Department of Respiratory Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiyuki Katsuta
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyuki Kadoya
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
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10
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Khalifa J, Lerouge D, Le Péchoux C, Pourel N, Darréon J, Mornex F, Giraud P. Radiotherapy for primary lung cancer. Cancer Radiother 2021; 26:231-243. [PMID: 34953709 DOI: 10.1016/j.canrad.2021.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Herein are presented the recommendations from the Société française de radiothérapie oncologique regarding indications and modalities of lung cancer radiotherapy. The recommendations for delineation of the target volumes and organs at risk are detailed.
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Affiliation(s)
- J Khalifa
- Département de radiothérapie, Institut universitaire du cancer de Toulouse - Oncopole, 1, avenue Irène-Joliot-Curie, 31100 Toulouse, France.
| | - D Lerouge
- Département de radiothérapie, centre François-Baclesse, 3, avenue du General-Harris, 14076 Caen, France
| | - C Le Péchoux
- Département de radiothérapie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - N Pourel
- Département de radiothérapie, institut Sainte-Catherine, 250, chemin de Baigne-Pieds, CS80005, 84918 Avignon cedex 9, France
| | - J Darréon
- Service de physique médicale, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - F Mornex
- Service de radiothérapie, CHU Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France
| | - P Giraud
- Service d'oncologie radiothérapie, hôpital européen Georges-Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, Paris, France; Université de Paris, 85, boulevard Saint-Germain, 75006 Paris, France
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11
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Alipour R, Bucknell N, Bressel M, Everitt S, MacManus M, Siva S, Hofman MS, Akhurst T, Hicks RJ, Iravani A. Nodal metabolic tumour volume on baseline 18 F-FDG PET/CT and overall survival in stage II and III NSCLC patients undergoing curative-intent chemoradiotherapy/radiotherapy. J Med Imaging Radiat Oncol 2021; 65:748-754. [PMID: 34318603 DOI: 10.1111/1754-9485.13294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/11/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This study aims to investigate whether nodal metabolic tumour volume (nMTV) and nodal total lesion glycolysis (nTLG) on Fluorine-18 fluoro-deoxy-glucose positron emission tomography-computed tomography (18 F-FDG PET/CT) in inoperable node-positive stage II and III non-small cell lung cancer (NSCLC) are independent predictors of overall survival (OS) in patients undergoing curative-intent chemoradiotherapy/radiotherapy (CRT/RT). METHODS Data from two prospective trials between 2004 and 2016 were analysed retrospectively. Primary, nodal and total metabolic tumour volume and total lesion glycolysis (pMTV, nMTV, tMTV, pTLG, nTLG and tTLG, respectively) were derived from baseline 18 F-FDG PET/CT. Cox regressions were used to model OS by 18 F-FDG PET/CT parameters adjusting for overall stage. RESULTS 89 patients with stage II (8%) and stage III (92%) were included. The median age at diagnosis was 67 years; 62% were male. The median follow-up was 6.9 years; the median OS was 2.2 years (95% CI 1.7-3.1). The median pMTV, nMTV and tMTV were 14 mL (range 0-360), 8 mL (range 0-250) and 34 mL (range 3-384), respectively. In 3 patients, the primary lesion could not be delineated from the central hilar mass. There was no association between nMTV (adjusted HR 1.04, 95% CI 0.95-1.15, P-value 0.43), pMTV (adjusted HR 1.0, 95% CI 0.96-1.04, P-value 0.92), tMTV (adjusted HR 1.0, 95% CI 0.97-1.04, P-value 0.88), nTLG, pTLG or tTLG and OS. Consistent results were noted when patients with central hilar lesions were excluded from analysis. CONCLUSION In node-positive stage II and III NSCLC patients who underwent 18 F-FDG PET/CT-guided target delineation curative-intent concurrent CRT/RT, metabolic parameters did not appear to provide independent prognostication.
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Affiliation(s)
- Ramin Alipour
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nick Bucknell
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Mathias Bressel
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Sarah Everitt
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael MacManus
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Shankar Siva
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael S Hofman
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tim Akhurst
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rodney J Hicks
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amir Iravani
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia.,Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
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12
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McAleese J, Mooney L, Walls GM. Reducing the Risk of Death From Pneumocystis jirovecii Pneumonia After Radical Radiation Therapy to the Lung. Clin Oncol (R Coll Radiol) 2021; 33:780-787. [PMID: 34253423 DOI: 10.1016/j.clon.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/31/2021] [Accepted: 06/17/2021] [Indexed: 12/25/2022]
Abstract
AIMS Lung cancer is the leading cause of cancer death. Radiotherapy given in the curative setting is associated with a 3% risk of death from Pneumocystis jirovecii pneumonia (PJP). Prolonged courses of high-dose steroids also increase the risk of PJP. International guidelines recommend the use of chemoprophylaxis with trimethoprim-sulfamethoxazole for patients at high risk. We assessed the effect of an intervention designed to reduce the impact of PJP. MATERIALS AND METHODS Prophylaxis guidelines were introduced in 2016. Case records of patients treated with radical radiotherapy were examined for the periods 2014 to 2015 (pre-intervention) and 2017 to 2018 (post-intervention). In total, 247 patients were treated pre-intervention and 334 post-intervention. RESULTS Freedom from PJP death at 1 year was 96% before intervention and 99% after (hazard ratio 0.3, 95% confidence interval 0.1-0.9, P = 0.029). Although the rate of use of chemoprophylaxis according to the guideline rose from 1% to 13% (P = 0.003), the use of high-dose steroids also fell from 35% to 16% (P < 0.00001). CONCLUSIONS Reducing radiotherapy-associated infections is an important component of radical treatment in lung cancer. Highlighting chemoprophylaxis guidelines reduced the death rate from PJP, with an associated more judicious use of steroids. Advocating prophylaxis in patients with lymphocyte count <0.6 × 109/l is the next intervention to be studied.
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Affiliation(s)
- J McAleese
- Cancer Centre Belfast City Hospital, Belfast, UK
| | - L Mooney
- Cancer Centre Belfast City Hospital, Belfast, UK
| | - G M Walls
- Cancer Centre Belfast City Hospital, Belfast, UK; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK.
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13
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Qiu B, Xiong M, Luo Y, Li Q, Chen N, Chen L, Guo S, Wang B, Huang X, Lin M, Hu N, Guo J, Liang Y, Fang Y, Li J, Yang Y, Huang Y, Zhang L, Wang S, Liu H. Hypofractionated Intensity Modulated Radiation Therapy With Concurrent Chemotherapy in Locally Advanced Non-Small Cell Lung Cancer: A Phase II Prospective Clinical Trial (GASTO1011). Pract Radiat Oncol 2021; 11:374-383. [PMID: 34157448 DOI: 10.1016/j.prro.2021.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE We aimed to explore the efficacy and toxicity of split-course hypofractionated radiotherapy with concurrent chemotherapy (HRT-CHT) in patients with locally advanced non-small cell lung cancer (LANSCLC) in this single-arm, phase II study. METHODS LANSCLC patients were considered eligible if their forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC%) and carbon monoxide diffusing capacity (DLCO%) were ≥40% and ≥45%, respectively. HRT-CHT using the IMRT technique was administered with 51 Gy in 17 fractions as the first course followed by a break. Patients without disease progression or persistent ≥grade 2 toxicities had an HRT-CHT of 15-18 Gy in 5-6 fractions as a boost. The primary endpoint was progression-free survival (PFS), and the secondary endpoint was overall survival (OS). RESULTS Eighty-nine patients were enrolled and analyzed. The median follow-up was 29.5 months for all patients and 35.3 months for the survivors. The objective response rate was 97.8%; the median PFS and OS were 11.0 months and 27.0 months, respectively. Grade 3 acute esophagitis/pneumonitis occurred in 15 (16.9%)/7 (7.9%) patients. Grade 3/5 late pneumonitis occurred in 2 (2.2%)/1 (1.1%) patients. Of the 78 (87.6%) who completed the split-course HRT-CHT per protocol, patients with better FEV1/FVC% and DLCO% after the break had significantly better OS (for the FEV/FVC1%≥80% vs 60-79% vs 41-59% groups, 2-year OS values were 57.2% vs 56.9% vs 0%, respectively, p=0.024; for the DLCO%≥80% vs 60-79% vs 45-59% groups, 2-year OS values were 70.4% vs 48.4% vs 37.5%, respectively, p=0.049). CONCLUSIONS Split-course HRT-CHT achieved a promising response rate and survival with tolerable toxicity in LANSCLC. Pulmonary function tests are necessary indicators for radiation treatment planning and dose escalation.
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Affiliation(s)
- Bo Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Mai Xiong
- Department of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - YiFeng Luo
- Pulmonary and Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - QiWen Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - NaiBin Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Li Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - SuPing Guo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Bin Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - XiaoYan Huang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - MaoSheng Lin
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Nan Hu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - JinYu Guo
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Ying Liang
- Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Yi Fang
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou
| | - JiBin Li
- Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou.
| | - YunPeng Yang
- Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou
| | - Yan Huang
- Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou
| | - Li Zhang
- Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou
| | - SiYu Wang
- Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Guangdong Association Study of Thoracic Oncology, Guangzhou
| | - Hui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou; State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou; Lung Cancer Institute of Sun Yat-sen University, Guangzhou.; Guangdong Association Study of Thoracic Oncology, Guangzhou.
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14
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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: 0.5] [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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15
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Chen N, Li Q, Wang S, Xiong M, Luo Y, Wang B, Chen L, Lin M, Jiang X, Fang J, Guo S, Guo J, Hu N, Ai X, Wang D, Chu C, Liu F, Long H, Wang J, Qiu B, Liu H. Hypo-fractionated radiotherapy with concurrent chemotherapy for locoregional recurrence of non-small cell lung cancer after complete resection: A prospective, single-arm, phase II study (GASTO-1017). Lung Cancer 2021; 156:82-90. [PMID: 33933895 DOI: 10.1016/j.lungcan.2021.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/25/2021] [Accepted: 04/22/2021] [Indexed: 09/30/2022]
Abstract
OBJECTIVES To explore the efficacy and toxicities of split-course hypo-fractionated radiotherapy with concurrent chemotherapy (HFRT-CHT) with intensity modulated radiotherapy (IMRT) technique in non-small cell lung cancer (NSCLC) patients with postoperative locoregional recurrence (LRR). MATERIALS AND METHODS NSCLC patients were eligible if confirmed as LRR disease without distant metastasis after complete resection. HFRT-CHT using IMRT technique was administered with 51 Gy in 17 fractions or 40 Gy in 10 fractions as the first course followed by a break. Patients with no disease progression and no persistent Grade ≥2 toxicities had the second course of 15 Gy in 5 fractions or 28 Gy in 7 fractions as a boost. The primary endpoint was progression-free survival (PFS). RESULTS Fifty-eight patients were enrolled and analyzed. With a median follow-up of 23.9 months for all, the 2-year and 3-year PFS rate was 59.7 % and 46.4 %, the 2-year and 3-year OS rate was 72.5 % and 52.2 %, respectively, and a favorable objective response rate of 95.9 % was obtained after the whole courses protocol. Grade 3 acute pneumonitis and esophagitis occurred in 2 (3.4 %) and 7 (12.1 %) patients, and fatal pneumonitis was reported in one case (1.7 %). Exploratory subgroup analysis showed that performance status (PS) (PS 0 vs. 1: 2-year PFS, 88.1 % vs. 46.9 %,P = 0.001; 2-year OS, 100 % vs. 59.4 %, P < 0.001), recurrence site (single vs. multiple: 2-year PFS, 93.8 % vs. 47.4 %, P = 0.008; 2-year OS, 100 % vs. 63.0 %, P = 0.001), and gross tumor volume (GTV) (<50cm3 vs. ≥ 50cm3: 2-year PFS, 70.6 % vs. 46.2 %, P = 0.024; 2-year OS, 85.6 % vs. 57.4 %, P = 0.034) were significantly associated with PFS and OS. CONCLUSION Split-course HFRT-CHT with IMRT technique achieved promising disease control and satisfactory survival with moderate toxicities in postoperative LRR of NSCLC. Good PS, a single recurrence site and GTV<50cm3 tended to have prolonged PFS and OS. Early detection of LRR may improve the efficacy of HFRT-CHT.
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Affiliation(s)
- NaiBin Chen
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - QiWen Li
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - SiYu Wang
- Department of Thoracic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Mai Xiong
- Department of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - YiFeng Luo
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bin Wang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Li Chen
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - MaoSheng Lin
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - XiaoBo Jiang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - JianLan Fang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - SuPing Guo
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - JinYu Guo
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Nan Hu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - XinLei Ai
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - DaQuan Wang
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Chu Chu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - FangJie Liu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Hao Long
- Department of Thoracic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - JunYe Wang
- Department of Thoracic Surgery, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China
| | - Bo Qiu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China.
| | - Hui Liu
- Department of Radiation Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; Lung Cancer Institute of Sun Yat-sen University, Guangzhou, China; Guangdong Association Study of Thoracic Oncology, Guangzhou, China.
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16
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Nestle U, Le Pechoux C, De Ruysscher D. Evolving target volume concepts in locally advanced non-small cell lung cancer. Transl Lung Cancer Res 2021; 10:1999-2010. [PMID: 34012809 PMCID: PMC8107754 DOI: 10.21037/tlcr-20-805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Radiotherapy (RT) target volume concepts for locally advanced lung cancer have been under discussion for years. Although they may be as important as treatment doses, many aspects of them are still based on conventions, which, due to the paucity of prospective data, rely on long-term practice or on clinical knowledge and experience (e.g., on patterns of spread or recurrence). However, in recent years, large improvements have been made in medical imaging and molecular imaging methods have been implemented, which are of great interest in RT. For lung cancer, in recent years, 18F-fluoro-desoxy-glucose (FDG)-positron-emission tomography (PET)/computed tomography (CT) has shown a superior diagnostic accuracy as compare to conventional imaging and has become an indispensable standard tool for diagnostic workup, staging and response assessment. This offers the chance to optimize target volume concepts in relation to modern imaging. While actual recommendations as the EORTC or ESTRO-ACROP guidelines already include imaging standards, the recently published PET-Plan trial prospectively investigated conventional versus imaging guided target volumes in relation to patient outcome. The results of this trial may help to further refine standards. The current review gives a practical overview on procedures for pre-treatment imaging and target volume delineation in locally advanced non-small cell lung cancer (NSCLC) in synopsis of the procedures established by the PET-Plan trial with the actual EORTC and ACROP guidelines.
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Affiliation(s)
- Ursula Nestle
- Department of Radiation Oncology, University of Freiburg, Medical Center Faculty of Medicine, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, Kliniken Maria Hilf, Mönchengladbach, Germany
| | - Cecile Le Pechoux
- Department of Radiation Oncology, Gustave Roussy, Institut d'Oncologie Thoracique (IOT), Villejuif, France
| | - Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Center+, GROW Research Institute, Maastricht, The Netherlands
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17
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Kepka L, Socha J. Dose and fractionation schedules in radiotherapy for non-small cell lung cancer. Transl Lung Cancer Res 2021; 10:1969-1982. [PMID: 34012807 PMCID: PMC8107746 DOI: 10.21037/tlcr-20-253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the field of radiotherapy (RT), the issues of total dose, fractionation, and overall treatment time for non-small cell lung cancer (NSCLC) have been extensively investigated. There is some evidence to suggest that higher treatment intensity of RT, when given alone or sequentially with chemotherapy (CHT), is associated with improved survival. However, there is no evidence that the outcome is improved by RT at a higher dose and/or higher intensity when it is used concurrently with CHT. Moreover, some reports on the combination of full dose CHT with a higher biological dose of RT warn of the significant risk posed by such intensification. Stereotactic body radiotherapy (SBRT) provides a high rate of local control in the management of early-stage NSCLC through the use of high ablative doses. However, in centrally located tumors the use of SBRT may carry a risk of serious damage to the great vessels, bronchi, and esophagus, owing to the high ablative doses needed for optimal tumor control. There is a similar problem with moderate hypofractionation in radical RT for locally advanced NSCLC, and more evidence needs to be gathered regarding the safety of such schedules, especially when used in combination with CHT. In this article, we review the current evidence and questions related to RT dose/fractionation in NSCLC.
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Affiliation(s)
- Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
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18
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Phase 2 Study of Nimotuzumab in Combination With Concurrent Chemoradiotherapy in Patients With Locally Advanced Non-Small-Cell Lung Cancer. Clin Lung Cancer 2020; 22:134-141. [PMID: 33518480 DOI: 10.1016/j.cllc.2020.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND We evaluated the tolerability and efficacy of nimotuzumab, a humanized IgG1 monoclonal anti-epidermal growth factor receptor antibody, with concurrent chemoradiotherapy in patients with unresectable locally advanced non-small-cell lung cancer. PATIENTS AND METHODS In this multicenter, single-arm, open-label, phase 2 trial conducted in Japan (JapicCTI-090825), patients received thoracic radiotherapy (60 Gy, 2 Gy per fraction, 6 weeks) and four 4-week cycles of chemotherapy (day 1, cisplatin 80 mg/m2; days 1 and 8, vinorelbine 20 mg/m2). Nimotuzumab 200 mg was administrated weekly for 16 weeks. The primary endpoint was treatment completion rate, defined as the percentage of patients completing 60 Gy of radiotherapy within 8 weeks, 2 cycles of chemotherapy, and at least 75% of the required nimotuzumab dose during the initial 2-cycle concurrent chemoradiotherapy period. RESULTS Of 40 patients enrolled, 39 received the study treatment, which was well tolerated, with a completion rate of 87.2%. Thirty-eight patients completed 60 Gy of radiotherapy within 8 weeks. Infusion reaction, grade 3 or higher rash, grade 3 or higher radiation pneumonitis, or grade 4 or higher nonhematologic toxicity were not observed. The objective response rate was 69.2%. The median progression-free survival (PFS) and 5-year PFS rate were 508 days and 29.0%, respectively. The 5-year PFS rate in patients with non-squamous cell carcinoma (n = 23) was 13.7% and in patients with squamous cell carcinoma (n = 16) was 50.0%. The 5-year overall survival rate was 58.4%. CONCLUSION Addition of nimotuzumab to the concurrent chemoradiotherapy regimen was well tolerated and showed potential for treating patients with locally advanced non-small-cell lung cancer, particularly squamous cell carcinoma.
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19
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Mix M, Bogart JA. A biologically effective dose threshold for stereotactic body radiation therapy-can we put the issue to BED? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1533. [PMID: 33313278 PMCID: PMC7729357 DOI: 10.21037/atm-20-3689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Michael Mix
- Department of Radiation Oncology, Upstate Cancer Center, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Jeffrey A Bogart
- Department of Radiation Oncology, Upstate Cancer Center, SUNY Upstate Medical University, Syracuse, NY, USA
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20
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Liu YE, Xue XY, Zhang R, Chen XJ, Ding YX, Liu CX, Qin YL, Li WQ, Ren XC, Lin Q. Study protocol: a multicentre, prospective, phase II trial of isotoxic hypofractionated concurrent chemoradiotherapy for non-small cell lung cancer. BMJ Open 2020; 10:e036295. [PMID: 33099491 PMCID: PMC7590348 DOI: 10.1136/bmjopen-2019-036295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 09/08/2020] [Accepted: 10/09/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Concurrent chemoradiotherapy with conventional fractionation has been acknowledged as one of the standard treatments for locally advanced non-small cell lung cancer (NSCLC). The radiotherapy dose of 60 Gy is far from enough for local tumour control. Due to this fact, hypofractionated radiotherapy can shorten the total treatment duration, partially counteract the accelerated repopulation of tumour cells and deliver a higher biological effective dose, it has been increasingly used for NSCLC. In theory, concurrent hypofractionated chemoradiotherapy can result in an enhanced curative effect. To date, the vast majority of radiotherapy prescriptions assign a uniform radiotherapy dose to all patients. However this kind of uniform radiotherapy prescription may lead to two consequences: excess damage to normal tissues for large tumours and insufficient dose for small tumours. Our study aims to evaluate whether delivering individualised radiotherapy dose is feasible using intensity-modulated radiotherapy. METHODS AND ANALYSIS Our study of individualised radiotherapy is a multicenter phase II trial. From April 2019, a total of 30 patients from three Chinese centres, with a proven histological or cytological diagnosis of inoperable NSCLC, will be recruited. The dose of radiation will be increased until one or more of the organs at risk tolerance or the maximum dose of 69 Gy is reached. The primary end point is feasibility, with response rates, progression-free survival and overall survival as secondary end points. The concurrent chemotherapy regimen will be docetaxel plus lobaplatin. ETHICS AND DISSEMINATION The study has been approved by medical ethics committees from three research centres. The trial is conducted in accordance with the Declaration of Helsinki.The trial results will be disseminated through academic conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03606239.
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Affiliation(s)
- Yue-E Liu
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Xiao-Ying Xue
- Department of Radiotherapy, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Rui Zhang
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Xue-Ji Chen
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Yu-Xia Ding
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Chao-Xing Liu
- Department of Oncology, No.1 Hospital of Shijiazhuang City, Shijiazhuang, Hebei, China
| | - Yue-Liang Qin
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Wei-Qian Li
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Xiao-Cang Ren
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
| | - Qiang Lin
- Department of Oncology, North China Petroleum Bureau General Hospital, Hebei Medical University, Renqiu, Hebei, China
- Hebei Medical University, Shijiazhuang, Hebei, China
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21
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Prasad RN, Williams TM. A narrative review of toxicity of chemoradiation and immunotherapy for unresectable, locally advanced non-small cell lung cancer. Transl Lung Cancer Res 2020; 9:2040-2050. [PMID: 33209624 PMCID: PMC7653152 DOI: 10.21037/tlcr-20-638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Despite declining smoking rates, lung cancer remains the second most common malignancy in the United States and the leading cause of cancer-related mortality. Non-small cell lung cancer (NSCLC) comprises roughly 85% of cases, and patients tend to present with advanced disease. Historically, concurrent chemoradiotherapy (CRT) has been the standard of care for stage III unresectable NSCLC but outcomes even with multimodal therapy have remained relatively poor. Efforts to improve outcomes through radiation dose escalation with conventional dose fractionation were unsuccessful with RTOG 0617, demonstrating significantly decreased overall survival (OS) with high dose radiation with respect to standard therapy. The recent PACIFIC trial established a new role for consolidative immune checkpoint blockade therapy after CRT using the programmed death ligand 1 (PD-L1) inhibitor durvalumab, by demonstrating significantly improved progression free survival and OS. Although promising, the addition of immunotherapy to multimodal therapy has generated debate regarding the most effective immune pathways to target, appropriate sequencing of therapy, most effective radiation techniques, and toxicity-related concerns. This review will highlight recent and ongoing trials in unresectable, locally advanced NSCLC that incorporate chemotherapy, radiation, and immunotherapy with an emphasis on analysis of treatment-related toxicities and implications for future study design.
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Affiliation(s)
- Rahul N Prasad
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
| | - Terence M Williams
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
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22
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Zehentmayr F, Grambozov B, Kaiser J, Fastner G, Sedlmayer F. Radiation dose escalation with modified fractionation schedules for locally advanced NSCLC: A systematic review. Thorac Cancer 2020; 11:1375-1385. [PMID: 32323484 PMCID: PMC7262927 DOI: 10.1111/1759-7714.13451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/04/2020] [Accepted: 04/05/2020] [Indexed: 12/25/2022] Open
Abstract
Concomitant chemo‐radiotherapy (cCRT) with 60 Gy in 30 fractions is the standard of care for stage 111 non‐small cell lung cancer (NSCLC). With a median overall survival of 28.7 months at best and maximum locoregional control rates of 70% at two years, the prognosis for these patients is still dismal. This systematic review summarizes data on dose escalation by alternative fractionation, which has been explored as a primary strategy to improve both local control and overall survival over the past three decades. A Pubmed literature search was performed according to the PRISMA guidelines. Because of the large variety of radiation regimens total doses were converted to EQD2,T. Only studies using an EQD2,T of at least 49.5 Gy, which corresponds to the conventional 60 Gy in six weeks, were included. In a total of 3256 patients, the median OS was 17 months (range 7.4–30 months). While OS was better for patients treated after the year 2000 (P = 0.003) or with a mandatory 18F‐FDG‐PET‐CT in the diagnostic work‐up (P = 0.001), treatment sequence did not make a difference (P = 0.106). The most commonly reported toxicity was acute esophagitis (AE) with a median rate of 24% (range 0%–84%). AE increased at a rate of 0.5% per Gy increment in EQD2,T (P = 0.016). Dose escalation above the conventional 60 Gy using modified radiation fractionation schedules and shortened OTT yield similar mOS and LRC regardless of treatment sequence with a significant EQD2,T dependent increase in AE. Key points Significant findings
Modified radiation dose escalation sequentially combined with chemotherapy yields similar outcome as concomitant treatment. OS is better with the mandatory inclusion of FDG‐PET‐CT in the diagnostic work‐up. The risk of acute esophagitis increases with higher EQD2,T. What this study adds
Chemo‐radiotherapy (CRT) with modified dose escalation regimens yields OS and LC rates in the range of standard therapy regardless of treatment sequence. This broadens the database of curative options in patients who are not eligible concomitant CRT.
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Affiliation(s)
- Franz Zehentmayr
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia.,Institute for Research and Development on Advanced Radiation Technologies (radART), Paracelsus Medical University, Salzburg, Australia
| | - Brane Grambozov
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia
| | - Julia Kaiser
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia
| | - Gerd Fastner
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia
| | - Felix Sedlmayer
- Department of Radiation Oncology, Paracelsus Medical University, Salzburg, Australia.,Institute for Research and Development on Advanced Radiation Technologies (radART), Paracelsus Medical University, Salzburg, Australia
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23
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Kim DW, Lee G, Lee H, Mahal AR, Lam MB, Ng AK. Response to hyperfractionated accelerated radiotherapy in chemotherapy-refractory non-Hodgkin lymphoma. Leuk Lymphoma 2020; 61:1428-1434. [PMID: 32102580 DOI: 10.1080/10428194.2020.1719096] [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: 10/25/2022]
Abstract
Patients with chemotherapy-refractory non-Hodgkin lymphoma (NHL) have a poor prognosis with a median overall survival (OS) of only 10 months. To investigate the role of radiotherapy (RT) in such patients, we conducted a retrospective review of 17 patients with biopsy-proven refractory NHL who received hyperfractionated accelerated RT between 2000 and 2017. Forty-seven percent had stages I and II and 53% had stages III and IV disease. Majority (59%) had diffuse large B-cell lymphoma. One-year local control rate was 82%. Fifty-nine percent proceeded to hematopoietic stem cell transplantation (HSCT). At a median follow-up time of 8.8 months (range: 13 days to 17.4 years), 10 were alive with five in remission. Six patients were long-term survivors with a median OS of 8.1 years. Hyperfractionated accelerated RT in chemotherapy-refractory NHL provides durable local disease control in the majority of cases. Combined with HSCT, the RT regimen may also provide long-term disease remission in a subset of patients.
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Affiliation(s)
- Daniel W Kim
- Department of Radiation Oncology, Brigham and Women's/Dana-Farber Cancer Center, Boston, MA, USA
| | - Grace Lee
- Harvard Medical School, Boston, MA, USA
| | - Hwan Lee
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's/Dana-Farber Cancer Center, Boston, MA, USA
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham and Women's/Dana-Farber Cancer Center, Boston, MA, USA
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24
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Nouizi F, Brooks J, Zuro DM, Madabushi SS, Moreira D, Kortylewski M, Froelich J, Su LM, Gulsen G, Hui SK. Automated in vivo Assessment of Vascular Response to Radiation using a Hybrid Theranostic X-ray Irradiator/Fluorescence Molecular Imaging System. IEEE ACCESS : PRACTICAL INNOVATIONS, OPEN SOLUTIONS 2020; 8:93663-93670. [PMID: 32542176 PMCID: PMC7295127 DOI: 10.1109/access.2020.2994943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Hypofractionated stereotactic body radiotherapy treatments (SBRT) have demonstrated impressive results for the treatment of a variety of solid tumors. The role of tumor supporting vasculature damage in treatment outcome for SBRT has been intensely debated and studied. Fast, non-invasive, longitudinal assessments of tumor vasculature would allow for thorough investigations of vascular changes correlated with SBRT treatment response. In this paper, we present a novel theranostic system which incorporates a fluorescence molecular imager into a commercial, preclinical, microCT-guided, irradiator and was designed to quantify tumor vascular response (TVR) to targeted radiotherapy. This system overcomes the limitations of single-timepoint imaging modalities by longitudinally assessing spatiotemporal differences in intravenously-injected ICG kinetics in tumors before and after high-dose radiation. Changes in ICG kinetics were rapidly quantified by principle component (PC) analysis before and two days after 10 Gy targeted tumor irradiation. A classifier algorithm based on PC data clustering identified pixels with TVR. Results show that two days after treatment, a significant delay in ICG clearance as measured by exponential decay (40.5±16.1% P=0.0405 Paired t-test n=4) was observed. Changes in the mean normalized first and second PC feature pixel values (PC1 & PC2) were found (P=0.0559, 0.0432 paired t-test), suggesting PC based analysis accurately detects changes in ICG kinetics. The PC based classification algorithm yielded spatially-resolved TVR maps. Our first-of-its-kind theranostic system, allowing automated assessment of TVR to SBRT, will be used to better understand the role of tumor perfusion in metastasis and local control.
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Affiliation(s)
- Farouk Nouizi
- Tu and Yuen Center for Functional Onco-Imaging, Department of Radiological Sciences, University of California Irvine, Irvine, CA 92697 USA
| | - Jamison Brooks
- Department of Radiation Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010 USA
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN 55455 USA
| | - Darren M. Zuro
- Department of Radiation Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010 USA
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN 55455 USA
| | - Srideshikan Sargur Madabushi
- Department of Radiation Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010 USA
| | - Dayson Moreira
- Department of Immuno-Oncology, Beckman Research Institute at City of Hope, Duarte, CA 91010 USA
| | - Marcin Kortylewski
- Department of Immuno-Oncology, Beckman Research Institute at City of Hope, Duarte, CA 91010 USA
| | - Jerry Froelich
- Department of Radiology, University of Minnesota, Minneapolis, MN
| | - Lydia M. Su
- Tu and Yuen Center for Functional Onco-Imaging, Department of Radiological Sciences, University of California Irvine, Irvine, CA 92697 USA
| | - Gultekin Gulsen
- Tu and Yuen Center for Functional Onco-Imaging, Department of Radiological Sciences, University of California Irvine, Irvine, CA 92697 USA
| | - Susanta K. Hui
- Department of Radiation Oncology, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010 USA
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25
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Carcinoma Lung. Pract Radiat Oncol 2020. [DOI: 10.1007/978-981-15-0073-2_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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26
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Gao H, Kelsey CR, Boyle J, Xie T, Catalano S, Wang X, Yin FF. Impact of Esophageal Motion on Dosimetry and Toxicity With Thoracic Radiation Therapy. Technol Cancer Res Treat 2019; 18:1533033819849073. [PMID: 31130076 PMCID: PMC6537299 DOI: 10.1177/1533033819849073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose: To investigate the impact of intra- and inter-fractional esophageal motion on dosimetry
and observed toxicity in a phase I dose escalation study of accelerated radiotherapy
with concurrent chemotherapy for locally advanced lung cancer. Methods and Materials: Patients underwent computed tomography imaging for radiotherapy treatment planning (CT1
and 4DCT1) and at 2 weeks (CT2 and 4DCT2) and 5 weeks (CT3 and 4DCT3) after initiating
treatment. Each computed tomography scan consisted of 10-phase 4DCTs in addition to a
static free-breathing or breath-hold computed tomography. The esophagus was
independently contoured on all computed tomographies and 4DCTs. Both CT2 and CT3 were
rigidly registered with CT1 and doses were recalculated using the original
intensity-modulated radiation therapy plan based on CT1 to assess the impact of
interfractional motion on esophageal dosimetry. Similarly, 4DCT1 data sets were rigidly
registered with CT1 to assess the impact of intrafractional motion. The motion was
characterized based on the statistical analysis of slice-by-slice center shifts (after
registration) for the upper, middle, and lower esophageal regions, respectively. For the
dosimetric analysis, the following quantities were calculated and assessed for
correlation with toxicity grade: the percent volumes of esophagus that received at least
20 Gy (V20) and 60 Gy (V60), maximum esophageal dose, equivalent uniform dose, and
normal tissue complication probability. Results: The interfractional center shifts were 4.4 ± 1.7 mm, 5.5 ± 2.0 mm and 4.9 ± 2.1 mm for
the upper, middle, and lower esophageal regions, respectively, while the intrafractional
center shifts were 0.6 ± 0.4 mm, 0.7 ± 0.7 mm, and 0.9 ± 0.7 mm, respectively. The mean
V60 (and corresponding normal tissue complication probability) values estimated from the
interfractional motion analysis were 7.8% (10%), 4.6% (7.5%), 7.5% (8.6%), and 31% (26%)
for grade 0, grade 1, grade 2, and grade 3 toxicities, respectively. Conclusions: Interfractional esophageal motion is significantly larger than intrafractional motion.
The mean values of V60 and corresponding normal tissue complication probability,
incorporating interfractional esophageal motion, correlated positively with esophageal
toxicity grade.
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Affiliation(s)
- Hao Gao
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Chris R Kelsey
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - John Boyle
- 2 Essentia Health Radiation Oncology, Northwest Wisconsin Cancer Center, Ashland, WI, USA
| | - Tianyi Xie
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Suzanne Catalano
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Xiaofei Wang
- 3 Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Fang-Fang Yin
- 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA.,4 Medical Physics Graduate Program, Duke Kunshan University, Kunshan, Jiangsu, China
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27
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Ito H, Matsuo Y, Ohtsu S, Nishimura T, Terada Y, Sakamoto T, Mizowaki T. Impact of histology on patterns of failure and clinical outcomes in patients treated with definitive chemoradiotherapy for locally advanced non-small cell lung cancer. Int J Clin Oncol 2019; 25:274-281. [PMID: 31667664 DOI: 10.1007/s10147-019-01566-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 10/19/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chemoradiotherapy is the standard treatment for locally advanced non-small cell lung cancer. Unlike metastatic disease, histological differences are usually not considered while planning chemoradiotherapy. This study aimed to compare clinical outcomes and relapse patterns between squamous cell carcinomas and adenocarcinomas, and investigated possible histology-specific approaches for chemoradiotherapy in locally advanced non-small cell lung cancer. METHODS We retrospectively analyzed the outcomes and relapse patterns in patients who received definitive chemoradiotherapy for locally advanced non-small cell lung cancer in Katsura hospital between 2003 and 2012. RESULTS A total of 68 and 33 patients with squamous cell carcinomas and adenocarcinomas, respectively, were enrolled. Patients with adenocarcinoma had less advanced T stages, and a larger proportion of female patients. Other factors were not different between the two groups. The median follow-up duration in all patients and survivors was 21.3 months and 91.4 months, respectively. Median survival and relapse-free survival were not significantly different between the two groups. In contrast, the failure patterns and incidences of distant failure were significantly different. Patients with squamous cell carcinomas had predominantly locoregional disease features and a shorter duration from relapse to death compared to patients with adenocarcinoma. CONCLUSION Failure pattern was significantly different between the two histologies. Among relapsed patients, the prognosis was poorer in those with squamous cell carcinomas than those with adenocarcinomas. Further studies, to evaluate histology-specific approaches in chemoradiotherapy, are warranted.
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Affiliation(s)
- Hitoshi Ito
- Department of Radiation Oncology, Kyoto Katsura Hospital, 17 Yamadahirao-cho, Nsikyo-ku, Kyoto, 615-8256, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Shuji Ohtsu
- Department of Radiation Oncology, Kyoto City Hospital, 1-2 Mibu Takadahigashi-cho, Nakagyo-ku, Kyoto, 604-8845, Japan
| | - Takashi Nishimura
- Department of Respiratory Medicine, Respiratory Disease Center, Kyoto Katsura Hospital, 17 Yamadahirao-cho, Nsikyo-ku, Kyoto, 615-8256, Japan
| | - Yasuji Terada
- Department of Thoracic Surgery, Respiratory Disease Center, Kyoto Katsura Hospital, 17 Yamadahirao-cho, Nsikyo-ku, Kyoto, 615-8256, Japan
| | - Takashi Sakamoto
- Department of Radiation Oncology, Kyoto Katsura Hospital, 17 Yamadahirao-cho, Nsikyo-ku, Kyoto, 615-8256, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Curative Radiotherapy for Non-small Cell Lung Cancer: Practice Changing and Changing Practice? Clin Oncol (R Coll Radiol) 2019; 31:678-680. [DOI: 10.1016/j.clon.2019.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/31/2019] [Indexed: 12/15/2022]
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Alaswad M, Kleefeld C, Foley M. Optimal tumour control for early-stage non-small-cell lung cancer: A radiobiological modelling perspective. Phys Med 2019; 66:55-65. [DOI: 10.1016/j.ejmp.2019.09.074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/06/2019] [Accepted: 09/08/2019] [Indexed: 12/25/2022] Open
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Nix MG, Rowbottom CG, Vivekanandan S, Hawkins MA, Fenwick JD. Chemoradiotherapy of locally-advanced non-small cell lung cancer: Analysis of radiation dose-response, chemotherapy and survival-limiting toxicity effects indicates a low α/β ratio. Radiother Oncol 2019; 143:58-65. [PMID: 31439448 DOI: 10.1016/j.radonc.2019.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/21/2019] [Accepted: 07/22/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To analyse changes in 2-year overall survival (OS2yr) with radiotherapy (RT) dose, dose-per-fraction, treatment duration and chemotherapy use, in data compiled from prospective trials of RT and chemo-RT (CRT) for locally-advanced non-small cell lung cancer (LA-NSCLC). MATERIAL AND METHODS OS2yr data was analysed for 6957 patients treated on 68 trial arms (21 RT-only, 27 sequential CRT, 20 concurrent CRT) delivering doses-per-fraction ≤4.0 Gy. An initial model considering dose, dose-per-fraction and RT duration was fitted using maximum-likelihood techniques. Model extensions describing chemotherapy effects and survival-limiting toxicity at high doses were assessed using likelihood-ratio testing, the Akaike Information Criterion (AIC) and cross-validation. RESULTS A model including chemotherapy effects and survival-limiting toxicity described the data significantly better than simpler models (p < 10-14), and had better AIC and cross-validation scores. The fitted α/β ratio for LA-NSCLC was 4.0 Gy (95%CI: 2.8-6.0 Gy), repopulation negated 0.38 (95%CI: 0.31-0.47) Gy EQD2/day beyond day 12 of RT, and concurrent CRT increased the effective tumour EQD2 by 23% (95%CI: 16-31%). For schedules delivered in 2 Gy fractions over 40 days, maximum modelled OS2yr for RT was 52% and 38% for stages IIIA and IIIB NSCLC respectively, rising to 59% and 42% for CRT. These survival rates required 80 and 87 Gy (RT or sequential CRT) and 67 and 73 Gy (concurrent CRT). Modelled OS2yr rates fell at higher doses. CONCLUSIONS Fitted dose-response curves indicate that gains of ~10% in OS2yr can be made by escalating RT and sequential CRT beyond 64 Gy, with smaller gains for concurrent CRT. Schedule acceleration achieved via hypofractionation potentially offers an additional 5-10% improvement in OS2yr. Further 10-20% OS2yr gains might be made, according to the model fit, if critical normal structures in which survival-limiting toxicities arise can be identified and selectively spared.
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Affiliation(s)
- Michael G Nix
- Department of Medical Physics and Engineering, Leeds Teaching Hospitals NHS Trust, United Kingdom.
| | - Carl G Rowbottom
- Department of Physics, Clatterbridge Cancer Centre, Wirral, United Kingdom; Department of Physics, University of Liverpool, Oliver Lodge Laboratory, Liverpool, United Kingdom
| | - Sindu Vivekanandan
- Guy's Hospital Cancer Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Maria A Hawkins
- Department of Oncology, University of Oxford, United Kingdom
| | - John D Fenwick
- Department of Physics, Clatterbridge Cancer Centre, Wirral, United Kingdom; Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, United Kingdom
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Peulen H, Franssen G, Belderbos J, van der Bijl E, Tijhuis A, Rossi M, Sonke JJ, Damen E. SBRT combined with concurrent chemoradiation in stage III NSCLC: Feasibility study of the phase I Hybrid trial. Radiother Oncol 2019; 142:224-229. [PMID: 31431387 DOI: 10.1016/j.radonc.2019.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE To assess the technical and clinical feasibility of the phase I Hybrid trial (NCT01933568), combining SBRT of the primary tumor (PT) and fractionated radiotherapy (FRT) to the lymph nodes (LN). MATERIALS AND METHODS Ten patients with stage III NSCLC with a peripheral PT < 5 cm were prospectively selected. The EQD2 corrected normal tissue dose parameters of the FRT plan of 24×2.75 Gy to PT and 24×2.42 Gy to LN (IMRT) was compared with 3×18 Gy on the PT and 24×2.42 Gy on the LN (VMAT) using a Wilcoxon signed-rank test. To anticipate differential motion between PT and LN, worst-case scenarios for OAR were calculated. Electronic portal imaging device (EPID) dosimetry analysis was performed to rule out dosimetric errors during delivery. RESULTS The Hybrid plans revealed a significant decrease of esophagus EUD n = 0.13, lung V5 and V20 and a significant increase in Dmax of the PRV of the mediastinal envelope. Plans were robust against differential motion of 5 mm between PT and LN in 8 patients and failed in 2 patients due to spinal cord constraints. Average pass rates were ≥87% for EPID dosimetry. CONCLUSIONS SBRT and FRT could be combined within the given OAR constraints. Safety will be assessed in the Hybrid trial.
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Affiliation(s)
- Heike Peulen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Gijs Franssen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - José Belderbos
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Erik van der Bijl
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Angela Tijhuis
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Maddalena Rossi
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Eugène Damen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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McAleese J, Taylor A, Walls GM, Hanna GG. Differential Relapse Patterns for Non-small Cell Lung Cancer Subtypes Adenocarcinoma and Squamous Cell Carcinoma: Implications for Radiation Oncology. Clin Oncol (R Coll Radiol) 2019; 31:711-719. [PMID: 31351746 DOI: 10.1016/j.clon.2019.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/17/2019] [Accepted: 06/07/2019] [Indexed: 12/25/2022]
Abstract
AIMS Curative-intent (radical) radiotherapy aims to control local disease and cure non-small cell lung cancer (NSCLC). The predominant subtypes of NSCLC are adenocarcinoma and squamous cell carcinoma (SCC). The radiotherapy paradigm offered to patients does not differ according to these two subtypes. Relapse patterns and disease control rates for adenocarcinoma and SCC treated with radical radiotherapy were determined. MATERIALS AND METHODS A radical radiotherapy database covering the period from 2004 to June 2016 was examined to determine the first sites of relapse and the actuarial local and distant control rates. RESULTS In total, 537 patients with known pathological subtype were treated over the period. In 39 (7%), the site of first relapse was uncertain. Of the remainder, 203 (41%) had adenocarcinoma and 295 (59%) had SCC. At a median follow-up of 16.4 months, 58% had relapsed. There was a difference in relapse patterns (chi-squared test P < 0.0005), with a higher rate of first relapse locally in SCC (42% of all patients versus 24%) and a higher rate of first relapse in the brain for adenocarcinoma (14% versus 3%). The actuarial local control rate was worse for SCC (hazard ratio 0.6, 95% confidence interval 0.5-0.9, P = 0.002). The brain metastasis-free survival was worse for adenocarcinoma (hazard ratio 4.1, 95% confidence interval 2.2-7.5, P < 0.0001). CONCLUSION There is a difference in relapse patterns between NSCLC histological subtypes, indicating that these are distinct entities. This may have implications for follow-up policy and strategies to improve disease control.
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Affiliation(s)
- J McAleese
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, UK
| | - A Taylor
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, UK
| | - G M Walls
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, UK; Centre for Cancer Research & Cell Biology, Queen's University of Belfast, Belfast, UK.
| | - G G Hanna
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Belfast, UK; Centre for Cancer Research & Cell Biology, Queen's University of Belfast, Belfast, UK
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Huber RM, De Ruysscher D, Hoffmann H, Reu S, Tufman A. Interdisciplinary multimodality management of stage III nonsmall cell lung cancer. Eur Respir Rev 2019; 28:28/152/190024. [PMID: 31285288 DOI: 10.1183/16000617.0024-2019] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/24/2019] [Indexed: 12/12/2022] Open
Abstract
Stage III nonsmall cell lung cancer (NSCLC) comprises about one-third of NSCLC patients and is very heterogeneous with varying and mostly poor prognosis. It is also called "locoregionally or locally advanced disease". Due to its heterogeneity a general schematic management approach is not appropriate. Usually a combination of local therapy (surgery or radiotherapy, depending on functional, technical and oncological operability) with systemic platinum-based doublet chemotherapy and, recently, followed by immune therapy is used. A more aggressive approach of triple agent chemotherapy or two local therapies (surgery and radiotherapy, except for specific indications) has no benefit for overall survival. Until now tumour stage and the general condition of the patient are the most relevant prognostic factors. Characterising the tumour molecularly and immunologically may lead to a more personalised and effective approach. At the moment, after an exact staging and functional evaluation, an interdisciplinary discussion amongst the tumour board is warranted and offers the best management strategy.
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Affiliation(s)
- Rudolf M Huber
- Division of Respiratory Medicine and Thoracic Oncology, Dept of Medicine, University of Munich - Campus Innenstadt, and Thoracic Oncology Centre Munich, Member of the German Centre of Lung Research, Munich, Germany
| | - Dirk De Ruysscher
- Maastricht University Medical Center, Dept of Radiation Oncology (MAASTRO clinic), GROW School for Oncology and Developmental Oncology, Maastricht, The Netherlands
| | - Hans Hoffmann
- Division of Thoracic Surgery, Technical University of Munich, Munich, Germany
| | - Simone Reu
- Institute of Pathology, University of Würzburg, Würzburg, Germany
| | - Amanda Tufman
- Division of Respiratory Medicine and Thoracic Oncology, Dept of Medicine, University of Munich - Campus Innenstadt, and Thoracic Oncology Centre Munich, Member of the German Centre of Lung Research, Munich, Germany
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Shrimali RK, Nallathambi C, Saha A, Das A, Prasath S, Mahata A, Arun B, Mallick I, Achari R, Dabkara D, Thambudorai R, Chatterjee S. Radical radiotherapy or chemoradiotherapy for inoperable, locally advanced, non-small cell lung cancer: Analysis of patient profile, treatment approaches, and outcomes for 213 patients at a tertiary cancer center. Indian J Cancer 2019; 55:125-133. [PMID: 30604722 DOI: 10.4103/ijc.ijc_469_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Radical radiotherapy (RT) with curative intent, with or without chemotherapy, is the standard treatment for inoperable, locally advanced nonsmall cell lung cancer (NSCLC). MATERIALS AND METHODS We retrospectively reviewed the data for all 288 patients who presented with inoperable, locally advanced NSCLC at our institution, between May 2011 and December 2016. RESULTS RT alone or sequential chemoradiotherapy (SCRT) or concurrent chemoradiotherapy (CCRT) was used for 213 patients. Median age was 64 years (range: 27-88 years). Stage-III was the biggest stage group with 189 (88.7%) patients. Most patients with performance status (PS) 0 or 1 received CCRT, whereas most patients with PS 2 received RT alone (P < 0.001). CCRT, SCRT, and RT alone were used for 120 (56.3%), 24 (11.3%), and 69 (32.4%) patients, respectively. A third of all patients (32.4%) required either volumetric-modulated arc radiotherapy (VMAT) or tomotherapy. Median follow-up was 16 months. The median progression-free survival and median overall survival (OS) were 11 and 20 months, respectively. One-year OS and 2-year OS were 67.9% and 40.7%, respectively. Patients treated using CCRT lived significantly longer with a median survival of 28 months, compared with 13 months using SCRT and RT alone (P < 0.001). On multivariate analysis, OS was significantly affected by age, stage group, treatment approach, and response to treatment. CONCLUSION RT including CCRT is feasible, safe, and well tolerated in our patient population and results in survival benefits comparable with published literature. CCRT should be considered for all patients with inoperable, locally advanced NSCLC, who are fit and have good PS.
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Affiliation(s)
- Raj Kumar Shrimali
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - Chandran Nallathambi
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - Animesh Saha
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - Avipsa Das
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - Sriram Prasath
- Department of Radiotherapy Physics, Tata Medical Center, Kolkata, West Bengal, India
| | - Anurupa Mahata
- Department of Radiotherapy Physics, Tata Medical Center, Kolkata, West Bengal, India
| | - B Arun
- Department of Radiotherapy Physics, Tata Medical Center, Kolkata, West Bengal, India
| | - Indranil Mallick
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - Rimpa Achari
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - Deepak Dabkara
- Department of Medical Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - Robin Thambudorai
- Department of Thoracic Surgery, Tata Medical Center, Kolkata, West Bengal, India
| | - Sanjoy Chatterjee
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
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Radiation Therapy in Non-small-Cell Lung Cancer. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_34-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Roach MC, Bradley JD, Robinson CG. Optimizing radiation dose and fractionation for the definitive treatment of locally advanced non-small cell lung cancer. J Thorac Dis 2018; 10:S2465-S2473. [PMID: 30206492 DOI: 10.21037/jtd.2018.01.153] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Radiation therapy is the foundation for treatment of locally advanced non-small cell lung cancer (NSCLC), a disease that is often inoperable and has limited long term survival. Local control of disease is strongly linked to patient survival and continues to be problematic despite continued attempts at changing the dose and fractionation of radiation delivered. Technological advancements such as 4-dimensional computed tomography (CT) based planning, positron emission tomography (PET) based target delineation, and daily image guidance have allowed for ever more accurate and conformal treatments. A limit to dose escalation with conventional fractions of 2 Gy once per day appears to have been reached at 60 Gy in the randomized trial Radiation Therapy Oncology Group (RTOG) 0617. Higher doses were surprisingly associated with worse overall survival. Approaches other than conventional dose escalation have been explored to better control disease including accelerating treatment to limit tumor repopulation both with hyperfractionation and its multiple small (<2 Gy) fractions each day and with hypofractionation and its single larger (>2 Gy) fraction each day. These accelerated regimens are increasingly being used with concurrent chemotherapy, and multiple institutions have reported it as tolerable. Tailoring treatment to individual patient disease and normal anatomic characteristics has been explored with isotoxic dose escalation up to the tolerance of organs at risk, with both hyperfractionation and hypofractionation. Metabolic imaging during and after treatment is increasingly being used to boost doses to residual disease. Boost doses have included moderate hypofractionation of 2-4 Gy, and more recently extreme hypofractionation with stereotactic body radiation therapy (SBRT). In spite of all these changes in dose and fractionation, lung and cardiovascular toxicity remain obstacles that limit disease control and patient survival.
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Affiliation(s)
- Michael C Roach
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Jeffrey D Bradley
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Cliff G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
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Zhang H, Song Y, Zhou C, Bai Y, Yuan D, Pan Y, Shao C. Blocking Endogenous H 2S Signaling Attenuated Radiation-Induced Long-Term Metastasis of Residual HepG2 Cells through Inhibition of EMT. Radiat Res 2018; 190:374-384. [PMID: 30016218 DOI: 10.1667/rr15074.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Recurrence and metastasis of hepatocellular carcinoma (HCC) after radiotherapy are frequently observed in clinical practice. To date, the involved mechanism, endogenous hydrogen sulfide (H2S), has not been well understood and warrants investigation. Here we demonstrated that both single-dose and fractionated irradiation enhanced metastasis of HCC cells both in vitro and in vivo at 20-60 days postirradiation. In particular, a gain in epithelial-mesenchymal transition (EMT) and mesenchymal features was observed. Further experiments revealed that endogenous H2S signaling was constitutively activated after irradiation. Knockdown of cystathionine-γ-lyase (CSE) or cystathionine-β-synthase (CBS), two main H2S-producing proteins, significantly diminished the increased expressions of EMT-related proteins induced by radiation through the p38MAPK pathway, leading to impaired invasion and metastasis of the residual HepG2 cells and their xenograft tumors. Moreover, blocking of the H2S pathway increased the radiosensitivity of the HepG2 xenograft tumor. Collectively, our results strongly suggest that endogenous H2S/CSE contributes to the long-term cell invasion and tumor metastasis induced by fractionated exposures and therefore, could become an attractive therapeutic target of HCC to eliminate radiotherapy-induced adverse effects.
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Affiliation(s)
- Hang Zhang
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Yimeng Song
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Cuiping Zhou
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Yang Bai
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Dexiao Yuan
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Yan Pan
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
| | - Chunlin Shao
- Institute of Radiation Medicine, Fudan University, Shanghai 200032, China
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Shrimali RK, Arunsingh M, Das A, Mallick I, Mahata A, Prasath S, Achari R, Chatterjee S. Continuous hyperfractionated accelerated radiotherapy using modern radiotherapy techniques for nonsmall cell lung cancer patients unsuitable for chemoradiation. Indian J Cancer 2018; 54:120-126. [PMID: 29199674 DOI: 10.4103/ijc.ijc_158_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The continuous hyperfractionated and accelerated radiotherapy (CHART) regimen of radiotherapy (RT) for nonsmall cell lung cancer is underused outside the UK. We present the first Indian experience of using CHART for patients, who were not suitable for chemotherapy or concurrent chemo-RT. METHODS We retrospectively reviewed the data of patients treated using CHART at our institution between January 2014 and December 2015. RESULTS Thirty-seven patients were treated using CHART. Planning methods and dosimetry parameters are described. Three-dimensional conformal RT was used for treatment planning and delivery in 23 patients and volumetric modulated arc RT was necessary for 14 patients. Patients in our series had a median age of 70 years (interquartile range 65.50-74.00) and 86.5% had Stage III disease. Median follow-up was short at 13.0 months. Actuarial rates of 1-year progression-free survival, 1-year overall survival (OS), and 2-year OS were 31.9%, 59.5%, and 28.5%, respectively. This treatment was well tolerated with manageable and some reversible acute esophageal toxicity (91.9% CONCLUSION: Our results indicate that CHART is feasible, safe, and well tolerated in Indian patients who are clinically found to be not suitable for either sequential or concurrent chemo- RT.
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Affiliation(s)
- R K Shrimali
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - M Arunsingh
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - A Das
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - I Mallick
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - A Mahata
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - S Prasath
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - R Achari
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
| | - S Chatterjee
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, India
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Abstract
Over the last few decades, advances in radiation therapy technology have markedly improved radiation delivery. Advancements in treatment planning with the development of image-guided radiotherapy and techniques such as proton therapy, allow precise delivery of high doses of radiation conformed to the tumor. These advancements result in improved locoregional control while reducing radiation dose to surrounding normal tissue. The radiologic manifestations of these techniques can differ from radiation induced lung disease seen with traditional radiation therapy. Awareness of these radiologic manifestations and correlation with radiation treatment plans are important to differentiate expected radiation induced lung injury from recurrence, infection and drug toxicity.
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Calikusu Z, Altinok P. Treatment of locally advanced, unresectable or medically inoperable stage III non-small-cell lung cancer; the past, present and future of chemoradiotherapy. JOURNAL OF ONCOLOGICAL SCIENCES 2018. [DOI: 10.1016/j.jons.2018.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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41
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Accelerated hypofractionated radiotherapy for advanced lung cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2018. [DOI: 10.1017/s1460396917000401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroduction – purposeThe aim of this study is to review the results of applying a hypofractionated radiotherapy schedule for locally advanced inoperable lung cancer in patients who have received chemotherapy. Lung cancer and especially non-small-cell lung cancer is prone to accelerated repopulation and shorter treatment schedules in the form of accelerated radiotherapy have been shown to improve treatment outcome.Patients – methodIn total, 29 patients with inoperable lung cancer (stage II, IIIa,b, IV) were treated with accelerated hypofractionated 3D conformal radiotherapy. All patients received a dose of 55 Gy in 20 fractions (daily dose of 2·75 Gy). The median age was 65·5 years, 87% of patients had stage III–IV disease, 93% of patients received sequential chemotherapy with their radiotherapy. Median follow-up of patients was 36 months.ResultsThe median overall survival from time of diagnosis was 16·5 months and the 1 year overall survival was 31%. Complications were present in 44·8% of the patients and the most common complication (20·7%) was pneumonitis alone. The complication rate was not significantly different according to histological type, stage, type of chemotherapy, presence of recurrence or death.ConclusionAlthough our study limitation is the small number of patients, these data suggest that the efficacy of this hypofractionated schedule could be considered as alternative option to the conventional regimen of 66 Gy given in 33 fractions.
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Long-term quality of life in inoperable non-small cell lung cancer patients treated with conventionally fractionated compared to hyperfractionated accelerated radiotherapy – Results of the randomized CHARTWEL trial. Radiother Oncol 2018; 126:283-290. [DOI: 10.1016/j.radonc.2017.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 12/03/2017] [Accepted: 12/04/2017] [Indexed: 12/25/2022]
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Sanganalmath P, Lester JE, Bradshaw AG, Das T, Esler C, Roy AEF, Toy E, Lester JF, Button M, Wilson P, Comins C, Atherton P, Pickles R, Foweraker K, Walker GA, Keni M, Hatton MQ. Continuous Hyperfractionated Accelerated Radiotherapy (CHART) for Non-small Cell Lung Cancer (NSCLC): 7 Years' Experience From Nine UK Centres. Clin Oncol (R Coll Radiol) 2018; 30:144-150. [PMID: 29336865 DOI: 10.1016/j.clon.2017.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 08/27/2017] [Accepted: 11/06/2017] [Indexed: 01/15/2023]
Abstract
AIM Continuous hyperfractionated accelerated radiotherapy (CHART) remains an option to treat non-small cell lung cancer (NSCLC; NICE, 2011). We have previously published treatment outcomes from 1998-2003 across five UK centres. Here we update the UK CHART experience, reporting outcomes and toxicities for patients treated between 2003 and 2009. MATERIALS AND METHODS UK CHART centres were invited to participate in a retrospective data analysis of NSCLC patients treated with CHART from 2003 to 2009. Nine (of 14) centres were able to submit their data into a standard database. The Kaplan-Meier method estimated survival and the Log-rank test analysed the significance. RESULTS In total, 849 patients had CHART treatment, with a median age of 71 years (range 31-91), 534 (63%) were men, 55% had undergone positron emission tomography-computed tomography (PET-CT) and 26% had prior chemotherapy; 839 (99%) patients received all the prescribed treatment. The median overall survival was 22 months with 2 and 3 year survival of 47% and 32%, respectively. Statistically significant differences in survival were noted for stage IA versus IB (33.2 months versus 25 months; P = 0.032) and IIIA versus IIIB (20 months versus 16 months; P = 0.018). Response at 3 months and outcomes were significantly linked; complete response showing survival of 34 months against 19 months, 15 months and 8 months for partial response, stable and progressive disease, respectively (P < 0.001). Age, gender, performance status, prior chemotherapy and PET-CT did not affect the survival outcomes. Treatment was well tolerated with <5% reporting ≥grade 3 toxicity. CONCLUSION In routine practice, CHART results for NSCLC remain encouraging and we have been able to show an improvement in survival compared with the original trial cohort. We have confirmed that CHART remains deliverable with low toxicity rates and we are taking a dose-escalated CHART regimen forward in a randomised phase II study of sequential chemoradiotherapy against other accelerated dose-escalated schedules.
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Affiliation(s)
| | | | - A G Bradshaw
- Weston Park Hospital, Sheffield, UK; Newcastle on Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle, UK
| | - T Das
- Weston Park Hospital, Sheffield, UK
| | - C Esler
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - A E F Roy
- Plymouth Hospitals NHS Trust, Plymouth, UK
| | - E Toy
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - M Button
- Velindre Cancer Centre, Cardiff, UK
| | - P Wilson
- University Hospitals Bristol NHS Trust, Bristol, UK
| | - C Comins
- University Hospitals Bristol NHS Trust, Bristol, UK
| | - P Atherton
- Newcastle on Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle, UK
| | - R Pickles
- Newcastle on Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle, UK
| | - K Foweraker
- Nottingham University Hospitals NHS Trust, City Hospital, Nottingham, UK
| | - G A Walker
- Derby Hospitals NHS Trust, Royal Derby Hospital, UK
| | - M Keni
- Derby Hospitals NHS Trust, Royal Derby Hospital, UK
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44
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Re-irradiation for Locally Recurrent Lung Cancer: Evidence, Risks and Benefits. Clin Oncol (R Coll Radiol) 2017; 30:101-109. [PMID: 29223641 DOI: 10.1016/j.clon.2017.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/16/2017] [Accepted: 10/26/2017] [Indexed: 12/12/2022]
Abstract
In spite of recent improvements in both the technical delivery of radiotherapy and systemic therapy in the treatment of non-small cell lung cancer, local recurrence rates after radiotherapy remain a significant challenge. In the setting of local relapse after radiotherapy, treatments such as surgical resection or radiofrequency ablation are often not appropriate owing to disease and patient factors. Re-irradiation may be a potential treatment option. This overview considers the published evidence and potential treatment strategies.
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45
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Blyth BJ, Cole AJ, MacManus MP, Martin OA. Radiation therapy-induced metastasis: radiobiology and clinical implications. Clin Exp Metastasis 2017; 35:223-236. [PMID: 29159430 DOI: 10.1007/s10585-017-9867-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 11/11/2017] [Indexed: 12/19/2022]
Abstract
Radiation therapy is an effective means of achieving local control in a wide range of primary tumours, with the reduction in the size of the tumour(s) thought to mediate the observed reductions in metastatic spread in clinical trials. However, there is evidence to suggest that the complex changes induced by radiation in the tumour environment can also present metastatic risks that may counteract the long-term efficacy of the treatment. More than 25 years ago, several largely theoretical mechanisms by which radiation exposure might increase metastatic risk were postulated. These include the direct release of tumour cells into the circulation, systemic effects of tumour and normal tissue irradiation and radiation-induced changes in tumour cell phenotype. Here, we review the data that has since emerged to either support or refute these putative mechanisms focusing on how the unique radiobiology underlying modern radiotherapy modalities might alter these risks.
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Affiliation(s)
- Benjamin J Blyth
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, 3000, Australia. .,Cancer Research Division, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, 3000, Australia.
| | - Aidan J Cole
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, 3000, Australia.,Centre for Cancer Research and Cell Biology, Queen's University Belfast, Lisburn Road, Belfast, BT9 7BL, UK
| | - Michael P MacManus
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, 3000, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, 3010, Australia
| | - Olga A Martin
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, 3000, Australia.,Cancer Research Division, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, 3000, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC, 3010, Australia
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46
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De Ruysscher D, Lambrecht M, van Baardwijk A, Peeters S, Reymen B, Verhoeven K, Wanders R, Öllers M, van Elmpt W, van Loon J. Standard of care in high-dose radiotherapy for localized non-small cell lung cancer. Acta Oncol 2017; 56:1610-1613. [PMID: 28840754 DOI: 10.1080/0284186x.2017.1349337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
- Radiation Oncology, KU Leuven, Leuven, Belgium
| | - Maarten Lambrecht
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Angela van Baardwijk
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stéphanie Peeters
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bart Reymen
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karolien Verhoeven
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rinus Wanders
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michel Öllers
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Judith van Loon
- Department of Radiation Oncology (Maastro Clinic), GROW Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
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47
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Pezzi TA, Tang C, Swanick CW, Fang P, Hess K, Xu T, Hahn SM, Chang JY, Liao Z, Gomez D. Patterns and correlates of treatment failure in relation to isodose distribution in non-small cell lung cancer: An analysis of 1522 patients in the modern era. Radiother Oncol 2017; 125:325-330. [PMID: 29054376 DOI: 10.1016/j.radonc.2017.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 09/09/2017] [Accepted: 09/16/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND PURPOSE To examine the relationship between radiation dose and tumor control in limited stage non-small cell lung cancer (NSCLC). MATERIALS AND METHODS We searched a database of 1552 patients who received radiation therapy for non-metastatic NSCLC between 2000 and 2016. The primary endpoint was freedom from in-field failure. RESULTS Increasing BED correlated with decreasing estimated gross tumor volume-planning target volume expansion, and on multivariable analysis increasing BED was associated with an increased chance of field-edge failures (hazard ratio [HR] 1.032, 95% confidence interval [CI] 1.004-1.062, P = 0.027). Increasing BED also correlated with improved freedom from in-field failure on multivariable analysis (HR 0.978, 95% CI 0.964-0.993, P = 0.003), with the dose-response curve showing a sigmoidal relationship between increasing BED and freedom from in-field failure. CONCLUSION In this large study of patients treated in the modern era with varying dose fractionation regimens, higher BED was associated with improved freedom from in-field failure, and that this relationship appeared to be consistent with the classically described sigmoid shape. We also found that increased BED was associated with higher field-edge failures, implying that margin size may need to be further studied in patients receiving ablative regimens of radiation.
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Affiliation(s)
- Todd A Pezzi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Chad Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cameron W Swanick
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Penny Fang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kenneth Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ting Xu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Stephen M Hahn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Daniel Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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48
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McAleese J, Baluch S, Drinkwater K, Bassett P, Hanna GG. The Elderly are Less Likely to Receive Recommended Radical Radiotherapy for Non-small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2017; 29:593-600. [PMID: 28735769 DOI: 10.1016/j.clon.2017.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 06/12/2017] [Accepted: 06/15/2017] [Indexed: 12/25/2022]
Affiliation(s)
- J McAleese
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK.
| | - S Baluch
- Queen Alexandra Hospital, Cosham, Portsmouth, UK
| | | | - P Bassett
- Royal College of Radiologists, London, UK
| | - G G Hanna
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK; Centre for Cancer Research and Cell Biology, Queen's University of Belfast, Belfast, UK
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49
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Kalman NS, Weiss E, Walker PR, Rosenman JG. Local Radiotherapy Intensification for Locally Advanced Non-small-cell Lung Cancer - A Call to Arms. Clin Lung Cancer 2017; 19:17-26. [PMID: 28712978 DOI: 10.1016/j.cllc.2017.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/24/2017] [Accepted: 05/30/2017] [Indexed: 12/25/2022]
Abstract
Chemoradiotherapy, the standard of care for locally advanced non-small-cell lung cancer (NSCLC), often fails to eradicate all known disease. Despite advances in chemotherapeutic regimens, locally advanced NSCLC remains a difficult disease to treat, and locoregional failure remains common. Improved radiographic detection can identify patients at significant risk of locoregional failure after definitive treatment, and newer methods of escalating locoregional treatment may allow for improvements in locoregional control with acceptable toxicity. This review addresses critical issues in escalating local therapy, focusing on using serial positron emission tomography-computed tomography to select high-risk patients and employing stereotactic radiotherapy to intensify treatment. We further propose a clinical trial concept that incorporates the review's findings.
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Affiliation(s)
- Noah S Kalman
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Paul R Walker
- Division of Hematology/Oncology, Department of Internal Medicine, East Carolina University, Greenville, NC
| | - Julian G Rosenman
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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50
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Chen HHW, Kuo MT. Improving radiotherapy in cancer treatment: Promises and challenges. Oncotarget 2017; 8:62742-62758. [PMID: 28977985 PMCID: PMC5617545 DOI: 10.18632/oncotarget.18409] [Citation(s) in RCA: 182] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 04/18/2017] [Indexed: 12/25/2022] Open
Abstract
Effective radiotherapy for cancer has relied on the promise of maximally eradicating tumor cells while minimally killing normal cells. Technological advancement has provided state-of-the-art instrumentation that enables delivery of radiotherapy with great precision to tumor lesions with substantial reduced injury to normal tissues. Moreover, better understanding of radiobiology, particularly the mechanisms of radiation sensitivity and resistance in tumor lesions and toxicity in normal tissues, has improved the treatment efficacy of radiotherapy. Previous mechanism-based studies have identified many cellular targets that can affect radiation sensitivity, notably reactive oxygen species, DNA-damaging response signals, and tumor microenvironments. Several radiation sensitizers and protectors have been developed and clinically evaluated; however, many of these results are inconclusive, indicating that improvement remains needed. In this era of personalized medicine in which patients’ genetic variations, transcriptome and proteomics, tumor metabolism and microenvironment, and tumor immunity are available. These new developments have provided opportunity for new target discovery. Several radiotherapy sensitivity-associated “gene signatures” have been reported although clinical validations are needed. Recently, several immune modifiers have been shown to associate with improved radiotherapy in preclinical models and in early clinical trials. Combination of radiotherapy and immunocheckpoint blockade has shown promising results especially in targeting metastatic tumors through abscopal response. In this article, we succinctly review recent advancements in the areas of mechanism-driven targets and exploitation of new targets from current radio-oncogenomic and radiation-immunotherapeutic approaches that bear clinical implications for improving the treatment efficacy of radiotherapy.
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Affiliation(s)
- Helen H W Chen
- Division of Clinical Radiation Oncology, Department of Radiation Oncology, National Cheng Kung University Hospital, Department of Radiology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Macus Tien Kuo
- Division of Clinical Radiation Oncology, Department of Radiation Oncology, National Cheng Kung University Hospital, Department of Radiology, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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