Radiotherapy alone in technically operable, medically inoperable, early-stage (I/II) non-small-cell lung cancer

Real-World Treatment Patterns of Lung Cancer in a Resource-Restricted Country: the Experience of Georgia

Lung cancer (LC) is the most common malignancy responsible for 1.8 million of deaths worldwide. Lung and bronchus cancer represents 13% (n = 1217) of all new cancer cases in Georgia. In 2018, in Georgian males lung cancer age-standardized incidence rate was 35.7/per 100 000, less compared to regional countries as Turkey (70.6), Russia (48.2), Ukraine (41.7), and Armenia (58.5), but higher than in neighbor Azerbaijan (25.5). Incidence is higher compared to central and eastern Europe (27.3) and near similar to North America (34.5). Georgia is an Eastern European, middleincome country with 3.7 million residents and one of the highest numbers of active smokers in the European Region. The Georgian health care system is divided into a public and a private sector, with coverage of nearly 100% of the population. There is a national healthcare system as well as private insurance and all patients, irrespective of insurance (private or governmental) can choose the hospital for treatment by themselves all over the country. The Basic Package of the Universal Health Care Program includes the treatment of oncologic patients, specifically surgery, chemotherapy, hormone therapy and radiotherapy and investigations and medications related to these procedures. The program covers all types of laboratory and instrumental investigations related to planned treatment. Georgia lacks an LC screening program for smokers and partially because of this, the majority of patients with lung cancer present at an advanced stage. The National Centre for the Disease Control (NCDC) showed that almost 90% of LC patients in the country present with advanced stages (III-IV) with 60% of patients having stage IV disease at diagnosis . Lung cancer is generally diagnosed at an advanced stage. For non-small cell lung cancer (NSCLC), the proportion with metastatic disease (TNM stage IV) ranged from 46.8% to 61.2% in developed countries. In recent years, there have been several publications addressing specifics of LC worldwide, but none concerning Georgia. In light of the rapidly changing landscape in the diagnosis, staging, and treatment of LC, we thought to define the state of practice in Georgia by convening specialists who treat LC across 13 institutions in our country with the goal to describe differences in access and approaches to LC.

Racial and socioeconomic disparities in the use of stereotactic body radiotherapy for treating non-small cell lung cancer: a narrative review

In the past two decades, there has been a steady increase in the use of stereotactic body radiotherapy (SBRT) as an alternative to surgical intervention for early-stage non-small cell lung cancer (NSCLC) patients; however, not much is known about the impact of race and socioeconomic status (SES) on the delivery of SBRT. Here, we conduct a narrative review to examine potential disparities in the use of SBRT. Keyword searches of MEDLINE/PubMed, Web of Science, Embase, and Google Scholar databases were performed for studies focused on race, SES, and the use of SBRT published between 2000 and 2020. Six studies were identified, and showed that minority patients, especially Blacks, were less likely to receive SBRT and had a significantly longer median time between diagnosis to SBRT treatment. Patients with lower income or lower education, as well as those from lower socioeconomic regions were less likely to receive SBRT; they were more likely to receive conventionally fractionated external beam radiation (CFRT) or no treatment. These racial and socioeconomic factors were associated with worse survival in other general early-stage NSCLC studies. In conclusion, the limited number of published studies suggest significant disparities in the treatment of early-stage NSCLC with SBRT. These factors potentially lead to worse survival outcomes among vulnerable patient populations. Equal access to SBRT should be a focus of healthcare delivery systems, to ensure optimal clinical outcomes for patients with early-stage NSCLC.

An improved method for analyzing and reporting patterns of in-field recurrence after stereotactic ablative radiotherapy in early-stage non-small cell lung cancer

INTRODUCTION

Patterns of local, regional, and distant failure after stereotactic ablative radiotherapy (SABR) for early-stage non-small cell lung cancer (NSCLC) have been widely reported. However, reliable methods for analyzing causes of local failure are lacking. We describe a method for analyzing and reporting patterns of in-field recurrence after SABR, incorporating dosimetric parameters from initial treatment plan as well as geometric information from diagnostic images at recurrence.

MATERIAL AND METHODS

Diagnostic CT images at recurrence were registered with initial treatment planning images and radiation dose by deformable image registration. Recurrent gross tumor volume (rGTV) and centroid (geometric center of rGTV) were delineated. In-field failure was classified as centroids originating within the original planning target volume. Dose-volume histograms for each rGTV were used to further classify in-field recurrences as central high-dose (dose to 95% of rGTV [rGTVD95%] ≥95% of dose prescribed to PTV) or peripheral high-dose (rGTVD95% <95% of dose prescribed to PTV).

RESULTS

634 patients received SABR from 2004 to 2014 with 48 local recurrences. 35 of these had evaluable images with 16 in-field recurrences: 9 central high-dose, 6 peripheral high-dose, and 1 had both. Time to and volume of recurrence were not statistically different between central versus peripheral high-dose recurrences. However mean rGTV dose, mean centroid dose, and rGTVD95% were higher for central versus peripheral high-dose recurrences.

CONCLUSION

We report a standardized method for analysis and classification of in-field recurrence after SABR. There were more central as opposed to peripheral high-dose recurrences, suggesting biological rather than technical issues underlying majority of in-field failures.

Comparison between computed tomography-guided percutaneous microwave ablation and thoracoscopic lobectomy for stage I non-small cell lung cancer

Background

The study was conducted to investigate the effectiveness and cost of computed tomography (CT)‐guided percutaneous microwave ablation (MWA) and thoracoscopic lobectomy for stage I non‐small cell lung cancer (NSCLC).

Methods

We retrospectively analyzed the data of 46 and 85 patients with stage I NSCLC treated with CT‐guided percutaneous MWA or thoracoscopic lobectomy, respectively, at our center from July 2013 to June 2015. Overall survival (OS), disease‐free survival (DFS), local control rate, hospital stay, and cost were evaluated. Survival curves were constructed using the Kaplan–Meier method and compared using the log‐rank test.

Results

The one and two‐year OS rates were 97.82% and 91.30% and 97.65% and 90.59% in the MWA and lobectomy groups, respectively. The one and two‐year DFS rates were 95.65% and 76.09% and 95.29% and 75.29%, respectively. No significant differences were observed in log‐rank analysis between the groups (P = 0.169). The hospital stays in the MWA and lobectomy groups were 6.62 ± 2.31 and 9.57 ± 3.19 days, respectively. The costs of MWA and lobectomy were US$3274.50 ± US$233.91 and US$4678.87 ± US$155.96, respectively. The differences were all significant (P = 0.003).

Conclusion

MWA and thoracoscopic lobectomy for stage I NSCLC demonstrate similar one and two‐year OS and DFS, with no significant differences between the two groups. MWA involved a shorter hospital stay and lower cost, thus should be considered a better option for patients with severe cardiopulmonary comorbidity and patients unwilling to undergo surgery.

Implantation of computed tomography-guided Iodine-125 seeds in combination with chemotherapy for the treatment of stage III non-small cell lung cancer

Purpose

We investigated the role of computed tomography (CT)-guided Iodine-125 (¹²⁵I) seed implantation in combination with chemotherapy for the treatment of stage III non-small cell lung carcinoma (NSCLC).

Material and methods

The data from 182 patients with stage III NSCLC who were treated with radioactive ¹²⁵I seed implantation between June 2002 and June 2009, and who received sequential platinum-based combination chemotherapy using the most common combination of platinum and gemcitabine, were retrospectively reviewed. The 182 patients received a prescribed dose of 110.0 Gy, with a median radioactivity of 0.70 mCi (range, 0.64-0.78 mCi, 2.37-3.26 × 107 Bq). The median number of ¹²⁵I seeds was 38 pellets (range, 6-105 pellets). The median post-operation dose covering 100% of the target volume (D₁₀₀) was 94.5 Gy (range, 54.6-125.5 Gy). The median D₉₀ was 143.0 Gy (range, 121.6-184.0).

Results

The 1-, 3-, and 5-year overall survival rates were 83.35%, 25.57%, and 11.34%, respectively; the median survival time was 24.76 months. At 1, 3, and 5 years, the local control rates were 92.01%, 86.51%, and 76.45%, respectively; the median local control time was 25.28 months. For patients with stage IIIA and IIIB NSCLC, the median survival times were 26.67 and 24.59 months, respectively (p = 0.2). Pre-treatment hemoglobin level, tumor volume, and postoperative D₁₀₀ were significantly associated with survival. A total of 24 patients experienced pneumothorax (incidence rate, 13.20%), and 17 patients experienced hemothorax (incidence rate, 5.0%).

Conclusions

CT-guided ¹²⁵I seed implantation combined with chemotherapy is an effective, minimally invasive method for the treatment of stage III NSCLC. Furthermore, hemoglobin levels before treatment, D₁₀₀, and the maximum diameter of the tumor may be prognostic factors in patients with NSCLC treated sequentially with radiotherapy and chemotherapy.

Advances in radiotherapy techniques and delivery for non-small cell lung cancer: benefits of intensity-modulated radiation therapy, proton therapy, and stereotactic body radiation therapy

The 21st century has seen several paradigm shifts in the treatment of non-small cell lung cancer (NSCLC) in early-stage inoperable disease, definitive locally advanced disease, and the postoperative setting. A key driver in improvement of local disease control has been the significant evolution of radiation therapy techniques in the last three decades, allowing for delivery of definitive radiation doses while limiting exposure of normal tissues. For patients with locally-advanced NSCLC, the advent of volumetric imaging techniques has allowed a shift from 2-dimensional approaches to 3-dimensional conformal radiation therapy (3DCRT). The next generation of 3DCRT, intensity-modulated radiation therapy and volumetric-modulated arc therapy (VMAT), have enabled even more conformal radiation delivery. Clinical evidence has shown that this can improve the quality of life for patients undergoing definitive management of lung cancer. In the early-stage setting, conventional fractionation led to poor outcomes. Evaluation of altered dose fractionation with the previously noted technology advances led to advent of stereotactic body radiation therapy (SBRT). This technique has dramatically improved local control and expanded treatment options for inoperable, early-stage patients. The recent development of proton therapy has opened new avenues for improving conformity and the therapeutic ratio. Evolution of newer proton therapy techniques, such as pencil-beam scanning (PBS), could improve tolerability and possibly allow reexamination of dose escalation. These new progresses, along with significant advances in systemic therapies, have improved survival for lung cancer patients across the spectrum of non-metastatic disease. They have also brought to light new challenges and avenues for further research and improvement.

Technical Description, Phantom Accuracy, and Clinical Feasibility for Single-Session Lung Radiosurgery Using Robotic Image-Guided Real-time Respiratory Tumor Tracking

To describe the technological background, the accuracy, and clinical feasibility for single session lung radiosurgery using a real-time robotic system with respiratory tracking. The latest version of image-guided real-time respiratory tracking software (Synchrony®, Accuray Incorporated, Sunnyvale, CA) was applied and is described. Accuracy measurements were performed using a newly designed moving phantom model. We treated 15 patients with 19 lung tumors with robotic radiosurgery (CyberKnife®, Accuray) using the same treatment parameters for all patients. Ten patients had primary tumors and five had metastatic tumors. All patients underwent computed tomography-guided percutaneous placement of one fiducial directly into the tumor, and were all treated with single session radiosurgery to a dose of 24 Gy. Follow up CT scanning was performed every two months.

All patients could be treated with the automated robotic technique. The respiratory tracking error was less than 1 mm and the overall shape of the dose profile was not affected by target motion and/or phase shift between fiducial and optical marker motion. Two patients required a chest tube insertion after fiducial implantation because of pneumothorax. One patient experienced nausea after treatment. No other short-term adverse reactions were found. One patient showed imaging signs of pneumonitis without a clinical correlation.

Single-session radiosurgery for lung tumor tracking using the described technology is a stable, safe, and feasible concept for respiratory tracking of tumors during robotic lung radiosurgery in selected patients. Longer follow-up is needed for definitive clinical results.

Patient outcomes of monotherapy with hypofractionated three-dimensional conformal radiation therapy for stage T2 or T3 non-small cell lung cancer: a retrospective study

Background

Hypofractionated three-dimensional conformal radiation therapy (3D-CRT) is a treatment option for patients with early-stage non-small cell lung cancer (NSCLC) who are medically unable to tolerate surgery and who are not amenable to treatment with stereotactic body radiotherapy. This study assessed the efficacy and safety of 3D-CRT as a monotherapy in patients with localized stage T2 or T3 NSCLC.

Methods

This retrospective study consisted of 29 patients (20 males) aged 56–89 years (median, 76 years) with histologically confirmed NSCLC who underwent 3D-CRT between 2005 and 2014.

Results

The median duration of patient observation was 17.0 months (range, 1.0–64.0 months). Complete and partial responses occurred in 13.8 and 44.8 % of patients, respectively, and the overall response rate was 58.2 %. Meanwhile, the 1- and 3-year survival rates were 65.8 and 33.8 %, respectively. In T2 NSCLC, the median survival time (MST) was 12 months, and the 1- and 3-year survival rates were 62.4 and 21.4 %, respectively. In T3 NSCLC, the MST was 17 months, and the 1- and 3-year survival rates were 72.9 and 48.6 %, respectively. Severe toxicities (Common Terminology Criteria Grade 3) were not observed. The mean biologically effective dose required to improve local control exceeded 80 Gy (range, 67.2–96.0 Gy).

Conclusion

These findings support a role for 3D-CRT as a treatment option for patients who refuse or could not tolerate surgical therapy with early-stage NSCLC. Although this was a small, retrospective study, it may form the basis for future, larger controlled studies on 3D-CRT as a monotherapy for NSCLC.

Triaging early-stage lung cancer patients into non-surgical pathways: who, when, and what?

More lung cancer patients are being diagnosed at an earlier stage due to improved diagnostic imaging techniques, a trend that is expected to accelerate with the dissemination of lung cancer screening. Surgical resection has always been considered the standard treatment for patients with early-stage non-small cell lung cancer (NSCLC). However, non-surgical treatment options for patients with early-stage NSCLC have evolved significantly over the past decade with many new and exciting alternative treatments now available. These alternative treatments include radiofrequency ablation (RFA), microwave ablation (MWA), percutaneous cryoablation therapy (PCT), photodynamic therapy (PDT) and external beam radiation therapy (EBRT), including stereotactic body radiation therapy (SBRT) and accelerated hypofractionated radiation therapy. We describe the established alternatives to surgical resection, their advantages and disadvantages, potential complications and efficacy. We then describe the optimal treatment approach for patients with early-stage NSCLC based on tumor operability, size and location. Finally, we discuss future directions and whether any alternative therapies will challenge surgical resection as the treatment of choice for patients with operable early-stage lung cancer.

LungTech, an EORTC Phase II trial of stereotactic body radiotherapy for centrally located lung tumours: a clinical perspective

Evidence supports stereotactic body radiotherapy (SBRT) as a curative treatment option for inoperable early stage non-small-cell lung cancer (NSCLC) resulting in high rates of tumour control and low risk of toxicity. However, promising results are mainly derived from SBRT of peripheral pulmonary lesions, whereas SBRT for the central tumours can lead to severe radiation sequelae owing to the spatial proximity to the serial organs at risk. Robust data on the tolerance of mediastinal structures to high-dose hypofractionated radiation are limited; furthermore, there are many open questions regarding the efficiency, safety and response assessment of SBRT in inoperable, centrally located early stage NSCLC, which are addressed in a prospective multicentre study [sponsored by the European Organization for Research and Treatment of Cancer (EORTC 22113-08113-LungTech)]. In this review, we summarize the current status regarding SBRT for centrally located early stage NSCLC that leads to the rationale of the LungTech trial. Outline and some essential features of the study with focus on a summary of current experiences in dose/fraction-toxicity coherences after SBRT to the mediastinal structures that lead to LungTech normal tissue constraints are provided.

Racial disparities in the use of SBRT for treating early-stage lung cancer

OBJECTIVES

Prior studies have shown that the surgical resection rate for black patients with early-stage lung cancer is significantly lower than that of white patients, which may partially explain the worse outcomes observed in this group. Over the past decade, however, there has been increasing utilization of stereotactic body radiotherapy (SBRT) as an alternative to surgical resection for inoperable patients. We undertook a population-based study to evaluate potential racial disparities in the use of SBRT.

MATERIALS AND METHODS

Using the National Cancer Database, black and white patients with Stage I NSCLC between 2003 and 2011 were identified. Patients were categorized based on primary treatment modality. Univariable and multivariable analyses were performed to identify demographic predictors of SBRT utilization in the non-operative population.

RESULTS

A total of 113,312 patients met the inclusion criteria. When compared to white patients, black patients were less likely to receive surgical intervention (66% vs. 58%, P<0.001) or SBRT (6.1% vs. 5.5%, P<0.001), and more likely to receive standard fractionated external beam radiation (EBRT) or no treatment. When confined to the non-operative cohort, multivariable logistic regression confirmed black race to be negatively associated with SBRT use compared to less aggressive therapy.

CONCLUSION

In this national dataset, we confirmed prior observations that black patients are less likely to receive surgery than white patients, and also found that black patients are less likely to receive SBRT. This suggests that even with emerging utilization of SBRT for inoperable candidates, black patients continue to receive less aggressive therapy.

Primary Treatment Options for High-Risk/Medically Inoperable Early Stage NSCLC Patients

Lung cancer is among the most common cancers worldwide and is the leading cause of cancer death in both men and women. For patients with early stage (American Joint Committee on Cancer T1-2, N0) non-small-cell lung cancer, the current standard of care is lobectomy with systematic lymph node evaluation. Unfortunately, patients with lung cancer often have medical comorbities, which may preclude the option of surgical resection. In such cases, a number of minimally invasive to noninvasive treatment options have gained popularity in the treatment of these high-risk patients. These modalities provide significant advantages, including patient convenience, treatment in an outpatient setting, and acceptable toxicities, including reduced impact on lung function and a modest risk of postprocedure chest wall pain. We provide a comprehensive review of the literature, including reported outcomes, complications, and limitations of sublobar resection with or without intraoperative brachytherapy, radiofrequency ablation, microwave ablation, percutaneous cryoablation, photodynamic therapy, and stereotactic body radiotherapy.

DART-bid: dose-differentiated accelerated radiation therapy, 1.8 Gy twice daily: high local control in early stage (I/II) non-small-cell lung cancer

BACKGROUND

While surgery is considered standard of care for early stage (I/II), non-small-cell lung cancer (NSCLC), radiotherapy is a widely accepted alternative for medically unfit patients or those who refuse surgery. International guidelines recommend several treatment options, comprising stereotactic body radiation therapy (SBRT) for small tumors, conventional radiotherapy ≥ 60 Gy for larger sized especially centrally located lesions or continuous hyperfractionated accelerated RT (CHART). This study presents clinical outcome and toxicity for patients treated with a dose-differentiated accelerated schedule using 1.8 Gy bid (DART-bid).

PATIENTS AND METHODS

Between April 2002 and December 2010, 54 patients (median age 71 years, median Karnofsky performance score 70%) were treated for early stage NSCLC. Total doses were applied according to tumor diameter: 73.8 Gy for <  2.5 cm, 79.2 Gy for 2.5-4.5 cm, 84.6 Gy for 4.5-6 cm, 90 Gy for > 6 cm.

RESULTS

The median follow-up was 28.5 months (range 2-108 months); actuarial local control (LC) at 2 and 3 years was 88%, while regional control was 100%. There were 10 patients (19%) who died of the tumor, and 18 patients (33%) died due to cardiovascular or pulmonary causes. A total of 11 patients (20%) died intercurrently without evidence of progression or treatment-related toxicity at the last follow-up, while 15 patients (28%) are alive. Acute esophagitis ≤ grade 2 occurred in 7 cases, 2 patients developed grade 2 chronic pulmonary fibrosis.

CONCLUSION

DART-bid yields high LC without significant toxicity. For centrally located and/or large (> 5 cm) early stage tumors, where SBRT is not feasible, this method might serve as radiotherapeutic alternative to present treatment recommendations, with the need of confirmation in larger cohorts.

Delayed esophageal perforation from stereotactic body radiation therapy for locally recurrent central nonsmall cell lung cancer

Stereotactic body radiation therapy (SBRT) is a novel form of external beam radiation therapy. It is used to treat early and locally recurrent nonsmall cell lung cancer (NSLC) in medically inoperable patients. It uses high dose, hypofractionated radiotherapy, with targeting of the tumor by precise spatial localization, thus minimizing injury to surrounding tissues. It can be safely used to ablate NSLC in both central and peripheral locations. We present two cases of delayed esophageal perforation after SBRT for locally recurrent central NSLC. The perforations occurred several months after the therapy. They were treated with covered esophageal stents, with mortality, due to the perforation in one of the patients. SBRT should be judiciously used to ablate centrally located NSLC and patients who develop episodes of esophagitis during or after SBRT, need to be closely followed with endoscopy to look for esophageal ulcerations. These ulcers should be closely followed for healing as these may degenerate into full thickness perforations several months after SBRT.

Hypofractionated three-dimensional conformal radiotherapy for medically inoperable early stage non-small-cell lung cancer

Purpose

The purpose of this study was to assess the clinical outcomes of hypofractionated radiotherapy (HFRT) with three-dimensional conformal technique for medically inoperable patients with early stage non-small-cell lung cancer (NSCLC) and to evaluate prognostic factors.

Materials and Methods

We performed a retrospective review of 26 patients who underwent HFRT for early stage NSCLC between September 2005 and August 2011. Only clinical stage T1-3N0 was included. The median RT dose was 70 Gy (range, 60 to 72 Gy) and the median biologically equivalent dose (BED) was 94.5 Gy (range, 78.0 to 100.8 Gy). In 84.6% of patients, 4 Gy per fraction was used. Neoadjuvant chemotherapy with paclitaxel and cisplatin was given to 2 of 26 patients.

Results

The median follow-up time for surviving patients was 21 months (range, 13 to 49 months). The overall response rate was 53.9%, and the initial local control rate was 100%. The median survival duration was 27.8 months. Rates of 2-year overall survival, progression-free survival (PFS), local control (LC), and locoregional-free survival (LRFS) were 54.3%, 61.1%, 74.6%, and 61.9%, respectively. Multivariate analysis showed that BED (>90 vs. ≤90 Gy) was an independent prognostic factor influencing PFS, LC, and LRFS. Severe toxicities over grade 3 were not observed.

Conclusion

Radical HFRT can yield satisfactory disease control with acceptable rates of toxicities in medically inoperable patients with early stage NSCLC. HFRT is a viable alternative for clinics and patients ineligible for stereotactic ablative radiotherapy. BED over 90 Gy and 4 Gy per fraction might be appropriate for HFRT.

Stereotactic body radiation therapy in non-small-cell lung cancer: linking radiobiological modeling and clinical outcome

For patients with peripheral, early-stage non-small-cell lung cancer, it has been found feasible to deliver 5 or fewer fractions of large doses through stereotactic body radiation therapy (SBRT) without causing severe early or late injury and with impressive tumor control. In this review, we employ radiobiological modeling with the linear quadratic formulation to explore the adequacy of various dose schedules used for tumor control in the lung as supported by clinical evidence, the influence of dose distribution and delivery time on local control, and how to decrease the likelihood of severe toxicity following SBRT. Furthermore, the validity of the linear quadratic formalism in the high dose range of SBRT for lung cancer is explored.

Image-guided radiofrequency ablation for the treatment of early-stage non-small cell lung neoplasm in high-risk patients

Lung cancer is the most common cause of cancer-related mortality in the United States. Surgical resection with a lobectomy is the standard treatment for stage I non-small cell lung cancer. With an aging population, however, there are a significant number of patients who have other comorbidities that preclude surgical resection. Image-guided radiofrequency ablation is a new emerging modality of treatment which may be applicable in this high-risk group of patients. In this article, we review the principles of radiofrequency ablation, the common devices in use, the results of ablate and resect studies, future directions, and the results of treatment for stage I non-small cell lung neoplasm.

Hypofractionated radiotherapy for lung tumors with online cone beam CT guidance and active breathing control

Background

To study the set-up errors, PTV margin and toxicity of cone beam CT (CBCT) guided hypofractionated radiotherapy with active breathing control (ABC) for patients with non-small cell lung cancer (NSCLC) or metastatic tumors in lung.

Methods

32 tumors in 20 patients were treated. Based on the location of tumor, dose per fraction given to tumor was divided into three groups: 12 Gy, 8 Gy and 6 Gy. ABC is applied for every patient. During each treatment, patients receive CBCT scan for online set-up correction. The pre- and post-correction setup errors between fractions, the interfractional and intrafractional, set-up errors, PTV margin as well as toxicity are analyzed.

Results

The pre-correction systematic and random errors in the left-right (LR), superior-inferior (SI), anterior-posterior (AP) directions were 3.7 mm and 5.3 mm, 3.1 mm and 2.1 mm, 3.7 mm and 2.8 mm, respectively, while the post-correction residual errors were 0.6 mm and 0.8 mm, 0.8 mm and 0.8 mm, 1.2 mm and 1.3 mm, respectively. There was an obvious intrafractional shift of tumor position. The pre-correction PTV margin was 9.5 mm in LR, 14.1 mm in SI and 8.2 mm in AP direction. After CBCT guided online correction, the PTV margin was markedly reduced in all three directions. The post-correction margins ranged 1.5 to 2.1 mm. The treatment was well tolerated by patients, of whom there were 4 (20%) grade1-2 acute pneumonitis, 3 (15%) grade1 acute esophagitis, 2 (10%) grade1 late pneumonitis and 1 (5%) grade 1 late esophagitis.

Conclusion

The positioning errors for lung SBRT using ABC were significant. Online correction with CBCT image guidance should be applied to reduce setup errors and PTV margin, which may reduce radiotherapy toxicity of tissues when ABC was used.

Do we have enough evidence to implement particle therapy as standard treatment in lung cancer? A systematic literature review

BACKGROUND

The societal burden of lung cancer is high because of its high incidence and high lethality. From a theoretical point of view, radiotherapy with beams of protons and heavier charged particles, for example, carbon ions (C-ions), should lead to superior results, compared with photon beams. In this review, we searched for clinical evidence to justify implementation of particle therapy as standard treatment in lung cancer.

METHODS

A systematic literature review based on an earlier published comprehensive review was performed and updated through November 2009.

RESULTS

Eleven fully published studies, all dealing with non-small cell lung cancer (NSCLC), mainly stage I, were identified. No phase III trials were found. For proton therapy, 2- to 5-year local tumor control rates varied in the range of 57%-87%. The 2- and 5-year overall survival (OS) and 2- and 5-year cause-specific survival (CSS) rates were 31%-74% and 23% and 58%-86% and 46%, respectively. Radiation-induced pneumonitis was observed in about 10% of patients. For C-ion therapy, the overall local tumor control rate was 77%, but it was 95% when using a hypofractionated radiation schedule. The 5-year OS and CSS rates were 42% and 60%, respectively. Slightly better results were reported when using hypofractionation, 50% and 76%, respectively.

CONCLUSION

The present results with protons and heavier charged particles are promising. However, the current lack of evidence on the clinical (cost-)effectiveness of particle therapy emphasizes the need to investigate the efficiency of particle therapy in an adequate manner. Until these results are available for lung cancer, charged particle therapy should be considered experimental.

Systemic review of the patterns of failure following stereotactic body radiation therapy in early-stage non-small-cell lung cancer: clinical implications

PURPOSE

To analyze the patterns of failure, the toxicity profile, and the factors influencing efficacy of stereotactic body radiation (SBRT) for early-stage non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

A search was based on PubMed electronic databases. All searches were conducted in May, 2009.

RESULTS

The local control ranged from 80% to 100% in most studies with adequate isocentric or peripheral biologically effective dose (BED). Recurrences were associated with increased tumor size. The main pattern of failure after SBRT was distant metastasis. Grades 3-5 toxicity occurred mostly in centrally located tumors, and adjuvant chemotherapy may further decrease all recurrences; possibly translating to a survival benefit in large or centrally located tumors where high BED cannot be safely reached.

CONCLUSION

SBRT is an excellent treatment option for early-stage, and mostly medically inoperable, NSCLC. BED at both the isocenter and the tumor periphery is very important for optimal tumor control; higher doses are required for large (T2) lesions; SBRT for centrally located tumors can be feasible with a much less aggressive dose regimen than 60-66Gy/3 fractions and adjacent critical structures excluded from the target volume; chemotherapy may optimize the clinical outcome in large or centrally located lesions.

Image-guided radiofrequency ablation of lung neoplasm in 100 consecutive patients by a thoracic surgical service

BACKGROUND

Surgical resection is the standard of care for patients with resectable non-small cell lung cancer or selected patients with pulmonary metastases. However, for high-risk patients radiofrequency ablation (RFA) may offer an alternative option. The objective of this study was to evaluate computed tomography-guided RFA for high-risk patients and report our initial experience in 100 consecutive patients by a thoracic surgical service.

METHODS

Medically inoperable patients were offered RFA. Thoracic surgeons evaluated and performed RFA under computed tomography guidance. Patients were followed in the thoracic surgery clinic. The primary end point evaluated was overall survival.

RESULTS

One hundred patients underwent image-guided RFA for lung neoplasm (40 men, 60 women; median age, 73.5 years; range, 26 to 95 years). Forty-six patients (46%) with primary lung neoplasm, 25 patients (25%) with recurrent cancer, and 29 patients (29%) with pulmonary metastases underwent RFA. The mean follow-up for alive patients was 17 months. The median overall survival for the entire group of patients was 23 months. The probabilities of 2-year overall survival for the entire group, primary lung cancer patients, recurrent cancer patients, and metastatic cancer patients were 49% (95% confidence interval, 37 to 60), 50% (95% confidence interval, 33 to 65), 55% (95% confidence interval, 25 to 77), and 41% (95% confidence interval, 19 to 62), respectively.

CONCLUSIONS

Our experience indicates that image-guided RFA done by the thoracic surgeons is feasible and safe in high-risk patients with lung neoplasm with reasonable results in patients who are not fit for surgery. Thoracic surgeons can perform RFA safely, and should continue to investigate this new image-guided modality that may offer an alternative option in medically inoperable patients.

Radiofrequency ablation for the treatment of stage I non-small cell lung neoplasm

Lung cancer is the most common cause of cancer related mortality in the United States. Surgical resection is the standard treatment for stage I non-small cell lung cancer (NSCLC). However, many patients who have resectable cancer may have significant comorbidities precluding surgical resection. Radiofrequency ablation is an emerging modality of treatment and may be applicable in this high-risk group of patients. In this article, we review the principles of radiofrequency ablation, the common devices in use, and the results of treatment for stage I non-small cell lung neoplasm.

Radiofrequency ablation for the treatment of lung neoplasm

Lung cancer is the most common cause of cancer-related mortality in the USA. Surgical resection is the standard treatment for resectable disease; however, a significant percentage of patients with otherwise resectable lung cancer may have other comorbidities, precluding surgical resection. In patients with Stage I non-small-cell lung cancer, conventional external-beam radiotherapy is typically offered as treatment in medically inoperable, high-risk patients with reported 5-year survival rates of 10-30%. An emerging technology in the treatment of lung tumors is radiofrequency ablation, which is a thermal ablative technique and may be applicable in high-risk patients with lung cancer. In this article we will review the principles of radiofrequency ablation, the common devices in use, the experimental background, the results of 'ablate and resect' studies and the clinical experience with radiofrequency ablation in the treatment of lung neoplasm.

CT-guided permanent brachytherapy for patients with medically inoperable early-stage non-small cell lung cancer (NSCLC)

Seven patients with early stage T1N0M0 NSCLC who had medical contraindications for surgical resection were treated with CT-guided percutaneous implantation of (103)Pd or (125)I seeds. After the procedure, two patients developed pneumothorax and hemo/pneumothorax that was managed with aspirative drainage. One patient developed a focal pneumonitis 3 months after the procedure. After a median follow-up of 13 months (4.6-41.0+ months), no patient has developed local or regional failure.

Proton therapy in lung cancer: clinical outcomes and technical issues. A systematic review

BACKGROUND AND PURPOSE

To determine whether, according to the currently available literature, proton therapy (PT) has a role in the treatment of non-small-cell lung cancer (NSCLC), to assess its safety and efficacy and to evaluate the main technical issues specifically related to this treatment technique.

MATERIALS AND METHODS

During March 2007, two independent researchers conducted a systematic review of the current data on the treatment of NSCLC with PT.

RESULTS

In total, 113 reports were retrieved, 17 of which were included in the analysis. There were no prospective trials (randomized or non-randomized). Nine uncontrolled single-arm studies were available from three PT centers, providing clinical outcomes for 214 patients in total. These reports were mainly related to stage I-II tumors, with results comparable to those obtained with surgery, without significant toxicity. In addition, two papers were found that compared photon and proton dose distributions, which showed a potential for dose escalation and/or a sparing of the organ at risk with PT. Finally, six studies analyzed dosimetric and technical issues related with PT, mainly underlining the difficulties in designing dose distributions that are representative of the dose actually delivered during treatment.

CONCLUSIONS

Although from a physical point of view PT is a good option for the treatment of NSCLC, limited data are available on its application in the clinical practice. Furthermore, the application of PT to lung cancer does present technical challenges. Because of the small number of institutions involved in the treatment of this disease, number of patients, and methodological weaknesses of the trials it is therefore not possible to draw definitive conclusions about the superiority of PT with respect to the photon techniques currently available for the treatment of NSCLC.

Particle therapy in lung cancer: where do we stand?

BACKGROUND

From a theoretical point of view, charged particles should lead to superior results compared to photons. In this review, we searched for clinical evidence that protons or C-ions are really beneficial to patients with lung cancer.

METHODS

A systematic literature review based on an earlier published comprehensive review was performed and updated until November 1st 2007.

RESULTS

Ten fully published series, all dealing with non-small cell lung cancer (NSCLC), mainly stage I, were identified. No phase III trials were found. On proton therapy, 2-5 year local tumor control rates varied between 87% and 57%. The 2 year/5 year overall survival and 2 year/5 year cause specific survival varied between 31-74%/23% and 58-86%/46%, respectively. Late side effects were observed in about 10% of the patients. For C-ion therapy, the local tumor control rate was 77%, while 95% when using a hypofractionated radiation schedule. The 5 year overall survival and cause specific survival rates were 42% and 60%, respectively. Slightly better results were reported when using hypofractionation, 50% and 76%, respectively. The reported late side effects for C-ions were 4%.

CONCLUSION

The results with charged particles, at least for stage I disease, seem to be promising. A gain can be expected in reduction of late side effects, especially after treatment with C-ions. Available data demonstrate that particle therapy in general is a safe and feasible treatment modality. Although current results are promising, more evidence is required before particle therapy can become internationally the standard treatment for (subsets of) lung cancer patients.