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Mansur A, Saleem Z, Beqari J, Mathey-Andrews C, Potter AL, Cranor J, Nees AT, Srinivasan D, Yang ME, Yang CFJ, Auchincloss HG. Wedge Resection versus Stereotactic Body Radiation Therapy for Non-Small Cell Lung Cancer Tumors ≤8 mm. Curr Oncol 2024; 31:1529-1542. [PMID: 38534949 PMCID: PMC10969215 DOI: 10.3390/curroncol31030116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/12/2024] [Accepted: 03/01/2024] [Indexed: 05/26/2024] Open
Abstract
The objective of this study was to evaluate the overall survival of patients with ≤8 mm non-small cell lung cancer (NSCLC) who undergo wedge resection versus stereotactic body radiation therapy (SBRT). Kaplan-Meier analysis, multivariable Cox proportional hazards modeling, and propensity score-matched analysis were performed to evaluate the overall survival of patients with ≤8 mm NSCLC in the National Cancer Database (NCDB) from 2004 to 2017 who underwent wedge resection versus patients who underwent SBRT. The above-mentioned matched analyses were repeated for patients with no comorbidities. Patients who were coded in the NCDB as having undergone radiation because surgery was contraindicated due to patient risk factors (e.g., comorbid conditions, advance age, etc.) and those with a history of prior malignancy were excluded from analysis. Of the 1505 patients who had NSCLC ≤8 mm during the study period, 1339 (89%) patients underwent wedge resection, and 166 (11%) patients underwent SBRT. In the unadjusted analysis, multivariable Cox modeling and propensity score-matched analysis, wedge resection was associated with improved survival when compared to SBRT. These results were consistent in a sensitivity analysis limited to patients with no comorbidities.
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Affiliation(s)
- Arian Mansur
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA 02114, USA; (Z.S.); (J.B.); (C.M.-A.); (A.L.P.); (J.C.); (A.T.N.); (D.S.); (M.E.Y.); (C.-F.J.Y.); (H.G.A.)
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2
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Buchberger DS, Videtic GMM. Stereotactic Body Radiotherapy for the Management of Early-Stage Non-Small-Cell Lung Cancer: A Clinical Overview. JCO Oncol Pract 2023; 19:239-249. [PMID: 36800644 DOI: 10.1200/op.22.00475] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Affiliation(s)
- David S Buchberger
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Gregory M M Videtic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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3
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Timmerman R. A Story of Hypofractionation and the Table on the Wall. Int J Radiat Oncol Biol Phys 2022; 112:4-21. [PMID: 34919882 DOI: 10.1016/j.ijrobp.2021.09.027] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/07/2021] [Accepted: 09/14/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas.
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4
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Lin Y, Mak KS. Racial and socioeconomic disparities in the use of stereotactic body radiotherapy for treating non-small cell lung cancer: a narrative review. J Thorac Dis 2021; 13:3764-3771. [PMID: 34277068 PMCID: PMC8264671 DOI: 10.21037/jtd-20-3199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 03/04/2021] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Yue Lin
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Kimberley S Mak
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, USA
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5
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Khorfan R, Kruser TJ, Coughlin JM, Bharat A, Bilimoria KY, Odell DD. Survival of Primary Stereotactic Body Radiation Therapy Compared With Surgery for Operable Stage I/II Non-small Cell Lung Cancer. Ann Thorac Surg 2020; 110:228-234. [PMID: 32147416 DOI: 10.1016/j.athoracsur.2020.01.073] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/14/2020] [Accepted: 01/30/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) is an accepted primary treatment option for inoperable early-stage non-small cell lung cancer (NSCLC). The role of SBRT in the treatment of operable disease remains unclear. We retrospectively evaluated patients with operable early-stage NSCLC who elected to receive primary SBRT, examined factors associated with SBRT, and compared overall survival after surgical resection and SBRT. METHODS The National Cancer Database was queried for patients with stage I/II, N0 NSCLC from 2004 to 2016. The proportion of patients who refused recommended surgery and were treated with SBRT was calculated. A propensity score predicting the probability of refusing surgery and receiving SBRT was generated and used to match SBRT and resected patients. Long-term overall survival was compared in the matched cohort using the Kaplan-Meier method and Cox regression. RESULTS We identified 1359 patients (0.98%) who refused recommended surgery and elected SBRT. This proportion increased annually, from 0.1% in 2004 to 1.7% in 2016. Factors associated with SBRT were older age, black race, Medicaid coverage, lower T stage, and more recent diagnosis year. Propensity matching resulted in 1315 well-balanced pairs. Surgery was associated with higher median survival (74 vs 47 months, P < .01) in the matched cohort. Survival benefit persisted after adjusting for covariates on Cox regression (hazard ratio, 1.69; P < .01). CONCLUSIONS Median survival was significantly higher after surgery compared with SBRT in a risk-adjusted matched cohort of patients judged to be surgical candidates. Operable patients considering primary SBRT should be educated regarding this difference in survival.
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Affiliation(s)
- Rhami Khorfan
- Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Timothy J Kruser
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia M Coughlin
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David D Odell
- Surgical Outcomes and Quality Improvement Center (SOQIC), Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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6
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Blom EF, ten Haaf K, Arenberg DA, de Koning HJ. Disparities in Receiving Guideline-Concordant Treatment for Lung Cancer in the United States. Ann Am Thorac Soc 2020; 17:186-194. [PMID: 31672025 PMCID: PMC6993802 DOI: 10.1513/annalsats.201901-094oc] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
Rationale: The level of adherence to lung cancer treatment guidelines in the United States is unclear. In addition, it is unclear whether previously identified disparities by racial or ethnic group and by age persist across all clinical subgroups.Objectives: To assess the level of adherence to the minimal lung cancer treatment recommended by the National Comprehensive Cancer Network guidelines (guideline-concordant treatment) in the United States, and to assess the persistence of disparities by racial or ethnic group and by age across all clinical subgroups.Methods: We evaluated whether 441,812 lung cancer cases in the National Cancer Database diagnosed between 2010 and 2014 received guideline-concordant treatment. Logistic regression models were used to assess possible disparities in receiving guideline-concordant treatment by racial or ethnic group and by age across all clinical subgroups, and whether these persist after adjusting for patient, tumor, and health care provider characteristics.Results: Overall, 62.1% of subjects received guideline-concordant treatment (range across clinical subgroups = 50.4-76.3%). However, 21.6% received no treatment (range = 10.3-31.4%) and 16.3% received less intensive treatment than recommended (range = 6.4-21.6%). Among the most common less intensive treatments for all subgroups was "conventionally fractionated radiotherapy only" (range = 2.5-16.0%), as was "chemotherapy only" for nonmetastatic subgroups (range = 1.2-13.7%), and "conventionally fractionated radiotherapy and chemotherapy" for localized non-small-cell lung cancer (5.9%). Guideline-concordant treatment was less likely with increasing age, despite adjusting for relevant covariates (age ≥ 80 yr compared with <50 yr: adjusted odds ratio = 0.12, 95% confidence interval = 0.12-0.13). This disparity was present in all clinical subgroups. In addition, non-Hispanic black patients were less likely to receive guideline-concordant treatment than non-Hispanic white patients (adjusted odds ratio = 0.78, 95% confidence interval = 0.76-0.80). This disparity was present in all clinical subgroups, although statistically nonsignificant for extensive disease small-cell lung cancer.Conclusions: Between 2010 and 2014, many patients with lung cancer in the United States received no treatment or less intensive treatment than recommended. Particularly, elderly patients with lung cancer and non-Hispanic black patients are less likely to receive guideline-concordant treatment. Patterns of care among those receiving less intensive treatment than recommended suggest room for improved uptake of treatments such as stereotactic body radiation therapy for subjects with localized non-small-cell lung cancer.
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Affiliation(s)
- Erik F. Blom
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; and
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kevin ten Haaf
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; and
| | - Douglas A. Arenberg
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Harry J. de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; and
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7
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Timmerman RD, Hu C, Michalski JM, Bradley JC, Galvin J, Johnstone DW, Choy H. Long-term Results of Stereotactic Body Radiation Therapy in Medically Inoperable Stage I Non-Small Cell Lung Cancer. JAMA Oncol 2019; 4:1287-1288. [PMID: 29852036 DOI: 10.1001/jamaoncol.2018.1258] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Robert D Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Chen Hu
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania.,Sydney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeff M Michalski
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - Jeffrey C Bradley
- Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri
| | - James Galvin
- Imaging and Radiation Oncology Core, Philadelphia, Pennsylvania
| | - David W Johnstone
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee
| | - Hak Choy
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas
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8
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Feldman AM, Modh A, Glide-Hurst C, Chetty IJ, Movsas B. Real-time Magnetic Resonance-guided Liver Stereotactic Body Radiation Therapy: An Institutional Report Using a Magnetic Resonance-Linac System. Cureus 2019; 11:e5774. [PMID: 31723533 PMCID: PMC6825488 DOI: 10.7759/cureus.5774] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/23/2019] [Indexed: 12/22/2022] Open
Abstract
Background Stereotactic body radiation therapy (SBRT) is a proven and effective modality for treatment of hepatic primary and metastatic tumors. However, these lesions are challenging for planning and treatment execution due to natural anatomic changes associated with respiration. Magnetic resonance imaging (MRI) offers superior soft tissue contrast resolution and the ability for real-time image-guided treatment delivery and lesion tracking. Objective To evaluate the plan quality, treatment delivery, and tumor response of a set of liver SBRT cancer treatments delivered with magnetic resonance (MR)-guided radiotherapy on a MR-linear accelerator (MR-linac). Methods Treatment data from 29 consecutive patients treated with SBRT were reviewed. All treatments were performed using a step and shoot technique to one or more liver lesions on an MR-linac platform. Patients received 45 to 50 Gy prescribed to at least 95% of the planning target volume (PTV) in five fractions except for two patients who received 27-30 Gy in three fractions. Computed tomography and MRI simulation were performed in the supine position prior to treatment in the free-breathing, end exhalation, and end inhalation breath-hold positions to determine patient tolerability and potential dosimetric advantages of each technique. Immobilization consisted of using anterior and posterior torso MRI receive coils embedded in a medium-sized vacuum cushion. Gating was performed using sagittal cine images acquired at 4 frames/second. Gating boundaries were defined in the three major axes to be 0.3 to 0.5 cm. An overlapping region of interest, defined as the percentage volume allowed outside the boundary for beam-on to occur, was set between 1 and 10%. The contoured target was assigned a 5-mm PTV expansion. Organs at risk constraints adopted by the American Association of Physicists in Medicine Task Group 101 were used during optimization. Results Twenty-nine patients, with a total of 34 lesions, successfully completed the prescribed treatment with minimal treatment breaks or delays. Twenty-one patients were treated at end-exhale, and six were treated at end-inhale. Two patients were treated using a free-breathing technique due to poor compliance with breath-hold instructions. The reported mean liver dose was 5.56 Gy (1.39 - 10.43; STD 2.85) and the reported mean liver volume receiving the prescribed threshold dose was 103.1 cm3 (2.9 - 236.6; STD 75.2). Follow-up imaging at one to 12 months post treatment confirmed either stable or decreased size of treated lesions in all but one patient. Toxicities were mild and included nausea/vomiting, abdominal pain and one case of bloody diarrhea. Four patients died due to complications from liver cirrhosis unrelated to radiation effect. Conclusion SBRT treatment using a gated technique on an MR-linac has been successfully demonstrated. Potential benefits of this modality include decreased liver dose leading to decreased toxicities. Further studies to identify the benefits and risks associated with MR-guided SBRT are necessary.
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Affiliation(s)
| | - Ankit Modh
- Radiation Oncology, Henry Ford Health System, Detroit, USA
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9
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Yan SX, Qureshi MM, Dyer M, Truong MT, Mak KS. Stereotactic body radiation therapy with higher biologically effective dose is associated with improved survival in stage II non-small cell lung cancer. Lung Cancer 2019; 131:147-153. [PMID: 31027693 DOI: 10.1016/j.lungcan.2019.03.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/14/2019] [Accepted: 03/30/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The role of stereotactic body radiation therapy (SBRT) in treating stage II non-small cell lung cancer (NSCLC) remains unclear. This study evaluates SBRT dose prescription patterns and survival outcomes in Stage II NSCLC using the National Cancer Database (NCDB). MATERIALS AND METHODS Patients diagnosed with Stage II NSCLC and treated with SBRT between 2004-2013 were identified in NCDB. The biologically effective dose with α/β = 10 Gy (BED10) was calculated. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox regression models. RESULTS Of 56,543 patients with Stage II NSCLC, 451 (0.8%) received SBRT. There were 360 patients (79.8%) with node-negative and 91 patients (20.2%) with node-positive disease. The most common prescriptions were 10 Gy x 5 (35.9%) and 12 Gy x 4 (19.3%). The mean and median BED10 were 114.9 Gy and 105.6 Gy, respectively. With median follow-up of 19.3 months, overall median survival was 23.7 months. Median survival was 22.4 months for those treated with BED10 < 114.9 Gy versus 31.5 months for BED10 ≥ 114.9 Gy (p = 0.036). On multivariate analysis, BED10 as a continuous variable (hazard ratio [HR] 0.991, p = 0.009) and ≥ 114.9 Gy (HR 0.63, p = 0.015) were associated with improved survival in node-negative patients. BED10 as a continuous variable (HR 0.997, p = 0.465) and ≥ 114.9 Gy (HR 0.81, p = 0.546) were not significant factors for predicting survival in node-positive patients. CONCLUSION SBRT is infrequently utilized to treat Stage II NSCLC in the United States. Treatment with higher BED10 was associated with improved survival, and the benefit was limited to patients with node-negative disease.
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Affiliation(s)
- Sherry X Yan
- Boston Medical Center, One Boston Medical Center Pl., Boston, MA 02118, USA
| | - Muhammad M Qureshi
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave. Moakley LL, Boston, MA 02118, USA; Boston University School of Medicine, 72 E. Concord St., Boston, MA 02118, USA
| | - Michael Dyer
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave. Moakley LL, Boston, MA 02118, USA; Boston University School of Medicine, 72 E. Concord St., Boston, MA 02118, USA
| | - Minh Tam Truong
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave. Moakley LL, Boston, MA 02118, USA; Boston University School of Medicine, 72 E. Concord St., Boston, MA 02118, USA
| | - Kimberley S Mak
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave. Moakley LL, Boston, MA 02118, USA; Boston University School of Medicine, 72 E. Concord St., Boston, MA 02118, USA.
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10
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Bowling MR, Folch EE, Khandhar SJ, Kazakov J, Krimsky WS, LeMense GP, Linden PA, Murillo BA, Nead MA, Pritchett MA, Teba CV, Towe CW, Williams T, Anciano CJ. Fiducial marker placement with electromagnetic navigation bronchoscopy: a subgroup analysis of the prospective, multicenter NAVIGATE study. Ther Adv Respir Dis 2019; 13:1753466619841234. [PMID: 30958102 PMCID: PMC6454637 DOI: 10.1177/1753466619841234] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 03/08/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Fiducial markers (FMs) help direct stereotactic body radiation therapy (SBRT) and localization for surgical resection in lung cancer management. We report the safety, accuracy, and practice patterns of FM placement utilizing electromagnetic navigation bronchoscopy (ENB). METHODS NAVIGATE is a global, prospective, multicenter, observational cohort study of ENB using the superDimension™ navigation system. This prospectively collected subgroup analysis presents the patient demographics, procedural characteristics, and 1-month outcomes in patients undergoing ENB-guided FM placement. Follow up through 24 months is ongoing. RESULTS Two-hundred fifty-eight patients from 21 centers in the United States were included. General anesthesia was used in 68.2%. Lesion location was confirmed by radial endobronchial ultrasound in 34.5% of procedures. The median ENB procedure time was 31.0 min. Concurrent lung lesion biopsy was conducted in 82.6% (213/258) of patients. A mean of 2.2 ± 1.7 FMs (median 1.0 FMs) were placed per patient and 99.2% were accurately positioned based on subjective operator assessment. Follow-up imaging showed that 94.1% (239/254) of markers remained in place. The procedure-related pneumothorax rate was 5.4% (14/258) overall and 3.1% (8/258) grade ⩾ 2 based on the Common Terminology Criteria for Adverse Events scale. The procedure-related grade ⩾ 4 respiratory failure rate was 1.6% (4/258). There were no bronchopulmonary hemorrhages. CONCLUSION ENB is an accurate and versatile tool to place FMs for SBRT and localization for surgical resection with low complication rates. The ability to perform a biopsy safely in the same procedure can also increase efficiency. The impact of practice pattern variations on therapeutic effectiveness requires further study. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02410837.
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Affiliation(s)
- Mark R. Bowling
- Department of Internal Medicine, Division of
Pulmonary, Critical Care and Sleep Medicine, Brody School of Medicine, East
Carolina University, 521a Moye Boulevard, Greenville, NC 27834, USA
| | - Erik E. Folch
- Massachusetts General Hospital, Harvard Medical
School, Boston, MA, USA
| | | | - Jordan Kazakov
- University Hospitals Cleveland Medical Center
and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | | | | | - Philip A. Linden
- University Hospitals Cleveland Medical Center
and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | | | | | - Michael A. Pritchett
- Pulmonary Department, Pinehurst Medical Clinic
and FirstHealth Moore Regional Hospital, Pinehurst, NC, USA
| | - Catalina V. Teba
- University Hospitals Cleveland Medical Center
and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Christopher W. Towe
- University Hospitals Cleveland Medical Center
and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Terence Williams
- Department of Radiation Oncology, Ohio State
University Wexner Medical Center, Columbus OH, USA Brigham and Women’s
Hospital, Boston, MA, USA
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Yan SX, Qureshi MM, Suzuki K, Dyer M, Truong MT, Litle V, Mak KS. Definitive treatment patterns and survival in stage II non-small cell lung cancer. Lung Cancer 2018; 124:135-142. [PMID: 30268452 DOI: 10.1016/j.lungcan.2018.07.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/19/2018] [Accepted: 07/20/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVES This study delineated definitive treatment patterns for Stage II non-small cell lung cancer (NSCLC) in the United States and evaluated survival by treatment approach. MATERIALS AND METHODS Patients with clinically-staged Stage II NSCLC treated with surgery-based therapy, chemoradiation, conventionally-fractionated radiation (CFR), or stereotactic body radiotherapy (SBRT) were identified using the National Cancer Database (NCDB). Median survival was estimated using Kaplan-Meier analysis. Crude and adjusted hazard ratios (HR) and 95% confidence intervals were computed using Cox regression modeling. RESULTS Between 2004-2012, 19,749 patients met study criteria: 13,382 (67.8%) underwent surgery-based treatment, 4,310 (21.8%) received chemoradiation, 1,606 (8.1%) received CFR, and 451 (2.3%) received SBRT. Surgery and SBRT utilization increased over time while CFR and chemoradiation decreased (all p ≤ 0.002). Patients receiving radiation-based treatments were older, with more comorbidities, and higher T/N stage (all p < 0.0001). With median follow-up of 25.2 months, median survival was 51.6, 23.3, 15.4, and 23.7 months for surgery-based treatment, chemoradiation, CFR, and SBRT, respectively (p < 0.0001). On multivariate analysis, chemoradiation (HR 1.67 [1.59-1.75], p < 0.0001), CFR (HR 2.38 [2.22-2.55], p < 0.0001), and SBRT (HR 1.76 [1.53-2.01], p < 0.0001) were associated with decreased survival versus surgery-based treatment. CFR was associated with decreased survival versus chemoradiation (HR 1.52 [1.41-1.63], p < 0.0001) and SBRT (HR 1.39 [1.19-1.61], p < 0.0001). SBRT was associated with similar survival versus chemoradiation (HR 1.10 [0.95-1.27], p = 0.212). CONCLUSION NCDB data demonstrate increasing use of surgery-based treatments and SBRT for Stage II NSCLC over time. Radiation-based therapies were associated with decreased survival compared to surgery. CFR was associated with decreased survival compared to chemoradiation and SBRT.
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Affiliation(s)
- Sherry X Yan
- Boston Medical Center, One Boston Medical Center Pl., Boston, MA, 02118, USA
| | - Muhammad M Qureshi
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave. Moakley LL, Boston, MA, 02118, USA; Boston University School of Medicine, 72 E. Concord St., Boston, MA, 02118, USA
| | - Kei Suzuki
- Boston University School of Medicine, 72 E. Concord St., Boston, MA, 02118, USA; Division of Thoracic Surgery, Department of Surgery, Boston Medical Center, 830 Harrison Ave. 3rd Floor, Boston, MA, 02118, USA
| | - Michael Dyer
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave. Moakley LL, Boston, MA, 02118, USA; Boston University School of Medicine, 72 E. Concord St., Boston, MA, 02118, USA
| | - Minh Tam Truong
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave. Moakley LL, Boston, MA, 02118, USA; Boston University School of Medicine, 72 E. Concord St., Boston, MA, 02118, USA
| | - Virginia Litle
- Boston University School of Medicine, 72 E. Concord St., Boston, MA, 02118, USA; Division of Thoracic Surgery, Department of Surgery, Boston Medical Center, 830 Harrison Ave. 3rd Floor, Boston, MA, 02118, USA
| | - Kimberley S Mak
- Department of Radiation Oncology, Boston Medical Center, 830 Harrison Ave. Moakley LL, Boston, MA, 02118, USA; Boston University School of Medicine, 72 E. Concord St., Boston, MA, 02118, USA.
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12
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Treatment trends in early-stage lung cancer in the United States, 2004 to 2013: A time-trend analysis of the National Cancer Data Base. J Thorac Cardiovasc Surg 2018; 156:1233-1246.e1. [PMID: 30119287 DOI: 10.1016/j.jtcvs.2018.03.174] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 03/14/2018] [Accepted: 03/22/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The study objective was to evaluate trends in the use of surgical therapy for patients with early-stage (IA-IIA) non-small cell lung cancer when stereotactic ablative radiotherapy was introduced in the United States. METHODS Patients with clinical stage IA to IIA non-small cell lung cancer diagnosed from January 1, 2004, to December 31, 2013, were identified in the National Cancer Data Base. The Cochran-Armitage trend test was used to evaluate the change in the proportion of patients undergoing surgery over time. Logistic regression was used to identify the factors associated with receipt of surgery compared with radiation. RESULTS Of 200,404 eligible patients from 1235 hospitals, 79.8% (n = 159,943) underwent surgery. For all stages combined, the rate of surgery decreased from 83.9% in 2004 to 75.1% in 2013 (P < .0001), with the largest decrease seen in patients with stage IIA: stage IA 86.5% to 77.1% (P < .0001); stage IB 79.6% to 71.5% (P < .0001); and stage IIA 94.7% to 70.3% (P < .001). Patients were more likely to undergo surgery if they were younger and white, had higher income, or had private or Medicare insurance. CONCLUSIONS From 2004 to 2013, there was an overall decrease in the use of surgical therapy for lung cancer in early-stage disease. Because resection remains the standard of care for most patients with early-stage disease, these data suggest a potentially significant quality gap in the treatment of patients with non-small cell lung cancer.
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Berry MF, Gao R, Kunder CA, Backhus L, Khuong A, Kadoch M, Leung A, Shrager J. Presence of Even a Small Ground-Glass Component in Lung Adenocarcinoma Predicts Better Survival. Clin Lung Cancer 2018; 19:e47-e51. [DOI: 10.1016/j.cllc.2017.06.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 01/15/2023]
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Patient-clinician communication among patients with stage I lung cancer. Support Care Cancer 2017; 26:1625-1633. [PMID: 29209835 DOI: 10.1007/s00520-017-3992-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 11/20/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE Limited data exist about patient-centered communication (PCC) and patient-centered outcomes among patients who undergo surgery or stereotactic body radiation therapy (SBRT) for stage I non-small cell lung cancer (NSCLC). We aimed to examine the relationship between PCC and decision-making processes among NSCLC patients, using baseline data from a prospective, multicenter study. METHODS Patients with stage 1 NSCLC completed a survey prior to treatment initiation. The survey assessed sociodemographic characteristics, treatment decision variables, and patient psychosocial outcomes: health-related quality of life (HRQOL), treatment self-efficacy, decisional conflict, and PCC. RESULTS Fifty-two percent (n = 85) of 165 individuals planned to receive SBRT. There were no baseline differences detected on patient psychosocial outcomes between those who planned to receive SBRT or surgery. All participants reported high HRQOL (M = 72.5, SD = 21.3) out of 100, where higher scores indicate better functioning; high self-efficacy (M = 1.5, SD = 0.5) out of 6, where lower numbers indicate higher self-efficacy; minimal decisional conflict (M = 15.2, SD = 12.7) out of 100, where higher scores indicate higher decisional conflict; and high levels of patient-centered communication (M = 2.4, SD = 0.8) out of 7 where higher scores indicate worse communication. Linear regression analyses adjusting for sociodemographic and clinical variables showed that higher quality PCC was associated with higher self-efficacy (β = 0.17, p = 0.03) and lower decisional conflict (β = 0.42, p < 0.001). CONCLUSIONS Higher quality PCC was associated with higher self-efficacy and lower decisional conflict. Self-efficacy and decisional conflict may influence subsequent health outcomes. Therefore, our findings may inform future research and clinical programs that focus on communication strategies to improve these outcomes.
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Hsieh SS, Ng LW. Real-time tomosynthesis for radiation therapy guidance. Med Phys 2017; 44:5584-5595. [DOI: 10.1002/mp.12530] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/27/2017] [Accepted: 08/07/2017] [Indexed: 12/25/2022] Open
Affiliation(s)
- Scott S. Hsieh
- Department of Radiological Sciences; Univ. of California Los Angeles; Los Angeles CA USA
| | - Lydia W. Ng
- Department of Radiation Oncology; University of Southern California; Los Angeles CA USA
- Department of Radiation Oncology; Mayo Clinic; Rochester MN USA
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A national analysis of wedge resection versus stereotactic body radiation therapy for stage IA non–small cell lung cancer. J Thorac Cardiovasc Surg 2017; 154:675-686.e4. [DOI: 10.1016/j.jtcvs.2017.02.065] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 01/08/2017] [Accepted: 02/12/2017] [Indexed: 12/25/2022]
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Modiri A, Sabouri P, Gu X, Timmerman R, Sawant A. Inversed-Planned Respiratory Phase Gating in Lung Conformal Radiation Therapy. Int J Radiat Oncol Biol Phys 2017; 99:317-324. [PMID: 28871981 DOI: 10.1016/j.ijrobp.2017.05.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 05/02/2017] [Accepted: 05/24/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To assess whether the optimal gating window for each beam during lung radiation therapy with respiratory gating will be dependent on a variety of patient-specific factors, such as tumor size and location and the extent of relative tumor and organ motion. METHODS AND MATERIALS To create optimal gating treatment plans, we started from an optimized clinical plan, created a plan per respiratory phase using the same beam arrangements, and used an inverse planning optimization approach to determine the optimal gating window for each beam and optimal beam weights (ie, monitor units). Two pieces of information were used for optimization: (1) the state of the anatomy at each phase, extracted from 4-dimensional computed tomography scans; and (2) the time spent in each state, estimated from a 2-minute monitoring of the patient's breathing motion. We retrospectively studied 15 lung cancer patients clinically treated by hypofractionated conformal radiation therapy, for whom 45 to 60 Gy was administered over 3 to 15 fractions using 7 to 13 beams. Mean gross tumor volume and respiratory-induced tumor motion were 82.5 cm3 and 1.0 cm, respectively. RESULTS Although patients spent most of their respiratory cycle in end-exhalation (EE), our optimal gating plans used EE for only 34% of the beams. Using optimal gating, maximum and mean doses to the esophagus, heart, and spinal cord were reduced by an average of 15% to 26%, and the beam-on times were reduced by an average of 23% compared with equivalent single-phase EE gated plans (P<.034, paired 2-tailed t test). CONCLUSIONS We introduce a personalized respiratory-gating technique in which inverse planning optimization is used to determine patient- and beam-specific gating phases toward enhancing dosimetric quality of radiation therapy treatment plans.
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Affiliation(s)
- Arezoo Modiri
- Department of Radiation Oncology, School of Medicine, University of Maryland, Baltimore, Maryland.
| | - Pouya Sabouri
- Department of Radiation Oncology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Xuejun Gu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Houston, Texas
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Houston, Texas
| | - Amit Sawant
- Department of Radiation Oncology, School of Medicine, University of Maryland, Baltimore, Maryland
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Cox ML, Yang CFJ, Speicher PJ, Anderson KL, Fitch ZW, Gu L, Davis RP, Wang X, D'Amico TA, Hartwig MG, Harpole DH, Berry MF. The Role of Extent of Surgical Resection and Lymph Node Assessment for Clinical Stage I Pulmonary Lepidic Adenocarcinoma: An Analysis of 1991 Patients. J Thorac Oncol 2017; 12:689-696. [PMID: 28082103 DOI: 10.1016/j.jtho.2017.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 12/12/2016] [Accepted: 01/02/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND This study examined the association of extent of lung resection, pathologic nodal evaluation, and survival for patients with clinical stage I (cT1-2N0M0) adenocarcinoma with lepidic histologic features in the National Cancer Data Base. METHODS The association between extent of surgical resection and long-term survival for patients in the National Cancer Data Base with clinical stage I lepidic adenocarcinoma who underwent lobectomy or sublobar resection was evaluated using Kaplan-Meier and Cox proportional hazards regression analyses. RESULTS Of the 1991 patients with cT1-2N0M0 lepidic adenocarcinoma who met the study criteria, 1544 underwent lobectomy and 447 underwent sublobar resection. Patients treated with sublobar resection were older, more likely to be female, and had higher Charlson/Deyo comorbidity scores, but they had smaller tumors and lower T status. Of the patients treated with lobectomy, 6% (n = 92) were upstaged because of positive nodal disease, with a median of seven lymph nodes sampled (interquartile range 4-10). In an analysis of the entire cohort, lobectomy was associated with a significant survival advantage over sublobar resection in univariate analysis (median survival 9.2 versus 7.5 years, p = 0.022, 5-year survival 70.5% versus 67.8%) and after multivariable adjustment (hazard ratio = 0.81, 95% confidence interval: 0.68-0.95, p = 0.011). However, lobectomy was no longer independently associated with improved survival when compared with sublobar resection (hazard ratio = 0.99, 95% confidence interval: 0.77-1.27, p = 0.905) in a multivariable analysis of a subset of patients in which only those patients who had undergone a sublobar resection including lymph node sampling were compared with patients treated with lobectomy. CONCLUSIONS Surgeons treating patients with stage I lung adenocarcinoma with lepidic features should cautiously utilize sublobar resection rather than lobectomy, and they must always perform adequate pathologic lymph node evaluation.
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Affiliation(s)
- Morgan L Cox
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chi-Fu Jeffrey Yang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Paul J Speicher
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Kevin L Anderson
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Zachary W Fitch
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Lin Gu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | | | - Xiaofei Wang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Thomas A D'Amico
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - David H Harpole
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, California.
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Bablekos GD, Analitis A, Michaelides SA, Charalabopoulos KA, Tzonou A. Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:213. [PMID: 27386487 DOI: 10.21037/atm.2016.06.02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients. METHODS Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses. RESULTS The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability. CONCLUSIONS Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.
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Affiliation(s)
- George D Bablekos
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
| | - Antonis Analitis
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
| | - Stylianos A Michaelides
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
| | - Konstantinos A Charalabopoulos
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
| | - Anastasia Tzonou
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
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Follow-up of patients after stereotactic radiation for lung cancer: a primer for the nonradiation oncologist. J Thorac Oncol 2016; 10:412-9. [PMID: 25695219 DOI: 10.1097/jto.0000000000000435] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The use of stereotactic ablative radiotherapy (SABR) as primary treatment for early stage non-small-cell lung cancer, or for ablation of metastases, has increased rapidly in the past decade. With local recurrence rates reported at approximately 10%, and a patient population that is becoming increasingly fit and amenable to salvage treatment, appropriate multidisciplinary follow-up care is critical. Appropriate follow-up will allow for detection and management of radiation-related toxicity, early detection of recurrent disease and differentiation of recurrence from radiation-induced lung injury. METHODS This narrative review summarizes issues surrounding follow-up of patients treated with SABR in the context of a multidisciplinary perspective. We summarize treatment-related toxicities including radiation pneumonitis, chest wall pain, rib fracture, and fatal toxicity, and highlight the challenges of early and accurate detection of local recurrence, while avoiding unnecessary biopsy or treatment of benign radiation-induced fibrotic lung damage. RESULTS Follow-up recommendations based on the current evidence and available guidelines are summarized. Imaging follow-up recommendations include serial computed tomography (CT) imaging at 3-6 months posttreatment for the initial year, then every 6-12 months for an additional 3 years, and annually thereafter. With suspicion of progressive disease, recommendations include a multidisciplinary team discussion, the use of high-risk CT features for accurate detection of local recurrence, and positron emission tomography/CT SUV max cutoffs to prompt further investigation. Biopsy and/or surgical or nonsurgical salvage therapy can be considered if safe and when investigations are nonreassuring. CONCLUSIONS The appropriate follow-up of patients after SABR requires collaborative input from nearly all members of the thoracic multidisciplinary team, and evidence is available to guide treatment decisions. Further research is required to develop better predictors of toxicity and recurrence.
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Retention Rate of Electromagnetic Navigation Bronchoscopic Placed Fiducial Markers for Lung Radiosurgery. Ann Thorac Surg 2015; 100:1163-5; discussion 1165-6. [DOI: 10.1016/j.athoracsur.2015.04.060] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 03/31/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
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Classification and Reporting of Late Radiographic Changes After Lung Stereotactic Body Radiotherapy: Proposing a New System. Clin Lung Cancer 2015; 16:e245-51. [PMID: 26077096 DOI: 10.1016/j.cllc.2015.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 05/21/2015] [Accepted: 05/26/2015] [Indexed: 12/25/2022]
Abstract
UNLABELLED Radiation-induced parenchymal lung changes after stereotactic body radiotherapy are common, and can obscure the primary tumor site. In this study we propose a structured radiographic reporting tool for characterization of these changes, pilot its feasibility in a group of radiation oncologists, and test the interrater agreement. We could demonstrate the applicability of the scale, with a fair to moderate agreement. BACKGROUND The purpose of the study was to design and pilot a synoptic scale for characterization of late radiographic changes after lung stereotactic body radiotherapy (SBRT). PATIENTS AND METHODS A participatory design process involving 6 radiation oncologists and 2 thoracic radiologists was used in the scale's design. Seventy-seven early-stage non-small-cell lung cancer patients who were treated with SBRT were included, and after treatment their serial computed tomography (CT) images were scored by 6 radiation oncologists. Gwet's First-order Agreement Coefficient (AC1) and a leave-one-out (LOO) analysis was used to assess interrater reliability and variability among raters, respectively. RESULTS The scale reports on 5 independent categories including "tumor in primary site," "tumor in involved lobe," "consolidation," "volume loss," and "ground-glass or interstitial changes." At each time point, each category is reported as "increased," "stable," "decreased," "obscured," or "not present," compared with the previous. The total number of rated images for the pilot ranged from 450 at 6 months to 84 at 48 months. The primary tumor site was scored as obscured in 38% to 40% of ratings from 12 months onward; 3% to 5% of primary tumors were scored as "increased." Consolidation, volume loss, and ground-glass or interstitial changes were increasingly marked as "stable" with time. At 24 months, AC1 was 0.28 (LOO, 0.22-0.42), 0.47 (LOO, 0.39-0.72), 0.45 (LOO, 0.42-0.50), 0.21 (LOO, 0.15-0.26), and 0.25 (LOO, 0.20-0.38) for the 5 categories listed, respectively. CONCLUSION In a population of clinicians, this scale could be implemented to characterize evolving lung changes after SBRT, and had fair to moderate interrater agreement. Obscured tumor site is a common challenge of follow-up CT imaging, and new imaging techniques should be explored. This scale provides a tool for communicating changes after SBRT.
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Corso CD, Park HS, Kim AW, Yu JB, Husain Z, Decker RH. Racial disparities in the use of SBRT for treating early-stage lung cancer. Lung Cancer 2015; 89:133-8. [PMID: 26051446 DOI: 10.1016/j.lungcan.2015.05.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 04/22/2015] [Accepted: 05/02/2015] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Christopher D Corso
- Yale University School of Medicine, Department of Therapeutic Radiology, New Haven, CT, United States.
| | - Henry S Park
- Yale University School of Medicine, Department of Therapeutic Radiology, New Haven, CT, United States
| | - Anthony W Kim
- Yale University School of Medicine, Department of Surgery, New Haven, CT, United States
| | - James B Yu
- Yale University School of Medicine, Department of Therapeutic Radiology, New Haven, CT, United States
| | - Zain Husain
- Yale University School of Medicine, Department of Therapeutic Radiology, New Haven, CT, United States
| | - Roy H Decker
- Yale University School of Medicine, Department of Therapeutic Radiology, New Haven, CT, United States
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Owen D, Olivier KR, Mayo CS, Miller RC, Nelson K, Bauer H, Brown PD, Park SS, Ma DJ, Garces YI. Outcomes of stereotactic body radiotherapy (SBRT) treatment of multiple synchronous and recurrent lung nodules. Radiat Oncol 2015; 10:43. [PMID: 25889747 PMCID: PMC4341868 DOI: 10.1186/s13014-015-0340-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 01/28/2015] [Indexed: 11/17/2022] Open
Abstract
Background Stereotactic body radiotherapy (SBRT) is evolving into a standard of care for unresectable lung nodules. Local control has been shown to be in excess of 90% at 3 years. However, some patients present with synchronous lung nodules in the ipsilateral or contralateral lobe or metasynchronous disease. In these cases, patients may receive multiple courses of lung SBRT or a single course for synchronous nodules. The toxicity of such treatment is currently unknown. Methods Between 2006 and 2012, 63 subjects with 128 metasynchronous and synchronous lung nodules were treated at the Mayo Clinic with SBRT. Demographic patient data and dosimetric data regarding SBRT treatments were collected. Acute toxicity (defined as toxicity < 90 days) and late toxicity (defined as toxicity > = 90 days) were reported and graded as per standardized CTCAE 4.0 criteria. Local control, progression free survival and overall survival were also described. Results The median age of patients treated was 73 years. Sixty five percent were primary or recurrent lung cancers with the remainder metastatic lung nodules of varying histologies. Of 63 patients, 18 had prior high dose external beam radiation to the mediastinum or chest. Dose and fractionation varied but the most common prescriptions were 48 Gy/4 fractions, 54 Gy/3 fractions, and 50 Gy/5 fractions. Only 6 patients demonstrated local recurrence. With a median follow up of 12.6 months, median SBRT specific overall survival and progression free survival were 35.7 months and 10.7 months respectively. Fifty one percent (32/63 patients) experienced acute toxicity, predominantly grade 1 and 2 fatigue. One patient developed acute grade 3 radiation pneumonitis at 75 days. Forty six percent (29/63 patients) developed late effects. Most were grade 1 dyspnea. There was one patient with grade 5 pneumonitis. Conclusion Multiple courses of SBRT and SBRT delivery after external beam radiotherapy appear to be feasible and safe. Most toxicity was grade 1 and 2 but the risk was approximately 50% for both acute and late effects.
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Affiliation(s)
- Dawn Owen
- Department of Radiation Oncology, University of Michigan, 1500 E Medical Drive, Ann Arbor, MI, 48105, USA. .,Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - Kenneth R Olivier
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - Charles S Mayo
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - Robert C Miller
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - Kathryn Nelson
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - Heather Bauer
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - Paul D Brown
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA.
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - Daniel J Ma
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic Rochester, Rochester, MN, USA.
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Louie AV, Palma DA, Dahele M, Rodrigues GB, Senan S. Management of early-stage non-small cell lung cancer using stereotactic ablative radiotherapy: Controversies, insights, and changing horizons. Radiother Oncol 2015; 114:138-47. [DOI: 10.1016/j.radonc.2014.11.036] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 11/18/2014] [Accepted: 11/20/2014] [Indexed: 12/17/2022]
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Historical trends of radiotherapy use in prevalent malignancies over 38 years in SEER. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13566-015-0182-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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McGarry RC. Integrating stereotactic body radiation therapy in stage II/III non-small cell lung cancer: is local control important? Expert Rev Anticancer Ther 2014; 14:1419-27. [PMID: 25155973 DOI: 10.1586/14737140.2014.948858] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Local control for advanced non-small cell lung cancer (NSCLC) remains a significant problem with chemoradiation local failure rates in the chest of 30-50%. Despite attempts at dose escalation with conventional radiation therapy techniques, toxicities limit the amount of radiation that can be delivered. For stage I NSCLC, mounting evidence supports the use of hypofractionated radiation therapy (SBRT) to gain high local control rates with acceptable toxicity. For healthy patients with stage II/III NSCLC, the National Comprehensive Cancer Network guidelines suggest surgery is the preferred standard of care for patients with <N2 nodes or T3 tumors. In select patients who are surgical candidates or have more extensive disease, guidelines may include pre-operative chemoradiation followed by surgery, although this remains controversial and is the subject of a current national clinical trial (RTOG 0839). Dose escalation through conventional radiation therapy planning suggests that we can improve outcomes in stage III patients, but toxicity remains problematic. It follows that with improvements in imaging and delivery of radiotherapy, dose escalation with SBRT incorporation may improve local control in stage II/III NSCLC for medically inoperable patients. The rationale for dose escalation and some of the considerations for incorporation of SBRT dose escalation in stage III lung cancer are reviewed here.
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Affiliation(s)
- Ronald C McGarry
- Department of Radiation Medicine, University of Kentucky, 800 Rose St, C114C, Lexington, KY 40536, USA
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Thomas EM, Popple RA, Prendergast BM, Clark GM, Dobelbower MC, Fiveash JB. Effects of flattening filter-free and volumetric-modulated arc therapy delivery on treatment efficiency. J Appl Clin Med Phys 2013; 14:4328. [PMID: 24257275 PMCID: PMC5714642 DOI: 10.1120/jacmp.v14i6.4328] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 07/01/2013] [Accepted: 06/29/2013] [Indexed: 12/03/2022] Open
Abstract
Flattening filter‐free (FFF) beams are available on an increasing number of commercial linear accelerators. FFF beams have higher dose rates than flattened beams of equivalent energy which can lead to increased efficiency of treatment delivery, especially in conjunction with increased FFF beam energy and arc‐based delivery configurations. The purpose of this study is to quantify and assess the implications of improved treatment efficiency for several FFF delivery options on common types of linac applicable radiotherapy. Eleven characteristic cases representative of a variety of clinical treatment sites and prescription doses were selected from our patient population. Treatment plans were generated for a Varian TrueBeam linear accelerator. For each case, a reference plan was created using DMLC IMRT with 6 MV flat beams. From the same initial objectives, plans were generated using DMLC IMRT and volumetric‐modulated arc therapy (VMAT) with 6 MV FFF and 10 MV FFF beams (max. dose rates of 1400 and 2400 MU/min, respectively). The plans were delivered to a phantom; beam‐on time, total treatment delivery time, monitor units (MUs), and integral dose were recorded. For plans with low dose fractionations (1.8–2.0 & 3.85 Gy/fraction), mean beam‐on time difference between reference plan and most efficient FFF plan was 0.56 min (41.09% decrease); mean treatment delivery time difference between the reference plan and most efficient FFF plan was 1.54 min (range: 0.31–3.56 min), a relative improvement of 46.1% (range: 29.2%‐59.2%). For plans with high dose fractionations (16–20 Gy/fraction), mean beam‐on time difference was 6.79 min (74.9% decrease); mean treatment delivery time difference was 8.99 min (range: 5.40–13.05 min), a relative improvement of 71.1% (range: 53.4%‐82.4%). 10 MV FFF VMAT beams generated the most efficient plan, except in the spine SBRT case. The distribution of monitor unit counts did not vary by plan type. In cases where respiratory motion management would be applicable, 10 MV FFF DMLC IMRT reduced beam‐on time/field to less than 12 sec. FFF beams significantly reduced treatment delivery time. For radiosurgical doses, the efficiency improvement for FFF beams was clinically significant. For conventional fractionation, a large improvement in relative treatment delivery time was observed, but the absolute time savings were not likely to be of clinical value. In cases that benefit from respiratory motion management, beamon/field was reduced to a time for which most patients can comfortably maintain deep inspiratory breath hold. PACS numbers: 87.55.D‐, 87.55.de, 87.56.bd, 87.56.N‐
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Sheu T, Molkentine J, Transtrum MK, Buchholz TA, Withers HR, Thames HD, Mason KA. Use of the LQ model with large fraction sizes results in underestimation of isoeffect doses. Radiother Oncol 2013; 109:21-5. [PMID: 24060173 DOI: 10.1016/j.radonc.2013.08.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 08/15/2013] [Accepted: 08/17/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To test the appropriateness of the linear-quadratic (LQ) model to describe survival of jejunal crypt clonogens after split doses with variable (small 1-6 Gy, large 8-13 Gy) first dose, as a model of its appropriateness for both small and large fraction sizes. METHODS C3Hf/KamLaw mice were exposed to whole body irradiation using 300 kVp X-rays at a dose rate of 1.84 Gy/min, and the number of viable jejunal crypts was determined using the microcolony assay. 14 Gy total dose was split into unequal first and second fractions separated by 4 h. Data were analyzed using the LQ model, the lethal potentially lethal (LPL) model, and a repair-saturation (RS) model. RESULTS Cell kill was greater in the group receiving the larger fraction first, creating an asymmetry in the plot of survival vs size of first dose, as opposed to the prediction of the LQ model of a symmetric response. There was a significant difference in the estimated βs (higher β after larger first doses), but no significant difference in the αs, when large doses were given first vs small doses first. This difference results in underestimation (based on present data by approximately 8%) of isoeffect doses using LQ model parameters based on small fraction sizes. While the LPL model also predicted a symmetric response inconsistent with the data, the RS model results were consistent with the observed asymmetry. CONCLUSION The LQ model underestimates doses for isoeffective crypt-cell survival with large fraction sizes (in the present setting, >9 Gy).
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Affiliation(s)
- Tommy Sheu
- Department of Experimental Radiation Oncology, UT MD Anderson Cancer Center, Houston, USA
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Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e278S-e313S. [PMID: 23649443 DOI: 10.1378/chest.12-2359] [Citation(s) in RCA: 887] [Impact Index Per Article: 80.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined. METHODS The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. RESULTS Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.
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Affiliation(s)
- John A Howington
- NorthShore HealthSystem, University of Chicago Pritzker School of Medicine, Evanston, IL.
| | - Matthew G Blum
- Penrose Cardiothoracic Surgery, Memorial Hospital, University of Colorado Health, Colorado Springs, CO
| | | | - Alex A Balekian
- Division of Pulmonary, Critical Care, and Sleep Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Sudish C Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
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Treatment of Medically Inoperable Non–small-cell Lung Cancer with Stereotactic Body Radiation Therapy versus Image-guided Tumor Ablation: Can Interventional Radiology Compete? J Vasc Interv Radiol 2013; 24:1139-45. [DOI: 10.1016/j.jvir.2013.04.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 04/15/2013] [Accepted: 04/17/2013] [Indexed: 12/25/2022] Open
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