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Harada H, Suefuji H, Mori K, Ishikawa H, Nakamura M, Tokumaru S, Murakami M, Ogino T, Iwata H, Tatebe H, Kubo N, Waki T, Yoshida D, Nakamura M, Hashimoto T, Araya M, Nakajima M, Nakayama H, Satouchi M, Shioyama Y. Proton and carbon ion radiotherapy for operable early-stage lung cancer; a prospective nationwide registry. Radiother Oncol 2024; 198:110385. [PMID: 38901770 DOI: 10.1016/j.radonc.2024.110385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/06/2024] [Accepted: 06/12/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND AND PURPOSE To investigate the toxicity and survival outcomes of proton and carbon ion radiotherapy for patients with operable early-stage lung cancer who are eligible for lobectomy. MATERIALS AND METHODS This multicenter nationwide prospective cohort study included patients with operable early-stage lung cancer. Proton and carbon ion radiotherapy was performed according to the schedule stipulated in the unified treatment policy. Progression-free survival (PFS), overall survival (OS) and treatment-related toxicities were evaluated. RESULTS A total of 274 patients were enrolled and included in efficacy and safety analyses. The most common tumor type was adenocarcinoma (44 %), while 105 cases (38 %) were not histologically confirmed or diagnosed clinically. Overall, 250 (91 %) of the 274 patients had tumors that were peripherally situated, while 138 (50 %) and 136 (50 %) patients were treated by proton and carbon ion radiotherapy, respectively. The median follow-up time for all censored patients was 42.8 months (IQR 36.7-49.0). Grade 3 or severe treatment-related toxicity was observed in 4 cases (1.5 %). Three-year PFS was 80.5 % (95 % CI: 75.7 %-85.5 %) and OS was 92.5 % (95 % CI: 89.3 %-95.8 %). Pathological confirmation and clinical stage were factors significantly associated with PFS, while tumor location and particle-ion type were not. Meanwhile, clinical stage was significantly associated with OS, but pathological confirmation, tumor location, and particle-ion type were not. CONCLUSIONS Particle therapy for operable early-stage lung cancer resulted in excellent 3-year OS and PFS in each subset. In this disease context, proton and carbon ion beam therapies are feasible alternatives to curative surgery.
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Affiliation(s)
- Hideyuki Harada
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan.
| | - Hiroaki Suefuji
- Ion Beam Therapy Center, SAGA HIMAT Foundation, Tosu, Saga, Japan.
| | - Keita Mori
- Department of Biostatistics, Clinical Research Support Center, Shizuoka Cancer Center, Nagaizumi, Shizuoka, Japan.
| | - Hitoshi Ishikawa
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Chiba, Japan.
| | - Masaki Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.
| | - Sunao Tokumaru
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Masao Murakami
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Koriyama, Fukushima, Japan
| | - Takashi Ogino
- Medipolis Proton Therapy and Research Center, Ibusuki, Kagoshima, Japan.
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Aichi, Japan.
| | - Hitoshi Tatebe
- Fukui Prefectural Hospital Proton Therapy Center, Fukui, Fukui, Japan.
| | - Nobuteru Kubo
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Takahiro Waki
- Department of Radiology, Tsuyama Chuo Hospital, Tsuyama, Okayama, Japan
| | | | - Masatoshi Nakamura
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| | - Takayuki Hashimoto
- Global Center for Biomedical Science and Engineering, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan.
| | - Masayuki Araya
- Proton Therapy Center, Aizawa Hospital, Matsumoto, Nagano, Japan.
| | - Mio Nakajima
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Chiba, Japan.
| | - Haruhiko Nakayama
- Kanagawa Preventive Medicine Association, Yokohama, Kanagawa, Japan.
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McCullum LB, Karagoz A, Dede C, Garcia R, Nosrat F, Hemmati M, Hosseinian S, Schaefer AJ, Fuller CD. Markov models for clinical decision-making in radiation oncology: A systematic review. J Med Imaging Radiat Oncol 2024. [PMID: 38766899 DOI: 10.1111/1754-9485.13656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/03/2024] [Indexed: 05/22/2024]
Abstract
The intrinsic stochasticity of patients' response to treatment is a major consideration for clinical decision-making in radiation therapy. Markov models are powerful tools to capture this stochasticity and render effective treatment decisions. This paper provides an overview of the Markov models for clinical decision analysis in radiation oncology. A comprehensive literature search was conducted within MEDLINE using PubMed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only studies published from 2000 to 2023 were considered. Selected publications were summarized in two categories: (i) studies that compare two (or more) fixed treatment policies using Monte Carlo simulation and (ii) studies that seek an optimal treatment policy through Markov Decision Processes (MDPs). Relevant to the scope of this study, 61 publications were selected for detailed review. The majority of these publications (n = 56) focused on comparative analysis of two or more fixed treatment policies using Monte Carlo simulation. Classifications based on cancer site, utility measures and the type of sensitivity analysis are presented. Five publications considered MDPs with the aim of computing an optimal treatment policy; a detailed statement of the analysis and results is provided for each work. As an extension of Markov model-based simulation analysis, MDP offers a flexible framework to identify an optimal treatment policy among a possibly large set of treatment policies. However, the applications of MDPs to oncological decision-making have been understudied, and the full capacity of this framework to render complex optimal treatment decisions warrants further consideration.
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Affiliation(s)
- Lucas B McCullum
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Aysenur Karagoz
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Cem Dede
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raul Garcia
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Fatemeh Nosrat
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Mehdi Hemmati
- School of Industrial and Systems Engineering, The University of Oklahoma, Norman, Oklahoma, USA
| | | | - Andrew J Schaefer
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Computational Applied Mathematics & Operations Research, Rice University, Houston, Texas, USA
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Verma S, Young S, Kennedy TAC, Carvalhana I, Black M, Baer K, Churchman E, Warner A, Allan AL, Izaguirre-Carbonell J, Dhani H, Louie AV, Palma DA, Breadner DA. Detection of Circulating Tumor DNA After Stereotactic Ablative Radiotherapy in Patients With Unbiopsied Lung Tumors (SABR-DETECT). Clin Lung Cancer 2024; 25:e87-e91. [PMID: 38101984 DOI: 10.1016/j.cllc.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023]
Abstract
For patients with stage I/IIA non-small-cell lung cancer (NSCLC), surgical resection is the standard treatment. However, some of these patients are not candidates for surgery or refuse a surgical option. Definitive stereotactic ablative radiotherapy (SABR) is a standard approach in these patients. Approximately 15% of patients undergoing SABR for localized NSCLC will experience a recurrence within 2 years. Furthermore, many of these patients are deemed appropriate for SABR without a tissue diagnosis, based on the likelihood of malignancy which can be calculated by validated models. A liquid biopsy, detecting ctDNA, would be useful in early detection of recurrences, and documenting a cancer diagnosis in patients without a biopsy. This is a multi-institutional study enrolling patients with suspected stage I/IIA NSCLC and a pretreatment likelihood of malignancy of ≥60% using the validated models for patients without a tissue diagnosis, in cohort 1 (n = 45). The second cohort will consist of biopsied patients (n = 30-60). SABR will be delivered as per risk-adapted protocol. Plasma will be collected for ctDNA analysis prior to the first fraction of SABR, 24 to 72 hours after first fraction, and at 3, 6, 9, 12, 18, and 24-months. The patients will be followed up with imaging at 3, 6, 9, 12, 18, and 24-months. The primary objective is to assess whether a cancer detection liquid biopsy platform can predict recurrence of NSCLC. The secondary objectives are to assess the impact of SABR on detection rates of ctDNA in patients undergoing SABR and to correlate ctDNA positivity and pretreatment probability of malignancy (NCT05921474).
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Affiliation(s)
- Saurav Verma
- Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - Sympascho Young
- Division of Radiation Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - Thomas A C Kennedy
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ilda Carvalhana
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Morgan Black
- London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - Kathie Baer
- London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - Emma Churchman
- London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - Andrew Warner
- Division of Radiation Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Alison L Allan
- London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada; Department of Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | | | | | - Alexander V Louie
- Division of Radiation Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - David A Palma
- Division of Radiation Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - Daniel A Breadner
- Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada.
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Stereotactic Ablative Radiotherapy in the Treatment of Early-Stage Lung Cancer - A Done Deal? Clin Oncol (R Coll Radiol) 2022; 34:733-740. [PMID: 36050221 DOI: 10.1016/j.clon.2022.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 08/12/2022] [Indexed: 01/31/2023]
Abstract
Stereotactic ablative radiotherapy (SABR) is an important curative-intent treatment option for early-stage non-small cell lung cancer. It offers good cancer control without invasive surgery and has become the standard of care for medically inoperable patients. The literature on SABR for early-stage non-small cell lung cancer is substantial and continues to grow. However, there remain areas of controversy where data are limited - notably the use of SABR in medically operable patients. Other areas of some debate include the treatment of central/ultra-central and large (>5 cm) lesions, as well as treatment with co-existing interstitial lung disease. This review article provides an overview of the current literature together with a discussion of future directions.
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Samhouri BF, Kanj AN, Chehab O, Ryu JH. Outcomes for Elective Open and Thoracoscopic Surgical Lung Biopsies in the United States and Temporal Trends. MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES 2022; 6:87-97. [PMID: 35498392 PMCID: PMC9043564 DOI: 10.1016/j.mayocpiqo.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To elucidate the outcomes of surgical lung biopsies (SLBs) performed for indications other than interstitial lung disease (ILD) and stratify outcomes according to procedural approach (open vs thoracoscopic). Patients and Methods Using the Nationwide Inpatient Sample database (January 1, 2008, through December 31, 2014), we identified elective hospitalizations with International Classification of Diseases, Ninth Revision, Clinical Modification codes for open (33.28) and thoracoscopic (33.20) SLB. We stratified cases by the presence/absence of ILD. Our primary outcome was in-hospital mortality. Results There were 47,469 hospitalizations for elective SLB (26,540 [55.9%] thoracoscopic) during the study period; 23,930 patients (50.5%) were women, 17,019 (35.9%) had ILD, and the mean ± SD age was 62.6±13.0 years. Over the study period, thoracoscopic increasingly replaced open SLB, and in-hospital mortality declined (3.5% [308 of 8678] in 2008 vs 2.5% [130 of 5215] in 2014; P<.001). Mortality following thoracoscopic SLB was 2.1% (550 of 26,519; 1.9% [214 of 11,513] in ILD and 2.2% [336 of 15,006] in non-ILD), and mean ± SD length of stay was 5.1±6.9 days. Open SLBs had worse outcomes; mortality was 3.7% (782 of 20,914; 3.9% [214 of 5487] in ILD and 3.7% [568 of 15,427] in non-ILD), and mean ± SD length of stay was 8.2±12 days. On multivariable analysis, male sex, advanced age, ILD, and higher comorbidity index correlated with higher mortality. Conversely, lower mortality was observed among individuals with obesity (odds ratio, 0.73; 95% CI, 0.60-0.88) and those who had their thoracoscopic SLBs performed at high-volume centers (top quartile) (odds ratio, 0.73; 95% CI, 0.57-0.94). Conclusion Surgical lung biopsy is more often performed for non-ILD indications. Interstitial lung disease was an independent predictor of poor outcomes, but the unadjusted outcomes were worse in the non-ILD cohort due to differences in patient characteristics. Thoracoscopic SLBs performed at high-volume centers had superior outcomes.
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Milligan MG, Lennes IT, Hawari S, Khandekar MJ, Colson Y, Shepard JAO, Frank A, Sequist LV, Willers H, Keane FK. Incidence of Radiation Therapy Among Patients Enrolled in a Multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic. JAMA Netw Open 2022; 5:e224840. [PMID: 35357454 PMCID: PMC8972030 DOI: 10.1001/jamanetworkopen.2022.4840] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE The number of pulmonary nodules discovered incidentally or through screening programs has increased markedly. Multidisciplinary review and management are recommended, but the involvement of radiation oncologists in this context has not been defined. OBJECTIVE To assess the role of stereotactic body radiation therapy among patients enrolled in a lung cancer screening program. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was performed at a pulmonary nodule and lung cancer screening clinic from October 1, 2012, to September 31, 2019. Referrals were based on chest computed tomography with Lung Imaging Reporting and Data System category 4 finding or an incidental nodule 6 mm or larger. A multidisciplinary team of practitioners from radiology, thoracic surgery, pulmonology, medical oncology, and radiation oncology reviewed all nodules and coordinated workup and treatment as indicated. EXPOSURES Patients referred to the pulmonary nodule and lung cancer screening clinic with an incidental or screen-detected pulmonary nodule. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients undergoing therapeutic intervention with radiation therapy, stratified by the route of detection of their pulmonary nodules (incidental vs screen detected). Secondary outcomes were 2-year local control and metastasis-free survival. RESULTS Among 1150 total patients (median [IQR] age, 66.5 [59.3-73.7] years; 665 [57.8%] female; 1024 [89.0%] non-Hispanic White; 841 [73.1%] current or former smokers), 234 (20.3%) presented with screen-detected nodules and 916 (79.7%) with incidental nodules. For patients with screen-detected nodules requiring treatment, 41 (17.5%) received treatment, with 31 (75.6%) undergoing surgery and 10 (24.4%) receiving radiation therapy. Patients treated with radiation therapy were older (median [IQR] age, 73.8 [67.1 to 82.1] vs 67.6 [61.0 to 72.9] years; P < .001) and more likely to have history of tobacco use (67 [95.7%] vs 128 [76.6%]; P = .001) than those treated with surgery. Fifty-eight patients treated with radiation therapy (82.9%) were considered high risk for biopsy, and treatment recommendations were based on a clinical diagnosis of lung cancer after multidisciplinary review. All screened patients who received radiation therapy had stage I disease and were treated with stereotactic body radiation therapy. For all patients receiving stereotactic body radiation therapy, 2-year local control was 96.3% (95% CI, 91.1%-100%) and metastasis-free survival was 94.2% (95% CI, 87.7%-100%). CONCLUSIONS AND RELEVANCE In this unique prospective cohort, 1 in 4 patients with screen-detected pulmonary nodules requiring intervention were treated with stereotactic body radiation therapy. This finding highlights the role of radiation therapy in a lung cancer screening population and the importance of including radiation oncologists in the multidisciplinary management of pulmonary nodules.
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Affiliation(s)
- Michael G. Milligan
- Harvard Radiation Oncology Program, Boston, Massachusetts
- Department of Radiation Oncology, Massachusetts General Hospital, Boston
| | - Inga T. Lennes
- Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital, Boston
| | - Saif Hawari
- Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital, Boston
| | - Melin J. Khandekar
- Department of Radiation Oncology, Massachusetts General Hospital, Boston
| | - Yolonda Colson
- Department of Surgery, Massachusetts General Hospital, Boston
| | | | - Angela Frank
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Lecia V. Sequist
- Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital, Boston
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital, Boston
| | - Florence K. Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston
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Petranovic M, Raoof S, Digumarthy SR, Sharma A, Shepard JAO, Gainor JF, Pandharipande PV. Liquid Biopsy, Diagnostic Imaging, and Future Synergies. J Am Coll Radiol 2022; 19:336-343. [DOI: 10.1016/j.jacr.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 12/16/2022]
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Verhoeven RL, van der Sterren W, Kong W, Langereis S, van der Tol P, van der Heijden EH. Cone-beam CT and Augmented Fluoroscopy-guided Navigation Bronchoscopy: Radiation Exposure and Diagnostic Accuracy Learning Curves. J Bronchology Interv Pulmonol 2021; 28:262-271. [PMID: 34162799 PMCID: PMC8460082 DOI: 10.1097/lbr.0000000000000783] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The endobronchial diagnosis of peripheral lung lesions suspected of lung cancer remains a challenge from a navigation as well as an adequate tissue sampling perspective. Cone-beam computed tomography (CBCT) guidance is a relatively new technology and allows for 3-dimensional imaging confirmation as well as navigation and biopsy guidance, but, also involves radiation. This study investigates how radiation exposure and diagnostic accuracy in the CBCT-guided navigation bronchoscopy evolves with increasing experience, and, with a specific tailoring of CBCT and fluoroscopic imaging protocols towards the procedure. PATIENTS AND METHODS In this observational clinical trial, all 238 consecutive patients undergoing a CBCT-guided navigation bronchoscopy from the start of our CBCT-guided navigation bronchoscopy program (December 2017) until June 2020 were included. Procedural dose characteristics and diagnostic accuracy are reported as a function of time. RESULTS Procedural radiation exposure as measured by the dose area product initially was 47.5 Gy·cm2 (effective dose: 14.3 mSv) and gradually reduced to 25.4 Gy·cm2 (5.8 mSv). The reduction in fluoroscopic dose area product was highest, from 19.0 Gy·cm2 (5.2 mSv) to 2.2 Gy·cm2 (0.37 mSv, 88% reduction), despite a significant increase of fluoroscopy time. The diagnostic accuracy of navigation bronchoscopy increased from 72% to 90%. CONCLUSION A significant learning effect can be seen in the radiation safety and diagnostic accuracy of a CBCT-guided and augmented fluoroscopy-guided navigation bronchoscopy. With increasing experience and tailoring of imaging protocols to the procedure, the procedural accuracy improved, while the effective dose for patients and staff was reduced.
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Affiliation(s)
| | | | - Wens Kong
- Medical Imaging, Radboud University Medical Center, Nijmegen
| | - Sander Langereis
- Image Guided Therapy Systems Innovation, Philips, Best, The Netherlands
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Ubaldi L, Valenti V, Borgese RF, Collura G, Fantacci ME, Ferrera G, Iacoviello G, Abbate BF, Laruina F, Tripoli A, Retico A, Marrale M. Strategies to develop radiomics and machine learning models for lung cancer stage and histology prediction using small data samples. Phys Med 2021; 90:13-22. [PMID: 34521016 DOI: 10.1016/j.ejmp.2021.08.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 08/21/2021] [Accepted: 08/28/2021] [Indexed: 02/09/2023] Open
Abstract
Predictive models based on radiomics and machine-learning (ML) need large and annotated datasets for training, often difficult to collect. We designed an operative pipeline for model training to exploit data already available to the scientific community. The aim of this work was to explore the capability of radiomic features in predicting tumor histology and stage in patients with non-small cell lung cancer (NSCLC). We analyzed the radiotherapy planning thoracic CT scans of a proprietary sample of 47 subjects (L-RT) and integrated this dataset with a publicly available set of 130 patients from the MAASTRO NSCLC collection (Lung1). We implemented intra- and inter-sample cross-validation strategies (CV) for evaluating the ML predictive model performances with not so large datasets. We carried out two classification tasks: histology classification (3 classes) and overall stage classification (two classes: stage I and II). In the first task, the best performance was obtained by a Random Forest classifier, once the analysis has been restricted to stage I and II tumors of the Lung1 and L-RT merged dataset (AUC = 0.72 ± 0.11). For the overall stage classification, the best results were obtained when training on Lung1 and testing of L-RT dataset (AUC = 0.72 ± 0.04 for Random Forest and AUC = 0.84 ± 0.03 for linear-kernel Support Vector Machine). According to the classification task to be accomplished and to the heterogeneity of the available dataset(s), different CV strategies have to be explored and compared to make a robust assessment of the potential of a predictive model based on radiomics and ML.
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Affiliation(s)
- L Ubaldi
- Physics Department, University of Pisa, Pisa, Italy; National Institute for Nuclear Physics (INFN), Pisa Division, Pisa, Italy
| | - V Valenti
- REM Radiation Therapy Center, Viagrande (CT), I-95029 Catania, Italy
| | - R F Borgese
- Physics and Chemistry Department "Emilio Segrè", University of Palermo, Palermo, Italy; National Institute for Nuclear Physics (INFN), Catania Division, Catania, Italy
| | - G Collura
- Physics and Chemistry Department "Emilio Segrè", University of Palermo, Palermo, Italy; National Institute for Nuclear Physics (INFN), Catania Division, Catania, Italy
| | - M E Fantacci
- Physics Department, University of Pisa, Pisa, Italy; National Institute for Nuclear Physics (INFN), Pisa Division, Pisa, Italy
| | - G Ferrera
- Radiation Oncology, ARNAS-Civico Hospital, Palermo, Italy
| | - G Iacoviello
- Medical Physics Department, ARNAS-Civico Hospital, Palermo, Italy
| | - B F Abbate
- Medical Physics Department, ARNAS-Civico Hospital, Palermo, Italy
| | - F Laruina
- Physics Department, University of Pisa, Pisa, Italy; National Institute for Nuclear Physics (INFN), Pisa Division, Pisa, Italy
| | - A Tripoli
- REM Radiation Therapy Center, Viagrande (CT), I-95029 Catania, Italy
| | - A Retico
- National Institute for Nuclear Physics (INFN), Pisa Division, Pisa, Italy
| | - M Marrale
- Physics and Chemistry Department "Emilio Segrè", University of Palermo, Palermo, Italy; National Institute for Nuclear Physics (INFN), Catania Division, Catania, Italy
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Biopsy of Subsolid Nodules Suspicious for Adenocarcinoma: Counterpoint-Biopsy Has Limited Utility in the Diagnostic Evaluation of Subsolid Nodules. AJR Am J Roentgenol 2021; 217:815-816. [PMID: 33852361 DOI: 10.2214/ajr.20.25323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Affiliation(s)
- I T H Au-Yong
- Department of Radiology, Nottingham University Hospitals, Nottingham, UK
| | - W Hamilton
- University of Exeter Medical School, St Luke's Campus, Exeter EX1 2LU, UK
| | - J Rawlinson
- British Thoracic Oncology Group (advocate steering committee member), NCRI Lung subGroup (consumer), and European Lung Foundation LC Patient advisory group, Sandwell, UK
| | - D R Baldwin
- Respiratory Medicine, Nottingham University Hospitals, Nottingham, UK
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Ijsseldijk MA, Shoni M, Siegert C, Wiering B, van Engelenburg AKC, Tsai TC, Ten Broek RPG, Lebenthal A. Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis. Clin Lung Cancer 2020; 22:e235-e292. [PMID: 32912754 DOI: 10.1016/j.cllc.2020.04.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/21/2020] [Accepted: 04/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT). METHODS A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates. RESULTS A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses. CONCLUSION Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.
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Affiliation(s)
- Michiel A Ijsseldijk
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, The Netherlands; Division of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Melina Shoni
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Charles Siegert
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA; Division of Thoracic Surgery, West Roxbury Veterans Administration, West Roxbury, MA
| | - Bastiaan Wiering
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, The Netherlands
| | | | - Thomas C Tsai
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA
| | - Richard P G Ten Broek
- Division of Surgery, Slingeland Ziekenhuis, Doetinchem, The Netherlands; Division of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Abraham Lebenthal
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA; Division of Thoracic Surgery, West Roxbury Veterans Administration, West Roxbury, MA; Harvard Medical School, Boston, MA
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Dautruche A, Filion E, Mathieu D, Bahig H, Roberge D, Lambert L, Vu T, Campeau MP. To Biopsy or Not to Biopsy?: A Matched Cohort Analysis of Early-Stage Lung Cancer Treated with Stereotactic Radiation with or Without Histologic Confirmation. Int J Radiat Oncol Biol Phys 2020; 107:88-97. [PMID: 32004581 DOI: 10.1016/j.ijrobp.2020.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 01/11/2020] [Accepted: 01/21/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE For nonoperable stage I non-small cell lung cancer, stereotactic body radiation therapy (SBRT) has emerged as a standard treatment option. We aimed to compare the clinical outcomes of lung SBRT between patients with versus without pathologic cancer diagnosis. METHODS AND MATERIALS We included patients treated by SBRT for a single pulmonary lesion between July 2009 and July 2017. Patients in the clinical diagnosis group had a positron emission tomography/computed tomography scan showing hypermetabolism, growth of the mass on sequential computed tomography, and were not eligible for biopsy, refused biopsy, or had an inconclusive biopsy. For each of those patients, a matched pair in the pathologic diagnosis group was identified by matching for patient, treatment, and tumoral characteristics. We performed a power calculation to estimate the sample size required to detect a difference arising from a 5% or 15% rate of benign processes in the group without pathology. RESULTS A total of 924 lung SBRT treatments were performed among 878 patients from 2009 to 2017. Within this population, 131 patients were treated based on clinical findings. They were matched with 131 patients with a pathologic diagnosis who received treatment. At 3 years, no significant differences were observed in overall survival (hazard ratio [HR], 1.2; 95% confidence interval [CI], 0.7-2.1), local control (HR, 0.9; 95% CI, 0.4-2), or regional (HR, 0.5; 95% CI, 0.2-1.4) or distant recurrence (HR, 0.6; 95% CI, 0.3-1.1). CONCLUSIONS In our population, we found no clinically significant difference in patterns of recurrence or survival after lung SBRT for patients who had received clinical versus pathological diagnoses. There was, however, a trend toward more distant recurrences in the pathologic diagnosis group. Our power calculation suggests that data from multiple institutions would be required to rule out a difference in outcomes due to 5% to 15% of clinically diagnosed cases being treated for benign processes.
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Affiliation(s)
| | - Edith Filion
- Centre hospitalier de l'Université de Montréal, Quebec, Canada
| | | | - Houda Bahig
- Centre hospitalier de l'Université de Montréal, Quebec, Canada
| | - David Roberge
- Centre hospitalier de l'Université de Montréal, Quebec, Canada
| | - Louise Lambert
- Centre hospitalier de l'Université de Montréal, Quebec, Canada
| | - Toni Vu
- Centre hospitalier de l'Université de Montréal, Quebec, Canada
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Martinez-Zayas G, Almeida FA, Simoff MJ, Yarmus L, Molina S, Young B, Feller-Kopman D, Sagar AES, Gildea T, Debiane LG, Grosu HB, Casal RF, Arain MH, Eapen GA, Jimenez CA, Noor LZ, Baghaie S, Song J, Li L, Ost DE. A Prediction Model to Help with Oncologic Mediastinal Evaluation for Radiation: HOMER. Am J Respir Crit Care Med 2020; 201:212-223. [PMID: 31574238 PMCID: PMC6961739 DOI: 10.1164/rccm.201904-0831oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/27/2019] [Indexed: 02/06/2023] Open
Abstract
Rationale: When stereotactic ablative radiotherapy is an option for patients with non-small cell lung cancer (NSCLC), distinguishing between N0, N1, and N2 or N3 (N2|3) disease is important.Objectives: To develop a prediction model for estimating the probability of N0, N1, and N2|3 disease.Methods: Consecutive patients with clinical-radiographic stage T1 to T3, N0 to N3, and M0 NSCLC who underwent endobronchial ultrasound-guided staging from a single center were included. Multivariate ordinal logistic regression analysis was used to predict the presence of N0, N1, or N2|3 disease. Temporal validation used consecutive patients from 3 years later at the same center. External validation used three other hospitals.Measurements and Main Results: In the model development cohort (n = 633), younger age, central location, adenocarcinoma, and higher positron emission tomography-computed tomography nodal stage were associated with a higher probability of having advanced nodal disease. Areas under the receiver operating characteristic curve (AUCs) were 0.84 and 0.86 for predicting N1 or higher (vs. N0) disease and N2|3 (vs. N0 or N1) disease, respectively. Model fit was acceptable (Hosmer-Lemeshow, P = 0.960; Brier score, 0.36). In the temporal validation cohort (n = 473), AUCs were 0.86 and 0.88. Model fit was acceptable (Hosmer-Lemeshow, P = 0.172; Brier score, 0.30). In the external validation cohort (n = 722), AUCs were 0.86 and 0.88 but required calibration (Hosmer-Lemeshow, P < 0.001; Brier score, 0.38). Calibration using the general calibration method resulted in acceptable model fit (Hosmer-Lemeshow, P = 0.094; Brier score, 0.34).Conclusions: This prediction model can estimate the probability of N0, N1, and N2|3 disease in patients with NSCLC. The model has the potential to facilitate decision-making in patients with NSCLC when stereotactic ablative radiotherapy is an option.
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Affiliation(s)
- Gabriela Martinez-Zayas
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico
- Department of Pulmonary Medicine and
| | | | - Michael J. Simoff
- Department of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, Maryland; and
| | - Sofia Molina
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico
- Department of Pulmonary Medicine and
| | - Benjamin Young
- Division of Pulmonary and Critical Care Medicine, University Hospitals, Cleveland, Ohio
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, Maryland; and
| | | | - Thomas Gildea
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Labib G. Debiane
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, Maryland; and
| | | | | | | | | | | | | | | | - Juhee Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Liang Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
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15
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Fernandez C, Grills IS, Ye H, Hope AJ, Guckenberger M, Mantel F, Kestin LL, Belderbos J, Werner-Wasik M. Stereotactic Image Guided Lung Radiation Therapy for Clinical Early Stage Non-Small Cell Lung Cancer: A Long-Term Report From a Multi-Institutional Database of Patients Treated With or Without a Pathologic Diagnosis. Pract Radiat Oncol 2019; 10:e227-e237. [PMID: 31837478 DOI: 10.1016/j.prro.2019.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/07/2019] [Accepted: 12/02/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Early stage lung cancer is treated with stereotactic body radiation therapy (SBRT) in patients who are unable or unwilling to undergo surgical resection. Some patients' comorbidities are so severe that they are unable to even undergo a biopsy. A clinical diagnosis without biopsy before SBRT has been used, but there are limited data on its efficacy. METHODS AND MATERIALS Data on patients treated with SBRT for non-small cell lung cancer, with and without tissue confirmation, were collected from multiple institutions across Europe, Canada, and the United States. Patients with a minimum of 2 years of comprehensive follow up were selected for analysis. Treatment and patient characteristics were compared. Overall survival (OS), disease-free survival (DFS), cause-specific survival (CSS), and rates of local recurrence (LR), regional recurrence (RR), and distant metastasis (DM) were calculated and analyzed. RESULTS A total of 701 patients were identified, of which 67% had tissue confirmation of their tumors. The 3- and 5-year outcomes for OS, CSS, and DFS were 83.8%, 93.1%, 69%, and 60.6%, 86.7%, 45.5%, respectively. The rates for LR, RR, and DM at 3 and 5 years were 6.4%, 9.3%, 14.3%, and 10.5%, 14.3%, 19.7%, respectively. There were no statistically significant differences in survival outcomes or recurrences between the biopsy and no-biopsy cohorts. CONCLUSIONS SBRT for clinically diagnosed lung cancers is efficacious in appropriately selected patients, with similar outcomes as those with a pathologic diagnosis. Thorough clinical and radiographic evaluations in a multidisciplinary setting are critical to the management of these patients.
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Affiliation(s)
- Christian Fernandez
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Inga S Grills
- Department of Radiation Oncology, William Beaumont Health, Royal Oak, Michigan
| | - Hong Ye
- Department of Radiation Oncology, William Beaumont Health, Royal Oak, Michigan
| | - Andrew J Hope
- Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Frederick Mantel
- Department of Radiation Oncology, University of Würzburg, Würzburg, Germany
| | - Larry L Kestin
- Michigan Health Professionals, Radiation Oncology Institute, Farmington Hills, Michigan
| | - Jose Belderbos
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Maria Werner-Wasik
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, Pennsylvania
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Cuccia F, Mortellaro G, Mazzola R, Donofrio A, Valenti V, Tripoli A, Matranga D, Lo Casto A, Failla G, Di Miceli G, Ferrera G. Prognostic value of two geriatric screening tools in a cohort of older patients with early stage Non-Small Cell Lung Cancer treated with hypofractionated stereotactic radiotherapy. J Geriatr Oncol 2019; 11:475-481. [PMID: 31122872 DOI: 10.1016/j.jgo.2019.05.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/16/2019] [Accepted: 05/02/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To investigate whether assessment with two geriatric screening tools shows a correlation with clinical outcomes of patients aged 65 years or more, with early-stage Non-Small Cell Lung Cancer (es-NSCLC) treated with hypofractionated stereotactic radiotherapy. METHODS From March 2014 to June 2018 we retrospectively evaluated 42 patients with stage I and II lung tumors. Patients were assessed with Charlson Comorbidity Index (CCI) and G8 screening tool. Median age was 74 years (range, 65-91). Stereotactic radiotherapy was performed with Helical Tomotherapy delivering 50-70 Gray (Gy) in 8-10 fractions. Toxicity was evaluated using Common Terminology Criteria for Adverse Events v4.0 criteria. RESULTS Median CCI and G8 scores were 6 (4-11) and 14 (12-17), respectively. With a median follow-up of 14 months (3-37), we observed: 3 cases of acute Grade 2 (G2) radiation pneumonitis, 1 late G2 non-cardiac chest pain, 1 late G2 dysphagia and 1 case of late G2 radiation pneumonitis. At statistical analysis, G8 scores ≤14 were significantly associated with late toxicity rates (p = .0073). Local failure was predictive of disease free survival and Overall Survival (p < .001 and p = .001). Death occurred in 12 patients, 6 for non-cancer related causes, with 1- and 2-yrs cancer specific survival rates of 94.8% and 90%, 1- and 2-yrs OS rates of 93% and 80%, respectively. CONCLUSIONS Our experience shows a correlation between G8 scores and late toxicity in older patients treated with stereotactic radiotherapy for lung cancer, suggesting the need for prospective studies evaluating its use for the identification of patients at higher risk of adverse events.
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Affiliation(s)
- Francesco Cuccia
- Radiation Oncology School, University of Palermo, Palermo, Italy; Radiation Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | - Gianluca Mortellaro
- Radiation Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | - Rosario Mazzola
- Department of Radiation Oncology, IRCCS, Ospedale Sacro Cuore Don Calabria, Negrar, Verona, Italy
| | - Alessandra Donofrio
- Radiation Oncology School, University of Palermo, Palermo, Italy; Radiation Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | - Vito Valenti
- Radiation Oncology School, University of Palermo, Palermo, Italy; Radiation Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | - Antonella Tripoli
- Radiation Oncology School, University of Palermo, Palermo, Italy; Radiation Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | | | - Antonio Lo Casto
- Radiation Oncology School, University of Palermo, Palermo, Italy; Radiology Department, Di.Bi.Med., Radiation Oncology School, University of Palermo, Palermo, Italy
| | - Giuseppe Failla
- Interventional Endoscopic Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | - Giuseppe Di Miceli
- Chest Surgery Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Palermo, Italy
| | - Giuseppe Ferrera
- Radiation Oncology Unit, ARNAS Ospedale Civico Di Cristina Benfratelli, Palermo, Italy.
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Abstract
PURPOSE OF REVIEW Significant advances have been made in the field of stereotactic ablative radiotherapy (SABR) for the treatment of pulmonary neoplasms in recent years. This review aims to summarize recent salient evidence on SABR for early-stage nonsmall cell lung cancer (ES-NSCLC). RECENT FINDINGS In medically inoperable patients, SABR remains the standard of care. The optimal SABR dosing regimen is being studied. Comparisons with non-SABR radiotherapy regimens with lower doses per fraction revealed benefit of SABR. In operable patients, no prospective clinical trial comparing SABR and surgery has been completed, although multiple trials are currently underway to address this question. SABR is generally cost-effective and safe in most patients, with preserved patient-reported quality of life. However, increased toxicity with SABR is noted in patients with disease close to, or invading the proximal tracheobronchial tree. Significant SABR-related toxicity and mortality is also reported in patients with coexisting interstitial lung disease. Considerations on pathologic confirmation, surveillance and multiple primaries are also addressed. SUMMARY SABR is an effective and safe treatment for inoperable ES-NSCLC. Ongoing trials and comparative effectiveness research will help to clarify SABR's role in various lung cancer indications going forward.
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Berman AT, Jabbour SK, Vachani A, Robinson C, Choi JI, Mohindra P, Rengan R, Bradley J, Simone CB. Empiric Radiotherapy for Lung Cancer Collaborative Group multi-institutional evidence-based guidelines for the use of empiric stereotactic body radiation therapy for non-small cell lung cancer without pathologic confirmation. Transl Lung Cancer Res 2019; 8:5-14. [PMID: 30788230 PMCID: PMC6351405 DOI: 10.21037/tlcr.2018.12.12] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/20/2018] [Indexed: 12/15/2022]
Abstract
The standard of care for managing early stage non-small cell lung cancer (NSCLC) is definitive surgical resection. Stereotactic body radiation therapy (SBRT) has become the standard treatment for patient who are medically inoperable, and it is increasingly being considered as an option in operable patients. With the growing use of screening thoracic CT scans for patients with a history of heavy smoking, as well as improved imaging capabilities, the discovery of small lung nodes has become a common dilemma. As a result, clinicians are increasingly faced with managing lung nodules in patients in whom diagnostic biopsy is not safe or feasible. Herein, we describe the scope of the problem, tools available for predicting the probability that a lung nodule is a malignancy, staging procedures, benefits of pathology-proven and empiric SBRT, considerations of safety based on location of the lesion of concern, and overall efficacy of SBRT.
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Affiliation(s)
- Abigail T. Berman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Salma K. Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | - Anil Vachani
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cliff Robinson
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - J. Isabelle Choi
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ramesh Rengan
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Jeffrey Bradley
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Charles B. Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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20
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Zehentmayr F, Sprenger M, Rettenbacher L, Wass R, Porsch P, Fastner G, Pirich C, Studnicka M, Sedlmayer F. Survival in early lung cancer patients treated with high dose radiotherapy is independent of pathological confirmation. Thorac Cancer 2019; 10:321-329. [PMID: 30618120 PMCID: PMC6360228 DOI: 10.1111/1759-7714.12966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/11/2018] [Accepted: 12/12/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Approximately 15% of lung cancer patients are diagnosed in early stages. Microscopic proof of disease cannot always be obtained because of comorbidity or reluctance to undergo invasive diagnostic procedures. In the current study, survival data of patients with and without pathology are compared. METHODS One hundred and sixty three patients with NSCLC I-IIb (T3 N0) treated between 2002 and 2016 were eligible: 123 (75%) had pathological confirmation of disease, whereas 40 (25%) did not. In accordance with international guidelines, both groups received radiotherapy. Comorbidity was assessed with the Charlson Comorbidity Index (CCI). RESULTS The median follow-up was 28.6 months (range: 0.3-162): 66 (40%) patients are still alive, while 97 (59%) patients died: 48 (29%) cancer-related deaths and 49 (30%) from causes other than cancer. Median overall survival (OS) in patients without pathological confirmation was 58.6 months (range: 0.5-162), which did not differ from those with microscopic proof of disease (39.4 months, range: 0.3-147.5; logrank P = 0.481). Median cancer-specific survival (CSS) also did not differ at 113.4 months (range: 0.5-162) in the non-confirmation group (logrank P = 0.763) versus 51.5 months (range: 3.7-129.5) in patients with pathology. In Cox regression, a CCI of ≥ 3 was associated with poor OS (hazard ratio 2.0; range 1.2-3.4; P = 0.010) and CSS (hazard ratio 2.0; 1.0-4.0; P = 0.043). CONCLUSION OS and CSS in early lung cancer patients depend on comorbidity rather than on pathological confirmation of disease.
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Affiliation(s)
- Franz Zehentmayr
- Department of Radiation Oncology, Paracelsus Medical University, SALK, Salzburg, Austria.,radART, Paracelsus Medical University, Salzburg, Austria
| | - Martin Sprenger
- Postgraduate Public Health Program, Medical University of Graz, Graz, Austria
| | - Lukas Rettenbacher
- Department of Nuclear Medicine, Paracelsus Medical University, SALK, Salzburg, Austria
| | - Romana Wass
- Department of Pneumology, Paracelsus Medical University, SALK, Salzburg, Austria
| | - Peter Porsch
- Department of Pneumology, Paracelsus Medical University, SALK, Salzburg, Austria
| | - Gerd Fastner
- Department of Radiation Oncology, Paracelsus Medical University, SALK, Salzburg, Austria
| | - Christian Pirich
- Department of Nuclear Medicine, Paracelsus Medical University, SALK, Salzburg, Austria
| | - Michael Studnicka
- Department of Pneumology, Paracelsus Medical University, SALK, Salzburg, Austria
| | - Felix Sedlmayer
- Department of Radiation Oncology, Paracelsus Medical University, SALK, Salzburg, Austria.,radART, Paracelsus Medical University, Salzburg, Austria
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Stone E, Rankin N, Kerr S, Fong K, Currow DC, Phillips J, Connon T, Zhang L, Shaw T. Does presentation at multidisciplinary team meetings improve lung cancer survival? Findings from a consecutive cohort study. Lung Cancer 2018; 124:199-204. [PMID: 30268461 DOI: 10.1016/j.lungcan.2018.07.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/13/2018] [Accepted: 07/17/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Multidisciplinary team (MDT) presentation in lung cancer has the potential to improve longterm outcomes, although this varies between studies. This study aims to evaluate outcomes including survival, according to MDT presentation and to explore the utility of data obtained from local clinical sources. PATIENTS AND METHODS Prospective cases of lung cancer recorded in our institution's cancer registry were analyzed according to MDT presentation for patient and tumour characteristics, adjusted survival and referral to palliative care. RESULTS 1197 cases were included, 295 (24.6%) with MDT presentation and 902 (75.4%) without. 60% of patients were male with median (IQR) age at diagnosis of 70 years (62-78). Histopathology distribution (non-small cell lung cancer and small-cell lung cancer) was similar between the two groups. Compared with the non-MDT group, the MDT group had (1) ECOG score recorded more often (71.9% vs. 47.6%), (2) higher proportion of ECOG 0 cases (31.2% vs. 11.9%) and ECOG 1 cases (28.8% vs. 20.3%), (3) higher proportion of early stage disease (stage I - 23.1% vs. 9.7% stage II - 10.2% vs. 4.8%, stage IIIA - 14.6% vs 6.3%) and (4) lower proportion of metastatic disease (stage IV - 39.3% vs. 56.1%). Referral to palliative care was incompletely recorded in both groups (MDT: n = 116/295, 39.3%; non-MDT: n = 430, 47.7%) but did not differ significantly for stage IV cases. Survival analyzed by stage was greater in the MDT group at 1, 2 and 5 years for all stages except stage IIIB at 1 year post-diagnosis. Adjusted survival analysis for the entire cohort showed improved survival at 5 years for the MDT group (HR 0.7 (0.58-0.85), p < 0.001). CONCLUSION MDT presentation is associated with improved adjusted survival for lung cancer in this single institutional cohort in an analysis of local clinical cancer registry data.
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Affiliation(s)
- Emily Stone
- St Vincent's Hospital Thoracic Medicine and Cancer Services, Kinghorn Cancer Centre, Australia; St Vincent's Clinical School, UNSW, Australia; Faculty of Medicine, University of Sydney, Australia.
| | - Nicole Rankin
- Cancer Council NSW, Cancer Research Division University of Sydney, Sydney Health Partners, Office of the Pro-Vice Chancellor, Research in association with Charles Perkins Centre, University of Sydney, Faculty of Science, School of Psychology, Australia
| | | | - Kwun Fong
- UQ Thoracic Research Centre, The Prince Charles Hospital, Brisbane QLD, Australia
| | - David C Currow
- IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jane Phillips
- IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Lorena Zhang
- Royal North Shore Hospital, Reserve Rd, St Leonards NSW 2065, Australia
| | - Tim Shaw
- University of Sydney, Charles Perkins Centre, Australia
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Hasan S, Colonias A, Mickus T, VanDeusen M, Wegner RE. Image-based management of empiric lung stereotactic body radiotherapy (SBRT) without biopsy: Predictors from a 10-year single institution experience. Thorac Cancer 2018; 9:699-706. [PMID: 29697204 PMCID: PMC5983152 DOI: 10.1111/1759-7714.12635] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/02/2018] [Accepted: 03/02/2018] [Indexed: 12/25/2022] Open
Abstract
Background There is emerging reliance on clinical imaging for the diagnosis, prognosis, and treatment evaluation of early stage non‐small cell lung cancer (NSCLC) in patients deemed too high risk for biopsy. We report our experience of clinically diagnosed NSCLC treated empirically with stereotactic body radiotherapy (SBRT) to validate the imaging parameters used for management in this high‐risk population. Methods We reviewed 101 empiric lung SBRT cases and profiled imaging specifics of computed tomography and positron emission tomography for diagnosis and follow‐up. Secondarily, we identified potential correlates of disease progression with Cox regression multivariate analysis. Results Fifty‐seven men and 43 women aged 45–94 (median 76) were treated with a median dose of 48 Gy in four fractions. The median nodule diameter was 1.6 cm (0.6–4.5 cm) and most were spiculated (n = 58), right‐sided (n = 63), and in the upper lobe (n = 68). Median follow‐up and survival rates were 14 and 28 months, respectively. Local control at three years was 94%. Freedom from any progression at one and three years was 85% and 69%, respectively. Toxicity ≥ grade 3 included two grade 3 dyspneas. A pre‐treatment standard uptake value > 4.1 was the only significant predictor of disease progression. Conclusion This study illustrates the instrumental role of modern clinical imaging for the effective management of presumed early stage NSCLC treated with empiric lung SBRT. As lung SBRT without tissue confirmation becomes more common, hopefully these assertions can be prospectively validated.
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Affiliation(s)
- Shaakir Hasan
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Athanasios Colonias
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Timothy Mickus
- Division of Thoracic Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Matthew VanDeusen
- Division of Thoracic Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Every breath you take: The value of the electronic nose (e-nose) technology in the early detection of lung cancer. J Thorac Cardiovasc Surg 2018; 155:2622-2625. [PMID: 29602425 DOI: 10.1016/j.jtcvs.2017.12.155] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/27/2017] [Accepted: 12/09/2017] [Indexed: 02/06/2023]
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Optimal imaging surveillance after stereotactic ablative radiation therapy for early-stage non-small cell lung cancer: Findings of an International Delphi Consensus Study. Pract Radiat Oncol 2018; 8:e71-e78. [DOI: 10.1016/j.prro.2017.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/12/2017] [Accepted: 10/22/2017] [Indexed: 12/17/2022]
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Figlia V, Mazzola R, Cuccia F, Alongi F, Mortellaro G, Cespuglio D, Cucchiara T, Iacoviello G, Valenti V, Molino M, Verderame F, Matranga D, Casto AL, Ferrera G. Hypo-fractionated stereotactic radiation therapy for lung malignancies by means of helical tomotherapy: report of feasibility by a single-center experience. Radiol Med 2018; 123:406-414. [PMID: 29455424 DOI: 10.1007/s11547-018-0858-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 01/18/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Several experiences in the literature report SBRT as an effective treatment option for medically inoperable early stage non-small cell lung cancer (NSCLC) and oligometastatic disease. The optimal fractionation schedules and total dose remain controversial. In this study, we evaluated the safety in terms of toxicity and efficacy of using of 8-10 fractions schedules with Helical Tomotherapy (HT) for primary and metastatic lung lesions. METHODS Between March 2014 and May 2016, a total of 39 patients (median age 72 years, range 26-91) were treated with HT-SBRT for malignant lung lesions: 22 patients with early stage NSCLC, 17 with oligometastases. Patients received 8-10 fractions with lower daily dose for central and ultracentral lesions. Treatment-related toxicity was evaluated using CTCAE v 4.0 scale. Local control (LC), overall survival (OS) and toxicity rates were prospectively collected. RESULTS Median duration of RT was 15 days (range 10-26 days) and no interruption occurred. With a median follow-up of 13 months (range 3-29), we reported one G2 pneumonitis (2.6%) and one G2 chest pain (2.6%); no ≥ G2 esophagitis was registered. Actuarial local control rate was 95.5% both at 12 and 24 months for early stage NSCLC and 92.9% both at 12 and 24 months for metastatic patients. OS rate was 94.4 and 92.3% at 1 year, and 94.4 and 83.9% at 2 years in primary and metastatic group, respectively. CONCLUSIONS The use of 8-10 fractions schedule HT-SBRT for lung malignancies results in high LC and OS rates with minimal toxicities reported.
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Affiliation(s)
- Vanessa Figlia
- Radiation Oncology School, University of Palermo, Palermo, Italy
| | - Rosario Mazzola
- Radiation Oncology, Sacro Cuore Don Calabria Hospital, Verona, Negrar, Italy
| | - Francesco Cuccia
- Radiation Oncology School, University of Palermo, Palermo, Italy.
| | - Filippo Alongi
- Radiation Oncology, Sacro Cuore Don Calabria Hospital, Verona, Negrar, Italy
- University of Brescia, Brescia, Italy
| | | | | | | | | | - Vito Valenti
- Radiation Oncology School, University of Palermo, Palermo, Italy
| | - Massimo Molino
- Radiology Department, ARNAS-Civico Hospital, Palermo, Italy
| | | | | | - Antonio Lo Casto
- Radiation Oncology School, University of Palermo, Palermo, Italy
| | - Giuseppe Ferrera
- Statistic Science Faculty, University of Palermo, Palermo, Italy
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Weder W, Moghanaki D, Stiles B, Siva S, Rocco G. The great debate flashes: surgery versus stereotactic body radiotherapy as the primary treatment of early-stage lung cancer. Eur J Cardiothorac Surg 2017; 53:295-305. [DOI: 10.1093/ejcts/ezx410] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/23/2017] [Accepted: 10/28/2017] [Indexed: 12/25/2022] Open
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Dalwadi SM, Szeja SS, Bernicker EH, Butler EB, Teh BS, Farach AM. Practice Patterns and Outcomes in Elderly Stage I Non-Small-cell Lung Cancer: A 2004 to 2012 SEER Analysis. Clin Lung Cancer 2017; 19:e269-e276. [PMID: 29208356 DOI: 10.1016/j.cllc.2017.11.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/19/2017] [Accepted: 11/10/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND We reviewed the population-based treatment patterns and outcomes for elderly patients with stage I non-small-cell lung cancer (NSCLC) treated from 2004 to 2012. PATIENTS AND METHODS Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified biopsy-proven stage I NSCLC cases diagnosed from 2004 to 2012. The patients were divided into 5-year age subsets (60-64, 65-69, 70-74, 75-79, 80-84, 85-89, and ≥ 90 years). The demographic data, therapy, and survival were compared by year. Trends in overall survival (OS), cancer-specific survival (CSS), and practice patterns were analyzed. RESULTS A total of 62,213 cases were identified. The use of surgery declined sharply with age. Patients aged 60 to 64 years had a surgical rate of 81% compared with 21% for those aged ≥ 90 years (P < .0001). Radiation use increased (from 11% to 39%; P < .0001), as did the receipt of neither surgery nor radiation (from 7% to 40%; P < .0001). When analyzing the annual trends, radiation use increased, with fewer patients forgoing treatment from 2004 to 2012 (P < .0001). From 2004 to 2011, CSS at 2 years improved significantly for patients treated with radiation alone (from 48% to 72%; P < .0001) and more subtly for those receiving surgery alone (from 87% to 91%; P < .0001). The outcomes were stable for those receiving neither surgery nor radiation (38% to 45%; P = NS). Surgical outcomes declined with advancing age (P < .0001); however, the radiation outcomes did not (P = NS). CONCLUSION With advancing age, radiation replaces surgery as the most used treatment for early-stage NSCLC. OS and CSS have improved significantly for elderly stage I NSCLC patients treated with radiation alone during a timeline concurrent with the widespread adoption of stereotactic body radiation therapy. Dedicated prospective studies are indicated, because these findings are limited by the inherent biases of using the SEER database alone.
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Affiliation(s)
- Shraddha M Dalwadi
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX
| | - Sean S Szeja
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
| | - Eric H Bernicker
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX
| | - Andrew M Farach
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX.
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Royce TJ, Punglia RS, Chen AB, Patel SA, Thornton KA, Raut CP, Baldini EH. Cost-Effectiveness of Surveillance for Distant Recurrence in Extremity Soft Tissue Sarcoma. Ann Surg Oncol 2017; 24:3264-3270. [PMID: 28718037 DOI: 10.1245/s10434-017-5996-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Optimal distant recurrence (DR) surveillance strategies for extremity soft tissue sarcoma (STS) are unknown. We performed a cost-effectiveness analysis of different imaging modalities performed at guideline-specified intervals. METHODS We developed a Markov model simulating lifetime outcomes for 54-year-old patients after definitive treatment for American Joint Committee on Cancer stage II-III extremity STS using four surveillance strategies: watchful waiting (WW), chest X-ray (CXR), chest computed tomography (CCT), and positron emission tomography-computed tomography (PET/CT). Probabilities, utilities, and costs were extracted from the literature and Medicare claims to determine incremental cost-effectiveness ratios (ICER). RESULTS CCT was the most effective and most costly strategy with CXR the most cost-effective strategy at a societal willing-to-pay (WTP) of $100,000/quality-adjusted life year (QALY). The ICER was $12,113/QALY for CXR versus $104,366/QALY for CCT while PET/CT was never cost-effective. Sensitivity analyses demonstrated CCT becomes the preferred imaging modality as the lifetime risk of DR increases beyond 33% or as the WTP increases beyond $120,000/QALY. CONCLUSIONS Optimal DR surveillance imaging for stage II-III extremity STS should be individualized based on patients' risks for DR. These results suggest CXR, or CCT performed at more protracted intervals, may be preferred for lower-risk patients (i.e., DR risk <33%), whereas CCT may be preferred for higher-risk patients (i.e., DR risk >33%). Further study of optimal strategies is needed. In the interim, these findings may help to refine guidelines to reduce resource overutilization during routine surveillance of lower-risk sarcoma patients.
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Affiliation(s)
- Trevor J Royce
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA. .,Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.
| | - Rinaa S Punglia
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Aileen B Chen
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Sagar A Patel
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, MA, USA.,Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Katherine A Thornton
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Chandrajit P Raut
- Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Division of Surgical Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | - Elizabeth H Baldini
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Center for Bone and Soft Tissue Sarcoma, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
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Mazzola R, Fiorentino A, Di Paola G, Giaj Levra N, Ricchetti F, Fersino S, Tebano U, Pasetto S, Ruggieri R, Salgarello M, Alongi F. Stereotactic Ablative Radiation Therapy for Lung Oligometastases: Predictive Parameters of Early Response by 18FDG-PET/CT. J Thorac Oncol 2017; 12:547-555. [PMID: 28126325 DOI: 10.1016/j.jtho.2016.11.2234] [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: 06/28/2016] [Revised: 10/28/2016] [Accepted: 11/15/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The objective of this study was to investigate fludeoxyglucose F 18 positron emission tomography/computed tomography (18FDG-PET/CT) parameters as predictive of response after stereotactic ablative radiotherapy (SABR) for lung oligometastases. METHODS The inclusion criteria of the current retrospective study were as follows: (1) lung oligometastases treated by SABR, (2) presence of 18FDG-PET/CT before and after SABR for at least two subsequent evaluations, (3) Karnofsky performance status higher than 80, and (4) life expectancy longer than 6 months. All patients were treated with a biologically equivalent dose of at least 100 Gy with an alpha/beta ratio of 10. The following metabolic parameters were semiquantitatively defined: maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), metabolic tumor volume, and total lesion glycolysis. RESULTS A total of 50 patients met the inclusion criteria, for a total of 70 lung metastases. The pre-SABR median SUVmax was 6.5 (range 4-17), the median SUVmean was 3.7 (range 2.5-6.5), and the median metabolic tumor volume was 2.3 cm3 (0.2-31 cm3). The following metabolic parameters were significantly related to complete response at 6 months: SUVmax less than 5 (p < 0.001) and SUVmean less than 3.5 (p = 0.03). ΔSUVmax at 3 to 6 months was +126% for lesions with in-field progression versus -26% for the remaining lesions (p = 0.002). ΔSUVmean at 3 to 6 months was +15% for lesions with in-field progression versus -26% for the remaining metastases (p = 0.008). CONCLUSIONS In the current analysis, complete response from lung metastasis at 6 months after stereotactic body radiation therapy was significantly associated with both the maximum and mean values of pre-SABR 18FDG-PET/CT SUV. Longer-term trials are strongly advocated to improve the personalization of the monitoring of tumor response in patients with lung oligometastases and, consequently, monitoring of the cost-effectiveness of the health care.
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Affiliation(s)
- Rosario Mazzola
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy.
| | - Alba Fiorentino
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | | | - Niccolò Giaj Levra
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Francesco Ricchetti
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Sergio Fersino
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Umberto Tebano
- Radiation Oncology School, University of Padua, Padua, Italy
| | - Stefano Pasetto
- Nuclear Medicine, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Ruggero Ruggieri
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Matteo Salgarello
- Nuclear Medicine, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Filippo Alongi
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
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Tanner NT, Porter A, Gould MK, Li XJ, Vachani A, Silvestri GA. Physician Assessment of Pretest Probability of Malignancy and Adherence With Guidelines for Pulmonary Nodule Evaluation. Chest 2017; 152:263-270. [PMID: 28115167 DOI: 10.1016/j.chest.2017.01.018] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 11/25/2016] [Accepted: 01/02/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The annual incidence of pulmonary nodules is estimated at 1.57 million. Guidelines recommend using an initial assessment of nodule probability of malignancy (pCA). A previous study found that despite this recommendation, physicians did not follow guidelines. METHODS Physician assessments (N = 337) and two previously validated risk model assessments of pretest probability of cancer were evaluated for performance in 337 patients with pulmonary nodules based on final diagnosis and compared. Physician-assessed pCA was categorized into low, intermediate, and high risk, and the next test ordered was evaluated. RESULTS The prevalence of malignancy was 47% (n = 158) at 1 year. Physician-assessed pCA performed better than nodule prediction calculators (area under the curve, 0.85 vs 0.75; P < .001 and .78; P = .0001). Physicians did not follow indicated guidelines when selecting the next test in 61% of cases (n = 205). Despite recommendations for serial CT imaging in those with low pCA, 52% (n = 13) were managed more aggressively with PET imaging or biopsy; 12% (n = 3) underwent biopsy procedures for benign disease. Alternatively, in the high-risk category, the majority (n = 103 [75%]) were managed more conservatively. Stratified by diagnosis, 92% (n = 22) with benign disease underwent more conservative management with CT imaging (20%), PET scanning (15%), or biopsy (8%), although three had surgery (8%). CONCLUSIONS Physician assessment as a means for predicting malignancy in pulmonary nodules is more accurate than previously validated nodule prediction calculators. Despite the accuracy of clinical intuition, physicians did not follow guideline-based recommendations when selecting the next diagnostic test. To provide optimal patient care, focus in the areas of guideline refinement, implementation, and dissemination is needed.
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Affiliation(s)
- Nichole T Tanner
- Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC; Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Hospital, Charleston, SC.
| | | | | | | | - Anil Vachani
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Gerard A Silvestri
- Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
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Heuvelmans MA, Groen HJM, Oudkerk M. Early lung cancer detection by low-dose CT screening: therapeutic implications. Expert Rev Respir Med 2016; 11:89-100. [DOI: 10.1080/17476348.2017.1276445] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Marjolein A Heuvelmans
- University of Groningen, University Medical Center Groningen, Center for Medical Imaging – North East Netherlands, Groningen, The Netherlands
- Medisch Spectrum Twente, Department of Pulmonology, Enschede, The Netherlands
| | - Harry J M Groen
- University of Groningen, University Medical Center Groningen, Department of Pulmonology, Groningen, The Netherlands
| | - Matthijs Oudkerk
- University of Groningen, University Medical Center Groningen, Center for Medical Imaging – North East Netherlands, Groningen, The Netherlands
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Shaikh T, Churilla TM, Murphy CT, Zaorsky NG, Haber A, Hallman MA, Meyer JE. Absence of Pathological Proof of Cancer Associated with Improved Outcomes in Early-Stage Lung Cancer. J Thorac Oncol 2016; 11:1112-20. [PMID: 27109322 DOI: 10.1016/j.jtho.2016.03.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 03/15/2016] [Accepted: 03/20/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the trends in use of clinical diagnosis and its impact on treatment outcomes in patients receiving radiation therapy for early-stage lung cancer. METHODS The Surveillance, Epidemiology, and End Results registry was queried from 2004 to 2012 for patients at least 18 years old in whom stage I (clinical stage T1a-T2a) lung cancer had been diagnosed and who underwent radiation therapy alone. Trends in diagnostic confirmation patterns were characterized. A Cox proportional hazards model was used to assess overall survival, and competing risk regression analysis was used to assess cancer-specific survival (CSS). RESULTS A total of 7050 patients were included; the disease of 6399 of them (90.8%) was pathologically diagnosed and that of 651 (9.2%) was clinically diagnosed. There was no significant change in the utilization of clinical versus pathologic diagnosis (p = 0.172) over time. Patients with T1 disease (p < 0.001), tumors 0 to 1.9 cm in size (p < 0.001), and upper lobe tumors (p = 0.004) were more likely to have been clinically diagnosed. On multivariable analysis, clinical diagnosis was associated with an improved CSS (hazard ratio [HR] = 0.82, 95% confidence interval [CI]: 0.71-0.96) but was not associated with an improved overall survival (HR = 1.01, 95% CI: 0.90-1.13). When stratified by T stage, patients whose disease had been clinically diagnosed as stage T1a had an improved CSS (HR = 0.75, 95% CI: 0.58-0.96, p = 0.022). There was a trend toward improved CSS in patients with clinical stage T1b tumors (HR = 0.74, 95% CI: 0.55-1.00, p = 0.052). CONCLUSIONS The improved CSS in patients with a clinical diagnosis suggests treatment of benign disease, particularly in smaller tumors. Prudent patient selection is needed to reduce the potential for overtreatment.
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Affiliation(s)
- Talha Shaikh
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
| | - Thomas M Churilla
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Colin T Murphy
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Alan Haber
- Department of Pulmonary Medicine, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Mark A Hallman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Joshua E Meyer
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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SABR vs. Limited Resection for Non-small Cell Lung Cancer: Are We Closer to an Answer? Curr Treat Options Oncol 2016; 17:27. [DOI: 10.1007/s11864-016-0407-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Perandini S, Soardi GA, Motton M, Rossi A, Signorini M, Montemezzi S. Solid pulmonary nodule risk assessment and decision analysis: comparison of four prediction models in 285 cases. Eur Radiol 2015; 26:3071-6. [PMID: 26645862 DOI: 10.1007/s00330-015-4138-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/11/2015] [Accepted: 11/23/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The aim of this study was to compare classification results from four major risk prediction models in a wide population of incidentally detected solitary pulmonary nodules (SPNs) which were selected to crossmatch inclusion criteria for the selected models. METHODS A total of 285 solitary pulmonary nodules with a definitive diagnosis were evaluated by means of four major risk assessment models developed from non-screening populations, namely the Mayo, Gurney, PKUPH and BIMC models. Accuracy was evaluated by receiver operating characteristic (ROC) area under the curve (AUC) analysis. Each model's fitness to provide reliable help in decision analysis was primarily assessed by adopting a surgical threshold of 65 % and an observation threshold of 5 % as suggested by ACCP guidelines. RESULTS ROC AUC values, false positives, false negatives and indeterminate nodules were respectively 0.775, 3, 8, 227 (Mayo); 0.794, 41, 6, 125 (Gurney); 0.889, 42, 0, 144 (PKUPH); 0.898, 16, 0, 118 (BIMC). CONCLUSIONS Resultant data suggests that the BIMC model may be of greater help than Mayo, Gurney and PKUPH models in preoperative SPN characterization when using ACCP risk thresholds because of overall better accuracy and smaller numbers of indeterminate nodules and false positive results. KEY POINTS • The BIMC and PKUPH models offer better characterization than older prediction models • Both the PKUPH and BIMC models completely avoided false negative results • The Mayo model suffers from a large number of indeterminate results.
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Affiliation(s)
- Simone Perandini
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale Stefani 1, Verona, Italy, 37124.
| | - Gian Alberto Soardi
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale Stefani 1, Verona, Italy, 37124
| | - Massimiliano Motton
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale Stefani 1, Verona, Italy, 37124
| | - Arianna Rossi
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale Stefani 1, Verona, Italy, 37124
| | - Manuel Signorini
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale Stefani 1, Verona, Italy, 37124
| | - Stefania Montemezzi
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale Stefani 1, Verona, Italy, 37124
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Slatore CG, Horeweg N, Jett JR, Midthun DE, Powell CA, Wiener RS, Wisnivesky JP, Gould MK. An Official American Thoracic Society Research Statement: A Research Framework for Pulmonary Nodule Evaluation and Management. Am J Respir Crit Care Med 2015; 192:500-14. [PMID: 26278796 DOI: 10.1164/rccm.201506-1082st] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pulmonary nodules are frequently detected during diagnostic chest imaging and as a result of lung cancer screening. Current guidelines for their evaluation are largely based on low-quality evidence, and patients and clinicians could benefit from more research in this area. METHODS In this research statement from the American Thoracic Society, a multidisciplinary group of clinicians, researchers, and patient advocates reviewed available evidence for pulmonary nodule evaluation, characterized six focus areas to direct future research efforts, and identified fundamental gaps in knowledge and strategies to address them. We did not use formal mechanisms to prioritize one research area over another or to achieve consensus. RESULTS There was widespread agreement that novel tests (including novel imaging tests and biopsy techniques, biomarkers, and prognostic models) may improve diagnostic accuracy for identifying cancerous nodules. Before they are used in clinical practice, however, better evidence is needed to show that they improve more distal outcomes of importance to patients. In addition, the pace of research and the quality of clinical care would be improved by the development of registries that link demographic and nodule characteristics with patient-level outcomes. Methods to share data from registries are also necessary. CONCLUSIONS This statement may help researchers to develop impactful and innovative research projects and enable funders to better judge research proposals. We hope that it will accelerate the pace and increase the efficiency of discovery to improve the quality of care for patients with pulmonary nodules.
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[Positron emission tomography and stereotactic body radiation therapy for lung cancer: From treatment planning to response evaluation]. Cancer Radiother 2015; 19:790-4; quiz 795-9. [PMID: 26476702 DOI: 10.1016/j.canrad.2015.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 05/01/2015] [Accepted: 05/12/2015] [Indexed: 11/21/2022]
Abstract
Stereotactic body radiation therapy is the standard treatment for inoperable patients with early-stage lung cancer. Local control rates range from 80 to 90 % 2 years after treatment. The role of positron emission tomography in patient selection is well known, but its use for target definition or therapeutic response evaluation is less clear. We reviewed the literature in order to assess the current state of knowledge in this area.
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Petteys S, Zeman J, Stahlmann C. Overdiagnosis in Lung Cancer Screening, Cost-Effectiveness of Computed Tomography Screening for Lung Cancer, and Decision Analysis of Need for Biopsy-proven Diagnosis before Stereotactic Ablative Radiotherapy for Lung Cancer. Am J Respir Crit Care Med 2015; 192:1009-11. [DOI: 10.1164/rccm.201504-0804rr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Waissi W, Noël G, Giraud P. Surveillance après radiothérapie stéréotaxique des tumeurs pulmonaires. Cancer Radiother 2015; 19:566-72. [DOI: 10.1016/j.canrad.2015.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/11/2015] [Indexed: 12/25/2022]
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Callister MEJ, Baldwin DR, Akram AR, Barnard S, Cane P, Draffan J, Franks K, Gleeson F, Graham R, Malhotra P, Prokop M, Rodger K, Subesinghe M, Waller D, Woolhouse I. British Thoracic Society guidelines for the investigation and management of pulmonary nodules. Thorax 2015; 70 Suppl 2:ii1-ii54. [PMID: 26082159 DOI: 10.1136/thoraxjnl-2015-207168] [Citation(s) in RCA: 570] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- M E J Callister
- Department of Respiratory Medicine, Leeds Teaching Hospitals, Leeds, UK
| | - D R Baldwin
- Nottingham University Hospitals, Nottingham, UK
| | - A R Akram
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S Barnard
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle, UK
| | - P Cane
- Department of Histopathology, St Thomas' Hospital, London, UK
| | - J Draffan
- University Hospital of North Tees, Stockton on Tees, UK
| | - K Franks
- Clinical Oncology, St James's Institute of Oncology, Leeds, UK
| | - F Gleeson
- Department of Radiology, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | - P Malhotra
- St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - M Prokop
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - K Rodger
- Respiratory Medicine, St James's University Hospital, Leeds, UK
| | - M Subesinghe
- Department of Radiology, Churchill Hospital, Oxford, UK
| | - D Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - I Woolhouse
- Department of Respiratory Medicine, University Hospitals of Birmingham, Birmingham, UK
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41
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Abreu CECV, Ferreira PPR, de Moraes FY, Neves WFP, Gadia R, Carvalho HDA. Stereotactic body radiotherapy in lung cancer: an update. J Bras Pneumol 2015; 41:376-87. [PMID: 26398758 PMCID: PMC4635958 DOI: 10.1590/s1806-37132015000000034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 05/31/2015] [Indexed: 12/17/2022] Open
Abstract
For early-stage lung cancer, the treatment of choice is surgery. In patients who are not surgical candidates or are unwilling to undergo surgery, radiotherapy is the principal treatment option. Here, we review stereotactic body radiotherapy, a technique that has produced quite promising results in such patients and should be the treatment of choice, if available. We also present the major indications, technical aspects, results, and special situations related to the technique.
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Affiliation(s)
| | | | | | | | - Rafael Gadia
- Departamento de Radioterapia, Hospital Sírio-Libanês, Brasília (DF) Brasil
| | - Heloisa de Andrade Carvalho
- Departamento de Radioterapia, Hospital Sírio-Libanês, São Paulo (SP) Brasil
- Serviço de Radioterapia, Departamento de Radiologia e Oncologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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42
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Jones GC, Kehrer JD, Kahn J, Koneru BN, Narayan R, Thomas TO, Camphausen K, Mehta MP, Kaushal A. Primary Treatment Options for High-Risk/Medically Inoperable Early Stage NSCLC Patients. Clin Lung Cancer 2015; 16:413-30. [PMID: 26027433 DOI: 10.1016/j.cllc.2015.04.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 04/08/2015] [Accepted: 04/14/2015] [Indexed: 12/25/2022]
Abstract
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.
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43
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The Evolving Role of Molecular Imaging in Non–Small Cell Lung Cancer Radiotherapy. Semin Radiat Oncol 2015; 25:133-42. [DOI: 10.1016/j.semradonc.2014.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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44
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Ottlakan A, Martucci N, Rocco G. Is surgery still the best management option for early stage NSCLC? Transl Lung Cancer Res 2015; 3:159-63. [PMID: 25806295 DOI: 10.3978/j.issn.2218-6751.2014.06.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 06/10/2014] [Indexed: 12/25/2022]
Abstract
Under the formidable thrust of alternative management options for early stage lung cancer, the role of surgery in this disease subset has been questioned. Stereotactic body radiotherapy (SBRT) has been advocated as an ideal substitute for surgery not only in high risk patients or for the ones who refuse surgery but also in lieu of sublobar resection in otherwise fit patients. The therapeutic modalities for early stage NSCLC were compared as to warranting local control, enabling adequate tissue sampling for biomolecular studies, and effecting optimal pathologic staging while saving lung parenchyma. As a result, surgery still remains the best management option for early stage lung cancer in 2014.
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Affiliation(s)
- Aurel Ottlakan
- Division of Thoracic Surgery, Department of Thoracic Surgery and Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy
| | - Nicola Martucci
- Division of Thoracic Surgery, Department of Thoracic Surgery and Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy
| | - Gaetano Rocco
- Division of Thoracic Surgery, Department of Thoracic Surgery and Oncology, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS, Naples, Italy
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45
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Abstract
(18)F-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) plays a key role in the evaluation of undiagnosed lung nodules, when primary lung cancer is strongly suspected, or when it has already been diagnosed by other techniques. Although technical factors may compromise characterization of small or highly mobile lesions, lesions without apparent FDG uptake can generally be safely observed, whereas FDG-avid lung nodules almost always need further evaluation. FDG-PET/CT is now the primary staging imaging modality for patients with lung cancer who are being considered for curative therapy with either surgery or definitive radiation therapy.
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46
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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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