Feasibility and efficacy of helical intensity-modulated radiotherapy for stage III non-small cell lung cancer in comparison with conventionally fractionated 3D-CRT

Pneumonitis Risk After Chemoradiotherapy With and Without Immunotherapy in Patients With Locally Advanced Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis

PURPOSE

Chemoradiotherapy (CRT) combined with immune checkpoint inhibitors (ICIs) is the standard of care for patients with unresectable and locally advanced non-small cell lung cancer. This study aimed to determine whether the addition of ICIs to CRT is associated with an increased risk of pneumonitis.

METHODS AND MATERIALS

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for eligible studies published between January 1, 2015, and July 31, 2023. The outcome of interest was the incidence rate of pneumonitis. A random-effects model was used for statistical analysis.

RESULTS

A total of 185 studies with 24,527 patients were included. The pooled rate of grade ≥2 pneumonitis for CRT plus ICIs was significantly higher than that for CRT alone (29.6%; 95% CI, 25.7%-33.6% vs 20.2%; 95% CI, 17.7%-22.8%; P < .0001) but not that of grade ≥3 (5.7%; 95% CI, 4.8%-6.6% vs 5.6%; 95% CI, 4.7%-6.5%; P = .64) or grade 5 (0.1%; 95% CI, 0.0%-0.2% vs 0.3%; 95% CI, 0.1%-0.4%; P = .68). The results from the subgroup analyses of prospective studies, retrospective studies, Asian and non-Asian studies, concurrent CRT (cCRT), and durvalumab consolidation were comparable to the overall results. However, CRT or cCRT plus PD-1 inhibitors not only significantly increased the incidence of grade ≥2 but also that of grade ≥3 pneumonitis compared to CRT alone or cCRT plus PD-L1 inhibitors.

CONCLUSIONS

Compared with CRT alone, durvalumab consolidation after CRT appears to be associated with a higher incidence of moderate pneumonitis and CRT plus PD-1 inhibitors with an increased risk of severe pneumonitis. Nevertheless, these findings are based on observational studies and need to be validated in future large head-to-head studies.

Efficacy and Toxicity of Moderately Hypofractionated Radiation Therapy with Helical TomoTherapy Versus Conventional Radiation Therapy in Patients with Unresectable Stage III Non-Small Cell Lung Cancer Receiving Concurrent Chemotherapy: A Multicenter, Randomized Phase 3 Trial

PURPOSE

The standard treatment schedule for unresectable stage III non-small cell lung cancer (NSCLC) is chemotherapy with concurrent radiation therapy (60 Gy delivered in 30 fractions), although moderately hypofractionated radiation therapy (Hypo-RT) has also been considered as an alternative strategy. This study aimed to compare the efficacy and toxicity of moderately Hypo-RT with helical TomoTherapy versus conventionally fractionated radiation therapy (Con-RT) in patients with unresectable stage III NSCLC receiving concurrent chemotherapy.

METHODS AND MATERIALS

In this randomized, multicenter, nonblinded phase 3 clinical trial, eligible patients were randomised at a 1:1 ratio to either the Hypo-RT group (60 Gy in 20 fractions) or Con-RT group (60 Gy in 30 fractions). All patients received 2 cycles of concurrent platinum-based chemotherapy plus 2 cycles of consolidation therapy. The primary endpoint was 3-year overall survival (OS) in the intention-to-treat population. The secondary endpoints were progression-free survival and treatment-related adverse events.

RESULTS

A total of 146 patients were enrolled from July 27, 2018, to November 1, 2021. The median follow-up was 46 months. The 3-year OS rates in the Hypo-RT and Con-RT groups were 58.4% and 38.4%, respectively (P = .02). The median OS from randomisation was 41 months in the Hypo-RT group and 30 months in the Con-RT group (hazard ratio, 0.61; 95% confidence interval, 0.40-0.94; P = .02). There was no significant difference in the rates of grade ≥2 treatment-related adverse events between the 2 groups.

CONCLUSIONS

Moderately Hypo-RT using helical TomoTherapy may improve OS in patients with unresectable stage III NSCLC, while maintaining toxicity rates.

Impact of Radiation Therapy on Serum Humanin and MOTS-c Levels in Patients with Lung or Breast Cancer

BACKGROUND

Lung and breast cancer are the most frequent causes of death from cancer globally. The objectives of this research were to evaluate the serum mitochondrial open reading frame of the 12S rRNA-c (MOTS-c) and humanin levels in lung or breast cancer patients, and investigate the impacts of radiation therapy on the circulating levels of these peptides.

METHODS

35 lung cancer patients, 34 breast cancer patients, and healthy volunteers as a control group were recruited in this prospective observatory research. Lung cancer patients with stage IIIA/IIIB were treated with paclitaxel-based chemotherapy plus radiotherapy (2 Gy per day, 30 times, 60 Gy total dose). Breast cancer stage IIA/IIB patients were treated with postoperative locoregional radiation therapy (2 Gy per day, 25 times, 50 Gy total dose). The ELISA method was used to detect serum humanin and MOTS-c levels during, before, and after radiotherapy.

RESULTS

We observed marked elevations in circulating MOTS-c, but not humanin levels in patients with lung cancer (P < 0.001). Radiation therapy led to a marked augmentation in MOTS-c levels in these patients (P < 0.001). On the other hand, there was a marked decline in humanin, but not MOTS-c, levels in breast cancer patients (P < 0.001).

CONCLUSION

Our research has shown, for the first time, that increased MOTS-c and decreased humanin levels play a role in lung cancer and breast cancer, respectively. Additionally, radiotherapy modifies MOTS-c levels in patients with lung, but not breast cancer.

Comparison of post-chemoradiotherapy pneumonitis between Asian and non-Asian patients with locally advanced non-small cell lung cancer: a systematic review and meta-analysis

Background

Pneumonitis is a common complication for patients with locally advanced non-small cell lung cancer undergoing definitive chemoradiotherapy (CRT). It remains unclear whether there is ethnic difference in the incidence of post-CRT pneumonitis.

Methods

PubMed, Embase, Cochrane Library, and Web of Science were searched for eligible studies from January 1, 2000 to April 30, 2023. The outcomes of interest were incidence rates of pneumonitis. The random-effect model was used for statistical analysis. This meta-analysis was registered with PROSPERO (CRD42023416490).

Findings

A total of 248 studies involving 28,267 patients were included. Among studies of CRT without immunotherapy, the pooled rates of pneumonitis for Asian patients were significantly higher than that for non-Asian patients (all grade: 66.8%, 95% CI: 59.2%-73.9% vs. 28.1%, 95% CI: 20.4%-36.4%; P < 0.0001; grade ≥2: 25.1%, 95% CI: 22.9%-27.3% vs. 14.9%, 95% CI: 12.0%-18.0%; P < 0.0001; grade ≥3: 6.5%, 95% CI: 5.6%-7.3% vs. 4.6%, 95% CI: 3.4%-5.9%; P = 0.015; grade 5: 0.6%, 95% CI: 0.3%-0.9% vs. 0.1%, 95% CI: 0.0%-0.2%; P < 0.0001). Regarding studies of CRT plus immunotherapy, Asian patients had higher rates of all-grade (74.8%, 95% CI: 63.7%-84.5% vs. 34.3%, 95% CI: 28.7%-40.2%; P < 0.0001) and grade ≥2 (34.0%, 95% CI: 30.7%-37.3% vs. 24.6%, 95% CI: 19.9%-29.3%; P = 0.001) pneumonitis than non-Asian patients, but with no significant differences in the rates of grade ≥3 and grade 5 pneumonitis. Results from subgroup analyses were generally similar to that from the all studies. In addition, the pooled median/mean of lung volume receiving ≥20 Gy and mean lung dose were relatively low in Asian studies compared to that in non-Asian studies.

Interpretation

Asian patients are likely to have a higher incidence of pneumonitis than non-Asian patients, which appears to be due to the poor tolerance of lung to radiation. Nevertheless, these findings are based on observational studies and with significant heterogeneity, and need to be validated in future large prospective studies focusing on the subject.

Funding

None.

Development and validation of a random forest model for predicting radiation pneumonitis in lung cancer patients receiving moderately hypofractionated radiotherapy: a retrospective cohort study

Background

Radiation pneumonitis (RP) is a type of toxicity commonly associated with thoracic radiation therapy. We sought to establish a random forest (RF) model and evaluate its ability to predict RP in patients with non-small cell lung cancer (NSCLC) receiving moderately hypofractionated radiotherapy (hypo-RT).

Methods

A total of 106 patients with stage II-IVa NSCLC who received moderately hypofractionated helical tomotherapy (2.3-3.0 Gy/fraction) at Zhongshan Hospital were included. All enrolled patients were divided chronologically into the training (67 patients) and validation (39 patients) groups. Higher than or equal to grade 2 RP was defined as the end point. Logistic regression and RF models were established and compared using the receiver operating characteristic (ROC) and a confusion matrix in the training and validation groups.

Results

The cumulative incidence of the end point was 25.4% and 17.9% in the training and validation groups, respectively. Logistic regression models were constructed by dosage parameters of total lungs, ipsilateral or contralateral lungs, respectively. ROC analysis revealed that the dosimetric factors of total lungs yielded a superior classification performance than did that of the ipsilateral or contralateral lungs [area under the curve (AUC) =0.920, AUC =0.701, and AUC =0.661, respectively]. Furthermore, the RF model yielded a better prediction capacity than did the traditional logistic model based on the dosimetric factors of the total lungs (accuracy: 88.06%; precision: 84.62%; sensitivity: 64.71%; specificity: 96.00%). Moreover, the RF identified mean lung dose [MLD; mean decrease gini (MDG) =5.74], V20 (MDG =4.62), and V35 (MDG =3.08) of total lungs as the most common primary differentiators of RP.

Conclusions

Our RF model established based on the dosimetric parameters of the total lungs could accurately predict the RP risk in patients with NSCLC treated with moderately hypofractionated tomotherapy.

Comparison of clinical outcomes between cone beam CT-guided thermal ablation and helical tomotherapy in pulmonary metastases from hepatocellular carcinoma

Objective

This retrospective study compares the clinical results of cone beam CT (CBCT)-guided thermal ablation with those of helical tomotherapy in hepatocellular carcinoma (HCC) patients with pulmonary metastases.

Methods

A total of 110 patients undergoing thermal ablation or helical tomotherapy for pulmonary metastases from April 2014 to December 2020 were included in the study. The endpoints were local tumor progression-free survival (LTPFS), overall survival (OS), and complications. Univariate and multivariate analyses using the Cox proportional hazard model were conducted to identify independent factors (univariate: P &lt; 0.1; multivariate: P &lt; 0.05). The Kaplan–Meier method was used to calculate the LTPFS and OS rates.

Results

The results of 106 patients were taken into the final analysis. The 1- and 3-year LTPFS rates were 50 and 19% for the thermal ablation group and 65 and 25% for the helical tomotherapy group. The median LTPFS in the thermal ablation group was 12.1 months, while it was 18.8 months in the helical tomotherapy group (P = 0.25). The 1- and 3-year OS rates were 75 and 26% for the thermal ablation group and 77 and 37% for the helical tomotherapy group. The median OS was 18.0 months in the thermal ablation group and 23.4 months in the helical tomotherapy group (P = 0.38). The multivariate analyses found that α-fetoprotein (AFP) at &lt;400 ng/ml (P = 0.003) was significantly associated with better LTPFS. Tumor number &lt;3 and AFP &lt;400 ng/ml were favorable prognostic factors for OS. There were no grades 3–5 adverse events in both groups. Grade 2 was recorded in three patients (4.8%) in the thermal ablation group and two patients (4.7%) in the helical tomotherapy group.

Conclusions

For pulmonary metastases from HCC, CBCT-guided thermal ablation and helical tomotherapy provided comparable clinical effects and safety.

Outcomes of Image-Guided Moderately Hypofractionated Radiotherapy for Stage III Non-Small-Cell Lung Cancer

Objective

To evaluate the efficacy and toxicity of hypofractionated radiotherapy (hypo-RT) for stage III non-small-cell lung cancer (NSCLC) in the Chinese population.

Methods

Eighty-six stage III NSCLC patients who received hypo-RT (60 Gy/20 fractions, BED = 78.00 Gy: 73 patients; 62.5 Gy/25 fractions, BED = 78.13 Gy: 13 patients) were recruited. Fifty-seven patients who received conventional radiotherapy (60 Gy/30 fractions, BED = 72.00 Gy) during the same period were enrolled as the control group. All hypo-RT treatments were conducted using image-guided technology. The efficacy and toxicity of the treatment were compared between the two groups.

Results

The median duration of follow-up was 23.0 months (range: 4.0–82.0 months). Univariate and multivariate analyses of all 143 stage III NSCLC patients revealed that hypo-RT was an independent factor for progression-free survival (PFS) and overall survival (OS). The median PFS and OS of hypo-RT were significantly higher than in the conventional RT group (PFS: 14.30, 11.00 months, p=0.035; OS: 43.30, 31.50 months, p=0.045). The incidence rates of symptomatic radiation pneumonitis and radiation esophagitis (≥grade 2) were 17.77% and 27.91%, respectively, in the hypo-RT group. Compared to the conventional radiation therapy group (22.81% and 19.30%, respectively), no significant differences were found between the two common side effects (p=0.662 and p=0.241, respectively).

Conclusion

For Chinese stage III NSCLC patients, image-guided hypo-RT offers favorable prognosis, and the treatment toxicity was totally acceptable. This radiation modality deserves further prospective clinical trials.

Outcomes of Hypofractional Tomotherapy in Patients with Stage III Nonsmall Cell Lung Cancer Who Are Not Eligible for Surgery or Concurrent Chemoradiation

Purpose

We assessed the clinical outcomes and toxicities following hypofractionation with helical tomographic intensity-modulated radiotherapy technology (tomotherapy) in patients with stage III non-small cell lung cancer (NSCLC) who were not candidates for surgery or concurrent chemoradiation.

Methods

Forty-three patients with stage III NSCLC who were treated between 2011 and 2017 were enrolled. The prescription doses for gross target volume and clinical target volume were 70 Gy and 60 Gy (respectively) delivered in 15–25 fractions over 3–5 weeks.

Results

The median overall survival (OS) time was 34.23 (range 11.33–99.33) months. The estimated 1-, 2-, and 3-year OS rates were 97.7%, 74.4%, and 55.9%, respectively; the corresponding progression-free survival (PFS) rates were 79.1%, 53.5%, and 36.1%, respectively. The local disease recurrence, regional disease recurrence, and distant metastasis rates at 3 years were 4.7%, 11.62%, and 55.81%, respectively. On multivariate analysis, dose regimen (<19 f vs. ≥19 f) was an independent prognostic factor affecting OS, PFS, and DM (p < 0.05). Seven patients developed grade 1-2 acute radiation pneumonia (RP), 5 patients developed grade 1-2 late RP, while 3 patients developed grade 3 late RP. None of the patients developed grade 4-5 radiation lung injury.

Conclusion

Tomotherapy may be an effective treatment option for patients with stage III NSCLC. It may be a viable alternative to surgery with lower incidence of side effects.

Treatment-duration is related to changes in peripheral lymphocyte counts during definitive radiotherapy for unresectable stage III NSCLC

BACKGROUND

To investigate the potential impact of fractionation regimes and overall treatment time (OTT) on lymphopenia during definitive radiotherapy (RT) and its associations with patient outcomes in non-small cell lung cancer (NSCLC).

METHODS

Subjects consisted of 115 patients who had received definitive chemoradiation therapy (CRT) with different doses and fractions for unresectable stage III NSCLC. Clinical and laboratory records were reviewed to assess the changes in total lymphocyte counts (TLCs) during definitive RT. The associations of the TLCs with the clinical and treatment features, and outcomes were analyzed.

RESULTS

The median reduction of TLCs in the entire cohort was 1300 cells/μL (interquartile range [IQR], 950-1510 cells/μL). Of all patients, 63 (54.8%) experienced severe lymphopenia (SL) (TLC nadir < 500 cells/μL), which occurred at a median of the 5th week following RT initiation, not at the completion of RT or upon treatment with maximal doses. SL risk was increased over the first 5 weeks (odds ratio [OR] = 3.455, P = 0.007), after which, no increased risk was observed (OR = 0.562, P = 0.216). The median TLCs remained low and failed to recover to the initial normal values of their pre-RT level after 2 months of RT completion. Patients without SL exhibited significantly improved progression-free survival (hazard ratio [HR] = 0.544, P = 0.010) and overall survival (HR = 0.463, P = 0.011) after controlling for confounding variables in multivariate analyses. The incidence of SL was significantly lower (71.1% reduction in risk (OR = 0.289, P = 0.007)) in patients who received hypofractionated RT with an OTT within 4 weeks, compared to those who had an OTT of more than 4 weeks (32.1% vs 62.1%, P = 0.006). Multivariate analyses revealed that OTT within 4 weeks (OR = 0.322, P = 0.032) was significantly associated with a decreased risk of developing SL after controlling for confounding factors.

CONCLUSIONS

Hypofractionated RT was significantly associated with a decreased risk of SL and improved survival during definitive radiotherapy for unresectable stage III NSCLC.

Effects of lymph node metastasis of thoracic esophageal squamous cell carcinoma on design of radiotherapy target volume

Objective

To analyze the correlation between lymph node metastasis of thoracic esophageal squamous cell carcinoma (ESCC) and clinical and pathological factors, and to provide a reference for the outline of clinical target volume.

Methods

The pathological characteristics of 1034 thoracic ESCC patients after surgery were described, and the correlations between clinical and pathological factors and lymph node metastasis were studied by univariate and Logistic multivariate analyses.

Results

Lymph node metastasis was significantly correlated with tumor length, invasion depth and differentiation degree (P<0.01), but not gender, age, tumor site or pathological type (P>0.05). Logistic multivariate analysis showed that tumor length, invasion depth and differentiation degree were independent risk factors for thoracic ESCC. The lymph node metastasis rates of mid-thoracic ESCC in the middle mediastinum, lower-thoracic ESCC in the lower mediastinum and abdominal cavity were 18.5%, 35.3% and 19.7% respectively in the T1-T2 stage. In the T3-T4 stage, the lymph node metastasis rates of mid-thoracic ESCC in the middle mediastinum and abdominal cavity were 39.6% and 17.4% respectively, and those of lower-thoracic ESCC in middle and lower mediastina and abdominal cavity were 21.1%, 43.4% and 29.8% respectively. Highly/moderately differentiated mid-thoracic ESCC in the middle mediastinum, lower-thoracic ESCC in middle and lower mediastina and abdominal cavity had the lymph node metastasis rates of 34.7%, 15.1%, 33.5% and 23.7% respectively. Lowly differentiated mid-thoracic ESCC in the middle mediastinum and abdominal cavity had the lymph node metastasis rates of 46.9% a 29.6% respectively, and those of lower-thoracic ESCC in middle and lower mediastina and abdominal cavity were 25.5%, 49.1% and 27.3% respectively.

Conclusion

During the outline of radiotherapy target volume for thoracic ESCC, tumor length, invasion depth and differentiation degree should be comprehensively considered to selectively irradiate the regions prone to lymph node metastasis.

Hypofractionated radiation therapy in the management of locally advanced NSCLC: a narrative review of the literature on behalf of the Italian Association of Radiation Oncology (AIRO)-Lung Working Group

A systematic literature was performed to assess the benefit in terms of effectiveness and feasibility of hypofractionated radiotherapy (HypoRT), with or without chemotherapy (CT), in the treatment of locally advanced non-small cell lung cancer (NSCLC). We have identified all studies, published from 2007 onwards, on patients with locally advanced NSCLC treated with HypoRT with radical intent, with a minimal dose per fraction of 2.4 Gy, with or without concurrent chemotherapy. Twenty-nine studies were identified, for a total of 2614 patients. Patients were divided in the concurrent chemo-radiation therapy group (CT-RT) and radiotherapy alone (RT). In RT group, the delivered dose ranged from 45 to 85.5 Gy, with a dose/fraction from 2.4 to 4 Gy. Actuarial 2-year PFS ranged from 13 to 57.8%, and 1, 2- and 3-year overall survival (OS) ranged from 51.3 to 95%, from 22 to 68.7%, and from 7 to 32%, respectively. Acute Grade ≥ 3 esophagitis occurred in 0-15%, while late esophageal toxicity was 0-16%. Acute pneumonitis occured in 0-44%, whereas late pneumonitis occured in 0-47%, most commonly grade ≤ G3. In CT-RT group, the delivered dose ranged from 52.5 to 75 Gy, with a dose/fraction ranging from 2.4 to 3.5 Gy. Actuarial 2-year PFS ranged from 19 to 57.8%, and OS at 1, 2 and 3 years ranged from 28 to 95%, 38.6 to 68.7%, and 31 to 44%, respectively. Acute Grade 2 and 3 esophagitis occurred in 3-41.7%, while late esophageal toxicity occurred in 0-8.3%. Acute pneumonitis ranged from 0 to 23%, whereas late pneumonitis occured 0-47%. HypoRT seems to be safe in patients with locally advanced NSCLC. The encouraging survival results of several studies analyzed suggest that hypofractionated radiation schemes should be further investigated in the future.

Moderate hypofractionated image-guided thoracic radiotherapy for locally advanced node-positive non-small cell lung cancer patients with very limited lung function: a case report

Patients with locally advanced lung cancer and very limited pulmonary function (forced expiratory volume in 1 second [FEV1] ≤ 1 L) have dismal prognosis and undergo palliative treatment or best supportive care. We describe two cases of locally advanced node-positive non-small cell lung cancer (NSCLC) patients with very limited lung function treated with induction chemotherapy and moderate hypofractionated image-guided radiotherapy (Hypo-IGRT). Hypo-IGRT was delivered to a total dose of 45 Gy to the primary tumor and involved lymph nodes. Planning was based on positron emission tomography-computed tomography (PET/ CT) and four-dimensional computed tomography (4D-CT). Internal target volume (ITV) was defined as the overlap of gross tumor volume delineated on 10 phases of 4D-CT. ITV to planning target volume margin was 5 mm in all directions. Both patients showed good clinical and radiological response. No relevant toxicity was documented. Hypo-IGRT is feasible treatment option in locally advanced node-positive NSCLC patients with very limited lung function (FEV1 ≤ 1 L).