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Bourbonne V, Morjani M, Pradier O, Hatt M, Jaouen V, Querellou S, Visvikis D, Lucia F, Schick U. PET/CT-Based Radiogenomics Supports KEAP1/NFE2L2 Pathway Targeting for Non-Small Cell Lung Cancer Treated with Curative Radiotherapy. J Nucl Med 2024:jnumed.123.266749. [PMID: 38360055 DOI: 10.2967/jnumed.123.266749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/02/2024] [Indexed: 02/17/2024] Open
Abstract
In lung cancer patients, radiotherapy is associated with a increased risk of local relapse (LR) when compared with surgery but with a preferable toxicity profile. The KEAP1/NFE2L2 mutational status (MutKEAP1/NFE2L2) is significantly correlated with LR in patients treated with radiotherapy but is rarely available. Prediction of MutKEAP1/NFE2L2 with noninvasive modalities could help to further personalize each therapeutic strategy. Methods: Based on a public cohort of 770 patients, model RNA (M-RNA) was first developed using continuous gene expression levels to predict MutKEAP1/NFE2L2, resulting in a binary output. The model PET/CT (M-PET/CT) was then built to predict M-RNA binary output using PET/CT-extracted radiomics features. M-PET/CT was validated on an external cohort of 151 patients treated with curative volumetric modulated arc radiotherapy. Each model was built, internally validated, and evaluated on a separate cohort using a multilayer perceptron network approach. Results: The M-RNA resulted in a C statistic of 0.82 in the testing cohort. With a training cohort of 101 patients, the retained M-PET/CT resulted in an area under the curve of 0.90 (P < 0.001). With a probability threshold of 20% applied to the testing cohort, M-PET/CT achieved a C statistic of 0.7. The same radiomics model was validated on the volumetric modulated arc radiotherapy cohort as patients were significantly stratified on the basis of their risk of LR with a hazard ratio of 2.61 (P = 0.02). Conclusion: Our approach enables the prediction of MutKEAP1/NFE2L2 using PET/CT-extracted radiomics features and efficiently classifies patients at risk of LR in an external cohort treated with radiotherapy.
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Affiliation(s)
- Vincent Bourbonne
- Department of Radiation Oncology, University Hospital, Brest, France;
- LaTIM UMR 1101 INSERM, University Brest, Brest, France
| | - Moncef Morjani
- Department of Radiation Oncology, University Hospital, Brest, France
| | - Olivier Pradier
- Department of Radiation Oncology, University Hospital, Brest, France
- LaTIM UMR 1101 INSERM, University Brest, Brest, France
| | - Mathieu Hatt
- LaTIM UMR 1101 INSERM, University Brest, Brest, France
| | - Vincent Jaouen
- LaTIM UMR 1101 INSERM, University Brest, Brest, France
- Institut Mines-Télécom Atlantique, Brest, France
| | - Solène Querellou
- Nuclear Medicine Department, University Hospital, Brest, France; and
- Groupe d'Étude de la Thrombose Occidentale GETBO (INSERM UMR 1304), Université de Bretagne Occidentale, Brest, France
| | | | - François Lucia
- Department of Radiation Oncology, University Hospital, Brest, France
- LaTIM UMR 1101 INSERM, University Brest, Brest, France
| | - Ulrike Schick
- Department of Radiation Oncology, University Hospital, Brest, France
- LaTIM UMR 1101 INSERM, University Brest, Brest, France
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Öllers MC, Swinnen ACC, Verhaegen F. Acuros
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dose verification of ultrasmall lung lesions with EBT‐XD film in a homogeneous and heterogeneous anthropomorphic phantom setup. Med Phys 2020; 47:5829-5837. [DOI: 10.1002/mp.14485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/27/2020] [Accepted: 09/07/2020] [Indexed: 02/01/2023] Open
Affiliation(s)
- Michel C. Öllers
- Department of Radiation Oncology (Maastro) GROW School for Oncology Maastricht University Medical Centre+ Maastricht The Netherlands
| | - Ans C. C. Swinnen
- Department of Radiation Oncology (Maastro) GROW School for Oncology Maastricht University Medical Centre+ Maastricht The Netherlands
| | - Frank Verhaegen
- Department of Radiation Oncology (Maastro) GROW School for Oncology Maastricht University Medical Centre+ Maastricht The Netherlands
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Surgery and invasive diagnostic procedures for benign disease are rare in a large low-dose computed tomography lung cancer screening program. J Thorac Cardiovasc Surg 2020; 161:790-802.e2. [PMID: 33023746 DOI: 10.1016/j.jtcvs.2020.08.109] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/10/2020] [Accepted: 08/02/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Lung cancer screening with low-dose chest computed tomography improves survival. However, concerns about overdiagnosis and unnecessary interventions persist. We reviewed our lung cancer screening program to determine the rate of surgery and invasive procedures for nonmalignant disease. METHODS We reviewed all patients undergoing lung cancer screening from January 2012 to June 2017 with follow-up through January 2019. Patients with suspicious findings (Lung CT Screening Reporting and Data System 4) were referred for further evaluation. RESULTS Of 3280 patients screened, 345 (10.5%) had Lung CT Screening Reporting and Data System 4 findings. A total of 311 patients had complete follow-up, of whom 93 (29.9%) were diagnosed with lung cancer. Eighty-three patients underwent lung surgery (2.5% of screened patients). Forty patients underwent lobectomy (48.2%), 3 patients (3.6%) underwent bilobectomy, and 40 patients (48.2%) underwent sublobar resection. Fourteen patients underwent surgery for benign disease (0.43% of screened patients). Fifty-four patients, 5 with benign disease, had at least 1 invasive diagnostic procedure but never underwent surgery. The incidence of any invasive intervention for nonmalignant disease was 0.95% (31/3280 patients). There were no postprocedural deaths within 60 days. Twenty-five patients (0.76%) underwent stereotactic body radiation therapy; 19 patients (76%) had presumed lung cancer without pretreatment pathologic confirmation. CONCLUSIONS Surgical resection for benign disease occurred in 0.43% of patients undergoing lung cancer screening. The combined incidence of any invasive diagnostic or therapeutic intervention, including surgical resection, for benign disease was only 0.95%. Periprocedural complications were rare. These results indicate that concern over unnecessary interventions is overstated and should not hinder adoption of lung cancer screening. A multidisciplinary team approach, including thoracic surgeons, is critical to maintain an appropriate rate of interventions in lung cancer screening.
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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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Chua GWY, Chua KLM. Which patients benefit most from stereotactic body radiotherapy or surgery in medically operable non-small cell lung cancer? An in-depth look at patient characteristics on both sides of the debate. Thorac Cancer 2019; 10:1857-1867. [PMID: 31389163 PMCID: PMC6775005 DOI: 10.1111/1759-7714.13160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/18/2019] [Accepted: 07/20/2019] [Indexed: 12/25/2022] Open
Abstract
The role of stereotactic body radiotherapy (SBRT) in early stage medically operable non-small cell lung cancer is currently under debate. SBRT's advantage is its ability to provide high radiotherapy doses to a tumor in a short timeframe, without the risk of postoperative complications and mortality. Currently, in part due to limited prospective data comparing both treatments, international guidelines continue to recommend surgical resection as the gold standard for medically operable patients. However, not all patients possess uniform characteristics, and there is some evidence that certain subgroups of patients would benefit more from one form of treatment - SBRT or surgery - than the other. The aim of this review is to provide a brief summary of the evidence comparing SBRT to surgery, followed by a deeper discussion of the subgroups of patients who would benefit most from surgery: those with large tumors, centrally located tumors, increased risk of occult nodal metastases, increased risk of toxicity from radiotherapy and radioresistant histological tumor subtypes. Meanwhile, patients who could benefit most from SBRT might include elderly patients, those with reduced lung function or cardiac comorbidities, those with synchronous lung nodules, and those with specific tumor mutational status. We hope that this review will aid in the clinical decision-making process regarding patient selection for either treatment.
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Kjellsson Lindblom E, Ureba A, Dasu A, Wersäll P, Even AJG, van Elmpt W, Lambin P, Toma-Dasu I. Impact of SBRT fractionation in hypoxia dose painting - Accounting for heterogeneous and dynamic tumor oxygenation. Med Phys 2019; 46:2512-2521. [PMID: 30924937 DOI: 10.1002/mp.13514] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 02/18/2019] [Accepted: 03/13/2019] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Tumor hypoxia, often found in nonsmall cell lung cancer (NSCLC), implies an increased resistance to radiotherapy. Pretreatment assessment of tumor oxygenation is, therefore, warranted in these patients, as functional imaging of hypoxia could be used as a basis for dose painting. This study aimed at investigating the feasibility of using a method for calculating the dose required in hypoxic subvolumes segmented on 18 F-HX4 positron emission tomography (PET) imaging of NSCLC. METHODS Positron emission tomography imaging data based on the hypoxia tracer 18 F-HX4 of 19 NSCLC patients were included in the study. Normalized tracer uptake was converted to oxygen partial pressure (pO2 ) and hypoxic target volumes (HTVs) were segmented using a threshold of 10 mmHg. Uniform doses required to overcome the hypoxic resistance in the target volumes were calculated based on a previously proposed method taking into account the effect of interfraction reoxygenation, for fractionation schedules ranging from extremely hypofractionated stereotactic body radiotherapy (SBRT) to conventionally fractionated radiotherapy. RESULTS Gross target volumes ranged between 6.2 and 859.6 cm3 , and the hypoxic fraction < 10 mmHg between 1.2% and 72.4%. The calculated doses for overcoming the resistance of cells in the HTVs were comparable to those currently prescribed in clinical practice as well as those previously tested in feasibility studies on dose escalation in NSCLC. Depending on the size of the HTV and the distribution of pO2 , HTV doses were calculated as 43.6-48.4 Gy for a three-fraction schedule, 51.7-57.6 Gy for five fractions, and 59.5-66.4 Gy for eight fractions. For patients in whom the HTV pO2 distribution was more favorable, a lower dose was required despite a bigger volume. Tumor control probability was lower for single-fraction schedules, while higher levels of tumor control probability were found for schedules employing several fractions. CONCLUSIONS The method to account for heterogeneous and dynamic hypoxia in target volume segmentation and dose prescription based on 18 F-HX4-PET imaging appears feasible in NSCLC patients. The distribution of oxygen partial pressure within HTV could impact the required prescribed dose more than the size of the volume.
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Affiliation(s)
- Emely Kjellsson Lindblom
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, S-17176, Sweden
| | - Ana Ureba
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, S-17176, Sweden
| | | | - Peter Wersäll
- Department of Oncology, Karolinska University Hospital, Stockholm, S-17176, Sweden
| | - Aniek J G Even
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6229, The Netherlands
| | - Wouter van Elmpt
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6229, The Netherlands
| | - Philippe Lambin
- Department of Radiation Oncology (MAASTRO), GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, 6229, The Netherlands
| | - Iuliana Toma-Dasu
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, S-17176, Sweden.,Medical Radiation Physics, Department of Oncology and Pathology, Karolinska Institutet, Stockholm, S-17176, Sweden
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Kron T, Hardcastle N. SABR in clinical trials: what quality assurance (QA) is required and how can it be done? ACTA ACUST UNITED AC 2019. [DOI: 10.1088/1742-6596/1154/1/012014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Response to stereotactic ablative radiotherapy in a novel orthotopic model of non-small cell lung cancer. Oncotarget 2017; 9:1630-1640. [PMID: 29416719 PMCID: PMC5788587 DOI: 10.18632/oncotarget.22727] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 10/28/2017] [Indexed: 12/12/2022] Open
Abstract
Stereotactic ablative radiotherapy (SABR) is the main treatment for inoperable early-stage non-small cell lung cancer (NSCLC). Despite the widespread use of SABR, the biological determinants of response to SABR remain poorly investigated. We developed an orthotopic NSCLC animal model to study the response to clinically-relevant doses of SABR. Image-guided intra-thoracic injection of NSCLC cells was performed in the right lung of nude rats. A highly conformal dose of 34 Gy was delivered in a single fraction using clinical photon energies. Animals were sacrificed 10–60 days post treatment. Lung tumors were assessed for tumor differentiation, proliferation and invasiveness. An analysis of 770 cancer-related genes was performed on tumor-derived cell lines from treated animals at early and late time points after SABR. The majority of animals receiving SABR demonstrated complete response (67%), while 33% demonstrated local failure. 50% of animals with complete response failed distantly. Analysis of cancer-related genes revealed significant differences between tumors treated with SABR and untreated tumors. SABR significantly modulated expression of genes involved in adhesion, migration and angiogenesis. In particular, interleukin-8 (IL8) which plays a critical role in promoting tumor invasion was found to be secreted at high levels after SABR. In vitro invasion assays confirmed SABR-induced invasion and demonstrated induction of IL-8 secretion in multiple NSCLC cell lines. Our findings underscore the importance of developing targeted therapies that can circumvent the pro-invasive effects of SABR in NSCLC.
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