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Rim CH, Yoon WS, Park S. Safety and Efficacy of Moderate-Intensity Stereotactic Body Radiation Therapy for Ultra-Central Lung Tumor. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:538. [PMID: 38674184 PMCID: PMC11051908 DOI: 10.3390/medicina60040538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/08/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: Ultra-central (UC) lung tumors are defined as those abutting the proximal bronchial tree. Stereotactic body radiation therapy (SBRT) for UC tumors is difficult because of concerns about severe toxicities. Therefore, we report the safety and efficacy of moderate-intensity SBRT for UC tumors at our institution. Materials and Methods: From January 2017 to May 2021, we treated 20 patients with UC tumors with SBRT at a dose of 45-60 Gy in 10 fractions. The primary endpoints were local control (LC) and overall survival (OS). Results: The median follow-up time was 15.8 months (range: 2.7-53.8 months). Ten of the 20 patients (50.0%) showed a complete response, five (25.0%) had a partial response, two (10.0%) had stable disease, and three (15.0%) showed progressive disease (PD). The response and disease control rates were 75.0% and 85.0%, respectively. Patients with PD showed local progression at median 8.3 months (range: 6.8-19.1 months) after SBRT. One-year and 2-year OS rates were 79.4% and 62.4%, respectively. One-year and 2-year LC rates are 87.1% and 76.2%, respectively. Eight patients died due to a non-radiation therapy related cause. One patient experienced grade 5 massive hemoptysis 6 months after SBRT, resulting in death. One patient experienced grade 2 esophageal pain and two experienced grade 2 radiation pneumonitis. Otherwise, no grade 3 or higher toxicities were reported. Conclusions: Moderate-intensity SBRT offers effective control of UC tumors and is a well-tolerated treatment for such tumors.
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Affiliation(s)
| | | | - Sunmin Park
- Department of Radiation Oncology, Korea University Ansan Hospital, Ansan-si 15355, Gyeonggi-do, Republic of Korea; (C.H.R.); (W.S.Y.)
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Ahmadsei M, Jegarajah V, Dal Bello R, Christ SM, Mayinger MM, Sabrina Stark L, Willmann J, Vogelius IR, Balermpas P, Andratschke N, Tanadini-Lang S, Guckenberger M. Dosimetric Analysis of Proximal Bronchial Tree Subsegments to Assess The Risk of Severe Toxicity After Stereotactic Body Radiation Therapy of Ultra-central Lung Tumors. Clin Transl Radiat Oncol 2024; 45:100707. [PMID: 38125648 PMCID: PMC10731610 DOI: 10.1016/j.ctro.2023.100707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/17/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023] Open
Abstract
•Stereotactic body radiation therapy (SBRT) for ultra-central lung tumors is associated with high toxicity rates.•To evaluate differences in radiosensitivity within the proximal bronchial tree (PBT), the PBT was sub-segmented into seven anatomical sections.•A risk-adapted SBRT regimen of EQD2_10 = 54.4 Gy in 8 or 10 fractions results in excellent local control and low rates of severe toxicity.•Data from a recent meta-analysis, the NORDIC Hilus trial and dosimetric data from this study were combined to create a NTCP model.•A dose threshold of EQD2_3 = 100 Gy to the PBT or any of its subsegments is expected to result in low rates of severe bronchial toxicity.
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Affiliation(s)
- Maiwand Ahmadsei
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Vinojaa Jegarajah
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Riccardo Dal Bello
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sebastian M. Christ
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael M. Mayinger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luisa Sabrina Stark
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jonas Willmann
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Ivan R. Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Knap MM, Khan S, Khalil AA, Møller DS, Hoffmann L. Outcome of conventional radiotherapy in small centrally located tumours or lymph nodes: minimal toxicity, remarkable survival but challenging loco-regional control. Acta Oncol 2023; 62:1433-1439. [PMID: 37707506 DOI: 10.1080/0284186x.2023.2257872] [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: 05/22/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND In peripheral lung tumours, stereotactic body radiotherapy (SBRT) is superior to conventional RT. SBRT has also shown high loco-regional control (LC) in centrally located tumours, but there is a high risk of severe toxicity. The STRICTSTARLung trial (NCT05354596) examines if risk-adapted SBRT for central tumours is feasible. In this study, we examined overall survival (OS), Disease-free survival (DSF), LC, and toxicity in patients with central tumours that could have been candidates for SBRT but received conventional RT. MATERIAL AND METHODS Retrospectively, we evaluated 49 lung cancer patients that between 2008 and 2021 received RT (60-70Gy in 2 Gy fractions) for a solitary tumour or lymph node with a diameter <5cm located <2cm from the bronchial tree, oesophagus, aorta or heart. All tumours were pathologically verified; 30 were primary lung tumours (T1b-T4) and 19 were solitary lymph nodes (T0N1-N2). Chemotherapy was administered as concomitant (29) or sequential (4). OS and LC were analysed using Kaplan Meier. Cox proportional hazards model for OS and disease-free survival (DFS) was performed including tumour volume, histology, sex, T- vs N-site and chemotherapy. Toxicity was scored. RESULTS In 42 patients, the tumour was located <1 cm to mediastinum. Median follow-up time was 44 months (range: 7-123). The median OS was 51 months. OS at 1-, 3- and 5-year was 88% (SE:5), 59% (SE:7) and 50% (SE:8). Loco-regional recurrences occurred in 16 patients resulting in 1-, and 3-year LC rates of 77% (SE:6) and 64% (SE:8). The majority occurred within 3 years after RT. Only stage showed significant impact on OS and DFS. No patients experienced grade 4-5 toxicity. Seven patients developed grade 3 toxicity (5 oesophageal stenosis, 2 pneumonitis). CONCLUSION Conventional RT for patients with small central lung tumours or solitary lymph nodes is feasible. Median OS was 51 months, and toxicity was low with no grade 4-5 events.
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Affiliation(s)
- M M Knap
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - S Khan
- Department of Respiratory Diseases and Allergology, Aarhus University Hospital, Aarhus N, Denmark
| | - A A Khalil
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - D S Møller
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - L Hoffmann
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Tekatli H, Giraud N, van Eekelen R, Lagerwaard FJ, Senan S. Ten years outcomes after SABR in central and ultracentral primary lung tumors. Radiother Oncol 2023; 188:109848. [PMID: 37562553 DOI: 10.1016/j.radonc.2023.109848] [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: 04/12/2023] [Revised: 07/04/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE SABR performed for central and ultracentral lung tumors is associated with increased toxicity but limited data is available on late toxicities. We studied toxicity in patients followed-up ≥ 2 years post-SABR at a single-institution. METHODS All patients were treated using VMAT for a primary or recurrent central lung cancer between 2008-2015. 60 Gy was delivered in 8 or 12 fractions. Grade ≥ 3 clinical and radiological bronchial toxicity was scored. Multivariable Cox regression models were used to estimate hazard ratios. RESULTS Of 127 eligible patients, 63% were treated with 8 fractions. Median tumor diameter was 4.4 cm (range 1.3-12.0). Median overall survival was 25.0 months (95% CI 16.5-33.5); 4% developed isolated local recurrences. The actuarial 5-year rate for severe clinical toxicity was 34.1% (95% CI 21.2-44.9). Both clinical toxicity and fatal lung haemorrhage were most observed when tumors were located ≤ 1 cm from the trachea or main bronchi (46% of all cases). The 5-year actuarial rate of radiological bronchial toxicity was 37.5% (95% CI 21.5-50.2). Multivariable analysis revealed that a performance score of 2 or 3 (HR 3.6; 95% CI 1.7-7.8), and tumor location ≤ 1 cm from the trachea or main bronchi (HR 4.3; 95% CI 1.2-14.9) were significant predictors for severe clinical toxicity. CONCLUSION The actuarial rates for both severe clinical and radiological bronchial toxicity after central SABR was approximately 35% in patients surviving 5 years. Patients with tumors located ≤ 1 cm from the trachea or main bronchus were at the highest risk for severe clinical toxicity.
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Affiliation(s)
- Hilâl Tekatli
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands.
| | - Nicolas Giraud
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands
| | | | - Frank J Lagerwaard
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands; Cancer Center Amsterdam, Treatment and quality of life, Amsterdam, The Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands; Cancer Center Amsterdam, Treatment and quality of life, Amsterdam, The Netherlands
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Yan M, Louie AV, Kotecha R, Ashfaq Ahmed M, Zhang Z, Guckenberger M, Kim MS, Lo SS, Scorsetti M, Tree AC, Sahgal A, Slotman BJ. Stereotactic body radiotherapy for Ultra-Central lung Tumors: A systematic review and Meta-Analysis and International Stereotactic Radiosurgery Society practice guidelines. Lung Cancer 2023; 182:107281. [PMID: 37393758 DOI: 10.1016/j.lungcan.2023.107281] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is an effective and safe modality for early-stage lung cancer and lung metastases. However, tumors in an ultra-central location pose unique safety considerations. We performed a systematic review and meta-analysis to summarize the current safety and efficacy data and provide practice recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS). METHODS We performed a systematic review using PubMed and EMBASE databases of patients with ultra-central lung tumors treated with SBRT. Studies reporting local control (LC) and/or toxicity were included. Studies with <5 treated lesions, non-English language, re-irradiation, nodal tumors, or mixed outcomes in which ultra-central tumors could not be discerned were excluded. Random-effects meta-analysis was performed for studies reporting relevant endpoints. Meta-regression was conducted to determine the effect of various covariates on the primary outcomes. RESULTS 602 unique studies were identified of which 27 (one prospective observational, the remainder retrospective) were included, representing 1183 treated targets. All studies defined ultra-central as the planning target volume (PTV) overlapping the proximal bronchial tree (PBT). The most common dose fractionations were 50 Gy/5, 60 Gy/8, and 60 Gy/12 fractions. The pooled 1- and 2-year LC estimates were 92 % and 89 %, respectively. Meta-regression identified biological effective dose (BED10) as a significant predictor of 1-year LC. A total of 109 grade 3-4 toxicity events, with a pooled incidence of 6 %, were reported, most commonly pneumonitis. There were 73 treatment related deaths, with a pooled incidence of 4 %, with the most common being hemoptysis. Anticoagulation, interstitial lung disease, endobronchial tumor, and concomitant targeted therapies were observed risk factors for fatal toxicity events. CONCLUSION SBRT for ultra-central lung tumors results in acceptable rates of local control, albeit with risks of severe toxicity. Caution should be taken for appropriate patient selection, consideration of concomitant therapies, and radiotherapy plan design.
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Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, USA
| | - Md Ashfaq Ahmed
- Center for Advanced Analytics, Baptist Health South Florida, Miami, USA
| | - Zhenwei Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, USA
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mi-Sook Kim
- Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | - Marta Scorsetti
- Radiosurgery and Radiotherapy Department, IRCCS-Humanitas Research Hospital, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Owen D, Siva S, Salama JK, Robinson C, Kruser TJ, Giuliani M. If at First You Don't Succeed-Stereotactic Body Radiation Therapy for Recurrent Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2022; 114:5-9. [PMID: 35964631 DOI: 10.1016/j.ijrobp.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 04/05/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Center, Victoria, Australia
| | - Joseph K Salama
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Timothy J Kruser
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Meredith Giuliani
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Lodeweges JE, van Rossum PSN, Bartels MMTJ, van Lindert ASR, Pomp J, Peters M, Verhoeff JJC. Ultra-central lung tumors: safety and efficacy of protracted stereotactic body radiotherapy. Acta Oncol 2021; 60:1061-1068. [PMID: 34191670 DOI: 10.1080/0284186x.2021.1942545] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND For patients with early stage or medically inoperable lung cancer, stereotactic body radiotherapy (SBRT) is a general accepted and effective treatment option. The role of SBRT in ultra-central tumors remains controversial. The aim of this single-center retrospective analysis was to evaluate the safety and efficacy of protracted SBRT with 60 Gy in 12 fractions (with a biological effective dose (BED10) of 90-150 Gy) for patients with ultra-central lung tumors. MATERIALS AND METHODS Patients with ultra-central lung tumors treated in our institution with 60 Gy in 12 fractions from January 2012 until April 2020 were included. Ultra-central tumors were defined as planning target volume (PTV) abutting or overlapping the main bronchi and/or trachea and/or esophagus. Data regarding patient-, tumor-, and treatment-related characteristics were evaluated. RESULTS A total of 72 patients met the criteria for ultra-central tumor location. The PTV abutted the main bronchus, trachea or esophagus in 79%, 22% and 28% of cases, respectively. At a median follow-up of 19 months, 1- and 2-year local control rates were 98% and 85%, respectively. Overall survival rates at 1 and 2 years were 77% and 52%, respectively. Grade 3 or higher toxicity was observed in 21%, of which 10 patients (14% of total) died of bronchopulmonary hemorrhage. A significant difference between patients with or without grade ≥3 toxicity was found for the mean dose (Dmean) to the main bronchus (p = 0.003), where a Dmean BED3 of ≥91 Gy increased the risk of grade ≥3 toxicity significantly. DISCUSSION A protracted SBRT regimen of 60 Gy in 12 fractions for ultra-central lung tumors leads to high local control rates with toxicity rates similar to previous series, but with substantial risk of fatal bronchopulmonary hemorrhage. Therefore, possible risk factors of bronchopulmonary hemorrhage such as dose to the main bronchus should be taken into account.
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Affiliation(s)
- Joyce E. Lodeweges
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter S. N. van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcia M. T. J Bartels
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jacqueline Pomp
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost J. C. Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Mihai AM, Armstrong PJ, Hickey D, Milano MT, Dunne M, Healy K, Thirion P, Heron DE, ElBeltagi N, Armstrong JG. Late Toxicity and Long-Term Local Control in Patients With Ultra-Central Lung Tumours Treated by Intensity-Modulated Radiotherapy-Based Stereotactic Ablative Body Radiotherapy With Homogenous Dose Prescription. Clin Oncol (R Coll Radiol) 2021; 33:627-637. [PMID: 34092462 DOI: 10.1016/j.clon.2021.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/21/2021] [Accepted: 05/13/2021] [Indexed: 12/14/2022]
Abstract
AIMS To report late toxicity and long-term outcomes of intensity-modulated radiotherapy (IMRT)-based stereotactic ablative body radiotherapy (SABR) in patients with ultra-central lung tumours. MATERIALS AND METHODS This is a single-institution retrospective analysis of patients treated with SABR for ultra-central tumours between May 2008 and April 2016. Ultra-central location was defined as tumour (GTV) abutting or involving trachea, main or lobar bronchi. Respiratory motion management and static-field dynamic-IMRT were used, with dose prescribed homogeneously (maximum <120%). Descriptive analysis, Kaplan-Meier method, log-rank test and Cox regression were used to assess outcomes. RESULTS Sixty-five per cent of patients had inoperable primary non-small cell lung cancer and 35% had lung oligometastases. The median age was 72 (range 34-85) years. The median gross tumour volume and planning target volume (PTV) were 19.6 (range 1.7-203.3) cm3 and 57.4 (range 7.7-426.6) cm3, respectively. The most commonly used dose fractionation was 60 Gy in eight fractions (n = 51, 87.8%). Median BED10 for D98%PTV and D2%PTV were 102.6 Gy and 115.06 Gy, respectively. With a median follow-up of 26.5 (range 3.2-100.5) months, fatal haemoptysis occurred in five patients (8.7%), of which two were directly attributable to SABR. A statistically significant difference was identified between median BED3 for 4 cm3 of airway, for patients who developed haemoptysis versus those who did not (147.4 versus 47.2 Gy, P = 0.005). At the last known follow-up, 50 patients (87.7%) were without local recurrence. Freedom from local progression at 2 and 4 years was 92 and 79.8%, respectively. The median overall survival was 34.3 (95% confidence interval 6.1-61.6) months. Overall survival at 2 and 4 years was 55.1 and 41.2%, respectively. CONCLUSION In patients with high-risk ultra-central lung tumours, IMRT-based SABR with homogenous dose prescription achieves high local control, similar to that reported for peripheral tumours. Although fatal haemoptysis occurred in 8.7% of patients, a direct causality with SABR was evident in only 3%. Larger studies are warranted to ascertain factors associated with outcomes, especially toxicity, and identify patients who would probably benefit from this treatment.
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Affiliation(s)
- A M Mihai
- Department of Radiotherapy, Beacon Hospital, Dublin, Ireland.
| | - P J Armstrong
- University College Dublin School of Medicine, Dublin, Ireland
| | - D Hickey
- Department of Radiotherapy, Beacon Hospital, Dublin, Ireland
| | - M T Milano
- University of Rochester, Rochester, NY, USA
| | - M Dunne
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - K Healy
- University College Dublin School of Medicine, Dublin, Ireland
| | - P Thirion
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - D E Heron
- Bon Secours Mercy Health, Cincinnati, OH, USA
| | - N ElBeltagi
- St Luke's Radiation Oncology Network, Dublin, Ireland
| | - J G Armstrong
- Department of Radiotherapy, Beacon Hospital, Dublin, Ireland
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