Robot-assisted Extracranial Stereotactic Radiotherapy of Adrenal Metastases in Oligometastatic Non-small Cell Lung Cancer

Risk factors of local control in adrenal metastases treated by stereotactic body radiation therapy - a systematic review and meta-analysis

Purpose

This study is aimed to explore risk factors affect the therapy outcomes of adrenal metastases (AM) for stereotactic body radiation therapy (SBRT) and guide clinical dose selection.

Methods and materials

PubMed, Embase and Web of Science were searched in September 22, 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Subgroup analysis and meta-regression were used to search for sources of heterogeneity and identify risky outcomes factors. Publication bias test and sensitivity analysis were also conducted.

Results

Thirty-three studies with full text from 2009 to 2022 about AM with SBRT on 1483 patients were included. Pooled 1- and 2-year local control (LC) and overall survival(OS) were 81.7% (95% confidence interval [CI], 75.6%-86.5%), 62.8% (95% CI, 53.8%-71.8%), 67.4% (95%CI, 61.8%-73.1%) and 46.5% (95%CI, 40.4%-52.6%), respectively. Biological effective dose (BED, α/β=10Gy) and dose per fraction affected 1-year LC (Qm=23.89, 15.10; P<0.0001, 0.0001). In the range of 60-80Gy (BED10), the group of dose per fraction ≥ 9Gy achieved the excellent 1-year LC (< 9Gy: ≥ 9Gy =78%, 91%; χ2 = 10.16, P = 0.001). Tracking technology significantly affected 1- and 2-year OS (Qm = 5.73, 8.75; P = 0.017, 0.003) and high tracking adoption group showed excellent 1- and 2- year OS (78.7% [95%CI, 68.6%- 88.9%]; and 62.9% [95%CI, 53.1%-72.7%]).

Conclusion

Increasing the dose per fraction appropriately may help control locally AM lesious. Tracking technology might contribute to improve survival of advanced patients with AM. But these results need prospective studies to verify them.

Chemotherapy with a TP Regimen in Combination with Stereotactic Radiotherapy Could Significantly Optimize the Clinical Efficacy of NSCLC Treatment

The changes in lifestyle and bad living habits have a significant impact on the health of people, resulting in an increasing prevalence of lung cancer. The most prevalent kind of lung cancer is nonsmall cell lung cancer (NSCLC), which accounts for around 80% of all cases. Chemotherapy is a common treatment method in clinical practice with certain negative effects. The primary goal of this study is to investigate the clinical efficacy of stereotactic radiotherapy in combination with a docetaxel plus cisplatin (TP) chemotherapy regimen in patients with nonsmall cell lung cancer (NSCLC) and their impact on the levels of cytokeratin fragment 21-1 (CYFRA21-1) and metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) in NSCLC patients. Eighty patients who were admitted to the hospital between November 2016 and November 2019 were recruited and assigned to receive either chemotherapy with a TP regimen (the control group) or chemotherapy with a TP regimen plus stereotactic radiotherapy (the observation group). The WHO response evaluation criteria (REC) for solid tumors were adopted to analyze short-term efficacy, and the Karnofsky performance status (KPS) score was used to assess the quality of life by recording adverse reactions in the blood system, kidney, gastrointestinal tract, bladder, nervous system, and heart. The levels of CYFRA21-1 and MALAT1 in serum before and after the treatment were determined and compared. As a result, the observation group showed higher total efficacy and MALAT1 level, better quality of life, and lower CYFRA21-1 level than the control group (P < 0.05). Stereotactic radiotherapy plus TP regimen chemotherapy resulted in significantly better progression-free survival, overall survival, survival rate, and long-term prognosis versus chemotherapy alone. Moreover, combined therapy was associated with a lower incidence of hemoglobin reduction, gastrointestinal reaction, and renal impairment versus TP regimen chemotherapy (P < 0.05). Therefore, we concluded that stereotactic radiotherapy plus chemotherapy with a TP regimen significantly optimizes the clinical efficacy of the NSCLC treatment.

The expression of Nanog protein and fibroblast growth factor-inducible molecule 14 in patients with non-small cell lung cancer and their relationship with pathological characteristics and prognosis

Background

This study aimed to explore the expression of Nanog and fibroblast growth factor-inducible molecule 14 (Fn14) in patients with non-small cell lung cancer (NSCLC), and to explore their relationship with pathological characteristics and prognosis.

Methods

The clinical data of 89 patients with NSCLC admitted to this hospital from March 2015 to January 2019 were analyzed. The expression of Nanog and Fn14 in NSCLC tissues and normal tissues (5 cm around the tumor tissue) were analyzed by immunohistochemical staining. The relationship between Nanog and Fn14 expression and the patients’ pathological parameters was analyzed. Receiver operating characteristic curve (ROC) and Kaplan-Meier survival curves were drawn to analyze the influence of Nanog and Fn14 expression on prognosis, and logistic regression analysis was used to examine the related factors affecting the 2-year prognostic mortality of patients.

Results

The positive rates of Nanog and Fn14 in the observation group were significantly higher than those in the control group (P<0.05). The positive expression rates of Nanog and Fn14 were higher in patients with moderate/high differentiation, TNM stage III-IV, and lymph node metastasis (P<0.05). Among 89 patients with NSCLC, 25 patients died within 2 years of follow-up, with a survival rate of 71.91%. The mortality of patients with positive expression of Nanog and Fn14 was significantly higher than that of patients with negative expression (P<0.05). The median survival times of patients with negative and positive Nanog expression were (20.60±2.71) months and (18.03±2.11) months, respectively. The median survival times of patients with negative and positive Fn14 expression were (19.55±2.60) months and (15.65±2.14) months, respectively. The Kaplan-Meier survival curve showed that patients with both negative expression of Nanog and Fn14 had a longer survival time (P<0.05). Poor differentiation, TNM stage III-IV, lymph node metastasis, positive expression of Nanog, and positive expression of Fn14 were identified as risk factors affecting the prognostic mortality of patients with NSCLC (P<0.05).

Conclusions

Nanog and Fnl4 are closely related to the occurrence, development, and prognosis of NSCLC. Detection of their expression levels can provide reliable information for the early diagnosis of patients with NSCLC.

Phase II trial of stereotactic body radiation therapy on adrenal gland metastases: evaluation of efficacy and impact on hormonal production

PURPOSE

The purpose of this study was to assess prospectively the efficacy and safety of stereotactic body radiation therapy (SBRT) for adrenal gland metastasis, with a focus on the assessment of the irradiated subjects' endocrinological function.

MATERIALS AND METHODS

A total of 36 patients were enrolled from 2017 to 2020 in this prospective phase II trial. Patients were treated with Linac-based SBRT, with a dose of 45 Gy in 3 consecutive fractions. Primary end-point was local control (LC) of the treated lesions and secondary end-points included evaluation of acute and late toxicity, progression free survival (PFS), overall survival (OS) and the impact on the hormonal production of adrenal glands.

RESULTS

With a median follow-up of 9.5 months, LC rates at 1 and 2 years were 94.7% and 88.4%, respectively. Rates of PFS at 1 and 2 years were 50.5% and 29.8%, with a median PFS of 14.7 months. Rates of OS at 1 and 2 years were 62.9% and 44.1%. At univariate analysis, oligorecurrence was associated with better OS compared to oligoprogressive or synchronous metastatic disease. No grade 3 or greater toxicities were registered and only a minority of patients (22.2%) reported mild treatment-related side effects. Hormonal and electrolytes production was assessed before and after treatment, showing only a slight and transient variation within the reference ranges.

CONCLUSION

SBRT on adrenal metastases has been confirmed to be a feasible and effective treatment. With an excellent disease control and the preservation of the endocrine function, SBRT with ablative dose can be considered a viable alternative to more invasive approaches.

Radiotherapy for oligometastatic non-small cell lung cancer: a narrative review

Preclinical and early clinical evidence suggest that radical radiotherapy of oligometastatic disease in non-small cell lung cancer (NSCLC) patients can impact outcomes with relatively limited toxicity. Whilst data from phase 2 randomized trials suggesting an improved overall survival (OS) with this treatment is promising, it has also illustrated the heterogeneity in this patient population and treatment. Oligometastatic disease in itself comprises a broad spectrum of patients, in terms of tumor load and location, stage of the disease and treatment history. This real-life variety in patient characteristics is often reflected in studies to a certain extent, hinting to the fact that all might benefit from radical radiotherapy to limited metastatic disease, yet leaving the question unanswered as to whom the ideal candidate is. Furthermore, differences between and within studies with regards to treatment modality, timing, radiation technique, and radiation dose are substantial. Also, preclinical and early clinical trials suggest that radiotherapy can work synergistically with checkpoint inhibitors by acting as an in situ cancer vaccine, therefore the combination of these two treatments in oligometastatic patients might entail the largest benefit. Ongoing randomized controlled phase 3 trials and prospective registry trials will further elucidate the true extent of benefit of this local treatment strategy and aid in identifying the ideal patient population and therapy. The current narrative review summarizes the clinical evidence on radiotherapy for oligometastatic NSCLC and highlights the remaining unknowns.

Late metastatic presentation is associated with improved survival and delayed wide-spread progression after ablative stereotactic body radiotherapy for oligometastasis

Background

Stereotactic body radiotherapy (SBRT) is increasingly used to treat oligometastatic disease (OMD), but the effect of metastasis timing on patient outcomes remains uncertain.

Methods

An international database of patients with OMD treated with SBRT was assembled with rigorous quality assurance. Early versus late metastases were defined as those diagnosed ≤24 versus >24 months from the primary tumor. Overall survival (OS), progression‐free survival (PFS), and incidences of wide‐spread progression (WSP) were estimated using multivariable Cox proportional hazard models stratified by primary tumor types.

Results

The database consists of 1033 patients with median follow‐up of 24.1 months (0.3–104.7). Late metastatic presentation (N = 427) was associated with improved OS compared to early metastasis (median survival 53.6 vs. 33.0 months, hazard ratio [HR] 0.59, 95% confidence interval [CI]: 0.47–0.72, p < 0.0001). Patients with non‐small cell lung cancer (NSCLC, N = 255, HR 0.49, 95% CI: 0.33–0.74, p = 0.0005) and colorectal cancer (N = 235, HR 0.50, 95% CI: 0.30–0.84, p = 0.008) had better OS if presenting with late metastasis. Late metastasis correlated with longer PFS (median 17.1 vs. 9.0 months, HR 0.71, 95% CI: 0.61–0.83, p < 0.0001) and lower 2‐year incidence of WSP (26.1% vs. 43.6%, HR 0.60, 95% CI: 0.49–0.74, p < 0.0001). Fewer WSP were observed in patients with NSCLC (HR 0.52, 95% CI: 0.33–0.83, p = 0.006) and kidney cancer (N = 63, HR 0.37, 95% CI: 0.14–0.97, p = 0.044) with late metastases. Across cancer types, greater SBRT target size was a significant predictor for worse OS.

Conclusion

Late metastatic presentation is associated with improved survival and delayed progression in patients with OMD treated with SBRT.

Stereotactic body radiation therapy (SBRT) of adrenal gland metastases in oligometastatic and oligoprogressive disease

BACKGROUND

Stereotactic body radiation therapy (SBRT) as a form of noninvasive treatment that is becoming increasingly used to manage cancers with adrenal gland metastases. There is a paucity of data on safety and efficacy of this modality. The aim of the study was to evaluate the safety and efficacy of adrenal gland SBRT in oligometastatic and oligoprogressive disease.

MATERIALS AND METHODS

In this retrospective study, we performed a single-institution analysis of 26 adrenal lesions from 23 patients with oligometastatic or oligoprogressive disease treated from 2013 to 2019 with the goal of achieving durable local control. Palliative cases were excluded. Radiation dosimetry data was collected. Kaplan Meier product estimator and Cox proportional hazards regression analysis were used for statistical analysis.

RESULTS

The median dose was 36 Gy in 3 fractions (range: 24-50 Gy and 3-6 fractions) with a median biologically effective dose (BED10) of 72 (range: 40-100). 1-year local control rate was 80% and median local control was not achieved due to a low number of failures. 1- and 2-year overall survival rates were 66% and 32%. Toxicity was mild with only one case of grade 2 nausea and no grade 3-5 toxicity. Higher neutrophil to lymphocyte ratio was associated with worse overall survival and a trend toward worse progression-free survival. In addition, worse performance status and lower BED10 were associated with worse survival. No such association could be shown for primary tumor location, histology, size or stage.

CONCLUSION

Adrenal SBRT for oligometastatic or oligoprogressive disease is a safe and effective form of treatment.

Hypofractionated Radiotherapy for 35 Patients with Adrenal Metastases: A Single-Institution Experience

Objective

To investigate the clinical outcomes of hypofractionated radiotherapy for adrenal metastases.

Materials and Methods

We retrospectively reviewed patients diagnosed with adrenal metastases and treated with hypofractionated radiotherapy, who did not receive adrenalectomy or have disease progression after chemotherapy, from 2007 to 2019. The Kaplan–Meier method was used to estimate local control rate (LCR), progression-free survival (PFS), and overall survival (OS). Univariate analysis was performed using Log rank test.

Results

Thirty-five patients with 42 lesions were enrolled, and the lung was the most common primary site (80.0%). The median follow-up time was 46.4 months. The median volume of GTV and PTV was 23.2 cm³ (range: 3.5–97.8 cm³) and 38.3 cm³ (range: 10.2–135.6 cm³), respectively. The main dose regimens were 60 Gy delivered in 4–15 fractions, with the median dose of PTV being 60 Gy (range: 40–66.3 Gy) and the biologically effective dose (BED) being 84 Gy (range: 56–110 Gy). The 1-year and 2-year LCR, OS, and PFS were 92.7% and 88.1%, 76.9% and 45.4%, and 25.1% and 14.4%, respectively. Univariate analysis showed that chemotherapy, disease-free interval from primary disease diagnosis to adrenal metastases diagnosis, and age were significant factors for LCR, OS, and PFS, respectively (p=0.017, 0.049, and 0.004, respectively). No more than grade III toxicities were observed.

Conclusion

As a non-invasive approach, hypofractionated radiotherapy is safe and effective for metastatic adrenal lesions, without serious complications.

Stereotactic Body Radiation Therapy of Adrenal Metastases: A Pooled Meta-Analysis and Systematic Review of 39 Studies with 1006 Patients

PURPOSE

To perform a systematic review and pooled meta-analysis of adrenal metastasis stereotactic body radiation therapy (SBRT) outcomes, treatment characteristics, and toxicity to define the efficacy and propose guidelines for intervention.

METHODS AND MATERIALS

We performed a comprehensive literature search of the Embase and PubMed databases of studies reporting outcome or toxicity data for photon-based SBRT of adrenal metastases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We then conducted a meta-analysis to estimate pooled overall response, local control (LC), and overall survival and analyzed these outcomes in the context of dosimetric parameters and toxicity using metaregression.

RESULTS

Thirty-nine studies published between 2009 and 2019 reporting outcomes on 1006 patients were included. The median follow-up was 12 months, and the median biological equivalent dose (BED10, alpha/beta = 10) was 67 Gy. The pooled overall response was 54.6% (95% confidence interval [CI], 46.5%-62.5%). The pooled 1- and 2-year rates of LC were 82% (95% CI, 74%-88%) and 63% (95% CI, 50%-74%), respectively, and the pooled 1- and 2-year overall survival rates were 66% (95% CI, 57%-74%) and 42% (95% CI, 31%-53%), respectively. There was a strong positive association between SBRT dose and 1- and 2-year LC (P < .0001, P = .0002) and an association with 2-year OS (P = .03). Based on a metaregression of dose and LC, BED10 of 60 Gy, 80 Gy, and 100 Gy predicted 1-year LC of 70.5%, 84.8%, and 92.9% and 2-year LC of 47.8%, 70.1%, and 85.6%, respectively. The overall rate of grade 3 or higher toxicity was 1.8%.

CONCLUSIONS

SBRT of adrenal metastases provides good 1-year LC with an excellent safety profile, and dose escalation may be associated with improved LC. Prospective studies are needed to validate these findings and determine whether there are subsets of patients for whom adrenal metastasis-directed SBRT may confer a survival advantage.

Stereotactic Body Radiotherapy for Oligometastatic Disease in Non-small Cell Lung Cancer

Metastatic non-small cell lung cancer (NSCLC) is associated with a limited survival when treated with palliative intent platinum-based chemotherapy alone. Recent advances in imaging and therapeutic strategy have identified a subset of patients with limited metastases who may benefit from early local ablative therapy with either surgery or radiotherapy, in addition to standard treatment. Stereotactic body radiotherapy (SBRT) is increasingly used in the treatment of extra-cranial oligometastatic NSCLC (OM-NSCLC) due its non-invasive conduct and ability to deliver high doses. Clinical evidence supporting the use of SBRT in OM-NSCLC is emerging and consistently demonstrates significant benefit in local control and progression-free survival. Here, we discuss the definition of oligometastases (OM), review current available data on SBRT treatment in extra-cranial OM-NSCLC including evidence for site-specific SBRT in lung, liver, and adrenal metastases.

Real-Time Tumor-Tracking Radiotherapy and General Stereotactic Body Radiotherapy for Adrenal Metastasis in Patients With Oligometastasis

Background:

Precise local radiotherapy for adrenal metastasis can prolong the useful life of patients with oligometastasis. The aim of this retrospective, 2-center study was to establish the safety and effectiveness of real-time tumor-tracking radiotherapy and general stereotactic body radiotherapy in treating patients with adrenal metastatic tumors.

Materials and Methods:

Thirteen lesions in 12 patients were treated with real-time tumor-tracking radiotherapy (48 Gy in 8 fractions over 2 weeks) and 8 lesions in 8 patients were treated with general stereotactic body radiotherapy (40-50 Gy in 5-8 fractions over 2 weeks or 60-70 Gy in 10 fractions over 2 weeks). Overall survival rates, local control rates, and adverse effects were analyzed.

Results:

The actuarial overall survival rates for all patients at 1 and 2 years were 78.5% and 45.8%, respectively, with a median follow-up of 17.5 months, and the actuarial local control rates for all tumors at 1 and 2 years were 91.7% and 53.0%, respectively, with a median follow-up of 9 months. A complete local tumor response was obtained in 3 tumors treated by real-time tumor-tracking radiotherapy (lung adenocarcinomas with diameters of 35, 40, and 60 mm). There was a statistically significant difference in the local control between the groups treated by real-time tumor-tracking radiotherapy (100% at 1 year) and general stereotactic body radiotherapy (50% at 1 year; P < .001). No late adverse reactions at Grade 2 or higher were reported for either treatment group.

Conclusions:

This study showed that although both treatments are safe and effective, the real-time tumor-tracking radiotherapy is more effective than general stereotactic body radiotherapy in local control for adrenal metastasis.

Short-term outcomes and clinical efficacy of stereotactic body radiation therapy (SBRT) in treatment of adrenal gland metastases from lung cancer

Background

To assess the efficacy and safety of stereotactic body radiation therapy (SBRT) in the management of adrenal gland metastases (AGMs) from lung cancer. Moreover, it is the first two-institutional experience and the largest-to-date study to report the safety and efficacy of SBRT for inoperable AGM from lung cancer.

Methods

In this retrospective study, 30 patients (27 males, 3 females) with 32 AGMs were treated by SBRT from October 2006 to June 2016. Of these, 11 patients were treated with the intent of controlling all known metastatic sites and 19 for palliation of bulky AGMs. Follow-up was performed every 3 months for evaluations of efficacy and safety. Factors predictive of overall survival (OS) and local control (LC) were identified with univariate and then multivariate analysis.

Results

Median follow-up time was 10.7 months (2.9–96.4 months). The complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD) rates were 23.3%, 33.3%, 33.3% and 16.7% respectively. The 6-month, 1, and 2-year LC rates were 96.9%, 96.9%, and 72.7% respectively. Additionally, the 6-month, 1, and 2-year OS rates were 85.6%, 58.1%, and 54.0% respectively while 6-month, 1, and 2-year progression free survival (PFS) rates were 39.5%, 24.6%, and 8.2%, respectively. All the patients with cancer-induced pain (8 with abdominal pain and 6 with lumbar back pain) had significant alleviations after SBRT. The treatment was well tolerated with only 1 patient reporting grade-3 diarrhoea. No predictors of OS and LC were found after multivariate analysis, while it was demonstrated that biologic equivalent dose (BED₁₀, α/β = 10) ≥85.5Gy (P = 0.007) and gross tumor volume < 30 ml (P = 0.003) correlated with LC only after univariate analysis.

Conclusion

SBRT is a safe and effective treatment modality in the management of AGMs from lung cancer with high LC rates and acceptable toxicity.

Stereotactic body radiation therapy for adrenal gland metastases: Outcomes and toxicity

Purpose

This study aimed to report on our institutional experience in the use of stereotactic body radiation therapy (SBRT) for the treatment of adrenal gland metastases. Specifically, we examined the outcomes and toxicity from this treatment modality on adjacent organs at risk.

Methods and Materials

Data were retrieved from patients with adrenal metastases who were treated with SBRT between 2008 and 2017. Patients with primary adrenal malignancies were excluded. Toxicities were graded in accordance with the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03. Time-to-event rates were calculated from the date of SBRT delivery.

Results

In total, 35 patients with adrenal metastases were identified. Four patients were treated for bilateral disease. The median dose was 40 Gy (range, 20-54 Gy) in 5 fractions (range, 1-6 fractions). The median follow-up time was 37 months (range, 14-451 months) from disease diagnosis and 7 months (range, 1-54 months) from the SBRT start date. With death treated as a competing risk event, the cumulative incidence of local failure was 7.6% at 1 year after SBRT and 19.2% at 3 years. The median overall survival (OS) time was 19 months (95% confidence interval, 8-54 months) and tumor size correlated with survival (P = .0006). Patients with metastases <2.9 cm had a median OS of 54 months compared with 11 months for those with adrenal metastases ≥2.9 cm (P = .01). Incidence of grade 2 toxicity was 17% with no case of grade ≥3 toxicity. SBRT did not impact renal function with a mean estimated decline in glomerular filtration rate of only 2.6 ± 8 mL/min/1.73 m² compared with baseline. Combined kidneys V5 and combined renal cortex V17.5 did not correlate with a change in estimated glomerular filtration rate (P = .7 and P = .9, respectively).

Conclusions

SBRT offers excellent local control for the treatment of adrenal gland metastases with very low toxicity rates and no significant short-term impact on renal function.

Surgical approach in the oligometastatic patient

In the setting of a stage IV non-small cell lung cancer (NSCLC), oligometastatic patients represent a heterogeneous group whose incidence is increasing as far as with the adoption of new therapeutic regimens, the improvement of the molecular characterization assays and the increasing number of long-survivor patients. The oligometastatic state undergone a major revision with the introduction of the new TNM lung cancer staging system, being characterized by a different prognosis compared to multi-metastatic patients. Furthermore, the presence of a limited number of metastases imposes a local control especially when clonal selections occur during adjuvant therapy. In this regard, the review seeks to clarify the indications for surgical treatment by organ according to recent guidelines, by analyzing prognostic factors and outcome of patients. Although accurate patient stratification is mandatory, aggressive local control strategies represent a valid therapeutic approach in patients with oligometastatic NSCLC. At the same time, persevering with ablative strategies raises both medical and ethical issues about limits and reiteration, which certainly requires a deep reflection, being, on the other hand, in front of a metastatic disease.