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Han C, Qiu J, Bai L, Liu T, Chen J, Wang H, Dang J. Pneumonitis Risk After Chemoradiotherapy With and Without Immunotherapy in Patients With Locally Advanced Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2024; 119:1179-1207. [PMID: 38360117 DOI: 10.1016/j.ijrobp.2024.01.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 12/28/2023] [Accepted: 01/28/2024] [Indexed: 02/17/2024]
Abstract
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.
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Affiliation(s)
- Chong Han
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China
| | - Jingping Qiu
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China
| | - Lu Bai
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China
| | - Tingting Liu
- Department of Radiation Oncology, Anshan Cancer Hospital, Anshan, China
| | - Jun Chen
- Department of Radiation Oncology, Shenyang Tenth People's Hospital, Shenyang, China
| | - He Wang
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China
| | - Jun Dang
- Department of Radiation Oncology, First Hospital of China Medical University, Shenyang, China.
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Sun L, Wang Y, Zhu L, Chen J, Chen Z, Qiu Z, Wu C. Analysis of the risk factors of radiation pneumonitis in patients after radiotherapy for esophageal squamous cell carcinoma. Front Oncol 2023; 13:1198872. [PMID: 38023119 PMCID: PMC10662299 DOI: 10.3389/fonc.2023.1198872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To predict the risk factors of radiation pneumonitis (RP) in patients with esophageal squamous cell carcinoma (ESCC) who received radiotherapy. Methods From January 2015 to October 2021, 477 ESCC patients were enrolled and were assessed retrospectively. All these patients received radiotherapy for primary lesions or mediastinal metastatic lymph nodes. Clinical efficacy and adverse events (AEs) were observed. Univariate analysis identified clinical and dosimetric factors associated with the development of RP, and multivariate logistic regression analysis identified independent potential risk factors associated with the development of RP. Nomograms were constructed to predict RP based on the results of multivariate logistic regression analysis. Results Among the 477 ESCC patients, the incidence of RP was 22.2%, and the incidence of grade 4 or higher RP was 1.5%. Univariate analysis indicated that chronic obstructive pulmonary disease (COPD), pulmonary infection, leucopenia, PTV volume, V5, V20, V30 and MLD affected the occurrence of RP. The multivariate logistic regression analysis indicated that COPD (OR:1.821, 95%CI:1.111-2.985; P=0.017), pulmonary infection (OR:2.528, 95%CI:1.530-4.177; P<0.001), higher V20 (OR: 1.129, 95% CI:1.006-1.266; P=0.029) were significant independent predictors of RP in ESCC patients. COPD, pulmonary infection, V20 have been integrated for the RP nomogram. The rate of RP was significantly reduced in the V20<21.45% group. Further analysis indicated that the old age, diabetes, higher V20, and higher MLD were risk factors for grade 4 or higher RP. The area under the curve (AUC) value for V20 was 0.73 (95% CI, 0.567-0.893, P < 0.05). Conclusion We have determined the risk factors of RP and grade 4 or higher RP in ESCC patients after radiotherapy. MLD, V20, COPD were independent factors for RP. It was necessary to take measures to reduce or avoid the occurrence of RP for patients with these risk factors at the early stage.
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Affiliation(s)
- Lu Sun
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Yan Wang
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Lihua Zhu
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Jun Chen
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Zhifu Chen
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Zhiyuan Qiu
- Department of Oncology, the People’s Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
| | - Chaoyang Wu
- Department of Radiation Oncology, the People's Hospital Affiliated to Jiangsu University, Zhenjiang, Jiangsu, China
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Liu T, Li S, Ding S, Qiu J, Ren C, Chen J, Wang H, Wang X, Li G, He Z, Dang J. 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. EClinicalMedicine 2023; 64:102246. [PMID: 37781162 PMCID: PMC10539643 DOI: 10.1016/j.eclinm.2023.102246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023] Open
Abstract
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.
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Affiliation(s)
- Tingting Liu
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
- Department of Radiation Oncology, Anshan Cancer Hospital, Anshan, China
| | - Sihan Li
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Silu Ding
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Jingping Qiu
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Chengbo Ren
- Department of Radiation Oncology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, China
| | - Jun Chen
- Department of Radiation Oncology, Shenyang Tenth People's Hospital, Shenyang, China
| | - He Wang
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Xiaoling Wang
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Guang Li
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Zheng He
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Jun Dang
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
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Hoeller U, Borgmann K, Oertel M, Haverkamp U, Budach V, Eich HT. Late Sequelae of Radiotherapy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:205-211. [PMID: 34024324 DOI: 10.3238/arztebl.m2021.0024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 03/25/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Approximately half of all patients with tumors need radiotherapy. Long-term survivors may suffer from late sequelae of the treatment. The existing radiotherapeutic techniques are being refined so that radiation can be applied more precisely, with the goal of limiting the radiation exposure of normal tissue and reducing late sequelae. METHODS This review is based on the findings of a selective search in PubMed for publications on late sequelae of conventional percutaneous radiotherapy, January 2000 to May 2020. Late sequelae affecting the central nervous system, lungs, and heart and the development of second tumors are presented, and radiobiological mechanisms and the relevant technical and conceptual considerations are discussed. RESULTS The current standard of treatment involves the use of linear accelerators, intensity-modulated radiotherapy (IMRT), image-guided and respiratory-gated radiotherapy, and the integration of positron emission tomography combined with computed tomography (PET-CT) in radiation treatment planning. Cardiotoxicity has been reduced with regard to the risk of coronary heart disease after radiotherapy for Hodgkin's lymphoma (hazard ratio [HR] 0.44 [0.23; 0.85]). It was also found that the rate of radiation- induced pneumonitis dropped from 7.9% with conformal treatment to 3.5% with IMRT in a phase III lung cancer trial. It is hoped that neurocognitive functional impairment will be reduced by hippocampal avoidance in modern treatment planning: an initial phase III trial yielded a hazard ratio of 0.74 [0.58; 0.94]. It is estimated that 8% of second solid tumors in adults are induced by radiotherapy (3 additional tumors per 1000 patients at 10 years). CONCLUSION Special challenges for research in this field arise from the long latency of radiation sequelae and the need for largescale, well-documented patient collectives in order to discern dose-effect relationships, and take account of cofactors, when the overall number of events is small. It is hoped that further technical and conceptual advances will be made in the areas of adaptive radiotherapy, proton and heavy-ion therapy, and personalized therapy.
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Yang LT, Zhou L, Chen L, Liang SX, Huang JQ, Zhu XD. Establishment and Verification of a Prediction Model for Symptomatic Radiation Pneumonitis in Patients with Esophageal Cancer Receiving Radiotherapy. Med Sci Monit 2021; 27:e930515. [PMID: 33953150 PMCID: PMC8112075 DOI: 10.12659/msm.930515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study aimed to determine the value of the significant index in predicting symptomatic radiation pneumonitis (RP) in esophageal cancer patients, establish a nomogram prediction model, and verify the model. MATERIAL AND METHODS The patients enrolled were divided into 2 groups: a model group and a validation group. According to the logistic regression analysis, the independent predictors for symptomatic RP were obtained, and the nomogram prediction model was established according to these independent predictors. The consistency index (C-index) and calibration curve were used to evaluate the accuracy of the model, and the prediction ability of the model was verified in the validation group. Recursive partitioning analysis (RPA) was used for the risk stratification analysis. RESULTS The ratio of change regarding the pre-albumin at the end of treatment (P=0.001), platelet-to-lymphocyte ratio during treatment (P=0.027), and neutrophil-to-lymphocyte ratio at the end of treatment (P=0.001) were the independent predictors for symptomatic RP. The C-index of the nomogram model was 0.811. According to the risk stratification of RPA, the whole group was divided into 3 groups: a low-risk group, a medium-risk group, and a high-risk group. The incidence of symptomatic RP was 0%, 16.9%, and 57.6%, respectively. The receiver operating characteristic curve also revealed that the nomogram model has good accuracy in the validation group. CONCLUSIONS The developed nomogram and corresponding risk classification system have superior prediction ability for symptomatic RP and can predict the occurrence of RP in the early stage.
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Affiliation(s)
- Liu-Ting Yang
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China (mainland)
| | - Lei Zhou
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China (mainland)
| | - Long Chen
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China (mainland)
| | - Shi-Xiong Liang
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China (mainland)
| | - Jiang-Qiong Huang
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China (mainland)
| | - Xiao-Dong Zhu
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China (mainland).,Department of Oncology, Wuming Hospital of Guangxi Medical University, Nanning, Guangxi, China (mainland)
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Ni L, Koshy M, Connell P, Pitroda S, Golden DW, Al-Hallaq H, Hubert G, Kauffman G, McCall A, Malik R. Heart V5 predicts cardiac events in unresectable lung cancer patients undergoing chemoradiation. J Thorac Dis 2019; 11:2229-2239. [PMID: 31372260 DOI: 10.21037/jtd.2019.06.29] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Recent studies incorporating dose escalated radiation identified heart dose as a predictor of cardiac toxicity in unresectable lung cancer patients. Whether conventionally dosed radiation impacts cardiac events remains unclear. Methods Stage III lung cancer patients undergoing definitive chemoradiation to 60-70 Gy were analyzed. Clinical and dosimetric factors (mean heart dose, heart V5-60 in 5 Gy increments) were analyzed against freedom from ≥ grade 3 cardiac events and overall survival (OS) by log-rank test. Multivariable analysis (MVA) for factors significant on univariate analysis was performed by Cox proportional hazards. Results A total of 108 patients were identified. Median follow-up was 18.0 months. One- and two-year OS were 79% and 61%, respectively. On MVA, gross tumor volume (GTV) ≥98.6 cm3 [hazard ratio (HR): 2.11, 95% confidence interval (CI): 1.15-3.93, P=0.02] and female gender (HR: 2.01, 95% CI: 1.09-3.73, P=0.03) predicted for worse survival. Twelve patients (11%) developed ≥ grade 3 cardiac events. One- and two-year freedom from cardiac events (FFCE) was 94% and 84% respectively. On MVA, heart V5 ≥49% predicted for cardiac events (HR: 11.44, 95% CI: 1.31-111.60, P=0.03) while female gender was nearly significant (HR: 3.49, 95% CI: 0.97-16.80, P=0.06). Females presented with similar comorbidity scores, GTVs, and relapse rates but experienced higher heart doses than their male counterparts. Conclusions Heart V5 ≥49% predicted for cardiac events after chemoradiation. However, cardiac dosimetry was not associated with survival. Rather, female gender and GTV ≥98.6 cm3 led to worse survival. This study corroborates emerging data that low-dose radiation to the heart impacts cardiac toxicity.
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Affiliation(s)
- Lisa Ni
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Matthew Koshy
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Philip Connell
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Sean Pitroda
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Daniel W Golden
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Hania Al-Hallaq
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Greg Hubert
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Greg Kauffman
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Anne McCall
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Renuka Malik
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
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Abstract
PURPOSE OF REVIEW The aim of this article is to examine significant advances in our understanding of the late respiratory effects of cancer treatment, including surgery, radiotherapy, chemotherapy, biological therapies and haematopoietic stem cell transplant, and to provide a framework for assessing such patients. RECENT FINDINGS Oncology therapies have advanced considerably over recent years but pulmonary toxicity remains a concern. Advances have been made in our understanding of the risk factors, including genetic ones that lead to toxicity from radiotherapy and chemotherapy and risk stratification models are being developed to aid treatment planning. Targeted biological treatments are continuously being developed and consequently the Pneumotox database of pulmonary toxicity continues to be an essential resource. Early detection of bronchiolitis obliterans in haematopoietic stem cell transplant patients has been found to be critical, with some positive results from intervention trials. SUMMARY Pulmonary toxicity is a common unwanted consequence of life enhancing or saving cancer treatments which remain difficult to treat. Developments in these fields are mainly in the areas of prevention, early detection and monitoring of unwanted side effects. We discuss some of these developments within this review.
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