Impact of irradiation technique and tumor extent in tumor control and survival of patients with unresectable non-oat cell carcinoma of the lung: report by the Radiation Therapy Oncology Group

A comparison of the incidence of ≥ grade 2 radiation pneumonitis between intensity-modulated radiotherapy and three-dimensional conformal radiotherapy in patients with unresectable non-small cell lung cancer treated with durvalumab after concurrent chemoradiotherapy

BACKGROUND

Intensity-modulated radiation therapy (IMRT) has been increasingly used as a new radiation modality for unresectable non-small cell lung cancer (NSCLC). The risk factors for radiation pneumonitis (RP) during consolidation durvalumab following concurrent chemoradiotherapy (CCRT) using IMRT have not been thoroughly investigated.

METHODS

This retrospective study analyzed medical record data from consecutive patients diagnosed with NSCLC who underwent CCRT and consolidation durvalumab at our institution between April 2018 and September 2022. Since we adopted IMRT for the treatment of NSCLC in April 2020, these patients were categorized into two groups: those treated with IMRT after April 2020 and those treated with three-dimensional conformal radiotherapy (3D-CRT) before April 2020.

RESULTS

A total of 31 patients underwent IMRT (the IMRT group), while 25 patients underwent 3D-CRT (the 3D-CRT group). In both groups, the total dose was 60 Gy in 30 fractions. The cumulative incidence of ≥ grade 2 RP at 12 months was significantly lower in the IMRT group than in the 3D-CRT group (27.0% vs. 64.0%, hazard ratio [HR]: 0.338, 95% confidence interval [CI]: 0.144-0.793, p = 0.013). In the multivariable analysis, V20 (≥ 25.6%, HR: 2.706, 95% CI: 1.168-6.269, p = 0.020) and radiotherapy technique (IMRT, HR: 0.414, 95% CI: 0.172-0.994, p = 0.048) were identified as significant risk factors for ≥ grade 2 RP.

CONCLUSIONS

IMRT is associated with a lower rate of ≥ grade 2 RP in patients with NSCLC who received CCRT followed by durvalumab.

PACIFIC: shifting tides in the treatment of locally advanced non-small cell lung cancer

The treatment paradigm of stage III, unresectable non-small cell lung cancer (NSCLC) has had few advancement since concurrent chemoradiotherapy was established as standard of care treatment. Despite modifications to radiotherapy, chemotherapy and surgical approaches, loco-regional and distant relapse remain high, which unfortunately has translated to poor survival outcomes. The PACIFIC study introduced immunotherapy to the domain of stage III NSCLC and has emerged as the fourth pillar in cancer treatment for these patients. The positive results of the study have excited both the radiation and medical oncology communities, demonstrating improvements in overall and progression-free survival (PFS). In this review, we discuss the details and impacts of the PACIFIC study, as well as the future implications for the treatment of stage III NSCLC.

Efficacy of chemoradiotherapy versus radiation alone in patients with inoperable locally advanced non-small-cell lung cancer: A meta-analysis and systematic review

BACKGROUND

This meta-analysis compared radiotherapy (RT) versus concurrent chemoradiotherapy (RT+CT) in treating patients with inoperable stage III non-small-cell lung cancer (NSCLC).

METHODS

Medline, Cochrane, EMBASE, Google Scholar databases were searched until July 28, 2015 using the following keywords non-small cell lung cancer, advanced cancer, incurable/inoperable/unresectable, chemotherapy, radiotherapy, chemoradiotherapy/chemoradiation. Randomized controlled trials (RCTs) and two-armed prospective studies that compared combined RT+CT with RT alone in patients with locally advanced (stage III) nonresectable NSCLC were eligible for inclusion. Treatment effect on overall survival, progression-free survival (PFS), and objective response rate (ORR) were evaluated.

RESULTS

Ultimately, 13 RCT studies were included in the systematic review and meta-analysis. The 13 studies included a total of 1936 patients with incurable/inoperable stage III NSCLC, of which 975 received RT alone and 961 received RT+CT combination therapy. The average age ranged from 54 to 77 years. At 1 and 2 years after treatment, the pooled data reveal that patients receiving CT+RT combination therapy had higher overall survival (pooled hazard ratio (HR), 0.72; 95% CI, 0.62-0.84; P < .001; 1-yr: HR, 0.67; 95% CI, 0.54-0.84; P < .001; 2-year: HR, 0.57; 95% CI, 0.45-0.73; P < .001), higher PFS (pooled HR, 0.73, 95% CI, 0.60-0.89; P = .002; 1-year: HR, 0.36; 95% CI, 0.24-0.53; P < .001; 2-year: HR, 0.38; 95% CI, 0.23-0.63; P < .001).

CONCLUSION

Our findings show higher efficacy for concurrent CT+RT over RT alone in treating locally-advanced, unresectable stage III NSCLC.

Quality of reporting on thoracic radiotherapy technique in prospective lung cancer trials: A systematic review

BACKGROUND

The aim of this study is to assess the quality of reporting of thoracic (T) RT technique for curative intent treatment in prospective lung cancer trials.

METHODS

We searched MEDLINE for eligible trials published from 1996 to 2016. We assessed the included trials' reports on whether they reported the RT dose prescription method; RT dose-planning procedures; algorithm for tissue inhomogeneity dose corrections; organs at risk dose constraints; target volume definition, simulation and/or motion management procedures; treatment verification procedures; total RT dose; fractionation schedule; conduct of quality assurance as well as presence or absence of deviations in RT treatment planning and delivery adequately. We performed univariable and multivariable logistic regression to determine the factors that may influence the quality of reporting.

RESULTS

We found 85 eligible trial reports. Target volume definition, total RT dose, and fractionation schedules were reported adequately in more than 90% of the included trials. Algorithm for tissue inhomogeneity dose corrections, simulation and verification procedures, presence or absence of deviations in RT treatment planning and delivery were reported adequately in less than 20% of the included trials. Twenty-three trials (27%) reported 7 criteria or more adequately. Both univariable and multivariable logistic regression showed that trials with RT focused research question were more likely to have adequate quality in reporting (judged as adequate reporting in 7 criteria or more) than trials with non-RT focused question (odds ratio 4.11, 95% confidence interval 1.10 to 15.43, P value = .04).

CONCLUSION

There is significant variability in the quality of reporting on thoracic radiotherapy treatment in prospective lung cancer trials. Future research should focus on developing consensus guidelines to standardize the reporting of radiotherapy technique in clinical trials.

Preoperative contralateral lung radiation dose is associated with postoperative pulmonary toxicity in patients with locally advanced non-small cell lung cancer treated with trimodality therapy

PURPOSE

In patients with non-small cell lung cancer (NSCLC) who undergo trimodality therapy (chemoradiation followed by surgical resection), it is unknown whether limiting preoperative radiation dose to the uninvolved lung reduces postsurgical morbidity. This study evaluated whether radiation fall-off dose parameters to the contralateral lung that is unaffected by NSCLC are associated with postoperative complications in NSCLC patients treated with trimodality therapy.

METHODS AND MATERIALS

We retrospectively reviewed NSCLC patients who underwent trimodality therapy between March 2008 and October 2016, with available restored digital radiation plans. Fischer's exact test was used to assess associations between patient and treatment characteristics and the development of treatment-related toxicity. Spearman rank correlation was used to measure the strength of association between dosimetric parameters.

RESULTS

Forty-six patients were identified who received trimodality therapy with intensity modulated radiation (median, 59.4 Gy; range, 45-70) and concurrent platinum doublet chemotherapy, followed by surgical resection. The median age was 64.9 years (range, 45.6-81.6). The median follow-up time was 1.9 years (range, 0.3-8.4). Twenty-four (52.2%) patients developed any-grade pulmonary toxicity and 14 (30.4%) patients developed grade 2+ pulmonary toxicity. There was an increased incidence of any-grade pulmonary toxicity in patients with contralateral lung volume receiving at least 20 Gy (V20) ≥7% compared with <7% (90%, n = 9 vs 41.7%, n = 15; P = .01). Similarly, contralateral lung V10 ≥20% was associated with an increased rate of any-grade pulmonary toxicity compared with V10 <20% (80%, n = 12 vs 38.7%, n = 12; P = .01). Pneumonectomy/bilobectomy was associated with grade 2+ pulmonary toxicity (P = .04).

CONCLUSIONS

Patients who received a higher radiation fall-off dose volume parameter (V20 ≥7% and V10 ≥20%) to the contralateral uninvolved lung had a higher incidence of any-grade postoperative pulmonary toxicity. Limiting radiation fall-off dose to the uninvolved lung may be an important modifiable radiation parameter in limiting postoperative toxicity in trimodality patients.

Incident learning in radiation oncology: A review

Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and understanding of ILS, challenges remain in applying ILS to the radiation oncology context. This comprehensive review may serve as a springboard for further work.

Advances in proton therapy in lung cancer

Lung cancer remains the leading cause of cancer deaths in the United States (US) and worldwide. Radiation therapy is a mainstay in the treatment of locally advanced non-small cell lung cancer (NSCLC) and serves as an excellent alternative for early stage patients who are medically inoperable or who decline surgery. Proton therapy has been shown to offer a significant dosimetric advantage in NSCLC patients over photon therapy, with a decrease in dose to vital organs at risk (OARs) including the heart, lungs and esophagus. This in turn, can lead to a decrease in acute and late toxicities in a population already predisposed to lung and cardiac injury. Here, we present a review on proton treatment techniques, studies, clinical outcomes and toxicities associated with treating both early stage and locally advanced NSCLC.

Definitive Radiotherapy for Local Recurrence of NSCLC After Surgery

INTRODUCTION

Locoregional recurrence after resection of non-small-cell lung cancer (NSCLC) is common. We examined outcomes after definitive radiotherapy (RT) to identify prognostic factors for survival and further recurrence.

PATIENTS AND METHODS

We reviewed 152 patients who received RT for locoregional recurrent (LR)-NSCLC, and analyzed subsequent overall survival (OS), locoregional failure (LRF), distant metastasis (DM), and any disease progression (LRF and DM).

RESULTS

Two- and 5-year OS were 49% and 28%, respectively. Two- and 5-year LRF, DM, and any disease progression rates were 40% and 45%, 33% and 37%, and 53% and 57%, respectively. Performance status and intensity-modulated RT (IMRT) were independently associated with OS, as was RT dose ≥ 60 Gy. Stage, chemotherapy at recurrence, and surgery to recurrence interval were not independently associated with outcome. Chemotherapy at initial presentation, adenocarcinoma histology, and male sex were independently associated with higher rates of DM.

CONCLUSION

To our knowledge, this is the largest reported series of LR-NSCLC treated with definitive RT. Survival appears comparable to or greater than that of primary NSCLC. Subsequent LRF is more common than distant failure. Established prognostic factors for primary NSCLC, such as chemotherapy and stage, were not clearly prognostic in this analysis. IMRT and higher RT doses were associated with improved survival, though IMRT patients were also treated more recently. These data support definitive-intent RT with optimal dose and technique in such patients.

Endobronchial Ultrasound-guided Intratumoral Injection of Cisplatin for the Treatment of Isolated Mediastinal Recurrence of Lung Cancer

Isolated hilar and mediastinal recurrence (IMHR) following external beam radiation therapy (EBRT) in patients with lung cancer is common. These patients do not have many treatment options and are usually offered palliative chemotherapy or best supportive care. Endobronchial ultrasound (EBUS)-guided intratumoral injection of cisplatin (ITC) is a novel approach for these patients. The procedure is performed under conscious sedation. The lesion is located with a bronchoscopy using EBUS, and a 22-gauge EBUS needle is advanced through the working channel of the scope and locked in position. Under ultrasound guidance, the wall of the tracheobronchial tree is punctured and the needle is moved into the target lesion. The needle stylet is then removed and cisplatin (40 mg/40 mL) is injected into the lesion. One to two sites are treated per session. Details of the procedure are described in the protocol section of paper. At our center, 50 sites were treated in 36 patients (19 males, 17 females). The mean age of our cohort was 61.9 ±8.5 years. We performed final analyses on 35 patients and 41 sites. 24/35 (69%) had complete or partial response (responders), whereas 11/35 (31%) had stable or progressive disease (non-responders). Overall, survival in our group was 8 months (95% CI of 6-11 months), with patients who responded having significantly better survival than the ones who did not.

A randomized Phase III trial of comparing two dose-fractionations stereotactic body radiotherapy (SBRT) for medically inoperable Stage IA non-small cell lung cancer or small lung lesions clinically diagnosed as primary lung cancer: Japan Clinical Oncology Group Study JCOG1408 (J-SBRT trial)

A randomized Phase III trial commenced in Japan in February 2016. Currently, 42 Gy in four fractions of stereotactic body radiotherapy prescribed at the D_95% of the planning target volume, which is considered equal to the commonly used 48 Gy in four fractions at the isocenter using an old dose calculation algorithm, is the standard treatment in Japan for medically inoperable Stage IA non-small cell lung cancer and small lung lesions clinically diagnosed as primary lung cancer. This study aims to examine the superiority of 55 Gy in four fractions over 42 Gy in four fractions. A total of 750 patients are expected to be accrued in 5 years. The primary endpoint is overall survival and the secondary endpoints are progression-free survival, local progression-free survival, patterns of failure, local control period, adverse events and serious adverse events. This trial is registered at the UMIN Clinical Trials Registry as UMIN000021029 (http://www.umin.ac.jp/ctr/index.htm) the dose covering 95% of the volume (D_95%) of the planning target volume.

Definitive radiation therapy in locally advanced non-small cell lung cancer: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based clinical practice guideline

PURPOSE

To provide guidance to physicians and patients with regard to the use of definitive external beam radiation therapy (RT) in locally advanced non-small cell lung cancer (LA NSCLC) based on available medical evidence complemented by consensus-based expert opinion.

METHODS AND MATERIALS

A panel authorized by the American Society for Radiation Oncology (ASTRO) Board of Directors and Guidelines Subcommittee conducted 3 systematic reviews on the following topics: (1) ideal radical RT dose fractionation for RT alone; (2) ideal radical RT dose fractionation for chemoradiation; and (3) ideal timing of radical radiation therapy with systemic chemotherapy. Practice guideline recommendations were approved using an a priori-defined consensus-building methodology supported by ASTRO and approved tools for the grading of evidence quality and the strength of guideline recommendations.

RESULTS

For patients managed by RT alone, a minimum dose of 60 Gy of RT is recommended. Dose escalation beyond 60 Gy in the context of combined modality concurrent chemoradiation has not been found to be associated with any clinical benefits. In the context of combined modality therapy, chemotherapy and radiation should ideally be given concurrently to maximize survival, local control, and disease response rate.

CONCLUSIONS

A consensus and evidence-based clinical practice guideline for the definitive radiotherapeutic management of LA NSCLC has been created that addresses 3 important questions.

Automated Extraction of Dose/Volume Statistics for Radiotherapy-Treatment-Plan Evaluation in Clinical-Trial Quality Assurance

Radiotherapy clinical-trial quality assurance is a crucial yet challenging process. This note presents a tool that automatically extracts dose/volume statistics for determining dosimetry compliance review with improved efficiency and accuracy. A major objective of this study is to develop an automated solution for clinical-trial radiotherapy dosimetry review.

Treatment of isolated mediastinal and hilar recurrence of lung cancer with bronchoscopic endobronchial ultrasound guided intratumoral injection of chemotherapy with cisplatin

PURPOSE

A common pattern of recurrence in lung cancer after receiving full dose external beam radiation therapy (EBRT) to targeted sites is isolated mediastinal and hilar recurrence (IMHR). Treatment options for these patients are limited to palliative radiation, chemotherapy, and/or best supportive care. We describe our experience with treating IMHR with bronchoscopic endobronchial ultrasound (EBUS) guided intratumoral injection of cisplatin (ITC).

METHODS

Patients treated between Jan 2009-September 2014 with ITC for IMHR were included. Patient demographics, tumor histology, size, concurrent therapy, location, number of sites treated, treatment sessions, and encounters were abstracted. Responses were analyzed on follow-up scans 8-12 weeks after the last treatment session using RECIST 1.1 criteria. Locoregional recurrence, progression-free survival (PFS), and overall survival were measured.

RESULTS

50 sites were treated in 36 patients (19 males, 17 females) with mean age 61.9±8.5 years. Eight sites treated on subsequent encounters were excluded and one patient had an unevaluable response, leaving 35 patients and 41 sites for final analysis. 24/35 (69%) had complete or partial response (responders), whereas 11/35 (31%) had stable or progressive disease (non-responders). There were no significant differences in response based on histology, size, and concurrent therapy. Median survival for the group was 8 months (95% CI of 6-11 mo). Responders had significantly higher survival and PFS than non-responders. Two patients treated with concurrent EBRT, developed broncho-mediastinal fistula.

CONCLUSION

EBUS guided intratumoral cisplatin for IMHR appears to be safe and effective, and may represent a new treatment paradigm for this patient population.

Patient Safety Across Disciplines: Radiation Oncology Incident Learning System

The Radiation Oncology Incident Learning System is a national error reporting system that is voluntary and confidential. Participants collect and analyze their data, then institute corrective actions so that true incident learning takes place.

Hyperfractionated and accelerated radiotherapy in non-small cell lung cancer

Radical radiotherapy plays a major role in the treatment of non-small cell lung cancer (NSCLC) due to the fact that many patients are medically or surgically inoperable. Advances in technology and radiotherapy delivery allow targeted treatment of the disease, whilst minimizing the dose to organs at risk. This in turn creates an opportunity for dose escalation and the prospect of tailoring radiotherapy treatment to each patient. This is especially important in patients deemed unsuitable for chemotherapy or surgery, where there is a need to increase the therapeutic gain from radical radiotherapy alone. Recent research into fractionation schedules, with hyperfractionated and accelerated radiotherapy regimes has been promising. How to combine these new fractionated schedules with dose escalation and chemotherapy remains open to debate and there is local, national and international variation in management with a lack of overall consensus. An overview of the current literature on hyperfractionated and accelerated radiotherapy in NSCLC is provided.

Radiotherapy for postoperative thoracic lymph node recurrence of non-small-cell lung cancer provides better outcomes if the disease is asymptomatic and a single-station involvement

OBJECTIVE

Thoracic lymph node recurrence after complete resection is common in non-small-cell lung cancer but it mostly occurs along with distant metastases. The recurrent disease might be localized and curative intent radiation therapy is the treatment of choice if no evidence of hematogenous metastasis is observed. We sought to describe the outcomes of thoracic radiotherapy for thoracic lymph node recurrences.

METHODS

Fifty patients who had developed thoracic lymph node recurrence after complete resection received curative intent radiotherapy between 1997 and 2009. The clinical endpoints included the tumor response, overall survival, progression-free survival, locoregional recurrence within the irradiated field, and any other recurrence.

RESULTS

The planned total radiotherapy was completed in 49 patients with minor toxicity. The median follow-up time after radiotherapy was 41 (19-98) months among the survivors. The response to treatment was complete response in 65%, partial response in 24%, and progressive disease in 10% of the evaluated patients. The median overall survival after radiotherapy was 37.3 months. The 5-year overall survival, progression-free survival, and local control rate were 36.1%, 22.2%, and 61.1%, respectively. A multivariate analysis revealed that the absence of symptoms and the involvement of a single lymph node station were significant factors associated with a better overall survival.

CONCLUSIONS

Radiation therapy for thoracic lymph node recurrence after complete resection is safe and provides acceptable disease control. This treatment provides a better outcome if the disease is asymptomatic and has a single-station involvement. Early detection of the recurrence may thus improve the effectiveness of this treatment.

[Quality criteria in radiotherapy for head and neck cancers under the aegis of Head and Neck Intergroup]

The aim of radiotherapy is to deliver enough radiation to the tumor in order to achieve maximum tumour control in the irradiated volume with as few serious complications as possible with an irradiation dose as low as possible to normal tissue. The quality of radiotherapy is essential for optimal treatment and quality control is to reduce the bias in clinical trials avoiding possible major deviations. The assurance and quality control programs have been developed in large european (EORTC, GORTEC) and american cooperative groups (RTOG) of radiation oncology since the 1980s. We insist here on the importance of quality assurance in radiotherapy and the current status in this domain and the criteria for quality control especially for current clinical trials within GORTEC are discussed here.

Fluoroscopically guided balloon dilation for benign bronchial stricture occurring after radiotherapy in patients with lung cancer

PURPOSE

To evaluate the safety and clinical effectiveness of fluoroscopically guided balloon dilation in patients with benign bronchial stricture occurring after radiotherapy (RT).

METHODS

From March 2002 to January 2013, ten patients with benign bronchial stricture occurring after RT underwent fluoroscopically guided balloon dilation as their initial treatment. Technical success, primary and secondary clinical success, improvement in respiratory status, and complications were evaluated. The symptomatic improvement period was calculated.

RESULTS

A total of 15 balloon dilation sessions were performed in ten patients, with a range of 1-4 sessions per patient (mean 1.5 sessions). Technical success was achieved in 100 %. Six of the ten patients exhibited no symptom recurrence and required no further treatment until the end of follow-up (range 4-105 months). Four patients (40 %) experienced recurrent symptom, and two of four patients underwent repeat balloon dilations. The remaining two patients underwent cutting balloon dilation and temporary stent placement, respectively, and they exhibited symptom improvement after adjuvant treatment until the end of our study. Finally, primary clinical success was achieved in six of ten patients (60 %) and secondary clinical success was achieved in eight of ten patients (80 %). The mean symptom improvement period was 61.9 ± 16 months (95 % confidence interval 30.6-93.3).

CONCLUSION

Fluoroscopically guided balloon dilation seems to be safe and clinically effective for the treatment of RT-induced benign bronchial stricture. Temporary stent placement or cutting balloon dilation could be considered in patients with benign bronchial strictures resistant to fluoroscopically guided balloon dilation.

Accelerated hypo-fractionated radiotherapy for non small cell lung cancer: results from 4 UK centres

BACKGROUND AND PURPOSE

A variety of radiotherapy fractionations are used as potentially curative treatments for non-small cell lung cancer. In the UK, 55 Gy in 20 fractions over 4 weeks (55/20) is the most commonly used fractionation schedule, though it has not been validated in randomized phase III trials. This audit pooled together existing data from 4 UK centres to produce the largest published series for this schedule.

MATERIALS AND METHODS

4 UK centres contributed data (Cambridge, Cardiff, Glasgow and Sheffield). Case notes and radiotherapy records of radically treated patients between 1999 and 2007 were retrospectively reviewed. Basic patient demographics, tumour characteristics, radiotherapy and survival data were collected and analysed.

RESULTS

609 patients were identified of whom 98% received the prescribed dose of 55/20. The median age was 71.3 years, 62% were male. 90% had histologically confirmed NSCLC, 49% had stage I disease. 27% had received chemotherapy (concurrent or sequential) with their radiotherapy. The median overall survival from time of diagnosis was 24.0 months and 2 year overall survival was 50%.

CONCLUSION

These data show respectable results for patients treated with accelerated hypo-fractionated radiotherapy for NSCLC with outcomes comparable to those reported for similar schedules and represent the largest published series to date for 55/20 regime.

Sequential chemoradiotherapy with accelerated hypofractionated radiotherapy compared to concurrent chemoradiotherapy with standard radiotherapy for locally advanced non-small cell lung cancer

To compare the outcomes and treatment-related toxicities of two chemoradiotherapy schedules given to the patients with unresectable locally advanced non-small cell lung cancer (NSCLC): sequential chemotherapy with accelerated hypofractionated radiotherapy (SCRT), and concurrent chemotherapy with standard radiotherapy (CCRT), 68 patients from two prospective clinical trials were included. Thirty-four patients were treated with SCRT using an accelerated hypofractionated radiation schedule, 34 patients received CCRT with standard radiation. Between the two treatment groups there were no significant differences in terms of overall survival, progression-free survival (PFS), locoregional-PFS or distant metastasis-PFS. For the SCRT group, the median survival time and 2- and 4-year overall survival rates were 19 months, 38.2%, and 23.5%, respectively, and for the CCRT group these were 19 months, 44.1%, and 19.6%. Esophageal and constitutional toxicities were more pronounced in the CCRT group, while there was no significant difference in pulmonary toxicities. The results suggest that for unresectable stage III NSCLC, the outcomes of SCRT with accelerated hypofractionated radiotherapy and CCRT with standard radiotherapy are similar, but the toxicities associated with treatment are less in the SCRT group.

Predicting 2-year survival for radiation regimens in advanced non-small cell lung cancer

AIMS

Total dose, dose per fraction, number of fractions and treatment time are important determinants of the biological effect of a radiation regimen. Several randomised clinical trials (RCTs) have tested a variety of dosing regimens in advanced unresected non-small cell lung cancer, but survival remains poor. This work used past RCT data to develop and validate a predictive model that could help in designing new radiation regimens for successful testing in RCTs.

MATERIALS AND METHODS

Eleven RCTs that compared radiation regimens alone were used to define the relationship between radiation regimens and 2-year survival. On the basis of this relationship, predictive models were developed. Predicted values were internally and externally validated against observed values from the same 11 RCTs and 21 other RCTs. Scatter plots and Pearson's correlation coefficient (r) were used for validation. Finally, regimens were explored that could improve survival.

RESULTS

Increments in the total dose, dose per day and the number of treatment days were associated with improved survival; increments in dose-squared and treatment weeks were associated with reduced survival. The observed and predicted values were similar on internal (r = 0.96) and external validation (r = 0.76). Regimens that delivered a higher total dose over a shorter time had higher survival rates compared with the standard (60 Gy, 30 fractions, 6 weeks); survival may be improved by delivering the standard treatment in 5 weeks rather than 6 weeks.

CONCLUSION

The developed model can predict the effect of thoracic radiation on survival in advanced non-small cell lung cancer patients. It is a useful tool for designing new radiation regimens for clinical trials.

ACR appropriateness criteria nonsurgical treatment for non-small-cell lung cancer: poor performance status or palliative intent

Radiation therapy plays a potential curative role in the treatment of patients with non-small-cell lung cancer with locoregional disease who are not surgical candidates and a palliative role for patients with metastatic disease. Stereotactic body radiation therapy is a relatively new technique in patients with early-stage non-small-cell lung cancer. A trial from RTOG(®) reported >97% local control at 3 years. For patients with locally advanced disease, thoracic radiation to a dose of 60 Gy remains the standard of care. Sequential chemotherapy or radiation alone can be used for patients with poor performance status who cannot tolerate more aggressive approaches. Chemotherapy should be used for patients with metastatic disease. Radiation therapy is useful for palliation of symptomatic tumors, and a dose of approximately 30 Gy is commonly used. Endobronchial brachytherapy is useful for patients with symptomatic endobronchial tumors. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Evolution of modern-era radiotherapy strategies for unresectable advanced non-small-cell lung cancer

SUMMARY In patients with advanced non-small-cell lung cancer, the current standard of care is chemoradiotherapy, which offers better outcomes than sequential treatments. Conventional radiotherapy (60–66 Gy) is associated with poor local control and dismal survival. The challenge is to escalate and/or accelerate the radiation dose safely and effectively. Cutting-edge technologies, such as 4D image-based motion management, intensity-modulated radiation therapy, proton therapy and image-guided radiotherapy, have enabled the delivery of higher doses of radiation to the difficult-to-treat moving tumors with lower toxicity risks. Incorporating the motion in 4D planning, such as an average internal target volume, would enable radiation oncologists to integrate the interfractional anatomic changes in the course of treatment for proper estimation of the actual dose delivery. Optimizing the combination of systemic therapy with radiotherapy, using a personalized approach based on using cutting-edge technologies for knowledge-guided dose escalation/acceleration radiotherapy, are crucial to improving the therapeutic ratio of non-small-cell lung cancer.

Does quality of radiation therapy predict outcomes of multicenter cooperative group trials? A literature review

Central review of radiation therapy (RT) delivery within multicenter clinical trials was initiated in the early 1970s in the United States. Early quality assurance publications often focused on metrics related to process, logistics, and timing. Our objective was to review the available evidence supporting correlation of RT quality with clinical outcomes within cooperative group trials. A MEDLINE search was performed to identify multicenter studies that described central subjective assessment of RT protocol compliance (quality). Data abstracted included method of central review, definition of deviations, and clinical outcomes. Seventeen multicenter studies (1980-2012) were identified, plus one Patterns of Care Study. Disease sites were hematologic, head and neck, lung, breast, and pancreas. Between 0 and 97% of treatment plans received an overall grade of acceptable. In 7 trials, failure rates were significantly higher after inadequate versus adequate RT. Five of 9 and 2 of 5 trials reported significantly worse overall and progression-free survival after poor-quality RT, respectively. One reported a significant correlation, and 2 reported nonsignificant trends toward increased toxicity with noncompliant RT. Although more data are required, protocol-compliant RT may decrease failure rates and increase overall survival and likely contributes to the ability of collected data to answer the central trial question.

Predictors of radiation pneumonitis and pulmonary function changes after concurrent chemoradiotherapy of non-small cell lung cancer

Purpose

To evaluate the predictive factors of radiation pneumonitis (RP) and associated changes in pulmonary function after definitive concurrent chemoradiotherapy (CCRT) in patients with non-small cell lung cancer (NSCLC).

Materials and Methods

Medical records of 60 patients with NSCLC who received definitive CCRT were retrospectively reviewed. Dose volumetric (DV) parameters, clinical factors, and pulmonary function test (PFT) data were analyzed. RP was graded according to the CTCAE ver. 4.0. Percentage of lung volume that received a dose of threshold (Vdose) and mean lung dose (MLD) were analyzed for potential DV predictors. PFT changes were calculated as the difference between pre-RT and post-RT values at 3, 6, and 12 months after RT.

Results

Twenty-two patients (37%) developed grade ≥2 RP. Among clinical factors, tumor location in lower lobe was associated with RP. Among the DV parameters, only MLD >15 Gy was associated with grade ≥2 RP. There were statistically significant decreases in PFT at all points compared with pre-RT values in grade ≥2 RP group. MLD was associated with forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) changes at 6 and 12 months. V10 was associated with FVC changes at 12 months. V20 and V30 were associated with FEV1 changes at 6 months and FVC changes at 12 months.

Conclusion

After definitive CCRT in patients with NSCLC, MLD >15 Gy and lower lobe tumor location were predictors of grade ≥2 RP. Pulmonary functions were decreased after CCRT and the magnitude of changes was associated with DV parameters.

Radiotherapy protocol deviations and clinical outcomes: a meta-analysis of cooperative group clinical trials

BACKGROUND

Noncompliance with radiotherapy (RT) protocol guidelines has been linked to inferior clinical outcomes. We performed a meta-analysis of cooperative group trials to examine the association between RT quality assurance (QA) deviations and disease control and overall survival (OS).

METHODS

We searched MEDLINE and the Cochrane Central Register of Controlled Trials for multi-institutional trials that reported clinical outcomes in relation to RT QA results. Hazard ratios (HRs) describing the association between RT protocol noncompliance and patient outcomes were extracted directly from the original studies or calculated from survival curves. Inverse variance meta-analyses were performed to assess the association between RT QA deviations and OS. A second meta-analysis tested the association between RT QA deviations and secondary outcomes, including local or locoregional control, event-free survival, and relapse. Random-effects models were used in cases of statistically significant (P < .10) effect heterogeneity. The Egger test was used to detect publication bias. All statistical tests were two-sided.

RESULTS

Eight studies (four pediatric, four adult) met all inclusion criteria and were incorporated into this analysis. The frequency of RT QA deviations ranged from 8% to 71% (median = 32%). In a random-effects model, RT deviations were associated with a statistically significant decrease in OS (HR of death = 1.74, 95% confidence interval [CI] = 1.28 to 2.35; P < .001). A similar effect was seen for secondary outcomes (HR of treatment failure = 1.79, 95% CI = 1.15 to 2.78; P = .009). No evidence of publication bias was detected.

CONCLUSION

In clinical trials, RT protocol deviations are associated with increased risks of treatment failure and overall mortality.

Integration of targeted therapy in the management of locally advanced, unresectable non-small-cell lung cancer

SUMMARY The standard of care for unresectable, locally advanced non-small-cell lung cancer (NSCLC; stage IIIA and IIIB) in the past decade has been concomitant platinum-based chemoradiation therapy. Unfortunately, a plateau has been reached in terms of response and survival rates with the present chemotherapeutic paradigm. Targeted biological agents have significantly altered the treatment landscape for stage IV NSCLC and offer an opportunity to do the same for locally advanced NSCLC. While some early trials using unselected patients have shown modest promise for several biologic agents, the overall data remain mixed. One limitation of these trials has been the lack of patient enrichment based on molecular phenotype most likely to benefit from a particular targeted therapy. This review summarizes the most recent data for select classes of targeted agents being tested in the locally advanced NSCLC setting, and gives insights into future developments in this clinical area.

Radiation Dose Escalation in Stage III Non-Small-Cell Lung Cancer

For patients with stage III non-small-cell lung cancer with unresectable or inoperable tumors, definitive chemoradiotherapy is often utilized. Historically, local control and overall survival rates have been poor. In an effort to improve local control, new chemotherapeutic agents in combination with higher doses of radiotherapy have been investigated. Early dose escalation trials date back to the 1980s, and the feasibility and efficacy of dose escalation for patients with inoperable stage III lung cancer continue to be topics of investigation. Herein, we review the evolution of chemotherapy as it relates to treatment of unresectable stage III lung cancer, and we outline the early and the more recent dose escalation studies. While dose escalation appears to provide a modest benefit in terms of preventing local failure and improving overall survival, advances in diagnostic imaging and radiotherapy treatment have possibly resulted in selection of a more favorable patient population. These variables make statements regarding the benefit of dose escalation challenging.

Sequential vs. concurrent chemoradiation for stage III non-small cell lung cancer: randomized phase III trial RTOG 9410

BACKGROUND

The combination of chemotherapy with thoracic radiotherapy (TRT) compared with TRT alone has been shown to confer a survival advantage for good performance status patients with stage III non-small cell lung cancer. However, it is not known whether sequential or concurrent delivery of these therapies is the optimal combination strategy.

METHODS

A total of 610 patients were randomly assigned to two concurrent regimens and one sequential chemotherapy and TRT regimen in a three-arm phase III trial. The sequential arm included cisplatin at 100 mg/m2 on days 1 and 29 and vinblastine at 5 mg/m2 per week for 5 weeks with 63 Gy TRT delivered as once-daily fractions beginning on day 50. Arm 2 used the same chemotherapy regimen as arm 1 with 63 Gy TRT delivered as once-daily fractions beginning on day 1 [corrected]. Arm 3 used cisplatin at 50 mg/m2 on days 1, 8, 29, and 36 with oral etoposide at 50 mg twice daily for 10 weeks on days 1, 2, 5, and 6 with 69.6 Gy delivered as 1.2 Gy twice-daily fractions beginning on day 1. The primary endpoint was overall survival, and secondary endpoints included tumor response and time to tumor progression. Kaplan-Meier analyses were used to assess survival, and toxic effects were examined using the Wilcoxon rank sum test. All statistical tests were two-sided.

RESULTS

Median survival times were 14.6, 17.0, and 15.6 months for arms 1-3, respectively. Five-year survival was statistically significantly higher for patients treated with the concurrent regimen with once-daily TRT compared with the sequential treatment (5-year survival: sequential, arm 1, 10% [20 patients], 95% confidence interval [CI] = 7% to 15%; concurrent, arm 2, 16% [31 patients], 95% CI = 11% to 22%, P = .046; concurrent, arm 3, 13% [22 patients], 95% CI = 9% to 18%). With a median follow-up time of 11 years, the rates of acute grade 3-5 nonhematologic toxic effects were higher with concurrent than sequential therapy, but late toxic effects were similar.

CONCLUSION

Concurrent delivery of cisplatin-based chemotherapy with TRT confers a long-term survival benefit compared with the sequential delivery of these therapies.

Radiotherapy quality assurance review for a multi-center randomized trial of locally advanced esophageal cancer: the Japan Clinical Oncology Group (JCOG) trial 0303

BACKGROUND AND PURPOSE

The purpose of this study was to evaluate the radiotherapy (RT) quality assurance (QA) for JCOG 0303.

METHODS AND MATERIALS

JCOG 0303 was a multi-center phase II/III trial that compared two types of chemotherapy administered concomitantly with RT for locally advanced esophageal cancer. RT requirements included a total dose of 60 Gy in 30 fractions and CTV with a 2-cm margin cranio-caudally to the primary tumor. The QA assessment was given as per protocol (PP), deviation acceptable (DA), violation unacceptable (VU), and incomplete/not evaluable following predefined criteria for quality parameters.

RESULTS

A total of 142 cases were accrued. After excluding 36 incomplete/not evaluable, 106 (75%) were fully evaluable for RT quality review. Of these 106, there were 4 VU (4%) and overall RT compliance (PP + DA) was 96%. Comparing the incidence of VU based on the numbers enrolled by institution, the highest quarter of enrollment (≥7 cases) had no VU, while all VU (4; 11%) were from institutions enrolling <7 patients.

CONCLUSIONS

The results of the RTQA assessment for JCOG 0303 were sufficient to provide reliable results. Additional improvements will be needed for institutions with low accrual rates.

From Cisplatin-Containing Sequential Radiochemotherapy towards Concurrent Treatment for Patients with Inoperable Locoregional Non-Small Cell Lung Cancer: Still Unanswered Questions

Radiotherapy has been the mainstay of the treatment of stage III non-small cell lung cancer (NSCLC) patients. In the early nineties, combined treatment with chemotherapy was introduced. In 1995, a meta-analysis showed improved treatment outcome of the sequential use of radiochemotherapy (RCT) compared to radiotherapy alone, provided cisplatin was part of the chemotherapy course. Concurrent RCT compared to radiotherapy only yielded the same improvements of 4% in the 2-year and 2% in the 5-year overall survival rates. Just recently, two meta-analyses demonstrated that concurrent RCT is definitely superior to sequential RCT in terms of local control and 2-, 3-, and 5-year survival. However, several unanswered questions remain concerning the optimal chemotherapy regimen and radiotherapy doses and techniques in terms of treatment outcome and toxicity profile. Arguments supporting a daily low-dose cisplatin scheme are presented because of comparable radiosensitizing characteristics and favourable side effects. Increasing radiotherapy doses applied according to up-to-date techniques and combinations with new biologicals might lead to further treatment improvements.

Continuous hyperfractionated accelerated radiotherapy (CHART) and non-conventionally fractionated radiotherapy in the treatment of non-small cell lung cancer: a review and consideration of future directions

There is a well-established role for radiation treatment in the management of non-small cell lung cancer. As a single modality, it is indicated as a radical treatment option for patients deemed unsuitable for chemotherapy with inoperable locoregional disease or who decline surgery. In this patient group, the evidence shows advantages for accelerated treatment regimes, e.g. continuous hyperfractionated accelerated radiotherapy (CHART). Research efforts should be directed towards dose escalation with the application of the new technologies available. The multi-modality approach of chemoradiotherapy is established in the radical treatment of non-small cell lung cancer in those who are inoperable, radically treatable and fit enough to receive chemotherapy. How best these two modalities are combined remains unclear, and the combination of CHART and other non-conventionally fractionated radiotherapy schedules with chemotherapy and targeted agents is another potentially productive research area.

Effectiveness of radiation therapy for elderly patients with unresected stage I and II non-small cell lung cancer

RATIONALE

Radiotherapy (RT) is considered the standard treatment for patients with stage I or II non-small lung cancer who are not surgical candidates because of comorbities or preferences against surgery.

OBJECTIVES

To compare the outcomes of patients treated with RT alone with those who were untreated to assess the effect of RT on survival.

METHODS

Using the Surveillance, Epidemiology and End Results (SEER) registry linked to Medicare files, we identified 6,065 unresected patients with histologically confirmed stage I and stage II non-small cell lung cancer, diagnosed between 1992 and 2002. We used propensity score methods and instrumental variable analysis to control for the possible effects of known as well as unmeasured confounders.

MEASUREMENTS AND MAIN RESULTS

Overall, 59% of patients received RT. The overall and lung cancer-specific survival of unresected patients treated with RT was significantly better compared with the untreated cases (P < 0.0001 for both comparisons). RT was associated with a 6-month improvement in median overall survival. Propensity score analyses showed that RT was associated with improved overall (hazard ratio, 0.74; 95% confidence interval, 0.70-0.78) and lung cancer-specific survival (hazard ratio, 0.73; 95% confidence interval, 0.69-0.78). Instrumental variable analysis also indicated improved outcomes among patients treated with RT.

CONCLUSIONS

RT improves survival of elderly patients with unresected stage I or II lung cancer. These results should be confirmed in prospective trials.

Adenovirus-mediated transfer of siRNA against survivin enhances the radiosensitivity of human non-small cell lung cancer cells

Expression of survivin has been reported to be correlated with shorter survival in patients with non-small cell lung cancer (NSCLC), and overexpression of survivin may lead to radioresistance in various human cancers. In this study, we inhibited survivin expression by using an adenoviral vector (AdsiSurvivin)-mediated RNA interference to elucidate the combined effect of survivin-targeting gene therapy and radiotherapy on the NSCLC cells. Our data showed that AdsiSurvivin exerted survivin gene silencing, induced apoptosis, and significantly attenuated the growth potential in NSCLC cells within 72 h after infection. The combined treatment modalities with AdsiSurvivin infection and radiation were significantly more potent on cell-growth inhibition than monotherapy. In H1650, H460, A549, and H1975 human NSCLC cells, the survival ratios of AdsiSurvivin-treated groups at multiplicity of infection of 25 and 50 were significantly lower than those of control groups at varying radiation dose (0-8 Gy; three-way analysis of variance, P<0.05). The cytotoxicity of combined AdsiSurvivin infection and irradiation increased in a dose-dependent manner in both the virus and the irradiation treatment. Knockdown of the survivin gene expression seems to be a promising treatment strategy for NSCLC. Our data warrant the need for further effort to develop survivin-targeted radiosensitizer for lung cancer treatment.

Patient willingness to undergo chemotherapy and thoracic radiotherapy for locally advanced non-small cell lung cancer

OBJECTIVES

To determine how Japanese patients with lung cancer weigh the chance of cure and potential survival against the potential toxicity of different treatment strategies for locally advanced non-small cell lung cancer (NSCLC).

METHODS

We used a questionnaire describing a hypothetical situation involving locally advanced NSCLC. Seventy-three patients with lung cancer who had received chemotherapy and a control group of 120 patients without cancer were asked to state the minimal benefit that would make two hypothetical treatments acceptable.

RESULTS

Patients with lung cancer were significantly more likely than were patients without cancer to accept either intensive or less-intensive chemoradiotherapy for a potentially small benefit for 'chance of cure' and 'response but not cure'. The percentages of patients who would accept intensive or less-intensive chemoradiotherapy to prolong survival did not differ significantly between the two groups. When the chance of cure was 20%, 56 and 64% of patients with lung cancer were willing to receive intensive and less-intensive chemoradiotherapy, respectively. If their lives were prolonged by 6 months, 20 and 30% of patients with lung cancer would choose to receive intensive and less-intensive chemoradiotherapy, respectively. The chance of cure and the survival advantage that patients require for accepting chemoradiotherapy varied widely. No factors were associated with the choice of chemoradiotherapy in patients with lung cancer.

CONCLUSIONS

Physicians must consider the substantial range of attitudes to chemoradiotherapy among patients when selecting treatment and give patients opportunities to be included in the treatment-selection process.

Conformal radiotherapy for lung cancer: interobservers' variability in the definition of gross tumor volume between radiologists and radiotherapists

Background

Conformal external radiotherapy aims to improve tumor control by boosting tumor dose, reducing morbidity and sparing healthy tissues. To meet this objective careful visualization of the tumor and adjacent areas is required. However, one of the major issues to be solved in this context is the volumetric definition of the targets. This study proposes to compare the gross volume of lung tumors as delineated by specialized radiologists and radiotherapists of a cancer center.

Methods

Chest CT scans of a total of 23 patients all with non-small cell lung cancer, not submitted to surgery, eligible and referred to conformal radiotherapy on the Hospital A. C. Camargo (São Paulo, Brazil), during the year 2004 were analyzed. All cases were delineated by 2 radiologists and 2 radiotherapists. Only the gross tumor volume and the enlarged lymph nodes were delineated. As such, four gross tumor volumes were achieved for each one of the 23 patients.

Results

There was a significant positive correlation between the 2 measurements (among the radiotherapists, radiologists and intra-class) and there was randomness in the distribution of data within the constructed confidence interval.

Conclusion

There were no significant differences in the definition of gross tumor volume between radiologists and radiotherapists.

Radiotherapy quality assurance review in a multi-center randomized trial of limited-disease small cell lung cancer: the Japan Clinical Oncology Group (JCOG) trial 0202

Background

The purpose of this study was to analyze the radiotherapy (RT) quality assurance (QA) assessment in Japan Clinical Oncology Group (JCOG) 0202, which was the first trial that required on-going RT QA review in the JCOG.

Methods

JCOG 0202 was a multi-center phase III trial comparing two types of consolidation chemotherapy after concurrent chemoradiotherapy for limited-disease small cell lung cancer. RT requirements included a total dose of 45 Gy/30 fx (bis in die, BID/twice a day) without heterogeneity correction; elective nodal irradiation (ENI) of 30 Gy; at least 1 cm margin around the clinical target volume (CTV); and interfraction interval of 6 hours or longer. Dose constraints were defined in regards to the spinal cord and the lung. The QA assessment was classed as per protocol (PP), deviation acceptable (DA), violation unacceptable (VU), and incomplete/not evaluable (I/NE).

Results

A total of 283 cases were accrued, of which 204 were fully evaluable, excluding 79 I/NE cases. There were 18 VU in gross tumor volume (GTV) coverage (8% of 238 evaluated); 4 VU and 23 DA in elective nodal irradiation (ENI) (2% and 9% of 243 evaluated, respectively). Some VU were observed in organs at risk (1 VU in the lung and 5 VU in the spinal cord). Overall RT compliance (PP + DA) was 92% (187 of 204 fully evaluable). Comparison between the former and latter halves of the accrued cases revealed that the number of VU and DA had decreased.

Conclusion

The results of the RT QA assessment in JCOG 0202 seemed to be acceptable, providing reliable results.

Exclusion of elective nodal irradiation is associated with minimal elective nodal failure in non-small cell lung cancer

BACKGROUND

Controversy still exists regarding the long-term outcome of patients whose uninvolved lymph node stations are not prophylactically irradiated for non-small cell lung cancer (NSCLC) treated with definitive radiotherapy. To determine the frequency of elective nodal failure (ENF) and in-field failure (IFF), we examined a large cohort of patients with NSCLC staged with positron emission tomography (PET)/computed tomography (CT) and treated with 3-dimensional conformal radiotherapy (3D-CRT) that excluded uninvolved lymph node stations.

METHODS

We retrospectively reviewed the records of 115 patients with non-small cell lung cancer treated at our institution with definitive radiation therapy with or without concurrent chemotherapy (CHT). All patients were treated with 3D-CRT, including nodal regions determined by CT or PET to be disease involved. Concurrent platinum-based CHT was administered for locally advanced disease. Patients were analyzed in follow-up for survival, local regional recurrence, and distant metastases (DM).

RESULTS

The median follow-up time was 18 months (3 to 44 months) among all patients and 27 months (6 to 44 months) among survivors. The median overall survival, 2-year actuarial overall survival and disease-free survival were 19 months, 38%, and 28%, respectively. The majority of patients died from DM, the overall rate of which was 36%. Of the 31 patients with local regional failure, 26 (22.6%) had IFF, 5 (4.3%) had ENF and 2 (1.7%) had isolated ENF. For 88 patients with stage IIIA/B, the frequencies of IFF, any ENF, isolated ENF, and DM were 23 (26%), 3 (9%), 1 (1.1%) and 36 (40.9%), respectively. The comparable rates for the 22 patients with early stage node-negative disease (stage IA/IB) were 3 (13.6%), 1(4.5%), 0 (0%), and 5 (22.7%), respectively.

CONCLUSION

We observed only a 4.3% recurrence of any ENF and a 1.7% recurrence of isolated ENF in patients with NSCLC treated with definitive 3D-CRT without prophylactic irradiation of uninvolved lymph node stations. Thus, distant metastasis and IFF remain the primary causes of treatment failure and cancer death in such patients, suggesting little value of ENI in this cohort.