Radical radiotherapy for early nonsmall cell lung cancer

Five- Versus Ten-Fraction Regimens of Stereotactic Body Radiation Therapy for Primary and Metastatic NSCLC

INTRODUCTION

At our institution, stereotactic body radiotherapy (SBRT) has commonly been prescribed with 50 Gy in 5 fractions and in select cases, 50 Gy in 10 fractions. We sought to evaluate the impact of these 2 fractionation schedules on local control and survival outcomes.

METHODS

We reviewed patients treated with SBRT with 50 Gy/5 fraction or 50 Gy/10 fraction for early-stage non-small cell lung cancer (NSCLC) and metastatic NSCLC. Cumulative incidence of local failure (LF) was estimated using competing risk methodology. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method only for patients with stage I disease.

RESULTS

Of the 353 lesions, 300 (85%) were treated with 50 Gy in 5 fractions and 53 (15%) with 10 fractions. LFs at 3 years were 6.5% and 23.9% and Kaplan-Meier estimate of median time to LF was 17.5 months and 26.2 months, respectively. Multivariable analysis revealed increasing planning target volume (hazard ratio 1.01, P = .04) as an independent predictor of increased LF, but tumor size, ultracentral location, and 10 fractions were not. Among patients with stage I NSCLC (n = 298), overall median PFS was 35.6 months and median OS was 42.4 months. There was no difference in PFS or OS between the 2 treatment regimens for patients with stage I NSCLC. Low rates of grade 3+ toxicity were observed, with 1 patient experiencing grade 3 pneumonitis after a 5-fraction regimen of SBRT.

CONCLUSION

Dose-fractionation schemes with BED₁₀ ≥ 100 Gy provide superior local control and should be offered when meeting commonly accepted constraints. If those regimens appear unsafe, 50 Gy in 10 fractions may provide acceptable compromise between tumor control and safety with relatively durable control, and minimal negative impact on long-term survival.

A Prediction Model to Help with Oncologic Mediastinal Evaluation for Radiation: HOMER

Rationale: When stereotactic ablative radiotherapy is an option for patients with non–small cell lung cancer (NSCLC), distinguishing between N0, N1, and N2 or N3 (N2|3) disease is important.

Objectives: To develop a prediction model for estimating the probability of N0, N1, and N2|3 disease.

Methods: Consecutive patients with clinical-radiographic stage T1 to T3, N0 to N3, and M0 NSCLC who underwent endobronchial ultrasound–guided staging from a single center were included. Multivariate ordinal logistic regression analysis was used to predict the presence of N0, N1, or N2|3 disease. Temporal validation used consecutive patients from 3 years later at the same center. External validation used three other hospitals.

Measurements and Main Results: In the model development cohort (n = 633), younger age, central location, adenocarcinoma, and higher positron emission tomography–computed tomography nodal stage were associated with a higher probability of having advanced nodal disease. Areas under the receiver operating characteristic curve (AUCs) were 0.84 and 0.86 for predicting N1 or higher (vs. N0) disease and N2|3 (vs. N0 or N1) disease, respectively. Model fit was acceptable (Hosmer-Lemeshow, P = 0.960; Brier score, 0.36). In the temporal validation cohort (n = 473), AUCs were 0.86 and 0.88. Model fit was acceptable (Hosmer-Lemeshow, P = 0.172; Brier score, 0.30). In the external validation cohort (n = 722), AUCs were 0.86 and 0.88 but required calibration (Hosmer-Lemeshow, P < 0.001; Brier score, 0.38). Calibration using the general calibration method resulted in acceptable model fit (Hosmer-Lemeshow, P = 0.094; Brier score, 0.34).

Conclusions: This prediction model can estimate the probability of N0, N1, and N2|3 disease in patients with NSCLC. The model has the potential to facilitate decision-making in patients with NSCLC when stereotactic ablative radiotherapy is an option.

Treatment of T3N0 non-small cell lung cancer with chest wall invasion using stereotactic body radiotherapy

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The role of SBRT for T3N0 lung cancer invading the chest wall is unknown.

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We treated 12 patients with T3N0 chest wall-invading lung cancer with SBRT.

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Local control was excellent and no grade 3+ toxicity was observed.

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Pre-treatment chest wall pain was relieved after SBRT in most patients.

Objectives

Chest wall invasion (CWI) is observed in 5% of localized non-small cell lung cancer (NSCLC). The role of stereotactic body radiotherapy (SBRT) in these patients is unknown. We investigate the safety and efficacy of SBRT in patients with T3N0 NSCLC due to CWI.

Methods

Patients with T3N0 NSCLC due to CWI were identified using a prospective registry. CWI was defined as radiographic evidence of soft tissue invasion or bony destruction. We excluded patients with recurrent or metastatic disease. All patients were treated with definitive SBRT. Prescribed dose was 50 Gy in 5 fractions for most patients. Kaplan-Meier analysis was used to estimate survival outcomes.

Results

We identified 12 patients treated between 2006 and 2017. Median age was 70 (range, 58–85). Median tumor diameter was 3.0 cm (range, 0.9–7.2). Median survival was 12.0 months (range, 2.4–63). At a median follow-up of 8.9 months (range, 2.1–63), 1-year primary tumor control was 89%, involved lobar control was 89%, local–regional control was 82%, distant control was 91%, and survival was 63%. Of the 4 patients with pre-treatment chest wall pain, 3 reported improvement after SBRT. Two patients reported new grade 1–2 chest wall pain. No grade 3+ toxicity was reported, with 1 patient experiencing grade 1 skin toxicity and 3 patients experiencing grade 1–2 radiation pneumonitis.

Conclusions

SBRT for CWI NSCLC is safe, with high early tumor control and low treatment-related toxicity. Most patients with pre-treatment chest wall pain experienced relief after SBRT, with no grade 3+ toxicity observed.

Implantation of computed tomography-guided Iodine-125 seeds in combination with chemotherapy for the treatment of stage III non-small cell lung cancer

Purpose

We investigated the role of computed tomography (CT)-guided Iodine-125 (¹²⁵I) seed implantation in combination with chemotherapy for the treatment of stage III non-small cell lung carcinoma (NSCLC).

Material and methods

The data from 182 patients with stage III NSCLC who were treated with radioactive ¹²⁵I seed implantation between June 2002 and June 2009, and who received sequential platinum-based combination chemotherapy using the most common combination of platinum and gemcitabine, were retrospectively reviewed. The 182 patients received a prescribed dose of 110.0 Gy, with a median radioactivity of 0.70 mCi (range, 0.64-0.78 mCi, 2.37-3.26 × 107 Bq). The median number of ¹²⁵I seeds was 38 pellets (range, 6-105 pellets). The median post-operation dose covering 100% of the target volume (D₁₀₀) was 94.5 Gy (range, 54.6-125.5 Gy). The median D₉₀ was 143.0 Gy (range, 121.6-184.0).

Results

The 1-, 3-, and 5-year overall survival rates were 83.35%, 25.57%, and 11.34%, respectively; the median survival time was 24.76 months. At 1, 3, and 5 years, the local control rates were 92.01%, 86.51%, and 76.45%, respectively; the median local control time was 25.28 months. For patients with stage IIIA and IIIB NSCLC, the median survival times were 26.67 and 24.59 months, respectively (p = 0.2). Pre-treatment hemoglobin level, tumor volume, and postoperative D₁₀₀ were significantly associated with survival. A total of 24 patients experienced pneumothorax (incidence rate, 13.20%), and 17 patients experienced hemothorax (incidence rate, 5.0%).

Conclusions

CT-guided ¹²⁵I seed implantation combined with chemotherapy is an effective, minimally invasive method for the treatment of stage III NSCLC. Furthermore, hemoglobin levels before treatment, D₁₀₀, and the maximum diameter of the tumor may be prognostic factors in patients with NSCLC treated sequentially with radiotherapy and chemotherapy.

Technical Description, Phantom Accuracy, and Clinical Feasibility for Single-Session Lung Radiosurgery Using Robotic Image-Guided Real-time Respiratory Tumor Tracking

To describe the technological background, the accuracy, and clinical feasibility for single session lung radiosurgery using a real-time robotic system with respiratory tracking. The latest version of image-guided real-time respiratory tracking software (Synchrony®, Accuray Incorporated, Sunnyvale, CA) was applied and is described. Accuracy measurements were performed using a newly designed moving phantom model. We treated 15 patients with 19 lung tumors with robotic radiosurgery (CyberKnife®, Accuray) using the same treatment parameters for all patients. Ten patients had primary tumors and five had metastatic tumors. All patients underwent computed tomography-guided percutaneous placement of one fiducial directly into the tumor, and were all treated with single session radiosurgery to a dose of 24 Gy. Follow up CT scanning was performed every two months.

All patients could be treated with the automated robotic technique. The respiratory tracking error was less than 1 mm and the overall shape of the dose profile was not affected by target motion and/or phase shift between fiducial and optical marker motion. Two patients required a chest tube insertion after fiducial implantation because of pneumothorax. One patient experienced nausea after treatment. No other short-term adverse reactions were found. One patient showed imaging signs of pneumonitis without a clinical correlation.

Single-session radiosurgery for lung tumor tracking using the described technology is a stable, safe, and feasible concept for respiratory tracking of tumors during robotic lung radiosurgery in selected patients. Longer follow-up is needed for definitive clinical results.

WITHDRAWN: Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable)

The authors are unable to update this review. A new team is being sought to update it.

The editorial group responsible for this previously published document have withdrawn it from publication.

Stereotactic radiotherapy for pulmonary metastases

The most common treatment of pulmonary metastasis for solid tumors employs systemic chemotherapy, hormonal therapy, or biologic agents. Some series have suggested that aggressive surgical resection of pulmonary metastasis may improve patient outcomes in terms of quality of life and overall survival. Recently, data from clinical trials and retrospective series support the use of aggressive local control with high conformal dose radiotherapy (stereotactic body radiation therapy) in patients with limited metastases or oligometastases. Further evidence suggests that these patients represent a distinct clinical and biological class of patients. This review focuses on the role of ablative doses of radiotherapy in the treatment of pulmonary metastases. Specifically we discuss the rationale, treatment delivery, and local control that have led to the ongoing randomized clinical trials attempting to demonstrate a benefit over the current palliative standard of care.

Optimal beam arrangement for stereotactic body radiation therapy delivery in lung tumors

PURPOSE

To compare the different beam arrangement and delivery techniques for stereotactic body radiation therapy (SBRT) of lung lesions using the criteria of Radiation Therapy Oncology Group (RTOG) 0236 protocol.

MATERIAL AND METHODS

Thirty-seven medically inoperable lung cancers were evaluated with various planning techniques including multiple coplanar multiple static beams, multiple non-coplanar static beams and arc delivery. Twelve plans were evaluated for each case, including five plans using coplanar fixed beams, six plans using non-coplanar fixed beams and one plan using arc therapy. These plans were compared using the target prescription isodose coverage, high and low dose volumes, and critical organ dose-volume limits.

RESULTS

The prescription isodose coverage, high dose evaluation criteria and dose to critical organs were similar among treatment delivery techniques. However, there were differences in low dose criteria, especially in the ratio of the volume of 50% isodose of the prescription dose to the volume of planning treatment volume (R(50%)). The R(50%) in plans using non-coplanar static beams was lower than other plans in 30 of 37 cases (81%).

CONCLUSION

Based on the dosimetric criteria outlined in RTOG 0236, the treatment technique using non-coplanar static beams showed the most preferable results for SBRT of lung lesions.

Radiation therapy in the elderly: more side effects and complications?

Aging is associated with physiological changes and comorbid illnesses, which may affect an individual's tolerance to radiation. There is the belief that a relationship exists between age and radiation toxicity and therefore non-curative schemes are offered to older patients. Preclinical studies show that normal tissue radiation-induced toxicity differs little with age. In the clinical setting, retrospective and some prospective studies have reported that elderly patients treated with radical radiotherapy alone or in combination with chemotherapy, who do not have comorbidities and retain a good performance status, show a benefit in treatment outcomes. However, an increase in acute effects or a lowered functional tolerance has also been reported. To select candidates for radical treatments, a specific geriatric assessment should be used to stratify elderly patients as a function of the physiological status. Only specifically designed prospective studies can define the role of radiation treatment in elderly patients with different physiological status.

Safety and efficacy of percutaneous fiducial marker implantation for image-guided radiation therapy

PURPOSE

To evaluate the safety and technical success rate of percutaneous fiducial marker implantation in preparation for image-guided radiation therapy.

MATERIALS AND METHODS

From January 2003 to January 2008, we retrospectively reviewed 139 percutaneous fiducial marker implantations in 132 patients. Of the 139 implantations, 44 were in the lung, 61 were in the pancreas, and 34 were in the liver. Procedure-related major and minor complications were documented. Technical success was defined as implantation enabling adequate treatment planning and computed tomographic simulation.

RESULTS

The major and minor complication rates were 5% and 17.3%, respectively. Pneumothorax after lung implantation was the most common complication. Pneumothoraces were seen in 20 of the 44 lung implantations (45%); a chest tube was required in only seven of the 44 lung transplantations (16%). Of the 139 implantations, 133 were successful; in six implantations (4.3%) the fiducial markers migrated and required additional procedures or alternate methods of implantation.

CONCLUSIONS

Percutaneous implantation of fiducial marker is a safe and effective procedure with risks that are similar to those of conventional percutaneous organ biopsy.

Endovascular coils as lung tumour markers in real-time tumour tracking stereotactic radiotherapy: preliminary results

To evaluate the use of endovascular coils as markers for respiratory motion correction during high-dose stereotactic radiotherapy with the CyberKnife, an image-guided linear accelerator mounted on a robotic arm. Endovascular platinum embolisation coils were used to mark intrapulmonary lesions. The coils were placed in subsegmental pulmonary artery branches in close proximity to the target tumour. This procedure was attempted in 25 patients who were considered unsuitable candidates for standard transthoracic percutaneous insertion. Vascular coils (n = 87) were succesfully inserted in 23 of 25 patients. Only minor complications were observed: haemoptysis during the procedure (one patient), development of pleural pain and fever on the day of procedure (one patient), and development of small infiltrative changes distal to the vascular coil (five patients). Fifty-seven coils (66% of total inserted number) could be used as tumour markers for delivery of biologically highly effective radiation doses with automated tracking during CyberKnife radiotherapy. Endovascular markers are safe and allow high-dose radiotherapy of lung tumours with CyberKnife, also in patients who are unsuitable candidates for standard transthoracic percutaneous marker insertion.

CT-guided permanent brachytherapy for patients with medically inoperable early-stage non-small cell lung cancer (NSCLC)

Seven patients with early stage T1N0M0 NSCLC who had medical contraindications for surgical resection were treated with CT-guided percutaneous implantation of (103)Pd or (125)I seeds. After the procedure, two patients developed pneumothorax and hemo/pneumothorax that was managed with aspirative drainage. One patient developed a focal pneumonitis 3 months after the procedure. After a median follow-up of 13 months (4.6-41.0+ months), no patient has developed local or regional failure.

Four-dimensional Stereotactic Radiotherapy for Early Stage Non-Small Cell Lung Cancer: A Comparative Planning Study

In this study we sought to assess the potential of the respiratory tumor tracking system of the CyberKnife to administer 3 fractions of 15 Gy in the treatment of early stage non-small cell lung cancer (NSCLC). The CyberKnife plans were compared to those developed for 3-D conformal radiotherapy (3-D CRT) administering 20 fractions of 3 Gy based on a slow CT. Ten patients with stage I NSCLC, who were previously treated with 3-D CRT, were re-planned with the CyberKnife treatment planning system. In the 3-D CRT plan, the planning target volume (PTV) included the gross tumor volume (GTV)slow and a 15-mm margin, whereas in the CyberKnife plan the margin was 8 mm. The physical doses from both treatment plans were converted to normalized total doses (NTD) using the linear quadratic model with an α/βtumor of 10 Gy and α/βorgansatrisk(OAR) of 3 Gy. The average minimal and mean doses administered to the PTV with the CyberKnife and 3-D CRT were 93 and 115.8 Gy and 61 and 66 Gy, respectively (p<0.0001). The mean V20 of the CyberKnife and 3-D CRT plans were 8.2% and 6.8%, respectively (p=0.124). Both plans complied with the OAR constraints. In conclusion, 4-dimensional stereotactic radiotherapy can increase the minimal and mean biological dose with 51% and 75%, in comparison with 3-D CRT without significantly increasing the V20, respectively.

Lung tumor tracking during stereotactic radiotherapy treatment with the CyberKnife: Marker placement and early results

Lung tumor tracking during stereotactic radiotherapy with the CyberKnife requires the insertion of markers in or close to the tumor. To reduce the risk of pneumothorax, three methods of marker placement were used: 1) intravascular coil placement, 2) percutaneous intrathoracal, and 3) percutaneous extrathoracal placement. We investigated the toxicity of marker placement and the tumor response of the lung tumor tracking treatment. Markers were placed in 20 patients with 22 tumors: 13 patients received a curative treatment, seven a palliative. The median Charlson Comorbidity Score was 4 (range: 1-8). Platinum fiducials and intravascular embolisation coils were used as markers. In total, 78 markers were placed: 34 intrathoracal, 23 intravascular and 21 extrathoracal. The PTV equaled the GTV + 5 mm. A median dose of 45 Gy (range: 30-60 Gy, in 3 fractions) was prescribed to the 70-85% isodose. The response was evaluated with a CTscan performed 6-8 weeks after the last treatment and routinely thereafter. The median follow-up was 4 months (range: 2-11). No severe toxicity due to the marker placement was seen. Pneumothorax was not seen. The local control was 100%. Four tumors in four patients showed a complete response, 15 tumors in 14 patients a partial response, and three tumors in two patients with metastatic disease had stable disease. No severe toxicity of marker placement was seen due to the appropriate choice of one of the three methods. CyberKnife tumor tracking with markers is feasible and resulted in excellent tumor response. Longer follow-up is needed to validate the local control.

Stereotactic single-dose radiotherapy (radiosurgery) of early stage nonsmall-cell lung cancer (NSCLC)

BACKGROUND

The clinical results after stereotactic single-dose radiotherapy of nonsmall-cell lung cancer (NSCLC) stages I and II were evaluated.

METHODS

Forty-two patients with biopsy-proven NSCLC received stereotactic radiotherapy. Patients were treated in a stereotactic body frame and breathing motion was reduced by abdominal compression. The single doses used ranged between 19 and 30 Gy/isocenter.

RESULTS

After a median follow-up period of 15 months (range, 1.5-72 months) the actuarial overall survival rates and disease-free survival rates were 74.5%, 65.4%, 37.4%, and 70.2%, 49.1%, 49.1% at 12, 24, and 36 months after therapy, respectively. The actuarial local tumor control rates were 89.5%, 67.9%, and 67.9% at 12, 24, and 36 months after therapy, respectively. A significant difference (P = .032) in local tumor control was found for patients receiving 26-30 Gy (n = 32) compared with doses of less than 26 Gy (n = 10). The effect of the tumor volume on local tumor control was also evaluated. Although the difference was not statistically significant (P = .078), the subgroup of tumors with a tumor volume of less than 12 cm(3) (n = 10) experienced no tumor recurrence. Thirteen (31%) patients developed metastases during follow-up, whereas isolated regional lymph node recurrence was only encountered in 2 patients. No clinically significant treatment-associated side effects were documented.

CONCLUSIONS

Stereotactic single-dose radiotherapy is a safe and effective treatment option for patients with early stage NSCLC not suitable for surgery. Especially for small tumor volumes it seems to be equally effective as hypofractionated radiotherapy, while minimizing the overall treatment time.

Concurrent end-phase boost high-dose radiation therapy for non-small-cell lung cancer with or without cisplatin chemotherapy

The aim of this study was to audit the results of a high-dose, combined-modality prospective protocol for non-small-cell lung cancer in terms of survival, disease-specific survival and toxicity. One hundred and twenty-one patients with non-small-cell lung cancer were treated with a concurrent, end-phase, boost, high-dose radiotherapy protocol with 65 Gy in 35 fractions for more than 5 weeks. Sixty-six patients received radiotherapy alone (group 1), 29 received concurrent chemoradiation (group 2) and 26 received neoadjuvant and concurrent chemotherapy (group 3). Thirty-four patients had stage I disease, six had stage II and 81 had stage III. Overall median survival was 23 months: 75% at 1 year and 23% at 5 years. Median survivals for patients with stage I and stages II and III disease were 43 and 19 months, respectively. For stages II and III patients by groups 1-3, median survivals were 18, 25 and 18 months, respectively, and 2-year survivals were 36, 52 and 38%, respectively. Toxicity was acceptable. Overall, 9% had symptomatic pneumonitis and 7% had grades 3 and 4 oesophagitis. For those who had the mediastinum included in the volume, grade > or = 3 oesophagitis occurred in 0, 11 and 22% (n = 110, P = 0.001), respectively, for treatment groups 1-3. Overall treatment-related mortality was 3%, consisting of two septic deaths, one pneumonitis and possibly one late cardiac event, all occurring in patients who had chemotherapy (7% of 55 patients). Treatment-related mortality declined over the study period. Accelerated radiotherapy was well tolerated, with only moderate increased acute toxicity when combined with concurrent platinum chemotherapy. Toxicity was enhanced by induction chemotherapy. Overall survival outcomes were excellent for this condition. Continued use of this radiotherapy schedule is recommended as the platform for assessment of other chemotherapy schedules.

Comparison of outcomes for patients with medically inoperable Stage I non–small-cell lung cancer treated with two-dimensional vs. three-dimensional radiotherapy

PURPOSE

This retrospective analysis was performed to assess the outcomes of three-dimensional (3D) conformal radiotherapy and two-dimensional (2D) planning.

METHODS AND MATERIALS

Between 1978 and 2003, 200 patients with Stage I non-small-cell lung cancer (NSCLC) were treated with radiotherapy alone at M.D. Anderson Cancer Center. Eighty-five patients were treated with 3D conformal radiotherapy. For the 3D group, median age, radiation dose, and follow-up was 73 (range, 50-92), 66 Gy (range, 45-90.3 Gy), and 19 months (range, 3-77 months), respectively; and for the 2D group, 69 (range, 44-88), 64 Gy (range, 20-74 Gy), 20 months (range, 1-173 months), respectively. Overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), locoregional control (LRC), and distant metastasis-free survival (DMFS) rates were analyzed.

RESULTS

There was no statistically significant difference in patient and tumor characteristics between 2D and 3D groups, except the 3D patients were older (p = 0.006). The OS, DSS, and LRC rates were significantly higher in patients who were treated by 3D conformal radiotherapy. Two- and 5-year OS for the 3D group were 68% and 36%, respectively, and 47% and 10% in the 2D group (p = 0.001). DSS at 2 and 5 years for the 3D group were 83% and 68%, respectively, vs. 62% and 29% in the 2D group (p < 0.001). LRC rates at 2 and 5 years for patients in the 3D group were 77% and 70% and 53% and 34% in the 2D group (p < 0.001). On univariate analysis elective, nodal irradiation was associated with decreased OS, DSS, and LRC. On multivariate analysis, 3D conformal radiotherapy was associated with increased OS and DSS. Male sex, age > or =70, weight loss > or =5%, and tumor size > or =4 cm were associated with decreased OS and DSS.

CONCLUSIONS

This study demonstrates that 3D conformal radiotherapy improves outcomes in patients with medically inoperable Stage I NSCLC compared with 2D treatment and is an acceptable treatment for this group of patients.

Pretreatment prognostic factors in patients with early-stage (I/II) non–small-cell lung cancer treated with hyperfractionated radiation therapy alone

PURPOSE

To investigate influence of various pretreatment prognostic factors in patients with early stage (I/II) non-small-cell lung cancer (NSCLC) treated with hyperfractionated radiation therapy alone.

PATIENTS AND METHODS

One hundred and sixteen patients were treated with tumor doses of 69.6 Gy, 1.2-Gy, twice-daily fractionation. There were 49 patients with Stage I and 67 patients with Stage II. Eighty patients had Karnofsky performance status (KPS) 90-100 and 95 patients had <5% weight loss. Peripheral tumors were observed in 57 patients. Squamous histology was observed in 70 patients and the majority of patients had concomitant disease (n=72).

RESULTS

The median survival time for all patients was 29 months; 5-year survival was 29%. The median time to local progression and the distant metastasis were not achieved, whereas 5-year local progression-free and distant metastasis-free survivals were 50% and 72%, respectively. Multivariate analysis identified KPS, weight loss, location, histology, and the reason for not undergoing surgery as prognostic factors for survival. KPS, location, and histology influenced local progression-free survival, whereas only KPS and weight loss influenced distant metastasis-free survival.

CONCLUSIONS

This retrospective analysis identified KPS and weight loss as the most important prognostic factors of outcome in patients with early-stage NSCLC treated with hyperfractionation radiation therapy.

Radiation therapy alone in elderly with early stage non-small cell lung cancer

BACKGROUND

Radiation therapy (RT) alone is frequently used in elderly patients with medically inoperable early stage (I/II) non-small cell lung cancer (NSCLC). We retrospectively investigated the effectiveness of RT alone in this patient population treated in our institution.

MATERIAL AND METHODS

Between 1995 and 1999, a total of 33 patients were treated with RT alone in our institution, all being males. RT doses ranged 66-78 Gy (median, 70 Gy) using standard fractionation (2.0 Gy per fraction). The age range was 71-97 years (median, 75 years) with 11 patients being >or=80 years old. Twenty-two (67%) patients had a squamous cell carcinoma. There were 24 (73%) stage I and nine (27%) stage II patients.

RESULTS

Radiographic objective response rate was observed in 23 (70%) patients. The median survival time was 37.4 months and 3-year survival time was 50%, while the median cause-specific survival time was 48.1 months and a 3-year cause-specific survival rate was 55.3%. The median time to local recurrence was 36.8 months and a 3-year local recurrence-free survival rate was 50.2%, while the median time to distant metastasis was not achieved yet, the 3-year distant metastasis-free survival rate being 71.4%. One (3%) patient died of RT-induced acute lung toxicity, while only two (6%) patients experienced late grade 3 lung toxicity. No other high-grade toxicity was observed during this study.

CONCLUSIONS

RT alone was effective and low toxic in elderly with early stage (I/II) NSCLC and could be considered as treatment of choice in this patient population.

High-dose proton beam therapy for Stage I non-small-cell lung cancer

PURPOSE

To evaluate retrospectively the safety and efficacy of high-dose proton beam therapy (PBT) for Stage I non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

Between 1999 and 2003, 37 patients were treated in our institution. The indications for PBT were pathologically proven NSCLC, clinical Stage I, tumor size < or =5 cm, medically inoperable or refusal of surgery, and written informed consent. A total dose of 70-94 Gy(E) was delivered in 20 fractions (3.5-4.9 Gy(E) per fraction).

RESULTS

Patient characteristics (number of patients) were as follows: Stage IA/IB, 17 of 20; medically inoperable/refusal of surgery, 23/14; total dose 70/80/88/94 Gy(E), 3/17/16/1. With a median follow-up period of 24 months, the 2-year local progression-free and overall survival rates were 80% and 84%, respectively. The 2-year locoregional relapse-free survival rates in Stage IA and Stage IB were 79% and 60%, respectively. No serious acute toxicity was observed. Late Grades 2 and 3 pulmonary toxicities were observed in 3 patients each. Of these 6 patients, 5 had Stage IB disease.

CONCLUSIONS

Proton beam therapy is a promising treatment modality for Stage I NSCLC, though locoregional relapse and late pulmonary toxicities in Stage IB patients were substantial. Further investigation of PBT for Stage I NSCLC is warranted.

Long-term results of high-dose conformal radiotherapy for patients with medically inoperable T1–3N0 non–small-cell lung cancer: Is low incidence of regional failure due to incidental nodal irradiation?

PURPOSE

To report the results of high-dose conformal irradiation and examine incidental nodal irradiation and nodal failure in patients with inoperable early-stage non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

This analysis included patients with inoperable CT-staged T1-3N0M0 NSCLC treated on our prospective dose-escalation trial. Patients were treated with radiation alone (total dose, 63-102.9 Gy in 2.1-Gy daily fractions) with a three-dimensional conformal technique without intentional nodal irradiation. Bilateral highest mediastinal and upper/lower paratracheal, prevascular and retrotracheal, sub- and para-aortic, subcarinal, paraesophageal, and ipsilateral hilar regions were delineated individually. Nodal failure and doses of incidental irradiation were studied.

RESULTS

The potential median follow-up was 104 months. For patients who completed protocol treatment, median survival was 31 months. The actuarial overall survival rate was 86%, 61%, 43%, and 21% and the cause-specific survival rate was 89%, 70%, 53%, and 35% at 1, 2, 3, and 5 years, respectively. Weight loss (p = 0.008) and radiation dose in Gy (p = 0.013) were significantly associated with overall survival. In only 22% and 13% of patients examined did ipsilateral hilar and paratracheal (and subaortic for left-sided tumor) nodal regions receive a dose of > or = 40 Gy, respectively. Less than 10% of all other nodal regions received a dose of > or = 40 Gy. No patients failed initially at nodal sites.

CONCLUSIONS

Radiation dose is positively associated with overall survival in patients with medically inoperable T1-3N0 NSCLC, though long-term results remain poor. The nodal failure rate is low and does not seem to be due to high-dose incidental irradiation.

Concurrent hyperfractionated radiotherapy and low-dose daily carboplatin/paclitaxel in patients with early-stage (I/II) non-small-cell lung cancer: long-term results of a phase II study

PURPOSE

Feasibility and activity of concurrent hyperfractionated radiotherapy (Hfx RT) and low-dose, daily carboplatin and paclitaxel were investigated in patients with early-stage (I/II) non-small-cell lung cancer in a phase II study.

PATIENTS AND METHODS

Fifty-six patients started their treatment on day 1 with 30 mg/m2 of paclitaxel. Hfx RT using 1.3 Gy bid to a total dose of 67.6 Gy and concurrent low-dose daily carboplatin 25 mg/m2 and paclitaxel 10 mg/m2, both given Mondays through Fridays during the RT course, started from the second day.

RESULTS

There were 29 complete responses (52%) and 15 partial responses (27%), and 12 patients (21%), experienced stable disease. The median survival time was 35 months, and 3- and 5-year survival rates were 50% and 36%, respectively. The median time to local progression has not been achieved, but 3- and 5-year local progression-free survival rates were 56% and 54%, respectively. The median time to distant metastasis has not been achieved, but 3- and 5- year distant metastasis-free survival rates were 61% and 61%, respectively. The median and 5-year cause-specific survivals were 39 months and 43%, respectively. Acute high-grade (> 3) toxicity was hematologic (22%), esophageal (7%), or bronchopulmonary (7%). No grade 5 toxicity was observed. Late high-grade toxicity was rarely observed (total, 10%).

CONCLUSION

Hfx RT and concurrent low-dose daily carboplatin/paclitaxel was feasible with low toxicity and effective in patients with stage I/II non-small-cell lung cancer. It should continue to be investigated for this disease.

Prognostic factors for survival in stage III non-small-cell lung cancer treated with definitive radiation therapy: impact of tumor volume

PURPOSE

To investigate the impact of tumor volume on overall survival in patients with Stage III non-small-cell lung cancer (NSCLC) treated with definitive radiation therapy (RT).

METHODS AND MATERIALS

Between May 1997 and February 2003, 71 patients with Stage III NSCLC were treated with radiation therapy of 60 Gy or more. The total target dose was between 60 and 77 Gy (average, 66.3 Gy). Chemotherapy was used in 45 cases. The primary tumor and nodal volume were identified in pretreatment computed tomography scans. Univariate and multivariate analyses were used to evaluate the impact of tumor volume on survival after RT.

RESULTS

The overall 2-year survival rate was 23%, with a median survival time of 14 months. The median survival times were 10 months and 19 months with large primary tumor volume more than median volume and smaller primary tumor volume, respectively. At a univariate analysis, the total tumor volume (TTV) (p<0.0003) and the primary tumor volume (p<0.00008) were significant and the nodal volume was not. At multivariate analyses, both the TTV and the primary tumor volume were significant prognostic factors.

CONCLUSION

The primary tumor volume as well as TTV is a significant prognostic factor on survival in patients with Stage III NSCLC treated with RT and should be recorded in clinical results when the survivals are compared among clinical studies.

Endobronchial brachytherapy and optimization of local disease control in medically inoperable non-small cell lung carcinoma: a matched-pair analysis

PURPOSE

External beam radiation therapy (EBRT) alone for early stage, medically inoperable non-small cell lung cancer (MILC) can produce local disease control and sometimes cure. We have previously reported that higher EBRT doses result in improved disease control and, for patients with tumors > or =3.0 cm, improved survival. This report describes the impact of dose escalation with endobronchial brachytherapy boost during or following EBRT upon local disease control.

METHODS AND MATERIALS

Medical records of 404 patients with MILC treated with radiotherapy alone were reviewed. Thirty-nine patients received a planned endobronchial brachytherapy boost during or following a course of EBRT. A matched-pair analysis of disease control and survival was performed by matching each brachytherapy patient to 2 EBRT patients from a reference group of the remaining patients.

RESULTS

Endobronchial brachytherapy boost significantly improved local disease control over EBRT alone (58% vs. 32% at 5 years). The local control benefit for brachytherapy was found to be limited to patients with T(1-2) disease or tumors < or =5.0 cm. Among these patients treated with endobronchial boost, EBRT doses of > or =6500 cGy were necessary to optimize local disease control. No overall survival differences were observed at 3 years. Excess toxicity with brachytherapy was not observed.

CONCLUSION

Endobronchial brachytherapy boost enhances local disease control rates in MILC treated with EBRT. Local control outcome is optimized when radical EBRT doses are used in conjunction with brachytherapy.

Radiofrequency Ablation: Identification of the Ideal Patient

Radiofrequency (RF) ablation (RFA) is a relatively new modality that is being used for lung tumors with increasing frequency. Radiofrequency energy consists of an alternating current that moves from an active electrode that is placed within the tumor to dispersive electrodes that are placed on the patient. As the RF energy is applied, frictional heating of tissues results, with cell death occurring at temperatures > 60 degrees C. This article discusses preclinical and early clinical experience with RFA for lung tumors. Radiofrequency ablation has been used for patients with primary lung cancer and limited pulmonary metastases. Current data suggest that RFA is most suitable for tumors < or = 4 cm in size and is better for peripheral rather than centrally based nodules. Additionally, studies of RFA followed by resection have demonstrated a learning-curve effect with improved tumor kill in the later cases performed in these series. Surgical resection should continue to be the primary modality offered to patients with early-stage non-small-cell lung cancer and limited metastatic disease to the lungs (when the primary tumor is controlled). Radiofrequency ablation is a good option for those patients who are believed to be at increased risk for resection or who refuse resection, when operation would otherwise be appropriate therapy. Additionally, RFA may be used for local control of peripheral tumors in patients with more advanced cancers in combination with other therapies.

[Prognostic indicators in stage I non-small cell lung cancer]

INTRODUCTION

Determinating the prognosis of patients with stage I non-small cell lung cancer (NSCLC) is a challenge. Since up to 30% of patients who have undergone surgical resection experience recurrence, generally in distant organs, it is reasonable to postulate that neo-adjuvant or adjuvant treatments might be useful. Better knowledge of prognostic factors could perhaps define which patient populations should be targeted with such treatments.

STATE OF THE ART

Numerous potential prognostic factors, relating to the disease (TNM classification, histology, tumor size, blood vessels invasion, micro-metastasis, serum or molecular markers), the patient (gender, age, co-morbidity) as well as the treatment (delay, resection, lymph node dissection, neo-adjuvant and adjuvant treatments), are discussed.

PERSPECTIVES

These prognostic factors should be integrated into the design of future clinical trials of chemotherapy and/or radiotherapy attempting to evaluate the effectiveness of various combinations of neo-adjuvant or adjuvant therapies.

CONCLUSIONS

These factors may offer the opportunity to clinically and biologically characterize the different subgroups of patients, leading to a more rational, and perhaps individualized, choice of therapy.

Prognostic factors in non-small cell lung cancer

Identification of prognostic factors is critical in optimizing treatment for patients with cancer. The purpose of this work is to review the modern literature with regard to prognostic factors for patients with non-small-cell lung cancer (NSCLC) taking into account ongoing advances in clinical evaluation, staging, surgery, radiation therapy, chemotherapy, and molecular biology in this widely heterogeneous patient population.

Radiation therapy alone in early stage non-small cell lung cancer

Among the patients with early stage (I/II) non-small cell lung cancer (NSCLC), there are those who, due to medical comorbidities, advanced age, or refusal, never undergo surgery. For them, exclusive radiation therapy (RT) has been the treatment of choice, achieving median survival times of 30 months and 5-year survival of up to 42%. Doses of > or =65 Gy with standard fractionation (or its radiobiological equivalent when altered fractionation is used) are necessary for long-lasting local control of the disease, with smaller tumors having a more favorable prognosis. The issue of elective nodal irradiation (ENI) remains controversial, since failure patterns identified local failure as the predominant pattern. None of the potential pretreatment patient- and tumor-related prognostic factors has been shown to clearly influence survival. Toxicity is generally mild to moderate, although high doses (e.g., 80 Gy) may carry a risk for an excessive rate of side effects. Conformal treatment and consideration of comorbidities such as altered lung function may be essential, since simultaneous supportive treatment of acute sequelae (mainly acute esophagitis) is necessary. RT is an effective treatment modality in technically operable, but medically inoperable patients with early stage NSCLC and offers a long-lasting cure.

Effectiveness of radiation therapy on non-small-cell lung cancer

Radiotherapy is an effective locoregional cancer treatment aimed at achieving tumor control. For almost a century, radiation has been used as a curative and/or palliative form of treatment alone or in combination with other treatment modalities for non-small-cell lung cancer. Trials are ongoing to investigate the value of altered fractionation radiation therapy alone or in combination with novel chemotherapy agents such as taxanes and gemcitabine, while monitoring for related toxicities. Attempts at minimizing the amount of normal tissue irradiated with three-dimensional treatment planning and/or protecting normal tissues with a radioprotector may allow for therapeutic escalation of radiation dose with further success at treating our nation's number one cause of cancer-related mortality.

Stereotactic hypofractionated high-dose irradiation for stage I nonsmall cell lung carcinoma

BACKGROUND

Stereotactic irradiation (STI) has been actively performed using various methods to achieve better local control of Stage I nonsmall cell lung carcinoma (NSCLC) in Japan. The authors retrospectively evaluated results from a Japanese multiinstitutional study.

METHODS

Patients with Stage I NSCLC (n = 245; median age, 76 years; T1N0M0, n = 155; T2N0M0, n = 90) were treated with hypofractionated high-dose STI in 13 institutions. Stereotactic three-dimensional treatment was performed using noncoplanar dynamic arcs or multiple static ports. A total dose of 18-75 gray (Gy) at the isocenter was administered in 1-22 fractions. The median calculated biologic effective dose (BED) was 108 Gy (range, 57-180 Gy).

RESULTS

During follow-up (median, 24 months; range, 7-78 months), pulmonary complications of National Cancer Institute-Common Toxicity Criteria Grade > 2 were observed in only 6 patients (2.4%). Local progression occurred in 33 patients (14.5%), and the local recurrence rate was 8.1% for BED > or = 100 Gy compared with 26.4% for < 100 Gy (P < 0.05). The 3-year overall survival rate of medically operable patients was 88.4% for BED > or = 100 Gy compared with 69.4% for < 100 Gy (P < 0.05).

CONCLUSIONS

Hypofractionated high-dose STI with BED < 150 Gy was feasible and beneficial for curative treatment of patients with Stage I NSCLC. For all treatment methods and schedules, local control and survival rates were better with BED > or = 100 Gy compared with < 100 Gy. Survival rates in selected patients (medically operable, BED > or = 100 Gy) were excellent, and were potentially comparable to those of surgery.

The role of radiotherapy in treatment of stage I non-small cell lung cancer

Most information on results with radiotherapy (RT) for stage I non-small cell lung cancer (NSCLC) is based on retrospective studies on RT-treated inoperable NSCLC cases. Thus, the role of RT for stage I NSCLC, as a curative modality, has not yet been established. A literature search for studies on stage I non-small cell lung carcinoma (NSCLC) treated by RT alone resulted in 18 papers published between 1988 and 2000. The majority of stage I patients received RT treatment because they were medically inoperable. The main contraindications for surgery were grave impairment of pulmonary function and serious cardiovascular disease. Local recurrence was the most common reason for treatment failure (median value 40%) but varied highly between the studies, ranging from 6.4 to 70%. In contrast with local recurrence, regional failure was not a major problem (0-3.2%). Generally, smaller tumour size, low T-stage and increased dose had a favourable impact on local control and increased local control was followed by increased survival. No serious treatment complications were recorded in the majority of these studies. Overall treatment results were, however, disappointing. The median survival in these studies ranged from 18 to 33 months. The 3- and 5-year overall survival was 34+/-9 and 21+/-8% (mean value+/-1 S.E.), respectively. The cause-specific survival at 3 and 5 years was 39+/-10 and 25+/-9% (mean value+/-1 S.E.), respectively. Dose escalation, in a setting with conformal RT using involved field or stereotactic RT, should be the focus of developmental therapeutic strategies with inoperable stage I NSCLC to improve local control and survival.

Stereotactic single-dose radiotherapy of stage I non-small-cell lung cancer (NSCLC)

PURPOSE

The treatment of early-stage lung cancers is a primary domain of thoracic surgery, leading to persuasive results. In patients with medical contraindications, radiotherapy is an alternative, although with considerably worse outcome. Radiotherapy is associated with the risk of severe acute side effects and a permanent decrease of lung function. By the introduction of an extracranial stereotactic treatment technique, the amount of normal tissue in the high-dose region can be reduced, allowing the performance of single-dose treatment with high, biologically effective doses.

METHODS AND MATERIALS

Between October 1998 and May 2001, 10 patients with histologically confirmed Stage I non-small-cell lung cancer were treated with stereotactic single-dose radiotherapy. A self-developed stereotactic frame was used for patient positioning and navigation. Total doses applied ranged from 19 to 26 Gy. After treatment, regular CT-based follow-up was performed.

RESULTS

During a median follow-up period of 14.9 months, the tumors in 8 of 10 patients were locally controlled. The actuarial overall survival was 80% and 64%, respectively, 12 and 24 months after therapy. Actuarial local recurrence-free survival reached 88.9% and 71.1%, respectively. Therapy-related perifocal normal-tissue reaction occurred in 70% of all treated patients, although no major clinical symptoms were seen. In 5 patients, systemic metastases were found during follow-up; 1 patient developed suspect mediastinal lymph nodes.

CONCLUSION

Stereotactic single-fraction radiotherapy is a feasible, safe, and effective procedure for the treatment of Stage I non-small-cell lung cancer. It promises high local control with a reduced overall treatment time. However, further investigation in a larger patient collective with extended follow-up is necessary.