Radiotherapy for primary lung cancer

Recommendations for Post-Operative RadioTherapy After Complete Resection of Thymoma-a French DELPHI Consensus Initiative

INTRODUCTION

Thymomas are rare intrathoracic malignancies that can relapse after surgery. Whether or not Post-Operative RadioTherapy (PORT) should be delivered after surgery remains a major issue. RADIORYTHMIC is an ongoing, multicenter, randomized phase 3 trial addressing this question in patients with completely R0 resected Masaoka-Koga stage IIb/III thymoma. Experts in the field met to develop recommendations for PORT.

METHODS

A scientific committee from the RYTHMIC network identified key issues regarding the modalities of PORT in completely resected thymoma. A DELPHI method was used to question 24 national experts, with 115 questions regarding the following: (1) imaging techniques, (2) clinical target volume (CTV) and margins, (3) dose constraints to organs at risk, (4) dose and fractionation, and (5) follow-up and records. Consensus was defined when opinions reached more than or equal to 80% agreement.

RESULTS

We established the following recommendations: preoperative contrast-enhanced computed tomography (CT) scan is recommended (94% agreement); optimization of radiation delivery includes either a four-dimensional CT-based planning (82% agreement), a breath-holding inspiration breath-hold-based planning, or daily control CT imaging (81% agreement); imaging fusion based on cardiovascular structures of preoperative and planning CT scan is recommended (82% agreement); right coronary and left anterior descending coronary arteries should be delineated as cardiac substructures (88% agreement); rotational RCMI/volumetric modulated arc therapy is recommended (88% agreement); total dose is 50 Gy (81% agreement) with 1.8 to 2 Gy per fraction (94% agreement); cardiac evaluation and follow-up for patients with history of cardiovascular disease are recommended (88% agreement) with electrocardiogram and evaluation of left ventricular ejection fraction at 5 years and 10 years.

CONCLUSION

This is the first consensus for PORT in thymoma. Implementation will help to harmonize practices.

Real-life clinical management patterns in extensive-stage small cell lung cancer across France: a multi-method study

BACKGROUND

We designed this study based on both a physician practice survey and real-world patient data to: (1) evaluate clinical management practices in extensive-stage small cell lung cancer (ES-SCLC) among medical centers located across France; and (2) describe first-line treatment patterns among patients with ES-SCLC following the introduction of immunotherapy into clinical practice.

METHODS

A 50-item questionnaire was completed by physicians from 45 medical centers specialized in SCLC management. Responses were collected from June 2022 to January 2023. The survey questions addressed diagnostic workup of ES-SCLC, chemoimmunotherapy in first-line and second-line settings, and use of prophylactic cranial irradiation (PCI) and radiotherapy. In parallel, using a chart review approach, we retrospectively analyzed aggregated information from 548 adults with confirmed ES-SCLC receiving first-line treatment in the same centers.

RESULTS

In ES-SCLC, treatment planning is based on chest computed tomography (CT) (as declared by 100% of surveyed centers). Mean time between diagnosis and treatment initiation was 2-7 days, as declared by 82% of centers. For detection of brain metastases, the most common imaging test was brain CT (84%). The main exclusion criteria for first-line immunotherapy in the centers were autoimmune disease (87%), corticosteroid therapy (69%), interstitial lung disease (69%), and performance status ≥ 2 (69%). Overall, 53% and 36% of centers considered that patients are chemotherapy-sensitive if they relapse within ≥ 3 months or ≥ 6 months after first-line chemoimmunotherapy, respectively. Among the 548 analyzed patients, 409 (75%) received chemoimmunotherapy as a first-line treatment, 374 (91%) of whom received carboplatin plus etoposide and 35 (9%) cisplatin plus etoposide. Overall, 340/548 patients (62%) received maintenance immunotherapy. Most patients (68%) did not receive radiotherapy or PCI.

CONCLUSIONS

There is an overall alignment of practices reflecting recent clinical guidelines among medical centers managing ES-SCLC across France, and a high prescription rate of immunotherapy in the first-line setting.

Radiotherapy in the management of synchronous metastatic lung cancer

Metastatic lung cancer classically portends a poor prognosis. The management of metastatic lung cancer has dramatically changed with the emergence of immune checkpoint inhibitors, targeted therapy and due to a better understanding of the oligometastatic process. In metastatic lung cancers, radiation therapy which was only used with palliative intent for decades, represents today a promising way to treat primary and oligometastatic sites with a curative intent. Herein we present through a literature review the role of radiotherapy in the management of synchronous metastatic lung cancers.

Health Economic Evaluation of Proton Therapy for Lung Cancer: A Systematic Review

BACKGROUND

To our knowledge, there have been no systematic reviews of health economic evaluations of proton therapy specific to lung cancer.

METHODS

We conducted this systematic review according to the predefined protocol [PROSPERO CRD42022365869]. We summarized the results of the included studies via structured narrative synthesis.

RESULTS

We identified four studies (all used passively scattered proton therapy) from 787 searches. Two cost analyses reported that proton therapy was more costly than photon therapy for early- or locally advanced-stage non-small cell lung cancer, one cost-utility analysis reported that proton therapy was dominated by nonproton therapy in early-stage non-small cell lung cancer, and one cost-utility analysis reported that proton therapy was not cost-effective (vs. photon) in locally advanced non-small cell lung cancer.

CONCLUSIONS

Passively scattered proton therapy was more costly and not cost-effective than photon therapy for early- and locally advanced-stage non-small cell lung cancer. Further health economic evaluations regarding modern proton therapy (such as scanning beam) for common radiotherapy indications of lung cancer are eagerly awaited.

Frankincense essential oil nanoemulsion specifically induces lung cancer apoptosis and inhibits survival pathways

Background

The volatile fraction of frankincense (Boswellia sacra) oleogum was extracted, formulated in nanoemulsion and tested against lung cancer A549 cell line. First, the gum was hydro-distilled to isolate the volatile fraction (essential oil), which was analyzed via gas chromatography to identify its major volatile constituents. Then, the oil was formulated in two water-based nanoemulsions which differ from one another in the presence of propylene glycol (PG), which is used in the formulation step as a co-surfactant. The pure essential oil as well as its major volatile compound (α-pinene), its two nanoemulsions and a reference drug (Doxorubicin) were evaluated against lung cancer A549 cell lines and WI-38 normal lung cells. The evaluation included cytotoxicity (MTT and IC50), apoptosis (flow cytometric analysis) in addition to genetic assessments for some intrinsic and extrinsic genes relevant to apoptosis and survival pathways.

Results

Chromatographic analysis of frankincense essential oil revealed that α-pinene is the major volatile compound which constituent about 60% of that oil. Emulsification of the oil using the low energy technique gave nanoemulsions having major intense particles population (85–90%) with z-average diameter below 20.0 nm. Frankincense oil nanoemulsion fabricated with (PG) showed the best cytotoxic activity toward lung cancer A549 cell compared to PG-free nanoemulsion, α-pinene and the reference drug doxorubicin, along different incubation periods. Flow cytometric analysis also indicated that PG-containing nanoemulsion can induce cancer cells toward apoptosis better than the other formula and the pure oils. The same nanoemulsion was found to upregulate the pro-apoptotic genes [DR5, FAAD, Caspase 8 (Cas8), p53, and Bax] and downregulate the anti-apoptotic and reoccurrence genes (Bcl-2, NF-kB, and STAT-3). Most importantly, the PG-containing nanoemulsion had the least cytotoxic effect on the normal WI-38 lung cells.

Conclusions

These results point out to the potentials of frankincense essential oil (rich in α-pinene) and its PG-nanoemulsion as a promising adjuvant from plant-source to potentiate the activity of the systematic anti-lung cancer drugs.

CuS-131I-PEG Nanotheranostics-Induced "Multiple Mild-Hyperthermia" Strategy to Overcome Radio-Resistance in Lung Cancer Brachytherapy

Brachytherapy is one mainstay treatment for lung cancer. However, a great challenge in brachytherapy is radio-resistance, which is caused by severe hypoxia in solid tumors. In this research, we have developed a PEGylated ¹³¹I-labeled CuS nanotheranostics (CuS-¹³¹I-PEG)-induced "multiple mild-hyperthermia" strategy to reverse hypoxia-associated radio-resistance. Specifically, after being injected with CuS-¹³¹I-PEG nanotheranostics, tumors were irradiated by NIR laser to mildly increase tumor temperature (39~40 °C). This mild hyperthermia can improve oxygen levels and reduce expression of hypoxia-induced factor-1α (HIF-1α) inside tumors, which brings about alleviation of tumor hypoxia and reversion of hypoxia-induced radio-resistance. During the entire treatment, tumors are treated by photothermal brachytherapy three times, and meanwhile mild hyperthermia stimulation is conducted before each treatment of photothermal brachytherapy, which is defined as a "multiple mild-hyperthermia" strategy. Based on this strategy, tumors have been completely inhibited. Overall, our research presents a simple and effective "multiple mild-hyperthermia" strategy for reversing radio-resistance of lung cancer, achieving the combined photothermal brachytherapy.

Conformal radiotherapy in management of soft tissue sarcoma in adults

We present the update of the recommendations of the French society of radiation oncology on soft tissue sarcomas. Currently, the initial management of sarcomas is very important as it may impact on patients' quality of life, especially in limb soft tissue sarcomas, and on overall survival in trunk sarcomas. Radiotherapy has to be discussed within a multidisciplinary board meeting with results of biopsy, eventually reexamined by a dedicated sarcoma pathologist. The role of radiotherapy varies according to localization of soft tissue sarcoma. It is part of the standard treatment in grade 2 and 3 sarcomas of the extremities and superficial trunk>5cm. In case of R1 or R2 resection, reexcision should be discussed. In such cases, it may be delivered preoperatively (50Gy/25 fractions of 2Gy) or postoperatively. In retroperitoneal sarcomas, preoperative conformal radiotherapy with or without modulated intensity cannot be proposed systematically in daily practice. Concomitant chemoradiotherapy cannot be considered a standard treatment. Intensity-modulated radiotherapy has become widely available. Other soft tissue sarcoma sites such as trunk, head and neck and gynaecological soft tissue sarcomas will be addressed, as well as other techniques that may be used such as brachytherapy and proton therapy.