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Liu W, Feng H, Taylor PA, Kang M, Shen J, Saini J, Zhou J, Giap HB, Yu NY, Sio TS, Mohindra P, Chang JY, Bradley JD, Xiao Y, Simone CB, Lin L. NRG Oncology and Particle Therapy Co-Operative Group Patterns of Practice Survey and Consensus Recommendations on Pencil-Beam Scanning Proton Stereotactic Body Radiation Therapy and Hypofractionated Radiation Therapy for Thoracic Malignancies. Int J Radiat Oncol Biol Phys 2024; 119:1208-1221. [PMID: 38395086 PMCID: PMC11209785 DOI: 10.1016/j.ijrobp.2024.01.216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 11/25/2023] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Stereotactic body radiation therapy (SBRT) and hypofractionation using pencil-beam scanning (PBS) proton therapy (PBSPT) is an attractive option for thoracic malignancies. Combining the advantages of target coverage conformity and critical organ sparing from both PBSPT and SBRT, this new delivery technique has great potential to improve the therapeutic ratio, particularly for tumors near critical organs. Safe and effective implementation of PBSPT SBRT/hypofractionation to treat thoracic malignancies is more challenging than the conventionally fractionated PBSPT because of concerns of amplified uncertainties at the larger dose per fraction. The NRG Oncology and Particle Therapy Cooperative Group Thoracic Subcommittee surveyed proton centers in the United States to identify practice patterns of thoracic PBSPT SBRT/hypofractionation. From these patterns, we present recommendations for future technical development of proton SBRT/hypofractionation for thoracic treatment. Among other points, the recommendations highlight the need for volumetric image guidance and multiple computed tomography-based robust optimization and robustness tools to minimize further the effect of uncertainties associated with respiratory motion. Advances in direct motion analysis techniques are urgently needed to supplement current motion management techniques.
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Affiliation(s)
- Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Hongying Feng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona; College of Mechanical and Power Engineering, China Three Gorges University, Yichang, Hubei, China; Department of Radiation Oncology, Guangzhou Concord Cancer Center, Guangzhou, Guangdong, China
| | - Paige A Taylor
- Imaging and Radiation Oncology Core Houston Quality Assurance Center, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jatinder Saini
- Seattle Cancer Care Alliance Proton Therapy Center and Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Huan B Giap
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence S Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Pranshu Mohindra
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Joe Y Chang
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey D Bradley
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
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Valdes G, Scholey J, Nano TF, Gennatas ED, Mohindra P, Mohammed N, Zeng J, Kotecha R, Rosen LR, Chang J, Tsai HK, Urbanic JJ, Vargas CE, Yu NY, Ungar LH, Eaton E, Simone CB. Predicting the Effect of Proton Beam Therapy Technology on Pulmonary Toxicities for Patients With Locally Advanced Lung Cancer Enrolled in the Proton Collaborative Group Prospective Clinical Trial. Int J Radiat Oncol Biol Phys 2024; 119:66-77. [PMID: 38000701 DOI: 10.1016/j.ijrobp.2023.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 10/27/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023]
Abstract
PURPOSE This study aimed to predict the probability of grade ≥2 pneumonitis or dyspnea within 12 months of receiving conventionally fractionated or mildly hypofractionated proton beam therapy for locally advanced lung cancer using machine learning. METHODS AND MATERIALS Demographic and treatment characteristics were analyzed for 965 consecutive patients treated for lung cancer with conventionally fractionated or mildly hypofractionated (2.2-3 Gy/fraction) proton beam therapy across 12 institutions. Three machine learning models (gradient boosting, additive tree, and logistic regression with lasso regularization) were implemented to predict Common Terminology Criteria for Adverse Events version 4 grade ≥2 pulmonary toxicities using double 10-fold cross-validation for parameter hyper-tuning without leak of information. Balanced accuracy and area under the curve were calculated, and 95% confidence intervals were obtained using bootstrap sampling. RESULTS The median age of the patients was 70 years (range, 20-97), and they had predominantly stage IIIA or IIIB disease. They received a median dose of 60 Gy in 2 Gy/fraction, and 46.4% received concurrent chemotherapy. In total, 250 (25.9%) had grade ≥2 pulmonary toxicity. The probability of pulmonary toxicity was 0.08 for patients treated with pencil beam scanning and 0.34 for those treated with other techniques (P = 8.97e-13). Use of abdominal compression and breath hold were highly significant predictors of less toxicity (P = 2.88e-08). Higher total radiation delivered dose (P = .0182) and higher average dose to the ipsilateral lung (P = .0035) increased the likelihood of pulmonary toxicities. The gradient boosting model performed the best of the models tested, and when demographic and dosimetric features were combined, the area under the curve and balanced accuracy were 0.75 ± 0.02 and 0.67 ± 0.02, respectively. After analyzing performance versus the number of data points used for training, we observed that accuracy was limited by the number of observations. CONCLUSIONS In the largest analysis of prospectively enrolled patients with lung cancer assessing pulmonary toxicities from proton therapy to date, advanced machine learning methods revealed that pencil beam scanning, abdominal compression, and lower normal lung doses can lead to significantly lower probability of developing grade ≥2 pneumonitis or dyspnea.
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Affiliation(s)
- Gilmer Valdes
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Jessica Scholey
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Tomi F Nano
- Department of Radiation Oncology, University of California, San Francisco, California.
| | - Efstathios D Gennatas
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Pranshu Mohindra
- University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | - Nasir Mohammed
- Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - Jing Zeng
- University of Washington and Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Lane R Rosen
- Willis-Knighton Medical Center, Shreveport, Louisiana
| | - John Chang
- Oklahoma Proton Center, Oklahoma City, Oklahoma
| | - Henry K Tsai
- New Jersey Procure Proton Therapy Center, Somerset, New Jersey
| | - James J Urbanic
- Department of Radiation Oncology, California Protons Therapy Center, San Diego, California
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic Proton Center, Phoenix, Arizona
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic Proton Center, Phoenix, Arizona
| | - Lyle H Ungar
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric Eaton
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
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Hasan S, Verma V, Abel S, Wegner RE, Choi JI, Press RH, Chhabra A, Simone CB. Differences in Patterns of Care and Referral Between Proton and Photon Therapy. Int J Part Ther 2024; 11:100005. [PMID: 38757072 PMCID: PMC11095099 DOI: 10.1016/j.ijpt.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 05/18/2024] Open
Abstract
Purpose To report demographic and clinical characteristics of patients who were more likely to receive proton beam therapy (PBT) than photon therapy from facilities with access to proton centers. Materials and Methods We utilized the national cancer database to identify the facilities with access to PBT between 2004 and 2015 and compared the relative usage of photons and PBT for demographic and clinical scenarios in breast, prostate, and nonsmall cell cancer. Results In total, 231 facilities with access to proton centers accounted for 168 323 breast, 39 975 lung, and 77 297 prostate cancer patients treated definitively. Proton beam therapy was used in 0.5%, 1.5%, and 8.9% of breast, lung, and prostate cases. Proton beam therapy was correlated with a farther distance traveled and longer start time from diagnosis for each site (P < .05).For breast, demographic correlates of PBT were treatment in the west coast (odds ratio [OR] = 4.81), age <60 (OR = 1.25), white race (OR = 1.94), and metropolitan area (OR = 1.58). Left-sided cancers (OR = 1.28), N2 (OR = 1.71), non-ER+/PR+/Her2Neu- cancers (OR = 1.24), accelerated partial breast irradiation (OR = 1.98), and hypofractionation (OR = 2.35) were predictors of PBT.For nonsmall cell cancer, demographic correlates of PBT were treatment in the south (OR = 2.6), metropolitan area (OR = 1.72), and Medicare insurance (OR = 1.64). Higher comorbid score (OR = 1.36), later year treated (OR = 3.16), and hypofractionation (not SBRT) (OR = 3.7) were predictors of PBT.For prostate, correlates of PBT were treatment in the west coast (OR = 2.48), age <70 (OR = 1.19), white race (OR = 1.41), metropolitan area (OR = 1.25), higher income/education (OR = 1.25), and treatment at an academic center (OR = 33.94). Lower comorbidity score (OR = 1.42), later year treated (OR = 1.37), low-risk disease (OR = 1.45), definitive compared to postoperative (OR = 6.10), and conventional fractionation (OR = 1.64) were predictors of PBT. Conclusion Even for facilities with established referrals to proton centers, PBT utilization was low; socioeconomic status was potentially a factor. Proton beam therapy was more often used with left-sided breast and low-risk prostate cancers, without a clear clinical pattern in lung cancer.
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Affiliation(s)
- Shaakir Hasan
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA
- New York Proton Center, New York, NY, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Stephen Abel
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Rodney E. Wegner
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA
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Guo H, Yu R, Zhang H, Wang W. Cytokine, chemokine alterations and immune cell infiltration in Radiation-induced lung injury: Implications for prevention and management. Int Immunopharmacol 2024; 126:111263. [PMID: 38000232 DOI: 10.1016/j.intimp.2023.111263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
Radiation therapy is one of the primary treatments for thoracic malignancies, with radiation-induced lung injury (RILI) emerging as its most prevalent complication. RILI encompasses early-stage radiation pneumonitis (RP) and the subsequent development of radiation pulmonary fibrosis (RPF). During radiation treatment, not only are tumor cells targeted, but normal tissue cells, including alveolar epithelial cells and vascular endothelial cells, also sustain damage. Within the lungs, ionizing radiation boosts the intracellular levels of reactive oxygen species across various cell types. This elevation precipitates the release of cytokines and chemokines, coupled with the infiltration of inflammatory cells, culminating in the onset of RP. This pulmonary inflammatory response can persist, spanning a duration from several months to years, ultimately progressing to RPF. This review aims to explore the alterations in cytokine and chemokine release and the influx of immune cells post-ionizing radiation exposure in the lungs, offering insights for the prevention and management of RILI.
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Affiliation(s)
- Haochun Guo
- Department of Oncology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, China
| | - Ran Yu
- Department of Radiotherapy, Lianshui People's Hospital, Kangda College of Nanjing Medical University, Huai'an 223400, China; Jiangsu Nursing Vocational and Technical College, Huai'an 223400, China; School of Clinical Medicine, Medical College of Yangzhou University, Jiangsu Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Senile Diseases, Yangzhou 225009, China
| | - Haijun Zhang
- Department of Oncology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, China.
| | - Wanpeng Wang
- Department of Radiotherapy, Lianshui People's Hospital, Kangda College of Nanjing Medical University, Huai'an 223400, China; Jiangsu Nursing Vocational and Technical College, Huai'an 223400, China; School of Clinical Medicine, Medical College of Yangzhou University, Jiangsu Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Senile Diseases, Yangzhou 225009, China.
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Seo SH, Pyo H, Ahn YC, Oh D, Yang K, Kim N, Sun JM, Park S, Jung HA, Lee SH, Ahn JS, Ahn MJ, Noh JM. Pulmonary function and toxicities of proton versus photon for limited-stage small cell lung cancer. Radiat Oncol J 2023; 41:274-282. [PMID: 38185932 PMCID: PMC10772597 DOI: 10.3857/roj.2023.00773] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/26/2023] [Accepted: 10/10/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE We aimed to compare the oncological outcomes and toxicities of definitive proton beam therapy (PBT) and photon beam therapy in patients with limited-stage small cell lung cancer (LS-SCLC). MATERIALS AND METHODS We retrospectively reviewed 262 patients with newly diagnosed LS-SCLC who underwent definitive PBT (n = 20; proton group) or photon beam therapy (n = 242; photon group) with concurrent chemotherapy between January 2016 and February 2021 and compared overall survival (OS), progression-free survival (PFS), dose-volume parameters, and toxicities between the groups. RESULTS The median follow-up duration was 24.5 months (range, 3.7 to 78.7). Baseline lung function was significantly worse and clinical target volume (CTV) was larger in the proton group (CTV: 296.6 vs. 215.3 mL; p = 0.080). The mean lung V10 was 37.7% ± 16.8% and 51.6% ± 24.5% in the proton and photon groups, respectively (p = 0.002). Two-year OS and PFS rates were 57.2% and 35.7% in the proton group and 65.3% and 40.8% in the photon group, respectively (p = 0.542 and 0.748, respectively). Grade ≥2 radiation pneumonitis and esophagitis occurred in 5 (25.0%) and 7 (35.0%) PBT-treated patients and 66 (27.3%) and 40 (16.5%) photon beam therapy-treated patients, respectively (p = 0.826 and 0.062, respectively). CONCLUSION Although the proton group had poorer lung function and a larger CTV than that in the photon group, both groups exhibited comparable treatment outcomes and radiation-related toxicities in LS-SCLC. PBT may be a valuable therapeutic modality in patients with poor pulmonary function or extensive disease burden owing to its lung-sparing ability.
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Affiliation(s)
- Sang Hoon Seo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hongryull Pyo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dongryul Oh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyungmi Yang
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Mu Sun
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sehhoon Park
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Ae Jung
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Se-Hoon Lee
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Seok Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myung-Ju Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Sakane T, Nakajima K, Iwata H, Nakano T, Hagui E, Oguri M, Nomura K, Hattori Y, Ogino H, Haneda H. Lobectomy versus proton therapy for stage I non-small cell lung cancer. J Thorac Cardiovasc Surg 2023; 166:1490-1501.e2. [PMID: 37625619 DOI: 10.1016/j.jtcvs.2023.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/02/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Lobectomy is the standard treatment for patients with early-stage non-small cell lung cancer (NSCLC). In recent years, an increasing number of patients with lung cancer have been treated using proton therapy (PT). We conducted a propensity score-matched analysis to compare the treatment outcomes of these 2 modalities. METHODS We retrospectively reviewed data from 275 patients with histologically confirmed clinical stage I NSCLC who underwent lobectomy (n = 206) or PT (n = 69) at our institution from July 2013 to December 2020. The end points were overall survival (OS), cause-specific survival, recurrence-free survival (RFS), local control, regional lymph node control, and distant control. Propensity score matching was performed to reduce selection bias in the 2 groups. RESULTS The matched cohort consisted of 59 patients who underwent lobectomy and 59 patients who underwent PT with a median follow-up period of 50 months. There were no significant differences in OS (P = .26), cause-specific survival (P = .33), RFS (P = .53), local control (P = .41), regional lymph node control (P = .98), and distant control (P = .31). In the lobectomy and PT groups, the 5-year OS rate was 85.8% and 79.1%, respectively, the RFS rate was 82.3% and 77.8%, and the local control rate was 92.1% and 96.6%. CONCLUSIONS We found no difference in survival or disease control between lobectomy and PT in patients with histologically confirmed clinical stage I NSCLC. Despite these findings, the potential for unmeasured confounding factors remains, and randomized control trials are needed to better compare these treatment modalities.
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Affiliation(s)
- Tadashi Sakane
- Department of Thoracic Surgery, Nagoya City University West Medical Center, Nagoya, Japan.
| | - Koichiro Nakajima
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Tomoharu Nakano
- Department of Thoracic Surgery, Nagoya City University West Medical Center, Nagoya, Japan
| | - Emi Hagui
- Department of Thoracic Surgery, Nagoya City University West Medical Center, Nagoya, Japan
| | - Masanosuke Oguri
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Kento Nomura
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Yukiko Hattori
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, Japan
| | - Hiroshi Haneda
- Department of Thoracic Surgery, Nagoya City University West Medical Center, Nagoya, Japan
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Choi JI, Simone CB, Lozano A, Frank SJ. Advances and Challenges in Conducting Clinical Trials With Proton Beam Therapy. Semin Radiat Oncol 2023; 33:407-415. [PMID: 37684070 PMCID: PMC10503212 DOI: 10.1016/j.semradonc.2023.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Advances in proton therapy have garnered much attention and speculation in recent years as the indications for proton therapy have grown beyond pediatric, prostate, spine, and ocular tumors. To achieve and maintain consistent access to this cancer treatment and to ensure the future viability and availability of proton centers in the United States, a call for evidence has been heard and answered by proton radiation oncologists. Answers provided in this review include the evolution of proton therapy research, rationale for proton clinical trial design, challenges in and barriers to the conduct of proton therapy research, and other unique considerations for the study of proton therapy.
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Affiliation(s)
- J Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.; New York Proton Center, New York, NY..
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.; New York Proton Center, New York, NY
| | - Alicia Lozano
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Shukla S, Saha T, Rama N, Acharya A, Le T, Bian F, Donovan J, Tan LA, Vatner R, Kalinichenko V, Mascia A, Perentesis JP, Kalin TV. Ultra-high dose-rate proton FLASH improves tumor control. Radiother Oncol 2023; 186:109741. [PMID: 37315577 PMCID: PMC10527231 DOI: 10.1016/j.radonc.2023.109741] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND PURPOSE Proton radiotherapy (PRT) offers potential benefits over other radiation modalities, including photon and electron radiotherapy. Increasing the rate at which proton radiation is delivered may provide a therapeutic advantage. Here, we compared the efficacy of conventional proton therapy (CONVpr) to ultrahigh dose-rate proton therapy, FLASHpr, in a mouse model of non-small cell lung cancers (NSCLC). MATERIALS AND METHODS Mice bearing orthotopic lung tumors received thoracic radiation therapy using CONVpr (<0.05 Gy/s) and FLASHpr (>60 Gy/s) dose rates. RESULTS Compared to CONVpr, FLASHpr was more effective in reducing tumor burden and decreasing tumor cell proliferation. Furthermore, FLASHpr was more efficient in increasing the infiltration of cytotoxic CD8+ T-lymphocytes inside the tumor while simultaneously reducing the percentage of immunosuppressive regulatory T-cells (Tregs) among T-lymphocytes. Also, compared to CONVpr, FLASHpr was more effective in decreasing pro-tumorigenic M2-like macrophages in lung tumors, while increasing infiltration of anti-tumor M1-like macrophages. Finally, FLASHpr treatment reduced expression of checkpoint inhibitors in lung tumors, indicating reduced immune tolerance. CONCLUSIONS Our results suggest that FLASH dose-rate proton delivery modulates the immune system to improve tumor control and might thus be a promising new alternative to conventional dose rates for NSCLC treatment.
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Affiliation(s)
- Samriddhi Shukla
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Taniya Saha
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Nihar Rama
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Anusha Acharya
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Tien Le
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Fenghua Bian
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Johnny Donovan
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Lin Abigail Tan
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Ralph Vatner
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Vladimir Kalinichenko
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States; Neonatology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States; Center for Lung Regenerative Medicine, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States
| | - Anthony Mascia
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John P Perentesis
- Cincinnati Children's Hospital Medical Center, Division of Oncology, Division of Experimental Hematology, Division of Biomedical Informatics, Cincinnati, OH 45229, USA
| | - Tanya V Kalin
- Division of Pulmonary Biology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States; Neonatology, the Perinatal Institute of Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, United States.
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9
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Alaswad M. Locally advanced non-small cell lung cancer: current issues and recent trends. Rep Pract Oncol Radiother 2023; 28:286-303. [PMID: 37456701 PMCID: PMC10348324 DOI: 10.5603/rpor.a2023.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 03/29/2023] [Indexed: 07/18/2023] Open
Abstract
The focus of this paper was to review and summarise the current issues and recent trends within the framework of locally advanced (LA) non-small cell lung cancer (NSCLC). The recently proposed 8th tumour-node-metastases (TNM) staging system exhibited significant amendments in the distribution of the T and M descriptors. Every revision to the TNM classification should contribute to clinical improvement. This is particularly necessary regarding LA NSCLC stratification, therapy and outcomes. While several studies reported the superiority of the 8th TNM edition in comparison to the previous 7th TNM edition, in terms of both the discrimination ability among the various T subgroups and clinical outcomes, others argued against this interpretation. Synergistic cytotoxic chemotherapy with radiotherapy is most prevalent in treating LA NSCLC. Clinical trial experience from multiple references has reported that the risk of locoregional relapse and distant metastasis was less evident for patients treated with concomitant radiochemotherapy than radiotherapy alone. Nevertheless, concern persists as to whether major incidences of toxicity may occur due to the addition of chemotherapy. Cutting-edge technologies such as four-dimensional computed tomography (4D-CT) and volumetric modulated arc therapy (VMAT) should yield therapeutic gains due to their capability to conform radiation doses to tumours. On the basis of the preceding notion, the optimum radiotherapy technique for LA NSCLC has been a controversial and much-disputed subject within the field of radiation oncology. Notably, no single-perspective research has been undertaken to determine the optimum radiotherapy modality for LA NSCLC. The landscape of immunotherapy in lung cancer is rapidly expanding. Currently, the standard of care for patients with inoperable LA NSCLC is concurrent chemoradiotherapy followed by maintenance durvalumab according to clinical outcomes from the PACIFIC trial. An estimated 42.9% of patients randomly assigned to durvalumab remained alive at five years, and free of disease progression, thereby establishing a new benchmark for the standard of care in this setting.
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Affiliation(s)
- Mohammed Alaswad
- Comprehensive Cancer Centre, Radiation Oncology, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
- Princess Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
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10
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Kiseleva V, Gordon K, Vishnyakova P, Gantsova E, Elchaninov A, Fatkhudinov T. Particle Therapy: Clinical Applications and Biological Effects. Life (Basel) 2022; 12:2071. [PMID: 36556436 PMCID: PMC9785772 DOI: 10.3390/life12122071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Particle therapy is a developing area of radiotherapy, mostly involving the use of protons, neutrons and carbon ions for cancer treatment. The reduction of side effects on healthy tissues in the peritumoral area is an important advantage of particle therapy. In this review, we analyze state-of-the-art particle therapy, as compared to conventional photon therapy, to identify clinical benefits and specify the mechanisms of action on tumor cells. Systematization of published data on particle therapy confirms its successful application in a wide range of cancers and reveals a variety of biological effects which manifest at the molecular level and produce the particle therapy-specific molecular signatures. Given the rapid progress in the field, the use of particle therapy holds great promise for the near future.
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Affiliation(s)
- Viktoriia Kiseleva
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named after Academician V.I. Kulakov of Ministry of Healthcare of Russian Federation, 117198 Moscow, Russia
| | - Konstantin Gordon
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
- A. Tsyb Medical Radiological Research Center, 249031 Obninsk, Russia
| | - Polina Vishnyakova
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named after Academician V.I. Kulakov of Ministry of Healthcare of Russian Federation, 117198 Moscow, Russia
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Elena Gantsova
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
| | - Andrey Elchaninov
- National Medical Research Center for Obstetrics, Gynecology and Perinatology Named after Academician V.I. Kulakov of Ministry of Healthcare of Russian Federation, 117198 Moscow, Russia
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
- A.P. Avtsyn Research Institute of Human Morphology of Federal State Budgetary Scientific Institution “Petrovsky National Research Centre of Surgery”, 117418 Moscow, Russia
| | - Timur Fatkhudinov
- Research Institute of Molecular and Cellular Medicine, Peoples’ Friendship University of Russia (RUDN University), 117198 Moscow, Russia
- A.P. Avtsyn Research Institute of Human Morphology of Federal State Budgetary Scientific Institution “Petrovsky National Research Centre of Surgery”, 117418 Moscow, Russia
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11
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Yu NY, DeWees TA, Voss MM, Breen WG, Chiang JS, Ding JX, Daniels TB, Owen D, Olivier KR, Garces YI, Park SS, Sarkaria JN, Yang P, Savvides PS, Ernani V, Liu W, Schild SE, Merrell KW, Sio TT. Cardiopulmonary Toxicity Following Intensity-Modulated Proton Therapy (IMPT) Versus Intensity-Modulated Radiation Therapy (IMRT) for Stage III Non-Small Cell Lung Cancer. Clin Lung Cancer 2022; 23:e526-e535. [PMID: 36104272 DOI: 10.1016/j.cllc.2022.07.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/14/2022] [Accepted: 07/24/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Intensity-modulated proton therapy (IMPT) has the potential to reduce radiation dose to normal organs when compared to intensity-modulated radiation therapy (IMRT). We hypothesized that IMPT is associated with a reduced rate of cardiopulmonary toxicities in patients with Stage III NSCLC when compared with IMRT. METHODS We analyzed 163 consecutively treated patients with biopsy-proven, stage III NSCLC who received IMPT (n = 35, 21%) or IMRT (n = 128, 79%). Patient, tumor, and treatment characteristics were analyzed. Overall survival (OS), freedom-from distant metastasis (FFDM), freedom-from locoregional relapse (FFLR), and cardiopulmonary toxicities (CTCAE v5.0) were calculated using the Kaplan-Meier estimate. Univariate cox regressions were conducted for the final model. RESULTS Median follow-up of surviving patients was 25.5 (range, 4.6-58.1) months. Median RT dose was 60 (range, 45-72) Gy [RBE]. OS, FFDM, and FFLR were not different based on RT modality. IMPT provided significant dosimetric pulmonary and cardiac sparing when compared to IMRT. IMPT was associated with a reduced rate of grade more than or equal to 3 pneumonitis (HR 0.25, P = .04) and grade more than or equal to 3 cardiac events (HR 0.33, P = .08). Pre-treatment predicted diffusing capacity for carbon monoxide less than equal to 57% (HR 2.8, P = .04) and forced expiratory volume in the first second less than equal to 61% (HR 3.1, P = .03) were associated with an increased rate of grade more than or equal to 3 pneumonitis. CONCLUSIONS IMPT is associated with a reduced risk of clinically significant pneumonitis and cardiac events when compared with IMRT without compromising tumor control in stage III NSCLC. IMPT may provide a safer treatment option, particularly for high-risk patients with poor pretreatment pulmonary function.
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Affiliation(s)
- Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - Todd A DeWees
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, AZ
| | - Molly M Voss
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, AZ
| | - William G Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | - Julia X Ding
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - Thomas B Daniels
- Department of Radiation Oncology, NYU Langone Health, New York, NY
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | | | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Jann N Sarkaria
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Ping Yang
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ
| | | | - Vinicius Ernani
- Department of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | | | | | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ.
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12
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Carrasquilla M, Paudel N, Collins BT, Anderson E, Krochmal R, Margolis M, Balawi A, DeBlois D, Giaccone G, Kim C, Liu S, Lischalk JW. High-Risk Non-Small Cell Lung Cancer Treated With Active Scanning Proton Beam Radiation Therapy and Immunotherapy. Adv Radiat Oncol 2022; 8:101125. [PMID: 36578277 PMCID: PMC9791120 DOI: 10.1016/j.adro.2022.101125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/31/2022] [Indexed: 11/27/2022] Open
Abstract
Purpose Non-small cell lung cancer (NSCLC) is a deadly malignancy that is frequently diagnosed in patients with significant medical comorbidities. When delivering local and regional therapy, an exceedingly narrow therapeutic window is encountered, which often precludes patients from receiving aggressive curative therapy. Radiation therapy advances including particle therapy have been employed in an effort to expand this therapeutic window. Here we report outcomes with the use of proton therapy with curative intent and immunotherapy to treat patients diagnosed with high-risk NSCLC. Methods and Materials Patients were determined to be high risk if they had severe underlying cardiopulmonary dysfunction, history of prior thoracic radiation therapy, and/or large volume or unfavorable location of disease (eg, bilateral hilar involvement, supraclavicular involvement). As such, patients were determined to be ineligible for conventional x-ray-based radiation therapy and were treated with pencil beam scanning proton beam therapy (PBS-PBT). Patients who demonstrated excess respiratory motion (ie, greater than 1 cm in any dimension noted on the 4-dimensional computed tomography simulation scan) were deemed to be ineligible for PBT. Toxicity was reported using the Common Terminology Criteria for Adverse Events (CTCAE), version 5.0. Overall survival and progression-free survival were calculated using the Kaplan-Meier method. Results A total of 29 patients with high-risk NSCLC diagnoses were treated with PBS-PBT. The majority (55%) of patients were defined as high risk due to severe cardiopulmonary dysfunction. Most commonly, patients were treated definitively to a total dose of 6000 cGy (relative biological effectiveness) in 30 fractions with concurrent chemotherapy. Overall, there were a total of 6 acute grade 3 toxicities observed in our cohort. Acute high-grade toxicities included esophagitis (n = 4, 14%), dyspnea (n = 1, 3.5%), and cough (n = 1, 3.5%). No patients developed grade 4 or higher toxicity. The majority of patients went on to receive immunotherapy, and high-grade pneumonitis was rare. Two-year progression-free and overall survival was estimated to be 51% and 67%, respectively. COVID-19 was confirmed or suspected to be responsible for 2 patient deaths during the follow-up period. Conclusions Radical PBS-PBT treatment delivered in a cohort of patients with high-risk lung cancer with immunotherapy is feasible with careful multidisciplinary evaluation and rigorous follow-up.
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Affiliation(s)
- Michael Carrasquilla
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Nitika Paudel
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Brian T. Collins
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Eric Anderson
- Division of Pulmonary and Critical Care Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Rebecca Krochmal
- Division of Pulmonary and Critical Care Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Marc Margolis
- Division of Thoracic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Ahssan Balawi
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - David DeBlois
- Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC
| | - Giuseppe Giaccone
- Department of Hematology and Oncology, Weill Cornell Medical Center, New York, New York
| | - Chul Kim
- Lombardi Cancer Center, MedStar Georgetown University Hospital, Washington, DC
| | - Stephen Liu
- Lombardi Cancer Center, MedStar Georgetown University Hospital, Washington, DC
| | - Jonathan W. Lischalk
- Department of Radiation Oncology, Perlmutter Cancer Center at New York University Langone Hospital – Long Island, New York, New York,Corresponding author: Jonathan W. Lischalk, MD
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13
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Liu Y, Jiang S, Lin Y, Yu H, Yu L, Zhang X. Research landscape and trends of lung cancer radiotherapy: A bibliometric analysis. Front Oncol 2022; 12:1066557. [DOI: 10.3389/fonc.2022.1066557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022] Open
Abstract
Backgroundradiotherapy is one of the major treatments for lung cancer and has been a hot research area for years. This bibliometric analysis aims to present the research trends on lung cancer radiotherapy.MethodOn August 31, 2022, the authors identified 9868 articles on lung cancer radiotherapy by the Web of Science (Science Citation Indexing Expanded database) and extracted their general information and the total number of citations. A bibliometric analysis was carried out to present the research landscape, demonstrate the research trends, and determine the most cited papers (top-papers) as well as top-journals on lung cancer radiotherapy. After that, the authors analyzed the recent research hotspots based on the latest publications in top-journals.ResultsThese 9868 papers were cited a total of 268,068 times. “Durvalumab after chemoradiotherapy in stage III non–small-cell lung cancer” published in 2017 by Antonia et al.was the most cited article (2110 citations). Among the journals, New England Journal of Medicine was most influential. Moreover, J. Clin. Oncol. and Int. J. Radiat. Oncol. Biol. Phys. was both influential and productive. Corresponding authors represented the USA (2610 articles) and China mainland (2060 articles) took part in most publications and articles with corresponding authors from Netherlands were most cited (46.12 citations per paper). Chemoradiotherapy was the hottest research area, and stereotactic body radiotherapy has become a research hotspot since 2006. Radiotherapy plus immunotherapy has been highly focused since 2019.ConclusionsThis bibliometric analysis comprehensively and quantitatively presents the research trends and hotspots based on 9868 relevant articles, and further suggests future research directions. The researchers can benefit in selecting journals and in finding potential collaborators. This study can help researchers gain a comprehensive picture of the research landscape, historical development, and recent hotspots in lung cancer radiotherapy and can provide inspiration for future research.
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14
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Choi JI, Prabhu K, Hartsell WF, DeWees T, Sinesi C, Vargas C, Benda RK, Cahlon O, Chang AL. Outcomes and toxicities after proton partial breast radiotherapy for early stage, hormone receptor positive breast cancer: 3-Year results of a phase II multi-center trial. Clin Transl Radiat Oncol 2022; 37:71-77. [PMID: 36093343 PMCID: PMC9450061 DOI: 10.1016/j.ctro.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose Proton therapy (PT) for partial breast irradiation (PBI) in early-stage breast cancer can decrease morbidity versus photon PBI with superior organs-at-risk sparing. We report 3-year outcomes of the first prospective, multicenter, phase II trial of proton PBI. Methods and Materials This Proton Collaborative Group phase II trial (PCG BRE007-12) recruited women ≥ 50 years with node-negative, estrogen receptor (ER)-positive, ≤3cm, invasive ductal carcinoma (IDC) or ductal carcinoma in situ undergoing breast conserving surgery followed by proton PBI (40 Gy(RBE), 10 daily fractions). Primary endpoint was freedom from ipsilateral breast cancer recurrence. Adverse events were prospectively graded using CTCAEv4.0. Breast Cancer Treatment Outcome Scale (BCTOS) assessed patient-reported quality of life (PRQOL). Results Thirty-eight evaluable patients enrolled between 2/2013-11/2016. Median age was 67 years (range 50-79); 55 % had left-sided disease, and median tumor size was 0.9 cm. Treatment was delivered in ≥ 2 fields predominantly with uniform scanning PT (n = 37). At 35-month median follow-up (12-62), all patients were alive, and none had local, regional or distant disease progression. One patient developed an ER-negative contralateral IDC. Seven grade 2 adverse events occurred; no radiotherapy-related grade ≥ 3 toxicities occurred. Changes in BCTOS subdomain mean scores were maximum 0.36, indicating no meaningful change in PRQOL. Median heart volume receiving 5 Gy (V5Gy), lung V20Gy, and lung V10Gy were 0 %, 0 % and 0.19 %, respectively. Conclusion At 3 years, proton PBI provided 100 % cancer control for early-stage, ER-positive breast cancer. Toxicities are minimal, and PRQOL remains acceptable with continued follow-up. These findings support PT as a safe and effective PBI delivery option.
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Affiliation(s)
- J. Isabelle Choi
- New York Proton Center, 225 East 126th Street, New York, NY 10035, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Kiran Prabhu
- Integris Health, 5911 W. Memorial, Oklahoma City, OK 73142, USA
| | - William F. Hartsell
- Northwestern Medicine, Chicago Proton Center, 4455 Weaver Pkwy, Warrenville, IL 60555, USA
| | - Todd DeWees
- Department of Quantitative Health Sciences, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | - Christopher Sinesi
- Hampton University Proton Therapy Institute, 40 Enterprise Pkwy, Hampton, VA 23666, USA
| | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic, 5777 E Mayo Blvd, Scottsdale, AZ 85054, USA
| | - Rashmi K. Benda
- Lynn Cancer Institute, Boca Raton Regional Hospital, 701 NW 13 St, Boca Raton, FL 33486, USA
| | - Oren Cahlon
- New York Proton Center, 225 East 126th Street, New York, NY 10035, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Andrew L. Chang
- California Protons Cancer Therapy Center, 9730 Summers Ridge Rd, San Diego, CA 92121, USA
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15
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Amstutz F, Fabiano S, Marc L, Weber DC, Lomax AJ, Unkelbach J, Zhang Y. Combined proton-photon therapy for non-small cell lung cancer. Med Phys 2022; 49:5374-5386. [PMID: 35561077 PMCID: PMC9544482 DOI: 10.1002/mp.15715] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/18/2022] [Accepted: 05/08/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Advanced non-small cell lung cancer (NSCLC) is still a challenging indication for conventional photon radiotherapy. Proton therapy has the potential to improve outcomes, but proton treatment slots remain a limited resource despite an increasing number of proton therapy facilities. This work investigates the potential benefits of optimally combined proton-photon therapy delivered using a fixed horizontal proton beam line in combination with a photon Linac, which could increase accessibility to proton therapy for such a patient cohort. MATERIALS AND METHODS A treatment planning study has been conducted on a patient cohort of seven advanced NSCLC patients. Each patient had a planning CT and multiple repeated CTs from three different days and for different breath-holds on each day. Treatment plans for combined proton-photon therapy (CPPT) were calculated for individual patients by optimizing the combined cumulative dose on the initial planning CT only (non-adapted) as well as on each daily CT respectively (adapted). The impact of inter-fractional changes and/or breath-hold variability was then assessed on the repeat breath-hold CTs. Results were compared to plans for IMRT or IMPT alone, as well as against combined treatments assuming a proton gantry. Plan quality was assessed in terms of dosimetric, robustness and NTCP metrics. RESULTS Combined treatment plans improved plan quality compared to IMRT treatments, especially in regard to reductions of low and medium doses to organs at risk (OARs), which translated into lower NTCP estimates for three side effects. For most patients, combined treatments achieved results close to IMPT-only plans. Inter-fractional changes impact mainly the target coverage of combined and IMPT treatments, while OARs doses were less affected by these changes. With plan adaptation however, target coverage of combined treatments remained high even when taking variability between breath-holds into account. CONCLUSIONS Optimally combined proton-photon plans improve treatment plan quality compared to IMRT only, potentially reducing the risk of toxicity while also allowing to potentially increase accessibility to proton therapy for NSCLC patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Florian Amstutz
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.,Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Silvia Fabiano
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Louise Marc
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.,Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland.,Department of Radiation Oncology, University Hospital Bern, Bern, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.,Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Jan Unkelbach
- Department of Radiation Oncology, University Hospital Zurich, Zurich, Switzerland
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland
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16
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Nogueira LM, Sineshaw HM, Jemal A, Pollack CE, Efstathiou JA, Yabroff KR. Association of Race With Receipt of Proton Beam Therapy for Patients With Newly Diagnosed Cancer in the US, 2004-2018. JAMA Netw Open 2022; 5:e228970. [PMID: 35471569 PMCID: PMC9044116 DOI: 10.1001/jamanetworkopen.2022.8970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Black patients are less likely than White patients to receive guideline-concordant cancer care in the US. Proton beam therapy (PBT) is a potentially superior technology to photon radiotherapy for tumors with complex anatomy, tumors surrounded by sensitive tissues, and childhood cancers. OBJECTIVE To evaluate whether there are racial disparities in the receipt of PBT among Black and White individuals diagnosed with all PBT-eligible cancers in the US. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study evaluated Black and White individuals diagnosed with PBT-eligible cancers between January 1, 2004, and December 31, 2018, in the National Cancer Database, a nationwide hospital-based cancer registry that collects data on radiation treatment, even when it is received outside the reporting facility. American Society of Radiation Oncology model policies were used to classify patients into those for whom PBT is the recommended radiation therapy modality (group 1) and those for whom evidence of PBT efficacy is still under investigation (group 2). Propensity score matching was used to ensure comparability of Black and White patients' clinical characteristics and regional availability of PBT according to the National Academy of Medicine's definition of disparities. Data analysis was performed from October 4, 2021, to February 22, 2022. EXPOSURE Patients' self-identified race was ascertained from medical records. MAIN OUTCOMES AND MEASURES The main outcome was receipt of PBT, with disparities in this therapy's use evaluated with logistic regression analysis. RESULTS Of the 5 225 929 patients who were eligible to receive PBT and included in the study, 13.6% were Black, 86.4% were White, and 54.3% were female. The mean (SD) age at diagnosis was 63.2 (12.4) years. Black patients were less likely to be treated with PBT than their White counterparts (0.3% vs 0.5%; odds ratio [OR], 0.67; 95% CI, 0.64-0.71). Racial disparities were greater for group 1 cancers (0.4% vs 0.8%; OR, 0.49; 95% CI, 0.44-0.55) than group 2 cancers (0.3% vs 0.4%; OR, 0.75; 95% CI, 0.70-0.80). Racial disparities in PBT receipt among group 1 cancers increased over time (annual percent change = 0.09, P < .001) and were greatest in 2018, the most recent year of available data. CONCLUSIONS AND RELEVANCE In this cross-sectional study, Black patients were less likely to receive PBT than their White counterparts, and disparities were greatest for cancers for which PBT was the recommended radiation therapy modality. These findings suggest that efforts other than increasing the number of facilities that provide PBT will be needed to eliminate disparities.
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Affiliation(s)
- Leticia M. Nogueira
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Helmneh M. Sineshaw
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Craig E. Pollack
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health and Johns Hopkins School of Nursing, Baltimore, Maryland
| | | | - K. Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
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17
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Higgins KA, Puri S, Gray JE. Systemic and Radiation Therapy Approaches for Locally Advanced Non-Small-Cell Lung Cancer. J Clin Oncol 2022; 40:576-585. [PMID: 34985931 DOI: 10.1200/jco.21.01707] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The treatment for locally advanced non-small-cell lung cancer has changed dramatically over the past several years, with consolidative immunotherapy after concurrent chemoradiation becoming the new standard of care. Five-year survival outcomes have substantially improved with this approach. Despite these advances, further improvements are needed as the majority of patients ultimately develop progression of disease. The next-generation immunotherapy trials are currently being conducted that include approaches such as concurrent immunotherapy and addition of other therapeutic agents in the concurrent and consolidative settings. Specific unmet needs continue to exist for patients who develop disease progression after concurrent chemoradiation and immunotherapy, as well as defining the best treatment for patients with driver mutations. Future directions also include refinement of radiation techniques to reduce toxicities as much as possible, as well as the use of circulating tumor DNA in the surveillance setting. The current scientific landscape shows promising approaches that may further improve outcomes for patients with locally advanced non-small-cell lung cancer.
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Affiliation(s)
- Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Sonam Puri
- Division of Medical Oncology, The University of Utah Huntsman Cancer Institute, Salt Lake City, UT
| | - Jhanelle E Gray
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
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18
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Radiomic Phenotypes for Improving Early Prediction of Survival in Stage III Non-Small Cell Lung Cancer Adenocarcinoma after Chemoradiation. Cancers (Basel) 2022; 14:cancers14030700. [PMID: 35158971 PMCID: PMC8833400 DOI: 10.3390/cancers14030700] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/23/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023] Open
Abstract
We evaluate radiomic phenotypes derived from CT scans as early predictors of overall survival (OS) after chemoradiation in stage III primary lung adenocarcinoma. We retrospectively analyzed 110 thoracic CT scans acquired between April 2012-October 2018. Patients received a median radiation dose of 66.6 Gy at 1.8 Gy/fraction delivered with proton (55.5%) and photon (44.5%) beam treatment, as well as concurrent chemotherapy (89%) with carboplatin-based (55.5%) and cisplatin-based (36.4%) doublets. A total of 56 death events were recorded. Using manual tumor segmentations, 107 radiomic features were extracted. Feature harmonization using ComBat was performed to mitigate image heterogeneity due to the presence or lack of intravenous contrast material and variability in CT scanner vendors. A binary radiomic phenotype to predict OS was derived through the unsupervised hierarchical clustering of the first principal components explaining 85% of the variance of the radiomic features. C-scores and likelihood ratio tests (LRT) were used to compare the performance of a baseline Cox model based on ECOG status and age, with a model integrating the radiomic phenotype with such clinical predictors. The model integrating the radiomic phenotype (C-score = 0.69, 95% CI = (0.62, 0.77)) significantly improved (p<0.005) upon the baseline model (C-score = 0.65, CI = (0.57, 0.73)). Our results suggest that harmonized radiomic phenotypes can significantly improve OS prediction in stage III NSCLC after chemoradiation.
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Jongen A, Charlier F, Baker K, Chang J, Hartsell W, Laramore G, Mohindra P, Moretti L, Redman M, Rosen L, Tsai H, Van Gestel D, Vargas C, Rengan R. Clinical Outcomes After Proton Beam Therapy for Locally Advanced Non-Small Cell Lung Cancer: Analysis of a Multi-institutional Prospective Registry. Adv Radiat Oncol 2022; 7:100767. [PMID: 35071826 PMCID: PMC8767257 DOI: 10.1016/j.adro.2021.100767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/16/2021] [Indexed: 11/04/2022] Open
Abstract
Purpose For most disease sites, level 1 evidence is lacking for proton beam therapy (PBT). By identifying target populations that would benefit most from PBT, prospective registries could overcome many of the challenges in clinical trial enrollment. Herein, we report clinical outcomes of patients treated with PBT for locally advanced non-small cell lung cancer (LA-NSCLC). Methods and Materials Data were obtained from the multi-institutional prospective database of the Proton Collaborative Group (PCG). Inclusion criteria of our study were stage III de novo or recurrent LA-NSCLC, use of PBT, and availability of follow-up data. Overall survival (OS) time was calculated from the start of treatment until death or last follow-up. Kaplan-Meier curves were generated for groups of interest and compared with log-rank tests. Cox regression modeling was used to evaluate the multivariate association between selected covariates and OS. Results A total of 195 patients were included in the analysis. PBT was given with a median equivalent dose in 2 Gy fractions (EQD2) of 63.8 Gy (relative biological effectiveness). Pencil beam scanning was used in 20% of treatments. Treatment-related grade 3 adverse events were rare: 1 pneumonitis, 2 dermatitis, and 3 esophagitis. No grade 4 events were reported. Two cardiac-related grade 5 events occurred in patients with multiple risk factors. The median follow-up time for living patients was 37.1 months and the median OS was 19.0 months. On multivariate analysis, good performance status (hazard ratio, 0.27; [95% confidence interval, 0.15-0.46]; P < .0001), pencil beam scanning use (0.55; [0.31-0.97]; P = .04), and increased EQD2 (0.80; [0.71-0.90] - per 10 Gy increase; P = .0002) were associated with decreased mortality. Conclusions PBT appears to yield low rates of adverse events with an OS similar to other retrospective studies on PBT for LA-NSCLC. PBS use and increased EQD2 can potentially improve OS.
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Affiliation(s)
- Aurélien Jongen
- Department of Radiation Oncology, Zürich University Hospital, Zürich, Switzerland
| | - Florian Charlier
- Department of Radiation Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Kelsey Baker
- Clinical Statistics, Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - John Chang
- Oklahoma Proton Center, Oklahoma City, Oklahoma
| | - William Hartsell
- Northwestern Medicine Chicago Proton Center, Warrenville, Illinois
| | - George Laramore
- University of Washington and Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
| | - Pranshu Mohindra
- University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, Maryland
| | - Luigi Moretti
- Department of Radiation Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Mary Redman
- Clinical Statistics, Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Lane Rosen
- Willis-Knighton Medical Center, Shreveport, Louisiana
| | - Henry Tsai
- New Jersey Procure Proton Therapy Center, Somerset, New Jersey
| | - Dirk Van Gestel
- Department of Radiation Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Carlos Vargas
- Mayo Clinic Arizona Proton Therapy Program, Rochester, Minnesota
| | - Ramesh Rengan
- University of Washington and Seattle Cancer Care Alliance Proton Therapy Center, Seattle, Washington
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20
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Miyasaka Y, Sato H, Okano N, Kubo N, Kawamura H, Ohno T. A Promising Treatment Strategy for Lung Cancer: A Combination of Radiotherapy and Immunotherapy. Cancers (Basel) 2021; 14:203. [PMID: 35008367 PMCID: PMC8750493 DOI: 10.3390/cancers14010203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/26/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022] Open
Abstract
Lung cancer is a leading cause of cancer-related deaths worldwide despite advances in treatment. In the past few decades, radiotherapy has achieved outstanding technical advances and is being widely used as a definitive, prophylactic, or palliative treatment of patients with lung cancer. The anti-tumor effects of radiotherapy are considered to result in DNA damage in cancer cells. Moreover, recent evidence has demonstrated another advantage of radiotherapy: the induction of anti-tumor immune responses, which play an essential role in cancer control. In contrast, radiotherapy induces an immunosuppressive response. These conflicting reactions after radiotherapy suggest that maximizing immune response to radiotherapy by combining immunotherapy has potential to achieve more effective anti-tumor response than using each alone. Immune checkpoint molecules, such as cytotoxic T-lymphocyte-associated protein 4, programmed cell death-1/programmed death-ligand 1, and their inhibitors, have attracted significant attention for overcoming the immunosuppressive conditions in patients with cancer. Therefore, the combination of immune checkpoint inhibitors and radiotherapy is promising. Emerging preclinical and clinical studies have demonstrated the rationale for these combination strategies. In this review, we outlined evidence suggesting that combination of radiotherapy, including particle therapy using protons and carbon ions, with immunotherapy in lung cancer treatment could be a promising treatment strategy.
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Affiliation(s)
- Yuhei Miyasaka
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Hiro Sato
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Naoko Okano
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Nobuteru Kubo
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Hidemasa Kawamura
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan; (Y.M.); (N.O.); (N.K.); (H.K.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-Machi, Maebashi 371-8511, Japan
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21
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Daly ME, Singh N, Ismaila N, Antonoff MB, Arenberg DA, Bradley J, David E, Detterbeck F, Früh M, Gubens MA, Moore AC, Padda SK, Patel JD, Phillips T, Qin A, Robinson C, Simone CB. Management of Stage III Non-Small-Cell Lung Cancer: ASCO Guideline. J Clin Oncol 2021; 40:1356-1384. [PMID: 34936470 DOI: 10.1200/jco.21.02528] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To provide evidence-based recommendations to practicing clinicians on management of patients with stage III non-small-cell lung cancer (NSCLC). METHODS An Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary oncology, community oncology, research methodology, and advocacy experts was convened to conduct a literature search, which included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2021. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 127 relevant studies to inform the evidence base for this guideline. RECOMMENDATIONS Evidence-based recommendations were developed to address evaluation and staging workup of patients with suspected stage III NSCLC, surgical management, neoadjuvant and adjuvant approaches, and management of patients with unresectable stage III NSCLC.Additional information is available at www.asco.org/thoracic-cancer-guidelines.
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Affiliation(s)
| | - Navneet Singh
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Nofisat Ismaila
- American Society of Clinical Oncology (ASCO), Alexandria, VA
| | | | | | | | | | | | - Martin Früh
- Department of Medical Oncology Cantonal Hospital of St Gallen, St Gallen, Switzerland.,University of Bern, Bern, Switzerland
| | | | | | - Sukhmani K Padda
- Department of Medicine, Division of Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jyoti D Patel
- Northwestern University-Feinberg School of Medicine, Chicago, IL
| | | | - Angel Qin
- University of Michigan, Ann Arbor, MI
| | | | - Charles B Simone
- New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY
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22
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Boutros SW, Zimmerman B, Nagy SC, Lee JS, Perez R, Raber J. Amifostine (WR-2721) Mitigates Cognitive Injury Induced by Heavy Ion Radiation in Male Mice and Alters Behavior and Brain Connectivity. Front Physiol 2021; 12:770502. [PMID: 34867479 PMCID: PMC8637850 DOI: 10.3389/fphys.2021.770502] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/22/2021] [Indexed: 12/11/2022] Open
Abstract
The deep space environment contains many risks to astronauts during space missions, such as galactic cosmic rays (GCRs) comprised of naturally occurring heavy ions. Heavy ion radiation is increasingly being used in cancer therapy, including novel regimens involving carbon therapy. Previous investigations involving simulated space radiation have indicated a host of detrimental cognitive and behavioral effects. Therefore, there is an increasing need to counteract these deleterious effects of heavy ion radiation. Here, we assessed the ability of amifostine to mitigate cognitive injury induced by simulated GCRs in C57Bl/6J male and female mice. Six-month-old mice received an intraperitoneal injection of saline, 107 mg/kg, or 214 mg/kg of amifostine 1 h prior to exposure to a simplified five-ion radiation (protons, 28Si, 4He, 16O, and 56Fe) at 500 mGy or sham radiation. Mice were behaviorally tested 2-3 months later. Male mice that received saline and radiation exposure failed to show novel object recognition, which was reversed by both doses of amifostine. Conversely, female mice that received saline and radiation exposure displayed intact object recognition, but those that received amifostine prior to radiation did not. Amifostine and radiation also had distinct effects on males and females in the open field, with amifostine affecting distance moved over time in both sexes, and radiation affecting time spent in the center in females only. Whole-brain analysis of cFos immunoreactivity in male mice indicated that amifostine and radiation altered regional connectivity in areas involved in novel object recognition. These data support that amifostine has potential as a countermeasure against cognitive injury following proton and heavy ion irradiation in males.
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Affiliation(s)
- Sydney Weber Boutros
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, United States
| | - Benjamin Zimmerman
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, United States
- Advanced Imaging Research Center, Oregon Health & Science University, Portland, OR, United States
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, IL, United States
| | - Sydney C. Nagy
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, United States
| | - Joanne S. Lee
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, United States
| | - Ruby Perez
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, United States
| | - Jacob Raber
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, United States
- Departments of Neurology and Radiation Medicine, Oregon Health & Science University, Portland, OR, United States
- Division of Neuroscience, Oregon National Primate Research Center, Portland, OR, United States
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23
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Elbanna M, Chowdhury NN, Rhome R, Fishel ML. Clinical and Preclinical Outcomes of Combining Targeted Therapy With Radiotherapy. Front Oncol 2021; 11:749496. [PMID: 34733787 PMCID: PMC8558533 DOI: 10.3389/fonc.2021.749496] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/30/2021] [Indexed: 12/12/2022] Open
Abstract
In the era of precision medicine, radiation medicine is currently focused on the precise delivery of highly conformal radiation treatments. However, the tremendous developments in targeted therapy are yet to fulfill their full promise and arguably have the potential to dramatically enhance the radiation therapeutic ratio. The increased ability to molecularly profile tumors both at diagnosis and at relapse and the co-incident progress in the field of radiogenomics could potentially pave the way for a more personalized approach to radiation treatment in contrast to the current ‘‘one size fits all’’ paradigm. Few clinical trials to date have shown an improved clinical outcome when combining targeted agents with radiation therapy, however, most have failed to show benefit, which is arguably due to limited preclinical data. Several key molecular pathways could theoretically enhance therapeutic effect of radiation when rationally targeted either by directly enhancing tumor cell kill or indirectly through the abscopal effect of radiation when combined with novel immunotherapies. The timing of combining molecular targeted therapy with radiation is also important to determine and could greatly affect the outcome depending on which pathway is being inhibited.
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Affiliation(s)
- May Elbanna
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, United States.,Indiana University Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Nayela N Chowdhury
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ryan Rhome
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, United States.,Indiana University Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Melissa L Fishel
- Indiana University Simon Comprehensive Cancer Center, Indiana University School of Medicine, Indianapolis, IN, United States.,Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States.,Department of Pediatrics and Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, United States
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24
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Dosimetry, Efficacy, Safety, and Cost-Effectiveness of Proton Therapy for Non-Small Cell Lung Cancer. Cancers (Basel) 2021; 13:cancers13184545. [PMID: 34572772 PMCID: PMC8465697 DOI: 10.3390/cancers13184545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/04/2021] [Accepted: 09/07/2021] [Indexed: 12/24/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is the most common malignancy which requires radiotherapy (RT) as an important part of its multimodality treatment. With the advent of the novel irradiation technique, the clinical outcome of NSCLC patients who receive RT has been dramatically improved. The emergence of proton therapy, which allows for a sharper dose of build-up and drop-off compared to photon therapy, has potentially improved clinical outcomes of NSCLC. Dosimetry studies have indicated that proton therapy can significantly reduce the doses for normal organs, especially the lung, heart, and esophagus while maintaining similar robust target volume coverage in both early and advanced NSCLC compared with photon therapy. However, to date, most studies have been single-arm and concluded no significant changes in the efficacy for early-stage NSCLC by proton therapy over stereotactic body radiation therapy (SBRT). The results of proton therapy for advanced NSCLC in these studies were promising, with improved clinical outcomes and reduced toxicities compared with historical photon therapy data. However, these studies were also mainly single-arm and lacked a direct comparison between the two therapies. Currently, there is much emerging evidence focusing on dosimetry, efficacy, safety, and cost-effectiveness of proton therapy for NSCLC that has been published, however, a comprehensive review comparing these therapies is, to date, lacking. Thus, this review focuses on these aspects of proton therapy for NSCLC.
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25
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Han JE, Hasan S, Choi JI, Press RH, Simone CB. Optimal surgical timing and radiotherapy dose for trimodality therapy in locally advanced non-small cell lung cancer. Cancer Med 2021; 10:5794-5808. [PMID: 34350713 PMCID: PMC8419752 DOI: 10.1002/cam4.4123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose/Objectives Data are conflicting on the effects of time interval from neoadjuvant chemoradiation (NCRT) to surgery for locally advanced non‐small‐cell lung cancer (LA‐NSCLC). This study investigated the impact of surgical timing after NCRT and radiation dose on postoperative mortality and overall survival (OS). Materials and Methods Using the National Cancer Database, we identified 3489 LA‐NSCLC patients treated with NCRT and surgery. Multivariate Cox proportional hazards analysis (MVA) was used to examine the effects of surgery >7 weeks from NCRT completion on OS. Propensity score (PS)‐matched survival analysis for surgery ≤7 and >7 weeks was performed. Postoperative mortality was assessed. Results Median OS for surgery ≤7 weeks and >7 weeks after NCRT were 56.9 versus 45.6 months (hazard ratio, HR 1.18 [1.07–1.30]; p < 0.001). Surgery >7 weeks correlated with decreased OS on MVA (HR 1.15 [1.04–1.27]; p = 0.009) and PS matching (HR 1.16 [1.049–1.29]; p = 0.004). Time as a continuous variable correlated with OS on MVA (HR 1.003 [1.001–1.006]; p = 0.0056) and PS matching (HR 1.004 [1.001–1.006]; p = 0.004). Among 2902 lobectomy patients, the mortality rate for surgery ≤66 days was 5.2% versus 8.1% for >66 days (MVA HR 1.59 [1.02–2.49]; p = 0.04). Higher neoadjuvant radiotherapy dose correlated with surgery >7 weeks and lobectomy >66 days on MVA. Conclusions Increased interval >7 weeks from NCRT to surgery for LA‐NSCLC is correlated with worse OS and lobectomy ≤66 days correlated with improved OS. Surgery ≤7weeks may improve tumor control, whereas higher mortality for surgery >66 days may relate to late NCRT manifestations. Neoadjuvant doses of 44–50.4 Gy may minimize risks of radiation‐induced lung injury and surgical complications and facilitate surgery within the optimal 7‐week interval.
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Affiliation(s)
- James E Han
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Shaakir Hasan
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - Robert H Press
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
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26
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Clinical Outcomes of Pencil Beam Scanning Proton Therapy in Locally Advanced Non-Small Cell Lung Cancer: Propensity Score Analysis. Cancers (Basel) 2021; 13:cancers13143497. [PMID: 34298711 PMCID: PMC8307066 DOI: 10.3390/cancers13143497] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 12/25/2022] Open
Abstract
This study compared the efficacy and safety of pencil beam scanning proton therapy (PBSPT) versus intensity-modulated (photon) radiotherapy (IMRT) in patients with stage III non-small cell lung cancer (NSCLC). We retrospectively reviewed 219 patients with stage III NSCLC who received definitive concurrent chemoradiotherapy between November 2016 and December 2018. Twenty-five patients (11.4%) underwent PBSPT (23 with single-field optimization) and 194 patients (88.6%) underwent IMRT. Rates of locoregional control (LRC), overall survival, and acute/late toxicities were compared between the groups using propensity score-adjusted analyses. Patients treated with PBSPT were older (median: 67 vs. 62 years) and had worse pulmonary function at baseline (both FEV1 and DLCO) compared to those treated with IMRT. With comparable target coverage, PBSPT exhibited superior sparing of the lung, heart, and spinal cord to radiation exposure compared to IMRT. At a median follow-up of 21.7 (interquartile range: 16.8-26.8) months, the 2-year LRC rates were 72.1% and 84.1% in the IMRT and PBSPT groups, respectively (p = 0.287). The rates of grade ≥ 3 esophagitis were 8.2% and 20.0% after IMRT and PBSPT (p = 0.073), respectively, while corresponding rates of grade ≥ 2 radiation pneumonitis were 28.9% and 16.0%, respectively (p = 0.263). PBSPT appears to be an effective and safe treatment technique even for patients with poor lung function, and it does not jeopardize LRC.
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27
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Dougherty JM, Castillo E, Castillo R, Faught AM, Pepin M, Park SS, Beltran CJ, Guerrero T, Grills I, Vinogradskiy Y. Functional avoidance-based intensity modulated proton therapy with 4DCT derived ventilation imaging for lung cancer. J Appl Clin Med Phys 2021; 22:276-285. [PMID: 34159715 PMCID: PMC8292710 DOI: 10.1002/acm2.13323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 12/25/2022] Open
Abstract
The primary objective is to evaluate the potential dosimetric gains of performing functional avoidance‐based proton treatment planning using 4DCT derived ventilation imaging. 4DCT data of 31 patients from a prospective functional avoidance clinical trial were evaluated with intensity modulated proton therapy (IMPT) plans and compared with clinical volumetric modulated arc therapy (VMAT) plans. Dosimetric parameters were compared between standard and functional plans with IMPT and VMAT with one‐way analysis of variance and post hoc paired student t‐test. Normal Tissue Complication Probability (NTCP) models were employed to estimate the risk of two toxicity endpoints for healthy lung tissues. Dose degradation due to proton motion interplay effect was evaluated. Functional IMPT plans led to significant dose reduction to functional lung structures when compared with functional VMAT without significant dose increase to Organ at Risk (OAR) structures. When interplay effect is considered, no significant dose degradation was observed for the OARs or the clinical target volume (CTV) volumes for functional IMPT. Using fV20 as the dose metric and Grade 2+ pneumonitis as toxicity endpoint, there is a mean 5.7% reduction in Grade 2+ RP with the functional IMPT and as high as 26% in reduction for individual patient when compared to the standard IMPT planning. Functional IMPT was able to spare healthy lung tissue to avoid excess dose to normal structures while maintaining satisfying target coverage. NTCP calculation also shows that the risk of pulmonary complications can be further reduced with functional based IMPT.
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Affiliation(s)
| | - Edward Castillo
- Department of Computational and Applied Mathematics, Rice University, Houston, TX, USA.,Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Richard Castillo
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Austin M Faught
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mark Pepin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Chris J Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Thomas Guerrero
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, USA
| | - Yevgeniy Vinogradskiy
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
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28
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Paganetti H, Grassberger C, Sharp GC. Physics of Particle Beam and Hypofractionated Beam Delivery in NSCLC. Semin Radiat Oncol 2021; 31:162-169. [PMID: 33610274 PMCID: PMC7905707 DOI: 10.1016/j.semradonc.2020.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The dosimetric advantages of particle therapy lead to significantly reduced integral dose to normal tissues, making it an attractive treatment option for body sites such as the thorax. With reduced normal tissue dose comes the potential for dose escalation, toxicity reduction, or hypofractionation. While proton and heavy ion therapy have been used extensively for NSCLC, there are challenges in planning and delivery compared with X-ray-based radiation therapy. Particularly, range uncertainties compounded by breathing motion have to be considered. This article summarizes the current state of particle therapy for NSCLC with a specific focus on the impact of dosimetric uncertainties in planning and delivery.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Gregory C Sharp
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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29
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McGunigal M, Lischalk JW, Randolph-Jackson P, Khaitan PG. Radiation Modalities Used in Lung Cancer: An Overview for Thoracic Surgeons. Semin Thorac Cardiovasc Surg 2021; 33:1114-1121. [PMID: 33705939 DOI: 10.1053/j.semtcvs.2021.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/01/2021] [Indexed: 02/07/2023]
Abstract
Radiation is a constantly evolving technology which plays a role in the management of lung cancer in a variety of settings: as an adjunct to surgery, definitively, and palliatively. Key aspects of radiation oncology-including acute and chronic toxicities of thoracic radiation and rationale for choosing one modality of radiation over another-may be obscure to those outside the field. We aim to provide a useful overview relevant for the thoracic surgeon of radiation technology and delivery. A review was performed of salient articles identifying radiation technologies used in lung cancer which were summarized and expounded upon with focus on integrating their history, evolution, and landmark trials establishing basis of their use. This article reviews the four fundamental means of external beam radiation employed in managing lung cancer and provides visual examples of comparison plans. We also touch on potential practice-changing developments in regards to proton therapy and radiation in the era of immunotherapy. Radiation oncology has evolved considerably over time to become a critical part of lung cancer management, particularly in early-stage inoperable disease and locally advanced disease. Maximizing tumor control while minimizing toxicity drives treatment strategies. Knowledge of these fundamentals will help the thoracic surgeon answer many questions patients pose regarding radiation.
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Affiliation(s)
- Mary McGunigal
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Jonathan W Lischalk
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Pamela Randolph-Jackson
- Department of Radiation Oncology, Medstar Washington Hospital Center, Washington, District of Columbia.
| | - Puja Gaur Khaitan
- Department of Surgery, Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia
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Kumar R, Al-Turjman F, Anand L, Kumar A, Magesh S, Vengatesan K, Sitharthan R, Rajesh M. Genomic sequence analysis of lung infections using artificial intelligence technique. Interdiscip Sci 2021; 13:192-200. [PMID: 33558984 DOI: 10.1007/s12539-020-00414-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 02/04/2023]
Abstract
Attributable to the modernization of Artificial Intelligence (AI) procedures in healthcare services, various developments including Support Vector Machine (SVM), and profound learning. For example, Convolutional Neural systems (CNN) have prevalently engaged in a significant job of various classificational investigation in lung malignant growth, and different infections. In this paper, Parallel based SVM (P-SVM) and IoT has been utilized to examine the ideal order of lung infections caused by genomic sequence. The proposed method develops a new methodology to locate the ideal characterization of lung sicknesses and determine its growth in its early stages, to control the growth and prevent lung sickness. Further, in the investigation, the P-SVM calculation has been created for arranging high-dimensional distinctive lung ailment datasets. The data used in the assessment has been fetched from real-time data through cloud and IoT. The acquired outcome demonstrates that the developed P-SVM calculation has 83% higher accuracy and 88% precision in characterization with ideal informational collections when contrasted with other learning methods.
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Affiliation(s)
- R Kumar
- Department of Electronics and Instrumentation Engineering, National Institute of Technology, Chumkedima, Dimapur, Nagaland, 797103, India
| | - Fadi Al-Turjman
- Research Centre for AI and IoT, Near East University, Nicosia, Mersin 10, Turkey
| | - L Anand
- School Computing Science and Engineering, SRM Institute of Science and Technology, Kattankulathur, Chengalpattu, Tamil Nadu, India
| | - Abhishek Kumar
- School of Computer science and IT, JAIN (Deemed to be University), Banglore, Karnataka, India
| | - S Magesh
- Maruthi Technocrat E Services, Chennai, India
| | - K Vengatesan
- Department of Computer Science, Sanjivani College of Engineering, Kopargaon, India
| | - R Sitharthan
- Department of Electrical Engineering, School of Electrical Engineering, Vellore Institute of Technology and Science, Vellore, 632014, India.
| | - M Rajesh
- Department of Computer Science, Sanjivani College of Engineering, Kopargaon, India
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Boyce-Fappiano D, Nguyen QN, Chapman BV, Allen PK, Gjyshi O, Pezzi TA, De B, Gomez D, Lin SH, Chang JY, Liao Z, Lee P, Gandhi SJ. Single Institution Experience of Proton and Photon-based Postoperative Radiation Therapy for Non-small-cell Lung Cancer. Clin Lung Cancer 2021; 22:e745-e755. [PMID: 33707003 DOI: 10.1016/j.cllc.2021.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Postoperative radiation therapy (PORT) for non-small-cell lung cancer remains controversial with studies showing no overall survival (OS) benefit in the setting of excessive cardiopulmonary toxicity. Proton beam therapy (PBT) can potentially reduce toxicity with improved organ-at-risk sparing. We evaluated outcomes of PORT patients treated with PBT and intensity-modulated radiation therapy (IMRT). MATERIALS AND METHODS This is a retrospective review of 136 PORT patients (61 PBT, 75 IMRT) treated from 2003 to 2016. A Kaplan-Meier analysis was performed to assess oncologic outcomes. A Cox regression was conducted to identify associated factors. Total toxicity burden (TTB) was defined as grade ≥ 2 pneumonitis, cardiac, or esophageal toxicity. RESULTS Median OS was 76 and 46 months for PBT and IMRT with corresponding 1- and 5-year OS of 85.3%, 50.9% and 89.3%, 37.2% (P = .38), respectively. V30 Gy heart (odds ratio [OR], 144.9; 95% confidence interval [CI], 2.91-7214; P = .013) and V5 Gy lung (OR, 15.8; 95% CI, 1.22-202.7; P = .03) were predictive of OS. Organ-at-risk sparing was improved with PBT versus IMRT; mean heart 2.0 versus 7.4 Gy (P < .01), V30 Gy heart 2.6% versus 10.7% (P < .01), mean lung 7.9 versus 10.4 Gy (P = .042), V5 Gy lung 23.4% versus 42.1% (P < .01), and V10 Gy lung 20.4% versus 29.6% (P < .01). TTB was reduced with PBT (OR, 0.35; 95% CI, 0.15-0.83; P = .017). Rates of cardiac toxicity were 14.7% IMRT and 4.9% PBT (P = .09). Rates of ≥ grade 2 pneumonitis were 17.0% IMRT and 4.9% PBT (P = .104). CONCLUSION PBT improved cardiac and lung sparing and reduced toxicity compared with IMRT. Considering the impact of cardiopulmonary toxicity on PORT outcomes, PBT warrants prospective evaluation.
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Affiliation(s)
- David Boyce-Fappiano
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bhavana V Chapman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pamela K Allen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Olsi Gjyshi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Todd A Pezzi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian De
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel Gomez
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Percy Lee
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Saumil J Gandhi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Chiang JS, Yu NY, Daniels TB, Liu W, Schild SE, Sio TT. Proton beam radiotherapy for patients with early-stage and advanced lung cancer: a narrative review with contemporary clinical recommendations. J Thorac Dis 2021; 13:1270-1285. [PMID: 33717598 PMCID: PMC7947490 DOI: 10.21037/jtd-20-2501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although lung cancer rates are decreasing nationally, lung cancer remains the leading cause of cancer related death. Despite advancements in treatment and technology, overall survival (OS) for lung cancer remains poor. Proton beam therapy (PBT) is an advanced radiation therapy (RT) modality for treatment of lung cancer with the potential to achieve dose escalation to tumor while sparing critical structures due to higher target conformality. In early and late-stage non-small cell lung cancer (NSCLC), dosimetric studies demonstrated reduced doses to organs at risk (OARs) such as the lung, spinal cord, and heart, and clinical studies report limited toxicities with PBT, including hypofractionated regimens. In limited-stage SCLC, studies showed that regimens chemo RT including PBT were well tolerated, which may help optimize clinical outcomes. Improved toxicity profiles may be beneficial in post-operative radiotherapy, for which initial dosimetric and clinical data are encouraging. Sparing of OARs may also increase the proportion of patients able to complete reirradiation for recurrent disease. However, there are various challenges of using PBT including a higher financial burden on healthcare and limited data supporting its cost-effectiveness. Further studies are needed to identify subgroups that benefit from PBT based on prognostic factors, and to evaluate PBT combined with immunotherapy, in order to elucidate the benefit that PBT may offer future lung cancer patients.
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Affiliation(s)
- Jennifer S Chiang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Thomas B Daniels
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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Patel NV, Yu NY, Koroulakis A, Diwanji T, Sawant A, Sio TT, Mohindra P. Proton therapy for thoracic malignancies: a review of oncologic outcomes. Expert Rev Anticancer Ther 2021; 21:177-191. [PMID: 33118427 DOI: 10.1080/14737140.2021.1844567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Radiotherapy is an integral component in the treatment of the majority of thoracic malignancies. By taking advantage of the steep dose fall-off characteristic of protons combined with modern optimization and delivery techniques, proton beam therapy (PBT) has emerged as a potential tool to improve oncologic outcomes while reducing toxicities from treatment.Areas covered: We review the physical properties and treatment techniques that form the basis of PBT as applicable for thoracic malignancies, including a brief discussion on the recent advances that show promise to enhance treatment planning and delivery. The dosimetric advantages and clinical outcomes of PBT are critically reviewed for each of the major thoracic malignancies, including lung cancer, esophageal cancer, mesothelioma, thymic cancer, and primary mediastinal lymphoma.Expert opinion: Despite clear dosimetric benefits with PBT in thoracic radiotherapy, the improvement in clinical outcomes remains to be seen. Nevertheless, with the incorporation of newer techniques, PBT remains a promising modality and ongoing randomized studies will clarify its role to determine which patients with thoracic malignancies receive the most benefit. Re-irradiation, advanced disease requiring high cardio-pulmonary irradiation volume and younger patients will likely derive maximum benefit with modern PBT.
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Affiliation(s)
- Nirav V Patel
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Antony Koroulakis
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, MD, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Amit Sawant
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, MD, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine and Maryland Proton Treatment Center, Baltimore, MD, USA
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Lazarev S, Rosenzweig K, Samstein R, Salgado LR, Hasan S, Press RH, Sharma S, Powell CA, Hirsch FR, Simone CB. Where are we with proton beam therapy for thoracic malignancies? Current status and future perspectives. Lung Cancer 2020; 152:157-164. [PMID: 33421922 DOI: 10.1016/j.lungcan.2020.12.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/12/2020] [Accepted: 12/19/2020] [Indexed: 12/25/2022]
Abstract
Radiation therapy (RT) plays an important role in the curative treatment of a variety of thoracic malignancies. However, delivery of tumoricidal doses with conventional photon-based RT to thoracic tumors often presents unique challenges. Extraneous dose deposited along the entrance and exit paths of the photon beam increases the likelihood of significant acute and delayed toxicities in cardiac, pulmonary, and gastrointestinal structures. Furthermore, safe dose-escalation, delivery of concomitant systemic therapy, or reirradiation of a recurrent disease are frequently not feasible with photon RT. In contrast, protons have distinct physical properties that allow them to deposit a high irradiation dose in the target, while leaving a negligible exit dose in the adjacent organs at risk. Proton beam therapy (PBT), therefore, can reduce toxicities with similar antitumor effect or allow for dose escalation and enhanced antitumor effect with the same or even lower risk of adverse events, thus potentially improving the therapeutic ratio of the treatment. For thoracic malignancies, this favorable dose distribution can translate to decreases in treatment-related morbidities, provide more durable disease control, and potentially prolong survival. This review examines the evolving role of PBT in the treatment of thoracic malignancies and evaluates the data supporting its use.
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Affiliation(s)
- Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
| | - Kenneth Rosenzweig
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Robert Samstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lucas Resende Salgado
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | | | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Charles A Powell
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fred R Hirsch
- Center for Thoracic Oncology, The Tisch Cancer Institute at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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35
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Baumann BC, Mitra N, Harton JG, Xiao Y, Wojcieszynski AP, Gabriel PE, Zhong H, Geng H, Doucette A, Wei J, O'Dwyer PJ, Bekelman JE, Metz JM. Comparative Effectiveness of Proton vs Photon Therapy as Part of Concurrent Chemoradiotherapy for Locally Advanced Cancer. JAMA Oncol 2020; 6:237-246. [PMID: 31876914 DOI: 10.1001/jamaoncol.2019.4889] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Concurrent chemoradiotherapy is the standard-of-care curative treatment for many cancers but is associated with substantial morbidity. Concurrent chemoradiotherapy administered with proton therapy might reduce toxicity and achieve comparable cancer control outcomes compared with conventional photon radiotherapy by reducing the radiation dose to normal tissues. Objective To assess whether proton therapy in the setting of concurrent chemoradiotherapy is associated with fewer 90-day unplanned hospitalizations (Common Terminology Criteria for Adverse Events, version 4 [CTCAEv4], grade ≥3) or other adverse events and similar disease-free and overall survival compared with concurrent photon therapy and chemoradiotherapy. Design, Setting, and Participants This retrospective, nonrandomized comparative effectiveness study included 1483 adult patients with nonmetastatic, locally advanced cancer treated with concurrent chemoradiotherapy with curative intent from January 1, 2011, through December 31, 2016, at a large academic health system. Three hundred ninety-one patients received proton therapy and 1092, photon therapy. Data were analyzed from October 15, 2018, through February 1, 2019. Interventions Proton vs photon chemoradiotherapy. Main Outcomes and Measures The primary end point was 90-day adverse events associated with unplanned hospitalizations (CTCAEv4 grade ≥3). Secondary end points included Eastern Cooperative Oncology Group (ECOG) performance status decline during treatment, 90-day adverse events of at least CTCAEv4 grade 2 that limit instrumental activities of daily living, and disease-free and overall survival. Data on adverse events and survival were gathered prospectively. Modified Poisson regression models with inverse propensity score weighting were used to model adverse event outcomes, and Cox proportional hazards regression models with weighting were used for survival outcomes. Propensity scores were estimated using an ensemble machine-learning approach. Results Among the 1483 patients included in the analysis (935 men [63.0%]; median age, 62 [range, 18-93] years), those receiving proton therapy were significantly older (median age, 66 [range, 18-93] vs 61 [range, 19-91] years; P < .01), had less favorable Charlson-Deyo comorbidity scores (median, 3.0 vs 2.0; P < .01), and had lower integral radiation dose to tissues outside the target (mean [SD] volume, 14.1 [6.4] vs 19.1 [10.6] cGy/cc × 107; P < .01). Baseline grade ≥2 toxicity (22% vs 24%; P = .37) and ECOG performance status (mean [SD], 0.62 [0.74] vs 0.68 [0.80]; P = .16) were similar between the 2 cohorts. In propensity score weighted-analyses, proton chemoradiotherapy was associated with a significantly lower relative risk of 90-day adverse events of at least grade 3 (0.31; 95% CI, 0.15-0.66; P = .002), 90-day adverse events of at least grade 2 (0.78; 95% CI, 0.65-0.93; P = .006), and decline in performance status during treatment (0.51; 95% CI, 0.37-0.71; P < .001). There was no difference in disease-free or overall survival. Conclusions and Relevance In this analysis, proton chemoradiotherapy was associated with significantly reduced acute adverse events that caused unplanned hospitalizations, with similar disease-free and overall survival. Prospective trials are warranted to validate these results.
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Affiliation(s)
- Brian C Baumann
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia.,Department of Radiation Oncology, Washington University in St Louis, St Louis, Missouri.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Nandita Mitra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Joanna G Harton
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | | | - Peter E Gabriel
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - Haoyu Zhong
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - Huaizhi Geng
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - Abigail Doucette
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia
| | - Jenny Wei
- currently a medical student at Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter J O'Dwyer
- Division of Medical Oncology, University of Pennsylvania, Philadelphia.,Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Justin E Bekelman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - James M Metz
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia.,Abramson Cancer Center, University of Pennsylvania, Philadelphia
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Iwata H, Akita K, Yamaba Y, Kunii E, Takakuwa O, Yoshihara M, Hattori Y, Nakajima K, Hayashi K, Toshito T, Ogino H, Shibamoto Y. Concurrent Chemo-Proton Therapy Using Adaptive Planning for Unresectable Stage 3 Non-Small Cell Lung Cancer: A Phase 2 Study. Int J Radiat Oncol Biol Phys 2020; 109:1359-1367. [PMID: 33227444 DOI: 10.1016/j.ijrobp.2020.11.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/05/2020] [Accepted: 11/12/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE This study prospectively evaluated the efficacy and safety of concurrent chemo-proton therapy (CCPT) using adaptive planning for unresectable stage III non-small cell lung cancer (NSCLC). METHODS AND MATERIALS The primary endpoint was overall survival (OS). Secondary endpoints were local control rate (LCR), progression-free survival (PFS), incidence of grade 3 or higher adverse events, and changes in quality of life (QOL). Patients received cisplatin (60 mg/m2) on day 1 and S-1 (∼40 mg/m2 twice daily) on days 1 to 14, q4w, for up to 4 cycles, plus concurrent proton therapy at a total dose of 70 GyRBE for the primary lesion and 66 GyRBE for lymph node metastasis with 2 GyRBE per day. Proton therapy was performed using respiratory-gated and image guided techniques, and adaptive plans were implemented. RESULTS Forty-seven patients were enrolled between August 2013 and August 2018. Four cycles of cisplatin plus S-1 were completed in 34 patients. The mean number of cycles was 4 (range, 1-4). The median follow-up of all and surviving patients was 37 (range, 4-84) and 52 months (range, 26-84), respectively. The mean number of replanning sessions was 2.5 (range, 1-4). The 2- and 5-year OS, LCR, and PFS were 77% (95% confidence interval 64%-89%) and 59% (43%-76%), 84% (73%-95%) and 61% (44%-78%), and 43% (28%-57%) and 37% (22%-51%), respectively. The median OS was not reached. No grade 3 or higher radiation pneumonitis was observed. There was no significant deterioration in the QOL scores after 24 months except for alopecia. CONCLUSIONS CCPT with adaptive planning was well tolerated and yielded remarkable OS for unresectable stage III NSCLC.
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Affiliation(s)
- Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan; Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan.
| | - Kenji Akita
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Yusuke Yamaba
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Eiji Kunii
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Osamu Takakuwa
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Misuzu Yoshihara
- Department of Respiratory Tract Oncology Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Yukiko Hattori
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan
| | - Koichiro Nakajima
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan; Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kensuke Hayashi
- Department of Proton Therapy Technology, Nagoya Proton Therapy Center, Nagoya, Japan
| | - Toshiyuki Toshito
- Department of Proton Therapy Physics, Nagoya Proton Therapy Center, Nagoya, Japan
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City West Medical Center, Nagoya, Japan; Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Guo T, Zou L, Ni J, Chu X, Zhu Z. Radiotherapy for unresectable locally advanced non-small cell lung cancer: a narrative review of the current landscape and future prospects in the era of immunotherapy. Transl Lung Cancer Res 2020; 9:2097-2112. [PMID: 33209629 PMCID: PMC7653144 DOI: 10.21037/tlcr-20-511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Significant recent advances have occurred in the use of radiation therapy for locally advanced non-small cell lung cancer (LA-NSCLC). In fact, the past few decades have seen both therapeutic gains and setbacks in the evolution of radiotherapy for LA-NSCLC. The PACIFIC trial has heralded a new era of immunotherapy and has raised important questions for future study, such as the future directions of radiation therapy for LA-NSCLC in the era of immunotherapy. Modern radiotherapy techniques such as three-dimensional (3D) conformal radiotherapy and intensity-modulated radiotherapy (IMRT) provide opportunities for improved target conformity and reduced normal-tissue exposure. However, the low-dose radiation volume brought by IMRT and its effects on the immune system deserve particular attention when combing radiotherapy and immunotherapy. Particle radiotherapy offers dosimetric advantages and exhibits great immunoregulatory potential. With the ongoing improvement in particle radiotherapy techniques and knowledge, the combination of immunotherapy and particle radiotherapy has tremendous potential to improve treatment outcomes. Of particular importance are questions on the optimal radiation schedule in the settings of radio-immunotherapy. Strategies for the reduction of the irradiated field such as involved-field irradiation (IFI) and omission of clinical target volume (CTV) hold promise for better preservation of immune function while not compromising locoregional and distant control. In addition, different dose-fractionation regimens can have diverse effects on the immune system. Thus, prospective trials are urgently needed to establish the optimal dose fractionation regimen. Moreover, personalized radiotherapy which allows the tailoring of radiation dose to each individual's genetic background and immune state is of critical importance in maximizing the benefit of radiation to patients with LA-NSCLC.
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Affiliation(s)
- Tiantian Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College
| | - Liqing Zou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College
| | - Jianjiao Ni
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College
| | - Xiao Chu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College.,Institute of Thoracic Oncology, Fudan University, Shanghai, China
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38
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Brandal P, Bergfeldt K, Aggerholm-Pedersen N, Bäckström G, Kerna I, Gubanski M, Björnlinger K, Evensen ME, Kuddu M, Pettersson E, Brydøy M, Hellebust TP, Dale E, Valdman A, Weber L, Høyer M. A Nordic-Baltic perspective on indications for proton therapy with strategies for identification of proper patients. Acta Oncol 2020; 59:1157-1163. [PMID: 32902341 DOI: 10.1080/0284186x.2020.1817977] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The beneficial effects of protons are primarily based on reduction of low to intermediate radiation dose bath to normal tissue surrounding the radiotherapy target volume. Despite promise for reduced long-term toxicity, the percentage of cancer patients treated with proton therapy remains low. This is probably caused by technical improvements in planning and delivery of photon therapy, and by high cost, low availability and lack of high-level evidence on proton therapy. A number of proton treatment facilities are under construction or have recently opened; there are now two operational Scandinavian proton centres and two more are under construction, thereby eliminating the availability hurdle. Even with the advantageous physical properties of protons, there is still substantial ambiguity and no established criteria related to which patients should receive proton therapy. This topic was discussed in a session at the Nordic Collaborative Workshop on Particle Therapy, held in Uppsala 14-15 November 2019. This paper resumes the Nordic-Baltic perspective on proton therapy indications and discusses strategies to identify patients for proton therapy. As for indications, neoplastic entities, target volume localisation, size, internal motion, age, second cancer predisposition, dose escalation and treatment plan comparison based on the as low as reasonably achievable (ALARA) principle or normal tissue complication probability (NTCP) models were discussed. Importantly, the patient selection process should be integrated into the radiotherapy community and emphasis on collaboration across medical specialties, involvement of key decision makers and knowledge dissemination in general are important factors. An active Nordic-Baltic proton therapy organisation would also serve this purpose.
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Affiliation(s)
- Petter Brandal
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Section for Cancer Cytogenetics, Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
| | | | | | | | - Irina Kerna
- North Estonia Medical Centre, Tallinn, Estonia
| | | | | | | | - Maire Kuddu
- North Estonia Medical Centre, Tallinn, Estonia
| | | | | | - Taran P. Hellebust
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
| | - Einar Dale
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | | | | | - Morten Høyer
- Danish Center for Particle Therapy, Aarhus University Hospital, Denmark
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Teng F, Li M, Yu J. Radiation recall pneumonitis induced by PD-1/PD-L1 blockades: mechanisms and therapeutic implications. BMC Med 2020; 18:275. [PMID: 32943072 PMCID: PMC7499987 DOI: 10.1186/s12916-020-01718-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/24/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The synergistic effect of radiotherapy (RT) in combination with immunotherapy has been shown in several clinical trials and case reports. The overlapping pulmonary toxicity induced by thoracic RT and programmed death 1/programmed death ligand-1 (PD-1/PD-L1) blockades is an important issue of clinical investigation in combination treatment. Thus far, the underlying mechanism of this toxicity remains largely unknown. MAIN TEXT In this review, we discuss the unique pattern of radiation recall pneumonitis (RRP) induced by PD-1 blockade. The clinical presentation is different from common radiation pneumonitis (RP) or RRP induced by cytotoxic drugs. The immune checkpoint inhibitors may evoke an inflammatory reaction in patients' previously irradiated fields, with infiltrating lymphocytes and potential involvement of related cytokines. All RRP patients have showed durable response to anti-PD-1/PD-L1. RRP is manageable; however, interruption of checkpoint blockades is necessary and immunosuppressive treatment should be started immediately. Further analyses of the predictive factors, including RT dosimetric parameters, tumor-infiltrating lymphocytes (TILs), and PD-L1 expression, are needed given the wide use of immune checkpoint inhibitors and high mortality from lung toxicity with the combination treatment. CONCLUSION Immune checkpoint inhibitors may evoke an RRP in the patients' previously irradiated fields. Interactions between immune checkpoint inhibitors and radiotherapy should be studied further.
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Affiliation(s)
- Feifei Teng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, China
| | - Min Li
- Department of Surgery, Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, China.
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40
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Ning MS, Palmer MB, Shah AK, Chambers LC, Garlock LB, Melson BB, Frank SJ. Three-Year Results of a Prospective Statewide Insurance Coverage Pilot for Proton Therapy: Stakeholder Collaboration Improves Patient Access to Care. JCO Oncol Pract 2020; 16:e966-e976. [PMID: 32302271 PMCID: PMC8462618 DOI: 10.1200/jop.19.00437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Proton therapy is increasingly prescribed, given its potential to improve outcomes; however, prior authorization remains a barrier to access and is associated with frequent denials and treatment delays. We sought to determine whether appropriate access to proton therapy could ensure timely care without overuse or increased costs. METHODS Our large academic cancer center collaborated with a statewide self-funded employer (n = 186,000 enrollees) on an insurance coverage pilot, incorporating a value-based analysis and ensuring preauthorization for appropriate indications. Coverage was ensured for prospective trials and five evidence-supported anatomic sites. Enrollment initiated in 2016 and continued for 3 years. Primary end points were use, authorization time, and cost of care, with case-matched comparison of total charges at 1 month pretreatment through 6 months posttreatment. RESULTS Thirty-two patients were approved over 3 years, with only 22 actually receiving proton therapy, versus a predicted use by 120 patients (P < .01). Median follow-up was 20.1 months, and average authorization time decreased from 17 days to < 1 day (P < .01), significantly enhancing patient access. During this time, 25 patients who met pilot eligibility were instead treated with photons; and 17 patients with > 6 months of follow-up were case matched by treatment site to 17 patients receiving proton therapy, with no significant differences in sex, age, performance status, stage, histology, indication, prescribed fractions, or chemotherapy. Total medical costs (including radiation therapy [RT] and non-RT charges) for patients treated with PBT were lower than expected (a cost increase initially was expected), with no significant difference in total average charges (P = .82), in the context of overall ancillary care use. CONCLUSION This coverage pilot demonstrated that appropriate access to proton therapy does not necessitate overuse or significantly increase comprehensive medical costs. Objective evidence-based coverage polices ensure appropriate patient selection. Stakeholder collaboration can streamline patient access while reducing administrative burden.
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Affiliation(s)
- Matthew S. Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Laura C. Chambers
- Office of Employee Benefits, The University of Texas System, Austin, TX
| | - Laura B. Garlock
- Office of Employee Benefits, The University of Texas System, Austin, TX
| | - Benjamin B. Melson
- Department of Financial Planning and Analysis, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Steven J. Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Proton Therapy Center, The University of Texas MD Anderson Cancer Center, Houston, TX
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41
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Diwanji T, Sawant A, Sio TT, Patel NV, Mohindra P. Proton stereotactic body radiation therapy for non-small cell lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1198. [PMID: 33241047 PMCID: PMC7576051 DOI: 10.21037/atm-20-2975] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tejan Diwanji
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Amit Sawant
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.,Maryland Proton Treatment Center Baltimore, MD, USA
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Nirav V Patel
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.,Maryland Proton Treatment Center Baltimore, MD, USA
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42
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Simone CB. First Randomized Trial Supporting the Use of Proton Over Photon Chemoradiotherapy in Esophageal Cancer. J Clin Oncol 2020; 38:2952-2955. [PMID: 32706638 DOI: 10.1200/jco.20.01405] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Charles B Simone
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY
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43
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Simone CB, Plastaras JP, Jabbour SK, Lee A, Lee NY, Choi JI, Frank SJ, Chang JY, Bradley J. Proton Reirradiation: Expert Recommendations for Reducing Toxicities and Offering New Chances of Cure in Patients With Challenging Recurrence Malignancies. Semin Radiat Oncol 2020; 30:253-261. [PMID: 32503791 PMCID: PMC10870390 DOI: 10.1016/j.semradonc.2020.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Local and regional recurrences are common following an initial course of radiotherapy, yet management of these recurrences remains a challenge. Reirradiation may be an optimal treatment approach for providing durable tumor control and even offering select patients with locoregional recurrences or new primary tumors a chance of cure, but photon reirradiation can be associated with considerable risks of high grade acute and late toxicities. The high conformality and lack of exit dose with proton therapy offer significant advantages for reirradiation. By decreasing dose to adjacent normal tissues, proton therapy can more safely deliver definitive instead of palliative doses of reirradiation, more safely dose escalate reirradiation treatment, and more safely allow for concurrent systemic therapy in the reirradiation setting. In this case-based analysis, renowned experts in the fields of proton therapy and of reirradiation present cases for which they recently employed proton reirradiation. This manuscript focuses on case studies in patients with lung cancer, head and neck malignancies, and pelvic malignancies. Considerations for when to deliver proton therapy in the reirradiation setting and the pros and cons of proton therapy are discussed, and the existing literature supporting the use of proton reirradiation for these disease sites is assessed.
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Affiliation(s)
- Charles B Simone
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY.
| | - John P Plastaras
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
| | - Anna Lee
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy Y Lee
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joe Y Chang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey Bradley
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA
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44
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Borderías Villarroel E, Geets X, Sterpin E. Online adaptive dose restoration in intensity modulated proton therapy of lung cancer to account for inter-fractional density changes. Phys Imaging Radiat Oncol 2020; 15:30-37. [PMID: 33458323 PMCID: PMC7807540 DOI: 10.1016/j.phro.2020.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND PURPOSE In proton therapy, inter-fractional density changes can severely compromise the effective delivery of the planned dose. Such dose distortion effects can be accounted for by treatment plan adaptation, that requires considerable automation for widespread implementation in clinics. In this study, the clinical benefit of an automatic online adaptive strategy called dose restoration (DR) was investigated. Our objective was to assess to what extent DR could replace the need for a comprehensive offline adaptive strategy. MATERIALS AND METHODS The fully automatic and robust DR workflow was evaluated in a cohort of 14 lung IMPT patients that had a planning-CT and two repeated 4D-CTs (rCT1,rCT2). Initial plans were generated using 4D-robust optimization (including breathing-motion, setup and range errors). DR relied on isodose contours generated from the initial dose and associated patient specific weighted objectives to mimic this initial dose in repeated-CTs. These isodose contours, with their corresponding objectives, were used during re-optimization to compensate proton range distortions disregarding re-contouring. Robustness evaluations were performed for the initial, not-adapted and restored (adapted) plans. RESULTS The resulting DVH-bands showed overall improvement in DVH metrics and robustness levels for restored plans, with respect to not-adapted plans. According to CTV coverage criteria (D95%>95%Dprescription) in not-adapted plans, 35% (5/14) of the cases needed offline adaptation. After DR, Median(D95%) was increased by 1.1 [IQR,0.4] Gy and only one patient out of 14 (7%) still needed offline adaptation because of important anatomical changes. CONCLUSIONS DR has the potential to improve CTV coverage and reduce offline adaptation rate.
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Affiliation(s)
| | - Xavier Geets
- UCLouvain, Molecular Imaging-Radiotherapy and Oncology (MIRO), Brussels, Belgium
- Cliniques Universitaires Saint-Luc, Department of Radiation Oncology, Brussels, Belgium
| | - Edmond Sterpin
- UCLouvain, Molecular Imaging-Radiotherapy and Oncology (MIRO), Brussels, Belgium
- KU Leuven, Department of Oncology, Laboratory of Experimental Radiotherapy, Leuven, Belgium
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Chargari C, Levy A, Paoletti X, Soria JC, Massard C, Weichselbaum RR, Deutsch E. Methodological Development of Combination Drug and Radiotherapy in Basic and Clinical Research. Clin Cancer Res 2020; 26:4723-4736. [PMID: 32409306 DOI: 10.1158/1078-0432.ccr-19-4155] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/14/2020] [Accepted: 05/12/2020] [Indexed: 01/03/2023]
Abstract
Newer technical improvements in radiation oncology have been rapidly implemented in recent decades, allowing an improved therapeutic ratio. The development of strategies using local and systemic treatments concurrently, mainly targeted therapies, has however plateaued. Targeted molecular compounds and immunotherapy are increasingly being incorporated as the new standard of care for a wide array of cancers. A better understanding of possible prior methodology issues is therefore required and should be integrated into upcoming early clinical trials including individualized radiotherapy-drug combinations. The outcome of clinical trials is influenced by the validity of the preclinical proofs of concept, the impact on normal tissue, the robustness of biomarkers and the quality of the delivery of radiation. Herein, key methodological aspects are discussed with the aim of optimizing the design and implementation of future precision drug-radiotherapy trials.
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Affiliation(s)
- Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
- Université Paris-Sud, Orsay, France
- INSERM U1030, Molecular Radiotherapy, Gustave Roussy, Université Paris-Saclay, Villejuif, France
- Institut de Recherche Biomédicale des Armées, Brétigny sur Orge, France
| | - Antonin Levy
- Department of Radiation Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France.
- Université Paris-Sud, Orsay, France
- INSERM U1030, Molecular Radiotherapy, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Xavier Paoletti
- University of Versailles St. Quentin, France
- Institut Curie INSERM U900, Biostatistics for Personalized Medicine Team, St. Cloud, France
| | | | - Christophe Massard
- Université Paris-Sud, Orsay, France
- Drug Development Department (DITEP), Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Ralph R Weichselbaum
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Eric Deutsch
- Department of Radiation Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France.
- Université Paris-Sud, Orsay, France
- INSERM U1030, Molecular Radiotherapy, Gustave Roussy, Université Paris-Saclay, Villejuif, France
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46
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Giaj-Levra N, Borghetti P, Bruni A, Ciammella P, Cuccia F, Fozza A, Franceschini D, Scotti V, Vagge S, Alongi F. Current radiotherapy techniques in NSCLC: challenges and potential solutions. Expert Rev Anticancer Ther 2020; 20:387-402. [PMID: 32321330 DOI: 10.1080/14737140.2020.1760094] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Radiotherapy is an important therapeutic strategy in the management of non-small cell lung cancer (NSCLC). In recent decades, technological implementations and the introduction of image guided radiotherapy (IGRT) have significantly increased the accuracy and tolerability of radiation therapy.Area covered: In this review, we provide an overview of technological opportunities and future prospects in NSCLC management.Expert opinion: Stereotactic body radiotherapy (SBRT) is now considered the standard approach in patients ineligible for surgery, while in operable cases, it is still under debate. Additionally, in combination with systemic treatment, SBRT is an innovative option for managing oligometastatic patients and features encouraging initial results in clinical outcomes. To date, in inoperable locally advanced NSCLC, the radical dose prescription has not changed (60 Gy in 30 fractions), despite the median overall survival progressively increasing. These results arise from technological improvements in precisely hitting target treatment volumes and organ at risk sparing, which are associated with better treatment qualities. Finally, for the management of NSCLC, proton and carbon ion therapies and the recent development of MR-Linac are new, intriguing technological approaches under investigation.
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Affiliation(s)
- Niccolò Giaj-Levra
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Paolo Borghetti
- Dipartimento di Radioterapia Oncologica, Università e ASST Spedali Civili di Brescia, Brescia, Italy
| | - Alessio Bruni
- Radiotherapy Unit, Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Patrizia Ciammella
- Radiation Therapy Unit, Department of Oncology and Advanced Technology, AUSL-IRCCS, Reggio, Emilia, Italy
| | - Francesco Cuccia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Alessandra Fozza
- Department of Radiation Oncology, SS.Antonio e Biagio e C.Arrigo Hospital Alessandria, Alessandria, Italy
| | - Davide Franceschini
- Department of Radiotherapy and Radiosurgery, Humanitas Clinical and Research Center- IRCCS - Rozzano (MI), Milano, Italy
| | - Vieri Scotti
- Radiation Therapy Unit, Department of Oncology, Careggi University Hospital, Firenze, Italy
| | - Stefano Vagge
- Radiation oncology Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy.,University of Brescia, Italy
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Yang WC, Hsu FM, Chen YH, Shih JY, Yu CJ, Lin ZZ, Lu SH, Yang JCH, Cheng AL, Kuo SH. Clinical outcomes and toxicity predictors of thoracic re-irradiation for locoregionally recurrent lung cancer. Clin Transl Radiat Oncol 2020; 22:76-82. [PMID: 32280792 PMCID: PMC7139144 DOI: 10.1016/j.ctro.2020.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/15/2020] [Accepted: 03/21/2020] [Indexed: 12/25/2022] Open
Abstract
Background and purpose Thoracic re-irradiation may be an alternative treatment for lung cancer patients who develop intrathoracic locoregional recurrence without systemic progression. This study aimed to retrospectively assess locoregional control, clinical outcomes, and toxicities in lung cancer patients who received thoracic re-irradiation. Materials and methods We retrospectively reviewed 50 lung cancer patients who received thoracic re-irradiation using conventional photon radiotherapy (RT) and stereotactic body radiotherapy (SBRT) between 2009 and 2017. The correlations of clinicopathologic factors, treatment factors, and dosimetric factors of RT with time to local progression (TTLP), progression-free survival (PFS), and overall survival (OS) after starting thoracic re-irradiation were calculated using log-rank tests and Cox regression models. Results The median re-irradiation dose in equivalent dose in 2-Gy fractions was 51.1 Gy, and the mean re-irradiation planning target volume was 201.58 ml. The median mean lung dose (MLD) was 4.18 Gy, and the total lung volumes receiving a dose of 5 Gy (lung V5) and of 20 Gy (V20) were 19.8% and 5.85%, respectively. The TTLP, PFS, and OS were 18.0, 5.9, and 25.1 months, respectively. Lung V5 (p < 0.001), V20 (p = 0.011), and MLD (p = 0.002) were significantly associated with grade ≥2 lung toxicity. Seven (14%) patients developed lethal lung events. Subsequent chemotherapy following thoracic re-irradiation was significantly correlated with lethal lung events (p = 0.009). Conclusion Promising local control can be achieved with thoracic re-irradiation in lung cancer patients with locoregional recurrence. However, unexpected lethal lung events may occur, especially in patients receiving systemic therapy following thoracic re-irradiation.
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Affiliation(s)
- Wen-Chi Yang
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Feng-Ming Hsu
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Hsuan Chen
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jin-Yuan Shih
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Zhong-Zhe Lin
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Oncology, National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Szu-Huai Lu
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - James Chih-Hsin Yang
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan.,Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ann-Lii Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Oncology, National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sung-Hsin Kuo
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan.,Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan
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Zou Z, Bowen SR, Thomas HMT, Sasidharan BK, Rengan R, Zeng J. Scanning Beam Proton Therapy versus Photon IMRT for Stage III Lung Cancer: Comparison of Dosimetry, Toxicity, and Outcomes. Adv Radiat Oncol 2020; 5:434-443. [PMID: 32529138 PMCID: PMC7276696 DOI: 10.1016/j.adro.2020.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 02/03/2020] [Accepted: 03/10/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose There are limited clinical data on scanning-beam proton therapy (SPT) in treating locally advanced lung cancer, as most published studies have used passive-scatter technology. There is increasing interest in whether the dosimetric advantages of SPT compared with photon therapy can translate into superior clinical outcomes. We present our experience of SPT and photon intensity modulated radiation therapy (IMRT) with clinical dosimetry and outcomes in patients with stage III lung cancer. Methods and Materials Patients with stage III lung cancer treated at our center between 2013 and May 2018 were identified in compliance with our institutional review board (64 patients = 34 SPT + 30 IMRT). Most proton patients were treated with pencil beam scanning (28 of 34), and 6 of 34 were treated with uniform scanning. Fisher exact test, χ2 test, and Mann-Whitney test were used to compare groups. All tests were 2-sided. Results Patient characteristics were similar between the IMRT and SPT patients, except for worse lung function in the IMRT group. Mean dose to lung, heart, and esophagus was lower in the SPT group, with most benefit in the low-dose region (lungs, 9.7 Gy vs 15.7 Gy for SPT vs IMRT, respectively [P = .004]; heart, 7 Gy vs 14 Gy [P = .001]; esophagus, 28.2 Gy vs 30.9 Gy [P = .023]). Esophagitis and dermatitis grades were not different between the 2 groups. Grade 2+ pneumonitis was 21% in the SPT group and 40% in the IMRT group (P = .107). Changes in blood counts were not different between the 2 groups. Overall survival and progression-free survival were not different between SPT and IMRT (median overall survival, 41.6 vs 30.7 months, respectively [P = .52]; median progression-free survival, 19.5 vs 14.6 months [P = .50]). Conclusions We report our experience with SPT and IMRT in stage III lung cancer. Our cohort of patients treated with SPT had lower doses to normal organs (lungs, heart, esophagus) than our IMRT cohort. There was no statistically significant difference in toxicity rates or survival, although there may have been a trend toward lower rates of pneumonitis.
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Affiliation(s)
- Zhenwei Zou
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Stephen R Bowen
- Departments of Radiation Oncology, Seattle, Washington.,Radiology, University of Washington, Seattle, Washington
| | | | | | - Ramesh Rengan
- Departments of Radiation Oncology, Seattle, Washington
| | - Jing Zeng
- Departments of Radiation Oncology, Seattle, Washington
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49
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Li XD, Simone CB. The inflammatory response from stereotactic body proton therapy versus stereotactic body radiation therapy: implications from early stage non-small cell lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:S295. [PMID: 32016014 DOI: 10.21037/atm.2019.11.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Xingzhe D Li
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles B Simone
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,New York Proton Center, New York, NY, USA
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50
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van der Laan HP, Anakotta RM, Korevaar EW, Dieters M, Ubbels JF, Wijsman R, Sijtsema NM, Both S, Langendijk JA, Muijs CT, Knopf AC. Organ sparing potential and inter-fraction robustness of adaptive intensity modulated proton therapy for lung cancer. Acta Oncol 2019; 58:1775-1782. [PMID: 31556764 DOI: 10.1080/0284186x.2019.1669818] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background: The aim of this study was to compare adaptive intensity modulated proton therapy (IMPT) robustness and organ sparing capabilities with that of adaptive volumetric arc photon therapy (VMAT).Material and methods: Eighteen lung cancer patients underwent a planning 4DCT (p4DCT) and 5 weekly repeated 4DCT (r4DCT) scans. Target volumes and organs at risk were manually delineated on the three-dimensional (3D) average scans of the p4DCT (av_p4DCT) and of the r4DCT scans (av_r4DCT). Planning target volume (PTV)-based VMAT plans and internal clinical target volume (ICTV)-based robust IMPT plans were optimized in 3D on the av_p4DCT and re-calculated on the av_r4DCTs. Re-planning on av_r4DCTs was performed when indicated and accumulated doses were evaluated on the av_p4DCT.Results: Adaptive VMAT and IMPT resulted in adequate ICTV coverage on av_r4DCT in all patients and adequate accumulated-dose ICTV coverage on av_p4DCT in 17/18 patients (due to a shrinking target in one patient). More frequent re-planning was needed for IMPT than for VMAT. The average mean heart dose reduction with IMPT compared with VMAT was 4.6 Gy (p = .001) and it was >5 Gy for five patients (6, 7, 8, 15, and 22 Gy). The average mean lung dose reduction was 3.2 Gy (p < .001). Significant reductions in heart and lung V5 Gy were observed with IMPT.Conclusion: Robust-planned IMPT required re-planning more often than VMAT but resulted in similar accumulated ICTV coverage. With IMPT, heart and lung mean dose values and low dose regions were significantly reduced. Substantial cardiac sparing was obtained in a subgroup of five patients (28%).
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Affiliation(s)
- Hans Paul van der Laan
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R. Melissa Anakotta
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik W. Korevaar
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Margriet Dieters
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J. Fred Ubbels
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robin Wijsman
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nanna M. Sijtsema
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan Both
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Johannes A. Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Christina T. Muijs
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Antje C. Knopf
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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