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Shirai K, Aoki S, Endo M, Takahashi Y, Fukuda Y, Akahane K, Musha A, Sato H, Wakatsuki M, Ishikawa H, Sasaki R. Recent developments in the field of radiotherapy for the management of lung cancer. Jpn J Radiol 2024:10.1007/s11604-024-01663-8. [PMID: 39316285 DOI: 10.1007/s11604-024-01663-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Accepted: 09/10/2024] [Indexed: 09/25/2024]
Abstract
Lung cancer has a poor prognosis, and further improvements in outcomes are needed. Radiotherapy plays an important role in the treatment of unresectable lung cancer, and there have been recent developments in the field of radiotherapy for the management of lung cancer. However, to date, there have been few reviews on the improvement in treatment outcomes associated with high precision radiotherapy for lung cancer. Thus, this review aimed to summarize the recent developments in radiotherapy techniques and indicate the future directions in the use of radiotherapy for lung cancer. Stereotactic body radiotherapy (SBRT) for unresectable stage I lung cancer has been reported to improve local control rates without severe adverse events, such as radiation pneumonitis. For locally advanced lung cancer, a combination of chemoradiotherapy and adjuvant immune checkpoint inhibitors dramatically improves treatment outcomes, and intensity-modulated radiotherapy (IMRT) enables safer radiation therapy with less frequent pneumonitis. Particle beam therapy, such as carbon-ion radiotherapy and proton beam therapy, has been administered as advanced medical care for patients with lung cancer. Since 2024, it has been covered under insurance for early stage lung cancer with tumors ≤ 5 cm in size in Japan. In addition to chemotherapy, local ablative radiotherapy improves treatment outcomes in patients with oligometastatic stage IV lung cancer. A particular problem with radiotherapy for lung cancer is that the target location changes with respiratory motion, and various physical methods have been used to control respiratory motion. Recently, coronavirus disease has had a major impact on lung cancer treatment, and cancer treatment during situations, such as the coronavirus pandemic, must be performed carefully. To improve treatment outcomes for lung cancer, it is necessary to fully utilize evolving radiotherapy modalities, and the role of radiotherapy in lung cancer treatment is expected to increase.
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Affiliation(s)
- Katsuyuki Shirai
- Department of Radiology, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Saitama, Japan.
| | - Shuri Aoki
- QST Hospital, National Institutes for Quantum Science and Technology, Anagawa, Chiba, Japan
| | - Masashi Endo
- Department of Radiology, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Yuta Takahashi
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Saitama, Japan
| | - Yukiko Fukuda
- Department of Radiology, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Saitama, Japan
| | - Keiko Akahane
- Department of Radiology, Jichi Medical University Saitama Medical Center, Saitama, Saitama, Japan
| | - Atsushi Musha
- Gunma University Heavy Ion Medical Center, Maebashi, Gunma, Japan
| | - Harutoshi Sato
- Department of Radiology, Jichi Medical University Hospital, 3311-1, Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Masaru Wakatsuki
- QST Hospital, National Institutes for Quantum Science and Technology, Anagawa, Chiba, Japan
| | - Hitoshi Ishikawa
- QST Hospital, National Institutes for Quantum Science and Technology, Anagawa, Chiba, Japan
| | - Ryohei Sasaki
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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2
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Gkika E, Dejonckheere CS, Sahlmann J, Barth SA, Schimek-Jasch T, Adebahr S, Hecht M, Miederer M, Brose A, Binder H, König J, Grosu AL, Nestle U, Rimner A. Impact of mediastinal tumor burden and lymphatic spread in locally advanced non-small-cell lung cancer: A secondary analysis of the multicenter randomized PET-Plan trial. Radiother Oncol 2024; 200:110521. [PMID: 39236984 DOI: 10.1016/j.radonc.2024.110521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 08/30/2024] [Accepted: 09/02/2024] [Indexed: 09/07/2024]
Abstract
PURPOSE The aim of this secondary analysis of the prospective randomized phase 2 PET-Plan trial (ARO-2009-09; NCT00697333) was to evaluate the impact of mediastinal tumor burden and lymphatic spread in patients with locally advanced non-small-cell lung cancer (NSCLC). METHODS All patients treated per protocol (n = 172) were included. Patients received isotoxically dose-escalated chemoradiotherapy up to a total dose of 60-74 Gy in 30-37 fractions, aiming as high as possible while adhering to normal tissue constraints. Radiation treatment (RT) planning was based on an 18F-FDG PET/CT targeting all lymph node (LN) stations containing CT positive LNs (i.e. short axis diameter > 10 mm), even if PET-negative (arm A) or targeting only LN stations containing PET-positive nodes (arm B). LN stations were classified into echelon 1 (ipsilateral hilum), 2 (ipsilateral station 4 and 7), and 3 (rest of the mediastinum, contralateral hilum). The endpoints were overall survival (OS), progression-free survival (PFS), and freedom from local progression (FFLP). RESULTS The median follow-up time (95 % confidence interval [CI]) was 41.1 (33.8 - 50.4) months. Patients with a high absolute number of PET-positive LN stations had worse OS (hazard ratio [HR] = 1.09; 95 % CI 0.99 - 1.18; p = 0.05) and PFS (HR = 1.12; 95 % CI 1.04 - 1.20; p = 0.003), irrespective of treatment arm allocation. The prescribed RT dose to the LNs did not correlate with any of the endpoints when considering all patients. However, in patients in arm B (i.e., PET-based selective nodal irradiation), prescribed RT dose to each LN station correlated significantly with FFLP (HR=0.45; 95 % CI 0.24-0.85; p = 0.01). Furthermore, patients with involvement of echelon 3 LN stations had worse PFS (HR = 2.22; 95 % CI 1.16-4.28; p = 0.02), also irrespective of allocation. CONCLUSION Mediastinal tumor burden and lymphatic involvement patterns influence outcome in patients treated with definitive chemoradiotherapy for locally advanced NSCLC. Higher dose to LNs did not improve OS, but did improve FFLP in patients treated with PET-based dose-escalated RT.
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Affiliation(s)
- Eleni Gkika
- Department of Radiation Oncology, University Hospital Bonn, Bonn, Germany; Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | | | - Jörg Sahlmann
- Institute of Medical Biometry and Statistics (IMBI), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simeon Ari Barth
- Department of Pediatrics, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tanja Schimek-Jasch
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sonja Adebahr
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Markus Hecht
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center, Homburg, Germany
| | - Matthias Miederer
- Department of Translational Imaging in Oncology, National Center for Tumor Diseases (NCT/UCC) Dresden: Faculty of Medicine and University Hospital Carl Gustav Carus, University of Technology Dresden (TUD), Dresden, Germany; German Cancer Research Center (DKFZ) Heidelberg, Germany; Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
| | - Alexander Brose
- Department of Diagnostic and Interventional Radiology, University Hospital Giessen, Giessen, Germany
| | - Harald Binder
- Institute of Medical Biometry and Statistics (IMBI), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology, and Informatics, University Hospital Mainz, Mainz, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ursula Nestle
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Radiation Oncology, Kliniken Maria Hilf, Mönchengladbach, Germany
| | - Andreas Rimner
- Department of Radiation Oncology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Zhao L, Li M, Shen C, Luo Y, Hou X, Qi Y, Huang Z, Li W, Gao L, Wu M, Luo Y. Nano-Assisted Radiotherapy Strategies: New Opportunities for Treatment of Non-Small Cell Lung Cancer. RESEARCH (WASHINGTON, D.C.) 2024; 7:0429. [PMID: 39045421 PMCID: PMC11265788 DOI: 10.34133/research.0429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 06/26/2024] [Indexed: 07/25/2024]
Abstract
Lung cancer is the second most commonly diagnosed cancer and a leading cause of cancer-related death, with non-small cell lung cancer (NSCLC) being the most prevalent type. Over 70% of lung cancer patients require radiotherapy (RT), which operates through direct and indirect mechanisms to treat cancer. However, RT can damage healthy tissues and encounter radiological resistance, making it crucial to enhance its precision to optimize treatment outcomes, minimize side effects, and overcome radioresistance. Integrating nanotechnology into RT presents a promising method to increase its efficacy. This review explores various nano-assisted RT strategies aimed at achieving precision treatment. These include using nanomaterials as radiosensitizers, applying nanotechnology to modify the tumor microenvironment, and employing nano-based radioprotectors and radiation-treated cell products for indirect cancer RT. We also explore recent advancements in nano-assisted RT for NSCLC, such as biomimetic targeting that alters mesenchymal stromal cells, magnetic targeting strategies, and nanosensitization with high-atomic number nanomaterials. Finally, we address the existing challenges and future directions of precision RT using nanotechnology, highlighting its potential clinical applications.
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Affiliation(s)
- Lihong Zhao
- West China Hospital,
Sichuan University, Chengdu 610041, China
| | - Mei Li
- West China Hospital,
Sichuan University, Chengdu 610041, China
| | - Chen Shen
- West China Hospital,
Sichuan University, Chengdu 610041, China
| | - Yurui Luo
- West China Hospital,
Sichuan University, Chengdu 610041, China
| | - Xiaoming Hou
- West China Hospital,
Sichuan University, Chengdu 610041, China
| | - Yu Qi
- West China Hospital,
Sichuan University, Chengdu 610041, China
| | - Ziwei Huang
- West China Hospital,
Sichuan University, Chengdu 610041, China
| | - Wei Li
- West China Hospital,
Sichuan University, Chengdu 610041, China
| | - Lanyang Gao
- The Affiliated Hospital ofSouthwest Medical University, Southwest Medical University, Luzhou 646000, China
| | - Min Wu
- West China Hospital,
Sichuan University, Chengdu 610041, China
| | - Yao Luo
- West China Hospital,
Sichuan University, Chengdu 610041, China
- Zigong First People’s Hospital, Zigong 643000, China
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4
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Hoppen L, Sarria GR, Kwok CS, Boda-Heggemann J, Buergy D, Ehmann M, Giordano FA, Fleckenstein J. Dosimetric benefits of adaptive radiation therapy for patients with stage III non-small cell lung cancer. Radiat Oncol 2023; 18:34. [PMID: 36814271 PMCID: PMC9945670 DOI: 10.1186/s13014-023-02222-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Daily adaptive radiation therapy (ART) of patients with non-small cell lung cancer (NSCLC) lowers organs at risk exposure while maintaining the planning target volume (PTV) coverage. Thus, ART allows an isotoxic approach with increased doses to the PTV that could improve local tumor control. Herein we evaluate daily online ART strategies regarding their impact on relevant dose-volume metrics. METHODS Daily cone-beam CTs (1 × n = 28, 1 × n = 29, 11 × n = 30) of 13 stage III NSCLC patients were converted into synthetic CTs (sCTs). Treatment plans (TPs) were created retrospectively on the first-fraction sCTs (sCT1) and subsequently transferred unaltered to the sCTs of the remaining fractions of each patient (sCT2-n) (IGRT scenario). Two additional TPs were generated on sCT2-n: one minimizing the lung-dose while preserving the D95%(PTV) (isoeffective scenario), the other escalating the D95%(PTV) with a constant V20Gy(lungipsilateral) (isotoxic scenario). RESULTS Compared to the original TPs predicted dose, the median D95%(PTV) in the IGRT scenario decreased by 1.6 Gy ± 4.2 Gy while the V20Gy(lungipsilateral) increased in median by 1.1% ± 4.4%. The isoeffective scenario preserved the PTV coverage and reduced the median V20Gy(lungipsilateral) by 3.1% ± 3.6%. Furthermore, the median V5%(heart) decreased by 2.9% ± 6.4%. With an isotoxic prescription, a median dose-escalation to the gross target volume of 10.0 Gy ± 8.1 Gy without increasing the V20Gy(lungipsilateral) and V5%(heart) was feasible. CONCLUSIONS We demonstrated that even without reducing safety margins, ART can reduce lung-doses, while still reaching adequate target coverage or escalate target doses without increasing ipsilateral lung exposure. Clinical benefits by means of toxicity and local control of both strategies should be evaluated in prospective clinical trials.
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Affiliation(s)
- Lea Hoppen
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Gustavo R. Sarria
- grid.10388.320000 0001 2240 3300Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Chung S. Kwok
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Judit Boda-Heggemann
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Daniel Buergy
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Michael Ehmann
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Frank A. Giordano
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Jens Fleckenstein
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Mäurer M, Käsmann L, Fleischmann DF, Oertel M, Jazmati D, Medenwald D. PET/CT-based adaptive radiotherapy of locally advanced non-small cell lung cancer in multicenter yDEGRO ARO 2017-01 cohort study. Radiat Oncol 2022; 17:29. [PMID: 35139856 PMCID: PMC8827193 DOI: 10.1186/s13014-022-01997-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/25/2022] [Indexed: 12/25/2022] Open
Abstract
Background Stage III non-small cell lung cancer (NSCLC) represents a highly heterogeneous disease and treatment burden. Advances in imaging modality show promising results for radiotherapy planning. In this multicentric study, we evaluated the impact of PET/CT-based radiotherapy planning on the prognosis of patients with stage III NSCLC.
Method and patients A retrospective observational cohort study (ARO 2017-01/NCT03055715) was conducted by the young DEGRO trial group of the German Society for Radiation Oncology (DEGRO) with the primary objective to assess the effect of tumour volume change during chemoradiotherapy and the secondary objective to assess the effect of treatment planning on survival. Three hundred forty-seven patients with stage III NSCLC treated at 21 university centers between January 2010 and December 2013 were enrolled in this trial. Patients received primary curative chemoradiotherapy with an intended dose of 50 Gy (hypofractionated) or > 60 Gy (normofractionated). To assess the effect of radiotherapy planning modality on overall survival, we used multivariate frailty models. Models were adjusted for gross tumor volume at the initiation of therapy, age, sex, simultaneous chemotherapy, lung comorbidities, RT dose and tumor grade. By considering the random effect, we can account for heterogeneity in survival and considered covariates within the model in relation to the study side. Results Patients were predominantly male (n = 269, 78.4%) with mainly adenocarcinoma (56.4%) and an average of 67.2 years. Adaptation of radiotherapy with consecutive reduction of irradiation volume showed no significant disadvantage for patient survival (HR = 1.21, 95% CI 0.89–1.64). The use of PET/CT co-registration in radiation planning tended to result in better oncologic outcomes, although no significant association could be shown (HR = 0.8, 95% CI 0.56–1.16). Centers with a consistent planning strategy performed better than those without a preferred planning method (0.62, 95% CI 0.41–0.94). Conclusion A consistent planning strategy has positive effects on overall survival. The use of PET/CT-based adaptive radiotherapy planning shows a similar survival prospect with the prospective of lower treatment volumes. In future research, toxicities need to be analysed in order to assess such reasoning.
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Saffarzadeh AG, Canavan M, Resio BJ, Walters SL, Flores KM, Decker RH, Boffa DJ. Optimal Radiation Dose for Stage III Lung Cancer-Should "Definitive" Radiation Doses Be Used in the Preoperative Setting? JTO Clin Res Rep 2021; 2:100201. [PMID: 34590044 PMCID: PMC8474436 DOI: 10.1016/j.jtocrr.2021.100201] [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: 04/02/2021] [Revised: 06/01/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction There are currently two recommended radiation strategies for clinical stage III NSCLC: a lower "preoperative" (45-54 Gy) and a higher "definitive/nonsurgical" (60-70 Gy) dose. We sought to determine if definitive radiation doses should be used in the preoperative setting given that many clinical stage III patients planned for surgery are ultimately managed with chemoradiation alone. Methods Using the National Cancer Database data from 2006 to 2016, we performed a comparative effectiveness analysis of stage III N2 patients who received chemoradiotherapy. Patients were stratified into subgroups across 2 parameters: (1) radiation dose: lower (45-54 Gy) and higher (60-70 Gy); and (2) the use of surgery (i.e., surgical and nonsurgical treatment approaches). Long-term survival and perioperative outcomes were evaluated using multivariable Cox proportional hazards and logistic regression models. Results A cohort of 961 patients received radiation before surgery including 321 who received a higher dose and 640 who received a lower dose. A higher preoperative dose revealed similar long-term mortality risk (hazard ratio = 0.99, 95% confidence interval: 0.82-1.21, p = 0.951) compared with a lower dose. There was no significant association between radiation dose and 90-day mortality (p = 0.982), 30-day readmission (p = 0.931), or prolonged length of stay (p = 0.052) in the surgical cohort. A total of 17,904 clinical-stage IIIA-N2 patients were treated nonsurgically, including 15,945 receiving higher and 1959 treated with a lower dose. A higher dose was associated with a reduction in long-term mortality risk (hazard ratio = 0.64, 95% confidence interval: 0.60-0.67, p < 0.001) compared with a lower dose. Conclusions For clinical stage III NSCLC, the administration of 60 to 70 Gy of radiation seems to be more effective than the lower dose for nonsurgical patients without compromising surgical safety for those that undergo resection. This evidence supports the implementation of 60 to 70 Gy as a single-dose strategy for both preoperative and definitive chemoradiotherapy.
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Affiliation(s)
- Areo G Saffarzadeh
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Maureen Canavan
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.,Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, Connecticut
| | - Benjamin J Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Samantha L Walters
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Kaitlin M Flores
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Roy H Decker
- Hunter Radiation Therapy Center, Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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7
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Anderson JD, Hu J, Li J, Schild SE, Fatyga M. Impact of Cardiac Dose on Overall Survival in Lung Stereotactic Body Radiotherapy (SBRT) Compared to Conventionally Fractionated Radiotherapy for Locally Advanced Non-Small Cell Lung Cancer (LA-NSCLC). JOURNAL OF CANCER THERAPY 2021; 12:409-423. [PMID: 34367717 PMCID: PMC8341170 DOI: 10.4236/jct.2021.127036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To examine possible association between heart irradiation and Overall Survival (OS) in lung SBRT patients and to compare observed associations with cardiac toxicity models previously derived in LA-NSCLC patient studies. MATERIALS AND METHODS 197 Patients treated with lung SBRT at Mayo Clinic Arizona were selected for this IRB-approved study. Multivariate Cox model with Akaike Information Criterion (AIC) was used to select patient specific covariates associated with OS. Heart dosimetry was represented by VD indices, which is a percentage of volume exposed to dose D or greater. Multivariate Cox models with patient specific covariates and single VD index per model was used to find a range of doses which were predictive for OS. A digital subdivision of the heart was further used to determine the spatial distribution of doses which were predictive for OS. A coarse subdivision divided heart into 4 segments, while the fine subdivision divided heart into 64 segments. Knowledge constrained Fused Lasso operator was used to derive a more complete model which correlated heart dosimetry with OS. Results of statistical analysis were compared to predictions of a model of cardiac toxicity in LA-NSCLC patients. RESULTS Higher age (p < 0.001), higher stage (p < 0.001) and squamous cell histology (p = 0.001) were associated with reduced OS. Whole heart DVH analysis did not reveal associations between heart irradiation and reduced OS. Coarse subdivision of the heart into four segments revealed that the irradiation of two inferior segments of the heart with low doses was associated with reduced OS, V 2Gy in the right-inferior segment (HR = 1.012/1%, p = 0.02), and V 1Gy in the left-inferior segment (HR = 1.01/1%, p = 0.04). Maximum dose in the right-inferior segment of the heart was also associated with reduced OS (HR = 1.02/Gy, p = 0.02). Fine subdivision of the heart into 64 segments revealed that approximately 25% of heart volume in the inferior part of the heart (15/64 segments), when irradiated to doses in the 1 Gy - 5 Gy range, were predictive for reduced OS (HR = 1.01/1%, p = 0.01). A previously derived model of cardiac toxicity in LA-NSCLC patients did not predict a reduction of OS due to heart irradiation in lung SBRT patients, because of relatively low doses to the heart in most lung SBRT patients. CONCLUSIONS Doses lower than 5 Gy in the inferior segments of the heart may be associated with reduced overall survival in patients treated for lung lesions with SBRT. Stage and histology of the disease, as well as patients' age, were also associated with overall survival. Comparisons of cardiac toxicity patterns in LA-NSCLC patients and lung SBRT patients suggest different etiology of cardiac toxicity in the two groups.
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Affiliation(s)
| | - Jiuyun Hu
- School of Computing, Informatics, and Decision Systems Engineering, Tempe, Arizona, USA
| | - Jing Li
- School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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8
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Nestle U, Le Pechoux C, De Ruysscher D. Evolving target volume concepts in locally advanced non-small cell lung cancer. Transl Lung Cancer Res 2021; 10:1999-2010. [PMID: 34012809 PMCID: PMC8107754 DOI: 10.21037/tlcr-20-805] [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: 12/13/2022]
Abstract
Radiotherapy (RT) target volume concepts for locally advanced lung cancer have been under discussion for years. Although they may be as important as treatment doses, many aspects of them are still based on conventions, which, due to the paucity of prospective data, rely on long-term practice or on clinical knowledge and experience (e.g., on patterns of spread or recurrence). However, in recent years, large improvements have been made in medical imaging and molecular imaging methods have been implemented, which are of great interest in RT. For lung cancer, in recent years, 18F-fluoro-desoxy-glucose (FDG)-positron-emission tomography (PET)/computed tomography (CT) has shown a superior diagnostic accuracy as compare to conventional imaging and has become an indispensable standard tool for diagnostic workup, staging and response assessment. This offers the chance to optimize target volume concepts in relation to modern imaging. While actual recommendations as the EORTC or ESTRO-ACROP guidelines already include imaging standards, the recently published PET-Plan trial prospectively investigated conventional versus imaging guided target volumes in relation to patient outcome. The results of this trial may help to further refine standards. The current review gives a practical overview on procedures for pre-treatment imaging and target volume delineation in locally advanced non-small cell lung cancer (NSCLC) in synopsis of the procedures established by the PET-Plan trial with the actual EORTC and ACROP guidelines.
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Affiliation(s)
- Ursula Nestle
- Department of Radiation Oncology, University of Freiburg, Medical Center Faculty of Medicine, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, Kliniken Maria Hilf, Mönchengladbach, Germany
| | - Cecile Le Pechoux
- Department of Radiation Oncology, Gustave Roussy, Institut d'Oncologie Thoracique (IOT), Villejuif, France
| | - Dirk De Ruysscher
- Department of Radiation Oncology (Maastro Clinic), Maastricht University Medical Center+, GROW Research Institute, Maastricht, The Netherlands
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9
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Wang J, Xu W, Zhang N, Yang C, Xu H, Wang Z, Li B, Ding J, Chen X. X-ray-responsive polypeptide nanogel for concurrent chemoradiotherapy. J Control Release 2021; 332:1-9. [PMID: 33561483 DOI: 10.1016/j.jconrel.2021.02.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/30/2021] [Accepted: 02/04/2021] [Indexed: 02/06/2023]
Abstract
Concurrent chemoradiotherapy (CCRT) is a standard treatment regimen for medically inoperable stage III non-small-cell lung carcinoma (NSCLC) owing to its superior prognostics compared with the sequential modality. Nevertheless, the current pattern of CCRT still fails to provide satisfactory survival outcome. Furthermore, CCRT is always accompanied by a higher risk of severe side effects, limiting the dose escalation. Herein, an X-ray-responsive polypeptide nanogel (PNG) was developed for on-demand delivery of chemotherapeutic agent triggered by radiotherapy to synergistically improve the efficacy of CCRT with reduced side effects. The smart PNG was formed by crosslinking methoxy poly(ethylene glycol)-block-poly(L-glutamic acid-co-γ-2-chloroethyl-L-glutamate) (mPEG-b-P(LG-co-CELG)) with a diselenide (Se-Se) bond. The doxorubicin (DOX)-loaded polypeptide nanogel (PNG/DOX) exhibited accelerated drug release when exposed to X-ray irradiation as a result of Se-Se bond degradation. With prolonged circulation and enhanced intratumoral accumulation in vivo, PNG/DOX combined with X-ray irradiation exhibited better synergistic antitumor efficacy and fewer side effects toward human A549 lung carcinoma-bearing nude mice. The smart X-ray-responsive nanogel provides a promising bridge between chemotherapy and radiotherapy and enhances the potential application of CCRT in clinic.
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Affiliation(s)
- Juan Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Ji'nan 250117, PR China; Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, PR China
| | - Weiguo Xu
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, PR China
| | - Ning Zhang
- Department of Foot and Ankle Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, 247 Beiyuan Street, Ji'nan 250033, PR China
| | - Changsheng Yang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Ji'nan 250117, PR China
| | - Hengwei Xu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Ji'nan 250117, PR China
| | - Zhongtang Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Ji'nan 250117, PR China
| | - Baosheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, 440 Jiyan Road, Ji'nan 250117, PR China.
| | - Jianxun Ding
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, PR China.
| | - Xuesi Chen
- Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, 5625 Renmin Street, Changchun 130022, PR China
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Optimizing the Radiotherapy of Lung Cancer. J Thorac Oncol 2021; 15:1559-1560. [PMID: 32981597 DOI: 10.1016/j.jtho.2020.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
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Bernhardt D, Combs SE. [Target volume reduction by 18F-FDG-PET/CT-based involved-field irradiation of advanced non-small cell lung cancer possible new standard: results of the PET-plan study]. Strahlenther Onkol 2020; 196:743-746. [PMID: 32506140 DOI: 10.1007/s00066-020-01643-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Denise Bernhardt
- Medizinische Fakultät, Klinikum rechts der Isar, Technische Universität München (TUM), Ismaninger Straße 22, 81675, München, Deutschland.
| | - Stephanie E Combs
- Institut für Strahlenmedizin (IRM), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Deutschland
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Nestle U, Schimek-Jasch T, Kremp S, Schaefer-Schuler A, Mix M, Küsters A, Tosch M, Hehr T, Eschmann SM, Bultel YP, Hass P, Fleckenstein J, Thieme A, Stockinger M, Dieckmann K, Miederer M, Holl G, Rischke HC, Gkika E, Adebahr S, König J, Grosu AL. Imaging-based target volume reduction in chemoradiotherapy for locally advanced non-small-cell lung cancer (PET-Plan): a multicentre, open-label, randomised, controlled trial. Lancet Oncol 2020; 21:581-592. [PMID: 32171429 DOI: 10.1016/s1470-2045(20)30013-9] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/23/2019] [Accepted: 01/08/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND With increasingly precise radiotherapy and advanced medical imaging, the concept of radiotherapy target volume planning might be redefined with the aim of improving outcomes. We aimed to investigate whether target volume reduction is feasible and effective compared with conventional planning in the context of radical chemoradiotherapy for patients with locally advanced non-small-cell lung cancer. METHODS We did a multicentre, open-label, randomised, controlled trial (PET-Plan; ARO-2009-09) in 24 centres in Austria, Germany, and Switzerland. Previously untreated patients (aged older than 18 years) with inoperable locally advanced non-small-cell lung cancer suitable for chemoradiotherapy and an Eastern Cooperative Oncology Group performance status of less than 3 were included. Undergoing 18F-fluorodeoxyglucose (18F-FDG) PET and CT for treatment planning, patients were randomly assigned (1:1) using a random number generator and block sizes between four and six to target volume delineation informed by 18F-FDG PET and CT plus elective nodal irradiation (conventional target group) or target volumes informed by PET alone (18F-FDG PET-based target group). Randomisation was stratified by centre and Union for International Cancer Control stage. In both groups, dose-escalated radiotherapy (60-74 Gy, 2 Gy per fraction) was planned to the respective target volumes and applied with concurrent platinum-based chemotherapy. The primary endpoint was time to locoregional progression from randomisation with the objective to test non-inferiority of 18F-FDG PET-based planning with a prespecified hazard ratio (HR) margin of 1·25. The per-protocol set was included in the primary analysis. The safety set included all patients receiving any study-specific treatment. Patients and study staff were not masked to treatment assignment. This study is registered with ClinicalTrials.gov, NCT00697333. FINDINGS From May 13, 2009, to Dec 5, 2016, 205 of 311 recruited patients were randomly assigned to the conventional target group (n=99) or the 18F-FDG PET-based target group (n=106; the intention-to-treat set), and 172 patients were treated per protocol (84 patients in the conventional target group and 88 in the 18F-FDG PET-based target group). At a median follow-up of 29 months (IQR 9-54), the risk of locoregional progression in the 18F-FDG PET-based target group was non-inferior to, and in fact lower than, that in the conventional target group in the per-protocol set (14% [95% CI 5-21] vs 29% [17-38] at 1 year; HR 0·57 [95% CI 0·30-1·06]). The risk of locoregional progression in the 18F-FDG PET-based target group was also non-inferior to that in the conventional target group in the intention-to-treat set (17% [95% CI 9-24] vs 30% [20-39] at 1 year; HR 0·64 [95% CI 0·37-1·10]). The most common acute grade 3 or worse toxicity was oesophagitis or dysphagia (16 [16%] of 99 patients in the conventional target group vs 17 [16%] of 105 patients in the 18F-FDG PET-based target group); the most common late toxicities were lung-related (12 [12%] vs 11 [10%]). 20 deaths potentially related to study treatment were reported (seven vs 13). INTERPRETATION 18F-FDG PET-based planning could potentially improve local control and does not seem to increase toxicity in patients with chemoradiotherapy-treated locally advanced non-small-cell lung cancer. Imaging-based target volume reduction in this setting is, therefore, feasible, and could potentially be considered standard of care. The procedures established might also support imaging-based target volume reduction concepts for other tumours. FUNDING German Cancer Aid (Deutsche Krebshilfe).
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Affiliation(s)
- Ursula Nestle
- Department of Radiation Oncology, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany; German Cancer Consortium Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany; Department of Radiation Oncology, Kliniken Maria Hilf, Mönchengladbach, Germany.
| | - Tanja Schimek-Jasch
- Department of Radiation Oncology, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Stephanie Kremp
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center and Faculty of Medicine, Homburg/Saar, Germany
| | - Andrea Schaefer-Schuler
- Department of Nuclear Medicine, Saarland University Medical Center and Faculty of Medicine, Homburg/Saar, Germany
| | - Michael Mix
- Department of Nuclear Medicine, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Andreas Küsters
- Department of Radiation Oncology, Kliniken Maria Hilf, Mönchengladbach, Germany
| | - Marco Tosch
- Department of Nuclear Medicine, Helios University Hospital Wuppertal, Wuppertal, Germany; Department of Medicine, Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | - Thomas Hehr
- Department of Radiation Oncology, Marienhospital Stuttgart, Stuttgart, Germany
| | | | - Yves-Pierre Bultel
- Department of Radiation Oncology, Klinikum Mutterhaus der Boromäerinnen, Trier, Germany
| | - Peter Hass
- Department of Radiation Oncology, University Hospital Magdeburg, Magdeburg, Germany
| | - Jochen Fleckenstein
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Center and Faculty of Medicine, Homburg/Saar, Germany
| | - Alexander Thieme
- Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany; Department of Radiation Oncology, Berlin Institute of Health, Berlin, Germany
| | - Marcus Stockinger
- Department of Radiation Oncology, University Hospital Mainz, Mainz, Germany
| | - Karin Dieckmann
- Department of Radiotherapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Matthias Miederer
- Department of Nuclear Medicine, University Hospital Mainz, Mainz, Germany
| | - Gabriele Holl
- Department of Nuclear Medicine, Helios Kliniken Schwerin, Schwerin, Germany
| | - H Christian Rischke
- Department of Radiation Oncology, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany; Department of Nuclear Medicine, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Sonja Adebahr
- Department of Radiation Oncology, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany; German Cancer Consortium Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Hospital Mainz, Mainz, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany; German Cancer Consortium Partner Site Freiburg and German Cancer Research Center, Heidelberg, Germany
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