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Franceschini D, Teriaca MA, Mancosu P, Bertolini A, Lo Faro L, Spoto R, Dominici L, Badalamenti M, Bellu L, Dei D, La Fauci F, Franzese C, Scorsetti M. Prospective phase II trial on ablative stereotactic body radiation therapy (SBRT) for medically inoperable thoracic nodes metastases. Radiother Oncol 2024; 197:110335. [PMID: 38772477 DOI: 10.1016/j.radonc.2024.110335] [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: 11/29/2023] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Oligometastases in mediastinal nodes are increasingly prevalent, posing challenges for treatment with stereotactic body radiotherapy (SBRT) due to proximity to organs at risk (OARs). We report the results of a single prospective observational phase II trial on ablative SBRT for medically inoperable thoracic nodes metastases (NCT02970955). MATERIAL AND METHODS Since 2017, patients with < 3 nodal metastases were evaluated by the tumor board and included if deemed inoperable. SBRT was delivered using risk adaptive approach based on number, site and size of metastatic nodes (50 Gy/5fractions, 60 Gy/8fractions, 70 Gy/10 fractions). Planning target volume (PTV) partial underdosage was allowed. The primary end point was local control (LC) at 12 months. Secondary end points were: acute and late toxicities, overall survival (OS), progression free survival (PFS), and time to next systemic therapy (TTNS). RESULTS Between 03/2017-11/2021, 32 patients (41 nodal metastases) were included. NSCLC (13pts), breast (5pts) and colorectal cancer (4pts) were the most represented primary tumour. In 66 % cases, partial PTV undercoverage was necessary. LC at 1 and 2 years was 93.5 % and 82.3 %, respectively. Treatment was well-tolerated with no acute or late toxicity ≥ G3. Median OS was 59.7 months. OS at 1 and 2 years was 96.9 % and 83.8 % respectively. Median PFS was 12.2 months. PFS at 1 and 2 years was 53.1 % and 31.3 %, respectively. CONCLUSION This trial supported the feasibility and safety of ablative SBRT for thoracic nodes metastases thanks to risk adaptive approach allowing to delay of new systemic therapies. Larger studies are needed to confirm these observations.
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Affiliation(s)
- D Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy.
| | - M A Teriaca
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - P Mancosu
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - A Bertolini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
| | - L Lo Faro
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
| | - R Spoto
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - L Dominici
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - M Badalamenti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - L Bellu
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
| | - D Dei
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - F La Fauci
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy
| | - C Franzese
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
| | - M Scorsetti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele - Milan, Italy
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2
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Li GJ, Tan H, Nusrat H, Chang J, Chen H, Poon I, Shahi J, Tsao M, Ung Y, Cheung P, Louie AV. Safety and Efficacy of Stereotactic Body Radiation Therapy for Ultra-central Thoracic Tumors: A Single Center Retrospective Review. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00508-X. [PMID: 38621607 DOI: 10.1016/j.ijrobp.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 03/29/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE We sought to evaluate the toxicity and efficacy of stereotactic body radiation therapy (SBRT) for ultracentral thoracic tumors at our institution. METHODS AND MATERIALS Patients with ultracentral lung tumors or nodes, defined as having the planning target volume (PTV) overlapping or abutting the central bronchial tree and/or esophagus, treated at our institution with SBRT between 2009 and 2019 were retrospectively reviewed. All SBRT plans were generated with the goal of creating homogenous dose distributions. The primary endpoint was incidence of SBRT-related grade ≥3 toxicity, defined using the Common Terminology Criteria for Adverse Events (V5.0). Secondary endpoints included local failure (LF), progression-free survival (PFS), and overall survival. Competing risk analysis was used to estimate incidence and identify predictors of severe toxicity and LF, while the Kaplan-Meier method was used to estimate PFS and OS. RESULTS A total of 154 patients receiving 162 ultracentral courses of SBRT were included. The most common prescription was 50 Gy in 5 fractions (42%), with doses ranging from 30 to 55 Gy in 5 fractions (BED10 range, 48-115 Gy). The incidence of severe toxicity was 9.4% at 3 years. The most common severe toxicity was pneumonitis (n = 4). There was 1 possible treatment-related death from pneumonitis/pneumonia. Predictors of severe toxicity included increased PTV size, decreased PTV V95%, lung V5 Gy, and lung V20 Gy. The incidence of LF was 14% at 3 years. Predictors of LF included younger age and greater volume of overlap between the PTV and esophagus. The median PFS was 8.8 months, while the median overall survival was 44.0 months. CONCLUSIONS In the largest case series of ultracentral thoracic SBRT to date, homogenously prescribed SBRT was associated with relatively low rates of severe toxicity and LF. Predictors of toxicity should be interpreted in the context of the heterogeneity in toxicities observed.
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Affiliation(s)
- George J Li
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Hendrick Tan
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Humza Nusrat
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Joe Chang
- Liverpool Cancer Therapy Centre, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jeevin Shahi
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - May Tsao
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Yee Ung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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3
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Giuliani ME, Filion E, Faria S, Kundapur V, Toni Vu TTT, Lok BH, Raman S, Bahig H, Laba JM, Lang P, Louie AV, Hope A, Rodrigues GB, Bezjak A, Campeau MP, Duclos M, Bratman S, Swaminath A, Salunkhe R, Warner A, Palma DA. Stereotactic Radiation for Ultra-Central Non-Small Cell Lung Cancer: A Safety and Efficacy Trial (SUNSET). Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00480-2. [PMID: 38614279 DOI: 10.1016/j.ijrobp.2024.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/22/2024] [Accepted: 03/30/2024] [Indexed: 04/15/2024]
Abstract
PURPOSE The use of stereotactic body radiation therapy for tumors in close proximity to the central mediastinal structures has been associated with a high risk of toxicity. This study (NCT03306680) aimed to determine the maximally tolerated dose of stereotactic body radiation therapy for ultracentral non-small cell lung carcinoma, using a time-to-event continual reassessment methodology. METHODS AND MATERIALS Patients with T1-3N0M0 (≤6 cm) non-small cell lung carcinoma were eligible. The maximally tolerated dose was defined as the dose of radiation therapy associated with a ≤30% rate of grade (G) 3 to 5 prespecified treatment-related toxicity occurring within 2 years of treatment. The starting dose level was 60 Gy in 8 daily fractions. The dose-maximum hotspot was limited to 120% and within the planning tumor volume; tumors with endobronchial invasion were excluded. This primary analysis occurred 2 years after completion of accrual. RESULTS Between March 2018 and April 2021, 30 patients were enrolled at 5 institutions. The median age was 73 years (range, 65-87) and 17 (57%) were female. Planning tumor volume was abutting proximal bronchial tree in 19 (63%), esophagus 5 (17%), pulmonary vein 1 (3.3%), and pulmonary artery 14 (47%). All patients received 60 Gy in 8 fractions. The median follow-up was 37 months (range, 8.9-51). Two patients (6.7%) experienced G3-5 adverse events related to treatment: 1 patient with G3 dyspnea and 1 G5 pneumonia. The latter had computed tomography findings consistent with a background of interstitial lung disease. Three-year overall survival was 72.5% (95% CI, 52.3%-85.3%), progression-free survival 66.1% (95% CI, 46.1%-80.2%), local control 89.6% (95% CI, 71.2%-96.5%), regional control 96.4% (95% CI, 77.2%-99.5%), and distant control 85.9% (95% CI, 66.7%-94.5%). Quality-of-life scores declined numerically over time, but the decreases were not clinically or statistically significant. CONCLUSIONS Sixty Gy in 8 fractions, planned and delivered with only a moderate hotspot, has a favorable adverse event rate within the prespecified acceptability criteria and results in excellent control for ultracentral tumors.
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Affiliation(s)
| | - Edith Filion
- Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Sergio Faria
- McGill University Health Centre, Montréal, Canada
| | | | | | | | | | - Houda Bahig
- Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Joanna M Laba
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | - Pencilla Lang
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | - Alexander V Louie
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Andrew Hope
- Princess Margaret Cancer Centre, Toronto, Canada
| | - George B Rodrigues
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | | | | | - Marie Duclos
- McGill University Health Centre, Montréal, Canada
| | | | | | | | - Andrew Warner
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
| | - David A Palma
- Division of Radiation Oncology, London Health Sciences Centre and Western University, London, Canada
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Ahmadsei M, Jegarajah V, Dal Bello R, Christ SM, Mayinger MM, Sabrina Stark L, Willmann J, Vogelius IR, Balermpas P, Andratschke N, Tanadini-Lang S, Guckenberger M. Dosimetric Analysis of Proximal Bronchial Tree Subsegments to Assess The Risk of Severe Toxicity After Stereotactic Body Radiation Therapy of Ultra-central Lung Tumors. Clin Transl Radiat Oncol 2024; 45:100707. [PMID: 38125648 PMCID: PMC10731610 DOI: 10.1016/j.ctro.2023.100707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/17/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023] Open
Abstract
•Stereotactic body radiation therapy (SBRT) for ultra-central lung tumors is associated with high toxicity rates.•To evaluate differences in radiosensitivity within the proximal bronchial tree (PBT), the PBT was sub-segmented into seven anatomical sections.•A risk-adapted SBRT regimen of EQD2_10 = 54.4 Gy in 8 or 10 fractions results in excellent local control and low rates of severe toxicity.•Data from a recent meta-analysis, the NORDIC Hilus trial and dosimetric data from this study were combined to create a NTCP model.•A dose threshold of EQD2_3 = 100 Gy to the PBT or any of its subsegments is expected to result in low rates of severe bronchial toxicity.
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Affiliation(s)
- Maiwand Ahmadsei
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Vinojaa Jegarajah
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Riccardo Dal Bello
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sebastian M. Christ
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael M. Mayinger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luisa Sabrina Stark
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jonas Willmann
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen, Switzerland
| | - Ivan R. Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephanie Tanadini-Lang
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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5
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Csiki E, Simon M, Papp J, Barabás M, Mikáczó J, Gál K, Sipos D, Kovács Á. Stereotactic body radiotherapy in lung cancer: a contemporary review. Pathol Oncol Res 2024; 30:1611709. [PMID: 38476352 PMCID: PMC10928908 DOI: 10.3389/pore.2024.1611709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 02/15/2024] [Indexed: 03/14/2024]
Abstract
The treatment of early stage non-small cell lung cancer (NSCLC) has improved enormously in the last two decades. Although surgery is not the only choice, lobectomy is still the gold standard treatment type for operable patients. For inoperable patients stereotactic body radiotherapy (SBRT) should be offered, reaching very high local control and overall survival rates. With SBRT we can precisely irradiate small, well-defined lesions with high doses. To select the appropriate fractionation schedule it is important to determine the size, localization and extent of the lung tumor. The introduction of novel and further developed planning (contouring guidelines, diagnostic image application, planning systems) and delivery techniques (motion management, image guided radiotherapy) led to lower rates of side effects and more conformal target volume coverage. The purpose of this study is to summarize the current developments, randomised studies, guidelines about lung SBRT, with emphasis on the possibility of increasing local control and overall rates in "fit," operable patients as well, so SBRT would be eligible in place of surgery.
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Affiliation(s)
- Emese Csiki
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Mihály Simon
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Judit Papp
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Márton Barabás
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Johanna Mikáczó
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Doctoral School of Clinical Medicine, University of Debrecen, Debrecen, Hungary
| | - Kristóf Gál
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - David Sipos
- Faculty of Health Sciences, University of Pécs, Pecs, Hungary
| | - Árpád Kovács
- Department of Oncoradiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Bourbonne V, Lévy A, Khalifa J, Antoni D, Blais E, Darréon J, Le Péchoux C, Lerouge D, Giraud P, Marguerit A, Pourel N, Riet FG, Thureau S. Radiotherapy in the management of lung oligometastases. Cancer Radiother 2024; 28:36-48. [PMID: 38228422 DOI: 10.1016/j.canrad.2023.06.030] [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: 02/26/2023] [Revised: 06/07/2023] [Accepted: 06/29/2023] [Indexed: 01/18/2024]
Abstract
In recent years, the development of both medical imaging and new systemic agents (targeted therapy and immunotherapy) have revolutionized the field of oncology, leading to a new entity: oligometastatic disease. Adding local treatment of oligometastases to systemic treatment could lead to prolonged survival with no significant impact on quality of life. Given the high prevalence of lung oligometastases and the new systemic agents coming with increased pulmonary toxicity, this article provides a comprehensive review of the current state-of-art for radiotherapy of lung oligometastases. After reviewing pretreatment workup, the authors define several radiotherapy regimen based on the localization and size of the oligometastases. A comment on the synergistic combination of medical treatment and radiotherapy is also made, projecting on future steps in this specific clinical setting.
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Affiliation(s)
- V Bourbonne
- Radiation Oncology Department, CHU de Brest, Brest, France; LaTim, Inserm, UMR 1101, université de Bretagne occidentale, Brest, France
| | - A Lévy
- Department of Radiation Oncology, Centre international des cancers thoraciques (CICT), Gustave-Roussy, 94805 Villejuif, France; Faculté de médecine, université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France
| | - J Khalifa
- Department of Radiation Oncology, institut Claudius-Regaud, institut universitaire du cancer Toulouse-Oncopôle, Toulouse, France
| | - D Antoni
- Department of Radiation Oncology, Institut de cancérologie Strasbourg Europe, Strasbourg, France
| | - E Blais
- Department of Radiation Oncology, polyclinique Marzet, Pau, France
| | - J Darréon
- Department of Radiation Oncology, institut Paoli-Calmettes, Marseille, France
| | - C Le Péchoux
- Department of Radiation Oncology, Centre international des cancers thoraciques (CICT), Gustave-Roussy, 94805 Villejuif, France; Faculté de médecine, université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France
| | - D Lerouge
- Department of Radiation Oncology, centre François-Baclesse, Caen, France
| | - P Giraud
- Department of Radiation Oncology, hôpital européen Georges-Pompidou, Paris, France; Université Paris Cité, Paris, France
| | - A Marguerit
- Department of Radiation Oncology, Institut de cancérologie de Montpellier, Montpellier, France
| | - N Pourel
- Department of Radiation Oncology, institut Sainte-Catherine, Avignon, France
| | - F-G Riet
- Department of Radiation Oncology, centre hospitalier privé Saint-Grégoire, 35760 Saint-Grégoire, France
| | - S Thureau
- Radiotherapy Department, centre Henri-Becquerel, Rouen, France; QuantIF-Litis EA4108, université de Rouen, Rouen, France.
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Iovoli AJ, Yu H, Advani PG, Turecki L, Malhotra HK, Malik NK, Fung-Kee-Fung S, Singh AK, Farrugia MK. Sinoatrial Node Dose Is Associated With Worse Survival in Patients Undergoing Definitive Stereotactic Body Radiation Therapy for Central Lung Cancers. Pract Radiat Oncol 2024; 14:e40-e47. [PMID: 37804882 DOI: 10.1016/j.prro.2023.09.005] [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: 07/03/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE Our purpose was to evaluate the clinical consequences of sinoatrial node (SAN) and atrioventricular node (AVN) irradiation in patients undergoing stereotactic body radiation therapy (SBRT) for central non-small cell lung cancer (NSCLC) tumors. METHODS AND MATERIALS A single-institutional retrospective review of patients with primary NSCLC undergoing definitive SBRT for centrally located thoracic tumors from February 2007 to December 2021 was performed. The SAN and AVN were contoured in accordance with a published contouring atlas, and the maximum dose (Dmax) and mean dose (Dmean) for each structure were calculated. Sequential log rank testing between the 50th and 90th percentiles was used to identify potential cutoff values for the corresponding dosimetric parameters and overall survival. RESULTS Among 93 eligible patients, the median age was 72.5 years (IQR, 66.6-78.3), and median follow-up was 32.4 months (IQR, 13.0-49.6). The median SAN Dmax and Dmean were 95 cGy (range, 9-5394) and 58 cGy (range, 7-3168), respectively. The median AVN Dmax and Dmean were 45 cGy (range, 4-2121) and 34 cGy (range, 3-1667), respectively. Candidate cutoff values for SAN Dmax and Dmean were 1309 and 836 cGy, respectively. No associations between AVN parameters and survival outcomes were identified. Upon multivariate Cox regression, the SAN Dmax cutoff (hazard ratio [HR], 2.03 [1.09-3.79]; P = .026) and SAN Dmean cutoff (HR, 2.22 [1.20-4.12]; P = .011) were significantly associated with overall survival. For noncancer-associated survival, the SAN Dmax cutoff trended toward significance (HR, 2.02 [0.89-4.57]; P = .092), and the SAN Dmean cutoff remained significantly associated (HR, 2.34 [1.05-5.18]; P = .037). CONCLUSIONS For patients undergoing SBRT for NSCLC, SAN Dmax and Dmean were significantly associated with worse overall survival using cut-off values of 1309 and 836 cGy, respectively. Further studies examining the effect of SAN irradiation during SBRT are warranted.
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Affiliation(s)
| | - Han Yu
- Biostatistics & Bioinformatics
| | - Pragati G Advani
- Internal Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Lauren Turecki
- Jacobs School of Medicine and Biomedical Sciences University at Buffalo, Buffalo, New York
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8
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Gouw ZAR, Jeong J, Rimner A, Lee NY, Jackson A, Fu A, Sonke JJ, Deasy JO. "Primer shot" fractionation with an early treatment break is theoretically superior to consecutive weekday fractionation schemes for early-stage non-small cell lung cancer. Radiother Oncol 2024; 190:110006. [PMID: 37972733 DOI: 10.1016/j.radonc.2023.110006] [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: 07/18/2023] [Revised: 10/14/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE Radiotherapy is traditionally given in equally spaced weekday fractions. We hypothesize that heterogeneous interfraction intervals can increase radiosensitivity via reoxygenation. Through modeling, we investigate whether this minimizes local failures and toxicity for early-stage non-small cell lung cancer (NSCLC). METHODS Previously, a tumor dose-response model based on resource competition and cell-cycle-dependent radiosensitivity accurately predicted local failure rates for early-stage NSCLC cohorts. Here, the model mathematically determined non-uniform inter-fraction intervals minimizing local failures at similar normal tissue toxicity risk, i.e., iso-BED3 (iso-NTCP) for fractionation schemes 18Gyx3, 12Gyx4, 10Gyx5, 7.5Gyx8, 5Gyx12, 4Gyx15. Next, we used these optimized schedules to reduce toxicity risk (BED3) while maintaining stable local failures (TCP). RESULTS Optimal schedules consistently favored a "primer shot" fraction followed by a 2-week break, allowing tumor reoxygenation. Increasing or decreasing the assumed baseline hypoxia extended or shortened this optimal break by up to one week. Fraction sizes of 7.5 Gy and up required a single primer shot, while smaller fractions needed one or two extra fractions for full reoxygenation. The optimized schedules, versus consecutive weekday fractionation, predicted absolute LF reductions of 4.6%-7.4%, except for the already optimal LF rate seen for 18Gyx3. Primer shot schedules could also reduce BED3 at iso-TCP with the biggest improvements for the shortest schedules (94.6Gy reduction for 18Gyx3). CONCLUSION A validated simulation model clearly supports non-standard "primer shot" fractionation, reducing the impact of hypoxia-induced radioresistance. A limitation of this study is that primer-shot fractionation is outside prior clinical experience and therefore will require clinical studies for definitive testing.
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Affiliation(s)
- Z A R Gouw
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA; The Netherlands Cancer Institute, Amsterdam, Department of Radiation Oncology, the Netherlands.
| | - J Jeong
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
| | - A Rimner
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - N Y Lee
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY, USA
| | - A Jackson
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
| | - A Fu
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
| | - J-J Sonke
- The Netherlands Cancer Institute, Amsterdam, Department of Radiation Oncology, the Netherlands
| | - J O Deasy
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, New York, NY, USA
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Lee G, Han Z, Huynh E, Tjong MC, Cagney DN, Huynh MA, Kann BH, Kozono D, Leeman JE, Singer L, Williams CL, Mak RH. Widening the therapeutic window for central and ultra-central thoracic oligometastatic disease with stereotactic MR-guided adaptive radiation therapy (SMART). Radiother Oncol 2024; 190:110034. [PMID: 38030080 DOI: 10.1016/j.radonc.2023.110034] [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: 08/29/2023] [Revised: 10/13/2023] [Accepted: 11/24/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND/PURPOSE Central/ultra-central thoracic tumors are challenging to treat with stereotactic radiotherapy due potential high-grade toxicity. Stereotactic MR-guided adaptive radiation therapy (SMART) may improve the therapeutic window through motion control with breath-hold gating and real-time MR-imaging as well as the option for daily online adaptive replanning to account for changes in target and/or organ-at-risk (OAR) location. MATERIALS/METHODS 26 central (19 ultra-central) thoracic oligoprogressive/oligometastatic tumors treated with isotoxic (OAR constraints-driven) 5-fraction SMART (median 50 Gy, range 35-60) between 10/2019-10/2022 were reviewed. Central tumor was defined as tumor within or touching 2 cm around proximal tracheobronchial tree (PBT) or adjacent to mediastinal/pericardial pleura. Ultra-central was defined as tumor abutting the PBT, esophagus, or great vessel. Hard OAR constraints observed were ≤ 0.03 cc for PBT V40, great vessel V52.5, and esophagus V35. Local failure was defined as tumor progression/recurrence within the planning target volume. RESULTS Tumor abutted the PBT in 31 %, esophagus in 31 %, great vessel in 65 %, and heart in 42 % of cases. 96 % of fractions were treated with reoptimized plan, necessary to meet OAR constraints (80 %) and/or target coverage (20 %). Median follow-up was 19 months (27 months among surviving patients). Local control (LC) was 96 % at 1-year and 90 % at 2-years (total 2/26 local failure). 23 % had G2 acute toxicities (esophagitis, dysphagia, anorexia, nausea) and one (4 %) had G3 acute radiation dermatitis. There were no G4-5 acute toxicities. There was no symptomatic pneumonitis and no G2 + late toxicities. CONCLUSION Isotoxic 5-fraction SMART resulted in high rates of LC and minimal toxicity. This approach may widen the therapeutic window for high-risk oligoprogressive/oligometastatic thoracic tumors.
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Affiliation(s)
- Grace Lee
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Zhaohui Han
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Elizabeth Huynh
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, Canada
| | - Michael C Tjong
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel N Cagney
- Radiotherapy Department, Mater Private Network, Dublin, Ireland
| | - Mai Anh Huynh
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Benjamin H Kann
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - David Kozono
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jonathan E Leeman
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lisa Singer
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Christopher L Williams
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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10
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Lindberg S, Grozman V, Karlsson K, Onjukka E, Lindbäck E, Jirf KA, Lax I, Wersäll P, Persson GF, Josipovic M, Khalil AA, Møller DS, Hoffmann L, Knap MM, Nyman J, Drugge N, Bergström P, Olofsson J, Rogg LV, Hagen RK, Frøland AS, Ramberg C, Kristiansen C, Jeppesen SS, Nielsen TB, Lödén B, Rosenbrand HO, Engelholm S, Haraldsson A, Billiet C, Lewensohn R, Lindberg K. Expanded HILUS Trial: A Pooled Analysis of Risk Factors for Toxicity From Stereotactic Body Radiation Therapy of Central and Ultracentral Lung Tumors. Int J Radiat Oncol Biol Phys 2023; 117:1222-1231. [PMID: 37423292 DOI: 10.1016/j.ijrobp.2023.06.246] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE Stereotactic body radiation therapy for tumors near the central airways implies high-grade toxic effects, as concluded from the HILUS trial. However, the small sample size and relatively few events limited the statistical power of the study. We therefore pooled data from the prospective HILUS trial with retrospective data from patients in the Nordic countries treated outside the prospective study to evaluate toxicity and risk factors for high-grade toxic effects. METHODS AND MATERIALS All patients were treated with 56 Gy in 8 fractions. Tumors within 2 cm of the trachea, the mainstem bronchi, the intermediate bronchus, or the lobar bronchi were included. The primary endpoint was toxicity, and the secondary endpoints were local control and overall survival. Clinical and dosimetric risk factors were analyzed for treatment-related fatal toxicity in univariable and multivariable Cox regression analyses. RESULTS Of 230 patients evaluated, grade 5 toxicity developed in 30 patients (13%), of whom 20 patients had fatal bronchopulmonary bleeding. The multivariable analysis revealed tumor compression of the tracheobronchial tree and maximum dose to the mainstem or intermediate bronchus as significant risk factors for grade 5 bleeding and grade 5 toxicity. The 3-year local control and overall survival rates were 84% (95% CI, 80%-90%) and 40% (95% CI, 34%-47%), respectively. CONCLUSIONS Tumor compression of the tracheobronchial tree and high maximum dose to the mainstem or intermediate bronchus increase the risk of fatal toxicity after stereotactic body radiation therapy in 8 fractions for central lung tumors. Similar dose constraints should be applied to the intermediate bronchus as to the mainstem bronchi.
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Affiliation(s)
- Sara Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden.
| | - Vitali Grozman
- Section of Thoracic Radiology, Department of Imaging and Physiology, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Kristin Karlsson
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Onjukka
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Elias Lindbäck
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Karam Al Jirf
- Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden
| | - Ingmar Lax
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Wersäll
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Section of Radiotherapy, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Gitte Fredberg Persson
- Section of Radiotherapy, Department of Oncology, Rigshospitalet, Copenhagen, Denmark; Department of Oncology, Herlev-Gentofte Hospital, Herlev, Denmark; Department of Clinical Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mirjana Josipovic
- Section of Radiotherapy, Department of Oncology, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Azza Ahmed Khalil
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark; Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Ditte Sloth Møller
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark; Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lone Hoffmann
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark; Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne Marquard Knap
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Jan Nyman
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ninni Drugge
- Department of Therapeutic Radiation Physics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Bergström
- Department of Oncology, Northern Sweden University Hospital, Umeå, Sweden
| | - Jörgen Olofsson
- Department of Oncology, Northern Sweden University Hospital, Umeå, Sweden
| | | | | | | | - Christina Ramberg
- Department of Medical Physics, Oslo University Hospital, Oslo, Norway
| | - Charlotte Kristiansen
- Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Stefan Starup Jeppesen
- Department of Oncology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tine Bjørn Nielsen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark
| | - Britta Lödén
- Oncology Department, Central Hospital in Karlstad, Karlstad, Sweden
| | | | - Silke Engelholm
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - André Haraldsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Charlotte Billiet
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk, University of Antwerp, Antwerp, Belgium
| | - Rolf Lewensohn
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Lindberg
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden; Theme Cancer, Department of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Stockholm, Sweden
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11
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Gensheimer MF, Gee H, Shirato H, Taguchi H, Snyder JM, Chin AL, Vitzthum LK, Maxim PG, Wakelee HA, Neal J, Das M, Chang DT, Kidd E, Hancock SL, Shultz DB, Horst KC, Le QT, Wong S, Brown E, Nguyen N, Liang R, Loo BW, Diehn M. Individualized Stereotactic Ablative Radiotherapy for Lung Tumors: The iSABR Phase 2 Nonrandomized Controlled Trial. JAMA Oncol 2023; 9:1525-1534. [PMID: 37707820 PMCID: PMC10502697 DOI: 10.1001/jamaoncol.2023.3495] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/11/2023] [Indexed: 09/15/2023]
Abstract
Importance Stereotactic ablative radiotherapy (SABR) is used for treating lung tumors but can cause toxic effects, including life-threatening damage to central structures. Retrospective data suggested that small tumors up to 10 cm3 in volume can be well controlled with a biologically effective dose less than 100 Gy. Objective To assess whether individualizing lung SABR dose and fractionation by tumor size, location, and histological characteristics may be associated with local tumor control. Design, Setting, and Participants This nonrandomized controlled trial (the iSABR trial, so named for individualized SABR) was a phase 2 multicenter trial enrolling participants from November 15, 2011, to December 5, 2018, at academic medical centers in the US and Japan. Data were analyzed from December 9, 2020, to May 10, 2023. Patients were enrolled in 3 groups according to cancer type: initial diagnosis of non-small cell lung cancer (NSCLC) with an American Joint Committee on Cancer 7th edition T1-3N0M0 tumor (group 1), a T1-3N0M0 new primary NSCLC with a history of prior NSCLC or multiple NSCLCs (group 2), or lung metastases from NSCLC or another solid tumor (group 3). Intervention Up to 4 tumors were treated with once-daily SABR. The dose ranged from 25 Gy in 1 fraction for peripheral tumors with a volume of 0 to 10 cm3 to 60 Gy in 8 fractions for central tumors with a volume greater than 30 cm3. Main outcome Per-group freedom from local recurrence (same-lobe recurrence) at 1 year, with censoring at time of distant recurrence, death, or loss to follow-up. Results In total, 217 unique patients (median [IQR] age, 72 [64-80] years; 129 [59%] male; 150 [69%] current or former smokers) were enrolled (some multiple times). There were 240 treatment courses: 79 in group 1, 82 in group 2, and 79 in group 3. A total of 285 tumors (211 [74%] peripheral and 74 [26%] central) were treated. The most common dose was 25 Gy in 1 fraction (158 tumors). The median (range) follow-up period was 33 (2-109) months, and the median overall survival was 59 (95% CI, 49-82) months. Freedom from local recurrence at 1 year was 97% (90% CI, 91%-99%) for group 1, 94% (90% CI, 87%-97%) for group 2, and 96% (90% CI, 89%-98%) for group 3. Freedom from local recurrence at 5 years ranged from 83% to 93% in the 3 groups. The proportion of patients with grade 3 to 5 toxic effects was low, at 5% (including a single patient [1%] with grade 5 toxic effects). Conclusions and Relevance The results of this nonrandomized controlled trial suggest that individualized SABR (iSABR) used to treat lung tumors may allow minimization of treatment dose and is associated with excellent local control. Individualized dosing should be considered for use in future trials. Trial Registration ClinicalTrials.gov Identifier: NCT01463423.
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Affiliation(s)
- Michael F Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Harriet Gee
- Sydney West Radiation Oncology Network, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Hiroki Shirato
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Taguchi
- Department of Radiation Oncology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - John M Snyder
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Alexander L Chin
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Peter G Maxim
- Department of Radiation Oncology, University of California Irvine, Irvine, California
| | - Heather A Wakelee
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Joel Neal
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Millie Das
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth Kidd
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Steven L Hancock
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - David B Shultz
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Kathleen C Horst
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Quynh-Thu Le
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Samantha Wong
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Eleanor Brown
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Ngan Nguyen
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Rachel Liang
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
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12
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Tekatli H, Giraud N, van Eekelen R, Lagerwaard FJ, Senan S. Ten years outcomes after SABR in central and ultracentral primary lung tumors. Radiother Oncol 2023; 188:109848. [PMID: 37562553 DOI: 10.1016/j.radonc.2023.109848] [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: 04/12/2023] [Revised: 07/04/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE SABR performed for central and ultracentral lung tumors is associated with increased toxicity but limited data is available on late toxicities. We studied toxicity in patients followed-up ≥ 2 years post-SABR at a single-institution. METHODS All patients were treated using VMAT for a primary or recurrent central lung cancer between 2008-2015. 60 Gy was delivered in 8 or 12 fractions. Grade ≥ 3 clinical and radiological bronchial toxicity was scored. Multivariable Cox regression models were used to estimate hazard ratios. RESULTS Of 127 eligible patients, 63% were treated with 8 fractions. Median tumor diameter was 4.4 cm (range 1.3-12.0). Median overall survival was 25.0 months (95% CI 16.5-33.5); 4% developed isolated local recurrences. The actuarial 5-year rate for severe clinical toxicity was 34.1% (95% CI 21.2-44.9). Both clinical toxicity and fatal lung haemorrhage were most observed when tumors were located ≤ 1 cm from the trachea or main bronchi (46% of all cases). The 5-year actuarial rate of radiological bronchial toxicity was 37.5% (95% CI 21.5-50.2). Multivariable analysis revealed that a performance score of 2 or 3 (HR 3.6; 95% CI 1.7-7.8), and tumor location ≤ 1 cm from the trachea or main bronchi (HR 4.3; 95% CI 1.2-14.9) were significant predictors for severe clinical toxicity. CONCLUSION The actuarial rates for both severe clinical and radiological bronchial toxicity after central SABR was approximately 35% in patients surviving 5 years. Patients with tumors located ≤ 1 cm from the trachea or main bronchus were at the highest risk for severe clinical toxicity.
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Affiliation(s)
- Hilâl Tekatli
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands.
| | - Nicolas Giraud
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands
| | | | - Frank J Lagerwaard
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands; Cancer Center Amsterdam, Treatment and quality of life, Amsterdam, The Netherlands
| | - Suresh Senan
- Department of Radiation Oncology, Amsterdam UMC, The Netherlands; Cancer Center Amsterdam, Treatment and quality of life, Amsterdam, The Netherlands
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13
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Zarębska I, Harat M. An optimal dose-fractionation for stereotactic body radiotherapy in peripherally, centrally and ultracentrally located early-stage non-small lung cancer. Thorac Cancer 2023; 14:2813-2820. [PMID: 37691151 PMCID: PMC10542466 DOI: 10.1111/1759-7714.15071] [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: 04/06/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT), also known as stereotactic ablative radiotherapy (SABR), is commonly used in inoperable patients with early-stage non-small lung cancer (NSCLC). This treatment has good outcomes and low toxicity in peripherally located tumors. However, in lesions which are located close to structures such as the bronchial tree or mediastinum the risk of severe toxicity increases. This review summarizes the evidence of dose-fractionation in SBRT of NSCLC patients in various locations.
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Affiliation(s)
- Izabela Zarębska
- Department of Neurooncology and RadiosurgeryFranciszek Lukaszczyk Oncology CenterBydgoszczPoland
- Department of RadiotherapyFranciszek Lukaszczyk Oncology CenterBydgoszczPoland
| | - Maciej Harat
- Department of Neurooncology and RadiosurgeryFranciszek Lukaszczyk Oncology CenterBydgoszczPoland
- Center of Medical SciencesUniversity of Science and TechnologyBydgoszczPoland
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14
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Kunkyab T, Mou B, Jirasek A, Haston C, Andrews J, Thomas S, Hyde D. Radiomic analysis for early differentiation of lung cancer recurrence from fibrosis in patients treated with lung stereotactic ablative radiotherapy. Phys Med Biol 2023; 68:165015. [PMID: 37164024 DOI: 10.1088/1361-6560/acd431] [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: 09/02/2022] [Accepted: 05/10/2023] [Indexed: 05/12/2023]
Abstract
Objective. The development of radiation-induced fibrosis after stereotactic ablative radiotherapy (SABR) can obscure follow-up images and delay detection of a local recurrence in early-stage lung cancer patients. The objective of this study was to develop a radiomics model for computer-assisted detection of local recurrence and fibrosis for an earlier timepoint (<1 year) after the SABR treatment.Approach. This retrospective clinical study included CT images (n= 107) of 66 patients treated with SABR. A z-score normalization technique was used for radiomic feature standardization across scanner protocols. The training set for the radiomics model consisted of CT images (66 patients; 22 recurrences and 44 fibrosis) obtained at 24 months (median) follow-up. The test set included CT-images of 41 patients acquired at 5-12 months follow-up. Combinations of four widely used machine learning techniques (support vector machines, gradient boosting, random forests (RF), and logistic regression) and feature selection methods (Relief feature scoring, maximum relevance minimum redundancy, mutual information maximization, forward feature selection, and LASSO) were investigated. Pyradiomics was used to extract 106 radiomic features from the CT-images for feature selection and classification.Main results. An RF + LASSO model scored the highest in terms of AUC (0.87) and obtained a sensitivity of 75% and a specificity of 88% in identifying a local recurrence in the test set. In the training set, 86% accuracy was achieved using five-fold cross-validation. Delong's test indicated that AUC achieved by the RF+LASSO is significantly better than 11 other machine learning models presented here. The top three radiomic features: interquartile range (first order), Cluster Prominence (GLCM), and Autocorrelation (GLCM), were revealed as differentiating a recurrence from fibrosis with this model.Significance. The radiomics model selected, out of multiple machine learning and feature selection algorithms, was able to differentiate a recurrence from fibrosis in earlier follow-up CT-images with a high specificity rate and satisfactory sensitivity performance.
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Affiliation(s)
- Tenzin Kunkyab
- Department of Physics, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | | | - Andrew Jirasek
- Department of Physics, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Christina Haston
- Department of Physics, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Jeff Andrews
- Department of Statistics, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | | | - Derek Hyde
- Department of Physics, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
- BC Cancer-Kelowna, Canada
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15
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Rock C, Sood S, Cao Y, Shelton S, Chen RC, Wang F. Ten fraction hypofractionated stereotactic body radiotherapy for the management of ultracentral lung tumors: a retrospective analysis of dosimetry, outcomes, and toxicity. Radiat Oncol 2023; 18:128. [PMID: 37533092 PMCID: PMC10394937 DOI: 10.1186/s13014-023-02298-1] [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: 01/05/2023] [Accepted: 06/15/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND The management of ultracentral thoracic tumors with ablative dose of radiotherapy remains challenging given proximity to critical central structures. We report patient outcomes, toxicity, and dosimetry for ultracentrally located tumors with hypofractionated stereotactic body radiotherapy (hfSBRT). METHODS Seventy-eight individuals (50 initial radiotherapy, 28 re-irradiation) undergoing 10 fraction hfSBRT for ultracentrally located thoracic tumors treated between 2009 and 2020 at a single institution were retrospectively reviewed. Overall survival (OS), progression free survival (PFS), and local control (LC) were calculated. Incidence and grade of treatment related toxicity were evaluated. Dosimetric analysis of treatment plans and critical adjacent OARs was performed. RESULTS At a median follow up time of 13 months, 1- and 3-year OS, PFS, and LC were 89%/63%, 37%/18%, and 84%/65%, respectively. Median dose was 65 Gy (BED10 = 107.25 Gy). Median primary bronchial tree maximum dose (Dmax) was 60 Gy (V50 = 0.96 cc). Median esophageal Dmax was 38 Gy (V40 = 0 cc). Median great vessel Dmax was 68 Gy (V50 = 3.53 cc). The most common ≥ grade 2 adverse event was pneumonitis, in 15 individuals (20%). Grade 3 or higher toxicity was observed in 9 individuals (12%): three cases of grade 3 pneumonitis (two re-irradiation, one initial radiotherapy), one grade 3 esophageal stricture following re-irradiation, two grade 3 endobronchial obstructions both following initial radiotherapy, and three grade 5 hemoptysis events (two re-irradiation, one initial radiotherapy). One hemoptysis event was categorized as "possibly" related to treatment, while the remaining two events were categorized as "unlikely" related to treatment in patients with clear evidence of disease progression. CONCLUSIONS hfSBRT to ultracentral lung tumors delivered over 10 fractions is a safe and effective treatment option, with acceptable rates of toxicity and good rates of tumor control. TRIAL REGISTRATION IRB registration number 12573.
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Affiliation(s)
- Crosby Rock
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sumit Sood
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Ying Cao
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Shary Shelton
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Fen Wang
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA.
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16
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Lau BC, Wu YF, No HJ, Ko RB, Devine MD, Das MS, Neal JW, Wakelee HA, Ramchandran K, Gensheimer MF, Diehn M, Chin AL, Loo BW, Vitzthum LK. Pulmonary Hemorrhage in Patients Treated With Thoracic Stereotactic Ablative Radiotherapy and Antiangiogenic Agents. J Thorac Oncol 2023; 18:922-930. [PMID: 37085030 DOI: 10.1016/j.jtho.2023.04.007] [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: 12/16/2022] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Severe pulmonary hemorrhage can occur in patients treated with thoracic stereotactic ablative radiotherapy (SABR) and vascular endothelial growth factor inhibitors (VEGFis). There is limited understanding of which patients are at risk for toxicity with the combination of thoracic SABR and VEGFis or how the risk differs over either therapy alone. METHODS We evaluated a prospectively maintained cohort of 690 patients with 818 pulmonary tumors treated with highly conformal SABR. Rates of any-grade and grade 3 plus (G3+) pulmonary hemorrhage were compared between patients treated with or without VEGFi therapy across tumor locations. Outcomes were compared between patients treated with SABR plus VEGFi and a propensity-matched cohort of those treated with VEGFi therapy alone. RESULTS Treatment with VEGFi plus SABR was associated with higher rates of G3+ pulmonary hemorrhage compared with those treated with SABR alone for the overall cohort (3-y incidence: 7.9% versus 0.6%, p < 0.01) and those with central tumors (19.1% versus 3.3%, p = 0.04). When further subdivided, there were significantly higher toxicity rates with VEGFi for the ultracentral (9.0% versus 45.0%, p = 0.044), but not central nonabutting tumors (0.0% versus 1.3%, p = 0.69). There was an increased incidence of G3+ hemorrhage in patients treated with VEGFi plus SABR compared with VEGFi alone (9.6% versus 1.3%, p = 0.04). CONCLUSIONS The combination of VEGFi and SABR was associated with an increased risk of high-grade pulmonary hemorrhage over either therapy alone. Low rates of toxicity were observed when excluding patients with SABR to ultracentral tumors and applying highly conformal SABR techniques.
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Affiliation(s)
- Brianna C Lau
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Yufan F Wu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Hyunsoo J No
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Ryan B Ko
- Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | - Max D Devine
- University of Nebraska College of Medicine, Omaha, Nebraska
| | - Millie S Das
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California; Veteran Affairs (VA) Palo Alto Health Care System, Palo Alto, California
| | - Joel W Neal
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Heather A Wakelee
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Kavitha Ramchandran
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Michael F Gensheimer
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California
| | - Alexander L Chin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; Stanford Cancer Institute, Stanford, California.
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Yan M, Louie AV, Kotecha R, Ashfaq Ahmed M, Zhang Z, Guckenberger M, Kim MS, Lo SS, Scorsetti M, Tree AC, Sahgal A, Slotman BJ. Stereotactic body radiotherapy for Ultra-Central lung Tumors: A systematic review and Meta-Analysis and International Stereotactic Radiosurgery Society practice guidelines. Lung Cancer 2023; 182:107281. [PMID: 37393758 DOI: 10.1016/j.lungcan.2023.107281] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is an effective and safe modality for early-stage lung cancer and lung metastases. However, tumors in an ultra-central location pose unique safety considerations. We performed a systematic review and meta-analysis to summarize the current safety and efficacy data and provide practice recommendations on behalf of the International Stereotactic Radiosurgery Society (ISRS). METHODS We performed a systematic review using PubMed and EMBASE databases of patients with ultra-central lung tumors treated with SBRT. Studies reporting local control (LC) and/or toxicity were included. Studies with <5 treated lesions, non-English language, re-irradiation, nodal tumors, or mixed outcomes in which ultra-central tumors could not be discerned were excluded. Random-effects meta-analysis was performed for studies reporting relevant endpoints. Meta-regression was conducted to determine the effect of various covariates on the primary outcomes. RESULTS 602 unique studies were identified of which 27 (one prospective observational, the remainder retrospective) were included, representing 1183 treated targets. All studies defined ultra-central as the planning target volume (PTV) overlapping the proximal bronchial tree (PBT). The most common dose fractionations were 50 Gy/5, 60 Gy/8, and 60 Gy/12 fractions. The pooled 1- and 2-year LC estimates were 92 % and 89 %, respectively. Meta-regression identified biological effective dose (BED10) as a significant predictor of 1-year LC. A total of 109 grade 3-4 toxicity events, with a pooled incidence of 6 %, were reported, most commonly pneumonitis. There were 73 treatment related deaths, with a pooled incidence of 4 %, with the most common being hemoptysis. Anticoagulation, interstitial lung disease, endobronchial tumor, and concomitant targeted therapies were observed risk factors for fatal toxicity events. CONCLUSION SBRT for ultra-central lung tumors results in acceptable rates of local control, albeit with risks of severe toxicity. Caution should be taken for appropriate patient selection, consideration of concomitant therapies, and radiotherapy plan design.
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Affiliation(s)
- Michael Yan
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, USA
| | - Md Ashfaq Ahmed
- Center for Advanced Analytics, Baptist Health South Florida, Miami, USA
| | - Zhenwei Zhang
- Center for Advanced Analytics, Baptist Health South Florida, Miami, USA
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mi-Sook Kim
- Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, USA
| | - Marta Scorsetti
- Radiosurgery and Radiotherapy Department, IRCCS-Humanitas Research Hospital, Rozzano-Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Alison C Tree
- Division of Radiotherapy and Imaging, The Royal Marsden NHS Foundation Trust, Sutton, UK; The Institute of Cancer Research, Sutton, UK
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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Camps-Malea A, Pointreau Y, Chapet S, Calais G, Barillot I. Stereotactic body radiotherapy for mediastinal lymph node with CyberKnife®: Efficacy and toxicity. Cancer Radiother 2023; 27:225-232. [PMID: 37080855 DOI: 10.1016/j.canrad.2022.11.002] [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: 10/10/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 04/22/2023]
Abstract
PUPRPOSE Stereotactic body radiotherapy is more and more used for treatment of oligometastatic mediastinal lymph nodes. The objective of this single-centre study was to evaluate its efficacy in patients with either a locoregional recurrence of a pulmonary or oesophageal cancer or with distant metastases of extrathoracic tumours. PATIENTS AND METHODS Patients with oligometastatic mediastinal lymph nodes treated with CyberKnife from June 2010 to September 2020 were screened. The primary endpoint was to assess local progression free survival and induced toxicity. Secondary endpoints were overall survival and progression free survival. The delay before introduction of systemic treatment in the subgroup of patients who did not receive systemic therapy for previous progression was also evaluated. RESULTS Fifty patients were included: 15 with a locoregional progression of a thoracic primary tumour (87% pulmonary) and 35 with mediastinal metastasis of especially renal tumour (29%). Median follow-up was 27 months (6-110 months). Local progression free survival at 6, 12 and 18 months was respectively 94, 88 and 72%. The rate of local progression was significantly lower in patients who received 36Gy in six fractions (66% of the cohort) versus other treatment schemes. Two grade 1 acute oesophagitis and one late grade 2 pulmonary fibrosis were described. Overall survival at 12, 18 and 24 months was respectively 94, 85 and 82%. Median progression free survival was 13 months. Twenty-one patients were treated by stereotactic body irradiation alone without previous history of systemic treatment. Among this subgroup, 11 patients (52%) received a systemic treatment following stereotactic body radiotherapy with a median introduction time of 17 months (5-52 months) and 24% did not progress. CONCLUSION Stereotactic body irradiation as treatment of oligometastatic mediastinal lymph nodes is a well-tolerated targeted irradiation that leads to a high control rate and delay the introduction of systemic therapy in selected patients.
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Affiliation(s)
- A Camps-Malea
- Service de radiothérapie, centre Henry-S-Kaplan, CHRU Bretonneau, Tours, France.
| | - Y Pointreau
- Service de radiothérapie, centre Henry-S-Kaplan, CHRU Bretonneau, Tours, France; Institut Inter-régional de cancérologie, centre Jean-Bernard, clinique Victor-Hugo, Le Mans, France
| | - S Chapet
- Service de radiothérapie, centre Henry-S-Kaplan, CHRU Bretonneau, Tours, France
| | - G Calais
- Service de radiothérapie, centre Henry-S-Kaplan, CHRU Bretonneau, Tours, France
| | - I Barillot
- Service de radiothérapie, centre Henry-S-Kaplan, CHRU Bretonneau, Tours, France
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Comparison of Survival Outcomes of Single- and Five-Fraction Schedules of Stereotactic Body Radiation Therapy for Early-Stage Central or Peripheral NSCLC. Cancers (Basel) 2023; 15:cancers15061648. [PMID: 36980533 PMCID: PMC10046844 DOI: 10.3390/cancers15061648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023] Open
Abstract
Background: The treatment of early-stage non-small cell lung cancer (NSCLC) with stereotactic body radiation therapy (SBRT) frequently involves different fractionation schemes for peripheral and central tumors due to concerns with toxicity. We performed an observational cohort study to determine survival outcomes for patients with peripheral and central NSCLC treated with SBRT. Methods: A single-institutional database of patients with early-stage NSCLC treated with SBRT from September 2008 to December 2018 was evaluated. Outcomes were progression-free survival (PFS), overall survival (OS), local failure (LF), nodal failure (NF), and distant failure (DF). Cox multivariable analysis (MVA), Kaplan–Meier plotting, Fine–Gray competing risk MVA, and propensity score matching were performed. Results: A total of 265 patients were included with a median follow-up of 44.2 months. There were 191 (72%) and 74 (28%) patients with peripheral and central tumors treated with single-fraction SBRT to a dose of 27 Gy and five-fraction SBRT to a dose of 50 Gy, respectively. On Cox MVA, there was no difference in OS (adjusted hazards ratio (aHR) of 1.04, 95% CI of 0.74–1.46) or PFS (aHR of 1.05, 95% CI of 0.76–1.45). On Fine–Gray competing risk MVA, there were no differences in LF, NF, or DF. Propensity matching confirmed these findings. Conclusion: The survival outcomes of patients treated with SBRT for early-stage NSCLC were equivalent for central and peripheral tumors.
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Ito K, Minakami S, Nakajima Y, Karasawa K. Accelerated hypofractionated radiotherapy with 3 Gy per fraction for central/ultra-central lung tumors: toxicity to mediastinal organs. Jpn J Clin Oncol 2023; 53:237-244. [PMID: 36478043 DOI: 10.1093/jjco/hyac181] [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: 08/23/2022] [Accepted: 11/04/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Accelerated hypofractionated radiotherapy with 3 Gy per fraction is routinely performed for central lung tumors in Japan. However, the tolerable doses to mediastinal organs at risk during this procedure are unclear. This study aimed to clarify the rate of toxicities and tolerable doses to mediastinal organs. METHODS Patients treated with accelerated hypofractionated radiotherapy using a total dose of 60-75 Gy, with 3 Gy per fraction, for central lung tumors (July 2009-April 2021) were retrospectively reviewed. We extracted patients who received ≥30 Gy irradiation to each mediastinal organ and analyzed dosimetric factors, including doses to 0.03, 0.5, 1, 4 and 10 mL of each organ, in relation to grade 3-5 toxicities, except for radiation pneumonitis. RESULTS In total, 251 organs in 91 (ultra-central, 24) lesions were analyzed, with a median follow-up duration of 26 months (range, 4-94). The prescribed doses were 75/72/69/66/63/60 Gy for 52/14/16/3/2/4 lesions, respectively. Grade 3 bronchopulmonary hemorrhage was confirmed in two (2.2%) patients, whose tumors were located ultra-centrally. The two patients with toxicity received up to 74.5 and 71.6 Gy to the bronchus. Among patients who received 70 Gy or more to the bronchus, the incidence rate was 7% (2/28 patients). CONCLUSION The rate of severe toxicities was low (2.2%). Although we did not identify the dose tolerance of the organs, because of the low incidence rate, we did note that doses of >70 Gy to the bronchus were likely to cause bronchopulmonary hemorrhage.
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Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Shota Minakami
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.,Department of Radiological Sciences, Komazawa University, Tokyo, Japan
| | - Katsuyuki Karasawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
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Song X, Zhao L, Jiang N, Ding N, Zong D, Zhang N, Wang D, Wen J, He X, Kong C, Zhu X. Long-term outcomes in patients with central and ultracentral non-small cell lung cancer treated with stereotactic body radiotherapy: single-institution experience. Curr Probl Cancer 2023; 47:100956. [DOI: 10.1016/j.currproblcancer.2023.100956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 03/13/2023]
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22
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Zeng KL, Poon I, Ung Y, Tsao M, Zhang L, Cumal A, Louie AV, Cheung P. Accelerated Hypofractionated Radiotherapy for Centrally Located Lung Tumours Not Suitable for Stereotactic Body Radiotherapy or Chemoradiotherapy. Clin Oncol (R Coll Radiol) 2023; 35:e173-e181. [PMID: 36470682 DOI: 10.1016/j.clon.2022.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 06/01/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022]
Abstract
AIMS Accelerated hypofractionated radiotherapy is used at our institution for non-small cell lung cancer (NSCLC) patients not eligible for stereotactic body radiotherapy or chemoradiotherapy. The purpose of this study was to report clinical outcomes of delivering 60 Gy in 15 fractions for these patients. MATERIALS AND METHODS All NSCLC patients who received 60 Gy in 15 fractions were reviewed. Outcomes of interest were local failure, regional failure, distant progression, overall survival and treatment-associated toxicities. RESULTS In total, 111 patients were included. The median age was 78.8 years and most tumours were adenocarcinoma (n = 55, 49.6%). Sixty-five patients (58.6%) were N0. The cumulative incidence of local failure at 12 and 24 months in the N0 cohort was 5.2% and 14.2%, respectively, compared with 11.5% and 14.8% for N+ patients. Tumour size >35 mm predicted for local failure (hazard ratio 2.706, 95% confidence interval 1.002-7.307, P = 0.0494). Distant progression at 12 and 24 months in N0 patients was 13.7% and 24.3% compared with 24.6% and 33.5% in N+ patients. In N0 patients, larger tumour size was associated with increased risk of distant progression. The median overall survival was 38.1 months in N0 patients versus 31.7 months in N+ patients. The most common toxicity was radiation pneumonitis (n = 6, 6.4%). The incidence of any grade 3 toxicity was 10.3% at ≥1 year. There were no deaths or hospitalisations attributed to treatment. CONCLUSIONS Accelerated hypofractionated radiotherapy is well tolerated and resulted in favourable clinical outcomes in various stages of NSCLC patients.
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Affiliation(s)
- K L Zeng
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - I Poon
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - Y Ung
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - M Tsao
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - L Zhang
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - A Cumal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - A V Louie
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada
| | - P Cheung
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Canada.
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23
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Survival and Prognostic Factors of Ultra-Central Tumors Treated with Stereotactic Body Radiotherapy. Cancers (Basel) 2022; 14:cancers14235908. [PMID: 36497390 PMCID: PMC9737655 DOI: 10.3390/cancers14235908] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction: Stereotactic body radiotherapy (SBRT) reported excellent outcomes and a good tolerability profile in case of central lung tumors, as long as risk-adapted schedules were adopted. High grade toxicity was more frequently observed for tumors directly touching or overlapping the trachea, proximal bronchial tree (PBT), and esophagus. We aim to identify prognostic factors associated with survival for Ultra-Central (UC) tumors. Methods: We retrospectively evaluated patients treated with SBRT for primary or metastatic UC lung tumors. SBRT schedules ranged from 45 to 60 Gy. Results: A total number of 126 ultra-central lung tumors were reviewed. The Median follow-up time was 23 months. Median Overall Survival (OS) and Progression Free Survival (PFS) was 29.3 months and 16 months, respectively. Local Control (LC) rates at 1 and 2 were 86% and 78%, respectively. Female gender, age < 70 years, and tumor size < 5 cm were significantly associated with better OS. The group of patients with tumors close to the trachea but further away from the PBT also correlated with better OS. The acute G2 dysphagia, cough, and dyspnea were 11%, 5%, and 3%, respectively. Acute G3 dyspnea was experienced by one patient. Late G3 toxicity was reported in 4% of patients. Conclusion: risk-adaptive SBRT for ultra-central tumors is safe and effective, even if it remains a high-risk clinical scenario.
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Stereotactic Ablative Radiotherapy in the Treatment of Early-Stage Lung Cancer - A Done Deal? Clin Oncol (R Coll Radiol) 2022; 34:733-740. [PMID: 36050221 DOI: 10.1016/j.clon.2022.08.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 08/12/2022] [Indexed: 01/31/2023]
Abstract
Stereotactic ablative radiotherapy (SABR) is an important curative-intent treatment option for early-stage non-small cell lung cancer. It offers good cancer control without invasive surgery and has become the standard of care for medically inoperable patients. The literature on SABR for early-stage non-small cell lung cancer is substantial and continues to grow. However, there remain areas of controversy where data are limited - notably the use of SABR in medically operable patients. Other areas of some debate include the treatment of central/ultra-central and large (>5 cm) lesions, as well as treatment with co-existing interstitial lung disease. This review article provides an overview of the current literature together with a discussion of future directions.
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Stereotactic body radiation therapy for metastatic lung metastases. Jpn J Radiol 2022; 40:995-1005. [PMID: 36097233 PMCID: PMC9529709 DOI: 10.1007/s11604-022-01323-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/25/2022] [Indexed: 11/08/2022]
Abstract
Although systemic therapy is standard management for patients with metastatic disease, several recent reports have indicated that an addition of local therapies including stereotactic body radiation therapy (SBRT) for patients with oligometastatic disease (OMD) could improve survival. The lung is the most common site of distant metastasis from many solid tumors, and the strategy of SBRT, such as dose-fraction schedules, timing, etc., would be different depending on the type of primary tumor, location, and patterns of OMD. This review describes the role of SBRT with curative-intent for patients with pulmonary OMD for each of these variables. First, differences according to the type of primary tumor, for which many studies suggest that SBRT-mediated local control (LC) for patients with pulmonary OMD from colorectal cancer (CRC) is less successful than for those from non-CRC tumors. In addition, higher dose-fraction schedules seemed to correlate with higher LC; hence, different SBRT treatment strategies may be needed for patients with pulmonary OMD from CRC relative to other tumors. Second, differences according to location, where the safety of SBRT for peripheral pulmonary tumors has been relatively well established, but safety for central pulmonary tumors including pulmonary OMD is still considered controversial. To determine the optimal dose-fraction schedules, further data from prospective studies are still needed. Third, differences according to the patterns of OMD, the number of metastases and the timing of SBRT whereby 1–5 lesions in most patients and patients with synchronous or metachronous OMD are considered good candidates for SBRT. We conclude that there are still several problems in defining suitable indications for local therapy including SBRT, and that further prospective studies are required to resolve these issues.
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Rich BJ, Spieler BO, Yang Y, Young L, Amestoy W, Monterroso M, Wang L, Dal Pra A, Yang F. Erring Characteristics of Deformable Image Registration-Based Auto-Propagation for Internal Target Volume in Radiotherapy of Locally Advanced Non-Small Cell Lung Cancer. Front Oncol 2022; 12:929727. [PMID: 35936742 PMCID: PMC9353179 DOI: 10.3389/fonc.2022.929727] [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: 04/27/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeRespiratory motion of locally advanced non-small cell lung cancer (LA-NSCLC) adds to the challenge of targeting the disease with radiotherapy (RT). One technique used frequently to alleviate this challenge is an internal gross tumor volume (IGTV) generated from manual contours on a single respiratory phase of the 4DCT via the aid of deformable image registration (DIR)-based auto-propagation. Through assessing the accuracy of DIR-based auto-propagation for generating IGTVs, this study aimed to identify erring characteristics associated with the process to enhance RT targeting in LA-NSCLC.Methods4DCTs of 19 patients with LA-NSCLC were acquired using retrospective gating with 10 respiratory phases (RPs). Ground-truth IGTVs (GT-IGTVs) were obtained through manual segmentation and union of gross tumor volumes (GTVs) in all 10 phases. IGTV auto-propagation was carried out using two distinct DIR algorithms for the manually contoured GTV from each of the 10 phases, resulting in 10 separate IGTVs for each patient per each algorithm. Differences between the auto-propagated IGTVs (AP-IGTVs) and their corresponding GT-IGTVs were assessed using Dice coefficient (DICE), maximum symmetric surface distance (MSSD), average symmetric surface distance (ASSD), and percent volume difference (PVD) and further examined in relation to anatomical tumor location, RP, and deformation index (DI) that measures the degree of deformation during auto-propagation. Furthermore, dosimetric implications due to the analyzed differences between the AP-IGTVs and GT-IGTVs were assessed.ResultsFindings were largely consistent between the two algorithms: DICE, MSSD, ASSD, and PVD showed no significant differences between the 10 RPs used for propagation (Kruskal–Wallis test, ps > 0.90); MSSD and ASSD differed significantly by tumor location in the central–peripheral and superior–inferior dimensions (ps < 0.0001) while only in the central–peripheral dimension for PVD (p < 0.001); DICE, MSSD, and ASSD significantly correlated with the DI (Spearman’s rank correlation test, ps < 0.0001). Dosimetric assessment demonstrated that 79% of the radiotherapy plans created by targeting planning target volumes (PTVs) derived from the AP-IGTVs failed prescription constraints for their corresponding ground-truth PTVs.ConclusionIn LA-NSCLC, errors in DIR-based IGTV propagation present to varying degrees and manifest dependences on DI and anatomical tumor location, indicating the need for personalized consideration in designing RT internal target volume.
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Affiliation(s)
- Benjamin J. Rich
- Department of Radiation Oncology, University of Miami, Miami, FL, United States
| | - Benjamin O. Spieler
- Department of Radiation Oncology, University of Miami, Miami, FL, United States
| | - Yidong Yang
- Department of Radiation Oncology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Lori Young
- Department of Radiation Oncology, University of Washington, Seattle, WA, United States
| | - William Amestoy
- Department of Radiation Oncology, University of Miami, Miami, FL, United States
| | - Maria Monterroso
- Department of Radiation Oncology, University of Miami, Miami, FL, United States
| | - Lora Wang
- Department of Radiation Oncology, University of Miami, Miami, FL, United States
| | - Alan Dal Pra
- Department of Radiation Oncology, University of Miami, Miami, FL, United States
| | - Fei Yang
- Department of Radiation Oncology, University of Miami, Miami, FL, United States
- *Correspondence: Fei Yang,
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Korpics MC, Katipally RR, Partouche J, Cutright D, Pointer KB, Bestvina CM, Luke JJ, Pitroda SP, Dignam JJ, Chmura SJ, Juloori A. Predictors of Pneumonitis in Combined Thoracic Stereotactic Body Radiotherapy and Immunotherapy. Int J Radiat Oncol Biol Phys 2022; 114:645-654. [PMID: 35753553 DOI: 10.1016/j.ijrobp.2022.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Thoracic stereotactic body radiotherapy (SBRT) is associated with high rates of local control but carries a risk of pneumonitis. Immunotherapy is a standard treatment for patients with metastatic disease but can also cause pneumonitis. To evaluate the feasibility and safety of thoracic SBRT with systemic immunotherapy, clinical outcomes of patients treated with immune checkpoint blockade (ICB) and SBRT on prospective trials were reviewed. METHODS AND MATERIALS Three consecutive phase 1 trials of combination SBRT and ICB conducted between 2016-2020 for widely metastatic solid tumors were reviewed. The protocols mandated adherence to NRG BR001/BR002 OAR constraints, resulting in <100% coverage of some target volumes. ICB was administered either sequentially (within 7 days after completion of SBRT) or concurrently (before or at the start of SBRT), depending on protocol. Endpoints included pneumonitis, dose-volume constraints, local failure, and overall survival (OS). The cumulative incidence estimator and Kaplan-Meier method were used. RESULTS 123 patients met eligibility with 311 metastases irradiated. The most common histologies included non-small cell lung cancer (33%) and colorectal cancer (12%). Median follow up was 12 months. The overall rate of grade 3+ pneumonitis was 8.1%. 1-year local failure was 3.6%. Established dosimetric parameters were significantly associated with the development of pneumonitis (p<0.05). In most patients, the lungs were not challenged with high doses of radiation, defined as receiving ≥75% of the maximum for a given lung dose-volume constraint. Patients who were challenged were not found to have a significantly higher risk of pneumonitis. CONCLUSIONS In the largest series of thoracic SBRT and immunotherapy, local control was excellent with acceptable toxicity and support the conclusion that established dose-volume constraints for the lung are safe. However, these results highlight the potential value in reporting of OARs being challenged with doses approaching protocol specified limits.
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Affiliation(s)
- Mark C Korpics
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Rohan R Katipally
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States; Department of Medicine, Section of Hematology/Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, United States
| | - Julien Partouche
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Dan Cutright
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Kelli B Pointer
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Christine M Bestvina
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Jason J Luke
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Sean P Pitroda
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - James J Dignam
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, United States
| | - Steven J Chmura
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States
| | - Aditya Juloori
- Department of Radiation and Cellular Oncology, University of Chicago Medical Center, Chicago, Illinois, United States.
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Lessons in stereotactic radiotherapy for oligometastases. J Med Imaging Radiat Sci 2022; 53:S63-S65. [DOI: 10.1016/j.jmir.2022.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/24/2022]
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Rijksen BLT, Rossi MMG, Walraven I, Stam B, Knegjens JL, van Diessen JNA, Lalezari F, Sonke JJ, Belderbos JSA. Bronchial stenosis in central pulmonary tumors treated with Stereotactic Body Radiation Therapy: Bronchial stenosis in central lung tumors after SBRT. Pract Radiat Oncol 2022; 12:e382-e392. [PMID: 35452867 DOI: 10.1016/j.prro.2022.03.016] [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: 09/16/2021] [Revised: 03/01/2022] [Accepted: 03/31/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) in lung tumors has an excellent local control due to the high delivered dose. Proximity of the proximal bronchial tree (PBT) to the high dose area may result in pulmonary toxicity. Bronchial stenosis is an adverse event that can occur after high dose to the PBT. Literature on the risk of developing bronchial stenosis is limited. We therefore evaluated the risk of bronchial stenosis for tumors central to the PBT and correlated the dose to the bronchi. METHODS AND MATERIALS Patients with a planning tumor volume (PTV) ≤2cm from PBT receiving SBRT (8 × 7.5Gy) between 2015-2019 were retrospectively reviewed. Main bronchi and lobar bronchi were manually delineated. Follow-up CT-scans were analyzed for bronchial stenosis and atelectasis. Bronchial stenosis was assessed using CTCAEv4. Patient, tumor, dosimetric factors and survival were evaluated between patients with and without stenosis using uni- and multivariate and Kaplan Meier analysis. RESULTS Fifty-one patients were analyzed with a median age of 70 years and WHO≤1 in 92.2%. Median follow-up was 36 months (IQR 19.6-45.4) and median OS 48 months (IQR 21.5-59.3). In fifteen patients (29.4%) bronchial stenosis was observed on FU-CT-scan. Grade 1 stenosis was seen in 21.6% (n=11), grade 2 in 7.8% (n=4). No grade ≥3 stenosis was observed. Median time to stenosis was 9.6 months (IQR 4.4-19.2). Patients who developed stenosis had significantly larger gross tumor volume (GTV) with a median of 19cc (IQR 7.7-63.2) versus 5.2cc (IQR 1.7-11.3, p<0.01). Prognostic factors in multivariate analysis for stenosis were age (p=0.03; OR 1.1), baseline dyspnea (p=0.02 OR 7.7) and the mean lobar bronchus dose (p=0.01; OR 1.1). CONCLUSION Low grade (≤2) lobar bronchial stenosis is a complication in approximately one third of patients following SBRT for lung tumors with a PTV ≤2cm from PBT. Prognostic risk factors were age, baseline dyspnea and mean dose on a lobar bronchus.
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Affiliation(s)
- Barbara L T Rijksen
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Maddalena M G Rossi
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Iris Walraven
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Barbara Stam
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Joost L Knegjens
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Judi N A van Diessen
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Ferry Lalezari
- Netherlands Cancer Institute, Department of Radiology, Amsterdam, The Netherlands
| | - Jan-Jakob Sonke
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - José S A Belderbos
- Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands.
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Hoffmann L, Persson G, Nygård L, Nielsen T, Borrisova S, Gaard-Petersen F, Josipovic M, Khalil A, Kjeldsen R, Knap M, Kristiansen C, Møller D, Ottosson W, Sand H, Thing R, Pøhl M, Schytte T. Thorough design and pre-trial quality assurance (QA) decrease dosimetric impact of delineation and dose planning variability in the STRICTLUNG and STARLUNG trials for stereotactic body radiotherapy (SBRT) of central and ultra-central lung tumours. Radiother Oncol 2022; 171:53-61. [DOI: 10.1016/j.radonc.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/28/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
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31
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Regnery S, Buchele C, Weykamp F, Pohl M, Hoegen P, Eichkorn T, Held T, Ristau J, Rippke C, König L, Thomas M, Winter H, Adeberg S, Debus J, Klüter S, Hörner-Rieber J. Adaptive MR-Guided Stereotactic Radiotherapy is Beneficial for Ablative Treatment of Lung Tumors in High-Risk Locations. Front Oncol 2022; 11:757031. [PMID: 35087746 PMCID: PMC8789303 DOI: 10.3389/fonc.2021.757031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 12/02/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To explore the benefit of adaptive magnetic resonance-guided stereotactic body radiotherapy (MRgSBRT) for treatment of lung tumors in different locations with a focus on ultracentral lung tumors (ULT). PATIENTS & METHODS A prospective cohort of 21 patients with 23 primary and secondary lung tumors was analyzed. Tumors were located peripherally (N = 10), centrally (N = 2) and ultracentrally (N = 11, planning target volume (PTV) overlap with proximal bronchi, esophagus and/or pulmonary artery). All patients received MRgSBRT with gated dose delivery and risk-adapted fractionation. Before each fraction, the baseline plan was recalculated on the anatomy of the day (predicted plan). Plan adaptation was performed in 154/165 fractions (93.3%). Comparison of dose characteristics between predicted and adapted plans employed descriptive statistics and Bayesian linear multilevel models. The posterior distributions resulting from the Bayesian models are presented by the mean together with the corresponding 95% compatibility interval (CI). RESULTS Plan adaptation decreased the proportion of fractions with violated planning objectives from 94% (predicted plans) to 17% (adapted plans). In most cases, inadequate PTV coverage was remedied (predicted: 86%, adapted: 13%), corresponding to a moderate increase of PTV coverage (mean +6.3%, 95% CI: [5.3-7.4%]) and biologically effective PTV doses (BED10) (BEDmin: +9.0 Gy [6.7-11.3 Gy], BEDmean: +1.4 Gy [0.8-2.1 Gy]). This benefit was smaller in larger tumors (-0.1%/10 cm³ PTV [-0.2 to -0.02%/10 cm³ PTV]) and ULT (-2.0% [-3.1 to -0.9%]). Occurrence of exceeded maximum doses inside the PTV (predicted: 21%, adapted: 4%) and violations of OAR constraints (predicted: 12%, adapted: 1%, OR: 0.14 [0.04-0.44]) was effectively reduced. OAR constraint violations almost exclusively occurred if the PTV had touched the corresponding OAR in the baseline plan (18/19, 95%). CONCLUSION Adaptive MRgSBRT is highly recommendable for ablative treatment of lung tumors whose PTV initially contacts a sensitive OAR, such as ULT. Here, plan adaptation protects the OAR while maintaining best-possible PTV coverage.
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Affiliation(s)
- Sebastian Regnery
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Carolin Buchele
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Fabian Weykamp
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Pohl
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Philipp Hoegen
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Tanja Eichkorn
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Held
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jonas Ristau
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany
| | - Carolin Rippke
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Laila König
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Thomas
- National Center for Tumor diseases, Heidelberg, Germany.,Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research, Heidelberg, Germany
| | - Hauke Winter
- National Center for Tumor diseases, Heidelberg, Germany.,Translational Lung Research Center Heidelberg, Member of the German Center for Lung Research, Heidelberg, Germany.,Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Sebastian Klüter
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,National Center for Radiation Oncology, Heidelberg Institute for Radiation Oncology, Heidelberg, Germany.,National Center for Tumor diseases, Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center, Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center, Heidelberg, Germany
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Guillaume E, Tanguy R, Ayadi M, Claude L, Sotton S, Moncharmont C, Magné N, Martel-Lafay I. Toxicity and efficacy of stereotactic body radiotherapy for ultra-central lung tumours: a single institution real life experience. Br J Radiol 2022; 95:20210533. [PMID: 34797724 PMCID: PMC8722247 DOI: 10.1259/bjr.20210533] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES The use of stereotactic body radiotherapy (SBRT) to treat ultra-central lung tumours remains more controversial than for peripheral and central tumours. Our objective was to assess toxicities, local control (LC) rate and survival data in patients with ultra-central lung tumours treated with SBRT. METHODS We conducted a retrospective and monocentric study about 74 patients with an ultra-central lung tumour, consecutively treated between 2012 and 2018. Ultra-central tumours were defined as tumours whose planning target volume overlapped one of the following organs at risk (OARs): the trachea, right and left main bronchi, intermediate bronchus, lobe bronchi, oesophagus, heart. RESULTS Median follow-up was 25 months. Two patients (2.7%) showed Grade 3 toxicity. No Grade 4 or 5 toxicity was observed. 11% of patients experienced primary local relapse. LC rate was 96.7% at 1 year and 87.6% at 2 years. Median progression free survival was 12 months. Median overall survival was 31 months. CONCLUSION SBRT for ultra-central tumours remains safe and effective as long as protecting organs at risk is treatment-planning priority. ADVANCES IN KNOWLEDGE The present study is one of the rare to describe exclusively ultra-central tumours through real-life observational case reports. Globally, literature analysis reveals a large heterogeneity in ultra-central lung tumours definition, prescribed dose, number of fractions. In our study, patients treated with SBRT for ultra-central lung tumours experienced few Grade 3 toxicities (2.7%) and no Grade 4 or 5 toxicities, due to the highest compliance with dose constraints to OARs. LC remained efficient.
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Affiliation(s)
| | - Ronan Tanguy
- Department of Radiation Oncology, Léon Bérard Cancer Centre, Lyon, France
| | - Myriam Ayadi
- Department of Radiation Oncology, Léon Bérard Cancer Centre, Lyon, France
| | - Line Claude
- Department of Radiation Oncology, Léon Bérard Cancer Centre, Lyon, France
| | - Sandrine Sotton
- Department of Radiation Oncology, Lucien Neuwirth Cancer Centre, Saint-Priest-en-Jarez, France
| | | | - Nicolas Magné
- Department of Radiation Oncology, Lucien Neuwirth Cancer Centre, Saint-Priest-en-Jarez, France
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Eriguchi T, Tsukamoto N, Kumabe A, Ogata T, Inoue Y, Sugawara A. Suitability of Metastatic Lung Tumors for Stereotactic Body Radiotherapy. Cancer Invest 2021; 40:378-386. [PMID: 34894945 DOI: 10.1080/07357907.2021.2017950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We investigated factors influencing local control of lung metastases treated with stereotactic body radiotherapy (SBRT) and determined the type of lesions for which SBRT is more suitable. Ninety-six patients and 196 tumors were included. Median follow-up duration was 32.0 months (range 4.7-95.8). The two-year local recurrence rate was 15.2% (95% confidence interval: 10.2-21.3). Multivariate analysis revealed biological effective dose, ultracentral tumor location, reirradiation, and prior chemotherapy as significant factors. SBRT is suitable for lung metastases, especially for peripheral tumors and those located in the inner lung parenchyma. For ultracentral lesions and recurrent lesions after SBRT, metastasectomy is recommended.
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Affiliation(s)
- Takahisa Eriguchi
- Department of Radiation Oncology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan.,Radiation Oncology Center, Ofuna Chuo Hospital, Kamakura, Japan.,Department of Radiation Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Nobuhiro Tsukamoto
- Department of Radiation Oncology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Atsuhiro Kumabe
- Department of Radiation Oncology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Takeru Ogata
- Department of Radiation Oncology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Yoshimasa Inoue
- Department of Thoracic Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Akitomo Sugawara
- Department of Radiation Oncology, Tokai University School of Medicine, Isehara, Japan
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34
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Abstract
We present an update of the French society of oncological radiotherapy recommendation regarding indication, doses, and technique of radiotherapy for intrathoracic metastases. The recommendations for delineation of the target volumes and critical organs are detailed.
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Affiliation(s)
- A Lévy
- Département d'oncologie radiothérapie, Gustave-Roussy, 94805 Villejuif, France; Université Paris-Saclay, Inserm U1030, radiothérapie moléculaire, 94805, Villejuif, France; Faculté de médecine, université Paris-Saclay, 94270 Le Kremlin-Bicêtre, France.
| | - J Darréon
- Département d'oncologie radiothérapie, institut Paoli-Calmettes, 13000 Marseille, France; CRCM Inserm U1068, 13000 Marseille, France
| | - F Mornex
- Département d'oncologie radiothérapie, centre hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; EMR 3738, université Claude-Bernard Lyon1, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
| | - P Giraud
- Service d'oncologie radiothérapie, hôpital européen-Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université de Paris, 12, rue de l'École-de-Médecine, 75006 Paris, France
| | - S Thureau
- Département de d'oncologie radiothérapie, centre Henri-Becquerel, 1, rue d'Amiens, 76000 Rouen, France; QuantIf Litis EA4108, université de Rouen, 76000 Rouen, France
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35
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Lindberg K, Onjukka E. Medical consequences of radiation exposure of the bronchi-what can we learn from high-dose precision radiation therapy? JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2021; 41:S355-S370. [PMID: 34547741 DOI: 10.1088/1361-6498/ac28ef] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/21/2021] [Indexed: 06/13/2023]
Abstract
The bronchial tolerance to high doses of radiation is not fully understood. However, in the event of a radiological accident with unintended exposure of the central airways to high doses of radiation it would be important to be able to anticipate the clinical consequences given the magnitude of the absorbed dose to different parts of the bronchial tree. Stereotactic body radiation therapy (SBRT) is a radiation treatment technique involving a few large fractions of photon external-beam radiation delivered to a well-defined target in the body. Despite generally favourable results, with high local tumour control and low-toxicity profile, its utility for tumours located close to central thoracic structures has been questioned, considering reports of severe toxic symptoms such as haemoptysis (bleedings from the airways), bronchial necrosis, bronchial stenosis, fistulas and pneumonitis. In conjunction with patient- and tumour-related risk factors, recent studies have analysed the absorbed radiation dose to different thoracic structures of normal tissue to better understand their tolerance to these high doses per fraction. Although the specific mechanisms behind the toxicity are still partly unknown, dose to the proximal bronchial tree has been shown to correlate with high-grade radiation side effects. Still, there is no clear consensus on the tolerance dose of the different bronchial structures. Recent data indicate that a too high dose to a main bronchus may result in more severe clinical side effects as compared to a smaller sized bronchus. This review analyses the current knowledge on the clinical consequences of bronchial exposure to high dose hypofractionated radiation delivered with the SBRT technique, and the tolerance doses of the bronchi. It presents the current literature regarding types of high-grade clinical side effects, data on dose response and comments on other risk factors for high-grade toxic effects.
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Affiliation(s)
- Karin Lindberg
- Section of Head, Neck, Lung and Skin tumours, Department of Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Eva Onjukka
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden
- Section of Radiotherapy Physics and Engineering, Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
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36
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The Nordic-HILUS Trial: Ultracentral Lung Stereotactic Ablative Radiotherapy and a Narrow Therapeutic Window. J Thorac Oncol 2021; 16:e79-e80. [PMID: 34561039 DOI: 10.1016/j.jtho.2021.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 12/21/2022]
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37
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Louie AV, Tjong MC, Siva S. Surgery versus SABR for early-stage lung cancer-time to call it a draw? Lancet Oncol 2021; 22:1355-1357. [PMID: 34529929 DOI: 10.1016/s1470-2045(21)00457-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M5M 2W9, Canada.
| | - Michael C Tjong
- Department of Radiation Oncology, Odette Cancer Center, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON M5M 2W9, Canada
| | - Shankar Siva
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, University of Melbourne, VIC, Australia
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38
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Khalil AA, Knap MM, Møller DS, Nyeng TB, Kjeldsen R, Hoffmann L. Local control after stereotactic body radiotherapy of centrally located lung tumours. Acta Oncol 2021; 60:1069-1073. [PMID: 33988493 DOI: 10.1080/0284186x.2021.1914345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- A. A. Khalil
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - M. M. Knap
- Department of Oncology, Aarhus University Hospital, Aarhus N, Denmark
| | - D. S. Møller
- Department of Medical Physics, Aarhus University Hospital, Aarhus N, Denmark
| | - T. B. Nyeng
- Department of Medical Physics, Aarhus University Hospital, Aarhus N, Denmark
| | - R. Kjeldsen
- Department of Oncology, Aalborg University Hospital, Aarhus N, Denmark
| | - L. Hoffmann
- Department of Medical Physics, Aarhus University Hospital, Aarhus N, Denmark
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Lodeweges JE, van Rossum PSN, Bartels MMTJ, van Lindert ASR, Pomp J, Peters M, Verhoeff JJC. Ultra-central lung tumors: safety and efficacy of protracted stereotactic body radiotherapy. Acta Oncol 2021; 60:1061-1068. [PMID: 34191670 DOI: 10.1080/0284186x.2021.1942545] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND For patients with early stage or medically inoperable lung cancer, stereotactic body radiotherapy (SBRT) is a general accepted and effective treatment option. The role of SBRT in ultra-central tumors remains controversial. The aim of this single-center retrospective analysis was to evaluate the safety and efficacy of protracted SBRT with 60 Gy in 12 fractions (with a biological effective dose (BED10) of 90-150 Gy) for patients with ultra-central lung tumors. MATERIALS AND METHODS Patients with ultra-central lung tumors treated in our institution with 60 Gy in 12 fractions from January 2012 until April 2020 were included. Ultra-central tumors were defined as planning target volume (PTV) abutting or overlapping the main bronchi and/or trachea and/or esophagus. Data regarding patient-, tumor-, and treatment-related characteristics were evaluated. RESULTS A total of 72 patients met the criteria for ultra-central tumor location. The PTV abutted the main bronchus, trachea or esophagus in 79%, 22% and 28% of cases, respectively. At a median follow-up of 19 months, 1- and 2-year local control rates were 98% and 85%, respectively. Overall survival rates at 1 and 2 years were 77% and 52%, respectively. Grade 3 or higher toxicity was observed in 21%, of which 10 patients (14% of total) died of bronchopulmonary hemorrhage. A significant difference between patients with or without grade ≥3 toxicity was found for the mean dose (Dmean) to the main bronchus (p = 0.003), where a Dmean BED3 of ≥91 Gy increased the risk of grade ≥3 toxicity significantly. DISCUSSION A protracted SBRT regimen of 60 Gy in 12 fractions for ultra-central lung tumors leads to high local control rates with toxicity rates similar to previous series, but with substantial risk of fatal bronchopulmonary hemorrhage. Therefore, possible risk factors of bronchopulmonary hemorrhage such as dose to the main bronchus should be taken into account.
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Affiliation(s)
- Joyce E. Lodeweges
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter S. N. van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcia M. T. J Bartels
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jacqueline Pomp
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Max Peters
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joost J. C. Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Virbel G, Le Fèvre C, Noël G, Antoni D. Stereotactic Body Radiotherapy for Patients with Lung Oligometastatic Disease: A Five-Year Systematic Review. Cancers (Basel) 2021; 13:3623. [PMID: 34298836 PMCID: PMC8303507 DOI: 10.3390/cancers13143623] [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] [Received: 05/22/2021] [Revised: 07/09/2021] [Accepted: 07/15/2021] [Indexed: 12/25/2022] Open
Abstract
For several years, oligometastatic disease has represented an intermediate state between localized disease accessible to local treatment and multimetastatic disease requiring systemic therapy. The lung represents one of the most common metastatic locations. Stereotactic body radiation therapy (SBRT) appears to be the treatment of choice for these patients. There are few data defining the place of radiotherapy and reporting outcome after SBRT in lung metastases. This 5-year review aimed to determine areas of SBRT usefulness and methods for the management of pulmonary metastasis in oligometastatic patients. A search for articles on PubMed allowed selection of the most relevant studies. Eighteen articles were selected according to pre-established criteria for this purpose. The analysis concludes that SBRT is an effective and safe treatment in selected patients when the disease remains localized from one to three organs.
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Affiliation(s)
| | | | - Georges Noël
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 17 Rue Albert Calmette, BP 23025, 67033 Strasbourg, France; (G.V.); (C.L.F.); (D.A.)
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Exceeding Radiation Dose to Volume Parameters for the Proximal Airways with Stereotactic Body Radiation Therapy Is More Likely for Ultracentral Lung Tumors and Associated with Worse Outcome. Cancers (Basel) 2021; 13:cancers13143463. [PMID: 34298677 PMCID: PMC8305634 DOI: 10.3390/cancers13143463] [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: 06/10/2021] [Revised: 07/01/2021] [Accepted: 07/07/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary The optimal way to treat central (CLT) and ultracentral (UCLT) lung tumors with curative radiation is unclear. We evaluated 83 patients with CLT and UCLT who underwent a curative radiotherapy technique called stereotactic body radiation therapy (SBRT). On statistical analysis, patients with UCLT had worse overall survival. Using a cohort of patients matched for relevant variables such as gender and performance status, we evaluated radiation doses to critical central structures such as the airway and heart. In this group, patients with UCLT were more likely to exceed dose constraints as compared CLT, particularly constraints regarding the airway. Additionally, patients had worse non-cancer associated survival when radiation doses were higher than 18 Gy to 4cc’s of either the trachea or proximal bronchial tree. Based on these findings, patients with UCLT have worse outcomes which could be secondary to higher radiation doses to the trachea and proximal bronchial tree. Abstract The preferred radiotherapeutic approach for central (CLT) and ultracentral (UCLT) lung tumors is unclear. We assessed the toxicity and outcomes of patients with CLT and UCLT who underwent definitive five-fraction stereotactic body radiation therapy (SBRT). We reviewed the charts of patients with either CLT or UCLT managed with SBRT from June 2010–April 2019. CLT were defined as gross tumor volume (GTV) within 2 cm of either the proximal bronchial tree, trachea, mediastinum, aorta, or spinal cord. UCLT were defined as GTV abutting any of these structures. Propensity score matching was performed for gender, performance status, and history of prior lung cancer. Within this cohort of 83 patients, 43 (51.8%) patients had UCLT. The median patient age was 73.1 years with a median follow up of 29.9 months. The two most common dose fractionation schemes were 5000 cGy (44.6%) and 5500 cGy (42.2%) in five fractions. Multivariate analysis revealed UCLT to be associated with worse overall survival (OS) (HR = 1.9, p = 0.02) but not time to progression (TTP). Using propensity score match pairing, UCLT correlated with reduced non-cancer associated survival (p = 0.049) and OS (p = 0.03), but not TTP. Within the matched cohort, dosimetric study found exceeding a D4cc of 18 Gy to either the proximal bronchus (HR = 3.9, p = 0.007) or trachea (HR = 4.0, p = 0.02) was correlated with worse non-cancer associated survival. In patients undergoing five fraction SBRT, UCLT location was associated with worse non-cancer associated survival and OS, which could be secondary to excessive D4cc dose to the proximal airways.
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Andruska N, Stowe HB, Crockett C, Liu W, Palma D, Faivre-Finn C, Badiyan SN. Stereotactic Radiation for Lung Cancer: A Practical Approach to Challenging Scenarios. J Thorac Oncol 2021; 16:1075-1085. [PMID: 33901637 DOI: 10.1016/j.jtho.2021.04.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/02/2021] [Accepted: 04/07/2021] [Indexed: 12/18/2022]
Abstract
Stereotactic body radiation therapy (SBRT) is an effective and well-tolerated treatment for medically inoperable patients with early stage NSCLC. SBRT is a noninvasive treatment involving the delivery of ablative radiation doses with high precision in the course of a few treatments. Relative to conventionally fractionated radiation, SBRT achieves superior local control and survival. SBRT use has increased dramatically in the past 15 years and is currently considered the standard of care in cases of inoperable early stage NSCLC. It is being increasingly applied to more complex patient populations at higher risk of treatment-related toxicity. In these more complex patients, there is an increasing need to balance patient and treatment factors in selecting the optimal patients for SBRT. Here, we review several challenging clinical scenarios often encountered in thoracic multidisciplinary tumor boards.
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Affiliation(s)
- Neal Andruska
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Hayley B Stowe
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Cathryn Crockett
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Wei Liu
- Division of Radiation Oncology, Western University, London, Ontario, Canada
| | - David Palma
- Division of Radiation Oncology, Western University, London, Ontario, Canada; Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester and The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St Louis, Missouri.
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The HILUS-Trial-a Prospective Nordic Multicenter Phase 2 Study of Ultracentral Lung Tumors Treated With Stereotactic Body Radiotherapy. J Thorac Oncol 2021; 16:1200-1210. [PMID: 33823286 DOI: 10.1016/j.jtho.2021.03.019] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Stereotactic body radiation therapy of thoracic tumors close to the central airways implies risk of severe toxicity. We report a prospective multicenter phase 2 trial for tumors located less than or equal to 1 cm from the proximal bronchial tree with primary end point of local control and secondary end point of toxicity. METHODS Stereotactic body radiation therapy with 7 Gy × 8 was prescribed to the 67% isodose encompassing the planning target volume. The patients were stratified to group A (tumors ≤ 1 cm from the main bronchi and trachea) or group B (all other tumors). Risk factors for treatment-related death were tested in univariate analysis, and a logistic regression model was developed for fatal bronchopulmonary bleeding versus dose to the main bronchi and trachea. RESULTS A total of 65 patients (group A/group B, n = 39/26) were evaluated. The median distance between the tumor and the proximal bronchial tree was 0 mm (0-10 mm). The 2-year local control was 83%. Grade 3 to 5 toxicity was noted in 22 patients, including 10 cases of treatment-related death (bronchopulmonary hemorrhage, n = 8; pneumonitis, n = 1; fistula, n = 1). Dose to the combined structure main bronchi and trachea and tumor distance to the main bronchi were important risk factors. Dose modeling revealed minimum dose to the "hottest" 0.2 cc to the structure main bronchi and trachea as the strongest predictor for lethal bronchopulmonary hemorrhage. CONCLUSIONS On the basis of the presented data, 7 Gy × 8, prescribed to the planning target volume-encompassing isodose, should not be used for tumors located within 1 cm from the main bronchi and trachea. Group B-type tumors may be considered for the treatment on the basis of an individual risk-benefit assessment and a maximum dose to the main bronchi and trachea in the order of 70 to 80 Gy (equivalent dose in 2 Gy fractions).
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Abstract
Radiation treatment of early stage nonsmall cell lung cancer has evolved over the past 2 decades to progressively more hypofractionated treatment courses. Results comparable to surgical resection are seen with stereotactic body radiotherapy, which is now the standard of care for medically inoperable patients, and a treatment option for operable patients as well. Understanding of the optimal radiation dose and fractionation are evolving, especially for central tumors which have higher treatment toxicity than peripheral tumors.
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Affiliation(s)
- Anna Wrona
- Medical University of Gdansk, Department of Oncology and Radiotherapy, Gdansk, Poland
| | - Francoise Mornex
- Radiation Oncology Department, CHU Lyon, Université Claude Bernard Lyon1, Lyon, France.
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Steinfort DP, Christie M, Antippa P, Rangamuwa K, Padera R, Müller MR, Irving LB, Valipour A. Bronchoscopic Thermal Vapour Ablation for Localized Cancer Lesions of the Lung: A Clinical Feasibility Treat-and-Resect Study. Respiration 2021; 100:432-442. [PMID: 33730740 DOI: 10.1159/000514109] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 12/23/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bronchoscopic thermal vapour ablation (BTVA) is an established and approved modality for minimally invasive lung volume reduction in severe emphysema. Preclinical data suggest potential for BTVA in minimally invasive ablation of lung cancer lesions. OBJECTIVES The objective of this study is to establish the safety, feasibility, and ablative efficacy of BTVA for minimally invasive ablation of lung cancers. METHODS Single arm treat-and-resect clinical feasibility study of patients with biopsy-confirmed lung cancer. A novel BTVA for lung cancer (BTVA-C) system for minimally invasive treatment of peripheral pulmonary tumours was used to deliver 330 Cal thermal vapour energy via bronchoscopy to target lesion. Patients underwent planned lobectomy to complete oncologic care. Pre-surgical CT chest and post-resection histologic analysis were performed to evaluate ablative efficacy. RESULTS Six patients underwent BTVA-C, and 5 progressed to planned lobectomy. Median procedure duration was 12 min. No major procedure-related complications occurred. All 5 resected lesions were part-solid lung adenocarcinomas with median solid component size 1.32±0.36 cm. Large uniform ablation zones were seen in 4 patients where thermal dose exceeded 3 Cal/mL, with complete/near-complete necrosis of target lesions seen in 2 patients. Tumour positioned within ablation zones demonstrated necrosis in >99% of cross-sectional area examined. CONCLUSION BTVA of lung tumours is feasible and well tolerated, with preliminary evidence suggesting high potential for effective ablation of tumours. Thermal injury is well demarcated, and uniform tissue necrosis is observed within ablation zones receiving sufficient thermal dose per volume of lung. Treatment of smaller volumes and ensuring adequate thermal dose may be important for ablative efficacy.
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Affiliation(s)
- Daniel P Steinfort
- Department Respiratory Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia, .,Department of Medicine, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, Victoria, Australia,
| | - Michael Christie
- Department of Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Phillip Antippa
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kanishka Rangamuwa
- Department Respiratory Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Robert Padera
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Rolf Müller
- Department of Thoracic Surgery, North Clinic Vienna, Karl-Landsteiner-Institute of Thoracic Oncology, Sigmund-Freud-University Medical Faculty, Vienna, Austria
| | - Louis B Irving
- Department Respiratory Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry & Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Klinik Floridsdorf, Vienna, Austria
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Crockett CB, Samson P, Chuter R, Dubec M, Faivre-Finn C, Green OL, Hackett SL, McDonald F, Robinson C, Shiarli AM, Straza MW, Verhoeff JJC, Werner-Wasik M, Vlacich G, Cobben D. Initial Clinical Experience of MR-Guided Radiotherapy for Non-Small Cell Lung Cancer. Front Oncol 2021; 11:617681. [PMID: 33777759 PMCID: PMC7988221 DOI: 10.3389/fonc.2021.617681] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/12/2021] [Indexed: 02/06/2023] Open
Abstract
Curative-intent radiotherapy plays an integral role in the treatment of lung cancer and therefore improving its therapeutic index is vital. MR guided radiotherapy (MRgRT) systems are the latest technological advance which may help with achieving this aim. The majority of MRgRT treatments delivered to date have been stereotactic body radiation therapy (SBRT) based and include the treatment of (ultra-) central tumors. However, there is a move to also implement MRgRT as curative-intent treatment for patients with inoperable locally advanced NSCLC. This paper presents the initial clinical experience of using the two commercially available systems to date: the ViewRay MRIdian and Elekta Unity. The challenges and potential solutions associated with MRgRT in lung cancer will also be highlighted.
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Affiliation(s)
- Cathryn B. Crockett
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Pamela Samson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Robert Chuter
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Michael Dubec
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
| | - Olga L. Green
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Sara L. Hackett
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Fiona McDonald
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - Anna-Maria Shiarli
- Department of Radiotherapy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Michael W. Straza
- Department of Radiation Oncology, Froedtert and the Medical College of Wisconsin, Milwaukee, WI, United States
| | - Joost J. C. Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Maria Werner-Wasik
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA, United States
| | - Gregory Vlacich
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO, United States
| | - David Cobben
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
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Safety and Efficacy of Stereotactic Body Radiotherapy in Ultracentral Lung Tumors Using a Risk-optimized Fractionation Scheme. Clin Lung Cancer 2020; 22:332-340.e3. [PMID: 33281061 DOI: 10.1016/j.cllc.2020.11.003] [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] [Received: 07/22/2020] [Revised: 10/28/2020] [Accepted: 11/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Delivery of stereotactic body radiotherapy (SBRT) to ultracentral lung tumors remains a major challenge, with potentially excessive SBRT-related toxicity. This study investigates a risk-optimized approach to ultracentral SBRT in an elderly and comorbid patient cohort. PATIENTS AND METHODS Analysis encompassed 129 patients (mean age: 70 ± 11 years, median Charlson comorbidity index: 4 [range, 3-5]) following risk-adapted SBRT to central or ultracentral primary and secondary lung tumors between 2012 and 2019 (78 central, 51 ultracentral). Ultracentral tumors were defined by planning target volume overlap with the proximal bronchial tree. Whereas ultracentral tumors were treated with a risk-optimized fractionation scheme of 50 Gy in 10 fractions, central tumors received higher-fractionated 60 Gy in 8 fractions. Outcome parameters and toxicity for ultracentral and central tumors were assessed using Kaplan-Meier and competing risk analyses. RESULTS Local failure rate was not significantly increased in ultracentral tumors compared with central tumors (2-year local failure rate ultracentral, 26.9%; 95% confidence interval [CI], 12.2%-44.2%; central, 14.6%; 95% CI, 6.6%-25.5%; P = .17). Overall survival was similar in both groups (2-year overall survival central, 55.4%; 95% CI, 44.5%-68.9%; ultracentral, 54.9%; 95% CI, 40.8%-73.9%; P = .6). Toxicity was moderate, with toxicity ≥ grade 3 rates of 15.3% (95% CI, 5.9%-28.9%) for ultracentral and 7.3% (95% CI, 2.7%-15.0%) for central tumors after 2 years (P = .27). No grade 4 toxicity and only 1 potential grade 5 toxicity were observed in the ultracentral cohort. CONCLUSION Risk-optimized SBRT to ultracentral lung tumors is a reasonably effective and safe treatment alternative in frail patients.
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Stereotactic Body Radiation Therapy for Mediastinal and Hilar Lymph Node Metastases. Int J Radiat Oncol Biol Phys 2020; 109:764-774. [PMID: 33115687 DOI: 10.1016/j.ijrobp.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/26/2020] [Accepted: 10/05/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) to metastatic mediastinal and hilar lymphadenopathy (MHL) is challenging owing to the proximity of centrally located organs-at-risk. As limited data exist on the safety and efficacy of SBRT for MHL, a retrospective review of clinical outcomes was conducted from a large academic center. METHODS AND MATERIALS Eligible patients received SBRT to MHL between 2014 to 2019 for the following indications: oligometastases, oligoprogression, or local control of a dominant area of progression. The primary endpoint was grade ≥3 toxicity (Common Terminology Criteria for Adverse Events, version 5.0). The cumulative incidence function evaluated local failure (LF) and starting or changing systemic therapy (SCST). Kaplan-Meier methodology estimated progression-free survival (PFS) and overall survival (OS). RESULTS Fifty-two patients (84 metastases) were included. Median follow-up was 20 months. Primary cancer sites included kidney (53.8%), lung (13.4%), breast (7.7%), and other (25.1%). Indications for SBRT were oligoprogression (n = 35; 67.3%), oligometastases (n = 10; 19.2%), or local failure of a dominant area of progression (n = 7; 13.5%). The majority (n = 31; 59.6%) received SBRT to a single lymph node metastasis. Median SBRT dose was 35 Gy (range, 30-50 Gy) with a median biologically effective dose of 59.5 Gy (range, 48-100 Gy). All treatments were in 5 fractions. Seven grade ≥3 toxicities were experienced by 6 patients (11.5%) and were mostly transient (5/7; 71%). There was a single (1.9%) grade 5 toxicity (radiation pneumonitis). The cumulative incidence of LF was 9.0% at 2 years. The cumulative incidence of SCST was 33.2% and 57.1% at 1 and 2 years, respectively. Median PFS was 4.0 months (95% confidence interval, 2.8-7.3) and median OS was 31.7 months (95% confidence interval, 23.8-87.5). CONCLUSIONS In one of the largest single institutional series of SBRT for MHL, moderate rates of grade ≥3 toxicity were observed, although the majority were transient. This treatment resulted in low LF rates and potentially delayed SCST for many patients.
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Dose coverage impacts local control in ultra-central lung oligometastases treated with stereotactic radiotherapy. Strahlenther Onkol 2020; 197:396-404. [PMID: 32970163 DOI: 10.1007/s00066-020-01687-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/24/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The use of Stereotactic Body Radiotherapy (SBRT) is controversial in Ultra-Central lung tumors, a subset of central lung tumors characterized by proximity to critical mediastinal structures. This is of interest in oligometastatic (≤3 metastases) patients, who can yield survival benefit from local treatments. The aim of our study is to assess the determinants of efficacy and toxicity in this setting. MATERIALS AND METHODS Clinical and dosimetric parameters were reviewed in a cohort of oligometastatic patients treated with SBRT for ultra-central tumors. Local control rate (LC) and toxicity were assessed. Statistical Analysis was carried out to assess the impact of those predictors on local recurrence and adverse events. RESULTS One-hundred-nine consecutive patients were included. A median Biologic Effective Dose (BED) of 105 (75-132) Gy10 was prescribed. At a median follow-up of 17 (range 3-78) months, 2-year LC was 87%. Improved LC was correlated to Planning Treatment Volume (PTV) covered by 95% of the prescription dose (V95% PTV) > 85% (HR 0.15, 95%CI 0.05-0.49, p = 0.0017) and to Gross Tumor Volume (GTV) < 90 cm3 (HR 0.2, 95%CI 0.07-0.56, p = 0.0021). Overall and grade ≥ 3 toxicity incidence was 20% and 5%, respectively. Patients experiencing acute and late toxicities received significantly higher dose to 1 cm3 (D1cm3) of esophagus and lung volume receiving ≥5 Gy (V5Gy) (p = 0.016 and p = 0.013), and higher dose to 0.1 cm3 (D0.1cm3) of heart (p = 0.036), respectively. CONCLUSION V95% PTV > 85% and GTV < 90 cm3 are independent predictors of LC. Dose to esophagus, lung and heart should be carefully assessed to minimize treatment-related toxicities.
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Faivre-Finn C, Fenwick JD, Franks KN, Harrow S, Hatton MQF, Hiley C, McAleese JJ, McDonald F, O'Hare J, Peedell C, Pope T, Powell C, Rulach R, Toy E. Reduced Fractionation in Lung Cancer Patients Treated with Curative-intent Radiotherapy during the COVID-19 Pandemic. Clin Oncol (R Coll Radiol) 2020; 32:481-489. [PMID: 32405158 PMCID: PMC7218369 DOI: 10.1016/j.clon.2020.05.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/22/2020] [Indexed: 12/14/2022]
Abstract
Patients treated with curative-intent lung radiotherapy are in the group at highest risk of severe complications and death from COVID-19. There is therefore an urgent need to reduce the risks associated with multiple hospital visits and their anti-cancer treatment. One recommendation is to consider alternative dose-fractionation schedules or radiotherapy techniques. This would also increase radiotherapy service capacity for operable patients with stage I-III lung cancer, who might be unable to have surgery during the pandemic. Here we identify reduced-fractionation for curative-intent radiotherapy regimes in lung cancer, from a literature search carried out between 20/03/2020 and 30/03/2020 as well as published and unpublished audits of hypofractionated regimes from UK centres. Evidence, practical considerations and limitations are discussed for early-stage NSCLC, stage III NSCLC, early-stage and locally advanced SCLC. We recommend discussion of this guidance document with other specialist lung MDT members to disseminate the potential changes to radiotherapy practices that could be made to reduce pressure on other departments such as thoracic surgery. It is also a crucial part of the consent process to ensure that the risks and benefits of undergoing cancer treatment during the COVID-19 pandemic and the uncertainties surrounding toxicity from reduced fractionation have been adequately discussed with patients. Furthermore, centres should document all deviations from standard protocols, and we urge all colleagues, where possible, to join national/international data collection initiatives (such as COVID-RT Lung) aimed at recording the impact of the COVID-19 pandemic on lung cancer treatment and outcomes.
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Affiliation(s)
- C Faivre-Finn
- The Christie NHS Foundation Trust, Manchester, UK; The University of Manchester, Manchester, UK.
| | - J D Fenwick
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Department of Physics, Clatterbridge Cancer Centre, Bebington, Wirral, UK
| | - K N Franks
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK; University of Leeds, Leeds, UK
| | - S Harrow
- Beatson West of Scotland Cancer Centre, Glasgow, UK; University of Glasgow, Glasgow, UK
| | | | - C Hiley
- CRUK Lung Cancer Centre of Excellence, University College London, London, UK; Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J J McAleese
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK
| | - F McDonald
- The Royal Marsden NHS Foundation Trust, London, UK
| | - J O'Hare
- Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, UK
| | - C Peedell
- James Cook University Hospital, Middlesbrough, UK
| | - T Pope
- Clatterbridge Cancer Centre, Bebington, Wirral, UK
| | - C Powell
- South West Wales Cancer Centre, Singleton Hospital, Swansea, UK; Velindre Cancer Centre, Cardiff, UK
| | - R Rulach
- Beatson West of Scotland Cancer Centre, Glasgow, UK; University of Glasgow, Glasgow, UK
| | - E Toy
- Royal Devon and Exeter NHS Foundation Trust, Exeter Hospital, Exeter, UK
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