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Chen D, Qin H, Deng G, Wang Q, Wang H, Liu X. Pre-radiotherapy systemic immune inflammation index associated with overall survival in patients with advanced EGFR mutant non-small cell lung cancer receiving thoracic radiotherapy. Clin Transl Oncol 2023; 25:226-235. [PMID: 36070068 PMCID: PMC9813231 DOI: 10.1007/s12094-022-02936-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/22/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE This study aimed to investigate the prognostic potential of the pre-radiotherapy systemic immune-inflammation index (SII) for the survival of advanced lung adenocarcinoma patients with epidermal growth factor receptor (EGFR) mutations, which might provide a basis for optimizing the comprehensive treatment scheme. METHODS A total of 111 lung adenocarcinoma patients with EGFR mutations, who received thoracic radiotherapy, were included in this retrospective study. The primary endpoint of the study was based on the overall survival (OS) of patients. The receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off value of each immune inflammation index. Kaplan-Meier analysis was performed for the comparison of OS. The Cox proportional-hazard model was used for the multivariate and univariate regression analyses to determine the correlations of prognostic factors with the disease. RESULTS SII was divided into the high SII group (≥ 620.2; 45.95%) and the low SII group (SII < 620.2; 54.05%) based on the optimal cutoff values. The median OS rates were 53.3 and 33.3 months in the low and high SII groups, respectively, showing statistically significant differences ( hazard ratio (HR) = 0.459; 95% CI 0.286-0.736; P < 0.001). The multivariate analysis showed that, after adjusting for the significant covariates, the SII values were independently associated with the improved OS of the patients (adjusted HR = 0.444; 95% CI 0.279-0.709; P = 0.001). The low NLR values were associated with the better OS of patients (HR = 0.509; 95% CI 0.326-0.792; P = 0.005) and vice versa (HR = 0.422; 95% CI 0.213-0.836; P < 0.001). The patients in the low LMR group before radiotherapy exhibited longer OS as compared to those in the high LMR group (HR = 0.497; 95% CI 0.308-0.802; P = 0.001). CONCLUSIONS This study showed that these inflammatory indices might have an important prognostic potential for advanced lung adenocarcinoma patients with EGFR mutations, receiving thoracic radiotherapy and might provide a basis for the individualized treatment of these patients.
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Affiliation(s)
- Dujuan Chen
- Dongming People’s Hospital, Heze, Shandong Province China
| | - Hongyue Qin
- grid.410587.fShandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117 Shandong Province China ,grid.440144.10000 0004 1803 8437Department of Radiation Oncology, Shandong First Medical University and Shandong Academy of Medical Sciences, Shandong Cancer Hospital and Institute, Jinan, 250117 Shandong Province China
| | - Guangchuan Deng
- grid.410587.fShandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117 Shandong Province China ,grid.440144.10000 0004 1803 8437Department of Radiation Oncology, Shandong First Medical University and Shandong Academy of Medical Sciences, Shandong Cancer Hospital and Institute, Jinan, 250117 Shandong Province China
| | - Qi Wang
- grid.410587.fShandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117 Shandong Province China ,grid.440144.10000 0004 1803 8437Department of Radiation Oncology, Shandong First Medical University and Shandong Academy of Medical Sciences, Shandong Cancer Hospital and Institute, Jinan, 250117 Shandong Province China
| | - Haiyong Wang
- grid.440144.10000 0004 1803 8437Department of Internal Medicine-Oncology, Department of Radiation Oncology, Shandong First Medical University and Shandong Academy of Medical Sciences, Shandong Cancer Hospital and Institute, Jinan, 250117 Shandong Province China
| | - Xijun Liu
- grid.440144.10000 0004 1803 8437Department of Radiation Oncology, Shandong First Medical University and Shandong Academy of Medical Sciences, Shandong Cancer Hospital and Institute, Jinan, 250117 Shandong Province China
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The prospect of combination therapies with the third-generation EGFR-TKIs to overcome the resistance in NSCLC. Biomed Pharmacother 2022; 156:113959. [DOI: 10.1016/j.biopha.2022.113959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
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Shi Y, Xu H, Raynor WY, Ding J, Lin L, Zhou C, Wang W, Meng Y, Wu X, Chen X, Lv D, Yang H. Efficacy and Failure Patterns of Early SBRT to the Primary Tumor in Advanced EGFR-Mutation-Positive Lung Cancer with EFGR-TKI Treatment: A Prospective, Single Arm, Phase II Study. LIFE (BASEL, SWITZERLAND) 2022; 12:life12121954. [PMID: 36556319 PMCID: PMC9783042 DOI: 10.3390/life12121954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
Abstract
Early stereotactic body radiation therapy (SBRT) to the primary tumor combined with epidermal growth factor receptor tyrosine kinase inhibitor (EFGR-TKI) treatment may increase progression-free survival (PFS) by delaying resistance in patients with advanced EGFR-mutant non-small cell lung cancer (NSCLC). In this prospective, single arm, phase II study, patients with advanced NSCLC were treated with EGFR-TKI (icotinib 125 mg tid or gefitinib 250 mg qd) for one month followed by SBRT (40-60 Gy/5-8 F/5-10 d) to the primary tumor with concurrent EGFR-TKI until disease progression. The primary endpoint was PFS and the patterns of failure. Overall survival (OS) and adverse effects (AEs) were secondary endpoints. Overall, 41 advanced NSCLC patients with EGFR mutations received treatment with 24.42 months of median follow-up time. On average, SBRT was initiated 1.49 months after EGFR-TKI administration. Tumors were found to have an average shrinkage rate of 42.50%. Median PFS was 15.23 months (95% CI 13.10-17.36), while median OS was 27.57 months (95% CI 23.05-32.09). Thirty-three patients were found to have disease progression, of which new site failure (NF) (22 patients, 66.66%) was the most common pattern, followed by original site failure (OF) (7 patients, 21.21%) and simultaneous OF/NF (ONF) (4 patients, 12.12%). There were no Aes equal to or greater than grade 3, with the most frequent AE being radiation pneumonitis. Therefore, administering therapy targeted at the primary tumor using early SBRT after EGFR-TKI initiation is a new potentially safe and effective approach to treat EGFR-mutant advanced NSCLC.
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Affiliation(s)
- Yangyang Shi
- Key Laboratory of Radiation Oncology of Taizhou, Radiation Oncology Institute of Enze Medical Health Academy, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Department of Radiation Oncology, University of Arizona, Tucson, AZ 86721, USA
| | - Hailing Xu
- Key Laboratory of Radiation Oncology of Taizhou, Radiation Oncology Institute of Enze Medical Health Academy, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Department of Pulmonary Medicine, Enze Hospital, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
| | - William Y. Raynor
- Key Laboratory of Radiation Oncology of Taizhou, Radiation Oncology Institute of Enze Medical Health Academy, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Department of Radiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Jiapei Ding
- Key Laboratory of Radiation Oncology of Taizhou, Radiation Oncology Institute of Enze Medical Health Academy, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Department of Radiation Oncology, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
| | - Ling Lin
- Department of Pulmonary Medicine, Enze Hospital, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
| | - Chao Zhou
- Key Laboratory of Radiation Oncology of Taizhou, Radiation Oncology Institute of Enze Medical Health Academy, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Department of Radiation Oncology, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
| | - Wei Wang
- Key Laboratory of Radiation Oncology of Taizhou, Radiation Oncology Institute of Enze Medical Health Academy, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Department of Radiation Oncology, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
| | - Yinnan Meng
- Key Laboratory of Radiation Oncology of Taizhou, Radiation Oncology Institute of Enze Medical Health Academy, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Department of Radiation Oncology, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
| | - Xiaomai Wu
- Department of Pulmonary Medicine, Enze Hospital, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
| | - Xiaofeng Chen
- Enze Medical Health Academy, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Dongqing Lv
- Department of Pulmonary Medicine, Enze Hospital, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Correspondence: (D.L.); (H.Y.); Tel.: +86-138-676-22009 (D.L.); +86-138-196-39006 (H.Y.)
| | - Haihua Yang
- Key Laboratory of Radiation Oncology of Taizhou, Radiation Oncology Institute of Enze Medical Health Academy, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Department of Radiation Oncology, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou 317000, China
- Correspondence: (D.L.); (H.Y.); Tel.: +86-138-676-22009 (D.L.); +86-138-196-39006 (H.Y.)
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Effect of thoracic radiotherapy dose on the prognosis of advanced lung adenocarcinoma harboring EGFR mutations. BMC Cancer 2022; 22:1012. [PMID: 36153486 PMCID: PMC9509658 DOI: 10.1186/s12885-022-10095-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The aim of this study was to investigate the effects of different thoracic radiotherapy doses on OS and incidence of radiation pneumonia which may provide some basis for optimizing the comprehensive treatment scheme of these patients with advanced EGFR mutant lung adenocarcinoma.
Methods
Data from 111 patients with EGFR-mutant lung adenocarcinoma who received thoracic radiotherapy were included in this retrospective study. Overall survival (OS) was the primary endpoints of the study. Kaplan–Meier method was used for the comparison of OS. The Cox proportional-hazard model was used for the multivariate and univariate analyses to determine the prognostic factors related to the disease.
Results
The mOS rates of the patients, who received radiotherapy dose scheme of less than 50 Gy, 50–60 Gy (including 50 Gy), and 60 Gy or more were 29.1 months, 34.4 months, and 51.0 months, respectively (log-rank P = 0.011). Although trend suggested a higher levels of pneumonia cases with increasing radiation doses, these lack statistical significance (χ2 = 1.331; P = 0.514). The multivariate analysis showed that the thoracic radiotherapy dose schemes were independently associated with the improved OS of patients (adjusted hazard ratio [HR], 0.606; 95% CI, 0.382 to 0.961; P = 0.033).
Conclusions
For the patients with advanced EGFR-mutant lung adenocarcinoma, the radical thoracic radiotherapy dose scheme (≥ 60 Gy) could significantly prolong the OS of patients during the whole course management.
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Deng R, Liu J, Song T, Xu T, Li Y, Duo L, Xiang L, Yu X, Lei J, Cao F. Primary lesion radiotherapy during first-line icotinib treatment in EGFR-mutated NSCLC patients with multiple metastases and no brain metastases: a single-center retrospective study. Strahlenther Onkol 2022; 198:1082-1093. [PMID: 35819466 DOI: 10.1007/s00066-022-01971-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 06/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The most frequent mode of progression in the majority of non-small cell lung cancer (NSCLC) patients treated with Epidermal growth factor - receptor tyrosine kinase inhibitors (EGFR-TKIs) is failure to respond to treatment at the primary lesion, suggesting that concurrent radiotherapy (CRT) to the primary lesion (CPRT) during first-line treatment with EGFR-TKI may be a novel therapeutic approach with a potential of additional benefit for metastatic NSCLC. Therefore, this study investigated the progression-free survival (PFS) and safety of CPRT during first-line icotinib treatment in NSCLC patients with EGFR mutations. METHODS EGFR-mutant NSCLC patients diagnosed with limited multiple metastases were treated with first-line icotinib. The decision to treat the primary lesions with radiation largely depended on the patient's preference. The study endpoints included PFS, toxicity, progression pattern, and acquisition of the T790M mutation. RESULTS The median PFS in the CPRT and Non-CPRT groups was 13.6 and 10.6 months (hazard ratio [HR] 0.23, 95% confidence interval [CI] 0.15-0.37, P < 0.001). Subgroup analysis showed that the results were statistically significant with 14.7 and 11.5 months for the 19del mutation (HR 0.20, 95% CI 0.10-0.40, P < 0.001) and 12.9 and 9.9 months for the L858R mutation (HR 0.25, 95% CI 0.13-0.48, P < 0.001). There were no reports of interstitial pneumonia associated with treatment at grade 4 or above. Patients who received CPRT during first-line icotinib treatment had the potential to decrease the primary lesion progression (P < 0.05) without increasing newly metastatic lesions (P > 0.05). The proportion of acquired T790M mutations was 26.7% and 45.7% in both groups (P > 0.05). CONCLUSION This study suggests that CPRT is a viable option for patients with EGFR-sensitive mutations in NSCLC with limited multiple metastases during first-line icotinib treatment, which can significantly improve PFS with acceptable toxicities. Data on progression patterns and T790M mutations suggest the need to further investigate the benefits of radiation treatment from a molecular perspective.
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Affiliation(s)
- Rui Deng
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Jinkun Liu
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
- Jinzhou Medical University, 121000, Jinzhou, Liaoning, China
| | - Tongjun Song
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
- Hubei University of Medicine, 442000, Shiyan, Hubei, China
| | - Tao Xu
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Yong Li
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
- Institute of Cancer Research, Renmin Hospital, Hubei University of Medicine, 442000, Shiyan, Hubei, China
| | - Long Duo
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Longchao Xiang
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Xiongjie Yu
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Jinhua Lei
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China
| | - Fengjun Cao
- Department of Oncology, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, 442000, Shiyan, Hubei, China.
- Institute of Cancer Research, Renmin Hospital, Hubei University of Medicine, 442000, Shiyan, Hubei, China.
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Cui J, Li L, Yuan S. The Value of Radiotherapy for Advanced Non-Small Cell Lung Cancer With Oncogene Driver-Mutation. Front Oncol 2022; 12:863715. [PMID: 35646640 PMCID: PMC9139486 DOI: 10.3389/fonc.2022.863715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/11/2022] [Indexed: 11/26/2022] Open
Abstract
Due to the widespread use of tyrosine kinase inhibitors (TKIs), which have largely supplanted cytotoxic chemotherapy as the first-line therapeutic choice for patients with advanced non-small cell lung cancer (NSCLC) who have oncogene driver mutations, advanced NSCLC patients with oncogene driver mutations had much long median survival. However, TKIs’ long-term efficacy is harmed by resistance to them. TKIs proved to have a limited potential to permeate cerebrospinal fluid (CSF) as well. Only a small percentage of plasma levels could be found in CSF at usual doses. Therefore, TKIs monotherapy may have a limited efficacy in individuals with brain metastases. Radiation has been demonstrated to reduce TKIs resistance and disrupt the blood-brain barrier (BBB). Previous trials have shown that local irradiation for bone metastases might improve symptoms, in addition, continuous administration of TKIs combined with radiotherapy was linked with beneficial progression-free survival (PFS) and overall survival (OS) for oligometastasis or bone metastasis NSCLC with oncogene driver mutations. The above implied that radiotherapy combined with targeted therapy may have a synergistic impact in patients with advanced oncogene driver-mutated NSCLC. The objective of this article is to discuss the value of radiotherapy in the treatment of those specific individuals.
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Affiliation(s)
- Jinfeng Cui
- Clinical Medical College, Shandong University, Jinan, China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Shandong Cancer Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Li Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Shandong Cancer Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shuanghu Yuan
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Shandong Cancer Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
- Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Shuanghu Yuan,
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Li X, Wang J, Chang X, Gao Z, Teng F, Meng X, Yu J. Optimal Initial Time Point of Local Radiotherapy for Unresectable Lung Adenocarcinoma: A Retrospective Analysis on Overall Arrangement of Local Radiotherapy in Advanced Lung Adenocarcinoma. Front Oncol 2022; 12:793190. [PMID: 35223474 PMCID: PMC8867094 DOI: 10.3389/fonc.2022.793190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
Local radiotherapy (LRT) is reported to be of survival benefit for advanced non-small cell lung cancer (NSCLC) in accumulating evidence, but research on the optimal initial time point remains scarce. This IRB-approved retrospective analysis identified patients diagnosed with stage IIIb–IV unresectable lung adenocarcinoma who initiated front-line LRT at our institution between 2017 and 2020. The receiver operating characteristic (ROC) curve analyses were used to cut off the initial time of LRT (before and beyond 53 days). Patients were divided into two groups: one early to initiate radiotherapy group (≤53 days, EAR group) and one deferred radiotherapy group (>53 days, DEF group). The Kaplan–Meier method was used to estimate time-to-event endpoints; the Cox proportional hazard model was used to find out predictors of progression-free survival (PFS) and overall survival (OS). A total of 265 patients with a median age of 57 were enrolled. The median follow-up time was 26.4 months (ranging from 2.2 to 69.7 months). The mOS was 38.6 months and mPFS was 12.7 months. Age >60, bone and brain metastases, multisite metastases, and EGFR 19 mutation were independent predictors associated with OS. Early initiation of local radiotherapy within 53 days after diagnosis resulted in better PFS, but not in OS. A better OS was observed in patients with bone metastasis who underwent local radiotherapy initiated within 53 days.
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Affiliation(s)
- Xinge Li
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jie Wang
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Xu Chang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Zhenhua Gao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Feifei Teng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Xue Meng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jinming Yu
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
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Zeng Y, Yu D, Tian W, Wu F. Resistance mechanisms to osimertinib and emerging therapeutic strategies in nonsmall cell lung cancer. Curr Opin Oncol 2022; 34:54-65. [PMID: 34669648 DOI: 10.1097/cco.0000000000000805] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review aims to introduce the resistance mechanisms to osimertinib, discuss the therapeutic strategies, and make clinical updates in overcoming resistance to osimertinib. RECENT FINDINGS Osimertinib has shown favorable efficacy on second-line and first-line treatments in EGFR-mutant advanced nonsmall cell lung cancer (NSCLC). However, the presence of primary and acquired resistance to osimertinib restricts its clinical benefits. The primary resistance mainly consists of BIM deletion polymorphism and EGFR exon 20 insertions. Meanwhile, the heterogeneous mechanisms of acquired resistance include EGFR-dependent (on-target) and EGFR-independent (off-target) mechanisms. EGFR C797S mutation, MET amplification, HER2 amplification, and small cell lung cancer transformation were identified as frequent resistance mechanisms. Recently, more novel mechanisms, including rare EGFR point mutations and oncogenic fusions, were reported. With the results of completed and on-going clinical trials, the emerging therapeutic strategies of postosimertinib progression are summarized. SUMMARY The resistance mechanisms to osimertinib are heterogeneous and gradually perfected. The combination of osimertinib with bypass targeted therapy and other therapeutic approaches emerge as promising strategies.
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Affiliation(s)
- Yue Zeng
- Department of Oncology, The Second Xiangya Hospital, Central South University
| | - Danlei Yu
- Department of Oncology, The Second Xiangya Hospital, Central South University
- Department of Oncology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu
| | - Wentao Tian
- Department of Oncology, The Second Xiangya Hospital, Central South University
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Fang Wu
- Department of Oncology, The Second Xiangya Hospital, Central South University
- Hunan Cancer Mega-Data Intelligent Application and Engineering Research Centre
- Hunan Key Laboratory of Tumor Models and Individualized Medicine
- Hunan Key Laboratory of Early Diagnosis and Precision Therapy in Lung Cancer, The Second Xiangya Hospital, Central South University, Changsha, Hunan
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Wei H, Zhou X, Yang H, Gong Y, Wang J, Xu Y, Zhou L, Xue J, Zou B, Zhang Y, Zhu J, Peng F, Huang M, Lu Y, Liu Y. Stereotactic body radiotherapy to the primary lung lesion improves the survival of the selected patients with non-oligometastatic NSCLC harboring EGFR activating mutation with first-line EGFR-TKIs: a real-world study. J Cancer Res Clin Oncol 2021; 148:2589-2598. [PMID: 34669037 DOI: 10.1007/s00432-021-03831-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/10/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE This study aimed to explore the clinical value of SBRT for primary lung lesions of EGFR-mutant NSCLC patients with non-oligometastatic disease during first-line EGFR-TKI treatment. METHODS We identified patients with stage IV EGFR-mutant non-oligometastatic NSCLC who were suitable to receive SBRT for the primary tumors after EGFR-TKI treatment. All selected patients were treated with first-line EGFR-TKIs and SBRT for their primary lesions. The primary endpoints were the progression-free survival 1 (PFS1, time of first TKI dose relative to disease progression based on RECIST) and PFS2 (time of first TKI dose relative to disease progression after SBRT). The secondary endpoints were overall survival (OS) and safety. RESULTS Seventy-nine patients were enrolled, including 45 patients who received SBRT for their primary tumor at the maximal response of EGFR-TKI (the preemptive RT group) and 34 patients who received SBRT for their primary tumor after the occurrence of oligoprogression (the delayed RT group). The preemptive RT group had a significantly better median PFS1 than the delayed RT group (22.3 months vs. 12.9 months, P = 0.0031). The median PFS2 in the preemptive RT and delayed RT groups were 22.3 and 28.9 months, respectively (P = 0.17). The median OS did not differ significantly between the preemptive RT group and the delayed RT group (46.6 versus 51.3 months, P = 0.54). No severe toxicities (≥ grade 3) were recorded. CONCLUSION This real-world study showed that preemptive RT to primary lung tumors is a feasible option for selected patients with EGFR-mutant non-oligometastatic NSCLC who had stable disease during first-line EGFR-TKI treatment, and that it significantly improved PFS.
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Affiliation(s)
- Hao Wei
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xiaojuan Zhou
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hui Yang
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China.,Department of Radiation Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Youling Gong
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jin Wang
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yong Xu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Lin Zhou
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jianxin Xue
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Bingwen Zou
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yan Zhang
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jiang Zhu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Feng Peng
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Meijuan Huang
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - You Lu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yongmei Liu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Li Q, Liang N, Zhang X, Zhang Y, Ouyang W, Su S, Ma Z, Hu Y, Geng Y, Chen X, Lu B. Reasonable Timing of Radiotherapy for Stage IV Non-Small-Cell Lung Cancer During Targeted Therapy Based on Tumour Volume Change. Front Oncol 2021; 11:705303. [PMID: 34631535 PMCID: PMC8496348 DOI: 10.3389/fonc.2021.705303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose The aim of this study was to investigate the reasonable timing of radiotherapy for stage IV non-small-cell lung cancer (NSCLC) with EGFR-positive mutations during targeted therapy based on tumour volume change (TVC). Patients and Methods Simulation Computed Tomography Scan (SCTS) measurements were taken to test TVC in patients with stage IV NSCLC during targeted therapy at intervals of 10 days. The SCTS measurement was terminated when the tumour volume shrinkage rate in the latter simulation compared with the previous simulation was ≤5% or when the time after treatment was 90 days. Then, primary tumour radiotherapy was performed. Related parameters of the radiotherapy plan were compared between the implementation and simulation plans. Results Twenty-seven patients were enrolled in the analysis. After treatment, shrinkage of the primary tumour was observed in all patients, but the rate and speed were inconsistent. The average tumour volume decreased obviously within 40 days and was significantly different every 10 days (P ≤ 0.001). The average volume decreased slowly and tended to be stable (P>0.05) after 40 days. After the termination of SCTSs, 21 patients accepted primary tumour radiotherapy. No patients experienced grade 3+ acute radiation toxicity. The implementation radiotherapy plan was significantly better than that before treatment (all P<0.05) but not better than that on the 40th day after treatment (all P>0.05). Conclusions To obtain a high radiation dose and control radiation toxicity, the 40th day after targeted therapy may be a reasonable time to start radiotherapy for stage IV NSCLC with EGFR-positive mutations. Clinical Trial Registration https://www.clinicaltrials.gov/ct2/show/NCT03258671, identifier, NCT03258671.
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Affiliation(s)
- Qingsong Li
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Na Liang
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Xia Zhang
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guiyang Guihang Hospital, Guiyang, China
| | - Yi Zhang
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Weiwei Ouyang
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Shengfa Su
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Zhu Ma
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Yinxiang Hu
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Yichao Geng
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Xiaxia Chen
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
| | - Bing Lu
- Department of Oncology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Department of Oncology, Guizhou Cancer Hospital, Guiyang, China
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11
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Chai R, Yin Y, Cai X, Fu X, Zhang Q. Patterns of Failure in Patients With Advanced Non-Small Cell Lung Cancer Treated With Immune Checkpoint Inhibitors. Front Oncol 2021; 11:724722. [PMID: 34557412 PMCID: PMC8454403 DOI: 10.3389/fonc.2021.724722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/13/2021] [Indexed: 11/13/2022] Open
Abstract
Objective The advent of immune checkpoint inhibitors (ICIs) has rapidly transformed the treatment paradigm of non-small cell lung cancer (NSCLC). Despite the durability of response to ICIs, the vast majority of patients will later develop progression. However, the failure patterns of ICI treatment are unknown. Here, our study explored the failure patterns in advanced NSCLC patients treated with ICIs. Methods A cohort of 156 IIIB or IV NSCLC patients treated with first-/second-line ICIs were retrospectively analyzed. Patients who experienced clinical benefit and then developed progression were identified. The disease progression patterns were divided into three categories: progression in new sites, progression in existing sites, and combined progression. The number of progression sites was also recorded. Results Before the cutoff date, 91 (77.1%) patients had experienced disease progression; 34% of patients had progressed in the last 9 months of the first year. Fifty-three (58.2%) patients had developed progression at existing lesions, and 56 (61.5%) patients had shown ≤2 progression sites (oligo-progression). In patients with oligo-progression, the median time of disease progression was 8.23 months and the counterpart (systemic progression) was 5.97 months. The oligo-progression patients showed prolonged median overall survival (27.23 months) compared with patients with systemic progression (18.87 months). Conclusions Failure patterns of ICI therapy were predominantly “existing” sites, and the most common lesions of progression were the lung and lymph nodes. Most patients experienced oligo-progression which occurred later than systemic progression and showed prolonged overall survival. The control of the local lesions might be beneficial to improve ICI treatment efficacy.
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Affiliation(s)
- Rong Chai
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yipengchen Yin
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xuwei Cai
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaolong Fu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Qin Zhang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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12
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Wang X, Lu Z, Zeng Z, Cai J, Xu P, Liu A. Thoracic stereotactic body radiation therapy plus first-line tyrosine kinase inhibitors for patients with epidermal growth factor receptor-mutant polymetastatic non-small-cell lung cancer: A propensity-matched retrospective study. Medicine (Baltimore) 2021; 100:e27279. [PMID: 34664886 PMCID: PMC8448028 DOI: 10.1097/md.0000000000027279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/31/2021] [Indexed: 02/07/2023] Open
Abstract
The role of thoracic stereotactic body radiation therapy (SBRT) in addition to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in EGFR-mutant polymetastatic non-small-cell lung cancer (NSCLC) has not been well established. This retrospective study aimed to evaluate the efficacy and safety of EGFR-TKIs with thoracic SBRT for the treatment of this patient group.Polymetastatic NSCLC was defined as having >5 metastatic lesions. Patients with polymetastatic NSCLC harboring positive EGFR mutations after initial TKI therapy for at least 8 weeks were eligible for SBRT between August 2016and August 2019. Eligible patients were treated with thoracic SBRT, and TKIs were administered for the duration of SBRT and continued after SBRT until they were considered ineffective. The control group was treated with TKI monotherapy. Propensity score matching (ratio of 1:4) was used to account for differences in baseline characteristics. Progression-free survival (PFS), overall survival, and treatment safety were evaluated.In total, 136 patients were included in the study population. Among them, 120 patients received TKIs alone, and 16 patients received TKIs with thoracic SBRT. The baseline characteristics did not significantly differ between the two cohorts after propensity score matching. The median PFS was 17.8 months in the thoracic SBRT group and 10.8 months in the control group (P = .033). In the multivariate analysis, a Cox regression model showed that thoracic SBRT was an independent statistically significant positive predictor of improved survival, with a hazard ratio of 0.54 (P = .046). We recorded no severe toxic effects or grade 4 to 5 toxicities.Real-world data demonstrate that thoracic SBRT significantly extends PFS in EGFR-mutant polymetastatic NSCLC patients with tolerable toxicity. Given these results, randomized studies are warranted.
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Affiliation(s)
- Xia Wang
- Department of Oncology, The Second Affiliated Hospital of Nanchang University
| | - Zhiqin Lu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University
| | - Zhimin Zeng
- Department of Oncology, The Second Affiliated Hospital of Nanchang University
- Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, China
| | - Jing Cai
- Department of Oncology, The Second Affiliated Hospital of Nanchang University
| | - Peng Xu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University
| | - Anwen Liu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University
- Jiangxi Key Laboratory of Clinical Translational Cancer Research, Nanchang, China
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13
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Zhang Y, Wang W, Xu X, Li Y, Zhang H, Li J, Li Z. Impact of Radiotherapy Pattern on the Prognosis of Stage IV Lung Adenocarcinomas Harboring EGFR Mutations. Cancer Manag Res 2021; 13:3293-3301. [PMID: 33883942 PMCID: PMC8055281 DOI: 10.2147/cmar.s299563] [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: 12/29/2020] [Accepted: 03/26/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction The aim of this study was to investigate the role of local radiotherapy in the management of epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancers (NSCLCs) treated with EGFR tyrosine kinase inhibitors (TKIs). Materials and Methods Patients with stage IV EGFR-mutant NSCLC treated with radiotherapy concomitant to EGFR TKIs from May 2010 to December 2017 were retrospectively identified. Overall survival (OS) was the primary endpoints of the study. Results A total of 205 patients were enrolled in the study. One hundred eleven patients received one-time single-site radiotherapy (SSR), and 94 patients received multiple-site radiotherapy (MSR). Patients who received MSR had longer OS (median OS, 40.0 months; 95% confidence interval [CI], 29.6 to 50.4) than those who received SSR (median OS, 28.9 months; 95% CI, 24.3 to 33.5; P=0.031). Thoracic radiotherapy was associated with prolonged median OS (41.7 months, 95% CI, 29.0 to 54.4 vs 27.1 months, 95% CI 22.7 to 31.5; log-rank P<0.001). Multivariate analysis confirmed that thoracic radiotherapy was independently associated with improved OS (adjusted hazard ratio [HR], 0.514; 95% CI 32.3% to 81.8%; P=0.005). Conclusion MSR improves survival outcomes in patients with advanced-stage, EGFR-mutant, lung adenocarcinoma, with thoracic radiotherapy having the most significant effect on prognosis.
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Affiliation(s)
- Yingyun Zhang
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, People's Republic of China.,Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Wei Wang
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, People's Republic of China.,Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Xuedong Xu
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, People's Republic of China.,Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Yankang Li
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, People's Republic of China.,Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
| | - Hui Zhang
- Tumor Hospital of Xiangxi Tujia and Miao Autonomous Prefecture, Jishou, People's Republic of China
| | - Jianbin Li
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, People's Republic of China.,Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Zhenxiang Li
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, People's Republic of China
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14
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Jia W, Gao Q, Wang M, Li J, Jing W, Yu J, Zhu H. Overlap time is an independent risk factor of radiation pneumonitis for patients treated with simultaneous EGFR-TKI and thoracic radiotherapy. Radiat Oncol 2021; 16:41. [PMID: 33622352 PMCID: PMC7903606 DOI: 10.1186/s13014-021-01765-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/11/2021] [Indexed: 11/29/2022] Open
Abstract
Background The exact rate and relevant risk factors of radiation pneumonitis (RP) for non-small-cell cancer (NSCLC) patients treated with the combination of epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) and thoracic radiotherapy have not been reported. Thus, this study aimed to investigate the rate and risk factors of RP for EGFR-positive NSCLC patients simultaneously treated with first-generation EGFR-TKI and TRT. Patients and methods We retrospectively evaluated NSCLC patients simultaneously treated with first-generation EGFR-TKI and thoracic radiotherapy between January 2012 and December 2019 at Shandong Cancer Hospital and Institute, Shandong, China. RP was diagnosed via computed tomography and was classified according to the Common Terminology Criteria for Adverse Events v5.0. The risk factors of RP were identified using uni- and multivariate analyses. Results Of the 67 patients included, 44.78% (30/67) developed grade ≥ 2 RP. Grade ≥ 2 RP occurred within a median of 3.48 (range 1.07–13.6) months. The EGFR-TKI icotinib, ipsilateral lung V30 > 34%, and overlap time of > 20 days between EGFR-TKI and thoracic radiotherapy were identified to be independent predictive factors of grade ≥ 2 RP. Conclusions Grade ≥ 2 RP is highly frequent in NSCLC patients simultaneous treated with first-generation EGFR-TKI and thoracic radiotherapy. Icotinib, ipsilateral lung V30 ≤ 34%, and overlap time of ≤ 20 days for EGFR-TKI and thoracic radiotherapy will be helpful to lower the risk of RP in these patients. The addition of thoracic radiotherapy should be cautious, and the treatment strategies can be optimized to reduce the rate of RP for patients treat with simultaneous EGFR-TKI and thoracic radiotherapy.
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Affiliation(s)
- Wenxiao Jia
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong University, Shandong First Medical University, Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China
| | - Qianqian Gao
- Department of Obstetrics and Gynecology, Qilu Hospital Affiliated to Shandong University, Jinan, 250012, Shandong Province, China
| | - Min Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China
| | - Ji Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China
| | - Wang Jing
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong University, Shandong First Medical University, Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China. .,Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China.
| | - Hui Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong University, Shandong First Medical University, Shandong Academy of Medical Sciences, 440 Jiyan Road, Jinan, 250117, Shandong Province, China. .,Department of Radiation Oncology, Shandong Cancer Hospital and Institute Affiliated to Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China.
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