Acute esophagitis for patients with local-regional advanced non small cell lung cancer treated with concurrent chemoradiotherapy

Dosimetric risk factors for radiation esophagitis in patients with breast cancer following regional nodal radiation

BACKGROUND

Radiation esophagitis (RE) is one of the most common clinical symptoms of regi-onal lymph node radiotherapy for breast cancer. However, there are fewer studies focusing on RE caused by hypofractionated radiotherapy (HFRT).

AIM

To analyze the clinical and dosimetric factors that contribute to the development of RE in patients with breast cancer treated with HFRT of regional lymph nodes.

METHODS

Between January and December 2022, we retrospectively analysed 64 patients with breast cancer who met our inclusion criteria underwent regional nodal intensity-modulated radiotherapy at a radiotherapy dose of 43.5 Gy/15F.

RESULTS

Of the 64 patients in this study, 24 (37.5%) did not develop RE, 29 (45.3%) developed grade 1 RE (G1RE), 11 (17.2%) developed grade 2 RE (G2RE), and none developed grade 3 RE or higher. Our univariable logistic regression analysis found G2RE to be significantly correlated with the maximum dose, mean dose, relative volume 20-40, and absolute volume (AV) 20-40. Our stepwise linear regression analyses found AV30 and AV35 to be significantly associated with G2RE (P < 0.001). The optimal threshold for AV30 was 2.39 mL [area under the curve (AUC): 0.996; sensitivity: 90.9%; specificity: 91.1%]. The optimal threshold for AV35 was 0.71 mL (AUC: 0.932; sensitivity: 90.9%; specificity: 83.9%).

CONCLUSION

AV30 and AV35 were significantly associated with G2RE. The thresholds for AV30 and AV35 should be limited to 2.39 mL and 0.71 mL, respectively.

Effect of 3-Dimensional Interstitial High-Dose-Rate Brachytherapy With Regional Metastatic Lymph Node Intensity-Modulated Radiation Therapy in Locally Advanced Peripheral Non-Small Cell Lung Cancer: 5-Year Follow-up of a Phase 2 Clinical Trial

PURPOSE

We aimed to reveal the 5-year clinical outcomes of 3-dimensional (3D) interstitial high-dose-rate (HDR) brachytherapy with regional metastatic lymph node intensity modulated radiation therapy (IMRT) for locally advanced peripheral non-small cell lung cancer (NSCLC), which has been shown to have low toxicity and improved 2-year survival rates in patients with this disease.

METHODS AND MATERIALS

In this phase 2, single-arm, open-label clinical trial, 83 patients with locally advanced peripheral NSCLC were enrolled (median follow-up [range], 53.7 [4.3-120.4] months). All eligible patients received 3D interstitial HDR brachytherapy with regional metastatic lymph node IMRT. The primary endpoint was overall survival (OS). Secondary endpoints were local recurrence-free survival, regional recurrence-free survival, progression-free survival, distant metastasis-free survival, toxicities, and quality of life.

RESULTS

The final analysis included 75 patients (19 [25.3%] females, 56 [74.7%] males; median [range] age, 64 [44-80] years; stage IIIA, 34 [45.3%]; stage IIIB, 41 [54.7%]). At the latest follow-up, 32 (42.7%) patients had survived. The median OS was 38.0 months (5-year OS, 44.5%; 95% confidence interval [CI], 33.8%-58.6%). Local recurrence-free survival, recurrence-free survival, and distant metastasis-free survival at 5 years were 79.2% (95% CI, 68.5%-91.5%), 73.6% (95% CI, 61.5%-88.1%), and 50.3% (95% CI, 38.3%-66.1%), respectively. The dominant failure pattern was distant disease, corresponding to 40% (30 of 75) of patients and 65.2% (30 of 46) of all failures. Two (2.7%) patients developed grade 1 acute pneumonitis. Grade 2 and 3 acute esophagitis occurred in 11 (14.7%) and 4 (5.3%) patients, respectively. No late radiation-related grade ≥2 late adverse events were observed.

CONCLUSIONS

3D interstitial HDR brachytherapy with regional metastatic lymph node IMRT for locally advanced peripheral NSCLC shows significant OS and has a low toxicity rate. Additional evaluation in a phase 3 trial is recommended to substantiate these findings.

Radiation-Induced Esophagitis in Non-Small-Cell Lung Cancer Patients: Voxel-Based Analysis and NTCP Modeling

Simple Summary

Radiation-induced esophagitis (RE) is a common dose-limiting complication associated with concurrent chemoradiation therapy for Non-Small-Cell Lung Cancer (NSCLC), and a wide range of esophageal dosimetric parameters have been described as predictive of RE. In this study, we characterize the risk of RE for NSCLC patients enrolled in a prospective trial comparing intensity-modulated RT versus passive scattering proton therapy for locally advanced NSCLC. Dose patterns associated with RE were analyzed by applying voxel-based analysis approaches, and predictive models for RE were finally investigated. Two predictive models for acute RE with good cross-validated predictive performances and discrimination capability were developed (thoracic esophageal model: ROC-AUC = 0.73; whole esophagus model: ROC-AUC = 0.70).

Abstract

The aim of our study is to characterize the risk of radiation-induced esophagitis (RE) in a cohort of Non-Small-Cell Lung Cancer (NSCLC) patients treated with concurrent chemotherapy and photon/proton therapy. For each patient, the RE was graded according to the CTCAE v.3. The esophageal dose-volume histograms (DVHs) were extracted. Voxel-based analyses (VBAs) were performed to assess the spatial patterns of the dose differences between patients with and without RE of grade ≥ 2. Two hierarchical NTCP models were developed by multivariable stepwise logistic regression based on non-dosimetric factors and on the DVH metrics for the whole esophagus and its anatomical subsites identified by the VBA. In the 173 analyzed patients, 76 (44%) developed RE of grade ≥ 2 at a median follow-up time of 31 days. The VBA identified regions of significant association between dose and RE in a region encompassing the thoracic esophagus. We developed two NTCP models, including the RT modality and a dosimetric factor: V_55Gy for the model related to the whole esophagus, and the mean dose for the model designed on the thoracic esophagus. The cross-validated performance showed good predictions for both models (ROC-AUC of 0.70 and 0.73, respectively). The only slight improvement provided by the analysis of the thoracic esophageal subsites might be due to the relevant sparing of cervical and lower thoracic esophagus in the analyzed cohort. Further studies on larger cohorts and a more heterogeneous set of dose distributions are needed to validate these preliminary findings and shed further light on the spatial patterns of RE development.

Account for the Full Extent of Esophagus Motion in Radiation Therapy Planning: A Preliminary Study of the IRV of the Esophagus

Objective

Accounting for esophagus motion in radiotherapy planning is an important basis for accurate assessment of toxicity. In this study, we calculated how much the delineations of the esophagus should be expanded based on three-dimensional (3D) computed tomography (CT), four-dimensional (4D) average projection (AVG), and maximum intensity projection (MIP) scans to account for the full extent of esophagus motion during 4D imaging acquisition.

Methods and Materials

The 3D and 4D CT scans of 20 lung cancer patients treated with conventional radiotherapy and 20 patients treated with stereotactic ablative radiation therapy (SBRT) were used. Radiation oncologists contoured the esophagus on the 3DCT, AVG, MIP and 25% exhale scans, and the combination of the esophagus in every phase of 4DCT. The union of all 4D phase delineations (U4D) represented the full extent of esophagus motion during imaging acquisition. Surface distances from U4D to 3D, AVG, and MIP volumes were calculated. Distances in the most extreme surface points (1.5 cm most superoinferior, 10% most right/left/anteroposterior) were used to derive margins accounting only for systematic (delineation) errors.

Results

Esophagus delineations on the MIP were the closest to the full extent of motion, requiring only 6.9 mm margins. Delineations on the AVG and 3D scans required margins up to 7.97 and 7.90 mm, respectively. The largest margins were for the inferior, right, and anterior aspects for the delineations on the 3D, AVG, and MIP scans, respectively.

Conclusion

Delineations on 3D, AVG, or MIP scans required extensions for representing the esophagus’s full extent of motion, with the MIP requiring the smallest margins. Research including daily imaging to determine the random components for the margins and dosimetric measurements to determine the relevance of creating a planning organ at risk volume (PRV) of the esophagus is required.

Evaluation of Epigallocatechin-3-Gallate as a Radioprotective Agent During Radiotherapy of Lung Cancer Patients: A 5-Year Survival Analysis of a Phase 2 Study

Background

Previous analysis of the study (NCT02577393) had demonstrated the application of epigallocatechin-3-gallate (EGCG) could be safe and effective in the prevention and treatment of acute radiation esophagitis in patients with advanced lung cancer. EGCG seemed to improve the response rate of small cell lung cancer (SCLC) to radiotherapy in a subgroup analysis. This research continued to analyze the impact of EGCG application on cancer-radiation efficacy and patient survival.

Methods

All patients with SCLC in the NCT02577393 study were included. Patients were randomized into EGCG group or conventional therapy group as protocol. The primary endpoints of the study were radiation response rate and progression-free survival (PFS). Overall survival (OS) and the efficacy of EGCG in the treatment of esophagitis were assessed as secondary endpoints.

Results

A total of 83 patients with lung cancer in the NCT02577393 study were screened, and all 38 patients with SCLC were eligible for analysis. No significant differences with regard to baseline demographic and clinical characteristics were observed between the two groups. The objective response rate (ORR) was higher than that of conventionally treated patients (84.6 vs 50%, P = 0.045), while the median PFS and OS were not significantly prolonged. At data cut-off (1 January 2021), 5-year PFS was 33% with EGCG versus 9.3% with conventional treatment, and 5-year OS was 30.3% versus 33.3%, respectively. The mean adjusted esophagitis index and pain index of patients with EGCG application were lower than conventional treatment (5.15 ± 2.75 vs 7.17 ± 1.99, P = 0.030; 8.62 ± 5.04 vs 15.42 ± 5.04, P < 0.001).

Conclusion

The study indicates EGCG may alleviate some esophagitis-related indexes in SCLC patients exposed to ionizing radiation without reducing survival. However, this conclusion should be confirmed by further studies with large sample size.

A systematic review and meta-analysis of treatment-related toxicities of curative and palliative radiation therapy in non-small cell lung cancer

Treatment-related toxicity is an important component in non-small cell lung cancer (NSCLC) management decision-making. Our aim was to evaluate and compare the toxicity rates of curative and palliative radiotherapy with and without chemotherapy. This meta-analysis provides better quantitative estimates of the toxicities compared to individual trials. A systematic review of randomised trials with > 50 unresectable NSCLC patients, treated with curative or palliative conventional radiotherapy (RT) with or without chemotherapy. Data was extracted for oesophagitis, pneumonitis, cardiac events, pulmonary fibrosis, myelopathy and neutropenia by any grade, grade ≥ 3 and treatment-related deaths. Mantel–Haenszel fixed-effect method was used to obtain pooled risk ratio. Forty-nine trials with 8609 evaluable patients were included. There was significantly less grade ≥ 3 acute oesophagitis (6.4 vs 22.2%, p < 0.0001) and any grade oesophagitis (70.4 vs 79.0%, p = 0.04) for sequential CRT compared to concurrent CRT, with no difference in pneumonitis (grade ≥ 3 or any grade), neutropenia (grade ≥ 3), cardiac events (grade ≥ 3) or treatment-related deaths. Although the rate of toxicity increased with intensification of treatment with RT, the only significant difference between treatment regimens was the rate of oesophagitis between the use of concurrent and sequential CRT. This can aid clinicians in radiotherapy decision making for NSCLC.

Risk factors for esophagitis after hypofractionated palliative (chemo) radiotherapy for non-small cell lung cancer

Introduction

Esophagitis influences quality of life and might cause treatment interruption and hospitalization. Previous studies of risk factors focused on curative treatment for non-small cell lung cancer (NSCLC), which often involves concomitant chemoradiation (CRT). Given the uncertainty around extrapolation of dose constraints, we analyzed risk factors in patients treated with hypofractionated palliative regimens.

Patients and methods

A retrospective review of 106 patients treated with palliative radiotherapy or CRT between 2009 and 2017 was performed. Inclusion criteria: prescribed total dose 30–54 Gy, dose per fraction 2.5–4 Gy, esophageal dose > 1 Gy. Uni- and multivariate analyses were performed in 97 eligible patients to identify predictive factors for acute esophagitis grade ≥ 1 (CTCAE 5.0).

Results

Forty percent of patients were treated with 15 fractions of 2.8 Gy (42 Gy) and 28% also received chemotherapy according to the CONRAD study regimen (induction and concomitant Carboplatin/Vinorelbine) published by the Norwegian Lung Cancer Group. Thirty-four percent were treated with 10 fractions of 3 Gy. Stage IV NSCLC was present in 47%. Esophagus Dmax was 39 Gy (population median) and Dmean 15 Gy. Overall 31% of patients developed esophagitis (26% grade 2–3, no grade 4–5). Several dosimetric parameters correlated with the risk of esophagitis (Dmax, Dmean, D5cc, V20, V30, V35, V40). Dmax outperformed other dosimetric variables in multivariate analysis. Furthermore, concomitant chemotherapy significantly increased the risk of esophagitis, while oral steroid medication reduced it. In patients with Dmax ≥40 Gy a reduced Dmean (≤20 Gy) was beneficial.

Conclusion

In order to reduce esophagitis after hypofractionated palliative treatment lower doses than those recommended in curative NSCLC settings are preferable. Besides esophageal dose, CRT is the main risk factor for esophagitis. Additional work is needed to confirm that steroids are able to modify the risk (or to rule out confounding effects of baseline variables not included in our database).

A prospective, three-arm, randomized trial of EGCG for preventing radiation-induced esophagitis in lung cancer patients receiving radiotherapy

BACKGROUND AND PURPOSE

This trial investigated whether epigallocatechin-3-gallate (EGCG), a radioprotector, could be effective in the prevention and treatment of acute radiation-induced esophagitis (ARIE).

METHODS AND MATERIALS

This is a phase II study of EGCG combined with chemoradiation in unresectable stage III non-small-cell lung cancer or limited stage small cell lung cancer. Patients were randomized into a prophylactic EGCG group (arm A), a therapeutic EGCG group after the occurrence of esophagitis (arm B) or conventional therapy group (arm C). Esophagitis grades, pain and dysphagia scores were recorded weekly. Adjusted esophagitis index (AEI), pain index (API) and dysphagia index (ADI) were calculated to reflect changes in esophagitis grade, pain score and dysphagia score throughout treatment.

RESULTS

A total of 83 patients were eligible for toxicity analysis (arm A vs arm B vs arm C: N = 28:27:28). There was no significant difference in the baseline characteristics among three arms of the patients. The difference in the maximum esophagitis grade among three groups was statistically significant (P = 0.004). The maximum ARIE for patients with EGCG was significantly lower than for those with conventional therapy. The mean AEI of arm A was lower than that of arm B, while the mean AEI of arm C was the highest (arm A vs arm B, P = 0.028; arm B vs arm C, P = 0.002). Furthermore, API and ADI were significantly lower in patients receiving EGCG than in conventionally treated patients.

CONCLUSION

The application of EGCG could effectively alleviate acute radiation esophagitis in advanced lung cancer without obvious side effects. Prophylactic application of EGCG had a slight advantage over therapeutic use in treatment of acute esophagitis.

Clinical, dosimetric, and position factors for radiation-induced acute esophagitis in intensity-modulated (chemo)radiotherapy for locally advanced non-small-cell lung cancer

Purpose

The purpose of this study was to estimate the relation between acute esophagitis (AE) and clinical, dosimetric, and position factors in patients with locally advanced non-small-cell lung cancer (NSCLC) receiving intensity-modulated (chemo)radiotherapy.

Materials and methods

A retrospective cohort analysis was performed to identify factors associated with Common Toxicity Criteria for Adverse Events grade 2 or worse AE (AE2+). A multivariable model was established including patient- and treatment-related variables and esophageal dose–volume histogram parameters. The esophagus was divided according to physiological anatomy, and logistic regression was used to analyze the position parameter for its correlation with AE2+.

Results

The incidence of AE2+ was 27.5%. All models included gender, concurrent chemo-radiotherapy (CCRT), position parameter, and one of the dosimetric variables. The model with mean dose showed the best goodness of fit. Gender (OR=2.47, P=0.014), CCRT (OR=3.67, P=0.015), mean dose (OR=1.33, P<0.001), and maximum radiation position (OR=1.65, P=0.016) were significantly related to AE2+.

Conclusion

Gender, concurrent chemotherapy, maximum radiation position, and mean dose were independent risk factors for AE2+. The upper part of the esophagus showed a higher sensitivity to radiation toxicity.

DBCG hypo trial validation of radiotherapy parameters from a national data bank versus manual reporting

INTRODUCTION

The current study evaluates the data quality achievable using a national data bank for reporting radiotherapy parameters relative to the classical manual reporting method of selected parameters.

METHODS

The data comparison is based on 1522 Danish patients of the DBCG hypo trial with data stored in the Danish national radiotherapy data bank. In line with standard DBCG trial practice selected parameters were also reported manually to the DBCG database. Categorical variables are compared using contingency tables, and comparison of continuous parameters is presented in scatter plots.

RESULTS

For categorical variables 25 differences between the data bank and manual values were located. Of these 23 were related to mistakes in the manual reported value whilst the remaining two were a wrong classification in the data bank. The wrong classification in the data bank was related to lack of dose information, since the two patients had been treated with an electron boost based on a manual calculation, thus data was not exported to the data bank, and this was not detected prior to comparison with the manual data. For a few database fields in the manual data an ambiguity of the parameter definition of the specific field is seen in the data. This was not the case for the data bank, which extract all data consistently.

CONCLUSIONS

In terms of data quality the data bank is superior to manually reported values. However, there is a need to allocate resources for checking the validity of the available data as well as ensuring that all relevant data is present. The data bank contains more detailed information, and thus facilitates research related to the actual dose distribution in the patients.

Subjective Global Assessment (SGA) Score Could Be a Predictive Factor for Radiation Pneumonitis in Lung Cancer Patients With Normal Pulmonary Function Treated by Intensity-Modulated Radiation Therapy and Concurrent Chemotherapy

INTRODUCTION

To investigate the relationship between malnutrition and the severity of radiation pneumonitis (RP) in patients with lung cancer with normal baseline pulmonary function and lungs' V20 < 35% treated by intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy.

MATERIALS AND METHODS

A total of 150 patients with lung cancer who received definitive IMRT (≥ 60 Gy) and concurrent chemotherapy were enrolled. In the condition of normal baseline pulmonary function and strict constraints of the irradiation dose to normal lung tissues, we recorded Eastern Cooperative Oncology Group score; concurrent chemotherapy; clinical stage; the level of albumin (ALB), hemoglobin, and C-reactive protein; Subjective Global Assessment (SGA) scores; radiation esophagitis grade; V20 of lungs; and mean lung dose. These factors were correlated with RP using univariate and multivariate regression analyses.

RESULTS

Of 150 patients, 12 patients (8.0%) developed Grade 3 to 5 RP, 37 (24.6%) patients developed grade 3 to 5 esophageal toxicity. In univariate analysis, ALB level (P = .002), radiation esophagitis (P < .001), and SGA score (P < .001) were significantly associated with RP. Multivariate analysis revealed that SGA (P < .001) was the independent predictor of RP.

CONCLUSIONS

SGA could be a predictor for RP in patients with lung cancer treated with definitive IMRT and concurrent chemotherapy.

Is there a different dose-effect relation between the primary tumor and involved lymph nodes in locally advanced non-small-cell lung cancer? A hypothesis-generating study

PURPOSE

It is unknown whether the dose-response relation of the primary tumor in NSCLC is different from that of the involved lymph nodes (LN). As the recurrence rate is much lower in LN, we hypothesized that LN need a lower radiation dose.

MATERIAL AND METHODS

A retrospective analysis of prospective data was performed on patients with locally advanced NSCLC treated with (chemo)radiotherapy. The impact of EQD_2,T prescription dose on relapse was analyzed using Cox regression modeling correcting for baseline diameter.

RESULTS

From 2006 to 2010, 75 consecutive patients were included, resulting in 142 lymph nodes in the analysis. Any relapse (locoregional/distant) occurred in 58 patients (77%), while involved nodal relapse (INR) was observed in 13% of patients. No dose-response relationship was observed for INR (p = .22). Primary tumor progression was seen in 40% of patients together with a significant dose-response relationship (p = .033). Baseline nodal diameter was not associated with INR (p = .76), while primary tumor diameter was a highly significant predictor for relapse (p = .0031).

CONCLUSIONS

These results suggest that LN control may be achieved at lower radiation doses than needed for the primary tumor. Prospective dose de-escalation studies on LN are warranted to decrease the incidence of severe esophagitis without compromising local tumor control.

Stage III Non-Small Cell Lung Cancer in the elderly: Patient characteristics predictive for tolerance and survival of chemoradiation in daily clinical practice

BACKGROUND

In unselected elderly with stage III Non-Small Cell Lung Cancer (NSCLC), evidence is scarce regarding motives and effects of treatment modalities.

METHODS

Hospital-based multicenter retrospective study including unresectable stage III NSCLC patients aged ⩾70 and diagnosed between 2009 and 2013 (N=216). Treatment motives and tolerance (no unplanned hospitalizations and completion of treatment), and survival were derived from medical records and the Netherlands Cancer Registry.

RESULTS

Patients received concurrent chemoradiation (cCHRT, 33%), sequential chemoradiation (sCHRT, 24%), radical radiotherapy (RT, 16%) or no curative treatment (27%). Comorbidity, performance status (58%) and patient refusal (15%) were the most common motives for omitting cCHRT. Treatment tolerance for cCHRT and sCHRT was worse in case of severe comorbidity (OR 6.2 (95%CI 1.6-24) and OR 6.4 (95%CI 1.8-22), respectively). One-year survival was 57%, 50%, 49% and 26% for cCHRT, sCHRT, RT and no curative treatment, respectively. Compared to cCHRT, survival was worse for no curative treatment (P=0.000), but not significantly worse for sCHRT and RT (P=0.38).

CONCLUSION

Although relatively fit elderly were assigned to cCHRT, treatment tolerance was worse, especially for those with severe comorbidity. Survival seemed not significantly better as compared to sCHRT or RT. Prospective studies in this vital and understudied area are needed.

Oesophagus side effects related to the treatment of oesophageal cancer or radiotherapy of other thoracic malignancies

The oesophagus as a serial organ located in the central chest is frequent subject to "incidental" dose application in radiotherapy for several thoracic malignancies including oesophageal cancer itself. Especially due to the radiosensitive mucosa severe radiotherapy induced sequelae can occur, acute oesophagitis and strictures as late toxicity being the most frequent side-effects. In this review we focus on oesophageal side effects derived from treatment of gastrointestinal cancer and secondly provide an overview on oesophageal toxicity from conventional and stereotactic fractionated radiotherapy to the thoracic area in general. Available data on pathogenesis, frequency, onset, and severity of oesophageal side effects are summarized. Whereas for conventional radiotherapy the associations of applied doses to certain volumes of the oesophagus are well described, the tolerance dose to the mediastinal structures for hypofractionated therapy is unknown. The review provides available attempts to predict the risk of oesophageal side effects from dosimetric parameters of SBRT.