Radical radiotherapy for medically inoperable non-small cell lung cancer in clinical stage I: a retrospective analysis of 149 patients

Surgery or radiotherapy improves survival in elderly patients with early non-small cell lung cancer: A population-based analysis

OBJECTIVE

There is a lack of evidence to support a consensus on whether surgery or radiotherapy is optimal for elderly or very elderly patients with early-stage non-small cell lung cancer (NSCLC). We aimed to assess the impact of surgery or radiotherapy on survival in elderly (≥70 years) and very elderly (≥80 years) patients with early-stage NSCLC.

METHODS

Patients aged ≥70 years diagnosed with early-stage NSCLC between January 1, 1975, and December 31, 2018, were identified in the Surveillance, Epidemiology, and End Results (SEER) database. Overall survival (OS) and cancer-specific survival (CSS) were assessed based on surgery, radiotherapy, and no-treatment groups.

RESULTS

Data for 15,224 NSCLC patients aged ≥70 years were collected, which consisted of 6949 (45.6%) patients who underwent surgery alone, 5014 (32.9%) who underwent radiotherapy alone, and 3261 (21.5%) who received no treatment. Surgery significantly improved patient survival compared with no treatment (MST: 74 months vs. 7 months, HR: 0.201, 95% CI: 0.186-0.217, P < 0.001), as did radiotherapy (MST: 28 months vs. 7 months, HR: 0.440; 95% CI: 0.413-0.469, P < 0.001). Surgery also resulted in improved survival compared with radiotherapy (74 months vs. 28 months, HR: 0.455; 95% CI: 0.430-0.482, P < 0.001). A similar conclusion was made from the analysis of CSS. A subgroup analysis further confirmed the survival benefits.

CONCLUSIONS

The results of this large-scale retrospective study indicate that both surgery and radiotherapy significantly enhance survival outcomes in patients aged ≥70 or ≥80 years with early-stage NSCLC. The survival benefits of surgery were particularly notable.

Efficacy and tolerance of thoracic radiotherapy in the oldest old patients: A case series

BACKGROUND

There are only scarce data on the management of nonagenarians with lung cancer, and more particularly on the place of radiation therapy. The aim of the present study was to retrospectively evaluate the efficacy and tolerance of radiotherapy (RT) in nonagenarians with thoracic cancer.

PATIENTS AND METHODS

Records from RT departments from four institutions were reviewed to identify patients 90 years old of age and older undergoing RT over the past decade for thoracic cancer and more particularly lung cancer. Tumors' characteristics as well as treatment specificities and its intent were examined.

RESULTS

Thirteen patients receiving RT courses were identified, mean age 91.9 years. Treatment was given with curative and palliative intent in 15.4% and 84.6%, respectively. The median total prescribed dose was 30 Gy (4-70). The median number of fractions was equal to 10 (1-35). The median dose received for each fraction was 3 Gy (1.7-7). RT could not be completed in 2 patients (15.4%). At last follow-up, 11 patients (76.9%) were deceased, cancer being the cause of death for 90% of them. Most toxicities were grade 1 or 2. Two patients (15.4% of cases) have developed grade 2 toxicity during treatment. One patient (7.7% of cases) experienced an acute grade 3 toxicity.

CONCLUSION

The study shows that RT for thoracic cancer is feasible in nonagenarians. Although the definitive benefit of RT could not be addressed here, hypofractionated therapy allowed a certain measure of control with acceptable side effects.

Final report of survival and late toxicities in the Phase I study of stereotactic body radiation therapy for peripheral T2N0M0 non-small cell lung cancer (JCOG0702)

Purpose

A dose escalation study to determine the recommended dose with stereotactic body radiation therapy (SBRT) for peripheral T2N0M0 non-small cell carcinomas (JCOG0702) was conducted. The purpose of this paper is to report the survival and the late toxicities of JCOG0702.

Materials and methods

The continual reassessment method was used to determine the dose level that patients should be assigned to and to estimate the maximum tolerated dose. The starting dose was 40 Gy in four fractions at D₉₅ of PTV.

Results

Twenty-eight patients were enrolled. Ten patients were treated with 40 Gy at D₉₅ of PTV, four patients with 45 Gy, eight patients with 50 Gy, one patient with 55 Gy and five patients with 60 Gy. Ten patients were alive at the last follow-up. Overall survival (OS) for all patients was 67.9% (95% CI 47.3–81.8%) at 3 years and 40.8% (95% CI 22.4–58.5%) at 5 years. No Grade 3 or higher toxicity was observed after 181 days from the beginning of the SBRT. Compared to the toxicities up to 180 days, chest wall related toxicities were more frequent after 181 days.

Conclusions

The 5-year OS of 40.8% indicates the possibility that SBRT for peripheral T2N0M0 non-small cell lung cancer is superior to conventional radiotherapy. The effect of the SBRT dose escalation on OS is unclear and further studies are warranted.

Impact of Interstitial Lung Disease Classification on the Development of Acute Exacerbation of Interstitial Lung Disease and Prognosis in Patients with Stage III Non-Small-Cell Lung Cancer and Interstitial Lung Disease Treated With Chemoradiotherapy

Introduction: Data on the efficacy and risk of curative-intent chemoradiotherapy in patients with inoperable stage III non-small-cell lung cancer (NSCLC) and interstitial lung disease (ILD) are limited. The aim of this study was to explore the impact of ILD classification on acute exacerbation (AE) of ILD and prognosis in patients with stage III NSCLC and ILD treated with chemoradiotherapy.

Materials and methods: We retrospectively reviewed the medical records of patients with stage III NSCLC and ILD treated with curative-intent chemoradiotherapy as the first-line treatment at the Shizuoka Cancer Center between June 2009 and May 2014.

Results: Of 37 patients, 17 (46%) developed AE of ILD worse than grade 3 within 1 year after the last irradiation. In univariate analysis, the incidence rate of AE of ILD was lower in patients with a non-usual interstitial pneumonia (UIP) pattern than in those with a UIP pattern. Multivariate analysis showed that ILD classification was significantly associated with the incidence of AE of ILD. The median overall survival (OS) durations in patients with a non-UIP pattern and a UIP pattern were 16.5 and 9.3 months, respectively. In univariate analysis, patients with a non-UIP pattern showed better survival. Multivariate analysis showed that ILD classification was a significant independent prognostic factor.

Conclusion: The incidence of AE of ILD was high in patients with stage III NSCLC and ILD treated with chemoradiotherapy as the first-line treatment. However, diagnosis of a non-UIP pattern could predict lower risk of AE of ILD and longer OS durations.

Stereotactic body radiotherapy for lung cancer patients with idiopathic interstitial pneumonias

PURPOSE

To compare toxicity and survival after stereotactic body radiotherapy (SBRT) between lung cancer patients with or without idiopathic interstitial pneumonias (IIPs), and to investigate the potential value of SBRT for the patients.

METHODS

Among lung cancer patients receiving SBRT between 2005 and 2016, we evaluated those treated with a total dose of 40-60Gy in five fractions with curative intent who either were staged as cT1-4N0M0 or experienced postoperative isolated local recurrence. We analyzed the incidence of radiation pneumonitis (RP) in all patients and local recurrence and overall survival (OS) in T1a-2a patients.

RESULTS

A total of 508 patients were eligible, including 42 with IIPs. The median follow-up was 32.3 (6.0-120.9) months. Significantly more patients with IIPs had grade ≥3RP than did those without IIPs (12% vs. 3%, p=0.009). The 2-year local recurrence rate was low in both groups (3.4% vs. 5.6%, p=0.38). The 2-year OS rate was significantly lower in the patients with IIPs (42.2% vs. 80.9%, p<0.001), although death from lung cancer was comparable (p=0.74).

CONCLUSION

SBRT achieved excellent local control with acceptable pulmonary toxicity in lung cancer patients with IIPs. SBRT can be a reasonable option for early lung cancer patients with IIPs.

Clinical Outcomes and Prognostic Factors of High-Dose Proton Beam Therapy for Peripheral Stage I Non-Small-Cell Lung Cancer

BACKGROUND

The efficacy, toxicity, and prognostic factors of high-dose proton beam therapy (PBT) for peripheral stage I non-small-cell lung cancer were assessed in this retrospective study.

MATERIALS AND METHODS

Fifty patients with peripheral stage I non-small-cell lung cancer, two of whom had heterochronic multiple lung cancers, underwent high-dose PBT between January 2009 and September 2014. The relative biological effectiveness of the proton beam was defined as 1.1. The beam energy and spread-out Bragg peak were fine-tuned for the 90% isodose volume of the prescribed dosage to encompass the planning target volume. The cumulative survival curves were calculated using the Kaplan-Meier method. Treatment toxicities were evaluated using version 4 of the Common Terminology Criteria for Adverse Events, version 4.

RESULTS

The study included 35 males and 15 females with a median age of 72.5 years. The median follow-up period was 22.8 months. The clinical stage was IA in 44 (85%) and IB in eight (15%) tumors. The total dose of PBT was 66 GyE in 10 fractions in all tumors. Three-year overall survival rate among all patients was 87.9% (95% confidence interval [CI], 94.8%-73.2%). Forty-five patients were alive, and 5 were dead. Three-year local control and progression-free survival rates were 95.7% (95% CI, 98.9%-83.8%) and 76.3% (95% CI, 86.9%-59.3%), respectively. Only one patient experienced Grade 2 pneumonitis.

CONCLUSION

High-dose PBT may be an effective and safe treatment option for patients with stage I non-small-cell lung cancer.

A design of a DICOM-RT-based tool box for nonrigid 4D dose calculation

The study was aimed to introduce a design of a DICOM-RT-based tool box to facilitate 4D dose calculation based on deformable voxel-dose registration. The computational structure and the calculation algorithm of the tool box were explicitly discussed in the study. The tool box was written in MATLAB in conjunction with CERR. It consists of five main functions which allow a) importation of DICOM-RT-based 3D dose plan, b) deformable image registration, c) tracking voxel doses along breathing cycle, d) presentation of temporal dose distribution at different time phase, and e) derivation of 4D dose. The efficacy of using the tool box for clinical application had been verified with nine clinical cases on retrospective-study basis. The logistic and the robustness of the tool box were tested with 27 applications and the results were shown successful with no computational errors encountered. In the study, the accumulated dose coverage as a function of planning CT taken at end-inhale, end-exhale, and mean tumor position were assessed. The results indicated that the majority of the cases (67%) achieved maximum target coverage, while the planning CT was taken at the temporal mean tumor position and 56% at the end-exhale position. The comparable results to the literature imply that the studied tool box can be reliable for 4D dose calculation. The authors suggest that, with proper application, 4D dose calculation using deformable registration can provide better dose evaluation for treatment with moving target.

WITHDRAWN: Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable)

The authors are unable to update this review. A new team is being sought to update it.

The editorial group responsible for this previously published document have withdrawn it from publication.

Stereotactic radiotherapy for pulmonary metastases

The most common treatment of pulmonary metastasis for solid tumors employs systemic chemotherapy, hormonal therapy, or biologic agents. Some series have suggested that aggressive surgical resection of pulmonary metastasis may improve patient outcomes in terms of quality of life and overall survival. Recently, data from clinical trials and retrospective series support the use of aggressive local control with high conformal dose radiotherapy (stereotactic body radiation therapy) in patients with limited metastases or oligometastases. Further evidence suggests that these patients represent a distinct clinical and biological class of patients. This review focuses on the role of ablative doses of radiotherapy in the treatment of pulmonary metastases. Specifically we discuss the rationale, treatment delivery, and local control that have led to the ongoing randomized clinical trials attempting to demonstrate a benefit over the current palliative standard of care.

Safety and efficacy of thoracoscopic wedge resection for elderly high-risk patients with stage I peripheral non-small-cell lung cancer

Background

Elderly patients with severe cardiopulmonary and other system dysfunctions are unable to tolerate pulmonary lobectomy. This study aimed to evaluate the risk and efficacy of wedge resection under video-assisted thoracoscopic surgery (VATS) on elderly high-risk patients with stage I peripheral non-small-cell lung cancer (PNSCLC).

Methods

Elderly patients (≥70 years) with suspected PNSCLC were divided into high-risk group and conventional risk group. The high-risk patients confirmed in stage I by the examination of positron emission tomography computed tomography (PET-CT) and the postoperative patients in stage I PNSCLC with negative incisal margin were treated with VATS wedge resection. The conventional risk patients were treated with VATS radical resection and systematic lymphadenectomy. The clinical and pathological data were recorded. The total survival, tumor-free survival, recurrence time and style of patients were followed up.

Results

The operative time and blood loss of the VATS wedge resection group (69.4 ± 15.5 min, 52.1 ± 11.2 ml) were significantly less than those of the VATS radical resection group (128 ± 35.5 min, 217.9 ± 87.1 ml). Neither groups had postoperative death. The overall and tumor-free survival rate of the VATS wedge resection group within three years were 66.7% and 60.0%, and those of the VATS radical resection group were 93.8% and 94.1%, without significant difference (P > 0.05). The recurrence rates of the VATS wedge resection group and VATS radical resection group were 14.3% and 3.0%, without significant difference (P > 0.05).

Conclusion

It is safe, minimally invasive and meaningful to perform VATS wedge resection on the elderly high-risk patients with stage I PNSCLC.

Outcome of the radical hypofractioned radiotherapy treatment in patients with stage I and II of non-small cell lung cancer

Introduction: Surgery is the treatment of choice in stage I and II non-small-cell lung cancer (NSCLC). In the management of patients who are medically unfit to tolerate surgical intervention or who refuse surgery, radiotherapy is an acceptable alternative. We have performed a retrospective analysis of the effectiveness of radical radiotherapy in patients with early stage NSCLC treated over a period of 4 years.

Methods: Thirty nine patients treated with radiotherapy of radical intent were identified. All patients received hypofractionated radiotherapy with a total dose of 55Gy in 20 fractions.

Results: The median survival of all cases was 29 months. The one and two-year survival was respectively 61 % and 41%. The median survival of patients ≥75 years was 28 months, and age was the only prognostic factor identified in this analysis that affected survival.

Conclusions: The presented survival results are consistent with those from other series published in the literature. At present, radical radiotherapy is often offered to patients with medically inoperable stage I and II NSCLC or those who decline surgery. But there is emerging evidence that some new techniques like stereotactic radiotherapy could be also used in the operable, early stage NSCLC.

Particle radiotherapy with carbon ion beams

Carbon ion radiotherapy offers superior dose conformity in the treatment of deep-seated malignant tumours compared with conventional X-ray therapy. In addition, carbon ion beams have a higher relative biological effectiveness compared with protons or X-ray beams. The algorithm of treatment planning and beam delivery system is tailored to the individual parameters of the patient. The present article reviews the available literatures for various disease sites including the head and neck, skull base, lung, liver, prostate, bone and soft tissues and pelvic recurrence of rectal cancer as well as physical and biological properties.

Optimal radiotherapy for non-small-cell lung cancer: current progress and future challenges

Radiotherapy has a key role in treating lung cancer. Advances in physics and computer technology have improved radiation delivery systems. With innovations in the radiation therapy of non-small-cell lung cancer (NSCLC), new strategies have emerged, such as intensity-modulated radiation therapy, stereotactic body radiation therapy, and particle therapy. Compared with previous methods, these newer technologies can deliver even higher doses precisely to the tumor while minimizing doses to normal tissues, which should lead to better tumor control with less toxicity. In patients with stage I NSCLC, stereotactic body radiation therapy is highly effective and may achieve local control and survival equivalent to that achieved with surgery. In patients with stage III NSCLC, dose escalation has been investigated using three-dimensional conformal radiation therapy, intensity-modulated radiation therapy, and particle therapy. The results from ongoing randomized trials on both patient populations are awaited. It is important to generate new hypotheses and to explore newer radiotherapy approaches to overcome NSCLC.

Stereotactic body radiation therapy and 3-dimensional conformal radiotherapy for stage I non-small cell lung cancer: A pooled analysis of biological equivalent dose and local control

PURPOSE

To determine the relationship between tumor control probability (TCP) and biological effective dose (BED) for radiation therapy in medically inoperable stage I non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

Forty-two studies on 3-dimensional conformal radiation therapy (3D-CRT) and SBRT for stage I NSCLC were reviewed for tumor control (TC), defined as crude local control ≥ 2 years, as a function of BED. For each dose-fractionation schedule, BED was calculated at isocenter using the linear quadratic (LQ) and universal survival curve (USC) models. A scatter plot of TC versus BED was generated and fitted to the standard TCP equation for both models.

RESULTS

A total of 2696 patients were included in this study (SBRT: 1640; 3D-CRT: 1056). Daily fraction size was 1.2-4 Gy (total dose: 48-102.9) with 3D-CRT and 6-26 (total dose: 20-66) with SBRT. Median BED was 118.6 Gy (range, 68.5-320.3) and 95.6 Gy (range, 46.1-178.1) for the LQ and USC models, respectively. According to the LQ model, BED to achieve 50% TC (TCD50) was 61 Gy (95% confidence interval, 50.2-71.1). TCP as a function of BED was sigmoidal, with TCP ≥ 90% achieved with BED ≥ 159 Gy and 124 Gy for the LQ and USC models, respectively.

CONCLUSIONS

Dose-escalation beyond a BED 159 by LQ model likely translates into clinically insignificant gain in TCP but may result in clinically significant toxicity. When delivered with SBRT, BED of 159 Gy corresponds to a total dose of 53 Gy in 3 fractions at the isocenter.

Effect of radiotherapy planning complexity on survival of elderly patients with unresected localized lung cancer

PURPOSE

To evaluate whether complex radiotherapy (RT) planning was associated with improved outcomes in a cohort of elderly patients with unresected Stage I-II non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

Using the Surveillance, Epidemiology, and End Results registry linked to Medicare claims, we identified 1998 patients aged >65 years with histologically confirmed, unresected stage I-II NSCLC. Patients were classified into an intermediate or complex RT planning group using Medicare physician codes. To address potential selection bias, we used propensity score modeling. Survival of patients who received intermediate and complex simulation was compared using Cox regression models adjusting for propensity scores and in a stratified and matched analysis according to propensity scores.

RESULTS

Overall, 25% of patients received complex RT planning. Complex RT planning was associated with better overall (hazard ratio 0.84; 95% confidence interval, 0.75-0.95) and lung cancer-specific (hazard ratio 0.81; 95% confidence interval, 0.71-0.93) survival after controlling for propensity scores. Similarly, stratified and matched analyses showed better overall and lung cancer-specific survival of patients treated with complex RT planning.

CONCLUSIONS

The use of complex RT planning is associated with improved survival among elderly patients with unresected Stage I-II NSCLC. These findings should be validated in prospective randomized controlled trials.

[Radiotherapy of lung cancer: Any room left for elective mediastinal irradiation in 2011?]

Traditionally, the target volumes of curative-intent radiotherapy for non-small cell lung cancer include all uninvolved mediastinal nodes. However, an improvement in tumour control requires an increase of the total dose to the macroscopic target volume. This is only achievable if the irradiation of the organs at risk is reduced, i.e. elective irradiation of the mediastinum is omitted. The available data suggest that elective mediastinal irradiation may be safely omitted, provided that an adequate staging procedure, including FDG PET-CT, has been performed.

Lung cancer in octogenarians

BACKGROUND

Lung cancer has progressively become a disease of older people, with the median age at diagnosis now exceeding 70 years. Octogenarians represent a rapidly growing proportion of patients diagnosed with lung cancer and can present distinct challenges. Nevertheless, current literature that has set the evidence-based standards of care in this disease does not include significant numbers of patients older than 80 years.

METHODS

We have compiled and reviewed the available literature on the specific management and treatment of lung cancer in patients older than 80 years.

RESULTS

Retrospective series suggest that surgery is safe and effective in treating early-stage non-small cell lung cancer in selected patients older than 80 years. There is minimal data to support the use of adjuvant chemotherapy in this group. In addition, no data exist on the use of combined chemotherapy and radiotherapy for locally advanced disease. In advanced or metastatic disease, similar to younger elderly populations, single-agent chemotherapy is feasible and seems to offer benefit in terms of symptoms and outcomes. Small cell lung cancer in this population is not well characterized, but small studies suggest symptom improvement and prolongation of survival with the use of chemotherapy.

CONCLUSION

Based on retrospective series, octogenarians with lung cancer can derive benefit from many of the treatment modalities used for younger patients including surgery for early-stage disease and single-agent chemotherapy for advanced disease. More elderly specific trials are needed to better refine treatment decisions and improve the care of lung cancer in this group.

Hypofractionated radiotherapy for lung tumors with online cone beam CT guidance and active breathing control

Background

To study the set-up errors, PTV margin and toxicity of cone beam CT (CBCT) guided hypofractionated radiotherapy with active breathing control (ABC) for patients with non-small cell lung cancer (NSCLC) or metastatic tumors in lung.

Methods

32 tumors in 20 patients were treated. Based on the location of tumor, dose per fraction given to tumor was divided into three groups: 12 Gy, 8 Gy and 6 Gy. ABC is applied for every patient. During each treatment, patients receive CBCT scan for online set-up correction. The pre- and post-correction setup errors between fractions, the interfractional and intrafractional, set-up errors, PTV margin as well as toxicity are analyzed.

Results

The pre-correction systematic and random errors in the left-right (LR), superior-inferior (SI), anterior-posterior (AP) directions were 3.7 mm and 5.3 mm, 3.1 mm and 2.1 mm, 3.7 mm and 2.8 mm, respectively, while the post-correction residual errors were 0.6 mm and 0.8 mm, 0.8 mm and 0.8 mm, 1.2 mm and 1.3 mm, respectively. There was an obvious intrafractional shift of tumor position. The pre-correction PTV margin was 9.5 mm in LR, 14.1 mm in SI and 8.2 mm in AP direction. After CBCT guided online correction, the PTV margin was markedly reduced in all three directions. The post-correction margins ranged 1.5 to 2.1 mm. The treatment was well tolerated by patients, of whom there were 4 (20%) grade1-2 acute pneumonitis, 3 (15%) grade1 acute esophagitis, 2 (10%) grade1 late pneumonitis and 1 (5%) grade 1 late esophagitis.

Conclusion

The positioning errors for lung SBRT using ABC were significant. Online correction with CBCT image guidance should be applied to reduce setup errors and PTV margin, which may reduce radiotherapy toxicity of tissues when ABC was used.

Effectiveness of radiation therapy for elderly patients with unresected stage I and II non-small cell lung cancer

RATIONALE

Radiotherapy (RT) is considered the standard treatment for patients with stage I or II non-small lung cancer who are not surgical candidates because of comorbities or preferences against surgery.

OBJECTIVES

To compare the outcomes of patients treated with RT alone with those who were untreated to assess the effect of RT on survival.

METHODS

Using the Surveillance, Epidemiology and End Results (SEER) registry linked to Medicare files, we identified 6,065 unresected patients with histologically confirmed stage I and stage II non-small cell lung cancer, diagnosed between 1992 and 2002. We used propensity score methods and instrumental variable analysis to control for the possible effects of known as well as unmeasured confounders.

MEASUREMENTS AND MAIN RESULTS

Overall, 59% of patients received RT. The overall and lung cancer-specific survival of unresected patients treated with RT was significantly better compared with the untreated cases (P < 0.0001 for both comparisons). RT was associated with a 6-month improvement in median overall survival. Propensity score analyses showed that RT was associated with improved overall (hazard ratio, 0.74; 95% confidence interval, 0.70-0.78) and lung cancer-specific survival (hazard ratio, 0.73; 95% confidence interval, 0.69-0.78). Instrumental variable analysis also indicated improved outcomes among patients treated with RT.

CONCLUSIONS

RT improves survival of elderly patients with unresected stage I or II lung cancer. These results should be confirmed in prospective trials.

Stereotactic body radiation therapy for early stage non-small cell lung cancer: results of a prospective trial

Patients affected with early stage (IA-IB) non-small cell lung cancer (NSCLC), deemed medically inoperable, are usually treated by conventional 3D-CRT, with poor results in terms of local tumour control and survival. Hypofractionated stereotactic body radiation therapy (SBRT) appears to be a valid alternative option, with high rates of local control and promising survival rates according to recent reported series. We herein report the final results of a prospective phase II trial of SBRT in 62 stage I NSCLC patients, homogeneously treated with three fractions of 15Gy each, given every other day during a 1 week time, up to a total dose of 45Gy; dose was prescribed to the 80%-isodose encompassing planning target volume. Patients were immobilized in a dedicated stereotactic body frame; margins around gross tumour volume were 5mm in the axial plane and 10mm in the longitudinal direction. Median age was 73.7 years. A pathologic confirmation of NSCLC was obtained in 64.5% of patients. Forty-three patients had stage IA and 19 stage IB disease. The majority of patients did not experience any toxicity; mild skin reactions, fatigue, dyspnea/cough or transient thoracic pain were recorded in approximately 10% of patients. With a median follow-up time of 28 months, 2 patients experienced an isolated local relapse, 4 an isolated nodal relapse and 15 a systemic failure. At 3 years, local control rate was 87.8%, cancer-specific survival 72.5%, overall survival 57.1%, with 8 out of 20 non-cancer related deaths. In multivariate analysis, tumour volume was associated with a better outcome. In our series, SBRT was well tolerated and confirmed its efficacy, with local control and survival rates globally superior to those reported using conventional radiotherapy. A longer follow-up is needed in order to establish a correct comparison with surgical series, and to fully ascertain a potential negative impact of SBRT on comorbidities of such a fragile patients population.

Comparisons of dose-volume histograms for proton-beam versus 3-D conformal x-ray therapy in patients with stage I non-small cell lung cancer

PURPOSE

Dose-volume histograms (DVHs) were reviewed to determine if there is an advantage of the two modalities when treating patients with non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

24 stage I NSCLC patients who underwent proton-beam therapy (PBT) from June 2003 to May 2007 were included in this study. Based on the same clinical target volumes (CTVs), treatment planning was made to cover CTV within 90% isodose lines. Each patient was evaluated by two sets of DVHs, one for PBT and the other for three-dimensional conformal X-ray therapy (3D-CRT).

RESULTS

For all patients, the 95% isodose line covered 86.4% of the CTV for PBT, and 43.2% for 3D-CRT. PBT was associated with significantly lower mean doses to the ipsilateral lung, total lung, heart, esophagus, and spinal cord than 3D-CRT. PBT offered reduced radiation doses to the lung when evaluated in terms of percentage lung volumes receiving > or = 5 Gy (V(5)), > or = 10 Gy (V(10)), and > or = 20 Gy (V(20)) when compared to 3D-CRT.

CONCLUSION

PBT is advantageous over 3D-CRT in reducing doses to the lung, heart, esophagus, and spinal cord in treating stage I NSCLC.

Identifying patients with peripheral-type early non-small cell lung cancer (T1N0M0) for whom irradiation of the primary focus alone could lead to successful treatment

We investigated the indication of radiotherapy in operable patients with peripheral-type early non-small cell lung cancer (T1N0M0 (TNM staging in 1997)). The subjects comprised 396 patients with non-small cell lung cancer in whom the clinical stage was evaluated as IA. We examined age, gender, Brinkmann's index, histopathological type, the grade of histopathological differentiation, tumour diameter and the level of carcinoembryonic antigen as factors involved in lymph node metastasis. Lymph node metastasis was detected in 79 patients (20%). Factors such as the grade of histopathological differentiation and tumour diameter were involved in lymph node metastasis. In well-differentiated lesions, the probability of metastasis was <10% even when the tumour diameter exceeded 2 cm. However, the probability rapidly increased with tumour size in moderately and poorly differentiated lesions. Among the patients with peripheral-type early non-small cell lung cancer (T1N0M0), the risk of lymph node metastasis was low in those with well-differentiated carcinoma and those with moderately differentiated lesions measuring </=1.5 cm in diameter. The proportion of our patients fitting these criteria was approximately 30%. For these patients, stereotactic body radiotherapy and particle therapy may be indicated.

Hypofractionated stereotactic radiotherapy for medically inoperable stage I non-small cell lung cancer--report on clinical outcome and dose to critical organs

We report 20 cases using hypofractionation stereotactic radiotherapy in medically inoperable stage I non-small cell lung cancer with dose escalation of 45-54 Gy prescribed at 85 or 90% isodose level in 3-4 fractions. Two-year local control and cancer-specific survival were 94.7 and 77.6%, respectively, with minimal toxicity. Though, large fraction size can be safely given to peripheral lung tumors, normal tissue tolerance to hypofractionated radiotherapy to esophagus, trachea, main bronchi, aorta and heart remains unknown. Therefore we also reported the maximum point doses to these critical organs to contribute information to extend this technique to more centrally located lung tumors in future.

A phase II study on stereotactic body radiotherapy for stage I non-small cell lung cancer

BACKGROUND AND PURPOSE

The outcome of stage I non-small cell lung cancer (NSCLC) patients treated with conventional radiotherapy is inferior to that of patients treated surgically. We aimed to evaluate the clinical outcome of stereotactic body radiotherapy (SBRT) in the treatment of stage I NSCLC.

MATERIALS AND METHODS

We performed SBRT for 31 stage I NSCLC patients. Of these, 20 were medically inoperable, and 11 refused surgery. Nineteen tumours were T1-stage masses, and 12 tumours were T2. Median tumour size was 25 mm. SBRT was administered as 45 Gy/3 fractions; however, when the tumour was close to an organ at risk, 60 Gy/8 fractions were used. These doses were prescribed at the centre of the tumours.

RESULTS

The median duration of observation for all patients was 32 months (range, 4-87 months). In 9 of the 31 cases, local recurrence was observed. The 3-year local control rates of T1 and T2 tumours were 77.9% and 40.0%, respectively. The 3-year overall and cause-specific survival rates were 71.7% and 83.5%, respectively. Although the symptoms improved with medical treatment, 5 patients developed acute pulmonary toxicity > or =grade 2.

CONCLUSIONS

SBRT is safe and effective for stage I NSCLC patients. However, a more intensive treatment regimen should be considered for T2 tumours.

Image-guided radiotherapy via daily online cone-beam CT substantially reduces margin requirements for stereotactic lung radiotherapy

PURPOSE

To determine treatment accuracy and margins for stereotactic lung radiotherapy with and without cone-beam CT (CBCT) image guidance.

METHODS AND MATERIALS

Acquired for the study were 308 CBCT of 24 patients with solitary peripheral lung tumors treated with stereotactic radiotherapy. Patients were immobilized in a stereotactic body frame (SBF) or alpha-cradle and treated with image guidance using daily CBCT. Four (T1) or five (T2/metastatic) 12-Gy fractions were prescribed to the planning target volume (PTV) edge. The PTV margin was >or=5 mm depending on a pretreatment estimate of tumor excursion. Initial daily setup was according to SBF coordinates or tattoos for alpha-cradle cases. A CBCT was performed and registered to the planning CT using soft tissue registration of the target. The initial setup error/precorrection position, was recorded for the superior-inferior, anterior-posterior, and medial-lateral directions. The couch was adjusted to correct the tumor positional error. A second CBCT verified tumor position after correction. Patients were treated in the corrected position after the residual errors were <or=2 mm. A final CBCT after treatment assessed intrafraction tumor displacement.

RESULTS

The precorrection systematic (Sigma) and random errors (sigma) for the population ranged from 2-3 mm for SBF and 2-6 mm for alpha-cradle patients; postcorrection errors ranged from 0.4-1.0 mm. Calculated population margins were 9 to 13 mm (SBF) and 10-14 mm (cradle) precorrection, 1-2 mm (SBF), and 2-3 mm (cradle) postcorrection, and 2-4 mm (SBF) and 2-5 mm (cradle) posttreatment.

CONCLUSIONS

Setup for stereotactic lung radiotherapy using a SBF or alpha-cradle alone is suboptimal. CBCT image guidance significantly improves target positioning and substantially reduces required target margins and normal tissue irradiation.

Steep dose-response relationship for stage I non-small-cell lung cancer using hypofractionated high-dose irradiation by real-time tumor-tracking radiotherapy

PURPOSE

To investigate the clinical outcomes of patients with pathologically proven, peripherally located, Stage I non-small-cell lung cancer who had undergone stereotactic body radiotherapy using real-time tumor tracking radiotherapy during the developmental period.

METHODS AND MATERIALS

A total of 41 patients (25 with Stage T1 and 16 with Stage T2) were admitted to the study between February 2000 and June 2005. A 5-mm planning target volume margin was added to the clinical target volume determined with computed tomography at the end of the expiratory phase. The gating window ranged from +/-2 to 3 mm. The dose fractionation schedule was 40 or 48 Gy in four fractions within 1 week. The dose was prescribed at the center of the planning target volume, giving more than an 80% dose at the planning target volume periphery.

RESULTS

For 28 patients treated with 48 Gy in four fractions, the overall actuarial survival rate at 3 years was 82% for those with Stage IA and 32% for those with Stage IB. For patients treated with 40 Gy in four fractions within 1 week, the overall actuarial survival rate at 3 years was 50% for those with Stage IA and 0% for those with Stage IB. A significant difference was found in local control between those with Stage IB who received 40 Gy vs. 48 Gy (p = 0.0015) but not in those with Stage IA (p = 0.5811). No serious radiation morbidity was observed with either dose schedule.

CONCLUSION

The results of our study have shown that 48 Gy in four fractions within 1 week is a safe and effective treatment for peripherally located, Stage IA non-small-cell lung cancer. A steep dose-response curve between 40 and 48 Gy using a daily dose of 12 Gy delivered within 1 week was identified for Stage IB non-small-cell lung cancer in stereotactic body radiotherapy using real-time tumor tracking radiotherapy.

Radical Radiotherapy in Stage I Non-small Cell Lung Cancer (NSCLC) – Singapore National Cancer Centre Experience

Introduction: The aim of this study was to assess the outcome of radical treatment for stage I non-small cell lung cancer (NSCLC) with external beam radiation therapy. Materials and Methods: A retrospective series of 23 patients with stage I NSCLC treated radically with radiotherapy from September 1997 to December 2004 at the National Cancer Centre, Singapore. Eighteen patients had 3D conformal radiotherapy and 5 patients had 2D planning. The median radiation dose delivered was 55 Gy (range, 50 to 67.5 in 20 to 33 fractions). The estimated median BED10 was 63.9 Gy (range, 57.6 to 70.1). Complete response (CR) rates, overall survival and cause-specific survival rates were analysed for evaluation of treatment results. Local regional failure was defined as disease in the ipsilateral lung and entire mediastinum. Recurrence at the contralateral lung and other distal organs was defined as distant metastases. Survival data were calculated using the Kaplan-Meier method and tested for significance with log-rank statistics. Results: A total of 23 patients (16 males, 7 females) with a median age of 73 years (range, 45 to 88) were analysed. Six (26%) had stage IA and 17 (74%) had stage IB disease. Eleven patients refused surgery and 12 patients were medically inoperable. The median follow-up was 18.9 months (range, 6.2 to 117.4). The overall survival at 2 years and 3 years was 54.7% and 24.3% respectively. The overall cause-specific survival was 57.4% at 2 years and 25.6% at 3 years. Radiological CR was obtained in 6/23 patients (26%) and the median survival was 24.8 months as compared to 20 months in patients who attained partial response (PR) or unknown response (P = 0.24). The median survival for 12 patients who received a BED10 of ≥63.9Gy was not reached as compared to 20 months in 11 patients with BED10 of <63.9 Gy (P = 0.03). Sixteen patients died, 14 due to disease recurrence or progression and 2 of unrelated causes. Seven patients (29.2%) remained alive. The longest surviving patient had a follow-up time of 117.4 months. Four of these 7 patients were disease-free and 3 were alive with disease (2 with bone metastases and 1 with recurrence in the primary site). Conclusion: Our data are consistent with the reported literature for stage I NSCLC treated with radical radiotherapy. Patients who received a higher dose of radiation have a better outcome. The 3-year cause-specific survival of 25.6% is less than ideal and further investigations into dose escalation with modern radiotherapy techniques and perhaps the addition of chemotherapy or new targeted agents to radiation are warranted to improve the outcome. Key words: Dose fractionations, Stereotactic body radiotherapy (SBRT), Survival rates

Charged particle radiotherapy at the Hyogo Ion Beam Medical Center: Characteristics, technology and clinical results

The Hyogo Ion Beam Medical Center was constructed in 2001 as the world's first charged particle radiotherapy center where both proton and carbon-ion radiotherapy can be performed. From April 2001 to February 2007, more than 1,400 patients with a variety of cancers were treated. Most of the tumors except for prostate cancer were considered hard to cure with standard treatments such as surgery or conventional x-ray radiotherapy. The clinical results obtained so far are very encouraging, mainly due to the excellent dose localization to the tumor and strong cell killing effects of protons and carbon-ions. The good indications are localized tumors including skull base tumors, head and neck tumors, cancers of the lung, the liver, and the prostate, and bone and soft tissue sarcomas. Charged particle radiotherapy will significantly improve the quality of life of cancer patients and promote their speedy return to normal lives or work if it is used for early stage cancer.

A potential to reduce pulmonary toxicity: The use of perfusion SPECT with IMRT for functional lung avoidance in radiotherapy of non-small cell lung cancer

BACKGROUND AND PURPOSE

The study aimed to examine specific avoidance of functional lung (FL) defined by a single photon emission computerized tomography (SPECT) lung perfusion scan, using intensity modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3-DCRT) in patients with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Patients with NSCLC underwent planning computerized tomography (CT) and lung perfusion SPECT scan in the treatment position using fiducial markers to allow co-registration in the treatment planning system. Radiotherapy (RT) volumes were delineated on the CT scan. FL was defined using co-registered SPECT images. Two inverse coplanar RT plans were generated for each patient: 4-field 3-DCRT and 5-field step-and-shoot IMRT. 3-DCRT plans were created using automated AutoPlan optimisation software, and IMRT plans were generated employing Pinnacle(3) treatment planning system (Philips Radiation Oncology Systems). All plans were prescribed to 64 Gy in 32 fractions using data for the 6 MV beam from an Elekta linear accelerator. The objectives for both plans were to minimize the volume of FL irradiated to 20 Gy (fV(20)) and dose variation within the planning target volume (PTV). A spinal cord dose was constrained to 46 Gy. Volume of PTV receiving 90% of the prescribed dose (PTV(90)), fV(20), and functional mean lung dose (fMLD) were recorded. The PTV(90)/fV(20) ratio was used to account for variations in both measures, where a higher value represented a better plan.

RESULTS

Thirty-four RT plans of 17 patients with stage I-IIIB NSCLC suitable for radical RT were analysed. In 6 patients with stage I-II disease there was no improvement in PTV(90), fV(20), PTV/fV(20) ratio and fMLD using IMRT compared to 3-DCRT. In 11 patients with stage IIIA-B disease, the PTV was equally well covered with IMRT and 3-DCRT plans, with IMRT producing better PTV(90)/fV(20) ratio (mean ratio - 7.2 vs. 5.3, respectively, p=0.001) and reduced fMLD figures compared to 3-DCRT (mean value - 11.5 vs. 14.3 Gy, p=0.001). This was due to reduction in fV(20) while maintaining PTV coverage.

CONCLUSION

The use of IMRT compared to 3-DCRT improves the avoidance of FL defined by perfusion SPECT scan in selected patients with locally advanced NSCLC. If the dose to FL is shown to be the primary determinant of lung toxicity, IMRT would allow for effective dose escalation by specific avoidance of FL.