Standard-dose versus high-dose conformal radiotherapy with concurrent and consolidation carboplatin plus paclitaxel with or without cetuximab for patients with stage IIIA or IIIB non-small-cell lung cancer (RTOG 0617): a randomised, two-by-two factorial phase 3 study

Prediction for cardiac and pulmonary toxicity in a multicentric cohort of advanced stage NSCLC patients using sub-regions of the heart

Purpose

Follow-up investigations in locally advanced stage non-small cell lung cancer (NSCLC) patients treated with radiochemotherapy (RCHT) regularly focus around lung toxicity. However, Cardiac Adverse Events (CAE) can occur much earlier in patients than originally anticipated with serious repercussions for patient quality-of-life and survival.Therefore, here we investigated spatial dependencies of dose within the heart and their correlation with toxicity, with dosimetric parameters of sub-regions of the heart at the focus of this analysis.Additionally, we aimed to explore the connection between cardiac toxicity and pulmonary toxicity.

Methods

Patient treatment plans with dosimetric data for the lungs and the heart, as well as toxicity data for 502 NSCLC patients treated with either passively scattered proton therapy (PSPT), intensity modulated radiation therapy (IMRT), three-dimensional conformal radiation therapy (3DCRT) or volumetric arc therapy (VMAT) with or without chemotherapy was retrospectively retrieved from prospective clinical studies of three international centers. Cardiac toxicity data was not available for all patients. Data was randomly split into a training set (336) and validation set (166). Statistical analyses were performed using binomial logistic regression.

Results

In univariate modeling, the Mean Lung Dose (MLD) significantly predicted CAE grade ≥ 3 in the training-set (pMLD = 0.02, AUCtrain = 0.69), which was confirmed in validation (AUCval, = 0.77). No suitable candidates for the construction of multivariate models could be identified. Parameters of the heart and its subregions did not significantly predict CAE grade ≥ 3 in the investigated cohorts. No parameters were found to significantly predict CAE grade ≥ 2 or RP. Finally, no spatial dependency was found in the investigated toxicity data.

Conclusion

The pulmonary dosimetric parameter MLD successfully predicted CAE grade ≥ 3 in a cohort treated with either photons or protons. Cardiac dosimetric parameters as well as spatial parameters did not perform similarly. No parameters were found to significantly predict RP in the investigated cohorts.

Diagnosis and treatment of radiation induced pneumonitis in patients with lung cancer: An ESTRO clinical practice guideline

The incidence of radiation pneumonitis (RP) has decreased significantly compared to historical series, mainly due to improved radiotherapy techniques and patient selection. Nevertheless, some patients still develop RP. This guideline provides user-friendly flowcharts to address common clinical practice questions regarding RP. We summarize the current state of the art regarding the mechanisms, risk factors, diagnosis and treatment of RP. Dosimetric constraints to minimize the incidence of RP, as well as risk factors for developing RP, such as idiopathic pulmonary fibrosis (IPF) were identified. The combination of radiotherapy and medication as a risk factor for the development of RP was reviewed. RP remains a diagnosis of exclusion, but an algorithm for reaching the diagnosis has been proposed. Finally, practical approaches to the treatment of RP are outlined.

Randomized Evaluation of the PET-Adjusted IMRT for NSCLC Trial (REPAINT)

BACKGROUND

Standard radiation therapy (RT) for locally advanced nonsmall cell lung cancer (LA-NSCLC) employs a uniform dose of approximately 60 Gy. Recent trials demonstrated that RT dose escalation may not improve outcomes and may cause added toxicity. We previously performed a single-arm trial testing a personalized, risk-adapted, and deintensified RT strategy. We now report findings from a randomized trial testing this novel approach.

METHODS AND MATERIALS

Patients with LA-NSCLC with Eastern Cooperative Oncology Group performance status 0-2 were eligible for this trial. Metabolic tumor volume for each pulmonary tumor and involved lymph node was calculated using fludeoxyglucose PET. Participants were randomly assigned 1:1 to receive standard RT (60 Gy in 30 fractions delivered to pulmonary tumors and involved lymph nodes) versus dose-painted RT (55 Gy delivered to tumors and lymph nodes with metabolic volume exceeding 20 cm3 and 44-48 Gy to other lesions, all in 20 fractions). Concurrent chemotherapy and standard adjuvant therapy were given in both arms. The primary objective was to characterize patient-reported outcomes using Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events. Secondary objectives included comparing outcomes between study arms.

RESULTS

Fifty patients were enrolled. The most common grade 3 patient-reported adverse events within 90 days of RT completion were dysphagia (38%), fatigue (38%), cough (32%), and wheezing (28%). The median progression-free survival duration is 18 months, and the median overall survival duration is 42 months. Progression-free survival and overall survival rates are similar across study arms (logrank P = .562 and .765, respectively). There have been 3 cases of in-field disease progression, with 1 in the control arm and 2 in the dose-painted arm. Grade 3-4 lymphopenia was reduced with dose-painted RT (48% vs 81%, chi-square P = .012).

CONCLUSION

High-grade patient-reported toxicity in patients with LA-NSCLC who are treated with concurrent chemoradiotherapy is common. We found no evidence that risk-adapted RT de-escalation compromises clinical outcomes. Follow-up studies testing the ability of this approach to improve the safety profile of chemoradiotherapy are warranted.

Carbon Ion Radiation Therapy with Pencil Beam Scanning for Stage III Non-Small Cell Lung Cancer: Toxicity Profiles, Survival Outcomes, and Prognostic Indicators

PURPOSE

To evaluate the toxicities and survival outcomes associated with carbon ion radiation therapy (CIRT) using pencil beam scanning (PBS) technique and to assess the prognostic factors for patients with stage III non-small cell lung cancer (NSCLC) using a local effect model (LEM)-based biological dose calculation.

METHODS AND MATERIALS

This analysis included patients with stage III NSCLC (n = 181) who received CIRT between December 2016 and June 2023. CIRT was administered at a relative biological effectiveness-weighted dose of 77 Gy (range, 69-83.6 Gy) in 22 fractions (Fx) (range, 19-24 Fx). Most patients (96.1%) underwent systemic therapy before and/or after CIRT. Toxicities and survival outcomes were recorded, and statistical analyses conducted.

RESULTS

The median follow-up period was 18.2 months. Grade 1, 2, 3, and 4 acute toxicities were observed in 62.4%, 30.4%, 2.8%, and 0.6% of patients, respectively, with hematological toxicities accounting for all grade ≥ 3 acute toxicities. Grade 1, 2, 3, and 4 late toxicities occurred in 40.3%, 30.9%, 4.4%, and 1.7% of patients, respectively, with most grade ≥ 3 CIRT-induced late toxicities (72.7%) observed in patients receiving a CIRT dose ≥ 79.2 Gy. The median overall survival (OS) and progression-free survival (PFS) were 37.1 and 16.7 months, respectively. The 2-year locoregional control, OS, PFS, and distant metastasis-free survival rates were 66.1%, 64.2%, 40.3%, and 49.5%, respectively. Patients who received a CIRT dose ≤ 77 Gy had better OS (P = .047), but worse locoregional control compared with those who received higher doses (P = .026). Post-CIRT immunotherapy was an independent prognostic factor for improved OS, distant metastasis-free survival, and PFS (P = .002, P < .001, and P < .001, respectively).

CONCLUSIONS

CIRT with pencil beam scanning was effective for locally advanced NSCLC, resulting in acceptable toxicities and promising OS outcomes, particularly with doses of 69 to 77 Gy and post-CIRT immunotherapy.

Optimizing Dose Reduction to the Left Anterior Descending Artery in Patients With Locally Advanced Lung Cancer Treated With Definitive Radiation Therapy: A Feasibility Study of Coplanar Treatments Using Double-Stacked Multileaf Collimator

Purpose

Recent studies have shown that cardiac substructures and particularly left anterior descending artery (LAD) dose strongly correlates with the incidence of late adverse cardiac events. We evaluated whether greater cardiac and, importantly, LAD dose sparing could be achieved using a newly introduced closed bore (O-ring gantry) linac with a double-stacked multileaf collimator (Varian Ethos) relative to conventional linacs.

Methods and Materials

Twenty patients with locally advanced non-small cell lung cancer previously treated with definitive chemoradiotherapy were retrospectively evaluated. Volumetric modulated arc therapy plans were retrospectively generated for the Ethos system using optimization criteria focused on reducing overall heart and LAD doses (Heart_Ethos). Plans were also reoptimized using the same optimization criteria on a conventional C-arm linac (Heart_TB). Investigational plans were compared with the original plans and with each other using standard dose-volume histogram metrics such as percentage (V) volume receiving a specific dose (x) in Gy (Vx) or mean dose (Dmean) in Gy.

Results

Statistically significant decreases existed between the Heart_Ethos and original plans for mean heart dose (11.3 vs 14.8 Gy; P < .001) and V5, V30, and V50 (63.6% vs 75.2%; P < .001, 7.1% vs 12.3%; P < .001, 2.1% vs 2.9%; P = .03, respectively) and also for LAD mean dose (4.8 Gy vs 12.0 Gy [P < .001]) and V15 (4.9% vs 21.5%; P < .001). Compared with Heart_TB, Heart_Ethos plans had significantly less mean heart dose (11.6 vs 12.2 Gy; P = .006), and less heart V5 (64.4% vs 67.2%; P = .049) and V30 (7.7% vs 8.8%; P = .03), whereas other parameters were not significant. Optimal target coverage and other organs at risk constraints were maintained for all generated plans.

Conclusions

Heart_Ethos plans showed significant reduction in cardiac and LAD doses in comparison to the original plans while maintaining target and organ at risk goals. Our findings suggest that Ethos technology has the potential for better cardiac toxicity safety because Heart_Ethos plans were still able to reduce cardiac dose compared with Heart_TB plans.

Management of Stage IVB Cervical Cancer Including the Role of Radiotherapy

OPINION STATEMENT

The treatment of stage IVB cervical cancer is undergoing a paradigm shift, moving beyond palliation toward strategies that may improve survival rates in select patients. Radiation therapy is a key component of this shift, not only for local control, but also for enhancing systemic treatment efficacy and improving survival time. Stereotactic body radiation therapy (SBRT) for oligometastatic disease and image-guided brachytherapy improve tumor control while minimizing toxicity. The incorporation of immune checkpoint inhibitors into frontline therapy represents a significant advancement, particularly for PD-L1-positive tumors. However, durable responses remain a challenge, necessitating continued research into novel biomarkers and combination therapies. Personalized treatment approaches, integrating molecular profiling and adaptive therapy strategies, are essential for optimizing outcomes. Future clinical trials should evaluate the synergy between radiation and immunotherapy in order to refine curative approaches in stage IVB cervical cancer.

Inhalable biomimetic polyunsaturated fatty acid-based nanoreactors for peroxynitrite-augmented ferroptosis potentiate radiotherapy in lung cancer

The limited efficacy and poor tumor accumulation remain crucial challenges for radiotherapy against lung cancer. To address these limitations, we rationally developed a polyunsaturated fatty acid (PUFA)-based nanoreactor (DHA-N@M) camouflaged with macrophage cell membrane to improve tumoral distribution and achieve peroxynitrite-augment ferroptosis for enhanced radiotherapy against lung cancer. After nebulization, the nanoreactors exhibited superior pulmonary accumulation in orthotopic lung cancer-bearing mice, with 70-fold higher than intravenously injected nanoreactors at 12 h post-administration, and distributed deeply in the tumors. DHA-N@M selectively released nitric oxide (NO) in glutathione (GSH)-enriched tumor cells, with consumption of GSH and subsequent inactivation of glutathione peroxidase 4 (GPX4). Under radiation, NO reacted with radiotherapy-induced reactive oxygen species (ROS) to generate peroxynitrite (ONOO-), resulting in redox homeostasis disruption. Combined with docosahexaenoic acid (DHA)-induced lipid metabolism disruption, overwhelming ferroptosis was induced both in vitro and in vivo. Notably, DHA-N@M mediated ferroptosis-radiotherapy significantly suppressed tumor growth with a 93.91% inhibition in orthotopic lung cancer models. Therefore, this design provides a nebulized ferroptosis-radiotherapy strategy for lung cancer.

WDR11-DT enhances radiosensitivity via promoting PARP1 degradation and homologous recombination deficiency

Radiotherapy is an important management for non-small cell lung cancer (NSCLC). Although long non-coding RNAs (lncRNAs) have been reported to be involved in modulating radiosensitivity, the underlying mechanisms are still largely unclear. Here, we found that tumor suppressor WDR11-DT is a novel radiation-induced lncRNA, which is transcriptionally regulated by SPDEF, in NSCLC. In contrast to normal tissues, WDR11-DT is down-regulated in NSCLC specimens and its low expression was associated with poor prognosis of patient receiving radiotherapy. Importantly, WDR11-DT can markedly enhance NSCLC cells' radiosensitivity in vitro and in vivo. WDR11-DT functions through distinct mechanisms via binding different proteins. WDR11-DT facilitates interactions between PARP1 and its E3 ligase TRIP12, promotes PARP1 protein degradation and suppresses PARP1-controlled Single-strand breaks (SSBs) repair. Additionally, WDR11-DT binds RNA-bind protein HNRNPK, represses its functions in improving RNA stability of homologous recombination (HR) genes, decreases expression of BRCA1, ATM, BLM and RAD50, and suppresses radiotherapy-triggered HR repair. WDR11-DT-induced dual restraints of PARP1 and the HR pathway lead to the accumulation of double-strand breaks as well as synthetic lethal effects of malignant cells, which, thereby, enhances radiosensitivity and inhibits progression of lung cancer. These results extend our current knowledge of radio-biology and elucidate that WDR11-DT may be a new target for boosting cancer radiotherapy.

Equalizing prognostic disparities in KRAS-mutated stage III NSCLC patients: addition of durvalumab to combined chemoradiotherapy improves survival

INTRODUCTION

Stage III non-small cell lung cancer (NSCLC) is a heterogeneous group and identification of subgroups with differential treatment responses is crucial. Addition of durvalumab to concurrent chemoradiotherapy (cCRT) has previously been shown to improve survival outcomes. Meanwhile, subgroups harboring KRAS mutations have been shown to have worse prognosis. We investigated whether KRAS mutational status may affect survival outcomes after adjuvant durvalumab following cCRT in stage III NSCLC.

METHODS

In this multi-center retrospective study, we present a real-world dataset of all stage III NSCLC patients treated with curative-intent cCRT with molecular assessment, between 2016 and 2021 in the Västra Götaland Region of western Sweden. The study period includes the standard practice prior to the introduction of durvalumab, enabling evaluation of the potential impact of immune checkpoint blockade (ICB). Primary study outcomes were overall survival (OS) and progression free survival (PFS).

RESULTS

We identified 145 patients who received cCRT with curative intent, and 32 % harbored an activating mutation in the KRAS gene (KRASMUT; n = 46). Compared to patients with wild-type KRAS (KRASWT; n = 99), KRASMUT had worse OS (p = 0.047) and PFS (p = 0.038). This finding persisted on multivariate analysis with OS (HR 1.703, 95 % CI 1.074-2.702, p = 0.024) and PFS (HR 1.628, 95 % CI 1.081-2.453, p = 0.020). Within the subgroup that received cCRT alone, KRASMUT patients (n = 35) exhibited worse OS (p = 0.036) and PFS (p = 0.037) compared with KRASWT (n = 35). However, among those who received additional durvalumab after cCRT (KRASWT; n = 99. KRASMUT; n = 11) there were no significant differences in OS (0.788) or PFS (0.855) between the groups.

CONCLUSIONS

KRAS mutations are a negative prognostic factor after cCRT in stage III NSCLC, and the addition of durvalumab ameliorates the negative impact of harboring this mutation.

Prognostic factors after radical local therapy for oligo-recurrence of non-small cell lung cancer

OBJECTIVE

Oligo-recurrence refers to the presence of a limited number of metachronous recurrences that can be treated with radical local therapy, and most patients have a good prognosis. However, the clinical course after local therapy for oligo-recurrence of non-small cell lung cancer (NSCLC) varies, and the prognostic factors are unclear. The aim of this study was to elucidate the prognostic factors of patients with oligo-recurrence of NSCLC who underwent radical local therapy.

METHODS

Between 2004 and 2015, 901 patients who underwent complete resection for NSCLC were included. We defined oligo-recurrence as two or fewer recurrences and retrospectively examined the factors that affected post-recurrence survival in patients who underwent radical local therapy for oligo-recurrence.

RESULTS

Recurrence was confirmed in 267 patients, and among them, 125 experienced oligo-recurrence. Eighty-five patients with oligo-recurrence received local therapy, and their 5-year post-recurrence survival rate was 42.8%. Multivariable analysis of the prognostic factors of these patients revealed that single recurrence (hazard ratio = 2.19, P = 0.005) and systemic therapy (hazard ratio = 1.75, P = 0.043) were significant favorable prognostic factors associated with post-recurrence survival. However, the presence or absence of epidermal growth factor gene mutations, which is generally a prognostic factor for NSCLC recurrence, did not affect the prognosis of these patients.

CONCLUSIONS

The number of recurrences and receiving systemic therapy are important prognostic factors for patients with oligo-recurrence who undergo radical local therapy, and these patients have a particularly favorable prognosis.

Association between dose to cardiac structures and overall survival: A multivariable analysis in a large, multi-institutional database of stage III NSCLC patients with external validation

BACKGROUND AND PURPOSE

Inconsistencies in identifying dose-limiting cardiovascular substructures for treating stage III non-small cell lung cancer (NSCLC) have hindered the implementation of cardiac sparing treatment planning guidelines. This study aims to address these inconsistencies by performing a multivariable survival analysis with overall survival as the endpoint using a large, multinational database, followed by external validation.

MATERIALS AND METHODS

Clinical and dosimetric parameters from 1587 stage III NSCLC patients treated at five institutes were analyzed. The whole heart, four cardiac chambers, great vessels and their combinations were considered. The dataset was divided into a training set (four institutes) and a test set (one institute). The optimal parameter set was identified through cross-validation, and the resulting multivariable Cox regression model was externally validated using the test set. Adjusted hazard ratios (aHRs) for all cardiovascular parameters were evaluated.

RESULTS

The strongest associations were found for low Dx% parameters. However, their incremental contribution to model performance, compared to clinical and lung dosimetric parameters only, was low, with small effect sizes. Specifically, the cardiovascular parameter identified by parameter selection was Left Side D5% (aHR: 1.007 Gy-1, 95 % CI: 1.004 - 1.010 Gy-1, p < 0.0001), which provided a slight improvement in model concordance index of 0.0062 (95 % CI: 0.0000-0.0127) in the training set and 0.0037 (95 % CI: -0.0200-0.0280) in the test set.

CONCLUSIONS

Although significant associations between cardiovascular parameters and survival were found, their small effect sizes should be considered when prioritizing cardiac sparing in stage III NSCLC treatment.

Proteomics and lipidomics of human umbilical cord mesenchymal stem cells exposed to ionizing radiation

OBJECTIVES

Mesenchymal stem cell (MSC)-based therapies exhibit beneficial effects on various forms of tissue damage, including ionizing radiation-induced lesions. However, whether ionizing radiation affects the functions of human umbilical cord mesenchymal stem cells (hucMSCs) remains unclear. This study aimed to investigate the effect and possible mechanisms of ionizing radiation on the proliferation and differentiation of hucMSCs.

METHODS

The hucMSCs were divided into the 1 Gy group (exposure to a single dose (1 Gy) of X-ray radiation (1 Gy/min) for 14 days) and control (without radiation treatment) group. The proliferation, apoptosis, and adipogenic and osteogenic differentiation abilities of hucMSCs in the two groups were evaluated. Moreover, the lipidomics and proteomics analyses were conducted to explore crucial lipids and proteins by which ionizing radiation affected the functions of hucMSCs. In addition, the effects of BYSL on radiation-treated hucMSCs were explore, as well as the involved potential mechanisms.

RESULTS

X-ray radiation treatment inhibited proliferation, promoted apoptosis, and decreased adipogenic and osteogenic differentiation abilities of hucMSCs. Key lipids, such as triglyceride (TG) and phosphatidylcholine (PC), and hub proteins (BYSL, MRTO4, and RRP9) exhibited significant differences between the 1 Gy group and control group. Moreover, BYSL, MRTO4, and RRP9 were significantly correlated with TG and PC. BYSL overexpression evidently promoted the cell proliferation, adipogenic and osteogenic differentiation abilities of radiation-treated hucMSCs, as well as the protein expression levels of p-GSK-3β/GSK-3β and β-catenin, while suppressed cell apoptosis. However, the GSK-3β inhibitor (1-Az) treatment reversed the protein expression levels of p-GSK-3β/GSK-3β, β-catenin and BYSL, as well as the cell proliferation, apoptosis, adipogenic and osteogenic differentiation abilities of radiation-treated hucMSCs.

CONCLUSIONS

Our findings reveal that the proliferation and differentiation of hucMSCs are suppressed by radiation, which may be associated with the changes of key lipids (TG and PC) and proteins (BYSL, MRTO4, and RRP9). Furthermore, BYSL promotes adipogenic and osteogenic differentiation abilities of radiation-treated hucMSCs via GSK-3β/β-catenin pathway. These findings help explain the response of hucMSCs to radiation and have clinical implications for improving the outcomes of MSC-based therapies after radiotherapy.

Salvage thoracic reirradiation for recurrent non-small cell lung cancer: Clinical efficacy and the impact of consolidative immunotherapy

PURPOSE

To describe clinical outcomes in a large patient cohort treated with salvage thoracic reirradiation (reRT) for isolated locoregional recurrence of non-small cell lung cancer (NSCLC).

METHODS

Between 2011 and 2021, 1219 patients received thoracic radiotherapy for NSCLC; 130 patients underwent reRT, with doses ranging from 60-72 Gy. Primary outcomes were overall survival (OS), progression-free survival (PFS), and reRT toxicity; secondary outcomes were locoregional failure (LRF) and distant failure (DF). The Kaplan-Meier method and cumulative incidence with death as a competing risk were used for analysis, with multivariable modeling via Cox proportional hazards. Toxicity outcomes included grade 3 + non-hematologic event, hospitalization within 90 days of reRT, and grade 5 toxicity per Common Terminology Criteria for Adverse Events, version 5.0.

RESULTS

Median OS and PFS for the entire cohort were 17.4 months (95 % CI 14.1-22.9) and 8.1 months (95 % CI 6.7-10.8), respectively. 3-year OS was 25.9 % (95 % CI 19.3-34.8 %). The 3-year cumulative incidence of DF and LRF were 44 % and 46 %, respectively. Recipients of consolidative immunotherapy after reRT had improved OS (27.8 months [95 %CI 18.4-not reached] vs 15.8 months [95 %CI 12.1-22.1]; p = 0.035) and locoregional-free survival (22.8 months [95 %CI 9.8-not reached] vs 8.8 months [95 %CI 7.6-12.6]; p = 0.009). Multivariable analysis showed consolidative immunotherapy (HR 0.56, 95 %CI 0.32-1.03, p = 0.065) and hospitalization within 90 days of reRT (HR 2.03, 95 %CI 1.24-3.33, p = 0.005) were associated with OS. Nine patients (6.9 %) experienced grade 5 toxicities.

CONCLUSION

Thoracic reRT is a safe treatment option associated with long-term cure in select patients. Immunotherapy consolidation was associated with improved clinical outcomes.

Durvalumab Prolongs Overall Survival, Whereas Radiation Dose Escalation > 66 Gy Might Improve Long-Term Local Control in Unresectable NSCLC Stage III: Updated Analysis of the Austrian Radio-Oncological Lung Cancer Study Association Registry (ALLSTAR)

INTRODUCTION

Long-term analysis of PACIFIC revealed the clinical benefit of chemoradiotherapy combined with Durvalumab for unresectable non-small-cell lung cancer (NSCLC) stage III. ALLSTAR is a prospective registry aimed at validating the PACIFIC regimen in daily practice in Austria.

PATIENTS AND METHODS

Patients were eligible if they had pathologically confirmed unresectable NSCLC III with a curative treatment option. The endpoints for this analysis were overall survival (OS), updated local control (LC), and progression-free survival (PFS).

RESULTS

The 2- and 3-year LC rates in patients who received total radiation doses > 66 Gy were 80% and 75%, respectively, which were superior to the standard treatment (65% and 54%; p-value 0.085). This benefit was even more pronounced in Durvalumab patients with 2- and 3-year LC rates of 82% and 79% with >66 Gy (p-value 0.068). The 2- and 3-year OS with Durvalumab was 71% and 63%, respectively, compared to 58% and 44% without Durvalumab (HR 0.552; 95%-CI 0.347-0.881; p-value 0.011). Patients who were treated with Durvalumab also had a significantly longer 2- and 3-year PFS (56% and 48%) than those without (35% and 20%; HR 0.469; 95%-CI 0.312-0.707; p-value < 0.001). Pulmonary side effects were observed in 66/188 (35%) patients, with one case of grades 4 and 5 each. Oesophageal toxicity grade 1-3 occurred in 93/188 (49%) cases.

CONCLUSION

The updated ALLSTAR analysis demonstrated sustained benefit of Durvalumab for OS and PFS, as well as a possible long-term benefit of radiation dose escalation > 66 Gy on LC.

Impact of estimated dose of radiation to immune cells (EDRIC) in locally advanced Non-Small-Cell lung Cancer: A secondary analysis of the multicenter randomized PET-Plan trial

PURPOSE

A higher estimated dose of radiation to immune cells (EDRIC) has been proposed as an explanation for failed attempts at thoracic radiation intensification as a part of concurrent chemoradiotherapy (cCRT) for locally advanced non-small-cell lung cancer (NSCLC), as lymphopenia in particular is a negative prognostic factor in this context. We studied the impact of EDRIC on survival in this secondary analysis of the prospective PET-Plan trial (ARO-2009-09; NCT00697333). Considering the immune system as an organ at risk for radiotherapy is of major importance in the current era of consolidation immunotherapy.

METHODS

Eligible patients had previously received chemoradiotherapy up to 60-74 Gy with radiation treatment planning based on an 18F-FDG PET/CT targeting all CT positive lymph nodes plus 50 Gy elective nodal irradiation (arm A) versus targeting only PET-positive nodes (arm B). EDRIC was calculated with the original model by Jin et al. in addition to a modified score with cohort-specific weight parameters.

RESULTS

Sufficient data were available in 153 patients with a median follow-up time (95 % confidence interval [CI]) of 41.6 (34.6 - 53.7) months. Using the original model, the mean EDRIC (range) was 5.70 (3.23 - 8.44) Gy and showed a strong inverse correlation with PFS (hazard ratio [HR] = 1.77; 95 % CI 1.23-2.54; p = 0.002) and OS (HR = 1.72; 95 % CI 1.12-2.65; p = 0.01). The mean modified EDRIC (range) was 5.30 (3.01 - 8.38) Gy, again with a strong inverse correlation with PFS (HR = 1.66; 95 % CI 1.16-2.38; p = 0.006) but not OS (HR = 1.40; 95 % CI 0.91-2.15; p = 0.122). Neither radiation treatment allocation (arm A vs. B) nor technique (3D-CRT vs. IMRT) influenced EDRIC (p = 0.889 and p = 0.958, respectively) and EDRIC did not influence the rate of early or delayed hematological toxicity. On multivariate analysis, mean body dose (MBD) was the main contributing factor of the EDRIC equation to PFS and OS.

CONCLUSION

Higher doses of radiation to the immune system were associated with worse PFS in this secondary analysis of the PET-Plan trial. The omission of elective nodal irradiation did not influence EDRIC. MBD could potentially suffice as a surrogate for EDRIC, as it is more readily available and requires fewer calculations. Future trials should aim to refine existing models and investigate ways to reduce EDRIC to limit its effects in patients undergoing cCRT for locally advanced NSCLC.

Toxicity Within 6 Months of Heterogeneous Fluorodeoxyglucose-Guided Radiotherapy Dose Escalation for Locally Advanced Non-Small Cell Lung Cancer in the Scandinavian Randomized Phase III NARLAL2 Trial

PURPOSE

Radiation dose escalation for locally advanced non-small cell lung cancer (LA-NSCLC) has been challenged by toxicity concerns. The Scandinavian phase III multicenter dose-escalation trial NARLAL2 (ClinicalTrials.gov identifier: NCT02354274) used a novel approach to dose escalation: heterogeneous escalation driven by the fluorodeoxyglucose positron emission tomography-avid region, with strict normal tissue dose constraints. We report early toxicity within 6 months of random assignment.

MATERIALS AND METHODS

Patients were recruited from seven institutions in Scandinavia. Eligibility criteria included performance status 0-1, NSCLC stage IIB-IIIB, and feasibility of delivering 66 Gy/33 fraction treatment plan. Patients were randomly assigned between standard (66 Gy) and heterogeneously dose-escalated radiotherapy. Two treatment plans were made for each patient before random assignment with matched mean lung dose and V20Gy, and strict dose constraints for all normal tissues. Toxicity was evaluated weekly during radiotherapy, and every 3 months after random assignment. Concurrent chemotherapy was cisplatin/carboplatin and Navelbine.

RESULTS

Between January 2015 and March 2023, 350 patients were randomly assigned. The as-treated analysis included 178 patients in the standard and 172 in dose-escalated (mean tumor dose 88 Gy) arms. Median gross tumor and planning target volumes were, respectively, 54 cm3 and 321 cm3 (standard arm) and 61 cm3 and 339 cm3 (escalated arm). No difference in early toxicity between the two arms was observed. Grade 2 esophagitis during radiotherapy was 28.1% and 25.6%, grade 3 esophagitis 7.3% and 4.1%, grade 2 pneumonitis 15.7% and 20.3%, and grade 3 pneumonitis 3.9% and 5.8% in standard and escalated arms, respectively. For both arms, the maximum grade of early toxicity aggregated over all toxicities was 35% and 1% for grades ≥3 and 5, respectively. Four patients died from potential treatment-related toxicity.

CONCLUSION

Heterogeneous dose escalation did not increase early toxicity despite delivery of 88 Gy mean dose to the primary tumor, demonstrating this as an attractive strategy for LA-NSCLC radiotherapy dose escalation.

American Radium Society Appropriate Use Criteria Systematic Review and Guidelines on Reirradiation for Non-Small Cell Lung Cancer Executive Summary

Definitive thoracic reirradiation can improve outcomes for select patients with non-small cell lung cancer (NSCLC) with locoregional recurrences. To date, there is a lack of systematic reviews on safety or efficacy of NSCLC reirradiation and dedicated guidelines. This American Radium Society Appropriate Use Criteria Systematic Review and Guidelines provide practical guidance on thoracic reirradiation safety and efficacy and recommends consensus of strategy, techniques, and composite dose constraints to minimize risks of high-grade/fatal toxicities. Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review assessed all studies published through May 2020 evaluating toxicities, local control and/or survival for NSCLC thoracic reirradiation. Of 251 articles, 52 remained after exclusions (3 prospective) and formed the basis for recommendations on the role of concurrent chemotherapy, factors associated with toxicities, and optimal reirradiation modalities and dose-fractionation schemas. Stereotactic body radiation therapy improves conformality/dose escalation and is optimal for primary-alone failures, but caution is needed for central lesions. Concurrent chemotherapy with definitive reirradiation improves outcomes in nodal recurrences but adds toxicity and should be individualized. Hyperfractionated reirradiation may reduce long-term toxicities, although data are limited. Intensity modulated reirradiation is recommended over 3D conformal reirradiation. Particle therapy may further reduce toxicities and enable safer dose escalation. Acute esophagitis/pneumonitis and late pulmonary/cardiac/esophageal/brachial plexus toxicities are dose limiting for reirradiation. Recommended reirradiation composite dose constraints (2 Gy equivalents): esophagus V60 <40%, maximum point dose (Dmax) < 100 Gy; lung V20 <40%; heart V40 <50%; aorta/great vessels Dmax < 120 Gy; trachea/proximal bronchial tree Dmax < 110 Gy; spinal cord Dmax < 57 Gy; brachial plexus Dmax < 85 Gy. Personalized thoracic reirradiation approaches and consensus dose constraints for thoracic reirradiation are recommended and serve as the basis for ongoing Reirradiation Collaborative Group and NRG Oncology initiatives. As very few prospective and small retrospective studies formed the basis for generating the dose constraint recommended in this report, further prospective studies are needed to strengthen and improve these guidelines.

The evolving landscape of stage III unresectable non-small cell lung cancer "between lights and shadows"

Despite PACIFIC set a new milestone in the clinical management of unresectable stage III non-small cell lung cancer (NSCLC), it left some critical questions pending for clinical research: the efficacy of durvalumab in the real-world setting; the activity of less intensive regimens for frail populations; the role of targeted therapies in oncogene-addicted tumors; the selection of subsequent strategies at immunotherapy failure; the efficacy of novel and intensified treatments; the role of molecular biomarkers for patients' selection. This review aims to describe the evolving landscape of unresectable stage III NSCLC and provides an updated overview of the available evidence, analyzing lights and shadows emerging from recent clinical trials and discussing the most relevant challenges of post-PACIFIC era.

Evaluating the impact of cardiac substructure dosimetric parameters on survival in lung cancer patients undergoing postoperative radiotherapy

PURPOSE

The association of cardiac dosimetric parameters with survival in lung cancer patients is well established. However, most research has concentrated on patients undergoing definitive treatment. This study aims to investigate the relationship between cardiac dosimetric parameters and survival in patients receiving postoperative radiotherapy (PORT).

METHODS

Sixty patients who received PORT between 2011 and 2021 were retrospectively evaluated. The substructures of the heart were delineated on the simulation computed tomography scans of the patients. Univariate and multivariate Cox regression analyses were conducted to investigate the correlation between dosimetric parameters and overall survival. The Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM Corp., Armonk, NY, USA) was utilized for statistical analyses.

RESULTS

Right atrium (RA) maximum dose (Dmax) was the only variable that was significantly associated with a shorter OS. Further receiver operating characteristic (ROC) analysis revealed that the optimum cut-off value for RA Dmax was 43.6 Gy, with a sensitivity of 69% and a specificity of 62%. In addition, inclusion of the upper right paratracheal (2R), lower right paratracheal (4R), left pulmonary ligament (9L), and right hilus (10R) lymphatic stations in the treatment field led to an increase in RA Dmax.

CONCLUSION

The results of this retrospective study show that RA Dmax appears to have an impact on overall survival in patients undergoing PORT. Limiting the RA Dmax dose to below 43.6 Gy and avoiding elective nodal irradiation might potentially enhance survival in this patient cohort.

Prognostic Value of FDG PET Metabolic Parameters Before and After 42 Gy of Radiochemotherapy in Patients with Inoperable Stage III Nonsmall Cell Lung Cancer

The purpose of this study was to assess the prognostic value of 18F-FDG PET parameter variation between baseline and 42 Gy (PET2) of radiochemotherapy at 6 mo and 1 y of evaluation in patients with stage III inoperable nonsmall cell lung cancer based on RECIST 1.1. Methods: In total, 158 patients in a prospective multicenter phase II/III study were analyzed. Patients were randomized into 2 groups: an experimental arm (group A) and a standard arm (group B). Patients from group A with residual metabolism on PET2 (group A+) at 42 Gy received a radiation boost (74 Gy). Patients without residual uptake on 18F-FDG PET at 42 Gy (group A-) and patients in group B received a standard radiotherapy dose (66 Gy). We compared group A with group B. The 18F-FDG PET parameters SUVmax, SUVmean, SUVpeak, peak SUV normalized on lean body mass, mean SUV normalized on lean body mass, total lesion glycolysis, total metabolic tumor volume (MTV) (tumor and nodes), and tumor MTV were measured. All patients were evaluated with RECIST 1.1 using CT at 6 mo and 1 y after radiochemotherapy. Progression-free survival and overall survival were evaluated. Results: Except for the radiotherapy dose (P < 0.001), patient demographic characteristics were similar between the 2 groups (A vs. B). All 18F-FDG PET uptake and volume parameter measurements were correlated. Therefore, only the change in SUVmax (ΔSUVmax) and total MTV were selected for the analysis. There was no significant difference in any variable between the 2 groups. In the multivariate analysis, ΔSUVmax appeared to be the most important prognostic factor for overall survival, and SUVmax of PET2 appeared to be the most important prognostic factor for progression-free survival. Conclusion: 18F-FDG PET at 42 Gy can be used to identify good responders to radiochemotherapy in patients with inoperable stage III nonsmall cell lung cancer. The SUVmax of PET2 and ΔSUVmax are independent prognostic factors.

Multidisciplinary management of N2 stage III non-small cell lung cancer: opportunities and challenges for radiation oncology

Stage III non-small cell lung cancer (NSCLC) constitutes a heterogeneous ailment, with optimal treatment evolving. This is especially true in N2 disease, where definitive treatment is often a discussion of surgery versus definitive chemoradiotherapy (CRT). New developments in neoadjuvant and adjuvant systemic therapeutics have shifted treatment paradigms, emphasizing the importance of multidisciplinary team discussions. The recent revisions to the ninth edition of the American Joint Commission on Cancer (AJCC) staging system have prompted a realignment in nodal stage categorization, introducing refined subcategories of N2 disease (N2a and N2b), which enhance prognostic accuracy. Critical questions including defining resectability and operability, feasibility of definitive CRT for operable patients, radiotherapy in operative and non-operative disease, and advanced radiation technology for definitive CRT are needed to be considered and answered in clinical practice. The current review aims to present a comprehensive overview of radiation oncology in management of N2 stage NSCLC by summarizing key clinical trials as well as most advanced evidence, including defining resectability and operability, feasibility of definitive CRT for operable patients, radiotherapy in operative and non-operative disease, and advanced radiation technology for definitive CRT. The review summarizes the most recent evidence and insights for radiation oncologists and other specialists involved in the multidisciplinary thoracic oncology team, to provide a better understanding of the opportunities and challenges for radiotherapy in the management of N2 stage III NSCLC.

Patient selection, ventricular tachycardia substrate delineation, and data transfer for stereotactic arrhythmia radioablation: a clinical consensus statement of the European Heart Rhythm Association of the European Society of Cardiology and the Heart Rhythm Society

Stereotactic arrhythmia radioablation (STAR) is a novel, non-invasive, and promising treatment option for ventricular arrhythmias (VAs). It has been applied in highly selected patients mainly as bailout procedure, when (multiple) catheter ablations, together with anti-arrhythmic drugs, were unable to control the VAs. Despite the increasing clinical use, there is still limited knowledge of the acute and long-term response of normal and diseased myocardium to STAR. Acute toxicity appeared to be reasonably low, but potential late adverse effects may be underreported. Among published studies, the provided methodological information is often limited, and patient selection, target volume definition, methods for determination and transfer of target volume, and techniques for treatment planning and execution differ across studies, hampering the pooling of data and comparison across studies. In addition, STAR requires close and new collaboration between clinical electrophysiologists and radiation oncologists, which is facilitated by shared knowledge in each collaborator's area of expertise and a common language. This clinical consensus statement provides uniform definition of cardiac target volumes. It aims to provide advice in patient selection for STAR including aetiology-specific aspects and advice in optimal cardiac target volume identification based on available evidence. Safety concerns and the advice for acute and long-term monitoring including the importance of standardized reporting and follow-up are covered by this document. Areas of uncertainty are listed, which require high-quality, reliable pre-clinical and clinical evidence before the expansion of STAR beyond clinical scenarios in which proven therapies are ineffective or unavailable.

Dosimetric superiority of deep inspiration breath hold-proton beam therapy for cardiac metastasis

The purpose of this case report is to compare the dosimetric disparities between photon radiotherapy and intensity-modulated proton therapy (IMPT) with or without deep inspiration breath hold (DIBH) for cardiac tumors. We present a case involving a 66-year-old female with cardiac metastasis from thymic carcinoma. A total dose of 50Gy/50Gy(RBE) in 25 fractions was administered to the cardiac metastases. Two simulation CT scans were obtained during free breath (FB) and DIBH. Dose distribution to target and organs at risk(OARs) was compared between intensity modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT) and IMPT. All of the 6 plans satisfied treatment planning goals. The coronary artery (CA) Dmean (mean dose) was 28.32 Gy for IMRT-DIBH, 42.66 Gy for IMRT-FB, 26.44 Gy for VMAT-DIBH, 40.85 Gy for VMAT-FB, 27.71 Gy for IMPT-DIBH, and 39.51 Gy for IMPT-FB. The heart V50 (volume receiving ≥50 Gy) was 3.90 Gy for IMRT-DIBH, 6.71 Gy for IMRT-FB, 4.80 Gy for VMAT-DIBH, 6.63 Gy for VMAT-FB, 0.99 Gy for IMPT-DIBH, and 6.67 Gy for IMPT-FB, respectively. DIBH resulted in dose reductions in all OARs, particularly the heart and CA, compared to FB in all 3 planning techniques (IMRT, VMAT, and IMPT). Similarly, compared with IMRT or VMAT, IMPT reduced radiation doses to most OARs, including the heart and CA, in both FB and DIBH. DIBH-IMPT demonstrated superior dose coverage and OARs sparing in this thymic carcinoma patient with cardiac metastasis. Given the anticipated reduction in toxicities, IMPT with DIBH is preferred for cardiac tumors. The potential for broader application of IMPT with DIBH in clinical practice is currently being evaluated, and further studies are needed.

Beta-adrenergic receptor blockers improve survival in patients with advanced non-small cell lung cancer combined with hypertension undergoing radiotherapy

Hypertension (HTN) is prevalent in non-small cell lung cancer (NSCLC) patients, yet the cardioprotective and survival benefits of β-adrenergic blockers during radiotherapy (RT) remain underexplored. We analyzed data from a Chinese clinical cohort of 750 patients with stage IIIA to IIIB NSCLC and HTN receiving RT between 2014 and 2018. The findings were further validated using data from the NHANES database. In Chinese clinical cohort, β-adrenergic blockers were associated with improved OS (β-adrenergic blockers: median overall survival (mOS) 17.64 months, 95% CI, 15.95-19.33; no β-adrenergic blockers: mOS 13.16 months, 95% CI, 12.62-13.70; p < 0.0001) and PFS (β-adrenergic blockers: median progression-free survival (mPFS) 7.50 months, 95% CI, 6.50-8.50; without β-adrenergic blockers: mPFS 4.91 months, 95% CI, 4.53-5.31; p < 0.0001). Simultaneously, in the NHANES database, the utilization of β-adrenergic blockers exhibited no discernible impact on OS within the entire tumor population, as evidenced by the Kaplan-Meier curve, which revealed no statistically significant difference between the two groups (p = 0.254). β-adrenergic blockers may improve OS and PFS in patients with HTN and NSCLC undergoing RT. β-adrenergic blockers show potential and warrant further investigation in the context of RT.

Esophageal Toxicity After Dose-Escalated Radiation Therapy for Stage II-III Non-Small Cell Lung Cancer: A Secondary Analysis of the Phase 2 Randomized ARTFORCE PET-Boost Trial

PURPOSE

We previously reported unexpected high rates of severe esophageal toxicity (ET) in patients with stage II-III non-small cell lung cancer treated in the randomized ARTFORCE PET-Boost dose-escalation trial (clinicaltrials.gov: NCT01024829). The aim of this study is to evaluate clinical factors and dose metrics associated with ET in patients treated within the trial.

METHODS AND MATERIALS

Patients received 24 fractions of 3.0-5.4 Gy, planned isotoxically to the primary tumor as a whole (>4 cm) or to an 18F-FDG-PET defined subvolume within the primary tumor. Lymph nodes received 24 × 2.75Gy. Radiation therapy was combined with concurrent or sequential chemotherapy, or given alone. We evaluated the incidence and time to grade ≥ 3 (G ≥ 3) ET, and patient-reported symptoms. Follow-up time was estimated using the reverse Kaplan-Meier method. Uni- and multivariable logistic regression analyses with Firth's penalization were performed to assess the associations between clinical variables, dose parameters, and the incidence of G ≥ 3 ET.

RESULTS

Median follow-up was 73.3 months. Of 107 patients randomized, 24(22.4%) experienced G ≥ 3 ET. There were 3 (2.8%) ET-related deaths, all esophageal fistulas. Median esophagus mean dose and D0.1% (EQD2) were 25.2 Gy (IQR, 18.9-33.2), and 69.5Gy (IQR, 66.4-75.4), respectively. G ≥ 3 ET occurred less frequently (19/54[35.2%] vs 5/53[9.4%]; P = .001) after a dose constraint for esophagus + 5 mm was introduced mid-trial (D0.1% < 70 Gy EQD2). Concurrent platinum-doublet chemotherapy, (compared with concurrent daily low-dose cisplatin or sequential/no chemotherapy) and higher esophageal doses, especially volume receiving >50 Gy, near maximum doses, and the equivalent uniform dose, were significantly associated with G ≥ 3 ET in multivariable regression.

CONCLUSIONS

Concurrent platinum-doublet chemotherapy, as well as high doses to the esophagus, was independently associated with risk of severe ET. Stricter dose constraints led to significant reduction in G ≥ 3 ET. Future dose-escalation studies should lower doses to the esophagus, especially when combined with concurrent chemotherapy.

[Prognosis-guided optimization of intensity-modulated radiation therapy plans for lung cancer]

OBJECTIVES

To propose a new method for optimizing radiotherapy planning for lung cancer by incorporating prognostic models that take into account individual patient information and assess the feasibility of treatment planning optimization directly guided by minimizing the predicted prognostic risk.

METHODS

A mixed fluence map optimization objective was constructed, incorporating the outcome-based objective and the physical dose constraints. The outcome-based objective function was constructed as an equally weighted summation of prognostic prediction models for local control failure, radiation-induced cardiac toxicity, and radiation pneumonitis considering clinical risk factors. These models were derived using Cox regression analysis or Logistic regression. The primary goal was to minimize the outcome-based objective with the physical dose constraints recommended by the clinical guidelines. The efficacy of the proposed method for optimizing treatment plans was tested in 15 cases of non-small cell lung cancer in comparison with the conventional dose-based optimization method (clinical plan), and the dosimetric indicators and predicted prognostic outcomes were compared between different plans.

RESULTS

In terms of the dosemetric indicators, D95% of the planning target volume obtained using the proposed method was basically consistent with that of the clinical plan (100.33% vs 102.57%, P=0.056), and the average dose of the heart and lungs was significantly decreased from 9.83 Gy and 9.50 Gy to 7.02 Gy (t=4.537, P<0.05) and 8.40 Gy (t=4.104, P<0.05), respectively. The predicted probability of local control failure was similar between the proposed plan and the clinical plan (60.05% vs 59.66%), while the probability of radiation-induced cardiac toxicity was reduced by 1.41% in the proposed plan.

CONCLUSIONS

The proposed optimization method based on a mixed objective function of outcome prediction and physical dose provides effective protection against normal tissue exposure to improve the outcomes of lung cancer patients following radiotherapy.

Establishing a Deep Learning Model That Integrates Pretreatment and Midtreatment Computed Tomography to Predict Treatment Response in Non-Small Cell Lung Cancer

PURPOSE

Patients with identical stages or similar tumor volumes can vary significantly in their responses to radiation therapy (RT) due to individual characteristics, making personalized RT for non-small cell lung cancer (NSCLC) challenging. This study aimed to develop a deep learning model by integrating pretreatment and midtreatment computed tomography (CT) to predict the treatment response in NSCLC patients.

METHODS AND MATERIALS

We retrospectively collected data from 168 NSCLC patients across 3 hospitals. Data from Shanghai General Hospital (SGH, 35 patients) and Shanxi Cancer Hospital (SCH, 93 patients) were used for model training and internal validation, while data from Linfen Central Hospital (LCH, 40 patients) were used for external validation. Deep learning, radiomics, and clinical features were extracted to establish a varying time interval long short-term memory network for response prediction. Furthermore, we derived a model-deduced personalize dose escalation (DE) for patients predicted to have suboptimal gross tumor volume regression. The area under the receiver operating characteristic curve (AUC) and predicted absolute error were used to evaluate the predictive Response Evaluation Criteria in Solid Tumors classification and the proportion of gross tumor volume residual. DE was calculated as the biological equivalent dose using an /α/β ratio of 10 Gy.

RESULTS

The model using only pretreatment CT achieved the highest AUC of 0.762 and 0.687 in internal and external validation respectively, whereas the model integrating both pretreatment and midtreatment CT achieved AUC of 0.869 and 0.798, with predicted absolute error of 0.137 and 0.185, respectively. We performed personalized DE for 29 patients. Their original biological equivalent dose was approximately 72 Gy, within the range of 71.6 Gy to 75 Gy. DE ranged from 77.7 to 120 Gy for 29 patients, with 17 patients exceeding 100 Gy and 8 patients reaching the model's preset upper limit of 120 Gy.

CONCLUSIONS

Combining pretreatment and midtreatment CT enhances prediction performance for RT response and offers a promising approach for personalized DE in NSCLC.

Simultaneous integrated dose reduction intensity-modulated radiotherapy improves survival in patients with locally advanced non-small cell lung cancer by reducing cardiac irradiation exposure

The study aimed to evaluate the safety and efficacy of simultaneous integrated dose reduction intensity-modulated radiotherapy (SIR-IMRT) in patients with locally advanced non-small-cell lung cancer (LA-NSCLC). In the SIR-IMRT conhort, the prescribed irradiation dose was 60 Gray (Gy) for the planning gross tumor volume (PGTV) and 54 Gy for the planning target volume (PTV), while in the conventional intensity-modulated radiotherapy (C-IMRT) cohort, it was 60 Gy for both PGTV and PTV. The SIR-IMRT group demonstrated better overall survival (OS) than the C-IMRT group, with a median OS of 37.7 versus 31.2 months. The SIR-IMRT group also experienced lower cardiac and esophagusal doses, along with a lower incidence of acute radiation esophagitis and ≥ grade 3 radiation pneumonitis. HeartV20 (the volume of the heart receiving at least 20 Gy) was the only independent risk factor associated with survival. SIR-IMRT significantly reduced cardiac irradiation exposure, improving patient survival and offering a new therapeutic direction for future studies.

Cartilage Oligomeric Matrix Protein Promotes Radiation Resistance in Non-Small Cell Lung Cancer In Vitro

Cartilage oligomeric matrix protein (COMP) is an extracellular matrix protein that has recently been associated with worse patient outcomes in breast, prostate, colorectal and hepatocellular cancers. This study aimed to determine whether COMP was also associated with increased progression and resistance to radiation in non-small cell lung cancer (NSCLC). The proliferation, migration, invasion and cell viability of wild-type and COMP overexpressing NSCLC cell lines were assessed when treated with exogenous COMP, with or without radiation. In addition, these cells were treated with inhibitors of downstream signaling intermediates of COMP. Proteomics were performed on the A549 cell line treated with COMP, radiation and inhibitors. NSCLC cells treated with COMP or overexpressing COMP had greater proliferation, migration, invasion and viability when irradiated compared to non-overexpressed cells treated with radiation alone, but this effect was reversed when treated with Src or PI3k inhibitors. The NCI-H1437 cell line exhibited a decrease in proliferation when treated with exogenous COMP, however COMP overexpression mitigated the radiation-induced reduction. Proteomics analyses indicate that COMP promotes oxidative phosphorylation and drug resistance pathways. Therefore, COMP overexpression and treatment with exogenous COMP appears to protect NSCLC cells against radiation in vitro, however treatment with inhibitors reverses COMP-mediated protection and progression.

Cardioprotective Effects of Dapagliflozin Against Radiotherapy Induced Cardiac Damage

BACKGROUND

With the increasing incidence of cancer among the adult population, radiotherapy (RT) is frequently used as a critical component in the treatment of various cancer types. Due to the nature of ionizing radiation, damage usually occurs within the tissues in anatomical neighborhood with the primary tumor localization. Dapagliflozin (DAPA), originally developed as an oral anti-diabetic medication, has been shown to have potent cardioprotective effects in the DAPA-HF trial. The cardioprotective effects of DAPA against RT induced cardiac cellular damage were investigated in this study.

METHODS

A total of 40 male Wistar albino rats were obtained and were subjected to a 10-day pretreatment period to accommodate laboratory settings. Afterwards, the rats were divided into 4 groups consisting of 10 each (control = 10, DAPA = 10, RT = 10, RT + DAPA = 10). Meanwhile, the RT and RT + DAPA groups received a single dose of 20 Gray (Gy) x-ray to 4 × 4 cm area at 0.60 Gy/min, and DAPA and RT + DAPA groups were gavaged daily with 10 mg/kg DAPA. In the second week of the study, rats were examined by echocardiography and electrocardiogram. Furthermore, histopathological method was used to evaluate the level of cardiotoxicity.

RESULTS

The ejection fraction value decreased by 17.3% lower in the DAPA + RT group compared with the RT group (P < .001). In addition, corrected QT interval prolongation and QRS widening were 11.5% and 17.4% higher in the RT group compared with the DAPA + RT group, respectively (P < .001 for both values). While sarcomyolysis, inflammatory cell infiltration, and necrotic changes were found to be severe in the RT group, the DAPA + RT group had 68% less sarcomyolysis, 64% less inflammatory cell infiltration, and 55% less necrosis (P < .001 for all values).

CONCLUSIONS

The protective effects of DAPA against left ventricular remodeling and dysfunction in RT-induced cardiomyopathy model were observed in this study.

Preclinical evaluation of 64Cu-labeled cetuximab in immuno-PET for detecting sentinel lymph node metastasis in epidermal growth factor receptor-positive breast cancer

BACKGROUND

Despite advances in breast cancer imaging, reliable detection of sentinel lymph node (SLN) metastasis remains challenging. This study aimed to determine the ability of immuno-positron emission tomography (PET) using 64Cu-labeled cetuximab to detect SLN metastasis in a model of epidermal growth factor receptor (EGFR)-positive breast cancer.

METHODS

The SLN metastasis model was established using the EGFR-strongly-expressing MDA-MB-468 breast cancer cell line. In this xenograft model, [64Cu]Cu-PCTA-cetuximab was administered intravenously (5.8 ± 0.9 MBq; n = 12) or both intradermally and subdermally into the parapapillary region of the tumor-containing mammary gland (4.3 ± 0.4 MBq; n = 11), after which PET was performed. 18F-FDG PET was also performed intravenously (9.1 ± 1.4 MBq; n = 4) or intradermally/subdermally (5.4 ± 2.2 MBq; n = 3) in the same cohort before [64Cu]Cu-PCTA-cetuximab PET. PET/computed tomography was performed 60 min after administration of 18F-FDG and 24 h after administration of [64Cu]Cu-PCTA-cetuximab. Delayed PET/CT scans were conducted 48 h after administration for all mice in the intradermally/subdermally administered [64Cu]Cu-PCTA-cetuximab group and for four of the 12 mice in the intravenously administered [64Cu]Cu-PCTA-cetuximab group. SLNs were identified using blue dye, and PET and pathological evaluations of the resected SLN were performed to confirm metastases.

RESULTS

After intravenous administration of [64Cu]Cu-PCTA-cetuximab (n = 12), accumulation was detected in the primary tumor in all mice and in the axilla of eight mice (67%, SUVmax 1.24 ± 0.51), all of which were found to have SLNs with histologically confirmed metastasis. The sensitivity, specificity, accuracy, and negative and positive predictive values for PET with intravenously administered [64Cu]Cu-PCTA-cetuximab were 89%, 100%, 92%, 75%, and 100%, respectively. In contrast, all mice with intradermal/subdermal administration (n = 11) showed high accumulation in both the primary tumor and axillary lymph nodes (SUVmax 4.28 ± 1.19), with six mice (55%, SUVmax 5.01 ± 1.12) having histologically confirmed metastasis. The sensitivity, specificity, accuracy, and positive predictive values for PET with intradermally/subdermally administered [64Cu]Cu-PCTA-cetuximab were 100%, 0%, 55% and 55%, respectively. SLN metastasis was not detectable by intravenous or intradermal/subdermal 18F-FDG PET.

CONCLUSIONS

PET with intravenously administered [64Cu]Cu-PCTA-cetuximab demonstrated high precision for diagnosis of SLN metastasis in a xenograft model of EGFR-positive human breast cancer. Although further evaluation is necessary, intradermal/subdermal administration could be a useful therapeutic approach owing to its high accumulation in SLNs.

Real-World Insights into the Impact of Durvalumab on Stage III Unresectable Non-Small Cell Lung Cancer-A Narrative Review

INTRODUCTION AND AIM

Stage III Non-Small Cell Lung Cancer (NSCLC) has a poor prognosis, with median survival ranging from 9 to 34 months. The PACIFIC trial demonstrated that durvalumab after platinum-based chemoradiotherapy (CRT) improves overall survival (OS) and progression-free survival (PFS). This review evaluates real-world evidence (RWE) on durvalumab's efficacy and safety, focusing on patient characteristics, prognostic factors, treatment protocols, and outcomes beyond progression.

MATERIALS AND METHODS

A literature search of PubMed, Embase, and Google Scholar identified 49 observational studies published from January 2017 to August 2024 on unresectable stage III NSCLC. Clinical trials, early-stage disease, and alternative treatments were excluded.

RESULTS

Compared to the PACIFIC trial, real-world patients were older, had poorer ECOG performance (≥2), and more comorbidities like COPD. Despite this, durvalumab provided consistent survival benefits. Positive prognostic factors included non-squamous histology, high PD-L1 expression, and timely durvalumab initiation (≤42 days post-CRT). Most radiotherapy regimens mirrored PACIFIC (54-66 Gy). Concomitant CRT was used in 90% of cases, with sequential CRT for frail patients. Chemotherapy regimens varied. Immune-mediated pneumonitis was a major adverse event, with incidence rates between 15% and 100%. Severe cases led to treatment discontinuation, impacting survival. Treatment beyond progression remains uncertain, with limited benefits from immunotherapy rechallenge.

CONCLUSIONS

RWE supports durvalumab's efficacy, emphasizing the need for personalized treatment strategies and further research to improve long-term outcomes.

Cardiotoxicity following thoracic radiotherapy for lung cancer

Radiotherapy is the standard of care treatment for unresectable NSCLC, combined with concurrent chemotherapy and adjuvant immunotherapy. Despite technological advances in radiotherapy planning and delivery, the risk of damage to surrounding thoracic tissues remains high. Cardiac problems, including arrhythmia, heart failure and ischaemic events, occur in 20% of patients with lung cancer who undergo radiotherapy. As survival rates improve incrementally for this cohort, minimising the cardiovascular morbidity of RT is increasingly important. Problematically, the reporting of cardiac endpoints has been poor in thoracic radiotherapy clinical trials, and retrospective studies have been limited by the lack of standardisation of nomenclature and endpoints. How baseline cardiovascular profile and cardiac substructure radiation dose distribution impact the risk of cardiotoxicity is incompletely understood. As Thoracic Oncology departments seek to expand the indications for radiotherapy, and as the patient cohort becomes older and more comorbid, there is a pressing need for cardiotoxicity to be comprehensively characterised with sophisticated oncology, physics and cardio-oncology evaluations. This review synthesises the evidence base for cardiotoxicity in conventional radiotherapy, focusing on lung cancer, including current data, unmet clinical needs, and future scientific directions.

[Current standards for the management of locally advanced unresectable non small cell lung cancer]

Non-small cell lung cancers (NSCLC) account for 85 % of bronchopulmonary cancers and are most often diagnosed at an advanced stage. In case of resectable locally advanced NSCLC (LA-NSCLC) in a patient fit, surgery is the cornerstone of treatment in combination with perioperative treatment based on chemotherapy +/- immunotherapy. However, for a large proportion of LA-NSCLC, surgery is not a preferred option because the patient is medically inoperable or because of an unresectable disease. Since the early 2000s, the standard treatment for these patients who cannot benefit from surgical treatment had been a chemoradiotherapy, ideally given concurrently. The recent addition of consolidation immunotherapy following concurrent chemoradiotherapy has led to a clear improvement in median overall survival (OS) in this population. The objective of this article is to detail the standard treatment in 2024 of unresectable (or inoperable) LA-NSCLC and to discuss the main therapeutic perspectives in this indication, both regarding radiotherapy and systemic treatment and especially combination strategies with immunotherapy.

Advances of PET/CT in Target Delineation of Lung Cancer Before Radiation Therapy

In the clinical management of lung cancer, radiotherapy remains a cornerstone of multimodal treatment strategies, often used alongside surgery or in combination with systemic therapies such as chemotherapy, tyrosine kinase inhibitors, and immune checkpoint inhibitors. While conventional imaging modalities like computed tomography (CT) and magnetic resonance imaging (MRI) continue to play a central role in staging, response assessment, and radiotherapy planning, advanced imaging techniques, particularly [18F]FDG PET/CT, are being increasingly integrated into routine clinical practice. These advanced techniques address the limitations of standard imaging by providing insight into molecular and metabolic tumor characteristics, enabling precise tumor visualization, accurate target volume delineation, and early treatment response assessment. This review examines the role of radiotherapy in the multidisciplinary management of lung cancer, detailing current concepts of morphological and functional imaging for staging and treatment planning. It also highlights the growing importance of PET-based radiotherapy planning, emphasizing its contributions to target volume definition and predictive value for treatment outcomes. Recent methodological advances, including the integration of artificial intelligence (AI), radiomics, technical innovations, and novel PET ligands, are discussed, highlighting their potential to improve the precision, efficacy, and personalization of lung cancer radiotherapy planning.

PLK4 inhibition as a strategy to enhance non-small cell lung cancer radiosensitivity

Lung cancer is the leading cause of cancer-related mortality worldwide. Non-small cell lung cancer (NSCLC) is the most common subtype of lung cancer and comprises 85% of cases. Despite treatment advances, local control after curative-intent chemoradiation for NSCLC remains suboptimal. Polo-like kinase 4 (PLK4) is a serine-threonine kinase that plays a critical role in the regulation of centrosome duplication and cell cycle progression and is overexpressed in NSCLC, thus, making it a potential therapeutic target. CFI-400945 is an orally available PLK4 inhibitor currently undergoing clinical trial evaluation. As radiation causes cell death primarily by mitotic catastrophe, a process enhanced by alterations in centrosome amplification, we hypothesized that disruption of the mitotic machinery by inhibition of PLK4 would enhance the effects of radiation in NSCLC. PLK4 inhibition by CFI-400945 resulted in radiosensitization of NSCLC cell lines. In contrast, CFI-400945 had no effect on the radiosensitivity of normal lung fibroblasts. PLK4 inhibition did not affect cell-cycle phase distribution prior to radiation, but rather the combination of CFI-400945 and radiation resulted in increased G2/M cell cycle arrest, increased centrosome amplification, and a concomitant increase in cell death through mitotic catastrophe. Lastly, CFI-400945 treatment enhanced the radiation-induced tumor growth delay of NSCLC tumor xenografts. These data indicate that targeting PLK4 is a novel approach to enhance the radiation sensitivity of NSCLC in vitro and in vivo through potentiation of centrosome amplification and cell death through mitotic catastrophe.

Impact of radiation dose to immune cells on survival in patients with esophageal cancer receiving neoadjuvant chemoradiotherapy: a retrospective analysis

BACKGROUND

Neoadjuvant chemoradiotherapy (NCRT) is the standard treatment for locally advanced esophageal squamous cell carcinoma (ESCC). This study aims to explore the effect of the estimated dose of radiation to immune cells (EDRIC) on lymphocytes in patients with locally advanced ESCC undergoing NCRT and evaluate the impact of EDRIC on patient prognosis.

METHODS

This retrospective study included patients with locally advanced ESCC who received NCRT followed by radical esophagectomy at our institution between March 2016 and December 2022. EDRIC was calculated as a function of the number of fractions and the average doses to the lungs, heart, and remaining body. The optimal cut-off value of EDRIC was determined based on disease-free survival (DFS), and patients were divided into two groups according to this cut-off value. Kaplan-Meier and Cox proportional hazards regression analyses were used to estimate overall survival (OS) and DFS.

RESULTS

The 182 patients included in the study had a mean EDRIC of 5.41 ± 1.70 Gy and an EDRIC cut-off value of 6.86 Gy. Patients with an EDRIC ≤ 6.86 Gy had a significant advantage in DFS (hazard ratio [HR]: 0.37, 95% confidence interval [CI]: 0.20-0.68, P = 0.001) and OS (HR: 0.22, 95% CI: 0.10-0.48, P = 0.001). EDRIC was closely associated with the lymphocyte nadir (P < 0.001) and lymphocytopenia values (P < 0.001). Patients with a lymphocyte nadir ≤ 0.16 × 109/L had poorer DFS (HR: 2.04, 95% CI: 1.07-3.88, P = 0.025) and OS (HR: 2.52, 95% CI: 1.14-5.56, P = 0.018).

CONCLUSION

EDRIC is an independent prognostic factor for patients with locally advanced ESCC undergoing NCRT. A higher EDRIC is associated with poorer DFS and OS and is closely related to reduced lymphocyte counts. As a quantifiable parameter, future research should explore methods of lowering EDRIC during NCRT while ensuring adequate tumor coverage and sufficient dosage.

Comparative analysis of VMAT plans on Halcyon and infinity for lung cancer radiotherapy

Objective The dosimetric characteristics and treatment efficiency of VMAT plans using two linear accelerator platforms, Halcyon and Infinity, in conventional radiotherapy for non-small cell lung cancer (NSCLC) are compared to provide data for selecting clinical equipment. The study also explores potential confounding factors that may influence treatment outcomes. Methods This retrospective cohort study aims to compare the dosimetric characteristics and treatment efficiency of VMAT plans delivered using Halcyon and Infinity linear accelerator platforms in patients with NSCLC. A retrospective analysis was performed on 60 NSCLC patients receiving conventional fractionated radiotherapy with VMAT plans developed for both Halcyon and Infinity. These plans were optimized with RayStation 9A with identical dose constraints and optimization parameters. The groups were compared in terms of target dose coverage, normal tissue sparing, plan complexity, and treatment efficiency. The dosimetric parameters included D98%, D2%, and Dmean for both the CTV and PTV and dose distributions for organs at risk (OARs), including the heart, lungs, and spinal cord. Logistic regression was performed to account for potential confounding factors, such as PTV volume, tumor stage, and tumor location. Results The VMAT plans of both platforms met the clinical dosimetric requirements. Halcyon showed superior protection of normal tissues in low-dose areas (e.g., Lungs V5Gy and Heart V30Gy), whereas Infinity excelled in controlling hot spots and achieving rapid dose fall-off at the target margins. Furthermore, Halcyon has fewer plan monitoring units and lower complexity than Infinity and reduced treatment time by 24.0%. Logistic regression analysis revealed that PTV volume was a significant predictor for dose metric differences, while tumor stage and tumor location had variable effects depending on the dose metric, highlighting the need to account for these factors in clinical comparisons. Overall, there was no significant difference in target dose coverage or uniformity between the platforms; each demonstrated specific strengths in protecting different OARs and in treatment execution efficiency. Conclusion Halcyon and Infinity offer distinct advantages in radiotherapy for NSCLC. Halcyon provides better protection of normal tissues and performance in low-dose regions, whereas Infinity offers greater treatment efficiency and superior control in high-dose regions. The study also highlights that PTV volume is an important factor influencing dosimetric outcomes. In choosing optimal radiotherapy equipment in clinical practice, the study results suggest that treatment planning should leverage the unique technical features of different accelerators to achieve the best individualized outcomes. Future studies should increase the sample size and employ prospective research designs to confirm the clinical relevance of these findings.

Cardiac CT reveals high prevalence of coronary artery disease in esophageal cancer eligible for radiotherapy

BACKGROUND

Assessment of cardiac disease before cancer therapy is crucial, as advancements in cancer treatment have led to prolonged survival and an increase in cardiovascular complications. Specifically, esophageal cancer and heart disease share common risk factors, such as smoking and obesity. Radiation therapy (RT) for esophageal cancer is associated with elevated cardiac radiation exposure. This study aimed to assess the prevalence of coronary artery disease (CAD) in patients with esophageal cancer who were eligible for RT.

METHODS

We examined the prevalence of coronary artery stenosis, abnormal myocardial perfusion, and late enhancement using pre-RT cardiac computed tomography (CT) data of 41 patients with thoracic esophageal cancer who were referred for RT between January 2017 and June 2023 and had no history of ischemic heart disease.

RESULTS

The median age of the 41 patients was 71 years, with 40 patients being male. Cardiac CT identified significant coronary stenosis (≥50% luminal narrowing) in 18 patients (44%), among whom 9 (50%) had severe stenosis, multivessel disease, or myocardial ischemia. Significant stenosis was most frequently observed in the left anterior descending artery (16/18). Late enhancement, indicating myocardial infarction, was observed in seven patients (17%).

INTERPRETATION

Patients with esophageal cancer without a history of ischemic heart disease had a high prevalence (44%) of CAD, with half of them having severe stenosis, multivessel disease, or myocardial ischemia. Given the high prevalence of coronary stenosis, pre-treatment cardiac evaluation is crucial for patients with esophageal cancer. Incorporating cardiac CT findings into radiotherapy planning is recommended to optimize patient care.

Recent developments in the field of radiotherapy for the management of lung cancer

Lung cancer has a poor prognosis, and further improvements in outcomes are needed. Radiotherapy plays an important role in the treatment of unresectable lung cancer, and there have been recent developments in the field of radiotherapy for the management of lung cancer. However, to date, there have been few reviews on the improvement in treatment outcomes associated with high precision radiotherapy for lung cancer. Thus, this review aimed to summarize the recent developments in radiotherapy techniques and indicate the future directions in the use of radiotherapy for lung cancer. Stereotactic body radiotherapy (SBRT) for unresectable stage I lung cancer has been reported to improve local control rates without severe adverse events, such as radiation pneumonitis. For locally advanced lung cancer, a combination of chemoradiotherapy and adjuvant immune checkpoint inhibitors dramatically improves treatment outcomes, and intensity-modulated radiotherapy (IMRT) enables safer radiation therapy with less frequent pneumonitis. Particle beam therapy, such as carbon-ion radiotherapy and proton beam therapy, has been administered as advanced medical care for patients with lung cancer. Since 2024, it has been covered under insurance for early stage lung cancer with tumors ≤ 5 cm in size in Japan. In addition to chemotherapy, local ablative radiotherapy improves treatment outcomes in patients with oligometastatic stage IV lung cancer. A particular problem with radiotherapy for lung cancer is that the target location changes with respiratory motion, and various physical methods have been used to control respiratory motion. Recently, coronavirus disease has had a major impact on lung cancer treatment, and cancer treatment during situations, such as the coronavirus pandemic, must be performed carefully. To improve treatment outcomes for lung cancer, it is necessary to fully utilize evolving radiotherapy modalities, and the role of radiotherapy in lung cancer treatment is expected to increase.

Imaging lung tumor motion using integrated-mode proton radiography-A phantom study towards tumor tracking in proton radiotherapy

BACKGROUND

Motion of lung tumors during radiotherapy leads to decreased accuracy of the delivered dose distribution. This is especially true for proton radiotherapy due to the finite range of the proton beam. Methods for mitigating motion rely on knowing the position of the tumor during treatment.

PURPOSE

Proton radiography uses the treatment beam, at an energy high enough to traverse the patient, to produce a radiograph. This work shows the first results of using an integrated-mode proton radiography system to track the position of moving objects in an experimental phantom study; demonstrating the potential of using this method for measuring tumor motion.

METHODS

Proton radiographs of an anthropomorphic lung phantom, with a motor-driven tumor insert, were acquired approximately every 1 s, using tumor inserts of 10, 20, and 30 mm undergoing a known periodic motion. The proton radiography system used a monolithic scintillator block and digital cameras to capture the residual range of each pencil beam passing through the phantom. These ranges were then used to produce a water equivalent thickness map of the phantom. The centroid of the tumor insert in the radiographs was used to determine its position. This measured position was then compared to the known motion of the phantom to determine the accuracy.

RESULTS

Submillimeter accuracy on the measurement of the tumor insert was achieved when using a 30 mm tumor insert with a period of 24 s and was found to be improved for decreasing motion amplitudes with a mean absolute error (MAE) of 1.0, 0.9, and 0.7 mm for 20, 15, and 10 mm respectively. Using smaller tumor inserts reduced the accuracy with a MAE of 1.8 and 1.9 mm for a 20 and 10 mm insert respectively undergoing a periodic motion with an amplitude of 20 mm and a period of 24 s. Using a shorter period resulted in significant motion artifacts reducing the accuracy to a MAE of 2.2 mm for a 12 s period and 3.1 mm for a 6 s period for the 30 mm insert with an amplitude of 20 mm.

CONCLUSIONS

This work demonstrates that the position of a lung tumor insert in a realistic anthropomorphic phantom can be measured with high accuracy using proton radiographs. Results show that the accuracy of the position measurement is the highest for slower tumor motions due to a reduction in motion artifacts. This indicates that the primary obstacle to accurate measurement is the speed of the radiograph acquisition. Although the slower tumor motions used in this study are not clinically realistic, this work demonstrates the potential for using proton radiography for measuring tumor motion with an increased scanning speed that results in a decreased acquisition time.

Strategies to Reduce Left Anterior Descending Artery and Left Ventricle Organ Doses in Radiotherapy Planning for Left-Sided Breast Cancer

Background

One of the most significant long-term toxicities of breast cancer radiotherapy is major adverse cardiac events (MACE). In current radiotherapy practice, the mean heart dose is the most commonly used parameter. The aim of our study was to reduce the doses of organs at risk (OAR) in the left anterior descending artery (LAD) and left ventricle (LV) by including the LAD and LV in planning radiotherapy while maintaining adequate dose coverage for patients with left-sided breast cancer.

Methods

We retrospectively analyzed left-sided breast cancer cases treated at the Kocaeli University Faculty of Medicine. Only patients with local and locally advanced breast cancer were included in the analysis. A total of 77 patients who were treated between 2020 and 2024 were included. The doses to the LAD and LV were added to the optimization algorithms. Two volumetric modulated arc therapy (VMAT) plans were created for each patient. A total of 154 plans were made, including standard and LAD and LV sparing plans.

Results

There was no statistically significant difference in all VMAT plans regarding planning target volume (PTV) D2, D50, and D98 (dose receiving volume of PTV 2%, 50%, and 98%) (p > 0.05). However, a significant decrease was observed in heart V5 (the percentage of the heart receiving at least 5 gray (Gy)) and mean heart dose. A decrease in the mean heart dose was observed in the standard plan compared with the LAD and LV sparing plan (p < 0.001). Similarly, the heart V5 value decreased significantly (p < 0.001). Additionally, significant reductions were measured in all LAD and LV parameters after re-optimization.

Conclusions

We achieved significant reductions in all heart, LAD, and LV parameters without making any changes to the planned treatment volume coverage by adding LAD and LV OARs to the optimization algorithms. The potential risk of MACE can be significantly reduced by implementing this strategy.

Immunotherapy Improves Clinical Outcome in Kirsten Rat Sarcoma Virus-Mutated Patients with Unresectable Non-Small Cell Lung Cancer Stage III: A Subcohort Analysis of the Austrian Radio-Oncological Lung Cancer Study Association Registry (ALLSTAR)

Background/Objectives: Current evidence suggests that patients with unresectable non-small cell lung cancer (NSCLC) whose tumours harbour driver mutations do not benefit from immune checkpoint inhibition. Kirsten rat sarcoma virus mutations (KRASmts), however, seem to be the exceptions to the rule. To this end, we compared KRASmt patients who were treated with immunotherapy to those without. Methods: ALLSTAR is a nationwide registry for patients with histologically verified non-operable NSCLC aged 18 or older having a curative treatment option. This report presents a subcohort of KRASmt patients who were recruited between 2020/03 and 2023/04. The diagnostic work-up included 18F-FDG-PET-CT scan and contrast-enhanced cranial CT or-preferably-MRI. Patients were treated with chemoradiotherapy (CRT) either followed by immune checkpoint inhibition (ICI) or not. Results: Thirty-two KRASmt patients with a median follow-up of 25.9 months were included in this analysis. After CRT, 27/32 (84%) patients received ICI. The 2-year overall survival rate in KRASmt patients who received immunotherapy was significantly better compared to those without ICI (N = 32; 84% versus 20%; p < 0.001). Likewise, the 2-year progression-free-survival with immunotherapy was also significantly better than in those without ICI (N = 32; 75% versus 20%; p < 0.001). Of the 12/32 patients (38%) who had received radiation doses > 66 Gy, none had a locoregional relapse, whereas in the other 20 patients, 5 (25%) events occurred (p-value = 0.116). Conclusions: Since KRASmt patients could benefit from ICI treatment, immunotherapy should be offered to these patients, similar to those without actionable genetic drivers. Additionally, radiation dose escalation > 66 Gy may also improve locoregional control in this subset of patients.

Comparison of Various GAN-Based Bone Suppression Imaging for High-Accurate Markerless Motion Tracking of Lung Tumors in CyberKnife Treatment

Stereotactic body radiation therapy (SBRT) is a highly effective treatment for lung cancer; however, challenges arise from tumor motion induced by respiration. The CyberKnife system, incorporating both fiducial-based and fiducial-free tracking modalities, aims to mitigate these challenges, yet tumor recognition can be compromised by overlapping bone structures. This study introduces a novel bone suppression imaging technique for kilovolt X-ray imaging using generative adversarial networks (GANs) to enhance tumor tracking in SBRT by reducing interference from bony structures. Computed tomography (CT) images, both with and without bone structures, were generated using a four-dimensional extended cardiac-torso phantom (XCAT phantom) across 56 cases. X-ray projections were captured from left and right oblique 45° angles and divided into nine segments, producing 1120 images. These images were processed through six pre-trained GAN models-CycleGAN, DualGAN, CUT, FastCUT, DCLGAN, and SimDCL-yielding bone-suppressed images on the XCAT phantom (BSIphantom). The resulting images were evaluated against bone-shadow-free images using structural similarity index measure (SSIM), peak signal-to-noise ratio (PSNR), and Frechet inception distance (FID). Additionally, bone-suppressed images (BSIpatient) were derived from 1000 non-simulated patient images. BSIphantom images achieved SSIM and PSNR values of 0.96 ± 0.02 and 36.93 ± 3.93, respectively. SimDCL exhibited optimal performance with an FID score of 68.93, indicative of superior image generation quality. This GAN-based bone suppression imaging technique markedly improved image recognition and refined dynamic tumor tracking, enhancing the accuracy and efficacy of SBRT.

Surgery/non-surgery-based strategies for invasive locally-advanced non-small cell lung cancer in the era of precision medicine

BACKGROUND

Treatments for invasive T4 non-small cell lung cancer (NSCLC) tumors have been traditionally individualized and often require multidisciplinary team (MDT) evaluation. Advances in precision medicine may open up new opportunities for these patients.

METHODS

This retrospective cohort study, using the Surveillance, Epidemiology, and End Results (SEER) database, identified T4N0-3M0 NSCLC patients with central structure invasion from 2010 to 2020. Precision medicine has progressed in three periods: 2010-2014 (targeted therapy), 2015-2017 (initial immunotherapy), and 2018-2020 (latest immunotherapy). We utilized Propensity Score Matching (PSM) to control confounding factors and competing risk regression models to evaluate cancer-specific survival (CSS).

RESULTS

A total of 9,106 cases were matched after PSM. For all populations, the median overall survival (OS) significantly increased with the advancement of precision medicine: 23.0 months in Period I (95 ​% CI: 22.0-25.0), 28.0 months in Period II (95 ​% CI: 26.0-31.0), and not reached (NR) in Period III (95 ​% CI: 30.0 - NR). Multivariate analysis also revealed a sequential survival improvement from Period I to III (p ​< ​0.001). Surgery-based treatment yielded the longest median OS at 46.0 months (95 ​% CI: 43.0-49.0, p ​< ​0.001), compared with chemoradiotherapy, chemotherapy alone and radiation alone. Surgery-based treatment has also yielded the best survival in three precision medicine eras, in both N0-1 and N2-3 categories. After analyzing CSS, the results above remained consistent. The survival following chemoradiotherapy and chemotherapy alone has seen significant and progressive enhancements across the three eras of precision medicine. There were no significant survival differences between Periods I and II among surgery-based patients, but a slight improvement trend was noted in Period III.

CONCLUSION

This retrospective study indicated that as precision medicine for NSCLC evolved, personalized treatment strategies supported by effective MDT led to survival improvement. Notably, for invasive stage III patients, surgery-based strategies have consistently shown substantial benefits across all the periods, irrespective of the N stage. The integration of perioperative therapies to enhance surgical feasibility, especially the latest immunotherapy, holds particular promise for further survival benefits.

Radiotherapy toxicities: mechanisms, management, and future directions

For over a century, radiotherapy has revolutionised cancer treatment. Technological advancements aim to deliver high doses to tumours with increased precision while minimising off-target effects to organs at risk. Despite advancements such as image-guided, high-precision radiotherapy delivery, long-term toxic effects on healthy tissues remain a great clinical challenge. In this Review, we summarise common mechanisms driving acute and long-term side-effects and discuss monitoring strategies for radiotherapy survivors. We explore ways to mitigate toxic effects through novel technologies and proper patient selection and counselling. Additionally, we address policies and management strategies to minimise the severity and impact of toxicity during and after treatment. Finally, we examine the potential advantages of emerging technologies and innovative approaches to improve conformity, accuracy, and minimise off-target effects.

Canine lung carcinoma-A descriptive review

Primary lung cancer is a relatively uncommon tumor in dogs, accounting for about 1% of all canine malignancies. Clinical signs in affected dogs can range from being asymptomatic to exhibiting chronic cough, and in rare cases, dyspnoea. Surgical excision of the primary tumor, along with resection of the affected locoregional lymph nodes is the preferred treatment option for most cases. Although chemotherapy, targeted therapy and radiation therapy have been employed, their effectiveness remain controversial. Dogs with stage T1 tumors can experience extended survival times of up to 2 years. However, the prognosis for dogs with advanced metastatic tumors is generally very poor. This review article discusses the etiology, clinical signs, diagnosis, staging, treatment options, and prognosis of primary lung carcinoma in dogs.

Cardiac Exposure Related to Adjuvant Radiotherapy in Patients Affected by Thymoma: A Dosimetric Comparison of Photon or Proton Intensity-Modulated Therapy

BACKGROUND

Radiotherapy for thymoma is delivered post-operatively in selected cases. Given the particular location of the thymic bed and the excellent prognosis, late cardiac toxicities may be an issue. The purpose of this retrospective dosimetric study is to investigate whether intensity-modulated proton beam therapy (IMPT) compared to photon therapy could better spare cardiac substructures, given prespecified dose constraints.

METHODS

We retrospectively selected patients treated with adjuvant radiotherapy for thymoma in our institution. We manually contoured fourteen cardiac substructures (CSs), with the supervision of a team of cardioradiologists. The photon-based plans were re-optimized in adherence to the volumetric modulated arc therapy (VMAT) technique with specific dose constraints for the new contoured structures. The proton-based plans were optimized in adherence to intensity-modulated proton therapy (IMPT) using the beam spot scanning technique.

RESULTS

Twenty-nine patients treated with adjuvant radiotherapy with a prescribed dose of 50 Gy in 25 daily fractions for radically resected thymoma were selected. IMPT demonstrated better sparing of most cardiac substructures in terms of Dmax, Dmean and V5Gy. Finally, IMPT plans more easily achieved the proposed dose constraints.

CONCLUSIONS

Cardiac substructures can be successfully spared with IMPT. Clinical studies are needed to establish a relationship between dose parameters and the development of cardiac events.

How I Do It: Management of Pleural-attached Pulmonary Nodules in Low-Dose CT Screening for Lung Cancer

Lung cancer is the leading cause of cancer deaths globally. In various trials, the ability of low-dose CT screening to diagnose early lung cancers leads to high cure rates. It is widely accepted that the potential benefits of low-dose CT screening for lung cancer outweigh the harms. The ability to reliably predict the benignity of nodules, especially at the baseline round, further reduces the potential for harm. Pleural-attached nodules are an important subgroup that represents nodules attached (distance from any pleural surface, 0 mm) to any pleural surfaces (fissural, costal, mediastinal, and diaphragmatic). Pleural-attached solid nodules less than 10 mm in average diameter with smooth margins and triangular, lentiform, oval, or semicircular shapes have a high likelihood of benignity. The 2019 Lung CT Screening Reporting and Data System (Lung-RADS) version 1.1 assigned pleural-attached nodules with these features to categories 3 (probably benign, recommend follow-up in 6 months) or 4 (suspicious for malignancy, recommend follow-up in 3 months or PET/CT). However, Lung-RADS version 2022 now recommends annual follow-up rather than short-term follow-up. These changes downgrade these nodules to category 2 (benign) and limits additional workup. This review article summarizes the terminology used to describe these nodules, characteristics for determining benignity, and the accuracy of the evidence used to make these recommendations.