Stereotactic body radiation therapy (SBRT) for early-stage lung cancer in the elderly

Overall survival in low-comorbidity patients with stage I non-small cell lung cancer who chose stereotactic body radiotherapy compared to surgery

OBJECTIVE

To evaluate trends in the utilization of stereotactic body radiotherapy (SBRT) and to compare overall survival (OS) of patients with early-stage non-small cell lung cancer (NSCLC) undergoing SBRT versus those undergoing surgery.

METHODS

The National Cancer Database was queried for patients without documented comorbidities who underwent surgical resection (lobectomy, segmentectomy, or wedge resection) or SBRT for clinical stage I NSCLC between 2012 and 2018. Peritreatment mortality and 5-year OS were compared among propensity score-matched cohorts.

RESULTS

A total of 30,658 patients were identified, including 24,729 (80.7%) who underwent surgery and 5929 (19.3%) treated with SBRT. Between 2012 and 2018, the proportion of patients receiving SBRT increased from 15.9% to 26.0% (P < .001). The 30-day mortality and 90-day mortality were higher among patients undergoing surgical resection versus those receiving SBRT (1.7% vs 0.3%, P < .001; 2.8% vs 1.7%, P < .001). In propensity score-matched patients, OS favored SBRT for the first several months, but this was reversed before 1 year and significantly favored surgical management in the long term (5-year OS, 71.0% vs 41.8%; P < .001). The propensity score-matched analysis was repeated to include only SBRT patients who had documented refusal of a recommended surgery, which again demonstrated superior 5-year OS with surgical management (71.4% vs 55.9%; P < .001).

CONCLUSIONS

SBRT is being increasingly used to treat early-stage lung cancer in low-comorbidity patients. However, for patients who may be candidates for either treatment, the long-term OS favors surgical management.

Inflammation index predicts radiation-induced lung injury and prognosis in lung tumors treated with stereotactic body radiation therapy

PURPOSE

To investigate the effect of inflammation-based indexes in predicting radiation pneumonitis (RP) and prognosis in lung tumor patients treated with stereotactic body radiation therapy (SBRT).

MATERIALS AND METHODS

The data of one hundred and seventy-two patients with 272 lung lesions from November 2015 to December 2020 were retrospectively analyzed. Pretreatment hematological indexes including platelet count, neutrophil count, and lymphocyte count were collected before treatment. Systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were calculated. The receiver operating characteristic (ROC) curve was established to predict the RP and overall survival of patients, and the Youden index was calculated to determine the cutoff values of SII, NLR, and PLR before radiotherapy.

RESULTS

Pretreatment SII, NLR, and PLR could predict RP in lung tumor patients treated with SBRT, the optimal cutoff values of SII, NLR, and PLR were 355.38, 2.04, and 141.09, respectively. Pretreatment PLR could predict survival and the optimal cutoff value of PLR was 166.83, patients with a PLR > 166.83 predict worse overall survival (OS) (P < 0.001). The 1-year and 2-year OS for patients with a PLR ≤ 166.83 were 96.3% and 82.4%, while for those with a PLR > 166.83 were 82.0% and 58.5%, respectively.

CONCLUSION

In lung tumor patients treated with SBRT, pretreatment SII, NLR, and PLR can effectively predict RP and a higher PLR predicts poor OS. These inflammation-based indexes could serve as reliable and convenient predictors to guide treatment for physicians in clinical practice.

Radiation dose, schedule, and novel systemic targets for radio-immunotherapy combinations

Immunotherapy combinations are being investigated to expand the benefit of immune checkpoint blockade across many cancer types. Radiation combinations, in particular using stereotactic body radiotherapy, are of keen interest because of underlying mechanistic rationale, safety, and availability as a standard of care in certain cancers. In addition to direct tumor cytotoxicity, radiation therapy has immunomodulatory effects such as induction of immunogenic cell death, enhancement of antigen presentation, and expansion of the T-cell receptor repertoire as well as recruitment and increased activity of tumor-specific effector CD8+ cells. Combinations of radiation with cytokines and/or chemokines and anti-programmed death 1 and anticytotoxic T-lymphocyte antigen 4 therapies have demonstrated safety and feasibility, as well as the potential to improve long-term outcomes and possibly induce out of irradiated field or abscopal responses. Novel immunoradiotherapy combinations represent a promising therapeutic approach to overcome radioresistance and further enhance systemic immunotherapy. Potential benefits include reversing CD8+ T-cell exhaustion, inhibiting myeloid-derived suppressor cells, and reversing M2 macrophage polarization as well as decreasing levels of colony-stimulating factor-1 and transforming growth factor-β. Here, we discuss current data and mechanistic rationale for combining novel immunotherapy agents with radiation therapy.

Real-World Results of Stereotactic Body Radiotherapy for 399 Medically Operable Patients with Stage I Histology-Proven Non-Small Cell Lung Cancer

Surgery is the standard treatment for stage I non-small cell lung cancer (NSCLC); however, no clear randomized trial demonstrates its superiority to stereotactic body radiotherapy (SBRT) regarding survival. We aimed to retrospectively evaluate the treatment outcomes of SBRT in operable patients with stage I NSCLC using a large Japanese multi-institutional database to show real-world outcome. Exactly 399 patients (median age 75 years; 262 males and 137 females) with stage I (IA 292, IB 107) histologically proven NSCLC (adenocarcinoma 267, squamous cell carcinoma 96, others 36) treated at 20 institutions were reviewed. SBRT was prescribed at a total dose of 48-70 Gy in 4-10 fractions. The median follow-up period was 38 months. Local progression-free survival rates were 84.2% in all patients and 86.1% in the T1, 78.6% in T2, 89.2% in adenocarcinoma, and 70.5% in squamous cell subgroups. Overall 3-year survival rates were 77.0% in all patients: 90.7% in females, 69.6% in males, and 41.2% in patients with pulmonary interstitial changes. Fatal radiation pneumonitis was observed in two patients, all of whom had pulmonary interstitial changes. This real-world evidence will be useful in shared decision-making for optimal treatment, including SBRT for operable stage I NSCLC, particularly in older patients.

CT-derived radiomic analysis for predicting the survival rate of patients with non-small cell lung cancer receiving radiotherapy

BACKGROUND

Radiomics provides an opportunity to minimize adverse effects and optimize the efficacy of treatments noninvasively. This study aims to develop a computed tomography (CT) derived radiomic signature to predict radiological response for the patients with non-small cell lung cancer (NSCLC) receiving radiotherapy.

METHODS

Total 815 NSCLC patients receiving radiotherapy were sourced from public datasets. Using CT images of 281 NSCLC patients, we adopted genetic algorithm to establish a predictive radiomic signature for radiotherapy that had optimal C-index value by Cox model. Survival analysis and receiver operating characteristic curve were performed to estimate the predictive performance of the radiomic signature. Furthermore, radiogenomics analysis was performed in a dataset with matched images and transcriptome data.

RESULTS

Radiomic signature consisting of three features was established and then validated in the validation dataset (log-rank P = 0.0047) including 140 patient, and showed a significant predictive power in two independent datasets totaling 395 NSCLC patients with binary 2-year survival endpoint. Furthermore, the novel proposed radiomic nomogram significantly improved the prognostic performance (concordance index) of clinicopathological factors. Radiogenomics analysis linked our signature with important tumor biological processes (e.g. Mismatch repair, Cell adhesion molecules and DNA replication) associated with clinical outcomes.

CONCLUSIONS

The radiomic signature, reflecting tumor biological processes, could noninvasively predict therapeutic efficacy of NSCLC patients receiving radiotherapy and demonstrate unique advantage for clinical application.

Impact of stereotactic body radiation therapy volume on surgical patient selection, short-term survival, and long-term survival in early-stage non-small cell lung cancer

OBJECTIVES

Stereotactic body radiation therapy (SBRT) is increasingly used to treat non-small cell lung cancer. The purpose of this study is to analyze relationships between facility SBRT utilization and surgical patient selection and survival after surgery.

METHODS

Data on patients with TI/T2N0M0 lesions and treatment facility characteristics were abstracted from the National Cancer Database, 2008 to 2017. Facilities were stratified using an SBRT/surgery ratio previously associated with short-term survival benefit for patients treated surgically, and by a previously identified surgical volume threshold. Multiple regression analyses, Cox proportional-hazard regressions, and Kaplan-Meier log rank test were employed.

RESULTS

In total, 182,610 patients were included. Proportion of high SBRT:surgery ratio (≥17%) facilities increased from 118 (11.5%) to 558 (48.4%) over the study period. Patients undergoing surgery at high-SBRT facilities had comparable comorbidity scores and tumor sizes to those at low-SBRT facilities, and nonclinically significant differences in age, race, and insurance status. Among low-volume surgical facilities, treatment at a high SBRT-using facility was associated with decreased 30-day mortality (1.8% vs 1.4%, P < .001) and 90-day mortality (3.3% vs 2.6%, P < .001). At high-volume surgical facilities, no difference was observed. At 5 years, a survival advantage was identified for patients undergoing resection at facilities with high surgical volumes (hazard ratio, 0.91; confidence interval, 0.90-0.93 P < .001) but not at high SBRT-utilizing facilities.

CONCLUSIONS

Differences in short-term survival following resection at facilities with high-SBRT utilization may be attributable to low surgical volume facilities. Patients treated at high volume surgical facilities do not demonstrate differences in short-term or long-term survival based on facility SBRT utilization.

Hospital Utilization of Stereotactic Body Radiation Therapy and Rates of Surgical Refusal

BACKGROUND

Increasingly, stereotactic body radiation therapy (SBRT) is used for patients unfit for or unwilling to undergo operation for early-stage non-small cell lung cancer. It remains unclear how SBRT utilization has influenced patient refusal of surgical resection.

METHODS

A retrospective cohort analysis was completed using the National Cancer Database for patients with T1/T2 N0 M0 lesions from 2008 to 2017. Facilities were categorized into tertiles by SBRT/surgery ratio for each year of analysis. Propensity score matching was used to compare rates of surgical refusal and rates of postrefusal receipt of SBRT. Multivariable regression analysis was performed to evaluate effect size.

RESULTS

The study included 129 901 patients; 63 048 were treated at low-tertile SBRT/surgery facilities, 41 674 at middle-tertile SBRT/surgery facilities, and 25 179 at high-tertile SBRT/surgery facilities. Patients refusing surgery at high SBRT/surgery facilities had fewer comorbid conditions and smaller tumors. Rates of SBRT after surgical refusal differed (low SBRT/surgery facilities, 17.2%; high SBRT/surgery facilities, 55.9%; P < .001). In a matched cohort of 76 636, surgical refusal differed (low SBRT/surgery facilities, 4.2%; high SBRT/surgery facilities, 6.0%; P < .001). On multivariable regression, treatment at a top-tertile SBRT/surgery facility was the largest risk factor for surgical refusal (odds ratio, 3.82 [3.53-4.13]; P < .001) and was most strongly associated with postrefusal receipt of SBRT (odds ratio, 6.11 [5.09-7.34]; P < .001).

CONCLUSIONS

Patients treated at high SBRT-using facilities are more likely to refuse surgical resection and more likely to receive radiation therapy after surgical refusal. Further analysis is needed to better understand patient refusal of surgery in the setting of early-stage non-small cell lung cancer.

Deep inspiratory breath hold assisted by continuous positive airway pressure ventilation for lung stereotactic body radiotherapy

PURPOSE

Continuous positive airway pressure (CPAP) ventilation hyperinflates the lungs and reduces diaphragmatic motion. We hypothesized that CPAP could be safely combined with deep inspiratory breath hold (CPAP-DIBH) during lung stereotactic radiotherapy (SBRT).

MATERIAL AND METHODS

Patients with stage-1 lung cancer or lung metastasis treated with CPAP-DIBH SBRT between 3/2017-5/2021 were analyzed retrospectively. Patient characteristics, treatment parameters, duration of breath holds in all sessions and tolerance to CPAP-DIBH were recorded. Local control (LC) was assessed from CT or PET-CT imaging. The distances between the tumor and mediastinal organs at risk (OAR) in centrally located tumors using either free breathing (FB) or CPAP-DIBH were compared. Toxicity was graded retrospectively.

RESULTS

Forty-five patients with 71 lesions were treated with CPAP-DIBH SBRT. Indications for CPAP-DIBH were prior radiation (35/71, 65%), lower lobe location (34/71, 48%), multiple lesions (26/71, 36.6%) and proximity to mediastinal OAR (7/71, 10%). Patient characteristics were: F:M 43%: 57%; mean gross tumor volume 4.5cm³ (SD 7.9), mean planning target volume 20cm³ (SD 27), primary: metastatic lesions (7%:93%). Mean radiation dose was 52.5 Gray (SD3.5). Mean lung volume was 5292cm³ (SD 1106). Mean duration of CPAP-DIBH was 41.3s (IQR 31-46.8). LC at 2 years was 89.5% (95% CI 76-95.5). In patients with central lesions, the distance between the tumor and mediastinal OAR increased from 0.84cm (SD 0.65) with FB to 1.23cm (SD 0.8) with CPAP-DIBH (p=0.002). Most patients tolerated CPAP well and completed all treatments after starting therapy. Three patients did not receive treatment: 2 were unable to tolerate CPAP and 1 had syncope (pre-existing). Toxicity was grade 2 in 4/65 (6%) and grade 3 in 1/65 (1.5%). There was no grade 2 or higher esophageal or tracheal toxicities.

CONCLUSION

CPAP-DIBH assisted lung SBRT was tolerated well and was associated with minimal toxicity and favorable LC. This technique may be considered when treating multiple lung lesions, lesions located in the lower lobes or adjacent to mediastinal OAR.

Changes in Treatment Patterns and Costs for Lung Cancer Have Not Resulted in Relevant Improvements in Survival: A Population-Based Observational Study in Catalonia

OBJECTIVE

Few published studies have described multidisciplinary therapeutic strategies for lung cancer. This study aims to describe the different approaches used for treating lung cancer in Catalonia in 2014 and 2018 and to assess the associated cost and impact on patient survival.

METHODS

A retrospective observational cohort study using data of patients with lung cancer from health care registries in Catalonia was carried out. We analyzed change in treatment patterns, costs and survival according to the year of treatment initiation (2014 vs. 2018). The Kaplan-Meier method was used to estimate survival, with the follow-up until 2021.

RESULTS

From 2014 to 2018, the proportion of patients undergoing surgery increased and treatments for unresectable tumors decreased, mainly in younger patients. Immunotherapy increased by up to 9% by 2018. No differences in patient survival were observed within treatment patterns. The mean cost per patient in the first year of treatment increased from EUR 14,123 (standard deviation [SD] 4327) to EUR 14,550 (SD 3880) in surgical patients, from EUR 4655 (SD 3540) to EUR 5873 (SD 6455) in patients receiving curative radiotherapy and from EUR 4723 (SD 7003) to EUR 6458 (SD 10,116) in those treated for unresectable disease.

CONCLUSIONS

From 2014 to 2018, surgical approaches increased in younger patients. The mean cost of treating patients increased, especially in pharmaceutical expenditure, mainly related to the use of several biomarker-targeted treatments. While no differences in overall patient survival were observed, it seems reasonable to expect improvements in this outcome in upcoming years as more patients receive innovative treatments.

Race is a Risk Factor for the Deferral of Resection and Radiation for Early-Stage Lung Cancer

PURPOSE

There remain profound race-related disparities in the treatment of non-small cell lung cancer (NSCLC). Deferral of operative management for early-stage disease is recognized as driver of this disparity. Black race has been associated with higher rates of surgical deferral. It remains unclear how race impacts likelihood of receiving radiation therapy after declining surgical management of NSCLC.

PATIENTS AND METHODS

A retrospective cohort analysis was completed using data from the National Cancer Database (NCBD) for patients 18 and over with stage I NSCLC offered surgical resection from 2004 to 2015 (N = 89,462). Multivariable logistic regression identified predictors of surgical deferral and predictors for deferral of radiation after deferral of surgery. Kaplan-Meier survival analysis with log-rank tests and multivariable Cox proportional hazards regressions were performed.

RESULTS

87,293 (97.6%) patients underwent surgery, 2169 (2.4%) deferred. Patients who deferred had 2.1 times higher hazard ratio for mortality, (HR = 2.08, [1.97, 2.29], P < .001). Of those that deferred, 1250 (57.6%) received postdeferral radiation. Compared to White patients, Black patients had OR of 1.82 for deferring both surgery and radiation (aOR: 1.82, [1.31, 2.53], P < .001) and Asian and Pacific Island (API) patients had an OR of 2.67 (aOR: 2.67, [1.27, 4.64], P = .008). Other predictors of deferral of therapy included: Medicare or lack of insurance, and treatment at nonacademic medical centers.

CONCLUSION

Insurance status and Black race, and API race are associated with deferring surgical therapy and radiation therapy for NSCLC. These findings are consistent with the large body of work showing worse outcomes for treatment of NSCLC in minority patients.

Stereotactic body radiotherapy for recurrent and oligometastatic soft tissue sarcoma

Background

Soft tissue sarcoma (STS) is a malignant tumor of highly heterogeneous mesenchymal origin. STS has a biological pattern and clinical transformation with localized invasive growth and is susceptible to hematogenous metastasis. Local therapeutic strategies may treat recurrent and oligometastatic STS, including surgery and radiation therapy. This study aimed to evaluate the safety and efficacy of stereotactic body radiotherapy (SBRT) for recurrent and oligometastatic STS.

Methods

We retrospectively analyzed 37 recurrent and oligometastatic STS patients with 58 lesions treated with SBRT from 2009 to 2019 at our institution. Oligometastatic is defined as metastatic lesions less than or equal to 3. The primary endpoint was local control (LC); secondary endpoints were survival and toxicity.

Results

The median follow-up was 21.0 months (3.0 to 125.0 months). Among 37 patients, 18 were recurrent patients, and 19 were oligometastatic patients. Median LC was 25.0 months (95% CI 20.0–45.0). The 1-, 2-, and 3-year LC rates were 80.2%, 58.3%, and 46.6%, respectively. Median overall survival (OS) was 24.0 months (95% CI 13.0–28.0), and the survival rates after SBRT were 71.5%, 40.0%, and 29.1% at 1, 2, and 3-year, respectively. Median progression-free survival (PFS) was 10.0 months (95% CI 8.0–15.0 months), PFS rate after SBRT was 43.6%, 26.8%, and 18.4% at 1, 2, and 3 years, respectively. Late grade 3 radiation dermatitis was observed in one patient (2.7%). Using univariate and multivariate COX analysis, better OS, PFS, and LC were obtained in the histologic grade 1(G1) group, and tumor size and a number of lesions influenced LC.

Conclusions

SBRT is a safe and effective treatment for patients with recurrent and oligometastatic STS. Histological grade influences local control and survival. SBRT may be a promising treatment option for recurrent and oligometastatic STS.

Application of real-time MRI-guided linear accelerator in stereotactic ablative body radiotherapy for non-small cell lung cancer: one step forward to precise targeting

PURPOSE

Tumor motion is a major challenge in stereotactic ablative body radiotherapy (SABR) for non-small cell lung cancer (NSCLC), causing excessive irradiation to compensate for this motion. Real-time tumor tracking with a magnetic resonance imaging-guided linear accelerator (MR-Linac) could address this problem. This study aimed to assess the effects and advantages of MR-Linac in SABR for the treatment of lung tumors.

METHODS

Overall, 41 patients with NSCLC treated with SABR using MR-Linac between March 2019 and December 2021 were included. For comparison, 40 patients treated with SABR using computed tomography-based modalities were also enrolled. The SABR dose ranged from 48 to 60 Gy in 3-5 fractions. The primary endpoint was a lower radiation volume compared to CT-based SABR. The secondary endpoint was the local control rate of SABR using the MR-Linac.

RESULTS

The median follow-up time was 19 months (range: 3-105 months). There was no significant difference in the gross tumor volume between the MR and CT groups (7.1 ± 9.3 cm³ vs 8.0 ± 6.8 cm³, p = 0.643), but the planning target volume was significantly smaller in the MR group (20.8 ± 18.8 cm³ vs 34.1 ± 22.9 cm³, p = 0.005). The 1-year local control rates for the MR and CT groups were 92.1 and 75.4%, respectively (p = 0.07), and the 1-year overall survival rates were 87.4 and 87.0%, respectively (p = 0.30).

CONCLUSION

Lung SABR with MR-Linac can reduce the radiation field without compromising the local control rate. Further follow-up is needed to assess the long-term effects.

Clinical Outcomes Following Proton and Photon Stereotactic Body Radiation Therapy for Early-Stage Lung Cancer

Simple Summary

The current study reports the clinical outcomes of proton and photon stereotactic body radiation therapy (SBRT) for early-stage lung cancer. Out of 202 patients who met the inclusion criteria, 34 received proton SBRT and 168 received photon SBRT. Patients at high risk of developing post-SBRT radiation pneumonitis tended to receive proton SBRT. Oncologic outcomes and toxicity profiles were comparable between treatment modalities. Proton SBRT could be considered for patients with high risk of radiation pneumonitis.

Abstract

We aimed to report the clinical outcomes following stereotactic body radiation therapy (SBRT) using photon or proton equipment in early-stage lung cancer. We retrospectively reviewed 202 cT1-2N0M0 lung cancer patients who underwent SBRT with 60 Gy in four consecutive fractions between 2010 and 2019 at our institution: 168 photon SBRT and 34 proton SBRT. Patients who underwent proton SBRT had relatively poor baseline lung condition compared to those who underwent photon SBRT. Clinical outcomes were comparable between treatment modalities: 5-year local control (90.8% vs. 83.6%, p = 0.602); progression-free survival (61.6% vs. 57.8%, p = 0.370); overall survival (51.7% vs. 51.9%, p = 0.475); and cause-specific survival (70.3% vs. 62.6%, p = 0.618). There was no statistically significant difference in grade ≥ 2 toxicities: radiation pneumonitis (19.6% vs. 26.4%, p = 0.371); musculoskeletal (13.7% vs. 5.9%, p = 0.264); and skin (3.6% vs. 0.0%, p = 0.604). In the binary logistic regression analysis of grade ≥3 radiation pneumonitis, poor performance status and poor baseline diffusion capacity of lung for carbon monoxide were significant. To summarize, though patients with high risk of developing lung toxicity underwent proton SBRT more frequently, the SBRT techniques resulted in comparable oncologic outcomes with similar toxicity profiles. Proton SBRT could be considered for patients at high risk of radiation pneumonitis.

Applying Artificial Neural Networks to Develop a Decision Support Tool for Tis-4N0M0 Non-Small-Cell Lung Cancer Treated With Stereotactic Body Radiotherapy

PURPOSE

Clear evidence indicating whether surgery or stereotactic body radiation therapy (SBRT) is best for non-small-cell lung cancer (NSCLC) is lacking. SBRT has many advantages. We used artificial neural networks (NNs) to predict treatment outcomes for patients with NSCLC receiving SBRT, aiming to aid in decision making.

PATIENTS AND METHODS

Among consecutive patients receiving SBRT between 2005 and 2019 in our institution, we retrospectively identified those with Tis-T4N0M0 NSCLC. We constructed two NNs for prediction of overall survival (OS) and cancer progression in the first 5 years after SBRT, which were tested using an internal and an external test data set. We performed risk group stratification, wherein 5-year OS and cancer progression were stratified into three groups.

RESULTS

In total, 692 patients in our institution and 100 patients randomly chosen in the external institution were enrolled. The NNs resulted in concordance indexes for OS of 0.76 (95% CI, 0.73 to 0.79), 0.68 (95% CI, 0.60 to 0.75), and 0.69 (95% CI, 0.61 to 0.76) and area under the curve for cancer progression of 0.80 (95% CI, 0.75 to 0.84), 0.72 (95% CI, 0.60 to 0.83), and 0.70 (95% CI, 0.57 to 0.81) in the training, internal test, and external test data sets, respectively. The survival and cumulative incidence curves were significantly stratified. NNs selected low-risk cancer progression groups of 5.6%, 6.9%, and 7.0% in the training, internal test, and external test data sets, respectively, suggesting that 48% of patients with peripheral Tis-4N0M0 NSCLC can be at low-risk for cancer progression.

CONCLUSION

Predictions of SBRT outcomes using NNs were useful for Tis-4N0M0 NSCLC. Our results are anticipated to open new avenues for NN predictions and provide decision-making guidance for patients and physicians.

Evaluation of response to stereotactic body radiation therapy for nonsmall cell lung cancer: PET response criteria in solid tumors versus response evaluation criteria in solid tumors

OBJECTIVE

Recommendations for surveillance after stereotactic body radiation therapy (SBRT) for early-stage nonsmall cell lung cancer (NSCLC) are not well defined. Recently, PET response criteria in solid tumors (PERCIST) have been proposed as a new standardized method to assess radiotherapeutic response both quantitatively and metabolically. The aim of this study was to evaluate therapeutic response following SBRT in early-stage NSCLC patients by comparing PERCIST with the currently widely used RECIST.

MATERIALS AND METHODS

Forty-nine patients with early-stage NSCLC who had been prescribed SBRT were studied. Responses of lesion were evaluated using CT and 18F-FDG PET according to the RECIST and PERCIST methods. PET-CT scans were obtained before SBRT and 3-6 months after SBRT. Associations between overall survival (OS) and clinicopathologic results (histology, tumor location, tumor size, lymphatic invasion, clinical stage, and radiotherapeutic responses in RECIST and PERCIST) were statistically analyzed. The median patient follow-up was 30 months.

RESULTS

Thirteen patients had stage IA, 9 stage IB, 10 stage IIA, and 17 stage IIB biopsy-proven NSCLC. Three-year OS was 79.6%. CT scans indicated three regional recurrences. PET-CT/chest indicated three regional recurrences and distant metastasis. Significant differences were observed in response classification between RECIST and PERCIST (Wilcoxon signed-rank test, P = 0.0041). Univariate analysis showed that clinical stage, RECIST, and PERCIST were significant factors associated with OS, whereas by multivariate analysis PERCIST was the only predictor of OS. SMD, PMD/PMR, and CMR in PERCIST criteria were indicative of a 9.900-fold increase in the risk of OS in early NSCLC patients [risk ratio, 9.900 (95% CI, 1.040-21.591); P = 0.001].

CONCLUSION

RECIST based on the anatomic size reduction rate did not demonstrate the correlation between radiotherapeutic response and prognosis in patients with early-stage NSCLC receiving SBRT. However, PERCIST was shown as the strongest independent predictor of outcomes. PERCIST might be considered more suitable for the evaluation of NSCLC tumor response to SBRT than RECIST.

In situ real time dosimetric studies for spine stereotactic body radiation therapy in a cadaver implanted with carbon fiber and titanium instrumentation

OBJECTIVE

To compare the dosimetric accuracy of post-operative SBRT in a carbon-fiber versus titanium instrumented spine using cadaveric model METHODS: In situ cadaveric implantation of titanium and carbon fiber instrumentation and dosimeter chips in a thoracic spine. The cadaver underwent SBRT and dose of RT was calculated, measured, and then compared. The sensors were placed in positions to provide data on dosimetry near the screws (within 1 cm) as well as between the screws. The differences between calculated and measured doses were reported as in percentage.

RESULTS

There was a significant difference in the dosimetry from calculated versus measured values near the screws of carbon fiber compared to titanium (P = 0.0057) with a mean percentage difference of only 2.93 for CF and a much higher value of 19.32 for titanium near the screws. There was also greater variability in the percent difference for the two screw types, with differences ranging from -16.54% to 35.20% near titanium screws and -3.37% to 1.66% near CF screws.

CONCLUSION

More accurate dosimetry and RT delivery with carbon fiber screws compared to traditional titanium screws may have implications on optimal radiation delivery as well as complication avoidance. This may be due to reduced scatter and thus lower variability in radiation delivery with VMAT technique.

Patterns of Use of Stereotactic Body Radiation Therapy Compared With Surgery for Definitive Treatment of Primary Early-stage Non-small Cell Lung Cancer

OBJECTIVE

As stereotactic body radiation therapy (SBRT) becomes widely available for early-stage non-small cell lung cancer (NSCLC), there may be concerns in the surgical community that SBRT is being offered for patients with operable tumors, even though surgery is standard of care. We evaluated the trends in SBRT and surgery over time for patients with NSCLC.

MATERIALS AND METHODS

The National Cancer Database was queried for patients with node-negative NSCLC ≤5 cm from 2004 to 2016. The relationships between definitive local treatment modalities and year were analyzed using a multinomial regression model while controlling for other covariates.

RESULTS

Among the 202,367 patients who met the inclusion criteria, there was a steady decrease in mean tumor size in all treatment modalities, from 2.44 cm (SD=1.08) to 2.25 cm (SD=1.00) over the study period. In the multinomial model, the probability of receiving lobectomy demonstrated a slight decline from 58% (2004) to 53% (2016). The use of SBRT increased from 1% to 20%, while patients receiving no therapy declined from 27% to 16%. The likelihood of SBRT increased with year of diagnosis (P<0.0001) and decreasing tumor size (P<0.0001), compared with lobectomy. Age, race, income, facility, and Charlson-Deyo score were also associated with treatment modality.

CONCLUSIONS

The mean tumor size of early-stage NSCLC decreased over the study period for all treatment modalities. SBRT use has increased, mostly among older patients with smaller tumors and Charlson-Deyo scores ≥3. The increase in SBRT contributed to the significant decline in patients who had no therapy.

Cost-effectiveness of stereotactic body radiotherapy in the treatment of non-small-cell lung cancer (NSCLC): a systematic review

OBJECTIVES

This study aims to systematically review the studies on the cost-effectiveness of stereotactic body radiotherapy (SBRT) in the treatment of non-small-cell lung cancer (NSCLC).

METHODS

A systematic literature search was performed in databases from 2000 through April 2021. The search terms included 'economics,' 'cost,' 'cost effectiveness,' 'SBRT,' and all names for NSCLC. Two reviewers independently screened the titles, abstracts and full texts to determine the studies for the final sample. The quality of the included studies was assessed using the Quality of Health Economic Studies checklist.

RESULTS

Eleven studies were identified and included in our final review. SBRT was reported to be a cost-effective (5 of 5) option compared to conventional radiotherapy, radiofrequency ablation, and best supportive care for medically inoperable, early-stage NSCLC. However, the identified studies revealed that no single treatment was found to be more cost-effective than others between SBRT and surgical interventions. The key drivers of this cost-effectiveness were the cost of the treatment, utility value, and the rate of surgical mortality.

CONCLUSIONS

SBRT may be considered a more cost-effective strategy for medically inoperable, early-stage NSCLC. Considering the limited studies available, more related research should be conducted to further validate these results.

Are older patients with non-small cell lung cancer receiving optimal care? A population-based study

BACKGROUND

Results from studies addressing age-related patterns of cancer care have found evidence of unjustified differences in management between younger and older patients.

METHODS

We examined associations between age and clinical presentation, management and mortality in patients diagnosed with non-small cell lung cancer (NSCLC) between 2002 and 2016. Analyses were adjusted for comorbidity and other factors that may have affected management decisions and outcomes.

RESULTS

The study population encompassed 40,026 patients with NSCLC. Stage at diagnosis did not differ between age groups ≤ 84. The diagnostic intensity was similar in age groups <80 years. In patients with stage IA-IIB disease and PS 0-2, surgery was more common in the youngest age groups and decreased with increasing age, and was rarely performed in those ≥ 85 years. The use of stereotactic body radiotherapy (SBRT) increased with age (≤69 years 5.4%; ≥85 years 35.8%). In patients with stage IIIA disease and PS 0-2, concurrent chemoradiotherapy was more common in younger patients (≤69 years 55.3%; ≥85 years 2.2%). In stage IA-IIIA disease, no major differences in treatment-related mortality was observed. In stage IIIB-IV and PS 0-2, chemotherapy was more common in patients <80 years. However, 58.1% of patients 80-84 years and 30.3% ≥ 85 years received treatment. In stage IA-IIIA, overall and cause-specific survival decreased with increasing age. No age-differences in survival were observed in patients with stage IIIB-IV NSCLC.

CONCLUSION

Treatments were readily given to older patients with metastatic disease, but to a lesser degree to those with early stage disease. Significant differences in cause specific survival were observed in early, but not late stage disease. Our findings underscore the importance of individualized assessment of health status and life expectancy. Our results indicate that older patients with early stage lung cancer to a higher extent should be considered for curative treatment.

Verification of an optimizer algorithm by the beam delivery evaluation of intensity-modulated arc therapy plans

Background

In the case of dynamic radiotherapy plans, the fractionation schemes can have dosimetric effects. Our goal was to define the effect of the fraction dose on the plan quality and the beam delivery.

Materials and methods

Treatment plans were created for 5 early-stage lung cancer patients with different dose schedules. The planned total dose was 60 Gy, fraction dose was 2 Gy, 3 Gy, 5 Gy, 12 Gy and 20 Gy. Additionally renormalized plans were created by changing the prescribed fraction dose after optimization. The dosimetric parameters and the beam delivery parameters were collected to define the plan quality and the complexity of the treatment plans. The accuracy of dose delivery was verified with dose measurements using electronic portal imaging device (EPID).

Results

The plan quality was independent from the used fractionation scheme. The fraction dose could be changed safely after the optimization, the delivery accuracy of the treatment plans with changed prescribed dose was not lower. According to EPID based measurements, the high fraction dose and dose rate caused the saturation of the detector, which lowered the gamma passing rate. The aperture complexity score, the gantry speed and the dose rate changes were not predicting factors for the gamma passing rate values.

Conclusions

The plan quality and the delivery accuracy are independent from the fraction dose, moreover the fraction dose can be changed safely after the dose optimization. The saturation effect of the EPID has to be considered when the action limits of the quality assurance system are defined.

Development and Validation of an E2F-Related Gene Signature to Predict Prognosis of Patients With Lung Squamous Cell Carcinoma

Background

Lung squamous cell carcinoma (LUSC) generally correlates with poor clinical prognoses due to the lack of available prognostic biomarkers. This study is designed to identify a potential biomarker significant for the prognosis and treatment of LUSC, so as to provide a scientific basis for clinical treatment decisions.

Methods

Genomic changes in LUSC samples before and after radiation were firstly discussed to identify E2 factor (E2F) pathway of prognostic significance. A series of bioinformatics analyses and statistical methods were combined to construct a robust E2F-related prognostic gene signature. Furthermore, a decision tree and a nomogram were established according to the gene signature and multiple clinicopathological characteristics to improve risk stratification and quantify risk assessment for individual patients.

Results

In our investigated cohorts, the E2F-related gene signature we identified was capable of predicting clinical outcomes and therapeutic responses in LUSC patients, besides, discriminative to identify high-risk patients. Survival analysis suggested that the gene signature was independently prognostic for adverse overall survival of LUSC patients. The decision tree identified the strong discriminative performance of the gene signature in risk stractification for overall survival while the nomogram demonstrated a high accuracy.

Conclusion

The E2F-related gene signature may help distinguish high-risk patients so as to formulate personalized treatment strategy in LUSC patients.

Diagnostic Performance of Electromagnetic Navigation Bronchoscopy-Guided Biopsy for Lung Nodules in the Era of Molecular Testing

Electromagnetic navigation bronchoscopy (ENB) is an emerging technique used to evaluate peripheral lung lesions. The aim of this study was to determine the diagnostic yield, safety profile, and adequacy of specimens obtained using ENB for molecular testing. This single-center, prospective pilot study recruited patients with peripheral pulmonary nodules that were not suitable for biopsy via percutaneous transthoracic needle biopsy methods. The possibility of molecular testing, including epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), and programmed death ligand 1 (PD-L1), was identified with non-small cell lung cancer (NSCLC) tissue obtained using ENB. ENB-guided biopsy was performed on 30 pulmonary nodules in 30 patients. ENB-guided biopsy was successfully performed in 96.6% (29/30) of cases, but one case failed to approach the target lesion. The diagnostic accuracy of ENB-guided biopsy was 68.0% (17/25). Biopsy-related pneumothorax occurred in one patient and there was no major bleeding or deaths related to the procedure. Among 13 patients diagnosed with NSCLC, molecular testing was successfully performed in 92.3% (12/13). ENB-guided biopsy demonstrated acceptable accuracy and excellent sample adequacy, with a high possibility of achieving molecular testing and a good safety profile to evaluate peripheral pulmonary nodules, even when the percutaneous approach was difficult and/or dangerous.

Radiation-Induced Dyspnea in Lung Cancer Patients Treated with Stereotactic Body Radiation Therapy

Simple Summary

Dyspnea is a common symptomatic side-effect of thoracic radiation therapy. The aim of this study is to build a predictive model of any-grade radiation-induced dyspnea within six months after stereotactic body radiation therapy in patients treated for non-small cell lung cancer. The occurrence of pre-treatment chronic obstructive pulmonary disease and higher relative lungs volume receiving more than 15 Gy as well as heart volume were shown to be risk factors for dyspnea. The obtained results encourage further studies on the topic, which could validate the present organ-based findings and explore the voxel-based landscape of radiation dose sensitivity in the development of dyspnea.

Abstract

In this study, we investigated the prognostic factors for radiation-induced dyspnea after hypo-fractionated radiation therapy (RT) in 106 patients treated with Stereotactic Body RT for Non-Small-Cell Lung Cancer (NSCLC). The median prescription dose was 50 Gy (range: 40–54 Gy), delivered in a median of four fractions (range: 3–12). Dyspnea within six months after SBRT was scored according to CTCAE v.4.0. Biologically Effective Dose (α/β = 3 Gy) volume histograms for lungs and heart were extracted. Dosimetric parameters along with patient-specific and treatment-related factors were analyzed, multivariable logistic regression method with Leave-One-Out (LOO) internal validation applied. Model performance was evaluated by the area under the receiver operating characteristic (ROC) curve (AUC) and calibration plot parameters. Fifty-seven patients (53.8%) out of 106 developed dyspnea of any grade after SBRT (25/57 grade ≥ 2 cases). A three-variable predictive model including patient comorbidity (COPD), heart volume and the relative lungs volume receiving more than 15 Gy was selected. The model displays an encouraging performance given by a training ROC-AUC = 0.71 [95%CI 0.61–0.80] and a LOO-ROC-AUC = 0.64 [95%CI 0.53–0.74]. Further modeling efforts are needed for dyspnea prediction in hypo-fractionated treatments in order to identify patients at high risk for developing lung toxicity more accurately.

Gamma Radiation-Induced Rib Necrosis and Stereotactic Radiosurgery Failure

Stereotactic radiosurgery, or SRS, uses focused beams of gamma radiation targeted to specific areas of the body and has been used for multiple forms of non-small cell lung cancer. In this article, the authors describe two incidental cases of osteonecrosis in patients who had previously undergone stereotactic radiosurgery with recurrence of tumor. While this is a known side effect of traditional radiation therapy, it has not been described in the context of stereotactic radiosurgery. Further, these lesions were immediately deep to a rib, which may have shielded the lesion, and led to SRS failure. Osteonecrosis of the rib is a rare clinical entity but has been found to occur with glucocorticoid use, bisphosphonates, radiation therapy, and radiofrequency ablation. In the authors' review of the literature on SRS for lung cancer and intrathoracic pathology, rib osteonecrosis was not described and has not been mentioned as a possible side effect. Patients who have undergone thoracic stereotactic radiotherapy may develop side effects of traditional radiotherapy. We identified two patients who developed rib osteonecrosis though that has not been previously described as an adverse effect of stereotactic radiotherapy. The patients described in this case did not have any radiographic evidence of disease on imaging, suggesting that further research is warranted on the diagnosis and management of this rare disease entity.

Radiation exposure triggers the malignancy of non‑small cell lung cancer cells through the activation of visfatin/Snail signaling

It is estimated that one-half of patients with non-small cell lung cancer (NSCLC) undergo radiotherapy worldwide. However, the outcome of radiotherapy alone is not always satisfactory. The aim of the present study was to evaluate the effects of radiotherapy on the malignancy of NSCLC cells. It was demonstrated that radiation therapy could increase the migration and invasion of NSCLC cells in vitro. Moreover, the upregulation of visfatin, a 52-kDa adipokine, mediated radiation-induced cell motility. A neutralizing antibody specific for visfatin blocked radiation-induced cell migration. Radiation and visfatin induced the expression of Snail, a key molecule that regulates epithelial to mesenchymal transition in NSCLC cells. Furthermore, visfatin positively regulated the mRNA stability of Snail in NSCLC cells, but had no effect on its protein degradation. This may be explained by visfatin-mediated downregulation of microRNA (miR)-34a, which was shown to bind the 3′ untranslated region of Snail mRNA to promote its decay. Collectively, these findings suggested that radiation could induce cell motility in NSCLC cells through visfatin/Snail signaling.

Immunomodulatory Effects of Radiotherapy

Radiation therapy (RT), an integral component of curative treatment for many malignancies, can be administered via an increasing array of techniques. In this review, we summarize the properties and application of different types of RT, specifically, conventional therapy with x-rays, stereotactic body RT, and proton and carbon particle therapies. We highlight how low-linear energy transfer (LET) radiation induces simple DNA lesions that are efficiently repaired by cells, whereas high-LET radiation causes complex DNA lesions that are difficult to repair and that ultimately enhance cancer cell killing. Additionally, we discuss the immunogenicity of radiation-induced tumor death, elucidate the molecular mechanisms by which radiation mounts innate and adaptive immune responses and explore strategies by which we can increase the efficacy of these mechanisms. Understanding the mechanisms by which RT modulates immune signaling and the key players involved in modulating the RT-mediated immune response will help to improve therapeutic efficacy and to identify novel immunomodulatory drugs that will benefit cancer patients undergoing targeted RT.

Thermal Ablation Versus Wedge Resection for Stage I Non-small Cell Lung Cancer Based on the Eighth Edition of the TNM Classification: A Population Study of the US SEER Database

Background

The incidence rates of early-stage non-small cell lung cancer (NSCLC) are now increasing, and therapies such as thermal ablation have shown potential therapeutic promise. This study aimed to determine the influence of different surgical methods on overall survival (OS) and cancer-specific survival (CSS) in patients with stage I NSCLC.

Methods

Patients diagnosed with stage I NSCLC who had received thermal ablation or wedge resection between 2004 and 2014 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was performed according to the surgical method. Kaplan–Meier curves and a Cox proportional hazard model were used to evaluate OS and CSS.

Results

In all, 4,372 patients with stage I NSCLC were included. Before PSM, the respective 3- and 5-year OS rates were 68.9 and 52.7% in the wedge resection group and 68.5 and 47.8% in the thermal ablation group (p < 0.0001); the corresponding CSS rates were 79.1 and 69.4% and 62.6 and 46.0% (p < 0.0001). After PSM, survival analysis showed that wedge resection had better OS (44.5% vs. 30.1%, p = 0.033) and CSS (63.5% vs. 46%, p = 0.038) than thermal ablation. After PSM, Cox regression showed that treatment was not associated with OS or CSS. For patients aged >75 years, thermal ablation showed similar OS and CSS as wedge resection (OS: 30.6% vs. 41.7%, p = 0.470; CSS: 46.4% vs. 64.1%, p = 0.100). After PSM, thermal ablation still had OS (30.6% vs. 41.0%, p = 0.470) and CSS (46.4% vs. 59.8%, p = 0.100) comparable to wedge resection.

Conclusion

For patients with stage I NSCLC who are unfit for lobectomy, thermal ablation could be a potential therapeutic option, especially for those >75 years old.

Deterioration in health-related quality of life is associated with lower lung resection rates in older adults

BACKGROUND

Lung cancer disproportionately affects older adults. Surgical treatment may result in decreased functional status and health-related quality of life (HRQOL). Population-based data about patient-reported health outcomes for patients with early-stage lung cancer who do not undergo surgery is lacking.

METHODS

We identified lung cancer patients with localized disease from the SEER-Medicare Health Outcomes Survey (MHOS) linked database. Patients with baseline HRQOL survey prior to cancer diagnosis and follow-up survey ≥1 year after diagnosis were selected. Generalized estimating equation (GEE) model was used to compare patients who underwent surgery versus those who did not by demographics and HRQOL measures.

RESULTS

Overall, 108 patients were evaluated, of whom 75 (69%) underwent surgery. Surgical patients were younger (mean 73 versus 80 years, p < 0.001); otherwise, patient groups were similar. Surgery was not performed based on surgeon recommendation (n = 21, 64%), contraindication(s), or patients' decision. Both groups experienced similar declines in physical HRQOL, mental HRQOL, and activities of daily living (ADL) scores; and increased major comorbidities. However, non-surgical patients had significant declines in mobility and personal care activities compared to surgical counterparts. On GEE, non-surgical patients were significantly more likely to experience an increase in number of comorbidities (OR 3.3, p = 0.02) compared to surgical patients.

CONCLUSIONS

Patients undergoing lung cancer surgery experience significant declines in functional status and HRQOL. However, similar declines are seen in non-surgical patients. More information is needed about long term QOL trajectories with and without surgery so that patients and surgeons can make informed decisions balancing survival benefit and QOL interests.

Recommendations for acting in elective and urgent thoracic surgery during SARS-CoV-2 pandemic. Spanish Society of Thoracic Surgery

La expansión de la pandemia producida por el nuevo coronavirus SARS-CoV-2 ha obligado a focalizar casi toda la asistencia sanitaria en pacientes con enfermedad COVID-19, obligando a suspender la mayoría de intervenciones quirúrgicas electivas programadas. La cirugía torácica es eminentemente oncológica, por lo que resulta obligada una adecuada priorización de los pacientes para ser intervenidos lo antes posible y en condiciones de máxima seguridad. Por otra parte, la afectación pulmonar grave COVID-19 presenta complicaciones que con frecuencia requieren procedimientos quirúrgicos torácicos urgentes en un contexto nuevo. La Sociedad Española de Cirugía Torácica (SECT) ha desarrollado este documento para establecer unas recomendaciones básicas para mantener la actividad quirúrgica electiva imprescindible y para orientar a los cirujanos que deban afrontar urgencias torácicas en este nuevo y desconocido entorno.

Recent advances in de-intensification of radiotherapy in elderly cancer patients

Cancer in the elderly remains an evolving issue and a health challenge. Several improvements in the radiotherapy field allow the delivery of higher doses/fractions with a safe toxicity profile, permitting the reduction of radiation treatment protocols in the elderly. Regarding breast, prostate, and lung cancer, the under-representation of older patients in clinical trials limits the extension of treatment recommendations to elderly patients in routine clinical practice. Among the feasible alternatives to standard whole breast radiotherapy (WBRT) in older patients are shorter courses using higher hypofractionation (HF) and accelerated partial breast irradiation (APBI). The boost continues to be used in women at high risk of local recurrence but is less widely accepted for women at lower risk and patients over 70 years of age. Regarding prostate cancer, there are no published studies with a focus on the elderly. Current management decisions are based on life expectancy and geriatric assessment. Regimens of HF and ultra-HF protocols are feasible strategies for older patients. Several prospective non-randomized studies have documented the safe delivery of ultra-HF for patients with localized prostate cancer, and multiple phase III trials and meta-analyses have confirmed that the HF regimen should be offered with similar acute toxicity regardless of patient age and comorbidity. A recent pooled analysis from two randomized trials comparing surgery to stereotactic body radiation therapy (SBRT) in older adult patients with early stage non-small cell lung cancer did show comparable outcomes between surgery and SBRT. Elderly cancer patients are significantly under-represented in all clinical trials. Thus, the inclusion of older patients in clinical studies should be strongly encouraged to strengthen the evidence base for this age group. We suggest that the creation of oncogeriatric coordination units may promote individualized care protocols, avoid overtreatment with aggressive and unrecommended therapies, and support de-escalating treatment in elderly cancer patients.

Endobronchial Ultrasound-Guided Radiofrequency Ablation of Lung Tumors and Mediastinal Lymph Nodes: A Preclinical Study in Animal Lung Tumor and Mediastinal Adenopathy Models

Radiofrequency ablation (RFA) can be a therapeutic option in medically inoperable lung cancer patients. In this study, we evaluated a prototype bipolar RFA device applicator that can be deployed from a standard endobronchial ultrasound (EBUS) bronchoscope to determine feasibility and histopathological analysis in animal models. Rabbit lung cancers were created by transbronchial injection of VX2 rabbit cancer cells. Once the tumors were developed, they were ablated transpleurally, under EBUS guidance using the prototype RFA device. The animals were then sacrificed for specimen resection. Pig inflammatory lung pseudo-tumors and lymphadenopathy were created by transbronchial injection of a talc paste and ablated transbronchially under EBUS guidance. Pigs were evaluated at 5 days, 2 weeks, and 4 weeks following ablation by bronchoscopy and cone beam computed tomography before necropsy. Nicotinamide adenine dinucleotide hydrogen diaphorase staining was employed to measure the ablation area. Twenty-four VX2 rabbit tumors were ablated. The total ablated area ranged from 0.6 to 3.0 cm² (mean: 1.8 cm²), corresponding to a total energy range of 1 to 6 kJ. Six pig lung pseudo-tumors and 5 mediastinal lymph nodes were ablated. Adjacent airway ulceration was observed in 3 ablations of lymph nodes. These airway complications resolved within 4 weeks of RFA without any treatment. There was no hemoptysis, air embolism, respiratory distress, or other serious complication noted. In these 2 animal models, we provide evidence that EBUS-guided bipolar RFA is feasible and histopathology shows that can ablate lung tumors and mediastinal lymph nodes under real-time ultrasound guidance.

Survival after stereotactic radiotherapy in patients with early-stage non-small cell lung cancer

Introduction: Stereotactic radiotherapy (SBRT) is the treatment of choice for inoperable early stage non-small cell lung cancer (NSCLC). We report analyses of the influence of age on survival after SBRT. Methods and material: From 2005 to 2017, 544 previously un-irradiated patients with early stage NSCLC had SBRT. The data were analyzed in four age groups: A: -69 (176 pts), B: 70-74 (115 pts), C: 75-79 (131 pts) and D: 80 years or older (122 pts). Two SBRT dose regimes were used: 45 Gy/3F (N = 103) and 66 Gy/3F (N = 441). Results: All patients had a follow up (time to censoring, FU) of at least 16 months, the median FU being 48.0 months. The median age was 74.4 years. The overall survival (OS) was associated with age. The median OS was 50.7, 45.9, 45.4 and 33.0 months, and the 5-year OS was 45%, 32%, 33% and 18% in groups A, B, C and D, respectively. No difference was found between groups B and C, while OS in group A was significantly better than remaining groups, and the OS in group D significantly poorer. In multivariable analyses, OS was heavily influenced by age, Charlson's comorbidity index (CCI) and performance status (PS). For lung cancer-specific survival (LCSS), only increasing tumor diameter and PS were associated with poor survival. Conclusions: The OS was influenced by age, but the study suggests that a cut point of 75 year is inappropriate in evaluating the effect of old age on survival. Poor PS was associated with poor OS. CCI influenced OS, but not LCSS, which was only affected by PS and tumor size.

Endobronchial and surgical treatment of pulmonary carcinoid tumors: A systematic literature review

The treatment of pulmonary carcinoid has changed over the last decades. Although surgical resection is still the gold standard, minimally invasive endobronchial procedures have emerged as a parenchyma sparing alternative for tumors located in the central airways. This review was performed to identify the optimal treatment strategy for pulmonary carcinoid, with a particular focus on the feasibility and outcome of parenchyma sparing techniques versus surgical resection. A systematic review of the literature was carried out using MEDLINE, Embase and the Cochrane databases, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two separate searches of publications in endobronchial and surgical treatment in patients with pulmonary carcinoid, were performed. Outcomes were overall survival, disease free survival, recurrence rate, complications, quality of life, and healthcare costs. Combining the two main searches for endobronchial therapy and surgical therapy yielded 3111 records. Finally, 43 studies concerning surgical treatment and 9 studies related to endobronchial treatment for pulmonary carcinoid were included. Assessment of included studies showed that lymph node involvement, histological grade, tumor location and tumor diameter were identified as poor prognostic factors and seem to be important for patients with pulmonary carcinoid. For patients with a more favorable prognosis, tumor location and tumor diameter are important factors that can help decide on the optimal treatment strategy. Centrally located small intraluminal pulmonary carcinoids, without signs of metastasis can be treated with minimally invasive alternatives such as endobronchial treatment or parenchyma sparing surgical resection. Patients with parenchyma sparing resections should be followed with long term follow up to exclude recurrence of disease. In a multidisciplinary setting, it should be determined whether individual patients are eligible for parenchyma sparing procedures or anatomical resection. Overall evidence is of low quality and future studies should focus on prospective trials in the treatment of pulmonary carcinoid.

Multiple primary lung cancer: a rising challenge

With the use of high-resolution chest imaging system and lung cancer screening program, patients with multiple primary lung cancers (MPLCs) are becoming a growing population in clinical practice worldwide. The diagnostic criteria for MPLCs has been established and modified by three major lung cancer research institutes. However, due to the fact that the differential diagnosis between MPLCs and a recurrence, metastatic, or satellite lesion arising from the original lesion remains ambiguous and confusing, there is still insufficient evidence to support a uniform guideline. Newly developed molecular and genomic methods have the potential to better define the relationship among multiple lesions and bring the possibility of targeted therapy. Surgical resection remains the first choice for the treatment of MPLCs and detailed strategy should be carefully planned taking characteristics of the tumor and status of patients into consideration. For those who are intolerant to surgery, a new technology called stereotactic body radiation therapy (SBRT) is now an optional therapeutic strategy. Furthermore, multiple GGOs are unique MPLCs that need special attentions in the clinical practice.