Impact of Intensity-Modulated Radiation Therapy Technique for Locally Advanced Non-Small-Cell Lung Cancer: A Secondary Analysis of the NRG Oncology RTOG 0617 Randomized Clinical Trial

Construction of a novel radioresistance-related signature for prediction of prognosis, immune microenvironment and anti-tumour drug sensitivity in non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) is a fatal disease, and radioresistance is an important factor leading to treatment failure and disease progression. The objective of this research was to detect radioresistance-related genes (RRRGs) with prognostic value in NSCLC.

METHODS

The weighted gene coexpression network analysis (WGCNA) and differentially expressed genes (DEGs) analysis were performed to identify RRRGs using expression profiles from TCGA and GEO databases. The least absolute shrinkage and selection operator (LASSO) regression and random survival forest (RSF) were used to screen for prognostically relevant RRRGs. Multivariate Cox regression was used to construct a risk score model. Then, Immune landscape and drug sensitivity were evaluated. The biological functions exerted by the key gene LBH were verified by in vitro experiments.

RESULTS

Ninety-nine RRRGs were screened by intersecting the results of DEGs and WGCNA, then 11 hub RRRGs associated with survival were identified using machine learning algorithms (LASSO and RSF). Subsequently, an eight-gene (APOBEC3B, DOCK4, IER5L, LBH, LY6K, RERG, RMDN2 and TSPAN2) risk score model was established and demonstrated to be an independent prognostic factor in NSCLC on the basis of Cox regression analysis. The immune landscape and sensitivity to anti-tumour drugs showed significant disparities between patients categorized into different risk score subgroups. In vitro experiments indicated that overexpression of LBH enhanced the radiosensitivity of A549 cells, and knockdown LBH reversed the cytotoxicity induced by X-rays.

CONCLUSION

Our study developed an eight-gene risk score model with potential clinical value that can be adopted for choice of drug treatment and prognostic prediction. Its clinical routine use may assist clinicians in selecting more rational practices for individuals, which is important for improving the prognosis of NSCLC patients. These findings also provide references for the development of potential therapeutic targets.

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.

Concurrent and Consolidative Carboplatin Plus Nab-Paclitaxel or Paclitaxel in Locally Advanced NSCLC: A Multicenter, Randomized Clinical Trial

PURPOSE

We investigated the efficacy and toxicity of thoracic radiation therapy (RT) plus concurrent and consolidation carboplatin with either solvent-based paclitaxel (sb-paclitaxel) or solvent-free nanoparticle albumin-bound paclitaxel (nab-paclitaxel).

METHODS AND MATERIALS

This multicenter phase 1/2 randomized trial included patients with inoperable stage IIIA/B nonsmall cell lung cancer (AJCC 7) and an Eastern Cooperative Oncology Group performance status of 0-1. In phase 1, 6 patients received weekly nab-paclitaxel (50 mg/m²) and carboplatin (AUC 2) with concurrent thoracic RT (60 Gy in 30 fractions), followed by nab-paclitaxel (100 mg/m²) on days 1, 8, and 15 and carboplatin (AUC 6) on day 1 for two 21-day cycles. In phase 2, 92 patients were randomly assigned to weekly sb-paclitaxel (50 mg/m²) or nab-paclitaxel (40 mg/m²) with concurrent RT, followed by consolidation therapy with sb-paclitaxel or nab-paclitaxel and carboplatin for 2 cycles.

RESULTS

Two phase 1 patients had dose-limiting toxicities, setting the phase 2 nab-paclitaxel dose at 40 mg/m². For the phase 2 cohort, 2-year overall survival was 67% for sb-paclitaxel and 56% for nab-paclitaxel (P = .10), with progression-free survival of 44% and 27%, respectively (P = .14). Fewer patients completed consolidation with nab-paclitaxel (26%) versus sb-paclitaxel (58%) (P = .005). Grade 3 and higher adverse events were more frequent with nab-paclitaxel (56%) than with sb-paclitaxel (30%) (P = .029).

CONCLUSIONS

Nab-paclitaxel was associated with higher toxicity and numerically lower efficacy than sb-paclitaxel when used with thoracic radiation in locally advanced nonsmall cell lung cancer.

Intensity-Modulated Radiotherapy for Locally Advanced Lung Cancer in the Immunotherapy Era: A Prospective Study WJOG12019L

Introduction

Chemoradiotherapy (CRT) followed by durvalumab is the standard of care for unresectable locally advanced NSCLC. Limited prospective data have been reported on intensity-modulated radiotherapy (IMRT)-adapted CRT in the immunotherapy era.

Methods

In this multicenter prospective observational study, patients underwent IMRT-adapted CRT (platinum-doublet chemotherapy plus 60 Gy IMRT in 30 fractions under a prespecified radiation protocol), followed by consolidative durvalumab. The primary outcome was the durvalumab introduction rate within 42 days post-CRT.

Results

Thirty-two patients with unresectable locally advanced NSCLC were enrolled between November 2019 and February 2021. Among the 28 evaluable cases, durvalumab was introduced in 24 (85.7%, 90% confidence interval: 70.2%-95.0%) of 28 patients after CRT, achieving the primary end point. All 29 patients who received IMRT completed the scheduled 60 Gy radiotherapy dose. One year of durvalumab treatment was completed in 12 of 24 patients (50%). In the 24 patients who were durvalumab-introduced, the median progression-free survival and overall survival were 20.9 (95% confidence interval: 6.9-not evaluable) months and not reached, respectively. Two-year progression-free survival and overall survival rates were 44% and 73%, respectively. Among the 29 patients in the safety analysis set, there were no treatment-related deaths or grade 4 nonhematological adverse events. Pneumonitis grade 1 was observed in 13 patients (45%), grade 2 in seven (24%), and grade 3 in one (3%).

Conclusions

High durvalumab introduction rate was reported after the completion of IMRT-adapted CRT under a prespecified radiation protocol. Its efficacy has been suggested, with favorable safety profiles, including a low incidence of severe pneumonitis.

Trial Registration

University Hospital Medical Information Network database ID: UMIN000038366.

A Japanese national survey on IMRT/SBRT in 2023 by the JASTRO High-Precision External Beam Radiotherapy Group

The purpose of this study was to investigate the utilization and implementation of stereotactic body radiotherapy (SBRT) and intensity-modulated radiotherapy (IMRT) in Japan up to 2023. The survey was conducted by the Japanese Society for Radiation Oncology High-Precision External Beam Radiotherapy Group Subcommittee from December 2023 to February 2024. The study targeted patients treated with IMRT or SBRT between January 2021 and December 2022. A comprehensive web-based questionnaire was distributed to 880 facilities, with separate sections for radiation oncologists and medical physicists/radiotherapy technologists. A total of 360 facilities responded (response rate: 40.9%) for the section of radiation oncologists, and 405 facilities responded (response rate: 46.0%) for medical physicists/radiotherapy technologists, providing data on the implementation status, techniques, workload and challenges associated with IMRT and SBRT. Based on the responses in the section of radiation oncologists, IMRT was used in 68.6% of responding institutes, and SBRT in 87.8%. VMAT emerged as the most common IMRT technique (78.3%). The survey highlighted a high demand for medical physicists to perform IMRT (86.9%). Based on the responses in the section of medical physicists/radiotherapy technologists, 84.6% of the facilities that have not performed IMRT reported that the main reason was a lack of radiation oncologists. Furthermore, the survey also noted significant variations in prescribed doses and margin sizes across facilities, indicating the need for further standardization. High-precision radiation techniques such as IMRT and SBRT are getting popular, however, the facility requirements which mandate the presence of at least two radiation oncologists prevents IMRT from becoming more widespread in Japan.

Second Generation Gd-Bi Ultrasmall Nanoparticles Amplify the Effects of Clinical Radiation Therapy and Provide Clinical MRI Contrast

PURPOSE

AGuIX nanoparticles consisting of Gd atoms chelated to a polysiloxane matrix are under clinical evaluation as theranostic agents with radiation therapy. A new generation, AGuIX-Bi, replaces 70% of the Gd atoms in AGuIX with Bi atoms, improving radiation dose amplification while maintaining MRI contrast. The therapeutic efficacy of AGuIX-Bi was investigated under clinical megavoltage and MRI conditions in two of non-small cell lung cancer (NSCLC) models.

METHODS AND MATERIALS

Murine (LLC) and human (A549) NSCLC were studied in mice, with animals inoculated and divided into cohorts for control (saline, AGuIX, AGuIX-Bi) and irradiation (saline+RT, AGuIX+RT, AGuIX-Bi+RT). Nanoparticle cohorts were injected 24-hours prior to delivering 10 Gy of irradiation using a 6 MV flattening-filter-free (FFF) beam. Tumors were measured until euthanasia was necessary, taken as time-to-tumor doubling (TTD). Additionally, AGuIX and AGuIX-Bi phantoms were constructed with T1-weighted images and maps taken using a 3T clinical MRI scanner. T1-images of A549 inoculated mice were obtained on the same scanner with injection of AGuIX or AGuIX-Bi 2- and 24-hrs prior to imaging.

RESULTS

No toxicity was observed due to nanoparticle injection, anaesthesia, or irradiation. In both LLC and A549 models, AGuIX-Bi+RT significantly outperformed both saline+RT and AGuIX+RT in reducing tumor growth (p<0.05). Median TTD for AGuIX-Bi+RT compared to AGuIX+RT groups was increased by 160% for A549, and by 60% for LLC models (p<0.05). Longitudinal relaxivity constants (r1) derived from phantom T1-mapping were 6.9 mM-1 s-1 for AGuIX and 8.4 mM-1 s-1 for AGuIX-Bi. Additionally, T1-weighted mouse tumor imaging showed contrast-to-noise (CNR) of AGuIX-Bi to be roughly half that of AGuIX.

CONCLUSIONS

AGuIX-Bi nanoparticles proved more effective than AGuIX at delaying tumor growth for both NSCLC models while maintaining sufficient MRI contrast at 3T. Replacing some Gd atoms with bismuth improves the efficacy of AGuIX nanoparticles under clinical megavoltage energies without compromising imaging.

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.

Expert consensus on cancer treatment-related lung injury

Background

Although advancements in cancer therapies have substantially improved the survival of cancer patients, these treatments may also result in acute or chronic lung injury. Cancer treatment-related lung injury (CTLI) presents with a diverse array of clinical manifestations and can involve multiple sites. Due to the lack of specific diagnostic protocols, CTLI can deteriorate rapidly and may be life-threatening if not promptly addressed. Unfortunately, there is no universally accepted consensus document on the diagnosis and management of CTLI.

Methods

A multidisciplinary panel comprising experts from respiratory and critical care medicine, oncology, radiation oncology, thoracic surgery, radiology, pathology, infectious diseases, pharmacy, and rehabilitation medicine participated in this consensus development. Through a systematic literature review and detailed panel discussions, the team formulated nine key recommendations.

Results

This consensus document addresses the concept, epidemiology, pathogenesis, risk factors, diagnostic approach, evaluation workflow, management strategies, differential diagnosis, type-specific management and clinical staging of CTLI. Emphasis is placed on raising awareness among clinicians and therapeutic practices through comprehensive guidelines.

Conclusions

The consensus provides a detailed diagnostic protocol for CTLI and introduces a structured management framework based on grading, typing, and staging. It highlights the critical role of multidisciplinary team (MDT) collaboration and emphasizes the need for individualized, whole-process patient care strategies to optimize clinical outcomes.

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.

Incidences of pneumonitis associated with the combination of radiotherapy and immune checkpoint inhibitors in lung cancer: a systematic review and meta-analysis

Objective

Recently, the therapeutic effects of the combination of radiotherapy (RT) and immune checkpoint inhibitors (ICIs) on lung cancer (LC) have piqued the interest of the scientific community. Clinical trials have confirmed that RT and ICI therapy exert synergistic therapeutic effects. However, treatment with the RT-ICI combination can lead to the occurrence of pneumonitis, limiting the implementation of the treatment plan, decreasing the tumor control rate, and inducing immunosuppressive pneumonitis and radiation pneumonitis. Therefore, this study performed a systematic review and meta-analysis of pneumonitis prevalence among patients with LC who were treated with a combination of ICIs and chemoradiotherapy (CRT).

Methods

Literature published between January 1, 2010, and October 15, 2023, were searched in the PubMed, Cochrane Library, Embase, and Web of Science databases by two authors. The primary outcomes analyzed in this study were the incidence rates of all-grade pneumonitis and ≥ grade 3 pneumonitis.

Results

This study analyzed 53 studies involving 4226 patients. The pooled incidence rates of all-grade and ≥ grade 3 pneumonitis were 36.0% (95% confidence interval (CI): 30.0-41.0) and 3.0% (95% CI: 2.0-4.0), respectively. The all-grade pneumonitis incidence rates in Asian patients (51%; 95% CI: 38%-63%) were higher than those in non-Asian patients (26%; 95% CI: 22%-31%). Conventional RT was associated with higher rates of all-grade pneumonitis than stereotactic body radiation therapy (SBRT) (37%; 95% CI: 31%-42% vs. 26.0%; 95% CI: 20%-33%). Additionally, sequential immunotherapy was associated with higher rates of all-grade pneumonitis than concurrent immunotherapy ((38%; 95% CI: 31%-45% vs. 25.0%; 95% CI: 20%-30%)). Furthermore, anti-PD1 therapy was associated with higher rates of all-grade pneumonitis than PD-L1 therapy (40%; 95% CI: 32%-47% vs. 20.0%; 95% CI: 16%-24%). Similar incidence rates of ≥ grade 3 pneumonitis were reported in all included studies.

Conclusion

This study suggests that the combination of ICIs and RT/CRT is a safe and feasible therapeutic regimen for patients with LC. However, these findings are based on observational studies and are associated with significant heterogeneity. Hence, large prospective studies are needed to validate the findings of this meta-analysis.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier CRD42023485613.

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.

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.

Current Approaches to Radiation Oncology Target Volume Delineation Using PET/Computed Tomography

PET is a versatile imaging modality widely used in oncology for diagnosing, staging, predicting outcomes, and surveillance for a variety of cancers. In radiation oncology, combining PET and computed tomography imaging can markedly enhance treatment planning through improved target volume delineation. This review examines data and clinical approaches across 3 major cancer types to evaluate the role of PET in target volume delineation, with data and current approaches for thoracic, genitourinary, and head and neck malignancies detailed. Additionally, it emphasizes various practical applications of PET in radiation therapy planning, several of which have been recently demonstrated in clinical trials.

Global Longitudinal Strain: A Potential Noninvasive Tool for Early Detection of Radiation-Induced Cardiac Dysfunction in Patients With Lung Cancer Receiving Thoracic Radiation Therapy

PURPOSE

Radiation-induced cardiac dysfunction (RICD) is a competing cause of morbidity and mortality in patients receiving thoracic radiation therapy (RT). Currently, there are no clinically-validated approaches for early detection of RICD at a time point that affords the potential for mitigation. The goal of this study was to evaluate the potential of global longitudinal strain (GLS) derived from standard-of-care echocardiogram (ECHO) for the early detection of RICD and to assess the association between adverse GLS changes and survival in patients receiving thoracic RT.

METHODS AND MATERIALS

A retrospective review of changes in GLS was carried out in patients with primary or secondary lung cancer who received standard-of-care thoracic RT with a mean heart dose of ≥5 Gy and had measurable GLS on ECHOs performed before and after RT. Changes in 2-chamber (2C), 3-chamber (3C), and 4-chamber (4C) GLS and peak average GLS after RT (relative to pre-RT baseline) were quantified. Survival probabilities were estimated in patients with normal versus abnormal GLS.

RESULTS

Thirty-eight patients had measurable GLS before and after RT. Abnormal GLS (defined as <18% or >15% relative decline in GLS after RT from a normal baseline value) was present in 31.6% of patients before RT and 57.9% of patients after RT (P = .012). On paired comparisons, the absolute median reduction (IQR) in 2-chamber, 3-chamber, 4-chamber, and average GLS after RT relative to pre-RT baseline was 1.90 (4.43), 3.00 (3.83), 2.50 (3.63), and 2.25 (3.53), respectively, all P < .001. No statistically significant change in left ventricular ejection fraction was noted after RT. Patients with abnormal GLS after RT had significantly worse survival than those with normal GLS on univariable analysis (P = .049). Despite the small sample size of the study, the survival detriment in patients with abnormal GLS after RT strongly trended toward significance on multivariable analysis (P = .063).

CONCLUSIONS

Adverse changes in GLS are detectable on standard-of-care ECHOs and precede significant changes in left ventricular ejection fraction in this cohort of high-risk patients with primary and secondary lung cancer receiving thoracic RT. Thus, ECHO-derived GLS has the potential to serve as an early and noninvasive marker of RICD in this patient population and may enable early adoption of GLS-guided cardioprotective therapy, which has been shown to mitigate cardiac dysfunction in patients with cancer receiving cardiotoxic treatments.

Clinical, Dosimetric and Radiomic Features Predictive of Lung Toxicity After (Chemo)Radiotherapy

BACKGROUND

Treatment of locally advanced non small cell lung cancer (LA-NSCLC) is based on (chemo)radiotherapy, which may cause acute lung toxicity: radiation pneumonitis (RP). Its frequency seems to increase by the use of adjuvant durvalumab therapy.

AIMS

To identify clinical, dosimetric, and radiomic factors associated with grade (G)≥2 RP and build a prediction model based on selected parameters.

PATIENTS AND METHODS

This is a retrospective multicenter cohort study including patients receiving radiation therapy between 2015 and 2019 for LA-NSCLC. Baseline computed tomography scanners were segmented to extract radiomic features from the "Lung - Tumor" volume. Variables associated with the risk of G≥2 RP in the descriptive analysis were then selected for explanatory analysis, followed by predictive analysis.

RESULTS

153 patients were included in 4 centers (51 with G≥2 RP). Factors associated with G≥2 RP included a high initial hemoglobin level, dosimetric factors (mean dose to healthy lungs, lung V20Gy and V13Gy), the addition of maintenance durvalumab, and 7 radiomic features (intensity distribution and texture). Other factors were associated with an increased risk of G≥2 RP in our explanatory model, such as older age, low Tiffeneau ratio, and a decreased initial platelet count. The best-performing predictive model was a random forest-based learning model using clinical, dosimetric, and radiomic variables, with an area under the ROC curve of 0.72 (95%CI [0.63; 0.80]) versus 0.64 for models using one type of data.

CONCLUSION

The addition of radiomic features to clinical and dosimetric ones improves prediction of the occurrence of G≥2 RP in patients receiving radiotherapy for lung cancer.

Integrating knowledge-based planning and noncoplanar oblique VMAT arcs: A study of dose to the heart and immune cells in thoracic radiotherapy

Background

Recent patient studies have linked higher immune cell doses with worse quality of life and survival. For thoracic radiotherapy, heart dose is a major contributor to the effective dose to immune cells (EDIC).

Purpose

This study investigates heart and immune cell doses for plans optimized using a cardiac-sparing knowledge-based planning (KBP) model and the impact of carefully crafted beam geometry.

Methods

Sixteen stage III NSCLC patients previously treated to 60 Gy in 30 fractions using coplanar VMAT arcs were replanned using a cardiac-sparing KBP model with either the clinical field arrangement or noncoplanar oblique arcs that prioritize heart sparing. The cardiac-sparing KBP model consisted of fifteen substructures, all of which were used during optimization. All plans were normalized to 95% PTV coverage at 60 Gy. Statistical significance was assessed for EDIC (Jin Model), along with mean doses to the heart, lungs, body, and both the mean dose and D0.03 cc values for cardiac substructures, using the Wilcoxon signed-rank test.

Results

Compared to the clinically treated plans with the same beam geometry, cardiac-sparing KBP reduced mean heart dose from 8.50 Gy to 4.09 Gy and EDIC from 4.27 Gy to 3.81 Gy (p < 0.001). For the novel arcs, the mean heart dose was reduced to 3.70 Gy, significantly lower than KBP with clinical beam geometry (p = 0.001). EDIC, however, was equivalent. No statistically meaningful differences were observed for the remaining organs at risk, and all plans met institutional planning goals.

Conclusion

Cardiac-sparing RapidPlan is a valuable tool for reducing heart dose and lowering EDIC in NSCLC patients. Additional heart sparing is possible by strategically crafting noncoplanar oblique beams to minimize heart dose.

Current utilisation of advanced techniques and technologies in palliative radiation therapy in Australia and New Zealand

INTRODUCTION

The techniques employed in palliative radiation therapy are highly variable, ranging from basic (2D/3D-conformal) to more advanced (beam modulation and stereotactic techniques), and their relative use has not previously been formally investigated at a national level. The purpose of this work was to assess the current utilisation of palliative techniques and technologies in Australia and New Zealand (ANZ).

METHODS

A voluntary, anonymous, internet-based, RANZCR approved survey was offered to all practising radiation oncology (RO) Fellows in ANZ. Participants selected their preferred methods of managing patients in five case studies involving bone, brain, lung metastases and locally advanced lung cancer.

RESULTS

From October 2022 to February 2023, 146 of 485 eligible participants (30%) responded. In all, 61% and 81% would treat an uncomplicated breast cancer solitary spinal metastasis with stereotactic body radiation therapy routinely and ideally, respectively; 11% and 32% would treat a solitary lung cancer brain metastasis with dedicated stereotactic radiosurgery routinely and ideally; 36% and 56% would treat multiple low-volume brain metastases with a stereotactic technique routinely and ideally. There was negligible difference in the routine and preferred use of advanced technologies for a solitary bowel cancer lung metastasis; 69% and 77% would treat a locally advanced primary lung cancer with an advanced technique routinely and ideally. Relative to Australia, NZ ROs routinely treat uncomplicated solitary spinal metastases (P < 0.001), solitary brain metastases (P < 0.001), multiple low-volume brain metastases (P < 0.02), and locally advanced primary lung cancer (P < 0.001) more commonly with basic technologies, mainly due to limited local availability of advanced technology and departmental waiting lists.

CONCLUSION

Participants generally favoured treating with advanced techniques and technologies in palliative settings, if available, but there were notable disparities between the two countries. Enhanced local access and clinical training may facilitate optimal utilisation of advanced technologies and improve clinical 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.

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.

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.

Stage IIIA Non-Small Cell Lung Cancer Treatment and Outcomes: A Single Institution Retrospective Analysis

OBJECTIVES

Stage III non-small cell lung cancer (NSCLC) treatment remains challenging, with a multitude of treatment options available. We assessed Stage IIIA NSCLC outcomes by treatment received.

METHODS

We performed a single-institution retrospective review of NSCLC patients with Stage IIIA disease treated January 01, 2010-March 01, 2022. Demographics, treatments, outcomes, and failure patterns were collected. Progression-free survival (PFS) and overall survival (OS) were assessed using Kaplan-Meier analysis. Failure patterns were assessed for differences using chi-square analysis.

RESULTS

Of 270 Stage III NSCLC patients, 134 had Stage IIIA disease with a median follow-up of 29.9 months and a median age of 66 years (IQR 60-75). 66 (49.3%) patients were male, and 105 (78.4%) were current/former smokers (with 30 median pack-years). Patients were treated with definitive radiation with/without chemotherapy (CRT; n = 77, 57.5%), surgery with neoadjuvant chemotherapy and/or radiation (Neoadj; n = 42, 31.3%), and surgery without neoadjuvant therapy (Surg; n = 15, 11.2%). Median PFS was 25.4 months (95% CI 12.5-42.6) for CRT, 22.6 months (95% CI 12.2-44.4) for Neoadj, and 22.8 months (95% CI 5.2-NA) for Surg with no significant intergroup difference (p = 0.99). Median OS was 57.0 months (95% CI 37.4-77.5) for CRT, 51.5 months (95% CI 36.7-65.5) for Neoadj, and 35.3 months (95% CI 16.8-NR) for Surg with no significant intergroup difference (p = 0.99).

CONCLUSIONS

In this single institution retrospective study, we find no significant differences in PFS, OS, and failure patterns between patients with Stage IIIA NSCLC treated with definitive (chemo)radiation and surgery with or without neoadjuvant therapy. Further work in the immunotherapy era is needed.

Ninety-day mortality following curative intent radiotherapy for stage I-III lung cancer in the Netherlands

BACKGROUND AND PURPOSE

The 90-day mortality following lung cancer treatment is a common performance indicator. The aim of this study was to investigate 90-day mortality following (chemo)radiotherapy for stage I-III lung cancer to evaluate the applicability of this outcome indicator in this patient population.

MATERIALS AND METHODS

The Netherlands National Cancer Registry was queried for this retrospective population-based study. Early mortality rates from the start and end of radiotherapy are reported with 95% confidence intervals (CI). The association between clinical characteristics and 90-day mortality was evaluated with multivariable logistic regression analysis.

RESULTS

18,355 Patients treated between 2015 and 2020 were included. The 90-day mortality was 2.56% in stages I-II and 4.60% in stage III, was significantly higher in males, elderly patients and patients with a poor performance status and independent of facility volume. In stage I-II, 90-day mortality was lower after stereotactic versus conventional radiotherapy (2.0% versus 5.25%, OR 0.5 (95%CI 0.4-0.7)). In stage III, mortality decreased from 5.26% in 2015-2016 to 3.73% in 2019-2020 (OR 0.7 (95% CI 0.5-0.9)) and was lower after concurrent versus sequential chemoradiotherapy (3.4% versus 5.9%, OR 1.5 (95%CI 1.2-1.9)). Early mortality increased to 3.20% in stages I-II and 6.70% in stage III when calculated from the end of radiotherapy.

CONCLUSION

Short-term mortality rates following curative intent radiotherapy for lung cancer in the Netherlands are low and independent of facility volume. It was demonstrated that 90-day mortality is an arguable indicator to monitor radiotherapy quality and that standardization of definitions and relevant case-mix factors is warranted.

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.

Feasibility of Left Anterior Descending Coronary Artery Sparing Radiation Therapy for Locally Advanced Lung Cancer

Efforts to mitigate radiation therapy (RT)-associated cardiotoxicity have focused on constraining mean heart dose. However, recent studies have shown greater predictive power with cardiac substructure dose metrics, such as the left anterior descending (LAD) coronary artery volume (V) receiving 15 Gy (V15Gy) ≥10%. Herein, we investigated the feasibility of LAD radiation sparing in contemporary intensity modulated RT (IMRT)/volumetric modulated arc therapy (VMAT) lung cancer plans. Single institution retrospective analysis of 54 patients with locally advanced lung cancer treated with thoracic RT was conducted between February 2018 and August 2021. After excluding 33 (5 = non-IMRT/VMAT or intentionally LAD-optimized; 28 = LAD V15Gy <10%), 21 plans with LAD V15Gy ≥10% were identified for LAD reoptimization with intent to meet LAD V15Gy <10% while maintaining meeting organ at risk (OAR) metrics and target coverage with original plan parameters. Dosimetric variables were compared using paired t tests. Most patients (57.1%, 12/21) were treated with definitive RT, 8 of 21 patients (38.1%) with postoperative RT, and 1 with neoadjuvant RT. The median prescribed RT dose was 60 Gy (range, 50.4-66 Gy) in 30 fractions (range, 28-33 fractions). LAD reoptimized plans (vs original) led to significant reductions in mean LAD V15Gy (39.4% ± 13.9% vs 9.4% ± 13.0%; P < .001) and mean LAD dose (12.9 Gy ± 4.6 Gy vs 7.6 Gy ± 2.8 Gy; P < .001). Most (85.7%; 18/21) LAD reoptimized plans achieved LAD V15Gy <10%. There were no statistically significant differences in overall lung, esophageal, or spinal cord dose metrics. Only 1 reoptimization (1/21) exceeded an OAR constraint that was initially met in the original plan. To our knowledge, this is the first report describing the feasibility of LAD-optimized lung cancer RT planning using the newly identified LAD V15Gy constraint. We observed that LAD V15Gy <10% is achievable in more than 85% of plans initially exceeding this constraint, with minimal dosimetric tradeoffs. Our results support the feasibility of routine incorporation of the LAD as an OAR in modern thoracic IMRT/VMAT planning.

Dose-volume predictors of cardiac adverse events after high-dose thoracic radiation therapy for lung cancer: a systematic review and meta-analysis

BACKGROUND

Lung cancer is a leading cause of cancer mortality and may require high-dose thoracic radiation therapy (RT). However, RT significantly increases the risk of radiation-induced cardiac events, such as pericarditis, cardiomyopathy, and ischemic heart diseases. Despite evidence from clinical trials showing that higher RT doses are associated with poorer survival outcomes due to these cardiac effects, data on dose-volume predictors of such events in lung cancer remain sparse.

OBJECTIVE

To systematically synthesize the incidence of cardiac events following radiation therapy for lung cancer treatment and dose-volume metrics predictors of radiation therapy-induced cardiac events in lung cancer treatment.

METHODS

This systematic review, registered on PROSPERO (CRD42024565103), adhered to PRISMA guidelines to investigate cardiac events and its dose-volume predictors following high-dose radiation therapy in adults with lung cancer. Data were extracted from longitudinal observational studies and randomized controlled trials. A comprehensive literature search was conducted across MEDLINE, Cochrane CENTRAL, and Embase, with studies selected based on predefined criteria, focusing on clinical cardiac outcomes. Data extraction followed CHARMS guidelines, and study quality was reported using the PROBAST tool. Results were synthesized narratively, with meta-analyses performed where appropriate using R software to estimate pooled effect sizes, heterogeneity, and publication bias.

RESULTS

The systematic review included 21 studies and identified a significant association between high-dose thoracic radiation therapy (RT) and an increased incidence of cardiac adverse events in lung cancer patients. The review revealed that higher dose-volume parameters, notably higher mean heart doses (MHD), were predictive of major cardiac events such as pericardial effusion, arrhythmias, and acute coronary syndrome. The meta-analysis showed a significant 4% (95% confidence interval: 3%-6%) increased probability of the occurrence of cardiac events per additional Gray of MHD, with low heterogeneity among studies (I2 = 23%). No publication bias was evidenced.

CONCLUSION

This study underscores the importance of dose-volume parameters as predictors of cardiac adverse events following high-dose thoracic RT in lung cancer treatment. The findings highlight the need for careful consideration of heart dose constraints in RT planning to mitigate the risk of radiation-induced cardiotoxicity, thereby improving the therapeutic ratio for lung cancer patients. Future research should focus on refining these dose constraints and exploring cardioprotective strategies during lung cancer radiotherapy.

Updates in Management of Unresectable Stage III Non Small Cell Lung Cancer: A Radiation Oncology Perspective

Unresectable stage III non-small-cell lung cancer (NSCLC) remains a clinical challenge, due to the need for optimal local and systemic control. The management of unresectable Stage III NSCLC has evolved with advancements in radiation therapy (RT), systemic therapies, and immunotherapy. For patients with locally advanced NSCLC who are not surgical candidates, concurrent chemoradiotherapy (CRT) has modest survival outcomes, due to both local progression and distant metastasis. Efforts to enhance outcomes have led to dose-escalation trials, advances in modern RT techniques such as intensity-modulated RT (IMRT) and proton beam therapy (PBT), and the integration of adaptive RT to optimize target coverage while sparing organs at risk. Concurrent and consolidative immunotherapy, particularly with PD-L1 inhibitors, has shown promise, as evidenced by the PACIFIC trial, which demonstrated improved progression-free survival (PFS) and overall survival (OS) with durvalumab following CRT. Ongoing trials are now investigating novel immunotherapy combinations and targeted therapies in this setting, including dual checkpoint inhibition, DNA repair inhibitors, and molecularly targeted agents like osimertinib for EGFR-mutated NSCLC. Emerging biomarkers, such as circulating tumor DNA and radiomics, offer potential for personalizing treatment and predicting outcomes. Additionally, PBT and MR-guided adaptive RT have shown the potential to reduce toxicities while maintaining efficacy. Integrating these novel approaches may offer opportunities for optimizing treatment responses and minimizing adverse effects in this challenging patient population. Further investigation into patient stratification, biomarker-driven therapy, and refined therapeutic combinations is essential to improve long-term outcomes in unresectable Stage III NSCLC. This narrative review explores the current management strategies for unresectable Stage III NSCLC, from a radiation oncology perspective.

Evaluation of Anti-Angiogenic Therapy Combined with Immunotherapy and Chemotherapy as a Strategy to Treat Locally Advanced and Metastatic Non-Small-Cell Lung Cancer

Immunotherapy has made recent improvements in disease-free survival (DFS) and/or overall survival (OS) in all stages of non-small-cell lung cancer (NSCLC). Here, we review the tumor microenvironment and its immunosuppressive effects and discuss how anti-angiogenic therapies may potentiate the anti-carcinogenic effects of immunotherapy. We also review all the past literature and discuss strategies of combining anti-angiogenic therapy and immunotherapy +/- chemotherapy and hypothesize how we can use this strategy for non-small-cell lung cancer in metastatic previously untreated/previously treated settings in previously treated EGFR-mutated NSCLC for the upfront treatment of brain metastases prior to radiation therapy and for the incorporation of this strategy into stage III unresectable disease. We assert the use of anti-angiogenic therapy and immunotherapy when combined appropriately with chemotherapy and radiotherapy has the potential to increase the long-term survivals in both the stage III and metastatic setting so that we can now consider more patients to experience curative treatment.

Moving beyond mean heart dose: The importance of cardiac substructures in radiation therapy toxicity

Normal tissue tolerance dose limits to the heart have been established to reduce the risk of radiation-induced cardiac disease (RICD). Dose constraints have been developed based on either the mean dose delivered to the whole heart (MHD) or the dose delivered to a specific volume, for example, volume of heart receiving equal to or greater than 30 Gy (V30). There is increasing evidence that the impact of thoracic radiation on cardiac morbidity and mortality has been underestimated. Consequently, there is a need to reduce the dose delivered to the heart in radical radiotherapy treatment planning. The pathophysiology of RICD may relate to dose to specific cardiac substructures (CS) rather than the traditionally observed MHD for common toxicities. The MHD or V30 Gy threshold dose rarely represents the true dose delivered to individual CS. Studies have shown the dose to specific areas may be more strongly correlated with overall survival (OS). With advances in modern radiotherapy techniques, it is vital that we develop robust, evidence-based dose limits for CS, to fully understand and reduce the risk of RICD, particularly in high-risk populations with cardiac risk factors. The following review will summarise the existing evidence of dose limits to CS, explain how dose limits may vary according to different disease sites or radiation techniques and propose how radiotherapy plans can be optimised to reduce the dose to these CS in clinical practice.

Real-World Efficacy and Safety of Durvalumab Administration Following Chemoradiotherapy in Elderly Patients With Unresectable Locally Advanced Nonsmall Cell Lung Cancer: A Multicenter, Retrospective Study

BACKGROUND

The PACIFIC trial established durvalumab administration after chemoradiotherapy as the standard of care for unresectable locally advanced nonsmall cell lung cancer (LA-NSCLC). However, the efficacy and safety of durvalumab in elderly patients aged 75 years or above remains unclear. This study aimed to investigate the real-world efficacy and safety of durvalumab for LA-NSCLC, with a specific focus on elderly patients.

PATIENTS AND METHODS

We reviewed 214 patients who received durvalumab out of 278 patients with unresectable LA-NSCLC who underwent chemoradiotherapy at 7 institutions between July 2018 and March 2022. Propensity score matching (PSM) analysis was performed to evaluate the efficacy of durvalumab in elderly patients.

RESULTS

The 2-year progression-free survival (PFS) and 2-year overall survival (OS) rates were 42.2% (95% confidence interval [CI], 34.7%-49.5%) and 77.1% (95% CI, 70.1-82.7%), respectively. Grade ≥ 3 immune-related adverse events (irAEs) occurred in 8.2% of patients. PSM analysis revealed that OS was significantly shorter in elderly patients (≥ 75 years) than in younger patients (< 75 years) (hazard ratio [HR]; 95% CI, 1.39-8.99; P = .008), whereas PFS did not differ significantly between the 2 groups (HR: 1.50, 95% CI, 0.84-2.68, P = .169). The frequency of irAEs did not differ between these groups.

CONCLUSIONS

The real-world efficacy and safety of durvalumab administration following chemoradiotherapy for LA-NSCLC coincided with the PACIFIC trial's findings. Disease control achieved with this protocol did not differ significantly between elderly and younger patients but had acceptable tolerability, demonstrating its benefit even in elderly LA-NSCLC patients aged 75 years or above.

Overview of cardiac toxicity from radiation therapy

Radiotherapy is an essential part of treatment for many patients with thoracic cancers. However, proximity of the heart to tumour targets can lead to cardiac side effects, with studies demonstrating link between cardiac radiation dose and adverse outcomes. Although reducing cardiac dose can reduce associated risks, most cardiac constraint recommendations in clinical use are generally based on dose to the whole heart, as dose assessment at cardiac substructure levels on individual patients has been limited historically. Furthermore, estimation of an individual's cardiac risk is complex and multifactorial, which includes radiation dose alongside baseline risk factors, and the impact of systemic therapies. This review gives an overview of the epidemiological impact of cancer and cardiac disease, risk factors contributing to radiation-related cardiotoxicity, the evidence for cardiac side effects and future directions in cardiotoxicity research. A better understanding of the interactions between risk factors, balancing treatment benefit versus toxicity and the ongoing management of cardiac risk is essential for optimal clinical care. The emerging field of cardio-oncology is thus a multidisciplinary collaborative effort to enable better understanding of cardiac risks and outcomes for better-informed patient management decisions.

American Radium Society Appropriate Use Criteria on Cardiac Toxicity Prevention and Management After Thoracic Radiotherapy

INTRODUCTION

The multidisciplinary American Radium Society Thoracic Committee was assigned to create appropriate use criteria on cardiac toxicity prevention and management for patients undergoing radiotherapy.

METHODS

A systematic review of the current literature was conducted. Case variants of patients with thoracic malignancies undergoing radiation were created based on presence or absence of cardiovascular risk factors and treatment-related risks assessed by dose exposure to the heart and cardiac substructures. Modified Delphi methodology was used to evaluate the variants and procedures, with less than or equal to three rating points from median defining agreement/consensus.

RESULTS

A total of six variants were evaluated. The panel felt that patients with cardiac comorbidities at high risk for radiation-related cardiac toxicity should undergo a prescreening cardiac-focused history and physical (H&P) examination, electrocardiogram, cardiac imaging including an echocardiogram, and referral to a cardiologist/cardio-oncologist. Recommendations for those without cardiac comorbidities at low risk for cardiac toxicity were to undergo a baseline H&P examination only. Conversely, those without cardiac comorbidities but at high risk for radiation-related cardiac toxicity were recommended to undergo a prescreening electrocardiogram, in addition to a H&P examination. For patients with cardiac comorbidities at low risk for cardiac toxicity, the panel felt that prescreening and postscreening tests may be appropriate.

CONCLUSIONS

The American Radium Society Thoracic appropriate use criteria panel has developed multidisciplinary consensus guidelines for cardiac toxicity prevention, surveillance, and management after thoracic radiotherapy based on cardiac comorbidities at presentation and risk of radiation-related cardiac toxicity.

Consequences of ionizing radiation exposure to the cardiovascular system

Ionizing radiation is widely used in various industrial and medical applications, resulting in increased exposure for certain populations. Lessons from radiation accidents and occupational exposure have highlighted the cardiovascular and cerebrovascular risks associated with radiation exposure. In addition, radiation therapy for cancer has been linked to numerous cardiovascular complications, depending on the distribution of the dose by volume in the heart and other relevant target tissues in the circulatory system. The manifestation of symptoms is influenced by numerous factors, and distinct cardiac complications have previously been observed in different groups of patients with cancer undergoing radiation therapy. However, in contemporary radiation therapy, advances in treatment planning with conformal radiation delivery have markedly reduced the mean heart dose and volume of exposure, and these variables are therefore no longer sole surrogates for predicting the risk of specific types of heart disease. Nevertheless, certain cardiac substructures remain vulnerable to radiation exposure, necessitating close monitoring. In this Review, we provide a comprehensive overview of the consequences of radiation exposure on the cardiovascular system, drawing insights from various cohorts exposed to uniform, whole-body radiation or to partial-body irradiation, and identify potential risk modifiers in the development of radiation-associated cardiovascular disease.

Can We Offset Local Recurrence in Locally Advanced Non-Small Cell Lung Cancer? The Merry-Go-Round of Radiation Dose Escalation and Stubborn Outcomes

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Daily CBCT-based dose calculations for enhancing the safety of dose-escalation in lung cancer radiotherapy

PURPOSE

Dose-escalation in lung cancer comes with a high risk of severe toxicity. This study aimed to calculate the delivered dose in a Scandinavian phase-III dose-escalation trial.

METHODS

The delivered dose was evaluated for 21 locally-advanced non-small cell lung cancer (LA-NSCLC) patients treated as part of the NARLAL2 dose-escalation trial. The patients were randomized between standard and escalated heterogeneous dose-delivery. Both treatment plans were created and approved before randomization. Daily cone-beam CT (CBCT) for patient positioning, and adaptive radiotherapy were mandatory. Standard and escalated plans, including adaptive re-plans, were recalculated on each daily CBCT and accumulated on the planning CT for each patient. Dose to the clinical target volume (CTV), organs at risk (OAR), and the effects of plan adaptions were evaluated for the accumulated dose and on each treated fraction scaled to full treatment.

RESULTS

For the standard treatment, plan adaptations reduced the number of patients with CTV-T underdosage from six to one, and the total number of fractions with CTV-T underdosage from 161 to 56; while for the escalated treatment, the number of patients was reduced from five to zero and number of fractions from 81 to 11. For dose-escalation, three patients had fractions exceeding trial constraints for heart, bronchi, or esophagus, and one had an accumulated heart dose above the constraints.

CONCLUSION

Dose-escalation for LA-NSCLC patients, using daily image guidance and adaptive radiotherapy, is dosimetrically safe for the majority of patients. Dose calculation on daily CBCTs is an efficient tool to monitor target coverage and OAR doses.

Impact of Durvalumab on the Duration and Complexity of Corticosteroid Therapy for Pneumonitis After Chemoradiotherapy

INTRODUCTION

It is unclear how the duration and tapering pattern of corticosteroid therapy for pneumonitis changed after the introduction of durvalumab consolidation therapy.

METHODS

We retrospectively evaluated the medical records of patients diagnosed with nonsmall cell lung cancer who received chemoradiotherapy between January 2014 and December 2020.

RESULTS

Data for 135 patients treated before durvalumab approval and 100 patients treated with durvalumab after its approval were analyzed. In both groups, more than 70% were male, with a median age of 66 y. Approximately 85% were smokers, and the most common tumor histology was adenocarcinoma. Most patients were treated with doses of 60 and 66 Gy (n = 127 [94%] vs. n = 95 [95%]). Among the patients treated with durvalumab, 57%, 38%, and 5% had grade 1, grade 2, and grade 3 pneumonitis; none had grade 4 or 5 pneumonitis. Patients treated with durvalumab exhibited a longer duration of corticosteroid therapy for pneumonitis (17 wk; range: 2-88 wk) than patients not treated with durvalumab (7 wk; range: 0.4-21 wk; P < 0.001). Pneumonitis relapse was more frequent in patients treated with durvalumab (n = 8; 23%) than in patients not treated with durvalumab (n = 2; 7%). Among the 8 patients treated with durvalumab, 2 had recurrent pneumonitis, 1 could not terminate corticosteroids.

CONCLUSIONS

Our data show that durvalumab prolongs the duration of corticosteroid therapy and increases the complexity of corticosteroid tapering patterns. This study can help manage pneumonitis caused by immune checkpoint inhibitors and other drugs used after chemoradiotherapy in routine practice and clinical trials.

Esophagitis and Pneumonitis Related to Concurrent Chemoradiation ± Durvalumab Consolidation in Unresectable Stage III Non-Small-Cell Lung Cancer: Risk Assessment and Management Recommendations Based on a Modified Delphi Process

The addition of durvalumab consolidation to concurrent chemoradiation therapy (cCRT) has fundamentally changed the standard of care for patients with unresectable stage III non-small-cell lung cancer (NSCLC). Nevertheless, concerns related to esophagitis and pneumonitis potentially impact the broad application of all regimen components. A Canadian expert working group (EWG) was convened to provide guidance to healthcare professionals (HCPs) managing these adverse events (AEs) and to help optimize the patient experience. Integrating literature review findings and real-world clinical experience, the EWG used a modified Delphi process to develop 12 clinical questions, 30 recommendations, and a risk-stratification guide. The recommendations address risk factors associated with developing esophagitis and pneumonitis, approaches to risk mitigation and optimal management, and considerations related to initiation and re-initiation of durvalumab consolidation therapy. For both AEs, the EWG emphasized the importance of upfront risk assessment to inform the treatment approach, integration of preventative measures, and prompt initiation of suitable therapy in alignment with AE grade. The EWG also underscored the need for timely, effective communication between multidisciplinary team members and clarity on responsibilities. These recommendations will help support HCP decision-making related to esophagitis and pneumonitis arising from cCRT ± durvalumab and improve outcomes for patients with unresectable stage III NSCLC.

Assessment of radiation pneumonitis and predictive factors in patients with locally advanced non-small cell lung cancer treated with chemoradiotherapy

PURPOSE

Radiation pneumonitis (RP) is a dose-limiting toxicity associated with increased mortality for patients with non-small cell lung cancer (NSCLC) treated with chemoradiotherapy (CRT). This study aims to assess the incidence of symptomatic RP (grade 2-5), rate of recovery and associated predictive factors.

MATERIAL AND METHODS

We performed a retrospective population-based study including 602 patients with NSCLC who were treated with CRT between 2002 and 2016. RP and rate of recovery were analysed using Common Terminology Criteria for Adverse Events version 4.0. Stepwise logistic regression was performed to analyse potential predictive factors for the two endpoints RP grade ≥ 2 and RP grade ≥ 3.

RESULTS

A total of 136 (23%) patients developed symptomatic RP and 37 (6%) developed RP grade ≥ 3. A total of 67 (71%) recovered, whereas the remaining 27 (29%), with the major proportion of patients belonging to the RP grade ≥ 3 group, suffered from prevailing sequelae. On multivariable analysis, the selected model for predicting RP grade ≥ 2 included the factors V20, smoking status, average fractions per week and chemotherapy agent. V20 and age were selected factors for RP grade ≥ 3.

INTERPRETATION

The results suggest that regardless of all proposed factors predictive for RP, the most important influenceable significant factor still is dose to the lung. The main aim should be to avoid RP grade ≥ 3, where a substantial proportion of patients suffer from prevailing sequalae. Consequently, the technical improvement and precision of radiotherapy delivery should continue to focus on lung sparing techniques also in the ongoing immunotherapy-containing schedules where the risk of pneumonitis may be increased. e factor still is dose to the lung. Consequently, the technical improvement and precision of radiotherapy delivery should continue to focus on lung sparing techniques also in the ongoing immunotherapy-containing schedules where the risk of pneumonitis may be increased.

Effect of replanning boost radiotherapy plan in locally advanced unresectable middle to lower thoracic esophageal cancer

Thoracic bulky esophageal cancer shrinks during radiotherapy, changing the location and shape of the surrounding heart and lungs. The current study aimed to explore how replanning by volumetric-modulated arc radiotherapy (VMAT) and three-dimensional conformal radiotherapy (3DCRT) influences the target coverage and dose to organs at risk in locally advanced unresectable middle to lower thoracic esophageal cancer. We retrospectively collected CT simulation images of initial and boost radiotherapy plans for locally advanced unresectable thoracic esophageal cancer in 17 consecutive patients. First, we created boost plans of 20 Gy using 3DCRT and VMAT on the initially acquired CT images. Second, we replicated the process on CT images acquired after 20-40 Gy of radiotherapy. We then compared non-replanned boost radiotherapy plans with replanned boost plans. Replanned radiotherapy delivered more conformal doses to the target and reduced heart and lung doses. VMAT reduced more irradiated mean doses to the heart than 3DCRT in the case of replanning (1.7 and 1.1 Gy, p < 0.001). Replanning to accommodate tumor shrinkage during radiotherapy effectively lowers the irradiated doses to the heart and lungs in patients with locally advanced unresectable middle to lower thoracic esophageal cancer, especially those treated with VMAT.

Safety and Efficacy of HL301 In Radiation Pneumonitis in Patients With Unresectable Non-Small Cell Lung Cancer Receiving Curative Concurrent Chemoradiotherapy: A Multicenter, Randomized, Double-Blinded, Placebo-Controlled, Phase 2a Clinical Trial

PURPOSE

We aimed to investigate the safety and efficacy of HL301, a standardized combination product of 7 medicinal plants, in radiation pneumonitis in patients with unresectable non-small cell lung cancer undergoing curative concurrent chemoradiotherapy.

METHODS AND MATERIALS

The target accrual was 87 and a total of 63 patients were enrolled due to poor accrual rate. We randomly assigned the 63 patients to receive a placebo (arm A), or 1200 mg HL301 (arm B), or 1800 mg HL301 (arm C). Patients received weekly paclitaxel and carboplatin concurrently with intensity-modulated radiation therapy at 60 to 66 Gy in conventional fractionation. Durvalumab was administered as a maintenance treatment according to standard clinical practice. HL301 was administered orally, daily for 12 weeks. The primary endpoint was incidence of grade ≥2 radiation pneumonitis at 24 weeks postchemoradiotherapy.

RESULTS

The baseline characteristics of the patients were well balanced. The drug was tolerable with a compliance rate of 86.6%, 86.2%, and 88.8% in arms A, B, and C, respectively (P = .874). None of the patients experienced severe drug-related adverse events. No significant difference in the rate of adverse events were observed between the treatment arms. The incidence of grade ≥2 radiation pneumonitis at 24 weeks postchemoradiotherapy was 37.5% (95% CI, 18.5%-61.4%), 55.6% (95% CI, 33.7%-75.4%), and 52.4% (95% CI, 32.4%-71.7%) in arms A, B, and C, respectively (P = .535).

CONCLUSIONS

This is the first exploratory clinical trial to test the safety and efficacy of HL301 in patients with non-small cell lung cancer. Safety and feasibility of HL301 were established but no signals of efficacy in reducing radiation pneumonitis was observed in this dose level.

Harnessing Bacterial Membrane Components for Tumor Vaccines: Strategies and Perspectives

Tumor vaccines stand at the vanguard of tumor immunotherapy, demonstrating significant potential and promise in recent years. While tumor vaccines have achieved breakthroughs in the treatment of cancer, they still encounter numerous challenges, including improving the immunogenicity of vaccines and expanding the scope of vaccine application. As natural immune activators, bacterial components offer inherent advantages in tumor vaccines. Bacterial membrane components, with their safer profile, easy extraction, purification, and engineering, along with their diverse array of immune components, activate the immune system and improve tumor vaccine efficacy. This review systematically summarizes the mechanism of action and therapeutic effects of bacterial membranes and its derivatives (including bacterial membrane vesicles and hybrid membrane biomaterials) in tumor vaccines. Subsequently, the authors delve into the preparation and advantages of tumor vaccines based on bacterial membranes and hybrid membrane biomaterials. Following this, the immune effects of tumor vaccines based on bacterial outer membrane vesicles are elucidated, and their mechanisms are explained. Moreover, their advantages in tumor combination therapy are analyzed. Last, the challenges and trends in this field are discussed. This comprehensive analysis aims to offer a more informed reference and scientific foundation for the design and implementation of bacterial membrane-based tumor vaccines.

Computed tomography patterns and clinical outcomes of radiation pneumonitis in non-small-cell lung cancer patients

Background

Radiation pneumonitis (RP) is not an uncommon complication in lung cancer patients undergoing radiation therapy (RT) and symptomatic RP can affect their quality of life.

Purpose

To investigate the CT findings of RP in non-small cell lung cancer (NSCLC) patients and their relationship with clinical outcomes.

Materials and methods

We reviewed data from 240 NSCLC patients who underwent RT between 2014 and 2022. CT findings of RP were evaluated for parenchymal abnormalities and distribution, which were then classified into three patterns: localized pneumonia (LP), cryptogenic organizing pneumonia (COP), and acute interstitial pneumonia (AIP). Clinical outcomes of RP were evaluated based on Common Terminology Criteria for Adverse Events (CTCAE) grade.

Results

Of the 153 patients, 135 developed RP. The most common pattern was LP (n = 78), followed by COP (n = 30) and AIP (n = 25). Among the three CT patterns, CTCAE grade and days between the start of RT and the onset of RP (RT-RP days) were statistically significantly different (p < 0.05). The patients with AIP patterns exhibited higher CTCAE grade, and fewer RT-RP days compared to those with non-AIP patterns (p < 0.05). In these patients, lung-to-lung metastasis and underlying interstitial lung abnormality were observed more frequently (p < 0.05). Underlying pulmonary fibrosis, the AIP pattern, and higher CT extent scores were more frequently observed in higher CTCAE grade group (p < 0.001). In multiple regression analysis, age, bilateral distribution, RT-RP days, and CT extent score ≥3 were independent predicting factors for higher CTCAE grade.

Conclusions

RP in NSCLC patients can be classified into LP, COP, and AIP patterns and they exhibit different severities in clinical outcomes.

Cardiac Substructure Dose and Survival in Stereotactic Radiotherapy for Lung Cancer: Results of the Multi-Centre SSBROC Trial

BACKGROUND AND PURPOSE

Stereotactic ablative body radiotherapy (SABR) is increasingly used for early-stage lung cancer, however the impact of dose to the heart and cardiac substructures remains largely unknown. The study investigated doses received by cardiac substructures in SABR patients and impact on survival.

MATERIALS AND METHODS

SSBROC is an Australian multi-centre phase II prospective study of SABR for stage I non-small cell lung cancer. Patients were treated between 2013 and 2019 across 9 centres. In this secondary analysis of the dataset, a previously published and locally developed open-source hybrid deep learning cardiac substructure automatic segmentation tool was deployed on the planning CTs of 117 trial patients. Physical doses to 18 cardiac structures and EQD2 converted doses (α/β = 3) were calculated. Endpoints evaluated include pericardial effusion and overall survival. Associations between cardiac doses and survival were analysed with the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

Cardiac structures that received the highest physical mean doses were superior vena cava (22.5 Gy) and sinoatrial node (18.3 Gy). The highest physical maximum dose was received by the heart (51.7 Gy) and right atrium (45.3 Gy). Three patients developed grade 2, and one grade 3 pericardial effusion. The cohort receiving higher than median mean heart dose (MHD) had poorer survival compared to those who received below median MHD (p = 0.00004). On multivariable Cox analysis, male gender and maximum dose to ascending aorta were significant for worse survival.

CONCLUSIONS

Patients treated with lung SABR may receive high doses to cardiac substructures. Dichotomising the patients according to median mean heart dose showed a clear difference in survival. On multivariable analyses gender and dose to ascending aorta were significant for survival, however cardiac substructure dosimetry and outcomes should be further explored in larger studies.

Forecasting Daily Radiotherapy Patient Volumes in a Tertiary Hospital Using Autoregressive Integrated Moving Average (ARIMA) Models

PURPOSE

The purpose is to predict the volume of patients treated daily with radiotherapy using the autoregressive integrated moving average (ARIMA) model.

METHODS

In this retrospective study, data from the billing records detailing daily radiotherapy treatment sessions were extracted from the Hospital Information System and analyzed. The study included all patients treated from January 2004 to December 2022. The analysis was divided into two parts: First, the data were summarized using descriptive statistics. Second, time series forecasting with the implementation of an ARIMA model for estimating patient volumes. For the ARIMA modeling process, the Akaike Information Criterion (AIC) was used for classical model optimization. The Mean Absolute Percentage Error (MAPE) was used for evaluating between different models. Residual analysis was performed in each model using the Ljung-Box test, Jarque-Bera test, and heteroskedasticity test to identify autocorrelation, normal distribution, and variances that could undermine the reliability of the model.

RESULTS

A total of 895,808 radiotherapy sessions were included in the study. The median number of radiotherapy sessions per day was 181 (150, 205). A clear transition to more modern radiotherapy equipment, particularly the Truebeam accelerator, was observed, indicating a growing dependency on advanced techniques such as volumetric-modulated arc therapy (VMAT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS). The best ARIMA model predicted an increase in demand, projecting an average daily patient volume of 279.40 by 2030.

CONCLUSION

The study highlights the need for advanced forecasting methodologies in healthcare resource planning and emphasizes the importance of considering environmental and external factors for effective and accurate resource allocation strategies.

"Mid-P strategy" versus "internal target volume strategy in locally advanced non small cell lung cancer: Clinical results from the randomized non-comparative phase II study Mid-P

BACKGROUND

Locally advanced non-small cell lung cancer (LA-NSCLC) reported poor 5-year survival rates with frequent local or regional recurrences. Personalized RT may contribute to improve control and clinical outcome. We investigated efficacy and tolerance of "Mid-position" (Mid-P) strategy versus the conventional Internal Target Volume (ITV) strategy in LA-NSCLC patients treated by definitive conformal radiotherapy.

METHODS

This prospective non-comparative randomized monocentric phase II trial included adult patients with non-resected, non-metastatic, non-previously irradiated proven LA-NSCLC treated with definitive normo-fractionated conformal radiotherapy (+/- chemotherapy). Allocated patients (randomisation 2:1) were treated using Mid-P or ITV strategy. A Fleming single-stage design (1-sided α = 0.1, 80 % power, P0 = 30 %, P1 = 50 %) planned enrolment of 36 patients in the Mid-P group. The ITV group ensured the absence of selection bias. The primary outcome was 1-year progression-free- survival (1y-PFS) rate.

RESULTS

Among 54 eligible patients included from September 2012 to May 2018, 51 patients were analyzed (Mid-P: N = 34; ITV: 17). The 1y-PFS was 38 % (1-sided 95 %CI 25 %-not reached) with Mid-P strategy, and 47 % (95 %CI [27 %-not reached[) with ITV. Loco-regional failure as first event mainly occurred within radiation-field regardless the strategy. Acute and middle-term radiation toxicities were observed with both strategies.

CONCLUSION

Local control and survival remain poor using the Mid-P strategy in this prospective randomized non-comparative monocentric study investigating Mid-P strategy versus ITV strategy in LA-NSCLC. Since the Mid-P strategy is not integrated into routine software, and perceived as a time-consuming method, Mid-P strategy cannot be recommended in LA-NSCLCC treated by definitive normo-fractionated conformal radiotherapy outside clinical trials.

Integrating local and distant radiation-induced lung injury: Development and validation of a predictive model for ventilation loss

BACKGROUND

Investigations on radiation-induced lung injury (RILI) have predominantly focused on local effects, primarily those associated with radiation damage to lung parenchyma. However, recent studies from our group and others have revealed that radiation-induced damage to branching serial structures such as airways and vessels may also have a substantial impact on post-radiotherapy (RT) lung function. Furthermore, recent results from multiple functional lung avoidance RT trials, although promising, have demonstrated only modest toxicity reduction, likely because they were primarily focused on dose avoidance to lung parenchyma. These observations emphasize the critical need for predictive dose-response models that effectively incorporate both local and distant RILI effects.

PURPOSE

We develop and validate a predictive model for ventilation loss after lung RT. This model, referred to as P+A, integrates local (parenchyma [P]) and distant (central and peripheral airways [A]) radiation-induced damage, modeling partial (narrowing) and complete (collapse) obstruction of airways.

METHODS

In an IRB-approved prospective study, pre-RT breath-hold CTs (BHCTs) and pre- and one-year post-RT 4DCTs were acquired from lung cancer patients treated with definitive RT. Up to 13 generations of airways were automatically segmented on the BHCTs using a research virtual bronchoscopy software. Ventilation maps derived from the 4DCT scans were utilized to quantify pre- and post-RT ventilation, serving, respectively, as input data and reference standard (RS) in model validation. To predict ventilation loss solely due to parenchymal damage (referred to as P model), we used a normal tissue complication probability (NTCP) model. Our model used this NTCP-based estimate and predicted additional loss due radiation-induced partial or complete occlusion of individual airways, applying fluid dynamics principles and a refined version of our previously developed airway radiosensitivity model. Predictions of post-RT ventilation were estimated in the sublobar volumes (SLVs) connected to the terminal airways. To validate the model, we conducted a k-fold cross-validation. Model parameters were optimized as the values that provided the lowest root mean square error (RMSE) between predicted post-RT ventilation and the RS for all SLVs in the training data. The performance of the P+A and the P models was evaluated by comparing their respective post-RT ventilation values with the RS predictions. Additional evaluation using various receiver operating characteristic (ROC) metrics was also performed.

RESULTS

We extracted a dataset of 560 SLVs from four enrolled patients. Our results demonstrated that the P+A model consistently outperformed the P model, exhibiting RMSEs that were nearly half as low across all patients (13 ± 3 percentile for the P+A model vs. 24 ± 3 percentile for the P model on average). Notably, the P+A model aligned closely with the RS in ventilation loss distributions per lobe, particularly in regions exposed to doses ≥13.5 Gy. The ROC analysis further supported the superior performance of the P+A model compared to the P model in sensitivity (0.98 vs. 0.07), accuracy (0.87 vs. 0.25), and balanced predictions.

CONCLUSIONS

These early findings indicate that airway damage is a crucial factor in RILI that should be included in dose-response modeling to enhance predictions of post-RT lung function.

Effect of FDG PET-CT for Staging and Radiotherapy Planning - A Comparison of Cohorts From Two Randomized Trials of Thoracic Radiotherapy in Limited-Stage SCLC

Introduction

18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) is recommended for staging and defining target volume in limited-stage SCLC, though the impact on outcomes compared with CT staging and elective nodal irradiation (ENI) is not well documented. We analyzed patients receiving 45 Gy/30 fractions in two randomized trials of thoracic radiotherapy (TRT) in limited-stage SCLC (HAST and THORA trials) to evaluate whether PET-CT for staging and radiotherapy planning reduces radiotoxicity and improves survival.

Methods

Patients in HAST were staged with CT of the thorax and upper abdomen and brain magnetic resonance imaging of the brain. Patients in THORA were staged with PET-CT in addition. All patients were to receive four courses of platinum/etoposide chemotherapy and concurrent TRT starting three to four weeks after the first chemotherapy course. In HAST, target volumes included pathological lesions on CT plus ENI of lymph node stations 4-7 (bilateral). In THORA, target volumes were limited to PET-CT-positive lesions (selective nodal irradiation [SNI]).

Results

A total of 149 patients were included (PET-CT/SNI: n = 76, CT/ENI: n=73); the median age was 64 years, 56% were women, 85% had PS 0 to 1, and 81% had stage III disease. The PET-CT/SNI group experienced less grade 3-4 esophagitis (18% versus 33%, p = 0.043), less grade >=1 pneumonitis (5% versus 16%, p = 0.028), and less dysphagia after TRT (mean scores on European Organisation for Research and Treatment of Cancer 13-item lung cancer module: 45 versus 72). There was no difference in median overall survival (24 versus 25 mo, p = 0.59) or progression-free survival (11 versus 11 mo, p = 0.23).

Conclusions

Using PET-CT for staging and target volume definition of TRT reduces acute radiotoxicity but does not improve overall or progression-free survival in limited-stage SCLC.

Outcomes of adjuvant lymph node field radiotherapy and immunotherapy for stage III melanoma

PURPOSE

With the promising results of immunotherapy in patients with stage III melanoma, the role of adjuvant radiotherapy after resection and complete lymph-node dissection must be reassessed. We evaluate the outcomes and safety of adjuvant radiotherapy and immunotherapy compared to immunotherapy only in patients with resected stage III melanoma.

PATIENTS AND METHODS

This retrospective and single institution study included patients treated for a stage III melanoma with complete lymph-node dissection and adjuvant immunotherapy from January 2019 to December 2022. The radiotherapy associated with immunotherapy group was defined by completion of immunotherapy and adjuvant radiotherapy in the lymph-node dissection area. The primary endpoint was disease-free survival. The secondary endpoints were locoregional progression, incidence of adverse events grade 3 or above and disease-free survival rate in patients with high risk of locoregional recurrence.

RESULTS

Thirty-three patients were included. Among them, twelve received adjuvant lymph-node field radiotherapy. The median duration of follow-up was 17months (range: 8-45months). Patients receiving radiotherapy and immunotherapy had a significantly higher disease stage and more frequent extracapsular extension. At 12months, the disease-free survival rate was 66.7% for the patients receiving immunotherapy alone (95% CI: 42.5-82.5%) and 83.3% for those receiving radiotherapy and immunotherapy (95% CI: 48.2-95.6%; P=0.131). The locoregional progression rate was 24% in patients receiving immunotherapy and 8% in patients receiving immunotherapy and radiotherapy (P=0.379). After adjuvant treatment, 6% of patients developed grade 3 or above immunotherapy-related events and none developed grade 3 or above radiation-related adverse events.

CONCLUSION

In patients with stage III melanoma, adjuvant lymph-node field radiotherapy combined with immunotherapy seems to be associated with longer disease-free survival, with acceptable tolerance. However, these results need to be confirmed by long-term and prospective studies.

Long-term outcome of definitive radiotherapy for locally advanced non-small cell lung cancer: A real-world single-center study in the pre-durvalumab era

BACKGROUND

There was limited research data on large-scale locally advanced non-small cell lung cancer (LA-NSCLC) radical radiotherapy (RT) reported in China. This study examined overall survival (OS), progression-free survival (PFS), treatment effectiveness, and toxicity in patients with LA-NSCLC treated with definitive RT in the pre-durvalumab era.

METHODS

A retrospective analysis of demographic information, clinical characteristics, treatment patterns, and clinical outcomes of 789 patients with LA-NSCLC who underwent radical RT at our center between January 2005 and December 2015 was performed. The Kaplan-Meier method and log-rank test were used for survival comparisons, and Cox regression was used for multivariate analysis.

RESULTS

There were 328 patients with stage IIIA disease and 461 with stage IIIB disease. By the last follow-up, there were 365 overall deaths and 576 cases of recurrence, metastasis, or death. The median survival time was 31 months. The OS rates at 1, 2, 5, and 10 years were 83.7%, 59.5%, 28.8%, and 18.9%, respectively. PFS rates at 1, 2, 5, and 10 years were 48%, 24.5%, 11.9%, and 5.5%, respectively. Rates of ≥grade 3 acute radiation pneumonitis or esophagitis were 7.6% and 1.9%, respectively. Rates of ≥grade 3 chronic radiation pneumonitis and esophagitis were 11% and 0.4%, respectively. Multivariate analysis showed that the Karnofsky Performance Status (KPS) score, smoking status, and combined chemotherapy were prognostic factors for OS (p < 0.05). Multivariate analysis revealed that combined chemotherapy and radiation dose were prognostic factors for PFS (p < 0.05).

CONCLUSIONS

Our center's data showed that the survival prognosis of locally advanced patients receiving RT and chemotherapy in China was consistent with international levels during the same period. Patients with a KPS score of 80 or higher, who had never smoked or received combined RT, had a more favorable prognosis than those with a KPS of less than 80, who had smoked, or only received RT. The combination of RT and chemotherapy, with a reasonable radiation dose, was the key to improving the therapeutic effect.