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Smesseim I, Mets OM, Daniels JMA, Bahce I, Senan S. Diagnosis and management of pneumonitis following chemoradiotherapy and immunotherapy in stage III non-small cell lung cancer. Radiother Oncol 2024; 194:110147. [PMID: 38341099 DOI: 10.1016/j.radonc.2024.110147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/29/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND In inoperable stage III NSCLC, the standard of care is chemoradiotherapy and adjuvant durvalumab (IO) for 12 months. Pneumonitis is the commonest toxicity leading to discontinuation of IO. A failure to distinguish between expected radiation-induced changes, IO pneumonitis and infection can lead to unnecessary durvalumab discontinuation. We investigated the use of a structured multidisciplinary review of CT-scans, radiation dose distributions and clinical symptoms for the diagnosis of IO pneumonitis. METHODS A retrospective study was conducted at an academic medical center for patients treated for stage III NSCLC with chemoradiotherapy and adjuvant durvalumab between 2018 and 2021. An experienced thoracic radiologist reviewed baseline and follow-up chest CT-scans, systematically scored radiological features suspected for pneumonitis using a published classification system (Veiga C, Radioth Oncol 2018), and had access to screenshots of radiation dose distributions. Next, two experienced thoracic oncologists reviewed each patients' case record, CT-scans and radiation fields. A final consensus diagnosis incorporating views of expert clinicians and the radiologist was made. RESULTS Among the 45 included patients, 14/45 (31.1%) had a pneumonitis scored in patient records and durvalumab was discontinued in 11/45 cases (24.4%). Review by the radiologist led to a diagnosis of immune-related pneumonitis only in 6/45 patients (13.3%). Review by pulmonary oncologists led to a diagnosis of immune-related pneumonitis in only 4/45 patients (8.9%). In addition a suspicion of an immune-related pneumonitis was rejected in 3 separate patients (6.7%), after the thoracic oncologists had reviewed the patients' radiation fields. CONCLUSIONS In patients treated using the PACIFIC regimen, multidisciplinary assessment of CT-scans, radiation doses and patient symptoms, resulted in fewer diagnoses of immune-related pneumonitis (8.9%). Our study underscores the challenges in accurately diagnosing either IO-related or radiation pneumonitis in patients undergoing adjuvant immunotherapy after chemoradiotherapy and highlights the need for multidisciplinary review in order to avoid inappropriate cessation of adjuvant IO.
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Affiliation(s)
- I Smesseim
- Department of Thoracic Oncology, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands.
| | - O M Mets
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - J M A Daniels
- Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - I Bahce
- Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - S Senan
- Department of Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Meldgaard P, Kristensen M, Conte S, Kaae Andersen K, Jovanovic A, Meldgaard E. Improved overall survival for Stage III NSCLC patients treated with curative-intended therapy from 2010 to 2018-a cohort study in Denmark. Acta Oncol 2023; 62:1672-1679. [PMID: 37699061 DOI: 10.1080/0284186x.2023.2254474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/06/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Despite advances in treatment strategies and improved clinical outcomes, an unmet need remains for NSCLC patients. With an increased real-world knowledge of NSCLC, clinicians could offer patients optimal tailored treatment and disease management. In this retrospective cohort study, we describe patient characteristics, treatment patterns and modality, and survival in NSCLC patients diagnosed and treated at Aarhus University Hospital, Denmark. METHODS Data on Stage III NSCLC patients aged ≥18 years diagnosed 2010-2018 were obtained from a regional cancer database and linked to national registries for information on socioeconomic and vital status. Patients were stratified by planned treatment intention at diagnosis (curative/palliative). Treatment patterns and overall survival (OS) were estimated using time-to-event methods. RESULTS Broad patient and diseases characteristics and multiple treatment options demonstrated the heterogeneity of this patient cohort. Of 851 Stage III NSCLC patients, 599 (70%) and 252 (30%) were offered curative- and palliative-intended treatment, respectively, upon evaluation by a multidisciplinary team (MDT). The most frequent treatment modalities were CRT (n = 328; 55%) and RT (n = 97; 38%) in the curative and palliative setting, respectively. Age, disease stage, performance status and comorbidity were associated with curative-intended treatment initiation. Curative-intended treatment was associated with an improved OS of 14.6 months (median OS 24.4 months, 95% CI 21.1-27.6). Being offered curative-intended treatment and/or being diagnosed in the more contemporary study period (2016-2018) were significantly correlated with better OS (p < 0.001). CONCLUSION Stage III NSCLC is a heterogeneous disease as regards patient and clinical characteristics, multiple treatment options, and outcomes. Age, disease staging, performance status, and comorbidity, as well as MDT evaluation and matching treatment intent, are important determinants of curative-intended treatment. Notably, an NSCLC diagnosis in the more contemporary study period was statistically significantly associated with better OS.
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Affiliation(s)
- Peter Meldgaard
- Institute for Clinical Medicine, Department of Oncology, Aarhus University Hospital, Denmark
| | | | | | | | - Aleksander Jovanovic
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Ebbe Meldgaard
- Department of Oncology, Aarhus University Hospital, Denmark
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3
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Amin SA, Baine MJ, Rahman I, Lin C. The Association of Immunotherapy With the Overall Survival of Inoperable Stage III Non-small Cell Lung Cancer Patients Who Do Not Receive Chemoradiation. J Immunother 2023; 46:14-21. [PMID: 36256124 DOI: 10.1097/cji.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/08/2022] [Indexed: 01/31/2023]
Abstract
Immunotherapy has been approved for stage III non-small cell lung cancer (NSCLC) as consolidation therapy after chemoradiation in patients whose disease does not progress after chemoradiation. However, many patients do not receive chemoradiation due to either the drugs' side effects or poor performance status. This study's objective is to investigate the association of immunotherapy combined with chemotherapy or Radiotherapy (RT) with the overall survival (OS) of stage III NSCLC patients who do not receive chemoradiation. Patients with stage III NSCLC who received either chemotherapy or RT with or without immunotherapy were identified from NCDB. The Cox proportional hazard regression analysis was implied to assess the effect of immunotherapy on survival after adjusting the model for age at diagnosis, race, sex, education, treatment facility type, insurance status, comorbidity score, histology year of diagnosis, and treatment types, such as chemotherapy and radiation therapy. The final analysis included 32,328 patients, among whom 3,205 (9.9%) received immunotherapy. In the multivariable analysis adjusted for all the factors previously mentioned, immunotherapy was associated with significantly improved OS (HR: 0.76, CI: 0.71-0.81) compared with no immunotherapy. Treatment with chemotherapy plus immunotherapy was significantly associated with improved OS (HR: 0.83, CI: 0.77-0.90) compared with chemotherapy without immunotherapy. Further, RT plus immunotherapy was associated with significantly improved OS (HR: 0.62, CI: 0.54-0.70) compared with RT alone. In this comprehensive analysis, the addition of immunotherapy to chemotherapy or radiotherapy was associated with improved OS compared with chemotherapy or radiation therapy without immunotherapy in stage III NSCLC patients.
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Affiliation(s)
- Saber A Amin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE
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4
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Kuang Y, Pierce CM, Chang HC, Sosinsky AZ, Deitz AC, Keller SM, Samkari A, Uyei J. Chemoradiation-induced pneumonitis in patients with unresectable stage III non-small cell lung cancer: A systematic literature review and meta-analysis. Lung Cancer 2022; 174:174-185. [PMID: 35717343 DOI: 10.1016/j.lungcan.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/23/2022] [Accepted: 06/07/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION High-grade pneumonitis is a severe and potentially life-threatening adverse event associated with concurrent chemoradiation (cCRT) in patients with non-small cell lung cancer (NSCLC). The aim of this study was to summarize and quantify the incidence of severe (grade 3-5) cCRT-induced pneumonitis in unresectable stage III NSCLC patients. METHODS A systematic literature review and meta-analysis were performed in accordance with PRISMA guidelines. Published literature was searched for randomized controlled trials (RCTs), observational studies, and non-randomized trials from 2014 to April 2020. The primary outcome of interest was incidence of grade 3-5 pneumonitis. RESULTS Included were 17 studies for the review and 11 for the meta-analysis (1,788 participants); all studies examined radiation-related pneumonitis (RP). The pooled incidence of cCRT-induced grade 3-5 RP in unresectable stage III NSCLC patients was estimated to be 3.62% [95% confidence interval (CI): 1.65-6.21] in RCTs, 5.98% [95% CI: 2.26-12.91] in observational studies, and 7.85% [95% CI: 4.08-13.10] in observational studies using platinum-based doublet chemotherapies. CONCLUSION These results suggest the incidence of severe and fatal RP in patients with unresectable stage III NSCLC treated with cCRT ranges from 3.62% to 7.85%, with incidence varying by study design and chemotherapy regimen. Estimates of RP incidence were higher in the real-world setting compared to RCTs. These results can be used to contextualize the baseline risk of cCRT-induced pneumonitis in unresectable stage III NSCLC to better understand the adverse event of pneumonitis associated with novel immunotherapy treatments indicated for concomitant use with this modality.
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Casal-Mouriño A, Ruano-Ravina A, Lorenzo-González M, Rodríguez-Martínez Á, Giraldo-Osorio A, Varela-Lema L, Pereiro-Brea T, Barros-Dios JM, Valdés-Cuadrado L, Pérez-Ríos M. Epidemiology of stage III lung cancer: frequency, diagnostic characteristics, and survival. Transl Lung Cancer Res 2021; 10:506-518. [PMID: 33569332 PMCID: PMC7867742 DOI: 10.21037/tlcr.2020.03.40] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stage III non-small cell lung cancer (NSCLC) includes a highly heterogeneous group of patients with differences in the extent and localization of disease. Many aspects of stage III disease are controversial. The data supporting treatment approaches are often subject to a number of limitations, due to the heterogeneous patient populations involved in the trials. Furthermore, the definition of stage III disease has changed over time, and early studies were frequently inadequately powered to detect small differences in therapeutic outcome, were not randomized, or had a limited follow-up times. Major improvements in therapy, including the use of more active chemotherapy agents and refinements in radiation and surgical techniques, also limit the interpretation of earlier clinical trials. Lastly, improvements in pretreatment staging have led to reclassification of patients with relatively minimal metastatic disease as stage IV rather than stage III, leading to an apparent increase in the overall survival of both stage III and IV patients. Median overall stage III NSCLC survival ranges from 9 to 34 months. Higher survival rates are observed in younger Caucasian women with good performance status, adenocarcinoma, mutations, stage IIIA, and in patients with multidisciplinary-team-based diagnoses.
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Affiliation(s)
- Ana Casal-Mouriño
- Department of Pneumology, Santiago de Compostela University Clinical Teaching Hospital, Galicia, Spain.,Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
| | - Alberto Ruano-Ravina
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain.,Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología and Salud Pública/CIBERESP), Madrid, Spain
| | - María Lorenzo-González
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain.,Population Screening Unit, Galician Regional Health Authority, Santiago de Compostela, Spain
| | - Ángeles Rodríguez-Martínez
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain.,Department of Oncology, Pontevedra University Hospital Complex, Pontevedra, Spain
| | - Alexandra Giraldo-Osorio
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain.,Research Group for Health Promotion and Disease Prevention, Department of Public Health, University of Caldas, Manizales, Colombia
| | - Leonor Varela-Lema
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain.,Scientific-Technical Advisory Unit, Galician Health Technology Assessment Agency, Health Knowledge Management Agency (Unidade de Asesoramento Científico-técnico/avalia-t, Axencia de Coñecemento en Saúde/ACIS), Galician Regional Health Authority, Galicia, Spain
| | - Tara Pereiro-Brea
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain.,Department of Pneumology, A Coruña University Teaching Hospital Complex, A Coruña, Spain
| | - Juan Miguel Barros-Dios
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
| | - Luis Valdés-Cuadrado
- Department of Pneumology, Santiago de Compostela University Clinical Teaching Hospital, Galicia, Spain.,Interdisciplinary Group of Research in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Mónica Pérez-Ríos
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain.,Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología and Salud Pública/CIBERESP), Madrid, Spain
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Arellano EA, Díaz VD, Rodríguez JJC. Current status and future directions in unresectable stage III non-small cell lung cancer. J Clin Transl Res 2020; 6:109-120. [PMID: 33521371 PMCID: PMC7837736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/10/2020] [Accepted: 10/09/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Patients with unresectable stage III non-small-cell lung cancer constitute a heterogeneous group in which the available treatments may range from radical therapies with radio-chemotherapy to supportive treatments depending on the extent of the disease and comorbidities present. For years the standard treatment based on the combination of chemotherapy and radiotherapy (RT) has remained unchanged and survival outcomes have been poor. AIM Recent advances in molecular biology and RT technology have resulted in improved survival. This article reviews the treatments that constitute current standard treatment in unresectable advanced lung cancer and the situations and indications for the management of patients who are not candidates for radical therapy. RELEVANCE FOR PATIENTS Although unresectable lung cancer does not have a good prognosis, new drugs and new technologies in radiation oncology can offer treatment options adapted to the patient's clinical situation, ranging from therapies administered with radical intent to others aimed mainly at improving the patient's quality of life, which, judiciously chosen, will provide optimal management of the patient.
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Affiliation(s)
| | - Verónica Díaz Díaz
- 2Department of Radiation Oncology, Universitary Hospital Puerta del Mar, Cádiz, Spain
| | - Joaquín José Cabrera Rodríguez
- 3Department of Radiation Oncology, Universitary Hospital of Badajoz, Badajoz, Spain,
Corresponding author Joaquín José Cabrera Rodríguez Department of Radiation Oncology, Universitary Hospital of Badajoz, 06080, Badajoz, Spain Tel.: +34 924 218100 (48542); Fax: +34 924 219871
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7
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Wang J, Zhang ZQ, Li FQ, Chen JN, Gong X, Cao BB, Wang W. Triptolide interrupts rRNA synthesis and induces the RPL23‑MDM2‑p53 pathway to repress lung cancer cells. Oncol Rep 2020; 43:1863-1874. [PMID: 32236588 PMCID: PMC7160537 DOI: 10.3892/or.2020.7569] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/09/2020] [Indexed: 12/15/2022] Open
Abstract
Lung cancer has one of the highest mortalities of any cancer worldwide. Triptolide (TP) is a promising tumor suppressor extracted from the Chinese herb Tripterygium wilfordii. Our previous proteomics analysis revealed that TP significantly interfered with the ribosome biogenesis pathway; however, the underlying molecular mechanism remains poorly understood. The aim of the present study was to determine the molecular mechanism of TP's anticancer effect by investigating the association between ribosomal stress and p53 activation. It was found that TP induces nucleolar disintegration together with RNA polymerase I (Pol I) and upstream binding factor (UBF) translocation. TP interrupted ribosomal (r)RNA synthesis through inhibition of RNA Pol I and UBF transcriptional activation. TP treatment increased the binding of ribosomal protein L23 (RPL23) to mouse double minute 2 protein (MDM2), resulting in p53 being released from MDM2 and stabilized. Activation of p53 induced apoptosis and cell cycle arrest by enhancing the activation of p53 upregulated modulator of apoptosis, caspase 9 and caspase 3, and suppressing BCL2. In vivo experiments showed that TP significantly reduced xenograft tumor size and increased mouse body weight. Immunohistochemical assays confirmed that TP significantly increased the p53 level and induced nucleolus disintegration, during which nucleolin distribution moved from the nucleolus to the nucleoplasm, and RPL23 clustered at the edge of the cell membrane. Therefore, it was proposed that TP induces ribosomal stress, which leads to nucleolus disintegration, and inhibition of rRNA transcription and synthesis, resulting in increased binding of RPL23 with MDM2. Consequently, p53 is activated, which induces apoptosis and cell cycle arrest.
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Affiliation(s)
- Juan Wang
- Department of Clinical Laboratory, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang 310012, P.R. China
| | - Zhi-Qian Zhang
- College of Medical Technology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310053, P.R. China
| | - Fang-Qiong Li
- Department of Clinical Laboratory, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang 310012, P.R. China
| | - Jia-Ning Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Xiaoting Gong
- Department of Clinical Laboratory, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang 310012, P.R. China
| | - Bei-Bei Cao
- Department of Clinical Laboratory, Hangzhou Linan District People's Hospital, Hangzhou, Zhejiang 311300, P.R. China
| | - Wei Wang
- Department of Clinical Laboratory, Tongde Hospital of Zhejiang Province, Hangzhou, Zhejiang 310012, P.R. China
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