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Deng L, Shayan G, Jiang W, Bi N, Wang L. Phase III, multicenter, randomized trial of 45 Gy versus 30 Gy thoracic radiation for extensive-stage small cell lung cancer (ES-SCLC): Study protocol. Thorac Cancer 2024; 15:938-943. [PMID: 38426233 PMCID: PMC11016412 DOI: 10.1111/1759-7714.15263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Consolidative thoracic radiotherapy (cTRT) has previously shown benefit to patients with extensive stage small cell lung cancer (ES-SCLC) who respond to chemotherapy. However, the optimum dose of cTRT is unknown. The purpose of this randomized trial is to compare the efficacy of 45 Gy in 15 fractions with 30 Gy in 10 fractions cTRT in ES-SCLC. METHODS This phase III, multicenter, randomized trial is designed to evaluate the safety and efficacy of different cTRT dose in ES-SCLC. Eligible patients with pathologically confirmed ES-SCLC who responded to 4-6 cycles of etoposide plus cisplatin (EP) or carboplatin (EC) chemotherapy were randomized 1:1 to receive either 30 Gy in 10 fractions (standard dose) or 45 Gy in 15 fractions (high dose) cTRT. The primary endpoint is 2-year overall survival (OS). Secondary endpoints include 2-year progression-free survival (PFS), 2-year local control (LC) and treatment related toxicity as measured by adverse events according to the Common Terminology Criteria for Adverse Events (version 4.0). DISCUSSION The present study is the first randomized phase III trial designed to evaluate the efficacy of higher versus lower dose cTRT in ES-SCLC, providing evidence for future clinical practice in prolonging survival of patients with ES-SCLC.
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Affiliation(s)
- Lei Deng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Gulidanna Shayan
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Wei Jiang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital and Shenzhen HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Nan Bi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina
| | - Luhua Wang
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital and Shenzhen HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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Li H, Zhao Y, Ma T, Shao H, Wang T, Jin S, Liu Z. Radiotherapy for extensive-stage small-cell lung cancer in the immunotherapy era. Front Immunol 2023; 14:1132482. [PMID: 37701437 PMCID: PMC10493776 DOI: 10.3389/fimmu.2023.1132482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 08/01/2023] [Indexed: 09/14/2023] Open
Abstract
Currently, chemoimmunotherapy is the first-line treatment for extensive-stage small-cell lung cancer (ES-SCLC). However, only 0.8%-2.5% of the patients presented complete response after chemoimmunotherapy. Considering that ES-SCLC is highly sensitive to radiotherapy, the addition of radiotherapy after first-line treatment for ES-SCLC could further improve local control, which may be beneficial for patients' survival. Prior studies have shown that consolidative thoracic radiotherapy (cTRT) can decrease disease progression and improve overall survival in patients with ES-SCLC who respond well to chemotherapy. However, the efficacy and safety of cTRT in the immunotherapy era remain unclear owing to a lack of prospective studies. Prophylactic cranial irradiation (PCI) has been shown to decrease brain metastasis (BM) and prolong survival in patients with limited-stage SCLC in previous reports. However, according to current guidelines, PCI is not commonly recommended for ES-SCLC. Immunotherapy has the potential to reduce the incidence of BM. Whether PCI can be replaced with regular magnetic resonance imaging surveillance for ES-SCLC in the era of immunotherapy remains controversial. Whole brain radiation therapy (WBRT) is the standard treatment for BM in SCLC patients. Stereotactic radiosurgery (SRS) has shown promise in the treatment of limited BM. Considering the potential of immunotherapy to decrease BM, it is controversial whether SRS can replace WBRT for limited BM in the immunotherapy era. Additionally, with the addition of immunotherapy, the role of palliative radiotherapy may be weakened in patients with asymptomatic metastatic lesions. However, it is still indispensable and urgent for patients with obvious symptoms of metastatic disease, such as spinal cord compression, superior vena cava syndrome, lobar obstruction, and weight-bearing metastases, which may critically damage the quality of life and prognosis. To improve the outcome of ES-SCLC, we discuss the feasibility of radiotherapy, including cTRT, PCI, WBRT/SRS, and palliative radiotherapy with immunotherapy based on existing evidence, which may offer specific prospects for further randomized trials and clinical applications.
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Affiliation(s)
- Huanhuan Li
- Department of Radiation Oncology, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Yangzhi Zhao
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Tiangang Ma
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Hao Shao
- Department of Radiation Oncology, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Tiejun Wang
- Department of Radiation Oncology, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Shunzi Jin
- NHC Key Laboratory of Radiobiology, Jilin University, Changchun, China
| | - Zhongshan Liu
- Department of Radiation Oncology, The Second Affiliated Hospital of Jilin University, Changchun, China
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Kassik MT, Vordermark D, Kornhuber C, Medenwald D. Factors associated with overall survival, progression-free survival and toxicity in patients with small cell lung cancer and thoracic irradiation in a clinical real-world setting. Radiat Oncol 2023; 18:70. [PMID: 37072833 PMCID: PMC10114406 DOI: 10.1186/s13014-023-02252-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 03/29/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Small-cell lung cancer (SCLC) is a malignant tumor known for its poor prognosis. In addition to chemotherapy and immunotherapy irradiation plays a big role especially in inoperability. This study evaluated prognostic factors in patients with SCLC, receiving chemotherapy and thoracic irradiation, that may affect overall survival (OS), progression-free survival (PFS) and toxicity. METHODS Patients with limited disease (LD) SCLC (n = 57) and extensive disease (ED) SCLC (n = 69) who received thoracic radiotherapy were analyzed retrospectively. The prognostic factors sex, age, Karnofsky performance status (KPS), tumor-, nodal-stage and timepoint of start of irradiation in relation to the first cycle of chemotherapy were evaluated. Start of irradiation was stratified as early ([Formula: see text] 2 cycles of chemotherapy), late (3 or 4 cycles) and very late ([Formula: see text] 5 cycles). Results were analyzed by Cox univariate and multivariate as well as logistic regression analysis. RESULTS The median OS of LD-SCLC patients was 23.7 months in early, and 22.0 months in late start of irradiation. In very late start, median OS was not reached. PFS was 11.8, 15.2 and 47.9 months, respectively. In patients with ED-SCLC OS was 4.3 months in early, 13.0 months in late and 12.2 months in very late start of irradiation. PFS was 6.7, 13.0 and 12.2 months, respectively. Prognosis of patients with LD- or ED-SCLC receiving late or very late start of irradiation was significantly prolonged in OS and PFS compared to an early start (p < 0.05). KPS [Formula: see text] 80 shows a significant increase of OS and PFS in ED-SCLC. Female sex and smaller mean lung dose were associated with lower risk of toxicity. CONCLUSION Late or very late start of irradiation is a prognosis-enhancing factor in LD-SCLC and ED-SCLC for OS and PFS. KPS [Formula: see text] 80 increases prognosis of OS and PFS in ED-SCLC as well. Toxicity is less common in female sex and patients with low mean lung dose in LD-SCLC.
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Affiliation(s)
- Marie-Theres Kassik
- Department of Radiation Therapy, University Hospital Halle/Saale, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Dirk Vordermark
- Department of Radiation Therapy, University Hospital Halle/Saale, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Christine Kornhuber
- Department of Radiation Therapy, University Hospital Halle/Saale, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Daniel Medenwald
- Department of Radiation Therapy, University Hospital Halle/Saale, Ernst-Grube-Str. 40, 06120, Halle, Germany.
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Daly ME, Ismaila N, Decker RH, Higgins K, Owen D, Saxena A, Franklin GE, Donaldson D, Schneider BJ. Radiation Therapy for Small-Cell Lung Cancer: ASCO Guideline Endorsement of an ASTRO Guideline. J Clin Oncol 2021; 39:931-939. [DOI: 10.1200/jco.20.03364] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The American Society for Radiation Oncology (ASTRO) produced an evidence-based guideline on radiation therapy (RT) for small-cell lung cancer (SCLC). Because of the relevance of this topic to ASCO membership, ASCO reviewed the guideline, applying a set of procedures and policies used to critically examine guidelines developed by other organizations. METHODS The ASTRO guideline on RT for SCLC was reviewed for developmental rigor by methodologists. Then, an ASCO Expert Panel reviewed the content and the recommendations. RESULTS The ASCO Expert Panel determined that the recommendations from ASTRO guideline on RT for SCLC, published in June 2020, are clear, thorough, and based upon the most relevant scientific evidence. ASCO endorsed ASTRO guideline on RT for SCLC with a few discussion points. RECOMMENDATIONS Recommendations addressed thoracic radiotherapy for limited-stage SCLC, role of stereotactic body radiotherapy in stage I or II node-negative SCLC, prophylactic cranial radiotherapy, and thoracic consolidation for extensive-stage SCLC. Additional information is available at www.asco.org/thoracic-cancer-guidelines .
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Han J, Fu C, Li B. Clinical outcomes of extensive-stage small cell lung cancer patients treated with thoracic radiotherapy at different times and fractionations. Radiat Oncol 2021; 16:47. [PMID: 33663551 PMCID: PMC7934361 DOI: 10.1186/s13014-021-01773-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 02/18/2021] [Indexed: 02/06/2023] Open
Abstract
Objective The purpose of this study was to assess whether thoracic radiotherapy (TRT) combined with chemotherapy (CHT) showed promising anti-tumour activity in extensive-stage small cell lung cancer (ES-SCLC), to explore practice patterns for the radiation time and dose/fractionation and to identify prognostic factors for patients who would benefit from CHT/TRT. Methods A total of 492 ES-SCLC patients were included from January 2010 to March 2019, 244 of whom received CHT/TRT. Propensity score matching was performed to minimize bias between the CHT/TRT and CHT-alone groups. Patients in the CHT/TRT group were categorized into four subgroups based on the number of induction CHT cycles. For effective dose fractionation calculations, we introduced the time-adjusted biological effective dose (tBED). Categorical variables were analysed with chi-square tests and Fisher’s exact tests. Kaplan–Meier curves were generated to estimate survival rates using the R-project. Multivariate prognostic analysis was performed with Cox proportional hazards models. Results Patients who received CHT/TRT experienced improved overall survival (OS) (18.1 vs 10.8 months), progression-free survival (PFS) (9.3 vs 6.0 months) and local recurrence-free survival (LRFS) (12.0 vs 6.6 months) before matching, with similar results after matching. In the CHT/TRT group, the median LRFS times for the groups based on the radiation time were 12.7, 12.0, 12.0, and 9.0 months, respectively. Early TRT had a tendency to prolong PFS (median 10.6 vs 9.8 vs 9.0 vs 7.7 months, respectively, p = 0.091) but not OS (median 17.6 vs 19.5 vs 17.2 vs 19.0 months, respectively, p = 0.622). Notably, patients who received TRT within 6 cycles of CHT experienced prolonged LRFS (p = 0.001). Regarding the radiation dose, patients in the high-dose group (tBED > 50 Gy) who achieved complete response and partial response (CR and PR) to systemic therapy had relatively short OS (median 27.1 vs 22.7, p = 0.026) and PFS (median 11.4 vs 11.2, p = 0.032), but the abovementioned results were not obtained after the exclusion of patients who received hyperfractionated radiotherapy (all p > 0.05). Conclusion CHT/TRT could improve survival for ES-SCLC patients. TRT performed within 6 cycles of CHT and hyperfractionated radiotherapy (45 Gy in 30 fractions) may be a feasible treatment scheme for ES-SCLC patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01773-x.
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Affiliation(s)
- Jinmin Han
- Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China
| | - Chengrui Fu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China.,Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Baosheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China.
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Tjong MC, Mak DY, Shahi J, Li GJ, Chen H, Louie AV. Current Management and Progress in Radiotherapy for Small Cell Lung Cancer. Front Oncol 2020; 10:1146. [PMID: 32760673 PMCID: PMC7372592 DOI: 10.3389/fonc.2020.01146] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/08/2020] [Indexed: 12/17/2022] Open
Abstract
Radiotherapy (RT) and chemotherapy continue to be widely utilized in small cell lung cancer (SCLC) management. In most limited stage (LS)-SCLC cases, the standard initial therapy remains concurrent chemoradiotherapy (CRT), typically with an etoposide and platinum-based regimen. Hyperfractionated twice daily (BID) RT remains the standard of care, though conventional daily (QD) RT is now a viable alternative supported by randomized evidence. In LS-SCLC patients who experienced good response to CRT, prophylactic cranial irradiation (PCI) remains the standard of care. Brain imaging, ideally with MRI, should be performed prior to PCI to screen for clinically apparent brain metastases that may require a higher dose of cranial irradiation. Platinum doublet chemotherapy alone is the historic standard initial therapy in extensive stage (ES)-SCLC. Addition of immunotherapy such as atezolizumab and durvalumab to chemotherapy is now recommended after their benefits were demonstrated in recent trials. In patients with response to chemotherapy, consolidation thoracic RT and PCI could be considered, though with caveats. Emergence of hippocampal avoidance cranial irradiation and SRS in SCLC patients may supplant whole cranial irradiation as future standards of care. Incorporation of novel systemic therapies such as immunotherapies has changed the treatment paradigm and overall outlook of patients with SCLC. This narrative review summarizes the current state, ongoing trials, and future directions of radiotherapy in management of SCLC.
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Affiliation(s)
- Michael C Tjong
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - David Y Mak
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeevin Shahi
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - George J Li
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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