Nimotuzumab plus concurrent chemo-radiotherapy in unresectable locally advanced oesophageal squamous cell carcinoma (ESCC): interim analysis from a Phase 3 clinical trial

BACKGROUND

This prospectively randomised, double-blinded, placebo-controlled, multicenter Phase 3 clinical trial was conducted to assess the efficacy and safety profile of nimotuzumab (nimo) plus concurrent chemo-radiotherapy (CCRT) in patients with unresectable locally advanced ESCC.

METHODS

Patients were randomly assigned (1:1) to receive CCRT plus nimotuzumab or placebo. The primary endpoint was overall survival (OS). In addition, interim analysis for short-term response rate was pre-defined.

RESULTS

A total of 201 patients were randomised into two groups. Eighty patients in the nimo group and eighty-two in the placebo group were evaluable. Three to six months after treatment, 26 (32.5%) patients achieved complete response (CR) in the nimo group, and 10 (12.2%) in the placebo group (P = 0.002). The ORR of the nimo group was significantly higher than the placebo group (93.8% vs. 72.0%, P < 0.001). The two groups' grade 3-5 adverse drug reactions were 11.1% vs. 10.9% (P > 0.05).

CONCLUSIONS

Nimotuzumab, in combination with chemo-radiotherapy, increased the CRR and ORR with a good safety profile. The OS is needed to be followed and finally analysed.

CLINICAL TRIAL REGISTRATION

NCT02409186.

Induction immunochemotherapy followed by radiotherapy for patients with unresectable locally advanced or metastatic esophageal cancer: A propensity score-matched analysis

BACKGROUND

The study aimed to investigate the efficacy of induction immunochemotherapy before radiotherapy (RT) for patients with locally advanced or metastatic esophageal cancer.

METHODS

Patients with unresectable locally advanced or metastatic esophageal cancer who received induction immunochemotherapy followed by RT (ICIs + RT group) and RT alone (RT group) were retrospectively identified in two cancer centers, respectively. Propensity score matching (PSM) was used to balance the potential confounders between the two groups. Overall survival (OS), progression-free survival (PFS), and recurrence patterns were evaluated.

RESULTS

A total of 467 patients were reviewed, and 66 were matched in each group. After PSM, the 1- and 2-year OS rates were 84.6% and 57.9% in ICIs + RT group, and 71.1% and 43.0% in RT group (HR 0.60, 95% CI 0.36-1.00, p = 0.050). The absolute increase of restricted mean survival time (RMST) for OS in ICIs + RT group compared with RT group were 0.89 years (p = 0.023) at one year and 2.59 years at two years (p = 0.030). The median PFS time, 1- and 2-year PFS rates were 20.3 months, 69.3%, and 45.7% in ICIs + RT group, and 12.2 months, 51.4%, and 35.8% in RT group (HR 0.64, 95% CI 0.41-0.99, p = 0.045). The cumulative locoregional recurrence (LRR) rate was significantly lower in ICIs + RT group (1-year rate, 17.4% vs. 38.8%, p = 0.011), and distant metastasis (DM) rates were comparable (p = 0.755). Consolidation ICIs was associated with a trend of improved 1-year OS and PFS.

CONCLUSION

Induction immunochemotherapy followed by RT might improve locoregional control and survival outcomes for patients with unresectable locally advanced or metastatic esophageal cancer.

High Dose Hyperfractionated Thoracic Radiotherapy vs. Standard Dose for Limited Stage Small-Cell Lung Cancer: A Multicenter, Open-Label Randomized, Phase 3 Trial

PURPOSE/OBJECTIVE(S)

Limited stage small-cell lung cancer (LS-SCLC) is associated with poor prognosis. We aimed to assess the efficacy and safety of high-dose, hyperfractionated thoracic radiotherapy of 54 Gy in 30 fractions compared with standard dose (45 Gy in 30 fractions) as a first-line treatment for LS-SCLC.

MATERIALS/METHODS

The study was an open-label, randomized, phase 3 trial, done at 16 public hospitals in China. Key inclusion criteria were patients aged 18-70 years, with previously histologically or cytologically confirmed LS-SCLC, previously untreated or received 1-2 courses of intravenous cisplatin (75 mg/m²of body-surface area, on day 1 or divided into two days of each cycle) or carboplatin (area under the curve of 5 mg/mL per min, day 1 of each cycle)and intravenous etoposide (100 mg/m²of body-surface area, on days 1-3 of each cycle), and an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1.Eligible patients were randomly assigned (1:1) to receive volumetric-modulated arc radiotherapy (VMAT) of 45 Gy in 30 fractions or the simultaneous integrated boost VMAT (SIB-VMAT) of 54 Gy in 30 fractions to the primary lung tumor and lymph node metastases starting 0-42 days after the first chemotherapy course. Both groups of patients received thoracic radiotherapy twice per day and 10 fractions per week. Prophylactic cranial radiation (PCI, 25 Gy in 10 fractions) was implemented to patients with responsive disease. The primary endpoint was overall survival. Safety was analyzed in the as-treated population.

RESULTS

Between June 30, 2017, and April 6, 2021, 224 eligible patients were enrolled and randomly assigned to 54 Gy (n = 108) or 45 Gy (n = 116). Median follow-up for the primary analysis was 45 months (IQR 41-48). Median overall survival was significantly improved in the 54 Gy group (62.4 months) compared with the 45 Gy group (43.1 months; p = 0.001). Median progression-free survival was significantly improved in the 54 Gy group (30.5 months) compared with the 45 Gy group (16.7 months; p = 0.044). The most common grade 3-4 adverse events were neutropenia (30 [28%] of 108 patients in the 54 Gy group vs 27 [23%] of 116 patients in the 45 Gy group), neutropenic infections (6 [6%] vs 2 [2%]), thrombocytopenia (13 [12%] vs 12 [10%]), anemia (6 [6%] vs 4 [3%]), and esophagitis (1 [1%] vs 3 [3%]). Treatment-related serious adverse events occurred in 9 [8%] patients in the 54 Gy group and 16 [14%] patients in the 45 Gy group. There were one treatment-related deaths in 54 Gy group (myocardial infarction).

CONCLUSION

Compared with standard thoracic radiotherapy dose of 45 Gy, the high dose of 54 Gy improved overall survival and progression-free survival without increasing toxicities in patients with LS-SCLC, supporting twice-daily hyperfractionated thoracic radiotherapy of 54 Gy with concurrent chemotherapy is an alternative treatment option for LS-SCLC. This study is complete and registered with ClinicalTrials.gov, NCT03214003.

Neoadjuvant chemoradiotherapy followed by oesophagectomy may be the optimal treatment option for lower thoracic oesophageal cancer with supraclavicular lymph node metastasis: An inverse probability of treatment-weighted analysis of SEER database

INTRODUCTION

Whether supraclavicular lymph node (SCLN) metastasis in patients with oesophageal cancer belongs to regional disease is controversial, leading to heterogeneity in clinical treatment decisions. This study aimed to determine the optimal treatment for lower thoracic oesophageal cancer (LTOC) with SCLN metastasis.

METHODS

Patients with LTOC registered in the Surveillance, Epidemiology, and End Results database during 2010-2015 were identified. Selected patients were grouped according to disease spread as those with locoregional disease, with SCLN metastasis or with distant metastasis, as well as according to treatment modality (neoadjuvant chemoradiotherapy followed by surgery (nCRT+S group), upfront surgery ± adjuvant therapy (upfront S group) and definitive chemoradiotherapy (dCRT group)). The Cox regression analysis and inverse probability of treatment weighting (IPTW) were used to identify the optimal treatment modality for different groups.

RESULTS

Of 11,767 LTOC patients identified from the database, the 5-year overall survival (OS) rates for patients with the locoregional disease (n = 7,541), SCLN metastasis (n = 120) and distant metastasis (n = 4,106) were 28.3%, 10.0% and 3.0%, respectively (P < 0.001). Among patients with SCLN metastasis, median OS in the nCRT+S, upfront S and dCRT groups were 25, 14 and 8 months, respectively (P < 0.001). After IPTW, the nCRT+S group was still associated with better median OS compared with other groups. The multivariate analysis identified treatment modality as an independent prognostic factor for OS.

CONCLUSIONS

Neoadjuvant chemoradiotherapy followed by oesophagectomy may be the optimal treatment modality for LTOC with SCLN metastasis. The findings of this study need to be validated in large prospective studies.

Radiotherapy Improves Survival of Patients With Lymphovascular Invasion in pT1b Esophageal Squamous Cell Cancer After Endoscopic Submucosal Dissection

INTRODUCTION

Adjuvant radiotherapy is recommended for pT1b esophageal squamous cell cancer (ESCC) after endoscopic submucosal dissection (ESD). However, it is unclear whether additional radiotherapy can improve patient survival. This study aimed to evaluate the efficacy of adjuvant radiotherapy after ESD for pT1b ESCC.

METHODS

This was a multicenter, cross-sectional study involving 11 hospitals in China. Between January 2010 and December 2019, patients with T1bN0M0 ESCC treated with or without adjuvant radiotherapy after ESD were included. Survival between groups was compared.

RESULTS

Overall, 774 patients were screened, and 161 patients were included. Forty-seven patients (29.2%) received adjuvant radiotherapy after ESD (RT group) and 114 (70.8%) underwent ESD alone (non-RT group). There were no significant differences in overall survival (OS) and disease-free survival (DFS) between the RT and non-RT groups. Lymphovascular invasion (LVI) was the only prognostic factor. In the LVI+ group, adjuvant radiotherapy significantly improved survival (5-year OS: 91.7% vs 59.5%, P = 0.050; 5-year DFS: 92.9% vs 42.6%, P = 0.010). In the LVI- group, adjuvant radiotherapy did not improve survival (5-year OS: 83.5% vs 93.9%, P = 0.148; 5-year DFS: 84.2% vs 84.7%, P = 0.907). The standardized mortality ratios were 1.52 (95% confidence interval 0.04-8.45) in the LVI+ group with radiotherapy and 0.55 (95% confidence interval 0.15-1.42) in the LVI- group without radiotherapy.

DISCUSSION

Adjuvant radiotherapy could improve survival in pT1b ESCC with LVI+ other than LVI- after ESD. Selective adjuvant radiotherapy based on LVI status achieved survival rates similar to those of the general population.

First-line atezolizumab/durvalumab plus platinum-etoposide combined with radiotherapy in extensive-stage small-cell lung cancer

BACKGROUND

Immunotherapy has made significant advances in the treatment of extensive-stage small-cell lung cancer (ES-SCLC), but data in combination with radiotherapy are scarce. This study aims to assess the safety and efficacy of chemoimmunotherapy combined with thoracic radiotherapy in patients with ES-SCLC.

METHODS

This single-center retrospective study analyzed patients with ES-SCLC who received standard platinum-etoposide chemotherapy combined with atezolizumab or durvalumab immunotherapy as induction treatment, followed by consolidative thoracic radiotherapy (CTRT) before disease progression in the first-line setting. Adverse events during radiotherapy with or without maintenance immunotherapy and survival outcomes were assessed.

RESULTS

Between December 2019 and November 2021, 36 patients with ES-SCLC were identified to have received such treatment modality at one hospital. The number of metastatic sites at diagnosis was 1-4. The biological effective dose of CTRT ranged from 52 to 113 Gy. Only two patients (6%) developed grade 3 toxic effect of thrombocytopenia, but none experienced grade 4 or 5 toxicity. Four patients developed immune-related pneumonitis during the induction treatment period but successfully completed later CTRT. The rate of radiation-related pneumonitis was 8% with grades 1-2 and well tolerated. The median progression-free survival (PFS) was 12.8 months, but the median overall survival (OS) was not determined. The estimated 1-year OS was 80.2% and 1-year PFS was 53.4%.

CONCLUSIONS

Immunotherapy combined with CTRT for ES-SCLC is safe and has ample survival benefit.

Nimotuzumab plus concurrent chemo-radiotherapy versus chemo-radiotherapy in unresectable locally advanced esophageal squamous cell carcinoma (ESCC): Interim analysis from a prospective, randomized-controlled, double-blinded, multicenter, and phase III clinical trial (NXCEL1311 Study)

4016

Background: 70% of esophageal carcinoma are unresectable at diagnosis. Despite active clinical research on the treatment of esophageal squamous cell carcinoma (ESCC), the long-term survival rate of advanced patients is still very low, with a 5-year survival rate of 30%-40%. A prospective, randomized-controlled, double-blinded, multicenter, and phase III study (NXCEL1311) was designed to investigate the efficacy and safety of nimotuzumab (anti-EGFR humanized monoclonal antibody;abbreviate,Nimo) plus concurrent chemo-radiotherapy compared with placebo plus chemo-radiotherapy in unresectable locally advanced ESCC. Methods: Unresectable locally advanced ESCC patients were randomized (1:1) to receive Nimo (400 mg, qw) or placebo in combination with concurrent chemo-radiotherapy (paclitaxel+ cisplatin+3DCRT/IMRT) for seven weeks. Patients were followed for five years.The primary endpoints were OS, and the secondary endpoints included ORR, DCR, PFS. Results: 200 patients were assigned to the Nimo group (n = 99) or placebo group (n = 101). An interim analysis was conducted for short term efficacy, i.e secondary endpoints (ORR, DCR) and safety, after completing the 6 months follow-up. The OS events are not enough for analysis. The two groups were comparable on baseline characteristics. Eighty patients in the Nimo group and eighty-two patients in the placebo group were evaluable. The ORR of the Nimo group (75/80, 93.8%) was significantly higher than the placebo group (59/82, 72.0%;Chi-square test, p < 0.001). Twenty-six patients in the Nimo group reached the complete response (CR), and ten placebo group patients were CR. The CR rate in the Nimo group was significantly higher than placebo group (32.5% vs.12.2%, p = 0.002). The DCR of the Nimo group and placebo group were 98.8% (79/80) and 91.5% (75/82), respectively (p = 0.064). Single factor logistic aggression analysis showed that age, sex, target lesion number, and BMI did not affect ORR, CR, and DCR (p > 0.05). Multiple factor correction analysis showed the difference of CR, ORR and DCR between two groups is 20% (95%CI 6.0%̃40.2%), 30% (95%CI 10.6%̃52.1%) and 10% (95%CI -5.2%̃31.1%). The incidence of grade 3-5 drug-related AEs was 11.1%vs.10.9% (p > 0.05). Common drug-related AEs in patients with Nimo plus chemo-radiotherapy treatment were leucopenia, neutrophilic granulocytopenia, thrombocytopenia, hemoglobin, bone marrow inhibition, nutritional anemia, and radioactive inflammation. Conclusions: This interim analysis showed that nimotuzumab in combination with chemo-radiotherapy is safe and can increase the CRR and ORR of the treated patients. The OS needs to be followed and finally analyzed. Clinical trial information: 02409186.

A prediction model for dosimetric-based lung adaptive radiotherapy

PURPOSE

Anatomical changes occurred during the treatment course of radiation therapy for lung cancer patients may introduce clinically unacceptable dosimetric deviations from the planned dose. Adaptive radiotherapy (ART) can compensate these dosimetric deviations in subsequent treatments via plan adaption. Determining whether and when to trigger plan adaption during the treatment course is essential to the effectiveness and efficiency of ART. In this study, we aimed to develop a prediction model as an auxiliary decision-making tool for lung ART to identify the patients with intrathoracic anatomical changes that would potentially benefit from the plan adaptions during the treatment course.

METHODS

Seventy-one pairs of weekly cone-beam computer tomography (CBCT) and planning CT (pCT) from 17 advanced non-small cell lung cancer patients were enrolled in this study. To assess the dosimetric impacts brought by anatomical changes observed on each CBCT, dose distribution of the original treatment plan on the CBCT anatomy was calculated on a virtual CT generated by deforming the corresponding pCT to the CBCT, and compared to that of the original plan. A replan was deemed needed for the CBCT anatomy once the recalculated dose distribution violated our dosimetric-based trigger criteria. A three-dimensional region of significant anatomical changes (region of interest, ROI) between each CBCT and the corresponding pCT was identified and 16 morphological features of the ROI were extracted. Additionally, eight features from the overlapped volume histograms (OVHs) of patient anatomy were extracted for each patient to characterize the patient specific anatomy. Based on the 24 extracted features and the evaluated replanning needs of the pCT-CBCT pairs, a nonlinear supporting vector machine was used to build a prediction model to identify the anatomical changes on CBCTs that would trigger plan adaptions. The most relevant features were selected using the sequential backward selection (SBS) algorithm and a shuffling-and-splitting validation scheme was used for model evaluation.

RESULTS

Fifty-Five CBCT-pCT pairs were identified of having a ROI, among which 21 CBCT anatomies required plan adaptions. For these 21 positive cases, statistically significant improvements in the sparing of lung, esophagus and spinal cord were achieved by plan adaptions. A high model performance of 0.929 AUC and 0.851 accuracy was achieved with six selected features including five ROI shape features and one OVH feature. Without involving the OVH features in the feature selection process, the mean AUC and accuracy of the model significantly decreased to 0.826 and 0.779, respectively. Further investigation showed that poor prediction performance with AUC of 0.76 was achieved by the univariate model in solving this binary classification task.

CONCLUSION

We built a prediction model based on the features of patient anatomy and the anatomical changes captured by on-treatment CBCT imaging to trigger plan adaption for lung cancer patients. This model effectively associated the anatomical changes with the dosimetric impacts for lung ART. This model can be a promising tool to assist the clinicians in making decisions for plan adaptions during the treatment courses. This article is protected by copyright. All rights reserved.

Effects of Enteral Nutrition on Patients With Oesophageal Carcinoma Treated With Concurrent Chemoradiotherapy: A Prospective, Multicentre, Randomised, Controlled Study

Background

The oesophageal carcinoma patients show high incidence of malnutrition, which negatively affects their therapy outcome. Moreover, benefits of enteral nutrition remain to be studied in details in these patients. Therefore, we set to assess the effects of enteral nutrition on the nutritional status, treatment toxicities and survival in the oesophageal carcinoma patients treated with concurrent chemoradiotherapy (CCRT).

Materials and Methods

Eligible patients were randomly assigned to either the experimental or control group. The patients in the experimental group were treated with a whole-course enteral nutrition management, while the control group were provided a unsystematic nutrition without setting intake goals for energy and protein. The primary endpoint was a change in body weight, while the secondary endpoints included nutrition-related haematological indicators, toxicities, completion rate of treatment and survival.

Results

A total of 222 patients were randomised to either the experimental (n=148) or control (n=74) group. Patients in the experimental group showed significantly less decrease in body weight, serum albumin and haemoglobin levels, a lower incidence rates of grade ≥3 myelosuppression and infection, and a higher completion rate of CCRT than those in the control group. While analyses of the 2 and 3 year overall survival (OS) and progression-free survival (PFS) did not reveal differences between these groups, we observed a significantly higher OS at 1 year (83.6% vs. 70.0%). In the subgroup analysis, patients with patient-generated subjective global assessment (PG-SGA)=C were likely to have better OS and PFS with enteral nutrition.

Conclusions

In EC patients treated with CCRT, enteral nutrition conferred positive effects on the nutritional status, treatment toxicities and prognosis, which mandate its inclusion in clinical practice.

Clinical Trial Registration

This prospective trial has been registered with www.clinicaltrials.gov as NCT02399306.

Postoperative lymphatic recurrence distribution and delineation of the radiation field in lower thoracic squamous cell esophageal carcinomas: a real-world study

Background

To study lymphatic recurrence distribution after radical surgery in the real world and guide clinical tumor volume delineation for regional lymph nodes during postoperative radiotherapy for lower thoracic squamous cell esophageal carcinomas.

Methods

We enrolled patients who underwent radical esophagectomy, without radiation before or after surgery, at 3 cancer hospitals. Patients were classified into groups according to tumor locations. We included patients with tumors in the lower thoracic segment and analyzed the postoperative lymph node recurrence mode. A cutoff value of 10% was used to differentiate high-risk lymph node drainage areas from others.

Results

We enrolled 1905 patients in the whole study series, including 652 thoracic esophageal carcinomas that met our inclusion criteria; there were 241 cases of lower thoracic esophageal carcinomas. 1st, 2nd, 4th, 7th, 8th groups of lymph nodes, according to the 8th edition of the AJCC classification, displayed as high-risk recurrence areas, representing 17.8%, 23.9%, 11.7%, 10.9% and 12.2% of lymph node recurrence. Stage III-IV tumors located in the lower segment of the thoracic esophagus showed a tendency to recur in the left gastric nodes (7.9%) and celiac nodes (10.6%).

Conclusions

According to our results, we recommended including the 4th, 7th and 8th groups of lymph nodes in the radiation field, and for patients with stage III-IV disease, the 17th and 20th groups of nodes should be irradiated during postoperative treatment. Whether including 1st/2nd groups in preventive irradiation needed more proofs.

Sugemalimab versus placebo after concurrent or sequential chemoradiotherapy in patients with locally advanced, unresectable, stage III non-small-cell lung cancer in China (GEMSTONE-301): interim results of a randomised, double-blind, multicentre, phase 3 trial

BACKGROUND

A substantial proportion of patients with unresectable stage III non-small-cell lung cancer (NSCLC) cannot either tolerate or access concurrent chemoradiotherapy, so sequential chemoradiotherapy is commonly used. We assessed the efficacy and safety of sugemalimab, an anti-PD-L1 antibody, in patients with stage III NSCLC whose disease had not progressed after concurrent or sequential chemoradiotherapy.

METHODS

GEMSTONE-301 is a randomised, double-blind, placebo-controlled, phase 3 trial in patients with locally advanced, unresectable, stage III NSCLC, done at 50 hospitals or academic research centres in China. Eligible patients were aged 18 years or older with an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 who had not progressed after concurrent or sequential chemoradiotherapy. We randomly assigned patients (2:1, using an interactive voice-web response system) to receive sugemalimab 1200 mg or matching placebo, intravenously every 3 weeks for up to 24 months. Stratification factors were ECOG performance status, previous chemoradiotherapy, and total radiotherapy dose. The investigators, trial coordination staff, patients, and study sponsor were masked to treatment allocation. The primary endpoint was progression-free survival as assessed by blinded independent central review (BICR) in the intention-to-treat population. Safety was assessed in all participants who received at least one dose of assigned study treatment. The study has completed enrolment and the results of a preplanned analysis of the primary endpoint are reported here. The trial is registered with ClinicalTrials.gov, NCT03728556.

FINDINGS

Between Aug 30, 2018 and Dec 30, 2020, we screened 564 patients of whom 381 were eligible. Study treatment was received by all patients randomly assigned to sugemalimab (n=255) and to placebo (n=126). At data cutoff (March 8, 2021), median follow-up was 14·3 months (IQR 6·4-19·4) for patients in the sugemalimab group and 13·7 months (7·1-18·4) for patients in the placebo group. Progression-free survival assessed by BICR was significantly longer with sugemalimab than with placebo (median 9·0 months [95% CI 8·1-14·1] vs 5·8 months [95% CI 4·2-6·6]; stratified hazard ratio 0·64 [95% CI 0·48-0·85], p=0·0026). Grade 3 or 4 treatment-related adverse events occurred in 22 (9%) of 255 patients in the sugemalimab group versus seven (6%) of 126 patients in the placebo group, the most common being pneumonitis or immune-mediated pneumonitis (seven [3%] of 255 patients in the sugemalimab group vs one [<1%] of 126 in the placebo group). Treatment-related serious adverse events occurred in 38 (15%) patients in the sugemalimab group and 12 (10%) in the placebo group. Treatment-related deaths were reported in four (2%) of 255 patients (pneumonia in two patients, pneumonia with immune-mediated pneumonitis in one patient, and acute hepatic failure in one patient) in the sugemalimab group and none in the placebo group.

INTERPRETATION

Sugemalimab after definitive concurrent or sequential chemoradiotherapy could be an effective consolidation therapy for patients with stage III NSCLC whose disease has not progressed after sequential or concurrent chemoradiotherapy. Longer follow-up is needed to confirm this conclusion.

FUNDING

CStone Pharmaceuticals and the National Key Research and Development Program of China.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Hypofractionated Volumetric-Modulated Arc Radiotherapy for Patients With Non-Small-Cell Lung Cancer Not Suitable for Surgery or Conventional Chemoradiotherapy or SBRT

Background

Hypofractionated radiotherapy (HypoRT) has been used to pursue an alternative treatment regimen for patients with non-small-cell lung cancer (NSCLC) who are not eligible for stereotactic ablative radiotherapy (SABR), surgery or concurrent chemoradiotherapy (CCRT) and has shown good local control and safety. We analyzed the feasibility of using volumetric-modulated arc radiotherapy (VMAT) with the simultaneous integrated boost (SIB) technique to achieve high local control with few treatment-related toxicities.

Patients and Methods

A total of 55 patients with stage I-IV NSCLC who were not candidates for SABR, surgery or CCRT were included in the present study. All patients received a prescribed dose of 60 to 66 Gy in 15 fractions. Local progression-free survival (LPFS), PFS, overall survival (OS), and toxicities were retrospectively analyzed.

Results

Thirty-three patients (60.0%) had stage IV or recurrent disease in this study. The median follow-up time was 8 months (interquartile range: 5.0-16.3 months). The 1-year and 2-year OS rates were 84.3% and 69.9%, and the 1-year and 2-year LPFS rates were 91.0% and 63.0%. The median OS (mOS) and median LPFS (mLPFS) were not reached, and median PFS (mPFS) was 15 months. Twenty-eight (51.9%) patients had disease progression at the time of analysis. Of these, 7 (13.0%), 7 (13.0%) and 21 (38.9%) had local recurrence, locoregional failure and distant metastasis, respectively. All cases of local recurrence were found within the SIB region. Four patients had grade 2-3 pneumonitis, and 8 patients had grade 2-3 esophagitis. Patients with grade 2-3 esophagitis had significantly higher maximum dose and dose to 5 cm³ volume to esophagus than those with grade 0-1 esophagitis. No grade 4 or higher toxicity was observed.

Conclusion

The 60 to 66 Gy in 15 fractions RT regimen provides favorable local control and survival with well-tolerated toxicities. Hypofractionated VMAT+SIB is an alternative treatment option for patients with NSCLC who cannot tolerate standard definitive therapy.

Learning from reproducing computational results: introducing three principles and the Reproduction Package

We carry out efforts to reproduce computational results for seven published articles and identify barriers to computational reproducibility. We then derive three principles to guide the practice and dissemination of reproducible computational research: (i) Provide transparency regarding how computational results are produced; (ii) When writing and releasing research software, aim for ease of (re-)executability; (iii) Make any code upon which the results rely as deterministic as possible. We then exemplify these three principles with 12 specific guidelines for their implementation in practice. We illustrate the three principles of reproducible research with a series of vignettes from our experimental reproducibility work. We define a novel Reproduction Package, a formalism that specifies a structured way to share computational research artifacts that implements the guidelines generated from our reproduction efforts to allow others to build, reproduce and extend computational science. We make our reproduction efforts in this paper publicly available as exemplar Reproduction Packages. This article is part of the theme issue 'Reliability and reproducibility in computational science: implementing verification, validation and uncertainty quantification in silico'.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Prediction of Clinical Outcome in Locally Advanced Non-Small Cell Lung Cancer Patients Treated With Chemoradiotherapy by Plasma Markers

Purpose

To identify cytokines in plasma that may predict objective response and progression-free survival (PFS) in patients with locally advanced non-small cell lung cancer (NSCLC) treated with chemoradiotherapy.

Materials and Methods

From April 2016 to May 2017, thirty-one patients with locally advanced inoperable/unresectable NSCLC were included, and treated with concurrent chemoradiotherapy (CCRT). No immune checkpoint inhibitors were administered after CCRT. Plasma from each patient was collected before radiotherapy, and 25 cytokines in the plasma were measured by Luminex or U-PLEX assays. Logistic regression and COX regression were performed to identify the predictive factors for objective response and PFS, respectively. Kaplan-Meier survival analysis was used to compare the PFS between the groups.

Results

High levels of IL-13 and TNF-α, and low levels of ICAM-1, IFN-γ, and soluble PD-L1 (sPD-L1) were significantly associated with objective response (P <0.05). High levels of IL-8, CCL5, and CXCL3 also showed a trend toward association with objective response (P <0.1). The combination of cytokines (IL-8 and ICAM-1, or TNF-α and sPD-L1) improved predictive accuracy. Univariate analysis identified IL-8 and ICAM-1 as potential markers to predict PFS. Multivariate analysis suggested that high level of IL-8 (P =0.010) and low level of ICAM-1 (P =0.011) correlated significantly with a longer PFS.

Conclusion

IL-8 and ICAM-1 in plasma have the potential to predict objective response and PFS in patients with locally advanced NSCLC underwent chemoradiotherapy.

Prediction of venous thromboembolism using clinical and serum biomarker data from a military cohort of trauma patients

INTRODUCTION

Venous thromboembolism (VTE) is a frequent complication of trauma associated with high mortality and morbidity. Clinicians lack appropriate tools for stratifying trauma patients for VTE, thus have yet to be able to predict when to intervene. We aimed to compare random forest (RF) and logistic regression (LR) predictive modelling for VTE using (1) clinical measures alone, (2) serum biomarkers alone and (3) clinical measures plus serum biomarkers.

METHODS

Data were collected from 73 military casualties with at least one extremity wound and prospectively enrolled in an observational study between 2007 and 2012. Clinical and serum cytokine data were collected. Modelling was performed with RF and LR based on the presence or absence of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). For comparison, LR was also performed on the final variables from the RF model. Sensitivity/specificity and area under the curve (AUC) were reported.

RESULTS

Of the 73 patients (median Injury Severity Score=16), nine (12.3%) developed VTE, four (5.5%) with DVT, four (5.5%) with PE, and one (1.4%) with both DVT and PE. In all sets of predictive models, RF outperformed LR. The best RF model generated with clinical and serum biomarkers included five variables (interleukin-15, monokine induced by gamma, vascular endothelial growth factor, total blood products at resuscitation and presence of soft tissue injury) and had an AUC of 0.946, sensitivity of 0.992 and specificity of 0.838.

CONCLUSIONS

VTE may be predicted by clinical and molecular biomarkers in trauma patients. This will allow the development of clinical decision support tools which can help inform the management of high-risk patients for VTE.

Cone-beam CT radiomics features might improve the prediction of lung toxicity after SBRT in stage I NSCLC patients

Background

Stereotactic body radiotherapy (SBRT) is the standard care for inoperable early stage non‐small cell lung cancer (NSCLC). The purpose of our study was to investigate whether a prediction model based on cone‐beam CT (CBCT) plus pretreatment CT radiomics features could improve the prediction of tumor control and lung toxicity after SBRT in comparison to a model based on pretreatment CT radiomics features alone.

Methods

A total of 34 cases of stage I NSCLC patients who received SBRT were included in the study. The pretreatment planning CT and serial CBCT radiomics features were analyzed using the imaging biomarker explorer (IBEX) software platform. Multivariate logistic regression was conducted for the association between progression‐free survival (PFS), lung toxicity and features. The predictive capabilities of the models based on CBCT and CT features were compared using receiver operating characteristic (ROC) curves.

Results

Five CBCT features and two planning CT features were correlated with disease progression. Six CBCT features and two planning CT features were related to lung injury. The ROC curves indicated that the model based on the CBCT plus planning CT features might be better than the model based on the planning CT features in predicting lung injury. The other ROC curves indicated that the model based on the planning CT features was similar to the model based on the CBCT plus planning CT features in predicting disease progression.

Conclusions

Both pretreatment CT and CBCT radiomics features could predict disease progression and lung injury. A model with CBCT plus pretreatment CT radiomics features might improve the prediction of lung toxicity in comparison with a model with pretreatment CT features alone.

Key points

Significant findings of the study: A model with cone‐beam CT radiomics features plus pre‐treatment CT radiomics features might improve the prediction of lung toxicity after SBRT in stage I NSCLC patients.

What this study adds: In the prediction of PFS and lung toxicity in early‐stage NSCLC patients treated with SBRT, CBCT radiomics could be another effective method.

Stereotactic ablative radiotherapy of 60 Gy in eight fractions is safe for ultracentral non-small cell lung cancer

Background

There is no consensus on the definition or recommended radiotherapy treatment of ultracentral non‐small cell lung cancer (NSCLC). Here, we report our institution's experience in treating ultracentral lung cancer patients with stereotactic ablative radiotherapy (SABR) of 60 Gy in eight fractions.

Methods

We retrospectively reviewed the outcomes of 21 ultracentral NSCLC patients treated with 60 Gy SABR in eight fractions. We defined ultracentral lung cancer as the planning target volume (PTV) directly abutting or overlapping central structures, including the proximal bronchial tree, heart, and great vessels but not the esophagus. The Kaplan‐Meier method was used to estimate overall survival (OS), progression‐free survival (PFS) and local control (LC). Toxicity was scored per the CTCAE v4.03.

Results

The median follow‐up time was 15 months, and the median OS was 15 months. The one‐ and two‐year OS rates were 87.5% and 76.6%, respectively. The one‐ and two‐year PFS rates were 71.1% and 64.0%, respectively. The one‐ and two‐year LC rates were 92.9% and 92.9%, respectively. The rate of grade 2 treatment‐related toxicities was 19.1%. There was no grade ≥ 3 treatment‐related toxicity.

Conclusion

SABR of 60 Gy in eight fractions is feasible for ultracentral NSCLC.

[Application of Simultaneous Integrated Boost Intensity Modulated Radiotherapy in Locally Advanced Non-small Cell Lung Cancer]

背景与目的

局部晚期非小细胞肺癌（non-small cell lung cancer, NSCLC）的标准治疗方案为放疗联合化疗，但其生存仍不令人满意。随着调强放疗技术的发展，同步推量（simultaneous integrated boost, SIB）技术成为局部晚期NSCLC的研究方向。本研究拟探讨局部晚期NSCLC采用SIB调强放疗技术的有效性和安全性。

方法

回顾性分析北京大学肿瘤医院2015年6月-2018年12月采用SIB技术进行放疗的局部晚期NSCLC患者资料，采用Kaplan-Meier方法进行统计分析，分析其疗效、生存及治疗相关毒性。

结果

研究纳入93例患者，中位随访时间34.23个月，3年生存率、无进展生存率、无局部区域复发生存率和无远处转移生存率分别为53.0%、37.0%、50.5%和50.5%。3级放射性食管炎发生率为5.4%，≥3级放射性肺炎发生率为2.2%。

结论

局部晚期NSCLC采用SIB调强放疗技术安全有效。

Optimal first-line treatment for advanced thymic carcinoma

Background

Thymic carcinomas (TCs) are rare aggressive tumors with no standard first‐line treatment. This study was conducted to determine the optimal chemotherapy regimen for advanced TC.

Methods

This retrospective study included 67 patients treated for stage IV TC in 2006–2015. The primary endpoints were the objective response rate (ORR) and progression‐free survival (PFS) with different chemotherapy regimens. Multivariate Cox regression analysis was used to identify factors associated with PFS, including metastatic status, radiotherapy post‐chemotherapy, primary lesion resection before chemotherapy, and chemotherapy regimen.

Results

A total of 36 patients received a paclitaxel‐platinum regimen, 31 received a gemcitabine‐platinum regimen, 14 underwent primary lesion resection, and 33 underwent radiotherapy. ORR was 31% (11/36) and 29% (9/31) in the paclitaxel‐platinum and gemcitabine‐platinum groups, respectively (P = 0.890). Median PFS, one‐year PFS rate, and two‐year PFS rate were 7.0 months, 26%, and 6% with paclitaxel‐platinum treatment and 12 months, 48%, and 24% with gemcitabine‐platinum treatment (log‐rank P = 0.030). Median PFS, one‐year PFS rate, and two‐year PFS rate were 18.0 months, 57%, and 33% with surgical resection and 7.3 months, 31%, and 7% without resection (log‐rank P = 0.030). Median PFS, one‐year PFS rate, and two‐year PFS rate were 13.0 months, 52%, and 20% with radiotherapy and 4.3 months, 22%, and 7% without radiotherapy (log‐rank P = 0.001). In multivariate analysis, metastatic status (hazard ratio [HR], 0.33, P = 0.004), surgical resection (HR, 0.32; P = 0.004), and radiotherapy (HR, 0.32; P < 0.001) were associated with superior PFS.

Conclusions

Both gemcitabine‐platinum and paclitaxel‐platinum regimens were efficacious for advanced TC. Primary lesion resection and radiotherapy may also benefit selected patients.

CD56bright natural killer cells induce HBsAg reduction via cytolysis and cccDNA decay in long-term entecavir-treated patients switching to peginterferon alfa-2a

HBV surface antigen (HBsAg) reduction is well observed in chronic hepatitis B (CHB) patients treated with pegylated interferon alpha-2a (PegIFNα). However, the mechanism of HBsAg suppression has not been fully elucidated. Twenty-seven of 55 entecavir-treated CHB e antigen positive patients were switched to PegIFNα treatment (Group A) whereas 28 patients continued entecavir treatment (Group B). The percentage or absolute number of CD56^bright /CD56^dim NK cells, expression of receptors and cytokines were evaluated by flow cytometry for 48 weeks and correlated with treatment efficacy. In vitro, purified NK cells were co-cultured with HepAD38 cells for measurement of HBsAg, apoptosis and covalently closed circular DNA (cccDNA). In association with a reduction of HBsAg, the percentage and absolute number of CD56^bright NK cells was significantly elevated in patients in group A, especially in Virologic Responders (VRs, HBsAg decreased). Furthermore, the percentage of NKp30⁺ , NKp46⁺ , TRAIL⁺ , TNF-α⁺ and IFNγ⁺ CD56^bright NK cells were significantly expanded in Group A, which were positively correlated with the decline of HBsAg at week 48. In vitro, peripheral NK cells from Group A induced a decline of HBsAg in comparison with NK cells from Group B which was significantly inhibited by anti-TRAIL, anti-TNF-α and anti-IFNγ antibodies. Furthermore, apoptosis of HepAD38 cells and levels of cccDNA, were significantly reduced by TRAIL⁺ and TNF-α⁺ /IFNγ⁺ NK cells from Group A, respectively. A functional restoration of CD56^bright NK cells in entecavir-treated patients who were switched to PegIFNα contributes to HBsAg and cccDNA clearance through TRAIL-induced cytolysis and TNF-α/IFNγ-mediated noncytolytic pathways.

Effect of local scrotal heating on the expression of tight junction-associated molecule Occludin in boar testes

The aim of this study was to determine whether local scrotal heating (42°C, for 1 hr) had an effect on the expression of tight junction (TJ)-associated molecule Occludin in boar testes. Adult boars (Landrace, n = 6) were used and randomly divided into two groups (n = 3 each). Three boars were given local scrotal exposure to 42°C for approximately 1 h with a home-made electric blanket of controlled temperature as local scrotal heating group, the other three boars received no heat treatment and were left at standard room temperature as control group. After 6 hr, all boars were castrated and the testes were harvested. qRT-PCR, Western blotting and immunohistochemistry were used to explore the expression and localization of Occludin. qRT-PCR and Western blotting showed that the protein and mRNA levels of Occludin significantly decreased in local scrotal heating group as compared to the control. Furthermore, immunoreactivity staining of Occludin was localized at the sites of the blood-testis barrier (BTB) and formed an almost consecutive and strong immunoreactivity strand in the control, while Occludin was limited to Sertoli cells (SCs) and no obvious immunoreactivity strand was present in local scrotal heating group. These data indicated that local scrotal heating decreased the expression of TJ-associated molecule Occludin, which may be involved in heat-induced spermatogenesis damage.

Etoposide and cisplatin versus paclitaxel and carboplatin with concurrent thoracic radiotherapy in unresectable stage III non-small cell lung cancer: a multicenter randomized phase III trial

Background

The optimal chemotherapy regimen administered currently with radiation in patients with stage III non-small cell lung cancer (NSCLC) remains unclear. A multicenter phase III trial was conducted to compare the efficacy of concurrent thoracic radiation therapy with either etoposide/cisplatin (EP) or carboplatin/paclitaxel (PC) in patients with stage III NSCLC.

Patients and methods

Patients were randomly received 60-66 Gy of thoracic radiation therapy concurrent with either etoposide 50 mg/m2 on days 1-5 and cisplatin 50 mg/m2 on days 1 and 8 every 4 weeks for two cycles (EP arm), or paclitaxel 45 mg/m2 and carboplatin (AUC 2) on day 1 weekly (PC arm). The primary end point was overall survival (OS). The study was designed with 80% power to detect a 17% superiority in 3-year OS with a type I error rate of 0.05.

Results

A total of 200 patients were randomized and 191 patients were treated (95 in the EP arm and 96 in the PC arm). With a median follow-up time of 73 months, the 3-year OS was significantly higher in the EP arm than that of the PC arm. The estimated difference was 15.0% (95% CI 2.0%-28.0%) and P value of 0.024. Median survival times were 23.3 months in the EP arm and 20.7 months in the PC arm (log-rank test P = 0.095, HR 0.76, 95%CI 0.55-1.05). The incidence of Grade ≥2 radiation pneumonitis was higher in the PC arm (33.3% versus 18.9%, P = 0.036), while the incidence of Grade ≥3 esophagitis was higher in the EP arm (20.0% versus 6.3%, P = 0.009).

Conclusion

EP might be superior to weekly PC in terms of OS in the setting of concurrent chemoradiation for unresectable stage III NSCLC.

Trial registration ID

NCT01494558.

[Phase I Study of Etoposide and Cisplatin Chemotherapy Dose Escalation with Concurrent Twice-daily Radiotherapy for Patients with Limited-stage Small Cell Lung Cancer]

背景与目的

加速超分割放疗（每日两次方案）联合EP方案同步化疗是美国国立综合癌症网络（National Comprehensive Cancer Network, NCCN）指南推荐的局限期小细胞肺癌的标准治疗方式，但国人对EP方案标准化疗剂量耐受性尚不明确。本研究旨在探讨局限期小细胞肺癌同步放化疗EP方案的最大耐受剂量。

方法

研究纳入病理证实的局限期小细胞肺癌患者，进行加速超分割放疗同步EP方案（依托泊苷+顺铂）化疗，放疗处方剂量为45 Gy/30 f，1.5 Gy/f，每日两次，同一日两次放疗间隔时间≥6 h，5天/周，共3周完成。化疗方案采用依托泊苷联合顺铂，每21天为1周期，具体依托泊苷100 mg/m²，d1-d3，顺铂采用剂量递增的方式（第1组为70 mg/m² d1，第2组为75 mg/m² d1）。主要观察指标为治疗期间的血液学毒性。次要观察指标为非血液学毒性和1年总生存期（overall survival, OS）、无进展生存期（progression free survival, PFS）。根据不良事件常用术语评定标准（Common Terminology Criteria for Adverse Events, NCI-CTCAE）4.0，最大耐受剂量设定为6例患者中不超过1例患者出现剂量限制毒性（4级血液学毒性）的剂量，同时下一剂量组6例患者至少2例出现剂量限制性毒性。

结果

研究共纳入20例局限期小细胞肺癌患者，平均年龄49.50（30-68）岁。第1组入组6例患者，1例患者出现4度中性粒细胞减少；后第2组入组14例患者，1例患者出现4度中性粒细胞减少。其中，第1组有4例患者出现≥3度血液学毒性，1例患者出现3度以上放射性食管炎；第2组有10例患者出现≥3度血液学毒性，无患者出现3度以上放射性食管炎。中位随访9.0个月（3.2个月-36.2个月），1年OS、PFS分别为91%、62%。

结论

局限期小细胞肺癌患者采用加速超分割放疗联合EP方案化疗将顺铂剂量递增至75 mg/m²是安全的，其有效性还需要进一步扩大样本量和随访更长的时间来证实。

[A Phase I/II Study of Chemotherapy Concurrent with Twice-daily Radiotherapy Schedules by Intensity Modulated Radiation Therapy Using Simultaneous Integrated Boost for Limited-stage Small Cell Lung Cancer]

背景与目的

同步放化疗是局限期小细胞肺癌的标准治疗，但患者局部复发率和远处转移率仍较高，本研究旨在评估同步推量调强放疗治疗局限期小细胞肺癌的安全性和有效性。

方法

符合局限期小细胞肺癌的患者纳入研究行同步放化疗，放疗采用每日两次方案，应用经典“3+3”模式对肿瘤大体体积（gross target volume, GTV）进行同步推量剂量递增，设定为三个剂量梯度，分别为45 Gy/30 f（单次剂量1.50 Gy）、50 Gy/30 f（单次剂量1.67 Gy）和54 Gy/30 f（单次剂量1.80 Gy）。计划靶体积均为45 Gy/30 f。主要研究终点为放疗期间及结束3个月内毒性反应。次要研究终点包括1年生存率、无进展生存期、局部无进展生存期。

结果

研究共入组26例患者，中位年龄为52岁（30岁-68岁）。26例患者中，1例出现3级放射性食管炎，未观察到3级及以上放射性肺炎。中位随访时间11.2（3.2-36.2）个月，1年生存率、无进展生存率和局部无进展生存率分别为89.0%、51.0%和85.0%。

结论

局限期小细胞肺癌采用化疗联合同步推量调强放疗，将GTV由45 Gy提升至54 Gy是安全有效的。

Phase 3 Randomized Low-Dose Paclitaxel Chemoradiotherapy Study for Locally Advanced Non-Small Cell Lung Cancer

Introduction

Concurrent chemoradiotherapy (CCRT) is the standard treatment for locally advanced non-small cell lung cancer (LA-NSCLC) but is associated with poor chest tumor control. Here, we report results of a randomized phase 3 study comparing two CCRT regimens in improving chest tumor control by low-dose paclitaxel chemoradiation for LA-NSCLC.

Methods

Due to the logistics of local referral pattern, the study was designed to enroll patients with stage III LA-NSCLC who had completed 2–4 cycles of full-dose chemotherapy. One hundred thirty four were randomized to either Arm 1 [paclitaxel at 15 mg/m², three times per week (Monday, Wednesday, and Friday) for 6 weeks, n = 74] or Arm 2 (weekly paclitaxel at 45 mg/m² for 6 weeks, n = 60). Chest radiotherapy was 60–70 Gy in standard fractionation. Response rate was the primary endpoint, with recurrence-free survival (RFS) as the secondary endpoint.

Results

From March 2006 to February 2013, 71 patients completed Arm 1 treatment and 59 completed Arm 2 treatment. The response rate for Arm 1 was significantly higher (83.1%) than Arm 2 (54.2%) (p=0.001). RFS was superior in Arm 1: median 14.6 vs. 9.4 months, p = 0.005, Hazard ratio (HR) 1.87 [95% confidence interval (CI) 1.20, 2.90]. Overall survival was not significantly different: median 32.6 months in Arm 1 vs. 31.3 months in Arm 2, p = 0.91, HR 0.97 (95% CI 0.55, 1.70). Toxicity was significantly lower in Arm 1 for Grade 3 and 4 leukopenia/neutropenia (p < 0.001).

Conclusion

Pulsed low-dose paclitaxel CCRT resulted in significantly better RFS and tumor response rate, and less hematologic toxicities than weekly CCRT for LA-NSCLC.

Cardiac atlas development and validation for automatic segmentation of cardiac substructures

PURPOSE

To develop and validate a set of atlases for auto-contouring cardiac substructures.

METHODS

Eight radiation oncologists manually and independently delineated 15 cardiac substructures from noncontrast CT images of 6 patients by referring to their respective fused contrast CT images. Individual contours were fused together for each structure, edited by 2 physicians, and became atlases to delineate other 6 patients. The auto-delineated contours of the 6 additional patients became templates for manual contouring. These 12 patients with well-defined contours composed the final atlases for multi-atlas segmentation.

RESULTS

The average time for manually contouring the 15 cardiac substructures was about 40min. Inter-observer variability was small for the heart, the chambers, and the aorta compared with that for other structures that were not clearly distinguishable in CT images. The mean dice similarity coefficient and mean surface distance of auto-segmented contours were within one standard deviation of expert contouring variability. Good agreement between auto-segmented and manual contours was observed for the heart, the chambers, and the great vessels. Independent validation on other 19 patients showed reasonable agreement for the heart chambers.

CONCLUSIONS

A set of cardiac atlases was created for auto-contouring from noncontrast CT images. The accuracy of auto-contouring for the heart, chambers, and great vessels was validated for potential clinical use.

[Current Status of Stereotactic Ablative Radiotherapy (SABR) for Early-stage Non-small Cell Lung Cancer]

目前比较立体定向消融放疗（stereotactic ablative radiotherapy, SABR）与手术治疗早期非小细胞肺癌（non-small cell lung cancer, NSCLC）的随机研究证据尚不多，高水平的循证医学证据更是缺乏。尽管STARS和ROSEL两项随机研究结果荟萃分析显示SABR较手术耐受性更好，生存不劣于手术，但是目前仍仅推荐拒绝手术或不可手术的早期NSCLC首选SABR，期待着正在进行的随机研究VALOR（Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy in the US）和SABRTooth（SABRTooth study in the United Kingdom）的结果。许多回顾性的研究和病例对照研究显示了SABR治疗的安全性和有效性（局部控制率达90%以上，5年生存率达70%），但是由于肿瘤分期定义、如何决定可否手术及手术患者采用手术方式（开胸或胸腔镜辅助）等不同，很难比较SABR和手术的优劣，尽管大部分结论是两种方法疗效相似，但难以成为循证医学证据，因此争论热点是哪一种方法更安全、创伤更小。本文将就以上争论热点进行述评。

[Deficiencies in the Diagnosis and Treatment of Pulmonary Metastatic Osteosarcoma: A Chinese Multidisciplinary Survey]

背景与目的

骨肉瘤是最常见的骨原发恶性肿瘤，好发于青少年。尽管多学科框架下骨肉瘤的治疗已经取得瞩目成就，然而影响骨肉瘤远期生存的重要因素是肺转移。约有1/2以上患者在其病程的不同时期会发生肺转移，其中10%~15%为同时性肺转移。毋庸置疑，治疗肺转移瘤的首选方法为外科切除，但因骨肉瘤肺转移的诊疗涉及多学科多专业，而由于各学科之间的理念存在差异，因此尚未形成标准化的诊疗模式。本研究通过问卷调查方式旨在了解当前我国骨肉瘤大型医疗中心在此领域中的诊疗模式现况。

方法

2015年9月-2015年11月期间，一项关于骨肉瘤肺转移的诊疗现况问卷在全国骨肉瘤大型诊疗中心范围内开展。根据调查对象所在单位、工作年限、年均收治病例数及医学专业不同，进一步行分层分析。

结果

调查共发放问卷150份，回收有效问卷105份，总应答率为70%。首先，关于骨肉瘤肺转移治疗的核心问题，41.0%的调查对象认同骨肿瘤外科专业在骨肉瘤肺转移多学科诊疗实践中的主导地位；首选肺转移瘤切除术作为转移灶局部控制措施的比例约64%；78.1%的调查对象会推荐患者行肺转移瘤切除术；骨科及胸外科医师较之其他专业更加积极（同骨科专业相比，OR_其他专业=0.02；95%CI：0.00-0.22；P=0.001）；胸外科医师更倾向根据经验决定肺转移瘤切除术的指证，而非受限于病灶具体数目（OR_{胸外科专业}=20.93；95%CI：2.05-213.64；P=0.001）。其次，关于骨肉瘤肺转移影像学诊断方法，约83%首选胸部计算机断层扫描（computed tomography, CT）；约70%的调查对象推荐原发灶切除术后3个月行胸部CT随诊；约68%认为CT诊断准确度90%水平；约92%同时推荐行肺外影像学评估。最后，关于术后生存获益的定义问题，约46%认为肺转移瘤术后生存期超过6个月即为生存获益。

结论

本次问卷调查提供了我国骨肉瘤肺转移诊疗模式的现况信息，其反映出缺少统一规范诊疗模式的不足。调查结果为今后研究方向及国际性临床指南提供了基线数据。

The PR status of the originating cell of ER/PR-negative mouse mammary tumors

Progesterone receptor (PR) is usually co-localized with estrogen receptor (ER) in normal mammary cells. It is not known whether ER/PR-negative human breast cancer arises from an ER/PR-negative cell or from an ER/PR-positive cell that later lost ER/PR. Using intraductal injection of a lentivirus to deliver both an oncogene (ErbB2) and a floxed green fluorescent protein (GFP) in PR(Cre/+)mice, whose Cre gene is under the control of the PR promoter, we were able to trace the PR status of the infected cells as they progressed to cancer. We found that the resulting early lesions stained negative for PR in most of the cells and usually retained GFP. The resulting tumors lacked ER and PR, and 75% (15/20) of them retained the GFP signal in all tumor cells, suggesting PR was never expressed throughout the evolution of a majority of these tumors. In conclusion, our data demonstrate that ErbB2-initiated ER/PR-negative mammary tumors primarily originate from the subset of the mammary epithelium that is negative for PR and probably ER as well. These findings also provide an explanation for why antihormonal therapy fails to prevent ER-negative breast cancers.

[Stereotactic Radiotherapy for Non-small Cell Lung Cancer with Small Lesions Applying A Flattening Filter Free Clinac]

BACKGROUND AND OBJECTIVE

With the rapid development of technology, stereotactic radiotherapy has been widely used. In a cohort of medically operable non-small cell lung cancer patients receiving stereotactic body radiation therapy (SBRT) survival rates "potentially equivalent to those of surgery" have been reported. Removing the field flattening filter, Clinac is capable of delivering dose rates much higher than conventional linac as well as reducing the treatment time. The goals of this work were to report safety and efficacy of SBRT treatment using a flattening filter-free model for non-small cell lung cancer (NSCLC) with small lesions.

METHODS

From December 2011 to December 2013, 31 NSCLC patients who were T1-2N0M0, solitary pulmonary recurrence after surgery, and stage IV with oligo metastasis were enrolled, receiving SBRT treatment (60 Gy/8 f or 48 Gy/4 f) applying a flattening filter-free model.

RESULTS

Compared with conventional technique, flattening filter-free model shortened the treating time with equivalent target dose and normal tissue dose. The median follow-up time is 19.4 mo. The 1-yr local control, regional control, distant control, progression free survival and overall survival rates were 96.8%, 96.8%, 83.9%, 77.4% and 96.8%. The most common side effects were radiation pneumonitis (29% grade 1, 3.2% grade 2) and chest pain (12.9% grade 1, 6.5% grade 2).

CONCLUSIONS

The use of flattening filter-free model in SBRT for small lesions of NSCLC patients is safe and effective. Long time follow-up and additional studies are still needed to validate our conclusions.

Feasibility of omitting clinical target volume for limited-disease small cell lung cancer treated with chemotherapy and intensity-modulated radiotherapy

Purpose

To analyze the feasibility of omitting clinical target volume (CTV) for limited small cell lung cancer treated with chemotherapy and intensity modulated radiotherapy.

Methods and materials

89 patients were treated from January 1, 2008 to August 31, 2011, 54 cases were irradiated with target volume without CTV, and 35 cases were irradiated with CTV. Both arms were irradiated post chemotherapy tumor extent and omitted elective nodal irradiation; dose prescription was 95% PTV56-63 Gy/28-35 F/5.6-7 weeks.

Results

In the arm without CTV and arm with CTV, the local relapse rates were 16.7% and 17.1% (p = 0.586) respectively. In the arm without CTV, of the 9 patients with local relapse, 6 recurred in-field, 2 recurred in margin, 1 recurred out of field. In the arm with CTV, of the 6 patients with local relapse, 4 recurred in-field, 1 recurred in margin, 1 recurred out of field. The distant metastases rates were 42.6% and 51.4% (p = 0.274) respectively. Grade 3-4 hematological toxicity and radiation esophagitis had no statistically significant, but grade 3-4 radiation pneumonia was observed in only 7.4% in the arm without CTV, compared 22.9% in the arm with CTV (p = 0.040). The median survival in the arm without CTV had not reached, compared with 38 months in the with CTV arm. The l- years, 2- years, 3- years survival rates of the arm without CTV and the arm with CTV were 81.0%, 66.2%, 61.5% and 88.6%, 61.7%, 56.6% (p = 0.517). The multivariate analysis indicated that the distant metastases (p = 0.000) and PCI factor (p = 0.004) were significantly related to overall survival.

Conclusions

Target delineation omitting CTV for limited-disease small cell lung cancer received IMRT was feasible. The distant metastases and PCI factor were significantly related to overall survival.

Abstract P5-03-14: Expression of ALDH1 in metastasizing axillary lymphnodes in breast cancer

Background: There is increasing evidences that a wide variety of malignancies, including breast cancer, may be driven by a small subset of ‘tumor-initiating cells’ or ‘cancer stem cells’ (CSC) which are able to form tumors in immunocompromised mice as well as to generate the phenotypic heterogeneity of the initial tumor. Enzyme aldehyde dehydrogenase (ALDH1) has been reported as a possible marker for mammary CSC. These cells are a source of tumor recurrence and metastasis, and are resistant to chemotherapy, radiotherapy and hormone therapy.

Objective: Assuming that the detection of CSC in axillary lymph nodes is more effective to predicting cancer outcome than the widely used detection of cancer cells in axillary lymph nodes, we measure ALDH1 levels to predict their presence into axillary lymph nodes on development of cancer and anticipate outcomes.

Methods: ALDH1 protein was detected by an immunohistochemical technique in 229 cases of breast cancer diagnosed from 2002 to 2011 Follow-up ranged from 11.5 months to 96.9 months, with a mean of 73.9 months. A survival assay was used to determine the relationship between distant metastatic rate and survival rate.

Results: ALDHl expression was detected in 79cases and the Positive rate in metastatic axillary lymph nodes was 34.5%. Negative ER, PR status were related to the ALDH1 positive cases(P = 0.012). See Table 1. Mortality rate between ALDH1 positive cases (50.8%) and negative cases (28.8%) were significantly different (P = 0.001). See Table 2. Further, survival analysis of recurrence-free survivals (RFS) and survival rate decreased significantly between ALDHl positive and negative cases (P = 0.001) (see table 2) and COX analysis shows that ALDH1 expression is an independent predictor of poor outcome in breast cancer(P = 0.011).

Discussion: What cancer stem cells migrate to the axillary nodes have more important prediction than that the matastesis of normal cancar cells in axillary node. It might be a role resulting in dying in breast cancer.

[Role of EGFR mutation status in patients with stage III non-squamous non-small cell lung cancer treated with chemoradiotherapy]

背景与目的

表皮生长因子受体（epidermal growth factor receptor, EGFR）突变状态与Ⅲ期非小细胞肺癌放化疗近期疗效和生存的关系是目前临床研究热点。本研究旨在探讨EGFR突变状态与Ⅲ期非鳞非小细胞肺癌放化疗疗效的关系。

方法

本研究共计入组187例Ⅲ期非鳞非小细胞肺癌患者，其中87例能够评估放化疗近期疗效和2年生存率，128例患者适合评估一线化疗疗效。采用变性高效液相色谱法检测EGFR基因突变状态。

结果

EGFR突变阳性患者对联合放化疗的客观缓解率为84.6%（33/39），明显高于EGFR突变阴性患者56.3%（27/48）（P=0.004）。2年生存率EGFR突变阳性患者为53.8%（21/39），EGFR突变阴性患者为50%（24/48），两组在长期生存方面无统计学差异（P=0.871）。

结论

在Ⅲ期非鳞非小细胞肺癌中，EGFR突变预示更高的放化疗近期疗效，与生存期无关。

P2-11-09: EGFR Overexpression in Triple Negative Breast Cancer (TNBC) and Its Association with the Prognosis

Objective: The aim of this study is to investigate EGFR expression in Triple Negative Breast Cancer (TNBC), and to find the relationship between EGFR overexpression and prognosis of TNBC, further to clarify the significance of EGFR in TNBC and provide valuable information for TNBC therapy.

Methods: 42 triple ***negandection ***ssitive breast cancer patients(studying group) and 40 HER2(3+) breast cancer patients(controling group) who underwent surgery from January 2000 to December 2005 were analyzed. 82 cases of paraffin-embedded specimens were detected by Immunohistochemistry(IHC), fluorescence in situ hybridization(FISH) and polymerase chain reaction(PCR) to investigate the overexpression, amplification and mutation of EGFR gene. The distant-free survival(DFS) and overall survival(OS) of these patients were used to investigate the relationship between EGFR overexpression and the prognosis of TNBC.

Results: 34(43.9%) EGFR overexpression was observed in all cases, while gene amplification was only 7(9.1%) cases. No EGFR gene mutation was found in all cases. Overexpression of EGFR occurring in 57.1% patients in TNBC group and 25.0% patients in HER2 group, and we didn't found any correlation between EGFR overexpression and clinicopathology. 50(61.0%) patients relapsed (TNBC 28,HER2 22) and 27(32.9%) patients died(TNBC 18,HER2 9) were observed during the more than 5 years follow-up. The 5-year DFS was 57.1% and 77.5% respectively, the 5-year OS was 71.4% and 87.5% in TNBC and HER2 groups. In TNBC group, the survival of the EGFR-overexpressing group patients was significantly lower than that of the non-EGFR-overexpressing group patients (p=0.018 for DFS, p=0.026 for OS); In HER2 group, no statistical difference was found (p=0.079 for DFS, p=0.055 for OS).

Conclusions: This study showed that EGFR overexpression increased significantly in TNBC patients, which was no correlation with their clinico-pathological data. EGFR gene amplification was much less frequent than its overexpression. It suggested that EGFR gene amplification may not be the unique mechanism of EGFR overexpression in TNBC. There may be other possible mechanisms and pathways that cause EGFR overexpression. In addition, it may suggest that gefitinib therapy is useless in TNBC patients because we did not find any mutations in the tested exons of TNBC. EGFR overexpression may associate with a poor outcome of TNBC patients which suggest it could be a significant prognostic factor for TNBC patients. EGFR may play important role for molecular-targeting therapy of TNBC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-11-09.