The Use of Palliative Radiotherapy in the Treatment of Lung Cancer

There have been significant advances in the systemic treatment of stage IV lung cancer, which is now recommended first line in patients with adequate fitness. This includes some patients with brain metastases due to the increased understanding of the central nervous system penetration of targeted therapies. The trials evidence base for palliative radiotherapy pre-dated this routine use of systemic therapy in our practice, which means that the sequence and role of palliative radiotherapy are not currently well defined in the first-line treatment setting. However, due to its efficacy in symptom control, radiotherapy remains a core component in the palliative management of lung cancer, particularly in the second-line setting and those unsuited to primary systemic treatment. This overview focuses on the evidence behind palliative radiotherapy to the thorax and brain for non-small cell and small cell lung cancer and the potential for future studies, including the TOURIST Trial Platform, to guide the future direction of these treatments.

Continuous Hyperfractionated Accelerated Radiotherapy (CHART) for Non-small Cell Lung Cancer (NSCLC): 7 Years' Experience From Nine UK Centres

AIM

Continuous hyperfractionated accelerated radiotherapy (CHART) remains an option to treat non-small cell lung cancer (NSCLC; NICE, 2011). We have previously published treatment outcomes from 1998-2003 across five UK centres. Here we update the UK CHART experience, reporting outcomes and toxicities for patients treated between 2003 and 2009.

MATERIALS AND METHODS

UK CHART centres were invited to participate in a retrospective data analysis of NSCLC patients treated with CHART from 2003 to 2009. Nine (of 14) centres were able to submit their data into a standard database. The Kaplan-Meier method estimated survival and the Log-rank test analysed the significance.

RESULTS

In total, 849 patients had CHART treatment, with a median age of 71 years (range 31-91), 534 (63%) were men, 55% had undergone positron emission tomography-computed tomography (PET-CT) and 26% had prior chemotherapy; 839 (99%) patients received all the prescribed treatment. The median overall survival was 22 months with 2 and 3 year survival of 47% and 32%, respectively. Statistically significant differences in survival were noted for stage IA versus IB (33.2 months versus 25 months; P = 0.032) and IIIA versus IIIB (20 months versus 16 months; P = 0.018). Response at 3 months and outcomes were significantly linked; complete response showing survival of 34 months against 19 months, 15 months and 8 months for partial response, stable and progressive disease, respectively (P < 0.001). Age, gender, performance status, prior chemotherapy and PET-CT did not affect the survival outcomes. Treatment was well tolerated with <5% reporting ≥grade 3 toxicity.

CONCLUSION

In routine practice, CHART results for NSCLC remain encouraging and we have been able to show an improvement in survival compared with the original trial cohort. We have confirmed that CHART remains deliverable with low toxicity rates and we are taking a dose-escalated CHART regimen forward in a randomised phase II study of sequential chemoradiotherapy against other accelerated dose-escalated schedules.

Stereotactic ablative radiotherapy in the UK: current status and developments

Stereotactic ablative radiotherapy (SABR) has developed from the principles and techniques used in the stereotactic radiosurgery treatment of brain metastases. Advances in computer technology, imaging, planning and treatment delivery and evidence from retrospective analysis of single- and multi-institutional early-phase studies have established SABR in the treatment of medically inoperable early lung cancer. Effective multidisciplinary team working is crucial to safe delivery of SABR. The variation in patient selection, radiotherapy planning and delivery techniques has led to a collective approach to SABR implementation across the UK. Centres developing the technique are represented in the UK SABR Consortium, which is supported by the relevant UK professional bodies and represents a platform to develop extracranial SABR across the UK. The uptake of SABR in the UK has been slowed by workforce issues, but at least 15 centres are currently delivering treatment with over 500 patients treated using UK SABR Consortium guidance. A mentoring program is being piloted helping new centres to develop their programs, and over 30 UK centres are expected to be offering SABR treatment by the end of 2014. The use of consistent guidance for patient selection, treatment planning and delivery in the UK gives the opportunity to collect and audit toxicity and outcome across the centres, contributing to the internationally reported SABR experience. Having established this service in the UK, the development of SABR through clinical research is a priority, and with input from the Radiotherapy Trials Quality Assurance Group, the UK is developing a national study program that includes participation in international trials.

Review of testing and use of adjuvant trastuzumab across a cancer network--are we treating the right patients?

This review of practice assessed all early breast cancer patients diagnosed over 12 months to determine the frequency of human epidermal growth factor receptor 2 (HER2) positivity and trastuzumab use. The frequency of HER2 positivity in routine practice (185/1319; 14%) was less than expected. A significant proportion of patients (56/185; 30%) did not receive trastuzumab, largely due to concerns about chemotherapy tolerability.

Accelerated radical radiotherapy for non-small cell lung cancer using two common regimens: a single-centre retrospective study of outcome

AIMS

A variety of radical radiotherapy regimens are in use for non-small cell lung cancer. Continuous hyperfractionated accelerated radiotherapy (CHART: 54 Gy in 36 fractions over 12 days) and accelerated hypofractionated radiotherapy using 55 Gy in 20 fractions over 4 weeks are standard fractionations in our centre. The primary aim of this retrospective study was to evaluate survival outcome seen in routine clinical practice.

MATERIALS AND METHODS

All case notes and radiotherapy records of radically treated patients between 1999 and 2004 were retrospectively reviewed. Basic patient demographics, tumours, characteristics, radiotherapy and survival data were collected.

RESULTS

In total, 277 patients received radical radiotherapy: 137 and 140 patients received CHART and hypofractionated radiotherapy, respectively. There were differences noted in the demographics between the two treatment schedules: median age 65 years (range 41-83) vs 73 years (range 33-87); histological confirmation rates 90% vs 76%; prior chemotherapy 34% vs 19% for CHART and hypofractionated treatment, respectively. For CHART patients, stages I, II, III and unclassified were 12, 8, 68 and 12% and the staging for the hypofractionated regimen was 54, 11, 34 and 2%, respectively. The median overall survival from the time of diagnosis was 20.4 months with a 40% 2-year survival rate. For the two fractionations the median survival was 16.6 months vs 21.4 months and 34% vs 45% of patients were alive at 2 years in the CHART and hypofractionated groups, respectively. On multivariate analysis, stage was the only factor affecting overall survival - no difference was seen according to radiotherapy regimen.

CONCLUSION

This single-centre study reflects the outcome of unselected consecutively treated non-small cell lung cancer patients. Adjusting for stage, there was no significant difference in survival seen according to regimen. Encouragingly, CHART outcome shows reproducibility with the original CHART paper. Our hypofractionated outcome is similar to that previously reported, but despite this being the UK's most common regimen, 55 Gy in 20 daily fractions remains unvalidated by phase III trial data.

Epirubicin/vinorelbine adjuvant chemotherapy in young women with breast cancer is associated with preservation of menstrual function

AIMS

To determine whether the epirubicin and vinorelbine regimen in the adjuvant (neoadjuvant) treatment of breast cancer has minimum adverse effects on menstrual function.

PATIENTS AND METHODS

Thirty-six premenopausal women with a median age of 32 (25-47) years received epirubicin and vinorelbine. Twenty-eight received only epirubicin and vinorelbine without any other neo/adjuvant chemotherapy agents. Amenorrhoea was defined as absence of periods 6 months after the completion of chemotherapy. The medical records of all patients were reviewed retrospectively.

RESULTS

Twenty-six patients were assessable for effects of epirubicin and vinorelbine on menstruation. All the 26 patients resumed menstruation within 6 months of completing epirubicin and vinorelbine treatment. Epirubicin and vinorelbine was well tolerated. After a median follow-up of 38.5 (11-78) months, six (21%) patients had developed disease relapse and three (11%) had died. The 6.5-year disease-free survival and overall survival probabilities were 77 and 86%, respectively.

CONCLUSION

Adjuvant (neoadjuvant) epirubicin and vinorelbine is an effective and well-tolerated regimen that is associated with the retention of menstrual function.

The use of lung dose-volume histograms in predicting post-radiation pneumonitis after non-conventionally fractionated radiotherapy for thoracic carcinoma

AIMS

To assess the use of lung dose-volume histogram (DVH) parameters (specifically V20Gy) in the prediction of radiation pneumonitis for non-conventional fraction sizes used in the treatment of lung cancer.

MATERIALS AND METHODS

Patients requiring computed tomography planning for thoracic radiotherapy between January 1999 and January 2002 were identified. The patients receiving radical or high-dose palliative radiotherapy had DVH produced routinely during planning. These were retrospectively reviewed and the case notes accessed for additional pre-treatment parameters, demographics and evidence of radiation pneumonitis. The severity of the pneumonitis was then scored using Radiation Therapy Oncology Group criteria. Data were analysed using the SPSS computer program.

RESULTS

One hundred and sixty consecutive patients were reviewed. Ninety patients received hypofractionated treatment (fraction size > 2.5 Gy) and 57 continuous hyperfractionated accelerated radiation therapy (CHART) (fraction size 1.5 Gy). Lung V20Gy values ranged from 3% to 53%, with a median value of 24%. Only six patients reported grade 2, and 16 patients grade 3 pneumonitis. Two patients developed fatal, grade 5 pneumonitis. No correlation between pneumonitis score and V20Gy or other possible predictive factors was found.

CONCLUSION

The 15% grade 2-5 pneumonitis rate we document is at the lower end of the spectrum reported in other studies. This suggests that using published data on limiting V20Gy values to reduce the risk of radiation pneumonitis can be extrapolated to planning treatment with non-conventionally fractionated radiotherapy.

The Management and Survival of Patients with Advanced Germ-Cell Tumours: Improving Outcome in Intermediate and Poor Prognosis Patients

AIMS

The survival of germ-cell tumours (GCT) was transformed after the introduction of cisplatin-based therapy. Previous trials have indicated BEP (bleomycin, etoposide and cisplatin) as the optimum treatment, although some centres including our own advocate the use of the alternating regimen POMB-ACE (cisplatin, vincristine, methotrexate, bleomycin and dactinomycin, cyclophosphamide and etoposide) for men with intermediate or poor prognosis disease. We analysed the survival and management of GCT patients treated at a specialist cancer centre in relation to internationally recognised prognostic groupings.

MATERIALS AND METHODS

We retrieved patient information using the Trent Testicular Tumour Registry and supplemented it with information from patient notes. This included all patients with Royal Marsden Hospital Stage II, III and IV disease and patients with stage I disease at diagnosis with raised markers or subsequent relapse. We compared the efficacy and toxicity of the BEP and POMB-ACE chemotherapy regimens, and assessed relapse-free and overall survival.

RESULTS

We identified 178 non-seminomatous germ cell tumours (NSGCT) and 71 seminoma patients. Overall survival was similar to the International Germ Cell Cancer Collaborative Group (IGCCCG) classification for the good (95% vs 92%) and intermediate groups (82% vs 80%). The outcome for the poor prognosis group was better than expected in our series (57% vs 48%). There was a higher proportion of both immediate and late side-effects with POMB-ACE.

CONCLUSION

Survival and disease progression rates at this single institution were at least as good as reported by the IGCCCG and somewhat better for the poor-prognosis group. This may reflect use of the POMB-ACE chemotherapy regimen as opposed to standard BEP regimen. However, a randomised comparison of BEP and POMB-ACE would be required to validate this.

The impact of virtual simulation in palliative radiotherapy for non-small-cell lung cancer

BACKGROUND AND PURPOSE

Radiotherapy is widely used to palliate local symptoms in non-small-cell lung cancer. Using conventional X-ray simulation, it is often difficult to accurately localize the extent of the tumour. We report a randomized, double blind trial comparing target localization with conventional and virtual simulation.

METHODS

Eighty-six patients underwent both conventional and virtual simulation. The conventional simulator films were compared with digitally reconstructed radiographs (DRRs) produced from the computed tomography (CT) data. The treatment fields defined by the clinicians using each modality were compared in terms of field area, position and the implications for target coverage.

RESULTS

Comparing fields defined by each study arm, there was a major mis-match in coverage between fields in 66.2% of cases, and a complete match in only 5.2% of cases. In 82.4% of cases, conventional simulator fields were larger (mean 24.5+/-5.1% (95% confidence interval)) than CT-localized fields, potentially contributing to a mean target under-coverage of 16.4+/-3.5% and normal tissue over-coverage of 25.4+/-4.2%.

CONCLUSIONS

CT localization and virtual simulation allow more accurate definition of the target volume. This could enable a reduction in geographical misses, while also reducing treatment-related toxicity.

Chemotherapy for neuroendocrine tumors: the Beatson Oncology Centre experience

The role of chemotherapy in malignant neuroendocrine tumours is difficult to assess because of their rarity and variation in biological behaviour. We present a retrospective review of chemotherapy given to 18 patients with metastatic and one with locally advanced neuroendocrine tumours. There were eight poorly differentiated neuroendocrine tumours, six thyroid medullary carcinomas, two phaeochromocytomas, two pancreatic islet cell tumours and one undifferentiated neuroblastoma. Four patients were given 3-weekly dacarbazine, vincristine and cyclophosphamide (DOC) chemotherapy. In eight patients, this regimen was modified by substituting the dacarbazine and cisplatin and etoposide (OPEC). A further six patients were treated with dacarbazine reintroduced into the 3-weekly regimen (DOPEC). The remaining patient received cisplatin and etoposide. There were two complete responses (both with OPEC) and eight partial responses (two with DOC, three with OPEC and three with DOPEC). Five patients had stable disease and four progressed. Four received further chemotherapy on relapse, producing one complete and one partial response. The median response duration to initial chemotherapy was 10 months (range 3-34). The median survival was 12 months (range 1-42). The main toxicity was haematological, with grade 3-4 neutropenia in 12 patients; eight suffered episodes of sepsis. One death was treatment related. Other toxicity was mild although three patients discontinued vincristine with grade 2 neurotoxicity. The response rate and side effects of these three regimens appear comparable. We conclude that, although these patient numbers are small, combination chemotherapy produces an encouraging response rate (53%; 95% CI 30-75) in malignant neuroendocrine tumours, with acceptable toxicity.

Acute changes in peak expiratory flow rate following palliative radiotherapy for bronchial carcinoma

PURPOSE

Changes in respiratory function occurring in the months and years following radiotherapy have been well documented. The changes that occur in the hours after treatment are less clear, we report a study that recorded peak expiratory flow rate (PEFR) in the 72 h following radiotherapy to the mediastinum and large airways.

METHODS

Fifty-six patients with carcinoma affecting the major bronchii were recruited; 39 were male, with a median age of 66 years; 49 had histologically confirmed lung cancer. The median baseline PEFR was 300 1/s (range: 120-600). Patients were asked to record home PEFR readings in the 72 h that followed the first fraction of radiotherapy. Doses ranges from an 8-Gy single fraction to 60 Gy in 30 fractions.

RESULTS

Forty-nine patients recorded a fall in PEFR (3%-60% of the baseline value) in the 24 h after radiotherapy, the mean for all 56 patients was a fall of 20.3% (95% confidence interval -15.8% to -24.8%). These lowest values occurred a median time of 6 h after treatment (range: 2-24 h). By 72 h the mean PEFR had returned to the baseline. Tumour site (central or lobar bronchus) and fraction size (<3 GY or >3 Gy) had no significant effect on the fall in PEFR (Mann-Whitney U-test P = 0.15 and P = 0.06, respectively).

CONCLUSION

We conclude that a fall in PEFR can occur after radiotherapy treatment to the mediastinum. This is of concern in patients being treated for bronchial carcinoma whose respiratory function may already be compromised.

Immediate side effects of large fraction radiotherapy

The use of hypofractionated radiotherapy regimens is becoming more widely recognized in the palliation of non-small cell lung carcinoma (NSCLC). Anecdotal reports of chest pain, rigors and fevers in the hours that follow radiotherapy led us to perform a survey estimating the frequency and severity of these symptoms following treatment to the thorax. One hundred and eighteen patients completed questionnaires 24 hours after palliative radiotherapy treatment; 84 were male. The median age was 67 years. One hundred and seven had histologically confirmed NSCLC. A parallel opposed technique was used in 113 patients. Doses ranged from 8 Gy in a single fraction to 60 Gy in 30 fractions. Chest pain was reported by 54 (45.8%) patients after the first radiotherapy fraction; in 42 it commenced within 12 hours of treatment. The pain varied in site, nature and duration; on 23 occasions, it lasted under 2 hours. Systemic symptoms (rigors, sweating, fevers) were documented on 43 questionnaires, starting within 12 hours of treatment in 33 patients and on 30 occasions lasting less than 2 hours. Chest pain and systemic symptoms occurred together in 28 patients. Only 49 (41.5%) patients reported no immediate side effects. We conclude that patients receiving palliative radiotherapy for bronchial carcinoma often develop significant symptoms in the hours following treatment. The timing and duration suggest a relationship with the radiotherapy, and we feel that patients should be warned of the possible occurrence of these symptoms.

Compliance with oral corticosteroids during steroid trials in chronic airways obstruction

BACKGROUND

Corticosteroid trials are an important part of the assessment of patients with chronic airways obstruction, but false negative results will occur if the treatment is not taken. To determine compliance low dose phenobarbitone has been used as a marker.

METHODS

Thirty six patients referred to a chest clinic for assessment of their airways obstruction were studied. They were instructed to take eight capsules (each containing 5 mg prednisolone and 0.5 mg phenobarbitone) per day for two weeks. The response was assessed by home peak flow monitoring and clinic spirometric tests. Plasma phenobarbitone levels were measured after the trial to enable calculation of the dose to plasma concentration ratio (level to dose ratio, LDR) and the result was compared with the reference range for fully compliant individuals.

RESULTS

Five patients defaulted from follow up, 23 had LDR values within the expected range, and eight had low LDR values consistent with poor compliance. The nine patients with steroid responsive disease (> 20% improvement in peak flow or spirometric parameters) all had LDR values in the expected range.

CONCLUSION

Excluding those who defaulted whose compliance must be questionable, eight (26%) patients did not fully comply with the steroid trial. Not all patients who fail to respond to a two week home steroid trial have a steroid "unresponsive" disease.

Carboplatin, 5-fluorouracil and folinic acid: a 48-hour chemotherapy regimen in advanced and recurrent squamous carcinoma of the head and neck

Eighty patients with advanced squamous carcinoma of the head and neck were entered into a study using a 2-day, inpatient, intravenous regimen. Folinic acid 200 mg/m2, 5-fluorouracil (5-FU) 500 mg/ m2 bolus followed by 5-FU 500 mg/m2 in a 22-hour infusion were given on days 1 and 2, with carboplatin 300 mg/m2 on day 2. The whole was repeated every 21 days. Forty-three patients had advanced disease with no prior treatment; 37 had recurred following radical treatment. Fifty-eight patients were male and the median age was 60 years. In total, 275 cycles of chemotherapy were given. The major toxicity was haematological, which delayed 65 cycles of chemotherapy and contributed to the death of two patients. Non-haematological toxicity was mild, with less than 8% of patients experiencing any toxicity greater than WHO grade 2. The patients who had had no previous treatment had a 65% response rate (95% confidence interval (95% CI) 48-80). Those who had been previously treated had a 37% response rate (95% CI 21-55). The overall response rate was 52% (95% CI 40-64), of whom 5% were complete responders. The median survival time was 36 weeks (95% CI 29-45), with the majority of patients dying with progressive disease. We conclude that this chemotherapy regimen was well tolerated and produced minimal toxicity, while maintaining an acceptable response rate of 52%.

Changes in the incidence and mortality of testicular cancer in Scotland with particular reference to the outcome of older patients treated for non-seminomatous germ cell tumours

This paper describes the temporal pattern of germ cell testicular cancer in Scotland between 1960 and 1990. The effect of age on the prognosis of patients with non-seminomatous germ cell tumours (NSGCT) has been assessed by studying all patients presenting in the West of Scotland between 1975 and 1989. Between 1960 and 1990, the number of testicular germ cell tumours registered has increased more than 2-fold; mortality rates have declined equally dramatically. Univariate and multivariate analysis of the data obtained on 440 patients with NSGCT showed age was not a prognostic factor influencing survival. 52 were patients over 40 years at presentation; their 5 years survival was 71% compared with 79% in the younger patients (n = 388). This small survival difference is probably explained by the higher proportion of older patients treated before 1980. Treatment for this older group should be approached with the same curative intent as for younger patients and the same expectation of success.

A comparison of 'abruptly stopping' with 'tailing off' oral corticosteroids in acute asthma

Systemic corticosteroids are almost universally used in the treatment of severe acute asthma but the optimum length of treatment with corticosteroids following recovery from an acute attack of asthma is not established. Thirty-five patients admitted with acute asthma and treated with oral prednisolone 40 mg daily in addition to bronchodilator therapy until full recovery, with stable peak expiratory flow recordings (PEF) within 15% of their previous best PEF or predicted PEF were studied. They were all discharged home on regular inhaled corticosteroids and regular or as required use of bronchodilators and randomized to receive either prednisolone 40 mg daily or placebo for the first 14 days. Median PEF values increased from 31% predicted on admission to hospital to 71% predicted on discharge from hospital in the active treatment group (19 patients) and from 32-73% in the placebo group (16 patients). There was no difference between the two groups in the median values of the forced expiratory volume in one second, forced vital capacity, total lung capacity or diurnal variation in PEF either at the time of discharge from hospital or at 14 and 28 days after discharge from hospital. This study suggests that there is no need to reduce prednisolone gradually following recovery from an exacerbation of asthma, provided systemic corticosteroid treatment is continued until a satisfactory and stable PEF is achieved.

Ulcerative skin reaction from subcutaneous infusion of isotonic methotrimeprazine and diamorphine

We report an ulcerative skin reaction resulting from a subcutaneous infusion of isotonic methotrimeprazine and diamorphine. Skin reactions are a recognized side effect of this treatment, although they are reduced by the use of the isotonic formulation of methotrimeprazine. Frank ulceration has not been previously reported. It occurred in our patient despite low doses of diamorphine and methotrimeprazine, an isotonic formulation, and a short infusion time.

The prevalence of menopausal symptoms in patients treated for breast cancer

A survey has been performed to discover the prevalence of menopausal symptoms in 108 patients successfully treated for breast cancer. Patients were assessed by them answering a custom designed questionnaire, and the use of the Hospital Anxiety and Depression (HAD) scale and the Greene Climacteric Scale. During the first year after treatment 70% of women suffered such symptoms; overall 60% of women surveyed were affected. Adjuvant hormonal treatment was the largest contributing factor in the development of symptoms. There was a relationship with borderline cases of anxiety, but not with definite cases of anxiety, as measured by the HAD scale. The high proportion of women shown to be affected means that treatment of menopausal symptoms should be incorporated into randomized trials of adjuvant therapy.

Pancoast syndrome: an unusual presentation of adenoid cystic carcinoma

We report on a patient with primary pulmonary adenoid cystic carcinoma presenting with Pancoast syndrome. Pancoast syndrome has not previously been described with this tumour. Other unusual features of this case include the peripheral origin and mediastinal involvement, with lack of proximal endobronchial spread.

Pancoast syndrome: an unusual presentation of adenoid cystic carcinoma

We report on a patient with primary pulmonary adenoid cystic carcinoma presenting with Pancoast syndrome. Pancoast syndrome has not previously been described with this tumour. Other unusual features of this case include the peripheral origin and mediastinal involvement, with lack of proximal endobronchial spread.