Fractionated stereotactic body radiotherapy for up to five prostate cancer oligometastases: Interim outcomes of a prospective clinical trial

Stereotactic body radiotherapy (SBRT) can delay escalation to systemic treatment in men with oligometastatic prostate cancer (PCa). However, large, prospective studies are still required to evaluate the efficacy of this approach in different patient groups. This is the interim analysis of a prospective, single institution study of men relapsing with up to five synchronous lesions following definitive local treatment for primary PCa. Our aim was to determine the proportion of patients not requiring treatment escalation following SBRT. In total, 199 patients were enrolled to receive fractionated SBRT (50 Gray in 10 fractions) to each visible lesion. Fourteen patients were castration resistant at enrolment. The proportion of patients not requiring treatment escalation 2 years following SBRT was 51.7% (95% CI: 44.1–59.3%). The median length of treatment escalation-free survival over the entire follow-up period was 27.1 months (95% CI; 21.8–29.4 months). Prior androgen deprivation therapy (ADT) predicted a significantly lower rate of freedom from treatment escalation at 2 years compared to no prior ADT (odds ratio = 0.21, 95% CI: 0.08–0.54, p = 0.001). There was no difference in the efficacy of SBRT when treating 4–5 vs. 1–3 initial lesions. A prostate-specific antigen (PSA) decline was induced in 75% of patients, with PSA readings falling to an undetectable level in six patients. No late grade three toxicities were observed. These interim results suggest that SBRT can be used to treat up to five synchronous PCa oligometastases to delay treatment escalation.     

Stereotactic body radiotherapy: A critical review for nonradiation oncologists

Stereotactic body radiotherapy (SBRT) involves the treatment of extracranial primary tumors or metastases with a few, high doses of ionizing radiation. In SBRT, tumor kill is maximized and dose to surrounding tissue is minimized, by precise and accurate delivery of multiple radiation beams to the target. This is particularly challenging, because extracranial lesions often move with respiration and are irregular in shape, requiring careful treatment planning and continual management of this motion and patient position during irradiation. This review presents the rationale, process workflow, and technology for the safe and effective administration of SBRT, as well as the indications, outcome, and limitations for this technique in the treatment of lung cancer, liver cancer, and metastatic disease. Cancer 2014;120:942–954 . © 2013 American Cancer Society.     

SABR和手术治疗早期NSCLC临床疗效分析

目的 对比立体定向消融放疗(SABR)和手术治疗早期NSCLC的疗效及安全性。方法 回顾分析2012—2016年间河南省肿瘤医院初治且临床资料完整的早期NSCLC患者,共227例,其中SABR组73例,手术组154例。Kaplan-Meier法计算生存率并Logrank检验,χ²检验分析组间基线资料差异。结果 所有患者均完成治疗,SABR组、手术组3年样本量分别为74、155例。SABR组、手术组3年OS率分别为81.9%、78.2%(P=0.603),3年PFS率分别为66.9%、66.9%(P=0.565),3年局部区域无进展率分别为84.0%、90.8%(P=0.133),3年远处无转移率分别为75.4%、69.8%(P=0.095)。结论 SABR与手术治疗早期NSCLC的OS率、PFS率、局部区域无进展率、远处无转移率相近,SABR是不可手术的早期NSCLC患者的可选择治疗方式。     

早期非小细胞肺癌的体部立体定向放射治疗进展

体部立体定向放射治疗（stereotactic body radiotherapy,SBRT）成为医学上不能手术的早期非小细胞肺癌（non-small cell lung cancer,NSCLC）的标准治疗方式。近十年的临床证据表明SBRT替代手术治疗效果可观。由于毒副作用小,SBRT同样适用于肺功能差、患有某些严重并发症的老年患者。最近针对可手术早期NSCLC患者的对比研究中发现SBRT可能同样适用于这一群体,但这些可观的结果仍需要长期随访的前瞻性实验的验证。本文就SBRT治疗早期非小细胞肺癌的临床进展做一综述。     

早期非小细胞肺癌的治疗决择:手术或立体定向放疗

在早期非小细胞肺癌的治疗中,手术治疗仍是最主要的治疗方式,包括胸腔镜下的微创肺段或亚段切除。然而,超大剂量分割的立体定向放疗(SBRT)已取得与手术相似或相同疗效,不仅是不能手术或拒绝手术者不可争议的治愈方式,而对于能手术者也发起了挑战,尽管还存在一些争议。因此,本综述将针对这两种治疗方式的优劣给予阐述,以利于为患者提供更适宜的治疗方式,并获得更多益处。尽管尚无大的随机临床研究比较SBRT与手术治疗疗效以及如何选择,但目前证据显示,对不能手术或拒绝手术者SBRT是治愈的方式;对于老年、合并心肺疾病、糖尿病等高或较高风险手术者,SBRT应成为主要的治疗,由于SBRT疗效不差于手术疗效,并发症更少且轻。总之,宜个体化的选择治疗方式,使患者获益更大,特别是在存在较大手术风险者。     

Stereotactic body radiotherapy for multisite extracranial oligometastases: final report of a dose escalation trial in patients with 1 to 5 sites of metastatic disease

BACKGROUND:

A subset of patients with metastatic cancer in limited organs may benefit from metastasis‐directed therapy. The authors investigated whether patients with limited metastases could be safely treated with metastasis‐directed radiotherapy.

METHODS:

Patients with 1 to 5 metastatic cancer sites with a life expectancy of >3 months received escalating stereotactic body radiotherapy (SBRT) doses to all known cancer sites. Patients were followed radiographically with CT scans of the chest, abdomen, and pelvis and metabolically with fluorodeoxyglucose‐positron emission tomography, 1 month after treatment, and then every 3 months. Acute toxicities were scored using the National Cancer Institute's Common Terminology Criteria for Adverse Events version 3.0, and late toxicities were scored using the Radiation Therapy Oncology Group late toxicity scoring system.

RESULTS:

Sixty‐one patients with 113 metastases were enrolled from November 2004 to November 2009 on a prospective radiation dose escalation study. Median follow‐up was 20.9 months. Patients tolerated treatment well; the maximal tolerated dose was not reached in any cohort. Eleven patients (18.3%) have not progressed. One and 2‐year progression‐free survival are 33.3% (95% confidence interval [CI], 22.8‐46.1) and 22.0% (95% CI, 12.8‐34.4); 1‐year and 2‐year overall survival are 81.5% (95% CI, 71.1‐91.1) and 56.7% (95% CI, 43.9‐68.9). Seventy‐two percent of patients whose tumors progressed did so in limited (1‐3) metastatic sites.

CONCLUSIONS:

Patients with 1 to 5 metastases can be safely treated to multiple body sites and may benefit from SBRT. Further investigation should focus on patient selection. Cancer 2011;. © 2011 American Cancer Society.     

Analysis of clinical outcomes and prognostic factors in 109 patients with early-stage non-small cell lung cancer treated with stereotactic ablation radiotherapy

Objective To evaluate the long-term survival and identify prognostic factors of patients diagnosed with early-stage non-small cell lung cancer (ES-NSCLC) receiving stereotactic ablation radiotherapy (SABR). Methods Clinical data of 109 ES-NSCLC patients treated with SABR in Henan Cancer Hospital from 2011 to 2018 were retrospectively analyzed. The overall survival (OS), cancer-specific survival (CSS) and progression-free survival (PFS) were calculated by Kaplan-Meier method and log-rank test. Multivariate prognostic analysis was performed by Cox regression model. Results The median follow-up time was 44 months (2-93 months). The median OS, CSS and PFS were 78 months, 78 months and 44 months, respectively. The 1-year OS, CSS and PFS were 95.4%, 97.2% and 84.1%, and 75.6%, 79.1% and 56.6% for the 3-year OS, CSS and PFS, and 55.6%, 60.7% and 37.3% for the 5-year OS, CSS and PFS, respectively. Univariate analysis showed that ECOG score, age, smoking history and derived-neutrophil/lymphocyte ratio (dNLR) were the influencing factors of OS (P=0.03, 0.02, 0.04, 0.001). Age, smoking history and dNLR were the influencing factors of CSS (P=0.02, 0.03, 0.001). Multivariate analysis demonstrated that dNLR was an independent prognostic factor for OS and CSS (P=0.001, 0.001). Conclusions ES-NSCLC patients treated with SABR can achieve favorable survival. The dNLR is an independent prognostic factor of OS and CSS, which can be considered in clinical application.     

Stereotactic body radiotherapy using a radiobiology-based regimen for stage I nonsmall cell lung cancer: a multicenter study

BACKGROUND:

The most common regimen of stereotactic body radiotherapy (SBRT) for stage I nonsmall cell lung cancer in Japan is 48 grays (Gy) in 4 fractions over 4 days. Radiobiologically, however, higher doses are necessary to control larger tumors, and interfraction intervals should be >24 hours to take advantage of reoxygenation. In this study, the authors tested the following regimen: For tumors that measured <1.5 cm, 1.5 to 3.0 cm, and >3.0 cm in greatest dimension, radiation doses of 44 Gy, 48 Gy, and 52 Gy, respectively, were given in 4 fractions with interfraction intervals of ≥3 days.

METHODS:

Among 180 patients with histologically proven disease who entered the study, 120 were medically inoperable, and 60 were operable. The median patient age was 77 years (range, 29‐92 years). SBRT was performed with 6‐megavolt photons using 4 noncoplanar beams and 3 coplanar beams. Isocenter doses of 44 Gy, 48 Gy, and 52 Gy were received by 4 patients, 124 patients, and 52 patients, respectively.

RESULTS:

The overall survival rate for all 180 patients was 69% at 3 years and 52% at 5 years. The 3‐year survival rate was 74% for operable patients and 59% for medically inoperable patients (P = .080). The 3‐year local control rate was 86% for tumors ≤3 cm (44/48 Gy) and 73% for tumors >3 cm (52 Gy; P = .050). Grade ≥2 radiation pneumonitis developed in 13% of patients (10% of the 44‐Gy/48‐Gy group and 21% of the 52‐Gy group; P = .056). All other grade 2 toxicities developed in <4% of patients.

CONCLUSIONS:

The SBRT protocol used in this study yielded reasonable local control and overall survival rates and acceptable toxicity. Dose escalation is being investigated. Cancer 2012;. © 2011 American Cancer Society.     

GOECP/SEOR clinical recommendations for lung cancer radiotherapy during the COVID-19 pandemic

The coronavirus disease 2019 crisis has had a major and highly complex impact on the clinical practice of radiation oncology worldwide. Spain is one of the countries hardest hit by the virus, with devastating consequences. There is an urgent need to share experiences and offer guidance on decision-making with regard to the indications and standards for radiation therapy in the treatment of lung cancer. In the present article, the Oncological Group for the Study of Lung Cancer of the Spanish Society of Radiation Oncology reviews the literature and establishes a series of consensus-based recommendations for the treatment of patients with lung cancer in different clinical scenarios during the present pandemic.     

Early metabolic response evaluation after stereotactic radiotherapy for lung cancer: pilot experience with 18F-fluorodeoxyglucose positron emission tomography-computed tomography

The early response of lung tumours to stereotactic radiotherapy was prospectively evaluated with 18F-fluorodeoxyglucose positron emission tomography-computed tomography. Three months after treatment, the maximum standardised uptake value and the tumour diameter fell by 64 and 30%, respectively. This imaging strategy therefore remains under ongoing evaluation with the aim of identifying predictive and prognostic factors.     

立体定向放疗用于结直肠癌肝与肺寡转移的研究进展

寡转移是肿瘤从局部区域病变进展到远处广泛转移过程中存在的一种中间状态,通过局部治疗有获得长期生存的可能。体部立体定向放疗(SBRT)单次剂量高、分割次数少,是一种高精准的局部消融治疗手段。结直肠癌有近一半患者会发生转移,主要转移部位为肝和肺。本文主要阐述SBRT治疗结直肠癌肝、肺寡转移灶的安全性、近期疗效及其影响因素,同时也总结了SBRT具体实施的要点。SBRT在严格的呼吸运动管理和放疗质控下是治疗结直肠癌寡转移的有效手段。     

Stereotactic body radiation therapy for early-stage non-small-cell lung cancer: the Japanese experience

Stereotactic body radiation therapy is a new treatment modality for early-stage non-small-cell lung cancer, and is being intensively investigated in the United States, the European Union, and Japan. We started a feasibility study of this therapy in July 1998, using a stereotactic body frame. The eligibility criteria for primary lung cancer were: (1) solitary tumor less than 4cm; (2) inoperable, or the patient refused operation; (3) histologically confirmed malignancy; (4) no necessity for oxygen support; (5) performance status equal to or less than 2, and (6) the tumor was not close to the spinal cord. A total dose of 48Gy was delivered in four fractions in 2 weeks in most patients. Lung toxicity was minimal. No grade II toxicities for spinal cord, bronchus, pulmonary artery, or esophagus were observed. Overall survival for 29 patients with stage IA, and 14 patients with stage IB disease was 87 % and 80 %, respectively. No local recurrence was observed in a follow-up of 3–50 months. Regional lymph node recurrence developed in 1 patient, and distant metastases developed in 4 patients. We retrospectively analyzed 241 patients from 13 Japanese institutions. The local recurrence rate was 20% when the biological equivalent dose (BED) was less than 100Gy, and 6.5% when the BED was over 100Gy. Overall survival at 3 years was 42% when the BED was less than 100Gy, and 46% when it was over 100Gy. In tumors which received a BED of more than 100Gy, overall survival at 3 years was 91% for operable patients, and 50% for inoperable patients. Long-term results, in terms of local control, regional recurrence, survival, and complications, are not yet evaluated. However, this treatment modality is highly expected to be a standard treatment for inoperable patients, and it may be an alternative to lobectomy for operative patients. A prospective trial, which is now ongoing, will, answer these questions.Presentation made at the ASCO-JSCO Joint Symposium in Sapporo, Japan, on October 22, 2003.