Treatment completion,treatment compliance and outcomes of old and very old patients treated by dose adapted stereotactic ablative radiotherapy (SABR) for T1-T3N0M0 non-small cell lung cancer

AimThis is a retrospective single-institution review of the treatment completion and clinical outcomes of patients aged 75 and older, treated with stereotactic ablative body radiotherapy (SABR) for T1-T3 N0 M0 non-small cell lung cancer (NSCLC).Material. MethodsFrom April 2008 to September 2015, 200 patients, aged 75–93, received respiratory–managed, intensity-modulated-based SABR. Dose fractionation was risk-adapted and delivered in 2–3 weekly treatments. Treatment completion, local control, overall survival and treatment-related toxicities were evaluated.ResultsAll patients completed the prescribed SABR course. However, 29 patients required interruption of at least one fraction of SABR and optimization of pain control before continuation of the fraction. Median follow-up was 20.9 months. The median OS was 31.6 months with 1-,3-year survival rates of 80.7%, and 44.4% respectively. Local control at 1- and 3- years were 97.6%, 83.5% respectively.Treatment was well-tolerated. However, there were two (1%) G5 (fatal) toxicities: one acute sudden dyspnoea of unknown cause and one late SABR-related haemoptysis. No statistically significant differences in outcomes/toxicities were observed between old (75–84 years old) and very old patients (>85 years old).ConclusionsOld and very old patients can successfully complete SABR for NSCLC, with good local control, survival and acceptable toxicity. Old patients might require increased supportive care for successful treatment delivery.     

Radiothérapie stéréotaxique (RTST) pulmonaire des tumeurs de moins de 3 cm (stade I) et 5 cm (stade II) non opérées : 10 ans d’expérience de l’Institut du Cancer de Montpellier (ICM)

PurposeSearch for predictive factors on survival and local control for less than 3 centimeters (cm) (stage I) and 5 cm (stage II) inoperable lung tumors treated by Stereotactic Body Radiation Therapy (SBRT) in a retrospective monocentric study from Montpellier Cancer Institute (ICM)Patients and methodEvery patients treated at ICM for a stage I or II inoperable lung tumors from 2009 to 2019 were analyzed.ResultsOne hundred and seventy nine lesions were treated in 176 patients, with a major part (82,7%) in operated due to chronic obstructive pulmonary disease. Median overall survival for all patients was 71,7 months with a 35 months follow-up and the 2 years loco-regional free survival was 94,0 months. Better associated outcomes were stage I (median overall survival 71,7 versus 29,0 months P = 0,004 ; HR = 2,37 P = 0,005), BED ≥ 150 Gy (median time-to-progression not reached versus 76,7 months P = 0,025), small size of Planning Target Volume (PTV) (HR = 0,42 P = 0,032 when PTV < 15,6 cc). 7,3% of all patients developed radiation pneumonitis.ConclusionSBRT is associated with an excellent overall survival and a high rate of local control for less than 3 cm (stage I) and 5 cm (stage II) lung tumors but a low rate of toxicities. For these patients with many comorbidities, BED over 150 Gy seems to be associated with a better loco-regional free survival, while cause of death is often other than lung cancer.     

Stereotactic Radiosurgery (SRS) with Volumetric Modulated Arc Therapy (VMAT): Interim Results of a Multi-arm Phase I Trial (DESTROY-2)

AimsTo present the interim results of a phase I trial on stereotactic radiosurgery (SRS) delivered using volumetric modulated arc therapy (VMAT) in patients with primary or metastatic tumours in different extracranial sites.Materials and methodsPatients were enrolled in different arms according to tumour site and clinical stage, and sequentially assigned to a given dose level. Acute toxicity, tumour response and early local control were investigated and reported.ResultsOne hundred lesions in 65 consecutive patients (male/female: 30/35, median age: 66 years; range: 40–89) were treated. Of these 100 lesions, 21 were primary or metastatic lung tumours, 24 were liver metastases, 30 were bone metastases, 24 were nodal metastases and one was a primary vulvar melanoma. The prescribed dose ranged from 12 (BED_2Gy,α/β:10 = 26.4 Gy) to 28 Gy (BED_2Gy,α/β:10 = 106.4 Gy) to the planning target volume. Twenty-one patients (32.3%) experienced grade 1–2 acute toxicity, which was grade 2 in only two cases. The overall response rate based on computed tomography/magnetic resonance imaging was 52% (95% confidence interval 40.1–63.2%) and based on positron emission tomography scan was 90% (95% confidence interval 76.2–96.4%). As of November 2013, the median duration of follow-up was 11 months (range = 1–38). Recurrence/progression within the SRS-VMAT treated field was observed in nine patients (total lesions = 18): the inside SRS-VMAT field local control expressed on a per lesion basis was 87.8% at 12 months and 71.9% at 24 months.ConclusionsThe maximum tolerable dose has not yet been reached in any study arm. SRS-VMAT resulted in positive early clinical results in terms of tumour response, local control rate and acute toxicity.     

Prostate Stereotactic Body Radiotherapy — First UK Experience

AimsStereotactic body radiotherapy (SBRT) combines image-guided radiotherapy with hypofractionation, both of which will probably result in improvements in patient outcomes in prostate cancer. Most clinical experience with this technique resides in North America. Here we present the first UK cohort to receive SBRT for prostate cancer.Materials and methodsFifty-one prostate cancer patients (10 low risk, 35 intermediate risk and 6 high risk) were treated with 36.25 Gy in five fractions over 1–2 weeks and gold seed image guidance. All patients had toxicity International Prostate Symptom score (IPSS) and Radiation Therapy Oncology Group recorded prospectively and prostate-specific antigen was measured 3–6 monthly during follow-up.ResultsThe median IPSS was 6, 11, 8 and 5 at baseline, 1–3 weeks, 4–6 weeks and 7–12 weeks after treatment. Radiation Therapy Oncology Group genitourinary and gastrointestinal toxicity of grade 2 was seen in 22% and 14%, respectively, at 1–3 weeks after treatment; no patient had grade 3+ toxicity at this time point, although two patients had grade 3 urinary frequency recorded during treatment. The median follow-up for the 42 patients who did not receive androgen deprivation was 14.5 months. Prostate-specific antigen at 13–18 months after treatment was 1.3 ng/ml.ConclusionProstate SBRT is a promising treatment for organ-confined prostate cancer and is currently being investigated in a UK-led phase III trial.     

A phase I trial of stereotactic body radiation therapy (SBRT) for liver metastases

PURPOSE: To determine the maximum tolerated dose (MTD) of stereotactic body radiation therapy (SBRT) for liver metastases. METHODS AND MATERIALS: A multicenter Phase I clinical trial was conducted. Eligible patients had one to three liver metastases, tumor diameter <6 cm, and adequate liver function. The first cohort received 36 Gy to the planning target volume (PTV) in three fractions (F). Subsequent cohorts received higher doses up to a chosen maximum of 60 Gy/3F. At least 700 mL of normal liver had to receive a total dose <15 Gy. Dose-limiting toxicity (DLT) included acute Grade 3 liver or intestinal toxicity or any acute Grade 4 toxicity. The MTD was exceeded if 2/6 patients in a cohort experienced DLT. RESULTS: Eighteen patients were enrolled (10 male, 8 female): median age, 55 years (range, 26-83 years); most common primary site, colorectal (6 patients); median aggregate gross tumor volume, 18 ml (range, 3-98 ml). Four patients had multiple tumors. No patient experienced a DLT, and dose was escalated to 60 Gy/3F without reaching MTD. CONCLUSIONS: Biologically potent doses of SBRT are well tolerated in patients with limited liver metastases. Results of this study form the basis for an ongoing Phase II SBRT study of 60 Gy over three fractions for liver metastases.     

Salvage thoracic surgery in patients with primary lung cancer

Background

Patients with advanced non-small cell lung cancer (NSCLC) continue to have a poor prognosis. The majority of patients are not indicated for surgery for a radical cure, and systemic chemotherapy is the mainstay of treatment. However, long-term survival is rare due to the resistance to therapy. On the other hand, surgery is performed only under certain conditions for colon cancer and esophageal cancer. Few reports are available about salvage thoracic surgery in patients with primary lung cancer. The purpose of this study was to show the outcomes of salvage surgery for lung cancer, and we discuss possible future treatment strategies based on our findings.

Methods

Three hundred and fifty-two patients with primary lung cancer underwent surgical resection, and we evaluated those who underwent salvage operations. We also examined the relationships between the performance of a salvage operation and the clinicopathological characteristics of the patients. The clinical outcomes of salvage surgery for lung cancer were assessed.

Results

Salvage thoracic operations were performed in eight (2.3%) of the 352 patients. The surgical procedures were lobectomy in four patients, segmentectomy in two, and pneumonectomy and wedge resection were each performed in one patient. There was no postoperative mortality. All patients were alive at the time of the analysis. The mean follow-up period for the salvage operation cases was 14.0 months. No significant correlation was identified between the incidence of salvage surgery and the age, gender, histology, postoperative stay or hospital stay. The incidence of advanced stage disease was higher in the salvage cases than in the overall cases.

Conclusions

Salvage thoracic surgery was possible, and moderately improved the prognosis, without prolongation of the postoperative stay or hospital stay. A salvage operation might be considered a reasonable and proper treatment for carefully selected patients.     

Comparison of Single- and Three-fraction Schedules of Stereotactic Body Radiation Therapy for Peripheral Early-stage Non–Small-cell Lung Cancer

Background

To compare the clinical outcomes of patients with early-stage non–small-cell lung cancer (NSCLC) who had undergone either single-fraction (SF) or three-fraction (TF) stereotactic body radiation therapy (SBRT) at a single institution during over 8-year period.