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S.K. Vinod
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MO17 - Radiotherapy I: Stereotactic Ablative Body Radiotherapy (ID 106)
- Event: WCLC 2013
- Type: Mini Oral Abstract Session
- Track: Radiation Oncology + Radiotherapy
- Presentations: 12
- Moderators:M. Zwitter, S.K. Vinod
- Coordinates: 10/29/2013, 16:15 - 17:45, Bayside 204 A+B, Level 2
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MO17.01 - Response assessment of Stereotactic Ablative Body Radiotherapy (SABR) for pulmonary metastases: utility of 4D-FDG-PET and CT perfusion (ID 2225)
16:15 - 16:20 | Author(s): S. Siva, R. Hicks, B. Sawyer, E. Pun, B. Chesson, M. Samuel, G. Wright, P. Antippa, J. Callahan, T. Kron, M. Macmanus, D. Ball
- Abstract
- Presentation
Background
Response assessment using conventional RECIST criteria after SABR of lung targets can be confounded by fibrotic response. The purpose of this study was to evaluate the utility of 4D-FDG-PET/CT and CT perfusion scans in the response assessment of single fraction SABR for inoperable pulmonary oligometastases.Methods
This is a prospective ethics approved clinical study of patients undergoing single fraction SABR with 26Gy for pulmonary metastases. Eligible patients had 1-2 metastases with no extrathoracic disease on staging FDG-PET. Serial 3D / 4D-FDG-PET and CT perfusion studies were performed at baseline, 14 days and 70 days after therapy. Two radiologists independently reported CT perfusion scans.Results
At a median follow-up of 16 months (range 3-27), 10 patients with 13 metastases received SABR. A further 7 patients (41%) were screened from the study due to interval progression of disease between the time of the original FDG-PET and trial 4D-FDG-PET / perfusion CT. The mean time between the original FDG-PET and trial scans was 62 days. No patient progressed locally, 7/10 patients progressed distantly of which 2/7 received subsequent SABR. At the end of study period, 5/10 patients are alive without disease. The median progression free survival was 14 months. The change in SUVmax from baseline was higher on 3D than 4D-PET by a mean of 20.6% (range 0.2%-47.2%) at 14 days and 14.8% (range 0-37.8%) at 70 days. Overall, the SUVmax increased at 14 days (mean 104.9%, p<0.01) and decreased at 70 days (mean=55.5%, p<0.01), despite persistent morphological lesions on the concurrent late timepoint CT. There was strong level of inter-observer agreement of CT perfusion interpretation with a median intraclass correlation coefficient of 89% (range 57%-98%). Perfusion parameters of Time to Peak Blood Flow and Blood Volume showed a median increase of 18.8% and 23.0% at 2 weeks post-therapy and decreased below baseline by a median 7.0% and 14.0% at 70 days (non-significant).Conclusion
High rates of interval progression between staging scans indicates a need to expedite management of oligometastases in a timely fashion. Increased tumour perfusion and FDG-PET intensity at 2 weeks post-RT is likely due to an inflammatory response to large single dose SABR. Late PET response was associated with tumour control despite CT apparent morphological lesions. Conventional 3D PET may overestimate change in PET intensity post SABR as compared to 4D PET. These findings, in particular CT perfusion findings, require a larger patient cohort for validation.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.02 - Radical Radiotherapy for Non-small Cell Lung Cancer - is it the end for 2 Gray per fraction? (ID 2247)
16:20 - 16:25 | Author(s): N. O'Rourke
- Abstract
- Presentation
Background
The standard of care worldwide for radiation dose scheduling in NSCLC has historically been 2Gy per fraction treating once daily over six weeks. The CHART regimen of accelerated hyperfractionated treatment first demonstrated significant survival benefit from a two week radical course, attributed to reduced repopulation and improved local control. A recent individual patient data meta-analysis confirms significant survival benefit from accelerated radiotherapy[1]. Meantime the evolving data on stereotactic radiotherapy treating early stage lung cancer over two weeks or less suggests marked improvement in local control rates compared with historical populations treated with conventional fractionation[2]. The latest challenge to 2Gy per fraction comes from the early stop to the dose escalation arm of RTOG 0617 with 74Gy actually appearing inferior to the 60Gy arm. We postulate that overall treatment time is a key factor in lung cancer radiotherapy outcomes and that standards of care need to be reviewed. This paper examines the current international guidelines on radical radiotherapy schedules, evaluates the supporting evidence and proposes new priorities for research.Methods
Five international guidelines on the management of lung cancer were reviewed. All were published 2010-2013: ESMO Clinical Practice Guideline on early stage and locally advanced lung cancer 2010, NICE guideline (England and Wales) 2011, Australian Government Clinical Practice Guideline for treatment of lung cancer 2012, Cancer Care Ontario evidence based series lung cancer guideline 2013, National Comprehensive Cancer Network (NCCN) Lung Cancer guideline v2.2013. Recommendations on radical radiotherapy dose and fractionation for NSCLC were collated from each guideline together with the references cited in support of these recommendations to assess levels of evidence.Results
Two guidelines specifically recommended hypofractionated SBRT for early stage inoperable disease -NICE and NCCN. The Australian guideline stated uncertainty over relative benefit SBRT versus conventional fractionation in stage I disease. England, Ontario and Australia all included CHART regimen as treatment of choice for stage II/III radical patients not receiving chemotherapy. Cancer Care Ontario undertook specific review of altered fractionation schedules identifying lack of evidence for hyperfractionation but suggesting possible benefit for hypofractionation. All five guidelines specified standard care, if given with chemotherapy, of conventional fraction size 2Gy: Ontario, ESMO and Australian guidance was a minimum of 60Gy in 30 fractions. NCCN offered a range of 60-74Gy at 2Gy/fraction. NICE alone proposed alternative standard of 55Gy in 20 fractions, a common UK schedule, or the option of 64-66Gy at 2Gy/fractionConclusion
International guidelines lag behind the emerging evidence for lack of benefit from dose escalation at 2Gy/fraction and apparent benefit from shorter treatment courses . We propose that accelerating treatment with hypofractionation and shorter overall treatment times should be the priority for radiotherapy development. We discuss current and pending trials examining this approach. 1. Mauguen A, Le Pechoux C, Saunders M et al: Hyperfractionated or accelerated radiotherapy in lung cancer: an individual patient data meta-analysis. J Clin Oncol 30:2788-2797, 2012 2. Timmerman R, Paulus R, Gavin J et al: Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA 303:1070-1076, 2010Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.03 - Incidental Prophylactic Nodal Irradiation and Patterns of Nodal Relapse in Inoperable Early Stage NSCLC Patients Treated with SBRT: A Case-Matched Analysis (ID 2024)
16:25 - 16:30 | Author(s): L. Lao, A. Hope, A. Brade, A. Bezjak, E.P. Saibishkumar, M. Giuliani, A. Sun, B.C.J. Cho
- Abstract
- Presentation
Background
Reported non-small cell lung cancer (NSCLC) nodal failure rates following stereotactic body radiotherapy (SBRT) are lower than those reported in the surgical series when matched for stage. We hypothesize that this effect is due to incidental prophylactic nodal irradiation.Methods
A prospectively collected group of medically inoperable early stage NSCLC patients (n=179) from 2004 to 2010 was used to identify a patient cohort with nodal relapses (n=19). These cases were matched, 1:2, to controls, controlling for tumour volume (i.e. same or greater) and tumour location (i.e. same lobe). Reference (normalized total) point doses at the ipsilateral hilum and carina, demographic data, and clinical outcomes were extracted from the medical record. Multivariate logistical regression analyses determined variables of interest.Results
The case and control cohorts were well matched with respect to age, sex, method of nodal staging, SUVmax, histology subtype, dose and length of follow up.. The controls, as expected, had larger gross tumour volumes (p=0.02). The mean hilar doses were 9.6 and 22.4 Gy for cases and controls, respectively (p=0.014). Similarly, the mean carinal doses were 7.0 and 9.2 Gy, respectively (p=0.13). The mean ipsilateral hilar doses were 19.8 and 3.6 Gy for ipsilateral non-hilar and hilar nodal relapses, respectively (p=0.01). The conditional density plot appears to demonstrate an inverse dose-effect relationship between ipsilateral hilar normalized total dose and risk of ipsilateral hilar relapse (Figure 1).Figure 1Conclusion
Incidental hilar dose greater than 20 Gy (normalized to 2Gy/fraction) appears to be correlated with lack of hilar relapses in inoperable early stage NSCLC patients treated with SBRT.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.04 - Endobronchial Fiducial Marker Safety and Stability (ID 696)
16:30 - 16:35 | Author(s): D.A. Nader
- Abstract
- Presentation
Background
Fiducial markers enable lesion tracking and localization with radiosurgery. Complications with percutaneous insertion are very common with pneumothorax rate reported as high as 67%, chest tube insertion 22% and migration of marker 19%. The purpose of this study was to assess complications associated with the bronchoscopic placement of a new commercial fiducial marker, designed for bronchoscopic insertion and to reduce migration. Twenty-one consecutive patients are reviewed in which 60 Cobra® (SuperDimension) fiducial markers were placed using electromagnetic navigational bronchoscopy. Accuracy of placement, utility of each marker, complications and migration are reported.Methods
The use of these markers was approved by a advisory committee at our institution. Records of 21 consecutive patients (12 men, 9 women; mean age 61) referred to the Interventional Pulmonary Division for fiducial marker placement before initiation of cyber knife radiosurgery (Accuray, Sunnyvale CA) between December 15, 2012 and June 15, 2013. Indications for radiosurgery included non-surgical patients with nonsmall cell lung cancer and metatatic disease to the lungs from colorectal carcinoma and renal cell carcinoma. Our institution's radiation oncologist requested between one and three fiducials placed within or adjacent to each lesion. A total of 60 Cobra® fiducial markers were placed. In each insertion procedure, a computerized tomogram of the chest was used to preplan ideal insertion site and fiducial location in relation to tumor mass. Bronchoscopy was performed, using the SuperDimension planning and navigation, 1 to 3 Cobra® fiducial markers were placed in proximity to 22 different tumors.Results
There were no instances of pneumothorax, with patient followup to one week. There no instances of fiducial migration greater than 3 mm from insertion site. There were 7 episodes of post procedure events, which included cough, dyspnea and hypoxemia. All events resolved prior to patient discharge from the outpatient treatment area. Imaging included chest radiograph, post procedure, on same day and CT chest within 1 week of procedure.Conclusion
In this limited series, the Cobra® fiducial marker, using bronchoscopy and SuperDimension planning and navigation resulted in no instances of pneumothorax and no significant fiducial migration. This contrasts many reports of percutaneous fiducial placements regarding complications and migration.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.05 - Recurrence, Survival, and Toxicity after Stereotactic Lung Radiotherapy (SBRT) for Central versus Peripheral Stage I Non-Small Cell Lung Cancer (NSCLC): Results from an International Collaborative Research Group (ID 3436)
16:35 - 16:40 | Author(s): I.S. Grills, V.S. Mangona, A. Hope, J. Belderbos, M. Werner-Wasik, J.J. Sonke, J. Bissonette, D. Ionascu, Y. Xiao, A. Toussaint, M. Guckenberger
- Abstract
- Presentation
Background
SBRT is an accepted safe and effective treatment modality for peripheral (P) stage I NSCLC tumors. Concern of excessive toxicity, however, limits its use for central (C) tumors. This study evaluates outcomes and toxicities after cone-beam CT (CBCT) image-guided SBRT for central vs. peripheral NSCLC.Methods
959 lung tumors were treated with lung SBRT from 1998-2012 at five international centers participating in the Elekta Collaborative Lung Research Group; 98% underwent online CBCT IGRT. 100 cases were classified as Central (C) and 869 Peripheral (P), defined as ≤2cm vs. >2cm from the proximal bronchial tree, respectively. Staging included chest CT and routine chemistry for all; 93% had PET staging (mean time PET to SBRT 6.4 weeks); 6% had mediastinal sampling (mediastinoscopy or endobronchial ultrasound). 61% had tumor biopsy (84% C vs. 59% P, p<0.001). 89% were medically inoperable with mean baseline FEV1 of 1.6L (63% of predicted) and mean baseline DLCO of 12.1 ml/min/mmHg (56% of predicted). Mean age was 74y (42-93) with a large range in ECOG performance status (27%; 47%; 23%; 26% for 0-3, respectively). Clinical stage was T1aN0 44%, T1bN0 30%, T2aN0 23%, T2bN0 32%. Mean tumor maximum dimension was 2.5cm (range 0.5-8.5cm); C tumors were larger (mean 3.lcm vs. 2.4 cm, p<0.001). Mean SBRT prescription dose was 51.5±6.4 Gy, with mean dose per fraction of 14.5±4.0 Gy in 3.9±1.5 fractions. Mean biological equivalent dose (BED) was 126.6±26.6 Gy, higher for P vs. C tumors (129.2 vs. 104.0 Gy, p<0.001. Chemotherapy was administered more for C (9%) than P tumors (2%), p<0.001. Groups were compared with t-test & chi-square. Competing risks analyses were used, accounting for the competing risk of death.Results
Mean follow-up for all cases was 1.8y (0.1-7.7y; mean potential follow-up 3.4y), similar for C&P. C tumors had higher Local Failure (LF) (3y-LF 16.2%C vs. 5.9%P; 5y-LF 20.4%C vs. 8.3%P, p<0.001), similar regional nodal recurrences (RR) (3y-RR 12%C vs.12%P, p=0.69) and distant metastases (DM) (3y-DM 19%C vs 20%P, p=0.75), lower cause-specific survival (CSS) (3yr-CSS 75%C vs. 88%P, p<0.001), but similar overall survival (OS) (3y-OS 50%C vs. 51%P, p=0.70). Grade > 2 pneumonitis was higher for C tumors (8%C vs. 1%P, p<0.001). Incidence of grade 3 pneumonitis, chest wall pain/myositis, rib fracture, and skin dermatitis were rare (0.8%, 0.5%, 0.4%, 0.6% respectively for all) with no differences between C&P. No grade 4 toxicities were noted, though 2 cases (1C & 1P) of fatal pneumonitis were potentially attributable to SBRT. On multivariate analysis, BED (HR:0.975, p<0.001) predicted CSS, and both BED (HR:0.978, p=0.002) and baseline SUVmax (HR:1.04, p=0.001) predicted LF. Weeks from PET-staging until SBRT (HR:1.25, p=0.004) and the percent of lungs receiving >20 Gy (HR:1.063, p=0.001) were the strongest independent predictors of OS.Conclusion
In this large data set, pneumonitis was higher for central tumors, but both central & peripheral SBRT were safe with similar overall and cause-specific survival. LF was higher for central tumors, which were larger, had higher baseline SUVmax, and received lower dose. Results of the ongoing RTOG 0813 dose-finding study for central tumors are awaited.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.06 - DISCUSSANT (ID 3933)
16:40 - 16:55 | Author(s): M. Hatton
- Abstract
- Presentation
Abstract not provided
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MO17.07 - The cost of stereotactic body radiotherapy in early-stage lung cancer: a multicenter cost-calculation. (ID 1772)
16:55 - 17:00 | Author(s): Y. Lievens, C. Obyn, A. Mertens, D. Van Halewyck, H. Engels, F. Hulstaert
- Abstract
- Presentation
Background
In the framework of a coverage with evidence development program on innovative radiotherapy techniques in Belgium, the cost of stereotactic body radiotherapy (SBRT) was calculated and compared to the cost of more standardized 3D-conformal (3D-CRT) and intensity-modulated (IMRT) radiotherapy treatments.Methods
Activity-Based Costing methodology was used to calculate resource costs of radiotherapy treatments delivered in ten operational Belgian departments. Cost inputs were defined as personnel costs (number of full-time equivalents (FTE) devoted to the actual radiotherapy process times reference wages according to the guidelines of the Belgian Health Care Knowledge Centre (KCE)), equipment costs (including maintenance and upgrade) and specific material costs. Following KCE guidelines, overhead was accounted at 56% of global costs excluding physician wages. The activities in scope comprised all activities performed during the radiotherapy process from the first consultation, over treatment preparation, delivery and quality assurance until completion of the treatment. Products included all radiotherapy treatments delivered in each specific department and combined indication with treatment site and technical complexity. In view of the comparative analysis, products were aggregated into larger categories.Results
The average cost of all SBRT treatments was calculated at 6,221€ (range 3,104€ - 12,649€) and compared favorably to the average cost of standard fractionated 3D-CRT (5,919€, range 4,557€ - 6,564€) and IMRT (7,379€, range 5,054€ - 8,733€). The average cost of hypofractionated 3D-CRT and IMRT was lower (3,993€ res. 4,730€). Apart from differences in investment costs, the relatively larger variability in fraction number and in time requirements for individual personnel types performing the radiotherapy activities explain the larger spread in treatment cost of SBRT compared to more standardized radiotherapy treatments. The figure demonstrates these differences for various technical SBRT solutions and for different 3D-CRT and IMRT fractionation schedules. The overall averages are shown by the bars, minimum and maximum center averages by the error bars. The number of centers is mentioned between brackets. Activity times shown combine time per personnel with number of FTE. Figure 1Conclusion
Cost calculation of radiotherapy treatments at the multi-institutional level using Activity-Based Costing is feasible. SBRT shows larger variation in cost than more standardized radiotherapy approaches in line with the larger variability in technical solutions, time requirements and resource consumption. Its average cost however does not exceed the average cost of standard curative radiotherapy. Careful interpretation of these variables within the applicable economic context is required when using such cost data for determining financing levels.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.08 - TCP modeling in Stereotactic Body Radiotherapy for early stage non small cell lung cancer: is a dose-volume effect present? (ID 2205)
17:00 - 17:05 | Author(s): H. Peulen, J. Belderbos, I. Grills, A. Hope, M. Guckenberger, M. Werner-Wasik, V.S. Mangona, Y. Xiao, A. Toussaint, D. Ionascu, J. Bissonnette, J.J. Sonke
- Abstract
- Presentation
Background
In early stage non-small cell lung cancer (NSCLC) stereotactic body radiotherapy (SBRT) has become standard of care for inoperable patients. Tumor size >3cm was reported to be a predictor of local recurrence (LR), suggesting a dose-volume effect. Recently, the dose effect relation was questioned[1]. We used a Tumor-Control-Probability (TCP) model on a large pooled multi-center cohort to test this.Methods
850 patients were analyzed from our five institutes. Patients received a 4D CT-scan and plans were inversely optimized using advanced dose calculation algorithms. Treatment was delivered using online cone-beam CT guidance. Immobilization, margins, dose prescription and treatment planning was performed according to institute specific protocols. Median tumor diameter was 2.2 cm (range:0.7-8.0), median prescribed dose was 54 Gy (range:18-64) and median number of fractions were 3 (range:1-10). LRs were either biopsy proven or defined as a FDG-PET positive growing mass on CT-scan. The Web-Nahum TCP-model[2] was fitted to LR-data using maximum-likelihood estimation by optimizing its parameters: α representing the population-average radio-sensitivity, σ~α~ representing the population-variation in α and ρ the clonogen density. Input variables were the patient specific Gross Tumor Volume (estimated from the tumor diameter), for the dosimetric parameter PTV-D~min~, D~max~, D~mean~, D~1~, D~99~ were evaluated after conversion to Biological-Effective-Dose (BED) using the LQ-model with α/β=10Gy. We tested the optimized TCP model against a random model in which TCP was fixed independent of dose and volume. The optimal model was selected based on the Akaike-Information-Criterion (AIC).Results
After a median follow up (FU) of 17 months (range:0-93), 43 LRs (5%) were diagnosed at 14 months FU (range:2-56), of which 25 tumors were biopsy proven and 18 recurrences diagnosed on PET-CT. The PTV-BED~mean~ based TCP model showed the best fit with parameters α=0.43Gy[-1] (CI:0.33–0.75) and σ~α~=0.17 Gy[-1] (CI:0.11–0.37). The model-fit was insensitive to ρ and set to literature values: 10[7]/cm[3]. The AIC of the optimal model was 12 units higher than the random model indicating a clear dose-volume-effect. At high PTV~mean~-BEDs, however, the volume effect is modest. Additionally, the AIC of the BED corrected model was 9.4 units higher than the BED uncorrected model. Figure 1Conclusion
A dose-volume-effect relation in SBRT for early stage NSCLC for local control was derived in a large cohort of patients. This dose-effect relation requires validation in independent datasets and prospective trials. 1.van Baardwijk,Rad.Onc.,2012. 2.Web&Nahum,PMB,1993.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.09 - Dosimetric Predictors of Esophageal Toxicity after Stereotactic Body Radiotherapy for Central Lung Tumors (ID 1674)
17:05 - 17:10 | Author(s): A. Modh, E. Williams, A. Rimner, A. Foster, E. Yorke, A. Jackson, A.J. Wu
- Abstract
- Presentation
Background
Stereotactic body radiotherapy (SBRT) is an effective treatment for early-stage non-small cell lung cancer (NSCLC) and lung metastases. However, increased toxicity has been observed for SBRT to lesions near the proximal airways or mediastinal structures. Reported toxicities have primarily pertained to pulmonary complications, but little is known about the risk for esophageal toxicity. Therefore, we sought to evaluate dosimetric predictors of esophageal toxicity in this patient cohort at our institution.Methods
We identified 125 patients who received SBRT for single lung tumors within 2 cm of the proximal bronchial tree (n=81) or whose planning target volume (PTV) intersected mediastinal structures (n=44). Ninety-one patients had primary NSCLC, 12 had recurrent NSCLC, and 22 had metastatic tumors involving the lung. Patients with prior thoracic radiotherapy were excluded. Toxicity was scored using the Common Terminology Criteria for Adverse Events v.4.0. Biological equivalent doses (BED) were calculated using the linear quadratic formula with either α/β=3 or 10 Gy. Dose-volume histogram variables for the esophagus (D~v~, minimum dose to the hottest volume v and V~d~, volume receiving doses greater than d) were then examined for all patients and correlation with toxicity was assessed using logistic regression. Log rank tests were performed using median splits for variables that were significant in logistic regression.Results
With a median follow-up of 14.3 months, the overall rate of grade ≥2 esophageal toxicity was 12.8% (n=16), including two grade 3 events. The median prescription dose was 45Gy. The most common fractionation schemes were 45Gy in 5 fractions (n=56), 48Gy in 4 fractions (n=21), or 50Gy in 5 fractions (n=14). Highly significant logistic models were generated on the basis of D~3.5cc~, D~5cc~, and D~max ~(p<0.001). For a complication rate < 20%, D~3.5cc~ ≤ 29.4 Gy~10~, D~5cc~ ≤ 25.4 Gy~10~, and D~max~ ≤ 50.1 Gy~10~ was observed based on these models (BED~10~). Log rank tests showed that at 2 years, the probability of complication of those with a BED~10~ D~3.5cc~ > 16.6 Gy was 25% (p<0.001), D~5cc~ > 15.1 Gy was 26% (p<0.001), and a D~max~ > 29.6 Gy was 21% (p=0.032). The probability of complication for those with a D~3.5cc~, D~5cc~, and D~max~ (BED~10~) less than or equal to the above limits were 2%, 2% and 7%, respectively. The analysis was insensitive to α/β, and the same D~v~ variables were found to be significant using α/β =3.Conclusion
This is a novel quantitative analysis providing dose guidelines for significant esophagitis in the setting of SBRT. Dose to the hottest 3.5cc, 5cc and D~max~ were the best parameters for prediction of esophageal toxicity. Converting the BED~10~ limits to physical doses, D~3.5cc ~to the esophagus should be kept less than 18.3, 19.7 and 20.8 Gy for 3, 4, and 5 fractions, respectively, to keep the esophagitis rate < 20%. However, these guidelines must be weighed against clinical considerations and potential compromise of target coverage. This information will be valuable for treatment planning and identifying patients at risk for esophageal complications from SBRT.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.10 - Late radiologic change after stereotactic ablative radiotherapy for early stage lung cancer: A comparison between fixed-beam versus arc delivery techniques (ID 1405)
17:10 - 17:15 | Author(s): S. Senthi, M. Dahele, P.M. Van De Ven, B.J. Slotman, S. Senan
- Abstract
- Presentation
Background
Treatment-related radiologic change occurs commonly following stereotactic ablative radiotherapy (SABR) and often confound the interpretation of follow-up CT scans. SABR is frequently delivered using both fixed-beams and rotational-arcs, resulting in different dose distributions and it is unclear how this influences radiological change. We studied the morphology, timing and severity of radiologic change after both delivery techniques.Methods
Twenty-nine patients with early stage non-small cell lung cancer receiving SABR by arc delivery, without clinical evidence of local recurrence, and a follow-up of more than two years, were assessed using a published scoring system [Dahele M, JTO 2011]. Here, the morphology of acute (within six months) radiologic change was characterized between ‘patchy (less than 5 cm) ground glass opacity’, ‘patchy consolidation’, ‘diffuse (more than 5 cm) ground glass opacity’, or ‘diffuse consolidation’. The late (after 6 months) morphology was characterized between ‘scar-like’, ‘mass-like’ and ‘modified conventional’. Additionally the severity of radiologic change was scored as ‘pronounced’ (more than expected), ‘expected’, ‘mild’ (less than expected) and none. These outcomes were compared to 54 patients treated with SABR by fixed-beam delivery, who we previously assessed using the same scoring system.Results
Baseline characteristics of the arc and fixed-beam cohorts were well matched and respective median follow-ups were no different, 31.7 vs. 28.4 months (p=0.20). Patients treated by arc delivery trended towards being more likely to have any radiologic change (p=0.06). This was strongly time-dependent (p<0.001) and more pronounced early, as by two years radiologic changes were almost universally present irrespective of delivery technique. Figure 1 shows the morphology of these changes with time. Acute changes were not technique dependent (p=0.23). After six months, arc delivery resulted in a modified-conventional morphology throughout follow-up, while fixed-beam delivery resulted in an increasing probability of scar-like or mass-like morphologies. The predicted probabilities of a modified-conventional pattern following SABR by arc and fixed-beam delivery were 96.3% vs. 68.9% (p<0.001) respectively. Following arc delivery, radiologic changes were more likely to be scored as pronounced or expected (p=0.009) than mild or none, a finding that became more evident with longer follow-up (p=0.014). The predicted probability of pronounced or expected changes two years following arc or fixed-beam delivery was 83.1% and 26.2%, respectively. Figure 1Conclusion
Patterns of radiologic change more than six months post-SABR are influenced by delivery technique. Diagnostic algorithms used to differentiate suspected local recurrence and benign change should therefore consider the delivery technique used.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.11 - Stereotactic ablative radiotherapy (SABR) for centrally located early-stage or isolated parenchymal recurrences of non-small cell lung cancer (NSCLC): How to fly in a "no fly zone" (ID 1961)
17:15 - 17:20 | Author(s): J.Y. Chang, Q. Xu, Q. Li, N. Rebueno, P. Balter, D. Gomez, R. Komaki, R. Mehran, S.G. Swisher, J. Roth
- Abstract
- Presentation
Background
SABR has become a standard treatment option for medically inoperable, peripherally located early-stage NSCLC. However, using SABR for centrally located lesions remains challenging because of the potential for severe side effects. Here we sought to validate our previous experience with SABR (50 Gy in 4 fractions) for central lesions, including the dose-volume constraints, and explore a new regimen of 70 Gy in 10 fractions for cases in which dose-volume constraints cannot be met with the previous regimen.Methods
We used 4D-based, volumetric image-guided SABR to treat 101 patients with biopsy-proven and PET/CT-staged centrally located (within 2 cm of bronchial tree, trachea, major vessels, esophagus, heart, pericardium, brachial plexus or vertebral body) T1-2N0M0 tumors (n=82) or isolated lung-parenchyma recurrent lesions (n=19). The treatment period spanned February 2005 through May 2011; follow-up visits (every 3 months for 2 years and every 6 months for the next 3 years) included chest CT or PET/CT. Endpoints were toxicity (CTCAE v3.0), survival, local control, regional control, and distant metastasis.Results
At a median follow-up time of 30.3 months for all patients (40.5 months for those alive), median overall survival time was 56.5 months and 5-year overall survival rate was 49.0%. Three-year actuarial local, regional, and distant control rates were 96.5%, 87.2% and 77.3%. The most common toxicities were chest-wall pain (18% grade 1 and 13% grade 2) and radiation pneumonitis (10.9% grade 2 and 1.9% grade 3). No patient experienced grade 4 toxicity and one patient with tumor invading bronchial tree who received 70 Gy in 10 fractions died from hemoptysis 13 months after SABR. The distance between tumor and chest was associated with chest wall pain (≤1 cm 45% vs >1 cm 17%, p=0.002). Univariate and multivariate analyses showed that for the 82 patients receiving 50 Gy in 4 fractions, mean total lung dose (MLD) >5 Gy or ipsilateral lung V~20~ (iV~20~) >16% were independent predictors of radiation pneumonitis; 3 of 9 patients in that group with D~max~ to brachial plexus >35 Gy experienced brachial neuropathy versus none of the 73 patients with brachial D~max~ ≤ 35 Gy (p=0.001).Conclusion
SABR for centrally located lesions produces clinical outcomes similar to those for peripheral lesions when normal tissue constraints are respected. For 50 Gy in 4 fractions, we recommend MLD ≤5 Gy, lung iV~20~ ≤16%; bronchial tree D~max~ ≤ 38 Gy, V~35~ ≤1 cm[3]; major vessel D~max~≤ 56 Gy, V~40~≤1 cm[3]; esophageal D~max~ ≤35 Gy, V~30~≤1 cm[3 ]; brachial plexus D~max~ ≤35 Gy, V~30~≤0.2 cm[3] and spinal cord D~max~ <25 Gy. Giving 70 Gy in 10 fractions is another option for challenging cases but can produce severe toxicity if significant amounts of critical structures are exposed to ≥70 Gy. Proper selection of cases (based on tumor location and normal tissue constraints) and SABR regimens and volumetric image-guided delivery are all crucial to avoid overdosing critical structures. Typically, a minimum 5-10 mm distance between critical structures and gross tumor is required to meet dose-volume constraints.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MO17.12 - DISCUSSANT (ID 3934)
17:20 - 17:35 | Author(s): S. Yom
- Abstract
- Presentation
Abstract not provided
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O14 - Radiotherapy - Toxicity and Clinical Trials (ID 105)
- Event: WCLC 2013
- Type: Oral Abstract Session
- Track: Radiation Oncology + Radiotherapy
- Presentations: 8
- Moderators:G. Pratt, S.K. Vinod
- Coordinates: 10/29/2013, 10:30 - 12:00, Parkside Ballroom A, Level 1
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O14.01 - Memory preservation with conformal avoidance of the hippocampus during whole-brain radiotherapy for patients with brain metastases: Preliminary results of RTOG 0933 (ID 2262)
10:30 - 10:40 | Author(s): V. Gondi, M.P. Mehta, S. Pugh, W.A. Tome, B. Corn, C. Caine, A. Kanner, H. Rowley, V. Kundapur, J.N. Greenspoon, A.A. Konski, G.S. Bauman, W. Shi, V. Kavadi, L. Kachnic
- Abstract
- Presentation
Background
Preclinical and clinical evidence suggests that hippocampal dose during whole-brain radiotherapy (WBRT) plays a role in cognitive decline. This may be preventable by conformally avoiding the hippocampus during WBRT (HA-WBRT). RTOG 0933 was a single-arm phase II study of HA-WBRT for brain metastases with cognitive function assessments and pre-specified comparison to a historical control of WBRT without hippocampal avoidance.Methods
Eligible adult patients with brain metastases received HA-WBRT to 30 Gy in 10 fractions. Standardized cognitive function assessments were performed at baseline, 2, 4, and 6 months. The primary endpoint was change in the Hopkins Verbal Learning Test-Revised Delayed Recall (HVLT-DR) at 4 months. The historical control consisted of brain metastases patients treated with WBRT on the PCI-P-120-9801 phase III trial, which demonstrated a 30% mean relative loss in HVLT-DR from baseline to 4 months. To detect a minimum relative 50% improvement in this end-point, leading to an absolute 15% or less mean relative loss in HVLT-DR following HA-WBRT, 51 analyzable patients were required to ensure 80% statistical power with a one-sided alpha=0.05.Results
113 patients were accrued from April 2011-November 2012; 56 out of 100 eligible patients had non-small cell lung cancer (NSCLC). One grade 3 toxicity of cerebral edema and no grade 4 or higher toxicities were reported. Median survival was 6.9 months (95% confidence interval (95% CI) 4.8-15.2 months). 41 patients were analyzable at 4 months. Mean relative change in HVLT-DR from baseline to 4 months was +3.3% (95%CI: -8.0% to +14.6%), which was significant in comparison to the historical control (p<0.0001) and substantially exceeded the hypothesized -15% value. 28 patients were analyzable at 6 months with a mean relative change in HVLT-DR from baseline to 6 months of +4.6% (95%CI: -8.6% to +17.8%), a finding in dramatic contrast to expected continued deterioration in HVLT-DR scores from other WBRT trials. In terms of patients with NSCLC, 21 patients were analyzable at 4 months, with a mean relative change in HVLT-DR from baseline to 4 months of +10.0% (95%CI: -9.5% to +27.1%). At 6 months, 14 patients with NSCLC were analyzable, with a mean relative change in HVLT-DR from baseline to 6 months of 0.0% (95%CI: -18.5% to +18.5%).Conclusion
Conformal avoidance of the hippocampus during WBRT is associated with memory preservation at 4 and 6 months follow-up in NSCLC patients, who comprised the majority of accrued and analyzable patients on this trial. These promising phase II results warrant further validation in a phase III trial, currently under development in the RTOG.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O14.02 - Vertebral fractures in NSCLC patients treated with IMRT and concurrent chemotherapy (ID 1880)
10:40 - 10:50 | Author(s): W. Uyterlinde, C. Chen, J.J. Sonke, J. De Bois, J. Belderbos, M. Van Den Heuvel
- Abstract
- Presentation
Background
Purpose To report on the incidence of vertebral fractures in locally advanced NSCLC patients treated with intensity modulated radiation therapy (IMRT) and concurrent chemotherapy. The RT dose to the vertebra was analyzed for its association with fractures.Methods
Methods A total of 524 patients were treated between 2007 and 2011, with hypofractionated IMRT (66Gy/24fx) and concurrent daily low dose cisplatin. Planning and follow-up CT or MRI scans were retrospectively utilized to identify vertebral collapse by an experienced radiologist and a technician. Clinical and dosimetric parameters were retrospectively collected. Patients were excluded if they had no follow-up CT/MRI scan; had prior irradiation for thoracic or head and neck cancer; showed a vertebral fracture in the planning CT; or had vertebral collapse due to other causes. First, we reported the incidence of vertebral fractures. Afterwards, we analyzed the RT dose effect relationship using the maximum (Dmax) and mean (Dmean) dose to each vertebra. Dose-response was modeled using Cox model with patient as random effect. Data were analyzed using R, package “coxme”.Results
Results Three hundred and thirty six patients were eligible for analysis. The median follow-up was 24 months The median age was 64 years (range 32-87); 40% of the patients female and 94% had a performance score (PS) 0-1. Twenty-eight (8%) patients developed ≥ 1 vertebral fracture; 22 had 1 vertebral fracture, 5 had 2 and 1 patient had 3 vertebral fractures. All fractures were located from the 6[th]-8[th] thoracic vertebra.The median onset time for the fracture was 7 months (range 2-26). The median age for the 28 fractured patients was 70 years (range 42-82); 61% were female, 89% had a PS of 0-1. The median Dmax was 40Gy (range 0-83) and 72Gy (range 42-83) for non-collapsed and fractured vertebrae, respectively. The median Dmean was 12Gy (range 0-65) and 51Gy (range 18-71) for non-collapsed and collapsed vertebras, respectively. Both Dmax and Dmean were significantly (p<0.001) associated with vertebral fractures.Conclusion
Conclusion Vertebral fractures were retrospectively identified in 8% of NSCLC patients treated with IMRT and concurrent chemotherapy. The median onset time was 7 months. Both Dmax and Dmean of the vertebra were significantly associated with collapse in the collapsed population. A case-control study is in progress to analyze the dose-response relationship in the entire population and incorporate clinical variables, such as age, performance status and menopause status.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O14.03 - Using generalized equivalent uniform dose (gEUD) to model volume effects for brachial plexopathy after high-dose stereotactic body radiation therapy (SBRT) (ID 2835)
10:50 - 11:00 | Author(s): S.U. Din, E.L. Williams, Y. Yamada, E. Yorke, A. Foster, E. Poppens, A.J. Wu, A. Jackson, A. Rimner
- Abstract
- Presentation
Background
Brachial plexopathy is a rare but important toxicity of radiation therapy because of its significant impact on quality of life. For standard fractionated raiation therapy, good models of brachial plexus (BP) tolerance exist. However, the tolerance of the BP to SBRT is not well understood. We combined data from SBRT for apical lung and metastatic lesions near the BP spanning a wide range of doses and hypofractionation schemes. We determined the clinical incidence of brachial plexopathy and modeled the correlation with generalized equivalent uniform dose (gEUD) for both physical and biologically effective doses (BED) using a range of fractionation-sensitivity parameters (α/β) and volume effect parameters (a).Methods
Between 2004 and 2012, 180 lesions (76 lung lesions and 104 metastatic lesions) located above the aortic arch and below the level of C3 were treated with SBRT. Patients with prior radiation therapy to this region were excluded. Metastases were treated to 14-30 Gy in 1-5 fractions and lung tumors to 22-60 Gy in 1-5 fractions. The BP was contoured per RTOG atlas definitions. For 54 centrally located spine metastases, both left and right BP were contoured and analyzed separately for a total of 234 BPs in 180 patients. Brachial plexopathy of ≥grade 1 (CTCAE v4.0) was the primary endpoint. Maximum dose to the BP (Dmax), minimum dose to the hottest 5% of the BP (D05), and their respective BEDs were calculated using α/β= 3 Gy. The gEUD was also calculated with the volume effect parameter (a) ranging from log~10~a= -1.0 to +1.0 in log~10~a steps of 0.1. A logistic regression model (LR) was fit to the data as a function of a. Clinical dose recommendations were derived with logrank tests using median splits.Results
With median follow-up of 15.1 months, brachial plexopathy due to SBRT occurred in 9/234 BPs. Severity of brachial plexopathy was grade 1 in two, grade 2 in five and grade 3 in two patients. Median time to onset of brachial plexopathy was 6.2 months and the 1-/2-year actuarial rates were 3.3%/5.6%. For all patients the median BED for BP Dmax was 117.5 Gy and for D05 was 89.3 Gy. Median BED Dmax for patients with and without brachial plexopathy was 234 Gy and 115.2 Gy respectively (p=0.002). Brachial plexopathy was significantly associated with BP BED Dmax (p=0.002), and D05 (p=0.015), but not with physical dose. Using LR, the strongest correlation of gEUD with brachial plexopathy occurred for log~10~a= 1.0 using BED (p=0.002), which is representative of the BED Dmax. LR models of BED Dmax versus brachial plexopathy for various α/β values showed that any α/β<25 was a significantly better predictor than physical dose.Conclusion
Brachial plexopathy is significantly associated with BED Dmax ≥117.5 Gy (equivalent to a physical dose of 17 Gy x1, 9.3 Gy x3 or 7 Gy x5 fractions) and D05 ≥89.3 Gy. BED Dmax was the most important predictor of this rare but serious toxicity.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O14.04 - DISCUSSANT (ID 3931)
11:00 - 11:15 | Author(s): F. Mornex
- Abstract
- Presentation
Abstract not provided
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O14.05 - Effect of Postoperative 3D-Conformal Radiotherapy (3DCRT) for Patients with pIIIA-N2 non-small-cell lung cancer (NSCLC) after Complete Resection and Adjuvant Chemotherapy: Interim Analysis of a Prospective Phase III Study (ID 2299)
11:15 - 11:25 | Author(s): Z. Hui, J. Liang, J. Lv, X. Wang, Z. Zhou, Q. Feng, Z. Xiao, D. Chen, H. Zhang, W. Yin, L. Wang
- Abstract
- Presentation
Background
For patients with completely resected pⅢA-N2 NSCLC, the role of postoperative radiotherapy (PORT) is not well defined. 3D-conformal radiotherapy (3DCRT) can deliver high dose to the target volume while decreasing the toxicity of normal tissues, which may improve the treatment outcomes. This interim analysis of our phase III randomized clinical trial (NCT00880971) is to evaluate the effect of postoperative 3DCRT on the overall survival (OS) and failure pattern in pⅢA-N2 NSCLC patients after complete resection and adjuvant chemotherapy.Methods
Between Jan. 2009 and May 2012, 128 consecutive patients with pⅢA-N2 NSCLC, after complete resection and four courses of platinum based chemotherapy, were randomized into PORT group or control group. Only patients who had finished the first follow-up 3 months after treatment were included in this interim analysis. PORT, using 3D conformal techniques, was 60 Gy by 30 fractions to the subcarinal nodes, ipsilateral mediastinum and ipsilateral hilum. The effect of PORT on survival was evaluated with Kaplan-Meier method and log-rank test. The treatment failure pattern was also analyzed. Pearson chi-Square test was used to compare the constituent ratios in different groups.Results
Totally 96 patients were analyzed, including 49 in the PORT group and 47 in the control group. The clinical features were comparable between the two groups. For all the patients, the 3-y OS, disease free survival (DFS), loco-regional recurrence free survival (LRFS) and distant metastasis free survival (DMFS) were 68.4%, 54.6%, 68.6% and 63.0%, respectively. The survival rates of patients in the PORT and control groups are listed in the table. PORT markedly increased the 3-y OS, DFS, LRFS and DMFS by 21.6%, 18.7%, 16.4% and 20.4%, respectively. But the difference was not statistically significant due to the limited samples. There were 33 patients (34.3%) with treatment failure, including 7 (7.3%) with loco-regional recurrence only, 13 (13.5%) with distant metastasis only, and 13 (13.5%) with the both. PORT markedly decreased the loco-regional recurrence from 27.7% to 14.3% (P=0.107), but not the distant metastasis (from 29.8% to 24.5%, P=0.559). Eight deaths were observed up to the last follow-up, which were all caused by cancer progression. No death caused by radiation toxicities was observed.
*Between PORT and control groups.All Patients (n=96) PORT Group (n=49) Control Group (n=47) P Value* OS 68.4% 80.8% 59.2% 0.432 DFS 54.6% 64.2% 45.5% 0.256 LRFS 68.6% 76.4% 60.0% 0.105 DMFS 63.0% 67.1% 46.7% 0.542 Conclusion
For pⅢA-N2 NSCLC patients after complete resection and adjuvant chemotherapy, postoperative 3DCRT can markedly improve the survival and loco-regional control. Further accumulation of patients in our prospective randomized study is warranted.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O14.06 - Investigation of a Patient Reported Outcome (PRO) tool to assess radiotherapy-related toxicity in patients with lung cancer (ID 1614)
11:25 - 11:35 | Author(s): M. Christodoulou, P. McCloskey, N. Stones, N. Bayman, P. Burt, A. Chittalia, M. Harris, L.W. Lee, L. Pemberton, H. Sheikh, R. Swindell, C. Faivre-Finn
- Abstract
- Presentation
Background
Discrepancies between clinician and patient reported symptoms validate the investigation of a PRO tool in clinical trials and routine practice. There is a paucity of data regarding the feasibility and relevance of PRO tools to assess radiotherapy toxicity in patients with lung cancer.Methods
From January to June 2013, lung cancer patients undergoing thoracic radiotherapy or chemo-radiotherapy completed a PRO toxicity tool (adapted Radiogenomics Biorepository and Databank lung questionnaire) consisting of 9 patient-adapted Common Terminology Criteria for Adverse Events (CTCAE) items and World Health Organisation (WHO) performance status (PS) at baseline, at the end of radiotherapy and at 4-10 weeks follow-up (FU). At the same time points, patients completed the European Organisation for Research and Treatment of Cancer Quality of Life (QoL) Questionnaire along with its lung cancer specific module (EORTC QLQ-C30/LC13) and the Hospital Anxiety and Depression Scale (HADS). Clinicians completed the same CTCAE items for each time point. Agreement between patients’ and clinicians’ toxicity reports was assessed using weighted kappa coefficients. The patients’ QoL and HADS scores were correlated with the patients’ and clinicians’ reported toxicity using Spearman rank correlation coefficients.Results
Of the 116 patients consented, 70 (85 paired responses) completed all 3 questionnaires for at least one time point excluding baseline. Median age was 71.5 years (39-89 years), 54.3% of the patients were male and 85.7% had a diagnosis of non-small cell lung cancer. Agreement between patients’ and clinicians’ reported toxicity ranged from poor to substantial (Figure 1). Perfect agreement was ≥50% for all assessed items with the exception of PS for both the end of radiotherapy and FU. The majority of discrepancies (≥74%) differed by 1 grade of toxicity. At the end of radiotherapy patients reported greater severity than clinicians for all items but not for PS; however this was less pronounced at FU. QoL scores were generally more strongly correlated with the patients’ compared to clinicians’ matching toxicity grades at the exception of dyspnoea. The correlation of HADS scores with patients’ CTCAE anxiety and depression grades ranged from moderate-to-low to moderate. There was no correlation with clinicians’ grading for depression and no-to-moderate correlation for anxiety. The adapted Radiogenomics Biorepository and Databank lung questionnaire demonstrated a high Cronbach’s α value (0.848) indicating good reliability. Figure 1Conclusion
The use of a PRO tool in radiotherapy for lung cancer is feasible, reliable and acceptable to patients and complements the clinicians’ assessment. Further research is required to evaluate its validity.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O14.07 - IDEAL CRT: Isotoxic Dose Escalation and Acceleration in Lung Cancer ChemoRadiotherapy - a phase I/II trial of concurrent chemoradiation with dose-escalated radiotherapy in patients with stage II or stage III Non-Small Cell Lung Cancer. (ID 1368)
11:35 - 11:45 | Author(s): D.B. Landau, I. Khan, Y. Ngai, L.L. Hughes, E. Miles, D. Wilkinson, E. Parsons, P. Mayles, H. Mayles, A.T. Bates, N. Mohammed, J. Hicks, S. Harden, M. Illsley, A. Garcia, Z. Malik, S. Hughes, J. Spicer, A. Baker, P. Wells, V. Laurence, J. Fenwick
- Abstract
- Presentation
Background
The IDEAL-CRT trial uses an individual patient approach to radiotherapy (RT) dose escalation, escalating the dose within a fixed overall treatment time, 6 weeks, by increasing dose per fraction. Isotoxic RT is based on the calculated risk of RT-pneumonitis (RTPN), RT dose being escalated so that all patients are exposed to the same RTPN risk. We investigated the feasibility and safety of individualised, isotoxic dose escalation for once daily RT delivered in 30 once-daily fractions with concurrent chemotherapy.Methods
Eligibility; NSCLC stage II/III, PS 0/1, FEV~1~ (≥40% predicted or ≥1L), DCLO (≥40% predicted). A radiobiological model was used to individualize RT dose-prescription – selecting a dose which, in 30# once daily for 6 weeks, is associated with a 10% risk of grade 3+ RTPN, but limiting prescribed doses to between 63Gy - 73Gy (2Gy dose equivalent α:β=10, 63.5Gy-86Gy). Dose constraints were fixed for spinal cord, heart, brachial plexus. In Arm 1, initially the maximum dose to 1cc oesophageal did not exceed 63Gy. Arm 2 comprised patients in whom oesophageal dose rather than lung dose limited the prescription dose: the oesophageal dose was raised from 65Gy to 68Gy, 71Gy and 73Gy in consecutive cohorts, the prescribed dose lying between 63Gy and 73Gy and being the highest consistent with the oesophageal limit. Dose escalation was determined using a 6+6 design. Dose limiting toxicity (DLT) was defined as Grade 3+ oesophagitis. MTD was determined if grade 3+ oesophagitis >42% (>5/12). Two cycles of Cisplatin-Vinorelbine chemotherapy given concurrently during RT. All contouring and dosimetry on planning CT scans was centrally reviewed. IMRT was introduced in November 2012. Primary endpoints: oesophagitis and RTPN. Serial pulmonary function tests and ECGs performed. Efficacy endpoints: overall survival (OS), progression free survival (PFS), and tumour response.Results
Between October 2010 and February 2013, 84 patients recruited (9 UK centres), 49 patients Arm 1, 35 patients Arm 2 (13 at 65Gy, 12 at 68Gy, 10 at 71Gy; none at 73Gy as the 73Gy upper prescription dose limit was only rarely associated with an oesophageal dose higher than 71Gy). Median follow up was 11 months (range 2,24); median age 66 years (range 43-84); 74% male; 39%/60% WHO 0/1; 30% adenocarcinoma, 54% squamous. Mean GTV 121cc (range 14-602cc). Mean prescribed dose for patients completing RT (n=80) 67.6Gy (range 63-73Gy) in Arm 1 and 70.1 Gy (63-73) in Arm 2. Mean 1cc-oesophageal-dose in Arm 1 55.5Gy (range 14.2-68.0Gy). In Arm 1 grade 3+ oesophagitis was 6% (3/49). In Arm 2, Grade 3+ oesophagitis was 17% (2/12) at 68Gy; no Grade 3+ oesophagitis in 65Gy (0/12) and 71Gy (0/10) cohorts. Grade 3+ RTPN 2% (1/49) in Arm 1 and 6% (2/35) in Arm 2. 1 year OS and PFS rates were 92% and 74% respectively.Conclusion
Isotoxic RT dose escalation was safe and feasible. The MTD for oesophagus was not reached. Acceleration of the IDEAL-CRT schedule to five weeks is under investigation in a second study, currently recruiting.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O14.08 - DISCUSSANT (ID 3932)
11:45 - 12:00 | Author(s): S.K. Vinod
- Abstract
- Presentation
Abstract not provided
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Author of
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O14 - Radiotherapy - Toxicity and Clinical Trials (ID 105)
- Event: WCLC 2013
- Type: Oral Abstract Session
- Track: Radiation Oncology + Radiotherapy
- Presentations: 1
- Moderators:G. Pratt, S.K. Vinod
- Coordinates: 10/29/2013, 10:30 - 12:00, Parkside Ballroom A, Level 1
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O14.08 - DISCUSSANT (ID 3932)
11:45 - 12:00 | Author(s): S.K. Vinod
- Abstract
- Presentation
Abstract not provided
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P3.24 - Poster Session 3 - Supportive Care (ID 160)
- Event: WCLC 2013
- Type: Poster Session
- Track: Supportive Care
- Presentations: 1
- Moderators:
- Coordinates: 10/30/2013, 09:30 - 16:30, Exhibit Hall, Ground Level
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P3.24-007 - Do patients discussed at Lung Cancer Multidisciplinary Team Meetings receive guideline-recommended treatment? (ID 321)
09:30 - 09:30 | Author(s): S.K. Vinod
- Abstract
Background
Many clinical practice guidelines recommend that all lung cancer patients should be discussed at a multidisciplinary team meeting (MDM) to determine a management plan. Previous studies have shown that lung cancer MDM recommendations are largely concordant with guidelines. There are limited data on whether these recommendations are translated into actual treatment received. The aim of this study was to evaluate whether patients discussed at a lung cancer MDM actually received guideline-recommended treatment (GRT) and determine reasons for not receiving GRT.Methods
The Liverpool/Macarthur lung cancer MDM prospectively collects data on new lung cancer patients including patient and tumour characteristics, staging investigations, referrals and treatment recommendations. All new lung cancer patients discussed at the MDM between 1/12/05 – 31/12/2010 were identified. Details of patient demographics, tumour characteristics and treatment were obtained from the MDM database and the Area Clinical Cancer Registry. GRT was assigned to each patient according to pathology, stage and ECOG performance status as per the 2004 Australian Lung Cancer Guidelines. This was compared to actual treatment received to determine adherence to GRT. For those who did not receive GRT, the medical record was reviewed to determine the reason why. Survival was compared between patients who did and did not receive GRT.Results
808 patients were discussed at the MDM. 64% were male and the median age was 68 years. Pathology was NSCLC in 657 (81%), SCLC in 119 (15%) and not confirmed in 32 (4%). 128 (16%) had Stage I or II NSCLC, 306 (38%) Stage III NSCLC or limited stage SCLC and 372 (46%) metastatic disease. GRT could be assigned in 98% of patients who had both stage and ECOG performance status documented. Overall 411 (51%) of patients received GRT, and 380 (47%) did not receive GRT. The main reasons for not receiving GRT were decline in performance status (24%), large tumour volume precluding radical RT (17%), co-morbidities (14%) and patient preference (13%). On multivariate analysis, ECOG performance status, stage and age were significantly associated with receipt of GRT. GRT, ECOG performance status and stage were significant predictors of survival.Conclusion
Despite discussion at an MDM, a significant proportion of patients were unable to receive GRT due to legitimate reasons. This may reflect the characteristics of the underlying lung cancer population who are older and have coexisting comorbidities. Alternative treatment strategies are needed for patients who are not suitable for GRT.
