Curative Intent Treatment For Patients Research Articles

Initial Clinical Experience of MR-Guided Radiotherapy for Non-Small Cell Lung Cancer.

Curative-intent radiotherapy plays an integral role in the treatment of lung cancer and therefore improving its therapeutic index is vital. MR guided radiotherapy (MRgRT) systems are the latest technological advance which may help with achieving this aim. The majority of MRgRT treatments delivered to date have been stereotactic body radiation therapy (SBRT) based and include the treatment of (ultra-) central tumors. However, there is a move to also implement MRgRT as curative-intent treatment for patients with inoperable locally advanced NSCLC. This paper presents the initial clinical experience of using the two commercially available systems to date: the ViewRay MRIdian and Elekta Unity. The challenges and potential solutions associated with MRgRT in lung cancer will also be highlighted.

Changes in Cardiac Volume during Concurrent Chemoradiotherapy for Esophageal Cancer Based on Repeated Enhanced 4DCT

Concurrent chemoradiotherapy is considered curative intent treatment for patients with non-operative esophageal cancer. Radiation-induced heart damage receives much attention. The aim of this study was to detect the change of cardiac volume over the course of radiotherapy for esophageal cancer based on repeated enhanced 4DCT and to explore the factors that might affect the change in cardiac volume during radiotherapy. In this prospective study, forty-six patients with pathologically proven thoracic esophageal squamous cell carcinoma who were scheduled to receive concurrent chemoradiotherapy with a total dose of 60Gy in 30 fractions in our department were enrolled in the study. All the patients underwent enhanced 4DCT and 3DCT scans before radiotherapy and then repeated the CT scans every 10 fractions during treatment. The heart was contoured on 3DCT, end expiratory (EE) of 4DCT and maximum intensity projection (MIP) of 4DCT by the same radiation oncologist according to the same guidelines. Heart volumes and other relative parameters during radiotherapy were analyzed. Compared with the initial value, heart volume decreased significantly at the tenth fraction (reduction = 3.27%, 4.45% and 4.52%, respectively, on 3DCT, EE and MIP, p < 0.05) and the twentieth fraction (reduction = 6.05%, 5.64% and 4.51%, respectively, on 3DCT, EE and MIP, p < 0.05). The reduction between the initial measurement and the measurement at the thirtieth fraction was not significant (p > 0.05). There was a decrease in both systolic (16.95 ± 16.69 mmHg, p < 0.05) and diastolic blood pressure (7.14 ± 11.64 mmHg, p < 0.05) and an increase in heart rate with 5.27 ± 6.25 beats/min (p < 0.05) after radiotherapy. The patients with mid-thoracic esophageal cancer were found to have significantly greater heart dose than the upper and lower tumors (p <0.05). None of the potential explanatory variables correlated with heart volume changes. By eliminating the effect of respiratory motion on the heart, 4DCT better reflects changes in cardiac volume during radiotherapy of esophageal cancer. Heart volume was significantly reduced in the early treatment stage and maintained the reduction until the middle treatment stage, then showed a tendency to restore to the initial level at the thirtieth fraction. The blood pressure decreased and the heart rate increased during radiotherapy. These observed changes may be valuable indicators of cardiac impairment and target dose changes.

P3.16-18 Modern Radiotherapy Increases Patient Access to Curative Intent Radiotherapy in Non-Small Cell Lung Cancer

Technical developments in the delivery of radiotherapy such as image-guided radiotherapy (IGRT) and intensity modulated radiotherapy (IMRT) have permitted the introduction of advanced radiation techniques such stereotactic ablative radiotherapy (SABR). These new techniques have the advantage of more accurate localisation of the tumour and reduced irradiation of normal tissues. In our centre, we have implemented a range of new techniques to deliver IGRT (such as PET/CT and 4-dimensional CT planning, and cone beam CT during treatment delivery). We postulate that using the advanced techniques increases the access to curative intent radiotherapy treatment of lung cancer. We seek to assess the access rates to curative intent thoracic radiotherapy. Using our institutional lung radiotherapy database we analysed the data recording intent of treatment with reference to the stage and performance status (PS) of all patients with stage 1-3 non-small cell lung cancer (NSCLC) in 2007 and compared this to the same population receiving radiotherapy during 2017 and up to April 2018. In 2007, 217 patients with stages 1-3 NSCLC received any radiotherapy compared to 218 patients for the 2017/2018 cohort. Within the 2017/2018 cohort 96% of patients (n=94) received radical radiotherapy compared to 28% of patients in 2007 (n=26). Of the 94 patients receiving radical treatment in 2017/2018, 61% received SABR. This increase was largely due to in the introduction of SABR. In those patients with stage 3 disease, overall fewer patients received any radiotherapy in 2017/2018 compared to 2007, however the number of patients receiving curative intent radiotherapy increased from 20 (13% of all stage 3 patients) to 44 (37%). Of note in those patients receiving curative intent radiotherapy there was an increase in access for patients with poorer PS, with only 7% of patients with a PS ≥2 in 2007 receiving curative intent radiotherapy compared with 42% of patients in 2017/2018. In our series, we report an increase in the proportion of patients with NSCLC receiving curative intent radiotherapy. Furthermore, more patients with a poorer performance status received curative intent radiotherapy. We suggest that the introduction of advanced radiotherapy techniques has permitted the curative intent treatment of patients who were previously treated with a palliative approach to management.

Stereotactic Body Radiation and Other Ablative Therapies

Lung cancer is the leading cause of cancer death in both men and women. This is related to the high prevalence and high mortality particularly when presenting at an advanced stage. Surgical resection remains the standard curative therapy for early-stage lung cancer. However, many patients are not able to tolerate resection secondary to poor respiratory reserve and other comorbid diseases. Stereotactic body radiation therapy (SBRT) and percutaneous thermal ablation are minimally invasive techniques that have been used to treat other solid tumors with curative intent. Over the past decade, there has been an expansion in the roles of both SBRT and thermal ablation in the treatment of early-stage lung tumors. The encouraging results from several studies have led to the incorporation of these therapies, particularly SBRT, as the standard of care for curative-intent treatment of patients with medically inoperable early-stage lung cancer. This chapter presents an overview of the approach to patient selection as well as provides a review of the current evidence for SBRT, percutaneous thermal ablation, and bronchoscopic ablation for early-stage nonsmall cell lung cancers. This review contains 3 figures, 4 tables, and 28 references Key Words: stereotactic body radiation therapy, percutaneous thermal ablation, cryoablation, microwave ablation, endoscopic ablation, bronchoscopic ablation, radiofrequency ablation, early stage NSCLC therapy

Changes in cardiac volume determined with repeated enhanced 4DCT during chemoradiotherapy for esophageal cancer

BackgroundConcurrent chemoradiotherapy is considered curative intent treatment for patients with non-operative esophageal cancer. Radiation-induced heart damage receives much attention. We performed repeated four-dimensional computed tomography (4DCT) to detect changes in cardiac volume during radiotherapy for esophageal cancer patients, and explored potential factors responsible for those changes.MethodsForty-six patients with esophageal cancer underwent enhanced 4DCT and three-dimensional (3D) CT scans before radiotherapy and every 10 fractions during treatment. The heart was contoured on 3DCT images, 4DCT end expiratory (EE) images and 4DCT maximum intensity projection (MIP) images by the same radiation oncologist. Heart volumes and other relative parameters were compared by the SPSS software package, version 19.0.ResultsCompared with its initial value, heart volume was smaller at the 10th fraction (reduction = 3.27%, 4.45% and 4.52% on 3DCT, EE and MIP images, respectively, p < 0.05) and the 20th fraction (reduction = 6.05%, 5.64% and 4.51% on 3DCT, EE and MIP images, respectively, p < 0.05), but not at the 30th fraction. Systolic and diastolic blood pressures were reduced (by 16.95 ± 16.69 mmHg and 7.14 ± 11.64 mmHg, respectively, both p < 0.05) and the heart rate was elevated by 5.27 ± 6.25 beats/min (p < 0.05) after radiotherapy. None of the potential explanatory variables correlated with heart volume changes.ConclusionsCardiac volume reduced significantly from an early treatment stage and maintained the reduction until the middle stage. The heart volume changes observed on 3DCT and 4DCT were consistent during radiotherapy. The changes in heart volume, blood pressure and heart rate may be valuable indicators of cardiac impairment and target dose changes.

Lymphadenectomy: how to do it?

According to the more recent European guidelines, the D2 lymphadenectomy is considered the standard for curative intent treatment of patients with gastric cancer. Although, the surgical definition of D2 dissection and its technical aspects had been learned from Eastern surgeons in the past decades, some variations in the approach to D2 lymphadenectomy by European surgeons were detectable in randomized clinical trials dealing with lymphadenectomy. Despite in more recent years an improvement in surgical quality has been reported in European series, some differences in the practice of D2 dissection are thought to persist. As, these may contribute to discrepancies in gastric cancer survival observed across European countries, the standardization of surgical quality is an urgent need to improve the outcome of gastric cancer patients in Europe. In this manuscript, we focus on the technical aspects of the D2 dissection both in open and laparoscopic gastrectomy in order to contribute to the improvement of surgical care of gastric cancer in the West.

Reduced incidence of interstitial pneumonitis after allogeneic hematopoietic stem cell transplantation using a modified technique of total body irradiation.

Allogeneic hematopoietic stem cell transplantation is a curative-intent treatment for patients with high-risk hematologic diseases. However, interstitial pneumonitis (IP) and other toxicities remain major concerns after total body irradiation (TBI). We have proposed using linear accelerators with rice-bag compensators for intensity modulation (IM-TBI), as an alternative to the traditional cobalt-60 teletherapy with lung-shielding technique (Co-TBI). Patients who received a TBI-based myeloablative conditioning regimen between 1995 and 2014 were recruited consecutively. Before March 2007, TBI was delivered using Co-TBI (n = 181); afterward, TBI was administered using IM-TBI (n = 126). Forty-four patients developed IP; of these cases, 19 were idiopathic. The IP-related mortality rate was 50% in the total IP cohort and 63% in the idiopathic subgroup. The 1-year cumulative incidences of IP and idiopathic IP were 16.5% and 7.4%, respectively; both rates were significantly higher in the Co-TBI group than in the IM-TBI group. Multivariate analysis revealed that Co-TBI was an independent prognostic factor for both total and idiopathic IP. In the acute myeloid leukemia subgroup, patients with different TBI techniques had similar outcomes for both overall and relapse-free survival. In conclusion, IM-TBI is an easy and effective TBI technique that could substantially reduce the complication rate of IP without compromising treatment efficacy.

Reduction of heart volume during neoadjuvant chemoradiation in patients with resectable esophageal cancer

Background and purposeNeoadjuvant chemoradiation (nCRT) followed by surgery is considered curative intent treatment for patients with resectable esophageal cancer. The aim was to establish hemodynamic aspects of changes in heart volume and to explore whether changes in heart volume resulted in clinically relevant changes in the dose distribution of radiotherapy. MethodsA prospective study was conducted in patients who were treated with nCRT consisting of carboplatin and paclitaxel concomitant with radiotherapy (41.4Gy/1.8Gy per fraction). Physical parameters, cardiac volume on CT and Cone beam CT, cardiac blood markers and cardiac ultrasound were obtained. ResultsIn 23 patients a significant decrease of 55.3ml in heart volume was detected (95% CI 36.7–73.8ml, p<0.001). There was a decrease in both systolic (mean decrease 18mmHg, 95% CI 11–26mmHg, p<0.001) and diastolic blood pressure (mean decrease 8mmHg, 95% CI 2–14mmHg, p=0.008) and an increase in heart rate with 6beats/min (95% CI 1–11beats/min, p=0.021). Except for Troponin T, no change in other cardiac markers and echocardiography parameters were observed. The change in heart volume did not result in a clinically relevant change in radiation dose distribution. ConclusionHeart volume was significantly reduced, but was not accompanied by overt cardiac dysfunction. All observed changes in hemodynamic parameters are consistent with volume depletion. Adaptation of the treatment plan during the course of radiotherapy is not advocated.

Reduction of heart volume during neoadjuvant chemoradiation in patients with resectable esophageal cancer.

4044 Background: Neoadjuvant chemoradiation (nCRT) followed by surgery based on the Dutch CROSS scheme is considered curative intent treatment for patients with resectable esophageal cancer. Ideall...

Acute toxicity of definitive chemoradiation in patients with inoperable or irresectable esophageal carcinoma

BackgroundDefinitive chemoradiation (dCRT) is considered curative intent treatment for patients with inoperable or irresectable esophageal cancer. Acute toxicity data focussing on dCRT are lacking.MethodsA retrospective analysis of patients treated with dCRT consisting of 6 cycles of paclitaxel 50 mg/m2 and carboplatin AUC2 concomitant with radiotherapy (50.4 Gy\\1.8Gy) from 2006 through 2011 at a single tertiary center was performed. Toxicity, hospital admissions and survival were analysed.Results127 patients were treated with definitive chemoradiation. 33 patients were medically inoperable, 94 patients were irresectable, Despite of a significantly smaller tumor length in inoperable patients grade ≥3 toxicity was significantly recorded more often in the inoperable patients (44%) than in irresectable patients (20%) (p < 0.05) Hospital admission occurred more often in the inoperable patients (39%) than in the irresectable patients (22%) (p < 0.05) Median number of cycles of chemotherapy was five for inoperable patients (p = 0.01), while six cycles could be administered to patients with irresectable disease. Recurrence and survival were not significantly different. The odds ratio for developing toxicity ≥ grade 3 was 2.6 (95% CI 1.0-6.4 p < 0.05) for being an inoperable patient and 1.2 (95% CI 1.0-1.4 p = 0.02) per 10 extra micromol/l creatinine.ConclusionsOur data show that acute toxicity of definitive chemoradiation is worse in patients with medically inoperable esophageal carcinoma compared to patients with irresectable esophageal cancer and mainly occurs in the 5th cycle of treatment. Improvement of supportive care should be undertaken in this more fragile group.

Abstract 2429: Airway necrosis after salvage esophagectomy.

Abstract Background: Recently definitive chemoradiotherapy (CRT) without surgery has been accepted as an alternative treatment for esophageal cancer. However, unfortunately, the tumors of 5-33% patients were resistant to CRT and persistent disease was detected soon after treatment, and 16-54% patients initially showed a response but locoregional disease was discovered later. Salvage esophagectomy is the sole curative intent treatment for patients with persistent or recurrent locoregional disease after definitive CRT for esophageal carcinoma. However, salvage esophagectomy is a very high-risk operation, and airway necrosis is a fatal complication. Methods: Between 1997 and 2007, 49 patients with thoracic esophageal squamous cell carcinoma underwent salvage esophagectomy after definitive CRT. All patients received more than 50 Gy of radiation plus concurrent chemotherapy for curative intent. We retrospectively compared patients with and without airway necrosis. Additionally, airway necrosis was categorized primary necrosis and secondary necrosis according to the cause of necrosis, and operative procedures related to airway necrosis were investigated. Result: Overall 23of 49 patients had at least one complication (morbidity: 46.9%), and 5 died during their hospitalization (mortality: 10.2%). Airway necrosis occurred in five patients (10.2%), of four patients (80%) died during their hospitalization. Airway necrosis seemed to be closely related to operative procedures, such as resection of bronchial artery (BA), cervical and subcarinal lymph node dissection (LND) and reconstruction route. Primary necrosis occurred in 3 patients with resection of BA, cervical LND, or subcarinal LND. And bronchogastric fistula following necrosis of gastric conduit occured in 2 patients reconstructed through posterior mediastinal route. Conclusions: Airway necrosis is a highly lethal complication after salvage esophagectomy. It is important in salvage esophagectomy to take airway blood supply into consideration sufficiently and to reconstruct through retrosternal route to prevent bronchogastric fistula. Citation Format: Norimitsu Tanaka, Nobukazu Hokamura, Yuji Tachimori. Airway necrosis after salvage esophagectomy. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2429. doi:10.1158/1538-7445.AM2013-2429