Treatment Of Early-stage Lung Cancer Research Articles

P05.07 Single-Fraction Carbon ion Radiotherapy for Patients with Early-Stage Lung Cancer with or without Interstitial Pneumonitis

Carbon ion radiotherapy (CIRT) is one of the treatment choices for lung cancer. In our institution, we administer 50Gy [relative biological effectiveness (RBE)] in 1 fraction to treat peripheral lung cancer. We retrospectively analyzed the outcomes of this treatment with special regard to prognostic impact of coexistent interstitial pneumonitis (IP). Between June 2011 and May 2018, patients with or without IP who received 50Gy (RBE) in 1 fraction CIRT for peripheral lung cancer and whose tumor diameters were 5 cm or smaller were retrospectively recruited from our database. Toxicities were evaluated using the Common Terminology Criteria for Adverse Events version 4.0. A total of 195 fulfilled the inclusion criteria. There were 33 patients with IP, and all of them except for one patient were inoperable. The median age was 75 years (range 42–95 years), median follow-up time was 39 months (range 2–97 months), and median tumor diameter was 24 mm (range 8–49 mm). Among all the patients, the 3-year overall survival (OS), local control (LC), and disease-free survival (DFS) rates were 86.3%, 94.5%, and 82.0%, respectively. The 3-year OS (58.8%), LC (79.8%), and DFS (56.8%) of patients with IP were significantly worse than those without IP (OS 91.1%, LC 96.7%, and DFS 85.9%; p < 0.001). IP was also a significant risk factor of OS (hazard ratio = 3.0; p = 0.015), LC (hazard ratio = 3.8; p = 0.022), and DFS (hazard ratio = 3.2; p = 0.006) in multivariate Cox analysis. There were 3 patients with grade 3 pneumonitis (all had IP), and 4 patients with grade 2 pneumonitis (2 had IP and 2 did not). Single-fraction CIRT is an effective and safe treatment for early-stage lung cancer, even in patients with IP, although the clinical results of patients with IP are worse than those of patients without IP.

A uniportal right upper lobectomy by three-arm robotic-assisted thoracoscopic surgery using the da Vinci (Xi) Surgical System in the treatment of early-stage lung cancer.

Minimally invasive techniques, typified by video-assisted thoracoscopic surgery, are widely practiced in the treatment of thoracic diseases all around the world, and video-assisted thoracoscopic surgery has been recognized as a standard treatment method for early staged lung cancer. Among them, robotic-assisted thoracoscopic surgery, which has the advantages of providing a three-dimensional view and better maneuverability, has emerged as a next-generation technique in the field of minimally invasive surgery and is also gaining its popularity with the idea of Enhanced Recovery After Surgery deeply rooted in patients’ minds. Up to now, robotic-assisted thoracoscopic surgery usually requires 3 or 4 ports with 1 or 2 additional access incisions. Meanwhile, traditional video-assisted thoracoscopic surgery can now be completed with uniportal method, with less postoperative pain and higher patient satisfaction with respect to the number of incisions in comparison with the multi-port technique. To inform the integration of these new minimally invasive techniques, here, we present a case in which uniportal right upper lobectomy was performed using the 4th generation da Vinci Robotic Surgical System (Xi). With continuous innovation in robotic minimally invasive techniques and improvements in surgical skills, we believe more patients will benefit from robotic-assisted thoracoscopic surgery with single port in the near future.

Application of Electromagnetic Navigation Bronchoscopy in the early diagnosis and treatment of lung cancer: a narrative review.

The diagnosis of lung cancer has long been a problem facing clinicians worldwide, and the emergence of electromagnetic navigation bronchoscopy (ENB) has played a critical role in the early diagnosis of lung cancer. Compared with other types of biopsy techniques (e.g., transthoracic needle biopsy, bronchoscopy, thoracoscopic biopsy, and thoracotomy), ENB guarantees high diagnostic accuracy and safety. In recent years, with the continuous development of ENB technology, the scope of its epitaxy has also expanded. This technology is no longer a simple auxiliary diagnosis test but an innovative technology that simultaneously assists in surgical treatment, opening new avenues of research for the treatment of early-stage lung cancer. However, ENB, as a human-mediated operating system, has some limitations and uncertainties in its actual clinical application and promotion, which need to be addressed as we continue to develop ENB technology. In response to the bottleneck in developing ENB technology in current clinical diagnosis and treatment, relevant scientific research and development personnel and clinicians have also performed continuing exploration and improvement of methods. However, to completely overcome the limitations of ENB, more technological innovations are needed. In this review, we describe the current major clinical application directions, application advantages, and limitations of ENB.

Stereotactic ablative radiotherapy versus surgery in older patients with stage I lung cancer.

Surgical resection is the best option for the treatment of early-stage lung cancer. However, older patients are less likely to receive curative treatment. Therefore, we compared long-term survival rates between surgical resection and stereotactic ablative radiotherapy (SABR) for the treatment of early-stage lung cancer in older patients. From 2013 to 2016, 272 patients aged ≥75 years with clinical stage I lung cancer underwent surgical resection (n = 191) or SABR (n = 81). A propensity score-matched analysis was performed. Overall survival, cumulative incidence of cancer-related death and recurrence were compared between the 2 groups. In the matched cohort, 48 well-balanced pairs were extracted. An overall survival benefit was associated with surgery (surgery vs SABR = 65.9% vs 40.3%; P = 0.034); however, there was no significant difference in the cumulative incidence of cancer-related death (P = 0.089) or recurrence (P = 0.111) between the 2 groups. Systemic dissemination was the dominant pattern of progression in both groups. The 3-year cumulative incidence of regional recurrence was significantly higher in the SABR group compared to the surgery group (surgery vs SABR = 0% vs 11.4%, P = 0.046). Surgical resection with mediastinal lymph node dissection provides better long-term survival compared to SABR in older patients with stage I lung cancer. Surgery should be considered for older patients aged ≥75 years who are appropriate candidates for surgery. SABR remains an alternative treatment with comparable cancer-related death and recurrence for patients unsuitable for surgery.

Developing Genomic Predictive Biomarkers for Survival Benefit from Adjuvant Chemotherapy in Early-Stage Lung Cancer Patients

Surgical resection only remains the standard choice for the treatment of early-stage non-small cell lung cancer (NSCLC) patients. Preliminary studies suggest that the application of adjuvant chemotherapy with surgery (ACT) is associated with a better prognosis for more severe NSCLC patients compared to those who only underwent surgical resection. However, at an individual level, not all patients may benefit from ACT. Given the well-known adverse effects and toxicity of ACT, finding the patients that are most likely to benefit from ACT is paramount. Thus, the purpose of this research is to utilize gene expression and clinical data from lung cancer patients to develop a statistical decision support algorithm to find predictive genomic biomarkers and identify subgroups of patients who benefit from ACT. Cox regression models are trained using a randomized controlled trial gene expression data from the National Cancer Institute utilizing explicit treatment interaction terms. To handle high dimensions inherent in gene expression data, a modified-covariate regularized Cox regression model with lasso penalty is applied to find the most significant interacting covariates. Then risk scores are constructed from these models and are used to stratify patients into a high risk or low risk group respective to ACT treatment. After applying the model to an independent validation genomic data set, our methods show that patients who underwent the treatment according to their risk group exhibit a slightly higher survival rate than those who do not.

Early-Stage Non-Small Cell Lung Cancer Stereotactic Body Radiation Therapy (SBRT) Outcomes in an Equal Access Military Setting.

IntroductionLung stereotactic body radiation therapy (SBRT) is a first-line treatment for early-stage lung cancer in non-surgical candidates or those who refuse surgery. We compared our institutional outcomes from a unique patient population with decreased barriers to care with a recently published prospective series.Materials and methods We retrospectively reviewed all patients who received definitive lung SBRT at the Walter Reed National Military Medical Center from 2015 to 2020. All patients underwent a positron emission tomography-computed tomography (PET-CT) and all were presented at a multidisciplinary tumor board. Patients were treated on a Trubeam linear accelerator (LINAC)-based system with daily cone-beam CT. The results were qualitatively compared to outcomes from prospective studies including RTOG 0236 and RTOG 0618.ResultsA total of 105 patients with 114 lesions were included. Median age was 77 years and 54.7% had ≥ 40-pack year smoking history. 36.8% did not have pathologic confirmation. With a median follow-up of 24 months, three-year local control (LC), disease-free survival (DFS) and overall survival (OS) rates were 92.4%, 81.0%, and 80.0%, respectively. Rates of Grade 1 and 2 toxicity were 21.9% and 6.7% and no patients experienced Grade ≥ 3 toxicity.ConclusionsIn our military setting with universal coverage and routine multidisciplinary care, lung SBRT provides outcomes comparable to prospective studies conducted at high-volume academic centers. More than one-third of patients were treated empirically without pathologic confirmation of disease, demonstrating a difference between clinical trials and community practice. Further investigation is warranted to integrate multidisciplinary management and achieve equal access to care to bridge existing health disparities in the community setting.

A narrative review of invasive diagnostics and treatment of early lung cancer.

The diagnosis and treatment of early-stage lung cancer remains a clinical challenge. The broadening implementation of lung cancer screening has resulted in positive findings in numerous patients that are mostly non-malignant. Many other patients have indeterminate nodules that are difficult to assess through simple observation. The critical interpretation of such screening results remains a challenge for radiologists and multidisciplinary teams involved in screening for lung cancer. The evaluation and diagnosis of each participant suspected for malignancy should be based on the basic clinical principles such as a carefully collected medical history, physical examination, and detailed analysis of all imaging tests performed. Indeed, the decision to go ahead with more invasive diagnostics requires consideration of the both the risks and benefits, with reflection upon the complete clinical and radiological picture. Although transthoracic needle aspiration biopsy remains the first-choice method of diagnosis, several newer technologies have slowly begun to emerge as potential replacements. The guiding strategy for method selection is to choose the least harmful approach that offers the most relevant potential insights. Transthoracic biopsy is an effective method that allows the collection of cytological and tissue material from small, peripheral tumors, but it carries a moderate risk of complications. Bronchofiberoscopy, especially in combination with electromagnetic navigation, fluoroscopy or radial EBUS, also allows effective diagnosis of the peripheral pulmonary nodules. One of the most important diagnostic methods is the EBUS examination, which allows determining of staging in addition to diagnosis. Anatomical lung lobe resection and lymphadenectomy or sampling of the hilar and mediastinal lymph nodes is currently the treatment of choice for patients with stage I and II non-small cell lung cancer (NSCLC), but sublobar resections are recommended when a patient has limited pulmonary function or other significant comorbidities. Notably, several studies have highlighted the potential utility of more limited resections in small malignant lesions less than 2cm in diameter, with pure AIS histology, when more than 50% of the diameter of pulmonary nodule has ground-glass opacity (GGO) attenuation on CT, or long volume doubling time (VDT). Videothoracoscopy is the preferred surgical approach for resection of early-stage lung cancer. Patients who are not candidates for surgery or do not agree to surgery can be offered radical radiotherapy. Stereotactic body radiation therapy (SBRT) is a type of radical radiotherapy with proven effectiveness, a high rate of local control and an acceptable risk of the development of later complications. Future trials are expected to define the role of SBRT in the treatment of early lung cancer in healthy subjects.

The safety and feasibility of three-dimension single-port video-assisted thoracoscopic surgery for the treatment of early-stage lung cancer.

BackgroundVideo-assisted thoracoscopic surgery (VATS) has been widely used in the lung resections. Reports regarding three-dimension (3D) single-port VATS are very limited. The purpose of this study is to evaluate the perioperative outcomes of 3D single-port VATS in a single medical center.MethodsTotally 523 clinical stage I lung cancer patients underwent surgical resection through VATS operation between September 2016 and October 2017 in our single institution were retrospectively collected and 374 were enrolled. The comparison between 3D single-port VATS and conventional VATS (c-VATS), single-port VATS was conducted focusing on intraoperative and postoperative outcomes. Continuous and categorical variables were analyzed through SPSS software.ResultsThe 3D singe-port VATS demonstrated no significant difference neither on the intraoperative outcomes including the operative time and the intraoperative blood loss nor the postoperative outcomes including the length of drainage duration and postoperative complications when against c-VATS and single-port VATS. Besides, 3D singe-port VATS elucidated comparable ability of lymph node dissection with c-VATS in subgroup analysis (P=0.192), both of which were better than single-port VATS group (P<0.001). What’s more, the rate of conversion as well as hospital stays of 3D single-port group were also comparable. In subgroup analysis, 3D singe-port VATS also elucidated its safety and feasibility when dealing with routine thoracic surgeries including lobectomy and segmentectomy.Conclusions3D single-port VATS, integrating the advantages of single-port VATS and three-dimensional vision of 3D VATS, is a safe and feasible technique and is promising for next-generation thoracoscopic surgery.

Performance at stair-climbing test is associated with postoperative complications after lung resection: a systematic review and meta-analysis

BackgroundThoracic surgery is the optimal treatment for early-stage lung cancer, but there is a high risk of postoperative morbidity. Therefore, it is necessary to evaluate patients’ preoperative general condition and...

Video-assisted thoracic surgery lobectomy simulation and training with a new human cadaver model

Video-assisted thoracic surgery (VATS) lobectomy is the gold standard for the treatment of early-stage lung cancer. The use of surgical models for training and simulation in minimally invasive surgery simulation is an integral part of surgical education and skills acquisition for residents, and also for more experienced surgeons.Live animals are still the most frequently used realistic surgical models. In this video tutorial, we demonstrate the use of a new human cadaver model with the aim of replacing the live animal model without compromising the fidelity of the simulation. To prepare the cadaver, selective cannulation of the heart was performed to fill the pulmonary vessels with a gel used to improve the visibility and tactile feed-back of the vessels, and to simulate any bleeding complications. The complete cadaver was then used for the simulation, with all the same instruments and devices required in normal clinical practice, to demonstrate and practice both surgical and non-surgical skills for VATS lobectomy. In our opinion this model provides most of the features necessary for a valid surgical simulator and allows realistic training for VATS lobectomy. We believe that the cadaver model can be an effective alternative to anesthetized animals for VATS lobectomy training and simulation.

Dose prescription in SBRT for early-stage non-small cell lung cancer: are we all speaking the same language?

Stereotactic body radiation therapy is increasingly used in the treatment of early-stage lung cancers. Guidelines provide indications regarding the constraints to the organs at risk (OARs) and the minimum coverage of the planning target volume but do not suggest optimal dose distribution. Data on dose distribution from the different published series are not comparable due to different prescription modalities and reported dose parameters. We conducted a review of the published data on dose prescription, focusing on the role of homogeneity on local tumor control, and present suggestions on how to specify and report the prescriptions to permit comparisons between studies or between cases from different centers. To identify the dose-prescription modality that better correlates with oncologic outcomes, future studies should guarantee a close uniformity of dose distribution between cases and complete dose parameters reporting for treatment volumes and OARs.

Delivery of magnetic resonance-guided single-fraction stereotactic lung radiotherapy.

Single-fraction stereotactic ablative radiotherapy (SABR) is an effective treatment for early-stage lung cancer, but concerns remain about the accurate delivery of SABR in a single session. We evaluated the delivery of single-fraction lung SABR using magnetic resonance (MR)-guidance. An MR-simulation was performed in 17 patients, seven of whom were found to be unsuitable, largely due to unreliable tracking of small tumors. Ten patients underwent single-fraction SABR to 34Gy on a 0.35T MR-linac system, with online plan adaptation. Gated breath-hold SABR was delivered using a planning target volume (PTV) margin of 5mm, and a 3mm gating window. Continuous MR-tracking of the gross tumor volume (GTVt) was performed in sagittal plane, with visual patient feedback provided using an in-room monitor. The real-time MR images were analyzed to determine precision and efficiency of gated delivery. All but one patient completed treatment in a single session. The median total in-room procedure was 120min, with a median SABR delivery session of 39min. Review of 7.4h of cine-MR imaging revealed a mean GTVt coverage by the PTV during beam-on of 99.6%. Breath-hold patterns were variable, resulting in a mean duty cycle efficiency of 51%, but GTVt coverage was not influenced due to real-time MR-guidance. On-table adaptation improved PTV coverage, but had limited impact on GTV doses. Single-fraction gated SABR of lung tumors can be performed with high precision using MR-guidance. However, improvements are needed to ensure MR-tracking of small tumors, and to reduce treatment times.

Lymphadenectomy is Unnecessary for Pure Ground-Glass Opacity Pulmonary Nodules.

Background: Lobectomy plus lymph node dissection is the standard treatment of early-stage lung cancer, but the low lymph node metastasis rate with ground-glass opacity (GGO) makes surgeons not perform lymphadenectomy. This study aimed to re-evaluate the lymph node metastasis rate of GGO to help make a clinical judgment. Methods: We performed this retrospective study to enroll patients who received lung cancer surgery from 2011 to 2016. Patient characteristics collected included tumor size, solid part size and lymph node metastasis rate. These patients were categorized into pure GGO and part solid GGO groups to undergo analysis. Results: Lymph node metastasis rates were 0%, 3.8% and 6.9% in order of the pure GGO group, the GGO predominant group and the solid predominant group. In the lobectomy patients, the solid predominant group still showed to have the highest lymph node metastasis rate and recurrence rate (8.3% and 10.1%). Conclusion: It is unnecessary to perform lymphadenectomy for patients with pure GGO in view of the 0% lymph node metastasis rate. The higher lymph node metastasis rate in the patients with the solid predominant group, 6.9%, suggested that surgeons should choose a rational lymphadenectomy method according to their GGO property and clinical judgment.

Prognosis and Risk Factors of Radiation-Induced Lymphopenia in Early-Stage Lung Cancer Treated With Stereotactic Body Radiation Therapy.

Background: To investigate the role of stereotactic body RT (SBRT) in decreased total peripheral lymphocyte count (TLC) in patients with early-stage lung cancer and to explore possible risk factors for RT-induced lymphopenia.Materials and Methods: We analyzed the TLCs and lymphocyte subsets of 76 patients in our prospective clinical database who received SBRT for early-stage lung cancer treatment. Relationships between clinical factors or dosimetric parameters and TLC were evaluated using Spearman's correlation analysis and Chi-square tests for continuous and categorical variables, respectively. Multivariate linear regression analysis was used to control for confounding factors. Kaplan–Meier analysis with a log-rank test and a multivariate Cox regression model were used for survival analysis.Results: Most patients (64/76, 84.2%) experienced decreased absolute lymphocyte counts following SBRT, as well as shifts in lymphocyte subset distributions. Spearman's correlation coefficients between post-SBRT TLC and the percentage of the lung and heart receiving 5 to 50 Gy (in 5 Gy increments) shown that most lung DVH parameters [V(10)-V(50)] were significantly negatively correlated with post-SBRT TLC, while only heart V(5), V(20), V(25), V(30), and V(45) were significant. Univariate analyses revealed that a lower Pre-SBRT TLC level, higher mean lung dose, longer treatment duration, and longer TBT were significantly associated with a lower Post-SBRT TLC level (all P < 0.05). Stepwise multivariate linear regression, which incorporated all of the significantly clinical variables and SBRT-related parameters in univariate analysis, revealed that lower pre -SBRT TLC (P < 0.001), higher heart V5 (P = 0.002), and longer total beam-on time (TBT) (P = 0.001) were the independent risk factors for decrease in post-SBRT TLC. Patients with lower post-SBRT TLC and longer TBT exhibited significantly inferior progression-free survival (PFS) (P < 0.001 and P = 0.013) and overall survival (P = 0.006 and P = 0.043).Conclusions: G2 and more severe lymphopenia after SBRT might be an independent prognostic factor for poorer outcome in early-stage lung cancer. Lowering heart V5 and TBT when designing SBRT plans may spare circulating lymphocytes and have the potential to further improve survival outcomes.

Current role of Uniportal Video Assisted Thoracic Surgery for lung cancer treatment

This article could help patients to understand how the UniVATS technique developed as part of the evolution of VATS, sharing its benefits and indications. Furthermore, patients would be able to understand technical aspects and the current applications of UniVATS for lung cancer treatment.

Imaging of Novel Oncologic Treatments in Lung Cancer Part 2: Local Ablative Therapies.

Conventional approaches to the treatment of early-stage lung cancer have focused on the use of surgical methods to remove the tumor. Recent progress in radiation therapy techniques and in the field of interventional oncology has seen the development of several novel ablative therapies that have gained widespread acceptance as alternatives to conventional surgical options in appropriately selected patients. Local control rates with stereotactic body radiation therapy for early-stage lung cancer now approach those of surgical resection, while percutaneous ablation is in widespread use for the treatment of lung cancer and oligometastatic disease for selected other malignancies. Tumors treated with targeted medical and ablative therapies can respond to treatment differently when compared with conventional therapies. For example, after stereotactic body radiation therapy, radiologic patterns of posttreatment change can mimic disease progression, and, following percutaneous ablation, the expected initial increase in the size of a treated lesion limits the utility of conventional size-based response assessment criteria. In addition, numerous treatment-related side effects have been described that are important to recognize, both to ensure appropriate treatment and to avoid misclassification as worsening tumor. Imaging plays a vital role in the assessment of patients receiving targeted ablative therapy, and it is essential that thoracic radiologists become familiar with these findings.

Near-infrared imaging for complex thoracoscopic resections

Lobectomy by video-assisted thoracic surgery (VATS) is now considered as a standard in the treatment of early-stage lung cancer with equivalent oncologic outcome as open lobectomy (1). Consequently, the widespread practice of thoracoscopic procedures pushed surgeons to perform more extended and complex resections. The feasibility of pulmonary segmentectomy, pneumonectomy, sleeve or carinal resections by VATS has been demonstrated in expert centers (2-4). However, the clinical and oncologic safety of such procedures has yet to be established.

Understanding patients’ values and preferences regarding early stage lung cancer treatment decision making

IntroductionWith advances in treatments among patients with lung cancer, it is increasingly important to understand patients’ values and preferences to facilitate shared decision making. MethodsProspective, multicenter study of patients with treated stage I lung cancer. At the time of study participation, participants were 4–6 months posttreatment. Value clarification and discrete choice methods were used to elicit participants’ values and treatment preferences regarding stereotactic body radiation therapy (SBRT) and surgical resection using only treatment attributes. ResultsAmong 114 participants, mean age was 70 years (Standard Deviation = 7.9), 65% were male, 68 (60%) received SBRT and 46 (40%) received surgery. More participants valued independence and quality of life (QOL) as “most important” compared to survival or cancer recurrence. Most participants (83%) were willing to accept lung cancer treatment with a 2% chance of periprocedural death for only one additional year of life. Participants also valued independence more than additional years of life as most (86%) were unwilling to accept either permanent placement in a nursing home or being limited to a bed/chair for four additional years of life. Surprisingly, treatment discordance was common as 49% of participants preferred the alternative lung cancer treatment than what they received. ConclusionsAmong participants with early stage lung cancer, maintaining independence and QOL were more highly valued than survival or cancer recurrence. Participants were willing to accept high periprocedural mortality, but not severe deficits affecting QOL when considering treatment. Treatment discordance was common among participants who received SBRT or surgery. Understanding patients’ values and preferences regarding treatment decisions is essential to foster shared decision making and ensure treatment plans are consistent with patients’ goals. Clinicians need more resources to engage in high quality communication during lung cancer treatment discussions.

National practice trends for the surgical management of lung cancer in the CMS population: an atlas of care.

Video-assisted thoracoscopic surgery (VATS) has been established as a safe and effective alternative to an open approach for the treatment of early-stage lung cancer. Despite this, differences in utilization across the nation are present. The aims of this study were to: (I) characterize trends in the use of open surgery and VATS for the management of lung cancer across the United States, and (II) describe if particular regions of the country utilize minimally invasive surgery more frequently. We studied all Medicare beneficiaries from the ages of 65 to 99 years with full Part A and B coverage and no HMO coverage for the years of 2006 and 2014 (the most recent year available at the time of this analysis). Beneficiaries with a diagnosis of lung cancer (ICD-9 codes: 162.0 162.2 162.3 162.4 162.5 162.8 162.9) were selected. Rates of thoracoscopic surgery (CPT codes: 32663, 32666, 32667, 32668, 32669, 32670, 32671) and open lung resections (32505, 32506, 32507, 32608, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488) were calculated by year and region. Rates in 2006 and 2014 with descriptive statistics and a univariate analysis were performed using Student's t-test and chi-square, as appropriate. A two-sided P value <0.05 was considered statistically significant. A total of 24,368,333 and 23,921,059 beneficiaries for the years of 2006 and 2014 were analyzed. A diagnosis of lung cancer was detected in claims of 167,418 patients (0.7%) in 2006 and 167,506 patients in 2014 (0.7%), which was not significantly different (P=0.7). Among these lung cancer patients, a surgical intervention was performed in 17,249 patients (10.3%) during 2006 and 18,603 patients (11.1%) in 2014 (P=0.01). Among those undergoing surgery, a VATS approach was performed in 2,512 patients (15%) during 2006 and 9,578 patients (54%) during 2014 (P=0.001). In 2006, California, New York, and New Jersey performed the most VATS procedures, in comparison to 2014, when New York, Florida, and California performed the highest number of VATS procedures. While the prevalence of lung cancer in the United States was unchanged between 2006 and 2014, the use of VATS techniques increased five-fold. Further studies to better understand the adoption or availability of new surgical techniques in lung cancer populations across geographic regions and patient populations are necessary.

Risk-adapted stereotactic ablative radiotherapy for central and ultra-central lung tumours

BackgroundSABR is a widely accepted treatment for early-stage lung cancer but there are safety concerns for central and ultra-central tumours. Herein we report our experience using risk-adapted fractionation (prescribed doses: 40–60 Gy in 3–8 fractions) with prioritization of dose to organs at risk. MethodsPatient declining or unsuitable for surgery with primitive or recurrent lung cancer were included. Tumours inside a 2 cm area around proximal bronchial tree (PBT) were classified as central while tumours with PTV overlapping PBT, oesophagus, great vessels and pericardial pleura were classified as ultra-central. We assessed overall survival (OS), disease-free survival (DFS), local control (LC) and toxicities. ResultsFrom 2009 to 2016, 137 patients were treated (median age: 75 years), with 60 central and 77 ultra-central tumours. Median follow-up was 36 months. Median tumour size, GTV and PTV were 2.5 cm (0.9–7), 7.8 cm3 (0.7–94.2) and 30.6 cm3 (6.5–274.3), respectively. For the whole population, median OS and DFS were 46 months and 33 months. One- and 2-years LC rates were 95% and 81%. Median OS between central and ultra-central tumours was statistically different with 57 vs 37 months (HR 0.48, p = 0.017), but LC was not different among them. We observed 4 Grade 3 and 6 Grade 5 toxicities (no grade 4). ConclusionsSABR for central and ultra-central tumours is associated with good OS, DFS and LC rates, with 7.3% grade 3–5 toxicities. Central tumours had a better prognosis in our cohort.