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S. Ishikura
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P2.05 - Poster Session with Presenters Present (ID 463)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Radiotherapy
- Presentations: 1
- Moderators:
- Coordinates: 12/06/2016, 14:30 - 15:45, Hall B (Poster Area)
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P2.05-050 - Impact of Inflammation and Sarcopenia on Outcomes after Stereotactic Body Radiotherapy for T1N0M0 Non-Small Cell Lung Cancer (ID 4059)
14:30 - 15:45 | Author(s): S. Ishikura
- Abstract
Background:
The purpose was to evaluate impact of systemic inflammation and sarcopenia on outcomes after stereotactic body radiotherapy (SBRT) for T1N0M0 non-small cell lung cancer (NSCLC) as a supplementary analysis of Japan Clinical Oncology Group (JCOG) study JCOG0403.
Methods:
Pretreatment serum C-reactive protein (CRP) was used as a marker for systemic inflammation. Patients were divided into high and low CRP groups with a threshold value of 0.3 mg/dL. Paraspinous musculature area (PMA) at a level of the 12th thoracic vertebra was measured on simulation CT with thresholding Hounsfield Units between -29 and 150. When PMA was lower than the gender-specific median, the patient was classified as sarcopenia. Toxicities, overall survival (OS) and cumulative incidence of cause-specific death were compared between groups. Kaplan-Meier method and cumulative incidence function were applied to estimate proportion of OS and cumulative incidence of cause-specific death, respectively.
Results:
Of 169 patients enrolled into JCOG0403, 60 operable and 92 inoperable patients were included into this study after excluding 5 patients ineligible for JCOG0403 and 12 patients whose simulation CT images were unavailable or unsuitable for the PMA measurement. Forty-two patients were classified as high CRP. Medians of PMA were 31.6 cm[2] (range, 12.6-52.9) and 25.1 cm[2] (range, 3.4-38.5) in male and female, respectively. Proportions of toxicities Grade 3-4 were 19.1% and 10.9% in the high and low CRP groups; and 17.1% and 9.2% in the sarcopenia and non-sarcopenia groups, respectively. In the operable patient cohort, OS significantly differed between the CRP groups (log-rank test P=0.009; hazard ratio of high CRP 2.43, 95% confidence interval 1.23-4.80; 3-year OS of 58.8% and 83.6% for high and low CRP, respectively). This difference in OS was mainly contributed by difference in lung cancer death (Gray’s test P=0.070; 3-year cumulative incidence of 29.4% and 7.1%, respectively). No impact of sarcopenia on OS was observed in operable patients. In the inoperable patient cohort, OS did not differ between the CRP groups (log-rank test P = 0.925). No significant difference was observed in OS between the sarcopenia groups, either.
Conclusion:
The present study suggests that systemic inflammation may provide prognostic information for operable patients receiving SBRT for early-stage NSCLC. Further studies are warranted to confirm these findings.
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YI02 - Basics of Radio-Oncology (ID 406)
- Event: WCLC 2016
- Type: Young Investigator Session
- Track: Radiotherapy
- Presentations: 1
- Moderators:C. Faivre-Finn, R. Lewensohn
- Coordinates: 12/07/2016, 14:30 - 15:45, Strauss 1
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YI02.02 - Modern Treatment Techniques in Lung Cancer: The Advantages of Conformal Radiotherapy, IMRT and Proton Therapy (ID 6911)
14:30 - 15:45 | Author(s): S. Ishikura
- Abstract
- Presentation
Abstract:
As technology has advanced, modern radiotherapy (RT) techniques, such as conformal radiotherapy (CRT), intensity-modulated radiation therapy (IMRT), and proton therapy (PT), have become available. In this session, the advantages of these techniques in the treatment of early-stage and locally-advanced lung cancer will be presented, along with their uncertainties. Conformal RT uses CT scans to create 3-dimensional images of the tumor and normal tissues, which leads to more accurate treatment planning. It also uses multiple radiation beams from various angles to concentrate the radiation dose to the tumor while reducing the dose to normal tissues. Furthermore, conformal RT improves tumor control and reduces toxicity compared to 2-dimensional RT (1). IMRT is a sophisticated form of CRT, which enables us to more exactly concentrate and shape the dose distribution to the tumor and spare normal tissues. It can also partially intensify doses to individual areas deemed to be more aggressive or radioresistant. PT uses charged particles, which have a unique physical characteristic called the Bragg peak. The Bragg peak describes a certain tissue depth at which the protons stop just after transferring most of their energy. This feature is particularly convenient for tumors located close to critical normal tissues. PT is commonly adopted for pediatric, central nervous system, and intraocular malignancies. Stereotactic body radiation therapy (SBRT), also called stereotactic ablative radiation therapy (SABR), is characterized by accurate target definition, precise tumor positioning, steep dose gradients outside targets, and very high dose per fraction. SBRT can be delivered using either CRT or IMRT. In the treatment of peripheral early-stage lung cancer, SBRT is widely adopted as a standard treatment and is considered better than conventional fractionated RT. PT can also be used in this setting, despite similar outcomes as SBRT (2); however, a recent systematic review of cost-effectiveness analyses did not support the use of PT (3). To improve outcomes in locally-advanced lung cancer, IMRT and PT have been actively investigated. Several in silico studies have suggested the superiority of IMRT over CRT, and PT over IMRT, but this remains to be demonstrated clinically. Subgroup analyses of RTOG 0617, which compared a high dose (74 Gy) vs. a standard dose (60 Gy) and allowed both CRT and IMRT, showed similar efficacy, less radiation pneumonitis, and better compliance of consolidative chemotherapy favoring IMRT over CRT, despite there being more advanced cases in the IMRT group (4). The study authors generated a hypothesis that dose intensification by IMRT may result in better efficacy with less toxicity. However, we could not determine the true difference between IMRT and CRT among patients who received the standard dose, which is our current practice, because their analysis included both high- and standard-dose arms; the differences might be more prominent in the high-dose arm. These investigators also suggested that increasing the radiation dose to the heart may worsen survival, so dose constraints to the heart became stricter thereafter. Results of a Bayesian phase II randomized trial of IMRT vs. PT were reported at the ASCO Annual Meeting earlier this year (5). The primary endpoint was incidence and time to protocol failure, defined as Grade 3 or higher pneumonitis or local failure. The observed local failure rates at 12 months were similar (13% vs. 12%). The investigators assumed Grade 3 or higher pneumonitis of 15% in the IMRT arm and 5% in the PT arm; however, they observed 6.5% in the IMRT arm, which was lower than the assumed probability, and 10.5% in the PT arm, higher than expected. Because this was a phase II trial with some limitations, firm conclusions could not be drawn. However, PT failed to suggest a clinical benefit over IMRT. A meta-analysis of the phase III trials conducted by the Radiation Therapy Oncology Group between 1968 and 2002 showed that new treatments were demonstrated to be better than existing ones in only 6 of 59 comparisons. In addition, overall survival of all of the accrued patients did not differ between groups, while the odds ratio of 1.76 for treatment-related death was significantly higher for the new treatments (6). These results clearly showed that “New is not always better.” We need to identify the subpopulations for whom new techniques are more effective and to demonstrate these have true value with scientifically strong evidence, instead of just believing in their efficacy, complaining about the challenges associated with evaluating them, or advertising them directly to patients. Figure 1 References 1. Chen AB, Neville BA, Sher DJ, et al. Survival outcomes after radiation therapy for stage III non-small-cell lung cancer after adoption of computed tomography-based simulation. J Clin Oncol 2011;29:2305-2311 2. Grutters JP, Kessels AG, Pijls-Johannesma M, et al. Comparison of the effectiveness of radiotherapy with photons, protons and carbon-ions for non-small cell lung cancer: a meta-analysis. Radiother Oncol 2010;95:32-40 3. Verma V, Mishra MV, Mehta MP. A systematic review of the cost and cost-effectiveness studies of proton radiotherapy. Cancer 2016;122:1483-1501 4. Chun SG, Hu C, Choy H, et al. Outcomes of intensity modulated and 3D-conformal radiotherapy for stage III non-small cell lung cancer in NRG Oncology/RTOG 0617. J Thorac Oncol 2015;10:S213 5. Liao ZX, Lee JJ, Komaki R, et al. Bayesian randomized trial comparing intensity modulated radiation therapy versus passively scattered proton therapy for locally advanced non-small cell lung cancer. J Clin Oncol 2016;34 (suppl; abstr 8500) 6. Soares HP, Kumar A, Daniels S, et al. Evaluation of new treatments in radiation oncology: are they better than standard treatments? JAMA 2005;293:970-978
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