Guideline for Radiotherapy with Curative Intent in Patients with Early-Stage Medically Inoperable Non-Small-Cell Lung Cancer

Abstract

Objectives For this guideline, we investigated the effectiveness of radiotherapy with curative intent in medically inoperable patients with early-stage non-small-cell lung cancer (nsclc). MethodsThe guideline was developed by Cancer Care Ontario's Program in Evidence-Based Care and by the Lung Cancer Disease Site Group through a systematic review of mainly retrospective studies, expert consensus, and formal internal and external reviews. Recommendations■ Stereotactic body radiation therapy (sbrt) with curative intent is an option that should be considered for patients with early-stage, node-negative, medically inoperable nsclc. Qualifying Statements ■Because of the high dose per fraction, the planning process and treatment delivery for sbrt require the use of advanced technology to maintain an appropriate level of safety. Consistent patient positioning and 4-dimensional analysis of tumour and critical structure motion during simulation and treatment delivery are essential. ■Preliminary results for proton-beam therapy have been promising, but the technique requires further clinical study.■ Recommended fractionation schemes for sbrt should result in a biologically effective dose of 100 or greater by the linear quadric model, choosing an α/β value of 10 [bed 10(LQ) ≥ 100]. Qualifying Statements ■Because of the increased risk of treatment-related adverse events associated with centrally located tumours, consideration of tumour size and proximity to critical central structures is required when determining the dose and fractionation. ■Examples of dose-fractionation schemes used in the included studies have been provided. ■Based on the current evidence and the opinion of the authors, radiation doses at bed 10(LQ) greater than 146 might significantly increase toxicity and should be avoided. ■Determination of the radiation bed by the linear quadratic model has limitations for the extreme hypofractionated schemes used in sbrt.

Jumonji Inhibitors Overcome Radioresistance in Cancer through Changes in H3K4 Methylation at Double-Strand Breaks

“…Current regimens for radiation therapy employ radiation alone or concurrent with cycles of standard chemotherapy ( Das et al, 2010 ; Song et al, 2014 ). This is often limited by toxicity to normal tissues and is complicated by the development of resistance ( Anscher, 2010 ; Crinó et al, 2010 ; Eberhardt et al, 2006 ; Falkson et al, 2017 ; Howington et al, 2013 ). Although the use of targeted therapies to radiosensitize is not yet current practice, DNA repair inhibitors, for example, have been tested in preclinical models and show efficacy ( Gil del Alcazar et al, 2014 , 2016 ; Provencio and Sa´ nchez, 2014 ; Tofilon and Camphausen, 2009 ).…”

Dosimetric comparison of CT-guided iodine-125 seed stereotactic brachytherapy and stereotactic body radiation therapy in the treatment of NSCLC

“…SBRT has evolved to become a standard option for the treatment of inoperable early stage NSCLC. It is noninvasive and mature, and most of the existing literature uses this technique[ 3 – 7 ]. Recently, some researchers reported that SBT is also a safe and effective modality for the treatment of inoperable early stage NSCLC[ 8 – 10 ].…”

“…Surgery is usually the standard option for the treatment of localized cancers, but not all patients with operable non-small cell lung cancer (NSCLC) are candidates for surgery[ 2 ]. Stereotactic body radiation therapy (SBRT), which delivers an ablative dose of radiation over a short period of time, has emerged to become a major noninvasive option for the treatment of early stage NSCLC[ 3 – 7 ]. This therapy is noninvasive and well-studied, and has high local control rates.…”

Prognostic Factors for Overall and Disease-specific Survival of Stage I Non-Small-Cell Lung Cancer after Stereotactic Body Radiotherapy: A Retrospective Analysis

“…The guidelines for radiotherapy with curative intent in patients with early-stage medically inoperable NSCLC recommend BED10 ≥ 100 Gy 4) . Even in the present study, decreases in LR and RR and improvement in DSS were observed with BED10 > 100 Gy.…”

“…Compared to surgical resection, SBRT is minimally invasive, and a complete cure can be expected. As such, it may be appropriately indicated for inoperable stage I NSCLC 4) . Furthermore, OS comparable to that achieved with surgical resection was reported in a prospective study including operable cases 5) .…”