Evidence-based clinical recommendations for hypofractionated radiotherapy: exploring efficacy and safety - Part 2. Lung (non-small cell lung cancer).

Several recent studies have investigated the use of hypofractionated radiotherapy (HFRT) for various cancers. However, HFRT for non-small cell lung cancer (NSCLC) with or without concurrent chemotherapy is not yet widely used because of concerns about serious side effects and the lack of evidence for improved treatment results. Investigations of HFRT with concurrent chemotherapy in NSCLC have usually been performed in single-arm studies and with a small number of patients, so there are not yet sufficient data. Therefore, the Korean Society for Radiation Oncology Practice Guidelines Committee planned this review article to summarize the evidence on HFRT so far and provide it to radiation oncology clinicians. In summary, HFRT has demonstrated promising results, and the reviewed data support its feasibility and comparable efficacy for the treatment of locally advanced NSCLC. The incidence and severity of esophageal toxicity have been identified as major concerns, particularly when treating large fraction sizes. Strategies, such as esophagus-sparing techniques, image guidance, and dose constraints, may help mitigate this problem and improve treatment tolerability. Continued research and clinical trials are essential to refine treatment strategies, identify optimal patient selection criteria, and enhance therapeutic outcomes.

Correction: Sung et al. Linear Tumor Regression of Rectal Cancer in Daily MRI during Preoperative Chemoradiotherapy: An Insight of Tumor Regression Velocity for Personalized Cancer Therapy. Cancers 2022, 14, 3749.

In the original publication [...].

Evidence-based clinical recommendations for hypofractionated radiotherapy: exploring efficacy and safety - Part 1. Brain and head and neck.

Advances in radiotherapy (RT) techniques, including intensity-modulated RT and image-guided RT, have allowed hypofractionation, increasing the fraction size over the conventional dose of 1.8-2.0 Gy. Hypofractionation offers advantages such as shorter treatment times, improved compliance, and under specific conditions, particularly in tumors with a low α/ß ratio, higher efficacy. It was initially explored for use in RT for prostate cancer and adjuvant RT for breast cancer, and its application has been extended to various other malignancies. Hypofractionated RT (HFRT) may also be effective in patients who are unable to undergo conventional treatment owing to poor performance status, comorbidities, or old age. The treatment of brain tumors with HFRT is relatively common because brain stereotactic radiosurgery has been performed for over two decades. However, re-irradiation of recurrent lesions and treatment of elderly or frail patients are areas under investigation. HFRT for head and neck cancer has not been widely used because of concerns regarding late toxicity. Thus, we aimed to provide a comprehensive summary of the current evidence for HFRT for brain tumors and head and neck cancer and to offer practical recommendations to clinicians faced with the challenge of choosing new treatment options.

Hypofractionated Partial Breast Irradiation With Intensity-Modulated Radiotherapy in Early Breast Cancer or Carcinoma In Situ: An Investigational Short-Term Analysis.

PURPOSE: This study aimed to analyze the treatment outcomes and adverse effects of moderately hypofractionated partial breast irradiation (PBI) in patients with early breast cancer. METHODS: In total, 473 patients with early breast cancer or carcinoma in situ were diagnosed with Tis or T1N0 disease and underwent PBI following breast-conserving surgery. All histologic tumor types, close surgical margins within 1 mm of the tumor, and multifocal tumors were included in this study. A radiation dose of 50 Gy in 20 fractions was delivered over 4 weeks using intensity-modulated radiotherapy technique. Dosimetric data, recurrence patterns, survival outcomes, and adverse events were retrospectively analyzed. RESULTS: During a median follow-up of 28.9 months, seven patients (1.5%) experienced ipsilateral breast tumor recurrence (IBTR). Two patients had regional recurrence, four patients developed contralateral breast cancer, and no distant metastases were observed. The locoregional recurrence rate in the ipsilateral breast was 1.8%. Two deaths occurred during the follow-up period, but were not attributed to breast cancer. The 2-year disease-free survival and 2-year overall survival rates were was 94.0% and 99.8%, respectively. Acute adverse events occurred in 131 patients (27.1%), and were distributed among all grades, with only two patients (0.4%) experiencing grade 3 events. Late adverse events were noted in 16 patients (3.4%), and were distributed among all grades, including grade 3 events in four patients (0.8%). No grade 4 or 5 events were observed. CONCLUSION: Hypofractionated PBI demonstrated favorable IBTR rates in patients with early breast cancer, with low incidence of acute and late toxicities in the short-term analysis.

The Effect of Intervention for Improving Colonoscopy Quality Is Associated with the Personality Traits of Endoscopists.

Background/Aims: This study investigated whether the personality traits of endoscopists are associated with the effect of interventions for the improvement of colonoscopy quality. Methods: This prospective, multicenter, single-blind study was performed with 13 endoscopists in three health screening centers over a 12-month period. Quality indicators (QIs), including adenoma detection rate (ADR), polyp detection rate (PDR), and withdrawal time, were measured every 3 months. Consecutive interventions for the improvement of colonoscopy quality were conducted every 3 months, which included the personal notification of QIs, the in-group notification of QIs, and finally a targeted "quality education" session. The personality traits of each endoscopist were evaluated for perfectionism, fear of negative evaluation, and cognitive flexibility after the last QI assessment. Results: A total of 4,095 colonoscopies were evaluated to measure the QIs of the individual endoscopists for 12 months. The mean ADR, PDR, and withdrawal time of the 13 endoscopists were 32.3%, 47.7%, and 394 seconds at baseline and increased to 39.0%, 55.1%, and 430 seconds by the end of the study (p=0.003, p=0.006, and p=0.004, respectively). Among the three interventions, only quality education significantly improved QIs: ADR, 36.0% to 39.0% (odds ratio, 1.28; 95% confidence interval, 1.01 to 1.63). The improvement of ADR and PDR by education was significantly associated with perfectionism (r=0.617, p=0.033 and r=0.635, p=0.027, respectively) and fear of negative evaluation (r=0.704, p=0.011 and r=0.761, p=0.004, respectively). Conclusions: Education can improve colonoscopy quality, and its effect size is associated with an endoscopist's personal traits such as perfectionism and fear of negative evaluation (Clinical-Trials.gov Registry NCT03796169).

One-Week versus Two-Week Chemoradiotherapy Followed by Curative Surgery in Rectal Cancer: Long-Term Comparative Pooled Analysis of Two Prospective Multicenter Phase II Trials.

PURPOSE: The optimal short-course chemotherapeutic regimen for rectal cancer has not been clearly defined until now. KROG 10-01 and KROG 11-02 prospective trials investigated the efficacy and safety of 1- and 2-week chemoradiotherapy (CRT), respectively. Materials and Methods: Patients eligible for KROG 10-01 and KROG 11-02 involved those with clinical T3-4N0-2M0 rectal cancers. They received preoperative CRT and total mesorectal excision. Patients in KROG 10-01 received radiation of 25 Gy in 5 fractions during 1 week with 5-fluorouracil/leucovorin. Patients in KROG 11-02 received radiation of 33 Gy in 10 fractions for 2 weeks with oral capecitabine. RESULTS: A total of 150 patients consisting of 70 patients from KROG 10-01 and 80 patients from KROG 11-02 were collectively analyzed. With a median follow-up time of 89.2 months, the 5-year overall survival rate was 86.5% in 1-week CRT and 85.3% in 2-week CRT (p=0.841). The 5-year recurrence-free survival rate was 83.5% in 1-week CRT and 77.1% in 2-week CRT (p=0.448). One patient (1.4%) in 1-week CRT and 11 patients (13.8%) in 2-week CRT exhibited pathologic complete regression (ypT0N0M0) after radiotherapy (p=0.006). One-week CRT had significantly higher acute hematologic (12.8% vs. 3.8%, p=0.040) and nonhematologic (38.6% vs. 16.3%, p=0.002) toxicity than 2-week CRT. CONCLUSION: Both 1- and 2-week schedules of CRT showed favorable survival outcomes after 7 years of follow-up. But, 2-week course achieved more increased tumor response and decreased acute toxicity than 1-week course.

Quality Assessment and Trend for Breast Cancer Treatment Practice across South Korea Based on Nationwide Analysis of Korean Health Insurance Data during 2013-2017.

PURPOSE: Quality assessment of breast cancer treatment in South Korea showed the upward standardization of the grade since 2013, but treatment disparities still have existed. This study analyzed the five year trend between 2013 and 2017 in the assessment of breast cancer treatment practice using the Korean health insurance data. Materials and Methods: All the medical records including surgery, chemotherapy, and radiotherapy for 7,354 patients a year on average were evaluated. Twenty indices were consisted of one structural, 17 process-related, and 2 result-related factors. We calculated the coefficient of variation (CV) annually to determine the variation in adherence rate of evaluation indices according to the type of institution (advanced vs. general hospital vs. clinic). RESULTS: Based on the initial assessment in 2013, 10 out of 20 indicators showed significant variation among the types of institutions with a CV of less than 0.1%. Six of them had a CV decline of less than 0.1%. The CV was still 0.1% or higher in the four indicators, including the composition of professional staff, the implementation of target therapy, the average length of hospital stay, and the hospitalization cost. Regarding the first-grade of assessment, there was a statistically significant relationship between the institution type (p=0.029) and region (metropolitan vs. province, p<0.001). CONCLUSION: There were disparities in the structural and systemic treatment factors depending on the institutional type. The quality improvement of the regional institutions and multidisciplinary experts for breast cancer is necessary.

Pathologic Implications of Radial Resection Margin and Perineural Invasion to Adjuvant Chemotherapy after Preoperative Chemoradiotherapy and Surgery for Rectal Cancer: A Multi-Institutional and Case-Matched Control Study.

We assessed the exact role of adjuvant chemotherapy after neoadjuvant chemoradiotherapy (CRT) and surgery in rectal cancer patients with positive surgical margin or perineural invasion (PNI). This multi-institutional study included 1799 patients with rectal cancer at cT3-4N0-2M0 stages. Patients were divided into two groups. The high-risk group had a positive margin and/or perineural invasion. The low-risk group showed no positive margin or PNI. Propensity-score matching analysis was performed, and a total of 928 patients, with 464 in each arm, were evaluated. The high-risk group showed significant differences in overall survival (OS, 73.4% vs. 53.9%, p < 0.01) and recurrence-free survival (RFS, 52.7% vs. 40.9%, p = 0.01) at five years between the adjuvant chemotherapy arm and observation arm. The low-risk group showed no significant differences in 5-year OS (p = 0.61) and RFS (p = 0.75) between the two arms. Multivariate analyses showed that age, pathologic N stage, and adjuvant chemotherapy were significantly correlated with OS and RFS in the high-risk group (all p < 0.05). Adjuvant chemotherapy improved OS and RFS more significantly in rectal cancer patients with positive surgical margin or PNI than in those with negative surgical margin and PNI.

Current Evidence of a Deintensification Strategy for Patients with HPV-Related Oropharyngeal Cancer.

Human papillomavirus (HPV)-related oropharyngeal cancer differs from HPV-negative oropharyngeal cancer in terms of etiology, epidemiology, and prognosis. Younger and lower comorbidity patient demographics and favorable prognosis allow HPV-related oropharyngeal cancer patients to anticipate longer life expectancy. Reducing long-term toxicities has become an increasingly important issue. Treatment deintensification to reduce toxicities has been investigated in terms of many aspects, and the reduction of radiotherapy (RT) dose in definitive treatment, replacement of platinum-based chemotherapy with cetuximab, response-tailored dose prescription after induction chemotherapy, and reduction of adjuvant RT dose after transoral surgery have been evaluated. We performed a literature review of prospective trials of deintensification for HPV-related oropharyngeal cancer. In phase II trials, reduction of RT dose in definitive treatment showed comparable survival outcomes to historical results. Two phase III randomized trials reported inferior survival outcomes for cetuximab-based chemoradiation compared with cisplatin-based chemoradiation. In a randomized phase III trial investigating adjuvant RT, deintensified RT showed noninferior survival outcomes in patients without extranodal extension but worse survival in patients with extranodal extension. Optimal RT dosage and patient selection require confirmation in future studies. Although many phase II trials have reported promising outcomes, the results of phase III trials are needed to change the standard treatment. Since high-level evidence has not been established, current deintensification should only be performed as part of a clinical study with caution. Implementation in clinical practice should not be undertaken until evidence from phase III randomized trials is available.

Linear Tumor Regression of Rectal Cancer in Daily MRI during Preoperative Chemoradiotherapy: An Insight of Tumor Regression Velocity for Personalized Cancer Therapy.

Objective: Neoadjuvant chemoradiotherapy (CCRT) is current standards of care for locally advanced rectal cancer. The precise and thorough investigation of a tumor during the full course of CCRT by means of daily MRI can provide an idea on real-time treatment sensitivity in addition to tumor biology. Tumor volumetry from daily MRI during CCRT may allow patient-driven treatment decisions. Material and Methods: Patients diagnosed with cT3-4 and/or cN+ rectal adenocarcinoma undergoing preoperative CCRT with capecitabine on the pelvis up to 50 Gy in 25 daily fractions from November 2018 to June 2019 were consecutively included. Rectal tumor volume was uniformly measured by a single physician (YKK) in daily 0.35T MRI obtained with MR-guided linear accelerator. Primary endpoint was to assess the pattern of tumor volume regression throughout the full course of CCRT using daily registration MRI. Secondary endpoint was to assess the effect of tumor regression velocity on disease-free survival (DFS). Tumor regression velocity (cc) per fraction of each patient was calculated using the simple regression analysis of tumor volumes from fraction 1 to fraction 25. Results: Twenty patients were included. Daily tumor volumetry demonstrated linear tumor regression during CCRT. The tumor regression velocity of all 20 patients was 2.40 cc per fraction (R2 = 0.93; p < 0.001). The median tumor regression velocity was 1.52 cc per fraction. Patients with tumor regression velocity ≥ 1.52 cc per fraction were grouped as rapid regressors (N = 9), and those with tumor regression velocity < 1.52 cc per fraction were grouped as slow regressors (N = 11). Rapid regressors had greater tumor regression velocity (4.58 cc per fraction) compared to that of slow regressors (0.78 cc per fraction) with statistical significance (p < 0.001). The mean DFS of rapid regressors was 36.8 months, numerically longer than the 31.9 months of slow regressors (p = 0.400) without statistical significance. Rapid regressors had numerically superior DFS rate compared to slow regressors without statistical significance. The 2-year DFS was 88.9% for rapid regressors and 72.7% for slow regressors, respectively (p = 0.400). Conclusion: This study is the first observation of linear tumor regression in daily MRI during the preoperative CCRT of locally advanced rectal cancer. Daily tumor regression velocity discriminated DFS, although without statistical significance. This study with a phenomenal approach is hypothesis-generating. Nevertheless, the potential of CCRT from therapeutics to a newer level, the "theranostics", has been inceptively suggested. Further validation studies for the value of daily tumor volumetry on treatment decisions are warranted.

A Differential Diagnosis of Unusual Gastric Ulcer.

The endoscopic findings of diffuse large B cell lymphoma have various presentations. In our case, the patient had developed multiple elevated central ulceration lesions, and the peripheral elevated portion had a heaped-up margin. The margin had a sharp, smooth edge that was not infiltrative and could be confused with a simple gastric ulcer. Endoscopists should be aware of the possibility of multiple lymphoma ulcers with heaped-up margins. We present some unusual endoscopic features of lymphoma, which are easily misdiagnosed as gastric ulcers.

Unexpected Movement of the Esophagus across the Aorta.

Tumor regression throughout treatment would induce organ movement, but little is known of this in the esophagus. To achieve successful tumor regression, radiation therapy requires several weeks of radiation to be delivered accurately to the tumor. Usually, a 5-10 mm margin is allowed for set-up error and internal organ motion. Our case exhibited an unexpectedly large movement of the esophagus across the aorta with tumor regression that extended outside the margin and thus outside the radiotherapy field. These movements may affect subsequent invasive procedures or treatment during cancer therapy. After the unexpected large movement of the esophagus due to tumor regression, we revised the radiotherapy plan to reflect the new esophageal position. This implied that regular imaging and close monitoring are required during treatment of esophageal cancer.

Colonoscopy decreases mortality in colorectal cancer patients compared with fecal immunochemical test.

BACKGROUND AND AIM: Colonoscopy and fecal immunochemical test (FIT) are commonly used screening methods for the detection of colorectal cancer (CRC), but their effects on survival have not been compared. We compared survival outcomes in patients with CRC according to the exposure history to colonoscopy or FIT before diagnosis of CRC. METHODS: We performed a nationwide population-based retrospective cohort study using Korean national-insurance claims data. In total, 24 875 patients with CRC diagnosed in 2012 were included. The patients were divided into three groups in terms of examinations performed during the 10 years prior to CRC diagnosis: the colonoscopy group, the FIT group, and the never-screened group. Survival outcomes were compared among the three groups. The colonoscopy group and FIT group were matched using propensity score-matching method. RESULTS: The cohort consisted of 9619 patients in the colonoscopy group, 6936 patients in the FIT group, and 8320 patients in the never-screened group. The 5-year overall survival rates were 74.1% in the colonoscopy group, 65.9% in the FIT group, and 59.6% in the never-screened group (P < 0.001). The adjusted hazard ratios for death were 0.56 (95% confidence interval [CI], 0.53-0.59) in the colonoscopy group and 0.78 (95% CI, 0.74-0.82) in the FIT group compared with the never-screened group. In the matched cohort, the adjusted hazard ratios for death was 0.76 (95% CI, 0.72-0.81) in the colonoscopy group compared with the FIT group. CONCLUSION: Colonoscopy is a more effective method for reducing mortality in patients with CRC compared with FIT.

Multidisciplinary treatment with immune checkpoint inhibitors for advanced stage hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is a cytotoxic chemotherapy-resistant tumor and most HCCs arise in a background of liver cirrhosis of various causes. Although the IMBrave150 trial showed remarkable advancements in the treatment of unresectable HCC with atezolizumab plus bevacizumab (AteBeva), therapeutic outcomes were unsatisfactory in more than half of the patients. Accordingly, many ongoing trials combine conventional modalities with new drugs such as immune checkpoint inhibitors for better treatment outcomes, and they are expected to benefit patients with limited responses to conventional treatment. Here, two patients with advanced stage HCC with preserved liver function and good performance status showed partial response after treatment with combination or sequential therapy of AteBeva, hepatic arterial infusion chemotherapy, radiation therapy, and transarterial chemoembolization. These findings indicate the efficacy of multidisciplinary treatment against advanced HCC. Additional studies are required to establish optimal treatment strategies.

Efficacy of concurrent chemoradiotherapy for patients with limited-disease small-cell lung cancer: a retrospective, nationwide, population-based cohort study.

BACKGROUND: Small-cell lung cancer (SCLC) is a highly proliferative, rapidly growing tumor with a poor prognosis, even in cases of limited disease (LD). Timely and accurate high-intensity therapy is necessary. For concurrent chemoradiotherapy (CCRT), etoposide/platinum (EP)-based regimens are recommended, although irinotecan/platinum (IP)-based regimens are also effective with radiotherapy. This large-scale, retrospective, nationwide cohort study aimed to analyze the efficacy of CCRT in patients with LD-SCLC. METHODS: Population data registered between January 2008 and December 2018 was extracted from the Health Insurance Review and Assessment Service of Korea database. Survival outcomes of 4446 LD-SCLC patients who received CCRT were analyzed. RESULTS: Patients who received EP-CCRT (n = 4187) showed better time to first subsequent therapy (TFST: 11.2 months) and overall survival (OS: 22.2 months) than those who received IP-CCRT (n = 259; TFST: 9.6 months, P = 0.0477; OS: 16.4 months, P <  0.0001). When CCRT failed, dual-agent chemotherapy (n = 925; OS: 9.1 months) provided a better survival benefit than single-agent chemotherapy (n = 815; OS: 7.5 months). IP-based chemotherapy resulted in better OS (9.6 months) than EP-based chemotherapy (7.1 months, P = 0.017) in platinum-resistant relapsed patients; the opposite was observed for platinum-sensitive relapsed patients (OS: EP, 17.2 months; IP, 6.6 months; P <  0.0001). Poisson regression analysis demonstrated that age, EP-CCRT, and hypercholesterolemia retained significant associations with OS after adjustment for all variables. CONCLUSION: In the Korean population, the effects of EP-CCRT on OS and TFST are significantly more favorable than those of IP-CCRT.

Treatment Outcomes of 9,994 Patients With Extensive-Disease Small-Cell Lung Cancer From a Retrospective Nationwide Population-Based Cohort in the Korean HIRA Database.

To investigate the efficacy of irinotecan-based (IP) and etoposide-based (EP) platinum combinations, and of single-agent chemotherapy, for treatment of extensive-disease small cell lung cancer (ED-SCLC), we performed a large-scale, retrospective, nationwide, cohort study. The population data were extracted from the Health Insurance Review and Assessment Service of Korea database from January 1, 2008, to November 30, 2016. A total of 9,994 patients were allocated to ED-SCLC and analyzed in this study. The primary objectives were to evaluate the survival outcomes of systemic first-line treatments for ED-SCLC. For first-line treatment, patients who received IP showed a better time to first subsequent therapy (TFST) of 8.9 months (95% confidence interval [CI], 8.50-9.40) than those who received EP, who had a TFST of 6.8 months (95% CI, 6.77-6.97, P < 0.0001). In terms of overall survival (OS), IP was superior to EP (median OS, 10.8 months; 95% CI, 10.13-11.33 vs. 9.5 months; 95% CI, 9.33-9.73; P < 0.0001). Taken together, in the Korean population, first-line IP combination chemotherapy had significantly favorable effects on OS and TFST.

Coronary Event Analysis in Breast Cancer Patients Who Received Breast-Conserving Surgery and Post-Operative Radiotherapy: a Korean Nationwide Cohort Study.

PURPOSE: Adjuvant breast radiotherapy (RT) following breast-conserving surgery (BCS) has been reported to induce cardiac toxicity in breast cancer patients. We investigated the incidence and risk factors of major coronary events after breast RT using Korean nationwide Health Insurance Review and Assessment data. METHODS: Using data from a nationwide quality assessment of breast cancer treatment, we identified 3,251 patients who received breast RT after BCS in 2013. Data about major coronary events were additionally collected from national claims data. We defined major coronary events according to the International Classification of Diseases, 10th revision (ICD-10) codes I20-25. RESULTS: A total of 172 major coronary events (5.3%) occurred among 3,251 breast cancer patients. The 1-year, 2-year, and 3-year coronary event-free survival rates were 98.1%, 96.4% and 95.2%, respectively. Patients with underlying diabetes mellitus (88.6% vs. 95.7%, p < 0.001), high blood pressure (HBP) (89.4% vs. 96.3%, p < 0.001), and cerebrovascular accident (CVA) (84.0% vs. 95.4%, p < 0.001) showed significantly worse 3-year coronary event-free survival rates than those without comorbidities. Multivariate analysis revealed that patient age (p < 0.001), HBP (p < 0.001), CVA (p = 0.025), adjuvant hormonal therapy (p = 0.034), and Herceptin therapy (p < 0.001) were significantly associated with major coronary events in breast cancer patients. CONCLUSION: The incidence of major coronary events after breast RT may be higher in breast-cancer patients with risk factors such as underlying HBP or CVA, or who were in receipt of adjuvant Herceptin therapy. Heart-sparing RT techniques or intensity-modulated RT should be considered for breast-cancer patients with risk factors for heart toxicity.

Upfront radiosurgery plus targeted agents followed by active brain control using radiosurgery delays neurological death in non-small cell lung cancer with brain metastasis.

The role of radiosurgery has become further accentuated in the era of targeted agents (TA). Thus, the neurologic outcome of radiosurgery in brain metastasis (BM) of non-small cell lung cancer (NSCLC) was reviewed. We analyzed 135 patients with BM of NSCLC who were administered Cyberknife radiosurgery (CKRS) as either initial or salvage therapy. We evaluated local failure (LF), intracranial failure (IF), and neurological death (ND) due to BM. Primary outcome was neurological death-free survival (NDFS). Median follow-up was 16.2 months. Median CKRS dose of 22 Gy was administered to median 2 targets per patient. Among 99 deaths, 14 (14%) were ND. Upfront treatment for BM included CKRS alone in 85 patients (63%), CKRS + TA in 26 patients (19%), and WBRT in 24 patients (18%). No patients or tumor related factors were associated with ND. However, the type of upfront treatment for BM was significantly associated with ND [HR 0.07 (95% CI 0.01-0.57) for CKRS + TA, HR 0.56 (95% CI 0.19-1.68) for CKRS alone] compared with the WBRT group (P = 0.01). The 2-year NDFS rates for the CKRS + TA, CRKS alone, and WBRT groups were 94%, 87%, and 78%, respectively (P = 0.03). Upfront CKRS showed significantly higher 2-year LF-free survival rate (P < 0.01). IF rate was insignificantly lower in the WBRT group compared with CKRS group (P = 0.38). Upfront CKRS + TA was associated with the best neurological outcome with high NDFS. Active brain control by early delivery of radiosurgery could achieve better neurological outcome in NSCLC with BM.

SUVmax Predicts Disease Progression after Stereotactic Ablative Radiotherapy in Stage I Non-small Cell Lung Cancer.

PURPOSE: Fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) is gaining evidence as a predictive factor in non-small cell lung cancer (NSCLC). Stereotactic ablative radiotherapy (SABR) is the standard treatment in early-stage NSCLC when a patient is unsuitable for surgery. We performed a study to assess the prognostic clinical significance of PET-CT after SABR in early-stage NSCLC. MATERIALS AND METHODS: Seventy-six patients with stage I NSCLC treated with SABR were investigated. Total radiation dose ranged from 36 to 63 Gy in three to eight fractions depending on tumor location and size. Respiratory motion control was implemented at simulation and during treatment. PET-CT prior to SABR was performed in 66 patients (86.8%). RESULTS: Median follow-up time was 32 months (range, 5 to 142 months). Local control rate at 1, 2, and 5 years were 95.9%, 92.8%, and 86.7%, respectively. Overall survival (OS) at 1, 2, and 5 years were 91.0%, 71.3%, and 52.1% respectively. Cause-specific survival at 1, 2, and 5 years were 98.6%, 93.1%, and 84.3% respectively. Tumor size and pre-SABR maximal standardized uptake value (SUVmax) demonstrated statistical significance in the Kaplan-Meier survival analyses with log-rank test. In multivariate analyses pre-SABR SUVmax remained statistically significant in correlation to OS (p=0.024; hazard ratio [HR], 3.2; 95% confidence interval [CI], 1.2 to 8.8) and with marginal significance in regards to regional progression-free survival (p=0.059; HR, 32.5; 95% CI, 2.6 to 402.5). CONCLUSION: Pre-SABR SUVmax demonstrated a predictive power in statistical analyses. Tumors with SUVmax above 6 at diagnosis were associated with inferior outcomes.

Pathologic Staging Inconsistency Between ypT4N0 (stage II) and ypT1-2N1 (stage III) After Preoperative Chemoradiotherapy and Total Mesorectal Excision in Rectal Cancer: A Multi-Institutional Study.

BACKGROUND: In the Surveillance, Epidemiology, and End Results population-based data, the survival curves reversed between T4N0 (stages IIB or IIC) and T1-2N1 (stage IIIA) in rectal cancer. However, T4N0 had a higher stage than T1-2N1 in the current colorectal staging system. PATIENTS AND METHODS: We analyzed 1804 patients with rectal cancer who were treated with preoperative chemoradiotherapy and curative surgery. We grouped patients by pathologic stage, and recurrence-free survival (RFS) and overall survival rates were calculated and compared for each stage. We evaluated prognostic factors that influenced recurrence and survival. RESULTS: In the recurrence and survival analysis, 3-year RFS rates were 95.9% for ypStage 0, 94.0% for ypStage I, 78.9% for ypStage IIA, 55.8% for ypStage IIB/C, 80.2% for ypStage IIIA, 64.6% for ypStage IIIB, and 44.9% for ypStage IIIC. Patients with ypStage IIB/C showed significantly worse RFS (P = .004) than did those with ypStage IIIA. The ypStage IIB/C group showed significantly higher rates of both locoregional recurrence (24.3% vs. 5.5%; P = .02) and distant metastasis (31.6% vs. 17.1%; P = .048) than did the ypStage IIIA group. Compared with ypStage IIIA, ypStage IIB/C showed significantly higher pre-chemoradiotherapy carcinoembryonic antigen (P = .004), circumferential radial margin involvement (P = .001), and positive perineural invasion (P = .014). CONCLUSION: Patients with rectal cancer staged ypT4N0 were associated with higher locoregional recurrence and distant metastasis rates than those staged ypT1-2N1 in the current staging system.