Role of stereotactic radiotherapy in the management of small-cell lung cancer.

Small-cell lung cancer is the most aggressive form of lung neoplasia, treated in recent decades with chemoradiotherapy in case of limited stage and chemotherapy alone at the metastatic stage. In the last few years, the advent of immunotherapy has changed the landscape in the treatment of non-small-cell lung cancer, and to a lesser degree in small-cell lung cancer. Despite the recent advances in research, small-cell lung cancer is still considered an aggressive and lethal disease characterized by high recurrence or metastatic potential. As stereotactic radiotherapy has established itself as the standard of care in the early stage of inoperable non-small-cell lung cancer and in metastatic disease to treat brain and extracranial metastases, these same issues now arise in the management of small-cell lung cancer. This article aims to review the current knowledge and the potential of stereotactic radiotherapy in small-cell lung cancer.

[Observational studies to evaluate robotic-assisted lung cancer surgery?] / Les études observationnelles pour évaluer la chirurgie robotique pour le cancer bronchique ?

BACKGROUND: The aim of this work is to assess the quality of observational studies and to make direct and indirect comparisons of robotic surgery with other approaches. METHOD: We searched various databases between 2014 and 2024 for observational studies comparing robotic-assisted surgery to thoracoscopy or thoracotomy. RESULTS: Eighteen studies were included in the meta-analysis. Risk of confounding bias was present in 90% of studies, while risk of classification bias appeared in 80%. Robotic-assisted surgery reduced the risk of conversion to thoracotomy compared with thoracoscopy with an odds ratio of 0.21 (95% confidence interval: 0.06-0.65), with high heterogeneity between studies (I2=80%). Robotic-assisted surgery did not significantly reduce postoperative complications or 30-day mortality compared with thoracotomy or thoracoscopy. For 5-year overall survival, comparisons of robotic-assisted surgery to thoracoscopy or thoracotomy were non-significant with I2 of 55%. CONCLUSION: This work demonstrates the need for a randomized controlled trial to validate robotic surgery for the treatment of bronchial cancer.

A prospective observational study evaluating two patient immobilisation methods in lung stereotactic radiotherapy.

PURPOSE: The main objective of this study was to assess inter- and intrafraction errors for two patient immobilisation devices in the context of lung stereotactic body radiation therapy: a vacuum cushion and a simple arm support. MATERIALS AND METHODS: Twenty patients who were treated with lung stereotactic body radiation therapy in supine position with arms above their head were included in the study. Ten patients were setup in a vacuum cushion (Bluebag™, Elekta) and ten other patients with a simple arm support (Posirest™, Civco). A pretreatment four-dimensional cone-beam computed tomography and a post-treatment three-dimensional cone-beam computed tomography were acquired to compare positioning and immobilisation accuracy. Based on a rigid registration with the planning computed tomography on the spine at the target level, translational and rotational errors were reported. RESULTS: The median number of fractions per treatment was 5 (range: 3-10). Mean interfraction errors based on 112 four-dimensional cone-beam computed tomographies were similar for both setups with deviations less than or equal to 1.3mm in lateral and vertical direction and 1.2° in roll and yaw. For longitudinal translational errors, mean interfraction errors were 0.7mm with vacuum cushion and -3.9mm with arm support. Based on 111 three-dimensional cone-beam computed tomographies, mean lateral, longitudinal and vertical intrafraction errors were -0.1mm, -0.2mm and 0.0mm respectively (SD: 1.0, 1.2 and 1.0mm respectively) for the patients setup with vacuum cushion, and mean vertical, longitudinal and lateral intrafraction errors were -0.3mm, -0.7mm and 0.1mm respectively (SD: 2.3, 1.8 and 1.4mm respectively) for the patients setup with arm support. Intrafraction errors means were not statistically different between both positions but standard deviations were statistically larger with arm support. CONCLUSION: The results of our study showed similar inter and intrafraction mean deviations between both positioning but a large variability in intrafraction observed with arm support suggested a more accurate immobilization with vacuum cushion.

[Targeting the spliceosome: A new therapeutic strategy to counteract chemotherapy resistance in lung cancer?] / Cibler le splicéosome : une nouvelle stratégie thérapeutique pour contrecarrer la résistance à la chimiothérapie dans les cancers du poumon ?

Lung cancer is the first cancer-related cause of death worldwide. This is in partially due to therapeutic resistance, which occurs in around 70% of patients, especially those receiving platinum salts, the gold-standard chemotherapy. The massive deregulation of alternative transcript splicing processes observed in many cancers has led to the development of a new class of pharmacological agents aimed at inhibiting the activity of the splicing machinery (spliceosome). The molecular mechanisms by which these inhibitors act remain largely unknown, as do the benefits of using them in combination with other therapies. In this context, our work is focused on an inhibitor of the SRPK1 kinase, a major regulator of the spliceosome.

Quality control of postoperative radiotherapy for non-small cell lung cancer: A study of mediastinal shift.

PURPOSE: This study aimed to assess the shifting patterns of the mediastinum, including the target volume and the isocenter point during the postoperative radiotherapy (PORT) process of non-small cell lung cancer (NSCLC), and to observe the occurrence of radiation injury. Additionally, we investigated the significance of mid-term assessment during the implementation of the PORT process. MATERIAL AND METHODS: We established coordinate axes based on bone anatomy and measured the mediastinum's three-dimensional direction and the shift of the isocenter point's shift in the PORT process. Statistical analysis was performed using Wilcoxon, Kruskal-Wallis, and the Chi-square test. P<0.05 was considered statistically significant. RESULTS: In this study, the analysis of patients revealed that the shift of anterior and posterior mediastinum (X), left and right mediastinum (Y), upper and lower mediastinum (Z), anterior and posterior isocenter point (Xi), and the left and right isocenter points (Yi) in the PORT process were 0.04-0.53, 0.00-0.84, 0.00-1.27, 0.01-0.86, and 0.00-0.66cm, respectively. The shift distance of the mediastinum was Z>Y>X, and the shift distance of the isocenter point was Xi>Yi. According to the ROC curve, the cut-off values were 0.263, 0.352, 0.405, 0.238, and 0.258, respectively, which were more significant than the cut-off values in 25 cases (25%), 30 cases (30%), 30 cases (30%), 17 cases (17%), and 15 cases (15%). In addition, there was a significant difference in the shift of the mediastinum and the isocenter point (all P=0.00). Kruskal-Wallis test showed no statistically significant difference between mediastinal shift and resection site in X, Y, and Z directions (P=0.355, P=0.239, P=0.256), surgical method (P=0.241, P=0.110, P=0.064). There was no significant difference in the incidence of RE and RP in PORT patients (P>0.05). No III-IV RP occurred. However, the incidence of ≥ grade III RE in the modified plan cases after M-S was significantly lower than in the original PORT patients, 0% and 7%, respectively (P=0.000). CONCLUSION: In conclusion, this study provides evidence that mediastinal shift is a potential complication during the PORT process for patients with N2 stage or R1-2 resection following radical resection of NSCLC. This shift affects about 20-30% of patients, manifesting as actual radiation damage to normal tissue and reducing the local control rate. Therefore, mid-term repositioning of the PORT and revision of the target volume and radiation therapy plan can aid in maintaining QA and QC during the treatment of NSCLC patients and may result in improved patient outcomes.

Radiotherapy in the management of lung oligometastases.

In recent years, the development of both medical imaging and new systemic agents (targeted therapy and immunotherapy) have revolutionized the field of oncology, leading to a new entity: oligometastatic disease. Adding local treatment of oligometastases to systemic treatment could lead to prolonged survival with no significant impact on quality of life. Given the high prevalence of lung oligometastases and the new systemic agents coming with increased pulmonary toxicity, this article provides a comprehensive review of the current state-of-art for radiotherapy of lung oligometastases. After reviewing pretreatment workup, the authors define several radiotherapy regimen based on the localization and size of the oligometastases. A comment on the synergistic combination of medical treatment and radiotherapy is also made, projecting on future steps in this specific clinical setting.

[The contribution of artificial intelligence (AI) subsequent to the processing of thoracic imaging]. / Apport de l'intelligence artificielle dans le post-traitement de l'imagerie thoracique.

The contribution of artificial intelligence (AI) to medical imaging is currently the object of widespread experimentation. The development of deep learning (DL) methods, particularly convolution neural networks (CNNs), has led to performance gains often superior to those achieved by conventional methods such as machine learning. Radiomics is an approach aimed at extracting quantitative data not accessible to the human eye from images expressing a disease. The data subsequently feed machine learning models and produce diagnostic or prognostic probabilities. As for the multiple applications of AI methods in thoracic imaging, they are undergoing evaluation. Chest radiography is a practically ideal field for the development of DL algorithms able to automatically interpret X-rays. Current algorithms can detect up to 14 different abnormalities present either in isolation or in combination. Chest CT is another area offering numerous AI applications. Various algorithms have been specifically formed and validated for the detection and characterization of pulmonary nodules and pulmonary embolism, as well as segmentation and quantitative analysis of the extent of diffuse lung diseases (emphysema, infectious pneumonias, interstitial lung disease). In addition, the analysis of medical images can be associated with clinical, biological, and functional data (multi-omics analysis), the objective being to construct predictive approaches regarding disease prognosis and response to treatment.

Metastasis-directed radiotherapy for non-small cell lung cancer failured under TKI: A case report and literature review.

Although tyrosine kinase inhibitors (TKI) have revolutionized the treatment of anaplastic lymphoma kinase rearranged non-small cell lung cancer (ALKr-NSCLC), radiotherapy (RT) still plays an essential role for treatment of both intracranial and extracranial metastases, particularly for patients experienced a TKI-failure. We reported the case of a 38-year-old woman with metastatic ALKr-NSCLC who received whole-brain radiotherapy (RT) for multiple brain metastases (BMs), initially. After RT, alectinib was initiated and the patient had a good clinico-radiological response in both intracranial and extracranial regions. However, intracranial progression was developed and, stereotactic radiosurgery (SRS) was applied to the four progressed BMs. Two months after SRS, all BMs disappeared. While patient was using alectinib, a recurrent lung lesion, a hilar lymph node and bone metastasis were detected. Stereotactic body radiotherapy (SBRT) was applied to all metastatic sites and, alectinib was continued again. Three months after SBRT, a complete response was obtained. She has been alive with the initial systemic therapy agent for more than 4years without evidence of neither disease nor toxicity. SRS/SBRT may eradicate the TKI-resistant tumoral clones and it may prevent switching the systemic therapy, even if there is a failure.

Stereotactic radiotherapy for ultracentral lung tumours.

Ultracentral (UC) lung lesions are generally defined by the presence of the tumour or the Planning Target Volume (PTV) abutting proximal bronchial tree (PBT) or the esophagus. Initial reports rose awareness regarding the potential toxicity of stereotactic body radiotherapy (SBRT) when delivered to UC lesions. Major concerns include necrosis, stenosis, and bleeding of the PBT. Technological improvements now enable the delivery of more accurate treatments, possibly redefining the historical "no-fly zone". In this review, studies focusing on the treatment of UC lesions with SBRT are presented. The narrow therapeutic window requires a multidisciplinary approach.

Clinical outcomes of intra-arterial chemotherapy combined with iodine-125 seed brachytherapy in the treatment of malignant superior vena cava syndrome caused by small cell lung cancer.

PURPOSE: Currently there is a lack of effective treatment strategies for malignant superior vena cava syndrome (SVCS). We aim to investigate the therapeutic effect of intra-arterial chemotherapy (IAC) combined with the Single Needle Cone Puncture method for the 125I brachytherapy (SNCP-125I) in treating SVCS caused by stage III/IV Small Cell Lung Cancer (SCLC). MATERIALS AND METHODS: Sixty-two patients with SCLC who developed SVCS from January 2014 to October 2020 were investigated in this study. Out of these 62 patients, 32 underwent IAC combined with SNCP-125I (Group A) and 30 patients received IAC treatment only (Group B). Clinical symptom remission, response rate, disease control rate, and overall survival of these two groups of patients were analyzed and compared. RESULTS: The remission rate of symptoms including dyspnea, edema, dysphagia, pectoralgia, and cough of malignant SVCS in Group A was significantly higher than that in Group B (70.5 and 50.53%, P=0.0004, respectively). The disease control rates (DCR, PR+CR+SD) of Group A and B were 87.5 and 66.7%, respectively (P=0.049). Response rates (RR, PR+CR) of Group A and Group B were 71.9 and 40% (P=0.011). The median overall survival (OS) of Group A was significantly longer than that in Group B which was 18 months compared to 11.75 months (P=0.0360). CONCLUSIONS: IAC treatment effectively treated malignant SVCS in advanced SCLC patients. IAC combined with SNCP-125I in the treatment of malignant SVCS caused by SCLC showed improved clinical outcomes including symptom remission and local tumor control rates than IAC treatment only in treating SCLC-induced malignant SVCS.

[Duodenal bleeding due to metastasis from lung adenocarcinoma controlled by radiotherapy: A case report and literature review]. / Saignement duodénal dû à une métastase d'un cancer pulmonaire contrôlé par radiothérapie : cas clinique et revue de la littérature.

INTRODUCTION: Gastrointestinal (GI) metastases in lung cancer rarely occur. CASE REPORT: We report here the case of a 43-year-old male active smoker who was admitted to our hospital for cough, abdominal pain and melena. Initial investigations revealed poorly differentiated adenocarcinoma of the superior-right lobe of the lung: positive for thyroid transcription factor-1 and negative for protein p40 and for antigen CD56, with peritoneal, adrenal and cerebral metastasis, as well as anemia requiring major transfusion support. Over 50% of cells were positive for PDL-1, and ALK gene rearrangement was detected. GI endoscopy showed a large ulcerated nodular lesion of the genu superius with active intermittent bleeding, as well as an undifferentiated carcinoma with positivity for CK AE1/AE3 and TTF-1, and negativity for CD117, corresponding to metastatic invasion originating from lung carcinoma. Palliative immunotherapy with pembrolizumab was proposed, followed by targeted therapy with brigatinib. Gastrointestinal bleeding was controlled with a single 8Gy dose of haemostatic radiotherapy. CONCLUSION: GI metastases are rare in lung cancer and present nonspecific symptoms and signs but no characteristic endoscopic features. GI bleeding is a common revelatory complication. Pathological and immunohistological findings are critical to diagnosis. Local treatment is usually guided by the occurrence of complications. In addition to surgery and systemic therapies, palliative radiotherapy may contribute to bleeding control. However, it must be used cautiously, given a present-day lack of evidence and the pronounced radiosensitivity of certain gastrointestinal tract segments.

[Chronic lung allograft dysfunction in 2022, past and updates]. / La dysfonction chronique du greffon pulmonaire en 2022 : une entité mieux comprise et un défi thérapeutique.

INTRODUCTION: While short-term results of lung transplantation have improved considerably, long-term survival remains below that achieved for other solid organ transplants. CURRENT KNOWLEDGE: The main cause of late mortality is chronic lung allograft dysfunction (CLAD), which affects nearly half of the recipients 5 years after transplantation. Immunological and non-immune risk factors have been identified. These factors activate the innate and adaptive immune system, leading to lesional and altered wound-healing processes, which result in fibrosis affecting the small airways or interstitial tissue. Several phenotypes of CLAD have been identified based on respiratory function and imaging pattern. Aside from retransplantation, which is possible for only small number of patients, no treatment can reverse the CLAD process. PERSPECTIVES: Current therapeutic research is focused on anti-fibrotic treatments and photopheresis. Basic research has identified numerous biomarkers that could prove to be relevant as therapeutic targets. CONCLUSION: While the pathophysiological mechanisms of CLAD are better understood than before, a major therapeutic challenge remains.

Extended Pulmonary Resection for T4 Non-Small Cell Lung Cancer.

T4 non-small cell lung cancer is a locally advanced disease with poor prognosis. The operation can be challenging even for an experienced surgeon. N2 disease has been shown repeatedly as a risk factor for poor outcome, and these patients should not be candidates for surgical treatment. Surgery for locally advanced T4 tumors without mediastinal lymph node involvement (T4N0 and T4N1) has been demonstrated to result in good outcomes in carefully selected patients. Patients with T4N0-1M0 should be rejected for surgery only after consulting an expert surgical center. As with other stages, the decision for resectability and surgery should be made by a multidisciplinary team.

[Lung cancer screening: Update, news and perspectives]. / Dépistage du cancer du poumon : mise au point, actualités et perspectives.

Lung cancer is the leading cause of cancer death in France and worldwide (20 % of cancer deaths). This mortality is partly linked to an overrepresentation of metastatic stages at diagnosis (approximately 55 % of lung cancers at diagnosis). Low-dose chest CT in a target population to detect early forms accessible to radical treatment has been evaluated through multiple randomized trials (NLST, NELSON, MILD, DANTE…). These trials demonstrated a reduction in lung cancer specific mortality. The current problem is to integrate a CT screening policy CT at a national level, which should be both efficient and cost-effective, while presenting the least harms for the eligible population. Finally, it is necessary to optimize the participation of the eligible population and particularly in the most deprived areas and ensure the proper implementation of smoking cessation measures.

[The role of endoscopy in exploration of the mediastinum, indications and results]. / Place de l'endoscopie dans l'exploration du médiastin, indications et résultats.

Since 2005, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a standard pulmonological tool. The procedure is safe and well tolerated by patients, with minimal morbidity and almost no mortality. A previous review on the technique was published in 2012. However, over the last ten years, a number of new studies have been published on "benign" (sarcoidosis, tuberculosis…) as well as "malignant" diseases (lung cancer, metastases of extra-thoracic cancers, search for mutations and specific oncogenic markers…). These developments have led to expanded indications for EBUS-TBNA, with which it is indispensable to be familiar, in terms of "staging" as well as "diagnosis". In view of optimizing lymph node sampling, several publications have described and discussed EBUS exploration by means of newly available tools (biopsy forceps, larger needles…), and proposed interpretation of the images thereby produced. Given the ongoing evolution of linear EBUS, it seemed indispensable that information on this marvelous tool be updated. This review is aimed at summarizing the novel elements we have found the most important.

[Epidemiological and clinical profile childhood cancers with pleural and pulmonary lesions in the pediatric oncology unit of Treichville University Hospital (Abidjan, Côte d'Ivoire)]. / Profil épidémiologique et clinique des cancers pédiatriques avec atteintes pleurales et pulmonaires au service de pédiatrie du CHU de Treichville (Abidjan, Côte d'Ivoire).

INTRODUCTION: Pediatric cancers are a major public health problem in sub-Saharan Africa. However, they are seldom studied, especially as regards in their extensive forms. METHODOLOGY: An eight-year retrospective and descriptive study was carried out so as to specify the epidemiological and clinical characteristics of cancers with pleural and pulmonary involvement in children of 0 to 14years of age in the pediatric oncology unit at the University Hospital of Treichville, Côte d'Ivoire (Ivory Coast). RESULTS: The frequency of pleural and pulmonary involvement in pediatric cancers was 13.8%. Children's average age was 7.2years, with sex ratio at 2.11. Solid tumors were predominant, with a predominance of Burkitt's lymphoma (39.3%) and nephroblastoma (35.7%). The most affected age groups were 10 to 15years (Burkitt's lymphoma) and 0 to 5years (nephroblastoma). Time to diagnosis ranged from 31 and 60days in 40.4% of cases, and time to treatment was at most 30 days, for the overwhelming majority (97.1%) of the children. Chemotherapy was initiated in 67.9% of patients. Hospital mortality was 73.2%. CONCLUSION: Through this study, the authors established the profile of childhood cancers with pleural and pulmonary involvement. Comparative studies of mortality in pediatric cancers with and without pleural and pulmonary involvement could further underline the importance of early management before dissemination.

[Stereotactic radiotherapy for localized primary lung tumours of stage T1-T2]. / Intérêt de la radiothérapie stéréotaxique pour les tumeurs primitives du poumon localisées de stade T1-T2.

The historical treatment for stage I non-small cell lung cancer is surgical. Parenchymal amputation is not always possible due to cardiopulmonary comorbidities and stereotactic radiotherapy is one of the alternatives to an invasive procedure. The excellent results observed for inoperable tumors raised the question of this treatment in operable patients. This article presents the data in these two situations and the future perspectives.