Smoking Cessation, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology.

Although the harmful effects of smoking after a cancer diagnosis have been clearly demonstrated, many patients continue to smoke cigarettes during treatment and beyond. The NCCN Guidelines for Smoking Cessation emphasize the importance of smoking cessation in all patients with cancer and seek to establish evidence-based recommendations tailored to the unique needs and concerns of patients with cancer. The recommendations contained herein describe interventions for cessation of all combustible tobacco products (eg, cigarettes, cigars, hookah), including smokeless tobacco products. However, recommendations are based on studies of cigarette smoking. The NCCN Smoking Cessation Panel recommends that treatment plans for all patients with cancer who smoke include the following 3 tenets that should be done concurrently: (1) evidence-based motivational strategies and behavior therapy (counseling), which can be brief; (2) evidence-based pharmacotherapy; and (3) close follow-up with retreatment as needed.

Approach to Oligometastatic Cancer in the Elderly Patient.

PURPOSE OF REVIEW: Patients with advanced cancer who have "oligometastatic" disease (OMD) have a limited burden of metastatic sites such that they may benefit from definitive therapies with limited toxicities. The incidence of cancers diagnosed in the elderly is increasing and treatment choices for them are often made because of their vulnerability to side effects. The present review discusses treatment of the elderly with OMD considering cancer outcomes and treatment toxicity. RECENT FINDINGS: Stereotactic body radiation therapy (SBRT) is emerging as a standard in the management of OMD because of its excellent local control and minimal toxicity. Phase II trials suggest that SBRT added to palliative therapy may improve overall survival and may delay the initiation of systemic therapy in OMD patients. Elderly patients are well represented in OMD studies SBRT will contribute significantly to the management of OMD in the elderly patient population by optimizing cancer control and limiting side effects.

Intra- and inter-fractional liver and lung tumor motions treated with SBRT under active breathing control.

PURPOSE: To assess intra- and inter-fractional motions of liver and lung tumors using active breathing control (ABC). METHODS AND MATERIALS: Nineteen patients with liver cancer and 15 patients with lung cancer treated with stereotactic body radiotherapy (SBRT) were included in this retrospective study. All patients received a series of three CTs at simulation to test breath-hold reproducibility. The centroids of the whole livers and of the lung tumors from the three CTs were compared to assess intra-fraction variability. For 15 patients (8 liver, 7 lung), ABC-gated kilovoltage cone-beam CTs (kV-CBCTs) were acquired prior to each treatment, and the centroids of the whole livers and of the lung tumors were also compared to those in the planning CTs to assess inter-fraction variability. RESULTS: Liver intra-fractional systematic/random errors were 0.75/0.39 mm, 1.36/0.97 mm, and 1.55/1.41 mm at medial-lateral (ML), anterior-posterior (AP), and superior-inferior (SI) directions, respectively. Lung intra-fractional systematic/random errors were 0.71/0.54 mm (ML), 1.45/1.10 mm (AP), and 3.95/1.93 mm (SI), respectively. Substantial intra-fraction motions (>3 mm) were observed in 26.3% of liver cancer patients and in 46.7% of lung cancer patients. For both liver and lung tumors, most inter-fractional systematic and random errors were larger than the corresponding intra-fractional errors. However, these inter-fractional errors were mostly corrected by the treatment team prior to each treatment based on kV CBCT-guided soft tissue alignment, thereby eliminating their effects on the treatment planning margins. CONCLUSIONS: Intra-fractional motion is the key to determine the planning margins since inter-fractional motion can be compensated based on daily gated soft tissue imaging guidance of CBCT. Patient-specific treatment planning margins instead of recipe-based margins were suggested, which can benefit mostly for the patients with small intra-fractional motions.

The Role of Radiotherapy in Small Cell Lung Cancer: a Revisit.

Small cell lung cancer is staged as either limited (potentially curable) or extensive (incurable), based on the extent of disease in the chest. Limited stage disease is treated with concurrent chemotherapy and thoracic radiotherapy followed by prophylactic cranial irradiation (PCI). The conventional approach to extensive disease is chemotherapy only, with radiotherapy reserved for site-specific palliation. Recent reports suggest increasing applications for radiotherapy. The administration of PCI to extensive stage patients demonstrating response to chemotherapy is now recommended due to local control and overall survival benefits. Likewise, the role of consolidation chest radiotherapy after chemotherapy for advanced disease patients has seen a resurgence of interest in light of a recent publication suggesting improved local benefits which may influence survival. Recent technical advances in radiotherapy such as stereotactic body treatment and intensity-modulated therapy may also provide new indications for radiation, to enhance delivery and minimize toxicities.

Dose differences in intensity-modulated radiotherapy plans calculated with pencil beam and Monte Carlo for lung SBRT.

For patients with medically inoperable early-stage non-small cell lung cancer (NSCLC) treated with stereotactic body radiation therapy, early treatment plans were based on a simpler dose calculation algorithm, the pencil beam (PB) calculation. Because these patients had the longest treatment follow-up, identifying dose differences between the PB calculated dose and Monte Carlo calculated dose is clinically important for understanding of treatment outcomes. Previous studies found significant dose differences between the PB dose calculation and more accurate dose calculation algorithms, such as convolution-based or Monte Carlo (MC), mostly for three-dimensional conformal radiotherapy (3D CRT) plans. The aim of this study is to investigate whether these observed dose differences also exist for intensity-modulated radiotherapy (IMRT) plans for both centrally and peripherally located tumors. Seventy patients (35 central and 35 peripheral) were retrospectively selected for this study. The clinical IMRT plans that were initially calculated with the PB algorithm were recalculated with the MC algorithm. Among these paired plans, dosimetric parameters were compared for the targets and critical organs. When compared to MC calculation, PB calculation overestimated doses to the planning target volumes (PTVs) of central and peripheral tumors with different magnitudes. The doses to 95% of the central and peripheral PTVs were overestimated by 9.7% ± 5.6% and 12.0% ± 7.3%, respectively. This dose overestimation did not affect doses to the critical organs, such as the spinal cord and lung. In conclusion, for NSCLC treated with IMRT, dose differences between the PB and MC calculations were different from that of 3D CRT. No significant dose differences in critical organs were observed between the two calculations.

ACR Appropriateness Criteria® nonsurgical treatment for locally advanced non-small-cell lung cancer: good performance status/definitive intent.

Concurrent chemotherapy/radiotherapy has been considered the standard treatment for patients with a good performance status and inoperable stage III non-small-cell lung cancer (NSCLC). Three-dimensional chemoradiation therapy and intensity-modulated radiation therapy have been reported to reduce toxicity and allow a dose escalation to 70 Gy and beyond. However, the Radiation Therapy Oncology Group 0617 trial recently showed that dose escalation from 60 Gy to 74 Gy with concurrent chemotherapy in stage III NSCLC was associated with higher toxicity and worse survival. A "one size fits all" treatment approach may need to be changed and adapted to each patient's particular disease and unique biologic/anatomic features, as well as the most appropriate radiotherapy modalities for that patient. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application, by the panel, of a well-established consensus methodology (modified Delphi technique) to rate the appropriateness of imaging and treatment procedures. In instances in which evidence is lacking or not definitive, expert opinion may be used as the basis for recommending imaging or treatment.

The role of stereotactic radiotherapy in the treatment of oligometastases.

"Oligometastasis" describes a limited number of metastases arising typically from solid tumors whose behavior suggests an "intermediate" malignant state since it may potentially have a more favorable prognosis. Historically, selected patients with oligometastases often underwent surgical resection since anecdotal evidence suggested it could improve progression-free or overall survival. No prospective randomized trial evidence to date supports survival benefits from surgery. Short courses of highly focused, very high dose radiotherapy (stereotactic radiosurgery; stereotactic body radiotherapy) have emerged as a surgical surrogate to manage oligometastates. For solitary brain metastases, randomized study evidence supports stereotactic radiosurgery as part of their management because of overall survival benefits. Modeled after stereotactic radiosurgery, stereotactic body radiotherapy for extracranial metastases is becoming increasingly common given its efficacy and low toxicity, is an active area of clinical research, and is the subject of this review.

Cyclotron and linear accelerator generated scanning proton beams for lung cancer SBRT: Interplay effects and mitigations.

BACKGROUND: Pencil beam scanning (PBS) proton therapy for moving targets is known to be impacted by interplay effects between the scanning beam and organ motion. While respiratory motion in the thoracic region is the major cause for organ motion, interplay effects depend on the delivery characteristics of proton accelerators. PURPOSE: To evaluate the impact of different types of PBS proton accelerators and spot sizes on interplay effects, mitigations, and plan quality for Stereotactic Body Radiation Therapy (SBRT) treatment of non-small cell lung cancer (NSCLC). METHODS: Twenty NSCLC patients treated with photon SBRT were selected to represent varying tumor volumes and respiratory motion amplitudes (median: 0.6 cm with abdominal compression) for this retrospective study. For each patient, plans were created using: (1) cyclotron-generated proton beams (CPB) with spot sizes of σ = 2.7-7.0 mm; (2) linear accelerator proton beams (LPB) (σ = 2.9-5.5 mm); and (3) linear accelerator proton minibeams (LPMB) (σ = 0.9-3.9 mm). The energy switching time is one second for CPB, and 0.005 s for LPMB and LPB. Plans were robustly optimized on the gross tumor volume (GTV) using each individual phase of four-dimensional computed tomography (4DCT) scans. Initially, single-field optimization (SFO) plans were evaluated; if the plan quality did not meet the dosimetric requirement, multi-field optimization (MFO) was used. MFO plans were created for all patients for comparisons. For each patient, all plans were normalized to have the same dose received by 99% of the GTV. Interplay effects were evaluated by computing the dose on 10 breathing phases, based on the spot distribution. Volumetric repainting (VR) was performed 2-6 times for each plan. We compared volume receiving 100% of the prescribed dose (V100%RX) of the GTV, and normal lung V20Gy. RESULTS: Twelve of 20 plans can be optimized sufficiently with SFO. SFO plans were less sensitive to the interplay effect compared to MFO plans in terms of target coverage for both LPB and LPMB. The following comparisons showed results utilizing the MFO technique. In the interplay evaluation without repainting, the mean V100%RX of the GTV were 99.42 ± 0.6%, 97.52 ± 3.9%, and 94.49 ± 7.3% for CPB, LPB, and LPMB plans, respectively. Following VR (2 × for CPB; 3 × for LPB; 5 × for LPMB), V100%RX of the GTV were improved (on average) by 0.13%, 1.84%, and 4.63%, respectively, achieving the acceptance criteria of V100%RX > 95%. Because of fast energy switch in linear accelerator proton machines, the delivery time for VR plans was the lowest for LPB plans, while delivery time for LPMB was on average 1 min longer than CPB plans. The advantage of small spot machines was better sparing in normal lung V20Gy, even when VR was applied. CONCLUSION: In the absence of repainting, proton machines with large spot sizes generated more robust plans against interplay effects. The number of VR increased with decreasing spot sizes to achieve the acceptance criteria. VR improved the plan robustness against interplay effects for modalities with small spot sizes and fast energy changes, preserving the low dose sparing aspect of the LPMB, even when motion is included.

Optimal management of radiation pneumonitis: Findings of an international Delphi consensus study.

PURPOSE: Radiation pneumonitis (RP) is a dose-limiting toxicity for patients undergoing radiotherapy (RT) for lung cancer, however, the optimal practice for diagnosis, management, and follow-up for RP remains unclear. We thus sought to establish expert consensus recommendations through a Delphi Consensus study. METHODS: In Round 1, open questions were distributed to 31 expert clinicians treating thoracic malignancies. In Round 2, participants rated agreement/disagreement with statements derived from Round 1 answers using a 5-point Likert scale. Consensus was defined as ≥ 75 % agreement. Statements that did not achieve consensus were modified and re-tested in Round 3. RESULTS: Response rate was 74 % in Round 1 (n = 23/31; 17 oncologists, 6 pulmonologists); 82 % in Round 2 (n = 19/23; 15 oncologists, 4 pulmonologists); and 100 % in Round 3 (n = 19/19). Thirty-nine of 65 Round 2 statements achieved consensus; a further 10 of 26 statements achieved consensus in Round 3. In Round 2, there was agreement that risk stratification/mitigation includes patient factors; optimal treatment planning; the basis for diagnosis of RP; and that oncologists and pulmonologists should be involved in treatment. For uncomplicated radiation pneumonitis, an equivalent to 60 mg oral prednisone per day, with consideration of gastroprotection, is a typical initial regimen. However, in this study, no consensus was achieved for dosing recommendation. Initial steroid dose should be administered for a duration of 2 weeks, followed by a gradual, weekly taper (equivalent to 10 mg prednisone decrease per week). For severe pneumonitis, IV methylprednisolone is recommended for 3 days prior to initiating oral corticosteroids. Final consensus statements included that the treatment of RP should be multidisciplinary, the uncertainty of whether pneumonitis is drug versus radiation-induced, and the importance risk stratification, especially in the scenario of interstitial lung disease. CONCLUSIONS: This Delphi study achieved consensus recommendations and provides practical guidance on diagnosis and management of RP.

The role of radiation therapy in small cell lung cancer.

Radiotherapy (RT) is fundamental to the care of patients diagnosed with small-cell lung cancer (SCLC). In the setting of limited stage disease (LS-SCLC), the addition of thoracic RT to chemotherapy (CHT) improves survival and local control, as demonstrated in decades-worth of randomized clinical trials and subsequent meta-analyses. In extensive stage disease (ES-SCLC), thoracic RT is invaluable in the palliation of chest symptoms but there are suggestions that its use in selected patients may potentially improve overall survival . Prophylactic cranial irradiation (PCI) also improves outcomes in SCLC. For LS-SCLC patients, it reduces brain metastases rates by half and improves overall survival with minimal impact on quality-of-life. Recently, favorable results for PCI with respect to survival and prevention of symptomatic brain disease have been observed for ES-SCLC patients with any response to CHT. Current phase III trials in SCLC RT include studies looking at the optimal dose and target for limited disease and the role of thoracic RT in extensive disease.

A prospective study of quality of life including fatigue and pulmonary function after stereotactic body radiotherapy for medically inoperable early-stage lung cancer.

PURPOSE: The study seeks to prospectively evaluate pulmonary function and quality of life (QOL) in medically inoperable early-stage lung cancer patients undergoing stereotactic body radiotherapy (SBRT). METHODS: QOL was assessed by Functional Assessment of Cancer Therapy-Lung (FACT-L) and the UCSD Medical Center Pulmonary Rehabilitation Program Shortness-of-Breath Questionnaire before and after SBRT at 6 weeks, and every 3 months until 12 months. Clinical investigations included pulmonary functions tests and blood profile and chemistries. SBRT was delivered on a Novalis/BrainLab system. RESULTS: Twenty-one analyzable patients were enrolled between July 2008 to April 2009. There were 12 males (52.4 %), 14 patients (66.7 %) had Zubrod performance 1, the median age was 77 years (range 61-90), and 87 % was inoperable because of pulmonary impairment. Median tumor size was 3.0 cm (range 1-4.6). Median follow-up was 17.6 months. One-year local control was 100 %. There were no significant changes in the median total FACT-L scores: 109 at baseline compared to 112 at 1 year. Mean UCSD scores were not significant for the year. No significant changes in mean baseline compared to 1-year FEV1 and 6-min walks as % predicted were seen but a significant DLCO change (p = 0.012) was attributed to the decreased range in the standard deviations. CONCLUSIONS: Following SBRT, QOL is not significantly degraded. Pulmonary function is likewise not significantly impaired overall. Along with favorable survival results, these findings confirm that SBRT is appropriate for this patient population.

Dose calculation differences between Monte Carlo and pencil beam depend on the tumor locations and volumes for lung stereotactic body radiation therapy.

Stereotactic body radiation therapy (SBRT) has been increasingly used as an efficacious treatment modality for early-stage non-small cell lung cancer. The accuracy of dose calculations is compromised due to the presence of inhomogeneity. For the purpose of a consistent prescription, radiation doses were calculated without heterogeneity correction in several RTOG trials. For patients participating in these trials, recalculations of the planned doses with more accurate dose methods could provide better correlations between the treatment outcomes and the planned doses. Using a Monte Carlo (MC) dose calculation algorithm as a gold standard, we compared the recalculated doses with the MC algorithm to the original pencil beam (PB) calculations for our institutional clinical lung SBRT plans. The focus of this comparison is to investigate the volume and location dependence on the differences between the two dose calculations. Thirty-one clinical plans that followed RTOG and other protocol guidelines were retrospectively investigated in this study. Dosimetric parameters, such as D1, D95, and D99 for the PTV and D1 for organs at risk, were compared between two calculations. Correlations of mean lung dose and V20 of lungs between two calculations were investigated. Significant dependence on tumor size and location was observed from the comparisons between the two dose calculation methods. When comparing the PB calculations without heterogeneity correction to the MC calculations with heterogeneity correction, we found that in terms of D95 of PTV: (1) the two calculations resulted in similar D95 for edge tumors with volumes greater than 25.1 cc; (2) an average overestimation of 5% in PB calculations for edge tumors with volumes less than 25.1 cc; and (3) an average overestimation of 9% or underestimation of 3% in PB calculations for island tumors with volumes smaller or greater than 22.6 cc, respectively. With heterogeneity correction, the PB calculations resulted in an average reduction of 23.8% and 15.3% in the D95 for the PTV for island and edge lesions, respectively, when compared to the MC calculations. For organs at risks, very small differences were found among all the comparisons. Excellent correlations for mean dose and V20 of lungs were observed between the two calculations. This study demonstrated that using a single scaling factor may be overly simplified when accounting for the effects of heterogeneity correction. Accurate dose calculations, such as the Monte Carlo algorithms, are highly recommended to understand dose responses in lung SBRT.

ASTRO Radiation Therapy Summary of the ASCO Guideline on Management of Stage III Non-Small Cell Lung Cancer.

PURPOSE: To develop a radiation therapy summary of recommendations on the management of locally advanced non-small cell lung cancer (NSCLC) based on the Management of Stage III Non-Small Cell Lung Cancer: American Society of Clinical Oncology Guideline, which was endorsed by the American Society for Radiation Oncology (ASTRO). METHODS: The American Society of Clinical Oncology, ASTRO, and the American College of Chest Physicians convened a multidisciplinary panel to develop a guideline based on a systematic review of the literature and a formal consensus process, that has been separately published. A new panel consisting of radiation oncologists from the original guideline as well as additional ASTRO members was formed to provide further guidance to the radiation oncology community. A total of 127 articles met the eligibility criteria to answer 5 clinical questions. This summary focuses on the 3 radiation therapy questions (neoadjuvant, adjuvant, and unresectable settings). RESULTS: Radiation-specific recommendations are summarized with additional relevant commentary on specific questions regarding the management of preoperative radiation, postoperative radiation, and combined chemoradiation. CONCLUSIONS: Patients with stage III NSCLC who are planned for surgical resection, should receive either neoadjuvant chemotherapy or chemoradiation. The addition of neoadjuvant treatment is particularly important in patients planned for surgery in the N2 or superior sulcus settings. Postoperatively, patients who did not receive neoadjuvant chemotherapy should be offered adjuvant chemotherapy. The use of postoperative radiation for completely resected N2 disease is not routinely recommended. Unresectable patients with stage III NSCLC should ideally be managed with combined concurrent chemoradiation using a platinum-based doublet with a standard radiation dose of 60 Gy followed by consolidation durvalumab in patients without progression after initial therapy. Patients who cannot tolerate a concurrent chemoradiation approach can be managed either by sequential chemotherapy followed by radiation or by dose-escalated or hypofractionated radiation alone.

Clinical Nomogram Using Novel Computed Tomography-Based Radiomics Predicts Survival in Patients With Non-Small-Cell Lung Cancer Treated With Stereotactic Body Radiation Therapy.

PURPOSE: Improved survival prediction and risk stratification in non-small-cell lung cancer (NSCLC) would lead to better prognosis counseling, adjuvant therapy selection, and clinical trial design. We propose the persistent homology (PHOM) score, the radiomic quantification of solid tumor topology, as a solution. MATERIALS AND METHODS: Patients diagnosed with stage I or II NSCLC primarily treated with stereotactic body radiation therapy (SBRT) were selected (N = 554). The PHOM score was calculated for each patient's pretreatment computed tomography scan (October 2008-November 2019). PHOM score, age, sex, stage, Karnofsky Performance Status, Charlson Comorbidity Index, and post-SBRT chemotherapy were predictors in the Cox proportional hazards models for OS and cancer-specific survival. Patients were split into high- and low-PHOM score groups and compared using Kaplan-Meier curves for overall survival (OS) and cumulative incidence curves for cause-specific death. Finally, we generated a validated nomogram to predict OS, which is publicly available at Eashwarsoma.Shinyapps. RESULTS: PHOM score was a significant predictor for OS (hazard ratio [HR], 1.17; 95% CI, 1.07 to 1.28) and was the only significant predictor for cancer-specific survival (1.31; 95% CI, 1.11 to 1.56) in the multivariable Cox model. The median survival for the high-PHOM group was 29.2 months (95% CI, 23.6 to 34.3), which was significantly worse compared with the low-PHOM group (45.4 months; 95% CI, 40.1 to 51.8; P < .001). The high-PHOM group had a significantly greater chance of cancer-specific death at post-treatment month 65 (0.244; 95% CI, 0.192 to 0.296) compared with the low-PHOM group (0.171; 95% CI, 0.123 to 0.218; P = .029). CONCLUSION: The PHOM score is associated with cancer-specific survival and predictive of OS. Our developed nomogram can be used to inform clinical prognosis and assist in making post-SBRT treatment considerations.

Stereotactic Body Radiation Therapy for Sarcoma Pulmonary Metastases.

BACKGROUND: Lung metastases are the most common form of distant failure for patients diagnosed with sarcoma with metastasectomy considered for some patients with limited metastatic disease and good performance status. Alternatives to surgery such as stereotactic body radiation therapy (SBRT) can be considered, though data are limited. We present outcomes after SBRT for sarcoma lung metastases. METHODS: Fifty sarcoma patients with 109 lung metastases were treated with SBRT between 2005 and 2021. Outcomes evaluated included local control (LC), overall survival (OS), and toxicity including lung pneumonitis/fibrosis, chest wall toxicity, dermatitis, brachial plexus, and esophageal toxicity. Systemic therapy receipt before and after SBRT was recorded. RESULTS: SBRT schedules were divided into 3 cohorts: 30 to 34 Gy/1fx (n=10 [20%]), 48 to 50 Gy/4 to 5fx (n=24[48%]), and 60 Gy/5fx (n=16[32%]). With a median follow-up of 19.5 months, 1/3-year LC rates were 96%/88% and 1/3-year OS 77%/50%, respectively. There was no differences between the 3 regimens in terms of LC, OS, or toxicity. Size >4 cm was a predictor of worse LC ( P =0.031) and worse OS ( P = 0.039) on univariate analysis. The primary pattern of failure was new metastases (64%) of which the majority were in the contralateral lung (52%). One-year chemotherapy-free survival was 85%. Overall, 76% of patients did not require chemotherapy initiation or change of chemotherapy regimen after lung SBRT. Toxicity was reported in 16% of patients overall, including 25%, 20%, and 14% in the 30 to 34 Gy/1fx, 48 to 50 Gy/4 to 5fx, and 60 Gy/5fx cohorts, respectively. CONCLUSIONS: SBRT outcomes for lung metastases from sarcoma demonstrate high rates of LC and are similar with different dose/fractionation regimens. Lung SBRT is associated with prolonged chemotherapy-free survival. Prospective validation of these results is warranted.

Early-Stage Primary Lung Neuroendocrine Tumors Treated With Stereotactic Body Radiation Therapy: A Multi-Institution Experience.

PURPOSE: Current guidelines recommend surgery as standard of care for primary lung neuroendocrine tumor (LNET). Given that LNET is a rare clinical entity, there is a lack of literature regarding treatment of LNET with stereotactic body radiation therapy (SBRT). We hypothesized that SBRT could lead to effective locoregional tumor control and long-term outcomes. METHODS AND MATERIALS: We retrospectively reviewed 48 tumors in 46 patients from 11 institutions with a histologically confirmed diagnosis of LNET, treated with primary radiation therapy. Data were collected for patients treated nonoperatively with primary radiation therapy between 2006 and 2020. Patient records were reviewed for lesion characteristics and clinical risk factors. Kaplan-Meier analysis, log-rank tests, and Cox multivariate models were used to compare outcomes. RESULTS: Median age at treatment was 71 years and mean tumor size was 2 cm. Thirty-two lesions were typical carcinoid histology, 7 were atypical, and 9 were indeterminate. The most common SBRT fractionation schedule was 50 to 60 Gy in 5 daily fractions. Overall survival at 3, 6, and 9 years was 64%, 43%, and 26%, respectively. Progression-free survival at 3, 6, and 9 years was 88%, 78%, and 78%, respectively. Local control at 3, 6, and 9 years was 97%, 91%, and 91%, respectively. There was 1 regional recurrence in a paraesophageal lymph node. No grade 3 or higher toxicity was identified. CONCLUSIONS: This is the largest series evaluating outcomes in patients with LNET treated with SBRT. This treatment is well tolerated, provides excellent locoregional control, and should be offered as an alternative to surgical resection for patients with early-stage LNET, particularly those who may not be ideal surgical candidates.

Association of Radiotherapy Duration With Clinical Outcomes in Patients With Esophageal Cancer Treated in NRG Oncology Trials: A Secondary Analysis of NRG Oncology Randomized Clinical Trials.

Importance: For many types of epithelial malignant neoplasms that are treated with definitive radiotherapy (RT), treatment prolongation and interruptions have an adverse effect on outcomes. Objective: To analyze the association between RT duration and outcomes in patients with esophageal cancer who were treated with definitive chemoradiotherapy (CRT). Design, Setting, and Participants: This study was an unplanned, post hoc secondary analysis of 3 prospective, multi-institutional phase 3 randomized clinical trials (Radiation Therapy Oncology Group [RTOG] 8501, RTOG 9405, and RTOG 0436) of the National Cancer Institute-sponsored NRG Oncology (formerly the National Surgical Adjuvant Breast and Bowel Project, RTOG, and Gynecologic Oncology Group). Enrolled patients with nonmetastatic esophageal cancer underwent definitive CRT in the trials between 1986 and 2013, with follow-up occurring through 2014. Data analyses were conducted between March 2022 to February 2023. Exposures: Treatment groups in the trials used standard-dose RT (50 Gy) and concurrent chemotherapy. Main Outcomes and Measures: The outcomes were local-regional failure (LRF), distant failure, disease-free survival (DFS), and overall survival (OS). Multivariable models were used to examine the associations between these outcomes and both RT duration and interruptions. Radiotherapy duration was analyzed as a dichotomized variable using an X-Tile software to choose a cut point and its median value as a cut point, as well as a continuous variable. Results: The analysis included 509 patients (median [IQR] age, 64 [57-70] years; 418 males [82%]; and 376 White individuals [74%]). The median (IQR) follow-up was 4.01 (2.93-4.92) years for surviving patients. The median cut point of RT duration was 39 days or less in 271 patients (53%) vs more than 39 days in 238 patients (47%), and the X-Tile software cut point was 45 days or less in 446 patients (88%) vs more than 45 days in 63 patients (12%). Radiotherapy interruptions occurred in 207 patients (41%). Female (vs male) sex and other (vs White) race and ethnicity were associated with longer RT duration and RT interruptions. In the multivariable models, RT duration longer than 45 days was associated with inferior DFS (hazard ratio [HR], 1.34; 95% CI, 1.01-1.77; P = .04). The HR for OS was 1.33, but the results were not statistically significant (95% CI, 0.99-1.77; P = .05). Radiotherapy duration longer than 39 days (vs ≤39 days) was associated with a higher risk of LRF (HR, 1.32; 95% CI, 1.06-1.65; P = .01). As a continuous variable, RT duration (per 1 week increase) was associated with DFS failure (HR, 1.14; 95% CI, 1.01-1.28; P = .03). The HR for LRF 1.13, but the result was not statistically significant (95% CI, 0.99-1.28; P = .07). Conclusions and Relevance: Results of this study indicated that in patients with esophageal cancer receiving definitive CRT, prolonged RT duration was associated with inferior outcomes; female patients and those with other (vs White) race and ethnicity were more likely to have longer RT duration and experience RT interruptions. Radiotherapy interruptions should be minimized to optimize outcomes.

Local Control With Single-Fraction Lung Stereotactic Body Radiotherapy is not influenced by Non-Small Cell Lung Cancer Histologic Subtype.

INTRODUCTION/BACKGROUND: For early stage medically inoperable lung cancer treated with fractionated stereotactic body radiotherapy (SBRT), higher local failure is associated with squamous carcinoma (SqC) compared to adenocarcinoma (AC). This study explored whether histology influences single-fraction SBRT local control. MATERIALS AND METHODS: We surveyed our prospective data registry from 12/2009 to 12/2019 for SF-SBRT cases with biopsy-proven AC or SqC only. Outcomes of interest included local (LF), nodal (NF), distant (DF) failure rates and overall survival (OS), as well as treatment-related toxicity. RESULTS: For the 10-year interval surveyed, 113 patients met study criteria. There was no association between histology and dose received (34 Gy or 30 Gy). Median follow up was 22.9 months. Patient characteristics were balanced between histologic cohorts. Median tumor size was 1.9 cm. Comparing total AC vs. SqC cohorts, 2-year LF rates (%) were 7.3 vs. 9.6, respectively (P = .9805). In %, 2-year LF, NF, DF and OS rates for AC for 30 Gy and 34 Gy, respectively, were 10.8 vs. 6.4; 10.5 vs. 16.2; 15.8 vs. 13.0; 77.9 vs.71.2 (all P = non-significant). In %, 2-year LF, NF, DF, and OS rates for SqC for 30 Gy and 34 Gy, respectively, were 11.8 vs. 8.1; 5.9 vs. 18.0; 23.5 vs. 9.7; 70.6 vs. 77.1 (all P = non-significant). When considering toxicities, there were no grade 4/5 toxicities and no significant differences in any other toxicity rate by histology or dose. CONCLUSION: SF-SBRT local control was not associated with histology, unlike fractionated schedules. This novel finding adds to the evolving understanding of this treatment schedule.

Esophageal adenocarcinoma: A dire need for early detection and treatment.

Esophageal cancer is the sixth most common cause of cancer-related death worldwide. Esophageal adenocarcinoma is the most common subtype of esophageal cancer in the United States, and its incidence has risen dramatically in the last few decades. Modern endoscopic and surgical techniques have significantly improved morbidity and mortality rates of patients undergoing treatment for esophageal cancer. However, most cases are diagnosed at a late stage when the prognosis is poor, emphasizing the need for an effective screening strategy. This clinical overview focuses on screening, multidisciplinary evaluation, and treatment of early esophageal adenocarcinoma.

Is adaptive planning necessary for patients with large tumor position displacements observed on daily image guidance during lung SBRT?

For patients undergoing stereotactic body radiation therapy for lung cancer, their tumor positions may vary due to anatomical changes. This study is to investigate whether adaptive re-planning is necessary for patients with large tumor position displacements observed from daily kV-cone-beam computed tomography (kV-CBCT). We selected 16 fractions from 16 patients with recorded treatment couch shifts greater than 1.5 cm under kV-CBCT guidance. The treatment positions for these patients were manually restored in kV-CBCTs via bone-to-bone alignments (B2B) and tumor-to-tumor alignments (T2T) with corresponding planning CTs. The tumor volumes, including PTVs, ITVs, and GTVs, were transferred from the planning CTs to these kV-CBCTs. With the planned beam configurations and treatment isocenters, kV-CBCTs were imported into the treatment planning system for dose recalculations. To minimize uncertainties of the Hounsfield Unit (HU) in kV-CBCTs, uniformed HU values were assigned to the externals, ITVs, and lungs. The percentage volumes of GTVs, ITVs, and PTVs receiving the prescription dose (VRx) and the dose to the normal structures were analyzed. Seven out of the 16 patients were identified with >5mm tumor position displacements after subtracting the recorded couch shifts from the shifts of B2B alignment. For T2T alignments, 9 out of 16 (56.3%) patients had VRx of PTV <95% (the planning goal) with 91.4% as the lowest, while VRx of the GTV and ITV remained 100% for all 16 patients. For B2B alignments, 14 out of 16 (87.5%) patients have VRx of PTV <95%; 5 patients (31.3%) had VRx of ITV <95%; and 4 patients (25.0%) had VRx of GTV <99%. T2T alignment with 5 mm PTV margin was found superior to B2B alignment, resulting in adequate dose coverage to the ITVs, even for tumors with large positional changes. Adaptive re-planning may not be necessary under these scenarios.