Characterizing Spatial Lung Function for Esophageal Cancer Patients Undergoing Radiation Therapy.

PURPOSE: Patients with esophageal cancer treated with chemoradiation and surgery can develop pulmonary complications. Four-dimensional computed tomography-ventilation (4DCT-ventilation) is a developing imaging modality that uses 4DCT data to calculate lung ventilation. 4DCT-ventilation has been studied in the lung-cancer population but has yet to be extended to patients with esophageal cancer. The purpose of this study was to characterize 4DCT-ventilation-based spatial lung function for patients with esophageal cancer. METHODS AND MATERIALS: Thirty-five patients with esophageal cancer who underwent 4DCT scans participated in the study. A 4DCT-ventilation map was calculated using the patient's 4DCT imaging and a density change-based algorithm. To assess each patient's ventilation profile, radiologist interpretations and quantitative metrics were used. A radiologist interpreted the 4DCT-ventilation images for lobar-based defects and gravity-dependent atelectasis. The 4DCT-ventilation maps were reduced to single metrics intended to reflect the degree of ventilation heterogeneity. The quantitative metrics included the coefficient of variation and metrics based on the ventilation in each lung and each lung third (superior-inferior ventilation [Vent-SI] and anteroposterior ventilation). The functional profile of patients with esophageal cancer was characterized and compared (using the Mann-Whitney test) for cohorts based on thoracic comorbidities and radiologist-identified defects. RESULTS: Radiologist observations revealed that 26% of patients with esophageal cancer had lobar-based defects and 46% had gravity-dependent atelectasis. The baseline values were 0.52 ± 0.20 (mean ± SD), 11.2 ± 12.5, and 72.5 ± 14.6 for the coefficient of variation, the ventilation ratio of right to left lung, and Vent-SI metrics, respectively. The Vent-SI values were significantly different between patients with and without thoracic comorbidities (P = .05), and the anteroposterior ventilation metric was able to delineate patients with and without gravity-dependent atelectasis (P < .01). CONCLUSIONS: Our data demonstrate that approximately 30% of patients with esophageal cancer have significant ventilation heterogeneities. The current work uses radiologist observations and quantitative metrics to characterize 4DCT ventilation-based lung function for patients with esophageal cancer and presents data that can be used for future applications of 4DCT-ventilation to reduce thoracic toxicity for patients with esophageal cancer.

Comparison of different registration landmarks for MRI-CT fusion in radiotherapy for lung cancer with post-obstructive lobar collapse.

The registration of the two sets of images based on the spine and pulmonary artery landmarks and the geometric center difference of the mean displacement in the X, Y, and Z directions (X, Y, and Z represent the directions of the body from left to right, superior to inferior, and anterior to posterior) between their MRI-CT fusions were compared, respectively. Fifty-five lung cancer patients with post-obstructive lobar collapse were enrolled in this study. Before radiation, two sets of simulating images according to the spine and the pulmonary artery registrations were obtained for each patient using MRI-CT fusion. The differences of mean displacement in the X, Y, and Z directions based on spine and pulmonary artery landmarks were of -0.29, 0.25, and 0.18 cm, respectively. The mean displacements of the pulmonary artery based images in the three directions were smaller than that in the spine registration images (P < 0.05). By the method of pulmonary artery landmark, MRI-CT has better registration accuracy and can better help confirm the target volume.

First clinical results of adaptive radiotherapy based on 3D portal dosimetry for lung cancer patients with atelectasis treated with volumetric-modulated arc therapy (VMAT).

UNLABELLED: Atelectasis in lung cancer patients can change rapidly during a treatment course, which may displace the tumor/healthy tissues, or change tissue densities locally. This may result in differences between the planned and the actually delivered dose. With complex delivery techniques treatment verification is essential and inter-fractional adaptation may be necessary. We present the first clinical results of treatment adaptation based on an in-house developed three-dimensional (3D) portal dose measurement (PDM) system. MATERIAL AND METHODS: A method was developed for 3D PDM combined with cone beam computed tomography (kV-CBCT) imaging. Lung cancer patients are monitored routinely with this imaging technique. During treatment, the first three fractions are analyzed with 3D PDM and weekly thereafter. The reconstructed measured dose is compared to the planned dose using dose-volume histograms and a γ evaluation. Patients having |γ|> 1 in more than 5% of the (primary tumor or organ at risk) volume were subjected to further analysis. In this study we show the PDM dose changes for five patients. RESULTS: We detected relevant dose changes induced by changes in atelectasis in the presented cases. Two patients received two treatment adaptations after being detected with PDM confirmed by visual inspection of the kV-CBCTs, and in two other patients the radiation treatment plan was adapted once. In one case no dose delivery change was detected with PDM. CONCLUSION: The first clinical patients show that 3D PDM combined with kV-CBCT is a valuable quality assurance tool for detecting anatomical alterations and their dosimetric consequences during the course of radiotherapy. In our clinic, 3D PDM is fully automated for ease and speed of the procedure, and for minimization of human error. The technique is able to flag patients with suspected dose discrepancies for potential adaptation of the treatment plan.

Predicting the need for palliative thoracic radiation after first-line chemotherapy for advanced nonsmall cell lung carcinoma.

BACKGROUND: The objective of this secondary analysis was to identify patients with selected stage IIIB/IV nonsmall cell lung carcinoma and good performance status who were at high risk for requiring subsequent palliative thoracic radiotherapy after initial treatment with first-line chemotherapy. METHODS: The authors conducted a pooled analysis of patients at a single institution who enrolled onto 10 prospective phase 2 and 3 clinical trials that involved first-line, platinum-based chemotherapy. Baseline lung-related characteristics before trial enrollment were analyzed as possible prognostic factors for freedom from pulmonary events (defined either as subsequent thoracic radiation or as a new collapsed lung, which is an indication for thoracic radiation). RESULTS: Of 244 consecutive patients who were reviewed, 42 patients received a palliative course of thoracic radiation, 40 exhibited evidence of new lobar collapse on follow-up chest imaging, and 14 received thoracic radiation for lobar collapse. On univariable analysis, pulmonary symptoms (P = .043) or pneumonia at presentation (P = .0001), increasing size of hilar disease (P < .0001), and evidence of obstruction of major bronchi or vessels (P = .0003) were associated with subsequent pulmonary events. On multivariable analysis, hilar disease measuring >3 cm (hazard ratio, 1.8; P = .003) and prechemotherapy pneumonia (hazard ratio, 2.1; P = .009) were associated with pulmonary events; patients who had both risk factors or hilar disease >5 cm in greatest dimension exhibited a >50% risk of subsequent events. CONCLUSIONS: Patients with bulky hilar disease and a history of pneumonia at presentation were at high risk for requiring palliative thoracic radiation. The authors propose studying these patients to determine whether early thoracic radiation may be beneficial by preserving quality of life and performance status.

Local determinants of response to endobronchial high-dose rate brachytherapy in bronchogenic carcinoma.

STUDY OBJECTIVE: We evaluated bronchoscopic tumor appearance and tumor location as determinants of response to high-dose rate brachytherapy (HDR-BT) in patients with symptomatic unresectable bronchogenic carcinoma previously treated with external-beam irradiation. PATIENTS AND METHODS: Thirty patients with symptomatic endobronchial bronchogenic carcinoma who had previously completed external irradiation were divided into two groups based on whether the initial bronchoscopic appearance showed an endoluminal mass or submucosal infiltration/extrinsic compression. Furthermore, patients were also classified based on tumor location: central (trachea or mainstem bronchi) and peripheral (lobar or segmental bronchi). Patients underwent three treatments of 800 cGy intraluminal irradiation at 2-week intervals, with follow-up evaluation 4 weeks later. We evaluated response in tumor extent based on bronchoscopic and chest radiograph appearance, as well as symptoms with standardized scales. RESULTS: Fifteen of 24 patients who underwent follow-up bronchoscopy had reductions in the degree of endobronchial obstruction. Seven of 24 patients had radiographic improvement in the extent of atelectasis. Patients with both tumor appearances (endoluminal and submucosal/extrinsic compression) had significant improvements following HDR-BT with regard to hemoptysis. Patients with submucosal disease also had improvement in cough. Patients with peripheral tumors had better rates of response for hemoptysis and cough than did those with central tumors. CONCLUSION: HDR-BT may result in symptomatic improvement in patients with bronchogenic carcinoma, whether characterized endoscopically as endoluminal projection or submucosal infiltration/extrinsic compression. Peripheral tumors have better rates of response than central tumors, possibly on the basis of less extensive disease.

High dose rate intraluminal radiotherapy for carcinoma of the bronchus: outcome of treatment of 406 patients.

In April 1988 the Christie Hospital started using the microSelectron-HDR machine to deliver intraluminal radiotherapy (ILT) to inoperable bronchial carcinomas causing symptoms due to endobronchial disease. Results of treatment in the first 406 patients with primary non-small-cell carcinoma are presented. Three main categories of patient were defined. Category 1 consisted of 324 patients (79.8%) who were previously unirradiated and received a single fraction of ILT as their primary treatment, mostly to a dose of 1500 cGy (76%) or 2000 cGy (23%) at 1 cm from the centre of the iridium-192 treatment source. The percentage of these patients whose symptoms or signs were improved at 6 weeks following ILT were as follows: stridor 92%, haemoptysis 88%, cough 62%, dyspnoea, 60%, pain, 50% and pulmonary collapse, 46%. Approximately two-thirds of these patients (67.3%) derived long lasting palliation and required no further treatment during their lifetime. The other third of patients needed subsequent treatment at some stage because of recurrence of their symptoms and in this situation external beam radiotherapy (EB) or a repeat ILT treatment was effectively utilised. Category 2 consisted of 65 patients (16%) who had previously received EB but required ILT when their tumour recurred. At 6 weeks post-ILT levels of symptom palliation were broadly similar to those obtained if ILT was used in previously unirradiated individuals, although the improvement was not so well sustained with time and only 7% showed improvement in pulmonary collapse at 6 weeks. Category 3 consisted of 17 patients (4.2%) in whom ILT was used concurrently with EB as a combined initial treatment. Similar levels of palliation were seen when compared with patients who received a single ILT treatment only. Overall, ILT was well tolerated in terms of early and late morbidity. In conclusion, the efficiency of a single ILT treatment in palliating symptoms due to endobronchial tumour in previously unirradiated individuals is comparable with that reported in series where treatment for advanced lung cancer combines a prolonged course of EB concurrently with several ILT treatments.

[Palliative bronchial deobstruction with kinetic radiotherapy in non-small cell lung cancer]. / Disostruzione bronchiale palliativa con radioterapia cinetica nel cancro polmonare non a piccole cellule.

The palliative treatment of lung atelectasis can significantly improve the quality of life in the patients who are unsuitable for cure. The authors present a new transcutaneous radiotherapy technique for treating this complication of lung cancer. After conventional and CT localization, a treatment is scheduled featuring a small (3-5 cm wide and 4-6 cm long) single 180 degrees arc beam giving 14 Gy to the 90% isodose line in two daily fractions. The treatment is repeated 3 weeks later (dosage: 28 Gy). The mean dosage to the ICRU reference point was 34 Gy; the min., max. and mean dosages to the planning target volume were 31, and 35 Gy, respectively, in 4 fractions over a 3-week period. Lesions were localized best by positioning the distal end of a fiberoscope close to the tumor and by checking its position under fluoroscopic guidance, on two orthogonal projections, immediately after every treatment session. Nine patients with histologically-proven non-small cell lung cancer were treated. They relapsed after surgery and/or full-course radiotherapy. Lung reventilation, demonstrated with fiberbronchoscopy and on chest films, was observed in 8/9 patients, in 1 of them lasting for about 40 days. In the extant 7/8 cases, it lasted longer (range: 60-180 days). Of the latter patients, 5 are alive and 2 died 60 and 86 days after treatment, with no atelectasis. The treatment was very well tolerated and severe symptoms were relieved with no complications.

Total atelectasis of the lung secondary to malignant airway obstruction. Response to radiation therapy.

From 1980 to 1986, 48 patients with bronchogenic carcinoma were diagnosed to have total atelectasis of the lung as a result of tumor obstructing the mainstem bronchus. These patients were treated with external beam radiotherapy with doses ranging from 30 to 60 Gy given in 2-6 weeks. Bronchial obstruction was relieved in 74% of patients, resulting in complete or partial reexpansion of the lung. Seventy-one percent of patients irradiated within 2 weeks after radiological evidence of atelectasis had complete reexpansion of their lungs, whereas only 23% of those irradiated after 2 weeks showed a similar response. Atelectasis recurred in 12% of those who initially responded to radiation therapy with complete or partial reexpansion.

Intraluminal irradiation for the palliation of lung cancer with the high dose rate micro-Selectron.

Fifty patients with inoperable, symptomatic endobronchial carcinoma were treated by a single exposure of intraluminal radiotherapy. A high dose rate afterloading system (the micro-Selectron-HDR) was used to minimise radiation exposure for staff. Haemoptysis was relieved in 24 of 28 patients, breathlessness in 21 of 33 patients, and cough in nine of 18 patients. Radiological collapse resolved in 11 of 24 patients. Treatment was given on an outpatient basis and was well tolerated. Intraluminal radiotherapy appears to offer an effective alternative to conventional fractionated external beam radiotherapy.

The response of atelectasis from lung cancer to radiation therapy.

Between January 1981 and June 1983, 33 newly diagnosed patients with lung cancer presented with radiological findings of atelectasis. These patients were treated by primary radiation therapy, with doses ranging from 1200 to 6000 cGy. The response of atelectasis to radiation therapy was established on the basis of follow-up chest roentgenograms. Of the 28 patients with non-small cell carcinoma of lung, there were 17 (61%) who had improvement of the atelectasis. Among these, 13 patients were treated with doses ranging from 5000 to 6000 cGy in 5 to 8 weeks; 9 of these (70%) responded. By histological subtype, the numbers, though small, show that three of eight patients with adenocarcinoma responded, as compared to 2 out of 4 with large cell undifferentiated carcinoma and 12 of 16 patients with squamous cell carcinoma. In patients treated by more than 5000 cGy, four of eight (50%) patients with squamous cell carcinoma had a complete response and three (37.5%) had a partial relief of atelectasis, for a total response of 87.5%. The study indicates the importance of radiation therapy in the management of atelectasis caused by primary lung cancer.

[A case of maxillary metastasis from breast cancer]. / Su un caso di carcinoma metastatico al mascellare superiore da localizzazione primaria alla mammella

The literature data relating to the jaws as a metastasis site are examined, along with the basic criteria and main symptomatological pictures observed. A personal and relatively unusual instance of metasis to the upper jaw from breast cancer is presented. The features that led to diagnosis are discussed. Reference is made to the reported theories that justify the rarity of metastasis from breast cancer to the maxillofacial bones.