Salvage SBRT for Previously Irradiated Lung Cancer

Steven K. Seung, Matthew Solhjem

.
The Oregon Clinic; 2The Earle A. Chiles Research Institute.

DOI: 10.4236/jct.2011.22024                

Abstract

Purpose: Patients with locally recurrent lung cancer after definitive radiation therapy pose a challenge in management. Surgery is often not an option and chemotherapy offers poor long-term local control. Stereotactic body radiotherapy (SBRT) was investigated in an attempt to salvage locally recurrent lung cancer. Materials and Methods: From March, 2009 to January, 2010, 8 patients who had previous definitive radiation therapy for lung cancer at least six months prior to the diagnosis of locally recurrent disease underwent SBRT. Local recurrence was documented by CT, PET, and/or biopsy. Patients had to have Karnofsky Performance Score (KPS) > 70, no distant metastases by CT/PET and brain MRI, and lesions amenable to SBRT. SBRT dose deliveries were 12 Gy x 4, 10 Gy x 5, 8 Gy x 5, or 20 Gy x 3 at the treating physician’s discretion. No adjuvant chemotherapy was delivered. Results: Eight patients were included in this study. Patient characteristics were: 6 females and 2 males; ages 50 - 85 (median 71); KPS 70 - 100 (median 80); previous stage I (T1/2 N0) in 4 and stage II/III (T1/2 N1/N2) in 3, 1 pt had limited stage small cell; previous radiation doses 50 - 68 Gy in 1.8/2.5 Gy fractions; time interval from previous RT to SBRT 8 - 57 months (median 36 months); target lesion diameters 1.2 - 7.3 cm (median 4.5 cm). With a median FU of 18 months (11 - 20 months), 7 patients are alive. Crude local/regional control to date is 86% with distant metastases in 1/7 surviving patients. Acute pulmonary toxicities: cough grade 0 7/8, grade 1 1/8; pain grade 0 6/8, grade 1 2/8; dyspnea grade 2 8/8. 1 patient died 12 months after SBRT due to complications from a hip fracture. Her disease was locally controlled at the time of death. Discussion: In carefully selected patients who recur locally after previous conventional radiation therapy for lung cancer, SBRT can offer a well tolerated salvage therapy. Further follow up is needed to assess long-term local control, survival and toxicities.

Keywords

SBRT, Lung Cancer, Re-Irradiation

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	P. Coy and G. M. Kennelly, “The Role of Curative Radiotherapy in the Treatment of Lung Cancer,” Cancer, Vol. 45, 1980, pp. 698-702. doi:10.1002/1097-0142(19800215)45:4<698::AID-CNCR2820450414>3.0.CO;2-8
[2]	P. H. Graham, V. J. Gebski and A. O. Langlands, “Radical Radiotherapy for Early Nonsmall Cell Lung Cancer,” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 31, 1995, pp. 261-266. doi:10.1016/0360-3016(94)E0137-9
[3]	D. E. Dosoretz, M. J. Katin, P. H. Blitzer, et al., “Medically Inoperable Lung Carcinoma: The Role of Radiation Therapy,” Seminars in Radiation Oncology, Vol. 6, No. 2, 1996, pp. 98-104. doi:10.1016/S1053-4296(96)80006-3
[4]	J. Noble, P. M. Ellis, J. A. Mackay and W. K. Evans, “Second-Line or Subsequent Systemic Therapy for Recurrent or Progressive Non-Small Cell Lung Cancer: A Systematic Review and Practice Guideline,” Journal of Thoracic Oncology, Vol. 1, No. 9, 2006, pp. 1042-1058. doi:10.1097/01243894-200611000-00021
[5]	K. L. Wu, G. L. Jiang, H. Qian, et al., “Three-Dimensional Conformal Radiotherapy for Locoregionally Recurrent Lung Carcinoma after External Beam Irradiation: A Prospective Phase I-II Clinical Trial,” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 57, No. 5, 2003, pp. 1345-1350. doi:10.1016/S0360-3016(03)00768-5
[6]	T. Tada, H. Fukuda, K. Matsui, et al., “Non-Small-Cell Lung Cancer: Reirradiation for Loco-Regional Relapse Previously Treated with Radiation Therapy,” International Journal of Clinical Oncology, Vol. 10, No. 4, 2005, pp. 247-250. doi:10.1007/s10147-005-0501-1
[7]	Y. Okamoto, M. Murakami, E. Yoden, et al., “Reirradiation for Locally Recurrent Lung Cancer Previously Treated with Radiation Therapy,” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 52, No. 2, 2002, pp. 390-396. doi:10.1016/S0360-3016(01)02644-X
[8]	N. Green and R. W. Melbye, “Lung Cancer: Retreatment of Local Recurrence after Definitive Irradiation,” Cancer, Vol. 49, No. 5, 1982, pp. 865-868. doi:10.1002/1097-0142(19820301)49:5<865::AID-CNCR2820490507>3.0.CO;2-H
[9]	J. F. Montebello, B. S. Aron, A. K. Manatunga, J. L. Horvath and F. W. Peyton, “The Reirradiation of Recurrent Bronchogenic Carcinoma with External Beam Irradiation,” American Journal of Clinical Oncology, Vol. 16, No. 6, 1993, pp. 482-488. doi:10.1097/00000421-199312000-00004
[10]	L. Leksell, “The Stereotaxic Method and Radiosurgery of the Brain,” Acta Chirurgica Scandinavica, Vol. 102, No. 4, 1951, pp. 316-319.
[11]	J. C. Flickinger, D. Kondziolka and L. D. Lunsford, “Clinical Applications of Stereotactic Radiosurgery,” Cancer Treatment and Research, Vol. 93, 1998, pp. 283-297.
[12]	D. A. Larson, P. H. Gutin, S. A. Leibel, T. L. Phillips, P. K. Sneed and W. M. Wara, “Stereotaxic Irradiation of Brain Tumors,” Cancer, Vol. 65, No. S3, 1990, pp. 792-799. doi:10.1002/1097-0142(19900201)65:3+<792::AID-CNCR2820651327>3.0.CO;2-P
[13]	J. S. Loeffler, D. C. Shrieve, P. Y. Wen, et al., “Radiosurgery for Intracranial Malignancies,” Seminars in Radiation Oncology, Vol. 5, No. 3, 1995, pp. 225-234. doi:10.1016/S1053-4296(05)80021-9
[14]	D. Kondziolka, A. Patel, L. D. Lunsford, A. Kassam and J. C. Flickinger, “Stereotactic Radiosurgery Plus Whole Brain Radiotherapy Versus Radiotherapy Alone for Patients with Multiple Brain Metastases,” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 45, No. 2, 1999, pp. 427-434. doi:10.1016/S0360-3016(99)00198-4
[15]	D. W. Andrews, C. B. Scott, P. W. Sperduto, et al., “Whole Brain Radiation Therapy with or without Stereotactic Radiosurgery Boost for Patients with One to Three Brain Metastases: Phase III Results of the RTOG 9508 Randomised Tria,” Lancet, Vol. 363, 2004, pp. 1665- 1672. doi:10.1016/S0140-6736(04)16250-8
[16]	K. K. Ang, L. J. Peters, R. S. Weber, et al., “Postoperative Radiotherapy for Cutaneous Melanoma of the Head and Neck Region,” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 30, No. 4, 1994, pp. 795-798.
[17]	M. D. Bonnen, M. T. Ballo, J. N. Myers, et al., “Elective Radiotherapy Provides Regional Control for Patients with Cutaneous Melanoma of the Head and Neck,” Cancer, Vol. 100, No. 2, 2004, pp. 383-389. doi:10.1002/cncr.11921
[18]	S. K. Seung, P. K. Sneed, M. W. McDermott, et al., “Gamma Knife Radiosurgery for Malignant Melanoma Brain Metastases,” Cancer Journal from Scientific American, Vol. 4, No. 2, 1998, pp. 103-109.
[19]	J. M. Balter and M. L. Kessler, “Imaging and Alignment for Image-Guided Radiation Therapy,” Journal of Clinical Oncology, Vol. 25, No. 8, 2007, pp. 931-937. doi:10.1200/JCO.2006.09.7998
[20]	R. D. Timmerman, B. D. Kavanagh, L. C. Cho, L. Papiez and L. Xing, “Stereotactic Body Radiation Therapy in Multiple Organ Sites,” Journal of Clinical Oncology, Vol. 25, 2007, pp. 947-952. doi:10.1200/JCO.2006.09.7469
[21]	L. Potters, M. Steinberg, C. Rose, et al., “American Society for Therapeutic Radiology and Oncology and American College of Radiology Practice Guideline for the Performance of Stereotactic Body Radiation Therapy,” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 60, No. 4, 2004, pp. 1026-1032. doi:10.1016/j.ijrobp.2004.07.701
[22]	L. Papiez, R. Timmerman, C. DesRosiers and M. Randall, “Extracranial Stereotactic Radioablation: Physical Principles,” Acta Oncologica, Vol. 42, No. 8, 2003, pp. 882-894. doi:10.1080/02841860310013490
[23]	H. Hof, K. K. Herfarth, M. Munter, et al., “Stereotactic Single-Dose Radiotherapy of Stage I Non-Small-Cell Lung Cancer (NSCLC),” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 56, No. 2, 2003, pp. 335-341. doi:10.1016/S0360-3016(02)04504-2
[24]	R. D. Timmerman, L. Papiez, R. McGarry, et al., “Extracranial Stereotactic Radioablation: Results of a Phase I Study in Stage I Non-Small Cell Lung Cancer,” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 124, No. 5, 2003, pp. S280-S281. doi:10.1016/S0360-3016(03)01131-3
[25]	Y. Nagata, Y. Negoro, T. Aoki, et al., “Clinical Outcomes of 3D Conformal Hypofractionated Single High-Dose Radiotherapy for One or Two Lung Tumors Using a Stereotactic Body Frame,” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 52, No. 4, 2002, pp. 1041-1046. doi:10.1016/S0360-3016(01)02731-6
[26]	M. Uematsu, A. Shioda, K. Tahara, et al., “Focal, High Dose, and Fractionated Modified Stereotactic Radiation Therapy for Lung Carcinoma Patients: A Preliminary Experience,” Cancer, Vol. 82, No. 6, 1998, pp. 1062- 1070. doi:10.1002/(SICI)1097-0142(19980315)82:6<1062::AID-CNCR8>3.0.CO;2-G
[27]	H. Onishi, T. Araki, H. Shirato, et al., “Stereotactic Hypofractionated High-Dose Irradiation for Stage I Nonsmall Cell Lung Carcinoma: Clinical Outcomes in 245 Subjects in a Japanese Multiinstitutional Study,” Cancer, Vol. 101, No. 7, 2004, pp. 1623-1631. doi:10.1002/cncr.20539
[28]	Q. T. Le, B. W. Loo, A. Ho, et al., “Results of a Phase I Dose-Escalation Study Using Single-Fraction Stereotactic Radiotherapy for Lung Tumors,” Journal of Thoracic Oncology, Vol. 1, No. 8, 2006, pp. 802-809. doi:10.1097/01243894-200610000-00008
[29]	P. Kelly, P. A. Balter, N. Rebueno, et al., “Stereotactic Body Radiation Therapy for Patients with Lung Cancer Previously Treated with Thoracic Radiation,” International Journal of Radiation Oncology ? Biology ? Physics, Vol. 78, No. 5, pp. 1387-1393. doi:10.1016/j.ijrobp.2009.09.070