Outcomes of Stereotactic Body Radiotherapy (SBRT) treatment of multiple synchronous and recurrent lung nodules

Abstract

BackgroundStereotactic body radiotherapy (SBRT) is evolving into a standard of care for unresectable lung nodules. Local control has been shown to be in excess of 90% at 3 years. However, some patients present with synchronous lung nodules in the ipsilateral or contralateral lobe or metasynchronous disease. In these cases, patients may receive multiple courses of lung SBRT or a single course for synchronous nodules. The toxicity of such treatment is currently unknown.MethodsBetween 2006 and 2012, 63 subjects with 128 metasynchronous and synchronous lung nodules were treated at the Mayo Clinic with SBRT. Demographic patient data and dosimetric data regarding SBRT treatments were collected. Acute toxicity (defined as toxicity < 90 days) and late toxicity (defined as toxicity > = 90 days) were reported and graded as per standardized CTCAE 4.0 criteria. Local control, progression free survival and overall survival were also described.ResultsThe median age of patients treated was 73 years. Sixty five percent were primary or recurrent lung cancers with the remainder metastatic lung nodules of varying histologies. Of 63 patients, 18 had prior high dose external beam radiation to the mediastinum or chest. Dose and fractionation varied but the most common prescriptions were 48 Gy/4 fractions, 54 Gy/3 fractions, and 50 Gy/5 fractions. Only 6 patients demonstrated local recurrence. With a median follow up of 12.6 months, median SBRT specific overall survival and progression free survival were 35.7 months and 10.7 months respectively. Fifty one percent (32/63 patients) experienced acute toxicity, predominantly grade 1 and 2 fatigue. One patient developed acute grade 3 radiation pneumonitis at 75 days. Forty six percent (29/63 patients) developed late effects. Most were grade 1 dyspnea. There was one patient with grade 5 pneumonitis.ConclusionMultiple courses of SBRT and SBRT delivery after external beam radiotherapy appear to be feasible and safe. Most toxicity was grade 1 and 2 but the risk was approximately 50% for both acute and late effects.

ESTRO ACROP consensus guideline on implementation and practice of stereotactic body radiotherapy for peripherally located early stage non-small cell lung cancer

“…Other factors like old patient age [32][33][34], severe comorbidities and poor pulmonary function should not prevent recommendation of SBRT as a curative and well tolerated option [35][36][37]. Clinical situations, which are potentially associated with an increased risk for toxicity, do not preclude use of SBRT, for example following a contralateral pneumonectomy [38][39][40], treatment of two simultaneous primaries [41,42] and treatment of centrally located NSCLC [43,44]. Recently, idiopathic pulmonary fibrosis (IPF) has been identified as a risk factor for severe radiation induced pneumonitis but was not a relative contraindication for SBRT in the majority of the institutions [45][46][47].…”

Management of Multifocal Lung Cancer: Results of a Survey

“…In this case, management of these clonally related lesions as independent primaries may be recommended. Until stronger evidence-based guidelines are available, we strongly consider the use of local therapies such as surgery 17 or radiation 18 when evidence for systemic (extra-pulmonary) spread of disease cannot be identified.…”

Which patients benefit most from stereotactic body radiotherapy or surgery in medically operable non‐small cell lung cancer? An in‐depth look at patient characteristics on both sides of the debate

“…Meanwhile, for patients who present with synchronous lung nodules in the ipsilateral or contralateral lobe where a curative surgical procedure would be extensive, SBRT has shown relatively good results. For instance, Owen et al . analysed 63 subjects with 128 metasynchronous and synchronous lung nodules treated with SBRT at the Mayo clinic between 2006 and 2012.…”