Proton therapy of lung cancer patients - Treatment strategies and clinical experience from a medical physicist's perspective.

Purpose: Proton therapy of moving targets is considered a challenge. At Maastro, we started treating lung cancer patients with proton therapy in October 2019. In this work, we summarise the developed treatment strategies and gained clinical experience from a physics point of view.

Comparison of photon intensity modulated, hybrid and volumetric modulated arc radiation treatment techniques in locally advanced non-small cell lung cancer.

Background And Purpose: There is no consensus on the best photon radiation technique for non-small cell lung cancer (NSCLC). This study quantified the differences between commonly used treatment techniques in NSCLC to find the optimal technique.

Materials And Methods: Treatment plans were retrospectively generated according to clinical guidelines for 26 stage III NSCLC patients using intensity modulated radiation therapy (IMRT), hybrid, and volumetric modulated arc therapy (VMAT, and VMAT optimized for lower lung and heart dose).

Clinical evaluation of synthetic computed tomography methods in adaptive proton therapy of lung cancer patients.

Background And Purpose: Efficient workflows for adaptive proton therapy are of high importance. This study evaluated the possibility to replace repeat-CTs (reCTs) with synthetic CTs (sCTs), created based on cone-beam CTs (CBCTs), for flagging the need of plan adaptations in intensity-modulated proton therapy (IMPT) treatment of lung cancer patients.

Materials And Methods: Forty-two IMPT patients were retrospectively included.

A traffic light protocol workflow for image-guided adaptive radiotherapy in lung cancer patients.

Background And Purpose: Image-guided radiotherapy using cone beam-CT (CBCT) images is used to evaluate patient anatomy and positioning before radiotherapy. In this study we analyzed and optimized a traffic light protocol (TLP) used in lung cancer patients to identify patients requiring treatment adaptation.

Materials And Methods: First, CBCT review requests of 243 lung cancer patients were retrospectively analyzed and divided into 6 pre-defined categories.

Prediction models for treatment-induced cardiac toxicity in patients with non-small-cell lung cancer: A systematic review and meta-analysis.

Background: To maximize the likelihood of positive outcome in non-small-cell lung cancer (NSCLC) survivors, potential benefits of treatment modalities have to be weighed against the possibilities of damage to normal tissues, such as the heart. High-quality data-driven evidence regarding appropriate risk stratification strategies is still scarce. The aim of this review is to summarize and appraise available prediction models for treatment-induced cardiac events in patients with NSCLC.

Treatment planning and 4D robust evaluation strategy for proton therapy of lung tumors with large motion amplitude.

Purpose: Intensity-modulated proton therapy (IMPT) for lung tumors with a large tumor movement is challenging due to loss of robustness in the target coverage. Often an upper cut-off at 5-mm tumor movement is used for proton patient selection. In this study, we propose (1) a robust and easily implementable treatment planning strategy for lung tumors with a movement larger than 5 mm, and (2) a four-dimensional computed tomography (4DCT) robust evaluation strategy for evaluating the dose distribution on the breathing phases.

Visually guided inspiration breath-hold facilitated with nasal high flow therapy in locally advanced lung cancer.

Background And Purpose: Reducing breathing motion in radiotherapy (RT) is an attractive strategy to reduce margins and better spare normal tissues. The objective of this prospective study (NCT03729661) was to investigate the feasibility of irradiation of non-small cell lung cancer (NSCLC) with visually guided moderate deep inspiration breath-hold (IBH) using nasal high-flow therapy (NHFT).

Material And Methods: Locally advanced NSCLC patients undergoing photon RT were given NHFT with heated humidified air (flow: 40 L/min with 80% oxygen) through a nasal cannula.

National costs and resource requirements of external beam radiotherapy: A time-driven activity-based costing model from the ESTRO-HERO project.

Background: The Health Economics in Radiation Oncology (ESTRO-HERO) project aims to provide a knowledge base for health economics in European radiotherapy. A cost-accounting model, providing data on national resource requirements and costs of external beam radiotherapy (EBRT), was developed.

Materials And Methods: Time-driven activity-based costing (TD-ABC) was applied from the healthcare provider perspective at national level.

Comparative evaluation of autocontouring in clinical practice: A practical method using the Turing test.

Purpose: Automated techniques for estimating the contours of organs and structures in medical images have become more widespread and a variety of measures are available for assessing their quality. Quantitative measures of geometric agreement, for example, overlap with a gold-standard delineation, are popular but may not predict the level of clinical acceptance for the contouring method. Therefore, surrogate measures that relate more directly to the clinical judgment of contours, and to the way they are used in routine workflows, need to be developed.

Study Protocol of the NVALT25-ELDAPT Trial: Selecting the Optimal Treatment for Older Patients With Stage III Non-small-cell Lung Cancer.

Background: Patients aged 75 years or older with stage III non-small-cell lung cancer (NSCLC) are underrepresented in clinical trials, leading to a lack of evidence for selection of the optimal treatment strategy. Information on benefits and harms of concurrent chemoradiotherapy among medically fit elderly patients is largely unknown, and reliable tools are needed to distinguish fit from frail patients for treatment selection. Also, information regarding quality of life during and after treatment is scarce.

The Prevention of Brain Metastases in Non-Small Cell Lung Cancer by Prophylactic Cranial Irradiation.

Background: Non-small cell lung cancer (NSCLC) patients frequently develop brain metastases (BM), even though the initial imaging with brain CT or MRI was negative. Stage III patients have the highest risk to develop BM, with an incidence of approximately 30%. BM can lead to neurocognitive disorders, loss of quality of life (QoL), and they are the most important factors influencing patient's overall survival (OS).

Comparison of SUVmax and SUVpeak based segmentation to determine primary lung tumour volume on FDG PET-CT correlated with pathology data.

Purpose: The aim of the study was to compare simple SUVmax and SUVpeak based segmentation methods for calculating the lung tumour volume, compared to a pathology ground truth.

Methods: Thirty patients diagnosed with early stage Non-Small Cell lung cancer (NSCLC) underwent surgical resection in the Netherlands between 2006 and 2008. FDG PET-CT scans for these patients were acquired within a median of 20 days before surgery.

Predictors for poor cosmetic outcome in patients with early stage breast cancer treated with breast conserving therapy: Results of the Young boost trial.

Purpose: In the Young Boost trial (YBT), breast cancer patients ≤50 years of age, treated with breast conserving therapy (BCT) were randomized between a 26 Gy boost dose and a 16 Gy boost dose, with local recurrence as primary and cosmetic outcome (CO) as secondary endpoint. Data of the YBT was used to investigate which factors are related with worse cosmetic outcome after BCT.

Methods: From 2004 to 2011, 2421 cT1-2N0-2a breast cancer patients were randomized.

Geriatric Assessment for Older Patients with Non-small Cell Lung Cancer: Daily Practice of Centers Participating in the NVALT25-ELDAPT Trial.

Introduction: Geriatric assessment (GA) for older patients with lung cancer could provide insight into vulnerability, cognitive impairment, and risk of toxicity. Discontinuation and complications of intensive treatment could potentially be prevented in vulnerable and frail patients. This study aimed to evaluate current clinical practice of GA for older patients with lung cancer in the Netherlands and identify potential hurdles for implementation.

Patterns of treatment and survival among older patients with stage III non-small cell lung cancer.

Introduction: Patterns of treatment and survival are largely unknown for older patients with stage III non-small cell lung cancer (NSCLC) in daily clinical practice.

Methods: All patients ≥65 years with stage III NSCLC (2009-2013) were included from the population-based Netherlands Cancer Registry. Descriptive and multivariable treatment and survival analyses were stratified for patients aged 65-74 years and ≥75 years.

Trends in treatment and relative survival among Non-Small Cell Lung Cancer patients in the Netherlands (1990-2014): Disparities between younger and older patients.

Background: This study aimed to describe trends over time regarding disparities in treatment and relative survival (RS) between younger and older patients with non-small cell lung cancer (NSCLC).

Methods: All patients diagnosed with pathologically verified NSCLC in 1990-2014 were included from the Netherlands Cancer Registry (n=187,315). Treatment and RS (adjusted for sex, histology and treatment) were analyzed according to age group (<70 years versus ≥70 years), stage and five-year period of diagnosis.

Timed Get Up and Go Test and Geriatric 8 Scores and the Association With (Chemo-)Radiation Therapy Noncompliance and Acute Toxicity in Elderly Cancer Patients.

Purpose: To investigate whether the Geriatric 8 (G8) and the Timed Get Up and Go Test (TGUGT) and clinical and demographic patient characteristics were associated with acute toxicity of radiation therapy and noncompliance in elderly cancer patients being irradiated with curative intent.

Methods And Materials: Patients were eligible if aged ≥65 years and diagnosed with breast, non-small cell lung, prostate, head and neck, rectal, or esophageal cancer, and were referred for curative radiation therapy. We recorded acute toxicity and noncompliance and identified potential predictors, including the G8 and TGUGT.

PET imaging of zirconium-89 labelled cetuximab: A phase I trial in patients with head and neck and lung cancer.

Background And Purpose: PET imaging of cetuximab uptake may help selecting cancer patients with the highest chance of benefit. The aim of this phase I trial was to determine the safety of the tracer Zr-cetuximab and to assess tumour uptake.

Methods: Two dose schedules were used; two consecutive doses of 60MBq Zr-cetuximab or a single dose of 120MBq, both preceded by 400mg/m of unlabelled cetuximab.

Stage III Non-Small Cell Lung Cancer in the elderly: Patient characteristics predictive for tolerance and survival of chemoradiation in daily clinical practice.

Background: In unselected elderly with stage III Non-Small Cell Lung Cancer (NSCLC), evidence is scarce regarding motives and effects of treatment modalities.

Methods: Hospital-based multicenter retrospective study including unresectable stage III NSCLC patients aged ⩾70 and diagnosed between 2009 and 2013 (N=216). Treatment motives and tolerance (no unplanned hospitalizations and completion of treatment), and survival were derived from medical records and the Netherlands Cancer Registry.

Factors associated with patient-reported cosmetic outcome in the Young Boost Breast Trial.

Purpose: To investigate which factors are related to patient reported cosmetic outcome (PRCO) after breast conserving therapy.

Methods: From 2004 to 2011, 2421 cT1-2N0-2a breast cancer patients were randomised in the Young Boost Trial between a 16 and a 26Gy boost to the tumour bed. Cosmesis was scored subjectively by the patient and physician, and objectively using BCCT.

Spacers in radiotherapy treatment of prostate cancer: is reduction of toxicity cost-effective?

Background And Purpose: To compare the cost-effectiveness of treating prostate cancer patients with intensity-modulated radiation therapy and a spacer (IMRT+S) versus IMRT-only without a spacer (IMRT-O).

Materials And Methods: A decision-analytic Markov model was constructed to examine the effect of late rectal toxicity and compare the costs and quality-adjusted Life Years (QALYs) of IMRT-O and IMRT+S. The main assumption of this modeling study was that disease progression, genito-urinary toxicity and survival were equal for both comparators.

Set-up verification and 2-dimensional electronic portal imaging device dosimetry during breath hold compared with free breathing in breast cancer radiation therapy.

Purpose: To compare set-up and 2-dimensional (2D) electronic portal imaging device (EPID) dosimetry data of breast cancer patients treated during voluntary moderately deep inspiration breath hold (vmDIBH) and free breathing (FB).

Methods And Materials: Set-up data were analyzed for 29 and 51 consecutively treated patients, irradiated during FB and vmDIBH, respectively. Of the 51 vmDIBH patients, the first 25 had undergone an extra trained computed tomography (CT) scan and used an additional "breathing stick" (vmDIBH_trained).

Total gross tumor volume is an independent prognostic factor in patients treated with selective nodal irradiation for stage I to III small cell lung cancer.

Purpose: In non-small cell lung cancer, gross tumor volume (GTV) influences survival more than other risk factors. This could also apply to small cell lung cancer.

Methods And Materials: Analysis of our prospective database with stage I to III SCLC patients referred for concurrent chemo radiation therapy.