Radiation Oncology/Reirradiation/Lung

Lung Reirradiation

External Beam Reirradiation

• China (1999–2001) -- Phase I-II
  • Reirradiation for 23 pts for local recurrence of lung cancer. Median time to retreatment was 13 months.
  • Initial RT median 66 Gy (range 30-78). Reirradiation dose median 51 Gy (range 46-60) in 1.8-2 Gy fractions. (If first course dose was <50 Gy, 60 Gy of reirradiation was given. If first course gave >= 50 Gy, 46-50 Gy was given.) Technique: 3D conformal. Chemotherapy: optional (median of 1 dose given prior to RT).
  • 2003: PMID 14630272 -- "Three-dimensional conformal radiotherapy for locoregionally recurrent lung carcinoma after external beam irradiation: a prospective phase I-II clinical trial." (Wu KL, Int J Radiat Oncol Biol Phys. 2003 Dec 1;57(5):1345-50.)
    • Median f/u 15 months. OS 1-yr 59%, 2-yr 21%. Locoregional PFS 1-yr 51%, 2-yr 42%.
    • Toxicity. Acute esophagitis 9% (Gr 1-2). Acute pneumonitis 22% (Gr 1-2). No cases of Grade 3 or higher acute toxicity. Pulmonary fibrosis 26% (Gr 2-3). No other severe late complications.
    • Conclusion: "Reirradiation using 3D-CRT was tolerated by this group of recurrent lung carcinoma patients without severe complications. The 2-year outcome was encouraging. Reirradiation with 3D-CRT can be considered an option for the management of locoregionally recurrent lung carcinoma."

• Japan (1979–2000)
  • Reirradiation for 34 pts for local recurrence of lung cancer. 18 treated with radical intent, 16 for palliation of symptoms.
  • Initial RT median 60 Gy (range 30-80) in 1.5-2 Gy fractions. For all pts, reirradiation dose median 50 Gy (range 10-70) in 1.8-3 Gy fractions. Combined dose median 110 Gy (range 56.5 - 150). 1 pt retreated twice.
    • For radical reirradiation, median 50 Gy (range 30-70) in 1.5-2 Gy fractions. For palliative RT, median 46 Gy (range 10-60) in 2-3 Gy fractions. Technique: parallel opposed beams.
    • Combined dose. For radical, median 110 Gy. For palliative, 91 Gy.
    • Chemotherapy: given in 16 pts (prior to RT in 11, concurrent in 5).
  • 2002: PMID 11872284 -- "Reirradiation for locally recurrent lung cancer previously treated with radiation therapy." (Okamoto Y, Int J Radiat Oncol Biol Phys. 2002 Feb 1;52(2):390-6.)
    • Response rate of 14 of 18 (78%) given radical treatment—CR in 6, PR in 8. Symptomatic benefit in 12 of 16 (75%) given palliative treatment.
    • Median survival 8 months; OS 43% at 1 year, 27% at 2 yrs. For radical treatment, MS 15 months. For palliative treatment, MS 3 months. 6 long-term survival lived > 20 months.
    • Toxicity: pneumonitis in 19 pts, radiation esophagitis in 6. No fatal toxicity. No myelopathy.
  • Conclusion: "Based on this study, external beam reirradiation can achieve satisfactory results for local recurrence of lung cancer provided that attention is paid to the possible hazards."

• Los Angeles, CA (LAC/USC Medical Center) (1963–1980)
  • Reirradiation of 29 patients for local recurrence of lung cancer. Previously treated with definitive (n=26) or adjuvant RT (n=3); median dose 5300 cGy (12 pts received 6000-6500). Median re-treatment dose 3500 cGy (range 600-5400), dose per fraction 160-200. Average combined dose (initial + retreatment) 8200 (range: 6000 - 16,600). 1 pt retreated twice. Median time to recurrence was 10 months.
  • Very few pts received adjuvant chemotherapy (no concurrent chemo).
  • 1982: PMID 7059924 -- "Lung cancer: retreatment of local recurrence after definitive irradiation." (Green N, Cancer. 1982 Mar 1;49(5):865-8.)
    • Treatment response in 20 of 27 (74%) evaluable pts. 3 of 27 (11%) had CR; 12 of 27 (62%) had PR. (Evaluated by chest x-ray). Median relapse-free interval after retreatment was 5 months (range 1-24 mo). 14 of 29 (48) had symptomatic improvement, lasting <= 5 months in most.
    • Median survival 5 months; at 6 months, 35% survival; at 1 year, 14%.
    • <10% had complications, none serious—1 pt with pneumonitis, 1 pt with rib fracture.

SBRT Reirradiation

• MSKCC;2013 (2004-2011) - PMID 23617949 -- "Toxicity and outcomes of thoracic re-irradiation using stereotactic body radiation therapy (SBRT)." (Reyngold M, Radiat Oncol. 2013 Apr 25;8:99.)
  • 39 pts. Prior RT dose 61 Gy (median). Median SBRT BED(10) 70.4 Gy.
  • Median f/u 12.6 mo. Local-progression free survival: 77% and 64% at 1 yr and 2 yrs. Median RFS 13.8 mo. MS 22 mo.
  • BED > 100 Gy associated with higher LPFS. Pulmonary toxicity G2 18%, G3 5%.
  • Conclusion: "SBRT can be safely and successfully administered to patients with prior thoracic RT. Dose reduction for cases with direct overlap of successive radiation fields results in acceptable re-treatment toxicity profile."

• MDACC;2010 - PMID 20381271 -- "Stereotactic body radiation therapy for patients with lung cancer previously treated with thoracic radiation." (Kelly P, Int J Radiat Oncol Biol Phys. 2010 Dec 1;78(5):1387-93.)
  • 36 pts. Median f/u 15 mo. LC 92%. 2-yr OS 59%; 2-yr PFS 26%.Primary site of failure is intrathoracic.
  • Toxicity: 50% with worsening dyspnea.
  • Conclusion: "SBRT can provide excellent in-field tumor control in patients who have received prior radiation therapy. Toxicity was significant but manageable. The high rate of intrathoracic failure indicates the need for further study to identify patients who would derive the most benefit from SBRT for this purpose."