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Joanne Carda

April 14, 2018

Research Gap Activity

Article 1: Stereotactic Body Radiation Therapy for Patients with Lung Cancer Previously
Treated with Thoracic Radiation
In this article by Kelley et al,1 the writers discuss the relatively new conundrum of
treating patients with stereotactic ablative radiation who have previously received thoracic
radiation. The study in question was limited retrospectively to 36 cases in which radiation
therapy was delivered at The University of Texas M.D. Anderson Cancer Center. The authors
evaluated patients based upon age, stage of cancer, method and goal of initial radiation,
chemotherapy intervention, mode of recurrence, and Stereotactic Body Radiation Therapy
(SBRT) dose and fractionation, and the nature and severity of treatment related side effects.
It is noted in the article that 92% of patients achieved in field local control. The primary
side effects encountered included dyspnea, 19% of reported cases required oxygen
supplementation, chest wall pain, and esophagitis. No high grade toxicities were reported. It was
thus concluded that SBRT is a viable treatment option for patients that have received previous
thoracic irradiation.1
Future Research Project Suggestion:
A future project suggestion, as indicated by the authors1, would be to evaluate what
patient subset is most appropriate for secondary treatment with SBRT. For example, does a
specific pathology (adenocarcinoma, squamous cell carcinoma) have a penchant for local
failure? Is widespread disease an indication that SBRT is inappropriate or does SBRT in patients
with metastatic disease improve their quality of life? Does chemotherapy regimen have a
correlation with degree of intrathoracic failure?
Article 2: Prognostic Value of [18F]-Fluoromethycholine Positron Emission
Tomography/Computed Tomography before Stereotactic Body Radiation Therapy for
Oligometastatic Prostate Cancer
This article by Cysouw et al,2 explores the usefulness of fluoromethylcholine as a
radionuclide for Positron Emission Tomography/Computed Tomography (PET/CT).
Specifically, they evaluate if using this radionuclide is a valid predictor of long term outcome
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and single site metastasis. The research was a retrospective study of 40 patients with 1 to 3 PET
avid lesion. Most of the lesions were lymph node metastasis with 13 out of 50 lesions being
classified as bone metastases. Results indicated that having more than one lesion was indicative
of a poorer prognosis and the size of the avid area appeared to be related to risk of progression.
Conversely the level of avidity of any single lesion was not indicative of prognosis.2
Future Research Project Suggestion:
As suggested by the authors, this research area would benefit from evaluation of
additional data from controlled trials that evaluate stereotactic ablative therapy that is guided
using prostate specific membrane antigen. Evaluating will further assist in determining if other
characteristics are indicative of prognosis or if its use is simply limited to deferring systemic
therapies such as androgen suppression.
Article 3: Lung Reirradiation with Stereotactic Body Radiotherapy (SBRT)
In this article by Ester et al,3 the authors retrospectively evaluated patients that had
received SBRT after they had previously received thoracic radiation. The 13 patients for this
study were taken from the University of Minnesota Medical Center. The patients of interest
received treatment from 2006 to 2012. The authors reviewed the charts of acceptable patients for
survival, mode of recurrence and radiation related toxicities. Of the 13 patients included, 10 had
received a previous course of conventional irradiation, while the remainder had previous SBRT.
Results of the study indicate that SBRT is a valid option for therapy of recurrent or second
primary lung cancer in those that have already received thoracic radiation.3
Future Research Project Suggestion:
As is plain in the number of patients evaluated, a greater number of cases to evaluate is
necessary. The scope of the research should be expanded, perhaps to all therapy centers with ties
to the University of Minnesota. It would also be helpful to know the location of the recurrence
and retreatment, i.e. central or peripheral.
Article 4: Lung Reirradiation with Stereotactic Body Radiotherapy
Maranzano et al,4 evaluated 18 patients retrospectively to evaluate to how safe
reirradiation to the lung is and how effective it is when it is utilized. Of the 18 patients evaluated,
14 had lung metastases and 4 had localized recurrences from primary lung carcinoma.
Cumulative doses were calculated and utilized to evaluate the biologic effective doses. In this
study, the authors indicated tumor location as peripheral or centrally located. The results of the
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study were that 17 of the evaluated patients obtained local control of their cancers for 43 months.
It was concluded that reirradiation of lung recurrent lesions is useful and reasonable. The authors
did mention in their conclusion that appropriate selection of patients is required for retreatment
to be a viable option.4
Future Research Project Suggestion:
A greater number of patients with recurrent lung lesions needs to be evaluated to truly
generalize the conclusion. It is challenging to calculate biologic effective dose in these cases and
data on initial doses to organs at risk as well as specific toxicities encountered is lacking. This
study did represent a longer follow up time, which generally seems to be lacking in articles
related to the topic of reirradiation with SBRT.
Article 5: Variations of Lung Density and Geometry on Inhomogeneity Correction
Algorithms: A Monte Carlo Dosimetric Evaluation
This article by Chow et al,5 discusses the inhomogeneity correction using the Monte
Carlo simulations. The purpose of the study was to evaluate the effect of lung electron density
and variation of the tissue geometrically on the accuracy of the inhomogeneity correction and to
see if a new method of calculation was feasible to replace an older calculation algorithm. It was
determined in the study that the previous calculation method results in a higher uncertainty in
dose calculation. It is also of note that the degree of deviation is dependent upon the beam energy
and the field size.
Future Research Project Suggestion:
This study evaluated the calculation algorithms based upon only 6 and 18MV photon
beams. It would be useful to supplement the conclusions by including tests on other commonly
used photon energies, such as 10 and 15 MV.
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References
1. Kelly P, Balter P, Rebueno N, et al. Stereotactic Body Radiation Therapy for Patients with
Lung Cancer Previously Treated with Thoracic Radiation. Int J Rad Onc Biol Phys.
2010;78(5):1387-1393. http://dx.doi.org/10.1016/j.jirobp.2009.09.070
2. Cysouw M, Bouman-Wammes E, Hoekstra O, et al. Prognostic Value of [18F]-
Fluoromethycholine Positron Emission Tomography/Computed Tomography before
Stereotactic Body Radiation Therapy for Oligometastatic Prostate Cancer. Int J Rad Onc Biol
Phys. 2018; In Press. http://dx.doi.org/10.1016/j.ijrobp.2018.02.005
3. Ester E, Jones D, Vernon M, et al. Lung Reirradiaiton with Stereotactic Body Radiotherapy
(SBRT). J Radiosurg SBRT. 2013; 2:325-331.
4. Maranzano E, Draghini L, Anselmo P, et al. Lung Reirradiation with Stereotactic Body
Radiotherapy. J Radiosurg SBRT. 2016; 4:61-68.
5. Chow J, Leung M, Dyk J. Variations of Lung Density and Geometry on Inhomogeneity
Correction Algorithms: A Monte Carlo Dosimetric Evaluation. Med Phys. 2009; 36(8) 3619-
3630. http://dx.doi.org/10.1118/1.3168966