Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany.
Radiat Oncol. 2019 Sep 4;14(1):163. doi: 10.1186/s13014-019-1304-2.
To determine the feasibility of PET/CT-based image-guided moderate hypofractionated thoracic irradiation (Hypo-IGRT) in locally advanced node-positive non-small cell lung cancer patients with highly compromised pulmonary function.
Eight highly-selected and closely monitored patients with highly diminished pulmonary function (FEV1 ≤ 1.0 L and/or DLCO-SB ≤ 40% and/or on long-term oxygen therapy) were treated with Hypo-IGRT. Planning was based on 18F-FDG-PET/CT and 4D-CT in the treatment position. Hypo-IGRT was delivered to a total dose of 45 Gy (ICRU) in 15 daily fractions under strict image-guidance. Vital capacity (VC), forced expiratory volume in 1 s (FEV1), and single-breath diffusing capacity of the lung for CO (DLCO-SB) were analyzed prior to, 3 and 6 months after Hypo-IGRT.
Eight patients with stage IIIA-C NSCLC (8th TNM Ed.) completed Hypo-IGRT. The median follow-up was 29.4 months. The median age was 64 years. Four, three and one patient(s) presented with COPD GOLD IV, III and II, respectively and 5 patients (63%) were on long-term oxygen therapy. The median PTV was 226.9 cc (range: 100.17-379.80 cc). Median PFS and OS were 19 and 34.3 months. The 6 months and 1-year OS rates were 100, 87.5%, respectively. The 6- and 12- months PFS rates were 87.5 and 52.5%. Three patients developed local failure. Median initial VC, FEV1 and DLCO-SB was 1.69 L/64.8% predicted (range: 1.36-2.66 L/33-80%), 1 L/39.4% predicted (range:0.78-1.26 L/28-60% predicted) and 33.3% (range: 13.3-54%) predicted, respectively. Median values for VC, FEV1, DLCO-SB 3 and 6 months after Hypo-IGRT were 2.05 L/56.35% predicted (range: 1.34-2.33 L/47-81.5%), 1.08 L/47.5% predicted (range: 0.74-1.60 L/30.8-59.59%), 38.55% (range: 24-68%) and 1.64 L/66% predicted (range: 1.41-2.79/35.5-75.5%), 1.0 L/47% predicted (range: 0.65-1.28 L/24.5-54.10%), 31% (range: 27-43%), respectively. Mean lung dose was 9.4 Gy (range: 5.3-11.6 Gy) and V20 for both lungs was 15% (range: 6-19%). Mean esophageal dose was 12.76 Gy (range: 2.1-26.7 Gy). There was no case of grade 2 or higher radiation pneumonitis. Four patients developed grade 2 radiation esophagitis.
Hypo-IGRT can be considered for individual and closely monitored patients with locally advanced node-positive NSCLC with highly compromised pulmonary function. No severe pulmonary toxicity and significant decline of pulmonary function parameters was observed in our cohort. Currently, this protocol is being assessed in an ongoing single-centre prospective study.
为了确定基于 PET/CT 的中度适形胸部放疗（Hypo-IGRT）在肺功能严重受损的局部晚期淋巴结阳性非小细胞肺癌患者中的可行性。
对 8 名肺功能严重受损（FEV1≤1.0 L 和/或 DLCO-SB≤40%和/或长期吸氧）的患者进行 Hypo-IGRT。计划是基于治疗位置的 18F-FDG-PET/CT 和 4D-CT。在严格的图像引导下，将 Hypo-IGRT 总剂量给予 45 Gy（ICRU），共 15 个每日分次。在 Hypo-IGRT 前、后 3 和 6 个月分别分析肺活量（VC）、1 秒用力呼气量（FEV1）和一氧化碳弥散量（DLCO-SB）。
8 例 IIIA-C 期 NSCLC（8th TNM Ed.）患者完成 Hypo-IGRT。中位随访时间为 29.4 个月。中位年龄为 64 岁。4、3 和 1 例患者（分别为）患有 COPD GOLD IV、III 和 II，5 例患者（63%）长期吸氧。中位 PTV 为 226.9 cc（范围：100.17-379.80 cc）。中位 PFS 和 OS 分别为 19 和 34.3 个月。6 个月和 1 年 OS 率分别为 100%和 87.5%。6 个月和 12 个月的 PFS 率分别为 87.5%和 52.5%。3 例患者发生局部失败。中位初始 VC、FEV1 和 DLCO-SB 分别为 1.69 L/64.8%预测值（范围：1.36-2.66 L/33-80%）、1 L/39.4%预测值（范围：0.78-1.26 L/28-60%）和 33.3%预测值（范围：13.3-54%）。Hypo-IGRT 后 3 和 6 个月 VC、FEV1、DLCO-SB 的中位值分别为 2.05 L/56.35%预测值（范围：1.34-2.33 L/47-81.5%）、1.08 L/47.5%预测值（范围：0.74-1.60 L/30.8-59.59%）、38.55%（范围：24-68%）和 1.64 L/66%预测值（范围：1.41-2.79/35.5-75.5%）、1.0 L/47%预测值（范围：0.65-1.28 L/24.5-54.10%）、31%（范围：27-43%）。平均肺剂量为 9.4 Gy（范围：5.3-11.6 Gy），双肺 V20 为 15%（范围：6-19%）。平均食管剂量为 12.76 Gy（范围：2.1-26.7 Gy）。没有发生 2 级或更高级别的放射性肺炎。4 例患者发生 2 级放射性食管炎。
对于肺功能严重受损的局部晚期淋巴结阳性非小细胞肺癌患者，可以考虑采用 Hypo-IGRT。在我们的队列中，没有观察到严重的肺毒性和肺功能参数的显著下降。目前，该方案正在一项正在进行的单中心前瞻性研究中进行评估。
