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      Stereotactic radiotherapy boost after definite chemoradiation for non-responding locally advanced NSCLC based on early response monitoring 18F-FDG-PET/CT


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          Background and purpose

          Prognosis of locally advanced non-small cell lung cancer remains poor despite chemoradiation. This planning study evaluated a stereotactic boost after concurrent chemoradiotherapy (30 × 2 Gy) to improve local control. The maximum achievable boost directed to radioresistant primary tumor subvolumes based on pre-treatment fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography ( 18F-FDG-PET/CT) (pre-treatment-PET) and on early response monitoring 18F-FDG-PET/CT (ERM-PET) was compared.

          Materials and methods

          For ten patients, a stereotactic boost (VMAT) was planned on ERM-PET (PTV boost;ERM) and on pre-treatment-PET (PTV boost;pre-treatment), using a 70% SUV max threshold with 7 mm margin to segmentate radioresistant subvolumes. Dose was escalated till organ at risk (OAR) constraints were met, aiming to plan at least 18 Gy in 3 fractions (EQD 2 84 Gy/BED 100.8 Gy).


          In five patients, PTV boost;ERM was 9–40% smaller relative to PTV boost;pre-treatment. Overlap of PTV boost;ERM with OARs decreased also compared to overlap of PTV boost;pre-treatment with OARs. However, any overlap with OAR remained in 4/5 patients resulting in minimal differences between planned dose before and during treatment. Median dose (EQD 2) covering 99% and 95% of PTV boost;ERM were 15 Gy and 18 Gy respectively. Median boost volume receiving a physical dose of  ≥ 18 Gy (V18) was 88%. V18 was ≥ 80% for PTV boost in six patients.


          A significant stereotactic boost to volumes with high initial or persistent 18F-FDG-uptake could be planned above 60 Gy chemoradiation. Differences between planned dose before and during treatment were minimal. However, as an ERM-PET also monitors changes in tumor position, we recommend to plan the boost on the ERM-PET.

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          Most cited references21

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          FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0

          The purpose of these guidelines is to assist physicians in recommending, performing, interpreting and reporting the results of FDG PET/CT for oncological imaging of adult patients. PET is a quantitative imaging technique and therefore requires a common quality control (QC)/quality assurance (QA) procedure to maintain the accuracy and precision of quantitation. Repeatability and reproducibility are two essential requirements for any quantitative measurement and/or imaging biomarker. Repeatability relates to the uncertainty in obtaining the same result in the same patient when he or she is examined more than once on the same system. However, imaging biomarkers should also have adequate reproducibility, i.e. the ability to yield the same result in the same patient when that patient is examined on different systems and at different imaging sites. Adequate repeatability and reproducibility are essential for the clinical management of patients and the use of FDG PET/CT within multicentre trials. A common standardised imaging procedure will help promote the appropriate use of FDG PET/CT imaging and increase the value of publications and, therefore, their contribution to evidence-based medicine. Moreover, consistency in numerical values between platforms and institutes that acquire the data will potentially enhance the role of semiquantitative and quantitative image interpretation. Precision and accuracy are additionally important as FDG PET/CT is used to evaluate tumour response as well as for diagnosis, prognosis and staging. Therefore both the previous and these new guidelines specifically aim to achieve standardised uptake value harmonisation in multicentre settings.
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            Standard-dose versus high-dose conformal radiotherapy with concurrent and consolidation carboplatin plus paclitaxel with or without cetuximab for patients with stage IIIA or IIIB non-small-cell lung cancer (RTOG 0617): a randomised, two-by-two factorial phase 3 study

            The Lancet Oncology, 16(2), 187-199
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              Outcomes after stereotactic lung radiotherapy or wedge resection for stage I non-small-cell lung cancer.

              PURPOSE To compare outcomes between lung stereotactic radiotherapy (SBRT) and wedge resection for stage I non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS One hundred twenty-four patients with T1-2N0 NSCLC underwent wedge resection (n = 69) or image-guided lung SBRT (n = 58) from February 2003 through August 2008. All were ineligible for anatomic lobectomy; of those receiving SBRT, 95% were medically inoperable, with 5% refusing surgery. Mean forced expiratory volume in 1 second and diffusing capacity of lung for carbon monoxide were 1.39 L and 12.0 mL/min/mmHg for wedge versus 1.31 L and 10.14 mL/min/mmHg for SBRT (P = not significant). Mean Charlson comorbidity index and median age were 3 and 74 years for wedge versus 4 and 78 years for SBRT (P .16). SBRT reduced the risk of local recurrence (LR), 4% versus 20% for wedge (P = .07). Overall survival (OS) was higher with wedge but cause-specific survival (CSS) was identical. Results excluding synchronous primaries, nonbiopsied tumors, or pathologic T4 disease (wedge satellite lesion) showed reduced LR (5% v 24%, P = .05), RR (0% v 18%, P = .07), and LRR (5% v 29%, P = .03) with SBRT. There were no differences in DM, FFF, or CSS, but OS was higher with wedge. CONCLUSION Both lung SBRT and wedge resection are reasonable treatment options for stage I NSCLC patients ineligible for anatomic lobectomy. SBRT reduced LR, RR, and LRR. In this nonrandomized population of patients selected for surgery versus SBRT (medically inoperable) at physician discretion, OS was higher in surgical patients. SBRT and surgery, however, had identical CSS.

                Author and article information

                Phys Imaging Radiat Oncol
                Phys Imaging Radiat Oncol
                Physics and Imaging in Radiation Oncology
                31 August 2018
                July 2018
                31 August 2018
                : 7
                : 16-22
                [a ]Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
                [b ]Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands
                [c ]Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
                [d ]Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
                [e ]Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
                [f ]Biomedical Photonic Imaging Group, MIRA Institute, University of Twente, Enschede, The Netherlands
                Author notes
                [* ]Corresponding author at: Department of Radiation Oncology (Internal postal code 874), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. Tineke.vanZon-Meijer@ 123456radboudumc.nl

                Contributed equally.


                Shared last author.

                © 2018 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                : 3 February 2018
                : 4 April 2018
                : 17 August 2018
                Original Research Article

                non-small cell lung cancer,early response monitoring fluorine 18 fluorodeoxyglucose positron emission tomography/computed tomography (18f-fdg-pet),stereotactic radiation boost


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