Clinical practice guideline for radiation therapy of non-small cell lung cancer (2020 version)
Radiation Oncology Branch of Chinese Medical Association, Radiation Oncologist Branch of Chinese Medical Doctor Association Professional Committee on Radiation Oncology, China AntiCancer Association Experts Committee on Radiation Oncology, Radiation Oncologist Branch of Chinese Society of Clinical Oncology
Abstract:With the rapid development of advanced technology, it has entered the era of precise radiotherapy, which significantly improves tumor control and reduces treatment-related toxicities. Currently, radiotherapy plays a critical role in different stages of non-small cell lung cancer (NSCLC). Additionaly, targeted therapy, immunotherapy, and other new drug therapies have made breakthrough progress, bringing survival benefits to patients with NSCLC in recent years. Based on the existing medical evidence of NSCLC in combination with the expert opinions, clinical practice guidelines for radiation therapy of non-small cell lung cancer in China (2020) has been formulated by Chinese Society for Radiation Oncology, Radiation Oncologist Branch of Chinese Medical Doctor Association Professional Committee on Radiation Oncology, China Anti-Cancer Association and Experts Committee on Radiation Oncology, Chinese Society of Clinical Oncology. The main contents include overview, diagnosis, treatment principles for early-, middle-and advanced-stage NSCLC, radiotherapy and follow-up, etc. The purpose of this paper is to provide NSCLC evidence-based medical guidance for clinicians and patients in China and guide clinical practice.
Radiation Oncology Branch of Chinese Medical Association,Radiation Oncologist Branch of Chinese Medical Doctor Association Professional Committee on Radiation Oncology,China AntiCancer Association Experts Committee on Radiation Oncology et al. Clinical practice guideline for radiation therapy of non-small cell lung cancer (2020 version)[J]. Chinese Journal of Radiation Oncology, 2020, 29(8): 599-607.
[1] Goldstraw P, Chansky K, Crowley J, et al. The IASLC lung cancer staging project:proposals for revision of the tnm stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer[J]. J Thorac Oncol, 2016, 11(1):39-51. DOI:10.1016/j.jtho.2015.09.009.
[2] Noone AM, Howlader N, Krapcho M, et al. SEER cancer statistics review, 1975-2015, based on November 2017 SEER data submission, posted to the SEER web site, April 2018[DB/OL][2020-05-20].https://seer.cancer.gov/csr/1975_2015/.
[3] National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening[J]. N Engl J Med, 2011, 365(5):395-409. DOI:10.1056/NEJMoa1102873.
[4] Expert Panel on Thoracic Imaging, de Groot PM, Chung JH, et al. ACR appropriateness criteria(®) noninvasive clinical staging of primary lung cancer[J]. J Am Coll Radiol, 2019, 16(5S):S184-S195. DOI:10.1016/j.jacr.2019.02.008.
[5] Videtic GMM, Donington J, Giuliani M, et al. Stereotactic body radiation therapy for early-stage non-small cell lung cancer:executive summary of an ASTRO evidence-based guideline[J]. PractRadiat Oncol, 2017, 7(5):295-301. DOI:10.1016/j.prro.2017.04.014.
[6] Guckenberger M, Andratschke N, Dieckmann K, et al. ESTRO ACROP consensus guideline on implementation and practice of stereotactic body radiotherapy for peripherally located early stage non-small cell lung cancer[J]. Radiother Oncol, 2017, 124(1):11-17. DOI:10.1016/j.radonc.2017.05.012.
[7] NCCN. NCCN clinical practice guidelines in oncology:non-small cell lung cancer.2020[DB/OL][2020-05-20]. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf.
[8] Wang C, Rimner A, Gelblum DY, et al. Analysis of toxic effects with antiangiogenic agents plus stereotactic body radiation in ultracentral lung tumors[J]. JAMA Oncol, 2019, 5(5):737-739. DOI:10.1001/jamaoncol.2019.0205.
[9] Eberhardt WE, Pöttgen C, Gauler TC, et al. Phase Ⅲ study of surgery versus definitive concurrent chemoradiotherapy boost in patients with resectable stage ⅢA(N2) and selected ⅢB non-small-cell lung cancer after induction chemotherapy and concurrent chemoradiotherapy (ESPATUE)[J]. J Clin Oncol, 2015, 33(35):4194-4201. DOI:10.1200/JCO.2015.62.6812.
[10] van Meerbeeck JP, Kramer GW, Van Schil PE, et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage ⅢA-N2 non-small-cell lung cancer[J]. J Natl Cancer Inst, 2007, 99(6):442-450. DOI:10.1093/jnci/djk093.
[11] Pless M, Stupp R, Ris HB, et al. Induction chemoradiation in stage ⅢA/N2 non-small-cell lung cancer:a phase 3 randomised trial[J]. Lancet, 2015, 386(9998):1049-1056. DOI:10.1016/S0140-6736(15)60294-X.
[12] Rusch VW, Giroux DJ, Kraut MJ, et al. Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas:long-term results of Southwest Oncology Group Trial 9416(Intergroup Trial 0160)[J]. J Clin Oncol, 2007, 25(3):313-318. DOI:10.1200/JCO.2006.08.2826.
[13] Kunitoh H, Kato H, Tsuboi M, et al. Phase Ⅱ trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus non-small-cell lung cancers:report of Japan Clinical Oncology Group trial 9806[J]. J Clin Oncol, 2008, 26(4):644-649. DOI:10.1200/JCO.2007.14.1911.
[14] Zhong WZ, Wang Q, Mao WM, et al. Gefitinib versus vinorelbine plus cisplatin as adjuvant treatment for stage Ⅱ-ⅢA(N1-N2) EGFR-mutant NSCLC (ADJUVANT/CTONG1104):a randomised, open-label, phase 3 study[J]. Lancet Oncol, 2018, 19(1):139-148. DOI:10.1016/S1470-2045(17)30729-5.
[15] Yue D, Xu S, Wang Q, et al. Erlotinib versus vinorelbine plus cisplatin as adjuvant therapy in Chinese patients with stage ⅢA EGFR mutation-positive non-small-cell lung cancer (EVAN):a randomised, open-label, phase 2 trial[J]. Lancet Respir Med, 2018, 6(11):863-873. DOI:10.1016/S2213-2600(18)30277-7.
[16] Feng W, Fu XL, Cai XW, et al. Patterns of local-regional failure in completely resected stage ⅢA(N2〖HT6) non-small cell lung cancer cases:implications for postoperative radiation therapy clinical target volume design[J]. Int J Radiat Oncol Biol Phys, 2014, 88(5):1100-1107. DOI:10.1016/j.ijrobp.2013.12.048.
[17] Machtay M, Lee JH, Shrager JB, et al. Risk of death from intercurrent disease is not excessively increased by modern postoperative radiotherapy for high-risk resected non-small-cell lung carcinoma[J]. J Clin Oncol, 2001, 19(19):3912-3917. DOI:10.1200/JCO.2001.19.19.3912.
[18] Corso CD, Rutter CE, Wilson LD, et al. Re-evaluation of the role of postoperative radiotherapy and the impact of radiation dose for non-small-cell lung cancer using the National Cancer Database[J]. J Thorac Oncol, 2015, 10(1):148-155. DOI:10.1097/JTO.0000000000000406.
[19] Auperin A, Le Pechoux C, Rolland E, et al. Meta-analysis of concomitant versus sequential radiochemotherapy in locally advanced non-small-cell lung cancer[J]. J Clin Oncol, 2010, 28(13):2181-2190. DOI:10.1200/JCO.2009.26.2543.
[20] Curran Jr WJ, Paulus R, Langer CJ, et al. Sequential vs. concurrent chemoradiation for stage Ⅲ non-small cell lung cancer:randomized phase Ⅲ trial RTOG 9410[J]. J Natl Cancer Inst, 2011, 103(19):1452-1460. DOI:10.1093/jnci/djr325.
[21] Ogawa K, Takahashi Y, Murase K, et al. Treatment outcome of patients with unresectable stage Ⅲ non-small cell lung cancer and interstitial pneumonia. Respir Investig, 2019, 57(4):388-394. DOI:10.1016/j.resinv.2019.02.004.
[22] Eberhardt WE, De Ruysscher D, Weder W, et al. 2nd ESMO consensus conference in lung cancer:locally advanced stage Ⅲ non-small-cell lung cancer[J]. Ann Oncol, 2015, 26(8):1573-1588. DOI:10.1093/annonc/mdv187.
[23] Bi N, Wang L. Superiority of concomitant chemoradiation over sequential chemoradiation in inoperable, locally advanced non-small cell lung cancer:challenges in the selection of appropriate chemotherapy[J]. SeminRadiat Oncol, 2015, 25(2):122-132. DOI:10.1016/j.semradonc.2014.11.003.
[24] Liang J, Bi N, Wu S, et al. Etoposide and cisplatin vs. paclitaxel and carboplatin with concurrent thoracic radiotherapy in unresectable stage Ⅲ non-small cell lung cancer:a multicenter randomized phase Ⅲ trial[J]. Ann Oncol, 2017, 28(4):777-783. DOI:10.1093/annonc/mdx009.
[25] Suresh S, Anthony B, Lu-hua W, et al. PROCLAIM:randomized phase Ⅲ trial of pemetrexed-cisplatin or etoposide-cisplatin plus thoracic radiation therapy followed by consolidation chemotherapy in locally advanced nonsquamous non–small-cell lung cancer[J]. J Clin Oncol, 2016, 34(9):953-962. DOI:10.1200/JCO.2015.64.8824.
[26] Vokes EE, Herndon JE 2nd, Kelley MJ, et al. Induction chemotherapy followed by chemoradiotherapy compared with chemoradiotherapy alone for regionally advanced unresectable stage Ⅲ non-small-cell lung cancer:cancer and leukemia group B[J]. J Clin Oncol, 2007, 25(13):1698-1704. DOI:10.1200/JCO.2006.07.3569.
[27] Hanna N, Neubauer M, Yiannoutsos C, et al. Phase Ⅲ study of cisplatin, etoposide, and concurrent chest radiation with or without consolidation docetaxel in patients with inoperable stage Ⅲ non-small-cell lung cancer:the Hoosier oncology group and U. S. oncology[J]. J Clin Oncol, 2008, 26(35):5755-5760. DOI:10.1200/JCO.2008.17.7840.
[28] Ahn JS, Ahn YC, Kim JH, et al. Multinational randomized phase Ⅲ trial with or without consolidation chemotherapy using docetaxel and cisplatin after concurrent chemoradiation in inoperable stage Ⅲ non-small-cell lung cancer:KCSG-LU05-04[J]. J Clin Oncol, 2015, 33(24):2660-2666. DOI:10.1200/JCO.2014.60.0130.
[29] Kelly K, Chansky K, Gaspar LE, et al. Phase Ⅲ trial of maintenance gefitinib or placebo after concurrent chemoradiotherapy and docetaxel consolidation in inoperable stage Ⅲ non-small-cell lung cancer:SWOG S0023[J]. J Clin Oncol, 2008, 26(15):2450-2456. DOI:10.1200/JCO.2007.14.4824.
[30] Antonia SJ, Villegas A, Daniel D, et al. Overall survival with durvalumab after chemoradiotherapy in stage Ⅲ NSCLC[J]. N Engl J Med, 2018, 379(24):2342-2350. DOI:10.1056/NEJMoa1809697.
[31] Antonia SJ, Villegas A, Daniel D, et al. Durvalumab after chemoradiotherapy in stage Ⅲ non-small-cell lung cancer[J]. N Engl J Med, 2017, 377(20):1919-1929. DOI:10.1056/NEJMoa1709937.
[32] Wang J, Zhou Z, Liang J, et al. Intensity-modulated radiation therapy may improve local-regional tumor control for locally advanced non-small cell lung cancer compared with three-dimensional conformal radiation therapy[J]. Oncologist, 2016, 21(12):1530-1537. DOI:10.1634/theoncologist.2016-0155.
[33] Chun SG, Hu C, Choy H, et al. Impact of Intensity-modulated radiation therapy technique for locally advanced non-small-cell lung cancer:a secondary analysis of the NRG oncology RTOG 0617 randomized clinical trial[J]. J Clin Oncol, 2017, 35(1):56-62. DOI:10.1200/JCO.2016.69.1378.
[34] Peng J, Pond G, Donovan E, et al. A comparison of radiation techniques in patients treated with concurrent chemoradiation for stage Ⅲ non-small cell lung cancer[J]. Int J Radiat Oncol Biol Phys, 2020, 106(5):985-992. DOI:10.1016/j.ijrobp.2019.12.027.
[35] Bradley JD, Paulus R, Komaki R, et al. 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[J]. Lancet Oncol, 2015, 16(2):187-199. DOI:10.1016/S1470-2045(14)71207-0.
[36] Su SF, Hu YX, Ouyang WW, et al. Overall survival and toxicities regarding thoracic three-dimensional radiotherapy with concurrent chemotherapy for stage ⅠV non-small cell lung cancer:results of a prospective single-center study[J]. BMC Cancer, 2013, 13:474. DOI:10.1186/1471-2407-13-474.
[37] Su S, Li T, Lu B, et al. Three-dimensional radiation therapy to the primary tumor with concurrent chemotherapy in patients with stage iv non-small cell lung cancer:results of a multicenter phase 2 study from PPRA-RTOG, China[J]. Int J Radiat Oncol Biol Phys, 2015, 93(4):769-777. DOI:10.1016/j.ijrobp.2015.08. 012.
[38] Moeller B, Balagamwala EH, Chen A, et al. Palliative thoracic radiation therapy for nonsmall cell lung cancer:2018 update of an American Society for Radiation Oncology (ASTRO) evidence-based guideline[J]. PractRadiat Oncol, 2018, 8(4):245-250. DOI:10.1016/j.prro.2018.02.009.
[39] Petrelli F, Ghidini A, Cabiddu M, et al. Addition of radiotherapy to the primary tumour in oligometastatic NSCLC:a systematic review and meta-analysis[J]. Lung Cancer, 2018, 126:194-200. DOI:10.1016/j.lungcan.2018.11.017.
[40] Hendriks LEL, Dooms C, Berghmans T, et al. Defining oligometastatic non-small cell lung cancer:A simulated multidisciplinary expert opinion[J]. Eur J Cancer, 2019, 123(1):28-35. DOI:10.1016/j.ejca.2019.09.013.
[41] Gomez DR, Tang C, Zhang J, et al. Local consolidative therapy vs. maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer:long-term results of a multi-institutional, phase Ⅱ, randomized study[J]. J Clin Oncol, 2019, 37(18):1558-1565. DOI:10.1200/JCO.19.00201.
[42] Gomez DR, Blumenschein GR Jr, Lee JJ, et al. Local consolidative therapy versus maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer without progression after first-line systemic therapy:a multicentre, randomised, controlled, phase 2 study[J]. Lancet Oncol, 2016, 17(12):1672-1682. DOI:10.1200/JCO.19.00201.
[43] Sperduto PW, Kased N, Roberge D, et al. Summary report on the graded prognostic assessment:an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases[J]. J Clin Oncol, 2012, 30(4):419-425. DOI:10.1200/JCO.2011.38.0527.
[44] Sperduto PW, Yang TJ, Beal K, et al. Estimating survival in patients with lung cancer and brain metastases:an update of the graded prognostic assessment for lung cancer using molecular markers (Lung-molGPA)[J]. JAMA Oncol, 2017, 3(6):827-831. DOI:10.1001/jamaoncol.2016.3834.
[45] Brown PD, Ballman KV, Cerhan JH, et al. Postoperative stereotactic radiosurgery compared with whole brain radiotherapy for resected metastatic brain disease (NCCTG N107C/CEC·3):a multicentre, randomised, controlled, phase 3 trial[J]. Lancet Oncol, 2017, 18(8):1049-1060. DOI:10.1016/S1470-2045(17)30441-2.
[46] Bi N, Ma Y, Xiao J, et al. A Phase Ⅱ trial of concurrent temozolomide and hypofractionated stereotactic radiotherapy for complex brain metastases[J]. Oncologist, 2019, 24(9):e914-e920. DOI:10.1634/theoncologist.2018-0702.
[47] Mulvenna P, Nankivell M, Barton R, et al. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ):results from a phase 3, non-inferiority, randomised trial[J]. Lancet, 2016, 388(10055):2004-2014. DOI:10.1016/S0140-6736(16)30825-X.
[48] Gondi V, Pugh SL, Tome WA, et al. Preservation of memory with conformal avoidance of the hippocampal neural stem-cell compartment during whole-brain radiotherapy for brain metastases (RTOG 0933):a phase Ⅱ multi-institutional trial[J]. J Clin Oncol, 2014, 32(34):3810-3816. DOI:10.1200/JCO.2014.57.2909.
[49] Brown PD, Gondi V, Pugh S, et al. Hippocampal avoidance during whole-brain radiotherapy plus memantine for patients with brain metastases:phase Ⅲ trial NRG oncology CC001[J]. J Clin Oncol, 2020, 38(10):1019-1029. DOI:10.1200/JCO.19.02767.
[50] Yang JJ, Zhou C, Huang Y, et al. Icotinib versus whole-brain irradiation in patients with EGFR-mutant non-small-cell lung cancer and multiple brain metastases (BRAIN):a multicentre, phase 3, open-label, parallel, randomised controlled trial[J]. Lancet Respir Med, 2017, 5(9):707-716. DOI:10.1016/S2213-2600(17)30262-X.