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Willers H.,Massachusetts General Hospital | Stinchcombe T.E.,University of North Carolina at Chapel Hill | Barriger R.B.,Indiana University | Chetty I.J.,Ford Motor Company | And 9 more authors.
American Journal of Clinical Oncology: Cancer Clinical Trials | Year: 2015

The integration of chemotherapy, radiation therapy (RT), and surgery in the management of patients with stage IIIA (N2) non-small-cell lung carcinoma is challenging. The American College of Radiology (ACR) Appropriateness Criteria Lung Cancer Panel was charged to update management recommendations for this clinical scenario. The Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. There is limited level I evidence to guide patient selection for induction, postoperative RT (PORT), or definitive RT. Literature interpretation is complicated by inconsistent diagnostic procedures for N2 disease, disease heterogeneity, and pooled analysis with other stages. PORT is an appropriate therapy following adjuvant chemotherapy in patients with incidental pN2 disease. In patients with clinical N2 disease who are potential candidates for a lobectomy, both definitive and induction concurrent chemotherapy/RT are appropriate treatments. In N2 patients who require a pneumonectomy, definitive concurrent chemotherapy/RT is most appropriate although induction concurrent chemotherapy/RT may be considered in expert hands. Induction chemotherapy followed by surgery +/- PORT may also be an option in N2 patients. For preoperative RT and PORT, 3-dimensional conformal techniques and intensity-modulated RT are most appropriate. © Copyright © 2014 American College of Radiology (ACR). Source


Ravenel J.G.,Medical University of South Carolina | Rosenzweig K.E.,Mount Sinai School of Medicine | Kirsch J.,Cleveland Clinic | Ginsburg M.E.,Columbia University | And 6 more authors.
Journal of the American College of Radiology : JACR | Year: 2014

In order to appropriately manage patients with lung cancer, it is necessary to properly stage the tumor. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved. Source


Ravenel J.G.,Medical University of South Carolina | Rosenzweig K.E.,Mount Sinai School of Medicine | Kirsch J.,Cleveland Clinic | Ginsburg M.E.,Columbia University | And 6 more authors.
Journal of the American College of Radiology | Year: 2014

In order to appropriately manage patients with lung cancer, it is necessary to properly stage the tumor. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. © 2014 American College of Radiology. Source


Kestin L.,21st Century Oncology Michigan Healthcare Professionals | Grills I.,William Beaumont Hospital | Guckenberger M.,University of Wurzburg | Belderbos J.,Netherlands Cancer Institute | And 6 more authors.
Radiotherapy and Oncology | Year: 2014

Purpose To examine potential dose-response relationships with various non-small-cell lung cancer (NSCLC) SBRT fractionation regimens delivered with online CT-based image guidance. Methods 505 tumors in 483 patients with clinical stage T1-T2N0 NSCLC were treated with SBRT using on-line cone-beam-CT-based image guidance at 5 institutions (1998-2010). Median maximum tumor dimension was 2.6 cm (range 0.9-8.5 cm). Dose fractionation prescription was according to each institution's protocol with the most common schedules of 18-20 GyX3, 12 GyX4, 12 GyX5, 12.5 GyX3, 7.5 GyX8 (median = 54 Gy, 3 fractions). Median prescription (Rx) BED10 = 132 Gy (50.4-180). Median values (Gy) of 3D planned doses for BED10 were GTVmin = 164.1, GTV mean = 188.4, GTVmax = 205.9, PTVmin = 113.9, PTV D99 = 123.9, PTVmean = 164.7, PTV D1 = 197.3, PTVmax = 210.7. Mean follow-up = 1.6 years. Results 26 cases (5%) had local recurrence (LR) for a 2-year rate of 6% and 3-year rate of 9%. All BED10 GTV&PTV endpoints were associated with LR as continuous variables on univariate analysis (p < 0.05). Rx and PTVmean dose appeared to have the highest correlation with LR with area under ROC curve of 0.69 and 0.65 respectively and optimal cut points of 105 and 125 Gy, respectively. 2-year LR was 4% for PTVmean > 125 vs 17% for <125 Gy (p < 0.01) with sensitivity = 84% and specificity = 57% for predicting LR. 2-year LR for Rx BED10 > 105 was 4% vs 15% for <105 Gy (p < 0.01). Longer treatment duration (≥11 elapsed days) demonstrated a 2-year LR of 14% vs 4% for ≤10 days (p < 0.01). GTV size was associated with LR on univariate analysis as a continuous variable (p = 0.02) with 2-year LR = 3% for <2.7 cm vs 9% for ≥2.7 cm (p = 0.03). BED10 (p = 0.01) and elapsed days during RT (p = 0.05) were independent predictors on multivariate analysis as continuous variables. Conclusions There is a substantial dose-response relationship for local control of NSCLC following image-guided SBRT with optimal PTVmean BED10 > 125 Gy. Shorter treatment duration was also associated with better local control in this dataset. © 2013 Elsevier Ireland Ltd. All rights reserved. Source


Videtic G.M.M.,Cleveland Clinic | Chang J.Y.,University of Texas M. D. Anderson Cancer Center | Chetty I.J.,Ford Motor Company | Ginsburg M.E.,Columbia University | And 8 more authors.
American Journal of Clinical Oncology: Cancer Clinical Trials | Year: 2014

Early-stage non-small-cell lung cancer (NSCLC) is diagnosed in about 15% to 20% of lung cancer patients at presentation. In order to provide clinicians with guidance in decision making for earlystage NSCLC patients, the American College of Radiology Appropriateness Criteria Lung Cancer Panel was recently charged with a review of the current published literature to generate up-to-date management recommendations for this clinical scenario. For patients with localized, mediastinal lymph node-negative NSCLC, optimal management should be determined by an expert multidisciplinary team. For medically perable patients, surgical resection is the standard of care, with generally no role for adjuvant therapies thereafter. For patients with medical comorbidities making them at high risk for surgery, there is emerging evidence demonstrating the availability of low toxicity curative therapies, such as stereotactic body radiotherapy, for their care. As a general statement, the American College of Radiology Appropriateness Criteria are evidencebased guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Copyright © 2013 American College of Radiology (ACR). Source

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