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Background: In limited disease small cell lung cancer, the convert trial has demonstrated similar results with once-daily (QD) radiotherapy (66 Gy) and twice-daily (BID) radiotherapy (45 Gy). The selection among these regimes may be influenced by several factors. Methods: Thirteen European radiotherapy experts in SCLC as defined by the European Society for Therapeutic Radiation Oncology (ESTRO) were asked to describe their strategies in the management of LD-SCLC. The decision criteria were unified, the strategies were converted into decision trees and analysed for consensus and discrepancies. Results: Logistical reasons, performance status of the patient and dose constraints were the three major decision criteria used by most experts in decision making. The use of QD and BID regimes was balanced among European experts, but there was a trend towards the BID regime for fit patients able to travel twice a day to the radiotherapy site. Conclusion: BID and QD radiotherapy are both accepted treatment options among experts and the decision may be influenced by pragmatic factors such as availability of transportation.

Background: Due to conflicting results between major trials the role of prophylactic cranial irradiation (PCI) in stage IV small cell lung cancer (SCLC) is controversial. Methods: We obtained a list of 13 European experts from both the European Society for Therapeutic Radiation Oncology (ESTRO) and the International Association for the Study of Lung Cancer (IASLC). The strategies in decision making for PCI in stage IV SCLC were collected. Decision trees were created representing these strategies. Analysis of consensus was performed with the objective consensus methodol-ogy. Results: The factors associated with the recommendation for the use of PCI included the fitness of the patient, young age and good response to chemotherapy. PCI was recommended by the majority of experts for non-elderly fit patients who had at least a partial response (PR) to chemotherapy (for complete remission (CR): 85% of radiation oncologists and 69% of medical oncologists, for partial remission: 85% of radiation oncol- ogists and 54% of medical oncologists). For patients with stable disease after chemotherapy, PCI was rec- ommended by 6 out of 13 (46%) radiation oncologists and only 3 out of 13 medical oncologists (23%). For elderly fit patients with CR, a majority recommended PCI (62%) and no consensus was reached for patients with PR. Conclusion: European radiation and medical oncologists specializing in lung cancer recommend PCI in selected patients and restrict its use primarily to fit, non-elderly patients who responded to chemotherapy.

Stereotactic body radiation therapy (SBRT) for painful spinal metastases has the potential to improve and extend pain relief, but prospective data on pain response are lacking. This prospective phase II trial addressed the question of overall (complete and partial) pain response after hypo-fractionated SBRT for painful, mechanically stable, previously un-irradiated spinal metastases?

Purpose: We externally validated a previously established multivariable normal-tissue complication probability (NTCP) model for Grade ≥2 acute esophageal toxicity (AET) after intensity-modulated (chemo-)radiotherapy or volumetric-modulated arc therapy for locally advanced non-small cell lung cancer. Experimental design: A total of 603 patients from five cohorts within four different Dutch institutes were included. Using the NTCP model, containing predictors concurrent chemoradiotherapy, mean esophageal dose, gender and clinical tumor stage, the risk of Grade ≥2 AET was estimated per patient and model discrimination and (re)calibration performance was evaluated for all cohorts. Results: Five validation cohorts experienced higher incidence of Grade ≥2 AET compared to the training cohort (49.3%-70.2% vs 35.6%; borderline significant for one cohort, highly significant for four cohorts). For three cohorts, discriminative performance was similar to the training cohort (area under the curve (AUC) 0.81-0.89 vs 0.84). In the two remaining cohorts the model showed poor discriminative power (AUC 0.64 and 0.63). Reasonable calibration performance was observed in two cohorts, and recalibration further improved performance in all three cohorts with good discrimination. Recalibration for the two poorly discriminating cohorts did not improve performance. Conclusions: The NTCP model for AET prediction was successfully validated in three out of five patient cohorts. The model did not perform well in two cohorts, which included patients receiving substantially 105 different treatment. Before applying the model in clinical practice validation of discrimination and calibration performance on a local cohort is recommended. Recalibration of the model is advised to match predicted probabilities to locally observed frequencies of AET.

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Radiotherapy has been the mainstay of the treatment of stage III non-small cell lung cancer (NSCLC) patients. In the early nineties, combined treatment with chemotherapy was introduced. In 1995, a meta-analysis showed improved treatment outcome of the sequential use of radiochemotherapy (RCT) compared to radiotherapy alone, provided cisplatin was part of the chemotherapy course. Concurrent RCT compared to radiotherapy only yielded the same improvements of 4% in the 2-year and 2% in the 5-year overall survival rates. Just recently, two meta-analyses demonstrated that concurrent RCT is definitely superior to sequential RCT in terms of local control and 2-, 3-, and 5-year survival. However, several unanswered questions remain concerning the optimal chemotherapy regimen and radiotherapy doses and techniques in terms of treatment outcome and toxicity profile. Arguments supporting a daily low-dose cisplatin scheme are presented because of comparable radiosensitizing characteristics and favourable side effects. Increasing radiotherapy doses applied according to up-to-date techniques and combinations with new biologicals might lead to further treatment improvements.

Patients with a non-small cell lung cancer stage III should preferably be treated with a combination of concomitant radiotherapy and platinum-containing chemotherapy. Concomitant chemoradiation results in improved survival compared to sequential chemoradiation, although this type oftreatment is associated with higher oesophagus toxicity. With concomitant chemoradiation the chemotherapy can be added in several ways to high-dosage radiotherapy, for example in the form of 2 courses of high dose, platinum-containing polychemotherapy once every 3 weeks. Concomitant chemoradiation with just a daily low dose of cisplatin is a good alternative. In view of its low risk of haematological and renal toxicity and ototoxicity and smaller cardiac load this is the therapy of choice and is also highly suitable for elderly patients with comorbidity

The purpose of this work was to study the feasibility of concurrent chemoradiation in patients with inoperable non-small cell lung cancer (NSCLC). 40 patients with inoperable NSCLC were treated with escalating doses of radiotherapy and cisplatin (cDDP). The radiation dose was increased step by step from 60.5 to 66 Gy in daily fractions of 2.75 Gy. Chemotherapy was also increased step by step from 20 to 24 daily doses of cDDP 6 mg/m(2) and given concurrently with radiotherapy. A dose of 40 Gy/2 Gy/20 fractions (fx) was given to the EPTV (elective planning target volume) which included the gross tumour volume with a margin of 2 cm and part of or the entire mediastinum. During each session a boost dose of 0.75 Gy was given simultaneously to the BPTV (boost planning target volume), which encompassed the GTV (gross tumour volume) with a margin of 1 cm, for the first 20 fx, so the total dose to the tumour was 55 Gy. Cisplatin 6 mg/m(2) was given 1 h prior to radiotherapy at each fraction. From then on the dose of radiation to the BPTV and the dose of cDDP were increased step by step. In group I the BPTV was irradiated with two extra fractions of 2.75 Gy to a total dose of 60. 5 Gy without cDDP. In group II the same total dose of 60.5 Gy was given but the last two fractions were combined with cDDP. In group III four extra fractions of 2.75 Gy were given to the BPTV to a total dose of 66 Gy, only two of these fractions combined with cDDP. Finally, in group IV a total dose of 66 Gy was given in 24 fractions, all fractions combined with cDDP. All patients were planned by means of a CT-based conformal treatment planning. The maximal length of the oesophagus receiving >/=60.5 Gy was 11 cm. 40 patients were evaluable for acute and late toxicity and for survival. Acute toxicity grade >/=3 (common toxicity criteria, CTC) was rarely observed; nausea/vomiting in 3 patients (8%), leucopenia in 2 patients (5%), thrombocytopenia in 2 patients (5%), whilst 2 patients (5%) suffered from severe weight loss. Late side-effects (European Organization for Research and Treatment of Cancer/Radiation Therapy Oncology Group, EORTC/RTOG) were: oesophageal toxicity >/=grade 3 in 2 patients (5%) and radiation pneumonitis grades 1 (3%) and 2 (3%) in 1 patient each. Overall actuarial 1- and 2-year survival was 53% and 40%, respectively. The 1- and 2-year local disease-free interval was 65% and 58% respectively. Radiotherapy at a dose of 66 Gy/2.75 Gy/24 fx combined with daily cDDP 6 mg/m(2) given over 5 weeks is feasible and results in a good local disease-free interval and a good survival rate. This treatment schedule is at present being tested as one of the two treatment arms of EORTC phase III study protocol 08972/22973