Validation of RTOG 0813 Proximal Bronchial Tree Constraints for Pulmonary Toxicity with Stereotactic Body Radiation Therapy for Central Non-Small Cell Lung Cancer.
RTOG 0813 近端支气管树约束对中心型非小细胞肺癌立体定向体部放射治疗肺毒性的验证。
- 作者列表："Manyam BV","Verdecchia K","Videtic GMM","Zhuang T","Woody NM","Wei W","Ouyang Z","Stephans KL
PURPOSE:Clinical validation of protocol-specified dosimetric constraints for the proximal bronchial tree (PBT) is limited for central non-small cell lung cancer treated with stereotactic body radiation therapy (SBRT). We sought to validate RTOG PBT constraints with a large institutional dataset. METHODS:Lesions ≤2 cm from the PBT treated with definitive SBRT from 2009 to 2016 were identified from a prospective registry of 1,462 patients. Every PBT dose and volume combination, ranging from 0 cGy to 8000 cGy in increments of 10 cGy, and volumes ranging from 0.03 cc to 50 cc in increments of 0.03 cc was analyzed. The sensitivity and specificity of these endpoints for identifying pulmonary toxicity was calculated. Pulmonary toxicity was classified as pneumonitis or non-pneumonitis toxicity (NPT) (fistula, stenosis, necrosis, hemoptysis, clinically significant pleural effusion). The optimal dosimetric predictor was chosen by calculation of F-score (highest sensitivity and specificity). RESULTS:The study included 132 patients, with 26.0 month median follow-up. Eight Grade ≥2 NPT (two Grade 5) and eight Grade 2 pneumonitis toxicities were observed. The PBT dosimetric endpoint with the highest F-score for identification of Grade 2-5 NPT was D0.03cc≤5000 cGy and Grade 3-5 NPT was D0.33cc≤4710 cGy, with sensitivity and specificity of 87.5% and 76.6% and 100.0% and 85.7%, respectively. Applying the RTOG 0813 PBT constraints to our dataset achieved a sensitivity and specificity of 33.3% and 92.1% for D4cc≤1800 cGy and 37.5% and 92.7% for D0.03cc≤5250 cGy for identification of Grade 2-5 NPT. A PBT dosimetric correlation for pneumonitis toxicity could not be identified. CONCLUSION:This novel dosimetric analysis validates current RTOG constraints and emphasizes high-dose, small-volume constraints as better predictors for NPT. We demonstrated a slightly lower maximum point dose PBT constraint may be optimal for identification of NPT. Validation of these findings in a larger cohort of patients with longer follow-up is necessary.
目的: 对于立体定向体部放射治疗 (SBRT) 治疗的中央型非小细胞肺癌，近端支气管树 (PBT) 方案指定剂量限制的临床验证是有限的。我们试图用一个大的机构数据集验证 RTOG PBT 约束。 方法: 从 2厘米例患者的前瞻性登记中确定了 2009年至 2016年接受确定性 SBRT 治疗的 PBT ≤ 1,462 的病变。分析每个 PBT 剂量和体积组合，范围从 0 cGy 到 8000 cGy，增量为 10 cGy，体积范围从 0.03 cc 到 50 cc，增量为 0.03 cc。计算这些终点识别肺毒性的敏感性和特异性。肺毒性分为肺炎或非肺炎毒性 (NPT) (瘘管、狭窄、坏死、咯血、有临床意义的胸腔积液)。通过计算 F 评分 (最高灵敏度和特异性) 选择最佳剂量学预测因子。 结果: 研究共纳入 132 例患者，中位随访时间为 26.0 个月。观察 8 例 ≥ 2 级 NPT (2 例 5 级) 和 8 例 2 级肺炎毒性。用于鉴定 2-5 级 NPT 的 F 评分最高的 PBT 剂量学终点为 D0.03cc ≤ 5000 cGy，3-5 级 NPT 为 D0.33cc ≤ 4710 cGy, 敏感性和特异性分别为 87.5% 和 76.6%，100.0% 和 85.7%。将 RTOG 0813 PBT 约束应用于我们的数据集，对于 D4cc ≤ 33.3% cGy 实现了 92.1% 和 1800 的灵敏度和特异性，对于 2-5 级 NPT 的鉴定，D0.03cc ≤ 37.5% cGy 实现了 92.7% 和 5250。未能确定肺炎毒性的 PBT 剂量相关性。 结论: 这种新型剂量学分析验证了当前的 RTOG 约束，并强调高剂量、小体积约束是 NPT 的更好预测因子。我们证明了稍低的最大点剂量 PBT 约束可能是识别 NPT 的最佳选择。在更大的随访时间更长的患者队列中验证这些发现是必要的。
METHODS:Background Dye localization is a useful method for the resection of unidentifiable small pulmonary lesions. This study compares the transbronchial route with augmented fluoroscopic bronchoscopy (AFB) and conventional transthoracic CT-guided methods for preoperative dye localization in thoracoscopic surgery. Methods Between April 2015 and March 2019, a total of 231 patients with small pulmonary lesions who received preoperative dye localization via AFB or percutaneous CT-guided technique were enrolled in the study. A propensity-matched analysis, incorporating preoperative variables, was used to compare localization and surgical outcomes between the two groups. Results After matching, a total of 90 patients in the AFB group ( N = 30) and CT-guided group ( N = 60) were selected for analysis. No significant difference was noted in the demographic data between both the groups. Dye localization was successfully performed in 29 patients (96.7%) and 57 patients (95%) with AFB and CT-guided method, respectively. The localization duration (24.1 ± 8.3 vs. 21.4 ± 12.5 min, p = 0.297) and equivalent dose of radiation exposure (3.1 ± 1.5 vs. 2.5 ± 2.0 mSv, p = 0.130) were comparable in both the groups. No major procedure-related complications occurred in either group; however, a higher rate of pneumothorax (0 vs. 16.7%, p = 0.029) and focal intrapulmonary hemorrhage (3.3 vs. 26.7%, p = 0.008) was noted in the CT-guided group. Conclusion AFB dye marking is an effective alternative for the preoperative localization of small pulmonary lesions, with a lower risk of procedure-related complications than the conventional CT-guided method.
METHODS:Background The use of artificial intelligence, including machine learning, is increasing in medicine. Use of machine learning is rising in the prediction of patient outcomes. Machine learning may also be able to enhance and augment anesthesia clinical procedures such as airway management. In this study, we sought to develop a machine learning algorithm that could classify vocal cords and tracheal airway anatomy real-time during video laryngoscopy or bronchoscopy as well as compare the performance of three novel convolutional networks for detecting vocal cords and tracheal rings. Methods Following institutional approval, a clinical dataset of 775 video laryngoscopy and bronchoscopy videos was used. The dataset was divided into two categories for use for training and testing. We used three convolutional neural networks (CNNs): ResNet, Inception and MobileNet. Backpropagation and a mean squared error loss function were used to assess accuracy as well as minimize bias and variance. Following training, we assessed transferability using the generalization error of the CNN, sensitivity and specificity, average confidence error, outliers, overall confidence percentage, and frames per second for live video feeds. After the training was complete, 22 models using 0 to 25,000 steps were generated and compared. Results The overall confidence of classification for the vocal cords and tracheal rings for ResNet, Inception and MobileNet CNNs were as follows: 0.84, 0.78, and 0.64 for vocal cords, respectively, and 0.69, 0.72, 0.54 for tracheal rings, respectively. Transfer learning following additional training resulted in improved accuracy of ResNet and Inception for identifying the vocal cords (with a confidence of 0.96 and 0.93 respectively). The two best performing CNNs, ResNet and Inception, achieved a specificity of 0.985 and 0.971, respectively, and a sensitivity of 0.865 and 0.892, respectively. Inception was able to process the live video feeds at 10 FPS while ResNet processed at 5 FPS. Both were able to pass a feasibility test of identifying vocal cords and tracheal rings in a video feed. Conclusions We report the development and evaluation of a CNN that can identify and classify airway anatomy in real time. This neural network demonstrates high performance. The availability of artificial intelligence may improve airway management and bronchoscopy by helping to identify key anatomy real time. Thus, potentially improving performance and outcomes during these procedures. Further, this technology may theoretically be extended to the settings of airway pathology or airway management in the hands of experienced providers. The researchers in this study are exploring the performance of this neural network in clinical trials.
METHODS:BACKGROUND:The optimal mode of delivering topical anesthesia during flexible bronchoscopy remains unknown. This article compares the efficacy and safety of nebulized lignocaine, lignocaine oropharyngeal spray, or their combination. METHODS:Consecutive subjects were randomized 1:1:1 to receive nebulized lignocaine (2.5 mL of 4% solution, group A), oropharyngeal spray (10 actuations of 10% lignocaine, group B), or nebulization (2.5 mL, 4% lignocaine) and two actuations of 10% lignocaine spray (group C). The primary outcome was the subject-rated severity of cough according to a visual analog scale. The secondary outcomes included bronchoscopist-rated severity of cough and overall procedural satisfaction on a visual analog scale, total lignocaine dose, subject's willingness to undergo a repeat procedure, adverse reactions to lignocaine, and others. RESULTS:A total of 1,050 subjects (median age, 51 years; 64.8% men) were included. The median (interquartile range) score for subject-rated cough severity was significantly lower in group B compared to group C or group A (4 [1-10] vs 11 [4-24] vs 13 [5-30], respectively; P < .001). The bronchoscopist-rated severity of cough was also the least (P < .001), and the overall satisfaction was highest in group B (P < .001). The cumulative lignocaine dose administered was the least in group B (P < .001). A significantly higher proportion of subjects (P < .001) were willing to undergo a repeat bronchoscopy in group B (73.7%) than in groups A (49.1%) and C (59.4%). No lignocaine-related adverse events were observed. CONCLUSIONS:Ten actuations of 10% lignocaine oropharyngeal spray were superior to nebulized lignocaine or their combination for topical anesthesia during diagnostic flexible bronchoscopy. TRIAL REGISTRY:ClinicalTrials.gov; No.: NCT03109392; URL: www.clinicaltrials.gov.