title: Risk of long-term complications after TFG-beta1-guided very-high-dose thoracic radiotherapy.
abstract: OBJECTIVE
  To report the incidence of late complications in long-term survivors of very-high-dose thoracic radiotherapy (RT) treated on a prospective clinical trial.
  
  
  METHODS
  Patients with locally advanced or medically inoperable non-small-cell lung cancer received three-dimensional conformal RT to the primary tumor and radiographically involved lymph nodes to a dose of 73.6 Gy at 1.6 Gy twice daily. If the plasma transforming growth factor-beta1 (TGF-beta1) level was normal after 73.6 Gy, additional twice-daily RT was delivered to successively higher total doses until the maximal tolerated dose was reached. Patients within a given dose level were followed for 6 months before escalation to the next dose level was permitted. Late complications were defined according to Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer criteria.
  
  
  RESULTS
  Thirty-eight patients were enrolled between 1996 and 1999. Twenty-four patients were not eligible for radiation dose escalation beyond 73.6 Gy because of persistently abnormal TGF-beta1 levels. Fourteen patients received dose escalation (80 Gy in 8; 86.4 Gy in 6). Grade 3 or greater late complications occurred in 4 of 24, 1 of 8, and 2 of 6 patients treated to 73.6, 80, and 86.4 Gy, respectively. The corresponding patient numbers with late Grade 4-5 toxicity were 3 of 24, 0 of 6, and 0 of 8. Overall, 7 (18%) of the 38 patients developed Grade 3-5 late toxicity. Nonpulmonary complications predominated (4 of 7). Five (71%) of seven serious complications developed within 11 months after RT; however, the remaining two complications (29%) occurred very late (at 43 and 62 months). The 5-year actuarial risk of late Grade 3-5 complications was 33%.
  
  
  CONCLUSIONS
  Long-term survivors of very-high-dose RT for non-small-cell lung cancer have a significant risk of severe treatment-related complications. At these high dose levels, the predominant toxicity may no longer be pulmonary. All Grade 4-5 complications occurred in patients whose dose was limited to 73.6 Gy because of a persistently elevated TGF-beta1. Thus, persistently elevated plasma TGF-beta1 levels toward the end of RT may identify patients at greatest risk of severe complications.
authors.affiliation: Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA. anscher@radonc.duke.edu
authors.forename: Mitchell S
authors.initials: MS
authors.lastname: Anscher
authors.forename: Lawrence B
authors.initials: LB
authors.lastname: Marks
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Shafman
authors.forename: Robert
authors.initials: R
authors.lastname: Clough
authors.forename: Hong
authors.initials: H
authors.lastname: Huang
authors.forename: Andrea
authors.initials: A
authors.lastname: Tisch
authors.forename: Michael
authors.initials: M
authors.lastname: Munley
authors.forename: James E
authors.initials: JE
authors.lastname: Herndon
authors.forename: Jennifer
authors.initials: J
authors.lastname: Garst
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Crawford
authors.forename: Randy L
authors.initials: RL
authors.lastname: Jirtle
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000097:blood* / Q000532:radiotherapy*; D018572:Disease-Free Survival; D004307:Dose-Response Relationship, Radiation; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000097:blood* / Q000532:radiotherapy*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D020266:Radiotherapy, Conformal / Q000009:adverse effects / Q000379:methods; D011882:Radiotherapy, High-Energy / Q000009:adverse effects* / Q000379:methods; D016212:Transforming Growth Factor beta / Q000097:blood*; D053773:Transforming Growth Factor beta1
chemical_list: C508960:TGFB1 protein, human; D016212:Transforming Growth Factor beta; D053773:Transforming Growth Factor beta1