International Journal of Clinical Case Reports 2024, Vol.14, No.5, 290-298 http://medscipublisher.com/index.php/ijccr 292 3.2 IMRT for locally advanced lung cancer Intensity-modulated radiotherapy (IMRT) has become the standard radiotherapy approach for locally advanced NSCLC, offering superior precision by modulating radiation doses to conform to the tumor’s shape. This allows for effective tumor targeting while minimizing radiation exposure to surrounding healthy tissues such as the heart and lungs. Clinical evidence from the NRG Oncology RTOG 0617 trial supports the use of IMRT, showing a reduction in severe radiation-induced pneumonitis and cardiac toxicity compared to older techniques like 3D-CRT (Chun et al., 2017). IMRT also enables better sparing of critical organs, leading to improved patient outcomes without compromising survival rates. 3.3 Proton therapy in lung cancer Proton therapy offers significant dosimetric advantages over photon-based therapies due to the unique properties of the proton beam, which deposits its dose in the tumor while minimizing exposure to surrounding healthy tissues. Clinical studies indicate that proton therapy is especially beneficial for treating lung cancer near sensitive structures, such as the heart and lungs, where it reduces the risk of radiation-induced toxicities. In patients with locally advanced NSCLC, proton therapy has been shown to lower the risk of pneumonitis and cardiac complications compared to IMRT, while maintaining similar survival rates (Harada and Murayama, 2017). Furthermore, studies highlight that proton therapy can achieve excellent local control rates and reduce toxicity even in high-risk patients with large tumors or poor lung function (Wang, 2024a). 4 Integration of Radiotherapy with Systemic Therapies 4.1 Combining radiotherapy with chemotherapy Radiotherapy combined with chemotherapy has long been a standard treatment for non-small cell lung cancer (NSCLC), especially in locally advanced stages. Chemotherapy, typically used concurrently with radiotherapy, sensitizes cancer cells to radiation, enhancing the efficacy of the treatment. This combination has been shown to improve overall survival and progression-free survival when compared to radiotherapy alone (Muto et al., 2020). However, combining radiotherapy and chemotherapy can increase the risk of treatment-related toxicity, particularly in normal tissues such as the lungs and esophagus (Sacco et al., 2017). 4.2 Radiotherapy and immunotherapy combinations In recent years, the combination of radiotherapy with immunotherapy has garnered significant attention, especially with the advent of immune checkpoint inhibitors like PD-1/PD-L1 inhibitors. Radiotherapy is thought to stimulate the immune system by inducing immunogenic cell death and increasing tumor antigen presentation, which enhances the efficacy of immunotherapy (Wirsdörfer et al., 2018). This combination has led to the observation of the "abscopal effect," where tumors outside the radiation field also respond to treatment, potentially mediated by immune activation (Bhalla et al., 2018). Trials such as the PACIFIC trial demonstrated the survival benefits of combining chemoradiotherapy with immune checkpoint inhibitors in stage III NSCLC. 4.3 Case study analysis: multimodal treatment approaches One case study analysis involved a patient with locally advanced NSCLC who underwent a multimodal approach combining chemoradiotherapy and immunotherapy. The patient received concurrent chemoradiotherapy followed by durvalumab, an anti-PD-L1 agent, as consolidation therapy. This approach led to a significant reduction in tumor size and prolonged progression-free survival, mirroring the positive outcomes seen in larger clinical trials such as the PACIFIC trial (Spaas and Lievens, 2019). The integration of these therapies provided both local control through radiotherapy and systemic immune responses via immunotherapy, demonstrating the potential of combined treatment strategies (Wang, 2024b). 5 Radiotherapy-Induced Toxicities and Management 5.1 Common side effects of lung cancer radiotherapy Radiotherapy for lung cancer is associated with several acute and late toxicities. The most common acute toxicities include radiation pneumonitis and esophagitis. Radiation pneumonitis can manifest within weeks to months after radiotherapy, leading to coughing, dyspnea, and fatigue. Esophagitis often occurs during treatment,
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