Top Line: Hemorrhage is a major concern when considering lung SABR in the setting of VEGF inhibitors (VEGFi) such as bevacizumab. The Study: This study!https://www.jto.org/article/S1556-0864(23)00494-X/fulltext took a look at 690 patients with 818 lung tumors treated with SABR, and they identified 44 patients (6.4%) with 52 tumors who received VEGFi at the time of SABR. About a third of patients received VEGFi before, after, or before and after SABR, respectively. Most targets were lung mets (59.6%) with the rest being either a primary tumor (32.7%) or a primary and mets (7.7%). The majority of tumors were peripherally located (76.9%), 11.5% had central tumors not abutting the trachea or proximal bronchial tree, and 11.5% had ultracentral tumors. The median BED10 was 100 Gy. 50% of patients were treated with a 4 fraction regimen and another 28.8% were treated in a single fraction. In the overall cohort, the rate of grade 3+ pulmonary hemorrhage was 3.2% at 3 years. The rate of grade 3+ pulmonary hemorrhage was significantly higher in patients treated with VEGFi (7.9% v 0.6%). While VEGFi increased the rate of grade 3+ hemorrhage for those with peripheral tumors (3.8% v 0.2%), the increase was most notable for those with central tumors (19.1% v 3.3%) and especially ultracentral tumors (45% v 9%). The authors also performed a propensity matched analysis with patients who received VEGFi alone (no SABR), and they found that the combination of SABR and VEGFi had a higher cumulative risk of grade 3+ pulmonary hemorrhage than with VEGFi alone (9.6% v 1.3%). TBL: This study found that the combination of VEGFi and lung SABR increases the risk of grade 3+ pulmonary hemorrhage. The absolute risk is relatively low with peripheral lesions, but significant caution should be exercised with central and ultracentral tumors where the risk could exceed 20%.
