Post on 24-Feb-2016
description
Approaching early stage diseaseSurgery vs SBRT vs RFA
November 16, 2012
Ramesh Rengan MD PhDChief, Thoracic ServiceAssistant Director of Clinical OperationsDepartment of Radiation Oncology
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DISCLOSURES Speaker Honoraria
• Philips Healthcare
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Introduction: The Scope of the Problem
213,380 patients are diagnosed yearly with lung cancer in the US with approximately 160,390 deaths
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What is “Early Stage” Disease?
Technically resectable disease without evidence of mediastinal involvement
IA T1N0M0
IB T2aN0M0
IIAT2bN0M0T1N1M0
T2aN1M0
IIB T2bN1M0T3N0M0
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Prognosis
5yr OSStage IA 75%
Stage IB 55%
Stage IIA 50%
Stage IIB 40%
Stage IIIA 10-35%
Stage IIIB 5-8%
Stage IV <5%
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Medical Operability2007 ACCP Guidelines Age alone is not a reason to deny resection. Operative mortality for a lobectomy:
~2% for age < 60, ~8% for age > 70
General targets:• FEV1 > 1.5L• FEV1 > 80% pred• DLCO > 60-80% pred
Danger signs: • FEV1 or DLCO < 40% predicted• FEV1/FVC < 50%• PCO2 > 50mmHg• Cor pulmonale• VO2 < 15cc/kg/min• Or, ability to walk 1 flight of stairs
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Treatment for Early Stage Operable Disease
Lobectomy + Mediastinal LND or LNS Remains current standard of care
• ACOSOG Z0030
With appropriate pt selection, periop mortality rates are low• Pneumonectomy 5%• Lobectomy 1-3%• Smaller Resections < 1%
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Treatment for Early Stage Operable Disease: ACOSOG Z0030
1111 patients enrolled; 1023 randomized• Extensive MLNS followed by observation vs MLND
No difference in overall survival
Darling et al J Thoracic and CV Surgery, 2011
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Treatment for Early Stage Operable Disease: Is there a lumpectomy for the lung?
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LCSG showed trend towards increased likelihood of death with limited resection
LCSG showed three-fold increase in local failure with wedge resection vs. lobectomy
Treatment for Early Stage Operable Disease: Is there a lumpectomy for the lung?
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Cor pulmonale Severe coronary artery
disease Renal failure Poor pulmonary function
• DLCO <50%• FEV1/FVC ratio < 50 –
75% of predicted Impaired nutritional status
Medically Inoperable Early Stage: Role of RT
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StudyAuthor
n Dose (Gy)
5-yr survival
5-yr CSS
5-yr local
Dosoretz 152 60-69 10%
Krol 108 60-65 15% 31% 25%
Kaskowitz 53 63 6% 13% 0%
Sibley 141 55-70 13%
Rosenzweig 32 70.2 33% 39% 43%
Medically Inoperable Early Stage: Role of RT
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Medically Inoperable Early Stage: SBRT
Nyman et al Lung Cancer 2006
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Fractionation Options Conventionally fractionated radiotherapy
- small daily doses- go to very high cumulative doses
Ablative radiotherapy- very high daily doses (8-20 Gy)- overwhelm tumor repair- causes “late” effects that may be intolerable
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Dose Fractionation: Implications for Tumor Control
100
2 4 6 8
Sur
viva
l
Dose (Gy)
10-1
10-2
singlefraction
multiple 2 Gy fractions
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Early Stage Disease: Stereotactic Body Radiation Therapy
Pretreatment 6-weeks Post-treatment
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Medically Inoperable Early Stage: SBRT
Author # of Patients
Local Control
Overall Survival
Onishi et al. 245 85% 56% (3-yr)Timmerman 70 98% 55% (2-yr)Nyman 45 80% 71% (2-yr)Baumann 57 92% 60% (3-yr)Nagata 31 98% 79% (2-yr)Uematsu 50 94% 66% (3-yr)Koto 31 78% 72% (3-yr)Fakiris 70 88% 43% (3-yr)
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Dose Fractionation: Implications for Tumor Control
100
2 4 6 8
Sur
viva
l
Dose (Gy)
10-1
10-2
singlefraction
multiple 2 Gy fractions
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p = 0.003
Medically Inoperable Early Stage: Toxicity of SBRT
Corradetti et al NEJM 2012JCO 2006
RTOG 0813 is currently accruing Would not treat centrally located tumors with SBRT off-protocol Standard of care for peripheral medically inoperable NSCLC
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SBRT: Emerging toxicity data
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Treatment of Early Stage Inoperable Disease: RFA
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Treatment of Early Stage Inoperable Disease: RFA
Multicenter prospective trial of 106 patients with 183 lung tumors
33 patients with NSCLC 48% 2-year survival
• 73% 2-year CSS 10% pneumothorax rate Median hospital stay 3
daysLancioni Lancet Oncol 2008
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RFA: Emerging toxicity data
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Early Stage NSCLC: Conclusions
NCCN Guidelines, 2012
Lobectomy + MLNS or MLNDWith adjuvant chemotherapy+/- RT in high risk cases
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