Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger...

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Staging

Transcript of Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger...

Page 1: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Staging

Page 2: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Staging

Page 3: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Treatment by Stage

For early stage lung cancers, surgery or radiation alone

For larger tumors (>4 cm) and N+, chemotherapy should be added as well

For metastatic disease, chemotherapy and palliative radiation is used

Page 4: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Surgery

Resection remains the preferred local tx modality

For smokers, encourage quitting and waiting 4 weeks smoke-free before surgery

Page 5: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Surgery for Early Stage

Sleeve lobectomy is preferred

Sublobar resection: Segmentectomy is preferred over wedge resection for pts with poor pulm reserve, small nodules of AIS, > 50% ground glass appearance, or long radiological doubling time

Goal of >2 cm margins, and should sample N1/N2 LN stations if possible

Page 6: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

VATS vs open thoracotomy

In centers with high volumes of VATS, there are improved early outcomes:

• Reduced pain

• Shortened hospital stay

• Faster recovery

• Fewer complications

• Similar rates of tumor control

Page 7: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Radiation in Early Stage

Stereotactic Body Radiotherapy (SBRT) delivers a high, tumor-ablative dose to the target while minimizing normal tissue dose

In Stage I NSCLC, SBRT shows rates of local tumor control (90-98%) and overall survival 30-80%) comparable to lobectomy

Page 8: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.
Page 9: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Stage III Controversies

Historically Stage IIIA/B have been considered unresectable and definitive chemotherapy and radiation (concurrently or sequentially) is the tx of choice

Two randomized studies have failed to show an OS benefit in adding surgical resection to chemo and RT, but NCCN guidelines still include it as an option to consider

Breaks from neoadjuvant tx for surgical evaluation should be < 1 week

Page 10: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Resection of Stage IIIA (N2)

In addition to N1/N2 dissection, ipsilateral mediastinal LN dissection should be done

Complete resxn (R0) = free margins, systemic LN sampling or dissections, and the highest mediastinal node taken should be negative for tumor

Incomplete: positive margins, unremoved positive LN’s, or positive pleural or pericardial effusion (R1 if microscopic, R2 if gross residual tumor)

Page 11: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Chemotherapy

Multiple randomized trials show the benefit of chemotherapy in Stage II and III NSCLC (maybe even Stage IB with tumor > 4cm)

Platinum-based doublet:

Cisplatin/etoposide

Cisplatin/vinblastine

Carboplatin/paclitaxel

Pemetrexed for nonsquamous histology, gemcitabine for squamous

Page 12: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

M1b, Solitary Site

• For solitary brain metastasis: resection + WBI, or SBI + SRS, or SRS alone

• For adrenal metastasis: resection or RT (SBRT) to metastasis

• Then tx the lung per it’s stage without the metastasis

Page 13: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Advanced or Metastatic Disease

• EGFR and ALK testing for non-squamous histologies

• Bevacizumab + chemotherapy in pts with good performance status

• Erlotinib is first line therapy in pts with EGFR mutation

• Crizotinib is first line therapy in pts who are ALK positive

Page 14: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Targeted Therapies

Bevacizumab (Avastin) – VEGF

Erlotinib (Tarceva) – EGFR

Gefitinib (Iressa) – EGFR

Crizotinib – ALK

These targets are mainly applicable in adenocarcinomas, with most SQCC lacking EGFR mutation and ALK rearrangement

Cetuximab has shown activity in SQCC’s with high EGFR expression (FLEX)

Page 15: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Future Targets for SQCC

In squamous cell NSCLC’s genomic profiling shows potential targets in PI3K pathway, FGFR1 amplifications and DDR2 mutations

ECLIPSE: Phase III trial of carboplatin/gemcitabine =/- iniparib (a PARP inhibitor) is underway

Phase III trial of carboplatin/paclitaxel +/- ipilimumab (targets the inhibition of cytotoxic T cells)

Page 16: Staging. Treatment by Stage For early stage lung cancers, surgery or radiation alone For larger tumors (>4 cm) and N+, chemotherapy should be added.

Follow Up

Physical exam and CT scan every 6 months for 2 years

Exam and CT scan every year after that