Approaching early stage disease
description
Transcript of Approaching early stage disease
![Page 1: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/1.jpg)
Approaching early stage diseaseSurgery vs SBRT vs RFA
November 16, 2012
Ramesh Rengan MD PhDChief, Thoracic ServiceAssistant Director of Clinical OperationsDepartment of Radiation Oncology
![Page 2: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/2.jpg)
2
DISCLOSURES Speaker Honoraria
• Philips Healthcare
![Page 3: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/3.jpg)
3
Introduction: The Scope of the Problem
213,380 patients are diagnosed yearly with lung cancer in the US with approximately 160,390 deaths
![Page 4: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/4.jpg)
4
What is “Early Stage” Disease?
Technically resectable disease without evidence of mediastinal involvement
IA T1N0M0
IB T2aN0M0
IIAT2bN0M0T1N1M0
T2aN1M0
IIB T2bN1M0T3N0M0
![Page 5: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/5.jpg)
5
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%
![Page 6: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/6.jpg)
6
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
![Page 7: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/7.jpg)
7
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%
![Page 8: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/8.jpg)
8
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
![Page 9: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/9.jpg)
9
Treatment for Early Stage Operable Disease: Is there a lumpectomy for the lung?
![Page 10: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/10.jpg)
10
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?
![Page 11: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/11.jpg)
11
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
![Page 12: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/12.jpg)
12
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
![Page 13: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/13.jpg)
13
Medically Inoperable Early Stage: SBRT
Nyman et al Lung Cancer 2006
![Page 14: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/14.jpg)
14
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
![Page 15: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/15.jpg)
15
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
![Page 16: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/16.jpg)
16
Early Stage Disease: Stereotactic Body Radiation Therapy
Pretreatment 6-weeks Post-treatment
![Page 17: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/17.jpg)
17
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)
![Page 18: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/18.jpg)
18
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
![Page 19: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/19.jpg)
19
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
![Page 20: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/20.jpg)
20
SBRT: Emerging toxicity data
![Page 21: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/21.jpg)
21
Treatment of Early Stage Inoperable Disease: RFA
![Page 22: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/22.jpg)
22
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
![Page 23: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/23.jpg)
23
RFA: Emerging toxicity data
![Page 24: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/24.jpg)
24
Early Stage NSCLC: Conclusions
NCCN Guidelines, 2012
Lobectomy + MLNS or MLNDWith adjuvant chemotherapy+/- RT in high risk cases
![Page 25: Approaching early stage disease](https://reader036.fdocuments.in/reader036/viewer/2022062323/56816614550346895dd95f2e/html5/thumbnails/25.jpg)
25