SURGEONS ROLE AND INVOLVEMENT IN SBRT PROGRAM Stephen R.
Hazelrigg, M.D. Professor and Chair, Cardiothoracic Surgery
Southern Illinois University, School of Medicine
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LUNG CANCER TREATMENT Early Stage What we agree upon: Good risk
early stage cancers should have surgery (lobectomy) Non-surgical
patients can benefit from SBRT
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LOBECTOMY VERSUS SBRT Hamaji etal. ATS April 2015 Kyoto
University Hospital Retrospective single institutional study All
biopsy proven and PET/CT negative with respect to nodes 413
lobectomies, 104 SBRT Same mean size (2.5 cm) Mean follow up 55
months
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SBRT Video-Assisted Thoracoscopic Lobectomy Versus Stereotactic
Radiotherapy for Stage I Lung Cancer Hamaji, April 2015
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LOBECTOMY VS. SBRT Incidental satellite lesion 2.66% Node
positive with negative clinical evaluation (PET) N1= 7% N2= 7%
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SBRT PROBLEMS Competitive environment Expensive equipment
Marketing done to attract patients Suggestions made that SBRT may
by the choice of treatment even in good risk patients for surgery
Look on-line at videos and ads.
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SBRT Can stereotactic fractionated radiation therapy become the
standard of care for early stage non-small cell lung carcinoma
Stereotactic body radiation therapy carries little morbidity and
provides local control comparable to lobectomy for early stage
NSCLC. Prospective studies should be performed to recruit operable
patients for SBRT to determine whether this therapy may be an
alternative option for surgery because of low complication
risks.
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LUNG CANCER TREATMENT Gray Area: 1. High risk patients 2. Lung
metastasis Problems: 1. Who defines high risk 2. Some need for
better data/science 3. Lack of accrual in prospective trials
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SBRT How do we define recurrence? Do all patients get tissue
diagnosis? Variables in dose of SBRT and techniques.
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SBRT Results worse and complications (hemoptysis, death) higher
for deeper more central tumors Challenges to surgery even for
operable early stage lung cancer
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SBRT PROGRAM/SURGEON INVOLVEMENT Even many variables for
surgery in high risk patients Arguments about who can tolerate
lobectomy Wedge +/- radiation (I , postage stamp) Segmentectomy
Other modalities (i.e. RFA, etc.)
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SURGICAL ADVANTAGE 1. Better local control (removes the cancer)
2. Better staging 3. For lobectomy, occasionally resects satellite
lesions
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WHAT SURGEONS WANT Non-surgical patient (inoperable) can only
be decided by a thoracic surgeon Multidisciplinary clinics and/or
conferences Participate in treatment planning for SBRT (if surgeon
wants) Honest longitudinal follow-up and results Best treatment for
our patients
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SBRT PROGRAM/SURGEON INVOLVEMENT All politics are local Who
controls referrals Who sees pulmonary nodules Relationship with
radiation therapy Ability to offer minimally invasive surgery with
good results
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OUR APPROACH 1. Try to maximize our exposure to lung cancer
patients early. Run pulmonary nodule clinics Work-up all patients
including their diagnostic studies 2. Establish good relationships
with our radiation therapy colleagues 3. Offer excellent surgical
results VATS procedure Careful follow-up 4. Multidisciplinary
clinics 5. Multidisciplinary conferences Discuss difficult patients
Intermittently evaluate results for surgery and SBRT 6. Patients
deemed unfit for surgery are evaluated by a surgeon