approaching early stage disease
DESCRIPTION
Approaching early stage disease. Surgery vs SBRT vs RFA. Ramesh Rengan MD PhD Chief, Thoracic Service Assistant Director of Clinical Operations Department of Radiation Oncology. November 16, 2012. DISCLOSURES. Speaker Honoraria Philips Healthcare. - PowerPoint PPT PresentationTRANSCRIPT
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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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