Download - Role of radiation in small cell lung cancer
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ROLE OF RADIATION IN SMALL CELL LUNG CANCERDr Bharti Devnani
Moderator:- Dr Sheh Rawat
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Staging of SCLC depends on radiation portals(Veteran’s administration lung group)
Limited Stage Disease confined to I/L hemithorax which
could be safely encompassed with in a tolerable RT field. T1, T2, nonmetastatic
Contralateral mediastinal and I/L SCF
Extensive stageBeyond I/L hemithorax T3,T4 and metastatic disease
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Definitive (For LS)Thoracic radiation as a part of CCRT
Adjuvant RTNode positive cases after lobectomy
Prophylactic cranial irradiation
Palliative EXRTThoracicBrain metsBone mets
Oncologic emergenciesSVCOSpinal cord compression
Palliative brachytherapyEndobronchial brachytherapy: Hemoptysis
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ROLE OF THORACIC RADIATION IN LIMITED STAGE
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EVOLUTION
Before the introduction of chemo in 1970, RT was the mainstay of treatment
CT
More local recurrences with chemo alone
CT+RT-Standarad of care
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EVIDENCE FOR THORACIC RADIOTHERAPY
25-30% reduction in the local recurrence with 5-7% increase in 2 year survival with addition of radiotherapy
Pignon et al NEJM 1992 327;1618-24
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ISSUES IN THORACIC RT OF SCLC
Sequencing with chemotherapy (concurrent v/s sequential)
Timing of RT (Early v/s late)
Portals (before chemotherapy v/s shrinking field)
Dose and fractionation schedules(conventional v/s hyperfractionation)
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ISSUES IN THORACIC RT OF SCLC
Sequencing with chemotherapy (concurrent v/s sequential)
Timing of RT (Early v/s late)
Portals (before chemotherapy v/s shrinking field)
Dose and fractionation schedules(conventional v/s hyperfractionation)
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Takada et al.J Clin Oncol 2002; 20:3054-60.
Better outcome with CCT with a trend towards improved OS.Concurrent RT reduces the risk of tumor repopulation and development of resistant clones. Radiosensitizing effect
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ISSUES IN THORACIC RT OF SCLC
Sequencing with chemotherapy (concurrent v/s sequential)
Timing of RT (Early v/s late)
Portals (before chemotherapy v/s shrinking field)
Dose and fractionation schedules(conventional v/s hyperfractionation)
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Benefit in 2 year survival rate with early RT(within 9 weeks or before 3rd cycle)
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Factors which have significant impact on the benefit of early RT were:-
Type of chemotherapy The fractionation scheme
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Concept of SER
Start of any treatment until the end of radiotherapy
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Cancer Treat Rev 2007; 33:461-73.
Significant 2 & 5 years improvement in survival when RT was started within 30 days of platinum based chemo (2-year survival: HR: 0.73, 5-year survival: HR: 0.65).
This was even more pronounced when the overall treatment time of chest radiotherapy was less than 30 days.
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Early and concurrent chemoradiation is preferred over late and sequential schedule.
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ISSUES IN THORACIC RT OF SCLC
Sequencing with chemotherapy (concurrent v/s sequential)
Timing of RT (Early v/s late)
Dose and fractionation schedules (conventional v/s hyperfractionation)
Portals (before chemotherapy v/s shrinking field)
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High chances of local recurrence with conventional RT, attempts made to improve the outcome by:-
Hyperfractionated Accelerated
radiotherapy Dose escalation
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417 patients LS-SCLC
45 Gy at 1.5 Gy/#B.D.x3week
s
45 Gy/25# at 1.8 Gy/# x5 weeks
Grade -3 Esophagitis
(27%v/s 11%)P<0.001
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ONGOING TRIALS (HYPERFRACTIONATION & DOSE ESCALATION)
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ISSUES IN THORACIC RT OF SCLC
Sequencing with chemotherapy (concurrent v/s sequential)
Timing of RT (Early v/s late)
Dose and fractionation schedules(conventional v/s hyperfractionation)
Portals (before chemotherapy v/s shrinking field)
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RT PORTALS
PET based planning should be used. (PET at the time of radiotherapy planning or within 4 weeks)
GTV = Post induction chemotherapy volume
Omission of elective nodal irradition.
Low rates of local recurrence(11% with only CT based planning, 3 % with PET based planning)
Decreases the esophageal toxicity significantly.
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ROLE OF THORACIC RT IN EXTENSIVE STAGE
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CR at distant sites and any response at
local site (n=210)
CT+
RT= 54 Gy/36#
CT alone
Median survival-17 months v/s 11 monthsSurvival rate at 3 years-22% v/s 13%Survival rate at 5 years-9% v/s 4%
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PROPHYLACTIC CRANIAL IRRADIATION
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Rationale Frequent brain mets in SCLC
20 %- at diagnosis
80%- during the course of the disease
Once symptomatic- results have been poor.
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Incidence of brain metastasis decreased by 25% at 3 years (58.6% v/s 33.3%)
5.4 % survival benefit with addition of PCI
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PCI IN EXTENSIVE STAGE DISEASE
14.6 % v/s 40.4%
27.1% v/s 13.3% at 1 yr
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DOSE OF PCI
Limited stage25 Gy/10#24 Gy/8#30Gy/15#Extensive stage25 Gy/10#Shorter fractionation scheme of 20 Gy/5# can
be used.
Dose>30 Gy should be avoided due to high risk of neurotoxicity
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ROLE OF RT IN ADJUVANT SETTING
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ROLE OF RT IN PALLIATION (EXRT)
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RADIATION FOR BRAIN METASTASIS
WBRT- 30Gy/10#
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BONE METS & PATHOLOGICAL FRACTURE
30 Gy/10#
20Gy/5#
24Gy/6#
8 Gy single fraction
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ROLE OF RADIATION IN ONCOLOGIC EMERGENCIES IN SCLC
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SPINAL CORD COMPRESSION
30Gy/10#
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SUPERIOR VENA CAVA OBSTRUCTION
Symptomatic relief in 70-90% cases with radiotherapy alone.
Dose- initial high dose fractionation of 3- 4 Gy followed by 1.8 Gy fractionation
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ROLE OF ENDOBRONCIAL BRACHYTHERAPY - HEMOPTYSIS
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TAKE HOME MESSAGE
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LS-SCLCConcurrent CCT/RTEarly(1st or 2nd cycle)Dose-45 Gy @1.5 Gy bd or 50-60 Gy @1.8 Gy once
dailyAny response to chemo-PCI to a dose of 25 Gy/10#
ES-SCLCAny response to chemo- PCI-25 Gy/10# or shorter 20
Gy/5# can be used.Possible value of local RT are the subject of ongoing
investigation.
Palliation
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Thank U
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Santa air hostess se-aapki shakal meri biwi se milti hai
Air hostess ne zordar thappad santa k muh pe mara
Santa- Kamal hai, Aadat bhi milti hai
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Very Touchy story:"Husband forgot to wish her on his Wife's birthday.
He came home late at night from the office .....His wife shouted: How would u feel if u dont see
me for next few days?He couldnt believe his luck. He replied at once.''
Wowww.....That would be great..!''Monday passed & he didn't see her. Tuesday he didnt see her
.
.& wednesday passed too
.
.On Thursday the swelling was better & he could
see her from the corner of his left eye...