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NON-SMALL CELL LUNG CANCER 2006 RADIOTHERAPY

NON-SMALL CELL LUNG CANCER 2006 RADIOTHERAPY. Prof Dr Serdar ÖZKÖK Ege University Medical School Department of Radiation Oncology. Stage I-II NSCLC. Postoperative RT Curative RT. PORT Meta-analysis (PORT Meta-analysis Trialist Group; Lancet 1998; 352;9124: 257).

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NON-SMALL CELL LUNG CANCER 2006 RADIOTHERAPY

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  1. NON-SMALL CELL LUNG CANCER 2006 RADIOTHERAPY Prof Dr Serdar ÖZKÖK Ege University Medical School Department of Radiation Oncology

  2. Stage I-II NSCLC • Postoperative RT • Curative RT

  3. PORT Meta-analysis(PORT Meta-analysis Trialist Group; Lancet 1998; 352;9124: 257)

  4. PORT Meta-Analysis Criticism • 26% of the cases were stage I. • There wasn’t enough information about mediastinal lymph node dissection. • KPS was evaluated only in three trials. • Nonpublished trials were included.

  5. PORT Meta-Analysis Criticism • Concerns about RT techniques • Treating with Co 60 • Wide RT portals • Insufficient total RT dose • High fractionation dose • BED values were not calculated • No 3-D Planning

  6. PORT • (+) Surgical margin • Insufficient surgery • Parietal Pleura Invasion • N2 • N1 (High risk of local recurrence)

  7. Curative Radiotherapy in Stage I-II NSCLC • 2-D Radiotherapy (60-66 Gy) • 3-D Conformal RT (66 Gy ) • Stereotactic RT

  8. STEREOTACTIC RADIOTERAPY Hypofractionated 3-D RT for small target volumes Immobilisation is important

  9. Hypofractionated SRT for Lung Tumors Advantages 1- Shortened Treatment Course 2- Adoption of a smaller irradiated volume Disadvantages 1- Uncertain effects of altered fractionation

  10. 4 Fx, 4-10 noncoplanar RT portals • 45 patients ( 22 of them were Stage IA and 13 of them were Stage IB) • Complete response: 16%, Partial response: 84%

  11. ASCO 2005

  12. Stage 3-A • Surgery ? • Chemoradiotherapy ?

  13. Phase III Study of Concurrent Chemotherapy and Radiotherapy (CT/RT) versus CT/RT followed by Surgical Resection for Stage IIIA(pN2) NSCLC RTOG (chair), SWOG, NCIC CTG, ECOG, CALGB and NCCTG Outcomes Update of North American Intergroup Trial 0139 (R9309)

  14. Lung Intergroup Trial 0139 Stratification KPS 70-80 vs 90-100 T1 vs T2 vs T3 RANDOMISATION Cisplatin, 50 mg/m2 IV d1, 8, 29, 36 Etoposide, 50mg/m2 IV d1-5, 29-33 Thoracic RT, 45 Gy(1.8 Gy/d), d1 InductionKT/RT Re-evaluation Re-evaluation 2-4 months after RT 7 days before completion of RT

  15. Lung Intergroup Trial 0139 No Progression Continuation of RT without interruption Surgery Consolidation cisplatin - etoposide X 2

  16. Intergroup 0139 • T1-3,pN2,Mo, technically resectable, 429 patients • Median Follow-up 81 months • Thoracotomy 81%, Complete resection 71% • ToNo: 15% - No: 38% • DFS: 12.8 vs 10.5 months • OS: 23.6 vs 22.2 months

  17. Trial Design

  18. EORTC 08941 • Pathological N2, technically unresectable • Induction CT to 579 patients, Randomisation of 332 patients • Response rates 62% • Complete resection 50%

  19. Stage 3-A • Chemoradiotherapy for: multiple positive lymph node stations, capsulery invasion, Bulky N2 Pneumonectomy

  20. Stage 3-B • Radiotherapy is standard • Chemoradiotherapy for high performance status patients • Sequentially • Concurrent (Eşzamanlı) • Radiotherapy after induction CT • Concurrent CRT after induction CT • Consolidation after concurrent CRT

  21. Concurrent vs SequentialChemoradiotherapy Concurrent Sequential No.of patients 156 158 Toxicity 8.9% 5% Response 84% 66% MS(months) 16.5* 13.3 5 year Surv. 16% 9% p<0.05 CT:MVP (Mitomycin, Vindesine, Cisplatin) RT: Split Course Furuse K. J. Clin Oncol 1999; 17: 2692

  22. RTOG 9410: Sequential vs Concurrent Sequential Concurrent Conc.(HFRT) MS 14.6 17* 15.6 Non-Hem. Tox. (Gr 3-4) 30% 48% 62**% Local Rec. 38% 33% 25**% *p= 0.038 **p < 0.05 Curran: ASCO, 2003

  23. Combined Chemoradiotherapy Regimens of Paclitaxel and Carboplatin for Locally Advanced Non–Small-Cell Lung Cancer: A Randomized Phase II Locally Advanced Multi-Modality Protocol Chandra P. Belani, Journal of Clinical Oncology, Vol 23, No 25 (September 1), 2005: pp. 5883-5891

  24. Chemoradiotherapy for Locally Advanced NSCLC • Chemoradiotherapy is the standard treatment. • In patients <70 year old and weight loss less than 5 –10%, KPS 70% and above • Concurrent chemoradiotherapy can be applied in experienced radiation oncology clinics in a multidisciplinary manner. In other cases the treatment is radiotherapy

  25. 3 D Conformal Treatment Planning • Doses above 70 Gy could not be delivered with standard RT. • With conformal RT: • Doses above 70 Gy can be achieved. (better survival with doses above 79 Gy) • Irradiated Lung Volume • Critical organ doses

  26. GTV • Primary tumor • Nodal diameter above 1 cm or nodes revealed by PET

  27. Prophylactic Mediastinal RT ? Isolated Lymph Node Recurrence 0 – 10% Hayman JA, JClinOncol 19:2001 Bradley J, Int J Radiat Oncol Biol 318-328- 2005

  28. PET • To be involved in RT Planning

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