Please note, these are the actual video-recorded proceedings from the live CME event and may include...
Download
1 / 30

Case History - PowerPoint PPT Presentation


  • 69 Views
  • Uploaded on

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Case History' - ferrol


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

Please note, these are the actual video-recorded proceedings from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.


Case history
Case History from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

84-year-old with poor pulmonary function, smoking history, and recent thromboembolic event

Underwent serial CT scans with these findings


CP1066773-47 from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.


Case history1
Case History from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

PET Positive there at SUV 10.1

OK elsewhere

FNA performed: Result C/W NSCLC

Patient considered unsuitable for lobectomy due to co-morbidities


Treatment options
Treatment Options from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

1. Observation?

2. Wedge Resection (VATS or Not)?

3. Radiofrequency Ablation?

4. Systemic Therapy?

Chemo or Oral TKI?

5. Radiosurgical Ablation?


Subsequent course
Subsequent Course from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

The patient received SBRT at 18 Gy times 3 without difficulty. On six -month follow-up, CT chest revealed a new moderate-sized ipsilateral pleural effusion and “scarring” at the primary tumor.


Final question
Final Question from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

This pleural effusion should be:

Tapped

Drained and Treated

Evaluated with PET

Evaluated with Thoracoscopy

Treated with Chemotherapy


Stereotactic rt in early stage lung cancer current and future applications
Stereotactic RT in Early Stage Lung Cancer from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.Current and Future Applications???

Walter J Curran, Jr, MD

Executive Director

Winship Cancer Institute of Emory University

Group Chairman

Radiation Therapy Oncology Group


Technology enabling sbrt
Technology Enabling SBRT from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.


What is sbrt
What is SBRT? from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

Potentially highly effective

Potentially extremely dangerous


Rt fractionation options
RT Fractionation Options from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

  • Conventionally Fractionated RT - small daily doses - go to very high cumulative doses - tolerable for most normal tissues

  • Hypofractionated RT - larger daily doses (3-8 Gy) - used mostly for palliation

  • Ablative RT (Stereotactic) - very high daily doses (8-20 Gy) - overwhelm tumor repair - causes “late” effects that may be intolerable


Ablative treatments stereotactic must exclude normal tissue
Ablative Treatments (Stereotactic) from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.Must Exclude Normal Tissue

  • Requirements for ablative hypofractionation:

    • Abandon prophylactic treatment

    • Account for organ motion

    • Achieve sharper dose fall-off gradients to normal tissue (mimic radiosurgery)

  • These requirements need advanced technology


Phase i dose response for local control
Phase I Dose Response for from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.Local Control


First North American cooperative group trial testing SBRT from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

Non-small cell lung cancer - biopsy proven

T1, T2 ( 5 cm) and T3 (chest wall only,  5 cm), N0, M0

Medical problems precluding surgery(e.g. emphysema, heart disease, diabetes)

No other planned therapy

:RTOG 0236

Robert Timmerman, MD; Rebecca Paulus, BS; James Galvin, PhD; Jeffrey Michalski, MD; William Straube, PhD; Jeffrey Bradley, MD; Achilles Fakiris, MD; Andrea Bezjak, MD; Gregory Videtic, MD;David Johnstone, MD; Jack Fowler, PhD; Elizabeth Gore, MD; Hak Choy, MD 


Compact Dose Deposition from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

Pulmonary Vein

Bronchus

Lung

Esophagus

Chestwall

Cord

Skin


Local Tumor Control Rate: from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.RTOG 0236

  • 1 failure within PTV, 0 within 1 cm of PTV

  • 36 months local control = 98% (CI: 84 -100%)


Regional and Disseminated Recurrence: RTOG 0236 from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

  • 2 patients have reported a regional failure, both after 2 years (2.8 and 3.0 years)

  • Eleven patients (20%) have experienced disseminated failure


Rtog 0236 best observed response
RTOG 0236 : Best Observed Response from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.


Post-SBRT Treatment Lung Reaction from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.


Grade 3-5 Toxicity: Location, Location from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.


Other rtog phase i ii trials sbrt
Other RTOG Phase I/II Trials SBRT from the live CME event and may include the use of trade names and other raw, unedited content. Select slides from the original presentation are omitted where Research To Practice was unable to obtain permission from the publication source and/or author. Links to view the actual reference materials have been provided for your use in place of any omitted slides.

  • RTOG 0618: SBRT for Operable Stage I NSCLC: Accrual complete

  • RTOG 0813: SBRT for Central Early Stage NSCLC: Nearly done

Future Plans


Japanese Pooled Retrospective Experience with SBRT in OPERABLE Patients

  • Stage IA (n=63), 5y OS 75% (95% CI 63-87%)

  • Stage IB (n=24), 5y OS 70% (95% CI 49-90%)


Legitimate alternative to lobectomy for stage i nsclc
Legitimate Alternative to Lobectomy for Stage I NSCLC?????? OPERABLE Patients

  • Requirements:

  • Local control 90% or more at 5 years (actuarial)

  • Survival 60-80% at 5 years (actuarial)

  • Grade III or higher toxicity <15-20%

  • Ideally less invasive than thoracotomy

  • Ideally more convenient

  • Ideally less costly

  • All proven by prospective testing


Phase III Study of Sublobar Resection (SR) versus SBRT in High Risk Patients with Stage I NSCLCZ4099 / R1021

  • Joint Trial between ACOSOG and RTOG

  • To ascertain whether patients treated by SBRT have 3-year overall survival (OS) rate that is no more than 10% less than patients treated with Surgery.


Phase III Study of Sublobar Resection versus SBRT in High Risk Patients with Stage I NSCLCZ4099 / R1021


Phase iii study of surgery vs sbrt in high risk pts with stage i nsclc z4099 r1021
Phase III Study of Surgery vs SBRT in Risk Patients with Stage I NSCLCHigh Risk Pts with Stage I NSCLC: Z4099 / R1021

  • Non-Inferiority Survival Design: 80% +/-10%

  • 420 Pts to be Enrolled

  • Activated 3/11

  • Brachytherapy with Sublobar Resection


What is the real debate question
What is the Real Debate Question? Risk Patients with Stage I NSCLC

  • Are American Docs Disciplined Enough to Enroll and Randomize Patients into this Surgery vs SBRT Trial?

  • Historic Record is Spotty

  • Likely Possible at Lower Velocity than Projected

  • NCI Early Stopping Rules will be an Issue!


Summary
Summary Risk Patients with Stage I NSCLC

  • SBRT is a new Standard for Medically Inoperable Stage I NSCLC

  • Operable Patients: Data from Phase II and Phase III Trials Necessary

  • Central Lesions: Data on RT Dose Pending


Sunday february 12 2012 hollywood florida

Sunday, February 12, 2012 Risk Patients with Stage I NSCLCHollywood, Florida

Co-Chairs

Rogerio C Lilenbaum, MD

Mark A Socinski, MD

Co-Chair and Moderator

Neil Love, MD

Faculty

Walter J Curran Jr, MD

David Jablons, MD

Mark G Kris, MD

Suresh Ramalingam, MD

Alan B Sandler, MD


ad