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Non–Small-Cell Lung Cancer Diagnosis and Staging

Non–Small-Cell Lung Cancer Diagnosis and Staging. Evaluation Purpose Physical examination Identify signs Chest x-ray Determine position, size, number of tumors Bronchoscopy Determine location of tumor, obtain biopsy Fine-needle aspiration Cytology

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Non–Small-Cell Lung Cancer Diagnosis and Staging

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  1. Non–Small-Cell Lung Cancer Diagnosis and Staging Evaluation Purpose Physical examination Identify signs Chest x-ray Determine position, size, number of tumors Bronchoscopy Determine location of tumor, obtain biopsy Fine-needle aspiration Cytology CT scan Identify chest-wall invasion, mediastinal lymphadenopathy, distant metastases PET scan Mediastinal, lymph-node and extrathoracic staging Laboratory analysis Detect changes in hormone production, and hematologic manifestations of lung cancer Mediastinoscopy Visualize and sample mediastinal lymph nodes

  2. TNM Staging of Non–Small-Cell Lung Cancer T = primary tumor; N = nodal involvement; M = distant metastasis. Mountain CF. Chest. 1997;111:1710.

  3. TNM Staging of Non–Small-Cell Lung Cancer T = primary tumor; N = nodal involvement; M = distant metastasis. Mountain CF. Chest. 1997;111:1710.

  4. Overview of NSCLC Treatment Options Early-stage tumor • Surgery • Radiation for inoperable patients Locally advanced tumor • Surgery • Chemoradiation • Surgery + chemoradiation Advanced tumor • Chemotherapy • Targeted therapy • Chemotherapy + targeted therapy NCCN Clinical Practice Guidelines in Oncology. NSCLC. V.I.2007. Available at: http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Accessed May 18, 2007.

  5. Postoperative RT 30–60 Gy; diverse planning Survival data on 2128 patients PORT 21% increase in risk of death Hazard ratio = 1.21P = .001 0 0.5 1.0 1.5 2.0 PORT better No PORT better Postoperative Radiation Therapy in NSCLC Systematic Review and Meta-analysis of 9 Randomized Controlled Studies No. Events/No. Entered Hazard ratio Trial PORT No PORT O-E Variance Belgium 88/98 80/104 16.04 40.67 LCSG 773 84/110 81/120 4.77 41.02 CAMS 83/153 100/164 1.07 44.88 Lille 59/81 45/82 10.87 25.66 EORTC 08861 26/52 20/54 5.53 11.20 MRC LU11 116/154 123/154 -2.48 59.39 GETCB 04CB86 69/99 59/90 4.95 31.59 Slovenia 30/35 33/39 -2.56 15.63 GETCB 05CB88 152/274 120/265 25.13 67.08 Total 707/1056 661/1072 63.33 337.12 PORT Meta-analysis Trialists Group. Lancet. 1998;352:257-263, with permission from Elsevier.

  6. ANITA1: Evaluation of PORT in Patients With Node-Positive Disease 5 Year-Survival According to N Stage 232/840 received radiation after chemotherapy or surgery Doulliard J-Y, et al. Int J Radiat Oncol. 2006;66:S2. Courtesy of Dr. Doulliard.

  7. PORT for Stage II or III NSCLC (SEER Database) Multivariate Analysis Overall Survival Disease-Specific Survival HR 95% Cl P HR 95% Cl P 1.176 1.005–1.376 .0435 1.361 1.134–1.633 .00091.00 (Ref) 1.00 (Ref) 1.097 1.015–1.186 .0196 1.082 0.990–1.182 .08221.00 (Ref) 1.00 (Ref) 0.855 0.762–0.959 .0077 0.850 0.748–0.967 .01331.00 (Ref) 1.00 (Ref) Nodal Stage N0 Radiotherapy Observation N1 Radiotherapy Observation N2 Radiotherapy Observation N = 7465; Hazard ratio (HR) <1 = improved overall survival. Conclusion In a population-based cohort, PORT use is associated with an increase in survival in patients with N2 nodal disease but not in patients with N1 and N0 nodal disease. Lally BE, et al. J Clin Oncol. 2006;24:2998-3006. Reprinted with permission from the American Society of Clinical Oncology.

  8. Phase III Trial of Chemoradiation ± Surgery in Stage IIIA pN2 Patients (INT 0139) INDUCTION CHEMORADIOTHERAPY Cisplatin 50 mg/m2 IV days 1, 8, 29, 36 + etoposide 50 mg/m2 IV days 1–5, 29–33 (PE) + RT to 45 Gy starting day 1 Resection if no progression, then PE x 2 (n = 202) Complete chemoradiotherapy to 61 Gy with PE x 2 (n = 194) 23.6 CT/RT/S CT/RT 22.2 25 20 12.8 15 10.5 Months 10 5-y PFS 22.4% 11.1% 5-y OS 27.2% 20.3% 5 0 Median PFS Median OS P = .017 HR 0.77 (0.62–0.96) P = .24 HR 0.87 (0.70–1.10) Albain KS, et al. J Clin Oncol. 2005;23:16S. Abstract 7014.

  9. INT 0139: Overall Survival of the Lobectomy Subset vs Matched CT/RT Subset 100 Deceased/Total CT/RT/S57/90 CT/RT74/90 75 Overall Survival (%) P = .002 / / / 50 / / / / CT/RT/S / / / / / / / / / / / 25 / / / CT/RT / / CT/RT/S CT/RT Median survival 34 mo 22 mo 5-y OS 36% 18% 0 0 12 24 36 48 60 Months from Randomization Albain KS, et al. J Clin Oncol. 2005;23:16S. Abstract 7014. Courtesy of Dr. K. Albain.

  10. Survival Comparison—Chemoradiation Sequencing 30 WJLCG 1 2 RTOG 9410 25 3 CALGB 39801 20 BROCAT 4 5 LAMP Median Overall Survival (%) 15 GLOT 6 7 CZECH 10 8 SWOG 9504 5 9 RTOG 9801C 9 RTOG 9801A 0 10 Concurrent CALGB 30105A Concurrent-Consolidation Sequential Induction- 10 Concurrent CALGB 30105B 1. Tada T, et al. Radiat Med. 2004;22:163. 2. Curran WJ, et al. Proc Am Soc Clin Oncol. 2003;22:621. Abstract 2499. 3. Vokes EE, et al. J Clin Oncol. 2004;22(suppl):7005. 4. Huber RM, et al. J Clin Oncol. 2006;24:4397. 5. Choy H, et al. Proc Am Soc Clin Oncol. 2002;21:1160. 6. Gournel P, et al. J Clin Oncol. 2005;23:5910. 7. Zatloukal P, et al. Lung Cancer. 2004;46:87. 8. Gandara DR, et al. Clin Lung Cancer. 2006;8:116. 9. Movsas B, et al. J Clin Oncol. 2005;23:2145. 10. Blackstock AW, et al. J Clin Oncol. 2006;24(suppl):7042.

  11. Chemoradiotherapy InductionCisplatin 50 mg/m2 days 1, 8, 29, 36Etoposide 50 mg/m2 IV days 1–5, 29–33Concurrent RT 59.4 Gy (1.8 Gy/d) Confirmation of Consolidation Chemotherapy in Unresectable Stage III NSCLC Hoosier Oncology Group (LUN01-24) Complete Response, Partial Response, or Stable DiseaseECOG PS 0–1 Randomize Docetaxel 75 mg/m2every 3 weeks  3 Observation http://www.clinicaltrials.gov/ct/show/NCT00216125?order=1

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