Stage 3 Lung CA Flashcards
What is Pancoast tumors also known as?
Superior sulcus tumors
What are the ways you can go about investigating the mediastinal lymph node status?
1) PET-CT
2) Endoscopic Bronchial US (EBUS)
3) endoscopic Ultrasound (EUS)
4) Cervical mediastinoscopy
5) Video-assisted Thoracoscopy (VATS) including Video-assisted mediastinal lymphadenectomy
If PET-mediastinal findings are negative, there are still some instances when invasive mediastinal staging is indicated. When are these?
1) Primary tumor >3cm large axis
2) Central tumors
3) cN1
4) CT-enlarged LN with small axis >1cm
What are the pulmonary function testing required in the assessment prior to surgery?
1) Spirometry
2) Diffusion capacity of the Lung for CO
3) Split function studies
- ESP perfusion scintigraphy
4) Exercise tests
- ESP peak oxygen consumption
What are the possible strategies in managing a pre-op Dx of Stage IIIA (N2) disease?
1) Induction chemo –> Surgery
2) Induction chemoRT –> Surgery
3) Concurrent definitive ChemoRT
Is Stage III disease = no surgery?
No.
Technically feasible for Stage IIIA, non-T4 disease if lung function permits
What is the evidence for Hyperfractionated RT?
CHART - Continuous Hyperfractionated accelerated RT
= 36# of 1.5Gy TDS = 54Gy in 12 consecutive days
Saunders Lancet 1997
Locally advanced NSCLC in whom radical RT was chosen as the definitive management
N=560
2 arms:
1) CHART
2) Conventional RT
- 30# 2Gy each = 60Gy in 6 weeks
RESULTS:
- 24% reduction in RR of death
- 2y OS 20% vs 30%
- largest benefit with Squamous cell CA (34% reduction in RR of death, with 2y OS improvement from 19% to 33%)
- Severe dysphasia occurred more often in CHART rout than in conventional RT group 19% vs 3%
What is the rationale for combining chemo and radiotherapy?
1) RT is meant to act on the main tumor bulk at the primary tumor site, chemo has an effect on systemic micro metastasis.
2) Chemo and RT may modify different tumor sub clones and combining both modalities should thus lead to an increased tumor cell death
3) Chemo and RT could potentially lead to different states of oxygenation of the tumor tissue.
- following induction chemo, the vascularization and oxygenation of residual tumor could be improved, consequently leading to a more favorable response to RT
Tell me about RTOG 9410
Curran JNCI 2011
Aim: To invx if sequential or concurrent CRT is better
N=600 3 arms: 1) CDDP (100) D1,29 Vinblastine (5mg/m2)/week X 5 weeks 60Gy RT from Day 50
2) CDDP (100) D1, 29
Vinblastine (5mg per week X 5)
60 Gy RT once daily from D1
3) CDDP 50mg/m2 D1,8,29 and 36
PO Etoposide (50mg) BD X 10 weeks on Days 1,2,5,6
RT 69.6Gy as 1.2Gy BD from D1
RESULTS:
- median survival times: 14.6m 17m and 15.6m
- 5y OS 10% vs 16% vs 13%
Tell me about the Kathy Albain Study
Kathy Albain
Lancet 2009
Aim: to compare concurrent CRT–> Resection vs concurrent CRT
N=400
T1-3pN2M0 NSCLC. 2 groups:
- Concurrent induction chemo/RT –> Surgery –> 2#
- Concurrent induction chemo/RT –> RT up to 61Gy –> 2#
Chemo = Cisplatin (50) D1,8, 29,36 + Etoposide (50) D1-5, D29-33
Results: - Median OS 24m vs 22m (p not sig) - 5y OS 27% vs 20% (p not sig) >> if N0 at Thoracoscopy, med OS 34m - PFS 12.8m vs 10.5m - 5y DFS: 20% vs 10% - main toxicities - neutropenia and oesophagitis - treatment related deaths 8% vs 2%
Tell me about the meta-analysis by Anne Apuerin re: concurrent vs sequential CRT
Lancet 2010
NSCLC Collaborative group
6 trials, 1200 patients
F/u 6 years
2 groups: concurrent versus sequential ChemoRT.
RESULT:
3y OS 6% (18% to 23%)
5y OS benefit of 4.5%
Concurrent ChemoRT decreased locoregional progression, but effect similar on distant progression
Concurrent ChemoRT increased acute esophageal toxicity from 4% to 18%, RR 4.9
No difference on acute pul toxicity
What is the PROCLAIM study about?
Vokes, Clin Lung Cancer 2009
Suresh Senan JCO 2016
Aim: Evaluate the efficacy of Pem/CDDP+RT–>consolidation Pem in Unresectable Stage IIIA/B NSCLC
No squamous histology
N=550
2 arms:
A) 3# Pem (500)/CDDP (75) q3w concurrent with TRT 60-66Gy –> Consolidated with Pemetrexed Q3w for 4#
B) 2# Etoposide (50)/CDDP (50) q4w concurrent with TRT –> 2# platinum-based doublet chemo (non Pem)
RESULTS:
Stopped early because of futility
OS 26.8m vs 25m (B) (P not sig)
A with lower incidence o drug-related G3-4 Adverse events
Some generalizations about Stage 3 staging.
All T3 and All T4 = Stage III
All N3 disease = Stage IIIB
What is the success of surgery in NSCLC dependent on?
1) Achieving anatomical resection
2) Negative margins
Is PET staging sufficient for Stage 3 Lung CA?
Sensitivity 80-90%
Specificity 85-95%
Good negative predictive value, but PPV not so good
What may not be detected on PET scan?
Tumors > 3cm
Central
cN1
CT LN 1cm only
