Download Role of radiotherapy in locally advanced lung cancer

Radiotherapy in locally advanced &
metastatic NSC lung cancer
Dr Raj Hegde. MD. FRANZCR
Consultant Radiation Oncologist.
William Buckland Radiotherapy Centre.
Latrobe Regional Hospital.
Locally advanced lung cancer
►Results of randomised trail indicate the chemo
radiotherapy is the standard care of locally
advanced lung cancer.
►Fatal toxicity uncommon after CT-RT but
morbidity can be high in unselected cases.
►Local control is suboptimal
►New RT techniques permit improved local control
WBRG/LRH work load. (2013-2014)
WBRG/ LRH
Stage III Lung cancer
Treatment of stage III NSCLC remains a very difficult
and controversial area mainly because of the large
heterogeneity of different pathological conditions
that are still included in stage III disease.
Outcomes of stage III NSCLC in
1990. 2D RT
Treatment Arms
Median survival
5 years survival
Standard RT
60Gy/30Fr. 1 Fr/day
11.4 months
5%
Hyperfractionated RT
69.9Gy 2 Fr /day
12 months
6%
Sequential CT-RT
CisPla VBL +60Gy
13.2 months
8%
Concurrent chemo RT
Median survival in phase three trials of Chemo RT
22.2 months Albain 2005.
17.79 months Curan 2002, Movsas 2005
Concurrent or sequential RT
►Concurrent CT-RT reduces the risk of death at 2
years.
►(RR 0.8:,95 CI 0.78 to 0.95: P=.003) but at the
expense of increased toxicity)
►Choice of optimal CT regime remains unclear.
►Uncertainties about true magnitude of benefit for
concurrent CT RT.
Advances in Radiotherapy planning
Advanced technology.
►Improved the staging
►Improved the compliance to treatment
►Reduced the toxicity
►Marginal improvement in overall survival
Stage IIIA
Groups
►T1a,b T2a, b
►T3 N1,2
►T4 N0 N1
Early stage and locally advanced (non-metastatic)
non-small-cell lung cancer.
Treatment Protocols
►One size does not fit all.
Selection of stage IIIA patients for radical
treatment
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Age ideally <80
Performance status. ECOG 1-2
No severe obstructive airway disease
Not more than 10% body weight loss.
Ideally less than 5 cm primary tumour
Ideally 1-2 mediastinal nodal sites are involved.
Less than 5cm distance between primary and nodal metastasis.
Normal tissue tolerance
Lung tolerance
V20 <30%
V30<20%
Mean lung dose <15Gy
Spinal cord <45 Gy
Oesophagus <11 cm
Heart V40 < 35Gy
Clinical scenario 1
PET
►84 year old male with
bad COPD.
►medically inoperable Ad
Ca lung T1N2 disease
Stereotactic radiotherapy
.
Bulky Primary disease
PET
Findings
►44 year man with bulky
primary disease invading
the mediastinum.
►Ad Ca
T4N2 M0.
Response
Clinical Scenario 3
67 year old fit asymptomatic lady
presented with bulky T2N2 MO
NSCLC
Treatment options
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Discussed in MDM ( Deemed inoperable)
Radical chemo radiotherapy
Induction chemo followed by radical RT
Palliative Chemo
Surgery Stage III disease
Surgery stage III disease
Yes we can burn that tumour –
Role of Radiation Oncologist with locally advanced and metastatic
lung cancer
Yes we can…
Treatment plan
Response
Role of induction chemotherapy prior to concurrent treatment
Cancer and Leukemia Group B 39801,
Cancer and Leukemia Group B
39801,
Induction Chemo + CRT
CRT
Median Survival
14months (95%CI 11 to16
months)
12 months (95%CI 10 to16
months
2 year survival
31months(95% CI 25 to 38%) 29 months(95% CI 22 to
35%)
Toxicity Gr 3 & 4
28 &8%
30& 2%
Role of induction chemotherapy prior to concurrent chemo RT
J Clin Oncol. 2007 May 1;25(13):1698-704
.
Neo adjuvant
Response after induction Chemo.
Response after induction Chemo
Complications
Late
►Radiation Pneumonitis.
► Radiation fibrosis of the
lung,
► oesophageal stricture.
►Radiation mylities.
Early
►Tiredness,
►Acute exacerbation
symptoms,
► odynophagia
Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer
Conclusion
► Among patients with metastatic nonsmall-cell lung cancer, early palliative
care led to significant improvements in
both quality of life and mood. As
compared with patients receiving
standard care, patients receiving early
palliative care had less aggressive care
at the end of life but longer survival.
Palliative radiotherapy
Radiotherapy plays an important role in palliative
medicine.
Around 20- 25% of patients are on palliative
treatment at any time in any Radiation Oncology
Dept.
Indication
►Pain relief from bone mets.
►Prevention of pathological #
►Spinal cord compression.
►Impending or actual obstruction hollow viscera.
►Brain mets.
►Control of Haemoptysis.
►Superior Vena caval obstruction.
Spinal cord compression
These are common symptoms:
► Pain and stiffness in the neck, back, or lower
back
► Numbness, cramping, or weakness in the
arms, hands, or legs
► Loss of sensation
► Difficulty with hand coordination
► "Foot drop," weakness in a foot that causes a
limp
► Loss of sexual ability
► Loss of bladder/ bowel control.
Spinal cord compression
Poor prognostic factors
►Complete paraplegia.
►Loss of Sphincter control.
►Rapid onset of symptoms ( Infarction).
Immediate action
►Dexamethasone tablets 8 mag start followed by 4
mg BD.
►Urgent MRI (If the facilities are available)
►Immediate referral to a tertiary hospital.
►Early treatment intervention likely to improve the
out come.
Metastatic Spinal cord
compression.
Superior Vena Caval Obstruction
Management
► High dose corticosteroids.
► Radiotherapy to the mediastinum.
► Superior Venacaval stenting.
► Chemotherapy (Sensitive tumors
like - Lymphomas, Small cell lung
cancer, Seminomas, Round cell
tumor
Brain Metastasis
Management- Solitary Brain Metastasis(Confirmed after an MRI scan)
►Good performance status
►Controlled extra cranial disease
►Peripheral lesions
►No significant co. morbid conditions,
Surgical excision could be an option
Brain Mets (Multiple )
Treatment
►Surgical excision of the
largest lesion improves
neurological deficit and
quality of life.
►Followed by whole brain
palliative radiotherapy.
Brain MetastasisRadiotherapy
►Palliative whole brain Radiotherapy.
►Stereotactic Radiotherapy for a solitary or couple
of lesions.
►Radiotherapy to the whole brain following
excision of the solitary lesion.
Stereotactic Radiosurgery
Bone Metastasis
►Pain
►Hypercalcemia
►Pathological #
►Spinal cord compression
Pathological Fracture
when > 50% of the cortex is destroyed, the fracture rate increases up
to 80%
Pathological #
►Needs Surgical fixation before Radiotherapy.
At MDM we make Taylor made outfits.
►Thank you.