Surgery vs SBRT vs RFA November 16 2012 Ramesh Rengan MD PhD Chief Thoracic Service Assistant Director of Clinical Operations Department of Radiation Oncology DISCLOSURES Speaker Honoraria ID: 485597
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Slide1
Approaching early stage disease
Surgery vs SBRT vs RFA
November 16, 2012
Ramesh Rengan MD PhD
Chief, Thoracic Service
Assistant Director of Clinical Operations
Department of Radiation OncologySlide2
DISCLOSURES
Speaker Honoraria
Philips HealthcareSlide3
Introduction: The Scope of the Problem
213,380 patients are diagnosed yearly with lung cancer in the US with approximately 160,390 deathsSlide4
What is “Early Stage” Disease?
Technically
resectable disease without evidence of mediastinal involvement
IA
T1N0M0
IB
T2aN0M0
IIA
T2bN0M0
T1N1M0
T2aN1M0
IIB
T2bN1M0
T3N0M0Slide5
Prognosis
5yr OS
Stage IA
75%
Stage IB
55%
Stage IIA
50%
Stage IIB
40%
Stage IIIA
10-35%
Stage IIIB
5-8%
Stage IV
<5%Slide6
Medical Operability
2007 ACCP
Guidelines
Age alone is not a reason to deny resection.
Operative mortality for a lobectomy:
~2% for age < 60, ~8% for age > 70
General targets:
FEV1 > 1.5L
FEV1 > 80% pred
DLCO > 60-80%
pred
Danger signs:
FEV1 or DLCO < 40% predicted
FEV1/FVC < 50%
PCO2 > 50mmHg
Cor pulmonale
VO2 < 15cc/kg/min
Or, ability to walk 1 flight of stairsSlide7
Treatment for Early Stage
Operable Disease
Lobectomy
+
Mediastinal
LND or LNS
Remains current standard of care
ACOSOG Z0030
With appropriate pt selection,
periop
mortality rates are low
Pneumonectomy
5%
Lobectomy
1-3%
Smaller Resections < 1%Slide8
Treatment for Early Stage
Operable Disease: ACOSOG Z0030
1111 patients enrolled; 1023 randomizedExtensive MLNS followed by observation
vs
MLND
No difference in overall survival
Darling et al J Thoracic and CV Surgery, 2011Slide9
Treatment for Early Stage
Operable
Disease: Is there a lumpectomy for the lung?Slide10
LCSG showed trend towards increased likelihood of death with limited resection
LCSG showed three-fold increase in local failure with wedge resection vs. lobectomy
Treatment for Early Stage
Operable
Disease: Is there a lumpectomy for the lung?Slide11
Cor
pulmonale
Severe coronary artery diseaseRenal failurePoor pulmonary function DLCO <50%
FEV1/FVC ratio < 50 – 75% of predicted
Impaired nutritional status
Medically Inoperable Early Stage:
Role
of RTSlide12
Study
Author
n
Dose (Gy)
5-yr survival
5-yr CSS
5-yr local
Dosoretz
152
60-69
10%
Krol
108
60-65
15%
31%
25%
Kaskowitz
53
63
6%
13%
0%
Sibley
141
55-70
13%
Rosenzweig
32
70.2
33%
39%
43%
Medically Inoperable Early Stage: Role of RTSlide13
Medically Inoperable Early
Stage: SBRT
Nyman et al Lung Cancer 2006Slide14
Fractionation Options
Conventionally fractionated
radiotherapy
- small daily doses
- go to very high cumulative doses
Ablative
radiotherapy
- very high daily doses (8-20
Gy
)
- overwhelm tumor repair
- causes “late” effects that may be intolerableSlide15
Dose Fractionation: Implications for Tumor Control
10
0
2
4
6 8
Survival
Dose (Gy)
10
-1
10
-2
single
fraction
multiple 2 Gy
fractionsSlide16
Early Stage Disease: Stereotactic Body Radiation Therapy
Pretreatment
6-weeks Post-treatmentSlide17
Medically Inoperable Early
Stage: SBRT
Author
# of Patients
Local Control
Overall Survival
Onishi et al.
245
85%
56% (3-yr)
Timmerman
70
98%
55% (2-yr)
Nyman
45
80%
71% (2-yr)
Baumann
57
92%
60% (3-yr)
Nagata
31
98%
79% (2-yr)
Uematsu
50
94%
66% (3-yr)
Koto
31
78%
72% (3-yr)
Fakiris
70
88%
43% (3-yr)Slide18
Dose Fractionation: Implications for Tumor Control
10
0
2
4
6 8
Survival
Dose (Gy)
10
-1
10
-2
single
fraction
multiple 2 Gy
fractionsSlide19
p = 0.003
Medically Inoperable Early
Stage: Toxicity of SBRT
Corradetti et al NEJM 2012
JCO 2006
RTOG 0813 is currently accruing
Would not treat centrally located tumors with SBRT off-protocol
Standard of care for peripheral medically inoperable NSCLCSlide20
SBRT: Emerging toxicity dataSlide21
Treatment of Early Stage Inoperable Disease: RFASlide22
Treatment of Early Stage Inoperable Disease: RFA
Multicenter prospective trial of 106 patients with 183 lung tumors
33 patients with NSCLC
48% 2-year survival
73% 2-year CSS
10%
pneumothorax
rate
Median hospital stay 3 days
Lancioni
Lancet
Oncol
2008Slide23
RFA: Emerging toxicity dataSlide24
Early Stage NSCLC
: Conclusions
NCCN Guidelines,
2012
Lobectomy
+ MLNS or MLND
With adjuvant chemotherapy
+/- RT in high risk casesSlide25