Radiotherapy in locally advanced & metastatic NSC lung cancer

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1 Radiotherapy in locally advanced & metastatic NSC lung cancer Dr Raj Hegde. MD. FRANZCR Consultant Radiation Oncologist. William Buckland Radiotherapy Centre. Latrobe Regional Hospital.

2 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

3 WBRG/LRH work load. ( )

4 WBRG/ LRH

5 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.

6 Outcomes of stage III NSCLC in D 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%

7 Concurrent chemo RT Median survival in phase three trials of Chemo RT 22.2 months Albain months Curan 2002, Movsas 2005

8 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.

9 Advances in Radiotherapy planning

10 Advanced technology. Improved the staging Improved the compliance to treatment Reduced the toxicity Marginal improvement in overall survival

11 Stage IIIA Groups T1a,b T2a, b T3 N1,2 T4 N0 N1

12 Early stage and locally advanced (non-metastatic) non-small-cell lung cancer. Treatment Protocols One size does not fit all.

13 Selection of stage IIIA patients for radical treatment 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.

14 Normal tissue tolerance Lung tolerance V20 <30% V30<20% Mean lung dose <15Gy Spinal cord <45 Gy Oesophagus <11 cm Heart V40 < 35Gy

15 Clinical scenario 1 84 year old male with bad COPD. medically inoperable Ad Ca lung T1N2 disease PET

16 Stereotactic radiotherapy

17 .

18 Bulky Primary disease PET Findings 44 year man with bulky primary disease invading the mediastinum. Ad Ca

19 T4N2 M0.

20 Response

21 Clinical Scenario 3 67 year old fit asymptomatic lady presented with bulky T2N2 MO NSCLC Treatment options Discussed in MDM ( Deemed inoperable) Radical chemo radiotherapy Induction chemo followed by radical RT Palliative Chemo

22 Surgery Stage III disease

23 Surgery stage III disease

24 Yes we can burn that tumour Role of Radiation Oncologist with locally advanced and metastatic lung cancer Yes we can

25 Treatment plan

26 Response

27 Role of induction chemotherapy prior to concurrent treatment Cancer and Leukemia Group B 39801,

28 Median Survival Cancer and Leukemia Group B 39801, Induction Chemo + CRT 14months (95%CI 11 to16 months) CRT 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%

29 Role of induction chemotherapy prior to concurrent chemo RT J Clin Oncol May 1;25(13):

30 Neo adjuvant

31 Response after induction Chemo.

32 Response after induction Chemo

33 Complications Late Early Radiation Pneumonitis. Radiation fibrosis of the lung, oesophageal stricture. Radiation mylities. Tiredness, Acute exacerbation symptoms, odynophagia

34 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.

35 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.

36 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.

37 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.

38 Spinal cord compression Poor prognostic factors Complete paraplegia. Loss of Sphincter control. Rapid onset of symptoms ( Infarction).

39 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.

40 Metastatic Spinal cord compression.

41 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

42 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

43 Brain Mets (Multiple ) Treatment Surgical excision of the largest lesion improves neurological deficit and quality of life. Followed by whole brain palliative radiotherapy.

44 Brain Metastasis- Radiotherapy Palliative whole brain Radiotherapy. Stereotactic Radiotherapy for a solitary or couple of lesions. Radiotherapy to the whole brain following excision of the solitary lesion.

45 Stereotactic Radiosurgery

46 Bone Metastasis Pain Hypercalcemia Pathological # Spinal cord compression

47 Pathological Fracture when > 50% of the cortex is destroyed, the fracture rate increases up to 80%

48 Pathological # Needs Surgical fixation before Radiotherapy.

49 At MDM we make Taylor made outfits.

50 Thank you.