Lung Ca Dose/Fraction

[Neoplastic]

Yet another lung thread -- seems to be the topic du jour lately...

Writing a presentation on lung cancer treatment and wanted to get a flavor for what dose and fraction are popular in the community and academic centers for unresectable stage III NSCLC lung cancer.

Please take a moment to let me know what dose/fraction regimen you use currently or have used frequently in the last decade for definitive treatment: 60/2, 66/2, 70.2/1.8, etc

Thanks in advance!

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[Gfunk6]

I always use 60/2 per the results of RTOG 0617.

 

[deleted4401]

60-66/2

Considering going down to 1.8 to 61.2. Stage III lung cancer treatment is aggressive palliation. I want to bring toxicity rate down even lower.

Anyone have experience with Japanese split course (from the positive trial, Furuse and his boys)?

S

 

[medgator]

66-70/2

I'm interested to see more final results from RTOG 0617 with regards to local control (any, for that matter)

I was trained to always use 2/day in definitive nsclc tx and the nccn also recommends this. The exception is if I'm doing preop where I go at 1.8 to 45 and also in inoperable pancoast tumors

 

[medgator]

I was trained the same way (2 Gy/fx) for definitive and 1.8 to 45 for pre-op. Any rationale or is it one of those things where the intergroup RT group wanted 1.8's and the RTOG definitive group used 2's?

Preop esophagus (1.8, minus that crazy Walsh trial regimen) is the same so there is probably some rationale.

 

[TarHeelRadOnc]

Yet another lung thread -- seems to be the topic du jour lately...

Writing a presentation on lung cancer treatment and wanted to get a flavor for what dose and fraction are popular in the community and academic centers for unresectable stage III NSCLC lung cancer.

Please take a moment to let me know what dose/fraction regimen you use currently or have used frequently in the last decade for definitive treatment: 60/2, 66/2, 70.2/1.8, etc

Thanks in advance!

60-66Gy/2

One of the problems with 0617 is that it didn't allow you to dose reduce in the 74Gy to meet lung constraints. If lung DVH parameters look good, I have no problem with 66Gy. 0617 is already practice changing, but needs to be published (hopefully soon)!

 

[Neoplastic]

Anyone use the MSK regimens that use 1.8 Gy per day for to 70(?) for definitive cases (not post-op)?

Does MSK even do this anymore?

 

[Palex80]

60-66/2 most of the times.
However, I have found myself doing concomitant boost or SBRT-boost in a couple of cases.

 

[Trevica]

Curious...what about treating IMRT? Or is there still a fair amount of 3D planning for conventionally fractionated lung?

 

[medgator]

Curious...what about treating IMRT? Or is there still a fair amount of 3D planning for conventionally fractionated lung?

Depends on what I'm treating. Imrt works well for specific situations (central disease near cord is a big one)

 

[Palex80]

IMRT is great in definitive treatment for centrally located tumors without lots of breathing movement. I am bit of sceptical about peripheral lesions, since we don't have a 4D CT & treatment capability.
I don't use IMRT for adjuvant cases.


On a side note: The Maastricht-folks (Netherlands), many of you may recall the name De Ruysscher, are doing simultaneous integrated boost with 3 Gy/fraction going up to 60 Gy and above.
The downside is, you need to do lots of adaptive planning, since small changes in tumor volume / atelectasis can cause lots of dose redistribution issues.

 

[deleted4401]

3/4 3D-CRT, 1/4 IMRT. Only do it if V20 constraint can't be met, but I think 37% seems to high, so if I can't get V20<30, I do IMRT. Totally agree with motion issues, but outcome has been fairly good, i.e. no marginal misses. They just met out.

 

[Neuronix]

We push for 70/2 whenever feasible based on several phase II studies, typically with concurrent Q3wk or weekly carbo/taxol (depending on the med onc and patient). We have a pretty large series based on our single institutional experience. One of these days we'll probably submit it for publication. This employs 4D-CT planning followed typically by 3D-CRT delivery (w/ respiratory gating or other techniques as tolerated), sometimes IMRT, and occasionally even compensators if it's a large mobile tumor. Agree with Simul that V20 < 30% is ideal, sometimes accept up to 35%.

My attending thinks the RTOG 0617 abstract results may have been cetuximab interacting with the 74 Gy dose. In any case, certainly the private practices in our area seem to be using 60/2.

 

[Gfunk6]

Totally agree with motion issues, but outcome has been fairly good, i.e. no marginal misses. They just met out.

And this, my friends, is the primary argument against dose-escalation.

 

[medgator]

60-66/2

Considering going down to 1.8 to 61.2. Stage III lung cancer treatment is aggressive palliation. I want to bring toxicity rate down even lower.

Totally agree with motion issues, but outcome has been fairly good, i.e. no marginal misses. They just met out.

And this, my friends, is the primary argument against dose-escalation.

Am I the only who's seen long-term (>1 year) survivors of Stage IIIA NSCLC treated with CRT with locally-controlled, non-metastatic disease?

Obviously there is pessimism in the data, but I am seeing back my 89 y/o T3N2 (single ipsilateral mediastinal LN), RUL IIIA SCC pt in clinic in 2 mos for his 1 year anniversary (getting PET/CT before then). The med onc wrote him off for chemo (understandably so, given his age in a community setting) despite his fairly good PS so I gave him 70/2 with IMRT. He's clinically/radiographically NED since completion of Tx. PET/CT at 3 mos showed minimal activity.

I know this is all anecdotal, but we treated lung pretty aggressively where I trained and I've seen an occasional case like this and more frequent cases like this when treated with CRT.

 

[Gfunk6]

I think we all have patients who bucked statistical 'norms' and lived much longer than average. However, when you have a national Phase III trial using modern technology that stopped early due to lack of survival benefit in the high-dose arm there is (in my mind) no benefit to treating much beyond 60 Gy.

Regrading your patient, I'd say three months is a pretty short metric. Not to be overly pessimistic, but he is most likey due for mets within the next few months.

 

[deleted4401]

One year is fine... but since the late 1970s if you look at stage III - RT alone - MS 10 months, Induction (Dillman) MS 14 months, modern concurrent trials MS is 17 months. 5 year survival is around 15%. The local control rate is barely 30% (probably lower, since once they met out, people don't really count LRs). So.. I don't know, those are the numbers on trials with excellent clinical support and better KPS than what I see. I see a lot of patients that last a year or more with tx, but even if you did RT alone, about 40% would live 12 months.

I'm not saying not to treat aggressively - I do it, too, and have people 2 years out. But, I do question it.
S

 

[medgator]

Regrading your patient, I'd say three months is a pretty short metric. Not to be overly pessimistic, but he is most likey due for mets within the next few months.

He was controlled at 3 mos. Getting a PET/CT for his 1-year anniversary in May 2013.

I really am intrigued to see more final results from 0617. I think there is something to be said about LC in these patients. The patient I treated above had rib erosion from his T3 pancoast tumor and those symptoms abated during Tx and have not returned since.

 

[medgator]

I'm not saying not to treat aggressively - I do it, too, and have people 2 years out. But, I do question it.
S

I question it less than the pancreatic/HG glioma patients that I treat I guess.

And I understand the rationale of why the 60 and 74 Gy arms were picked for RTOG 0617 despite many typically treating ~ 66 before those results were released (basically they figured it should show a big difference between a "wimpy" 60 Gy dose and an "aggressive" 74 Gy arm). Again, it'll be interesting to see the nuances of this trial in manuscript form.

 

[Palex80]

Stage migration my dear friends, stage migration is the key point here.

Half of the Stage IIIA NSCLC of the '70s would probably have been staged as Stage IV NSCLC nowadays, cause in the 70s and 80s you didn't have PET-CT or high quality MRI.

We are treating vastly better selected patients nowadays, that's why treatment results in lots of tumors have been improving in the past decades. It's not necessarily just the news drugs, the higher, more conformal dose or the better surgical results, it certainly has to do with stage migration as well.

 

[TarHeelRadOnc]

Stage migration my dear friends, stage migration is the key point here.

Half of the Stage IIIA NSCLC of the '70s would probably have been staged as Stage IV NSCLC nowadays, cause in the 70s and 80s you didn't have PET-CT or high quality MRI.

We are treating vastly better selected patients nowadays, that's why treatment results in lots of tumors have been improving in the past decades. It's not necessarily just the news drugs, the higher, more conformal dose or the better surgical results, it certainly has to do with stage migration as well.

Completely agree

 

[medgator]

Stage migration my dear friends, stage migration is the key point here.

Half of the Stage IIIA NSCLC of the '70s would probably have been staged as Stage IV NSCLC nowadays, cause in the 70s and 80s you didn't have PET-CT or high quality MRI.

We are treating vastly better selected patients nowadays, that's why treatment results in lots of tumors have been improving in the past decades. It's not necessarily just the news drugs, the higher, more conformal dose or the better surgical results, it certainly has to do with stage migration as well.

Completely forgot about that.... good point. There was no mandated head imaging (and sometimes no bone scan/PET staging) in many of the older trials like the Dilman study or the RTOG/ECOG study from the 80s

 

[Gfunk6]

Stage migration my dear friends, stage migration is the key point here.

Good point, but 0617 had mandatory w/u to r/o mets - still negative on the dose-escalation question

 

[Seldon1985]

66-74Gy/2Gy fx

 

[Palex80]

Good point, but 0617 had mandatory w/u to r/o mets - still negative on the dose-escalation question

I agree.
I was merely trying to make a point, why our "every day" patients sometimes tend to do a lot better in terms of survival, than the typical patient of a 70s,80s or even 90s-trial.