Bad Wegener's and Lung RT

[Haybrant]

69 yo man with COPD and ILD with Wegeners Granulomatosis (GPA) on 2-3L O2 at rest and 3-4L on exertion gets rituxan infusions and on chronic steroids for the GPA had incidentally found 3.5 cm perihilar mass that is touching the aorta from about 2-5 o'clock. Biopsy positive for squamous cell carcinoma. Staged T4N0. Lung function is bad but sounds like he's been stable for over a year since starting rituxan in additionto the chronic steroids. Was just referred to us in RT and referred to med onc who he hasnt seen yet. Just curious what you guys think. I suspect we dont have much of a choice but worry about really worsening his situation, his lungs look downright terrible. Should i consider referring for proton? Thanks

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[RickyScott]

69 yo man with COPD and ILD with Wegeners Granulomatosis (GPA) on 2-3L O2 at rest and 3-4L on exertion gets rituxan infusions and on chronic steroids for the GPA had incidentally found 3.5 cm perihilar mass that is touching the aorta from about 2-5 o'clock. Biopsy positive for squamous cell carcinoma. Staged T4N0. Lung function is bad but sounds like he's been stable for over a year since starting rituxan in additionto the chronic steroids. Was just referred to us in RT and referred to med onc who he hasnt seen yet. Just curious what you guys think. I suspect we dont have much of a choice but worry about really worsening his situation, his lungs look downright terrible. Should i consider referring for proton? Thanks

i wouldnt refer protons. Would use hypofract/sbrt.

 

[Haybrant]

i wouldnt refer protons. Would use hypofract/sbrt.

What’s your dose/frac? You’ll have airway and obviously aorta to contend with. Would also caution about 7-8% grade 5 with sbrt in patients with severe ild

 

[evilbooyaa]

Tough case. Is it just the PET avid area or the stuff lateral to the bronchial tree as well?

If just the PET avid area, not entirely sure how that's a t4 unless it was frankly invading the aorta...

50-60/5, limit aorta IRV (aorta drawn on 4DCT) to 52.5Gy in 5 fractions, limit bronchial tree to whatever your institutional guideline is. Could consider 60/8 or 60/15 as well with similar technique if imaging is a problem

100% would NOT send for protons - interface of tumor/high-dose PTV touching an organ that cannot handle being overdosed (if we think of 105% of Rx dose constraints for Aorta to not go beyond) is a mistake given recent proton data.

Lung DVH is nto going to be an issue for a tumor of this size. Protons can be helpful to lower V20 in a plan that VMAT can't meet. Not really the discussion point here....

 

[Haybrant]

Tough case. Is it just the PET avid area or the stuff lateral to the bronchial tree as well?

If just the PET avid area, not entirely sure how that's a t4 unless it was frankly invading the aorta...

50-60/5, limit aorta IRV (aorta drawn on 4DCT) to 52.5Gy in 5 fractions, limit bronchial tree to whatever your institutional guideline is. Could consider 60/8 or 60/15 as well with similar technique if imaging is a problem

100% would NOT send for protons - interface of tumor/high-dose PTV touching an organ that cannot handle being overdosed (if we think of 105% of Rx dose constraints for Aorta to not go beyond) is a mistake given recent proton data.

Lung DVH is nto going to be an issue for a tumor of this size. Protons can be helpful to lower V20 in a plan that VMAT can't meet. Not really the discussion point here....

Some extent is the stuff more lateral too. There is no plane with the aorta in this case, have sbrtd some patients like this but they had a clear plane. Don’t think it’s invading into aorta but it’s not good. T4 for mediastinal invasion?

 

[medgator]

No chemorads?

 

[Haybrant]

No chemorads?

Yes was thinking chemorads but didn’t realize so many cowboys would want to do 5 fraction sbrt. Not saying it’s a terrible idea but I’m scared not gonna lie. The lung function has be scared though, would anyone consider chemo/immuno alone.

 

[medgator]

Yes was thinking chemorads but didn’t realize so many cowboys would want to do 5 fraction sbrt. Not saying it’s a terrible idea but I’m scared not gonna lie. The lung function has be scared though, would anyone consider chemo/immuno alone.

Isn't Wegeners an autoimmune disease? I would just do chemorads with tight margins and watch

 

[Mandelin Rain]

Chemorads or 60/15 to 70/17 pending your comfort level.

 

[RickyScott]

Phase I study of accelerated conformal radiotherapy for stage I non-small-cell lung cancer in patients with pulmonary dysfunction: CALGB 39904 - PubMed

Accelerated conformal radiotherapy was well tolerated in a high-risk population with clinical stage I NSCLC. Outcomes are comparable to prospective reports of alternative therapies, including stereotactic body radiation therapy and limited resection, with less apparent severe toxicity. Further...

pubmed.ncbi.nlm.nih.gov

Older study but excellent local control similar to stereo despite 3d, large margins, and probably no igrt

 

[medgator]

Phase I study of accelerated conformal radiotherapy for stage I non-small-cell lung cancer in patients with pulmonary dysfunction: CALGB 39904 - PubMed

Accelerated conformal radiotherapy was well tolerated in a high-risk population with clinical stage I NSCLC. Outcomes are comparable to prospective reports of alternative therapies, including stereotactic body radiation therapy and limited resection, with less apparent severe toxicity. Further...

pubmed.ncbi.nlm.nih.gov

Older study but excellent local control similar to stereo despite 3d, large margins, and probably no igrt

70/17 great with a BED very close to 100

 

[Lamount]

54/15, no CTV

 

[medgator]

54/15, no CTV

Too low a dose?

 

[TheWallnerus]

The game is not always see who can name that tune in the fewest notes

69.6 Gy in 1.2 bid with concurrent low dose carbo weekly.

Tell your dosi to plan it stereotactically, non coplanarly, great CI, but keep the inhomogeneity less than 110%. After the plan is done type 69.6 Gy total dose and 58 fractions in the TPS. Same tumor BED as 50 Gy/10 fx but a lot less late BED.

 

[RadOncDoc21]

Fancy rad oncs with all your BED voodoo gibberish. Give him concurrent chemoRT 60 Gy/30 fx and call it a day.

 

[medgator]

Fancy rad oncs with all your BED voodoo gibberish. Give him concurrent chemoRT 60 Gy/30 fx and call it a day

66 4 lyfe

 

[TheWallnerus]

Fancy rad oncs with all your BED voodoo gibberish. Give him concurrent chemoRT 60 Gy/30 fx and call it a day.

I get the O’Reilly “We’ll do it live!” vibe, but lowering the per fraction size is best by test imho in rad onc for reducing the late effects of radiotherapy. (Heck if I could get my hands on some ethyol I might use it for this guy.) In dicey cases gilding the radiobiological lily gives me some comfort in the future when/if I need to think “I tried everything I could.”

 

[RadOncDoc21]

I get the O’Reilly “We’ll do it live!” vibe, but lowering the per fraction size is best by test imho in rad onc for reducing the late effects of radiotherapy. (Heck if I could get my hands on some ethyol I might use it for this guy.) In dicey cases gilding the radiobiological lily gives me some comfort in the future when/if I need to think “I tried everything I could.”

I forgot all about that O’Reilly outtake, of course family guy also did a spoof on it which was hilarious.

Nothing against anyone here personally just in general for any disease site, I feel like rad onc’s specifically are always “one upping” each other in which the fraction doses/numbers are an infinite amount of nuances especially when we are talking about cancer, not the game but cancer! (Iverson reference)

Cancer has shown his azz off too many times for us to really “know” what the right approach is and has raised his middle finger almost every step of the way. Maybe, it’s the boomer in me coming out but my approach now a days is to hit in the fairway and try not to outsmart something that always seems to win. If we ask 30 different rad oncs how to treat an early stage breast cancer or how to palliate a bone met, we’ll likely get 94 different answers.

I’m not saying we don’t save lives or provide a great need in the world, but at some point we all need to just be on the same page for once.

 

[TheWallnerus]

I forgot all about that O’Reilly outtake, of course family guy also did a spoof on it which was hilarious.

Nothing against anyone here personally just in general for any disease site, I feel like rad onc’s specifically are always “one upping” each other in which the fraction doses/numbers are an infinite amount of nuances especially when we are talking about cancer, not the game but cancer! (Iverson reference)

Cancer has shown his azz off too many times for us to really “know” what the right approach is to do and has raised its middle finger at almost every step of the way. Maybe, it’s the boomer in me coming out but my approach has been to hit the fairway and try not to outsmart something that always seems to win.

I’m not saying we don’t save lives or provide a great need in the world, but at some point we all need to just be on the same page for once.

Could I get someone on the same page as me if I said CHART (radiation three times a day for twelve days straight) is the only radiation regimen, on its own, ever “proven” to produce a survival improvement in advanced lung cancer? I have never CHARTed. But I think about it. (Even librarians argue sometimes over if a book, and its pages, goes in the fiction or non fiction section.)

 

[RadOncDoc21]

Could I get someone on the same page as me if I said CHART (radiation three times a day for twelve days straight) is the only radiation regimen, on its own, ever “proven” to produce a survival improvement in advanced lung cancer? I have never CHARTed. But I think about it. (Even librarians argue sometimes over if a book, and its pages, goes in the fiction or non fiction section.)

I’ll follow you and Simul to the end!

 

[evilbooyaa]

No chemorads?

Yes was thinking chemorads but didn’t realize so many cowboys would want to do 5 fraction sbrt. Not saying it’s a terrible idea but I’m scared not gonna lie. The lung function has be scared though, would anyone consider chemo/immuno alone.

Is there a single reported case out there where a patient developed a grade 5 aortic toxicity from 50Gy in 5 fractions in the non-reirradiation setting in lung SBRT, in the absence of say a connective tissue disorder like Marfans or Ehlers-Danlos?

This is small disease in an unfortunate area.

SBRT will have greater efficacy with less lung radiation dose than 60 in 30 with CTVs and radiosenitizing chemotherapy.

Yes was thinking chemorads but didn’t realize so many cowboys would want to do 5 fraction sbrt. Not saying it’s a terrible idea but I’m scared not gonna lie. The lung function has be scared though, would anyone consider chemo/immuno alone.

Shouldn't get immuno given the underlying diagnosis. RT to someone on 2-4LNC, either SBRT or chemoRT, as long as the volume is small, is not going to further harm the lung function. If this was a T3 (by size) of a lower lbe with N2 disease, then yeah maybe RT is dangerous. If doing 60/30, I shoot for lung V20 < 20-25%% rather than 30-37%

 

[medgator]

.

SBRT will have greater efficacy with less lung radiation dose than 60 in 30 with CTVs and radiosenitizing chemotherapy.

Have not seen that data, SBRT control rates drop precipitously as tumor size goes up, esp nearing 4 cm

 

[evilbooyaa]

Stereotactic ablative radiotherapy versus standard radiotherapy in stage 1 non-small-cell lung cancer (TROG 09.02 CHISEL): a phase 3, open-label, randomised controlled trial

In patients with inoperable peripherally located stage 1 NSCLC, compared with standard radiotherapy, SABR resulted in superior local control of the primary disease without an increase in major toxicity. The findings of this trial suggest that SABR should be the treatment of choice for this...

www.thelancet.com

BED 100 with 50/5 vs BED way less than 100 with 60-66 in 2Gy Fx.

 

[medgator]

Stereotactic ablative radiotherapy versus standard radiotherapy in stage 1 non-small-cell lung cancer (TROG 09.02 CHISEL): a phase 3, open-label, randomised controlled trial

In patients with inoperable peripherally located stage 1 NSCLC, compared with standard radiotherapy, SABR resulted in superior local control of the primary disease without an increase in major toxicity. The findings of this trial suggest that SABR should be the treatment of choice for this...

www.thelancet.com

BED 100 with 50/5 vs BED way less than 100 with 60-66 in 2Gy Fx.

Standard fx with chemo >>> standard fx without. Standard fx alone isn't what we are recommending here

 

[RadOncDoc21]

Standard fx with chemo >>> standard fx without. Standard fx alone isn't what we are recommending here

Right, I’m going at it like a locally advanced lung cancer.

 

[RickyScott]

Standard chemo/xrt has abt 50% chance of local control vs 90% with hypofract/sbrt regimens. I have also never heard of aortic toxicity. I think aortic tolerance comes from brachy in rats?

 

[RadOncDoc21]

Standard chemo/xrt has abt 50% chance of local control vs 90% with hypofract/sbrt regimens. I have also never heard of aortic toxicity. I think aortic tolerance comes from brachy in rats?

Hypofx/SBRT vs chemoRT for stage III?

 

[TheWallnerus]

I am not worried about "aortic toxicity." That's gotta be killer! To me, this is a classic min/max problem (well, rad onc always is... ok)... minimize the risk of pneumonitis (given the Wegener's) and maximize tumor control...

SBRT will have greater efficacy with less lung radiation dose than 60 in 30

...and while SBRT would have greater tumor efficacy (on paper), something like 60/30 would have **less lung BED** than the SBRT-dosed plan, and 69.6/58 would have **less lung BED** than 60/30.

 

[Lamount]

Too low a dose?

That's a fair point. It is a little low (but not by much).

I am assuming a poor PS, given the short history (perhaps erroneously). This strikes me as a patient who may not be a great candidate for chemotherapy (which is what I was assuming)... if this is true, I wouldn't necessarily make them come in for 6 weeks for RT alone. For stage III NSCLC in patients who are not candidates for chemo, I will usually give 54-67.5 Gy in 15/fractions, depending on location and risks of tx. Given the significant risks of tx in this patient with vasculitis, I would err on the side of 54/15.

If, indeed, they are a candidate for chemo (and seem better in person than they sound from the OP blurb), I would do CRT to 60 Gy.

 

[evilbooyaa]

Standard fx with chemo >>> standard fx without. Standard fx alone isn't what we are recommending here

Fair enough.

Do we think SBRT will have better or less tumor control than 60/30 with chemo? I think better.

Do we think chemoRT will have less toxicity than SBRT in this situation? Chemo toxicities are not negligible. If you keep volumes tight and plan it like you would SBRT (GTV --> PTV, no CTV) then lung DVH by BED will look better with chemoRT, sure. Is that what chemoRT advocates are saying? Or are you gonna slap 5-10mm CTV on this if you treat it?

Is the patient a chemo candidate at all?

But, we SBRT people who are on supplemental O2 ALL the time. If the lung toxicity concern is the issue here in this focal upper lobe tumor with SBRT, then we shouldn't be SBRTing way more people than we're currently not.

I understand it's being called T4 with aorta/mediastinal invasion, so nothing wrong with just saying "well T4N0, therefore chemoRT is the answer", just thinking about what toxicity is the biggest concern here and how to maximize tumor control.

 

[RadOncDoc21]

I understand it's being called T4 with aorta/mediastinal invasion, so nothing wrong with just saying "well T4N0, therefore chemoRT is the answer", just thinking about what toxicity is the biggest concern here and how to maximize tumor control.

This is my rationale. I’m ok with the SBRT fractionations and understand the rationale and logistics but just trying to keep a reasonable standard of what we’re recommending (If T4) and again if the patient is even a candidate for chemo.

 

[Mandelin Rain]

This tumor appears to be kissing aorta and LLL bronchus. There is a low, but real chance of Grade 5 toxicity here with SBRT. I've typically done the 70/17 thing here in patient's without a pre-existing inflammatory blood vessel disease. I think given the situation, chemoradiation is very reasonable.

 

[medgator]

This tumor appears to be kissing aorta and LLL bronchus. There is a low, but real chance of Grade 5 toxicity here with SBRT. I've typically done the 70/17 thing here in patient's without a pre-existing inflammatory blood vessel disease. I think given the situation, chemoradiation is very reasonable.

I think there is something synergistic with chemorads that isn't accounted for in bed calcs. And dose reduced carbo taxol is probably the the easiest chemo to get on the planet. If pt wasn't a chemo candidate (really rare imo), i would probably go the calgb/17 fx route

 

[TheWallnerus]

Do we think SBRT will have better or less tumor control than 60/30 with chemo? I think better.

Do we think chemoRT will have less toxicity than SBRT in this situation? Chemo toxicities are not negligible.

I think chemoRT could have less toxicity here yes (it's quite small volume disease... and thus, the mind also drifts to ultrahypofx dose regimens). The reason SBRT seems to have less toxicity is we almost always are irradiating orders of magnitude smaller volumes versus stage III e.g. If you SBRT'd a typical stage III lung cancer with SBRT doses you'd have a lot worse toxicity. I guess that's why we don't SBRT stage III, instead of 60/30, even though we know SBRT has "better... tumor control"

I think there is something synergistic with chemorads that isn't accounted for in bed calcs

Ah that's easy, multiply the BED-Gy10 by 1.1 if giving chemo

 

[TheWallnerus]

Which CTV... red, green, blue, neither...

 

[medgator]

This tumor appears to be kissing aorta and LLL bronchus. There is a low, but real chance of Grade 5 toxicity here with SBRT. I've typically done the 70/17 thing here in patient's without a pre-existing inflammatory blood vessel disease. I think given the situation, chemoradiation is very reasonable.

Fresh from a mednet email today:

"How do you treat a T3N0M0 NSCLC with chest wall invasion in an inoperable patient?"

68% chose chemorads @evilbooyaa

I see no reason why this would be any different. Could always combine with a little hypo too if you wanted... 2.1/2.2 a fraction

 

[RadOncDoc21]

Fresh from mednet email today:

"How do you treat a T3N0M0 NSCLC with chest wall invasion in an inoperable patient?"

68% chose chemorads. I see no reason why this would be any different. Could always combine with a little hypo too if you wanted... 2.1/2.2 a fraction

I prefer 2.125 Gy/fx

 

[evilbooyaa]

Fresh from a mednet email today:

"How do you treat a T3N0M0 NSCLC with chest wall invasion in an inoperable patient?"

68% chose chemorads @evilbooyaa

I see no reason why this would be any different. Could always combine with a little hypo too if you wanted... 2.1/2.2 a fraction

Sure, makes sense. You're worried about chest wall toxicity with SBRTing a tumor that is infiltrating the ribs, rib fracture, other significant, well documented toxicities seen with SBRT. I think chemoRT to avoid a very real chance of RT related toxicity that is well documented is not unreasonable, and is again a 'reasonable' option.

Also that question (theMednet) is from 2015 and I imagine polling would be different 8 years later....

What toxicity are you most concerned about in this specific patient in terms of SBRT? The lung toxicity? Or the aorta toxicity?

 

[Mandelin Rain]

Sure, makes sense. You're worried about chest wall toxicity with SBRTing a tumor that is infiltrating the ribs, rib fracture, other significant, well documented toxicities seen with SBRT. I think chemoRT to avoid a very real chance of RT related toxicity that is well documented is not unreasonable, and is again a 'reasonable' option.

Also that question (theMednet) is from 2015 and I imagine polling would be different 8 years later....

What toxicity are you most concerned about in this specific patient in terms of SBRT? The lung toxicity? Or the aorta toxicity?

Aortobronchial fistula (exsanguination)

 

[evilbooyaa]

Aortobronchial fistula (exsanguination)

Great to hear you are concerned.
Has there been a single reported case of aortic toxicity with 50Gy in 5 fractions SBRT? In the non-reirradiation setting. Let's say without Avastin although would be interested to read post-Avastin as well - this one case report was after hypofx proton RT 7 years later when patient was on Avastin:

Emergent salvage surgery for massive hemoptysis after proton beam therapy for lung cancer: a case report - Surgical Case Reports

Background Salvage surgery is an effective therapeutic option for patients experiencing relapses after chemoradiotherapy for advanced-stage lung cancer or after high-dose radiotherapy for early-stage lung cancer. We report a case involving an emergent salvage surgery for a patient with massive...

surgicalcasereports.springeropen.com

Review of the literature says no, but I'm happy to be educated.

theMednet

www.themednet.org

 

[medgator]

Sure, makes sense. You're worried about chest wall toxicity with SBRTing a tumor that is infiltrating the ribs, rib fracture, other significant, well documented toxicities seen with SBRT. I think chemoRT to avoid a very real chance of RT related toxicity that is well documented is not unreasonable, and is again a 'reasonable' option.

Also that question (theMednet) is from 2015 and I imagine polling would be different 8 years later....

What toxicity are you most concerned about in this specific patient in terms of SBRT? The lung toxicity? Or the aorta toxicity?

I honestly think it's safer and as, if not more, efficacious, esp with some gentle hypo-fx. Data free zone obviously.

SBRT control rates are known to drop significantly as a function of tumor size above 2-3 cm. 50/5 is borderline BED for a lung primary as well, i prefer 55/5 if i have to do 5 fx for some reason

 

[Mandelin Rain]

Great to hear you are concerned.
Has there been a single reported case of aortic toxicity with 50Gy in 5 fractions SBRT? In the non-reirradiation setting. Let's say without Avastin although would be interested to read post-Avastin as well - this one case report was after hypofx proton RT 7 years later when patient was on Avastin:

Emergent salvage surgery for massive hemoptysis after proton beam therapy for lung cancer: a case report - Surgical Case Reports

Background Salvage surgery is an effective therapeutic option for patients experiencing relapses after chemoradiotherapy for advanced-stage lung cancer or after high-dose radiotherapy for early-stage lung cancer. We report a case involving an emergent salvage surgery for a patient with massive...

surgicalcasereports.springeropen.com

Review of the literature says no, but I'm happy to be educated.

theMednet

www.themednet.org

Experience tells me it's possible.

 

[Lamount]

Aortobronchial fistula (exsanguination)

To be fair, it would probably cause asphyxiation first

 

[evilbooyaa]

I honestly think it's safer and as, if not more, efficacious, esp with some gentle hypo-fx. Data free zone obviously.

SBRT control rates are known to drop significantly as a function of tumor size above 2-3 cm. 50/5 is borderline BED for a lung primary as well, i prefer 55/5 if i have to do 5 fx for some reason

ChemoRT is Safer, sure, I'll buy that. Especially for the PBT, the esophagus, the ribs, maybe the lungs.

ChemoRT is as efficacious as SBRT? Or somehow more efficacious than SBRT? For two tumors of the same size?

SBRT control rates are known to drop with increasing tumor size because bigger tumors recur more locally. That is going to be true regardless of what BED you attempt to pump into a tumor, or even if you surgically remove it.

And how many of those series didn't use 4DCT and/or inappropriately small margins and/or lack of heterogeneity corrections to ensure edges of the tumor were appropriately dosed?

ChemoRT patients recur locally too (hence the series out there on salvage SBRT for local recurrence), it's just that they frequently recur distantly either simultaneously or first and thus have no additional indication for salvage local therapy.

If you think 50/5 is borderline BED, what do you think 60-66/30-33 is?

Sure, you could do 55/5. I guess I'm just nervous about going above 105% of Rx as per NCCN, and figured that meant 50Gy (as like an absolute lower limit of what's kosher to use for true ablative intent SBRT) , but you could do 55/5 and maybe just dose paint the aorta down to point dose of 52.5Gy.

 

[evilbooyaa]

Experience tells me it's possible.

If you know of a case, please write a case report and shut me up!

 

[RadOncDoc21]

Let’s say a tragic event does occur, rightly or wrongly we get blamed… which treatment argument would hold up better in court?

I’m actually asking because I don’t know!

 

[sirspamalot]

The answer to that question may be prefaced by "where are you practicing?"

If you're in a rural area, maybe leave the fancy stuff that has a perceived higher risk alone and stick with steak and potato approach.

 

[Lamount]

What toxicity are you most concerned about in this specific patient in terms of SBRT? The lung toxicity? Or the aorta toxicity?

Unless this patient has atypical anatomy, the LLL bronchus (or most of its segmental bronchi) are right there.

…would be very careful doing SBRT in this spot in a healthy patient, let alone someone on 3L O2 at rest. Aside from the risk of bronchial hemorrhage (which is higher in this patient due to the vasculitis), you could VERY easily take out most or all of the LLL due to stenosis of the segmental bronchi. Doesn’t sound like this patient can spare a lobe.

 

[Palex80]

Any chance this is resectable (probably not)?

 

[metview]

I think both are reasonable options with 50/5 having better control. With SBRT keep aorta Dmax below 105% and undercover PTV in that area (50/5). RTOG 0813 allowed Dmax 105% in OARs and there was no toxicity in 50-55/5 fx groups. But I am curious to see where the LLL bronchi is relative to the tumor. If there is PTV overlap with LLL bronchi, no way SBRT is appropriate; in this case, chemoRT or something more fractionated like 60/15, 60/10.