Case discussion: recurrent NSCLC

[Palex80]

Here's an interesting case, where I would like to hear your input.

A 55 year old male had been treated for adeno-nsclc 3 years ago with lobectomy. He had a Stage IIIB tumour (pT2 pN3 (11/30) cM0) back then.
The N3 was a contralateral paratracheal nodal metastasis and was not diagnosed preoperatively (preOp status was cT2 cN2 cM0).
The patient received postop chemotherapy with carbotaxol but no radiation therapy (for reasons unknown).

He has now been diagnosed with a paratracheal nodal recurrence and was referred to us for combined radiochemotherapy.

Question:

Would you irradiate the entire mediastinum and then boost the affected node or would you simply irradiate the affected node?
And idea on what dose you would use?

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[radonc]

i would send the patient to the surgeon to evaluate its resectability, and offer adjuvant therapy.

if it is unresectable, then i would treat the patient with concurrent chemo-rt, cis/eto or carbo/taxol and 60-66GY R (40-46Gy in 1.8-2Gy fractions directed at the mediastinum (Thoracic inlet to 2cm below disease), CD to 66Gyin 1.8-2Gy fractions to Pet/CT + disease with 1-2cm margin.

 

[OTN]

I'll second the above, with adding that even if the pt is resectable and undergoes a mediastinal LND, I would still offer adjuvant CRT, though I would probably treat to 60 Gy if there was no evidence of disease on his planning CT.

 

[medgator]

I'll second the above, with adding that even if the pt is resectable and undergoes a mediastinal LND, I would still offer adjuvant CRT, though I would probably treat to 60 Gy if there was no evidence of disease on his planning CT.

I was wondering why you picked 60 Gy? From what I've seen from studies giving post-op RT, the dose is ~ 50-50.4 Gy.

 

[radonc]

I'll second the above, with adding that even if the pt is resectable and undergoes a mediastinal LND, I would still offer adjuvant CRT, though I would probably treat to 60 Gy if there was no evidence of disease on his planning CT.

agreed. however, i would do sequential chemo-RT, and RT to 45-50.4Gy depending on functional status, pfts, etc.

 

[medgator]

agreed. however, i would do sequential chemo-RT, and RT to 45-50.4Gy depending on functional status, pfts, etc.

that's the approach that I've seen done in the post-op setting: sequential rather than concurrent.

Also, I would think that cis/etoposide should be used, as these patients are in the fittest condition (and could have received cis/etoposide in the neoadjuvant setting similar to the regimen used in the Albain study)

 

[radiaterMike]

There is a NEJM randomized study (Keller) that shows that concurrent chemoRT does not offer a benefit over RT alone. Sequential has become standard, and there is data to support it (though not much in the way of randomized data). For example, ANITA study (randimized control trial of chemo) had a retrospective analysis of patients who received versus did not receive RT.

 

[OTN]

I was wondering why you picked 60 Gy? From what I've seen from studies giving post-op RT, the dose is ~ 50-50.4 Gy.

Yeah, in going over everything, I'll agree that 60 is high. I'd be careful in applying adjuvant series in this case, however, as we are dealing with recurrent disease- this pt would never have qualified for those studies.

 

[medgator]

Yeah, in going over everything, I'll agree that 60 is high. I'd be careful in applying adjuvant series in this case, however, as we are dealing with recurrent disease- this pt would never have qualified for those studies.

That's true. If he was inoperable this time around, I'd treat him like a brand new stage III and give him chemo-RT to ~66 Gy (for his gross disease).

On another note, in case you guys weren't aware, the Albain intergroup CRT +/- surgery trial just got published as a manuscript in the lancet:
http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

 

[Palex80]

There is a NEJM randomized study (Keller) that shows that concurrent chemoRT does not offer a benefit over RT alone.

Two limitations are, that this study was performed on patients with completely resected NSCLC being treated for the first time.


Our patient here has lymph node recurrence, which may not be completely resectable (bearing in mind that it will be mediastinal in a preoperated area, thus surgically not trivial). Furthermore we are talking about a recurrence here, which means that this patients harbors aggressive disease (cancer cells that survived first line chemotherapy).

Therefore one could speculate that a simultaneous approach may be beneficial in this special case.

 

[radiaterMike]

I brought up the Keller study because others were asking about what to do in the post-op setting. Even though this is a recurrence (versus a 2nd primary 3 years out), there is no compelling randomized data to support concurrent chemoRT in the post-op setting, whether for the first primary, recurrence or 2nd primary, and the toxicity is significant with chemoRT.

Even with Stage III NSCLC, the benefit of concurrent chemoRT versus sequential chemoRT is only a couple of months (from the RTOG 9410) at the cost of higher toxicity. In fact survival might be worse with concurrent chemoRT, if one were to use a quality of life adjusted survival measure.

Nevertheless, I would probably advocate a simultaneous chemoRT approach if the disease is unresectable, but defintiely not in the post-op setting.

Two limitations are, that this study was performed on patients with completely resected NSCLC being treated for the first time.


Our patient here has lymph node recurrence, which may not be completely resectable (bearing in mind that it will be mediastinal in a preoperated area, thus surgically not trivial). Furthermore we are talking about a recurrence here, which means that this patients harbors aggressive disease (cancer cells that survived first line chemotherapy).

Therefore one could speculate that a simultaneous approach may be beneficial in this special case.

 

[Palex80]

Even with Stage III NSCLC, the benefit of concurrent chemoRT versus sequential chemoRT is only a couple of months (from the RTOG 9410) at the cost of higher toxicity. In fact survival might be worse with concurrent chemoRT, if one were to use a quality of life adjusted survival measure.

A couple of months are a lot, when median survival is in the range of 20 months or so...

 

[medgator]

Even with Stage III NSCLC, the benefit of concurrent chemoRT versus sequential chemoRT is only a couple of months (from the RTOG 9410) at the cost of higher toxicity. In fact survival might be worse with concurrent chemoRT, if one were to use a quality of life adjusted survival measure.

Nevertheless, I would probably advocate a simultaneous chemoRT approach if the disease is unresectable, but defintiely not in the post-op setting.

I agree. All of these trials were in the definitive setting, not the post-op one.

 

[qwert]

a bit out of topic

what is the evidence for using neoadjuvant chemo alone for pts with stage II and III NSCLC?

see this happening a lot lately

 

[G'ville Nole]

a bit out of topic

what is the evidence for using neoadjuvant chemo alone for pts with stage II and III NSCLC?

see this happening a lot lately

Hijacking right along with you...

There are several randomized trials (e.g. Roth 1994, Rosell 1996) that show an overall survival benefit of chemo-->surgery vs surgery alone in this group. A Cochrane meta-analysis in 2007 pooled data from seven RCTs and found an absolute survival benefit of 6% at 5 years, although if memory serves they did include trials such as the French study (DePierre?) that had a number of earlier stage patients involved.

It's not unreasonable to consider this approach as one of several viable options. Probably not the one I'd select, but that reflects my bias.

 

[Palex80]

a bit out of topic

what is the evidence for using neoadjuvant chemo alone for pts with stage II and III NSCLC?

see this happening a lot lately

Seduction by Induction....



It's really sad to see this happening more and more nowadays.

By the way the MD Anderson guys seem to like this kind of approach too:
http://www.chestjournal.org/content/134/6/1349