Mediastinal RT for resected N2 NSCLC

Gfunk6

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    Retrospective analysis of the ANITA trial.

    Conclusion:This retrospective evaluation suggests a positive effect of PORT in pN2 disease and a negative effect on pN1 disease when patients received adjuvant chemotherapy. The results support further evaluation of PORT in prospectively randomized studies in completely resected pN2 NSCLC.
     
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    medgator

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      Oh, never came across that! Thanks. Are you routinely not offering PORT?

      I do. It's in the NCCN algorithm, but I do discuss with patients the limitations of the available data (including the craptacular PORT meta-analysis from the 1990s). Chemotherapy gets a cat 1 recommendation from NCCN but, not XRT because we have a few randomized trials showing the OS benefit of chemo in these patients (IALT, ANITA etc)
       

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        Do you all follow the NCCN as written regarding chemotherapy? Note that in R0 patients it is sequential in the algorithm. This is reinforced in the Principle of Radiation Therapy section. Only for R1-2 do they recommend concurrent chemorads. They do have a "cop out" statement about medically fit R0 may receive concurrent and that optimal sequence is unknown.

        In my prior practice, I really stuck to no concurrent therapy for completely resected. I didn't get too much complaint from the med oncs as the toxicity was easier. Sequential may decrease the pneumonits rate and offset some of the morbidity, but that is just hypothesis. I recently changed practices and haven't had a PORT eligible patient to see which way the wind blows in this community.
         
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        deleted4401

          Well, yeah, for residual disease you have to give concurrent to give the patient a chance. I wouldn't give it concurrently, otherwise.

          But for resected R0, N2 disease, there is no clear answer, it turns out. ANITA and SEER were compelling to me, but this second SEER analysis makes me nervous. Maybe not offer it to patients over 65? We do know, for certain, that there is a big local control benefit. However, this is lung cancer and for stage IIIA, the driver of mortality is still overwhelmingly distant disease. I'm going to think harder about offering it routinely.

          It's curious, though. We know with modern techniques there should be no greater risk of intercurrent death (ECOG and other data) with RT. We know it reduces LRF. We know systemic therapy is more effective. PORT should work. Strange...
           

          Palex80

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            We also know that concurrent RCT is not superior to RT alone in terms of local control for completely resected NSCLC.

            http://www.ncbi.nlm.nih.gov/pubmed/11071672

            Therefore I do not see any benefit in giving concurrent RCT.

            Our standard practice is to give 4 cycles of adjuvant CT (mostly cisplatin/vinorelbin), followed by RT. We generally give 50.4 / 1.8 Gy.
             

            Neuronix

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              Related question for N1s. Got referred a patient from med onc for PORT in a woman ~65 years old T3, N1 s/p lobectomy margins negative. 3/6 level 10 nodes postive -ENE, samples of 7,8,9,11 all negative, +LVI.

              At first I said, N1 doesn't need PORT. I wondered why med onc sent the patient, and it's based on NCCN guidelines! NSCL-3 says:

              Stage IIIA (specifically mentioned T3, N1), Margins negative, Chemotherapy + RT.

              I read through the text and can't figure out where this recommendation is coming from. Is there data for this? Are there practices that would radiate in this circumstance?
               

              medgator

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                Related question for N1s. Got referred a patient from med onc for PORT in a woman ~65 years old T3, N1 s/p lobectomy margins negative. 3/6 level 10 nodes postive -ENE, samples of 7,8,9,11 all negative, +LVI.

                At first I said, N1 doesn't need PORT. I wondered why med onc sent the patient, and it's based on NCCN guidelines! NSCL-3 says:

                Stage IIIA (specifically mentioned T3, N1), Margins negative, Chemotherapy + RT.

                I read through the text and can't figure out where this recommendation is coming from. Is there data for this? Are there practices that would radiate in this circumstance?

                Feel like I'm missing something if that is the recommendation... I would have initially agreed with you.

                NSCL-5 says chemotherapy only if it's an R0 resection (T3 invasion, N0-1). Weird
                 

                Palex80

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                  Related question for N1s. Got referred a patient from med onc for PORT in a woman ~65 years old T3, N1 s/p lobectomy margins negative. 3/6 level 10 nodes postive -ENE, samples of 7,8,9,11 all negative, +LVI.

                  At first I said, N1 doesn't need PORT. I wondered why med onc sent the patient, and it's based on NCCN guidelines! NSCL-3 says:

                  Stage IIIA (specifically mentioned T3, N1), Margins negative, Chemotherapy + RT.

                  I read through the text and can't figure out where this recommendation is coming from. Is there data for this? Are there practices that would radiate in this circumstance?

                  7,8,9,11 are negative, but what about the rest of the mediastinum? Did the surgeons assess the rest of the stations? I am missing the paratracheal & paraaortic nodes.
                  Did this patient have a preop FDG-PET-CT and did the tumor & positive nodes show in it?


                  Could it be, that the recommendation to irradiate in T3 N0/1 (invasion) may refer to cases with chest wall invasion, which is considered by some as an indication for irradiation (of the invaded chest wall NOT the mediastinum)?
                   

                  Neuronix

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                    7,8,9,11 are negative, but what about the rest of the mediastinum? Did the surgeons assess the rest of the stations? I am missing the paratracheal & paraaortic nodes.
                    Did this patient have a preop FDG-PET-CT and did the tumor & positive nodes show in it

                    Pre-op PET/CT was negative for PET avid lymphadenopathy. It was only positive for the large hypermetabolic squamous cell ca. CT had some sub-centimeter mediastinal nodes that were not hypermetabolic--some of which looked like they were taken out on post-op CT and some of which were not. The remaining nodes were stable in size between the CTs (~2 months).
                     

                    Palex80

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                      Pre-op PET/CT was negative for PET avid lymphadenopathy. It was only positive for the large hypermetabolic squamous cell ca. CT had some sub-centimeter mediastinal nodes that were not hypermetabolic--some of which looked like they were taken out on post-op CT and some of which were not. The remaining nodes were stable in size between the CTs (~2 months).

                      I still have problems with the non-assessed paratracheal/paraaortic nodes, which don't show up in the pathology report (as it seems).
                      It wouldn't be a problem if this patient was N0, but with a N1 (and >1 N1 nodes positive), I want a surgically completely assessed mediastinum.
                       

                      Neuronix

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                        I still have problems with the non-assessed paratracheal/paraaortic nodes, which don't show up in the pathology report (as it seems).
                        It wouldn't be a problem if this patient was N0, but with a N1 (and >1 N1 nodes positive), I want a surgically completely assessed mediastinum.

                        The surgery was done at another institution. So, will this change your management of the patient? I'm not sending them back for repeat thoracotomy ;)
                         

                        Palex80

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                          The surgery was done at another institution. So, will this change your management of the patient? I'm not sending them back for repeat thoracotomy ;)

                          A not completely assessed mediastinum remains a problem in my eyes.
                          Under these circumastances, I may consider adjuvant RT for the mediastinum.
                          Perhaps talking to surgeon or having a second look into the operation report may explain, why these nodes were not assessed.
                           

                          TarHeelRadOnc

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                            Related question for N1s. Got referred a patient from med onc for PORT in a woman ~65 years old T3, N1 s/p lobectomy margins negative. 3/6 level 10 nodes postive -ENE, samples of 7,8,9,11 all negative, +LVI.

                            At first I said, N1 doesn't need PORT. I wondered why med onc sent the patient, and it's based on NCCN guidelines! NSCL-3 says:

                            Stage IIIA (specifically mentioned T3, N1), Margins negative, Chemotherapy + RT.

                            I read through the text and can't figure out where this recommendation is coming from. Is there data for this? Are there practices that would radiate in this circumstance?

                            Would not offer PORT for margin neg, T3N1 withouth ECE. Presence of ECE in N1 dz is soft criteria for PORT (I think this was inclusion criteria for Intergroup/Keller study); and I might consider PORT in this patient if it were present. Recent retrospective study from Duke suggests potential benefit of PORT in resected pN1 disease, but certainly no high quality evidence. Not sure where NCCN is coming from with this recommendation.
                             
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