Tumor Board debate

[IonsAreOurFuture]

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Interesting case, details blurred to protect the innocent.

Lung tumor 2 cm, patient is on 3 L O2 but only at night.

Surgeon recommends PFTs and that he see the patient for surgery, "maybe can't tolerate a lobectomy but sub-lobar resection might be a possibility."

I advised the patient not get surgery due to already being on oxygen, and sublobar resection less definite. Survival for operable patients just as good based on Rosell-STARS trial.

Debate ensues

 

[OTN]

If I were the patient I would elect SBRT

 

[BobbyHeenan]

YOu have an aggressive surgeon in my experience.
At 2cm already on oxygen our CT surgeons would say just get SBRT so I don't have these fights, fortunately.

With that said, recent surgery randomized lobectomy vs. sublobar showed no major differences, so sublobar isn't a bad surgical option it's just if you're already on O2 ....

 

[radiaterMike]

"sub-lobar resection might be a possibility" probably means that patient would not have been eligible for RCT of lobectomy vs. sublobar (i.e.<2 cm peripheral tumor for CALGB study)

 

[Palex80]

1. A sublobar resection is likely as good as, perhaps even superior to, a lobectomy in a 2cm large NSCLC.

Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial - PubMed

National Cancer Center Research and the Ministry of Health, Labour, and Welfare of Japan.

pubmed.ncbi.nlm.nih.gov

However, that sublobar resection must be an anatomic resection (=an oncologic procedure), meaning a segmentectomy. Not some silly wedge-resection.

2. One potential benefit of such a procedure is the lymph node staging that can be done (and you cannot do with an SBRT), something which may be relevant if that is a more centrally located tumor.

3. It would be interesting to know WHY the patient is on O2. There may be some conditions, I may also opt for surgery, for instance interstitial lung disease. If it's only "common" COPD, SBRT is certainly as safe as (and likely safer than) a surgical procedure and will lead to a better functional outcome.

4. Ultimately, it's all a matter of what the patient wants. He/She should speak to both you and the surgeon, that's how we tend to do it.

 

[RickyScott]

Interesting case, details blurred to protect the innocent.

Lung tumor 2 cm, patient is on 3 L O2 but only at night.

Surgeon recommends PFTs and that he see the patient for surgery, "maybe can't tolerate a lobectomy but sub-lobar resection might be a possibility."

I advised the patient not get surgery due to already being on oxygen, and sublobar resection less definite. Survival for operable patients just as good based on Rosell-STARS trial.

Debate ensues

just anecdotal, but ct surgeons seems to have become more aggressive over past 15 years. definitely doing less sbrt for stage I nsclc

 

[BobbyHeenan]

1. A sublobar resection is likely as good as, perhaps even superior to, a lobectomy in a 2cm large NSCLC.

Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial - PubMed

National Cancer Center Research and the Ministry of Health, Labour, and Welfare of Japan.

pubmed.ncbi.nlm.nih.gov

However, that sublobar resection must be an anatomic resection (=an oncologic procedure), meaning a segmentectomy. Not some silly wedge-resection.

2. One potential benefit of such a procedure is the lymph node staging that can be done (and you cannot do with an SBRT), something which may be relevant if that is a more centrally located tumor.

3. It would be interesting to know WHY the patient is on O2. There may be some conditions, I may also opt for surgery, for instance interstitial lung disease. If it's only "common" COPD, SBRT is certainly as safe as (and likely safer than) a surgical procedure and will lead to a better functional outcome.

4. Ultimately, it's all a matter of what the patient wants. He/She should speak to both you and the surgeon, that's how we tend to do it.

Yes!

We have a multi-disciplinary lung cancer clinic where they meet surgeon and I. It is a great service IMO.

...and ditto on the wedge thing. Wedge resections are crap. Very little rationale for a wedge over SBRT IMO. If sub-lobar it needs to be anatomic.

 

[medgator]

just anecdotal, but ct surgeons seems to have become more aggressive over past 15 years. I have definitely doing less sbrt for state I nsclc over time

Completely different experience in my book. I probably get at least one referral a month from an experienced, busy CTS who has been operating for a few decades.

Increasing LDCT screening is creating more business for both specialties IMO

 

[Bequerel]

opened thread hoping for a challenging case. There is nothing to debate here especially in a radiation forum 😂

 

[udrag14]

opened thread hoping for a challenging case. There is nothing to debate here especially in a radiation forum 😂

Agree with this. Definitely fortunate that our thoracic surgeons are very selective with patients. They usually push patients to SBRT over surgery a lot of the times.

 

[NotMattSpraker]

1. A sublobar resection is likely as good as, perhaps even superior to, a lobectomy in a 2cm large NSCLC.

Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial - PubMed

National Cancer Center Research and the Ministry of Health, Labour, and Welfare of Japan.

pubmed.ncbi.nlm.nih.gov

However, that sublobar resection must be an anatomic resection (=an oncologic procedure), meaning a segmentectomy. Not some silly wedge-resection.

2. One potential benefit of such a procedure is the lymph node staging that can be done (and you cannot do with an SBRT), something which may be relevant if that is a more centrally located tumor.

3. It would be interesting to know WHY the patient is on O2. There may be some conditions, I may also opt for surgery, for instance interstitial lung disease. If it's only "common" COPD, SBRT is certainly as safe as (and likely safer than) a surgical procedure and will lead to a better functional outcome.

4. Ultimately, it's all a matter of what the patient wants. He/She should speak to both you and the surgeon, that's how we tend to do it.

Great post. I work on this at the network level for my company. It is worth Rad Oncs knowing that sublobar resection is very good and in some centers, this is done minimally invasive with an average hospital stay of 1 day or less.

To #2, Im not sure it is irrelevant or that it cant be done. You can request an EBUS sampling for your SBRT cases. I do that.

I work in a place where a well selected 90 year old can do great with surgery. It's these borderline cases like this one where we would really benefit from better functional and QoL outcomes data, not just survival.

Rosell-Stars is really not a strong dataset to prove anything other than "SBRT is not substantially worse than surgery"... and if a surgeon says it is, there is a lot of other data you can use to say they are wrong.

 

[metallica81788]

I went from a job with minimal CT surgeon involvement and preference for SBRT to now a very surgeon-driven place. There are two surgeons and honestly, I see no need for both as one is part time. Here there is enough lung cancer that everyone can have decent volumes. They may be getting greedy since there is a very large cardiology place next door likely taking many of their potential patients.

However, I've been working for over a year to change the paradigm here where medical oncology seems to ALWAYS prefer surgery over SBRT, even in marginal candidates. They don't seem to understand the patients have a choice. It's like they don't even consider performance status. If they get to the surgeons, SBRT is never even considered and I've seen many local recurrences on people that never should have been operated on in the first place. I'm also worried about losing more chemoradiation lungs as the surgeons are very much "give them neoadjuvant and see" or "diagnostic AND therapeutic resection" types.
The situation is pushing me to be more aggressive but the battle is uphill and slow. I feel that I'm working against the historical older doctor here that wasn't very aggressive with SBRT and still trying to shake that. My volumes aren't hurting, but I could have so many more SBRTs if things were better.

 

[Palex80]

However, I've been working for over a year to change the paradigm here where medical oncology seems to ALWAYS prefer surgery over SBRT, even in marginal candidates. ... I'm also worried about losing more chemoradiation lungs as the surgeons are very much "give them neoadjuvant and see" or "diagnostic AND therapeutic resection" types.

Welcome to Europe!

 

[medgator]

I went from a job with minimal CT surgeon involvement and preference for SBRT to now a very surgeon-driven place. There are two surgeons and honestly, I see no need for both as one is part time. Here there is enough lung cancer that everyone can have decent volumes. They may be getting greedy since there is a very large cardiology place next door likely taking many of their potential patients.

However, I've been working for over a year to change the paradigm here where medical oncology seems to ALWAYS prefer surgery over SBRT, even in marginal candidates. They don't seem to understand the patients have a choice. It's like they don't even consider performance status. If they get to the surgeons, SBRT is never even considered and I've seen many local recurrences on people that never should have been operated on in the first place. I'm also worried about losing more chemoradiation lungs as the surgeons are very much "give them neoadjuvant and see" or "diagnostic AND therapeutic resection" types.
The situation is pushing me to be more aggressive but the battle is uphill and slow. I feel that I'm working against the historical older doctor here that wasn't very aggressive with SBRT and still trying to shake that. My volumes aren't hurting, but I could have so many more SBRTs if things were better.

Have you tried reaching out to pulmonary directly?

 

[NotMattSpraker]

Welcome to Europe!

US too.

The standard of care in the United States is surgery. If they are medically inoperable as determined by a surgeon, then the standard is SBRT.

Patient selection is almost a completely data free zone.

 

[metallica81788]

Have you tried reaching out to pulmonary directly?

Yes they are great and always send referrals to me and CT surgery. They don't really pick sides. It's still an uphill battle.
We are about to start a dedicated lung tumor board prospectively evaluating all patients. I'm not sure if this will help or hurt my cause.

 

[BobbyHeenan]

Yes they are great and always send referrals to me and CT surgery. They don't really pick sides. It's still an uphill battle.
We are about to start a dedicated lung tumor board prospectively evaluating all patients. I'm not sure if this will help or hurt my cause.

it will help I bet.

When they try to "convert" borderline resectable stage III cases you can tell them that's not how the neoadj chemo-IO trials went. Path CR is at best 30% so if they can't get all gross disease out (*including the lymph nodes*) then not worth it to do neoadj and/or is not applicable to the trials.

 

[evilbooyaa]

I can see a desire to consider an anatomical resection (NOT a wedge) that is sub-lobar in a 2cm tumor.

If the O2 requirement is due to ILD, would not be enthusiastic for SBRT.

I think joint referral to both CT Surgery and Rad Onc and having a shared decision making process between all 3 of those folks is what is in the patient's best interest.

I would probably counsel the patient on 3LNC at night that his O2 requirements are more likely to increase after surgical resection than after a sublobar resection. Both risks are probably stlil low.

Pathologic nodal evaluation could be done with EBUS if patient elected for SBRT, as based on shared decision making between Rad Onc and patient.

 

[NotMattSpraker]

I think joint referral to both CT Surgery and Rad Onc and having a shared decision making process between all 3 of those folks is what is in the patient's best interest.

I agree with this but a lot of places just follow the NCCN. Perhaps the radiation oncologists on the lung panel should speak up and ask them to change the language. That is not the standard right now.

 

[drowsy12]

1) you’ll get IR and iPulm saying they should be part of the shared decision making processs soon

2) I think it’s fair to still consider surgery the SOC until VALOR, officially; but on a local level agree that med oncs need to be convinced of the value of SBRT

 

[medgator]

1) you’ll get IR and iPulm saying they should be part of the shared decision making processs soon

Where's the data? Esp for rfa

 

[medgator]

If the O2 requirement is due to ILD, would not be enthusiastic for SBRT.

No ideal option there. Rfa and drop their lung? Resect with poor pfts and O2 req? Nope. Still doing sbrt in those cases

 

[drowsy12]

Where's the data? Esp for rfa

Oh I agree. Just saying watch out for them!

 

[OTN]

Oh I agree. Just saying watch out for them!

I had to start pushing back against RFA at least 5 years ago. Had one particularly aggressive pulmonologist who insisted he should be RFAing every lung nodule that he biopsies "because he's already there". I told him to go ahead, but given the poor results in the data we do have, I would go right ahead and SBRT each and every one of those as well if they weren't surgical candidates.

He told me of course I feel that way "because I'm a radiation oncologist." I explained that the data is what it is.

He's no longer in our area and RFA never got off the ground. Thankfully.

 

[wandering star]

...and ditto on the wedge thing. Wedge resections are crap. Very little rationale for a wedge over SBRT IMO. If sub-lobar it needs to be anatomic.

Interesting to read the take of a second phase III trial discussing this, which randomized 697 pts with T1aN0 disease to lobar or sublobar resection (that is, either anatomic segmentectomy or wedge) and found similar outcomes for either option. They write in Discussion:

"In the current trial [compared to the aforementioned Japan trial = segmentectomy only], both anatomical segmentectomy and wedge resection were considered to be acceptable methods of sublobar resection. Wedge resection was allowed in the current trial because it is the most frequently practiced method of sublobar resection in North America and Europe; thus, its inclusion would make the trial more representative of a “real world” setting."

https://www.nejm.org/doi/full/10.1056/NEJMoa2212083

Without question, segmentectomy is preferred, but by how much is hard to say. Couldn't find in the NEJM paper any descriptive statistics on how many patients received wedge vs. how many received segmentectomy; if it had 95% wedge, I would say we have a reasonable basis for doing wedge, if it had 5% wedge, I would say that we know very little.

 

[BobbyHeenan]

Interesting to read the take of a second phase III trial discussing this, which randomized 697 pts with T1aN0 disease to lobar or sublobar resection (that is, either anatomic segmentectomy or wedge) and found similar outcomes for either option. They write in Discussion:

"In the current trial [compared to the aforementioned Japan trial = segmentectomy only], both anatomical segmentectomy and wedge resection were considered to be acceptable methods of sublobar resection. Wedge resection was allowed in the current trial because it is the most frequently practiced method of sublobar resection in North America and Europe; thus, its inclusion would make the trial more representative of a “real world” setting."

https://www.nejm.org/doi/full/10.1056/NEJMoa2212083

Without question, segmentectomy is preferred, but by how much is hard to say. Couldn't find in the NEJM paper any descriptive statistics on how many patients received wedge vs. how many received segmentectomy; if it had 95% wedge, I would say we have a reasonable basis for doing wedge, if it had 5% wedge, I would say that we know very little.

I think what you're saying is a more balanced approach, I was giving some hot takes. I think too surgical technique has improved, a wedge today is probably not what it was back when I cut my teeth in training 10-20 years ago.

It looks like the slight majority in the trial randomized to sub lobar actually did hav ea wedge. Still waiting on more granular details regarding margins and local types of failures it implies in the paper.

===



My anecdotal experience is that wedge has a higher local relapse than anatomic sublobar....Do you think the ones that had wedge on the NEJM trail were the more favorable (of an already favorable group)?

I guess what I'm trying ot tease out is is there a difference in a case where the surgeon can do EITHER sub lobar or wedge and chooses a wedge versus their only option is a wedge.

VALOR cannot get here soon enough though I'm telling you all we're going to hear about is the data isn't applicable because too many patients had lobectomies instead of sub lobar (?unless the protocol was amended to allow sub lobar?).

 

[evilbooyaa]

I agree with this but a lot of places just follow the NCCN. Perhaps the radiation oncologists on the lung panel should speak up and ask them to change the language. That is not the standard right now.

Yeah... the old paradigm of 'if patient can get a lobectomy, they should go do that' bieng challenged for segmentectomy being considered 'equivalent' is a bit of a conundrum (for Rad Oncs, not for surgeons).

I do think for a very well medically operable patient (not someone on baseline O2) who ends up with a segmentectomy for peripheral disease and has not met with a radiation oncologist, I don't think that's wrong per se.

I do think for someone who is borderline as to wheter they are medically operable or not, meeting with both groups is prboably worthwhile, and maybe there needs to be a 'borderline for surgery' candidate where there is true equipoise between a segmentectomy and SBRT...

1) you’ll get IR and iPulm saying they should be part of the shared decision making processs soon

2) I think it’s fair to still consider surgery the SOC until VALOR, officially; but on a local level agree that med oncs need to be convinced of the value of SBRT

IR therpaies are not in NCCN. Just definitive RT, preferably SABR. RFAs/Cryoablations are not NCCN supported and are not on any sort of equivalent footing based on current evidence base. I guess pulm does RFA too?

No ideal option there. Rfa and drop their lung? Resect with poor pfts and O2 req? Nope. Still doing sbrt in those cases

I would be much more open to a segmentectomy (as opposed to SBRT) in a pt on 3LNC due to ILD than a pt on 3LNC due to COPD. Not saying it's wrong to still do SBRT, and ILD and its relationship to the low-dose volume in RT is not an absolute contraindication, but something to worry about.