What are your PFT thresholds before definitive radiation for NSCLC?

[Kroll2013]

Dear colleagues,

I am interested to know your experience/institutional guidelines on how to set PFT (FEV1, FEV1/FVC, TLC, DLCO) thresholds below which you refuse radical radiation to an 80 years old, fit patient, clinically not dyspneic nor depending on oxygen who presents with left lower lobe T3N0 NSCLC invading ribs and chest wall (<5cm).

Abnormal pulmonary function tests predict the ... - PubMedpubmed.ncbi.nlm.nih.gov › ...

do have any specific guidelines or recommendations?

Thank you

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[medgator]

Afaik, most do not use PFT cutoffs to withhold radiation, unlike surgery

 

[StIGMA]

Agree with above. Would strongly consider SBRT 50/5 in this case.

 

[RadRadRad]

Agree I don’t typically factor in pfts
My recollection from sbrt data is that there is minimal if any change in pfts from pre and post treatment. If they have pulmonary fibrosis then I’m more cautious. But what other option does this patient have...immunotherapy and hops they die of something else in the next 2 years ?

 

[RadRadRad]

I would not do sbrt in this case

 

[thecarbonionangle]

50/5 vs 60/5 vs 60/8 and done brotha. Do not overthink.

 

[OTN]

I’ve done SBRT in patients with very poor pulmonary function. Is always tolerated well.

 

[Mandelin Rain]

I’ve had one bad chest wall toxicity and it was a medium sized t3 with chest wall/rib invasion. Did 60 Gy in 8. I’d be more apt to 70 in 17 or whatever. But yeah, you’re treating.

 

[seper]

No cutoff but I did have 2 patients who crashed and ultimately died in the unit, towards the tail end of fractionated lung RT, without chemo. So I always talk to patients / family with poor PFT ever since, to warn them.

 

[medgator]

If largish (4+ cm) and good PS, I'd consider chemo-rads. a 7+ cm lesion is no longer t3/sbrt eligible anyways, and the literature doesn't document great control rates even in t2b/T3 disease with SBRT

 

[Lamount]

I think PFTs are helpful for surgeons as it lets them know which patients they should send to us. The only concerns I would have regarding pulmonary function is the patient's stability, functional status (to the extent that some should go to hospice), or if they have ILD (which can go badly quickly with radiation)

 

[Lamount]

...regarding fractionation, you could do something hypofractionated to minimize chance of chest wall toxicity, which wouldn't be good in an 80 yo.

Considering chest wall invasion, would consider:
10 x 6.5-7 Gy (V15 < 35%) -can probably do just fine with 6.5 Gy/fx
15 x 4.5 -5 Gy (V16 < 35%)

 

[evilbooyaa]

Not a fan of SBRTing T3N0 by size or CW invasion. LC rates are not good in this population. Agree with something slightly more hypofractionated but maintaining BED.

Would consider 60/15 assuming no chemo. If patient chemo eligible, would probably just go 60-66 at 2Gy/fx.

In regards to original question, case as described is going to do just fine in terms of constraints, so unless they had interstitial lung disease, beam on. Not unreasonable to get a baseline set of PFTs but it's not going to change management.

 

[FrostyHammer]

Not a fan of SBRTing T3N0 by size or CW invasion. LC rates are not good in this population. Agree with something slightly more hypofractionated but maintaining BED.

Would consider 60/15 assuming no chemo. If patient chemo eligible, would probably just go 60-66 at 2Gy/fx.

In regards to original question, case as described is going to do just fine in terms of constraints, so unless they had interstitial lung disease, beam on. Not unreasonable to get a baseline set of PFTs but it's not going to change management.

How is 60/15 "maintaining BED"?

I agree with carbonionangle and would strongly suggest SBRTing or ablatively hypofractionating it (e.g. the MDACC 70 Gy in 10 fractions) because 1) the tumor is <5 cm (T3 is because of chestwall/rib invasion, not size) and 2) I would much rather have a somewhat higher risk of chestwall/rib toxicity up-front than the tumor recurring and then there being very few good options. Of course, patient should consent to that specific item, but if its me in his/her seat, I'm 100% accepting that increased rib/chestwall toxicity risk if it means that my disease is much less likely to come back.

 

[evilbooyaa]

How is 60/15 "maintaining BED"?

I agree with carbonionangle and would strongly suggest SBRTing or ablatively hypofractionating it (e.g. the MDACC 70 Gy in 10 fractions) because 1) the tumor is <5 cm (T3 is because of chestwall/rib invasion, not size) and 2) I would much rather have a somewhat higher risk of chestwall/rib toxicity up-front than the tumor recurring and then there being very few good options. Of course, patient should consent to that specific item, but if its me in his/her seat, I'm 100% accepting that increased rib/chestwall toxicity risk if it means that my disease is much less likely to come back.

Fair point on bolded. I think 70/17 would be reasonable as a hypofractionation regimen that is ablative (BED10 of 98.77). 70/10 also reasonable although not something I have extensive experience with (although not super different from 60/8). The struggle becomes not causing a rib fracture in an elderly gentleman who already may have some physiologic lung issues at baseline.

 

[thecarbonionangle]

How is 60/15 "maintaining BED"?

I agree with carbonionangle and would strongly suggest SBRTing or ablatively hypofractionating it (e.g. the MDACC 70 Gy in 10 fractions) because 1) the tumor is <5 cm (T3 is because of chestwall/rib invasion, not size) and 2) I would much rather have a somewhat higher risk of chestwall/rib toxicity up-front than the tumor recurring and then there being very few good options. Of course, patient should consent to that specific item, but if its me in his/her seat, I'm 100% accepting that increased rib/chestwall toxicity risk if it means that my disease is much less likely to come back.

RO: “i dont want to cause chestwall toxicity”
Same rad onc at FU: “damn i guess the tumor is back, you have a broken rib because the tumor is eating right through it. Oh well at least i did not cause the fracture we all good! surgery says you are inoperable for a radical complete chest wall resection. I guess we can send you for palliate chemo or immuno, i can maybe consider 30/10 at a later date. I really helped you, didnt I? you’re welcome sir!”

 

[FrostyHammer]

Fair point on bolded. I think 70/17 would be reasonable as a hypofractionation regimen that is ablative (BED10 of 98.77). 70/10 also reasonable although not something I have extensive experience with (although not super different from 60/8). The struggle becomes not causing a rib fracture in an elderly gentleman who already may have some physiologic lung issues at baseline.

BED of 70/10 clearly higher than 60/8, would prefer the former over the latter most anytime. MDACC routinely dose-paints their gross disease up to ~75-80 Gy. Also seems that the OP's patient was fit and not O2 dependent like many SBRT patients. As carbonionangle nicely mentioned above, I (with patient's permission) would have no hesitation in ablating the snot out of this chestwall-invading tumor.

 

[evilbooyaa]

It's not to say that we should cause no toxicities ever, but that we should pick fractionation schemes that do good job with tumor control and simultaneously minimize risk of toxicity.

Risk of toxicity with 5 fractions is more than the same BED10 given over 10-15 fractions. After some more reflection I agree that giving sub-ablative doses would not be ideal in this situation.

 

[scarbrtj]

We use the word “ablation” injudiciously in rad onc, and it doesn’t mean what we probably intend to mean (this dose ablates, that dose doesn’t!) when we say “ablation,” especially just from an English language standpoint. But if we take “ablation” just to mean “makes it go away,” 70/35 has ablative powers in a lot of tumors, even T3 lung cancers (as does 30/10, or 4/2, in other tumors, and so on).

Carry on.