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Best of 51th ASTRO in 2009 Lung Cancer SessionJinming Yu MD. PhD; Shandong Cancer Hospital & Institute Shanghai, December 4, 2009Plataue for ChT & RT I n the Treatment of NSCLC ☐ASCO-2007: LA-NSCLC Data –From 1965 to 2004,15000 pts out of 64 centers–Sur+Cht 5y survival= 4%;RT+ChT 5y survival= 2.2% ☐Global of Lung Ca: WCLC-2009 –13% in 1975 Vs 15% in 2007 for 5yr survival–No significant survival increase over 30yrsNeed Better Understand BalanceRisks ?Benefits?Gold Standard☐Survival☐Quality☐CostUSA Japan Europe China Canada Korea Poster# 67 17 18 12 8 1 Oral # 21 3 1 1 2 0Discussion Total #89620221132121Accepted Abstracts of ASTRO for Lung Cancer-WorldwideThe total accepted number of abstracts in lung Cancer is 173Hospital NameTotalOralShandong Cancer Hospital 6 1 Air Force General Hospital 2 0 Fudan Cancer Hospital 2 0 Hebei Cancer Hospital 1 0 Tongji Hospital1Accepted Abstracts of ASTRO For Lung Cancer in ChinaThe total accepted number of China in lung Cancer is 12Presentation Outline ❒SBRT for early staged NSCLC AdvantagesChallenges & Pitfalls❒Treatments and outcomes❒Accurate target delineation Anatomic imaging guidedBiological imaging guidedPart One SBRT for Early Staged NSCLC(1)SBRT for Medically Inoperable Early Stage NSCLC Pts: Analysis of RTOG 0236R. D. Timmerman, J. Bradley, G. Videtic, H. Choy et alPurpose:The RTOG 0236 protocol was a phase II trial utilizing SBRT with ablative prescription dose to treat early staged and medically inoperable NSCLC ptsMaterial & Methods☐All pts with biopsy proven peripheral/unoperable T1-T2NoMo☐The prescription dose was 18-20Gy/f, 3 fxs, total dose of 54-60 Gy and the treatment was delivered in 1.5-2 wks☐The primary endpoint was 2 yr local control. The 2nd endpoint was OS, DFS, RT toxicity, & patterns of failure☐Local failure was defined as enlargement of at least 20% on CT and either biopsy confirming Cancer or PET higher uptakePreliminary Results☐Total of 59 pts in the study and of 55 evaluable pts, 44 had T1and 11 had T2 tumors. Median age was 72 years☐Grade 3 and 4 adverse events were reported in 13 (24%) & 2pts(4%), respectively, most common complications waspulmonary. No treatment related deaths were found☐Median follow-up of 24.8 mons, 3 pts (5%) have local failure, giving estimated2 yr local control of93.7%. Only 2 pts have regional failure while 11 pts (20%) experienced distant failure☐2yr DFS & OS were 66.6% and 72.0%,respectivelyConclusions☐SBRT using total dose of 54-60Gy in 3 fxs associated with very high local tumor control and moderate RT related morbidity in pts of medically inoperable early stage NSCLC peripheral lesions☐Despite clinical stage, local & regional failure was low but the significant distant mets was found☐This data showed: 2-yr DFS & OS are encouraging(2) SBRT Results of Promising Local Control In Pts With RecurrentOr 2nd Lung Ca After Definitive Conventional Thoracic RT Purpose:Recurrent or secondary lung Ca is common amongpts who have previously undergone definitive thoracic RT.To analyze tumor local control, patterns of failure, survival &toxicity after SBRT in such ptsP. Kelly, P. A. Balter, N. C. Z. Liao, R. Komaki, J Y. ChangMaterial & Methods☐Retrospectively identified 42 pts who were treated with SBRT to thethorax after prior RT to the chest. All pts had undergone definitivethoracic RT for primary lung Ca 88% or esophageal Ca 12%☐Recurrent, mets, or secondary lung Ca was histologically confirmedand staged with PET/CT. No pt had evidence of nodal mets but 4 had evidence of distant mets.☐All pts underwent 4DCT-based planning & daily in room CT guided,The most common prescribed doses were 40Gy(n=6) or 50Gy(n=33) to the PTV (the motion envelope of the GTV plus an 8mm margin for CTV plus a 3mm margin for daily targeting uncertainties), at 10 to 12.5 Gy/fraction delivered in 4 consecutive daysPreliminary Results☐The median period between treatment interval was 21.1 mons☐Median follow up time of 11.8 mons from SBRT,in-field local control rate was 95% and 1 yr overall survival rate was 86%☐The most common failure after SBRT was intrathoracic relapse outside the SBRT field(52%). Relapse occurred most often in the previouslyirradiated site, particularly when the interval to SBRT was < 6 mons ☐After SBRT, 40% of pts experienced worse shortness of breath vsbefore SBRT; 14% required supplemental oxygen; 16% experienced chest wall pain & 7% had grade 3 esophagitis. No grade 4 or 5 toxicityConclusionsSBRT provides a excellent local control & with acceptable toxicities for pts with recurrent or secondary lung cancer who were previously treated with definitive conventional thoracic RT(3) Outcomes Comparison: SBRT orWedge Resection for Stage I NSCLCI.S. Grills, V. Mangona, R. Welsh, G. Chmielewski, E. McInerney S. Martin, L. L. Kestin William Beaumont Hospital, Royal Oak, MI Purpose:Local failure after wedge resection (W) for early stage NSCLC is higher than after lobectomy,but borderline operable pts often undergo W aloneThat such pts might be equally good candidates for lung SBRT and also compares SBRT to WMaterial & Methods☐124 pts of Stage I (T1-2N0M0) NSCLC were treated with W (n=69) or image-guided SBRT (n=58) from 2/03-2/09☐SBRT pts were treated on a Phase II trial. All pts were ineligible for lobectomy; 95% undergoing SBRT were medically inoperable☐All pts were staged using CT, PET-CT, pulmonary function testing, and chemistries. SBRT pts had bone scan and brain MRI☐SBRT was prescribed as 48Gy(T1)- 60Gy(T2) in 4-5fxs to the edge of target. Adjuvant ChT given to 16% of SBRT & 10% of W pts☐No significant differences existed in T-stage or size for SBRT vs WPreliminary Results☐Median follow-up=2.5 yrs. No significant differences were identified in30mons in regional recurrence(RR) (4% SBRT vs 18% W), locoregional recurrence(LRR)(9% v 27%W), DM(19% SBRT v 21% W), or freedom from any failure (FFF) (77% v 65%W) between groups (p>0.16 for all)☐SBRT reduced the risk of local recurrence (LR), (4% vs 20% W, p=0.07) Overall survival (OS) was higher with W (87% v 72% , p=0.01), but cause-specific survival (CSS) was identical (93% W vs 94% SBRT)Conclusions for Part One☐SBRT is good treatment options for Stage-I NSCLC pts SBRT better than W/SLobectomy VS SBRT?☐SBRT was associated with the followingsIdentical survival, especially in CSSReduced LR, RR and LRR☐Pay more attentions to pts with heavy smoking & poor pulmonary function before RT for fetal lung damages我们真正需要有一个Phase III的临床研究来回答这个问题T 1N 0M 0临床与病理N 分期-山东资料周围型T 1N 0M 0(30例) 准确率22/25(88%)中心型T 1N 0M 0(38例)准确率30/38(79%)病理N0 N1 N2 T1 22 3 1 T231病理N0 N1 N2 T13044T2 0 0 0T 2N 0M 0临床与病理N 分期-山东资料中心型T 2N 0M 0(30例)–准确率22/27(81%)病理 N0 N1 N2 T1 1 1 0 T2 22 4 0 T330 0 病理N0N1N2T12 1 0 T2288T3 1 0 0周围型T2N0M0(40例)准确率28/37(80%)SBRT技术的不足点SBRT for Early Stage NSCLC ❑对原发灶缺乏准确的分期–容易导致靶区勾画的错误❑对淋巴结缺乏准确的分期–导致淋巴结的低分期问题❑不能正确指导治疗的问题–影响化疗及其放疗的选择❑不能正确判断患者的预后初步的结论是SBRT for Stage-I NSCLC ❒用于不能耐受手术的Stage-I患者( V ) ❒用于那些拒绝手术的Stage-I患者( V ) ❒用于能够切除的周围型T1N o患者( V) ❒用于3-5个或以下的肺转移病灶者( V) ❒用于能够切除的T2N o周围型患者( ? ) ❒用于能够切除的T2N o中心型患者( ? )杜绝治疗错误? CFRT=1/33 Vs SBRT=1/3-5Part Two Treatments & Outcomes(1) Survival Impacts of PCIfor Limited Stage SCLCM. E. Giuliani, A. Hope, A. Sun, D. Payne, N. Leighl, A. Bezjak Purpose:The objectives were to assess the impact of PCI on OS & brain failure free survival (FFS) in pts with limited stage SCLC. To assess the value of PCI & the factors impacting PCI utilization 主要是要回答PCI能否给SCLC治疗后达到CR的患者提高生存的问题Material & Methods☐From 1997 to 2007, 796 pts were treated at PMH for SCLC. Of these,227 pts (28.5%)had limited stage of disease treated radically☐OS and brain FFS were estimated which comparedthe pts treated with or without PCIPreliminary Results☐Of the 227 pts treated radically for LS-SCLC, 56% received PCI ☐The median follow-up time was 16.7 mons☐Brain FFS at 12, 24, 36 and 60 mons was 77%, 41%, 41% & 41% respectively for pts who did not receive PCI; & 95%, 77%, 75% and 69%, respectively for pts who did (p<0.001)☐Overall survival at 12, 24, 36 and 60 mons was 74%, 35%, 27% and 13% for pts who did not receive PCI;and 94%, 56%, 46%, 33% for pts who did (p<0.002)Conclusions☐PCI significantly improves overall survival &brain FFS in pts with LS-SCLC☐All pts with LS-SCLC who got CR should be considered for PCI(2) A Phase III Study of PCI VS Observationin Pts with LA-NSCLC; RTOG 0214QOL and Neurecognitive AnalysisB Movsas, H Choy; et alPurpose: To study the effects of PCI for the pts with NSCLC on neurocognitive function & QOL;To evaluate the benefits for OS and DFSBackground❑CNS failure rates are high for pts with LA-NSCLC❑Prior randomized studies showed that PCI can decrease risk of brain mets☐The effect to survival is contraversial?RTOG 0214: SchemaNo CNS metastases By Brain MRI or CT No tumorprogressionafter curativetherapy forStage ⅢA/BNSCLC S T R A T I FY Stage: 1. cStage-IIIa 2. cStage-IIIB Histology: 1. Squa-C-Ca 2. Non-SCCa Treatment: 1.Surgery or2.No Surgery R A N D O M I Z E PCI 30Gy at 2Gy/Fx OBSERVATIONTo accrual was 356 pts of the targeted 1058Preliminary Results❑1 yr OS was 75.6% VS 76.9% (p=0.86); and 1 yr DFS 56.4% VS 51.2%,(p=0.11) for PCI VS Observa respectively,with no significant differences❑The incidence of CNS mets at 1 yr was 7.7% VS 18% respectively☐There were no significant differences in global cognitive function or QOL following PCI, but there was a significant decline in memoryConclusion & Suggestion❑PCI significantly decreases the risk of CNS failure for pts with stage-III NSCLC; but no significantdifferences in OS or DFS❑There was no significant difference in cognitive function or QOL following PCI❑There was a significant declines in pt’s memory ❑We should limit PCI to very high risk pts only –Non-squamous NSCLC pts have 27% risk❑Use BBB-penetrating ChT agents such as TMZ(3) Patterns of First Failure In A Phase II Study of Accelerated High Dose Thoracic RT(TRT) With Concurrent ChT for LS-SCLCRTOG 0239 StudyR. U. Komaki, R. Paulus, G. Videtic, J. Bradley, B. Glisson, H.Choy Purpose:Total dose (45Gy) was low in an AcceleratedFractionation (AXHFX) trial (INT0096) which showed high local recurrence both in AXHFX (40%) and Daily FX (60%) arms.RTOG 0239 was a phase II trial to improve local-regionalcontrol and survival of LS-SCLC pts treated by higher dose ofAXHFX TRT with concurrent boost and EP X 4 Cycles主要回答>45Gy加速分割能否提高SCLC患者局部-区域控制与生存率Material & Methods☐TRT was given to large field to 28.8Gy/16Fx/once daily. followed by BID with large field in AM, boost in PM, then off-cord boost BID for last 5 days, all at 1.8Gy/FX, 5 days/wk. Total dose was61.2Gy 34 Fs/5 wks. Concurrent ChT was started with RT with EP Protocle ☐The patterns of first failures were studyed: local-regional failure(LRF), distant metastatic failure (DMF) and survivalsPreliminary Results☐Accrual 72 pts & the median follow-up is 19.0 mons for all pts☐41% of pts achieved a CR at 2 mons post-treatment, & another 39% had a PR☐The 2-yr survival rate was 36.6%☐Disease progression was present in 51 pts (72%). DM only was the leading site of first failure seen in 31 pts (61%). LRF only was seen in 14 pts (27%). Mixed LRF & DMF were seen in 6 pts (12%) ☐Liver & bone were the most common with 27% of pts & followedby brain mets (24%). Other DMF were 14% in the lung, 3% in the supraclavicular fossa and 3% in pleuralConclusions☐This accelerated higher dose TRT with concurrent boost and EP for LS-SCLC demonstrated a good loco-regional control☐Distant mets is higher. More efficacious systemic treatment as well as better staging workup suchas PET/CT is required to improve distant failures(4)Addition Of Erlotinib To Pre & Post-op ChT/RT And As Maintenance For Resectable Mediastinoscopy-defined Stage III NSCLC: Phase II TrialG. M. Videtic, T. Rice, M. Shapiro, C. Reddy, T. MekhailPurpose:To report on phase II trial results, testing theaddition of E to pre & post-op ChT/RT for potentiallyresectable stage III NSCLCMaterial & Methods☐Eligible pts had stage IIIA & B NSCLC as determined by mediastinoscopy and PET. They were judged surgicallyresectable. Pre & post-op ChTRT consisted of wkly PC & concurrent hyperfractionated RT(30Gy/1.5Gy BID,>6hrs) with daily oral E (150mg) for 28 days☐Following restage, non-progressors underwent resection.4 to 6 wks following surgery, ChTRT with E was re-administered, followed by 2 yrs of maintenance of EPreliminary Results☐Total 25 pts & median follow-up was 30.3 mons.64% were female.16% were never smokers. 92% had stage IIIA disease, 64% had adeno☐There were no pre & post-op esophageal & respiratory toxicities abovegrade 2; 8 pts (32%) had pneumonectomy. Downstage to N0-1 was seenin 50% pts.Surgery was the only significant factor accounting for change in pulmonary function (p <0.0001)☐Median duration of maintenance E was 6.9 mons. Median, 3 yr overall & relapse-free survival were: 41.4mons, 58.8% & 43.6%, respectively☐For downstaged pts, median 3yr overall and relapse-free survivals were 70% and 59.5%respectivelyConclusions☐Addition of E to pre & post-op ChTRT produced minimal toxicity & resulted in notable Down-staging☐Resulting in improved survival for this study and the further testing of this regimen is warrantedPart ThreeTarget Delineation for NSCLC(1) Use Of SUV-max & Metabolic Tumor Volume To Predict Microscopic Extensions For CTV Delineation Of NSCLC X. Meng, X. D. Sun, G. R. Yang, D. B. Mu, X. G. Zhao, J. M. YuPurpose:To investigate correlation both the SUVmax and Metabolic Target Volume(MTV) with the maximal Microscopic Extensions (MicExt) for primary tumor of NSCLC主要研究是回答 SUVmax & MTV 能否帮助我们个体化确定NSCLC的CTVMaterial & Methods☐38 NSCLC pts in stage I-IIIA had integrated FDG PET/CT scans before therapy☐SUVmax and MTV were calculated & all ptsunderwent thoracotomy within 5 days after FDG PET/CT study☐The tumor was transected postoperatively tointerpret correctly the limit of the MicExt. Wemeasure the maximum linear distance from the tumor margin to the farthest extent of the tumorSUV & MTV 与肿瘤镜下浸润范围关系 2009 ASTRO Oral Presentation-Chicago P=0.008 P<0.001 39例NSCLC ME 平均值为4.61mm ±2.71mm肿瘤最大SUV 的平均值为7.24±2.41肿瘤代谢体积的平均值为40.62cm 3±33.66cm 3Preliminary Results☐MicExt for all pts had a significant correlation with SUVmax (P=0.008) and a stronger correlation with MTV (P<0.001)☐SUVmax and MTV differed significantly across histologic subtypes. SCC had lower SUVmax and MTV compared with ADC (P=0.004 and P=0.001, respectively). Tumors with better differentiation had lowerSUVmax (P<0.001) and also had lower MTV (P<0.001)☐MicExt was also differed with tumor pathology. SCC were found tohave lower MicExt than ADC(P=0.002). The results obtained for FDG uptake, Well differentiatated tumors had lower MicExt (P<0.001)Conclusions☐This study demonstrated a clear relationship between SUVmax and MTV with MicExt in primary tumor of NSCLC, suggesting that high SUVmax and MTV have more microscopicextension and would therefore require more margin expansion from GTV to CTV☐These prospective results would probe intoallowing the CTV to be optimally adapted to individual situations in vivo(2) Local & Distant Failure Rate and Patterns of Recurrence in Stage-II & N1 Surgically resected NSCLC J. Varlotto, L. M Davis, E. Schaefer, M. DeCamp Purpose:This investigation will examine the failure pattern & factors associated with local & distant recurrence of surgically resected NSCLC with N1 nodal involvement主要是回答Stage II-N1病人主要失败方式及确定治疗手段Material & Methods☐This study included 457 pts treated who didn’t receive adjuvant or neoadjuvant RT, Who had at least 3 mons follow-up☐Of these, 51 pts(11.0%) had Stage II-N1 disease.They compared these to 224 Stage IA and 140 IB pts fromthe same series. Local and distant recurrence as well as survival were calculated and compared。
