What to do in stage III non small-cell lung cancer?
description
Transcript of What to do in stage III non small-cell lung cancer?
![Page 1: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/1.jpg)
What to do in stage III non small-cell lung cancer?
Miklos Pless
28. November 2013
![Page 2: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/2.jpg)
2
CRT: Concomitant vs. SequentialMeta-Analysis 2010 (HR 0.84, Cochrane 0.74)
Auperin, JCO 2010
![Page 3: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/3.jpg)
3
CRT: Chemotherapy type not so important?CALGB 9431 (phase II)
Vokes, JCO 2007
![Page 4: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/4.jpg)
4
Vokes, JCO 2007
CRT: Role of induction chemotherapyCALGB 39801
![Page 5: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/5.jpg)
5Yamamoto S. et al., J. Clin. Oncol. 30, 2012, suppl. Abstr.7000
45 trials, 9 phase III, 36 phase II with 51 arms
No difference between the two groups,
med OS: CT 18.5 mo vs no CT 18.1 mo
CRT: role of consolidation CT after CRT?
![Page 6: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/6.jpg)
6
HR 0.925
Curran, JNCI 2011
CRT: role of hyperfractionationRTOG 9410
Arm 3: 70 Gy: 1.2 Gy 2x/d
Arm 2: 63 Gy: 1.8 Gy/d
![Page 7: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/7.jpg)
7
CRT: Role of high doses of RTRTOG 0617
Bradley , ASCO 2013
![Page 8: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/8.jpg)
8
Operable stage IIIA:Adjuvant Chemotherapy: OS better!
Winton, NEJM 2005
![Page 9: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/9.jpg)
9PORT Cochrane, 2010
Operable Stage IIIADoes adjuvant RT help? NO!
![Page 10: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/10.jpg)
10
•Unresectable (?) N2
•With response to Induction
3 x Cis/Carbo + X
•OP vs. RT (60 Gy)
•1. EP: OS
•50% complete resection!
•41% downstaging to ≤ypN1
•Unresectable (?) N2
•With response to Induction
3 x Cis/Carbo + X
•OP vs. RT (60 Gy)
•1. EP: OS
•50% complete resection!
•41% downstaging to ≤ypN1
JNCI, 2007
![Page 11: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/11.jpg)
11
Resectable N2 Induction CRT:
3x Cis/Eto + RT 45 Gy
If no PD: RT to 61Gy vs. OP
1. EP: OS
Resectable N2 Induction CRT:
3x Cis/Eto + RT 45 Gy
If no PD: RT to 61Gy vs. OP
1. EP: OS
Lancet 2009
PFSOS
![Page 12: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/12.jpg)
12
The activity of the SAKK groupSAKK 16/96 (Phase II)
3 x Cisplatin/Taxotere neoadjuvant (Betticher, JCO 2003)Overall Survival (ITT population, n=90)
0
.2
.4
.6
.8
1
0 10 20 30 40 50 60
Months
Overall survival
complete
resection
incomplete
resectionp<0.0001
all
![Page 13: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/13.jpg)
13
Is trimodal better than bimodal?SAKK 16/00
Presented by: Miklos Pless
Stratification factors: Mediastinal bulk (≥5cm vs. <5cm), weight loss (≥5% vs. <5% in past 6 months), center
*
* *
* Staging: (PET-) CT: PD went off study
![Page 14: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/14.jpg)
14
Overall Survival
Treatment Median OS (95% CI)RT 27.1 (18.8, 42.8)
no RT 26.2 (21.0, 52.1)
HR = 1.145 (95% CI: 0.786-1669)
Pless ASCO 2013
Time (months)
Ove
rall
Su
rviv
al
// ////
//////////
/
///
/ ////
///
/ // // / / / //
/ /
///
/ //////
///////
/// / / / / / /////// /// /
/// // / / / / /
0 24 48 72 96 120 1440
0.2
0.4
0.6
0.8
1
# at riskRTno RT
98 43 19 7 6 1 097 41 21 10 2 0 0
Chemo/RT/SurgeryChemo/Surgery
![Page 15: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/15.jpg)
15
Stage III
• Very heterogeneous disease
• <30% can be cured (70-80% are NOT!)
• Both local and distant relapse are a problem!
• Requires bimodal treatment
• always Chemotherapy: minor effect
• Surgery vs. Radiotherapy?
• Trimodal treatment?
![Page 16: What to do in stage III non small-cell lung cancer?](https://reader035.fdocuments.us/reader035/viewer/2022062520/56815a91550346895dc8066a/html5/thumbnails/16.jpg)
16
Summary & Conclusions
Which Chemotherapy? (Cis-)Platinum based, concurrent
type and dose
Which Radiotherapy? >60 Gy, less than 70 Gy
type, dose, fraction
Which combination?
Surgery + Chemotherapy Stage IIIA/N2
Radiotherapy + Chemotherapy Stage IIIB/IIIA?
all three? Probably not