Role of radiation in small cell lung cancer

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  • Contralateral SCF and contralateralhilar excluded from the limited study in many studies. s
  • A 1992 meta-analysis evaluated randomized trials in which more than 2,100 patients with limited-stage SCLC were randomized to receive either chemotherapy alone or in combination with chest irradiation.236 Patients given combined modality therapy had a 14% reduction in death rate and an absolute 5.4% improvement in 3-year survival compared with those who received chemotherapy alone. Both differences were highly significant in this meta-analysis.(pignon and warde)
  • 25-217 days
  • We treated 231 patients withLS-SCLC. TRT consisted of 45 Gy over 3 weeks (1.5 Gytwice daily), and the patients were randomly assignedto receive either sequential or concurrent TRT. All patientsreceived four cycles of cisplatin plus etoposideevery 3 weeks (sequential arm) or 4 weeks (concurrentarm). TRT was begun on day 2 of the first cycle ofchemotherapy in the concurrent arm and after thefourth cycle in the sequential arm.Results: Concurrent radiotherapy yielded better survivalthan sequential radiotherapy (P .097 by logranktest). The median survival time was 19.7 monthsin the sequential arm versus 27.2 months in the concurrentarm. The 2-, 3-, and 5-year survival rates forpatients who received sequential radiotherapy were35.1%, 20.2%, and 18.3%, respectively, as opposed to54.4%, 29.8% and 23.7%, respectively, for the patientswho received concurrent radiotherapy. Hematologictoxicity was more severe in the concurrent arm. However,severe esophagitis was infrequent in both arms,occurring in 9% of the patients in the concurrent armand 4% in the sequential arm. Takada et al. (4) demonstrated that concurrent treatmentled to better outcomes than sequential. However, their studywas underpowered to demonstrate a survival benefit (114 patientsin each arm), but it did show a tendency for improvedsurvival (median 27 vs. 20 months; p < .10) with concurrenttreatment. The improved outcome was accompanied by a significantincrease in Grade 3 or greater leukopenia (85% vs.54%) (
  • This suggests that in the setting of combined-modality treatment, modest changes in treatment delivery can result in clinically significant changes in outcome.
  • investigators showed that a shorter interval between the first day of chemotherapy administration and the last day of RT was associated with improved survival (12), indicating that accelerated tumor repopulation plays an important role.
  • Role of radiation in small cell lung cancer

    1. 1. ROLE OF RADIATION IN SMALL CELL LUNG CANCER Dr Bharti Devnani Moderator:- Dr Sheh Rawat
    2. 2. Staging of SCLC depends on radiation portals (Veteran’s administration lung group) Limited Stage Disease confined to I/L hemithorax which could be safely encompassed with in a tolerable RT field. T1, T2, nonmetastatic  Contralateral mediastinal and I/L SCF Extensive stage Beyond I/L hemithorax T3,T4 and metastatic disease
    3. 3. Definitive (For LS) Thoracic radiation as a part of CCRT Adjuvant RT Node positive cases after lobectomy Prophylactic cranial irradiation Palliative EXRT Thoracic Brain mets Bone mets Oncologic emergencies SVCO Spinal cord compression Palliative brachytherapy Endobronchial brachytherapy: Hemoptysis
    4. 4. ROLE OF THORACIC RADIATION IN LIMITED STAGE
    5. 5. EVOLUTION Before the introduction of chemo in 1970, RT was the mainstay of treatment CT More local recurrences with chemo alone CT+RT-Standarad of care
    6. 6. EVIDENCE FOR THORACIC RADIOTHERAPY 25-30% reduction in the local recurrence with 5-7% increase in 2 year survival with addition of radiotherapy Pignon et al NEJM 1992 327;1618-24
    7. 7. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Portals (before chemotherapy v/s shrinking field)  Dose and fractionation schedules (conventional v/s hyperfractionation)
    8. 8. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Portals (before chemotherapy v/s shrinking field)  Dose and fractionation schedules (conventional v/s hyperfractionation)
    9. 9. Takada et al.J Clin Oncol 2002; 20:3054-60. Better outcome with CCT with a trend towards improved OS. Concurrent RT reduces the risk of tumor repopulation and development of resistant clones. Radiosensitizing effect
    10. 10. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Portals (before chemotherapy v/s shrinking field)  Dose and fractionation schedules (conventional v/s hyperfractionation)
    11. 11. Benefit in 2 year survival rate with early RT(within 9 weeks or before 3rd cycle)
    12. 12. Factors which have significant impact on the benefit of early RT were:-  Type of chemotherapy  The fractionation scheme
    13. 13. Concept of SER Start of any treatment until the end of radiotherapy
    14. 14. Cancer Treat Rev 2007; 33:461-73.  Significant 2 & 5 years improvement in survival when RT was started within 30 days of platinum based chemo (2-year survival: HR: 0.73, 5-year survival: HR: 0.65).  This was even more pronounced when the overall treatment time of chest radiotherapy was less than 30 days.
    15. 15. Early and concurrent chemoradiation is preferred over late and sequential schedule.
    16. 16. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Dose and fractionation schedules (conventional v/s hyperfractionation)  Portals (before chemotherapy v/s shrinking field)
    17. 17. High chances of local recurrence with conventional RT, attempts made to improve the outcome by:- Hyperfractionated Accelerated radiotherapy Dose escalation
    18. 18. 417 patients LS- SCLC 45 Gy at 1.5 Gy/#B.D.x3weeks 45 Gy/25# at 1.8 Gy/# x5 weeks Grade -3 Esophagitis (27%v/s 11%) P<0.001
    19. 19. ONGOING TRIALS (HYPERFRACTIONATION & DOSE ESCALATION)
    20. 20. ISSUES IN THORACIC RT OF SCLC  Sequencing with chemotherapy (concurrent v/s sequential)  Timing of RT (Early v/s late)  Dose and fractionation schedules (conventional v/s hyperfractionation)  Portals (before chemotherapy v/s shrinking field)
    21. 21. RT PORTALS  PET based planning should be used. (PET at the time of radiotherapy planning or within 4 weeks)  GTV = Post induction chemotherapy volume  Omission of elective nodal irradition.  Low rates of local recurrence(11% with only CT based planning, 3 % with PET based planning)  Decreases the esophageal toxicity significantly.
    22. 22. ROLE OF THORACIC RT IN EXTENSIVE STAGE
    23. 23. CR at distant sites and any response at local site (n=210) CT + RT= 54 Gy/36# CT alone Median survival-17 months v/s 11 months Survival rate at 3 years-22% v/s 13% Survival rate at 5 years-9% v/s 4%
    24. 24. PROPHYLACTIC CRANIAL IRRADIATION
    25. 25. Rationale  Frequent brain mets in SCLC  20 %- at diagnosis  80%- during the course of the disease  Once symptomatic- results have been poor.
    26. 26. Incidence of brain metastasis decreased by 25% at 3 years (58.6% v/s 33.3%) 5.4 % survival benefit with addition of PCI
    27. 27. PCI IN EXTENSIVE STAGE DISEASE 14.6 % v/s 40.4% 27.1% v/s 13.3% at 1 yr
    28. 28. DOSE OF PCI Limited stage 25 Gy/10# 24 Gy/8# 30Gy/15# Extensive stage 25 Gy/10# Shorter fractionation scheme of 20 Gy/5# can be used. Dose>30 Gy should be avoided due to high risk of neurotoxicity
    29. 29. ROLE OF RT IN ADJUVANT SETTING
    30. 30. ROLE OF RT IN PALLIATION (EXRT)
    31. 31. RADIATION FOR BRAIN METASTASIS WBRT- 30Gy/10#
    32. 32. BONE METS & PATHOLOGICAL FRACTURE 30 Gy/10# 20Gy/5# 24Gy/6# 8 Gy single fraction
    33. 33. ROLE OF RADIATION IN ONCOLOGIC EMERGENCIES IN SCLC
    34. 34. SPINAL CORD COMPRESSION 30Gy/10#
    35. 35. SUPERIOR VENA CAVA OBSTRUCTION  Symptomatic relief in 70-90% cases with radiotherapy alone.  Dose- initial high dose fractionation of 3- 4 Gy followed by 1.8 Gy fractionation
    36. 36. ROLE OF ENDOBRONCIAL BRACHYTHERAPY - HEMOPTYSIS
    37. 37. TAKE HOME MESSAGE
    38. 38. LS-SCLC Concurrent CCT/RT Early(1st or 2nd cycle) Dose-45 Gy @1.5 Gy bd or 50-60 Gy @1.8 Gy once daily Any response to chemo-PCI to a dose of 25 Gy/10# ES-SCLC Any response to chemo- PCI-25 Gy/10# or shorter 20 Gy/5# can be used. Possible value of local RT are the subject of ongoing investigation. Palliation
    39. 39. Thank U
    40. 40.  Santa air hostess se-aapki shakal meri biwi se milti hai  Air hostess ne zordar thappad santa k muh pe mara  Santa- Kamal hai, Aadat bhi milti hai
    41. 41. Very Touchy story: "Husband forgot to wish her on his Wife's birthday. He came home late at night from the office ..... His wife shouted: How would u feel if u dont see me for next few days? He couldnt believe his luck. He replied at once.'' Wowww.....That would be great..!'' Monday passed & he didn't see her. Tuesday he didnt see her . . & wednesday passed too . . On Thursday the swelling was better & he could see her from the corner of his left eye...

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