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S.H. How
Moderator of
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MS23 - Treatment of the Small Malignant Nodule (ID 40)
- Event: WCLC 2013
- Type: Mini Symposia
- Track: Pulmonology + Endoscopy/Pulmonary
- Presentations: 7
- Moderators:T. Sutedja, S.H. How
- Coordinates: 10/30/2013, 14:00 - 15:30, Bayside Auditorium B, Level 1
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Case Part 2 (ID 5670)
14:27 - 14:47 | Author(s): H. Jo
- Abstract
- Presentation
Abstract not provided
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MS23.1 - Case Part 1 (ID 567)
14:05 - 14:10 | Author(s): H. Jo
- Abstract
- Presentation
Abstract not provided
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MS23.2 - Is Tissue Diagnosis Necessary? (ID 568)
14:10 - 14:27 | Author(s): D.P. Steinfort
- Abstract
- Presentation
Abstract not provided
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MS23.3 - SABR for Early Stage Lung Cancer and Pulmonary Oligometastases (ID 569)
14:47 - 15:04 | Author(s): H. Onishi
- Abstract
- Presentation
Abstract
With the recent popularization of computed tomography (CT) screening, small malignant nodules are increasingly detected. In Japanese cases of lung cancer surgery, tumors in more than 60% of lung cancer patients were under 3cm in diameter. Stereotactic ablative radiotherapy (SABR) is a new treatment modality where narrow beams from several directions focus on the target while sparing the adjacent normal tissues with high accuracy. By SABR, the biological effect of radiation on tumors was increased and the overall treatment time was shortened. SABR has emerged as one of the radical treatment options for stage I non-small cell lung cancer (NSCLC), mainly in medically inoperable patients. First of all, Uematsu et al reported in 2001, that 3-year local control and overall survival rates of SABR (50-60Gy in 10 fractions) were 94% and 66%, respectively. Then Nagata et al reported in 2005, that 3-year overall survival rate of SABR (48Gy in 4 fractions) was 83% in stage IA and 72% in stage IB. In Japanese multi-centers large database of more than 2000 patients treated with SABR for stage I NSCLC, overall survival rate at three year (OS-3y) and disease-specific survival rate at three year of total patients was 72% and 85%, respectively. Locally progression free rate at three year of T1 and T2 tumors were 87% and 72%, respectively. In USA, Timmerman et al reported in 2010, that 3-year overall survival rate of SABR (54Gy in 3 fractions) was 55.8%. In Europe, Bauman et al reported in 2009, that 3-year overall survival rate of SABR (45Gy in 3 fractions) was 60%. According to a lot of previous studies demonstrating better results of SABR compared with conventional radiotherapy, a consensus that SABR is a standard radical treatment for inoperable patients with stage I NSCLC has been generally accepted. The overall survival rate for subgroup of medically operable patients who rejected surgery in retrospective and prospective studies was almost comparative to that of surgical series considering the same age range though its evidence level is not high. Onishi et al reported five-year overall survival of 87 patients with stage I NSCLC was 69% according to the multicenter retrospective study,. In the phase II trial of SABR with 48Gy in 4 fractions for stage IA (JCOG0403), Nagata et al reported three-year overall of 65 operable patients was 76%. For patients with stage I NSCLC, resection of full lobe and systemic lymph nodes represents standard treatment but can be associated with significant morbidity and even mortality, particularly because patients suffering from lung cancer are often elderly with high comorbidity rates. For such high-risk operable patients, SABR is considered as an alternative option of radical treatment. According to American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, SABR and surgical wedge resection are suggested over no therapy for patients with clinical stage I NSCLC who cannot tolerate a lobectomy or segmentectomy (Grade 2C), but surgical resection has the potential benefit of definitive histologic analysis and pathologic nodal information. In compromised patients for whom such information would not change management and also in patients for whom an adequate margin in unlikely with a surgical wedge resection, SABR is a preferred option. According to good results of these retrospective or prospective studies, some phase III prospective trials comparing SABR versus surgery (lobar resection) have been started, but the patient accrual seems to be difficult. Patient accrual of a trial exploring the efficacy and safety of sublobar resection for patients with smaller tumors has been completed by surgeon recently. SABR is a just local therapy, therefore it essentially should be compared with sublobar resection in high-risk operable patients for lobar resection with such small peripheral tumors. In the meantime, SABR represents a recent trend in radiation oncology also for oligometastases. Local aggressive therapy for oligometastases may improve outcomes, including survival in some cases. SABR has emerged as one option for local therapy against oligometastases in various body sites, most commonly in the lungs and liver. According to published papers of SABR for lung metastases, local control with SABR distributed from 70 to 90% with very low rates of serious toxicities. Although further investigation should be undertaken to clarify the benefits of SABR for the treatment of oligometastases, SABR may be worthwhile for patients who hope for treatment to acquire better local control and possible longer survival. Concerning toxicities, SABR for peripheral tumors is an almost safe and comfortable treatment. Rib fracture is a common adverse effect after SABR but the symptom is generally mild. But severe radiation-related pneumonitis occurs occasionally in the patients having pulmonary fibrosis. As the clear dose-constraint for mediastinal organs has not been demonstrated, the safety of SABR for cases with a central lesion has not been assured. When the tumor recurred only locally after SABR in operable patients, salvage radical surgery was mostly operated safely. Primary radiation therapy remains the primary curative intent approach generally for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable or high-risk operable. However, good tumor control, less toxicity, and fewer treatment courses of SABR decrease the indirect costs of cancer care, including lost time and economic productivity secondary to treatment-related and cancer-related illness and death. On the other hand of promising results and advantages of SABR, it is imperative to assess its cost-effectiveness as well as its efficacy because SABR is becoming used in more clinical situations. SABR employing image guidance, high-precision dose delivery, more accurate target definition with better anatomical and biological imaging, and the possibility of dose verification during treatment via dose-adaptive radiation therapy permits a higher probability of tumor control. Such major technological progress certainly comes at a higher cost, and there are many concerns regarding the value of that progress. In the symposium, we will discuss what the benefits and disadvantages of SABR compared to surgical treatment in high or low risk surgical patients with early-stage NSCLC or pulmonary oligometastases are, and how we can decide best to proceed with treatment.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MS23.4 - Surgery for Early Stage Lung Cancer and Oligometastases (ID 570)
15:04 - 15:21 | Author(s): H. Asamura
- Abstract
- Presentation
Abstract
Very recently, the revised international multidisciplinary classification of lung adenocarcinoma was published by the International Association for the Study of Lung Cancer (IASLC), American Thoracic Society, and European Respiratory Society.[1,2] This new classification is characterized by the creation/abandonment of some terminology for early and advanced adenocarcinomas and by a multidisciplinary approach for the application of the new classification in a clinical setting. In particular, the term "bronchioloalveolar carcinoma (BAC)" is no longer used and, instead, new concepts are introduced, such as “adenocarcinoma in situ (AIS)” and “minimally invasive adenocarcinoma (MIA)”. Invasive adenocarcinomas are classified according to the predominant pattern after comprehensive histologic subtyping with lepidic, acinar, papillary, micropapillary, and solid patterns. The term of mixed subtype adenocarcinoma is no longer used. The gold standard surgery for documented lung cancer has been lobectomy with lymph node sampling/dissection. The randomized, prospective study was performed between lobectomy and sublobar, limited resection in 1980’s by North American Lung Cancer Study Group (LCSG) and the results of this study justified the lobectomy as the standard surgical mode.[ 3] However, looking back this study from the present view point, it is obvious that the earlier forms of lung cancer, as mentioned above as adenocarcinomas of AIS or MIA, were not involved in the LCSG study, and its conclusion could not be applied for these tumors. The present-day issue of lung cancer surgery is to define the role of lobectomy or limited, sublobar resection in relation to newly defined pathological entities. The Japan Clinical Oncology Group (JCOG) has been focusing upon defining the most appropriate surgical approach for tumors of relatively early stages in recent series of clinical trials. JCOG 0201 was intended to define the radiological non-invasive lung cancer on the high-resolution CT image, and it has shown that a consolidation/tumor ratio (C/T ratio) on thin-section computed tomography (TSCT) ≤0.25 in cT1a (≤2.0 cm) could be used as a radiological criterion for a noninvasive pathology.[4] Further prognostic analyses have also indicated that according to this radiological definition of non-invasive lung cancer the 5-year overall survival rate at 97.1% could be achieved.[5] JCOG 0804 is a prospective phase II trial, targeting the radiological non-invasive lung cancers of a diameter of 2.0 cm.[6] Again, the radiological criteria of non-invasive lung cancer were defined as those with a consolidation/tumor ratio (C/T ratio) on thin-section computed tomography (TSCT) ≤0.25. For these tumors, the wide wedge resection or segmentectomy was performed. Targeted number of accrual is 340 patients, and accrual has been already over, awaiting the data maturation. JCOG 0802 is a prospective, randomized phase III trial between lobectomy and segmentectomy for peripheral lung cancers with a diameter of 2 cm or less in a non-inferiority setting.[6] The endpoints are overall survival (primary) and postoperative pulmonary function (secondary), and the targeted accrual is 1,100 patients. As of June, 2013, more than 800 patients were registered. In case that the prognosis of patients undergoing segmentectomy was not significantly inferior to that of those undergoing lobectomy and that the postoperative pulmonary function is significantly better for those undergoing segmentectomy, it can be definitively concluded that standard surgical mode for these early tumors are segmentectomy. The similar randomized trial is also underway in US (CALGB), and the sooner launch of these data is expected to change the daily practice of lung cancer surgery. Oligometastases are the state in which the patients show distant relapse in only a limited number of organs/sites. These distant, metastatic lesions are found both before and immediately after surgery, and obviously these indicate the systemic spread of the cancer cells as stage IV disease. The gold standard treatment for systemic disease has been systemic therapy (chemotherapy). However, it has been anecdotally reported that local treatment modality such as surgery for both primary and metastatic sites cure the patients. The present-day issue for patients with oligometastatic disease is the proper selection of surgical candidate who might benefit from such aggressive treatment in lung cancer. REFERENCES 1. Travis WD, Brambilla E, Noguchi M, et al. International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol 2011;6:144-85. 2.Van Schil P, Asamura H, Rusch VW, et al. Surgical implications of the new IASLC/ATS/ERS adenocarcinoma classification. Eur Respir J 2012;39:478-86. 3. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995;60:615-22. 4. Suzuki K, Koike T, Asakawa T, et al. A prospective radiological study of thin-section computed tomography to predict pathological noninvasiveness in peripheral clinical IA lung cancer (Japan Clinical Oncology Group 0201). J Thorac Oncol 2011;6:751-6. 5. Asamura H, Hishida T, Suzuki K, Japan Clinical Oncology Group Lung Cancer Surgical Study Group. Radiographically determined noninvasive adenocarcinoma of the lung: Survival outcomes of Japan Clinical Oncology Group 0201. J Thorac Cardiovasc Surg. 2013 [Epub ahead of print]. 6. Nakamura K, Saji H, Nakajima R, Okada M, Asamura H, Shibata T, et al. A phase III randomized trial of lobectomy versus limited resection for small-sized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L). Jpn J Clin Oncol 2010;40:271-4. 7. Niibe Y, Hayakawa K. Oligometastases and oligorecurrence: the new era of cancer therapy. Jpn J Clin Oncol 2010;40:107-11.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MS23.5 - Thermal Ablation for Early Stage Lung Cancer and Oligometastases (ID 571)
15:21 - 15:38 | Author(s): K. Steinke
- Abstract
- Presentation
Abstract
Lung cancer is the number one cancer killer worldwide accounting for more cancer deaths than colorectal cancer, breast cancer and prostate cancer combined. While the outlook is dismal in advanced lung cancer, when patients are diagnosed once they have become symptomatic, the prognosis is more favourable in early stage node-negative disease. Small lung cancers are increasingly diagnosed as incidental findings on cross-sectional imaging such as CT-coronary angiogram (CTCA), CT-pulmonary angiogram (CTPA), CT angiograms for vascular conditions or CT -intravenous pyelogram (CT-IVP). As many as 15% of patients with early stage NSCLC are not eligible for surgery due to comorbidities, usually poor cardio-respiratory reserve. This number doubles in the patient population 75y and older. Approximately 30% of patients dying of malignancy have pulmonary metastases at autopsy with some primary cancers metastasising exclusively to the lungs. In the setting of primary cancer site being under control, reasonably long disease free interval (DFI) and oligometastatic lung disease with metastases of reasonable size and in amenable positions, data shows a survival benefit for metastasectomy in a selected patient population. Metastasectomies, even if performed as sub-lobar or wedge resections, often carry a substantial morbidity and have a major impact on quality of life. Thermal ablations can be performed in an outpatient setting, they spare healthy tissue, are repeatable and are extremely well tolerated. Thermal ablation has been applied to lung tumours for over a decade and has managed to become an established minimally invasive therapy option for a selected patient population. It is used as a therapeutic means in primary and secondary lung cancer, both with a curative and palliative intent. Combination of thermal ablation with radiotherapy for NSCLC should be a viable consideration in the therapy planning pathway, with available radiofrequency ablation (RFA)/external radiation therapy (XRT) data showing convincing 5y cumulative survival rates of 39% at no additional toxicity. Microwave ablation (MWA) represents the most recent addition to the growing armamentarium of minimally invasive thermal ablation therapies. Advantages of microwave over RF energy are perceived to be many. RF heating requires an electrical conduction path and is therefore less effective in areas of low electrical conductivity and high baseline impedance such as lung parenchyma. Unlike RF and laser, microwaves can even penetrate through the charred or desiccated tissues that build up around all hyperthermic ablation applicators, resulting in limited power delivery for non-microwave energy systems. Further advantages of MWA over RFA are that the system does not require grounding pads, thus avoiding pad site burns, that implanted cardiac devices are less prone to malfunction during MWA than during RFA and that heating occurs faster with is less susceptibility to heat sink, allowing for larger and more homogenous ablation volumes. Multiple microwave antennas can be powered simultaneously to maximise the ablation volume when placed in close proximity to each other, or when widely spaced, to ablate several tumours simultaneously, particularly helpful in the case of multiple metastatic ablations. This presentation will focus on the indications for pulmonary thermal ablation, the limitations of the procedure and the advantages of MWA over RFA.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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MS23.6 - Panel Discussion (ID 572)
15:38 - 15:50 | Author(s): N. n/a
- Abstract
Abstract not provided
