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A.A. Khalil
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MINI 07 - ChemoRT and Translational Science (ID 110)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Locoregional Disease – NSCLC
- Presentations: 1
- Moderators:D. Raben, B. Kavanagh
- Coordinates: 9/07/2015, 16:45 - 18:15, 201+203
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MINI07.03 - The NARLAL2 Phase III Trial: Heterogeneous FDG-Guided Dose Escalation of Advanced NSCLC. A Clinical Trial by the Danish Lung Cancer Group (ID 2248)
16:55 - 17:00 | Author(s): A.A. Khalil
- Abstract
- Presentation
Background:
Locally advanced lung cancer lacks effective treatment options and requires aggressive radiotherapy (RT) with higher doses. In the light of RTOG 0617, multi-center dose escalation trials should avoid increasing organ at risk (OAR) toxicity and require strict quality assurance (QA). Exploiting the predictive value of FDG-PET, sub-volumes can be dose escalated, and by implementing image-guided adaptive RT, the total treatment volume (PTV) can be reduced. Incorporating these elements, the randomized multicenter trial NARLAL2 aims at increasing loco-regional control at 30 months without increasing major toxicity.
Methods:
Figure 1 In the standard arm, the PTV is treated with a homogenous dose of 66 Gy/33 fractions. In the experimental arm, the dose is heterogeneously escalated to the FDG-PET avid volumes, with mean doses up to 95 Gy/33 fractions and 74 Gy/33 fractions to the escalated volumes in the tumor and malignant lymph nodes, respectively. The escalation dose will be limited in favor of OAR constraints. A standard and an experimental treatment plan with similar mean lung doses of maximum 20 Gy are made for each patient prior to randomization. Quality Assurance: FDG-PET scans of a standard phantom (NEMA) and PET signal processing software from all centers were compared and acceptable agreement achieved. Multicenter delineation of OARs was performed and consensus achieved. Treatment planning and adaptive strategy consensus were based on a study including five patients with repeated CT-scans, requiring several steps before the achievable level of dose escalation and the number of patients needed in the trial could be defined. Daily online tumor set-up and adaptive strategies were mandatory. A QA committee for evaluation of RT plans and treatments and a central committee for evaluation of all non-biopsy-verified recurrences were established.
Results:
A mean dose of 91,9 Gy to the FDG-PET avid part of the tumor and 80 Gy to the clinical target volume was achieved in the planning study, corresponding to 16% estimated increase in locoregional control at 30 months. Assuming a loco-regional control of 56% at 30 months in the standard arm, a total of 330 patients were needed in order to resolve this effect with a power of 80% (95% significance level). Recalculation of escalated plans on CT-scans acquired at fraction 20 revealed an increase in OAR doses of 4-7Gy for two of five patients, endorsing the need for adaptive strategies.
Conclusion:
A dose escalation trial with strict QA has been set up. Patient enrollment started January 2015.
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P2.04 - Poster Session/ Biology, Pathology, and Molecular Testing (ID 234)
- Event: WCLC 2015
- Type: Poster
- Track: Biology, Pathology, and Molecular Testing
- Presentations: 1
- Moderators:
- Coordinates: 9/08/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P2.04-035 - Methods for Evaluating Early Response to Erlotinib Treatment Using FDG-PET/CT (ID 2865)
09:30 - 09:30 | Author(s): A.A. Khalil
- Abstract
Background:
Early evaluation of response to treatment with Fluoro-deoxy-glucose-Positron-Emission-Tomograpy-CT (FDG-PET/CT ) is increasing rapidly, but which method is the ideal to use is not clear. In this study early response (1-2 weeks) evaluation was performed using three different methods and compared to clinical response at three months.
Methods:
Forty-three patients with metastatic pulmonary adenocarcinoma had FDG-PET/CT scans performed prior to erlotinib treatment and after 1-2 weeks of treatment. The scans were evaluated by one experienced nuclear medicine specialist. The scans were evaluated by three different methods using Siemens Syngovia software: Visual evaluation, as according to Hicks et al, % change in SULpeak as according to PERCIST 1.0 , and finally calculating the % change in total tumor glycolysis (TLG) proposed in PERCIST 1.0. The early response was compared to response on CT at 12 weeks and to progression free survival (PFS)
Results:
The results are shown in figure 1. Defining response as “not progression” on CT at 12 weeks (10 in total), visual evaluation identifies 6 correctly, and 5 of 33 non-responders as responders. One patient classified as a responder who had a PFS of 0.9 months, had stopped treatment because of side effects. The SULpeak method identifies the same 6 responders correctly, and 3 of 33 non-responders as responders. TLG change identifies 4 responders correctly and 3 of 33 non-responders as responders. Looking at early progression (16 in total) , visual evaluation identified 6 correctly, The SULpeak method identified 4 correctly, the TLG method identified 2 early progressions correctly. Figure 1 Table 1: Response groups by patient, ordered by PFS (in months) as found by the three methods. 1 partial response, 2 stable disease and 3 progression. “true” progression and response values are highlighted in bold. Division lines in bold separates response and early progression from the middle group as according to PFS and CT. * Not Available, ** treatment stopped early because of side effects .
Conclusion:
Visual evaluation identified more responders and patients with early progression during treatment with erlotinib. The more objective method based on calculation of SUV calculations identified less responders as well as less patients with early progression, suggesting a lower sensibility for this method. This suggests that the 40% cut off in % change used in this study (as suggested by Wahl et al in the PERCIST criteria), and perhaps the 30% cut off used for SULpeak change are too high for very early evaluation.
