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Postoperative Radiotherapy (PORT) for Resected NSCLC

Postoperative Radiotherapy (PORT) for Resected NSCLC. Ido Wolf, Raphael Pfeffer. Radiation Oncology Unit The Institute of Oncology Sheba Medical Center. Adverse factors: inadequate mediastinal lymph node dissection, extracapsular spread, multiple positive hilar nodes, close margins.

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Postoperative Radiotherapy (PORT) for Resected NSCLC

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  1. Postoperative Radiotherapy (PORT) for Resected NSCLC Ido Wolf, Raphael Pfeffer Radiation Oncology Unit The Institute of Oncology Sheba Medical Center

  2. Adverse factors: inadequate mediastinal lymph node dissection, extracapsular spread, multiple positive hilar nodes, close margins.

  3. PORT Meta-analysis Trialists Group. Postoperative radiotherapy for non-small cell lung cancer. The Cochrane Database of Systematic Reviews 2005, Issue 2. • Main results • 2232 patients, 10 trials, median follow up of 4.25 years. • 18% relative increase in the risk of death (reducing overall survival from 58% to 52%). • This detrimental effect was most pronounced for patients with stage I/II, N0-N1 disease. • There was no clear evidence of an adverse effect for stage III, N2 patients. • Authors' conclusions • PORT is detrimental to patients with early stage completely resected NSCLC and should not be used in the routine treatment of such patients. • The role of PORT in the treatment of N2 tumors is not clear and may justify further research.

  4. PORT Meta-analysis Trialists Group. Postoperative radiotherapy for non-small cell lung cancer. The Cochrane Database of Systematic Reviews 2005, Issue 2.

  5. A Controlled Study of PORT forPatients with Completely Resected NSCLC (GETCB)Dautzenberg et al.Cancer 1999;86:265 International RCT, 1986-1994, 728 patients. Five-year overall survival: 43% for the control 30% for the RT group • However: • Stages 1 (30%) -2-3 (Changed recruitment criteria). • RT: Co-60 or Linac, 60Gy, (2.5 GyX4/w or 2GyX5/w). • 40 Gy: AP fields to the bronchial stump, ipsilateral hilum, upper and middle mediastinum, SC areas; 20 Gy: lateral or oblique fields.

  6. Postoperative radiotherapy after pneumonectomy: impact of modern treatment facilities.Philips et al.Int J Radiat Oncol Biol Phys. 1993;27:525 • Retrospective analysis 1970-1985 • 27 patients: no PORT. • 51 patients: PORT Co60 source. • 25 patients: PORT Linac + CT. • 5-year survival: • 31% no PORT. • 30% PORT Linac + CT. • 8% for Co60.

  7. Risk of Death From Intercurrent Disease Is Not Excessively Increased by Modern PORT for High-Risk Resected NSCLCMachtay et al.J Clin Oncol 2001:19:3912 • 202 patients, U of Pen., 1982-98. • Stages 2-3 • No pneumonectomy. • RT: LinAc, 3D, 1.8-2Gy. • Fields: mediastinum, ipsilateral hilum, bronchial stump (SC fossa only in some). • XRT dose > 54 Gy had a 16% DID compared with 2% for lower total dose.

  8. A Randomized Trial Of Postoperative Adjuvant Therapy In Patients With Completely Resected Stage II Or IIIa NSCLCKeller et al.N Engl J Med 2000;343:1217 Phase II trial of postoperative adjuvant paclitaxel/carboplatin and thoracic radiotherapy in resected stage II and IIIA NSCLC: Promising long-term results of RTOG 9705. J Clin Oncol 2005;23:3480. 488 patients, Stages II or IIIa RT (50.4 Gy) +/- Cis VP-16

  9. PORT for Stage II or III NSCLC Using the Surveillance,Epidemiology, and End Results DatabaseLally et al.J Clin Oncol 2006:24:2998 7465 patients of the SEER database, 1988-2002, no information about RT doses or administration of chemotherapy (Interesting fact: 60% RT in 1992, only 30% in 2002).

  10. Staging of NSCCL: lymph nodes N1: Ipsilateral peribronchial, hilar, intrapulmonary nodes (stations 10-13). N2: Ipsilateral mediastinal or subcarinal nodes (stations 1-9). N3: Contralateral mediastinal or hilar; ipsilateral or contralateral scalene; supraclavicular lymph nodes (stations 1-9). IA T1, N0, M0 IB T2, N0, M0 IIA T1, N1, M0 IIB T2, N1, M0 T3, N0, M0 IIIA T1, N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0

  11. Patterns of Failure After Complete Resection of NSCLCInt J Radiation Oncology Biol Phys 2006;65:1097 Duke University, 61 patients, 70% stage I, complete resection, no adjuvant RT. Non-continuous spread is common.

  12. Patterns of Failure After Complete Resection of NSCLCInt J Radiation Oncology Biol Phys 2006;65:1097

  13. Conclusions PORT may be less detrimental than previously thought: • Most studies in the meta-analysis used old techniques. • Reasonable morbidity for Linac+3D planning. PORT may be beneficial (?): • N2 disease (SEER data). Chemotherapy: • Better together than only chemo? N3? Which? Optimal planning: • Patients selection: high PS, no pneumonectomy (?), no stage I. • Up to 54 Gy, up to 2GyX5/w, Linac and 3D planning. • Try to avoid SC and entire mediastinum (Lt lung, RLL). • Careful observation.

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