Reirradiation in Lung Cancer

Summary:

Is it feasible to re-re-irradiate a patient with Lung Ca

Reirradiation in Lung Cancer

Santam Chakraborty 16 Jan 2011 02:39

56 Female, otherwise healthy
Early 2009 —> Dx with Metastatic NSCLC T1 (3cm) N2 ( subcarinal + stage 4 ) M1 ( brain; adrenal )
Started on chemo, WBRT to brain, XRT to adrenal : 30/10;
to chest and subcarinal : 20/5 AP/PA ( prophylaxy for SVCO ; nodes were bulky 3cm )
Cord received ~ 21-22Gy

Aug-2010 —> ECOG 0 ; doing fine on chemo no symptom. PET scan : small nodule in adrenal ( other side ) + subcarinal node uptake for subcentimeter two lymph nodes.
Received 30/10 with tomo to subcarinal LN
Cord almost received none.

Now presenting with severe SVCO, quickly progressive. Severe swelling in face and arms and some SOB.
CT-Scan confirming in field disease progression + severe SVCO.

Only systemic option is Tarceva. Patient started on Tarceva and Decadron. Question is if we can re-iradiate for the third time?
Major complication is tracheal/esophageal fistula.

Posted originally by adjuvant

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Last edited on 16 Jan 2011 02:49 by Santam Chakraborty Show more

Re: Reirradiation in Lung Cancer

Santam Chakraborty 16 Jan 2011 04:24

Hi,
In all about 4 -5 months have elapsed after the tomo and patient is almost now 2 years after the first course of radiation if I am getting the history correctly. If not then please correct me as further answers depend on these assumptions. In addition some additional information will be useful

1. The tempo of disease progression is most important in this patient - how much time has elapsed since she has started developing the SOB?
2. What is the nature of the progressive disease - extent, size nature etc.?
3. is there a thrombosis in the superior vena caval system?
4. What is the response to steroids?
5. What was the volume covered during Tomo?

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Re: Reirradiation in Lung Cancer

radtuxabhishek 16 Jan 2011 05:31

This is a very valid point i.e. thrombus in the SVC. If this is the case then it's very easy to get a stent deployed as an outpatient procedure.

Otherwise, decision to re-irradiate would depend on the answers above.

However, it can also be argued that this is a palliative situation. In any case, the Dmax to Cord (and hopefully to Brachial Plexus) has not been exceeded. Can a single fraction be delivered? (Provided all differentials have been ruled for SOB like COPD exacerbation etc).

Or a stent to be deployed first?

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Reality is merely a persistent illusion

Re: Reirradiation in Lung Cancer

adjuvant 16 Jan 2011 05:53

As you see , the SVCO is confirmed through chest CT. SOB is not a major issue. Patient has clinically progressive SVCO. There is no thromobosis reported by radiologist.
First time, treatment was AP-PA ==> Cord recieved about ~ 21 Gy max
Second time dose to cord was negligible.

The main concern to decide irradiation here was esophageal/tracheal fistula as they stay right in the field and have received 20/5 + 30/10.

Re: Reirradiation in Lung Cancer

adjuvant 16 Jan 2011 05:50

1- Disease progression is quite quick. First symptoms started early Dec. SOB is the least problem. Both arms and face are very swollen.
2- The disease volume is not massive but is significant enough to obstruct SVC.
3-No thrombosis reported
4-Steroid just started on Friday.
5-Small volume, subcarinal LN

Re: Reirradiation in Lung Cancer

Santam Chakraborty 16 Jan 2011 06:29

Nice pics and a great demonstration of the advantage of IMRT in the palliative setting :-) If this had been radiated with a paralllel opposed pair I guess we would not have been able to do much. Now the question is if we irradiate how much benefit can be given to her and what is the possibility of a QOL impairing side-effect.
Assuming you will be treating her with a parallel opposed pair I will think that the main issue as you pointed out would be the possibility of a TEF. Spinal cord toxicity is too rare to be considered at the doses we will be giving. Other than that she has the risk of developing a symptomatic pneumonitis.
Even assuming the short segment of esophagus has received 20 + 30 chances of TEF are remote unless there is disease invasion of the esophagus / trachea. We can treat esophagus with quite high doses without running into a fistula and most reported fistulas are seen in areas with malignancy (Even with endoluminal brachy where we deliver very high doses to esophagus chances of a perforation are rare unless there is a malignancy).
The main question in my mind is not the risk of SE but weather giving the RT would be of any benefit. Bearing in mind that the tumor cells residing there are radio and chemo resistant any benefit from RT would be marginal at best. From what I have seen in SVCO, recurrent SVCO doesnot respond well to radiation especially the swelling part. I presume that medical managment is including diuretics and a medical oncology consult for palliative CCT has been taken already.
Dr Sharma used to treat these patients in an inpatient setting with an "indefinite" course of 2.5 - 3 Gy and kept seeing the response. Having seen such treatments done at PGI I can say few patients did not respond at all. If the patient responded taking upto 25 - 30 Gy should be safe. If patient is not having a good symptomatic response to 1 or 2 fractions and steroids are not helping then there is really not much we can do. All the patients who did not respond to RT died in a span of few weeks (mostly within a week or so). This reference may help here (http://journals.lww.com/amjclinicaloncology/Abstract/2000/04000/Thoracic_Reirradiation_for_Symptomatic_Relief.11.aspx). If you need the full text tell me. Of course as Abhishek has pointed out an interventional radiology consultantion for stenting is not a bad idea at all
In such a situation a frank discussion is necessary with the patient and family about the goals of treatment and their decision is most important. It is important to realise that for the unfortunate lady we are probably reaching the end of therapeutic road and palliative care should be initiated at the earliest.

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Last edited on 16 Jan 2011 06:36 by Santam Chakraborty Show more

Re: Reirradiation in Lung Cancer

radtuxabhishek 16 Jan 2011 06:32

It can also be argued that Radiation may not help her at all; from the previous history and the fact that it is a "residual/recurrence" case.

I would strongly suggest that she undergo stenting upfront. There is no "recommendation" per se but I am attaching a book chapter I came across:
http://www.scribd.com/full/46946761?access_key=key-2k741suwuhubx9gqm5z4

Please feel free to download it.

The stent would help to relieve the symptoms immediately (there is enough evidence for that) and that should allow time enough to debate on Radiation vs Systemic chemotherapy. If for arguments sake, there is no other disease and she is fit enough, a surgical bypass can also be recommended.

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Reality is merely a persistent illusion

Re: Reirradiation in Lung Cancer

adjuvant 16 Jan 2011 06:49

This patient is asymptomatic otherwise. Her lungs are in very decent shape. No other co morbidity. I think stenting is a reasonable option. We have cyberknife in our center and I think the staff is thinking to re-treat her with cyberknife.

If TEF is not a major risk, then re-treating her sounds reasonable. As she never had SVCO. Previous treatments were prophylactic.

Thanks for the book and thanks for the article.

Great discussion.

Re: Reirradiation in Lung Cancer

Santam Chakraborty 16 Jan 2011 07:02

Are you planning on a single cyberknife fraction or multiple.. do give more details once your treatment plan is ready and operational. Some pics would be great too

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Re: Reirradiation in Lung Cancer

adjuvant 16 Jan 2011 07:04

For sure I will keep everyone updated.

Re: Reirradiation in Lung Cancer

radtuxabhishek 16 Jan 2011 11:25

Yes! It would be really worth it to see if you plan it with Cyberknife! How many fiducials would you place and where? It would be very instructive to learn for those who have not been exposed to Cyberknife.

Looking forward for the pictures. Thanks for bringing this up.

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Reality is merely a persistent illusion

Re: Reirradiation in Lung Cancer

Nikhilesh Patil 17 Jan 2011 03:31

Great discussion guys, if we have exhausted all the possible options only then will I consider treating this unfortunate lady with further RT. I cannot ignore natural history of lung cancer.
Will be more than happy to learn what cyber knife can do in this setting.
Thanks, Nikhilesh

Re: Reirradiation in Lung Cancer

adjuvant 17 Jan 2011 03:51

One thing with this specific patient is that she has been well for two years with diagnosis of metastatic NSCLC to brain and she is doing fine! She has been off chemo for 8 months! ( and actually maybe that's why she progressed! ) But at least in this specific situation her disease is not very fast growing.

I vote for stenting honestly.

Re: Reirradiation in Lung Cancer

Santam Chakraborty 17 Jan 2011 05:03

No one will disagree with you on that I think :-)

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