Andrews, Charles, MD

Friedman, Eliot L, MD

Kruklitis, Robert, MD

Leies, Kathleen A

Santiago, Ferdy

Szwerc, Michael F, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineNeo-adjuvant Chemotherapy and RadiationTherapy in Patients with Stage IIIA (N2) Non-Small Cell Lung Cancer (NSCLC): ARetrospective Analysis with Lessons LearnedEliot L. Friedman MDLehigh Valley Health Network, Eliot_L.Friedman@lvhn.orgMichael F. Szwerc MDLehigh Valley Health Network, Michael_F.Szwerc@lvhn.orgCharles Andrews MDLehigh Valley Health Network, Charles.Andrews@lvhn.orgRobert Kruklitis MDLehigh Valley Health Network, Robert.Kruklitis@lvhn.orgKathleen A. LeiesLehigh Valley Health NetworkSee next page for additional authorsFollow this and additional works at: http://scholarlyworks.lvhn.org/medicinePart of the Chemicals and Drugs Commons, Medical Sciences Commons, Oncology Commons,Pathology Commons, and the Surgery CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtFriedman, E., Szwerc, M., Andrews, C., Kruklitis, R., Leies, K., & Santiago, F. (2011). Neo-adjuvant chemotherapy and radiationtherapy in patients with stage IIIA (N2) non-small cell lung Ccncer (NSCLC): A retrospective analysis with lessons learned. Posterpresentation.AuthorsEliot L. Friedman MD, Michael F. Szwerc MD, Charles Andrews MD, Robert Kruklitis MD, Kathleen A.Leies, and Ferdy SantiagoThis poster is available at LVHN Scholarly Works: http://scholarlyworks.lvhn.org/medicine/38 All Patients (n=22)“Fibrosis” (n=11)“Viable” (n=11)Progression free survival 14.5 months 42 months 9 monthsOverall survival 19.5 months 44 months 19 monthsAlive NED 7 5 2Distal relapse (systemic) 7 1 6Distal relapse (CNS) 3 1 2Local relapse 3 3 0Died (unrelated cause) 2 1 1Mediastinal LN positive at surgery 5 1 4Lehigh Valley Health Network, Allentown, PennsylvaniaNeo-adjuvant Chemotherapy and Radiation Therapy in Patients with Stage IIIA (N2) Non-Small Cell Lung Cancer (NSCLC): A Retrospective Analysis with Lessons LearnedEliot L. Friedman, Michael Szwerc, Charles Andrews, Robert Kruklitis, Kathleen Leies, Ferdy SantiagoBackground: Post Treatment Pathology•		Neo-adjuvant	chemotherapy	offers	survival	benefit	compared	to	surgery	alone1•		Adjuvant	chemotherapy	and	radiation	offer	survival	benefit	in	patients	with	documented	Stage	IIIA	(N2+)	disease2,3,4		•		Preoperative	chemotherapy	with	radiotherapy	is	active	and	safe	in	patients	with	Stage	IIIA/B	disease5		•		The	role	of	surgery	following	concomitant	chemotherapy	with	radiation	is	an	area	of	active	investigation			1Pisters	K,	et	al.	Proc	ASCO	(2003)	Abstract	#25442Douillard	J-Y,	et	al.		Proc	ASCO	(2005)	Abstract	#	70133Winton	T,	et	al.	NEJM	352:	2589	(2005)			4IALT	Collaborative	Group		NEJM	350:	351	(2004)			5Albain	KS,	et	al.	The	Lancet	374:	379	(2009)•		Mean	age				 	 -	 57.6	years	(19-79)•		Gender				 	 -	 13	male,	13	female•		Pathology				 	 -	 Adenocarcinoma	-	10/25		 	 	 -	 Squamous	Cell	Carcinoma	-	13/25•		PET/CT	scan	positive	with	pathological	confirmation		 	 	 -	 10/26	(38%)•	PET/CT	scan	positive	only		 	 	 -	 16/26	(62%)Patient Characteristics: (n=26)Patient Selection: •		Patients	are	evaluated	simultaneously	at	weekly	multidisciplinary	lung	cancer	clinic	by	 	 	 -	 	Medical	oncologist	 	 	 -	 	Radiation	oncologist	•		Patients	selected	up-front	for	trimodality	therapy	(prior	to	initiation	of	treatment)	 	 	 -	 Stage	IIIA	(T1-3	N2	M0)	NSCLC	 	 	 -	 	Non-bulky	N2	disease	(<	3cm)	 	 	 -	 	Good	performance	status	(ECOG	0-1)	 	 	 -	 	Surgical	candidatesConclusions: •		Trimodality	therapy	is	feasible	and	safe	in	carefully	selected	patients	with	stage	III	NSCLC•		The	presence	of	residual	active	tumor	bodes	poorly	and	these	patients	may	not	benefit	from	definitive	resection.	•		Utilization	of	PET-CT	after	neoadjuvant	therapy	may	identify	“fibrosis”	vs.	“viable”•		Pathological	staging	of	mediastinum	(mediastinoscopy	or	EBUS)	prior	to	and	after	neoadjuvant	therapy	should	be	employed•		Chemotherapy	regimens	 	 	 -	 	Paclitaxel	50mg/m2	+	Carboplatin	AUC	2	weekly	(n	=	15)	 	 	 -	 Vinorelbine	25mg/m2	d1,	8,	15						 											Paclitaxel	140mg/m2	by	continuous																		24-hour	infusion	d1		 	 	 							Carboplatin	AUC	5	d2				(n=6)		 	 	 -	 	Paclitaxel	175mg/m2	+	carboplatin	AUC	6	q3wks	(n	=	4)	 	 	 -	 	Etoposide	50mg/m2	d	1-5	+	Cisplatin	50mg/m2	d1	and	8			(n	=	1)•		Radiation	Therapy	 	 	 -	 	4500	–	5040	cGy	(concomitant	with	chemotherapy)•		Surgery	 	 	 -	 	Pneumonectomy	(n	=	7)	 	 	 -	 	Lobectomy	/	bilobectomy	(n	=	16)Treatment:	 	 	 -	 	Thoracic	surgeon		 	 	 -	 	Pulmonologist	 	 	 -	 	Adenosquamous	1/26	 	 	 -	 	NSCLC	NOS	-	2/26Treatment Summary40x	H&E	stainLarge	sheets	of	viable	tumor	with	no	significant	fibrosis	or	necrosisTumor	wrapped	around	bronchus200x	H&E	stainLarge	sheets	of	viable	tumor	with	no	significant	fibrosis	or	necrosisViable (n=11) Measurable tumor with active cancer cells40x	H&E	stainSmall	residual	nest	of	tumor	cells	with	marked	tumor	necrosis400x	H&E	stainSmall	residual	nest	of	tumor	cells	in	dense	fibrous	backgroundFibrosis (n=11) <10% active cancer cells infibrotic/necrotic matrixSurvival DataProgression Free SurvivalAdenocarcinoma vs. Squamous Cell CarcinomaProgression Free SurvivalOverall SurvivalProgression Free SurvivalViable vs. Fibrosis26 patien ts com p le tedneoad juvant rad ia tionand chem othe rapy• 2 patien ts progressed fo llow ingneoad juvant therapy• 1 patien t had unexpected p leura ld isease and surgery was aborted• 23 patien ts com ple ted pu lm onaryresection– 16 lobectom y/b ilobectom y– 7 pneum onectom y1 patien t lost tofo llow -up after com ple tinga ll treatm ent22 patien ts inc luded incurren t ana lys isp = 0.0680 10 20 30 40 50 60020406080100Time (months)Survivalprobability(%)ViableFibrosisp = 0.0510 10 20 30 40 50 60020406080100Time (months)Survivalprobability(%)70ViableFibrosis0 10 20 30 40 50 601020406080100Time (months)Survivalprobability(%)30507090 p = NSSquamousAdeno0 10 20 30 40 50 70020406080100Time (months)Survivalprobability(%)3050709060p = NSSquamousAdeno

Neo-adjuvant Chemotherapy and Radiation Therapy in Patients with Stage IIIA (N2) Non-Small Cell Lung Cancer (NSCLC): A Retrospective Analysis with Lessons Learned

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1037&context=medicine

Neo-adjuvant Chemotherapy and Radiation Therapy in Patients with Stage IIIA (N2) Non-Small Cell Lung Cancer (NSCLC): A Retrospective Analysis with Lessons Learned

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