Tissue Diagnosis and Staging for SBRT 2012 Lung Cancer Summit – Focus on Thoracic Surgery: Lung Cancer Kazuhiro Yasufuku Director, Interventional Thoracic Surgery Program Assistant Professor, University of Toronto Division of Thoracic Surgery, Toronto General Hospital 1 Boston Marriott Copley Place, Boston, MA November 17th, 2012
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Tissue Diagnosis and Staging for SBRT 2012 Lung Cancer Summit – Focus on Thoracic Surgery: Lung Cancer Kazuhiro Yasufuku Director, Interventional Thoracic.
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Tissue Diagnosis and Staging for SBRT
2012 Lung Cancer Summit – Focus on Thoracic Surgery: Lung Cancer
Kazuhiro Yasufuku Director, Interventional Thoracic Surgery ProgramAssistant Professor, University of TorontoDivision of Thoracic Surgery, Toronto General Hospital
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Boston Marriott Copley Place, Boston, MA November 17th, 2012
Disclosure• Educational and research grants from Olympus Medical
Systems Corp.• Consultant for Olympus America Inc.• Consultant for Intuitive Surgical Inc.• Novadaq Corp.• Veran Medical Technologies
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Lung Cancer
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Tissue Diagnosis Staging
Treatment for Stage I NSCLC
• Anatomic resection is the gold standard• Local control ~90%• Overall Survival ~60-80%
• Medically inoperable stage I patients represent a big challenge• Up to 25% of all stage I patients• Untreated 5 year Overall Survival 5-10%
• Conventionally fractionated RT a poor second choice (~30 treatments over 6 weeks)
• 30-60% local control
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Survey of SBRT use in USA
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1600 American radiation oncologists Of 1373 contactable physicians, 551responses (40.1%) received
63.9% of physicians using SBRT of whom nearly half adopted it in 2008 or later
most common disease sites were lung (89.3%), spine (67.5%), and liver (54.5%) tumors
Cancer 2011;117:4566–72
Princess Margaret Hospital SBRT Criteria
• Ongoing phase II (2004 – present)• Pts deemed medically inoperable by a thoracic
surgeon• ECOG PS 0-3• NSCLC• T1 or T2 lesion, <5cm N0 M0 • PET –ve elsewhere• Previous thoracic RT acceptable provided no
significant overlap• No lower limit for lung function
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Surgery for Early Lung Cancer
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Lobectomy Limited Resection
CALGB 140503• Phase III Randomized Trial of Lobectomy vs Sublobar
Resection for Small (<2cm) Peripheral NSCLC
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Randomization
Surgery
Confirmation of NSCLC on PathN0 status on frozen section
(4R, 7, 10R on right)(5or6, 7, 10L on left)
Lobectomy Limited Resection
Options for high-risk pts with stage I NSCLC
• Sublobar resection (wedge or segmentectomy)• Surgery provides tumor histology• Lymph node sampling/dissection may provide identification of other
occult disease• Better pathological staging may inform decision of an adjuvant regimen• Better loco-regional control
• SBRT• May result in better QOL• Since better loco-regional control may not translate into better survival
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Diagnostic tools for peripheral lung nodules
• Clinical History• Old Films• Chest CT• FDG-PET
• CT guided TTNA• Bronchoscopy (EBUS, Navigational bronchoscopy, etc)• Surgery
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Is tissue Dx mandatory prior to SBRT?
• Stereotactic body radiotherapy (SBRT) SPN clinically diagnosed as lung cancer with no path confirmation: comparison with NSCLC
• Comparison of outcomes of Bx proven NSCLC (n=115) vs SPN clinically diagnosed as lung cancer (CDLC) (n=58) treated with SBRT (2005-2011)
• Treatment outcome of CDLC group was almost identical to that of NSCLC• SBRT can be legitimately applied to CDLC, provided that they are carefully diagnosed
by integrating various clinical findings
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Takeda et al, Lung Cancer. 2012 ;77(1):77-82
3y Local Control Regional-free Mets-free Cause-specific Survival
Overall Survival
NSCLC 80% 88% 70% 74% 54%
CDLC 87% 91% 74% 71% 57%
Mediastinal Staging• Clinical staging can markedly differ from pathologic staging