nsclc,lung cancer ,sbrt lung

1. Management of Lung Cancer
By
Dr Parneet Singh
1

2. 2

3. 3

4. NSCLC Stages at Presentation
10%
18%
32%
40%
stage I stage II
stage III stage IV
SEER 18 2005-2011, All Races,
Both Sexes by SEER
4

5. PROGNOSTIC FACTORS
• Patient related.
- Performance status.(ECOG>2)
- Weight loss>10% in 6 months
- Age <70.
- PFT.
• Tumor related.
- Stage
-Molecular markers(EGFR,ALK,TS,ERCC1)
• Treatment related.
- Completeness of resection.
- Addition of chemotherapy.
- Radiotherapy. Movsas JCO 2009
Lynch NEJM 2004 5

6. Treatment of Lung Cancer Stage wise
• Stage I- Surgery ; SBRT
• Stage II- Surgery ; SBRT
• Stage III- CT+RT ; Surgery+/- CT+RT
• Stage IV – Chemotherapy +RT (consolidation and high
palliation)
6

7. Surgery
• Surgery is done in early stage NSCLC (stage I, II & IIIA )
• Only about 20% of patients suitable for curative surgery
• In these the tumor has not extended beyond broncho
pulmonary lymph nodes
• Lobar resection with hilar and mediastinal lymph node
sampling is the standard surgical treatment . 7

8. Surgery : PFT based algorithm
Surgery Type
Lobectomy /Lesser Pneumonectomy
FEV1 > 1.5 L
FEV1> 60%
DLCO > 60%
FEV1 > 2 L
FEV1> 60%
DLCO > 60%
Operate Operate•V/Q scan
•Calculated Post operative FEV1 & DLCO
< 40% > 40%
Exercise study
V02 max < 15 ml/kg/min V02 max > 15 ml/kg/min
Medically inoperable
Average risk
8

9. Types of surgery
 Lobectomy
Single lobe of lung is removed
 Bilobectomy
2 lobes of the lung are removed
 Pneumonectomy
 Removal of entire lung
 When tumor extends close to carina T3N0
 Wedge Resection
 Removal of a small, pie shaped area of the
segment
 Segmentectomy
 A segment of the lung is removed
 Chest Wall Resection
 Removal of cancerous lung tissue for
cancers that have invaded the chest wall 9

11. 11

12. 12

13. 13

14. 14

15. 15

16. Lymph node dissection
• Mediastinal lymph node dissection:
– Provides complete nodal staging.
– Identifies patients who require adjuvant radiotherapy.
– Improves survival.
– Improves local control.
• At least nodal sampling should be performed, if not complete
lymphadenectomy.
• Lobe specific Mediastinal nodal dissection in NSCLC:
– Right Side:
• Upper lobe (1,2,3,4,7)
• Middle lobe (1,2,3,4,7)
• Lower lobe (1,2,3,4,7,8,9)
– Left Side:
• Upper lobe (4,5,6,7)
• Lower lobe (4,5,6,7,8,9)
Shinichiro et al Surg today 2014

17. Complete Resection
• Free resection margins proved microscopically
• At least a lobe specific mediastinal nodal dissection with complete
hilar and intrapulmonary nodal dissection.
• At least 6 nodes should have been removed with 3 from
mediastinal nodes.
• Highest mediastinal node removed should be microscopically free.
Ramon et al Lung Cancer 2005 17

18. Criteria for inoperability
Tumor based criteria
 Cytologically positive
effusions.
 Vertebral body invasion.
 Invasion or encasement of
great vessels.
 Extensive involvement of
Carina or trachea.
 Recurrent laryngeal nerve
paralysis.
 Extensive mediastinal lymph
node metastasis.
 Extensive N2 or any N3
disease
Patient related criteria
 Cor pulmonale
 CAD
 Poor pulmonary function
 Patient refusal
18

19. Segmentectomy or wedge resection vs
Lobectomy or Pneumonectomy
• Ginsberg et al Annals of Thoracic Surg,1995
• Three times higher recurrence rate in TI N0 with Limited
resections 15% vs 5%(p<.05)
• Morbidity, mortality equal in both arms.
• The Lung Cancer Study Group performed a randomized trial
of lobectomy vs limited surgical resection in patients with
T1N0or T2N0 NSCLC.
• Three times higher recurrence rate in TI N0 with Limited
resections 17% vs 6%(p = .008)
19

20. Results
• T1 tumors:
– 5year overall survival: 82%.
– 10 year overall survival: 74%.
• T2 tumors:
– 5year overall survival: 68%.
– 10 year overall survival: 60%
• Morbidity:
– 15% reduction in
spirometric values in
lobectomy
– 35% - 45% reduction after
pneumonectomy.
• Mortality:
– 5.9% perioperative
mortality for
pneumonectomy.
– 1.3% perioperative
mortality for lobectomy
Martini et al J Thor Cardiov Surg 1995
Watanabe Ann Thorac Surg 2004
20

21. Patterns of failure after Sx
• Patients who fail after surgery, present with extrathoracic disease 70% of the
time, local recurrence in 20% and local and distant metastasis in 10%.
• Tumors measuring 1-2 cm have a mediastinal nodal metastasis rate of 17%
as compared to those measuring 2 to 3 cm, when the rate is 37%
• Median overall survival was 9.1 years (stage T1) and 6.5 years (stage T2).
• Overall survival at 5 years was 72% (stage T1) and 55% (stage T2).
• Local recurrence-free survival at 5 years was 95% (stage T1) and 91% (stage
T2)
21
Martini et al J Thor Cardiov Surg 1995
Su et al J Thor Cardiov Surg 2014

22. Radiotherapy
 Important role in the management of patients with non small cell
lung cancers
 Radiotherapy (RT) series of Stage I patients treated definitively report
5-year survival rates ranging from 10% to 33% - Because of these
inferior outcomes, RT is only considered for patients who cannot
tolerate or refuse surgery
 But with SBRT in stage I and stage II overall survival increased to 75-
80%
 Intent - Radical
- Palliative
- Adjuvant
-Consolidation Onishi, IJROBP 201122

23. Role of radiotherapy
 Localized early stage disease
( I, II,IIIa) (Resectable)
a) Alternative to surgery (medical
contraindication / patients
choice
b) As adjuvant to surgery
 Locally advanced disease ( III)
(Unresectable)
Radical RT
― Alone
― With chemotherapy
 Stage IV - treatment remains
palliative
– Symptoms palliation
– Local RT for consolidation
– RT to bone / brain mets
• Brachytherapy
― Alone (very early endobronchial
disease
― For boost or Palliative tratment
23

24. Modalities
 Conventional 2 D planning
 3 D planning –
a) 3 DCRT
b) IMRT
c) Gated RT
d) SBRT
 Brachytherapy
24

25. Patient selection criteria for SBRT in early stage
• Medically inoperable – PFT ( FEV1 or DLCO<40%), DM/CAD,
cerebral disease, Pul. HTN
• Patient choice to avoid surgery
• PS 0-2
• Stage T1-2, N0 following PET-CT
• Max tumor size < 5cm
• Not adjacent to major vessels, heart, esophagus etc
25

26. Study fractionation Median
follow up
Local Control Overall survival Median
overall
survival
Other
Nyman et al Lung
Cancer 2006(74)
45Gy in 3 Fx
(BED 112.5),
43 mo 80%(2 years) OS 1/2/3/5 yr =
80/71/55/30%
39 mo
Van Zyp et
alRadiother and
Oncol 2009(70)
3 x 20Gy
(BED 180
15 mo 2yr LC 96% OS 1/2 yr =
83/62%
FFDM-90%
Timmerman
IJROBP 2009(70)
3 x 20Gy (T1),
3 x 22Gy (T2)
50 mo 3yr LC 88%, 3yr OS = 43% 32 mo FFDM 87%
DSS = 82%
FROG(118) 4 x 12-12.5Gy
(central)
3 x 22Gy
parenchymal
15 mo 2yr -93%, 2yr-74%, 2yr FFDM -
90%
2yr DFS 94%
26

27. SBRT vs Wedge resection in Stage I NSCLC
• 124 pts; T1-2N0MO
• 69 wedge resections, 58 SBRT
• SBRT prescribed as 48(T1) or 60(T2) Gy in 4 to 5 fractions
• Median follow up of 2.5 years
• No differences in DM, FFF, or CSS, but OS was higher with wedge
resection at 30 months.(87% vs 72%) p>.05
27
Inga et al JCO 2010

28. SBRT vs Surgery for Operable pts
Study Japan data (87 pts) Netherlands (177 pts)
Age 74 yrs 76 yrs
T1, T2 65, 22 pts (2.5 cm) 106, 71 pts (2.6 cm)
RT dose 42-72.5 Gy in 3-10 # 60 Gy in 3-8 #
Median FU 55 months 31.5 mo
5 yr OS 69.5% 51.3% (median: 61.5 mo)
5 yr LC (T1, T2) 92%, 73% 93% @ 3 yrs
Grade 3 RP 1.1% 2%
30 day mortality 0% 0%
28
Onishi, IJROBP 2011
Lagerwaard, IJROBP 2012

29. Recurrence Patterns After SBRT
29
Senthi S et al. Lancet Oncol 2012

30. 30

31. 31
Timmerman JAMA 2010

32. Technique for planning in 2 D RT
 Pt taken on couch after explaining procedure and taking consent.
 Position – supine with arms over head
 No rigid immobilization required
 2 cm margin around primary tumor & 1 cm margin around involved
regional lymph nodes
 If mediatinal Lymph nodes or hilar lymph nodes involvement then
to go 1.5-2 cm across midline
32

33. UPPER LOBE PRIMARY
Field borders :
• Superior – cover I/L supraclav fossa
•Inferior – 4 cm below carina (2 VB
below carina)
•Medial – 3 cm across midline on
opp. side (opp. upper
mediastinal LN)
•Lateral – 2 cm margin
33

34. MIDDLE LOBE PRIMARY
Field borders :
• Superior – Thoracic inlet or SSN (if
no gross mediastinal nodes) but
cover I/L SCL fossa (if med. nodes
+)
•Inferior – 8-9 cm below carina
•Medial – 3 cm across midline on
opp. side (opp. Upper mediastinal
LN)
•Lateral – 2 cm margin
34

35. LOWER LOBE PRIMARY
Field borders :
• Superior –Thoracic inlet or SSN (if
no gross mediastinal nodes but cover
I/L SCL fossa (if med.nodes +)
•Inferior– vertebral origin of
diaphragm
•Medial – 3 cm across midline of
opp. side (opp.mediastinal LN)
•Lateral – 2 cm margin
35

36. 36

37. 37

38. 38

39. Elective nodal irradiation
 Irradiation of electively treated lymph nodes not necessery
 Regional failure rates <10% where elective nodal areas not treated
 Rationale for treating local tumor volume alone appears justified
when pt’s outcome not negatively impacted if regional lymph node
excluded
 Rosenweig et al – IJROBP 2007
- 524 pt early stage treated to primary.
- No elective nodal irradiation.
- only 6.4% fail regionally. 39

40. Phase II
• Only primary tumour and ipsilateral hilum
• To reduce dose to cord
• To reduce dose to other critical structures
• Field arrangement like ant + post oblique or both oblique can
be used

41. Radical EBRT
 Dose: 60-64 Gyin 30-32 # over 6 weeks
 AP/PA portals treated till spinal cord tolerance ( ~ 45 Gy)
 3 field techniques also used
 Boost of 20 Gy delivered via oblique fields-3 fields anterior and posterior
oblique at 35-40 degrees with another anterior oblique at 50 degree
 At Max Hospital – total dose of 60-64Gy/30-32#
41

42. Postoperative Radiotherapy(PORT)
 Post-operative Radiotherapy (PORT):
– Indications:
– Residual disease post resection
– Incomplete resection (+ve / close margins)
– +ve mediastinal mets(N2 or N3)disease
 In stage IA , IB , IIA - Additional radiotherapy is generally not needed if
there is no evidence of cancer in the surgical margins.
 DOSE
 50-54 Gy/ 25-27 fr/ 5-6 weeks
 Phase I: 40 Gy/ 20 fr across the mediastinum
 Phase II: 10-14 Gy/ 5-7 fr/2 cm margin (off cord).
 PORT improves LRC but no ↑se in survival
Bradleyet al JCO 2005 42

43. • SEER (JCO 2006): 7,400 patients with stage II–III resected
NSCLC
• PORT used most often for patients <50 years, T3–4,larger T
size, increased N stage involved LN.
• Dose of 50 Gy f/b boost of 10 Gy to residual disease
• PORT improved 5-year OS for N2 patients(20→27%, HR
0.85)
• Reduced OS for N0 (41 → 31%, HR 1.2), and N1 (34 → 30%,
HR 1.1) patients.
44

44. Radiation for Medically Inoperable Early Stage
NSCLC
Author # PTs EBRT
Dose
(Gy)
%T1 %T2 Overall
5 yr
Survival
T1 5 yr
Survival
%
T2 5 Yr
Survival
%
Overall
Median
Survival
Local
Failure %
Haffty 1988 43 59 (con)
54 (split)
28 72 21% 28 mos 39
Noordijk
1988
50 60 (split) 50 50 16% 27( 4 yr) 15 4 yr
0 if>4cm
27 mos 70
Zhang
1989
44 55-70 14 86 32% 67 26 27 died
local failure
Talton
1990
77 60 3 75
22-T3
17% 50 18
Sandler
1990
77 32 32 53 3-6cm
12 > 6cm
17%
22%
30
3 yr
3-6 cm
17% 3 yr
20 mos 56 3 yr
Doseretz
1992
152 60-69 29 41
27-T3
10% 33-49
3 yr
22
3 yr
17 mos T1 30
T2 80
T3 86
Kaskowitz
1993
53 63.2 38 62 6% 20.9 49 3 yr
Slotman
1994
47 32-56
Hypofrac
32 68 25% 28 10 20 26
Graham
1995
103 56.8 34 66 13% 29 4 16.1 45

45. 46

46. Palliative Disease
 Aim:
– To achieve relief of symptoms only when disease is too advanced for
local control
 Indications:
– T4 disease - For symptom palliation the dose and fractionation is tailored
to the condition depending upon the life expectancy : Extensive N2 or N3
disease
– Distant metastasis
– Weight loss > 12% of body weight
– Performance status -Poor
Treatment schedules chosen:
• If life expectancy is > 3-4 months : 30 Gy in 10# over 2 weeks
• If life expectancy is from days to 3 months :
– 20 Gy in 5# over 1 week
– 8 Gy in single fraction
47

47. Target volume for 3D planning
 Modern treatment planning requires accurate target volume delineation:
1. The Gross Tumor Volume (GTV) - Primary tumors
- gross involved nodes + regional lymphnodes > 1cm in short axis
2. The Clinical Target Volume (CTV) - Areas suspected of subclinical
involvement ↓
- Margin around gross tumors (6mm for SCC & 8mm for adeno)
- Regional LNS(3mm for <2cm & 5mm for>2cm)
3. The Internal target volume for tumor motion 7mm-1.5cm fluroscopy based
4. At Max Hospital axially 0.5cm and cranio-caudal-1cm
BASED ON FLUROSCOPY
3. The Planning Target Volume (PTV)margin around ITV to compensate for
variation in treatment set up(5mm).
Grills et al IJROBP 2007
48

48. IMPACT OF CT WINDOW LEVEL
Countouring of primary tumor should always be done in lung window
rather than mediastinum window as it may lead to under estimation of
primary tumor

49. IMPACT OF PET ON RT PLANNING
Where ever possible PET should be fused with planning CT scan as it helps
to distinguish between tumor and atelectasis

50. Inter and intra-fractional organ motion
 Respiratory motion is an important source of uncertainty for target
delineation
 Interplay effect between tumor motion and leaf motion may increase
dosimetry uncertainty
 Respiratory motion may affect dose to tumor as well as to normal structures
(lung, heart , esophagus, cord, etc)
 Controlling tumor motion is of primary importance - reduction in margins
51

51. Tumor mobility
 Two approaches to reduce the effect of respiratory motion: respiration
gating of the patient or controlling patient breathing
 Patient’s breathing is monitored using a variety of devices & radiation is
delivered when the patient’s respiratory cycle reaches a specific phase
 The patient’s breathing is altered by speaking to the patient(breath in-
breath out)
 Breath-hold reduces tumor mobility but is poorly tolerated by patients with
lung cancer
 Breath-hold or gating should take place with on-line monitoring
52

52. Respiratory Gating
• Conforms to target
• Higher doses to target tissue
• Less side effects from normal tissue
• Sharp dose gradient between target tissue and normal
tissue
• Misjudgment causes
• Underdose target
• Overdose normal tissue
53

53. Tracking Respiration
• External Marker
– Camera system
• Sends signal
• Reflected off markers
• Internal Markers
– Implanted gold
visicoil markers
54

54. Dose Volume Constraints
Organ RT Alone CT+RT CT/RT f/b Sx
Lung V20<40%
MLD<20Gy
V20<35%
V10<45%
V5<65%
MLD<20Gy
V20<20%
V10<40%
V5<55%
MLD<20Gy
Esophagus Dmax<75Gy
V60<50%
Dmax<75Gy
V55<50%
Dmax<75Gy
V55<50%
Cord 50 Gy 45Gy 45Gy
Heart V40<50% Same as RT alone Same as RT alone
Kidney 20Gy(<50% of
combined both
kidneys or <75% ofone
side of kidney if
another kidney is not
functional)
Same as RT Same as RT
Liver 30Gy(<40%) Same as RT Same as RT
Marks et al IJROBP 201055

55. Brachytherapy
 Brachytherapy plays an important role in the palliative treatment of
obstructive disease
 Brachytherapy used as definitive treatment in selected cases of early
endobronchial disease
 Postoperative treatment of small residual peribronchial disease
 Intraluminal brachytherapy alone can also be considered for the palliative
treatment of Endobronchial or endotracheal recurrent tumor growth in
previously irradiated areas
56

56. Technique
 Uses Ir192 remote afterloading HDR brachytherapy
 The total length of endobronchial component with 2 cm margins on either
side treated
 Usual treatment length is 6-10 cm
 Source is passed through a catheter placed transnasally under
bronchoscopic guidance.
 Dose prescribed is 8 Gy in 2# after EBRT(depending on dose)
 At max hospital 5-6Gy/1#
 Dose is prescribed at 1 cm from the central axis of the source

57. Chemotherapy
 Based upon the premise that 70% - 80% patients will have micrometastasis
during presentation
 Situations where Chemotehrapy can be used:
• Neoadjuvant CT as an induction regimen
• Radical Concurrent CT wit Radiation
• Adjuvant chemotherapy with or without radiation
• Palliative chemotherapy in systemic disease
Currently platinum based combination chemotherapy regimen preferred
for the treatment NSCLC
58

58. Post op chemotherapy for high risk patients with
margin negative surgery
• Poorly differentiated histology
• Vascular invasion
• Wedge resection
• Tumor size>4 cm
• Incomplete nodal sampling
59

59. Chemoradiotherapy as a Primary Combined
Treatment of NSCLC
 Aim
1) Exploiting additive effect on the locoregional tumor.
2) The control of micrometastases by chemotherapy component
3) Mutual enhancement
 Types
 Sequential
 Concurrent
60

60. Sequential vs Concurrent chemo RT
61
The Lancet Oncology Vol 2 June 2001

61. 62

62. 63

63. 64

64. Chemotherapy at Max Hospital
• AdenoCarcinoma- Pemetrexed(500mg/m2)+ cisplatin(75mg/m2)/
Carboplatin (AUC-5)
• Squamous Cell carcinoma- Gemcitabine(1250mg/m2)+cisplatin or
Gemcitabine+ Carbopaltin or paclitaxel(50mg/m2)+Carboplatin
• For concurrent paclitaxel+ carboplatin (weekly) or cispaltin+
Etoposide(100mg/m2 D1-D3)
• NACT-3 cycles of chemo f/b reassessment
65

65. Anti-EGFR Targeted Agents: Biological Rationale
 Activation of EGFR linked with
 Increased cell proliferation
 Angiogenesis
 Metastasis
 EGFR expression correlates with
 Poor response to treatment
 Disease progression
 Poor survival
 Agents that selectively target EGFR could inhibit and prevent the
pathogenesis of various cancers
66

66. EGFR
 Gefitinib and erlotinib target the tyrosine kinase EGFR
 Only about 10% of patients have a rapid and dramatic clinical response to
gefitinib
 Efficacy may be attributed to somatic mutations in EGFR gene
 Erlotinib has activity in NSCLC (10-15% of tumors will shrink; ~30-40% will
be stable)
 Tarceva improves survival in patients with metastatic disease that have
failed first line chemotherapy
 Rash and diarrhea - most common side effects
 Gefitinib - 250 mg O.D. oral
 Erlotinib- 150mg OD oral
N Engl J Med. 2004;350:2129-2139
Cancer Res. 1997;57:4838
67

67. ALK Mutation
• EML4-ALK gene fusions occur almost exclusively in carcinomas
arising in non-smokers
• About 4% of non-small-cell lung carcinomas involve an EML4-ALK
tyrosine kinase fusion gene.
• EML4-ALK mutation rarely occurs in combination with K-RAS or
EGFR mutations.
• Crizotinb and Ceretinib FDA approved
Matelli et al M J Pathol 200968

68. NSCLC Survival
Stage TNM 5-y Survival
Stage IA T1N0M0 65%
Stage IB T2N0M0 45%
Stage IIA T1N1M0 30%
Stage IIB T2N1M0
T3N0M0
28%
25%
Stage IIIA T1-2N2M0
T3N1-2M0
20%
18%-20%
Stage IIIB T4N0-3M0
T1-4N3M0
5%
5%
Stage IV Any T, Any N, M1 <1%
Non-small cell lung cancer survival rates by stage (2013, July 12). American Cancer
Society.
69

69. Radiotherapy: Toxicity
• The most common and significant radiation toxicity is radiation
pneumonitis.
• Occurs in two forms:
– Acute (1-6 months).
– Late (months to years).
• While acute radiation pneumonitis responds to corticosteroids, late
pneumonitis does not respond.
• Other toxicities encountered include, transverse myelitis, esophageal
strictures or perforation.

70. Acute Toxicities
• Usually during treatment or within 1 month
• Acute esophagitis starts in 3rd week of RT
• Treatment includes xylocaine and analgesics
• Nutritional status has to be kept in mind
• If it falls nasogastric tube or PEG insertion has to be done
• Bacterial and fungal infection has to be ruled out
• Cough –relieved with anti-tussive therapy
71

71. Late Toxicities
• Radiation Pneumonitis
• Pulmonary fibrosis
• Esophageal stenosis, ulceration, perforation and fistula
formation5-15%
• Cardiac- Pericarditis
• Spinal cord myelopathy
72
Gasper Cancer 2000

72. Radiation Pneumonitis
• Incidence of radiation pneumonitis is
related to:
– Dose.
– Fractionation.
– Volume of lung irradiated.
– Pre-treatment pulmonary
function.
– Administration of concurrent
chemotherapy
• Asymptomatic radiological findings
may be seen in 50% patients.
• Clinical radiation pneumonitis may
develop in as many as 20% patients.
Latent phase: Loss of type 2 pneumocytes,
Depletion of surfactant production and
resultant protein translocation into the alveoli
Edema of interstitial spaces
Thickening of alveolar septa
Acute clinical phase: Cough, dyspnea
Loss of capillaries and collagen deposition
Chronic restrictive changes
Pathophysiology of Radiation Pneumonitis

73. Pneumonitis grading.
• Grade 1: asymptomatic radiographic changes.
• Grade 2: changes requiring steroids or diuretics; dyspnea on
exertion
• Grade 3: requires oxygen; shortness of breath at rest
• Grade 4: requires assisted ventilation
• Grade 5: death
74

74. Follow Up
75NCCN 2016

75. Conclusions
 NSCLC accounts for more than 75% of all cases of lung cancer
 Accurate staging of NSCLC is critical because treatment options depend on
the spread of the disease
 Surgery /SBRT done for early stage NSCLC
 Radiation has an important part to play in all stages & for radical treatment
as well as palliation
 A number of other molecularly targeted drugs are being actively
investigated
 Smoking cessation remains the only proven effective way to reduce the risk
lung cancer
76

76. 77
Special Thanks to Dr Ritesh Sharma

77. NSCLC
Stage I & II
Fit
Unfit
Surgery
RT (± CCT)
Stage IV
 Palliative RT / CCT
 Supportive care
 Medication
 Brachytherapy
Stage III
Operable
Inoperable
Borderline
Surgery
Adjuvant RT ± CCT
Induction CCT
Fitness
for Sx
No
Fitness for
Surgery
Margins –ve,
+CT(4-6 Cycles)
Margins +ve,
Post op RT+CT
f/b CT
Conclusions
SBRT
78

78. SVC Syndrome
Extrinsic compression of SVC
or intracaval thrombosis
ETIOLOGY:
• Bronchogenic ca 80%
• Malignant lymphoma 15%
• Benign 2-5%
MANAGEMENT:
• General measures
• Radiation
• Decongestive measures
prior to starting RT
– I/V steroids
– Moist Oxygen
– Bronchodilators
• RT induced edema can
exacerbate symptoms in the
first few days
• RT doses will depend upon
the GC of the patient.
• Usual doses:
– 30 Gy in 10# in 2 weeks
– 20 Gy in 5 # in 1 week
– 8 Gy in SF
• Regimen selected depends
on patient age and GC.
79

79. Pancoast Tumors (SST)
• Lung tumors originating at apical pleuropulmonary groove (superior sulcus)
• CLINICAL:
Pancoast’s Syndrome:
- Pain in shoulder/ scapula medially
- Radicular pain in ulnar distribution
- Horner’s Syndrome
• MANAGEMENT
Resection
Extended en bloc resection
Preoperative RT:
– 50% - 60% become operable after preoperative RT.
Postoperative RT:
– no survival benefit
– However difficulty in obtaining clear resection margins make post op RT
necessary
80

80. • In patients with painful apical syndrome only:
RT : 30 Gy / 10 #
FIELD BORDERS:
Superior - C5 level
Inferior - 5 cm below carina
Laterally - include the full width of the upper 4 ribs.
Medially - entire mediastium.
Patient is then assessed for surgery.
• When surgery C.I.
Treatment goal is palliation of symptoms.
RT/CCT as the main therapeutic modalities.
81

81. Management
Resection
Extended en bloc resection of the chest wall including:
Posterior portions of first three ribs , part of upper thoracic vertebrae
(transverse processes) , intercostal nerves , lower trunk of brachial plexus
, stellate ganglion , lung (usually lobectomy)
Postoperative RT - No survival benefit has been found
However difficulty in obtaining clear resection margins make post
operative RT necessary with an aim to improve local control
Inoperable
N2 Nodal Disease
Extensive Vertebral Body Invasion
Superior Vena Cava Syndrome
Invasion of Subclavian Artery
Extensive Brachial Plexus Involvement
Medically Inoperable (COPD)
Distant Metastases
Treatment goal is palliation of symptoms.
RT/CCT are the main therapeutic modalities.
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