Cancer Treatment Today » Cancers in the Chest (but not lung)

Unresectable Pancoast – pro

M Levin, MD — Mon, 10 Sep 2012 17:49:31 +0000

Pancoast tumor is a malignant lung mass that involves upper lung, often with involvement of surrounding structures. There usually is no metastatic disease and the goal is cure. Patients with a Pancoast tumor without evidence of mediastinal node involvement or distant metastases should be evaluated by an experienced thoracic surgeon for potential resection. Patients with a Pancoast tumor being considered for resection should undergo evaluation with a magnetic resonance imaging (MRI) of the thoracic inlet and brachial plexus, in addition to a computed tomography (CT) of the chest. Patients with a potentially resectable, nonmetastatic Pancoast tumor (and good performance status) should undergo preoperative chemoradiotherapy prior to resection. A reasonable alternative for such patients is preoperative radiotherapy. This is recommended by a referenced guidelines at level of evidence, fair; benefit, moderate; grade of recommendation, B. This is also what NCCN recommends.

Detterbeck FC, Jones DR, Kernstine KH, Naunheim KS. Presentations of lung cancer with special treatment considerations. Chest 2003 Jan;123(1 Suppl):244S-58S. [56 references]

Rusch VW, Giroux DJ, Kraut MJ, et al. Induction chemoradiation and surgical resection for non-small cell lung carcinomas of the superior sulcus: initial results of the Southwest Oncology Group Trial 9416 (Intergroup trial 0160). J Thorac Cardiovasc Surg. 2001;121:472-483.

NCCN.ORG

IMRT and Tomotherapy – pro

M Levin, MD — Mon, 27 Aug 2012 02:12:10 +0000

Lay Summary: An introduction to IMRT and Tomotherapy

IMRT is a rapidly evolving technique, which affords a more precise radiation dose delivery of escalated doses, in appropriate cases, to targeted tumors, while sparing nearby healthy tissue structures. The FDA clearance of numerous devices for the technical delivery of IMRT is based on the capability of this technology to incorporate accurate dose calculation algorithms, associated with a verifiable dose distribution, as managed by the treating physician, (i.e., radiation oncologist). Although, to date, no randomized trials have matured to document long-term outcomes data and efficacy for IMRT, the scientific evidence currently available indicates that IMRT permits better treatment planning and sparing of surrounding tissues, which is of particular usefulness with “Radiosensitive” tumors of the head/neck, prostate and CNS lesions where the target volume is in close proximity to critical healthy structures that must be protected. These results may be extrapolated to the treatment of other cancers at other anatomic sites; however, a number of technical issues need to be resolved before IMRT can be recommended routinely for lung cancer use, particularly the issue of tumor mobility must be addressed, (e.g., a lung tumor moving with respiration). The NCI was sufficiently concerned about these issues to issue a recently updated report for use in planning and design of clinical trials. It can be found at http://atc.wustl.edu/home/NCI/NCI_IMRT_Guidelines_2006.pdf

A recent retrospective review of uses of IMRT in anal cancer concluded: “Preliminary outcomes suggest that concurrent chemotherapy and IMRT for anal canal cancers is effective and tolerated favorably compared with historical standards.” More studies are needed.

Tomotherapy delivers varying intensity radiation with a rotating device. The intensity is varied by the placement of “leaves” which either block or allow the passage of radiation. The rotating component of this technique allows for more specific targeting of the cancer. In conventional radiation therapy, the beam is usually delivered from several different directions, possibly 5-10. The greater the number of beam directions, the more the dose will be confined to the target cancer cells, sparing normal cells from exposure. Tomotherapy delivers radiation from every point on a helix, or spiral, instead of from just a few points. The same caveats apply.

Differences between the prescribed dose of radiation in intensity modulated radiation therapy (IMRT) and the dose that’s actually delivered may make comparison studies in lung cancer difficult to interpret. These findings were reported in the Journal of the National Cancer Institute. For lung, there remains the issue of respiratory movement which makes accurate targeting more difficult, but a variety of technique have been developed to deal with it. A 2010 guideline says: “Insufficient evidence was obtained in this systematic review; therefore, it is not possible to propose recommendations on the use of intensity-modulated radiation therapy (IMRT) for lung cancer informed by evidence.”

Currently, there are no randomized controlled trials of IMRT compared with other radiation techniques for treatment of prostate cancer. Non-randomized studies consistently demonstrate reduced rates of toxicity in IMRT-treated patients. The 2010 Agency for Healthcare Research and Quality (AHRQ) comparative evaluation of radiation treatments for clinically localized prostate cancer concluded that data on comparative effectiveness between different forms of radiation treatments are inconclusive with respect to overall or disease-specific survival. In addition, the AHRQ technology assessment states that more studies of better quality are needed to confirm or refute the suggested findings in the studies that compared outcomes in patients treated with different forms of radiation therapy. Nevertheless, prostate cancer has become an accepted modality to treat prostate cancer.

Blue Cross Blue Shield Association. Special Report: Intensity Modulation Radiation Therapy for Cancer of the Breast or Lung. TEC Assessment. Chicago, IL. December 2005; 20 (13)

Das, I., Cheng, C., Chopra, K., et al. Intensity modulated radiation therapy dose prescription, recording, and delivery: patterns of variability among institutions and treatment planning systems. Journal of the National Cancer Institute. 2008.

Bezjak A, Rumble RB, Rodrigues G, Hope A, Warde P, IMRT Indications Expert Panel. The role of IMRT in lung cancer. Toronto (ON): Cancer Care Ontario (CCO); 2010 Nov 22. Various p. (Evidence-based series; no. 21-3-5). [46 references]

Available data are insufficient to determine whether IMRT is superior to 3D-CRT for improving health outcomes of patients with breast or lung cancer.

K . Ohnishi , H . Liu , Z . Liao , S . Yom , H . Jin , X . Wei , P . Allen , S . Tucker , R . Mohan , R . Komaki Clinical Outcomes and Treatment Planning Strategies for Advanced-Stage Non-Small Cell Lung Cancer (NSCLC) Treated With Intensity Modulated Radiation Therapy (IMRT) and Concurrent Chemotherapy (CCT)
International Journal of Radiation OncologyBiologyPhysics , Volume 69 , Issue 3 , Pages S522 – S522, 2007

http://atc.wustl.edu/home/NCI/NCI_IMRT_Guidelines_2006.pdf

J. K. Salama, L. K. Mell, D. A. Schomas, R. C. Miller, K. Devisetty, A. B. Jani, A. J. Mundt, J. C. Roeske, S. L. Liauw, and S. J. Chmura
Concurrent Chemotherapy and Intensity-Modulated Radiation Therapy for Anal Canal Cancer Patients: A Multicenter Experience
J. Clin. Oncol., October 10, 2007; 25(29): 4581 – 4586.

Parliament MB, et al: Preservation of oral health-related quality of life and salivary flow rates after inverse-planned intensity- modulated radiotherapy (IMRT) for head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2004 Mar 1;58(3):663-73.

Lee N, et al Intensity-modulated radiation therapy in head and neck cancers: An update. Head Neck. 2007 Apr;29(4):387-400.

Graff P, et al: Impact of intensity-modulated radiotherapy on health-related quality of life for head and neck cancer patients: Matched-pair comparison with conventional radiotherapy. Int J Radiat Oncol Biol Phys. 2007 Feb 6;

National Cancer Institute (NCI). National Cancer Institute Guidelines for the use of Intensity Modulated Radiation Therapy in Clinical Trials. Bethesda, MD: NCI; January 14, 2005

Garden AS, et al: Disease-control rates following intensity-modulated radiation therapy for small primary oropharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 2007 Feb 1;67(2):438-44. Epub 2006 Dec 4.

Braam PM, et al: Intensity-modulated radiotherapy significantly reduces xerostomia compared with conventional radiotherapy. Int J Radiat Oncol Biol Phys. 2006 Nov 15;66(4):975-80. Epub 2006 Sep 11.

Agency for Healthcare Research and Quality (AHRQ) Technology Assessments. Comparative evaluation of radiation treatments for clinically locazlized prostate cancer: an update. Available from: http://www.cms.gov/coveragegeninfo/downloads/id69ta.pdf

Wilt TJ, Shamliyan T, Taylor B et al. Comparative effectiveness of therapies for clinically localized prostate cancer. Comparative Effectiveness Review No. 13. Agency for Healthcare Research and Quality. February 2008.

Pearson SD, Ladapo, Prosser L. Intensity modulated radiation therapy (IMRT) for localized prostate cancer. Institute for Clinical and Economic Review. 2007.

Staffurth, J. A review of the clinical evidence for intensity-modulated radiotherapy. Clin Oncol (R Coll Radiol). 2010 Oct;22(8):643-57.

Zelefsky, MJ, Levin, EJ, Hunt, M, et al. Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys. 2008 Mar 15;70(4):1124-9.

Esophageal Cancer

To date there are insufficient clinical outcome study data comparing intensity modulated radiation therapy (IMRT) with three-dimensional conformal radiation therapy (3DCRT) in the treatment of gastrointestinal (GI) cancers. However, evidence from 19 non-comparative dosimetric and outcome studies has suggested that IMRT is an option for esophageal, gastric, bile duct, pancreatic, rectal, and anal cancers. These studies have demonstrated that IMRT can reduce radiation dose to organs at risk (OAR), while managing to deliver the prescribed radiation dose to target volumes. For this reason, IMRT may be considered a viable treatment option, as it is ethical to recommend a treatment with little known harm over one with greater expected harm prior to scientific proof of the difference in harm being established.

Wong RKW, Rumble RB, Warde P, IMRT Indications Expert Panel. The role of IMRT in gastrointestinal cancers. Toronto (ON): Cancer Care Ontario (CCO); 2010 Oct 29. Various p. (Evidence-based series; no. 21-3-10). [28 references]

Xeloda combinations for thymoma – pro

M Levin, MD — Fri, 24 Aug 2012 20:04:20 +0000

Thymoma is usually treated with surgery. Where surgery is inappropriate, chemotherapy concurrent with, or sequential to, radiation therapy is recommended. Cisplatin-based combination chemotherapy is an appropriate option. Octreotide, alone or in combination with a corticosteroid, may be a reasonable option for recurrent cases. A recent Phase II study revealed that complete responses (CR) and partial responses were observed in three (20%) and three (20%) patients for a 40% RR, respectively. Grade 1–2 neutropenia, anemia and thrombocytopenia were the most common side-effects, noted in seven (46.7%), five (33.3%) and five (33.3%) patients, respectively. The most common grade 3 toxicity was neutropenia in three patients (20%). Median PFS was 11 months (95% confidence interval 4–17). The 1- and 2-year survival rates were 80% and 67%, respectively. There are other phase II trials that also suggest that cepacitabine in combination is effective.

A phase II study by Giaccone suggested that: “Pembrolizumab is a promising treatment option in patients with thymic carcinoma. Because severe autoimmune disorders are more frequent in thymic carcinoma than in other tumour types, careful monitoring is essential. This is not a definitive study.

. Giaccone et al, Pembrolizumab in patients with thymic carcinoma: a single-arm, single-centre, phase 2 study The Lancet Oncology Volume 19, Issue 3, March 2018, Pages 347-355

Falkson C, Bezjak A, Darling G, Gregg R, Malthaner R, Maziak D, Yu E, Smith CA, McNair S, Ung Y, Evans WK, Lung Disease Site Group. The management of thymoma: guideline recommendations. Toronto (ON): Cancer Care Ontario Program in Evidence-based Care; 2008 Sep 26. 41 p. (Evidence-based series; no. 7-11). [58 references]

G. Palmieri , G. Merola , P. Federico , L. Petillo , M. Marino , M. Lalle , M. Milella , A. Ceribelli , L. Montella , C. Merola , S. Del Prete , M. Bergaglio , S. De Placido , and G. Di Lorenzo
Preliminary results of phase II study of capecitabine and gemcitabine (CAP-GEM) in patients with metastatic pretreated thymic epithelial tumors (TETs)
Annals of Oncology Advance Access published on October 30, 2009, DOI 10.1093/annonc/mdp483.

Palmieri, G., Merola, C., Petillo, L., Merola, G., Federico, P., Leopardo, D., Marino, M., Montella, L.
Gemcitabine-capecitabine in platinum-refractory patients with thymic epithelial tumors
J Clin Oncol (Meeting Abstracts) 2009 27: 7590

Stereotactic radiosurgery of lung – pro

M Levin, MD — Fri, 24 Aug 2012 17:44:49 +0000

Stereotactic body radiation therapy (SBRT) is a technique that utilizes precisely targeted radiation to a tumor while minimizing radiation to adjacent normal tissue. This targeting allows treatment of small- or moderate-sized tumors in either a single or limited number of dose fractions.Stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) initially was used successfully for intracranial, orbital, and base of skull tumors, as well as benign conditions that can use the skull as a reference system. The success of SRS for intracranial indications led to the development of techniques to extend this approach to extracranial targets, such as lung cancer. Stereotactic radiation therapy for extracranial sites is aided by technical advances including tumor imaging to guide radiation administration, patient immobilization, and conformal radiation delivery techniques.

The usual use for SBRT is to attempt a cure or occasionally to control symptomatic lung metastases. It should be realized that this is not a treatment that is free from potential side effects. American Society for Therapeutic Radiation and Oncology (ASTRO, 2007) stated that SBRT is considered appropriate for the treatment of the following conditions:

Lung or liver metastases not amenable to surgery
Medically inoperable early stage lung cancer
Primary liver cancer not amenable to surgery
Recurrent lung cancer amenable to salvage therapy
Recurrent pelvic tumors
Retroperitoneal tumors
Spinal and para-spinous tumors
Other recurrent cancers or tumors.

https://www.isrsy.org/en/radiosurgery/guidelineprojec, Accessed 12/24/2020

Arjun Pennathur, MD et al, Stereotactic Radiosurgery for the Treatment of Lung Neoplasm: Experience in 100 Consecutive Patients Ann Thorac Surg 2009;88:1594-1600

H. C. Fernando, M. Schuchert, R. Landreneau, and B. T. Daly
Approaching the High-Risk Patient: Sublobar Resection, Stereotactic Body Radiation Therapy, or Radiofrequency Ablation Ann. Thorac. Surg., June 1, 2010; 89(6): S2123 – S2127.

Dunlap NE, Cai J, Biedermann GB, et al. Chest wall volume receiving >30 Gy predicts risk of severe pain and/or rib fracture after lung stereotactic body radiotherapy. Int J Radiat Oncol Biol Phys 2010; 76:796.

Andolino DL, Forquer JA, Henderson MA, et al. Chest wall toxicity after stereotactic body radiotherapy for malignant lesions of the lung and liver. Int J Radiat Oncol Biol Phys 2011; 80:692.

Haute Autorite de sante/French National Authority for Health (HAS). Value of extra-cranial stereotactic radiotherapy [summary]. Saint-Denis La Plaine, France: HAS; 2007.

American Society for Therapeutic Radiation and Oncology (ASTRO). The ASTRO/ACR Guide to Radiation Oncology Coding 2007. Fairfax, VA: ASTRO; 2007.

Read the Layperson version here.

Chemotherapy and Carboplatin Paclitaxel for Thymic Cancer – pro

M Levin, MD — Sat, 23 Jun 2012 01:26:54 +0000

The thymus is a small organ located in the upper/front portion of your chest, extending from the base of the throat to the front of the heart. Thymic carcinomas are divided into low-grade (better prognosis) and high-grade (worse prognosis, that is, more likely to grow and spread quickly) categories. Around 25% of people with thymic carcinoma are cured.

Low-grade thymic carcinomas include well-differentiated squamous cell, mucoepidermoid, and basaloid types. High-grade thymic carcinomas include poorly differentiated squamous cell, small cell/neuroendocrine, clear cell, anaplastic/undifferentiated, and sarcomatoid types.

Several anticancer drugs have been used in the treatment of thymomas and thymic carcinomas. However, because thymic carcinoma is a rare neoplasm, treatment with chemotherapy has not been studied systematically. Based on case reports and series, the drugs most effective when given alone are doxorubicin (Adriamycin), cisplatin, ifosfamide, and corticosteroids (prednisone). Often, these drugs are given in combination to increase their effectiveness. Combinations used to treat thymic cancer include cisplatin, doxorubicin, etoposide and cyclophosphamide, and the combination of cisplatin, doxorubicin, cyclophosphamide, and vincristine. The role of radiation, with or without chemotherapy, is similarly undefined and reliant on case reports and series. Although there is a paucity of information, one might consider singe agents or combinaations that have been well-documented for therapy.

NCCN lists a variety of chemo combinations on p. THYM-C, 1. On p. MS-5 it recommends paclitaxel/carboplatin as having the highest reported response rate. It also specifically mentions the ADOC regimen, but cautions that it is more toxic than carbop/paclitaxel.

Lemma GL, Lee JW, Aisner SC, et al. Phase II study of carboplatin and paclitaxel in advanced thymoma and thymic carcinoma. J Clin Oncol 2011; 29:2060.

Wright CD, Choi NC, Wain JC, et al. Induction chemoradiotherapy followed by resection for locally advanced Masaoka stage III and IVA thymic tumors. Ann Thorac Surg 2008; 85:385.

Forquer JA, Rong N, Fakiris AJ, et al. Postoperative radiotherapy after surgical resection of thymoma: differing roles in localized and regional disease. Int J Radiat Oncol Biol Phys 2010; 76:440.

A. Kitami, T. Suzuki, Y. Kamio, and S. Suzuki
Chemotherapy of Thymic Carcinoma: Analysis of Seven Cases and Review of the Literature
Jpn. J. Clin. Oncol., December 1, 2001; 31(12): 601 – 604.

M. A. Greene and M. A. Malias
Aggressive multimodality treatment of invasive thymic carcinoma
J. Thorac. Cardiovasc. Surg., February 1, 2003; 125(2): 434 – 436.

NCCN, Thymoma and Thymic cancer, 2012