Radiation Oncology/NSCLC/Special Situations

Special Treatment Situations in NSCLC

Superior Sulcus Tumors

 * Arise in apex of lung and invade apical chest wall structures
 * Classic description of Pancoast syndrome: "pain in the eighth cervical and first and second thoracic trunk distribution, wasting of the muscles of the hand, and Horner's syndrome (Pancoast KH, JAMA 99:1391, 1932)
 * Modern description: 1) shoulder pain, 2) sensory/motor deficits and wasting of muscles of the hand due to brachial plexus involvement, 3) Horner's syndrome due to stellate ganglion involvement, and 4) arm edema due to compression of blood vessels
 * With improved radiographic imaging, any invasion of apical structures can be classified as Pancoast tumor, including ribs/periosteum, lower nerve roots of brachial plexus, sympathetic chain, or subclavian vessels. Pain radiating down the arm no longer required
 * Work-up should be treated like for any other potentially resectable lung tumor, including surgical staging of the mediastinum
 * Treatment with RT alone results in ~5% long-term survivors, although in series with potentially curable tumors, long-term survival is ~20%
 * Pre-op RT followed by resection results in 5-year survival ~30%, but R0 resection can be typically achieved in only 2/3 of patients. Majority of recurrences were in tumor bed. This was the standard of care from 1950's to 1990's
 * Induction chemoradiation based on SWOG 9416 allows R0 resection in 75%, good local control, and 5-year survival 44%

Anatomy:
 * MDACC; 2008 -- Imaging of non-small cell lung cancer of the superior sulcus (parts 1+2)
 * PMID 18349457 Full text -- "part 1: anatomy, clinical manifestations, and management." (Bruzzi JF, Radiographics. 2008 Mar-Apr;28(2):551-60.)
 * PMID 18349458 Full text -- "part 2: initial staging and assessment of resectability and therapeutic response." (Bruzzi JF, Radiographics. 2008 Mar-Apr;28(2):561-72.)

Guidelines:
 * ACCP 2nd edition guideline (PMID 17873175):
 * 1) Tissue diagnosis should be obtained prior to initiation of therapy
 * 2) If considered for curative resection, MRI should be performed to further evaluate resectability
 * 3) If considered for curative resection, invasive mediastinal staging and extra-thoracic staging are recommended. Involvement of mediastinal nodes is a contra-indication to resection
 * 4) If subclavian vessels or vertebral column involved, resection should be performed only at a specialized center
 * 5) If potentially resectable, pre-operative concurrent chemoradiotherapy is recommended
 * 6) If surgery performed, every effort should be made for complete resection
 * 7) If surgery performed, recommend a lobectomy over wedge resection, and resection of involved chest wall structures
 * 8) Regardles of resection status (R0 vs R1-2), post-operative RT not recommended because of lack of survival benefit
 * 9) If unresectable but non-metastatic tumor, definitive concurrent chemoradiation is recommended
 * 10) If not candidate for curative intention, palliative radiotherapy is recommended

Trials:
 * SWOG 9416 (1995-1999) -- Induction chemo-RT, surgery, adjuvant chemo
 * Prospective. 110 patients, solitary T3-T4 N0-N1 superior sulcus NSCLC. Induction chemo-RT (cisplatin 50 mg/m2 and etoposide 50 mg/m2 + RT 45/25 to primary tumor and ipsilateral SCV but not mediastinum/hilum.) Restaging 2-4 weeks later for surgery (lobectomy or pneumonectomy, with en-block resection of tumor, and mediastinal dissection). Thereafter adjuvant cisplatin/etoposide x2 cycles. No adjuvant RT
 * 4-years; 2007 PMID 17235046 -- "Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas: long-term results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160)." (Rusch VW, J Clin Oncol. 2007 Jan 20;25(3):313-8.) Median F/U 3.7 years
 * Compliance: induction completed by 95%, thoracotomy in 80%, R0 resection in 76% (94% of those going to surgery), pCR in 29% (36% of those going to surgery). PCR or microscopic residual disease was seen in 56% of the patients. Postop mortality 2%
 * Outcome: median OS 2.7 years, if R0 resection 7.8 years. 5-year OS 44%, if R0 resection 54%. No difference between T3 and T4. LR 17%, LR+DM 12%, DM 67% (~50% brain only)
 * Conclusion: Combined modality approach feasible, LC and OS seem improved relative to prior studies. Complete resection necessary for good outcome


 * University of Maryland; 2005 (1993-2003) PMID 15942564 -- "High-dose radiotherapy in trimodality treatment of Pancoast tumors results in high pathologic complete response rates and excellent long-term survival." (Kwong KF, J Thorac Cardiovasc Surg. 2005 Jun;129(6):1250-7.)
 * Retrospective. 36 patients with Pancoast tumors (Stage IIB 50%, IIIA 22%, IIIB 17%, IV with solitary brain mets 14%). Induction chemo-RT followed by surgery. RT mean dose 56.9 Gy
 * Outcome: pCR 40%. Median OS 2.6 years; if pCR 7.8 years. For failures, 50% in brain.
 * Conclusion: Surgical resection after high-dose RT and chemotherapy is feasible

Practice Guidelines

 * ACCP 2nd edition; 2007 PMID 17873175 -- "Special treatment issues in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)." (Shen KR, Chest. 2007 Sep;132(3 Suppl):290S-305S.)
 * Guideline: Pancoast tumors, T4N0-1, satellite nodules, synchronous/metachronous multiple primaries, solitary brain/adrenal metastases, chest wall involvement