Lung Cancer Local Recurrence Womens Lung Cancer Forum

Lung Cancer Local Recurrence Women’s Lung Cancer Forum November 12 th, 2018 Sasha Mahvi

Lung Cancer • By far the leading cause of cancer-related death • Estimated at 154, 050 in 2018 • Being diagnosed earlier with improving screening techniques

Definitive Treatment Options • Surgery is standard for resectable disease • • Lobectomy Segmental Resection Wedge Resection Pneumonectomy (entire lung) • SBRT (stereotactic body radiation therapy) is considered for early stage lung cancer in patients who cannot handle surgery • Prospective trials are ongoing comparing SBRT to surgery but no results yet

Surgery Treatment Options

Surveillance After Surgery • Goal is to detect either: • Recurrent lung cancer (from the original tumor) • New lung cancer (‘second primary’)

NCCN Surveillance Recommendations • History and physical exam with chest CT scan • Every 6 months for the first 2 years • Annually thereafter • There is no data that compares types of CT scans for surveillance • Full-dose vs. Low-dose • Postoperative CT scans preferred over chest x-rays • Large trial of 1775 found survival was 10. 3 years compared to 8. 2 years • Not statistically significant however

Rate of Isolated Thoracic Recurrence • Ranges from 5 -40% • Oftentimes this local recurrence is isolated • Not widely metastatic disease • Increases therapeutic options

Risk Factors for Recurrence • Higher stage cancer • Sublobar resection (wedge or segment) • Squamous/large cell histology • Lymphovascular invasion

Outcomes After Local Recurrence • Typical survival is under a year, worse when also metastatic recurrence • Location Dependent • Intrathoracic: 25. 5 months • Extrathoracic: 10. 1 months • Both: 4. 8 months

Current Treatment Options • Preventing Local Recurrence • Surgery • Chemotherapy • Radiation Therapy • Treating Local Recurrence • Repeat Surgery • Chemotherapy +/- Radiation Therapy

Extent of Surgery • Sublobar resections have higher positive margin rates • Lobectomy: 1. 4% • Segmentectomy: 2. 1% • Wedge Resection: 4. 0% • Have to balance with residual lung volume • Are negative margins enough? • Even negative margins <1 cm have increased local recurrence and lower overall survival

Systemic Chemotherapy • Many options • Platinum-based plus: • Docetaxel/paclitaxel • Gemcitabine • Bevacizumab • Adjuvant therapy indicated for stage II or IIIA • Neoadjuvant in some settings: • IIIA • Superior sulcus (Pancoast) • Chest wall invasion • Newer agents currently being researched as well • Molecularly targeted agents • i. e. Gefitinib for EGFR • Immunotherapy • i. e. Nivolumab

Local Radiation Therapy • Usually given after surgery • Positive surgical margins • Inadequate lymph node sampling • N 2 lymph node involvement • Given after chemotherapy if both are given

Surgery for Local Recurrence • No randomized trials, however seems to be beneficial when possible • One study found median survivals after local recurrence: • 9. 8 months is no treatment • 22. 9 months with surgery • 32. 8 months with surgery and isolated lung recurrence

Radiation or Chemotherapy for Recurrence • Radiation therapy can be added to surgery or separately • Small studies with no comparison show median survival of 11 -19 months • Chemotherapy should never be given alone for local recurrence • Can be combined with radiation therapy and/or surgery to treat micrometastatic disease

Novel Therapies • Brachytherapy seeds • Internal radiation therapy • ACOSOG Z 4032 phase III trial • 222 patients with stage I NSCLC with sublobar resection +/- seeds • Non-significant trend towards decreased local recurrence with brachytherapy seeds in patients with positive staple line cytology

Chemotherapy Polymer Film • Polymer films can deliver high doses of chemotherapy locally to resection bed • Has shown decreased local recurrence and improved survival in a mouse model

Nanoparticles • Can be given systemically or locally • Contain either chemotherapy and/or otherapeutic agents