SlideShare una empresa de Scribd logo
1 de 92
폐암의 방사선치료
RT for NSCLC
Yong Chan Ahn, MD, PhD
Dept. of Radiation Oncology
Samsung Medical Center
Sungkyunkwan University School of Medicine
21,577 Consultations (1994~2006)
Hepatobi l i ary
5.9%
Lymphoma &
Leuk emi a
6.8%
H&N
11.4%
Esophagus
1.8%
Stomach
4.5%
Lung
18.2%
Breast
13.6%
Cervi x &
uterus
8.2%
Col orectal
13.6%
Others
9.1%
Prostate
1.4%
Brai n
5.5%
Staging System
• AJCC 7th edition since January 2010
• Anatomical extent of disease is expressed by
TNM classification:
– Prediction of prognosis
– Therapeutic decision
• 1/6 patients will be classified in to a different
stage category
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1
T1a
T1b
Tumor ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of
invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)*
Tumor ≤2 cm in greatest dimension
Tumor >2 cm but ≤3 cm in greatest dimension
T2
T2a
T2b
Tumor >3 cm but ≤7 cm or tumor with any of the following features (T2 tumors with these features are
classified T2a if ≤5 cm)
Involves main bronchus, ≥2 cm distal to the carina
Invades visceral pleura (PL1 or PL2)
Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve
the entire lung
Tumor >3 cm but ≤5 cm in greatest dimension
Tumor >5 cm but ≤7 cm in greatest dimension
T3 Tumor >7 cm or one that directly invades any of the following: parietal pleural (PL3) chest wall (including
superior sulcus tumors), diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium; or tumor in the
main bronchus (<2 cm distal to the carina* but without involvement of the carina; or associated atelectasis or
obstructive pneumonitis of the entire lung or separate tumor nodule(s) in the same lobe
T4 Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, recurrent
laryngeal nerve, esophagus, vertebral body, carina, separate tumor nodule(s) in a different ipsilateral lobe
* The uncommon superficial spreading tumor of any size with its invasive component limited to the bronchial
wall, which may extend proximally to the main bronchus, is also classified as T1a.
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar
lymph nodes and intrapulmonary nodes, including involvement
by direct extension
N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph
node(s)
N3 Metastasis in contralateral mediastinal, contralateral hilar,
ipsilateral or contralateral scalene, or supraclavicular lymph
node(s)
Distant Metastasis (M)
M0 No distant metastasis (no pathologic M0; use clinical M to
complete stage group)
M1
M1a
M1b
Distant metastasis
Separate tumor nodule(s) in a contralateral lobe; tumor with
pleural nodules or malignant pleural (or pericardial) effusion*
Distant metastasis
* Most pleural (and pericardial) effusions with lung cancer are
due to tumor. In a few patients, however, multiple
cytopathologic examinations of pleural (pericardial) fluid are
negative for tumor, and the fluid is non-bloody and is not an
exudate. Where these elements and clinical judgment dictate
that the effusion is not related to the tumor, the effusion should
be excluded as a staging element and the patient should be
classified as M0.
AJCC Stage Group (7th edition)
T1a/b T2a T2b T3 T4
N0 IA IB IIA IIB IIIA
N1 IIA IIA IIB IIIA IIIA
N2 IIIA IIIA IIIA IIIB
N3 IIIB IIIB IIIB IIIB
Multi-modality Tx
Treatment Modalities for Cancer
• Loco-regional:
– Surgery
– Radiation therapy
• Systemic:
– Chemotherapy
– Immunotherapy
Radiation and Surgery
Rationale
Radiation usually fails in tumor center, and
rarely doses at periphery
Surgery usually fails at periphery because of
microscopic tumor cells left behind
Sequence of radiation and surgery
Preoperative radiation
Postoperative radiation
Intraoperative radiation
Limited Surgery and Radiation
Using surgery as boost technique
Full courses of radiation combined with
tumorectomy
Surgery can be done before or after the
irradiation
Examples
Breast – lumpectomy + definitive radiation
H/N cancer – definitive radiochemotherapy +
adjuvant neck dissection
Radiation and Chemotherapy
Purpose is not to decrease radiation dose
to gain the same effect, but rather to
increase therapeutic index
3 strategies:
Drugs directly modifying radiation survival
curve (synergy, sensitizer, potentiator)
Drugs specifically affecting tumor response
to radiation (hypoxic sensitizers)
Drugs with independent action or additivity
Theoretic Rationales of CMT
 Spatial cooperation
 Toxicity independence
 Reduction of toxicity
 Enhanced tumor response
 Prevention of emergence of resistant clones
Treatment Selection Factors
 Treatment-related factors
 Tumor-related factors
 Patient-related factors
 Physician-related factors
지피지기 (知彼知己)
백전백승 (百戰百勝)
Knowing oneself and one's opponent,
invincibility!
Tx Principle
Staging W/U for NSCLC at SMC
• Standard: Chest CT, PFT, Broncho, PET-CT
• Optional: Brain MR (if AD)
Medically operable vs Medically inoperable
Early, vs Advanced –M1 or wet T4
Locally advanced
Resectable
Potentially resectable
Unresectable
Mediastinoscopy &/or EBUS
for all potentially resectable
candidate
Tx Guideline for NSCLC at SMC
T
T1 T2 T3 T4
N
N0 IA-IIB
Op ± RT/CTx/CRT
Definitive RT alone
IIIB
(except wet T4)
Definitive
CCRT or RT
alone
N1 IIIA (T3N1)
N2
IIIA
Preop. CCRT + Op + RT
Definitive CCRT or RT alone
N3
Stage I/II
• Whenever possible, surgery is recommended
first.
• After surgery, CTx and/or RT may be
recommended to decrease recurrence risk.
• RT alone is recommended if surgery is not
feasible due to severe lung disease or other
underlying medical problems.
• A few individualized RT techniques and dose
schedules are used.
Stage III
• There is no one “best” treatment for stage III
NSCLC.
– Choice of Tx modality depends upon several factors
including size and location of tumor, N stage, and
physiologic status of patient.
• Whenever possible, combination of RT and CTx
(CCRT) is recommended first.
• Either RT or CTx alone is considered if
aggressive CCRT is not feasible.
Radiation Therapy:
From Basic to Up-to-date
How radiation kills cancer?
 Ionization --> Damage to DNA or membrane
--> Mutation, Cell death
 metabolically active for the time-being
 die out at time of cell division due to aberrant
reproduction
 takes time before cancer cells disappear
DNA Damage & Chromosome Aberration
DNA Damage & Chromosome Aberration
Direct vs Indirect Actions
Incident X-ray
(photon)
Fast electron (e-)
(10-15 sec)
Ion radical
(10-10 sec)
Free radical
(10-5 sec)
Chemical changes
(hours~years)
Biological effects
Discrepancy in Clinical and
Pathologic Responses
Patient-specific Radiation Therapy
• Individualized
• Customized
• Adaptive
Preparation for Radiation Therapy
• Acquisition of CT (MR, PET-CT)
• Contouring:
– Targets (GTV, CTV, ITV)
– Organs at risk
• Determination of beam arrangement, intensity
to achieve the most optimal plan among rival
plans
• Quality assurance
Image Guided RT
• RT procedure using image guidance at various
stages of its process (patient data acquisition,
treatment planning, treatment simulation,
patient setup, and target localization before
and during treatment)
To identify and correct problems
arising from inter- and intra-
fractional variations in patient setup
and anatomy
Image Guidance Technology
• Portal & radiographic imager (EPID)
• In-Room CT
• KV cone-beam CT
• MV cone-beam CT (Tomotherapy)
Stereotactic Body RT
• High ablative dose
• To small tumor (usually <3~4 cm)
• Within a few fractions
• Using multiple non-coplanar beams
• With adequate immobilization and motion
control
SBRT
• One of the state-of-the-art RT techniques
– Highly conformal and accurate radiation delivery
• Conformal high dose
• Compact intermediate dose
• Very large low dose volume
– High fractional dose (10~20 Gy * ≤4 fractions)
– Within short period of time (within 1 week)
– Patient-specific Tx planning
Conventional RT SBRT
Dose/fraction 1.8~3.0 Gy 10~20 Gy
Fraction number 10~30 fractions 1~5 fractions
Target delineation GTV, CTV, (ITV), PTV
GTV, CTV, ITV, PTV
(GTV CTV)
Margins cm range mm range
Need for mechanical
accuracy
Low to medium Very high
Need for respiratory
motion control
Moderate High
Radiobiology
Moderately well
understood
Still poorly understood
Interaction with
systemic therapy
Currently active Will become active
Toxicities of SBRT
• Acute:
– Fatigue, anorexia, nausea
– Pulmonary
– Skin
• Late:
– Pulmonary
– Chest wall
• Unknown:
– Heart
– Large vessel
– Etc
SBRT Experience at SMC
Rationale of SBRT in Stage I NSCLC
• RT is better than doing nothing.
• (+) dose-response relationship has been
confirmed with respect to local control.
• The smaller the tumor, the higher the local
control and survival by RT.
• Incidence of lymphatic metastasis is known to be
very low.
• Shorter RT duration is better than protracted RT
schedule in survival.
Importance of tumor size Importance of RT duration
SBRT Indications at SMC
• cT1-2,N0
• Single metastasis or recurrence
• ≤ 5 cm in size (preferably ≤ 3 cm)
• Location (peripheral > central, upper > lower)
Pinnacle®
Heterogeneity correction
Respiratory training for imaging & SBRT
4D CT; CTV-ITV (1.2+ cm margin around GTC-ITV)
CBCT for target localization
Respiratory Training
(Respiratory Signal Analysis Program)
Pre-SBRT
6 months
18 months
JTO, 2010
Characteristics # Pt (%)
Age Median 69 (39~88) years
Sex Male 98 (84.5%)
Female 18 (15.5%)
Tumor nature Primary 38 (32.8%)
Metastatic 78 (67.2%)
Lung 32 (41.0 %)
GI Track 24 (30.8 %)
Head & Neck 9 (11.5 %)
Others 13 (16.7 %)
Patients’ Characteristics I
(116 Patients: ’01/Feb~’10/Nov)
JTO, 2010
Characteristics # Pt (%)
Tumor size ≤ 2.0 cm 58 (50.0%)
> 2.0 cm 58 (50.0%)
RT dose 50 Gy/5 Fx’s (’01/Jun~’02/May) 8 ( 6.9%)
60 Gy/5 Fx’s (’02/June~’09/Dec) 72 (62.1%)
60 Gy/4 Fx’s (’10/Jan~’10/Dec) 36 (31.0%)
Patients’ Characteristics II
(116 Patients: ’01/Feb~’10/Nov)
JTO, 2010
Prognosticators on Local Control
Characteristics Crude LC p
Tumor nature
Primary (38) 92.1%
1.0
Metastatic (78) 91.0%
Pathology
Squamous (41) 90.2%
1.0Adenoca (34) 91.2%
Others (41) 92.7%
Tumor size
≤ 2.0 cm (58) 100%
0.001
> 2.0 cm (58) 82.8%
RT dose
50 Gy/5 Fx’s (8) 75.0%
0.01960 Gy/5 Fx’s (72) 88.9%
60 Gy/4 Fx’s (36) 100%JTO, 2010
Survival
Months
Probability
p = 0.036
66.4%
53.8%
JTO, 2010
Grade # Pt (%)
Grade 0 80 (69.0 %)
Grade 1 30 (25.9 %)
Grade 2 4 ( 3.4 %)
Grade 3 2 ( 1.7 %)
Symptomatic Radiation Pneumonitis
JTO, 2010
Summary
• SBRT to lung cancer at SMC:
– High local control (90%)
– Favorable 5 year survival (primary/metastatic –
66.4%/53.8%)
– Very low risk of complication (Grade 2/3 –
3.4%/1.7%)
– Highly effective and curative modality to patients
who are unfit for surgery.
JTO, 2010
Acta Oncologica, 2012
SBRT for Lung Metastasis
• SBRT to 57 patients, 67 metastatic lesions
• Sep. 2001~Nov. 2010
• Lung toxicity:
– Grade 2 in 4 patients (6.0%)
– Grade 5 in 1
Acta Oncologica, 2012
Acta Oncologica, 2012
Response at 1 month:
- CR in 17 (25%)
- PR in 40 (60%)
- SD in 10 (15%)
Local progression in 3 (5%)
94.5% at 3 years
Acta Oncologica, 2012
Acta Oncologica, 2012
59.7% 56.2%
at 2 years at 5 years
Acta Oncologica, 2012
Presence of extrathoracic disease was
the only significant factor (p=0.049)
on multivariate analysis.
64.0% vs 38.9%
at 3 years
66.1% vs 0%
at 3 years 71.1% vs 51.1%
at 3 years
Acta Oncologica, 2012
Acta Oncologica, 2012
Conclusion
• SBRT for single or oligo-metastasis seems
quite effective and safe.
• Tumor size, disease-free interval, and presence
of extrathoracic disease are prognosticators for
survival.
Acta Oncologica, 2012
Management of N2 Disease
Introduction
• Remarkable improvements in diagnosis of N2
disease -- CT, FDG PET-CT, mediastinoscopy,
VATS, and EBUS
• A few different ways of classifying N2 disease --
clinical vs surgical, minimal vs bulky etc…
• N2 disease is a very important prognostic
factor in NSCLC.
• There is no single answer that defines the best
treatment option for N2(+) NSCLC.
Trimodality for N2 Disease @ SMC
• TRT
– 45 Gy/25 Fx’s (’97~Sep ’09)
– 44 Gy/22 Fx’s (Oct ’09~)
• CTx
– EP #2 q 4 weeks (’97~Apr ’01)
– Weekly DP #5 (Mar ’01~)
• Surgery in 3-4 weeks
• Optional postop TRT (18~20 Gy/2 weeks)
• Optional CTx (usually sequential)
Acta Oncol, 2001
Acta Oncol, 2001
43.2%
51.8%
25.6%
37.2%
49.1%
35.5%
Summary (Acta Oncol, 2001)
• Preoperative CCRT resulted in fair pathologic
response, down-staging (68.2%), less radical
surgery, and 2-year OS with tolerable
morbidity.
• Surgery added to CCRT did not affect OS, but
altered failure pattern only.
Acta Oncol, 2001
Preop CCRT
(N=410)
Patients (June ’97~Aug ’11)
Surgical resection
(N=396)
Postop TRT (+)
(N=228)
Postop TRT (-)
(N=144)
Incomplete Tx,
progression, refusal (14)
Periop deaths (19)
Systemic progression (5)
Presented at ACOS, KOSRO, ASTRO meetings in 2012
Patients’ Characteristics (N=396)
Age Median 59 (18-76) years
Gender Male
Female
310 (78.3%)
86 (21.7%)
Histology Adenoca
Squamous cell ca
Large cell ca
Non-small cell ca, NOS
213 (53.8%)
157 (39.6%)
11 (2.8%)
15 (3.8%)
cT stage cT1
cT2
cT3
99 (25.0%)
239 (60.4%)
62 (15.6%)
Tumor size Mean 33 (9-128) mm
cN2 status (CT and/or PET-CT) Bulky
Minimal
276 (69.7%)
120 (30.3%)
Pathologic confirmation of N2 No
Yes
41 (10.4%)
355 (89.6%)
Number of (+) nodal station Single
Multiple
250 (63.1%)
146 (36.9%)
Preop Tx
TRT 45 Gy in 25 Fx’s (1997’ ~ Oct 2009’)
44 Gy in 22 Fx’s (Sep 2009’ ~ )
293 (74.0%)
103 (26.0%)
CTx EP q 3 weeks (1997’ ~ Jul 2001’)
Weekly DP (Jul 2001’ ~ )
48 (12.1%)
348 (87.9%)
Surgery
Sublobar resection
(Bi-)Lobectomy
Pneumonectomy
2 ( 0.5%)
335 (84.6%)
59 (14.9%)
Postop Tx
TRT No or incomplete
Yes (18-20 Gy in 10 Fx’s)
177 (44.7%)
219 (55.3%)
CTx No
Yes
301 (76.0%)
95 (24.0%)
Treatment Characteristics (N=396)
Factors No. of Pts
ypT stage* 0
1
2
3
4
65 (16.4%)
161 (40.7%)
126 (31.8%)
38 ( 9.6%)
6 ( 1.5%)
ypN stage* 0
1
2
3
164 (41.4%)
53 (13.4%)
177 (44.7%)
2 ( 0.5%)
ypM stage* 0
1a
394 (99.5%)
2 ( 0.5%)
TNM stage* 0
I
II
III
IV
55 (13.9%)
97 (24.5%)
57 (14.4%)
185 (46.7%)
2 ( 0.5%)
Factors No. of Pts
Tumor size Mean 24 (0-110) mm
Pleural
invasion
PL0
PL1
PL2
PL3
319 (80.6%)
10 ( 2.5%)
44 (11.1%)
23 ( 5.8%)
Resection
margin
Positive
Close (1-5 mm)
Negative
20 ( 5.1%)
24 ( 6.1%)
352 (88.8%)
No. of positive
N2 station
None
Single
Multiple
217 (54.8%)
102 (25.8%)
77 (19.4%)
N0. (+) LN Mean 2.4 (0-26)
Downstaging Yes
No
211 (53.3%)
185 (46.7%)
Pathologic Findings (N=396)
* AJCC 7Th ed.
Median 3-year 5-year
OS 46 (35-58) mo 56.9% 44.2%
PFS 21 (16-26) mo 37.5% 33.3%
LRC Not reached 76.2% 71.6%
DMFS 28 (21-34) mo 42.1% 37.7%
Survival Outcomes (N=396)
 Median F/U = 33 (4-156) months
Prognostic Factors – Multivariate analysis
P value
Factors LRC PFS OS
Age < 60 vs. ≥ 60 years 0.174 0.389 0.002
Gender Female vs. Male 1.000 0.578 0.291
Histology Adenoca vs. non-Adenoca 0.629 0.009 0.662
cT stage cT1-2 vs. cT3 0.847 0.847 0.481
Chemo regimen EP q 3 weeks vs. weekly DP 0.243 0.092 0.009
Op. type Lobectomy vs. Pneumonectomy 0.070 0.001 0.004
ypT stage ypT0-2 vs. ypT3-4 0.284 0.182 0.064
ypN stage ypN0 vs. ypN1-3 0.001 <0.001 <0.001
Resection margin Negative vs. Close/positive 0.294 0.380 0.811
Postop TRT No/incomplete vs. Yes 0.163 0.198 0.003
Postop chemo No vs. Yes 0.291 0.600 0.050
Summary
Excellent clinical outcomes (Median survival =
46 months; 5-year OS = 44.2%) with trimodality
therapy.
Pathologic nodal down-staging was the most
important prognostic factor.
SWOG 8805 RTOG 0229 INT 0139 SMC
Median 13 months 26.6 months 23.6 months 46 months
OS 27% (3-Yr) 54% (2-Yr) 27% (5-Yr) 44.2% (5-Yr)
Conclusions
• There definitely is positive role of surgical resection
following preoperative CCRT in cN2 disease.
• Benefit of surgery is summarized as improved loco-
regional control at no excess morbidity.
• Without loco-regional control,
real cure cannot be expected,
and surgery remains essential
under multi-disciplinary spirit.
Team Approach!
Multidisciplinary
approach
Multidisciplinary
approach
2007 헬스조선
2008 중앙일보
RT for lung cancer at SMC
RT for lung cancer at SMC

Más contenido relacionado

La actualidad más candente

Radiotherapy Planning For Esophageal Cancers
Radiotherapy Planning For Esophageal CancersRadiotherapy Planning For Esophageal Cancers
Radiotherapy Planning For Esophageal Cancersfondas vakalis
 
Radiotherapy in carcinoma rectum
Radiotherapy in carcinoma rectumRadiotherapy in carcinoma rectum
Radiotherapy in carcinoma rectumSagar Raut
 
Treatment Options for Cancer of the Bladder
Treatment Options for Cancer of the BladderTreatment Options for Cancer of the Bladder
Treatment Options for Cancer of the BladderRobert J Miller MD
 
Radiation for Colon and Rectal Cancer
Radiation for Colon and Rectal CancerRadiation for Colon and Rectal Cancer
Radiation for Colon and Rectal CancerRobert J Miller MD
 
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinar
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinarRadiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinar
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinarFight Colorectal Cancer
 
Non small cell lung cancer copy
Non small cell lung cancer   copyNon small cell lung cancer   copy
Non small cell lung cancer copyankitapandey63
 
Tumor board locally advanced rectal cancer
Tumor board locally advanced rectal cancerTumor board locally advanced rectal cancer
Tumor board locally advanced rectal cancerRanjita Pallavi
 
Small cell lung cancer
Small cell lung cancerSmall cell lung cancer
Small cell lung cancerMyatSu Aung
 
Post-operative Radiotherapy for Esophageal Cancer
Post-operative Radiotherapy for Esophageal CancerPost-operative Radiotherapy for Esophageal Cancer
Post-operative Radiotherapy for Esophageal Cancerfondas vakalis
 
Radiotherapy lymphoma
Radiotherapy lymphoma Radiotherapy lymphoma
Radiotherapy lymphoma vrinda singla
 
Rectal Cancer and Radiotherapy: What is the Clinical Implication of a Complet...
Rectal Cancer and Radiotherapy:What is the Clinical Implication of a Complet...Rectal Cancer and Radiotherapy:What is the Clinical Implication of a Complet...
Rectal Cancer and Radiotherapy: What is the Clinical Implication of a Complet...ensteve
 
Pelvic irradiation toxicity
Pelvic irradiation toxicityPelvic irradiation toxicity
Pelvic irradiation toxicitykilichophy
 
Preoperative radiotherapy and surgery rectal cancers: optimal interval
Preoperative radiotherapy and surgery rectal cancers: optimal intervalPreoperative radiotherapy and surgery rectal cancers: optimal interval
Preoperative radiotherapy and surgery rectal cancers: optimal intervalGaurav Kumar
 
Radiotherapy For Non Small Cell Lung Cancer
Radiotherapy For Non Small Cell Lung CancerRadiotherapy For Non Small Cell Lung Cancer
Radiotherapy For Non Small Cell Lung Cancerfondas vakalis
 
Carcinoma of unknown primary devnani
Carcinoma of unknown primary devnaniCarcinoma of unknown primary devnani
Carcinoma of unknown primary devnaniBharti Devnani
 
Contouring guidelines pancreatic malignancies
Contouring guidelines  pancreatic malignancies  Contouring guidelines  pancreatic malignancies
Contouring guidelines pancreatic malignancies astha17srivastava
 
Sclc sneha 4.10.16 new
Sclc sneha 4.10.16 newSclc sneha 4.10.16 new
Sclc sneha 4.10.16 newSneha George
 

La actualidad más candente (20)

Radiotherapy Planning For Esophageal Cancers
Radiotherapy Planning For Esophageal CancersRadiotherapy Planning For Esophageal Cancers
Radiotherapy Planning For Esophageal Cancers
 
Radiotherapy in carcinoma rectum
Radiotherapy in carcinoma rectumRadiotherapy in carcinoma rectum
Radiotherapy in carcinoma rectum
 
Treatment Options for Cancer of the Bladder
Treatment Options for Cancer of the BladderTreatment Options for Cancer of the Bladder
Treatment Options for Cancer of the Bladder
 
Radiation for Colon and Rectal Cancer
Radiation for Colon and Rectal CancerRadiation for Colon and Rectal Cancer
Radiation for Colon and Rectal Cancer
 
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinar
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinarRadiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinar
Radiation Treatment of Rectal and Colon Cancer :: July 2017 #CRCWebinar
 
Non small cell lung cancer copy
Non small cell lung cancer   copyNon small cell lung cancer   copy
Non small cell lung cancer copy
 
Tumor board locally advanced rectal cancer
Tumor board locally advanced rectal cancerTumor board locally advanced rectal cancer
Tumor board locally advanced rectal cancer
 
Small cell lung cancer
Small cell lung cancerSmall cell lung cancer
Small cell lung cancer
 
Lung cancer
Lung cancerLung cancer
Lung cancer
 
Post-operative Radiotherapy for Esophageal Cancer
Post-operative Radiotherapy for Esophageal CancerPost-operative Radiotherapy for Esophageal Cancer
Post-operative Radiotherapy for Esophageal Cancer
 
Radiotherapy lymphoma
Radiotherapy lymphoma Radiotherapy lymphoma
Radiotherapy lymphoma
 
Rectal Cancer and Radiotherapy: What is the Clinical Implication of a Complet...
Rectal Cancer and Radiotherapy:What is the Clinical Implication of a Complet...Rectal Cancer and Radiotherapy:What is the Clinical Implication of a Complet...
Rectal Cancer and Radiotherapy: What is the Clinical Implication of a Complet...
 
Small cell ca lung
Small cell ca lungSmall cell ca lung
Small cell ca lung
 
Pelvic irradiation toxicity
Pelvic irradiation toxicityPelvic irradiation toxicity
Pelvic irradiation toxicity
 
Preoperative radiotherapy and surgery rectal cancers: optimal interval
Preoperative radiotherapy and surgery rectal cancers: optimal intervalPreoperative radiotherapy and surgery rectal cancers: optimal interval
Preoperative radiotherapy and surgery rectal cancers: optimal interval
 
Radiotherapy For Non Small Cell Lung Cancer
Radiotherapy For Non Small Cell Lung CancerRadiotherapy For Non Small Cell Lung Cancer
Radiotherapy For Non Small Cell Lung Cancer
 
Carcinoma of unknown primary devnani
Carcinoma of unknown primary devnaniCarcinoma of unknown primary devnani
Carcinoma of unknown primary devnani
 
Contouring guidelines pancreatic malignancies
Contouring guidelines  pancreatic malignancies  Contouring guidelines  pancreatic malignancies
Contouring guidelines pancreatic malignancies
 
Sclc sneha 4.10.16 new
Sclc sneha 4.10.16 newSclc sneha 4.10.16 new
Sclc sneha 4.10.16 new
 
Radiation therapy in Cancer Oesophagus
Radiation therapy in Cancer Oesophagus Radiation therapy in Cancer Oesophagus
Radiation therapy in Cancer Oesophagus
 

Destacado

272927416fa0da4c5baf82065deb3ca8243a6175b7e0df78c
 272927416fa0da4c5baf82065deb3ca8243a6175b7e0df78c 272927416fa0da4c5baf82065deb3ca8243a6175b7e0df78c
272927416fa0da4c5baf82065deb3ca8243a6175b7e0df78cJordi Burrull Urbina
 
Carta Circular 5- 2014-2015
Carta Circular 5- 2014-2015Carta Circular 5- 2014-2015
Carta Circular 5- 2014-2015Belinda Torres
 
Woodpecker Office Park
Woodpecker Office ParkWoodpecker Office Park
Woodpecker Office Parkgarypope
 
Entrevista a Antonio Banda en "El Nuevo Lunes"
Entrevista a Antonio Banda en "El Nuevo Lunes"Entrevista a Antonio Banda en "El Nuevo Lunes"
Entrevista a Antonio Banda en "El Nuevo Lunes"Feelcapital
 
Enfoque Actual de las Lesiones Deportivas
Enfoque Actual de las Lesiones DeportivasEnfoque Actual de las Lesiones Deportivas
Enfoque Actual de las Lesiones DeportivasChaz Leal
 
Guía técnica para la evaluación y prevención de los riesgos relativos a l...
Guía técnica para la evaluación y prevención de los riesgos relativos a l...Guía técnica para la evaluación y prevención de los riesgos relativos a l...
Guía técnica para la evaluación y prevención de los riesgos relativos a l...David J Castresana
 
Descripción
DescripciónDescripción
Descripciónp_queipo
 
A L T A E N E L C I E L O
A L T A  E N  E L  C I E L OA L T A  E N  E L  C I E L O
A L T A E N E L C I E L Oeempimania
 
Joomla Content Delivery Networks
Joomla Content Delivery NetworksJoomla Content Delivery Networks
Joomla Content Delivery NetworksMike Carson
 
Sharath Technical Lead Resume
Sharath Technical Lead ResumeSharath Technical Lead Resume
Sharath Technical Lead ResumeSharath Babu
 

Destacado (17)

Caricom y petrocaribe
Caricom y petrocaribeCaricom y petrocaribe
Caricom y petrocaribe
 
Resume_Tirumala_updated
Resume_Tirumala_updatedResume_Tirumala_updated
Resume_Tirumala_updated
 
272927416fa0da4c5baf82065deb3ca8243a6175b7e0df78c
 272927416fa0da4c5baf82065deb3ca8243a6175b7e0df78c 272927416fa0da4c5baf82065deb3ca8243a6175b7e0df78c
272927416fa0da4c5baf82065deb3ca8243a6175b7e0df78c
 
Carta Circular 5- 2014-2015
Carta Circular 5- 2014-2015Carta Circular 5- 2014-2015
Carta Circular 5- 2014-2015
 
Woodpecker Office Park
Woodpecker Office ParkWoodpecker Office Park
Woodpecker Office Park
 
Entrevista a Antonio Banda en "El Nuevo Lunes"
Entrevista a Antonio Banda en "El Nuevo Lunes"Entrevista a Antonio Banda en "El Nuevo Lunes"
Entrevista a Antonio Banda en "El Nuevo Lunes"
 
Historia
HistoriaHistoria
Historia
 
Enfoque Actual de las Lesiones Deportivas
Enfoque Actual de las Lesiones DeportivasEnfoque Actual de las Lesiones Deportivas
Enfoque Actual de las Lesiones Deportivas
 
Guia de Aprendizaje SENA
Guia de Aprendizaje SENAGuia de Aprendizaje SENA
Guia de Aprendizaje SENA
 
Factor de Riesgo
Factor de RiesgoFactor de Riesgo
Factor de Riesgo
 
Guía técnica para la evaluación y prevención de los riesgos relativos a l...
Guía técnica para la evaluación y prevención de los riesgos relativos a l...Guía técnica para la evaluación y prevención de los riesgos relativos a l...
Guía técnica para la evaluación y prevención de los riesgos relativos a l...
 
Descripción
DescripciónDescripción
Descripción
 
A L T A E N E L C I E L O
A L T A  E N  E L  C I E L OA L T A  E N  E L  C I E L O
A L T A E N E L C I E L O
 
Joomla Content Delivery Networks
Joomla Content Delivery NetworksJoomla Content Delivery Networks
Joomla Content Delivery Networks
 
Sharath Technical Lead Resume
Sharath Technical Lead ResumeSharath Technical Lead Resume
Sharath Technical Lead Resume
 
Бодљокошци
БодљокошциБодљокошци
Бодљокошци
 
Bodljokošci
BodljokošciBodljokošci
Bodljokošci
 

Similar a RT for lung cancer at SMC

St gallen rectal carcinoma
St gallen rectal carcinomaSt gallen rectal carcinoma
St gallen rectal carcinomaParag Roy
 
Principles of oncology staging and management
Principles of oncology staging and managementPrinciples of oncology staging and management
Principles of oncology staging and managementShrutiDevendra
 
Radiotherapy for bladder cancers
Radiotherapy for bladder cancersRadiotherapy for bladder cancers
Radiotherapy for bladder cancersAshutosh Mukherji
 
LungCancerSlides.pptx
LungCancerSlides.pptxLungCancerSlides.pptx
LungCancerSlides.pptxHesocaHux
 
Pancreatic neuroendocrine tumors (pnets)
Pancreatic neuroendocrine tumors (pnets)Pancreatic neuroendocrine tumors (pnets)
Pancreatic neuroendocrine tumors (pnets)Dr Priyanka Vishwakarma
 
Locally Advanced Rectal Cancer
Locally Advanced Rectal CancerLocally Advanced Rectal Cancer
Locally Advanced Rectal CancerYamini Baviskar
 
Discuss the pathology of bladder cancers
Discuss the pathology of bladder cancersDiscuss the pathology of bladder cancers
Discuss the pathology of bladder cancersJim Badmus
 
Rectal MRI .pptx
Rectal MRI .pptxRectal MRI .pptx
Rectal MRI .pptxrojelio101
 
Treatment of Muscle Invasive Bladder Carcinoma
Treatment of Muscle Invasive Bladder Carcinoma Treatment of Muscle Invasive Bladder Carcinoma
Treatment of Muscle Invasive Bladder Carcinoma Dr.Bhavin Vadodariya
 
Management of locally advanced rectal cancer
Management of locally advanced rectal cancerManagement of locally advanced rectal cancer
Management of locally advanced rectal cancerDr. Abani Kanta Nanda
 
Surgical persrective in lung cancer
Surgical persrective in lung cancerSurgical persrective in lung cancer
Surgical persrective in lung cancerHarilal Nambiar
 
SBRT/SABR for Early Stage Lung Cancer: A Brief Overview
SBRT/SABR for Early Stage Lung Cancer: A Brief OverviewSBRT/SABR for Early Stage Lung Cancer: A Brief Overview
SBRT/SABR for Early Stage Lung Cancer: A Brief OverviewTodd Scarbrough
 
Management of small cell lung cancer
Management of small cell lung cancerManagement of small cell lung cancer
Management of small cell lung cancerDr Durgesh Kumar
 
Gastrointestinal stromal tumor (GIST) dr ridu kumar sharma
Gastrointestinal stromal tumor (GIST)  dr ridu kumar sharmaGastrointestinal stromal tumor (GIST)  dr ridu kumar sharma
Gastrointestinal stromal tumor (GIST) dr ridu kumar sharmaRidu Kumar Sharma
 
Management of Locally advanced NSCLC
Management of Locally advanced NSCLCManagement of Locally advanced NSCLC
Management of Locally advanced NSCLCDr Boaz Vincent
 

Similar a RT for lung cancer at SMC (20)

St gallen rectal carcinoma
St gallen rectal carcinomaSt gallen rectal carcinoma
St gallen rectal carcinoma
 
Principles of oncology staging and management
Principles of oncology staging and managementPrinciples of oncology staging and management
Principles of oncology staging and management
 
Radiotherapy for bladder cancers
Radiotherapy for bladder cancersRadiotherapy for bladder cancers
Radiotherapy for bladder cancers
 
LungCancerSlides.pptx
LungCancerSlides.pptxLungCancerSlides.pptx
LungCancerSlides.pptx
 
Pancreatic neuroendocrine tumors (pnets)
Pancreatic neuroendocrine tumors (pnets)Pancreatic neuroendocrine tumors (pnets)
Pancreatic neuroendocrine tumors (pnets)
 
Locally Advanced Rectal Cancer
Locally Advanced Rectal CancerLocally Advanced Rectal Cancer
Locally Advanced Rectal Cancer
 
Discuss the pathology of bladder cancers
Discuss the pathology of bladder cancersDiscuss the pathology of bladder cancers
Discuss the pathology of bladder cancers
 
Nasopharynx
Nasopharynx Nasopharynx
Nasopharynx
 
Rectal MRI .pptx
Rectal MRI .pptxRectal MRI .pptx
Rectal MRI .pptx
 
Treatment of Muscle Invasive Bladder Carcinoma
Treatment of Muscle Invasive Bladder Carcinoma Treatment of Muscle Invasive Bladder Carcinoma
Treatment of Muscle Invasive Bladder Carcinoma
 
Management of locally advanced rectal cancer
Management of locally advanced rectal cancerManagement of locally advanced rectal cancer
Management of locally advanced rectal cancer
 
Surgical persrective in lung cancer
Surgical persrective in lung cancerSurgical persrective in lung cancer
Surgical persrective in lung cancer
 
SBRT/SABR for Early Stage Lung Cancer: A Brief Overview
SBRT/SABR for Early Stage Lung Cancer: A Brief OverviewSBRT/SABR for Early Stage Lung Cancer: A Brief Overview
SBRT/SABR for Early Stage Lung Cancer: A Brief Overview
 
Management of small cell lung cancer
Management of small cell lung cancerManagement of small cell lung cancer
Management of small cell lung cancer
 
Rectal CA.pdf
Rectal CA.pdfRectal CA.pdf
Rectal CA.pdf
 
SBRTweb.nearmc
SBRTweb.nearmcSBRTweb.nearmc
SBRTweb.nearmc
 
Gastrointestinal stromal tumor (GIST) dr ridu kumar sharma
Gastrointestinal stromal tumor (GIST)  dr ridu kumar sharmaGastrointestinal stromal tumor (GIST)  dr ridu kumar sharma
Gastrointestinal stromal tumor (GIST) dr ridu kumar sharma
 
Management of Locally advanced NSCLC
Management of Locally advanced NSCLCManagement of Locally advanced NSCLC
Management of Locally advanced NSCLC
 
Soft tissue sarcoma dr mnr
Soft tissue sarcoma dr mnrSoft tissue sarcoma dr mnr
Soft tissue sarcoma dr mnr
 
Rectal cancer
Rectal cancerRectal cancer
Rectal cancer
 

Más de Yong Chan Ahn

1701 ahnyc imrt lung
1701 ahnyc imrt lung1701 ahnyc imrt lung
1701 ahnyc imrt lungYong Chan Ahn
 
Hn 1608 advanced lx cancer
Hn 1608 advanced lx cancerHn 1608 advanced lx cancer
Hn 1608 advanced lx cancerYong Chan Ahn
 
16 cco korean perspectives of nasopharynx cancer management
16 cco korean perspectives of nasopharynx cancer management16 cco korean perspectives of nasopharynx cancer management
16 cco korean perspectives of nasopharynx cancer managementYong Chan Ahn
 
1605 Salvage reRT for local recurrence of nasopharynx cancer
1605 Salvage reRT for local recurrence of nasopharynx cancer1605 Salvage reRT for local recurrence of nasopharynx cancer
1605 Salvage reRT for local recurrence of nasopharynx cancerYong Chan Ahn
 
1509 webinar oligometa lung
1509 webinar oligometa lung1509 webinar oligometa lung
1509 webinar oligometa lungYong Chan Ahn
 
1411 APLCC AHNYC Tri Bimodality N2
1411 APLCC AHNYC Tri Bimodality N21411 APLCC AHNYC Tri Bimodality N2
1411 APLCC AHNYC Tri Bimodality N2Yong Chan Ahn
 
1411 APLCC AHNYC SBRT & IMRT in Lung Cancer
1411 APLCC AHNYC SBRT & IMRT in Lung Cancer1411 APLCC AHNYC SBRT & IMRT in Lung Cancer
1411 APLCC AHNYC SBRT & IMRT in Lung CancerYong Chan Ahn
 
Role of RT in aggressive NHL 1406
Role of RT in aggressive NHL 1406Role of RT in aggressive NHL 1406
Role of RT in aggressive NHL 1406Yong Chan Ahn
 
ERT in Thyroid Cancer
ERT in Thyroid CancerERT in Thyroid Cancer
ERT in Thyroid CancerYong Chan Ahn
 
Novel RT techniques for treating lung cancer 1403
Novel RT techniques for treating lung cancer 1403Novel RT techniques for treating lung cancer 1403
Novel RT techniques for treating lung cancer 1403Yong Chan Ahn
 
Role of RT in oropharynx ca 2013 june
Role of RT in oropharynx ca 2013 juneRole of RT in oropharynx ca 2013 june
Role of RT in oropharynx ca 2013 juneYong Chan Ahn
 
Oropharynx cancer practical target delineation 2013 apr
Oropharynx cancer practical target delineation 2013 aprOropharynx cancer practical target delineation 2013 apr
Oropharynx cancer practical target delineation 2013 aprYong Chan Ahn
 
Esophageal cancer practical target delineation 2013 may
Esophageal cancer practical target delineation 2013 mayEsophageal cancer practical target delineation 2013 may
Esophageal cancer practical target delineation 2013 mayYong Chan Ahn
 

Más de Yong Chan Ahn (13)

1701 ahnyc imrt lung
1701 ahnyc imrt lung1701 ahnyc imrt lung
1701 ahnyc imrt lung
 
Hn 1608 advanced lx cancer
Hn 1608 advanced lx cancerHn 1608 advanced lx cancer
Hn 1608 advanced lx cancer
 
16 cco korean perspectives of nasopharynx cancer management
16 cco korean perspectives of nasopharynx cancer management16 cco korean perspectives of nasopharynx cancer management
16 cco korean perspectives of nasopharynx cancer management
 
1605 Salvage reRT for local recurrence of nasopharynx cancer
1605 Salvage reRT for local recurrence of nasopharynx cancer1605 Salvage reRT for local recurrence of nasopharynx cancer
1605 Salvage reRT for local recurrence of nasopharynx cancer
 
1509 webinar oligometa lung
1509 webinar oligometa lung1509 webinar oligometa lung
1509 webinar oligometa lung
 
1411 APLCC AHNYC Tri Bimodality N2
1411 APLCC AHNYC Tri Bimodality N21411 APLCC AHNYC Tri Bimodality N2
1411 APLCC AHNYC Tri Bimodality N2
 
1411 APLCC AHNYC SBRT & IMRT in Lung Cancer
1411 APLCC AHNYC SBRT & IMRT in Lung Cancer1411 APLCC AHNYC SBRT & IMRT in Lung Cancer
1411 APLCC AHNYC SBRT & IMRT in Lung Cancer
 
Role of RT in aggressive NHL 1406
Role of RT in aggressive NHL 1406Role of RT in aggressive NHL 1406
Role of RT in aggressive NHL 1406
 
ERT in Thyroid Cancer
ERT in Thyroid CancerERT in Thyroid Cancer
ERT in Thyroid Cancer
 
Novel RT techniques for treating lung cancer 1403
Novel RT techniques for treating lung cancer 1403Novel RT techniques for treating lung cancer 1403
Novel RT techniques for treating lung cancer 1403
 
Role of RT in oropharynx ca 2013 june
Role of RT in oropharynx ca 2013 juneRole of RT in oropharynx ca 2013 june
Role of RT in oropharynx ca 2013 june
 
Oropharynx cancer practical target delineation 2013 apr
Oropharynx cancer practical target delineation 2013 aprOropharynx cancer practical target delineation 2013 apr
Oropharynx cancer practical target delineation 2013 apr
 
Esophageal cancer practical target delineation 2013 may
Esophageal cancer practical target delineation 2013 mayEsophageal cancer practical target delineation 2013 may
Esophageal cancer practical target delineation 2013 may
 

Último

Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...
Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...
Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...BhumiSaxena1
 
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeTop Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeCall Girls Delhi
 
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In AhmedabadGENUINE ESCORT AGENCY
 
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...Sheetaleventcompany
 
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...Dipal Arora
 
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service AvailableCall Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service AvailableJanvi Singh
 
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...adilkhan87451
 
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...Sheetaleventcompany
 
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls ServiceGENUINE ESCORT AGENCY
 
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...khalifaescort01
 
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...hotbabesbook
 
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service AvailableGENUINE ESCORT AGENCY
 
Independent Call Girls Service Mohali Sector 116 | 6367187148 | Call Girl Ser...
Independent Call Girls Service Mohali Sector 116 | 6367187148 | Call Girl Ser...Independent Call Girls Service Mohali Sector 116 | 6367187148 | Call Girl Ser...
Independent Call Girls Service Mohali Sector 116 | 6367187148 | Call Girl Ser...karishmasinghjnh
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...chandars293
 
Call Girls Madurai Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Madurai Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Madurai Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Madurai Just Call 9630942363 Top Class Call Girl Service AvailableGENUINE ESCORT AGENCY
 
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...tanya dube
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...Arohi Goyal
 
Trichy Call Girls Book Now 9630942363 Top Class Trichy Escort Service Available
Trichy Call Girls Book Now 9630942363 Top Class Trichy Escort Service AvailableTrichy Call Girls Book Now 9630942363 Top Class Trichy Escort Service Available
Trichy Call Girls Book Now 9630942363 Top Class Trichy Escort Service AvailableGENUINE ESCORT AGENCY
 
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...Anamika Rawat
 

Último (20)

Call Girls in Gagan Vihar (delhi) call me [🔝 9953056974 🔝] escort service 24X7
Call Girls in Gagan Vihar (delhi) call me [🔝  9953056974 🔝] escort service 24X7Call Girls in Gagan Vihar (delhi) call me [🔝  9953056974 🔝] escort service 24X7
Call Girls in Gagan Vihar (delhi) call me [🔝 9953056974 🔝] escort service 24X7
 
Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...
Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...
Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...
 
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeTop Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
 
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
8980367676 Call Girls In Ahmedabad Escort Service Available 24×7 In Ahmedabad
 
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...
Low Rate Call Girls Bangalore {7304373326} ❤️VVIP NISHA Call Girls in Bangalo...
 
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
 
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service AvailableCall Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
 
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
 
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...
Call Girls Service Jaipur {9521753030} ❤️VVIP RIDDHI Call Girl in Jaipur Raja...
 
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
9630942363 Genuine Call Girls In Ahmedabad Gujarat Call Girls Service
 
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
💕SONAM KUMAR💕Premium Call Girls Jaipur ↘️9257276172 ↙️One Night Stand With Lo...
 
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
Night 7k to 12k Chennai City Center Call Girls 👉👉 7427069034⭐⭐ 100% Genuine E...
 
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Ahmedabad Just Call 9630942363 Top Class Call Girl Service Available
 
Independent Call Girls Service Mohali Sector 116 | 6367187148 | Call Girl Ser...
Independent Call Girls Service Mohali Sector 116 | 6367187148 | Call Girl Ser...Independent Call Girls Service Mohali Sector 116 | 6367187148 | Call Girl Ser...
Independent Call Girls Service Mohali Sector 116 | 6367187148 | Call Girl Ser...
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 9332606886 𖠋 Will You Mis...
 
Call Girls Madurai Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Madurai Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Madurai Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Madurai Just Call 9630942363 Top Class Call Girl Service Available
 
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
Premium Bangalore Call Girls Jigani Dail 6378878445 Escort Service For Hot Ma...
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
 
Trichy Call Girls Book Now 9630942363 Top Class Trichy Escort Service Available
Trichy Call Girls Book Now 9630942363 Top Class Trichy Escort Service AvailableTrichy Call Girls Book Now 9630942363 Top Class Trichy Escort Service Available
Trichy Call Girls Book Now 9630942363 Top Class Trichy Escort Service Available
 
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
Jogeshwari ! Call Girls Service Mumbai - 450+ Call Girl Cash Payment 90042684...
 

RT for lung cancer at SMC

  • 1. 폐암의 방사선치료 RT for NSCLC Yong Chan Ahn, MD, PhD Dept. of Radiation Oncology Samsung Medical Center Sungkyunkwan University School of Medicine
  • 2. 21,577 Consultations (1994~2006) Hepatobi l i ary 5.9% Lymphoma & Leuk emi a 6.8% H&N 11.4% Esophagus 1.8% Stomach 4.5% Lung 18.2% Breast 13.6% Cervi x & uterus 8.2% Col orectal 13.6% Others 9.1% Prostate 1.4% Brai n 5.5%
  • 3. Staging System • AJCC 7th edition since January 2010 • Anatomical extent of disease is expressed by TNM classification: – Prediction of prognosis – Therapeutic decision • 1/6 patients will be classified in to a different stage category
  • 4. Primary Tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ T1 T1a T1b Tumor ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)* Tumor ≤2 cm in greatest dimension Tumor >2 cm but ≤3 cm in greatest dimension T2 T2a T2b Tumor >3 cm but ≤7 cm or tumor with any of the following features (T2 tumors with these features are classified T2a if ≤5 cm) Involves main bronchus, ≥2 cm distal to the carina Invades visceral pleura (PL1 or PL2) Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung Tumor >3 cm but ≤5 cm in greatest dimension Tumor >5 cm but ≤7 cm in greatest dimension T3 Tumor >7 cm or one that directly invades any of the following: parietal pleural (PL3) chest wall (including superior sulcus tumors), diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium; or tumor in the main bronchus (<2 cm distal to the carina* but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung or separate tumor nodule(s) in the same lobe T4 Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, separate tumor nodule(s) in a different ipsilateral lobe * The uncommon superficial spreading tumor of any size with its invasive component limited to the bronchial wall, which may extend proximally to the main bronchus, is also classified as T1a.
  • 5.
  • 6.
  • 7. Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s) N3 Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)
  • 8.
  • 9. Distant Metastasis (M) M0 No distant metastasis (no pathologic M0; use clinical M to complete stage group) M1 M1a M1b Distant metastasis Separate tumor nodule(s) in a contralateral lobe; tumor with pleural nodules or malignant pleural (or pericardial) effusion* Distant metastasis * Most pleural (and pericardial) effusions with lung cancer are due to tumor. In a few patients, however, multiple cytopathologic examinations of pleural (pericardial) fluid are negative for tumor, and the fluid is non-bloody and is not an exudate. Where these elements and clinical judgment dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging element and the patient should be classified as M0.
  • 10.
  • 11. AJCC Stage Group (7th edition) T1a/b T2a T2b T3 T4 N0 IA IB IIA IIB IIIA N1 IIA IIA IIB IIIA IIIA N2 IIIA IIIA IIIA IIIB N3 IIIB IIIB IIIB IIIB
  • 13. Treatment Modalities for Cancer • Loco-regional: – Surgery – Radiation therapy • Systemic: – Chemotherapy – Immunotherapy
  • 14. Radiation and Surgery Rationale Radiation usually fails in tumor center, and rarely doses at periphery Surgery usually fails at periphery because of microscopic tumor cells left behind Sequence of radiation and surgery Preoperative radiation Postoperative radiation Intraoperative radiation
  • 15. Limited Surgery and Radiation Using surgery as boost technique Full courses of radiation combined with tumorectomy Surgery can be done before or after the irradiation Examples Breast – lumpectomy + definitive radiation H/N cancer – definitive radiochemotherapy + adjuvant neck dissection
  • 16. Radiation and Chemotherapy Purpose is not to decrease radiation dose to gain the same effect, but rather to increase therapeutic index 3 strategies: Drugs directly modifying radiation survival curve (synergy, sensitizer, potentiator) Drugs specifically affecting tumor response to radiation (hypoxic sensitizers) Drugs with independent action or additivity
  • 17. Theoretic Rationales of CMT  Spatial cooperation  Toxicity independence  Reduction of toxicity  Enhanced tumor response  Prevention of emergence of resistant clones
  • 18. Treatment Selection Factors  Treatment-related factors  Tumor-related factors  Patient-related factors  Physician-related factors 지피지기 (知彼知己) 백전백승 (百戰百勝) Knowing oneself and one's opponent, invincibility!
  • 20. Staging W/U for NSCLC at SMC • Standard: Chest CT, PFT, Broncho, PET-CT • Optional: Brain MR (if AD) Medically operable vs Medically inoperable Early, vs Advanced –M1 or wet T4 Locally advanced Resectable Potentially resectable Unresectable Mediastinoscopy &/or EBUS for all potentially resectable candidate
  • 21. Tx Guideline for NSCLC at SMC T T1 T2 T3 T4 N N0 IA-IIB Op ± RT/CTx/CRT Definitive RT alone IIIB (except wet T4) Definitive CCRT or RT alone N1 IIIA (T3N1) N2 IIIA Preop. CCRT + Op + RT Definitive CCRT or RT alone N3
  • 22. Stage I/II • Whenever possible, surgery is recommended first. • After surgery, CTx and/or RT may be recommended to decrease recurrence risk. • RT alone is recommended if surgery is not feasible due to severe lung disease or other underlying medical problems. • A few individualized RT techniques and dose schedules are used.
  • 23. Stage III • There is no one “best” treatment for stage III NSCLC. – Choice of Tx modality depends upon several factors including size and location of tumor, N stage, and physiologic status of patient. • Whenever possible, combination of RT and CTx (CCRT) is recommended first. • Either RT or CTx alone is considered if aggressive CCRT is not feasible.
  • 25.
  • 26. How radiation kills cancer?  Ionization --> Damage to DNA or membrane --> Mutation, Cell death  metabolically active for the time-being  die out at time of cell division due to aberrant reproduction  takes time before cancer cells disappear
  • 27. DNA Damage & Chromosome Aberration
  • 28. DNA Damage & Chromosome Aberration
  • 29. Direct vs Indirect Actions Incident X-ray (photon) Fast electron (e-) (10-15 sec) Ion radical (10-10 sec) Free radical (10-5 sec) Chemical changes (hours~years) Biological effects
  • 30. Discrepancy in Clinical and Pathologic Responses
  • 31.
  • 32. Patient-specific Radiation Therapy • Individualized • Customized • Adaptive
  • 33. Preparation for Radiation Therapy • Acquisition of CT (MR, PET-CT) • Contouring: – Targets (GTV, CTV, ITV) – Organs at risk • Determination of beam arrangement, intensity to achieve the most optimal plan among rival plans • Quality assurance
  • 34. Image Guided RT • RT procedure using image guidance at various stages of its process (patient data acquisition, treatment planning, treatment simulation, patient setup, and target localization before and during treatment)
  • 35. To identify and correct problems arising from inter- and intra- fractional variations in patient setup and anatomy
  • 36. Image Guidance Technology • Portal & radiographic imager (EPID) • In-Room CT • KV cone-beam CT • MV cone-beam CT (Tomotherapy)
  • 37.
  • 38. Stereotactic Body RT • High ablative dose • To small tumor (usually <3~4 cm) • Within a few fractions • Using multiple non-coplanar beams • With adequate immobilization and motion control
  • 39. SBRT • One of the state-of-the-art RT techniques – Highly conformal and accurate radiation delivery • Conformal high dose • Compact intermediate dose • Very large low dose volume – High fractional dose (10~20 Gy * ≤4 fractions) – Within short period of time (within 1 week) – Patient-specific Tx planning
  • 40. Conventional RT SBRT Dose/fraction 1.8~3.0 Gy 10~20 Gy Fraction number 10~30 fractions 1~5 fractions Target delineation GTV, CTV, (ITV), PTV GTV, CTV, ITV, PTV (GTV CTV) Margins cm range mm range Need for mechanical accuracy Low to medium Very high Need for respiratory motion control Moderate High Radiobiology Moderately well understood Still poorly understood Interaction with systemic therapy Currently active Will become active
  • 41. Toxicities of SBRT • Acute: – Fatigue, anorexia, nausea – Pulmonary – Skin • Late: – Pulmonary – Chest wall • Unknown: – Heart – Large vessel – Etc
  • 42.
  • 43.
  • 45. Rationale of SBRT in Stage I NSCLC • RT is better than doing nothing. • (+) dose-response relationship has been confirmed with respect to local control. • The smaller the tumor, the higher the local control and survival by RT. • Incidence of lymphatic metastasis is known to be very low. • Shorter RT duration is better than protracted RT schedule in survival.
  • 46. Importance of tumor size Importance of RT duration
  • 47. SBRT Indications at SMC • cT1-2,N0 • Single metastasis or recurrence • ≤ 5 cm in size (preferably ≤ 3 cm) • Location (peripheral > central, upper > lower)
  • 48. Pinnacle® Heterogeneity correction Respiratory training for imaging & SBRT 4D CT; CTV-ITV (1.2+ cm margin around GTC-ITV) CBCT for target localization
  • 52. Characteristics # Pt (%) Age Median 69 (39~88) years Sex Male 98 (84.5%) Female 18 (15.5%) Tumor nature Primary 38 (32.8%) Metastatic 78 (67.2%) Lung 32 (41.0 %) GI Track 24 (30.8 %) Head & Neck 9 (11.5 %) Others 13 (16.7 %) Patients’ Characteristics I (116 Patients: ’01/Feb~’10/Nov) JTO, 2010
  • 53. Characteristics # Pt (%) Tumor size ≤ 2.0 cm 58 (50.0%) > 2.0 cm 58 (50.0%) RT dose 50 Gy/5 Fx’s (’01/Jun~’02/May) 8 ( 6.9%) 60 Gy/5 Fx’s (’02/June~’09/Dec) 72 (62.1%) 60 Gy/4 Fx’s (’10/Jan~’10/Dec) 36 (31.0%) Patients’ Characteristics II (116 Patients: ’01/Feb~’10/Nov) JTO, 2010
  • 54. Prognosticators on Local Control Characteristics Crude LC p Tumor nature Primary (38) 92.1% 1.0 Metastatic (78) 91.0% Pathology Squamous (41) 90.2% 1.0Adenoca (34) 91.2% Others (41) 92.7% Tumor size ≤ 2.0 cm (58) 100% 0.001 > 2.0 cm (58) 82.8% RT dose 50 Gy/5 Fx’s (8) 75.0% 0.01960 Gy/5 Fx’s (72) 88.9% 60 Gy/4 Fx’s (36) 100%JTO, 2010
  • 56. Grade # Pt (%) Grade 0 80 (69.0 %) Grade 1 30 (25.9 %) Grade 2 4 ( 3.4 %) Grade 3 2 ( 1.7 %) Symptomatic Radiation Pneumonitis JTO, 2010
  • 57. Summary • SBRT to lung cancer at SMC: – High local control (90%) – Favorable 5 year survival (primary/metastatic – 66.4%/53.8%) – Very low risk of complication (Grade 2/3 – 3.4%/1.7%) – Highly effective and curative modality to patients who are unfit for surgery. JTO, 2010
  • 59. SBRT for Lung Metastasis • SBRT to 57 patients, 67 metastatic lesions • Sep. 2001~Nov. 2010 • Lung toxicity: – Grade 2 in 4 patients (6.0%) – Grade 5 in 1 Acta Oncologica, 2012
  • 61. Response at 1 month: - CR in 17 (25%) - PR in 40 (60%) - SD in 10 (15%) Local progression in 3 (5%) 94.5% at 3 years Acta Oncologica, 2012
  • 63. 59.7% 56.2% at 2 years at 5 years Acta Oncologica, 2012
  • 64. Presence of extrathoracic disease was the only significant factor (p=0.049) on multivariate analysis. 64.0% vs 38.9% at 3 years 66.1% vs 0% at 3 years 71.1% vs 51.1% at 3 years Acta Oncologica, 2012
  • 66. Conclusion • SBRT for single or oligo-metastasis seems quite effective and safe. • Tumor size, disease-free interval, and presence of extrathoracic disease are prognosticators for survival. Acta Oncologica, 2012
  • 67.
  • 68. Management of N2 Disease
  • 69. Introduction • Remarkable improvements in diagnosis of N2 disease -- CT, FDG PET-CT, mediastinoscopy, VATS, and EBUS • A few different ways of classifying N2 disease -- clinical vs surgical, minimal vs bulky etc… • N2 disease is a very important prognostic factor in NSCLC. • There is no single answer that defines the best treatment option for N2(+) NSCLC.
  • 70. Trimodality for N2 Disease @ SMC • TRT – 45 Gy/25 Fx’s (’97~Sep ’09) – 44 Gy/22 Fx’s (Oct ’09~) • CTx – EP #2 q 4 weeks (’97~Apr ’01) – Weekly DP #5 (Mar ’01~) • Surgery in 3-4 weeks • Optional postop TRT (18~20 Gy/2 weeks) • Optional CTx (usually sequential)
  • 71.
  • 74. Summary (Acta Oncol, 2001) • Preoperative CCRT resulted in fair pathologic response, down-staging (68.2%), less radical surgery, and 2-year OS with tolerable morbidity. • Surgery added to CCRT did not affect OS, but altered failure pattern only. Acta Oncol, 2001
  • 75.
  • 76.
  • 77.
  • 78. Preop CCRT (N=410) Patients (June ’97~Aug ’11) Surgical resection (N=396) Postop TRT (+) (N=228) Postop TRT (-) (N=144) Incomplete Tx, progression, refusal (14) Periop deaths (19) Systemic progression (5) Presented at ACOS, KOSRO, ASTRO meetings in 2012
  • 79. Patients’ Characteristics (N=396) Age Median 59 (18-76) years Gender Male Female 310 (78.3%) 86 (21.7%) Histology Adenoca Squamous cell ca Large cell ca Non-small cell ca, NOS 213 (53.8%) 157 (39.6%) 11 (2.8%) 15 (3.8%) cT stage cT1 cT2 cT3 99 (25.0%) 239 (60.4%) 62 (15.6%) Tumor size Mean 33 (9-128) mm cN2 status (CT and/or PET-CT) Bulky Minimal 276 (69.7%) 120 (30.3%) Pathologic confirmation of N2 No Yes 41 (10.4%) 355 (89.6%) Number of (+) nodal station Single Multiple 250 (63.1%) 146 (36.9%)
  • 80. Preop Tx TRT 45 Gy in 25 Fx’s (1997’ ~ Oct 2009’) 44 Gy in 22 Fx’s (Sep 2009’ ~ ) 293 (74.0%) 103 (26.0%) CTx EP q 3 weeks (1997’ ~ Jul 2001’) Weekly DP (Jul 2001’ ~ ) 48 (12.1%) 348 (87.9%) Surgery Sublobar resection (Bi-)Lobectomy Pneumonectomy 2 ( 0.5%) 335 (84.6%) 59 (14.9%) Postop Tx TRT No or incomplete Yes (18-20 Gy in 10 Fx’s) 177 (44.7%) 219 (55.3%) CTx No Yes 301 (76.0%) 95 (24.0%) Treatment Characteristics (N=396)
  • 81. Factors No. of Pts ypT stage* 0 1 2 3 4 65 (16.4%) 161 (40.7%) 126 (31.8%) 38 ( 9.6%) 6 ( 1.5%) ypN stage* 0 1 2 3 164 (41.4%) 53 (13.4%) 177 (44.7%) 2 ( 0.5%) ypM stage* 0 1a 394 (99.5%) 2 ( 0.5%) TNM stage* 0 I II III IV 55 (13.9%) 97 (24.5%) 57 (14.4%) 185 (46.7%) 2 ( 0.5%) Factors No. of Pts Tumor size Mean 24 (0-110) mm Pleural invasion PL0 PL1 PL2 PL3 319 (80.6%) 10 ( 2.5%) 44 (11.1%) 23 ( 5.8%) Resection margin Positive Close (1-5 mm) Negative 20 ( 5.1%) 24 ( 6.1%) 352 (88.8%) No. of positive N2 station None Single Multiple 217 (54.8%) 102 (25.8%) 77 (19.4%) N0. (+) LN Mean 2.4 (0-26) Downstaging Yes No 211 (53.3%) 185 (46.7%) Pathologic Findings (N=396) * AJCC 7Th ed.
  • 82. Median 3-year 5-year OS 46 (35-58) mo 56.9% 44.2% PFS 21 (16-26) mo 37.5% 33.3% LRC Not reached 76.2% 71.6% DMFS 28 (21-34) mo 42.1% 37.7% Survival Outcomes (N=396)  Median F/U = 33 (4-156) months
  • 83. Prognostic Factors – Multivariate analysis P value Factors LRC PFS OS Age < 60 vs. ≥ 60 years 0.174 0.389 0.002 Gender Female vs. Male 1.000 0.578 0.291 Histology Adenoca vs. non-Adenoca 0.629 0.009 0.662 cT stage cT1-2 vs. cT3 0.847 0.847 0.481 Chemo regimen EP q 3 weeks vs. weekly DP 0.243 0.092 0.009 Op. type Lobectomy vs. Pneumonectomy 0.070 0.001 0.004 ypT stage ypT0-2 vs. ypT3-4 0.284 0.182 0.064 ypN stage ypN0 vs. ypN1-3 0.001 <0.001 <0.001 Resection margin Negative vs. Close/positive 0.294 0.380 0.811 Postop TRT No/incomplete vs. Yes 0.163 0.198 0.003 Postop chemo No vs. Yes 0.291 0.600 0.050
  • 84. Summary Excellent clinical outcomes (Median survival = 46 months; 5-year OS = 44.2%) with trimodality therapy. Pathologic nodal down-staging was the most important prognostic factor. SWOG 8805 RTOG 0229 INT 0139 SMC Median 13 months 26.6 months 23.6 months 46 months OS 27% (3-Yr) 54% (2-Yr) 27% (5-Yr) 44.2% (5-Yr)
  • 85. Conclusions • There definitely is positive role of surgical resection following preoperative CCRT in cN2 disease. • Benefit of surgery is summarized as improved loco- regional control at no excess morbidity. • Without loco-regional control, real cure cannot be expected, and surgery remains essential under multi-disciplinary spirit.
  • 89.