Chapters Transcript Video Locally Advanced Disease: Panel Discussion and Case Studies With the benefit of prolonged time in the field, I would just point out that whenever you're talking about a trial that includes surgery. You have to be very careful to look at the surgical quality control. After I finished with Haas's current job as head of ECOG's lung committee many, many decades ago now, uh, my next task was as the executive officer for the lung cancer study group. And we finally got to the point of getting done with adjuvant studies and we were looking at neoadjuvant we're getting into that whole field and the issue became. How do you design a form so that a phys a surgeon in particular or their staff can check whether this patient is unresectable or resectable. It took 2 years to develop that form. It was very personality based because we had Bob Ginsberg in the group and he was, um, an outspoken candidate for that, but we had others like. Never mind who, who were the others. So the quality control of surgery is very important and it doesn't get done to my mind enough. The same thing happens in, in our more standard groups that we see that our patients in, in, in the community in particular don't do mediastyal staging the way we think we do it here and even within our own institutions. I think there's some variability in in that. So I would caution people to be very careful about the surgical quality control. I think we've got radiotherapy and chemotherapy down and maybe immunotherapy down pretty well, but I don't believe yet we have surgical quality control where it needs to be. Any questions for our speakers? Corey, not so much a question but a comment. I, we keep saying Pacific is the standard of care and it is, but that's for the folks who make it through chemo radiation in our institution, we look back at all those starting chemo radiation, and it's about 25-30% are not candidates for Pacific either because of disease progression, comorbidity, or toxicity, uh, and, and including exclusions for immunotherapy, so. Don't be surprised, and Samira, you had pointed this out, that the median PFS is lower in this broader population that starts out with, uh, chemo radiation. Any other questions? 25-30% surprises me, um, um. That's a large patient population. I'm glad you're putting it together. Hopefully you're presented at someplace and we can sort of talk about it all that, um, maybe we should look at our own data and our own institutions. What regimen, what chemotherapy regimen do you utilize? Because there's no question, full dose chemotherapy with radiation as opposed to low-dose carbotaxol. So pretty much, I suspect the same as uh most groups are using. Majority of folks are getting weekly pack carbo during RT, uh, for non-squamous will frequently employ a Penn Platinum combo. I can't remember the last time I, uh, gave, uh, oposide cisplat, although I have in the past, uh, but that's still, I, I would consider those three regimens the standards. I would, I would ask, uh, my colleague from Penn. Uh, have you been using, uh, proton-based therapy for lung cancer, particularly at Penn? I know that at the institution in Texas that cannot be named. That the uh usage of proton therapy was for any you required a pulse uh to get it. So, um, I personally have not been using it. I'm a medical oncologist, but our radiation oncologists are, um, how can I put this, uh, fairly enthused still, um, despite at least prior data that suggests perhaps it's not as great as it's been cracked up to be. There is, as pointed out by Samir and others, an ongoing phase 3 trial that is directly comparing photons to protons. So I think we'll finally have an answer. Um, again, uh, it's not appropriate for all patients. I think Chuck Simone's study looking, uh, that Samira, uh, pointed out looking at, uh, SBRT plus standard, uh, photon or proton mediastinal chemo radiation versus the older approach is probably gonna be more practice changing in the long run. Um, uh, there's a huge amount of real estate that's getting radiated that, uh, uh, with conventional fields that I think, uh, SBRT will, uh, help eliminate. Um, Jack, I share your skepticism about protons even though I work in an institution that loves protons. In the interest of time, can we get to the case then? Yes, we had who had the case? Was that Doctor Kumar? Yes, please. Do you have Doctor Kumar's slides? OK. Does anyone have the clicker? What do you need? The clicker? It's right there. Oh, yeah, sorry. OK, um, I was just asked to, uh, come up with a case, and if there's any questions or comments on this case, we can talk about it. Um, so we have a 71 year old female who had a fall. She had a CT of the T-spine at that time, which showed a mass in the right lung. Uh, she got, uh, diagnostic CT and that should say PET. I don't know why the P dropped off. Confirmed a hypermetabolic right middle lobe mass with enlarged lymph nodes in level 7 and 4R. Um, and you can see this is like the movie of the PET. I included this because you can see all the sites of the disease and you generally know where that is. Um, and EBAS confirmed that all sites, uh, are positive for adenocarcinoma, KISS G12C positive, and PDL1 of 60%. Um, she met with thoracic surgery and she went through pre-op testing. Um, I, I know that several people in this room know who this patient is right now. Um, she was deemed to be a good surgical candidate. She was planned for neoadjuvant, uh, carbopempem, uh, but unfortunately, after one cycle, she developed AKI and adrenal insufficiency, and she was started on high dose prednisone. Um, a subsequent CT one month later showed, I mean, this right middle lobe mass is tiny compared to what it was. And I know I don't, I don't have a CT, but you can see it's, it's much better than that, much smaller than little ditzel. So it's now 9 by 9 millimeters. Um, so it's much smaller, and the mediastinal lymphadenopathy was also smaller. Um, given her AKI, the decision was made to forego any chemo and just to get radiation alone. And so we did treat her with 60 gray and 15 fractions to the involved lymph nodes and, uh, the lesion in the right lung. She did well. She doesn't have any disease and she doesn't have any, uh, lasting toxicity. And that's the whole case. Sorry. Any comments Doctor Adelman about that case? Yeah, well, um, you know, to those who think that, uh, chemo immunotherapy induction is really an easy thing to do, uh, you know, just beware, you know, I mean, you know, chemotherapy toxicities I understand and I can deal with and Have been and they're straightforward and they go away, immunotherapy toxicities can be for life. You know, this lady stayed on high-dose steroids for months before her renal function, which is thankfully now beginning to improve, uh, the hypoadrenalism, that's for life. Um, so, you know, an interesting example here of, you know, once again, what could possibly go wrong. Um, you know, but just, these are not benign drugs. I mean, people who, you know, think that, oh gee, you know, we use immunotherapy, life is great, they don't have these initial infusion reactions or nausea, you know, these things, when you use it a lot, you suddenly discover every itis known to man, and a few that weren't previously. Alright, with that, uh, we're gonna end this session. We're gonna move on to the next. I'm gonna ask all of my faculty members, please meet us at the podium at the end of this session before lunch for a quick group photo, uh, to be posted on the FBI website, and then we'll go from there. Created by Related Presenters John C, FACP, MD Professor, Department of Hematology/Oncology, Fox Chase Cancer Center. View full profile
