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N. Kajiwara

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    SC08 - IASLC- ESTS Joint Symposium: The Borderline Patient (ID 332)

    • Event: WCLC 2016
    • Type: Science Session
    • Track: Pulmonology
    • Presentations: 1
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      SC08.04 - SABR Versus Surgery (ID 6631)

      16:00 - 17:30  |  Author(s): N. Kajiwara

      • Abstract
      • Presentation
      • Slides

      In recent years, the number of early stage lung cancers has enormously increased and this tendency is more prominent in octogenarians. Both curability and non-inavasiveness should be required for such situation. Surgery is the standard treatment for early stage lung cancer and VATS lobectomy or sublobar resection have been routinely performed for selected patients to maintain performance status[1)]. Especially, the indication of sublobar resection is considered to be related to the aggressive nature of tumors, thus several studies by HRCT findings and PET-CT were performed to predict the invasive nature as well as clinical stage. In JCOG 0201, 545 case who received lobectomy and mediastinal lymph node dissection due to stage I NSCLC were enrolled prospectively. Pathological non-invasive cancer (both vascular and lymphatic invasion negative) was evaluated by the consolidation/tumor ratio on preoperative HRCT. Adenocarcinoma <2.0 cm with <0.25 consolidation to the maximum tumor diameter (35 patients, 12.1%) revealed pathological non-invasiveness in 98.7% (95% CI: 93.2–100.0%), and this criterion could be used for radiological early lung cancer[2)]. The prognostic study of cases enrolled in JCOG0201 revealed that 5 year OS and RFS survivals of the entire patients were 90.6% and 84.7%, respectively. The 5-year OS of radiologic early and invasive adenocarcinomas were 97.1% and 92.4%, respectively (p=0.259). If the consolidation/tumor ratio lower than 0.5 in cT1a-b was used as a cutoff, the 5-year OS of radiologic early (121 patients, 22.2%) was 96.7% and invasive adenocarcinomas, 88.9% (p<0.01)[3)]. Based on the criteria of radiologic early cancer obtained by JCOG0201, randomised phase 3 trial to evaluate non-inferiority in OS of segmentectomy compared to lobectomy (JCOG0802)[4)]. The maxSUV of the primary tumor on PET/CT could be used as a prognostic marker of early stage lung cancer. Analyses of 610 resected stage IA adecocarcinoma showed that maxSUV and GGO ratio cutoffs to predict recurrence were 2.9 and 25%, respectively. They were also related to nodal metastasis, histological tumor invasiveness and recurrence. The 5-year RFS of cases with maxSUV <2.9 (n=456) was 95%, while cases with maxSUV>2.9 (n=154), 72% (p<0.001)[5)]. Surgical management of early stage lung cancer should be selected by based on the tumor size, GGO ratio and maxSUV to predict the biological malignancy of each case. Streotactic ablative radiotherapy (SABR) has attained importance for efficacy and safety for the treatment of early cancers located in the peripheral lung. There are two representative randomised phase 3 trial (STARS and ROSEL) to compare SABR and surgery. Eligible patients of these studies were T1-2a (<4cm) N0M0 and a total of 58 cases were registered (31 received SABR and 27, surgery). The combined analysis of these two studies revealed that 3 year OS in SABR (95%) was superior to that of surgery (79%) (p=0.037) and RFS at 3 years was similar; 86% in SBRT and 80% in surgery (p=0.54). Only 10% of cases in SBRT group suffered grade 3 toxicity but 44% of surgery group developed grade 3 and 4 toxicities. The pooled analysis of the two studies showed SBRT had similar treatment efficacy to that of surgery in spite of the small sample size[6)]. Japan Clinical Oncology Group evaluated the efficacy and safety of SBRT for operable/inoperable T1N0M0 patients (JCOG 0403). A total of 164 patients (100 inoperable and 64 inoperable) were treated by 48 Gy. The 3 year OS was 59.9% in inoperable patients and 76.5% in operable patients[7)]. Investigations into the effectiveness of SABR for operable patients as well as the optimal indication, dose and fraction should be clarified by prospective manner. SABR has become a radical treatment for inoperable stage I lung cancer. In addition, if operable cases treated by SABR in JCOG0403 show favorable outcome, further comparable trial of SABR versus less invasive surgery should be warranted. References 1) Committee for Scientific Affairs The Japanese Association for Thoracic Surgery, Thoracic and cardiovascular surgery in Japan during 2013 : Annual report by the Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg.2015;63:670-701. 2) Suzuki K, Koike T, Asakawa T, et al.: A prospective radiological study of thin-section computed tomography to predict pathological noninvasiveness in peripheral clinical IA lung cancer (Japan Clinical Oncology Group 0201). J Thorac Oncol 2011;6:751-756 3) Asamura H, Hishida T, Suzuki K, et al. Radiographically determined noninvasive adenocarcinoma of the lung: Survival outcomes of Japan Clinical Oncology Group 0201 J Thorac Cardiovasc Surg 2013;146:24-30 4) Nakamura K, Saji H, Nakajima R, A Phase III Randomized Trial of Lobectomy Versus Limited Resection for Small-sized Peripheral Non-small Cell Lung Cancer (JCOG0802/WJOG4607L) Jpn J Clin Oncol 2010;40:271–274 5) Uehara H, Tsutani Y, Okumura S, et al. Prognostic Role of Positron Emission Tomographyand High-Resolution Computed Tomography in Clinical Stage IA Lung Adenocarcinoma Ann Thorac Surg 2013;96:1958–1965 6) Chang JY, Senan S, Paul MA et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: A pooled analysis of two randomized trials. Lancet Oncol 2015;16:630–637. 7) Nagata Y, Hiraoka M, Shibata T, et al. Prospective trial of stereotactic body radiation therapy for both operable and inoperable T1N0M0 non-small cell lung cancer: Japan Clinical Oncology Group Study JCOG0403. Int J Radiat Oncol Biol Phys 2015;93;989-996.

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