Any advice for a tough lung case?

[iradi8u]

I have a 67 yo female with mixed connective tissue disease and colitis that are symptomatic & for which she's being treated with a biologic agent. She was recently found to have a T2N3M0 NSCLC (adeno) and I am asked to treat.
I'd be interested in knowing what others would do - I hesitate to push her dose beyond 60 Gy and I'll definitely look carefully at PFTs before proceeding, as I consider her V20 to represent tissue that will not recover, and I don't want to make her a pulmonary cripple.
I initially thought of IMRT to spare esophagus, given CVDs' tendency to cause significant strictures without radiotherapy, but I'm concerned that the impact to healthy lung may be too great.
Medonc wants to give her chemo, but I'm concerned about increasing toxicity, so I was considering an old-fashioned split course.
Does anyone have any experience or thoughts on this? Thanks in advance.

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[Palex80]

Stage IIIB NSCLC is in my opinion palliative. 5-10% of patients may be cured with concurrent radiochemotherapy, but that's not a lot.

In a case like this I would rather try a more "pragmatic" approach: Give her induction chemo alone and she how she responds to treatment. If she has a remarkable remission during chemo, then go on with RT and perhaps combine it with low toxicity chemo, perhaps in the form of daily cisplatin. Avoid taxanes at all costs. If she doesn't have remission during induction chemo, then it's certainly palliative, I would thus only treat then in case of symptoms with palliative doses of RT or further second line chemo.

I know that induction chemo before radiochemo does not prolog survival based on 2 randomized studies and I also know that concurrent radiochemo is better than sequential radiochemo based on several randomized studies. But still, this is a special case and special cases demand for special measures.

 

[medgator]

Stage IIIB NSCLC is in my opinion palliative. 5-10% of patients may be cured with concurrent radiochemotherapy, but that's not a lot.

In a case like this I would rather try a more "pragmatic" approach: Give her induction chemo alone and she how she responds to treatment. If she has a remarkable remission during chemo, then go on with RT and perhaps combine it with low toxicity chemo, perhaps in the form of daily cisplatin. Avoid taxanes at all costs. If she doesn't have remission during induction chemo, then it's certainly palliative, I would thus only treat then in case of symptoms with palliative doses of RT or further second line chemo.

I know that induction chemo before radiochemo does not prolog survival based on 2 randomized studies and I also know that concurrent radiochemo is better than sequential radiochemo based on several randomized studies. But still, this is a special case and special cases demand for special measures.

Agreed... I.do this approach sometimes for those really tough cases where I'll have to radiate a lot of lung.

Unfortunately in the U.S., a lot of med oncs like Carbo/taxol and I sometimes will "gently" show them the option of Carbo/alimta in that situation

 

[iradi8u]

Thank you both.
While I convinced the medonc to go with carbo/alimta, he and the patient are adamant that they want concurrent chemo/rads, despite the risks.
Politics suck.