ASTRO 2022: Interesting presentations

[Fpg1245]

Nobody can reduce the need for a radiation oncologist like a radiation oncologist.

Never ceases to amaze.

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[communitydoc13]

Late to this discussion, but receipt of XRT is counted a "skeletal event". Thus, the observation arm is skewed towards having more skeletal events. Bad design

I would like to see the breakdown of skeletal events. I am also not going to put too much stock in the survival numbers.

But.....if I were a medonc, and I knew that in this setting, when radonc does their thing (presumably the right thing and 8x1 for nearly all these lesions), less than 2% of my patients will need future referral for symptoms as opposed to 30%, I'm going for it. I'm making my life and many of my patient's lives easier with minimal inconvenience for those 70% who got single fraction treatment and didn't need it.

 

[Ray D. Ayshun]

Never ceases to amaze.

Was kinda tongue in cheek in this case. They proved that giving xrt reduces the need for xrt.

 

[salubalu]

Was kinda tongue in cheek in this case. They proved that giving xrt reduces the need for xrt.

You could say the same giving surgery prevents the need for surgery (ie prophylactic stabilization)

 

[Ray D. Ayshun]

Also, I'm happy with the findings and approach in this trial, though the definition of sre is kinda weird when you think about it.. I remember seeing ugly bone mets in training that weren't yet symptomatic and the thought was, don't treat as it may cause a fracture.

 

[CaesarRO]

Was kinda tongue in cheek in this case. They proved that giving xrt reduces the need for xrt.

Looking forward to the publication.

In a tweet Gillespie said even excluding RT for symptoms the results were still significant.

 

[seper]

Looking forward to the publication.

In a tweet Gillespie said even excluding RT for symptoms the results were still significant.

Prophylactic RT to bone is hit or miss. Sometimes we actually weaken the bone and induce fracture (e.g. vertebral fractures after lung or spine SBRT). Sometimes a metastasis is what actually is keeping bone together and prophylactic RT leads to a fracture. A good area to study, though.

 

[Palex80]

Prophylactic RT to bone is hit or miss. Sometimes we actually weaken the bone and induce fracture (e.g. vertebral fractures after lung or spine SBRT).

Indeed, but I believe this only has to do with very high BED, especially in the context of single or few fractions (e.g. 1x20 or 2x12 Gy).

Single fraction radiosurgery, fractionated radiosurgery, and conventional radiotherapy for spinal oligometastasis (SAFFRON): A systematic review and meta-analysis - PubMed

SF-SRS resulted in superior LC with a roughly 5% LC benefit for every 10 Gy₁₀ increase in BED₁₀ with higher VCF rates compared to MF-SRS. If LC is the goal of treatment, then SRS may be a preferred treatment modality. However, these results are hypothesis-generating, and...

pubmed.ncbi.nlm.nih.gov

I do not think there is any data, that 1 x 8 Gy or 5 x 4 Gy will induce fracture.

On a side note: This is mostly the reason, I don't like SBRT to vertebrae using only a few fractions. I mostly do 5-6 fractions.

Sometimes a metastasis is what actually is keeping bone together and prophylactic RT leads to a fracture. A good area to study, though.

I was under the impression that the post-SBRT fractures are mostly due to the very high BED killing vessels and inducing micro-emboli with avascular necrosis.

 

[CaesarRO]

Prophylactic RT to bone is hit or miss. Sometimes we actually weaken the bone and induce fracture (e.g. vertebral fractures after lung or spine SBRT). Sometimes a metastasis is what actually is keeping bone together and prophylactic RT leads to a fracture. A good area to study, though.

I feel like all the situations I've seen where this would be true are not situations that I'd call "prophylactic." There is already a path fracture and pain/mobility limitations and usually need Ortho to intervene first.

 

[thesauce]

Prophylactic RT to bone is hit or miss. Sometimes we actually weaken the bone and induce fracture (e.g. vertebral fractures after lung or spine SBRT). Sometimes a metastasis is what actually is keeping bone together and prophylactic RT leads to a fracture. A good area to study, though.

I’ve heard medonc make these comments, but I don’t know that there’s actually any truth to it. It’s kind of like their argument that giving RT to a few vertebrae will cause immunosuppression and prevent them from being able to give chemo.

 

[A_DeMichele]

I’ve heard medonc make these comments, but I don’t know that there’s actually any truth to it. It’s kind of like their argument that giving RT to a few vertebrae will cause immunosuppression and prevent them from being able to give chemo.

there are good data on RT-induced bone fractures, going all the way back to rib fractures in breast Ca, I guess

 

[A_DeMichele]

if I could count the number of times that told someone “let me know if any other spots seem to become painful” and then hear from them in less than a few weeks. Its definitely a confounded which is almost impossible to control for. But in this case I think the whole of the data is very promising. Let’s not go doing Evicores work for them.

can’t remember the actual trial, but prophylactic chest RT in metastatic lung Ca does not improve survival (compared to treating pts after they’ve obstructed)

 

[evilbooyaa]

https://www.nejm.org/doi/full/10.1056/nejmoa0912217

82% including stage 3-4. So I was guesstimating

Literally all of these patients received concurrent chemo. You said 90% cure (5-year PFS) with RT alone. I'm not saying 90% isn't doable in T1N1, just saying it's most likely gotta be with chemo.

You guys are confusing me today.

So when does "underwent a neck surgery" become a "HISTORY of neck dissection." One day? One month? One year?

Imagine the rad onc note: "The patient does not have a history of neck dissection but did undergo a neck dissection recently."

It means that the patient HAD a neck dissection or some other soft tissue neck surgery, THEN developed cancer. That's when the new lymphatic drainage patterns (due to the patient's history of surgery) can become wonky and spread to contralateral neck because the lymphatics were disturbed (before the patient developed cancer). Is this sarcasm? A joke? Serious question?

@RealSimulD I like ~90% cure rate for T1N1!

Intensity-modulated radiotherapy in the treatment of oropharyngeal cancer: an update of the Memorial Sloan-Kettering Cancer Center experience

Pretty much everyone got CHEMO - if you're saying 90% cure rate for T1N1, they gotta get the chemo!
Otherwise, show me the money!

 

[evilbooyaa]

Prophylactic RT to bone is hit or miss. Sometimes we actually weaken the bone and induce fracture (e.g. vertebral fractures after lung or spine SBRT). Sometimes a metastasis is what actually is keeping bone together and prophylactic RT leads to a fracture. A good area to study, though.

Not with conventional fractionation? And that is the exact reason I don't like 1 or 2 fraction SBRT given all the compression fractures seen.

I’ve heard medonc make these comments, but I don’t know that there’s actually any truth to it. It’s kind of like their argument that giving RT to a few vertebrae will cause immunosuppression and prevent them from being able to give chemo.

We really need to stop allowing this dogma to define any contemporary rad onc and their role in management of bone mets - RT caused the fracture? For standard palliative doses? C'mon man.

Late to this discussion, but receipt of XRT is counted a "skeletal event". Thus, the observation arm is skewed towards having more skeletal events. Bad design

Yes, you are late. Helps with non-RT events as well:

 

[deleted1111261]

Literally all of these patients received concurrent chemo. You said 90% cure (5-year PFS) with RT alone. I'm not saying 90% isn't doable in T1N1, just saying it's most likely gotta be with chemo.


It means that the patient HAD a neck dissection or some other soft tissue neck surgery, THEN developed cancer. That's when the new lymphatic drainage patterns (due to the patient's history of surgery) can become wonky and spread to contralateral neck because the lymphatics were disturbed (before the patient developed cancer). Is this sarcasm? A joke? Serious question?


Pretty much everyone got CHEMO - if you're saying 90% cure rate for T1N1, they gotta get the chemo!
Otherwise, show me the money!

I don’t think they need it.
But, that’s odd that T1N1 getting chemo.
Overkill

 

[temujim]

Literally all of these patients received concurrent chemo. You said 90% cure (5-year PFS) with RT alone. I'm not saying 90% isn't doable in T1N1, just saying it's most likely gotta be with chemo.


It means that the patient HAD a neck dissection or some other soft tissue neck surgery, THEN developed cancer. That's when the new lymphatic drainage patterns (due to the patient's history of surgery) can become wonky and spread to contralateral neck because the lymphatics were disturbed (before the patient developed cancer). Is this sarcasm? A joke? Serious question?


Pretty much everyone got CHEMO - if you're saying 90% cure rate for T1N1, they gotta get the chemo!
Otherwise, show me the money!

T1N1 ajcc 7 pretty much excluded from most chemoRT trials (particularly RTOG/NRG until 002/005)... bc cure rate with RT alone so high. 002 PFS at 2 years was ~90% with RT alone (and that was T1-2 N1-2b or T3N0-2b 7th ed).

 

[gmsquid]

Up to 3vm Single node t1-t2n0-n1 pfs of 90% using accelerated on rtog 0022

 

[evilbooyaa]

T1N1 ajcc 7 pretty much excluded from most chemoRT trials (particularly RTOG/NRG until 002/005)... bc cure rate with RT alone so high. 002 PFS at 2 years was ~90% with RT alone (and that was T1-2 N1-2b or T3N0-2b 7th ed).

Up to 3vm Single node t1-t2n0-n1 pfs of 90% using accelerated on rtog 0022

Are we saying that 90% PFS at 2-years (what the original report showed) in 68 patients is the same thing as 90% chance of cure?

46% of 0022 were rN0. 39% were rN1. cN rates are different, but I imagine we're all calling people N1 even if you can't clinically feel the node in the era of high res CT w/ contrast and PET/CT

10-year DFS was 50% on long-term f/u (Final Report of NRG Oncology RTOG 0022: A Phase I/II Study of Conformal and Intensity Modulated Radiation for Oropharyngeal Cancer), 67% OS.
Sure, they report that only 15% of the deaths were due to the index diagnosis, but no information on rates of need for salvage treatment are given. If someone has access to the presentation slides (appears it was presented at ASTRO 2021) please link.

I'm not saying it's wrong to do RT alone for T1N1, but saying cure rate is 90% at 5-years with RT alone.... I just don't think we have data to say that. I think offering RT alone to T1N1 is fine and well supported by NCCN. But, when med onc pushes to give chemo in N+ disease, I don't fight them. T1/T2N0, yes I say RT alone is all I would do, and actively push back against chemo.

 

[temujim]

Are we saying that 90% PFS at 2-years (what the original report showed) in 68 patients is the same thing as 90% chance of cure?

46% of 0022 were rN0. 39% were rN1. cN rates are different, but I imagine we're all calling people N1 even if you can't clinically feel the node in the era of high res CT w/ contrast and PET/CT

10-year DFS was 50% on long-term f/u (Final Report of NRG Oncology RTOG 0022: A Phase I/II Study of Conformal and Intensity Modulated Radiation for Oropharyngeal Cancer), 67% OS.
Sure, they report that only 15% of the deaths were due to the index diagnosis, but no information on rates of need for salvage treatment are given. If someone has access to the presentation slides (appears it was presented at ASTRO 2021) please link.

I'm not saying it's wrong to do RT alone for T1N1, but saying cure rate is 90% at 5-years with RT alone.... I just don't think we have data to say that. I think offering RT alone to T1N1 is fine and well supported by NCCN. But, when med onc pushes to give chemo in N+ disease, I don't fight them. T1/T2N0, yes I say RT alone is all I would do, and actively push back against chemo.

0022 was actually a true "clinical" N1; ie by clinical exam, not radiographic. By CT 10%+ ended up being N2a or N2b.

And of the 7 failures, 5 had evaluable plans, 2 of which had major dosimetric deviations (out of 6 total with major deviations).

So with modern staging and appropriate targeting/treatment planning 90% is a reasonable estimate for these patients.

From MD Anderson's HPVish experience:

"When the analysis was limited to 324 patients treated with intact primary disease and without systemic therapy, the 5-year PFS rates for T1,T2, and T3 disease were 90%, 83%..."

"The 2- and 5-year actuarial locoregional control rates were 96% and 94%, respectively". This is the overall cohort ie T1-3 N0-2b. "Five percent of patients treated with radiation had locoregional recurrences, whereas 8%of patients treated with radiation and systemic therapy did."

 

[Bequerel]

Single node < 3cm…I follow Nccn and do RT alone. Adding chemo is category 2B

 

[evilbooyaa]

0022 was actually a true "clinical" N1; ie by clinical exam, not radiographic. By CT 10%+ ended up being N2a or N2b.

And of the 7 failures, 5 had evaluable plans, 2 of which had major dosimetric deviations (out of 6 total with major deviations).

So with modern staging and appropriate targeting/treatment planning 90% is a reasonable estimate for these patients.

From MD Anderson's HPVish experience:

"When the analysis was limited to 324 patients treated with intact primary disease and without systemic therapy, the 5-year PFS rates for T1,T2, and T3 disease were 90%, 83%..."

"The 2- and 5-year actuarial locoregional control rates were 96% and 94%, respectively". This is the overall cohort ie T1-3 N0-2b. "Five percent of patients treated with radiation had locoregional recurrences, whereas 8%of patients treated with radiation and systemic therapy did."

Excellent link. Thank you. T1N1 (they didn't include T1N0) as minimum, RT alone, 5-year PFS 90%. I appreciate the data and withdraw my argument. May change how much I push against chemo on future patients with single node < 3cm. I would also advocate for these patients to have < 10 pack year history (ideally NO significant smoking history) to be eligible for this as reflected in the above study.

 

[Lamount]

Meanwhile, why isn't anyone talking about this: Keynote 799 -phase II for Pem/chemo -> Pem CRT -> Pem maintenance for unresectable stage III NSCLC. PFS competes very favorably with the EFS data from Checkmate 816... for resectable stage II/III

 

[seper]

Meanwhile, why isn't anyone talking about this: Keynote 799 -phase II for Pem/chemo -> Pem CRT -> Pem maintenance for unresectable stage III NSCLC. PFS competes very favorably with the EFS data from Checkmate 816... for resectable stage II/III

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Is this regimen it better than PACIFIC?
Or is it going to enable RT to replace surgery in stage III disease?

 

[Lamount]

Is this regimen it better than PACIFIC?
Or is it going to enable RT to replace surgery in stage III disease?

If it is replicated in a phase III, it could become the new SOC for unresectable… then someone may ask, is it ever worth resecting LN+ NSCLC if you can get the same results with NOM?

 

[RickyScott]

If it is replicated in a phase III, it could become the new SOC for unresectable… then someone may ask, is it ever worth resecting LN+ NSCLC if you can get the same results with NOM?

If equivocal, then operate is typically the paradigm in surgical oncology- prostate, bladder etc

 

[medgator]

If equivocal, then operate is typically the paradigm in surgical oncology- prostate, bladder etc

Lung isn't like those.... Different issues when lung vs prostate tissue removed. @Lamount is correct, unlike gu, CT surgeons aren't gatekeepers

 

[Lamount]

If equivocal, then operate is typically the paradigm in surgical oncology- prostate, bladder etc

RT has more of a foothold in LA-NSCLC and the surgeons aren’t the gatekeepers…
Also willl be interesting to see if it truly is equivocal. right now we are comparing operable stage II/ III patients to inoperable stage III. Wonder what the outcomes would be comparing apples to apples.

All that aside, 0617 had an OS ~30 months… now that may be the new PFS. Would be a huge advance in tx of LA-NSCLC

 

[grenz]

RT has more of a foothold in LA-NSCLC and the surgeons aren’t the gatekeepers…
Also willl be interesting to see if it truly is equivocal. right now we are comparing operable stage II/ III patients to inoperable stage III. Wonder what the outcomes would be comparing apples to apples.

All that aside, 0617 had an OS ~30 months… now that may be the new PFS. Would be a huge advance in tx of LA-NSCLC

How many of you don’t bother referring to thoracic surgery if the pulmonologist has referred directly to you because they unilaterally made the decision the patient isn’t medically operable? I feel compelled to get a surgery opinion on the record based on NCCN

 

[medgator]

How many of you don’t bother referring to thoracic surgery if the pulmonologist has referred directly to you because they unilaterally made the decision the patient isn’t medically operable? I feel compelled to get a surgery opinion on the record based on NCCN

I refer to surgery or at least curbside, assuming pt hasn't already been discussed at our multi-D conference.

Not going to lie, if they are O2 dependent with a borderline or kps and/or flat out refuse the eval, i will sometimes skip it, esp if fev1/dlco abysmal, particularly if it is a deep-seated lesion.

My preference is a wedge if at all possible, esp when no one has gotten any tissue

 

[Lamount]

How many of you don’t bother referring to thoracic surgery if the pulmonologist has referred directly to you because they unilaterally made the decision the patient isn’t medically operable? I feel compelled to get a surgery opinion on the record based on NCCN

For any <N2 disease who doesn’t have home O2 and happens to come to me first, I will refer to surgery (or curbside). For N2+, I am usually not sending them to see surgery. Most of these patients will get CRT and only the young fit ones with single station N2 are even considered for surgery (vast minority of N2+ in our population)… and these elite folks have likely already been presented at TB. Our group works together well so we usually all end up agreeing.

 

[communitydoc13]

only the young fit ones with single station N2 are even considered for surgery

Very community place where I'm at but pretty much same deal. We do have a thoracic board. Outside of when left upper lobectomy with dissection of an isolated level 6 node is going to get gross disease, I'm pushing chemorads and IO for all N2+.

If pulm has determined that a pt is medically inoperable, I trust them. In general, our pulm are not anti-surgery and they also have a sense based on experience (much better than mine) regarding how well a patient might do with surgery or single lung ventilation.

I am not seeking thoracic consult for any patient where bulk of disease in is mediastinum, ever. Even if healthy.

Regarding pancoast tumors and the traditional push for triple modality in these folks, they overwhelmingly do better no matter what we offer them in my experience.

I never try to steal T1T2N0 from surgery however. If they deem fit for surgery, that's it at present.

 

[OTN]

N2 disease: ChemoRT followed by immunotherapy. I haven't seen any data yet which has convinced me anything else should change that standard of care.

If a pulmonologist says a patient isn't a surgical candidate for early-stage lung cancer and sends my way, good enough for me. They have the most longitudinal idea of the patient's overall condition and tolerance for surgery, are internal medicine doctors, and I trust their opinion completely.

Pancoast: trimodality

 

[evilbooyaa]

If it is replicated in a phase III, it could become the new SOC for unresectable… then someone may ask, is it ever worth resecting LN+ NSCLC if you can get the same results with NOM?

I ask that even now in PACIFIC era for cN2 patients...
Surgeons are gonna find a reason to surgeon

 

[evilbooyaa]

How many of you don’t bother referring to thoracic surgery if the pulmonologist has referred directly to you because they unilaterally made the decision the patient isn’t medically operable? I feel compelled to get a surgery opinion on the record based on NCCN

If it's a multi-station N2 or would require significant shrinkage to get to a lobectomy or the patient is on supplemental O2 and the patient was referred to me alone by pulm/med onc, then I do not get thoracic surgery involved.

So pretty much everyone referred to me unless it's a joint referral to thoracic surgery. But again, the simultaneous referrals usually end up getting RT.