Whole Pelvis RT for Prostate Cancer

[Palex80]

Has anyone else read the latest answer of M. Roach to C. King in JCO?
http://jco.ascopubs.org/content/28/25/e450.full

I find it amusing to see, how Roach seems a bit "angry" over King's statements and theory...

I knew this was gonna be funny, when I read the second sentence:
"King and Kapp recently hypothesized that the apparent benefits of whole pelvic radiotherapy (WPRT) noted on RTOG 9413 in terms of improved prostate-specific antigen (PSA) control might well be explained by a higher dose of radiation scattered to the testes. Their rather lengthy commentary is backed by examples from a series of studies demonstrating the well-known fact that the testes are relatively radiosensitive organs and scattered radiation can have a modest impact on serum testosterone levels."

Ouch...
No "We would like to thank King and his colleagues for their comment on the RTOG 9413 results...", this is like "You are so wrong dude, prepare to get own3d!"

All the points raised by Roach are valid and the mystery concerning the RTOG 9413 results goes on...

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[Gfunk6]

I'm obviously biased being at UCSF and having heard Roach pontificate on this topic many times but . . .

I think RTOG 94-13 unequivocally proved what it set out to do. In men with high-risk prostate cancer, they are better served with WPRT + 2 mo NHT + 2 mo CHT. The PFS at 4 year is highly significant. Other trials (e.g. GETUG-01) have used "mini" pelvis fields which do not encompass all LN groups at risk.

The problem, of course, is a somewhat lacking biological explanation for this benefit.

One hurdle with prostate (and breast) literature is that copious f/u is needed and by the time said f/u occurs the treatment techniques become outdated.

Still, we treat WPRT in a highly conformal way with IMRT and, in our hands, shows minimal GI toxicity and excellent results in terms of bPFS.

 

[deleted4401]

Despite or because of Dr. Roach's pontifications, I imagine this will continue to be a controversial topic for years to come.

The data are what they are. There has been no consensus interpretation, but if you go as strict and conservatively as possible, the trial showed no benefit between PO vs Pelvis. I understand the hypothesis that there was an interaction between the timing of the hormones and the field size, but that wasn't what the study set out to prove. The 2 study questions that were asked about field size and the timing of the hormones were found to be negative, unequivocally. The subset analysis and especially the follow-up are not at all convincing. DFS benefit of 7% at 5 years that vanishes after a few more in a disease that hardly ever kills anyone doesn't blow most people's minds.

That being said, I'd treat the pelvis in certain situations because it doesn't make people too sick. I really have a hard time believing that 45-50 Gy can sterilize nodal disease (i.e. it is several log kills less than 75 Gy), but if I feel there is an indication of long term hormones (i.e. not the 6 month D'Amico style for a GS 7), I would do it, b/c that is how all the trials were set up. It has nothing to do with 9413.

GFunk, I gotta say, I know it's institutional bias but think about the other people from the other 100s of institutions out there - this is a negative trial! It did not answer the actual study questions affirmatively ...

-S

 

[Gfunk6]

Well the 2 x 2 design lets one answer two questions simultaneously. In this case WP + 2 mo NHT + 2 mo CHT was the best arm. That's the power of concurrent therapy. Consider the case of anal cancer -- Nigro's original data showed tumor eradication with a mere 36 Gy when combined with chemotherapy.

I agree that high PO doses are required for disease sterilization, but HT can help sterilize subclinical disease.

Also, there is no other Level 1 evidence to show that the winning arm of 94-13 shouldn't be the standard of care.

 

[Pewl]

Heh, this reminds me of a funny story. I was giving this short presentation on the treatment of prostate cancer during a rotation while I was a student. I briefly mentioned RTOG 9413 and Chris King was in the audience. He definitely voiced his stout opinion regarding that study. I didn't really know much about the controversy at the time. But, Chris King's a super nice guy! I wouldn't mind grabbing a beer with him.

 

[Palex80]

We also do Pelvis-RT in my institution for high-risk PC, however we keep the fields smaller and actually go only up to S3.
This does not cover all the lymph nodes, but we are concerned about late toxicity in bowel, etc.

 

[medgator]

Maybe we should make a "controversial clinic topics in rad onc" thread The PO vs WPRT definitely fits the bill.

How about WBRT + SRS vs SRS alone and surveillance for pts with 1-3 brain mets?? What do people think of Dr. Chang's study from MDACC suggesting a survival detriment?

 

[TarHeelRadOnc]

Well the 2 x 2 design lets one answer two questions simultaneously. In this case WP + 2 mo NHT + 2 mo CHT was the best arm. That's the power of concurrent therapy. Consider the case of anal cancer -- Nigro's original data showed tumor eradication with a mere 36 Gy when combined with chemotherapy.

I agree that high PO doses are required for disease sterilization, but HT can help sterilize subclinical disease.

Also, there is no other Level 1 evidence to show that the winning arm of 94-13 shouldn't be the standard of care.

Actually, a 2 x 2 design does not allow for comparison of all 4 arms in a statistically valid way. The statistically valid comparisons that can be made from this trial are WP vs PO and NC-ADT vs A-ADT. The WP + NC-ADT arm was the best of the four, but this is hypothesis generating only.... it is not level I data! Roach has tried to spin this result, but the data are clearly negative.

 

[deleted4401]

That's the problem. You can't compare the single arms to each other, the interaction theory is just hypothesis (that's whay I tried to say - THRO can speak more fluently).

Chang's smirk when he presented at ASTRO that year was priceless.

I have a hard time believing whole brain radiation and controlling "elsewhere tumor recurrences" kills people, but who knows?

-S

Actually, a 2 x 2 design does not allow for comparison of all 4 arms in a statistically valid way. The statistically valid comparisons that can be made from this trial are WP vs PO and NC-ADT vs A-ADT. The WP + NC-ADT arm was the best of the four, but this is hypothesis generating only.... it is not level I data! Roach has tried to spin this result, but the data are clearly negative.

 

[Palex80]

How about WBRT + SRS vs SRS alone and surveillance for pts with 1-3 brain mets?? What do people think of Dr. Chang's study from MDACC suggesting a survival detriment?

The study was designed to detect a difference in neurocognitive function after SRS or WBRT+SRS. It was terminated a bit over half way, because of bad neurocognitive function in the SRS+WBRT.
The lower survival in the SRS+WBRT was a secondary finding and not what the trial was looking for in the first place. Furthermore, I don't think that WBRT actually kills any patients, it simply has an impact on their neurocognitve function.


You can do SRS alone for 1-3 brain mets, the Aoyama study (or however you spell that guy's name!) showed that.

 

[medgator]

That's the problem. You can't compare the single arms to each other, the interaction theory is just hypothesis (that's whay I tried to say - THRO can speak more fluently).

Chang's smirk when he presented at ASTRO that year was priceless.

I totally agree. We had plenty of things to say in morning conference the week after that ASTRO was over

The study was designed to detect a difference in neurocognitive function after SRS or WBRT+SRS. It was terminated a bit over half way, because of bad neurocognitive function in the SRS+WBRT.
The lower survival in the SRS+WBRT was a secondary finding and not what the trial was looking for in the first place. Furthermore, I don't think that WBRT actually kills any patients, it simply has an impact on their neurocognitve function.


You can do SRS alone for 1-3 brain mets, the Aoyama study (or however you spell that guy's name!) showed that.

Extrapolating from the patchell study (http://www.ncbi.nlm.nih.gov/pubmed/9809728) though, we know that there is some detriment in just treating the lesions and observing. The neurocog issues will needed to be sorted out, but the idea of only addressing visible mets with SRS in diseases like NSCLC is something that is controversial IMO.

 

[Palex80]

Extrapolating from the patchell study (http://www.ncbi.nlm.nih.gov/pubmed/9809728) though, we know that there is some detriment in just treating the lesions and observing. The neurocog issues will needed to be sorted out, but the idea of only addressing visible mets with SRS in diseases like NSCLC is something that is controversial IMO.

The problem is that you are comparing two different things here:
SRS with Surgery.

While SRS can offer around 90% local tumor control, we know that surgery is associated with high local recurrence rates in the brain. The problem there is that you simply do not have a surgical tumor free margin.

Half of the brain recurrences in the Patchell study were pure local recurrences. The study showed 66% local control with surgery only (when it comes to first event). If you take into consideration all local recurrences (in the presence or not of distant recurrences), then you are looking at 46% local recurrences with surgery only.

The Patchell study did prove the point, that you need adjuant therapy after local surgery, but if the local recurrences had been less after surgery, then you would't have that much of a benefit through the adjuvant WBRT.

In short:
If your local control is good, then you can probably ommit WBRT. Therefore SRS alone is fine, while surgery alone is dangerous.

Histology is also an issue, good that you brought it up.
I treat adeno NSCLC with WBRT as a standard +/- SRS (according to number of mets). In my experience a G3 adeno NSCLC behaves almost like a SCLC when it comes to brain mets.

 

[TarHeelRadOnc]

The problem is that you are comparing two different things here:
SRS with Surgery.

While SRS can offer around 90% local tumor control, we know that surgery is associated with high local recurrence rates in the brain. The problem there is that you simply do not have a surgical tumor free margin.

Half of the brain recurrences in the Patchell study were pure local recurrences. The study showed 66% local control with surgery only (when it comes to first event). If you take into consideration all local recurrences (in the presence or not of distant recurrences), then you are looking at 46% local recurrences with surgery only.

The Patchell study did prove the point, that you need adjuant therapy after local surgery, but if the local recurrences had been less after surgery, then you would't have that much of a benefit through the adjuvant WBRT.

In short:
If your local control is good, then you can probably ommit WBRT. Therefore SRS alone is fine, while surgery alone is dangerous.

Histology is also an issue, good that you brought it up.
I treat adeno NSCLC with WBRT as a standard +/- SRS (according to number of mets). In my experience a G3 adeno NSCLC behaves almost like a SCLC when it comes to brain mets.

Great point about SRS vs surgery. Surgery alone is wholy inadequate. In the presentation of the recent EORTC trial of aggressive local Tx (SRS or surgery) +/- WBRT presented at ASCO and ASTRO 2009, the cumulative incidence of LF at 2yrs was 31% with SRS alone and 59.5% (!!!) with surgery alone. After WBRT (30Gy/10fx), the rate of LF was reduced to 19.2% and 27.2%, respectively, but still lower with SRS. This trial was the largest to date addressing this question (359 pts) and a neurologic CSS benefit was shown with the addition of WBRT to surgery or SRS.

It is interesting that the only trials that show a neuro CSS benefit with the addition of WBRT to local therapy are those trials in which that local therapy is surgery (EORTC [45% had surgery] and Patchell). The trials exclusively evaluating SRS +/- WBRT (Aoyama and Chang) have not shown a benefit in neuro CSS with the addition of WBRT.

 

[Palex80]

It is interesting that the only trials that show a neuro CSS benefit with the addition of WBRT to local therapy are those trials in which that local therapy is surgery (EORTC [45% had surgery] and Patchell). The trials exclusively evaluating SRS +/- WBRT (Aoyama and Chang) have not shown a benefit in neuro CSS with the addition of WBRT.

Good point.
Another point here, that has to be taken into consideration is that trials with surgery +/- WBRT include patients with 1 brain met, while SRS +/- WBRT trials generally include patients with 1-3 brain mets.
Extrapolating from the Andrews trial of WBRT +/- SRS, we know that the number of mets plays quite an important role in defining patients' survival.
Perhaps a subgroup analysis of the Aoyama and Chang trials in patients with single brain metastasis may have shown some OS benefit through additional WBRT, I fear however that there are simply not enough patients in these trials to make a valid statement.

 

[Radonc90]

Ironically, the very same high-risk prostate population: if they were to undergo surgery and found to have LN+ at surgery, guess what: hormonal therapy only (i.e., no RT).

For the most part, prostate cancer spreads hematogenously so any attempt at chasing LN is futile in my book.

Of course, the people who conceptualized and designed RTOG-9413 has to take care of "their baby".

In my practice, I don't treat Whole Pelvis for this group of pts. However, I give HT and RT as mentioned in the previous threads.

More readings:

http://jco.ascopubs.org/content/26/12/2055.full

http://jco.ascopubs.org/content/26/12/2056.full

Basically negative on long-term follow-up of RTOG-9413:
Int J Radiat Oncol Biol Phys 69:646-655, 2007
http://www.sciencedirect.com/scienc...b42a11f8394d0697346b73ce775&ie=/sdarticle.pdf

 

[Palex80]

Ironically, the very same high-risk prostate population: if they were to undergo surgery and found to have LN+ at surgery, guess what: hormonal therapy only (i.e., no RT).

This is not entirely standard practice in all clinics though.
1. Although one trial http://www.ncbi.nlm.nih.gov/pubmed/18823693 did demonstrate a survival benefit through the adjvuvant use of hormonal therapy this study was carried out largely in the pre-PSA area and hormonal therapy was often initiated in the not-adjuvant arm only after symptoms developed.
This is not standard practice today, since most physicians would initiate hormonal therapy before the first painful bone metastasis developed, but as soon as PSA rose.
2. There are some retrospective trials demonstrating a benefit over adjuvant hormonal therapy alone in postoperative pN+ patients through adjuvant EBRT and hormonal therapy, for example: http://www.ncbi.nlm.nih.gov/pubmed/17125912

For the most part, prostate cancer spreads hematogenously so any attempt at chasing LN is futile in my book.

This can be generally said for cancer and would mean that we should stop treating the neck in H&N cancer patients, the axilla in breast cancer patients and....

Of course, the people who conceptualized and designed RTOG-9413 has to take care of "their baby".

I think the main problem with RTOG 9413 was in its design. It was a study designed to answer too many questions with too little power. And when the results shifted into confusing conclusions all hell broke out.
We will probably never get the answer to the pelvis question in prostate cancer, it will likely remain a mystery like the IM-chain irradiation question.
You just need too many patients to answer such a clinical question and we don't have the capability to conduct such a trial.
Another problem with all these trials is the development dignostics and new drugs. 15 years after these trials are finished and their results mature, everything has changed in diagnostics & drugs, thus limiting the value of such trials.
A typical example would be the DLBCL-trials.
Once Rituximab came out you could basically question all the results of the numerous trials based on CHOP, since R-CHOP was a whole different ball game. Now we need to base our recommendations on retrospective evidence again, like the M.D. Anderson study published in JCO a couple of weeks ago: http://www.ncbi.nlm.nih.gov/pubmed/20713859

 

[Radonc90]

... This can be generally said for cancer and would mean that we should stop treating the neck in H&N cancer patients, the axilla in breast cancer patients and....

Nope, H&N cancer spreads in a very orderly manner down the cervical chain. Skip metastasis is very rare in H&N cancer.
This is why it makes every sense to treat the neck nodes (when applicable).

Breast cancer, in many respects, resembles prostate cancer in that a major mode of spread is hematogenous, and therefore chasing LN in prostate or breast is mostly futile. The issue is systemic treatment for these sites: development of new systemic treatment is crucial in these 2 body sites, if one wants to achieve significant outcome.

Regrading your 1st post, Roach is the RTOG author and he is sometimes opinionated.

 

[Gfunk6]

Regrading your 1st post, Roach is the RTOG author and he is sometimes opinionated.

I think this statement wins the SDN Rad Onc "biggest understatement of all time" award.

 

[Radonc90]

... Another problem with all these trials is the development dignostics and new drugs. 15 years after these trials are finished and their results mature, everything has changed in diagnostics & drugs, thus limiting the value of such trials.
A typical example would be the DLBCL-trials.
Once Rituximab came out you could basically question all the results of the numerous trials based on CHOP, since R-CHOP was a whole different ball game. Now we need to base our recommendations on retrospective evidence again, like the M.D. Anderson study published in JCO a couple of weeks ago: http://www.ncbi.nlm.nih.gov/pubmed/20713859

R-CHOP regimen kind of "put us out of business" in the Involved-field RT for DLCL. Remember many years ago when the Vancouver group pioneered CHOPx3 ---> IFRT, it became the "wow" factor, wow new treatment for DLCL! Then R-CHOP came along and IFRT is largely gone (except for bulky lymphoma), despite the fact that there has been no randomized trial of R-CHOP vs CHOPx3 ---> IFRT.
Now with the retrospective data from MDACC as you mentioned above, I'd not be surprised if one day R-CHOP ---> IFRT is the way to go. But I am speaking before any randomized trial has been done on this issue LOL!

 

[medgator]

R-CHOP regimen kind of "put us out of business" in the Involved-field RT for DLCL. Remember many years ago when the Vancouver group pioneered CHOPx3 ---> IFRT, it became the "wow" factor, wow new treatment for DLCL! Then R-CHOP came along and IFRT is largely gone (except for bulky lymphoma), despite the fact that there has been no randomized trial of R-CHOP vs CHOPx3 ---> IFRT.

Which is a shame considering the OS benefit seen in the SWOG trial. With the update of the trial, the OS curves crossed but it was because they were failing outside of the RT field (probably secondary to inadequate systemic Tx).

 

[Palex80]

Nope, H&N cancer spreads in a very orderly manner down the cervical chain. Skip metastasis is very rare in H&N cancer.
This is why it makes every sense to treat the neck nodes (when applicable).

But do we know if electively treating the lymphatics in H&N cancer changes overall survival?

We need to rethink about our model of metastasis.
Up until now, most people thought that cancer goes from the primary to the lymph nodes and then to the organs. This is probably not correct.
It seems that cancer spreads parallel both through the lymphatics and the blood system to lymph nodes and organs respectively.
Prostate cancer also spreads through the lymphatics in a very ordinary way. First the pelvic lymph nodes, then the paraaortic lymph nodes, etc...
The difference (as you said) between prostate cancer and H&N cancer, is that prostate cancer has a higher potential of primary systemic metastasis through the blood system than H&N cancer.

There are some authors, who are challenging extensive prophylactic treatment of the lymphatics as part of a primary cancer treatment and point out, that there are no trials showing a survival benefit through elective treatment of lymph nodes metastasis.
In fact, if you look at this point, they are kind of right.
There are no randomized trials which have demonstrated an overall survival benefit through electively treating the lymphatics in ANY type of cancer.
People don't die from microscopic lymph node metastasis, they die of hematogenous metastasis.

There is one point, where treating the lymphatics will change overall survival, which is when microscopic lymph node disease turns into macroscopic one. From that point on, macroscopic tumor in the lymphatics can cross into the blood system and cause hematogenous metastasis.
That's why treating cT3 cN2b larynx cancer with aggressive radiochemotherapy of primary & the neck can still cure around 20% of these patients. If you were to treat only the primary 0% would be cured.

Look at the facts: We don't have a single trial in ANY kind of cancer, which showed that removing or irradiating microscopic disease in lymph nodes changes overall survival.

 

[deleted4401]

Um ... Vulvar cancer. Groin recurrence is fatal. RT prevents this post-operatively, thereby improving overall survival.
There is a big GOG trial showing this. Something like 68% OS with RT and 54% without, or something like that. Big improvement. Pokes a big hole in the theory
S

 

[Radonc90]

1+,

I agree with SimulD, Vulvar Ca is a good example of treating LN makes a difference. Groin recurrence = fatal, period!

Back to the HN issue. Let's say we are dealing with T3N0 of the tonsil.
If we treat only the tonsil (neck not treated), then the pt recurs in the neck, now we are dealing with salvage (S + RT), which IMHO decreases survival because in my experience treating hundreds and hundreds of HN in the last 20 years, neck recurrence is no fun!

While I agree with Palex80 that there is no randomized trial comparing treating T only vs treating T & N (it would be a foolish trial to do btw), in my experience, if we were to do this trial, then the value of neck RT will be verified to improve survival.

Breast and Prostate is another story, chasing LN in these 2 tumors makes very very little difference, if any.

 

[Palex80]

Um ... Vulvar cancer. Groin recurrence is fatal. RT prevents this post-operatively, thereby improving overall survival.
There is a big GOG trial showing this. Something like 68% OS with RT and 54% without, or something like that. Big improvement. Pokes a big hole in the theory
S

I thought about vulvar cancer and the GOG trial too, but there are a couple of points to be raised concerning the study:
1. It's a 70s-80s study, meaning a lot of patients did not have CT scans and correct staging. Thus you could have been actually treating patients with macroscopic disease in the RT group and not microscopic one.
2. In the RT arm you also had prevention of a lot of primary recurrences. Recurrences you could not prevent in the lymphadenectomy arm, since no RT was allowed there. Noone said, that it was only the groin recurrences that killed the patients, some patients may have died due to primary tumor recurrences.

Now don't get me wrong:
I am not advocating to ommit lymphatics irradiation as a whole issue. I am just trying to shake a bit the dogmatic principle, that lymphatics metastasis leads to hematogenous metastasis.
We have tons of evidence concerning the benefits of adjuvant irradiation, it's just that when people started using radiation therapy, they automatically started including all the lymphatics into the fields, primarily led from the surgical point of view. This principle is not evidence based.


As far as the H&N case is concerned, a solitary neck recurrence can easily be salvaged with a neck dissection in many cases. Many people would then irradiate the neck (if that has not happened by then).
If you take a look at the evidence we have in the case of cervical CUP, you'll see that if the CUP is diagnosed through complete excision of all macroscopic tumor in the neck, there is not a lot of evidence showing an overall survival benefit through adjuvant RT. Surely you decrease recurrence rate, but if only one 2 cm node was clinically suspicious and was completely removed, some physicians will opt for active surveillance rather than adjuvant RT.

 

[Palex80]

While I agree with Palex80 that there is no randomized trial comparing treating T only vs treating T & N (it would be a foolish trial to do btw), in my experience, if we were to do this trial, then the value of neck RT will be verified to improve survival.

I don't know why you think that such a trial would be foolish to do.
If you look at what kind of randomized trials have been conducted in H&N cancer you will find dozens of trials on fractionation and the question of radio- or radiochemotherapy.
Yet some very crucial questions have not been asked, like:
1. Do we always have to treat both sides of the neck?
2. Do we actually have to treat the paraclavicular nodes?
3. What's the appropriate adjuvant dose in the involved / not involved neck regions?

All we have to answer these questions are retrospective patterns of care analysis, which showed that we don't have to treat the neck in T1-T2 glottic cancer and that we can ommit contralateral irradiation in the case of T1 N1 tonsilar cancer. Yet, there is not a single randomized trial carried out concerning size of radiation field.
Looking back at the DOZENS of randomized trials carried out testing all kind of fractionation schedules and chemotherapeutic substances in H&N cancer, I find it actually quite sad, that the really interesting questions concerning radiation therapy planning and treatment volume definition have not been asked.
I would happily trade off a couple of chemo vs. chemoRT studies for a decent target volume definition study.

 

[Cancerdancer]

Breast and Prostate is another story, chasing LN in these 2 tumors makes very very little difference, if any.

If you crunch the numbers, the survival benefits of PMRT in the Danish and BC trials can't be explained by preventing chest wall recurrences alone. I think it's clear that sterilizing the locoregional lymphatics has a survival benefit in high-risk patients...

 

[deleted4401]

GOG study for vulva was post-op, meaning groin was dissected and there is no gross disease left. It is irrelevant whether or not you did a scan before or after the surgery. Surgical dissection is gold standard of whether or not there is gross disease.

No vulva RT was given. 7-9% recurrence rate in vulva (in both arms, making up 23% of all recurrences) and some of these were salvaged. The survival benefit was b/c of groin recurrence prevention (these were salvaged 0% of the time), no question about it, since as mentioned, no vulva RT.

S

 

[deleted4401]

Also, for head and neck cancer...

We know that patients with certain high risk factors after a dissection (SM+, ECE, multiple nodes, etc.) have a high risk of recurrence. We know that these patients that recur do worse, and have a high risk of death due to disease. We know that RT decreases the risk of recurrence. I don't see the value of testing this - I really don't. I don't want a placebo arm that is being left at high risk for a neck recurrence, when I already know that RT works in decreasing them. Even (I don't believe this is true) if it didn't prevent future death, neck recurrences are horrible.

In fact, for HNC, the entire disease recurrence pattern has changed (increased distant mets, decreased local recurrences), and that's why med-oncs trying to get the juice in any way possible.

It works both ways - some diseases currently cause death because of distant recurrence, and when systemic therapy improves, local control becomes more important (i.e. post-op RT for N2 disease in resected lung cancer following adjuvant chemo). The opposite is also true - HNC was primarily a locoregional disease, and with great improvements in local control, the juice becomes more important.

-S

 

[Palex80]

Thanks a lot SimulD for the input.
I have to say, that I was wrong with the raised points concerning the vulva trial.

 

[TarHeelRadOnc]

Thanks a lot SimulD for the input.
I have to say, that I was wrong with the raised points concerning the vulva trial.

This topic has been more or less beaten to death, but two quick comments in relation to the HNSCC discussion:

1. Fortunately for patients, the DFS with cT3N2b larynx in modern (North American) trials of chemoRT is better than 20%. DFS is in the range of 40-50% and survival with salvage laryngectomy in range of 60%

2. Salvage rates after isolated neck failure are not that high. Obviously better if patient didn't receive prior RT, but still pretty low. That is the historical rationale for elective neck RT. Only site in head and neck with high salvage rate after locoregional recurrence is isolated local failure in larynx after chemoRT or RT alone... which is associated with high salvage rate (and bad toxicity profile!) with salvage laryngectomy.

 

[FFunk]

.

 

[memberBlue]

I think RTOG 94-13 unequivocally proved what it set out to do. In men with high-risk prostate cancer, they are better served with WPRT + 2 mo NHT + 2 mo CHT. The PFS at 4 year is highly significant. Other trials (e.g. GETUG-01) have used "mini" pelvis fields which do not encompass all LN groups at risk.

RTOG 9413 unequivocally proved that treating the pelvis provides no benefit. On the 7 year update using a nadir+2 definition for failure the p value comparing whole pelvis and prostate only RT was 0.99.

 

[Gfunk6]

We'll see after the results of RTOG 0924 are published. I suspect everyone will be using protons by then

 

[medgator]

We'll see after the results of RTOG 0924 are published. I suspect everyone will be using protons by then

Yeah since we don't fry the rectum enough with IMRT

 

[RadOncDoc21]

I have to say this thread helped to answer and raise a lot of questions for me.

I was just curious outside of the UCSF folks does anybody else treat elective pelvic nodes in prostate cancer anymore? Apparently it's still a debated topic in the field but from my reading, it seems a lot of historical studies did this.

 

[Pointless]

Look at the facts: We don't have a single trial in ANY kind of cancer, which showed that removing or irradiating microscopic disease in lymph nodes changes overall survival.

MA-20? I know its only in abstract form, but still....

 

[TarHeelRadOnc]

MA-20? I know its only in abstract form, but still....

In Palex's defense, look at the date on his post... Well before MA.20 (ASCO 2011)

 

[Pointless]

In Palex's defense, look at the date on his post... Well before MA.20 (ASCO 2011)

Ha! Good call, didn't realize this was a bumped thread...

 

[Palex80]

MA.20 will be the Herceptin of Radiation Oncology.

Trust me... When this trial is published and if its results in the full paper are the same as in the abstract, it's going to rock our world.
I expect in our clinic a rise of about 15% in IMRT treatments alone, since we are going to do IMRT for every single node-positive breast cancer patient and a bunch of "high risk" node negative ones...

 

[deleted4401]

How do you do IMRT for IMN patients? I don't get it really.
Do you do tangent fields, partially wide superiorly and then inversely plan? Or some other technique?
S

 

[Palex80]

Our main problem is, that our TPS does not support hybrid-IMRT at the moment. So we don't have that option available.

We treat IMN + Chest wall or Breast + Axilla + Supra as one volume usually 45/1.8. Then we boost breast/chest wall with tangents.

I may be able to post a plan here tomorrow. Cheers.

 

[Palex80]

Dear SimulD,

as promised, here's the plan.

7 beams.

 

[deleted4401]

That's what I was wondering. It's non-tangential. I'm uncomfortable with that. Everyone else doing it that way?

 

[medgator]

That's what I was wondering. It's non-tangential. I'm uncomfortable with that. Everyone else doing it that way?

I know some people who do it that way. I worry about contralateral breast dose (especially in our younger patients). I think it's probably a good idea to contour that other breast and keep that in mind.

Also, when I've looked at IMRT plans for trying to treat nodes, I don't end up seeing much of a benefit for things like lung-sparing compared to conventional planning. Perhaps Palex80 could give us his thoughts on that.

 

[Palex80]

] Also, when I've looked at IMRT plans for trying to treat nodes, I don't end up seeing much of a benefit for things like lung-sparing compared to conventional planning. Perhaps Palex80 could give us his thoughts on that.

The benefit of IMRT for treating nodes (especially axilla and IM) is that you can avoid a deeper tangent and thus more volume of the lung in the high dose area. Whenever we try to include the axilla into the PTV we end up with 3.5 cm of lung in our tangent, that's why we think IMRT may be beneficial for these patients.

We are currently looking into tangential techniques too, but are so far not very comfortable with them. We end up getting quite alot of hot spots in the axilla outside of the PTV.

I fully understand you argument about contralateral breast dose. Furthermore, the low-dose-bath to the ipsilateral lung should not be underestimated.

 

[Gfunk6]

Dear SimulD,

as promised, here's the plan.

7 beams.

Thanks for the pictures. From the placement of your beam angles, it almost seems like you are trying to replicate a half-arc of a VMAT plan.

 

[Palex80]

Thanks for the pictures. From the placement of your beam angles, it almost seems like you are trying to replicate a half-arc of a VMAT plan.

Precisely, because we (still) don't have VMAT.