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38 Pattern of recurrence after continuous, hyperfractionated, accelerated radiotherapy (CHART) in non-small cell lung cancer
Posters, 5th Annual BTOG Meeting, 2007 38 Pattern of recurrence after continuous, hyperfractionated, accelerated radiotherapy (CHART) in non-small cell lung cancer O. Din1 , A. Cameron2 , J. Lester2 , B. Moore2 , J. Ironside3 , J. Warnock3 , S. Erridge4 , A. Gee4 , S. Falk4 , J. Klinsman4 , S. Morgan5 , J. Worvill5 , M. Hatton1 . 1 Weston Park Hospital, Clinical Oncology, Sheffield, 2 Velindre Hospital, Clinical Oncology, Cardiff, 3 Western General Hospital, Clinical Oncology, Edinburgh, 4 Bristol Haematology and Oncology Centre, Clinical Oncology, Bristol, 5 Nottingham City Hospital, Clinical Oncology, Nottingham, UK Introduction: In 1997 Saunders et al showed improved local control and survival for the CHART fractionation (54 Gy in 36 fractions over 12 days) over conventional radiotherapy (60 Gy in 30 fractions over 6 weeks) in a randomised, multicentre trial. In 2005 the CHART Consortium identified and pooled data from 5 centres that had used CHART for more than 5 years. This abstract presents data on the pattern of relapse after CHART. Methods: Patients treated with CHART from 1997 to December 2003 were identified to allow a minimum of two years follow up. Basic patient demographics, tumour characteristics and survival were recorded retrospectively in a combined database. Results: 583 patients with NSCLC were identified. 69% were male with a median age of 68 (range 31 89). 83% had a performance status 0 or 1, and 43% of patients had stage 1 or 2 disease. The database documents a local recurrence in 24% and distant recurrence in 30%. The most common sites of metastases were bone (11.0%), brain (8.5%) and liver (3.8%). Conclusions: The site of relapse is not documented as well in this retrospective series when compared to the original CHART study. However, there is a significant incidence of brain metastases identified which supports the growing interest in the use of prophylactic cranial irradiation (PCI) with radical treatment of NSCLC. 39 INCH: induction chemotherapy & CHART in non-small cell lung cancer M. Hatton, on behalf of the INCH Trial Management Group. MRC Clinical Trials Unit, 222 Euston Road, London NW1 2DA, UK Non-Small Cell Lung Cancer (NSCLC) accounts for about 80% of all lung cancer. However treatment remains unsatisfactory with only 5% of UK patients surviving 5 years. For patients with inoperable stage I-III disease in the UK, CHART (54 Gy in 36 f for 12 consecutive days) is the ‘standard’ (though not widely available) treatment, with a demonstrated 9% improvement in 2 year survival when compared to conventional radical radiotherapy. Results suggest that survival can be improved by the sequential addition of cisplatin-based chemotherapy to conventional radical radiotherapy. Therefore the INCH trial aims to determine whether giving induction chemotherapy with CHART also confers a survival advantage. Trial participants have been discussing the treatment of stage III disease with CHART. Some believe that ‘bulky’ disease may be difficult to encompass without exceeding normal tissue tolerances and also that there is a high risk of latent distant metastatic disease. Therefore some prefer to give chemotherapy followed by conventional radical radiotherapy, even though such treatment is not proven against CHART alone. In addition some concern has been expressed about including elderly patients in INCH. To date 3 patients over 70 have been successfully recruited and treated. INCH has been open for 17 months but has recruited only 32 patients. Recruitment needs to improve rapidly now that more centres have joined the trial.
S11 40 Isotoxic hypofractionated radical radiotherapy for non-small cell lung cancer L. Wills1 , E. Hudson1 , M. Button1 , J. Fenwick2 , F. Macbeth1 , J. Lester1 . 1 Velindre Hospital, Cardiff, 2 Clatterbridge Centre for Oncology, UK Introduction: There are three dose-limiting organs at risk (OARs) in radical radiotherapy (RT) for NSCLC and treatment is designed to keep the dose to these within pre-defined limits; for lungs, mean normalized tolerance dose <17 Gy (NTDmean; mean dose to the lungs normalized to 2 Gy per fraction), spinal cord <44 Gy and oesophagus <58.5 Gy. Conventionally, the dose prescribed for all patients is the same as long as OAR limits are not exceeded. Doses received by OARs vary greatly between patients depending on the size and position of the tumour. Therefore, in some patients it should be possible to increase the dose prescribed whilst staying within OAR dose limits. In others, where OARs lie adjacent to the tumour within the high dose planning target volume (PTV), dose escalation will be limited. Methods: We conducted a retrospective review of 10 consecutive radical RT plans in patients prescribed 50 55 Gy in 20 fractions delivered using 3D conformal RT to assess the feasibility of a prospective dose escalation study. Doses were increased until the first OAR dose limit was reached. Results: In 5/10 patients, NTDmean was the first dose limit reached, and theoretical doses ranged from 77 166 Gy. In 2/10 patients oesophagus was the dose limit first reached (theoretical doses 62 Gy and 129 Gy). In 1/10 patients, the cord limited the theoretical dose to 81 Gy. 2/10 patients had oesophagus in the PTV, and no escalation was possible. Dose to the heart was insignificant in all cases. Conclusion: Clinical data suggest that there is a dose-response effect with RT in NSCLC. Where the oesophagus lies outside the PTV, significant dose escalation may be possible without unacceptable toxicity.
41 The QUARTZ Trial: Quality of life after radiotherapy and steroids in patients with inoperable brain metastases from non-small cell lung cancer B. Moore, H. Jones, I. Brisbane, F. Richards. MRC Clinical Trials Unit, 222 Euston Road, London NW1 2DA, UK For patients with multiple inoperable brain metastases the standard therapy is a combination of steroids and whole brain radiotherapy (WBRT). However, WBRT causes side effects and has never been shown to correlate with an improved quality or length of survival. Therefore, it is uncertain whether those clinicians who treat this group of patients should continue to include WBRT within the package of optimised supportive care offered via the multidisciplinary team. The QUARTZ trial will compare Optimal Supportive Care (OSC, including dexamethasone) alone with OSC (including dexamethasone) and WBRT in the treatment of patients with inoperable brain metastases from NSCLC, in terms of quality of life, overall survival, and side-effects. Once diagnosed with brain metastases, many of these patients will never be seen in the clinic again, therefore information on the patients’ well-being will be collected via weekly telephone assessments between the patient and their nurse. A questionnaire including the EQ-5D, EQ-VAS and a list of symptoms will be used. Carer concerns will also be assessed in the same way. The assessments are expected to take about 30 minutes and it is recommended that each centre has no more than two patients being followed up at any one time. We therefore hope that this trial will not cause too much additional work for centre staff. The QUARTZ trial is now open to recruitment, and we are aiming to recruit 1000 patients over 3 years. For more details or to register your centres interest please contact Jacque Millet ([email protected]).
S11 40 Isotoxic hypofractionated radical radiotherapy for non-small cell lung cancer L. Wills1 , E. Hudson1 , M. Button1 , J. Fenwick2 , F. Macbeth1 , J. Lester1 . 1 Velindre Hospital, Cardiff, 2 Clatterbridge Centre for Oncology, UK Introduction: There are three dose-limiting organs at risk (OARs) in radical radiotherapy (RT) for NSCLC and treatment is designed to keep the dose to these within pre-defined limits; for lungs, mean normalized tolerance dose <17 Gy (NTDmean; mean dose to the lungs normalized to 2 Gy per fraction), spinal cord <44 Gy and oesophagus <58.5 Gy. Conventionally, the dose prescribed for all patients is the same as long as OAR limits are not exceeded. Doses received by OARs vary greatly between patients depending on the size and position of the tumour. Therefore, in some patients it should be possible to increase the dose prescribed whilst staying within OAR dose limits. In others, where OARs lie adjacent to the tumour within the high dose planning target volume (PTV), dose escalation will be limited. Methods: We conducted a retrospective review of 10 consecutive radical RT plans in patients prescribed 50 55 Gy in 20 fractions delivered using 3D conformal RT to assess the feasibility of a prospective dose escalation study. Doses were increased until the first OAR dose limit was reached. Results: In 5/10 patients, NTDmean was the first dose limit reached, and theoretical doses ranged from 77 166 Gy. In 2/10 patients oesophagus was the dose limit first reached (theoretical doses 62 Gy and 129 Gy). In 1/10 patients, the cord limited the theoretical dose to 81 Gy. 2/10 patients had oesophagus in the PTV, and no escalation was possible. Dose to the heart was insignificant in all cases. Conclusion: Clinical data suggest that there is a dose-response effect with RT in NSCLC. Where the oesophagus lies outside the PTV, significant dose escalation may be possible without unacceptable toxicity.
41 The QUARTZ Trial: Quality of life after radiotherapy and steroids in patients with inoperable brain metastases from non-small cell lung cancer B. Moore, H. Jones, I. Brisbane, F. Richards. MRC Clinical Trials Unit, 222 Euston Road, London NW1 2DA, UK For patients with multiple inoperable brain metastases the standard therapy is a combination of steroids and whole brain radiotherapy (WBRT). However, WBRT causes side effects and has never been shown to correlate with an improved quality or length of survival. Therefore, it is uncertain whether those clinicians who treat this group of patients should continue to include WBRT within the package of optimised supportive care offered via the multidisciplinary team. The QUARTZ trial will compare Optimal Supportive Care (OSC, including dexamethasone) alone with OSC (including dexamethasone) and WBRT in the treatment of patients with inoperable brain metastases from NSCLC, in terms of quality of life, overall survival, and side-effects. Once diagnosed with brain metastases, many of these patients will never be seen in the clinic again, therefore information on the patients’ well-being will be collected via weekly telephone assessments between the patient and their nurse. A questionnaire including the EQ-5D, EQ-VAS and a list of symptoms will be used. Carer concerns will also be assessed in the same way. The assessments are expected to take about 30 minutes and it is recommended that each centre has no more than two patients being followed up at any one time. We therefore hope that this trial will not cause too much additional work for centre staff. The QUARTZ trial is now open to recruitment, and we are aiming to recruit 1000 patients over 3 years. For more details or to register your centres interest please contact Jacque Millet ([email protected]).