ONCAlert | Upfront Therapy for mRCC

Case 1: Surgery and Chemotherapy in Locally Advanced NSCLC

Targeted Oncology
Published Online:1:07 PM, Fri June 14, 2019


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Benjamin P. Levy, MD: Mickey, let’s talk a little bit about the surgeon’s role here. Quite a controversial area. This is a stage IIIb, so I don’t think there’s any role for surgery here, but if we were to back this up to a stage IIIa, we’re still talking about phase III. As far as opportunities for surgery, we’ve had some data showing the potential benefit if you can get a lobectomy instead of a pneumonectomy. Can you talk to us about your approach in these patients and your involvement?

Michael J. Walker, MD: Sure, Ben. Thank you. I think it’s important to separate N3 disease from N2 disease, and we have stage IIIa, IIIb, and IIIc. But I still think we should not operate on the N3s and focus on the N2s. With regards to N2 disease, there are some soft data. They are not hard data because it’s so controversial, but multistation N2 disease usually doesn’t fare well with surgical intervention. I think they should probably get definitive chemoradiotherapy. Others would disagree because there really are not a lot of data with that.

Other soft points are bulky nodes, and that can be defined as either greater than 2 cm or greater than 3 cm. I look anatomically if they’re sitting on the pulmonary artery, those big nodes, and they may need a pneumonectomy, but then I would probably not operate on them.

One other thing would be extracapsular spread. I would say that the most conservative people—if they have multistation N2 disease, bulky lymphadenopathy and/or extracapsular spread in those mediastinal nodes—would probably not involve surgery. Certainly, single-station N2 disease without bulky nodes could be considered for up-front chemotherapy radiation with a lower dose of radiation. Typically, I like to ensure the mediastinum has been sterilized. I particularly don’t like operating on it when the mediastinum is still involved. I think they should continue radiation without interruption and not go for a surgical resection. But in an isolated case of minimal disease—including PET [positron emission tomography] and potentially a repeat EBUS [endobronchial ultrasound]—although we know the results from repeat EBUS aren’t as good as regular EBUS, I would consider that group for surgical resection.

Benjamin P. Levy, MD: Lon, any comments on that and repeating EBUS? Do you get these referrals? This is a contentious issue—sterilizing the mediastinum. Do we need to make sure that’s sterilized before surgery? Is this something that you, as an interventional pulmonologist, get involved in?

Lonny Brett Yarmus, DO: We do. As Mickey said, the EBUS restaging literature certainly has a lower overall tissue acquisition ­­­­yield rate. The minimally invasive component of the procedure, and a pretty high rate of achieving a diagnosis, warrants it to be a reasonable first step toward these patients before a more invasive testing.

Benjamin P. Levy, MD: The patient has gone through the journey, tissue procurement, pathological assessment, a surgical evaluation. They’re seeing the radiation oncologist, and then of course the medical oncologist becomes very much involved in this case as well. Isabel, do you want to talk a little bit about a fit patient with stage III who’s going to get concurrent chemoradiation? Can you talk about chemotherapy, your options, and what you use for chemotherapy in a patient with stage III?

Isabel Preeshagul, DO, MBS: Sure. Thank you, Ben. The main things that I think about are obviously underlying histology, performance status of the patient, and underlying medical comorbidities. While there are many NCCN [National Comprehensive Cancer Network] Guideline–approved agents that we can use, 1 size does not fit all. Something that I found myself using more commonly would be a weekly carbo-taxol [carboplatin-paclitaxel] regimen in partnership with my radiation oncology colleagues, Anshu.

One thing that I like about a weekly carbo-taxol regimen is that it offers the opportunity for a frequent follow-up and check-in. These patients that may need hydration, may need extra TLC. They may need a nutrition consult when they didn’t initially. They may have esophagitis that may not get recognized by my radiation colleagues or may have been missed over the weekend—some complications like these. I think it allows for more frequent follow-up and more comprehensive care.

Benjamin P. Levy, MD: Yeah, I would agree. I think that we can move, and we’ll talk about the PACIFIC trial in a second, the data that have changed practice for stage III. I was brought up in a world where you used cisplatin always for curative intent patients. I still sometimes try to do that. If you look at the NCCN Guidelines, we try cisplatin for a very fit patient. But I’d say the majority of the time, we’ve been defaulting to carbo-taxol. Default is probably the wrong word. But it’s a well-tolerated regimen. As you said, it can certainly allow for an opportunity to check in on patients at a weekly interval.

I’ve been using cisplatin-pemetrexed for my adenocarcinoma patients. The standard is still, if you want to be an academic purist, cisplatin-etoposide, the SWOG regimen. That is not an easy regimen to give for patients with stage III, especially when you’re thinking about what you’re going to give these patients on the back end.

Transcript edited for clarity.


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Benjamin P. Levy, MD: Mickey, let’s talk a little bit about the surgeon’s role here. Quite a controversial area. This is a stage IIIb, so I don’t think there’s any role for surgery here, but if we were to back this up to a stage IIIa, we’re still talking about phase III. As far as opportunities for surgery, we’ve had some data showing the potential benefit if you can get a lobectomy instead of a pneumonectomy. Can you talk to us about your approach in these patients and your involvement?

Michael J. Walker, MD: Sure, Ben. Thank you. I think it’s important to separate N3 disease from N2 disease, and we have stage IIIa, IIIb, and IIIc. But I still think we should not operate on the N3s and focus on the N2s. With regards to N2 disease, there are some soft data. They are not hard data because it’s so controversial, but multistation N2 disease usually doesn’t fare well with surgical intervention. I think they should probably get definitive chemoradiotherapy. Others would disagree because there really are not a lot of data with that.

Other soft points are bulky nodes, and that can be defined as either greater than 2 cm or greater than 3 cm. I look anatomically if they’re sitting on the pulmonary artery, those big nodes, and they may need a pneumonectomy, but then I would probably not operate on them.

One other thing would be extracapsular spread. I would say that the most conservative people—if they have multistation N2 disease, bulky lymphadenopathy and/or extracapsular spread in those mediastinal nodes—would probably not involve surgery. Certainly, single-station N2 disease without bulky nodes could be considered for up-front chemotherapy radiation with a lower dose of radiation. Typically, I like to ensure the mediastinum has been sterilized. I particularly don’t like operating on it when the mediastinum is still involved. I think they should continue radiation without interruption and not go for a surgical resection. But in an isolated case of minimal disease—including PET [positron emission tomography] and potentially a repeat EBUS [endobronchial ultrasound]—although we know the results from repeat EBUS aren’t as good as regular EBUS, I would consider that group for surgical resection.

Benjamin P. Levy, MD: Lon, any comments on that and repeating EBUS? Do you get these referrals? This is a contentious issue—sterilizing the mediastinum. Do we need to make sure that’s sterilized before surgery? Is this something that you, as an interventional pulmonologist, get involved in?

Lonny Brett Yarmus, DO: We do. As Mickey said, the EBUS restaging literature certainly has a lower overall tissue acquisition ­­­­yield rate. The minimally invasive component of the procedure, and a pretty high rate of achieving a diagnosis, warrants it to be a reasonable first step toward these patients before a more invasive testing.

Benjamin P. Levy, MD: The patient has gone through the journey, tissue procurement, pathological assessment, a surgical evaluation. They’re seeing the radiation oncologist, and then of course the medical oncologist becomes very much involved in this case as well. Isabel, do you want to talk a little bit about a fit patient with stage III who’s going to get concurrent chemoradiation? Can you talk about chemotherapy, your options, and what you use for chemotherapy in a patient with stage III?

Isabel Preeshagul, DO, MBS: Sure. Thank you, Ben. The main things that I think about are obviously underlying histology, performance status of the patient, and underlying medical comorbidities. While there are many NCCN [National Comprehensive Cancer Network] Guideline–approved agents that we can use, 1 size does not fit all. Something that I found myself using more commonly would be a weekly carbo-taxol [carboplatin-paclitaxel] regimen in partnership with my radiation oncology colleagues, Anshu.

One thing that I like about a weekly carbo-taxol regimen is that it offers the opportunity for a frequent follow-up and check-in. These patients that may need hydration, may need extra TLC. They may need a nutrition consult when they didn’t initially. They may have esophagitis that may not get recognized by my radiation colleagues or may have been missed over the weekend—some complications like these. I think it allows for more frequent follow-up and more comprehensive care.

Benjamin P. Levy, MD: Yeah, I would agree. I think that we can move, and we’ll talk about the PACIFIC trial in a second, the data that have changed practice for stage III. I was brought up in a world where you used cisplatin always for curative intent patients. I still sometimes try to do that. If you look at the NCCN Guidelines, we try cisplatin for a very fit patient. But I’d say the majority of the time, we’ve been defaulting to carbo-taxol. Default is probably the wrong word. But it’s a well-tolerated regimen. As you said, it can certainly allow for an opportunity to check in on patients at a weekly interval.

I’ve been using cisplatin-pemetrexed for my adenocarcinoma patients. The standard is still, if you want to be an academic purist, cisplatin-etoposide, the SWOG regimen. That is not an easy regimen to give for patients with stage III, especially when you’re thinking about what you’re going to give these patients on the back end.

Transcript edited for clarity.
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