IBS13.01 Radiation Related Toxicities in Locally Advanced Non-Small Cell Lung Cancer (LA-NSCLC)

Abstract

Radical radiotherapy is used as definitive therapy in locally advanced non-small cell lung cancer (LA-NSCLC), either alone or in combination with chemotherapy and/or surgery. However, definitive doses of radiotherapy are associated with potential toxicity related to the organs at risk (OAR). The major OAR’s related to radical radiotherapy for LA-NSCLC include the lung and esophagus. Therefore, we need to be able to identify and manage radiation pneumonitis and esophagitis during and after a course of definitive radiotherapy. For good performance status, unresectable stage III NSCLC, radical radiotherapy is delivered either concurrently or sequentially with chemotherapy to total doses of 60Gy or higher. Although the best outcomes have been obtained with concurrent chemoradiotherapy, higher rates of toxicity have also been observed. With the advent of the establishment of adjuvant durvalumab after definitive concurrent chemoradiotherapy, the management of pneumonitis in particular has become even more of a challenge given the potential overlapping toxicities. For poorer performance status patients, radical radiotherapy may be used alone. For resectable patients with LA-NSCLC, radical radiotherapy can be given concurrently with chemotherapy prior to surgical resection as part of trimodality therapy. In other instances, radical radiotherapy can be given adjuvantly post-operatively for positive margins and can be considered in pathological N2 disease. Prophylactic Cranial Irradiation (PCI) has also been delivered in LA-NSCLC, although mostly in clinical trials as PCI has not been established as part of routine standard of care in stage III NSCLC. In this session, a discussion as well as case presentations will be used to illustrate how to identify and manage the above toxicities in stage III NSCLC. References (max 10) Baker S, Fairchild A. Radiation-induced esophagitis in lung cancer. Lung Cancer: Targets and Therapy 2016:7 119–127. (Review Article). Mehmood Q, Sun A, Becker N, et al. Predicting Radiation Esophagitis Using 18F-FDG PET During Chemoradiotherapy for Locally Advanced Non-Small Cell Lung Cancer. J Thorac Oncol. 2016: 1;11(2):213-21. Verma V, Simone CB, Werner-Wasik M. Acute and Late Toxicities of Concurrent Chemoradiotherapy for Locally-Advanced Non-Small Cell Lung Cancer. Cancers. 2017; 9:120. (Review Article). Jain V and Berman AT. Radiation Pneumonitis: Old Problem, New Tricks. Cancers (Basel). 2018 Jul 3; 10(7). (Review Article). Antonia SJ, Villegas A, Daniel D, et al. Overall Survival with Durvalumab after Chemoradiotherapy in Stage III NSCLC. N Engl J Med 2018; 2018 Sep 25. Shaverdian, N, Lisberg AE, Bornazyan, K et al. Previous radiotherapy and the clinical activity and toxicity of pembrolizumab in the treatment of non-small-cell lung cancer: A secondary analysis of the KEYNOTE-001 phase I trial. Lancet Oncol. 2017, 18(7), 895–903. Chuzi S, Tavora F, Cruz M, et al. Clinical features, diagnostic challenges, and management strategies in checkpoint inhibitor related pneumonitis. Cancer Manag Res. 2017;9:207-213. (Review Article). Sun A, Bae K, Gore EM, et al. Phase III trial of prophylactic cranial irradiation compared with observation in patients with locally advanced non-small-cell lung cancer: neurocognitive and quality-of-life analysis. J Clin Oncol 2011; 29: 279–86. Le Pechoux C, Sun A, Slotman BJ, et al. Prophylactic cranial irradiation for patients with lung cancer. Lancet Oncol 2016; 17(7): e277–293. (Review Article). Sun A, Hu C, Wong SJ, et al. Prophylactic Cranial Irradiation vs Observation in Patients With Locally Advanced Non-Small Cell Lung Cancer: A Long-term Update of the NRG Oncology/RTOG 0214 Phase 3 Randomized Clinical Trial. JAMA Oncol. 2019 Mar 14. Radiation Toxicity LA-NSCLC