Pancoast tumor medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mazia Fatima, MBBS [2]
Overveiw
The optimal management approach of Pancoast tumor depends on a series of characteristics, that include pre-treatment evaluation, location, and adequate staging. Common treatment options for management include radiation therapy alone, radiation therapy and surgery, concurrent chemotherapy with radiation therapy and surgery, surgery alone (for selected patients).
Management Approach
The optimal management approach of Pancoast tumor depends on a series of characteristics, that include pre-treatment evaluation, location, and adequate staging. Common treatment options for management include:[1][2][3][4][5]
- Radiation therapy alone
- Radiation therapy and surgery
- Concurrent chemotherapy with radiation therapy and surgery
- Surgery alone (for selected patients)
The treatment of Pancoast tumor may differ to that of other types of non-small cell lung cancer due to its position and close proximity to vital structures (such as nerves and spine) which may make surgery difficult to be undertaken. As a result, and depending on the stage of the cancer, treatment may often involve radiation and chemotherapy given pre-operatively (neoadjuvant treatment) prior to surgery.
Medical Therapy
Chemotherapeutic regimens are based on platinum agents such as cisplatin, carboplatin, oxaliplatin, and satraplatin. Alternative regimens include paclitaxel, gemcitabine, or etoposide. Chemotherapeutic regimens are adjusted based on individual characteristics and body surface. The regimen adjustment according to tumor evolution has demonstrated longer survival rates, optimal symptom control, and higher quality of life.
Chemotherapeutic Regimens
- Pancoast tumor is a subtype of lung cancer located at the lung apex.
- Chemotherapeutic regimens are based on platinum agents such as cisplatin, carboplatin, oxaliplatin, and satraplatin. Alternative regimens include paclitaxel, gemcitabine, or etoposide.
- Chemotherapeutic regimens are adjusted based on individual characteristics and body surface. The regimen adjustment according to tumor evolution has demonstrated longer survival rates, optimal symptom control, and higher quality of life.
- Shown below is a table depicting the different choices of regimens for the initial or adjuvant chemotherapy of patients with Panocast tumor. The list of regimens has been adapted from the 2014 NCCN lung cancer guidelines.[6][7]
Cisplatin Based Therapy
| Agent | Recommended regimen |
|---|---|
| Cisplatin 50 mg/m2 + vinorelbine 25 mg/m2 | Cisplatin on days 1 and 8, vinorelbine on days 1, 8, 15, 22, and every 28 days to a total of 4 cycles |
| Cisplatin 100 mg/m2 + vinorelbine 30 mg/m2 | Cisplatin on day 1, vinorelbine on days 1, 8, 15, 22, and every 28 days to a total of 4 cycles |
| Cisplatin 75-80 mg/m2 + vinorelbine 25-50 mg/m2 | Cisplatin on day 1, vinorelbine on days 1, 8, and every 21 days to a total of 4 cycles |
| Cisplatin 80 mg/m2 + vinorelbine 4 mg/m2 | Cisplatin on days 1, 22, 43, 64, then every 21 days to a total of 4 cycles, vinorelbine on days 1, 8, 15, 22, 29, every 2 weeks after day 43 until the completion of cisplatin treatment |
| Cisplatin 100 mg/m2 + etoposide 100 mg/m2 | Cisplatin on day 1, etoposide through days 1 to 3 and every 28 days to a total of 4 cycles |
| Cisplatin 75 mg/m2 + gemcitabine 1250 mg/m2 | Cisplatin on day 1, gemcitabine on days 1, 8, and every 21 days to a total of 4 cycles |
| Cisplatin 75 mg/m2 + docetaxel 75 mg/m2 | Cisplatin on day 1, docetaxel on day 1 and every 21 days to a total of 4 cycles |
| Cisplatin 50 mg/m2 + pemetrexed 500 mg/m2 | Cisplatin on day 1, pemetrexed on days 1 and every 21 days to a total of 4 cycles |
Alternative Regimen
Paclitaxel 200 mg/m2 on day 1 + carboplatin area under the concentration (AUC) 6 on day 1 and then every 21 days.[7]
Chemotherapy with Radiation Therapy Regimens
Chemotherapy plus Radiation Therapy
The list below show the options for concomitant chemotherapy plus radiation therapy based on the 2014 NCCN lung cancer guidelines.[7]
- Cisplatin 50 mg/m2 on days 1, 8, 29, and 36 + etoposide 50 mg/m2 through days 1 to 5 and then 29 to 33 + thoracic radiation therapy
- Cisplatin 100 mg/m2 on days 1 and 29 + vinblastine 5 mg/m2 weekly for 5 weeks + thoracic radiation therapy
- Cisplatin 75 mg/m2 on the first day + pemetrexed 500 mg/m2 on day 1 and then every 21 days to a total of 3 cycles + thoracic radiation therapy
- Carboplatin AUC 5 on the first day + pemetrexed 500 mg/m2 on day 1 and then every 21 days to a total of 3 cycles + thoracic radiation therapy
Chemotherapy Followed by Radiation Therapy
The list below show the options for chemotherapy followed by radiation therapy based on the 2014 NCCN lung cancer guidelines.[7]
- Cisplatin 100 mg/m2 on days 1 and 29 + vinblastine 5 mg/m2 per week on days 1, 8, 15, 22, and 29 followed by thoracic radiation therapy.
- Paclitaxel 200 mg/m2 administered for 3 hours in the first day + carboplatin AUC 6 administered in 1 hour and then every 21 days to a total of 2 cycles followed by thoracic radiation therapy.
Chemotherapy plus Radiation Therapy, Followed by Chemotherapy
The list below show the options for concomitant chemotherapy plus radiation therapy followed by chemotherapy based on the 2014 NCCN lung cancer guidelines.[7]
- Cisplatin 50 mg/m2 on days 1, 8, 29, and 36 + etoposide 50 mg/m2 through day 1 to 5 and then 29 to 33 + thoracic radiation therapy, then followed by cisplatin 50 mg/m2 + etoposide 50 mg/m2 to a total of 2 cycles.
- Paclitaxel 45 to 50 mg/m2 once a week + carboplatin AUC 2 + thoracic radiation therapy, then followed by Paclitaxel 200 mg/m2 + carboplatin AUC 6 to a total of 2 cycles.
Radiation therapy can be applied to any stage of non-small cell lung cancer. In general, radiation therapy is recommended as palliative care treatment among patients who develop an advanced stage of non-small cell lung cancer or symptomatic patients with local involvement (pain, vocal cord paralysis, and hemoptysis). Curative radiation therapy may be indicated in patients who are not suitable for surgery with early-stage non-small cell lung cancer. The main goal of radiation therapy for non-small cell lung cancer is maximum tumor control with minimal tissue toxicity. The two main types of radiation therapy for non-small cell lung cancer are external beam radiation therapy (thoracic radiotherapy), and brachytherapy (internal radiation therapy).
Radiation Therapy
Radiation Therapy Regimens
- Pancoast tumor, a subtype of lung cancer located at the lung apex. Shown below is a list of the different regimens radiation therapy for patients with Pancoast tumor. The list of regimens has been adapted from the 2014 NCCN lung cancer guidelines.[8][7]
Usual Dosages for Definitive Radiation Therapy
Administer fractions of 2 Gy over a period of 6 to 7.5 weeks to a total dose of 60 to 74 Gy
Neoadjuvant Radiation Therapy Regimen
Administer fractions of 1.8 to 2 Gy over a period of 5 weeks to a total dose of 45 to 50 Gy
Adjuvant Radiation Therapy Regimens
- Negative surgical piece margins: Administer fractions of 1.8 to 2 Gy over a period of 5 to 6 weeks to a total dose of 40 to 54 Gy
- Positive surgical piece margins: Administer fractions of 1.8 to 2 Gy over a period of 6 weeks to a total dose of 54 to 60 Gy
- Extracapsular nodal extension: Administer fractions of 1.8 to 2 Gy over a period of 6 weeks to a total dose of 60 to 70 Gy
- Residual tumor: Administer fractions of 2 Gy over a period of 6 to 7 weeks to a total dose of 54 to 60 Gy
Stereotactic Ablative Radiotherapy Usual Dosage
- Peripheral small tumors: 25 to 34 Gy not fractioned.
- Peripheral tumors and chest wall tumors larger than 1 cm: 45 to 60 Gy administered in 3 fractions
- Central or peripheral tumors smaller than 5 cm: 48 to 60 Gy administered in 4 fractions
- Central or peripheral tumors principally chest wall tumors smaller that 1 cm: 50 to 55 Gy administered in 5 fractions
- Central tumors: 60 to 70 Gy administered in 8 to 10 fractions
Palliative Radiation Therapy Regimens
Listed below are the recommended palliative radiation therapy regimens for patients with lung cancer according to the 2014 NCCN lung cancer guidelines.[7]
- Administer fractions of 3 Gy over a period of 2 to 3 weeks to a total dose of 30 to 45 Gy
- Bone metastases associated with soft tissue mass
- Administer fractions of 4 to 3 Gy over a period of 1 to 2 weeks to a total dose of 20 to 30 Gy
- Bone metastases not associated with soft tissue mass
- Administer fractions of 8 to 3 Gy over a period of 1 to 14 days to a total dose of 8 to 30 Gy
- Patients with poor performance status and symptomatic chest disease
- Administer fractions of 8.5 Gy over a period of 7 to 14 days to a total dose of 17 Gy
- Metastatic disease in patients who have a poor performance status:
- Administer fractions of 8 to 4 Gy over a period of 1 to 7 days to a total dose of 8 to 20 Gy
- Whole brain radiation therapy regimens for metastases to the brain, include the following:
- 10 fractions of 3 Gy each to a total of 30 Gy
- 15 fractions of 2.5 Gy each to a total of 37.5 Gy
- 5 fractions of 4 Gy each to a total of 20 Gy. Good option for patients with poor performance status.
References
- ↑ Davis GA, Knight SR (October 2008). "Pancoast tumors". Neurosurg. Clin. N. Am. 19 (4): 545–57, v–vi. doi:10.1016/j.nec.2008.07.002. PMID 19010280.
- ↑ Rosso L, Palleschi A, Mendogni P, Nosotti M (April 2016). "Video-assisted pulmonary lobectomy combined with transmanubrial approach for anterior Pancoast tumor resection: case report". J Cardiothorac Surg. 11 (1): 65. doi:10.1186/s13019-016-0446-7. PMC 4831106. PMID 27079507.
- ↑ Caronia FP, Fiorelli A, Ruffini E, Nicolosi M, Santini M, Lo Monte AI (September 2014). "A comparative analysis of Pancoast tumour resection performed via video-assisted thoracic surgery versus standard open approaches". Interact Cardiovasc Thorac Surg. 19 (3): 426–35. doi:10.1093/icvts/ivu115. PMID 25052071.
- ↑ Hubbard MO, Schroeder C, Linden PA (April 2011). "Routine use of staging thoracoscopy for pancoast tumors without overt radiographic chest wall invasion". Surg Laparosc Endosc Percutan Tech. 21 (2): 111–5. doi:10.1097/SLE.0b013e31821a3cb0. PMID 21471804.
- ↑ Tamura M, Hoda MA, Klepetko W (October 2009). "Current treatment paradigms of superior sulcus tumours". Eur J Cardiothorac Surg. 36 (4): 747–53. doi:10.1016/j.ejcts.2009.04.036. PMID 19699106.
- ↑ Alberti, W; Anderson, G; Bartolucci, A; Bell, D; et al. Chemotherapy in non-small cell lung cancer: A meta-analysis using updated data on individual patients from 52 randomised clinical trials. British Medical Journal, International edition311.7010 (Oct 7, 1995): 899
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf
- ↑ Pattern of use of radiotherapy for lung cancer: a descriptive study. BioMed Central. http://bmccancer.biomedcentral.com/articles/10.1186/1471-2407-14-697#CR6 Accessed on March 1, 2016