14.THE CHALLENGE OF DOSE ESCA­LATION FOR NON-SMALL CELLLUNG CANCER (NSCLC):A PARADOXAL ISSUE

Van Houtte P., Roelandts M., Mahin C.

Institut Jules Bordet, Brussels, Belgium

The loco-regional control of NSCLCremains a major challenge but it is arequirement for cure: classical radiationschedule delivering dose in the range of60 to 65 Gy yield a very poor local control(less than 20%). Recent trials have clearlydemonstrate that it was possible toimprove the local control and this translatein a clear survival benefit. This wasobserved with accelerated hyperfra­ctionated radiation (CHART and HART)but also with concurrent chemo-radiothe­rapy approach (Furuse, Schaake-Koningtrials). The recent major technologicaldevelopment both in treatment planningand radiation delivery has opened the roadto look for an escalation in the totalradiation dose far above the past thresholddose of 65 Gy. What have we learned fromthe current experience? It is possible to goabove this limit of 65 Gy but dosesescalation is often limited by the toleranceof normal tissues especially the amount ofirradiated normal lung. To overcome thisrestriction, the current philosophy is totreat only the gross tumor volume and toavoid any elective nodal irradiation. Thisimplies to have a good mediastinal eva­luation (PET is particularly useful). Indeed,nodal failures are reported to be a rareevent while controlling the primary tumorremains the challenge. Doses as high as90 Gy can be delivered but there is aparadoxal issue: this is often only possiblefor small tumors probably not requiring thishigh dose while larger tumors can not betreated to this level. The second problemis the issue of repopulation: increasingtreatment duration by only using daily 2 Gyper fraction will certainly not be aseffective as expected: the only solution iseither using an hyperfractionating sche­dule or higher daily dose (concomitantboost technique). Additional studies areclearly needed to see the real impact of

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this approach on a large population scaleand not only to very select patients able tofollow the guidelines for very complicateset-up (the different gating techniques).Furthermore, longer follow-up will beneeded to assess the possible late effectsat the level of the lung and the heart. Lastbut not least, this technique should be in anext step be part of a multimodalapproach.

15.COMBINED CHEMOTHERAPY ANDRADIATION IN LOCALLYADVANCED INOPERABLE NSCLC

Jassem J.

Medical University of Gdansk, Poland

Lung cancer is the leading cause ofcancer death around the world. Non-smallcell lung cancer (NSCLC) accounts forthree quarters of all lung tumors. Surgeryis the cornerstone of treatment in localizedNSCLC but only 20% of patients are con­sidered surgical candidates at presen­tation. The vast majority of patients cannotbe subjected to surgery either because oftumor advancement or poor medicalcondition. Radiation therapy has tradi­tionally been considered the mainstay oftreatment in inoperable stage III disease.Irradiation, however, is in principle used forpalliation since in most instances thismethod does not allow for eradication ofbulky disease in the thorax. Moreover,radiotherapy does not prevent uncontrolledsystemic disease, which is the majorcause of death in locally advancedNSCLC. In consequence, the prognosis ofpatients with locally advanced tumours isdismal and has remained essentiallyunchanged within the last decades. Thefive-year survival rates after irradiationvary between 3 and 6%. One of theattempts to improve the outcome iscombining radiation with chemotherapy.This strategy seems to be particularlyinteresting as it may potentially increasethe cure rate not only by improvedlocoregional tumour control but also byelimination of micrometastases outside theradiotherapy field. Chemotherapy andradiation may be applied in sequence or

Rep. Pract. Oncol. Radiother. 8 (S1) 2003

concurrently. The results of phase III trialsof radiation alone vs combined therapyusing platinum based regimens demon­strated some survival benefit. The positiveimpact of chemotherapy was also demon­strated in the metaanalysis. Of the twostrategies (chemotherapy followed byradiotherapy or concurrent chemoradio­therapy, the latter was found to be superiorto sequential application but at theexpense of increased early toxicity. Thevalue of new agents (taxanes, vinorelbine,gemcitabine and topoisomerase inhibitors)in combined modality therapy of NSCLCseems to be promising, but warrantsfurther clinical evaluation. In conclusion,chemotherapy may be useful as anadjunct to radiation in locally advancedNSCLC. However, the benefit of combinedapproach, in particular concomitant che­moradiation, should be balanced againstincreased toxicity.

16.WYNIKI BADAN KlINICZNYCH- ROZWAZANIA, WJ\TPLIWOSCI

Hliniak A.

Centrum Onkologii - InstytutWarszawa-Ursyn6w

W latach 2000-2002 ogtosilismy (A. Hli­niak i wsp6tp.) trzy opracowania dotyczqceradioterapii raka krtani (1. RadiotherapyOncology 62 2002-1-10; 2. Nowotwory 52(2002) Nr 2 -111; 3. Nowotwory 51 (2001­4-381 ).Cel badania - rozwazania i wqtpliwoscilekarza dotyczqce wniosk6w wynikajqcychz tych doniesien1. "Skr6cenie ,catkowitego ,czasu leczenia

o 7 dni nie wptyn~o na popraw~ wy­nik6w leczenia w spos6b istotny sta­tystycznie (p-0.37).Uwagi - w pierwszych miesiqcachpo leczeniu niepewna ocena wylecze­nia (obrz~k, stan zapalny, zmiany mar­twicze) - zwtaszcza w badaniach wie­loosrodkowych (r6zne doswiadczenieoceniajqcych). Wyniki leczenia stajqsi~ wiarygodne po 8-12 miesiqcachod zakonczenia terapii.

2. Chorzy leczeni wyzszymi dawkamirokujq gorzej. Potwierdzajq to uwagi

Rep. Praet. Oneol. Radiother. 8 (52) 2003

szeregu autor6w (Batani, Szutkowskietc.), ze wyzsze dawki stosuje si~

u chorych gorzej rokujqcych z wqtpliwqregresjq guza. Podanie wyzszychdawek tqczy si~ z wydtuzeniem catko­witego czasu leczenia. Moze to w spo­s6b istotny wptynqc na bt~dnq ocen~

zaleznosci dawka czas i duzq r6znic~

w ocenie tego czynnika w opracowa­niach retrospektywnych (Fowler).

3. Wyniki u chorych leczonych konwen­cjonalnie w badaniu prospektywnym Sqlepsze 0 15% niz w retrospektywnym(nadselekcja chorych?)

1, 2, 3. Stromy przebieg krzywych wyle­czalnosci w pierwszych 8-12 miesiqcachpo zakonczeniu radioterapii moze prowa­dzic do zbyt optymistycznych ocen nowychmetod leczenia, r6wniez kojarzonego(RT+chth?).

17.ESTRO IN TIMES OF CHOLERA

Heeren G..

Project Development and Public Relations,ESTRO Office, Ave E.Mounierlaan 83,1.200 Brussels

In the past five years ESTRO has knowna period of dynamic development.Membership figures show a steep growthcurve. ESTRO meetings grew in size andquality. The offer of teaching coursesnearly doubled. The citation index andnumber of papers submitted to the greenjournal went up dramatically. In a singleyear all 4 of the applications for EU sup­port submitted to the European Commi­ssion were funded. ESTRO extended itscooperatIon networks far beyond the ownspecialty: seeking strategic alliances withinternational organisations (such as IAEA),the EU and estranged family memberssuch as radiology, nuclear medicine andbasic science. Building on a broad basis ofactive members, the Society felt com­fortable in a leading position within theFederation of European Cancer Societies.ESTRO was also successful in setting upEuropean infrastructures for verifying theaccuracy of dosimetry in Europeanradiotherapy departments and assuringthe quality of radiotherapy trials.

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