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Advancing
Research for Lung Cancer Treatment at the University of Maryland Marlene and Stewart Greenebaum Cancer Center
Cover Feature
Advancing Research for
Lung Cancer Treatment
Dr. Battafarano, Dr. Edelman and Dr. Feigenberg
A
t UMGCC, a multidisciplinary approach is used
when treating lung cancer. No matter what stage of disease, patients cannot only count on receiving comprehensive care from physicians in a variety of specialties, including radiology, thoracic surgery and medical oncology, but also participating in one of many ongoing clinical trials when appropriate. UMGCC is designated by the National Cancer Institute, verifying its status as one of the top cancer treatment centers in the country. Currently, several research studies that have been developed by thoracic oncologists at UMGCC are undergoing nationwide clinical trials. “The Thoracic Oncology Program at UMGCC is one of the top research programs in the country that is currently conducting ongoing clinical research,” says Kevin Cullen, M.D., Director of UMGCC and professor of medicine at the University of Maryland School of Medicine. “We are very active in a number of national clinical trial organizations, and there have been several instances in which research developed and piloted through our Thoracic Oncology Program has been adopted for nationwide clinical studies.”
Current Research in Thoracic Oncology In terms of thoracic oncology, UMGCC is leading the way with several new advances in lung cancer treatment. One physician — Martin Edelman, M.D., Director of Solid Tumor Oncology at UMGCC and professor of medicine at the University of Maryland School of Medicine — recently received the honor of presenting two new research abstracts in the plenary session of the American Society of Oncology annual meeting in June 2010. “In the last few years, we have made significant advances in localized, locally advanced and advanced nonsmall cell lung cancer,” says Dr. Edelman. “In patients with advanced disease, several striking developments have been made, including the identification of several gene mutations that are present in predominately never-smokers.”
Lung cancer in never-smokers is the sixth most common cancer in the United States and is as common as ovarian cancer. By targeting specific gene mutations, best practices for treatment can be more readily identified. For patients who present with epidermal growth factor receptor (EGFR) translocation mutations, research is currently ongoing to determine whether erlotinib alone or in combination with carboplatin/paclitaxel will be most effective in treating advanced non-small cell lung cancer in never smokers. The use of Crizotinib (PF-02341066) for younger patients with advanced disease who were also never smokers is being clinically evaluated for the treatment of lung cancer caused by an EM4L-ALK translocation mutation. For patients with localized disease — who previously only underwent surgery and then ran a risk of probable cancer recurrence — UMGCC has found that patients who receive adjuvant chemotherapy can have an increased cure rate of 10% to 15%, which could lead to a 65% cure rate in some patients. Also, for 30% to 45% of patients who have locally advanced disease — involvement of lymph nodes in the chest and/or medial spine disease in addition to lung metastases — adjuvant chemotherapy, in addition to typical radiation treatment, can help to cure 20% to 30% of patients. One of the recent studies that was presented by Dr. Edelman focused on the lack of treatment that was provided for lung cancer patients over the age of 65. Typically, only one-third of these patients receive any kind of treatment, and most receive no treatment at all. However, recent research is proving that fit elderly patients can benefit from chemotherapy as much as younger patients. While most elderly patients who received treatment were receiving a single agent, it has been discovered that a platinum-based, two-agent chemotherapy drug is more effective than single-agent chemotherapy in elderly patients who have lung cancer. Even though this fact has been known for some time, the median age of patients who have been tested was 62.
Photos by Ryan Kalivretenos
The University of Maryland Marlene and Stewart Greenebaum Cancer Center (UMGCC), located in Baltimore, MD, is revolutionizing lung cancer treatment by conducting and applying research from all applicable medical disciplines, including radiology, medical oncology and thoracic surgery.
However, this study, which is based on a French study whose median patient age was 75, is proving that elderly patients can benefit from a two-drug chemotherapy regimen. A vaccine study, which hopes to reduce the high rate of recurrence in patients with early-stage disease, will also be available soon.
Surgical Advances New techniques that preserve lung tissue and yet still remove the necessary portion of diseased tissue are at the forefront of thoracic surgery developments. At UMGCC, video-assisted, minimally invasive techniques are being used on patients who are undergoing complex surgeries, such as a lobectomy. Extended lobectomy, lingula-sparing lobectomy, left upper lobectomy and sleeve right upper lobectomy — where a portion of the bronchus is actually excised with the upper lobe specimen and then the remaining lower lobe bronchus is reattached to the proximal main bronchus in an effort to ensure that the lung is not completely removed — are all available. There are also instances where surgeons can remove a portion of the pulmonary artery along with the lung cancer and then sew the remaining portions of the artery back together in an effort to save the lung, avoiding a pneumonectomy. “Parenchymal-saving techniques are currently used at UMGCC more frequently than at most other cancer centers,” says Richard Battafarano, M.D., Ph.D., Chief of the Division of Thoracic Surgery and associate professor of medicine at the Dr. Battafarano in operating room
Dr. Cullen and Dr. Edelman
Cover Feature
C atc h i n g Dis e as e at E ar ly Stag es Sometimes, when patients have CT scans performed, small
nodules are found in the lung that need to be monitored. While not all of these nodules require treatment or biopsy, for patients who have risk factors for lung cancer, including age, smoking history or family or personal history of the disease, excisional biopsy may be in the patient’s best interest. All patients who are found to have nodules in their CT scans can be referred to UMGCC’s Lung Nodule Clinic. At this clinic — where a multidisciplinary team of chest radiologists, pulmonologists and thoracic surgeons meet with patients every week to discuss the nodules — physicians will decide whether it is sufficient to follow the nodule over time, or whether an excisional biopsy will be necessary to ensure that if disease is present it can be treated in its earliest stages.
University of Maryland School of Medicine. “Allowing patients to keep as much of their lung as possible is of the upmost importance, and we have been at the forefront of lung-saving thoracic surgical techniques.”
Recent Research and Advances Pertaining to Radiology For patients who are not surgical candidates, UMGCC provides stereotactic body radiotherapy (SBRT), which is not only equivalent to traditional radiation therapy in terms of treatment outcomes, but also reduces the risk of side effects and lowers the toxicity levels that can occur from long-term radiation exposure. Using SBRT, patients have three to four treatments over the course of one week rather than daily treatments for seven weeks, which was typical with traditional radiation therapies. Current studies are also being carried out to measure the effectiveness of SBRT in patients who are also surgical candidates. To ensure that SBRT is safe and effective for patients, UMGCC uses CT imaging to guide the radiation therapy. Because lung tumors move when patients breathe, a simulation CT scan is conducted prior to the beginning of SBRT. During the CT scan patients are directed to hold their breath while the CT image of the diseased lung is taken. Then, using 4-D technology, simulation is constructed so physicians can track the movement that occurs while the patient breathes, ensuring that the dose is effectively targeting the necessary diseased tissue. Reprinted from Baltimore/Annapolis/Eastern Shore md news
“Prior to the use of tumor-specific motion technology, we had to create an arbitrary margin based on populations of patients who undergo the treatment,” says Steven Feigenberg, M.D., Director of Clinical/Translational Research in Radiation Oncology and associate professor at the University of Maryland School of Medicine. “By mapping each patient’s specific tumor movement, we are able to feel secure in the fact that we are hitting the tumor while decreasing the toxicity of treatment and increasing outcomes.” Currently, research is underway to determine how radiation therapy, such as SBRT, affects tissues at the molecular level, which can help physicians better understand how radiationinduced lung injury occurs. UMGCC uses a nonhuman primate lab, which is allowing physicians to characterize and establish a temporal model of radiation-induced injured lung tissue. By observing the primates prior to an injury, such as pneumonitis, and then continuing observation for several months after injury, novel compounds are being identified as mitigators and tested on nonhuman primates with radiation-induced injury. Within the next few years, it is hoped that the research will move into the trial stage, with the most promising candidates receiving treatment. “As important pathways are established and validated with respect to radiation injury and repair, targeted agents will be identified and tested and normal lung tissue injury will be minimized,” says Michael Garofalo, M.D., assistant professor in the Department of Radiation Oncology at the University of Maryland School of Medicine. “We aim to leverage the knowledge derived from our unique research environment toward improved clinical outcomes and reduced treatment side effects for our lung cancer patients.” For more information about the Thoracic Oncology Program at UMGCC, visit www.umgcc.org. n © 2010 Sunshine Media, Inc. Usage Agreement Good Through: 08/11/11