ESTRO 2024 Congress report

On the Sunday morning of the ESTRO Congress, I anticipated a routine meeting of the multidisciplinary tumour board (MDT), but what unfolded was anything but ordinary. Chaired by Dr Ursula Nestle, the session featured a distinguished panel that included clinical oncologist Krzysztof Konopa, medical oncologist Nicola Steele, and cardiothoracic surgeon Rocco Bilancia, who set the stage for a lively and engaging debate.

The first case, which involved a 60-year-old woman with stage 3 lung adenocarcinoma, seemed routine at first glance. However, the debate over whether to stage through the use of endobronchial ultrasound (EBUS) versus sole reliance on positron emission tomography (PET) scans quickly heated up. The need for staging via EBUS was debated in the case of obvious PET-positive mediastinal lymph nodes; however, could one be certain, considering recent evidence from the SEISMIC trial (Steinfort et al., 2024) that had been reported only weeks prior, that systematic endoscopic mediastinal staging in patients with locally advanced or unresectable non-small-cell lung cancer (NSCLC) was found to be more accurate than PET alone? In that trial, PET-occult lymph node metastases were identified in 12% of patients and contralateral PET-occult N3 disease in up to 7% of patients.

Then came the dreaded words “borderline resectable”. The low-pitch murmurs from the audience echoed the anxiety that permeated the room. Management strategies varied significantly worldwide. Some favoured upfront surgery, others leaned towards neoadjuvant chemotherapy, and the final vote revealed a preference for radical chemoradiation and adjuvant immunotherapy. Despite the large majority that held this opinion (>80%), speakers in the room acknowledged the validity of differing approaches. However, the fundamental point that was made in CheckMate 816 (Forde et al., 2022), which must not be forgotten, is patient selection. Patients who are selected for a neo-adjuvant approach are surgically resectable and not borderline resectable from the outset. This is where the fundamental problem lies.

Cardiothoracic surgery is intricate, and cases that are classified as "borderline resectable" reflect their challenging nature. Opting for a neo-adjuvant approach can put the patient at risk of harm due to the possibility of an incomplete (R1/R2) resection, which leaves the radiation oncologist with the task of addressing residual disease. This task is not relished, especially with the considerable morbidity it can entail, as evidenced by the lung adaptive radiation therapy (ART) study (Le Pechoux et al., 2022).

The second case featured a 70-year-old man with T2N2M0 adenocarcinoma and a single bulky node at 4L. Opinions regarding the best treatment diverged widely, from concurrent chemoradiation to upfront surgery, chemoimmunotherapy followed by surgery, and various radiotherapy treatments. Suggestions even included the use of stereotactic ablative radiotherapy (SABR) on the primary tumour and conventional radiotherapy on the nodes, or SABR on both areas. This led the panel to question the evidence that supported the use of these varied strategies, only to find there was none. By the session's end, confusion prevailed. The vote showed that a slim majority (40%) favoured neoadjuvant chemoimmunotherapy followed by surgery, but the real-world outcome, a complex R2 resection and anaplastic lymphoma kinase (ALK)-positive disease, sparked further debate regarding adjuvant therapy. The decision-making complexities were on full display, highlighting the intricacies of stage-3 lung cancer treatment.

This session epitomised the MDT's role in navigating these complexities. The chair and panel masterfully showcased the spectrum of global opinions and practices. Each patient is unique, and every treatment decision requires careful consideration of all pertaining factors. Engaging discussions must be held among surgical, medical, and radiation oncologists, as evidenced by this thought-provoking session. The evolving landscape of stage-3 lung cancer treatment promises many such lively discussions in the future. My first MDT session at ESTRO was a whirlwind of insights and debates, and I suspect it will not be my last.

 

Dr Suraiya R Dubash

MBBS, BSc, MRCP, FRCR, PhD

Consultant in clinical oncology

Mount Vernon Cancer Centre

Middlesex, UK

ESTRO lung focus group

suraiya.dubash@nhs.net

@SRDubash