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Non-small Cell Lung Cancer > Background and treatment recommendations > Flashcards

Background and treatment recommendations Flashcards

1
Q

Overall paradigm of T stage

A

T stage is by tumor size OR extent of invasion, whichever resulst in higher stage

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2
Q

T1a tumors

A

< 2 cm

No invasion of mainstem bronchus, visceral pleura and no atelectasis

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3
Q

T1b tumors

A

More than 2 cm but 3 cm or less in size

No invasion of mainstem bronchus, visceral pleura and no atelectasis

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4
Q

T2a tumors

A

Greater than 3 cm but not more than 5 cm

or

tumors that invade the visceral pleura, mainstem bronchus > 2 cm distal to the carina, or that are associated with atlectasis or pneumonitis that does not involve the entire lung

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5
Q

T2b tumors

A

Tumors that are more than 5 cm but 7 cm or less in size

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6
Q

T3 tumors

A

Tumors more than 7 cm

or

tumors that invade

  • Parietal pleura
  • Chest wall
  • Diaphragm
  • Phrenic nerve
  • Mediastinal pleura
  • Parietal pericardium
  • Main bronchus w/in 2cm from carina (but not involving carina)
  • A/w atelectasis or pneumonitis involving entire lung
  • Separate tumor nodule in same lobe
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7
Q

T4 tumors

A

Any size tumor that invades:

Mediastinum
Heart
Great vessels
Tracheda
Recurrent laryngeal nerve
Esophagus
Vertebral body
Carina
Separate tumor nodule in different ipsilateral lobe

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8
Q

N1

A

Ipsilateral peribronchial and/or hilar nodes, intrapulmonary nodes

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9
Q

N2

A

Ipsilateral mediastinal and/or subcarinal nodes

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10
Q

N3

A

Contralateral mediastinal or hilar adenopathy

Ipsilateral or contralateral scalene or supraclavicular nodes

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11
Q

Stage IA

A

T1a or T1b N0

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12
Q

Stage IB

A

T2a N0

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13
Q

Stage IIA

A

T2b N0
T1 N1
T2a N1

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14
Q

Stage IIB

A

T2b N1
T3 N0

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15
Q

Stage IIIA

A

T3 N1

T1-3 N2

T4 N0-1

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16
Q

Stage IIIB

A

N3 or T4 N2

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17
Q

What images are needed to complete work up of NSCLC?

A
  1. Diagnostic CT scan of the chest and upper abdomen (adrenals)
  2. MR of brain if Stage IIB or higher
  3. PET/CT scan
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18
Q

What counseling should be offered before treatment?

A
  1. Smoking cessation counseling
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19
Q

What nodes do we cover with RT?

A
  1. Nodes > 1 cm on CT
  2. PET positive nodes
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20
Q

What is the optimal concurrent chemotherapy regimen?

A

Cisplatin and etoposide given every 3 weeks.

50 mg/m2 for both.

Cisplatin is given days 1 and 8

Etoposide is given days 1-5

Give 2 cycles during and 2 cycles after completion of RT

21
Q

What are the indications for PORT?

A

CTV

  1. Bronchial Stump
  2. Ipsilateral hilum node region and extension to mediastinal pleura adjacent to resected tumor bed
  3. Mediastinal nodes between 2 positive nodal stations
  4. Subcarinal (LN7) and ipsilateral paratracheal nodes (LN4) are always included
  5. Left sided always include subaortic and para-aortic nodes (LN 5/6)
  6. Next nodal station superior and inferior to positive station is included
  7. Ipsilateral supraclavicular region will NOT be included in the CTV
  8. Only SURGICALLY POSITIVE nodes included ( no PET +nodes ).

PTV

  1. 5 mm
22
Q

What PFT values make someone eligible for a lobectomy?

A
  1. FEV1 > 75% or 1.2 L
  2. Predicted Post-op FEV1 of atleast 1 L
  3. DLCO > 60%
23
Q

CT simulation

A
  1. Arms up
  2. Supine
  3. Indexed bag
  4. 4D scan
  5. IV contrast scan
  6. Fuse PET/CT scan
24
Q

Preoperative CRT dose?

A

45 Gy at 1.8 Gy/fx

25
Q

What is the dose for definitive RT with concurrent chemotherapy?

A
  1. GTV Gross visible tumor and any bx proven node, PET positive nodes, and nodes > 1 cm
  2. ITV using the 4D scan
  3. CTV = GTV + 7 mm
  4. PTV = CTV + 5 mm
26
Q

What tumors are unresectable?

A

T4, Multistation N2, N3

27
Q

What tumors are resectable?

A

Stage I, II, T3 N1 and Single station N2

28
Q

What study supports neoadjuvant CRT for Stage III disease?

A

INT 0139

T1-3 N2 NSCLC

  1. Cis/etoposide + RT to 45 Gy + surgery
  2. Cis/etoposide + RT to 61 Gy

Both arms get consolidation chemo

No difference in OS

Sllight improvement in PFS, 23 vs. 22 months

Subgroup getting loectomy did better with surgery: 34 vs. 22 Months

Subgroup getting pneumonectomy did better with RT: 19 vs. 29 months

29
Q

What trial supports Concurrent chemoRT vs. InductionCRT?

A

RTOG 9410

  1. Induction chemo followed by RT
  2. Concurrent chemo plus daily RT
  3. Concurrent chemo plus BID RT

OS was better with concurrent chemotherapy

No benefit with hyperfractionation

30
Q

What dose constraint does the NCCN recommend for the heart?

A
  1. V40 < 80%
  2. V45 < 60%
  3. V60 < 30%
  4. Mean heart dose < 35 Gy
31
Q

What dose constraint does the NCCN recommend for the brachial plexus?

A
  1. Max dose < 66 Gy
32
Q

What does constrain does the NCCN recommend for the Spinal cord?

A
  1. Dmax < 50 Gy
33
Q

What does the NCCN recommend for esophageal dose constraints?

A
  1. Mean dose < 34 Gy
  2. Max dose < 105% of Rx dose?
34
Q

What dose constrains does the NCCN recommend for the lung?

A
  1. V20 < 30%
  2. V < 70%
  3. MLD < 20 Gy
35
Q

What older study established 60 Gy at the standard dose of RT?

36
Q

What study suggested that there is no benefit to dose escalation with concurrent RT?

A

RTOG 0617

  1. RT to 60 Gy with carbotaxol +/- cetuximab
  2. RT to 74 Gy +/- carbotaxol +/- cetuximab

All received consolidative chemo (carbotaxol x 2 cycles)

1 OS trended for being worse amonst patients recieveing 74 Gy, HR 1.45, p=0.07

37
Q

What study rejects ENI for NSCLC?

A

Rosenzweig et al

Isolated failure in untreated thoracic LNs is 8%

38
Q

What special studies are needed at work up?

A

Bronchscopy with EBUS and transbronchial US guide biopsy

PFTs

39
Q

Spinal cord constraint for 5 fraction SBRT?

40
Q

Esophageal constraint for SBRT given in 5 fractions?

41
Q

Brachial plexus constraint for SBRT given in 5 fractions?

42
Q

Heart/pericardium constraint for SBRT given in 5 fractions?

43
Q

Great vessel constraint for SBRT given in 5 fractions?

44
Q

Rib constraint for SBRT given in 5 fractions?

45
Q

Trachea and proximal bronchi constraint for SBRT given in 5 fractions?

46
Q

Skin constraint for SBRT given in 5 fractions?

47
Q

Stomach constraint for SBRT given in 5 fractions?

48
Q

Treatment for central Stage I-II NSCLC that is inoperable?

A

74 Gy at 2 Gy/fx

No chemo

or

60 Gy in 10 fractions

Non-small Cell Lung Cancer (1 decks)

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