Lung Flashcards
Lung LN Stations 2-14
LN stations:
2: upper paratracheal
3: retro tracheal/prevasc
4: lower paratracheal
5: AP window
6: paraaortic
7: subcarinal
8: paraesophageal
9: pulmonary ligament
10: hilar
11: interlobar
12: lobar
13: segmental
14: subsegmental
- picture
Lung Workup
Imaging:
- Prior chest imaging for comparison!!!
- CT chest & upper abdomen (liver, adrenals) w IV cont
- PET/CT (eval liver/adrenals)
- brain MRI (for Stage IB (consider) definite if above 1B) NSCLC, all SCLC)
Biopsy:
- Central – broch/EBUS; peripheral – CT-guided; effusion – thora
- EGFR, KRAS, ALK, ROS-1, BRAF, PD-1 for NSCLC
- mediastinal sampling for NSCLC
Other:
- PFTs
Lung Screening
Screening (USPSTF-2021): annual low dose CT for high risk (age 50-80, >20 pack year, quit <15 years ago)
When do you not need Mediastinal LN staging
Med LN staging necessary unless
peripheral solid <1cm or
non-solid <3cm that are negative on imaging
Bronch LNs
Bronch (EBUS w FNA):
- can access central primary
- LN 2, 4, 7, 10+
EUS LNs
EUS
- LN 4, 7, 8, 9
Cervical mediastinoscopy LNs
Cervical mediastinoscopy: recommend this if cannot see any nodes
- incision 1 cm above suprasternal notch
- LN 2, 4, 7, 10 – maybe
Chamberlin Procedure LNs
Chamberlin (anterior mediastinoscopy):
- incision at left 2nd intercostal space
- LN 4, 5, 6, 7
Lung Simulation
CT simulation: Supine, arms up, vac lock bag, wingboard. 4D CT with IV contrast from cricoid to L2
Iso at carina
PET/CT fusion (PET within 4 wks of treatment planning)
Use 6 MV beams in lung
If not meeting constraints (esp V20):
If not meeting constraints (esp V20):
- 3D->IMRT or Protons
- 4D planning to reduce margin
- Inspiration Breath hold
- Add non-coplanar beams
- Shrink margins (IGRT)
- Conedown or adaptive replan after 40 Gy
- Inc weighting of AP/PA vs. oblique
- Add extra beams (consider IMRT but watch V5)
- Neoadj chemo
Pneumonitis presentation and treatment
Pneumonitis:
- 6 wks to 4 months post RT
- sx: fever, dyspnea, tachycardia, and hypoxia
Grade 1: radiographic Grade 2: minor sx/steroids Grade 3: O2 Grade 4: hospitalized Grade 5: death
- Tx: Pred 1 mg/kg/day tapered over 2-3 months + Bactrim and PPI; monitor PFTs
- Diffusion capacity dec in early phase, radiographically diffuse inhomogeneous opacification in tx field
Adeno markers - 50%
periph; TTF-1, napsin; EGFR overexpress in 30%
SCC markers - 30%
SCC – central; p63, CK5/6; EGFR in 80%
Lung Ca # cases and deaths
240,000 cases
130,000 deaths
squamous cell paraneoplastic
Hypercalcemia (SCC)
medical operability
PFTs:
FEV1 and DLCO predicted post op: >40%
FEV1/FVC>75%,
DLCO>40% (post-op), >80% pre-op,
FEV1>1.2L (lobectomy) or 2L (pneumonectomy), post-op 0.8
-no severe pulm HTN, end-organ damage, severe vascular disease, severe chronic cardiac dz
Most common involved LN NSCLC
level 4(R/L) except LUL: 5, 6
Lung TNM Staging
T1a: up to 1 cm
T1b: > 1 – 2 cm
T1c: > 2 – 3 cm
T2a: 3.1 – 4 cm T2b: 4.1 – 5 cm -or mainstem bronchus, not carina -visceral pleura -atelectasis, obstructive pneumonitis to hilar region
T3: >5 – 7 cm
- separate nodule in same lobe
- chest wall, phrenic nerve, pericardium, parietal pleura
T4: >7cm
- mediastinum, heart, great vessels, carina, trachea, spine, esophagus, recurrent laryngeal, diaphragm
- separate nodule in different I/L lobe
N1: hilar
N2: ipsi mediastinal
N3: contralat med, supraclav
M1a: sep nodule in contralat lobe, pleur/pericard nodules, pleural effusion
M1b: single extrathoracic metastasis
M1c: multiple extrathoracic mets
Lung Overall Stage
Think about node neg and node positive separately, for N- go straight down the stages IA1-IIIA, N+ T1-2 and T3-4 go together
IA1: T1a 85% OS IA2: T1b IA3: T1c IB: T2a (70%) IIA: T2b (65%) IIB: T3N0, T1-2N1 (55%)
IIIA (5yrOS 40%):
- T1-2N2
- T3-4N1, T4N0
IIIB: T3-4N2, T1-2N3 (5yrOS 25%)
IIIC: T3-4N3 (10-15%)
IVA: M1a-1b (5yrOS 0-10%)
IVB: M1c (0%)
T1a: up to 1 cm
T1b: > 1 – 2 cm
T1c: > 2 – 3 cm
T2a: 3.1 – 4 cm T2b: 4.1 – 5 cm -or mainstem bronchus, not carina -visceral pleura -atelectasis, obstructive pneumonitis to hilar region
T3: >5 – 7 cm
- separate nodule in same lobe
- chest wall, phrenic nerve, pericardium, parietal pleura
T4: >7cm
- mediastinum, heart, great vessels, carina, trachea, spine, esophagus, recurrent laryngeal, diaphragm
- separate nodule in different I/L lobe
N1: hilar
N2: ipsi mediastinal
N3: contralat med, supraclav
M1a: sep nodule in contralat lobe, pleur/pericard nodules, pleural effusion
M1b: single extrathoracic metastasis
M1c: multiple extrathoracic mets
*picture
SBRT dose
SBRT, peripheral lesion: 18 Gy x 3
-tumor < 5 cm, > 2 cm from proximal bronchial tree (which includes mainstem bronchi, upper lobe bronchi, right middle lobe bronchus, left lingual bronchus, and lower lobe bronchi), node negative
SBRT apical, or chest wall: 10 Gy x 5 (say if can’t meet CW for 18 x 3)
(BED>100 Gy)
SBRT, central lesions: 10 Gy x 5, or if can’t meet constraints, then see alternative below
Alternatives:
4 Gy x 15 fx (NCIC)
7 Gy x 10 fx (MDACC)
SBRT sim/technique and volumes
Supine in full body vac bag immobilizer; consider abdominal compression if moving >1 cm
ITV = GTV + resp motion PTV = ITV + 0.5 cm
- There is no CTV
- If using free-breathing scan, PTV margins 1 cm sup/inf and 0.5 cm radially
- 6 MV
- 7-10 non-opposing, non-coplanar fields
- Field aperture from beam’s eye view should be PTV (no extra margin for dose buildup) except for small lesions
- Prescribe to IDL covering PTV – usually normalize to 80%
- Treat every other day (minimum 40 hours apart per RTOG 0236)
SBRT dose constraints 3 fraction
SBRT constraints for 3 fx (per NCCN): 6-8-10
- Cord: 6/fx :18 Gy
- Plexus/Skin/Esophagus: 8/fx: 24 Gy
- Rib/Heart/Trach/Bronchi: 10/fx: 30 Gy
- Total Lung - GTV: V20 <10%
SBRT dose constraints 5 fraction
SBRT constraints for 5 fx:
- Cord: 30 Gy
- Plexus/Skin: 32 Gy
All others: 105%
SBRT Planning Objectives
High dose spillage:
CI = 100% iso/PTV < 1.2
50% dose to be constrained within 2 cm – rapid fall-off
R50 – ratio of 50% isodose line to PTV < 3 to 4 (depending on PTV size)
95% PTV gets 100% dose
99% PTV gets >90% dose
SBRT 3 yr LC, OS
LC 90-95%
10% regional recurrence
55% OS
NSCLC Medically operative workup
Pre-thoracotomy LN sampling (for stage IB and above) -> lobectomy + mediastinal dissection/sampling
NSCLC Adjuvant chemo indication
N+
>4cm
chemo + atezolizumab
NSCLC PORT indications
PORT indications (54/2 or 1.8 – per ART):
-positive margin:
up to stage IIB(N1): re-resect-> chemo, consider CRT
Stage III: CRT(boost to 60)
Volumes: treat bronchial stump, ipsilateral hilum(10), ipsilateral lower paratracheal(4), subcarinal(7), + involved
STAGE III NSCLC treatment
definitive CRT -> adjuvant Durvalumab
concurrent cisplatin 50mg/m2 on D1, 8, 29, 36
etoposide 50 mg/m2 on d1-5 and 29-33
-start at same time as RT
Durvalumab (10mg/kg q2 wk for 12 months)
Definitive Lung NSCLC constraints
Cord: max < 50 Gy
Total lung - GTV:
V20 < 37%
MLD < 20 Gy
V5 < 60%
Esophagus
mean dose < 34
Brachial plexus max < 66 Gy
Heart
Mean dose < 20 Gy
V30 < 50%
95% of PTV gets 95% of dose
Stage III Lung PFS and OS
PFS: 33%
OS: 43%
Horner’s Syndrome
ptosis (falling eyelid), miosis (constricted pupil), anhidrosis (no sweating), can also see facial flushing, arm neuro exam, atrophy
Pancoast/Superior Sulcus treatment
Resectable: pre-op ChemoRT (re-image during last week of 45 Gy to see if resectable/non-metastatic) -> surgery (2-4 wks after) -> chemo + atezolizumab
- RT: 45/1.8 (but plan to 63 if not sure whether will be resectable)
- Chemo: cis 50/etop 50 q 3-4 week
- Adj chemo: cis/etop x 2
(i. e. EP 50/50 x 4 cycles total)
Unresectable: Def ChemoRT
- RT: 63/1.8 -> adj Durvalumab
Target = tumor + ipsi SCV
- did not include mediastinum/hilum
Plexus max 66 Gy
Bronchial Alveolar Carcinoma (BAC), Adenocarcinoma in Situ
- now called adenocarcinoma in situ (AIS)
- lepidic spread: spread along alveolar structure; do not invade stroma, pleura, or lymphatic spaces
- subtypes: mucinous, non-mucinous, mixed
- diffuse, multifocal have high rate of EGFR/ALK mutation
Lobectomy + mediastinal LN dissection/sampling
Targeted agent if mutation present
Pancoast/ Superior Sulcus definition
Pancoast/ Superior Sulcus
Superior sulcus = apex
Pancoast = Horners, shoulder pain, muscle wasting; and/or radiographic ribs/periosteum (above 2nd), brachial plexus, sympathetic chain, subclav vessels
T3 – chest wall, brachial plexus
T4 – subclavian, vertebral body
Carcinoid tumor workup and treatment
Med LN eval only for pts with abnormal LN on CT
Ocrtreotide scan if secreting
Carcinoid syndrome (5HIAA) – flushing, diarrhea, right sided valve issues, cough/wheezing
Typical, resectable: Lobectomy + LN dissection/sampling -> observe
Typical, unresectable: RT alone
Atypical: I-IIIA: lobectomy + mediastinal LN sampling
- if stage I, observe
- if stage II-III, adj chemo (EP) +/- RT
Stage IIIB or unresectable: definitive CRT w/ concurrent EP 50/50
Large cell – treat like NSCLC
Consider octreotide if secreting
SCLC pathology
Path:
- small round blue cells
- crush artifact on path
- if mixed SCLC/ NSCLC, tx like SCLC
Diff Dx small round blue cells
Diff Dx small round blue cells:
- SCLC
- lymphoma
- ALL
- Ewing sarcoma
- rhabdomyosarc
- neuroblastoma
- neuroepithelio.
- medulloblasto.
- retinoblastoma
Limited Stage SCLC treatment
Early concurrent CRT (cycle 1-2)-> restage chest/brain ->PCI
RT: 45/1.5 BID or 70/2 QD – bc CONVERT 45 looked better and was 66
Chemo: Cis 60 day 1 & Etop 120 day 1-3 q 3 wks x 4 cycles
- No GM-CSF w/ CRT
PCI (4-6 wks post-CRT): 25/2.5
Extensive Stage SCLC treatment
Chemo -> +/- PCI 25 Gy +/- thoracic RT 30 Gy for responders
Chemo:
Carbo or cisplatin /Etop/atezolizumab x 4-6c (cat 1) – doses
Cis 80 & Etop 80 x 4-6 cycles
SCLC constraints
- Cord max
BID: 41 Gy (36 Gy on Turrisi)
QD: 45-50.5 Gy - Lung-CTV: V20<30% (up to 40% by CALGB)
- Total lung mean < 20 Gy
- Esophagus (cricoid to GEJ): mean <34 (up to 10 cm can get 60 Gy)
- Heart (starts at origin of ascending aorta): V30 < 50%; mean 26 Gy
PTV: > 99% volume receives > 95% prescribed dose. No more than 2 cc getting 120%
Mesothelioma types
- Epithelial (best), sarcomatoid (worst), and biphasic
- > 80% due to asbestos (smoking not a risk fx)
Mesothelioma surgery types
EPP: En-bloc resection of entire pleura, lung, diaphragm, pericardium (peri-op mortality 6-30%)
Radical pleurectomy:
Removal of pleura and gross tumor (note: decort is palliative)
Mesothelioma additional Workup
CBC prognostic
Additional w/u:
- MRI chest/abd to rule diaphragm invasion
- PET/CT
- Pleural bx: VATS (needle biopsy can track)
If surgery planned:
- Med/EBUS of nodes
- cardiac stress test
Mesothelioma Staging
T1: pleura
T2: diaphragm or lung parenchyma
T3: locally adv resectable (focal chest wall, mediastinal FAT, pericardium)
T4: technically unresectable
(transdiaphr extension, unresectable CW, mediastin organs, spine)
N1: I/L hilar or med (int mam and peri-diaphragmatic nodes are mediastinal)
N2: C/L med or any SCV
I: T1-3N0
II: T1-2N1
III: T3N1, T1-3N2, T4
IV: M1
Mesothelioma T1-3N0-1 w/ epith hist, predicted post-op FEV1>1L
1) EPP -> RT -> chemo
- RT: hemi-thorax 54/1.8 Gy
- Chemo: cisplatin 75/pemtrexed 500 q 3 wks
- if not doing hemithoracic RT, consider drain/biopsy sites get RT 21/7
2) Radical pleurectomy/decortication -> chemo (will not give RT after P/D)
Mesothelioma T4, N2, M1, sarcomatoid or medically inoperable
T4, N2, M1, sarcomatoid or medically inoperable: chemo alone (cis/pem)
Mesothelioma treatment technique
3D technique: supine, arms akimbo
54 Gy / 1.8
•AP/PA covering entire hemithorax T1-L2, inclusive, covers across contralateral vertebral body (add 1.5 cm if positive mediastinum)
•Day 1 block liver, stomach, kidney, humeral head
•After 19.8 Gy block heart
•After 41.4 Gy block spinal cord by moving medial border to ipsilateral side of vertebral body
•Bolus scars, biopsy, and drain sites
•Supplement blocked area with electrons prescribed at depth of pleura, typically 1.53 Gy/Fx (+15% scatter)
•Can boost macroscopic residual to 60
IMRT technique (Harvard Allen 2007) – can we just say IMRT?
GTV=gross tumor + clips
CTV=GTV + entire pleural surface + incision sites
ENI not recommended
(restriced field technique) 9 fields with superior portion of PTV using only 3-4 fields
- note: their prior study showed almost 50% fatal pneumonitis w IMRT (need to have V20<7%). This was a dosi study.
Mesothelioma constraints
MLD <8.0 Gy V20 <10% (<7% if IMRT) V5 <50% Esophagus V55<30% Liver V30 <30% Kidney V15 <20% Heart V40 <50%
SCLC paraneoplastic
SIADH, ANP syndrome, Cushings, Lambert Eaton
Thymoma WHO histology
WHO Histology:
A – epithelial/spindle
AB – same as A, but with immature T cells
B1 – immature T cells
B2 – B1, but also clustered dendritic epithelial cells
B3 – sheets of polygonal (atypical) apithelial cells
C – thymic carcinoma
A best, C worst
-Anterior mediastinal mass Ddx:
- Anterior mediastinal mass Ddx: 4 Ts
- thymoma
- thyroid
- teratoma
- terrible lymphoma
Thymoma paraneoplastic
Paraneoplastic:
- MG: autoab to postsynaptic Ca++ channels. Weaker w activity. 40% thymoma have MG vs 15% MG with thymoma (anti-ACH receptor Ab 100% sensitive)
- Pure red cell aplasia (10%)
- Hypogammaglob (5%)
*make sure MG under control before surgery
Thymoma Masaoka Stage
I: no caps inv
II: transcapsular inv into fat or adherent to but not thru mediastinal pleura or pericardium (A: micro B: macro)
III: macro invasion into surrounds organs (A vs. B is without vs. w/ great vessel invasion)
IVA: pleural, pericardial dissemination
IVB: LN or distant
- picture
Thymoma Resectable treatment
Resectable: Surgery (total thymectomy)
- RT for III, R1/R2, thymic carcinoma (or carcinoid)
- add chemo for thymic carcinoma or R2 thymoma
Thymoma Unresectable treatment
Unresectable: neoadj chemo -> re-eval for surgery -> adjuvant RT if resectable; (cis)RT if unresectable
Chemo:
- thymoma: CAP (cyclophos 500, adria 50, cisplatinum 50) q 3 wks
- thymic carcinoma: carbo 6 /taxol 225 q 3 wks
Thymoma radiation dose
R0: 50.4 Gy R1: 54 Gy R2: 60 Gy Unresectable: 60-70 Gy Pre-op: 45 Gy
GTV = any gross disease CTV = any gross disease + pre-op tumor bed + clips + thymus (if left behind) + 1.5 cm (review w surgeon) PTV = CT + 0.5 cm
No elective LN treatment
Techniques:
- Wedge pair
- 3-field (2 ant, 1 PA, non-coplanar)
- AP/PA weighed heavily AP
- IMRT
Total Heart <30 Gy
Thymoma OS
5-yr OS I – 95% II – 85% III – 70% IV – 50%
