Lung Cancer Flashcards
Lung cancer
It is the most commonly diagnosed cancer in males as well as leading cause of cancer death.
TRUE or FALSE?
True
Chapter 54, Epidemiology
Lung cancer
In the US, lung cancer is the second most common cancer and the most common cause of cancer-related death in both men and women.
TRUE or FALSE?
True
Lung cancer
Among females “worldwide”, it is the fourth most commonly diagnosed cancer and the second leading cause of cancer death.
TRUE or FALSE?
True
Chapter 54, Epidemiology
Lung cancer
The overall 5-year survival rate for lung cancer is
approximately 18%.
TRUE or FALSE?
True
Lung cancer
Gender and racial disparities exist in the incidence
and mortality for lung cancer with rates highest in men, particularly those who
are of what ethnicity?
African American
Lung cancer
Most lung cancer
cases are attributable to cigarette smoking and second hand smoking (30% increased risk to those who live with smokers.
What is the second most common leading cause of lung cancer in the US after smoking?
Indoor radon exposure.
(Other known risk factors are exposure to occupational and environmental carcinogens such as asbestos, arsenic, and polycyclic aromatic hydrocarbons.)
Lung cancer
The lungs are conical in shape with an apex projecting upward into the neck for approximately _____ cm above the clavicle, a base sitting on the diaphragm, a costal surface along the chest wall, and a mediastinal surface that is molded to the heart and other mediastinal structures.
2 to 3
Lung cancer
The ___ lung is divided into the upper, middle, and lower lobes
by the oblique (major) and horizontal (minor) fissures.
right
Lung cancer
The ____ fissure runs
forward and downward from approximately the level of the fifth thoracic
vertebral body to the diaphragm, dividing the lungs into upper and lower lobes.
oblique (major)
Lung cancer
The horizontal fissure separates the right ____ from the right ____ lobe,
fanning out forward and laterally from the hilum.
upper from middle or vv.
Lung cancer
The ____, located in the left
upper lobe, is homologous to the right middle lobe and also touches the
diaphragm
lingula
Lung cancer
What is the functional unit of the lung.
bronchopulmonary segment
Lung cancer
What defines the BPS?
segmental bronchi
Lung cancer
What is the bony landmark for the bifurcation of the trachea (carina)?
junction of manubrium and body of the sternum
Lung cancer
The right and left main bronchi divides into lobar bronchi, each supplying a lobe of the lung (including the lingula)
TRUE or FALSE?
True
Lung cancer
Structures entering each
bronchopulmonary segment (i.e., bronchus and artery) tend to lie in the periphery.
Structures leaving the segment (i.e., veins and lymphatics) lie centrally.
TRUE or FALSE?
False.
It’s the other way around.
Structures entering each
bronchopulmonary segment (i.e., bronchus and artery) tend to lie centrally.
Structures leaving the segment (i.e., veins and lymphatics) lie in the periphery of
the segment within the connective tissue that separates the segments.
Lung cancer
Where does blood-gas exchange occur?
Alveoli
Which of the following is not a pattern of spread in lung cancer?
direct extension
lymph node involvement
hematogenous spread
None of the choices
Lung cancer
> 50% of the disease present with distant metastases (all histologies)
TRUE or FALSE?
True
Lung cancer
In NSCLC, approx. half presents with local disease, half with advanced disease.
TRUE or FALSE?
True.
For SCLC, majority are advanced (70% to 80%)
What is the most common presenting symptom of lung cancer?
Cough.
Cough is present in 50% to 75% of lung cancer patients at
presentation and occurs most frequently in patients with squamous cell and small
cell carcinomas because of their tendency to involve central airways.
Lung cancer
SVC syndrome is more common in patients with NSCLC than SCLC.
TRUE or FALSE?
False
What are the manifestations of Pancoast Syndrome?
shoulder pain, Horner syndrome, and brachial
plexopathy.
It is more common in NSCLC and only rarely in SCLC.
Lung cancer
Patients with an isolated metastasis to this site but otherwise limited thoracic disease seem to have a much
better prognosis than other stage IV disease and may be considered for
aggressive definitive management.
Adrenals
Lung cancer
What histology of NSCLC is more common to have brain metastases?
SCC? Adenocarcinoma? or anaplastic?
Adenocarcinoma
Lung cancer
Give 5 paraneoplastic syndromes of lung cancer
Cushing syndrome SIADH Hypercalcemia Lambert-Eaton myasthenic syndrome Hypertrophic Osteoarthropathy
Lung cancer
Identify the histologic subtype/s of lung cancer associated with the paraneoplastic syndrome:
Cushing syndrome
SCLC
carcinoid
*note, SLC patients with Cushing syndrome appear to have worse prognosis than those without
Lung cancer
Identify the histologic subtype/s of lung cancer associated with the paraneoplastic syndrome:
Hypercalcemia
squamous - 51%
adeno - 22%
SCLC - 15%
Lung cancer
Identify the histologic subtype/s of lung cancer associated with the paraneoplastic syndrome:
LEMS
SCLC
Lung cancer
Agent of choice for SIADH - paraneoplastic syndrome
demeclocycline
Lung cancer
Paraneoplastic syndrome
Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder
characterized by muscle weakness of the limbs that improves with repeated
testing.
TRUE or FALSE?
True.
In contrast to myasthenia gravis which worsens with repetition.
Lung cancer
Prognosis
How much weight loss from baseline has direct prognostic implications for survival in lung cancer?
> 5%
Lung cancer
Screening
What is the initial imaging procedure needed for patients suspected for lung cancer?
CT scan
Lung cancer
Screening
What imaging procedure can differentiate tumor from atelectasis?
PET scan
Lung cancer
Screening
What imaging procedure can detect malignant disease in
lymph nodes of normal size?
PET scan
Lung cancer screening
Because false positives and false negatives are
observed with imaging, tissue sampling should be pursued to confirm the presence
or absence of regional lymph node involvement before a treatment decision is
made.
TRUE or FALSE?
True
Also, a positive PET should not be considered proof of lymph node metastasis,
especially if such a conclusion would otherwise exclude surgery.
Lung cancer screening
PET-derived contour appears to be more
accurate than that derived from CT regardless of the algorithm employed
TRUE or FALSE?
False
Lung cancer screening
What is considered the gold-standard approach in assessing lymph node status in lung cancer?
Mediastinoscopy
Although considered the gold standard,
mediastinoscopy does have a false-negative rate of approximately 10%.
Furthermore, the role of mediastinoscopy for lung cancer has evolved recently.
Less invasive techniques such as EBUS-TBNA or EUS-FNA are frequently
utilized instead to sample lymph nodes found to be clinically suspicious on
imaging. Mediastinoscopy should still be considered in situations where less
invasive techniques are nondiagnostic.
Lung cancer screening
What technique is also extremely valuable for evaluation of suspected pleural disease when thoracentesis has been nondiagnostic?
Thoracoscopy
Lung cancer
AJCC 8th edition staging
Tx
Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy
Lung cancer
AJCC 8th edition staging
T1
Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)
Lung cancer
AJCC 8th edition staging
T1a, T1b, T1c
T1a Tumor is ≤1 cm in greatest dimension
T1b Tumor >1 cm but ≤2 cm in greatest dimension
T1c Tumor >2 cm but ≤3 cm in greatest dimension
Lung cancer
AJCC 8th edition staging
T1mi
Minimally invasive adenocarcinoma:
adenocarcinoma (≤3 cm in greatest dimension) with a predominantly lepidic pattern and ≤5 mm invasion in greatest dimension
Lung cancer
AJCC 8th edition staging
T2
Tumor >3 cm but ≤5 cm or having any of the following features:
involves the main bronchus but without involvement of the carina; invades the visceral pleura; or associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of the lung
Lung cancer
AJCC 8th edition staging
T2a, T2b
T2a Tumor >3 cm but ≤4 cm in greatest dimension
T2b Tumor >4 cm but ≤5 cm in greatest dimension
Lung cancer
AJCC 8th edition staging
T3
Tumor >5 cm but ≤7 cm in greatest dimension or directly invading any of the following: parietal pleura, chest wall (including superior sulcus tumors), phrenic nerve, parietal pericardium, or separate tumor nodule(s) in same lobe as the primary
Lung cancer
AJCC 8th edition staging
T4
Tumor >7 cm or tumor of any size of that invades diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina; separate tumor nodule(s) in an ipsilateral lobe different from that of the primary
Lung cancer
AJCC 8th edition staging
N1
Involvement of ipsilateral intrapulmonary, or peribronchial, hilar lymph nodes
Lung cancer
AJCC 8th edition staging
N2
Involvement of mediastinal or subcarinal lymph nodes
Lung cancer
AJCC 8th edition staging
N3
Involvement of contralateral mediastinal or hilar lymph nodes. Involvement of ipsilateral or contralateral scalene or supraclavicular nodes
Lung cancer
AJCC 8th edition staging
M1a
Separate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial nodule(s) or malignant pleural or pericardial effusion.
Lung cancer
AJCC 8th edition staging
M1b
Single extrathoracic metastasis
Lung cancer
AJCC 8th edition staging
M1c
Multiple extrathoracic metastases in one or several organs
Lung cancer
AJCC 8th edition staging
Stage 0, 1A1, 1A2, 1A3?
All N0, M0
0 - Tis
IA1 - T1(mi)
IA2 - T1a
IA3 - T1b
Lung cancer
AJCC 8th edition staging
Stage IVA vs IVB
IVA is M1a and M1b
IVB is M1c
Lung cancer
IASLC recommendation.
What nodal stations should be sampled for pathologic staging of a right-sided lung cancer?
- paratracheal (stations 2R and 4R)
- subcarinal (station 7)
- hilar (station 10R)
- interlobar lymph nodes (station 11R)
Lung cancer
IASLC recommendation.
What nodal stations should be sampled for pathologic staging of a left-sided lung cancer?
- aortopulmonary window (station 5)
- ascending aorta (station 6)
- subcarinal (station 7)
- hilar (station 10L)
- interlobar (station 11L) lymph nodes
Lung cancer
IASLC recommendation.
What nodal station should also be evaluated for lower lobe tumors?
pulmonary ligament lymph nodes (station 9)
Lung cancer
IASLC recommendation.
How many lymph nodes should be examined to meet the criteria for pN staging, which id not met, would classify the patient as pN0
At least 6
3 from mediastinal; 3 from hilar
Lung cancer
Pathologic classification
What are the 4 major classifications of lung cancer?
(a) squamous cell carcinoma (b) adenocarcinoma of the lung
(c) small cell
carcinoma
(d) large cell carcinoma
Lung cancer
Pathologic classification
Identify the involved histology:
VEGF inhibitors like Bevacizumab yield a significant survival advantege in patients, however, it produced grades 4 and 5 pulmonary hemorrhage in what histologic classification of lung cancer?
squamous
Lung cancer
Pathologic classification
Identify the involved histology:
improved survival with pemetrexed combined with platinum-based chemotherapy
adenocarcinoma and large cell
Lung cancer
Pathologic classification
Identify the involved histology:
associated with EGFR mutations that confer sensitivity to TKI therapy
adenocarcinoma
Lung cancer
Pathologic classification
Identify the involved histology:
associated with anaplastic lymphoma kinase (ALK) translocations that confer
sensitivity to the mesenchymal-epithelial transition factor (MET)/ALK inhibitor
crizotinib
adenocarcinoma
Lung cancer
Prognosis
According to Movsas et al., what is the most important patient-related predictor of long-term survival?
baseline qol
Lung cancer
Management
What is the standard of care for stage I and II NSCLC?
operable - complete surgical resection ± chemotherapy
inoperable - SBRT/SABR
Lung cancer
Management
What is the standard of care for stage III disease?
select stage IIIA candidates for surgery - neoadjuvant chemo/chemoRT + surgery
inoperable - concurrent chemoRT
Lung cancer
Management
Lung function measures that indicate that a patient may qualify for resection
FEV1 >60%
DLCO >60%
Lung cancer
Management
What is the standard of care surgical technique for stage I and II NSCLC?
lobectomy
The Lung Cancer Study Group performed a randomized trial of
lobectomy versus limited surgical resection (either wedge resection or
segmentectomy) in patients with T1N0 or T2N0 NSCLC. This trial randomized
276 patients and found a 17% risk of local recurrence with limited resection
versus 6% with lobectomy (P = .008) and a trend toward an increase in all-cause
and cancer-specific risk of death in patients randomized to limited resection
(30% and 50% increased risk, respectively [P = .09], for both). Additionally, the
report did not demonstrate any late functional advantages or decreased
perioperative morbidity with limited resection. This study firmly established
lobectomy as the standard of care for early-stage lung cancer.
Lung cancer
Management
What trial studied brachytherapy as an addition to sublobar resection for early-stage, high-risk NSCLC?
ACOSOG Z4032
There was no difference
between arms in time to local recurrence, LR (hazard ratio [HR] 1.01; 95%
confidence interval [CI] 0.51, 1.98; P = .98), or type of LR. In subgroups of
patients with potentially compromised surgical margin (margin < 1cm;
margin:tumor ratio <1; positive staple line cytology; wedge resection, nodule
size >2 cm), SRB did not reduce LR, although trends favored the SRB arm,
especially in the 14 patients with positive staple line cytology (HR 0.11, P =
.24). Overall 3-year survival was similar for SR (71%) and SRB (71%) (P = .97).
They concluded that there was no impact of brachytherapy on oncologic
outcome in these patients.
Lung cancer
Management
Is lymph node dissection required for early-stage N1 (except hilar) NSCLC?
No.
(ACOSOG) Z0030 trial was a randomized trial of 1,111 patients with N0
or N1 (less than hilar) early-stage NSCLC to either mediastinal lymph node
sampling or complete lymphadenectomy during pulmonary resection. The 5-year
disease-free survival was 69% in the mediastinal lymph node sampling group
and 68% in the mediastinal lymph node dissection group (P = .92). There was no
difference in local (P = .52), regional (P = .10), or distant (P = .76) recurrence
between the two groups,
suggesting that complete lymphadenectomy does not
improve survival in patients with early-stage NSCLC
Lung cancer management.
What phase II study was conducted to determine the role of SBRT for early-stage operable NSCLC?
RTOG 0618
The RTOG (RTOG 0618) initiated
a phase II study of SBRT in operable patients with early-stage NSCLC. Of 26
evaluable patients, 23 had T1 and 3 had T2 tumors. Four patients (16%) had
SBRT-related grade 3 AEs, whereas 0 had grade 4 to 5 AEs. Median follow-up
was 25 months. Two patients have been scored with in-field failure, INF (11.7
and 12.4 months post SBRT), and 1 with marginal failure, MF (32.5 months post
SBRT), giving an estimated 2-year primary tumor failure rate of 7.7% (95% CI
0.0%, 18.1%). Two-year estimates of LF (primary tumor plus involved lobe
failure), RF, and DF are 19.2% (95% CI 3.7%, 34.7%), 11.7% (95% CI 0.0%,
24.5%), and 15.4% (95% CI 1.2%, 29.6%), respectively. Only one patient was
eligible for attempted surgical salvage and underwent lobectomy 1.2 years post
SBRT complicated by a grade 4 cardiac arrhythmia. Two-year estimates of
progression-free survival (PFS) and OS are 65.4% (95% CI 44.0%, 80.3%) and
84.4% (95% CI 63.7%, 93.9%), respectively. This study suggested that SBRT
was associated with a high rate of tumor control, moderate treatment-related
morbidity, and infrequent need for surgical salvage in operable early-stage lung
cancer patients with peripheral lesions.
Lung cancer
Management
What is the ROSEL and START trial
They are prospective studies that tried to compare surgery and SBRT in early-stage operable NSCLC patients.
However, the trial closed early due to accrual,
but retrospective matching of these two trials showed a promising outcome as possible noninvasive alternative to surgery in the future.
Lung cancer
Management
Regarding definitive treatment after induction chemotherapy,
what is the preferred approach as concluded by Van Meerbeeck et al, based on the results of an EORTC phase III trial of surgical resection versus radiotherapy after induction
chemotherapy in patients with pathologically proven N2 disease?
RT
Median and 5-year OS for patients randomly assigned to
resection versus radiotherapy were 16.4 versus 17.5 months and 15.7% versus
14%, respectively (HR 1.06, 95% CI 0.84 to 1.35). Rates of PFS were also
similar in both groups. The authors concluded that radiotherapy is the preferred
approach in these patients owing to lower rates of treatment-related morbidity
and mortality.
Lung cancer
Management
In addition to facilitate complete surgical resection of disease, what is another benefit of induction chemotherapy?
potentially sterilize micrometastatic
disease beyond the thorax
Lung cancer
Management
This trial randomized 624 patients with stage IA (>2 cm), IB, II, or T3N1 to neoadjuvant versus adjuvant versus surgery alone. Chemotherapy was three cycles of carboplatin–paclitaxel
What is the trial and its results?
Neoadjuvant
versus Adjuvant Taxol/Carbo Hope trial (NATCH)
Neoadjuvant
arm had a trend toward better DFS than surgery alone arm, but results were not
statistically significant (5-year DFS 38% vs. 34%, HR 0.92, P = .176). One
possible explanation for the lack of benefit is due to the proportion of patients
with early-stage disease in the trial (75% had clinical stage I disease). With
subset analysis of only stage II-T3N1 patients, 5-year DFS was 36.6% in the
neoadjuvant arm and 25% in the surgery arm (HR 0.81, P = .07). The adjuvant
arm showed less benefit than the neoadjuvant arm, and more patients in the
neoadjuvant arm were able to complete their planned chemotherapy (90.4% vs.
60.9% for neoadjuvant vs. adjuvant).
Lung cancer
Management
This trial assigned 270 patients with stages IB-IIIA NSCLC to surgery versus neoadjuvant
cisplatin/gemcitabine for three cycles.
What is the trial and its results?
Chemotherapy for Early Stages Trial
PFS and OS HRs were 0.70 (95% CI,
0.50 to 0.97; P = .003) and 0.63 (95% CI, 0.43 to 0.92; P = .02), respectively,
both in favor of chemotherapy. When looking at just stage IIB/IIIA patients, a
statistically significant impact of neoadjuvant chemotherapy was seen (3-year
PFS rate: 36.1% vs. 55.4%; P = .002).
Lung cancer
Management
What trial tested the survival benefit by adding surgery after CRT in patients with stage IIIA/IIIB disease?
phase II by TROG
Overall, this trial
did not demonstrate a survival benefit for the addition of surgery to
chemoradiotherapy in patients with stage IIIA NSCLC.
Lung cancer
What is the predominant pattern of intrathoracic failure after surgical resection?
along surgical stump or in mediastinal nodes.
Lung cancer
Management
What is the benefit of PORT in operable NSCLC?
May have improved 5-year OS for pN2 patients but reduced OS for pN0 and pN1
(SEER)
Decrease in survival for pN1 disease, no survival difference for pN2 -(PORT-meta-analysis)
improved survival for pN2 disease with or without chemotherapy.
improved survival for pN1 but detrimental effect with chemo.
-(Adjuvant Navelbine International Trialist Association (ANITA) trial)
Lung cancer
Management
This trial compared observation vs. adjuvant cisplatin in resected I, II, III NSCLC.
There was significantly higher survival rate in the chemotherapy arm that diminished with longer follow-up.
What is this trial?
International Adjuvant Lung Cancer Trial (IALT)
In this trial, 1,867 patients were
randomized to cisplatin-based adjuvant chemotherapy or observation. With a
median follow-up duration of 56 months, patients receiving chemotherapy had a
significantly higher survival rate (44.5% vs. 40.4% at 5 years) and disease-free
survival rate (39.4% vs. 34.3% at 5 years) compared with observation. However,
after 7.5 years of follow-up, the survival curves started to converge and cross,
the benefit of chemotherapy decreased over time, and there were more deaths in
the chemotherapy group by 7.5 years (P = .10).
Lung cancer
Management
This trial compared observation vs. adjuvant vinorelbine+cisplatin in resected IB, II, NSCLC.
There was significantly higher survival rate in the chemotherapy arm that did not diminish with longer follow-up, although some of the benefits did.
Chemo is beneficial for stage II but not for IB.
What is this trial?
The National Cancer Institute of Canada JBR.10 trial
Compared to observation,
adjuvant chemotherapy significantly prolonged median OS (94 vs. 73 months)
and median relapse-free survival (not reached in chemo arm vs. 46.7 months)
compared to observation alone. Like the IALT trial, some of the benefit
diminished with longer follow-up; however, unlike IALT, the survival difference
remained statistically significant beyond 5 years. After 9 years of follow-up,
adjuvant chemotherapy was found beneficial for stage II (median survival 6.8 vs.
3.6 years), although not for stage IB patients.
Lung cancer
Management
This trial was one of the first multi-institutional randomized trials to
investigate postoperative chemoradiotherapy.
They compared osbervation versus 4 cycles of EP + 50.4 Gy/28
What is this trial and what is the result?
ECOG 3590
There was
no difference in local recurrence or survival between the two arms
Lung cancer
Management
This is a phase II combined modality study using a newer chemotherapy regimen
consisting of carboplatin and paclitaxel.
included 88 patients with
stage II and IIIA NSCLC after surgery who received PORT with concurrent
carboplatin and paclitaxel. Radiotherapy consisted of 50.4 Gy in 28 fractions
with a boost of 10.8 Gy in extranodal extension or T3 lesions.
What is this trial and what are the results?
RTOG 9705
At a median follow-up of 56.7
months, median OS time was 56.3 months, with 1-, 2-, and 3-year survival rates
of 86%, 70%, and 61%, respectively. The 1-, 2-, and 3- year PFS rates were
70%, 57%, and 50%, respectively. Toxicities were acceptable. When compared
to previously reported studies, the RTOG concluded that these results might
portend an improvement in OS and PFS with chemoradiotherapy in
postoperative resected NSCLC patients
Lung cancer
Management
What is the standard of care for stage I/II (early-stage) inoperable NSCLC?
Definitive RT alone
or
SABR/SBRT
Lung cancer
Management
Despite definitive conventionally fractionated RT for NSCLC, the OS rates for patients with medically inoperable early-stage NSCLC remain poor when compared to surgery.
Why?
-poorer overall health of the medically
inoperable patient
-most of these patients are clinically, rather
than surgically, staged
-a higher dose (up to 100 Gy) is required for the sterilization of most NSCLC tumors which is not usually achievable without toxicities.
Lung cancer
Management
This trial is a phase I/II trial of SBRT for centrally located NSCLC about testing the maximum tolerable dose for these tumors.
What is this trial?
RTOG 0813
Lung cancer
Management
This trial is a phase II trial of SBRT for NSCLC.
They evaluated 55 patients treated with 54 Gy/18/3
At a median follow-up of 34 months, they
reported a 3-year primary tumor control rate of 97.6% and a 3-year primary
tumor and involved lobe (local) control rate of 90.6%. Two patients experienced
regional failure; the locoregional control rate was 87.2%. Eleven patients
experienced distant recurrence with a 3-year rate of distant failure of 22.1%. The
rates for disease-free survival and OS at 3 years were 48.3% and 55.8%,
respectively. The median OS was 48.1 months.
What is this trial?
RTOG 0236 (Timmerman et al.)
Lung cancer
Management
This trial involves delivering SBRT in 2 arms, 34Gyx1 vs. 12Gyx4.
Ninety-four patients with T1-2N0M0 peripheral tumors
were accrued and 84 were analyzable. With a median follow-up of 30 months, 4
patients on arm 1 (10.3%) and 6 patients on arm 2 (13.3%) had grade 3+
protocol-specified toxicity. Two-year OS was 61.3% and 77.7% for Arms 1 and
2, respectively. One-year primary control was 97% for arm 1 and 92.7% for arm
2.
What is this trial?
RTOG 0915
Lung cancer
Management
Kubota et al. performed a prospective randomized trial in 63 patients with stage III NSCLC comparing chemotherapy alone to chemotherapy+thoracic RT.
What are the results?
increases long term survival
The survival rate in the thoracic RT group was 58% at 1 year, 36% at 2 years, and 29% at 3 years, compared with 66%, 9%, and 3% at 1, 2, and 3 years, respectively, in the chemotherapy-alone group.
The investigators concluded that thoracic RT “significantly increases the number of long-term survivors as compared with chemotherapy alone and that RT to bulky disease in the thorax is an important part of combined modality therapy, a necessary part of further studies in locally advanced disease.”
Lung cancer
Management
What is the standard of care dose for unresectable NSCLC?
(RTOG 7301)
60 Gy/2/30
Lung cancer
Management
Can ENI be omitted in the RT of inoperable locally advanced NSCLC?
Yes.
data suggest that IFRT can be
employed in patients with locally advanced NSCLC without risk of significant
compromise in clinical outcome
Lung cancer
Management
What is the standard of care treatment for unresectable NSCLC?
sequential chemo vs CCRT vs hyperfractionatedRT+chemo
CCRT.
Although this comes with greater esophageal toxicity.
Lung cancer
Management
Give 2 important factors to consider that might predict treatment outcomes in the treatment of locally advanced NSCLC
Performance status and weight loss
Lung cancer
Management
BONUS: What chemotherapy agent is useful only in nonsquamous NSCLC and costs higher than others?
Pemetrexed
Lung cancer
What is the most common symptom among superior sulcus tumor patients?
Shoulder pain (which may radiate down the arm)
Lung cancer
What is the triad of Horner syndrome?
ptosis,
pupillary miosis
hemifacial anhidrosis
Lung cancer
What is the management for superior sulcus tumors?
for small SSTs CCRT
for extensive, chemotherapy.
Assess for resectability
MDACC good results with resection + PORT.
Others RT+chemo…
Can be CRT then assess for resectability.
Lung cancer
What is the GTV?
clinically macroscopic disease, typically identified on any imaging modality.
Lung cancer
IV contrast is usually not necessary to delineate the primary tumor GTV but it may be helpful in what circumstances?
If the tumor is near the hilum or mediastinum.
Lung cancer
What is the standard windowing to delineate primary GTV?
Lung window
width 850 Hounsfield units
length -750 Hounsfield units
(-Harris et al.)
Lung cancer
The CTV is a volumetric expansion of the GTV.
How big is the expansion for the primary tumor if the histology is adenocarcinoma?
9mm
pathologically
derived correlative data have shown that a 9-mm margin would encompass all
microscopic disease in approximately 90% of lung adenocarcinomas.
Others
have advocated the use of a differential margin based on histology of 8 mm for
adenocarcinoma and 6 mm for squamous cell carcinomas to account for 95% of
the microscopic extension of disease.
Lung cancer
The CTV is a volumetric expansion of the GTV.
How big is the expansion for the nodal CTV if the lymph node is <2 cm to account for microscopic ENE?
For nodal disease, surgical series have
shown that a 3-mm margin will encompass 95% of the microscopic extranodal
extension of disease in lymph nodes <2 cm. However, larger margins may be
required for lymph nodes >2 cm.
Lung cancer
BONUS: What is the ITV?
The ITV is defined by the International Commission on Radiation Units and Measurements (ICRU) 62 as an expansion of the CTV to account for tumor motion.
Lung cancer
What are the PTV expansion options?
when using
stereotactic frame without CBCT
9-13 mm
with CBCT 1-2 mm.
For advanced-stage NSCLC, typical margins for the PTV are on the order of 5 to 10 mm if an ITV is used for motion compensation and daily image-guided RT is employed during treatment.
Lung cancer
Ways to improve treatment accuracy concerning tumor motion
- 4D scans,
- slow CT,
- abdominal compression,
- DIBH,
- automatic breathing control,
- respiratory gating,
- tumor tracking,
- MIP,
- CIP
Lung cancer
Management
What is the second-line TKI that is usually given after a resistance to initial TKI due to the mutation T790M
Osimertinib (third gen EGFR TKI)
Lung cancer
Management
Second gen ALK inhibitors that have good CNS activity
Ceritinib and alectinib
Lung cancer
Management
In SVC syndrome from SCLC, palliative RT is part of the initial therapy.
TRUE or FALSE?
False.
SVC syndrome from SCLC are more responsive to chemotherapy than from NSCLC.
Therefore, chemotherapy is initiated first and the post chemotherapy volume is treated with RT.
With NSCLC, RT can be initiated right away.
Lung cancer
What is the most clinically important prognostic factor in SCLC?
Stage
(limited vs. extensive)
Other clinical factors consistently reported to correlate with improved survival include good performance status, female gender, and normal LDH levels at baseline.
Lung cancer
Describe the 1973 Veteran’s Administration Lung Group
staging scheme.
1973 Veteran’s Administration Lung Group
staging scheme.
limited vs. extensive.
In this system, limited stage is defined as disease confined to
the ipsilateral hemithorax, which can be safely encompassed within a tolerable
radiation portal. Virtually all studies in limited disease exclude malignant pleural
effusions. From a practical standpoint, hemithoracic radiotherapy to encompass
the entire ipsilateral pleura has little justification because it would confer a
significant risk of pulmonary toxicity in a high-risk patient population with little
chance of cure. As such, patients with malignant pleural effusions are classified
as having extensive-stage disease.
Lung cancer
In SCLC, what is the primary mode of failure after surgical resection?
distant dissemination
Lung cancer
SCLC is radiosensitive.
TRUE or FALSE?
True
Lung cancer
management
Describe some dose escalation studies for SCLC treatment
Choi - phase I
RTOG 0239
CALGB 39808
CONVERT trial
Lung cancer
management
PCI has a benefit in _______-stage SCLC (limited vs. extensive)
limited
Auperin meta-analysis
Lung cancer
management
What is the only US FDA–approved second line chemotherapy for recurrence in extensive SCLC?
Topotecan
Lung cancer
When does radiation pneumonitis usually occur?
RP may occur during fractionated treatment or up to 18 months afterward, with a peak incidence at 2 to 6 months posttreatment.
Lung cancer
How does radiation pneumonitis appear on imaging?
Chest x-ray or CT scan may be normal, or, depending on the time course, there may be ground-glass opacification (within 2 to 6 months), patchy consolidation (4 to 12 months), or fibrosis (10 months or more) that loosely corresponds to the radiation field.
Lung cancer
RP risk is <20% for what MLD and Vdose?
conventional fractionation
MLD <20 Gy
V20 <35%
V5 <60%
V20 remained the most
accurate predictive metric of RP (RTOG 0617)
Lung cancer
Dose constraints for the bilateral lung 10 cc and 15 cc using SBRT
1, 3, and 5 fractions
For bilateral lung, they recommend maximum dose to 10 and 15 cc of lung of 7.4 and 7 Gy for single-fraction SBRT, 12.4 and 11.6 Gy for three-fraction SBRT, and 13.5 and 12.5 for five-fraction SBRT.
Lung cancer
QUANTEC recommendation on the maximum dose for the airways using conventional RT.
> 80 Gy
Lung cancer
Dose constraints for the proximal tracheobronchial tree (4cc and maximum point dose) using SBRT
1, 3, and 5 fractions
The AAPM Task Group 101 recommends maximum doses to 4 cc and maximum
point doses to the proximal tracheobronchial tree of 10.5 and 20.2 Gy for singlefraction
SBRT, 15 and 30 Gy for three-fraction SBRT, and 16.5 and 40 Gy for
five-fraction SBRT.
Lung cancer
QUANTEC analysis concludes that volumes treated above ___Gy correlate
with acute esophagitis and further suggests that no dose above prescription be
allowed to even small volumes of esophagus, to reduce the risk of severe
ulceration or fistula. This latter information is especially important for
heterogeneous IMRT planning
40 and 50 Gy
Lung cancer
The risk of pericarditis can be minimized by keeping the mean pericardial dose
26
46
Lung cancer
Point maximum dose limit for the brachial plexus (conventional fractionation)
66 Gy
(RTOG 0617)
for SBRT:
AAPM TG 101 recommends maximum dose to 3 cc and maximum point dose of 14 and 17.5 Gy for single-fraction SBRT, 20.4 and 24 Gy for three-fraction SBRT, and 27 and 30.5 Gy for five-fraction SBRT.
