Lung/Mediastinum Flashcards
What is the recommended management of limited stage SCLC?
A. Consolidation durvalumab after chemoRT
B. Surveillance MRI in lieu of PCI
C. 66 Gy in 33 Fx is recommended over BID fractionation
D. Adjuvant chemotherapy after lobectomy for stage I disease
D. Adjuvant chemotherapy after lobectomy for stage I disease
Choice D is the correct answer because SCLC is inherently a systemic disease, even at the earliest stages, and therefore even with effective local therapy like surgery in a resectable patient, adjuvant chemotherapy +/- PCI should be considered for all patients. Choice A is incorrect since durvalumab (or atezolizumab) is given with chemotherapy in extensive stage SCLC, and not a standard of care in limited stage SCLC. Consolidation durvalumab is given after chemoradiation for stage III NSCLC. Choice B is incorrect since PCI is still recommended for limited stage SCLC but based on Takahashi et al phase II RCT, consideration can be made to do MRI surveillance in lieu of PCI for extensive stage SCLC after chemotherapy. Choice C is incorrect since the CONVERT trial still considered 45 Gy in 30 fractions at 1.5 Gy BID (Turrisi regimen) as the standard since there is no difference in outcomes between the Turrisi regimen and the experimental arm of 66 Gy in 33 fractions when the primary hypothesis was that there would be benefit of the 66 Gy arm. However, there was no improved toxicity in the 66 Gy arm and no improvement in overall survival.
What is a treatment option for a patient with stage IA SCLC?
A. Platinum-etoposide doublet chemotherapy alone
B. SBRT followed by chemotherapy
C. SBRT alone
D. 45 Gy in 30 Fx BID RT alone
B. SBRT followed by chemotherapy
In the recent ASTRO SCLC guidelines either SBRT or conventional fractionation is recommended. Adding RT to chemotherapy is likely to improve survival rates compared to chemotherapy alone for LS-SCLC, hence option A is incorrect. For patients receiving SBRT, chemotherapy should be delivered to patients in whom it is medically tolerated. This was a strong recommendation supported by moderate evidence, hence option B is correct, with SBRT started and completed before initiation of chemotherapy or delivered between early cycles of chemotherapy. Standard fractionation is an option but is not evidence-based in the absence of radiosensitizing chemotherapy.
Based on the Impower133 and CASPIAN trials, the addition of which drugs, respectively, when combined with chemotherapy can improve OS as first-line treatment of extensive stage SCLC?
A. Durvalumab and nivolumab
B. Atezolizumab and durvalumab
C. Nivolumab and ipilimumab
D. Atezolizumab and ipilimumab
B. Atezolizumab and durvalumab
The IMpower133 and CASPIAN phase III randomized clinical trials demonstrated a median overall survival benefit of 2 to 3 months with the addition of the PDL-1 inhibitors atezolizumab and durvalumab, respectively, when added to the standard chemotherapy doublet of platinum-etoposide.
What were the rates of ≥ grade 3 esophagitis noted in the two arms of the CONVERT phase III randomized trial comparing concurrent once-daily chemoRT (66 Gy in 2 Gy Fx) versus twice-daily (45 Gy in 1.5 Gy Fx) for limited-stage SCLC?
A. 40% for daily, 20% for BID
B. 20% for both daily and BID
C. 20% for daily, 40% for BID
D. 40% for both daily and BID
B. 20% for both daily and BID
The CONVERT trial was designed to examine superiority of once-daily vs. twice daily RT, and at a median follow-up of 45 months, median overall survival was 30 months (95% CI 24–34) in the twice-daily group versus 25 months (21–31) in the once-daily group (HR in the once daily group 1·18 [95% CI 0·95–1·45]; p=0·14). Survival and toxicity did not differ except grade 4 neutropenia was higher with BID (49%) vs. daily RT (38%, p=0.05). Grade 3-4 esophagitis was 19% for both BID and daily RT groups (p=0.70), and grade 3-4 radiation pneumonitis was 3% for BID and 2% for daily RT (p=0.70).
What was the single fraction lung SBRT dose in the RTOG 0915 randomized phase II trial?
A. 18 Gy
B. 24 Gy
C. 34 Gy
D. 38 Gy
C. 34 Gy
RTOG 0915 compared 34 Gy in 1 fraction to the standard dose of 48 Gy in 4 fractions for patients with peripheral stage I NSCLC. The primary endpoint was toxicity rates. Rates of grade 3 and higher toxicity, and primary tumor control rates at 5 years were similar by arm. A larger trial will be necessary to detect any survival differences.
A patient with prior wedge-resection for an early stage NSCLC presents 2 years later with an enlarging lesion as seen abutting right mainstem bronchus, with SUV of 9.8 on PET-CT, biopsy confirmed to be recurrent NSCLC. What would be a preferred fractionation to treat this lesion with RT alone?
A. 30 Gy in 1 Fx SBRT
B. 50-54 Gy in 3 Fx SBRT
C. 60-70 Gy in 8-15 Fx hypofractionated RT
D. 60-70 Gy in 30-35 Fx conventionally fractionated RT
C. 60-70 Gy in 8-15 Fx hypofractionated RT
The demonstrated lesion is in direct contact with right mainstem bronchus. Tumors that directly abut proximal bronchial tree (or luminal mediastinal structures) are often labeled as “Ultracentral” tumors which are at a higher risk of serious complications with standard dose SBRT in 1-3 fractions. While such patients were included in the RTOG 0813 trial, they formed a small proportion of the patients. Most studies recommend use of more protracted regimens of 8-15 fractions. Conventionally fractionated RT alone is not a preferred option for these tumors.
What is the AJCC staging for a patient with biopsy proven lung adenocarcinoma with a 2.9 cm nodule in the right upper lobe, subaortic node involvement, and no other evidence of disease?
A. IIA
B. IIIB
C. IIIC
D. IVA
B. IIIB
Patient would be staged as cT1c (2.1-3cm) with contralateral mediastinal lymph node involvement (N3) with no distant metastasis (M0). The prognostic stage group is IIIB.
What is the benefit of the addition of local consolidative therapy in patients with oligometastatic (3 or fewer sites) NSCLC?
A. No significant difference in PFS or OS
B. Both PFS and OS improved
C. Only PFS improved
D. Only OS improved
B. Both PFS and OS improved
With a median follow-up time of 38.8 months, patients receiving local consolidative therapy had an improved median progression-free survival (23.1 months vs 14.2 months) and an improved overall survival (41.2 months vs 17 months).
A 65-year old smoker was found to have an asymptomatic mediastinal mass on screening low dose CT imaging that was biopsy proven to be an adenocarcinoma. Imaging showed numerous hepatic metastases and no brain metastasis. What is the recommended next step in management?
A. Start osimertinib
B. Request PD-L1 and mutation testing
C. Start palliative thoracic RT
D. Start platinum doublet chemotherapy
B. Request PD-L1 and mutation testing
Choice B is the correct answer since PD-L1 testing and mutation testing should be considered first in an asymptomatic good performance status patient to determine first line therapies. If there are no actionable mutations, immunotherapy based therapy (+/- chemotherapy) should be considered guided by PD-L1 testing results. Choice A is incorrect since osimertinib should not be started without knowing the EGFR mutation status, especially in a smoker with squamous cell carcinoma, since the possibility of an EGFR mutation is very small. Choice C is incorrect since this patient is asymptomatic and the tumor mass was found incidentally, and therefore palliative radiation should not be considered as the first treatment to be initiated. Choice D is incorrect since the patient likely has good performance status and would be a candidate for either targeted therapy or immunotherapy-based therapies, all of which will be guided by the biomarker testing. Systemic therapy with doublet chemotherapy should not be started without that information.
Which clinical scenario will be acceptable when planning hippocampal avoidance WBRT in a patient with multiple brain metastases?
A. Leptomeningeal disease
B. Metastases >5 mm from the hippocampi
C. Significant hydrocephalous
D. Symptomatic uncal herniation
B. Metastases >5 mm from the hippocampi
NRG CC001 study evaluated the role of hippocampal avoidance WBRT to help minimize neurocognitive toxicity of WBRT. Eligibility criteria excluded patients with LMD, patients within 5 mm of the hippocampi or radiographic evidence of hydrocephalus or other architectural distortion of the ventricular system, including placement of external ventricular drain or ventriculo-peritoneal shunt. These exclusions should be kept in mind when planning hippocampal avoidance WBRT.
What dose constraint is acceptable in thoracic RT in the following clinical scenarios?
A. Limited stage SCLC receiving 45 Gy at 1.5 Gy BID: Spinal cord Dmax ≤ 45 Gy
B. Mesothelioma after extrapleural pneumonectomy receiving adjuvant RT: Mean lung dose ≤ 18 Gy
C. Stage III NSCLC receiving chemoRT to 66 Gy in 33 fractions: Total lung V20 ≤ 35%
D. Early stage NSCLC receiving SBRT to 50 Gy in 4 fractions: Chest wall V30 ≤ 120 cc
C. Stage III NSCLC receiving chemoRT to 66 Gy in 33 fractions: Total lung V20 ≤ 35%
Choice C is correct because total lung dose constraint of V20≤35%-40% is the standard dose constraints for conventionally fractionated chemoradiation. Choice A is incorrect since the spinal cord Dmax constraint for 45 Gy in 1.5 Gy BID is 36 Gy (41 Gy is acceptable using modern IMRT techniques). Choice B is incorrect because the dose constraints for the remaining lung is mean dose < 8.5 Gy. Choice D is incorrect since the chest wall constraints for SABR 50 Gy in 4 fractions is V30 ≤ 30 cc (upwards of 50-70 cc is also acceptable with 5 fraction regimens).
What potential toxicity is MOST likely to be fatal in patients with ultracentral NSCLC treated with SBRT?
A. Radiation pneumonitis
B. Radiation esophagitis
C. Myocardial infarction
D. Pulmonary hemorrhage
D. Pulmonary hemorrhage
Tekatli et. al. treated 47 patients unfit for surgery with ultracentral NSCLC with 60 Gy in 12 fractions. Median overall survival was 15.9 months. No isolated local recurrences were observed. Grade 3 or higher toxicity was recorded in 38% of patients, with 21% scored as having a “possible” (n = 2) or “likely” (n = 8) treatment-related death between 5.2 and 18.2 months after treatment. Fatal pulmonary hemorrhage was the most likely cause of grade 5 toxicity and was observed in 15% of patients.
Which is the MOST appropriate first-line systemic therapy for metastatic squamous cell carcinoma of the lung with PD-L1 positivity of 10%?
A. Carboplatin-pemetrexed-pembrolizumab
B. Pembrolizumab alone
C. Carboplatin-paclitaxel-pembrolizumab
D. Atezolizumab-bevacizumab
C. Carboplatin-paclitaxel-pembrolizumab
Pemetrexed is a favored chemotherapy in non-squamous (adeno) NSCLC but appears to have less efficacy in squamous cell carcinoma. Pembro alone is reserved for patient with PD-L1 >50%. Combining pembrolizumab plus chemo was demonstrated to be superior in Keynote 407 in squamous cell carcinoma; hence option C is correct. Bevacizumab is contraindicated in lung squamous cell carcinoma given increased hemoptysis risk in this setting.
What drug is used as first line therapy for patients with metastatic ALK rearrangement positive NSCLC?
A. Afatinib
B. Osimertinib
C. Alectinib
D. Geftinib
C. Alectinib
Afatinib, Osimertinib and Geftinib are all used for treatment of EGFR mutation positive metastatic NSCLC. Alectinib is used in the management of ALK rearrangement positive metastatic NSCLC.
Which findings would be MOST consistent with a newly diagnosed thymoma?
A. Ptosis, miosis, and anhidrosis
B. Hyponatremia
C. Hypercalcemia
D. Muscle weakness with activity
D. Muscle weakness with activity
Choice D is correct since this is a classic sign of myasthenia gravis, which occurs in up to 50% of thymoma patients and manifests as easy fatigability with walking. Choice A is incorrect, and although ptosis is one presenting sign of myasthenia gravis, miosis and anhidrosis are not associated with myasthenia gravis. This trio of signs are known as Pancoast syndrome due to lung apex tumors. Choice B is incorrect since SIADH resulting in hyponatremia is often associated with small cell lung cancer. Choice C is incorrect since hypercalcemia of malignancy is often associated with squamous cell carcinoma of the lung.
