NCCN Non Small Cell Lung Cancer Flashcards
A patient presents with an incidental finding/nodule suspicious for cancer. What does the risk assessment in your workup consist of?
What is the first branch in the workup algorithm after the initial step?
Multidisciplinary evaluation (TFS, thoracic rads, pulm).
Smoking cessation counseling. Every patient. NCCN guidelines.
HP: age, smoking, ca hx, occupation hazards, other lung diseases, infectious exposure (think fungal or TB).
Look at the scan: size, shape, density, parenchymal abnormalities (scarring, inflammatory changes).
PET/CT.
Determine if solid or subsolid nodule. Size will determine what happens from there as long as no other confounding issues.
What extra workup does NSCLC need once they are >3cm? What is lowest possible stage of this size?
T2, at least stage Ib: invasive mediastinal node (N2) sampling (EBUS is fine); consider contrast brain MRI
*PET scan for ALL
*for sure brain MRI w/ con at 4cm, or node +
What extra workup does NSCLC need once they are >4cm?
T2b, at least stage II: add brain MRI in addition to invasive mediastinal staging for stage Ib (Ib - T2, 3cm).
*3 - m3d
*fore - brain
If EBUS is chosen for invasive mediastinal staging for NSCLC (at least 3cm, T2, Ib), and the sampling is negative, but the PET or CT is suspicious, what is the next step in workup?
Mediastinoscopy prior to surgical resection
What makes a stage IIIa NSCLC?
≤5 cm and nodes in same mediastinum (T1-2 and N2).
>5 cm but ≤7 and nodes in same hilum (T3, N1).
T4 and not past same mediastinum (N0 or N1).
small and mediastinal nodes, medium and hilar nodes, large without nodes
T4 = >7 cm or tumor of any size invading one or more of the following: diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina; separate tumor nodule(s) in an ipsilateral lobe different from that of the primary
If mediastinal node sampling for NSCLC is done, and ipsilateral mediastinal side (eg 7, 8, 9) is positive, what clinical N and overall stage are they at least?
N2, stage IIIa
What are other indications for NSCLC mediastinal sampling (other than >3cm/T2)?
IE What imaging findings would warrant med sampling?
Preop CT w/ mediastinal node suspicion (N2),
preop PET CT w/ hilar node suspicion (N1).
If NSCLC surgical margins are positive, what does the patient need postop? Can they be reresected?
Does stage matter?
Stage Ia (T1a-c; ie ≤3) - reresect (preferred) vs RT.
Stage Ib (T2aN0) - IIb (T3N0 or T2N1) - reresect w/ chemo vs chemoradx.
Stage IIIa-b (N2 or T4 or T3N1) - chemoradx. Cannot resect if mediastinal node positive.
What are stage IIb NSCLC?
≤5cm (T2b) and hilar positive (N1),
>5 but ≤7cm (T3) without node positivity (N0).
What adjuvant therapy do stage IIb NSCLC patients need postop?
What can be added depending on mutation?
In what setting can this treatment be delivered at an earlier stage (Ib or IIa)?
Chemotherapy and osimertinib (if EGFR-mutated = exon 19 deletion L858R).
Consider this in Stage Ib or IIa patients w/ high risk (poorly differentiated, NETs, vascular invasion, >4cm, visceral pleura involved).
Stage IIb = T1a-2bN1 or T3N0.
Patients who undergo NSCLC resection and are found on final pathology to have ipsilateral mediastinal disease or greater need what adjuvant therapy?
Sequential chemotherapy and RT; this is N2 disease.
What is the stage of NSCLC superior sulcus tumors (T)?
What is the effect on the workup?
T3.
Get full workup - invasive mediastinal sampling, PET, brain MRI.
How are NSCLC superior sulcus tumors managed (workup to definitive tx)?
Max workup, and Max management:
PET, mediastinal staging, and brain MRI.
If negative mediastinum (N0-N1) - preop chemoradx, then surgery, then chemo w/ osimertinib (if EGFR mutation exon 19 deletion or L858R).
How do you manage unresectable superior sulcus NSCLC tumors? Specific -mab needed?
Definitive chemoradiation and Durvalumab.
*Durvalumab is neither recommended for post-surgery pts (pneumonitis), nor for metastatic NSCLC.
*Durvalumab is offered as consolidation immunotherapy.
How do you manage NSCLC tumors greater than 7 cm?
Mediastinal staging, brain MRI. If negative mediastinum (N0-N1), then consider up to concurrent chemoradiation then surgery
Which NSCLC patients can get preop chemoradiation (induction)?
Induction recommended for superior sulcus; surgery preferred if T4 N0-1, chest wall involvement, mediastinal organ involvement, or proximal airway involvement… but can consider induction chemoradiation.
If preop mediastinal node sampling is positive in NSCLC, what are treatment options?
Does T stage affect treatment?
What do you do after the first stage of treatment?
Likely will get definitive chemoradiation. Can consider induction chemo and RT w/ resection if <7cm (T1-T3, but not invading chest wall) and tumor doesn’t progress with induction.
T3 with invasion and tumors progressing on induction will get definitive chemoradx.
What if NSCLC tumor is invading chest wall (regardless of size) with mediastinum positive? What is stage? Management?
At least T3 w/ N2 - definitive chemoradiation.
How do you stage ipsilateral separate pulmonary NSCLC nodules?
Same lobe is T3,
Different lobe but ipsilateral is T4.
How do you manage ipsilateral separate pulmonary NSCLC nodules? What stage?
T3 if same lobe, T4 if different lobe (ipsilateral).
Resect them. All get chemotherapy. Mediastinal positive (N2) can get radiation (after multidisciplinary discussion).
How do you stage and manage contralateral NSCLC pulmonary nodules?
At least stage IVa. Get mediastinal sampling, bronchoscopy, brain MRI.
If no nodes positive (N0), treat like two separate primary lung cancers.
How do you obtain stage info for suspected NSCLC contralateral mediastinal node disease? Management? What stage is it if +?
Need pathological proof (biopsy) of N3 (N3 includes ipsilateral scalene and supraclavicular nodes). If not metastatic, give definitive concurrent chemoradiation and Durvalumab. Stage IIIb if <5cm (T1-2/N3), stage IIIc if T3N3.
*Durvalumab is NOT recommended for post-surgery pts (pneumonitis).
*Darvalumab is NOT recommended for metastatic NSCLC.
*Durvalumab is offered as consolidation immunotherapy.
How do you manage stage IIIb NSCLC? What stage T and N stage is this?
IIIb = T1-2N3 (contra-hilar) or T4N2 (T3-4N3 is stage IIIc and treated the same; N2 = ipsilateral hilar).
If not metastatic, give definitive concurrent chemoradiation and Durvalumab.
*Durvalumab is NOT recommended for post-surgery pts (pneumonitis).
*Darvalumab is NOT recommended for metastatic NSCLC.
*Durvalumab is offered as consolidation immunotherapy.
How do you manage brain cancer mets of NSCLC?
Stereotactic radiosurgery vs resection followed by SRS or whole brain RT.
What is surveillance for NSCLC after definitive therapy?
Stage I-II if resected: CT q6mo x2-3yrs, then low-dose CT annually.
If had to give radiation (including stage I and II) or stage III or IV: CT q3-6mo x3yrs, q6mo x2, then low-dose CT annually.
What if there is a locoregional recurrence of NSCLC?
Resect if possible. Mediastinal disease gets chemoradiation (if radiation not given; ie mediastinal recurrence is unresectable).
Treatment for SVC obstruction on recurrence of NSCLC?
Concurrent chemoradiation if possible, consider SVC stent.
Treatment for endobronchial obstruction on recurrence of NSCLC?
Any combination: laser or stent or surgery, RT or brachytherapy, photodynamic therapy
How do you work up a NSCLC recurrence caught on surveillance?
PET/CT and brain MRI w/ contrast.
How do you workup advanced or metastatic NSCLC for targeted medicine?
Look for driver mutation:
Adeno always get molecular testing including EGFR (osemirtinib), ALK, PD-L1 (pembrolizumab), etc.
SCC can consider same testing.
When is segmentectomy appropriate for NSCLC? What is the surgical goal?
- Poor functional reserve (CPET shows VO2 max <20 ml/kg/hr).
- Peripheral, <2cm AND pure AIS, >50% GGO, or doubling time > 400 days.
Must sample N1 and N2 (ipsilat med) nodes.
Must get 2cm or margin = nodule size.
If surgery is pursued for NSCLC stage IIIa (ie w/ N2 disease), what must be added operatively?
Formal ipsilateral mediastinal node dissection.
What if there is a pleural or pericardial effusion associated with NSCLC?
Workup/Mgmt?
Possible Stage IV: need PET, brain MRI, and molecular testing. Thoracentesis to test if fluid is positive. Thoracoscopy if indeterminate.
If convincingly negative (unlikely) - treat tumor via normal algorithm.
If positive - systemic treatment and local palliation (pleurodesis, catheter, window).
How do you manage NSCLC thoracic disease if brain mets controlled?
What must be ruled out first?
Make sure NOT T4 or N2 (mediastinal disease must be ruled out) as these need definitive chemoradiation.
Otherwise, up to T3N1 can get resection (or SABR), control of metastatic site, and systemic treatment (if not already done).
Can manage limited pulmonary mets and limited pulmonary recurrence the same way.