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TSITE and CTS Boards (Updated 2024) > NCCN Non Small Cell Lung Cancer > Flashcards

NCCN Non Small Cell Lung Cancer Flashcards

1
Q

A patient presents with an incidental finding/nodule suspicious for cancer. What does the risk assessment in your workup consist of?

What lesion characteristics create the first branches in the workup algorithm?

A

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.

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2
Q

What extra workup does NSCLC need once they are >3cm? What is lowest possible stage of this size?

A

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 +

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3
Q

What extra workup does NSCLC need once they are >4cm?

A

T2b, at least stage II: add brain MRI in addition to invasive mediastinal staging for stage Ib (Ib - T2, 3cm).
*3 - m3d
*fore - brain

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4
Q

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?

A

Mediastinoscopy prior to surgical resection

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5
Q

What makes a stage IIIa NSCLC?

A

≤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

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6
Q

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?

A

N2, stage IIIa

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7
Q

What are other indications for NSCLC mediastinal sampling (other than >3cm/T2)?
IE What imaging findings would warrant med sampling?

A

Preop CT w/ mediastinal node suspicion (N2),
preop PET CT w/ hilar node suspicion (N1).

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8
Q

If NSCLC surgical margins are positive, what does the patient need postop? Can they be reresected?
Does stage matter?

A

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.

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9
Q

What are stage IIb NSCLC?

A

≤5cm (T2b) and hilar positive (N1),
>5 but ≤7cm (T3) without node positivity (N0).

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10
Q

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)?

A

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.

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11
Q

Patients who undergo NSCLC resection and are found on final pathology to have ipsilateral mediastinal disease or greater need what adjuvant therapy?

A

Sequential chemotherapy and RT; this is N2 disease.

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12
Q

What is the stage of NSCLC superior sulcus tumors (T)?
What is the effect on the workup?

A

T3.
Get full workup - invasive mediastinal sampling, PET, brain MRI.

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13
Q

How are NSCLC superior sulcus tumors managed (workup to definitive tx)?

A

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).

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14
Q

How do you manage unresectable superior sulcus NSCLC tumors? Specific -mab needed?

A

Definitive chemoradiation and Durvalumab.

*Durvalumab is neither recommended for post-surgery pts (pneumonitis), nor for metastatic NSCLC.
*Durvalumab is offered as consolidation immunotherapy.

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15
Q

How do you manage NSCLC tumors greater than 7 cm?

A

Mediastinal staging, brain MRI. If negative mediastinum (N0-N1), then consider up to concurrent chemoradiation then surgery

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16
Q

Which NSCLC patients can get preop chemoradiation (induction)?

A

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.

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17
Q

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?

A

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.

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18
Q

What if NSCLC tumor is invading chest wall (regardless of size) with mediastinum positive? What is stage? Management?

A

At least T3 w/ N2 - definitive chemoradiation.

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19
Q

How do you stage ipsilateral separate pulmonary NSCLC nodules?

A

Same lobe is T3,
Different lobe but ipsilateral is T4.

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20
Q

How do you manage ipsilateral separate pulmonary NSCLC nodules? What stage?

A

T3 if same lobe, T4 if different lobe (ipsilateral).

Resect them. All get chemotherapy. Mediastinal positive (N2) can get radiation (after multidisciplinary discussion).

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21
Q

How do you stage and manage contralateral NSCLC pulmonary nodules?

A

At least stage IVa. Get mediastinal sampling, bronchoscopy, brain MRI.
If no nodes positive (N0), treat like two separate primary lung cancers.

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22
Q

How do you obtain stage info for suspected NSCLC contralateral mediastinal node disease? Management? What stage is it if +?

A

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.

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23
Q

How do you manage stage IIIb NSCLC? What stage T and N stage is this?

A

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.

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24
Q

How do you manage brain cancer mets of NSCLC?

A

Stereotactic radiosurgery vs resection followed by SRS or whole brain RT.

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25
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.
26
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).
27
Treatment for SVC obstruction on recurrence of NSCLC?
Concurrent chemoradiation if possible, consider SVC stent.
28
Treatment for endobronchial obstruction on recurrence of NSCLC?
Any combination: laser or stent or surgery, RT or brachytherapy, photodynamic therapy
29
How do you work up a NSCLC recurrence caught on surveillance?
PET/CT and brain MRI w/ contrast.
30
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.
31
When is segmentectomy appropriate for NSCLC? What is the surgical goal?
1. Poor functional reserve (CPET shows VO2 max <20 ml/kg/hr). 2. 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.
32
If surgery is pursued for NSCLC stage IIIa (ie w/ N2 disease), what must be added operatively?
Formal ipsilateral mediastinal node dissection.
33
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).
34
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.
35
Incidental SOLID nodule found on chest CT. What would be high risk? What's next step?
Hx of smoking; lung ca in 1st degree relative; exposure to asbestos, radon, or uranium. Know size: <8mm need CT follow up. >8mm need either rpt CT 3 mo, PET (positive if SUV greater than mediastinal blood pool), or biopsy (even "low risk" has these requirements). Nodules < 6mm AND low risk don't require follow up.
36
Do all suspicious lung nodules require biopsy before surgery?n
No. If highly suspicious of stage IA (based on risk factors and radiological appearance), can proceed with intraop diagnosis. Biopsy adds time, cost, and procedural risk.
37
Before surgical resection, is a bronchoscopy required?
38
Best first step biopsy in patient with central lung mass and suspected endobronchial involvement (possible NSCLC)?
bronchoscopy (principle is least invasive with highest yield)
39
What lymph nodes can EBUS biopsy?
EBUS: 2R/2L, 4R/4L, 7, 10R/10L
40
(NSCLC workup) EBUS and TBNA negative for malignancy in PET positive mediastinum. What next?
Mediastinoscopy before surgery
41
In NSCLC workup, what diagnostic modality can access station 5, 7, 8, 9 lymph nodes?
EUS-guided. Can also access L adrenal gland.
42
In NSCLC workup, what diagnostic modality can access station 5 and 6?
Not much can get to station 6. TTNA and anterior mediastinotomy (Chamberlain). VATS biopsy is also an option if too close to aorta.
43
Before curative intent is attempted in pt w/ NSCLC and associated effusion, what should be done?
Initial thoracentesis negativity does not exclude pleural involvement. Additional thoracentesis or thoracoscopic evaluation of the pleura should be considered.
44
Patients w/ stage 1A NSCLC should have what pretreatment eval?
PFTs, bronch (intraop), FDG PET/CT. EVERY NSCLC gets PET.
45
At what point in pretreatment evaluation for NSCLC would you need pathological mediastinal lymph node evaluation and brain MRI w/ contrast?
Path LN eval: Stage Ib, ie T2aN0, ie >3cm. Brain MRI w/ con: Stage II (T1-2N1, T2bN0, T2b = 4cm), IIIa
46
NSCLC stage 1a w/ margin positive found at surgery, what is recommended management?
Re-resection; re-resection is an option up to stage IIB (T1-T2bN1 or T3N0). Otherwise chemoradiation.
47
When should adjuvant chemotherapy be given after NSCLC resection in margin negative patients?
T2a for high-risk patients (poorly differentiated, vascular invasion, wedge resection, visceral pleura involvement, unknown LN status).
48
For NSCLC, what pretreatment evaluation should be added with superior sulcus lesions abutting the spine, subclavian vessels, or brachial plexus?
MRI w/ contrast of spine and thoracic inlet
49
For NSCLC w/ superior sulcus tumor (T3 invasion, N0-1), what should initial treatment be? Then what? What about T4 superior sulcus tumor?
Preoperative concurrent chemoradiation, then surgery + chemotherapy, and atezolizumab (if PD-L1 expression) or osimertinib (if EGFR mutation exon 19 deletion or L858R). If T4 superior sulcus, make sure pt is resectable, and re-evaluate resectability after preop concurrent chemoradx w/ CT +/- PET.
50
NSCLC psx w/ chest wall, proximal airway, or mediastinal mass involvement (T3 invasion, N0-1; resectable T4 invasion N0-1). What is initial treatment and adjuvant?
Surgery is preferred. If margins positive, reresect and give chemo. If margins neg, just add adjuvant chemo and atezolizumab (if PD-L1 expression) or osimertinib (if EGFR mutation exon 19 deletion or L858R). Other option would be concurrent chemoradx w/ surgical re-evaluation w/ PET CT, then surgery. Margin positive here would need reresection and/or RT boost.
51
Stage IIIB (T1-2, N3) or Stage IIIC (T3, N3) NSCLC on clinical assessment. How do you confirm N3 disease? What if positive?
PET should already be done. Mediastinoscopy, SC lymph node biopsy, thoracoscopy, needle biopsy, mediastinotomy, EUS, or EBUS. If positive, definitive concurrent chemo and durvalumab.
52
A patient w/ NSCLC and brain mets gets some combination of stereotactic radiosurgery and surgical resection of brain mets. What should be done for the lung disease? Is any more workup needed to help decide? IE what are the decision making cutoffs for the treatment algorithm, and what workup do you need to get there?
Determine if definitive therapy feasible. Consider restaging. Pathological mediastinal nodal eval. Surgical resection, if possible, up to T3, N1. N1 dz chemoradx is preferred, but surgical resection can be done. N2 or T4 disease w/ brain mets should get definitive chemoradx.
53
What are some nonsurgical options for patients w/ NSCLC w/ local recurrence causing endobronchial obstruction or severe hemoptysis? Surveillance or further workup?
Laser therapy. External beam RT or brachytherapy. Photodynamic therapy. Embolization specific for bleeding. Stent specific for obstruction. Follow w/ chest CT w/ con, brain MRI w/ con, and PET to look for disseminated disease (would require systemic therapy).
54
In NSCLC, what can be done for distant mets w/ localized symptoms?
Palliative external-beam RT
55
In NSCLC, what can be done for diffuse brain mets?
Palliative external-beam RT
56
In NSCLC, what can be done for disseminated metastases?
Systemic therapy.
57
For pts w/ NSCLC, what management should be included in the preop evaluation for smoking patients (outside of regular preop operative workup)? What about active smokers - any change to treatment plan?
Provide counseling and smoking cessation support. This is in the guidelines. Active smoking - mild inc in incidence of postop pulm complications, should not be prohibitive risk for surgery.
58
For NSCLC, what is the resection goal for sublobar resection?
AT LEAST 2cm margin OR greater than size of nodule; also require adequate N1 and N2 node stations; segmentectomy preferred over wedge.
59
What are some reasons a segmentectomy may be more appropriate for pts w/ NSCLC?
Poor pulm reserve or other major comorbidity that contraindicates lobectomy. Peripheral nodule <2 cm WITH ONE OF THE FOLLOWING: - pure AIS histology - >50% ground-glass appearance on CT - long doubling time on radiology surveillance (400 days)
60
Compare VATS to open for NSCLC?
In high-volume centers w/ significant VATS experience, VATS lobectomy had improved early outcomes - dec pain, red length of stay, faster return to fct, fewer complications w/o compromised cancer outcomes
61
How do you manage the involved structure in T3 (invasion) and T4 NSCLC in surgery?
En-bloc resection of structure with negative margins.
62
What is T1 NSCLC? Include subdivisions.
T1a: ≤1cm in greatest dimension, no invasion of main bronch. T1b: >1cm but ≤2 T1c: >2cm but ≤3
63
T2 description NSCLC? Other features not size related? Subdivisions?
Tumor >3 cm but ≤5 cm OR any following: - main bronchus regardless of distance from the carina but without involvement of the carina - visceral pleura - atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of the lung T2a: >3 cm but ≤4 cm T2b: >4 cm but ≤5 cm
64
T3 description for NSCLC? Other features not related to size? Invades what structures?
>5 cm but ≤7 cm OR... - separate tumor nodule(s) in the same lobe as the primary - directly invades chest wall (inc parietal pleura, superior sulcus) - directly invades phrenic nerve - directly invades parietal pericardium
65
T4 NSCLC features and size? Multiple sites? Invasion of what structures? What nerve? What part of airway?
>7 cm OR… - separate nodule(s) in a different ipsilateral lobe than that of the primary - direct invasion of diaphragm (previously T3) - invasion of mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve (phrenic is T3), esophagus, vertebral body, and carina (bronchus w/o carina is T2).
66
What pts should be screened for lung cancer?
50 yrs old and 20 yrs smoking hx
67
When could a lung cancer NOT need a preop biopsy? Why is this possible? What would be your intraop strategy?
Strong suspicion for stage I or II lung cancer (based on risk factors and radiologic appearance) do not require a biopsy before surgery. - just adds time, cost, risk - get preop bx if non-lung ca dx suspected Intraop bronch should be done, then tissue diagnosis needed before anatomic resection (do needle or wedge and send for frozen).
68
NSCLC. When should a separate preoperative bronchoscopy be done?
Central tumor requires pre-resection evaluation for biopsy, surgical planning (eg, sleeve), or preop airway prep (eg, coring out obstructive lesion).
69
If a NSCLC central tumor is obstructive or may require sleeve, what invasive study should be added preoperatively?
Bronchoscopy - can change surgical plan for sleeve and can core out an obstructive lesion.
70
After PET for NSCLC, what is the diagnostic principle for choosing a site to biopsy if multiple sites are suspicious (eg, positive appearing mediastinum, contralateral lung, potential abdominal met)?
Choose the site that would confer the highest stage. This is why PET-CT is usually done before invasive staging for aggressive/advanced appearing NSCLC.
71
Following the principle of "least invasive biopsy with the highest yield," what biopsy method should be done for central mass suspicious for NSCLC?
bronchoscopy
72
Following the principle of "least invasive biopsy with the highest yield," what biopsy method should be done for peripheral (outer 1/3) nodule suspicious for NSCLC?
navigational bronchoscopy, radial EBUS or TTNA (transthoracic needle aspiration)
73
A NSCLC pt has PET suspicious for mediastinal positive disease. EBUS-TBNA is negative. Next step?
Need mediastinoscopy.
74
What are your options for biopsy of level 6 node?
Lvl 6 = para-aortic (ascending aorta or phrenic). TTNA or anterior mediastinotomy are first choice. VATS is second line.
75
Left adrenal looks positive on PET in NSCLC pt along with nodes 7 and 9. What single modality can reliably biopsy all of these sites?
EUS can biopsy all these sites (also 5 and 8). 5= sub-aortic/AP window,
76
A NSCLC pt being evaluated for surgery develops a pleural effusion. What should be done?
Thoracentesis and cytology.
77
A NSCLC pt being evaluated for surgery develops a pleural effusion. Initial thoracentesis is negative for cancer. What should be done?
Redo thoracentesis and/or VATS evaluation before curative intent.
78
A NSCLC pt has two discrete pulmonary nodules within the same lobe. Mediastinal staging reveals hilar nodes positive. What are the T and N stage and what is the first line of management?
T3. N1. Surgical resection. Can discuss induction chemotherapy/chemoimmunotherapy.
79
NSCLC pt has separate pulmonary nodules on separate lobes on same side of the chest. Mediastinal staging shows hilar nodes positive. What is T and N stage? What is treatment?
T4. N1. Surgery is first line. Can discuss chemo or chemoimmunotherapy for induction.
80
A NSCLC pt has a separate nodule on the opposite side of the chest. PET shows no suspicious mediastinal nodes. Invasive mediastinal staging is negative. What is stage? What is treamtent?
Stave IVA (N0, M1a). Treat as two primary lung tumors.
81
What if a pt presents w/ two pulmonary nodules, and they are different types (SCC and adeno)? How do you manage?
Rule out mediastinal nodal dz (N2). Then determine 1) if there are symptoms, and 2) if solitary metachronous lesions. Symptomatic lesions - definitive local therapy if possible (parenchymal sparing is preferred, or radiation or image-guided thermal ablation). Asymptomatic, solitary, metachronous lesions - definitive local therapy (as above). Asymptomatic multiple lesions w/ high risk of becoming symptomatic (subsolid nodules w/ accelerating growth, increasing solid component, increasing FDG uptake; even if small) - definitive local therapy (as above). Everything else gets palliative chemo with or without local palliative care. Or observation.
82
PET and CT scan for NSCLC should be performed within what time period before surgical evaluation?
60 days
83
Is SABR equal or medically preferable to resection for operable disease?
No. Resection is preferred if operative. SABR is for those high-risk or borderline operable. Multidisciplinary eval including rad onc is recommended.
84
What does NCCN have to say about thoracic surgery involvement in tumor board regarding NSCLC?
Thoracic surgeons should actively participate in multidisciplinary discussions and meetings regarding patients with lung cancer (eg, multidisciplinary clinic and/or tumor board).
85
If doing a sublobar resection for NSCLC, is node sampling necessary according to NCCN?
Sublobar resection should also sample appropriate N1 and N2 lymph node stations unless not technically feasible without substantially increasing the surgical risk.
86

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