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66 Cards in this Set

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What is Pancoast syndrome?
Pancoast syndrome is a result of apical tumors invading the thoracic inlet causing shoulder/arm pain, Horner syndrome, and paresthesias of hand in ulnar nerve distribution.
Please describe the initial evaluation for a patient suspected of having lung cancer.
H+P with focus wt loss > 5% over prior 3 months, KPS, tobacco history, neck exam for N3 disease, CBC, CMP, CT Chest to include adrenals or PET/CT. MRI for paraspinal/superior sulcus tumors. Diagnosis of lung cancer rendered by bx via transbronchial endoscopic or transthoracic FNA. Brain MRI for presumed stage II/III. Mediastinoscopy or EBUS for suspected hilar r/o N2 nodes. PFTs prior to treatment. Smoking cessation counseling.
What clinical characteristics are important to focus on to determine the nature of a solitary pulmonary nodule?
Nodule size (and whether there are changes in size in past 2 yrs), history of smoking, age, characteristics of nodule margin on CT imaging (ie spiculation)
Describe T-staging of NSCLC using 7th edition of TNM stage.
T1: ≤3cm, surrounded by lung parenchyma (T1a ≤2cm; T1b 2.1-3cm);
T2: >3cm to 7cm, +visceral pl, mainstem bronchus involved but >2cm from carina, +atelectasis to lobe (T2a 3.1-5cm ; T2b 5.1-7cm);
T3 >7cm, tumor invade mainstem bronchus <2cm from carina but not into carina, or invasion to diaphragm, CW, pericardium, mediastinal pleura, or associated atelectasis or obstructive pneumonitis of entire lung, or satellite nodule in same lobe;
T4: invasion of great vessels or adjacent organs, or nodules in separate lobe in ipsilateral lung.
Describe N-staging of NSCLC?
N1: ipsilat hilar or peribronchial nodes. N2: ipsilat mediastinal or subcarinal nodes. N3: any supraclav/scalene nodes or contralateral mediastinal/hilar nodes
In addition to stage, name 3 other poor prognostic factors in lung cancer pts.
In addition to stage, three other poor prognostic factors in lung cancer patients are: (1) KPS < 80%. (2) Wt loss > 5% in 3 months. (3) Age > 60.
What percentage of patients present with stage IIIA disease?
~30% of all NSCLC patients have stage IIIA disease at presentation.
What percentage of patients will have occult N2 dz found at time of surgery?
25% of patients will have occult N2 dz.
After definitive treatment of a primary lung tumor, what is the time period after which is considered a second primary tumor?
A tumor that develops 2 years or more after definitive treatment of primary lung cancer is likely a second primary. Any time a recurrence w/ identical histology occur before 2 yrs is considered a metastasis.
What is the TNM staging that defines IIIA
T3N1, T4N0-N1, T1-3 N2
What is the TNM staging that defines IIIB
T4 N2, Tany N3
What are the survival outcomes of stage IIIA disease with T3N1 vs TxN2 dz?
5 yr =20-25% for T3N1 vs 3-8% with N2 dz
Lung tumor invades the chest wall and is a superior sulcus tumor. Stage
T3 is >7 cm or invades chest wall, diaphragm, phrenic nv, mediastinal pleura, parietal pericardium, or is in the main bronchus not involving the carina.
Lung cancer that invades esophagus. T stage
T4 invades mediastinum, heart, great vessels, trachea, recurrent laryngeal nv, esophagus, vertebral body, carina or separate nodules in a different ipsilateral lobe.
Lung cancer with separate nodules in the same lobe is what T stage?
Separate nodules in the same lobe is T3. T3 can also be: >7 cm or invades chest wall, diaphragm, phrenic nv, mediastinal pleura, parietal pericardium, or is in the main bronchus not involving the carina.
A pt has a Stage IA lung cancer. What does this stage include. What are the treatment options if resected with positive or negative margins/
Stage IA is T1a or T1b. N0.
T1a is <= 2cm and T1b is >2-3 cm. If margins are negative, observe. If positive, re-resect if possible. If not possible, consider RT (cat 2B).
For tumors that are Stage IB and IIA and N0, (includes the T2b,N0) what is the recommendation after surgery for postive and negative margins
If margins are negative, you can observe or consider chemo for high risk patients. High risk patients include poorly differentiated tumors, vascular invasion, wedge resections, tumors greater than 4 cm, visceral pleura involvement, and Nx. If the margins are postive, re-resection is preferred +/- chemo or RT +chemo.
What surgery is performed for T1 lung cancer? What margin is necessary and do lymph nodes need to be sampled?
Lobectomy is preferred over wedge. If a wedge is done the margins should be > 2 cm or > the size of the nodule. When sublobar surgery is performed N1 and N2 nodes still need to be sampled
Sketch the bronchial tree showing the lymph node stations.
For pN2 lung cancer describe the adjuvant treatment recommendation for margin positive and margin negative scenarios.
For pN2 resected tumors with (-) margins: chemo then RT but the sequencing is debatable
For pN2 resected tumors with (+)margins: chemoRT. RT started early given concern for local recurrence
If a lung cancer is N2, what stage group would it fall into?
All N2 is IIIA except for T4N2 which is IIIB.
What factors determine post-operative lung cancer dosing? What is dose for: neg margins, pos margins, and residual gross disease?
Post-op (-) margins: 50.4 @ 1.8-2
Post-op ECE or micro (+): 54-60 @ 1.8-2 Gy
Gross Dz: 60-70 @ 1.8-2.0
In which Stage I lung ca patients is PORT not recommended?
In patients treated with surgery, PORT is not recommended unless there are positive margins or upstaging to N2 (see Locally Advanced Lung
Cancer below).
Which stage II-III NSCLC patients should not get PORT?
Postoperative radiotherapy (PORT) is not recommended for patients with pathologic stage N0-1 disease as it has been associated with increased mortality, at least when using older RT techniques. PORT meta-analysis 1998 showed significant adverse effect of RT on survival with an absolute survival detriment of 7% at 2 years (55 to 48%) in subgroup analysis, RT more detrimental for N0 vs N1. There was no clear detriment for N2. There was a local control improvement with PORT. Additionally, retrospective analysis of the ANITA trial suggests positive effect of PORT in pN2 and negative effect on pN1 when patients received adjuvant chemotherapy. (Adjuvant navelbine international trialist association=anita)
Describe the target and dose when PORT is used.
In PORT, the CTV includes the bronchial stump and high-risk draining lymph node stations. Standard doses after complete resection are
50-54 Gy in 1.8-2 Gy fractions, but a boost may be administered to high-risk regions including areas of nodal extracapsular extension or
microscopic positive margins.
Describe the dose of adjuvant and combined chemotherapy-rt for NSCLC
There are a number of choices and it may be tailored based on the individual patient but a standard regimen at our institution is:
Adjuvant chemo alone for patients with negative resection margins who are getting sequential chemo-rt: cisplatin 100 mg/m2 on day 1 and Etoposide 100 mg/m2 on days 1-3 Repeat q 4 wks for 4 cycles
Concurrent chemo/rt dosing: cisplatin 50 mg/m2 on day 1,8,29,36 and Etoposide 50mg/m2 days 1-5, 29-33
Peripheral T1 N0 s/p wedge of a 1cm tumor (Stage IA). What do you want to do? Patient is healthy firefighter (which to him meant I shouldn’t order PFTs). No evidence of residual disease on imaging.
● Perform lobectomy and sample/dissect mediastinum.
● If additional surgery is not done you observe (no indication for chemo or RT in stage IA with negative margins). If his tumor was T2a (now IB) his Nx status puts him in the high risk category and you could consider chemo.
● If/when it recurs consider resection or definitive chemoRT
80 year-old post-op with T3N2. What stage group is this and how would you manage? First, important step has been done for IIIA which is the lobectomy and lymphadenectomy.
● ChemoRT if margin (+)
● Chemo followed by RT if margin negative
● Remember, LCSG shows improvement in local control and ANITA shows a benefit for PORT in all N2 pts regardless of whether or not they got chemo. There aren’t any randomized phase II studies.
What lymph nodes stations and N-stage are invovled in this pt with NCSLCa?
N1--enlarged right hilar node, station 10-R
What lymph nodes stations and N-stage are invovled in this pt with NCSLCa?
N2, upper paratracheal, station 2
What lymph nodes stations and N-stage are invovled in this pt with NCSLCa?
Right Lower Lobe mass with an N2 subcarinal node, station 7.
What lymph nodes stations and N-stage are invovled in this pt with NCSLCa?
Axial Ct at the lung apices shows, N3, bilateral SCV nodal involvement.
What lymph nodes stations and N-stage are invovled in this pt with NCSLCa?
N3 contralat paratrach
Ways to reduce risk of pneumonitis if V20>30% and was IIIA/B tumor?
Optimize beam angles
Optimize/tighten ITV by 4DCT or inspiratory/expiratory CT scans
Induction chemo first
Re-CT after 36-45 Gy
Amifostine
2 diff types of mediastinoscopy?
Cervical mediastinoscopy assesses levels 1-4R
Anterior (Chamberlain) mediastinoscopy assesses 4L (L lower paratracheal), 5 (APW), 6 (paraaortic), & 7 (subcarinal)
Contraindications to surgery in III?
Poor PFTs
T4 or extracapsular disease
Multi-station N2 disease
Superior mediastinal involvement
Relative: pneumonectomy required

Any of the above has <10% OS even after GTR
None of the above has 20-30% OS after GTR
59-year-old man with ptosis of the left eyelid and pain radiating from the left shoulder to the medial two digits of the left hand but without motor dysfunction. Describe the image.
Superior sulcus tumor in a (a) Axial computed tomographic (CT) image at the apex of the thorax obtained as part of a neck CT examination shows a superior sulcus tumor (SST). The mass clearly abuts the neurovertebral foramen, but the presence and degree of any extension into the foramen are difficult to determine. T = trachea, V = vertebral body
3 yr OS for superior sulcus tumors
50% (better than other sites)
Pt is s/p surgery for pT3N2 NSCLca
Post-op RT indications?
Close (<5 mm)/+ margin, ENE, or N2
Pt goes to surgery. No preop chemo.
pT3N2, -margin
How do you sequence postop chemo & postop RT
Margin-, N2+: chemo x2-4c -> mediastinal RT
NCCN: what is the pre-op chemo/rt dose recommended?
In the preoperative chemoradiation setting, a total dose of 45-50 Gy in 1.8 to 2 Gy
fractions should be used to treat all volumes of gross disease, although
preoperative chemoradiotherapy should be avoided if a pneumonectomy is
required, to avoid post-operative pulmonary toxicity.
In the definitve chemo/rt setting, what dose of RT should be used?
n the definitive chemoradiation setting, a total dose of 60-70 Gy in 1.8 to 2 Gy
fractions should be used to treat all volumes of gross disease.
Is a complete lymphadenectomy recommended in patients with N0-N1 patients? What study supports answer?
The American College of Surgeons Oncology Group randomized trial
(ACOSOG Z0030) compared systematic mediastinal lymph node
sampling versus complete lymphadenectomy during pulmonary
resection in patients with N0 (no demonstrable metastasis to regional
lymph nodes) or N1 (metastasis to lymph nodes in the ipsilateral
peribronchial and/or hilar region, including direct extension) NSCLC
disease. In patients with early stage disease who had negative nodes
by systematic lymph node dissection, complete mediastinal lymph node
dissection did not improve survival.129-131 Thus, systematic lymph node
sampling is appropriate during pulmonary resection; one or more nodes
should be sampled from all mediastinal stations.
Should N2 patients have surgery?
Before
treatment, it is essential to carefully evaluate for N2 disease using
radiologic and invasive staging (i.e., endobronchial ultrasound-guided
procedures, mediastinoscopy, thorascopic procedures) and to discuss
whether surgery is appropriate in a multidisciplinary team (which should
include a board-certified thoracic surgeon).135 Randomized controlled
trials suggest that surgery does not increase survival in these
patients.
While most N2 patients should not have surgery, what is the exception?
Most clinicians agree that resection is
appropriate for patients with a negative preoperative mediastinum and
with a single positive node (< 3 cm) found at thoracotomy.
Is thorascopic lobectomy an appropriate surgical approach? What are the advantages?
Based on its favorable effects on postoperative
recovery and morbidity, thorascopic lobectomy is included in the NCCN
NSCLC algorithm as an acceptable approach for patients who are
surgically resectable (and have no anatomic or surgical
contraindications) as long as standard principles of thoracic surgery are
not compromised. Acute
and chronic pain associated with thorascopic lobectomy is minimal;
thus, this procedure requires shorter length of hospitalization.155,156
Thorascopic lobectomy is also associated with low postoperative
morbidity and mortality, minimal risk of intraoperative bleeding, or
minimal locoregional recurrence.157-161 Recent analyses show that
thoracoscopic lobectomy is associated with less morbidity than
lobectomy by thoracotomy
Why is the dose of pre-operative xrt 45 Gy?
Surgery in a field that has had 60 Gy is difficult,
because the landmarks disappear with high doses of radiation. Thus,
surgeons are often wary of resection in areas that have previously
received RT doses of more than 45 Gy, especially patients who have
received RT doses of more than 60 Gy (i.e., patients who have
received definitive concurrent chemoradiation). Therefore, the
radiation dose should be carefully considered if patients might be
eligible for surgery.
For stage I NSCL compare survival and local control between conventional fractionation and SABR.
With conventional
treatment, 3-year survival is only about 20%-35% in these patients.216
There is a high rate of local failure in patients receiving conventional
RT. However, local control is increased after SABR.217,218 In patients
with stage I NSCLC, SABR provides a significantly longer 5-year
survival than 3-D conformal RT.209 SABR yields median survival of 32
months and 3-year overall survival of about 43% in patients with stage I
disease; patients with T1 tumors survive longer than those with T2
tumors (39 versus 25 months).219
Describe management of a single brain met in a patient with lung cancer and good performance status.
Many patients with NSCLC have brain metastases (30%-50%), which
substantially affect their quality of life.234 Surgery followed by whole
brain RT is recommended (category 1) for select patients (those with
good PS) with a single brain metastasis (see the NCCN NSCLC and
the Central Nervous System Cancers algorithms).235-238 SRS is another
option after surgical resection, although there are only a few
retrospective case series supporting this option.235 Patients with a
single brain metastasis who cannot tolerate or refuse surgery may be
treated with SRS with or without whole brain RT.234,239,240 Note that
recent data suggest that erlotinib may be useful to manage brain
metastases.2
Does whole brain RT decrease neurocognitive function in patients with brain mets?
A study in 208 patients with brain metastases
found that patients who responded (with tumor shrinkage) after whole
brain radiation had improved neurocognitive function and that tumor
progression affects neurocognition more than whole brain radiation.245
In 132 patients with 1-4 brain metastases who received SRS with or
without whole brain RT, survival was similar in both groups.240 In a
subset of 92 of these patients who received SRS with or without whole
brain RT, controlling the brain tumor with combined therapy was more
important for stabilizing neurocognitive function. Li, JCO 2006
Is there any potential value to PCI in NSCLCa?
Prophylactic cranial irradiation (PCI) does not appear to improve
survival in patients with NSCLC; however, it may be considered in
individual patients. Although it closed early because of poor accrual, a
randomized phase III trial (RTOG 0214) of PCI for patients with stage
III NSCLC showed that the incidence of brain metastases was
decreased in patients who received PCI (18% versus 7.7%); however,
overall survival was not improved.249 Impaired memory (immediate and
delayed recall) was reported in these patients receiving PCI.250
What is the preferred approach for a solitary brain met?
Advances in surgical technique have rendered upfront resection
followed by WBRT the standard of care for solitary brain metastases.
What does WBRT add to surgery for a solitary brain met? Is there a survival difference?
Patchell and his group conducted a study that randomized 95 patients
with single intracranial metastases to complete resection alone or
surgery plus adjuvant WBRT.223 Postoperative radiation was associated
with dramatic reduction in tumor recurrence (18% vs 70%; P<0.001)
and likelihood of neurologic deaths (14% vs 44%; P=0.003). Overall
survival, a secondary endpoint, showed no difference between the
arms. Survival is worse if no surgery.
What is the appropriate treatment if >3 brain mets? What dose?
All patients diagnosed with more than three metastatic lesions should
be treated with WBRT as primary therapy. The standard regimens for
WBRT are 30 Gy in 10 fractions or 37.5 Gy in 15 fractions, but no
significant impact to survival was reported with variations in
fractionation and dosing according to a meta-analysis of nine
randomized trials.257 For patients with poor neurologic performance, a
more rapid course of RT can be considered (20 Gy, delivered in 5
fractions). SRS may be considered in select patients (eg., four small
lesions).
Best predictor of survival at time of diagnosis in lung cancer.
QOL assessment at diagnosis
– Best predictor of survival!
• Analysis of phase III RTOG 9801 study involving randomization to
+/- amifostine
• Movsas et al. J Clin Oncol. 2009 Dec 1;27(34):5816-22.
Does screening for lung cancer with CT scans lower mortality? Describe
The National Lung Screening Trial (NLST)
– Prospective randomized study of high-risk individuals
(≥ 30 pack-years, ages 55 to 74 years) in which
individuals were randomized to CT scans or chest xrays
annually for 3 years.
– Recently announced results demonstrated that CT
scan screening decreased lung cancer–specific
mortality by approximately 20% and reduced
all-cause mortality by about 7%
• N Engl J Med. 2011 Aug 4;365(5):395-409.
What constitutes stage group II NSCLC?
all T1-T2 that is N1. and T2bN0
What is the role/benefit for adjuvant treatment for stage II-III NSCLC?
All N+ patients have a survival benefit from adjuvant chemo of 5-15%.
1998 was a bad year for PORT--the lay media got the impression that radiotherapy kills people. What did the meta-analysis show?
PORT showed a 7% survival decrement for N0-N1 patients who got PORT. The decrement was not seen for N2 and there was a LC benefit.
What did the ANITA trial add to our understanding of PORT?
ANITA was a chemotherapy trial but institutions could add PORT. A retrospective analysis of results showed a detriment to adding PORT to N1 patients but an actual benefit for N2 patients.
Tumor less than or = to 5 cm invades the visceral pleura. What is T stage
T2a--once the visceral pleura is penetrated a tumor of less than 5 cm becomes a T2a. If it goes through the visceral pleura into the parietal pleura, it then has penetrated the chest wall and become a T3
How does proximity to the carina change the T stage of a lung cancer?
If it is >2 cm from the carina, it can invade the trachea or mainstem and still be a T2 (if it makes it by size). If it is within 2 cm of the carina, it becomes a T3, even if small.
Lung tumor is causing obstructive pneumonitis of entire ipsilateral lung. What T stage?
T3--can even cause atelectasis of the entire lung and still be a T3.
A lung cancer is compressing the SVC and involves the carina. What T stage?
If SVC is invaded, it would be T4. Involvement of the carina makes it T4 anyway.
What makes lung cancer M1a?
malignant pericardial or pleural effusions, met in contralateral lung
RML lung tumor measures4 cm and invades mainstem within 2 cm of carina. bilateral path pos mediastinal ln. stage?
T3 b/c w/in 2 cm of carina. N3 b/c contralat mediast ln. IIIB