PORT for a G3 NSCLC (Large-cell) pT2aN1, Stage IIB, Level 10 LN 2.5 cm with ECE?

[medgator]

72 y/o M with good PS, taken for EBUS pre-op which was negative everywhere. A PET/CT had been ordered for staging, and the CT chest with contrast didn't call the level 10 LN.

At the the time of surgery, the patient had a RUL NSCLC removed with negative margins via lobectomy along with lymphadenectomy at stations 4,7,8,9, and 10. Tumor was 5 cm, negative margins/negative pleural involvement. All of the nodal stations were negative except at station 10 where a 2.5 cm LN was found with extensive microscopic ECE.

Per surgeon, it was adjacent to the pulmonary artery at the R hilum but was not fixed to it.

Calling pathologist now, not sure you can really find a "margin" on a node with ECE next to the PA, right?

Would anyone offer port to the R hilum for an N1 node in this situation?

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[seper]

I would based on ECE, but only after chemo.

 

[medgator]

I would based on ECE, but only after chemo.

Yeah I would treat him sequentially after 4 cycles of a platinum doublet, figured I have some time to think about this.

 

[Palex80]

No data on that really. You can do it, but you don't have to.

Why on earth did the PET-CT miss a 2.5 cm node?

 

[medgator]

No data on that really. You can do it, but you don't have to.

Why on earth did the PET-CT miss a 2.5 cm node?

It was right next to a vessel but I agree. I'm curious to see the imaging when I finally see him in consult

 

[Phantom1]

Didn't most of the PORT meta-analyses show a survival determinant to PORT for N1 disease? I would recommend chemo alone if margin is negative. I would only offer him PORT if he is unable to receive or refuses chemo. Also is it Adeno or Squam? Targeted agents could be useful..

 

[medgator]

Didn't most of the PORT meta-analyses show a survival determinant to PORT for N1 disease? I would recommend chemo alone if margin is negative. I would only offer him PORT if he is unable to receive or refuses chemo. Also is it Adeno or Squam? Targeted agents could be useful..

It's a large cell, poorly-differentiated. Receptors are all negative. My reasons for hesitating a bit are exactly as you pointed out.... the data from ANITA, SEER etc (since we lacke really good randomized data for PORT) suggests a benefit only in N2 patients, a possible detriment in N0-1 patients (especially if the N1 patients do in fact get chemo).

https://en.wikibooks.org/wiki/Radiation_Oncology/NSCLC/Early_Stage_Operable#Post-operative_EBRT

The patient will be getting 4 cycles of a platinum doublet. Pathologist is going to look at the LN carefully, if there is clear evidence of ECE out to the periphery (i.e. cells next to an "inked" margin), I will probably be a little more comfortable treating him.... even then, it's crossed my mind to send him out for a second opinion

 

[NotBeyonce]

I would based on ECE, but only after chemo.

As you stated, PORT typically not recommended for pN1. However, guidelines give equivocal recommendation for pN1: "PORT if adverse factors present."
So, I would probably consider it (ECE in any other disease site buys you PORT, since chemo will not take care of it), but know that the patient is at high risk of distant failure.
You could also consider re-staging scans after finishing chemo, and then go from there...

 

[Reaganite]

Seems like you can justify RT if you consider this a "positive margin" and just target the pre-chemo extent of disease in the hilum. To me, this is a lot different than targeting the entire mediastinum as they did in the older PORT trials.

 

[medgator]

As you stated, PORT typically not recommended for pN1. However, guidelines give equivocal recommendation for pN1: "PORT if adverse factors present."
So, I would probably consider it (ECE in any other disease site buys you PORT, since chemo will not take care of it), but know that the patient is at high risk of distant failure.
You could also consider re-staging scans after finishing chemo, and then go from there...

Which guideline has that? Nccn?

 

[medgator]

Spoke with the original reading pathologist who went ahead and took a closer look at the 10R LN. He put in an addendum stating "The extracapsular extension does appear to focally extend to the cauterized margin of resection"

Sounds like a "positive margin" to me that needs to be treated. 54 Gy to the hilum... would anyone do different?

 

[Palex80]

60 Gy

 

[medgator]

60 Gy

Just checked, as per NCCN, it's a range when it comes to ECE/+microscopic margins of 54-60 Gy