Advanced Lung Cancer Case

[Haybrant]

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Somewhat quirky lung case. 65 year old guy big time smoker, mediastinal lesions on CT. Pet showed subcarinal uptake and left hilar uptake. Biopsy positive for NSCLC favoring adenoCA, PDL-1 is 5% all others negative. On the bronch they saw some endoluminal lesions in the right middle lobe and bronchus intermedius. This picture is attached. They brush cytologied this and it also returned as NSCLC. How do you stage this? Is it considered stage IV mets. I was going to plan him see how bad the dvh looks then treat chemo/rt. Also, he had bronchoscope but not an endoscopy, is that necessary? Lesion is ttf-1 positive.

 

[evilbooyaa]

Idk I don't see huge honking endoluminal lesions unless I'm missing something on the picture. What's the significance of small endoluminal NSCLCs that aren't even visible on CT. Not sure it's worth treating the endoluminal lesions (at least at this point).

Is he having esophageal symptoms? I'm not sure what an EGD will tell you that will change your management (you're not going to not treat him because it's invading esophagus, and you're not going to stent him or something), just respect esophageal tolerances in that area, discuss risk of hole in esophagus is present given extent of disease.

I'd try to do a directional block through the right lung, in case you need to treat those lesions later (potentially with SBRT) it doesn't become problematic overlapping with his current treatment.

 

[scarbrtj]

How do you stage this?

T3N3?
(different lesions same lobe, contralateral hilar+)

Not sure it's worth treating the endoluminal lesions (at least at this point).

If one didn't, wouldn't that be the 'ol field-within-the-tumor technique (usually much less effective than the 'ol tumor-within-the-field technique).

 

[evilbooyaa]

T3N3?
(different lesions same lobe, contralateral hilar+)

If one didn't, wouldn't that be the 'ol field-within-the-tumor technique (usually much less effective than the 'ol tumor-within-the-field technique).

FDG avid lesion is in the left hilum extending into the lung parenchyma (at least on PET). I think that's the real primary unless proven different. I'd look at the CT alone and there's probably a discrete lesion in the left lung parenchyma.

I wouldn't expect small endobronchial lesions (seriously, can somebody point them out to me on the scope image?) to lead to significant mediastinal lymphadenopathy.

The endobronchial lesions are in the right lung, so in a heavy smoker, I'm questioning their clinical utility, I guess. I mean you wouldn't be able to treat them anyways with RT (can't localize to anything, can't find them on planning unless they clipped the areas of concern).

 

[Haybrant]

Ya that small stuff in the lumen is whatever to me but they biopsied it and its positive. I was just going to chase the middle lobe airway out with the field and see what it looks like when its planned. If it is massively exceeding tolerance then maybe ill just pull back and not treat in the interest of treating what is obviously PET positive.

 

[scarbrtj]

Not sure it's worth treating the endoluminal lesions (at least at this point).

Huh. Well pulm saw something; assume it wasn't just a blind bx/brush. I see something. May not be visible on CT, but who ya gonna believe: CT or the endoscopist's eyes. The bronchus intermedius is a defineable thing; it's contourable. The lesions are grossly visible, implying gross disease, implying millions and millions of cancer cells. If left untreated, no matter how high a dose or how well you treat the other PET+ stuff, he has a 100% chance of failure (unless you're Dr. Abe Scopal). I think you could get a V20 <35% with R bronch intermedius+PET positive disease+margin, Rx 60 Gy. WITH IMRT.

 

[mavrik13]

I assume you spoke with the respirologist who confirmed the findings (i.e. the pictures aren't just mislabeled from side to side?) - it's very odd and if it is true contralateral disease, seems more likely to represent a second synchronous primary rather than mets... not unreasonable to treat, but I'd definitely be on the phone getting confirmation prior to treating something I don't see on CT or PET

 

[Haybrant]

I assume you spoke with the respirologist who confirmed the findings (i.e. the pictures aren't just mislabeled from side to side?) - it's very odd and if it is true contralateral disease, seems more likely to represent a second synchronous primary rather than mets... not unreasonable to treat, but I'd definitely be on the phone getting confirmation prior to treating something I don't see on CT or PET

Yep he confirmed it and documented it as concern for right endoluminal disease. They didn’t biopsy 4R/L which is annoying but I’m concerned it’s all positive and there is pet update. Having to cover bilateral hilum and bilat mediastinum I’m concerned how the v20 is going to look but I’ll see an initial plan tomorrow and can decide

 

[seper]

This will behave aggressively. I would, however, try to radiate.

 

[evilbooyaa]

Huh. Well pulm saw something; assume it wasn't just a blind bx/brush. I see something. May not be visible on CT, but who ya gonna believe: CT or the endoscopist's eyes. The bronchus intermedius is a defineable thing; it's contourable. The lesions are grossly visible, implying gross disease, implying millions and millions of cancer cells. If left untreated, no matter how high a dose or how well you treat the other PET+ stuff, he has a 100% chance of failure (unless you're Dr. Abe Scopal). I think you could get a V20 <35% with R bronch intermedius+PET positive disease+margin, Rx 60 Gy. WITH IMRT.

I guess I don't think that's unreasonable, but trying to treat all of that is going to be difficult. But you'd treat the entire bronchus intermedius? For that like 2mm ditzel? Based on just brushings that likely say atypical cells? Without a needle biopsy, CT, or PET/CT correlate?

I guess see what you can come up with for a plan, but I wouldn't break constraints to chase that little thing.

Agree with mavrik that it's most likely a synchronous primary as I don't know that I've ever seen an endoluminal metastasis.

Are all lung cancers created equal? Guess this is more like a scarbrtj post, but there's literature out there that non-aggressive lung cancers exist. This one, which wouldn't even show up on imaging, is it worthy to potentially cause significant toxicity in order to include in the treatment field? Clinically detected non-aggressive lung cancers: implications for overdiagnosis and overtreatment in lung cancer screening

 

[scarbrtj]

I wouldn't break constraints to chase that little thing.

"Little" things need (sort of) about as much dose as what you'd call "big." A "little" lesion of the vocal cord needs 63-70 Gy e.g. For the rad onc, there are three soi-disant sizes of things that need an XRT dose: gross, subclinical, and microscopic disease. "Big" is gross. "Little" is gross. Visible endoluminal lesions, path-positive, are gross. I'm a Fletcherian purist.

In oral boards the examiner in peds shows an Ewing's case of the c-spine... the examinee suggests a 50+ Gy dose... and the examiner says "You don't want to violate spinal cord tolerance do you?" (That's a trap btw.) Breaking a constraint doesn't guarantee a toxicity. Not treating gross disease (usually) guarantees local failure, or at least a toxicity which affects QOL more than XRT late effects.

non-aggressive lung cancers exist.

Perhaps & agree. But they are likely not stage N3.

 

[Palex80]

These could be either metastatic lesions (spread either through blood as distant mets or through submucosal lymphatics) or simultaneous secondary primaries (less likely).

I‘d treat all. But it‘s probably palliative, 5–year OS something like 5–10%.

 

[Haybrant]

The doses weren’t great v20 40%, mld 19 and v5 95%. Gonna come off the right and treat What I see which is hard enough to control then have the pulm go back in and take a look after rt and consider pdt or something after. Will talk about it w patient so he consents too

 

[medgator]

The doses weren’t great v20 40%, mld 19 and v5 95%. Gonna come off the right and treat What I see which is hard enough to control then have the pulm go back in and take a look after rt and consider pdt or something after. Will talk about it w patient so he consents too

Take it to 40-44 and re scan for a boost is an option as well