Lung Cancer in IPF Patient

[Haybrant]

Have an old patient 86 yo man 40 pack year smoker quit 30 years ago who is diagnosed with IPF with a FEV1 of 1 and DLCO 30% who has a IIIA NSCLC type pending but TTF-1 negative based on an fna so favoring SCC. He has a 3 cm LUL primary with a 4 cm left hilar lesion and a 3cm subcarinal lesion. He is on 2 to 3 L of O2 with light exertion which was started in the last 6 months. His ECOG is 2

What is the appropriate considerations here? Obviously he is quite old, bad lungs, and on O2. I also recall from somewhere that IPF patients do really poorly with RT and you that the risk of tipping them into respiratory failure is quite high but im not finding studies on this right now. Patient and family interested in being aggressive

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[Gfunk6]

See this article: Radiation pneumonitis and pulmonary fibrosis in non-small-cell lung cancer: pulmonary function, prediction, and prevention. - PubMed - NCBI

It extensively discusses all the data regarding XRT for NSCLC in patients with preexisting pulmonary fibrosis. The bottom line is that doing XRT in these scenarios is not an absolute contraindication but there are some evidence-based steps you can take to minimize toxicity.

 

[Palex80]

I am afraid this is quite a challenging case. I can't tell you, if I would go for concurrent RCT in such a patient. A sequential approach sounds reasonable as well, although inferior in terms of tumor control efficacy. You are going to have to treat quite a large volume, from what you have described.

This is a left lower lobe primary, meaning that the contralateral mediastinum is also at risk, especially since you have a positive infracarinal N2 node. In a lung-healthy patient many would advise to perform limited elective nodal irradiation of the right mediastinum (primarily station 4R).

I would advise you to try to get a SPECT-CT. Trying to avoid bringing the beams through the best functioning parts of his lungs may limit his pulmonary function loss after RT.

 

[seper]

Agree, talk to tour MedOnc and agree that combined CRT is not advisable.

 

[Mandelin Rain]

I recently saw a similar patient (old, limited stage III) carrying a diagnosis Scleroderma with primarily pulmonary fibrotic manifestations and a moderate to severe restrictive pattern on PFTs.

We decided to start with chemo, get her on some maintenance Alimta/Tarceva/Something, and follow closely. At some point maybe our hand gets forced to irradiate something, but I'm loathe to potentially hasten her demise given the low cure rates/survival post chemorads in even ideal stage III patients.

 

[medgator]

Tough situation, and these are patients who are going to be left behind by the move to more PD1/PD-L1 inhibitor therapy in NSCLC

 

[napoleondynamite]

Opdivo is an option if patients fail platinum-based treatment. Sometimes my medoncs will give a very brief 'trial' of platinum..like a baby squirt..so that a patient can meet criteria for a less toxic therapy. Maybe that's an option here..

If the patient is a candidate for Opdivo, one compelling option could be SBRT the primary and start Opdivo. Not standard, but you have a patient who cannot tolerate standard treatment, so I don't think anyone would fault you for being creative. A small SBRT field to the peripheral lung lesion is unlikely to do harm and would not burn the bridge to (heaven forbid) future mediastinal RT if the subcarinal or hilar node become a problem.

 

[medgator]

Opdivo is an option if patients fail platinum-based treatment. Sometimes my medoncs will give a very brief 'trial' of platinum..like a baby squirt..so that a patient can meet criteria for a less toxic therapy. Maybe that's an option here..

If the patient is a candidate for Opdivo, one compelling option could be SBRT the primary and start Opdivo. Not standard, but you have a patient who cannot tolerate standard treatment, so I don't think anyone would fault you for being creative. A small SBRT field to the peripheral lung lesion is unlikely to do harm and would not burn the bridge to (heaven forbid) future mediastinal RT if the subcarinal or hilar node become a problem.

My point was that those therapies are going to be tough in patients with underlying autoimmune disease. I imagine they might even be relative contraindications, esp if someone has IPF already.

 

[napoleondynamite]

My point was that those therapies are going to be tough in patient with underlying autoimmune disease. I imagine they might even be relative contraindications, esp if someone has IPF already.

Oh, duh - I'm sure you're probably right on that.

 

[Haybrant]

Thanks guys.

Different lung patient but somewhat similar situation. I have a pt w bilateral supraclav and pretty extensive mediastinal positive nodes with a 3 cm LUL primary and left hilar adenopathy. Super high risk obviously but no distant dz at present. In this situation is a sequential approach reasonable to see if pt does met out? And if you do sequential what is the appropriate protocol - get imaging after 2 cycles/4 cycles? Do you RT all initial sites? I actually think I could get it all without exceed lung tolerance right now, the patient is young and motivated, but more concerned about how extensive it is at present

 

[evilbooyaa]

Given that it's upper lobe, I would guess you'd be able to meet lung constraints, so I would lean towards concurrent chemoRT. It's more toxic but I wouldn't withhold curative (obviously low rates though) treatment for consideration of sequential. If you do induction chemo, I would still do chemoRT and not RT alone afterwards.

However, if you did chemo, I would still treat all initial sites, then boost persistent gross disease. Time to re-imaging is variable but we seem to do it after 2 or 3 cycles of chemo here.

Any trials open at your institution to intensify chemoRT? There are some in the area looking at adding immunotherapy in conjunction with definitive chemoRT for stage III NSCLC.

 

[medgator]

I've treated a sclc with bilateral scv disease curatively. Had a CR on PET, refused PCI, ended up with isolated brain mets 6 months later, got wbrt elsewhere fwiw. Assuming the pt doesn't have ipf, it's worth a shot to go concurrent, esophagus will get toasted, go induction first if you are really concerned and if they met out, your decision is made.

 

[Haybrant]

thanks guys that's all helpful. Yah for SCLC I get that, I think that turisi trial actually covered bilat supraclav electiveley but ya for NSCLC its bad news but will give it a shot and see how it goes.

Lets say med onc decides to give full course chemo for a guy like that who has extensive adenopathy and poorly located primary that your lung doses are crushing the V20. After they complete chemo in that setting (6 cycles), what consolidative RT fields do you offer?

 

[evilbooyaa]

thanks guys that's all helpful. Yah for SCLC I get that, I think that turisi trial actually covered bilat supraclav electiveley but ya for NSCLC its bad news but will give it a shot and see how it goes.

Lets say med onc decides to give full course chemo for a guy like that who has extensive adenopathy and poorly located primary that your lung doses are crushing the V20. After they complete chemo in that setting (6 cycles), what consolidative RT fields do you offer?

I would feel silly not treating previously involved sites to at least some dose. Might be some rationale to doing areas of complete response to 50Gy, as kind of a microscopic dosing?
The upside is the covering area to 60Gy (or whatever your definitive lung dose is) will be smaller so smaller PTVs overall (even when you're treating similar areas).

At least 50Gy to areas that resolved post-chemo. 60-66Gy to areas that still have gross disease. Manage lung DVH as however you normally would otherwise (do you push lung doses to get curative dose to necessary areas? or are you OK with poorer coverage to spare more of the lung) in this setting. Would do sequential boosts, tight along post-chemo positive areas.

 

[Haybrant]

what are you all's single lung constraint? Like we always talk about pneumonitis and mean lung dose and V20 of total lung - GTV -- but what is reasonable for the single lung? Had some patients do less than stellar after having high unilat lung doses. Thanks

 

[medgator]

what are you all's single lung constraint? Like we always talk about pneumonitis and mean lung dose and V20 of total lung - GTV -- but what is reasonable for the single lung? Had some patients do less than stellar after having high unilat lung doses. Thanks

The right lung has more functional capacity than left as a general rule (rml > lingula). You could always get a lung perfusion scan to see which areas are most functional. My guess is cutting the constraints by 50-60% (???) Depending on which lung you are radiating

 

[Haybrant]

The right lung has more functional capacity than left as a general rule (rml > lingula). You could always get a lung perfusion scan to see which areas are most functional. My guess is cutting the constraints by 50-60% (???) Depending on which lung you are radiating

what do you mean cutting the constraints by 50-60%? Like what V20/MLD would be reasonable when looking just at the 1 lung?

 

[medgator]

what do you mean cutting the constraints by 50-60%? Like what V20/MLD would be reasonable when looking just at the 1 lung?

As a percentage I would guess it would be the same actually.... do you have an fev1 of that lung?

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[Haybrant]

As a percentage I would guess it would be the same actually.... do you have an fev1 of that lung?

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FEV1 is 1.28L but I don't have a VQ to know what % from each lung. DLCO is 28%. It is a small cell patient w dz in hilum and level 7. Mean Lung for just the unilateral lung is 27 however, and V30 is 40%. For the total lung the V20 is 25% and MLD is 13.

 

[Haybrant]

FEV1 is 1.28L but I don't have a VQ to know what % from each lung. DLCO is 28%. It is a small cell patient w dz in hilum and level 7. Mean Lung for just the unilateral lung is 27 however, and V30 is 40%. For the total lung the V20 is 25% and MLD is 13.

Bumping for input on the single lung measures here. Thank you

 

[medgator]

Bumping for input on the single lung measures here. Thank you

Well fwiw, I've seen xrt patients come to me with baseline fev1 measurements of 0.6L, so I'd think you'd have some room to play with.... of course those pts usually came in on oxygen and weren't really moving a whole lot

 

[evilbooyaa]

Bumping for input on the single lung measures here. Thank you

I don't routinely have any single lung measures as long as they have two relatively functional lungs, even if FEV1 is 1.28L. I mean, the V20 on the side that has the disease is going to be higher than the side that doesn't, but that's obvious. I think all you can do is minimize it, try to push the V20 bowing out more into esophagus/trachea/mediastinum (from the hilum) and out of the lung as much as possible if that's your main concern. Be OK coming in through the spinal cord, as necessary. Obviously plan IMRT to minimize V20. After 0617, I'm no longer confident that V5 is a big player. Nice to keep track of, but not worth improving to sacrifice V20.