80 year old guy with NSCLCa. Lesion measures approximately 5 cm in largest dimension. Mediastinum negative. Pt has a hiatal hernia (blue contour). Wondering what you guys would offer?
Lung Case
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Wow, that's a really tough case. You may want to scan with oral contrast to precisely identify the location of the stomach in relation to the hernia. But I guess that the blue contour is all stomach which would make even 5 fraction SBRT very difficult.
Some possibilities:
1. Hypofrationated XRT alone (a la Slotman)
2. Make up an SBRT regimen to maximize BED and minimize gastric point dose. Look at RTOG protocols for 3 and 5 fraction constraints to stomach.
3. Radiofrequency Ablation
4. Ask surgeon to patch hiatal hernia so you can do SBRT
5. Wedge resection +/- mesh brachytherapy
Some possibilities:
1. Hypofrationated XRT alone (a la Slotman)
2. Make up an SBRT regimen to maximize BED and minimize gastric point dose. Look at RTOG protocols for 3 and 5 fraction constraints to stomach.
3. Radiofrequency Ablation
4. Ask surgeon to patch hiatal hernia so you can do SBRT
5. Wedge resection +/- mesh brachytherapy
I wonder what the PET shows. IT looks like there may be some collapsed lung in that "mass" and mediastinal structures seem to be pulled to tumor.
I was hoping for that, but unfortunately contour was based on the PET
Great case and discussion. I would be a little concerned about hypofractionation unless you are very careful to access and control motion. I would expect you have to think about motion of both the tumor and the hernia. How did you account for motion?
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was the patient npo for simulation? i had a similar case about three months ago, though not nearly as close to the stomach as your case. I brought the patient back for sim NPO and then there was much more room between GTV and stomach and I was able to do stereotactic and I did daily CBCT and verified that I was off the stomach.
If the patient is npo and you have this issue, i personally would be very hesitant to offer stereotactic in this situation since the GTV is basically next to the stomach and you need a BED of at least 100 for local control. You really don't want a gastric ulcer or major bleed or even worse on your hands from this. I would probably consult thoracic surgery to see if the patient is a candidate for surgery and if could get surgery i would go for that over xrt. If not a surgical candidate, could look into getting hernia fixed and hopefully could be medically cleared for that kind of surgery.
If the patient is npo and you have this issue, i personally would be very hesitant to offer stereotactic in this situation since the GTV is basically next to the stomach and you need a BED of at least 100 for local control. You really don't want a gastric ulcer or major bleed or even worse on your hands from this. I would probably consult thoracic surgery to see if the patient is a candidate for surgery and if could get surgery i would go for that over xrt. If not a surgical candidate, could look into getting hernia fixed and hopefully could be medically cleared for that kind of surgery.
