Thoracic Flashcards
(268 cards)
1
Q
What is 2L chemo for SCLC
A
topotecan
2
Q
NCCN guidelines for 2L treatment of ES-SCLC
A
If relapse <6 months post platinum, preferred regimen is topotecan, lurbinectidin or clinical trial, ipi/nivo is classified as other
3
Q
Number of cases of lung cancer per year
A
220000
4
Q
What percentage of cases is SCLC
A
15%
5
Q
Of the patients diagnosed with SCLC what share have LS
A
30%
6
Q
Prognostic factors for LS-SCLC
A
- age
2. gender
7
Q
Prognostic factors for ES-SCLC
A
age KPS gender # met sites baseline Cr
8
Q
Markers positive for SCLC
A
synaptophysin
chromogranin A
CD56
9
Q
Treatment for LS-SCLC
A
concurrent chemoRT
cis-etoposide x 4 cycles with RT to 45 Gy in 1.5 Gy BID
10
Q
Dose of cisplatin for SCLC
A
80 mg/m2 day 1
11
Q
Dose of etoposide for SCLC
A
100 mg/m2 day 1,2,3
12
Q
How often are cycles of cis-etop given
A
q3 weeks
13
Q
What is OS for chemoRT for LS-SCLC
A
4 year OS of 30%
14
Q
Pignon meta-analysis compared
A
RT alone vs. CRT for LS-SCLC
15
Q
Findings of Pignon
A
CRT 3 year OS of 14% vs. 9% RT alone so absolute OS benefit of 5%
16
Q
What is absolute OS benefit for CRT over RT
A
5%
17
Q
Per Pignon meta analysis which group benefited more
A
younger pts
18
Q
Meta analysis showed that max benefit occurs when RT starts by week X of chemo
A
9
19
Q
CONVERT trial design
A
Phase III of LS-SCLC randomized to
- 66/33 + cis etop 4-6 cycles
- 45/30 BID + cis etop 4-6
20
Q
Findings of CONVERT
A
Failed to show superiority of QD vs. BID and stated BID should remain SC
21
Q
CONVERT toxicity differences
A
No differences between arms in G3-4
22
Q
For CONVERT trial when did RT start
A
cycle 2
23
Q
V20 goal for SCLC
A
<30-40%
24
Q
Mean lung dose goal
A
<20 Gy
25
Esophagus mean dose goal
<34 Gy
26
Spinal cord dose max goal
<36-37 Gy
27
SCLC Turissi volumes
GTV + 1.5 cm
28
What is the first line regimen for ES-SCLC
Carbo+Etoposide+Atezolizumab
29
OS in IMPOWER133 trial
Atezo: 12.3 months
| No atezo: 10 months
30
CREST (Slotman) trial for ES-SCLC design
RCT of 4-6 cycles of EP --> any response
1. thoracic RT + PCI
2. PCI alone
31
Dose of thoracic RT used on Slotman trial
30/10
32
Outcome of Slotman trial
Improved OS at 2 years
chest RT: 13%
no RT: 3%
Improved PFS
33
Chest volumes included on Slotman trial
Post chemo tumor + 1.5 cm
| Pre chemo nodes (even if CR)
34
Lung constraint on Slotman trial
V20 < 35%
| Defined lung as lung - PTV
35
When should PCI be offered to patients
3-6 weeks after completion of chemo
36
Auperin meta analysis
Compared PCI vs. no PCI for patients with LS-SCLC
37
Results of Auperin meta-analysis
5% OS benefit at 3 years for patients who had PCI (20% v. 15%)
38
Dose of PCI
25/10 (studies of 36 Gy no better)
39
Slotman ES-SCLC PCI study
Any response to chemo randomized to
1. PCI (20-30 Gy)
2. no PCI
40
Slotman finding
1 year OS
27% with PCI, 13% without PCI
Brain met risk
15% (PCI) --> 40% (no PCI)
41
Any additional tox with PCI
did not affect global health score
42
Criticism of Slotman study
no pre PCI brain imaging unless symptomatic
43
Japanese PCI study
ES-SCLC with any response to chemo --> no brain mets on MRI --> randomized to
1. PCI (25/10)
2. no PCI
44
Results of PCI/no PCI OS
PCI: median of 11.6 months
| No PCI: 13.7 months
45
Rate of BM at 12 months without PCI
60% no PCI
| 33% PCI
46
Reduction in lung cancer specific mortality with low dose CT annually
20%
47
What proportion of NSCLC has EGFR mutation
10%
48
What subtypes more likely to spread to brain?
adenocarcinoma, large cell
49
PET false negative rate for mediastinum
10%
50
Chamberlain procedure is needed to sample which stations
5, 6
| Can also get 4, 7
51
Level 5 nodes aka
AP window
52
Optimal treatment of stage I NSCLC
lobectomy
| MLND
53
Can consider SBRT for lesions < X mm
5
54
Which factors are utilized to determine if patient is surgical candidate
FEV1
| DLCO
55
5 year OS with surgery alone for stage I
80%
56
RTOG 0236 for peripheral tumors dose
20 x 3 to PTV but was actually 18 x 3
57
What was the local control on 0236
90% ar 3 years, 80% at 5 years
58
What was OS at 3 years for this study
55%
59
What was GTV expansion on 0236
1 cm craniocaudal, 0.5 cm radially unless 4D and image guidance in which case 0.5 cm circumferentially
60
SPACE trial
Randomized patients to
1. 66 / 3 SBRT
2. 70 / 35 3DCRT
61
Results of SPACE
no diff in OS
| Trend towards improved LC, higher QOL with SBRT
62
pCR rate 10 weeks after SBRT
60%
63
PORT meta analysis OS
7% survival DECREASE with PORT
64
PORT meta analysis locoregional failure
24% decrease in LRR with PORT
65
Possible explanation of PORT metaanalysi
Old techniques (Co)
Weird fractionations
Early stage patients included
66
SEER Data suggests PORT may be advantageous for pts with
pN2
67
ANITA analysis
pN1 - harmed by adjuvant RT (unless no chemo)
| pN2 - benefit
68
Chemo regimens for adenocarcinoma
1. Cis/Pemetrexed
| 2. Carbo/Taxol +/- Bev
69
Chemo regimen for SCC
cis/etoposide
70
When should adjuvant chemo be given
stage I - maybe if >4 cm
| stage II/III yes
71
Mgmt of superior sulcus tumors
ChemoRT --> surgical resection
72
SWOG 9416 trial design
2 cycles of cis-etoposide --> 45 Gy / 1.8 Gy
| Additional RT to 60 Gy if unresectable
73
What patients were included on Pancoast trial
T3-T4
| N0-1
74
What percentage of patients underwent surgery
80%
75
What were the surgical advantages of preop CRT
94% R0
29% CR
36% minimal microscopic residual
76
Auperin meta analysis for locally advanced concluded that concurrent CRT had X% OS advantage
5%
77
RTOG 0617
RCT of two dosing schedules
1. 60/30
2. 74/37
78
What chemo was used on 0617
Concurrent weekly carbo-taxol
Carbo AUC 2
Taxol 45 mg/2
then consolidation carbo-taxol
79
Heart constraint on 0617
V60 < 1/3
80
What heart dosimetric metric was identified as prognostic
Cardiac V50
| V40 as well
81
Findings of 0617
high dose associated with poorer survival and control
82
Benefit of IMRT on 0617
IMRT had less G3+ pneumonitis
| Associated with lower heart dose
83
Factors associated with improved OS on 0617
```
60 Gy
Smaller PTV volume
Lower heart V5
Max esophagitis grade
Higher institutional accrual
Non-LLL or central location
```
84
PACIFIC trial design
ChemoRT to 60 Gy
| Randomized to get durvalumab q2w for up to a year
85
When do patients start durvalumab
1-42 days post CRT
86
12 month PFS benefit for durva
durva: 55%
placebo: 35%
87
Other endpoints improved with durva
Response rate
Duration of response
Time to death or distant mets
88
Preferred systemic therapy option for M1 disease
PDL1 > 50% - pembro
| PDL1 < 50% - chemo+pembro
89
RTOG 0937 [PCI + PCI + consolidative RT to intrathoracic/extracranial mets for ES-SCLC] dose to thoracic/extracranial disease
45 Gy in 15
90
RTOG 0937 [PCI + PCI + consolidative RT to intrathoracic/extracranial mets for ES-SCLC] OS findings
No difference at 1 year [60% vs. 51%, NSS]
| But oligometastatic ES-SCLC outcomes similar to LS-SCLC
91
RTOG 0937 [PCI + PCI + consolidative RT to intrathoracic/extracranial mets for ES-SCLC] time to progression
Favored consolidation arm and most pts on PCI only arm failed in initially involved sites
92
How was CONVERT trial designed?
To show superiority of 66 Gy QD vs. 45 BID
93
How many cycles of chemo on CONVERT?
4-6 cycles of cis-etoposide q3w
94
When did RT start on CONVERT
day 22 (with cycle 2)
95
Design of RTOG 0617
2x2 factorial study randomized to
1. 60 Gy
2. 74 Gy
3. 60 Gy + Cetuximab
4. 74 Gy + Cetuximab
96
Patients included on 0617
Unresectable stage III, no SCV or contralateral hilar nodes
97
Chemo used on 0617
concurrent and adjuvant
concurrent carbo (AUC 2) and paclitaxel (45 mg/m2) weekly
adjuvant 2 cycles of carbo (AUC 6) and paclitaxel (200 mg/m2) q3w
98
Dose of cetuximab on 0617
400 mg/m2 (day 1) --> 250 (weekly)
99
Median OS for 60 Gy arm
29 months
100
Median OS for 74 Gy arm
20 months
101
Median OS for cetux vs. no cetux
25 vs. 24 months (NSS)
102
1 year LF for 60 vs 74 Gy arm
16% vs. 25% (NSS)
103
0617 differences in toxicity by dose
No differences between G3+ by dose level
104
0617 differences in toxicity by cetux/no cetux
86% for cetux vs. 70% for no cetux
105
What tox was worse with 74 Gy
severe esophagitis
106
From 0617 factors associated with OS
1. 60 Gy
2. Max esophagitis grade
3. PTV size
4. Heart V5 and V30
107
AP/PA field border for hemithoracic RT for meso - superior
Top of T1
108
AP/PA field border for hemithoracic RT for meso - inferior
bottom of L2
109
AP/PA field border for hemithoracic RT for meso - lateral
flash skin
110
AP/PA field border for hemithoracic RT for meso - medial
if N+: 1.5-2 cm beyond contralateral vertebral body border
| if N-: contralateral vertebral body border
111
INT 0096 Turrisi study design
LS-SCLC randomized to either
1. 45 Gy (1.8 daily)
2. 45 Gy (1.5 BID)
112
INT 0096 Turrisi study chemo used
cis: 60 mg/m2
etoposide: 120 mg/m2
q3w x 4 cycles
113
5y OS results for INT 0096
Hyperfractionation 26%
| Standard fractionation 16%
114
CHISEL study design [TROG 09.02]
Stage I NSCLC (T1-2aN0) peripherally located randomized 2:1 to
1. SBRT
2. standard RT
115
CHISEL results - LC
SBRT: 89%
Standard: 65%
116
Median OS
SBRT 5 years
| Standard: 3 years
117
Conclusion of CHISEL
In patients with peripheral stage I NSCLC, SBRT resulted in superior tumor control and OS compared to standard RT
118
When doing SBRT for large tumors, what was different from doing daily fx vs. QOD
Rate of G2+ toxicity
119
Gomez study patients
Stage IV NSCLC
3 or fewer mets
No POD at 3 or more months after front line systemic therapy
120
Gomez study design
RCT of
1. Maintenance therapy or obs
2. SBRT to all active disease sites
121
Gomez study results - PFS
SBRT: 14 months
| Systemic therapy: 4 months
122
Gomez study results - OS
SBRT: 41 months
Systemic: 17 months
123
On Gomez study any differences in tox
no significant G3+ differences
124
SBRT dose for peripheral tumors
18 x 3
| 60/8 if >5 cm
125
SBRT dose for central tumors
12.5 x 4
10 x 5
60/8
126
SBRT dose for ultracentral tumors
60/8
65/10
70/10
Concurrent CRT
127
Chest wall constraint for SBRT
V30 < 30 cc
128
Lung constraint for SBRT
V20 < 25% (ipsi lung)
| V20 < 12.5% (both lungs)
129
PORT dose
50.4 Gy
| 10 Gy boost for + margin or ECE
130
Indications for PORT
N2
| Positive margin
131
Conventional RT constraint for V20
<30-35%
132
Conventional RT constraint for lung mean dose
20 Gy
133
Conventional RT constraint for Heart V50
<25%
134
Conventional RT constraint for Heart mean dose
20 Gy
135
Conventional RT constraint for spinal cord Dmax
50 Gy
136
Conventional RT constraint for esophagus mean
34 Gy
137
Conventional RT constraint for Dmax esophagus
<105%
138
Conventional RT constraint for esophagus V60
<17%
139
Conventional RT constraint for brachial plexus
<66-69 Gy
140
Where does brachial plexus run through
anterior and middle scalene
141
Risk of RT pneumonitis is
5-15% 1-3 months post RT
142
What does grade 2 pneumonitis require
steroids
143
What does grade 3 pneumonitis require
oxygen
144
Steroid dose for RT pneumonitis
60 mg pred x 2 weeks
| Slow taper over 6-12 weeks
145
T1 lung
<3 cm
146
T1a lung
0-1
147
T1b lung
1-2 cm
148
T2 lung
3-5 cm
149
T2a lung
3-4 cm
150
T2b lung
4-5 cm
151
T3 lung
Tumor 5-7
Invasion of chest wall, parietal pleura/pericardium
Two nodules in same lobe
152
T4 lung
Tumor >7 cm
Invasion of heart, great vessels, diaphragm, trachea, carina, separate nodules in ipsilateral lobe different from primary
153
N1 lung
Ipsi peribronchial or hilar node
154
N2 lung
Ipsi mediastinal and/or subcarinal node
155
N3 lung
Contralateral mediastinal
Contralateral hilar
Ipsi or contra SCV node
156
M1a
Tumor nodules in contralateral lobe
Pleural or pericardial nodules
Malignant pleural/pericardial effusion
157
Thymoma typically affects what chamber of mediastinum
anterior (most common tumor)
158
Median age of patients with thymoma
older than 50
159
What % of patients with myasthenia gravis have thymoma
10-15%
160
What determines prognosis of thymoma
invasiveness
| completeness of surgical resection
161
Treatment of choice for thymoma
en bloc surgical resection
162
Masaoka stage I
grossly and microscopically completely encapsulated
163
Masaoka stage IIa
Microscopic transcapsular invasion
164
Masaoka stage IIb
Macroscopic invasion into thymic or surrounding fatty tissue or grossly adherent to pleura/pericardium but not through
165
Masaoka stage III
Macroscopic invasion into neighboring organ (pericardium, great vessel, lung)
invasion into pleura
166
Masaoka stage IVa
Pleural or pericardial mets
167
Masaoka stage IVb
lymphogenous or hematogenous mets
168
What determines Masaoka stage
depth of invasion
169
Which RO stage thymoma should get PORT
stage II-IV only if close margins (45-50)
170
R1 resections should get what dose
54
171
For R2 resections or unresectable
60-70 Gy to entire thymic bed often with concurrent cisplatin
172
Stage I meso
pleura only
173
Stage II meso
diaphragm or lung involvement
174
Stage III meso
chest wall, potentially resectable
175
Stage IV meso
unresectable
176
What is the preferred surgical approach for meso
extrapleural pneumonectomy
177
What is the other surgical option
pleurectomy/decortication
178
Common preop dose
45 Gy
179
Patients with borderline N2 nodes on PET should undergo
pathologic staging of mediastinum prior to committing to a treatment strategy
180
What stage is N3 lung disease
T1-T2: IIIB
| T3-T4: IIIC
181
Which two veins converge to form SVC
Left brachiocephalic vein
| Right brachiocephalic vein
182
The brachiocephalic artery becomes the
R common carotid
| R subclavian artery
183
RTOG 0813 centrally located SBRT trial lung constraint V20
<10%
184
RTOG 0813 centrally located SBRT trial lung constraint volume getting less than 12.5 Gy
>1500 cc
185
RTOG 9410 (Curran) sequential vs. concurrent CRT patients
medically or surgically inoperable stage II-IIIB
186
9410 design
RCT of 3 arms
1. Induction chemo --> RT cis/vinorelbine
2. Concurrent ChemoRT (63 Gy), 1.8 x 25 then 2 x 9 cis/vinorelbine
3. Concurrent Hyperfractionated CRT (69.6 Gy in BID fractions) with cis/etoposide
187
Chemo used in 9410
Cisplatin 100 mg/m2 day 1/29
| Vinorelbine 5 mg/m2 weekly x 5 weeks
188
Survival conclusion from 9410
OS advantage for the two concurrent arms over the sequential
189
Toxicity conclusion from 9410
Early toxicity was worse with concurrent (especially esophagitis) but late was similar
190
T1c lung
2-3 cm
191
Invasion of visceral pleura is what T stage
T2a
192
Invasion of parietal pleura is what T stage
T3
193
Mainstem bronchus invasion is what T stage
T2
194
Atelectasis/obstructive pneumonitis extending to hilum is what T stage
T2
195
Invasion of diaphragm is what stage
T4
196
Chest wall invasion is what T stage
T3
197
Superior sulcus tumor is what T stage
T3
198
What paraneoplastic syndrome associated with lung SCC
PTHrP associated hyperCa
199
What paraneoplastic syndrome associated with SCLC
Lambert-Eaton
cerebellar ataxia
SIADH
200
Osimertinib improves DFS or death by what % post resection?
80%
201
From ADAURA trial did osimertinib decrease rates of locoregional or distance recurrence?
Both
202
FEV1 requirments for surgery
FEV1 < 40-50%
| Predicted postop FEV1 <30%
203
What is top risk for RFA of early stage lung cancer
pneumothorax
204
Results from Slotman CREST trial
No difference in 1 year OS (primary outcome)
13% vs. 3% difference for 2 year OS
Improved PFS
205
CALGB 39801 (Volkes trial) conclusion
No benefit for induction chemo --> chemoRT for nonoperable Stage III patients
206
Albain 2009 research question
For patients with borderline IIIA disease, is there a benefit for induction chemoRT prior to resection vs. definitive chemoRT
207
Albain conclusion
No difference in survival, possible benefit for those downstaged to require just lobectomy
208
RTOG 9410 (Curran) research question
Is concurrent chemoRT superior to sequential chemo --> RT (yes!)
209
At what dose should heart be blocked for meso treatment
19.8 Gy
210
What structure is blocked for full meso treatment
stomacjh
211
Median survival of stage I lung cancer without treatment
1 year
212
On subgroup analysis from Albain neoadjuvant chemoRT trial found improved OS for which group
Pts who got lobectomy
Trimodality: 36%
ChemoRT: 18%
213
KEYNOTE 189
Found that pemrbo + chemo increases PFS and OS in all PDL1 statuses
214
What subgroup benefits most from pembro+chemo
PDL1 > 50% but all subgroups do benefit even PDL <1%
215
Where are primary tracheal ACC usually located
proximal trachea
slow growth
late distant mets
possibility of perineural spread
216
Patients with radiographically negative PET have X% chance of N2 disease on surgical staging
15%
217
What tumors had higher risk of occult N2 disease
Central tumors
RUL
N1 disease on PET
218
Which patients should get adjuvant chemo
I: if >4 cm
| II/III: all
219
T1 meso
ipsi parietal pleura
220
T2 meso
ipsi parietal pleura with involvement of underlying lung or diaprhgammatic muscle
221
T3 meso
locally advanced, potentially resectable
222
T4 meso
unresectable
223
N1 meso
ipsi hilar, mediastinal, IMN, peridiagrphrammaic, intercostal nodes
224
N2 meso
contra mediastinal, ipsi/contra SCV
225
Thymoma RT dose for gross residual disease
60-70
226
Thymoma RT dose for involved margins
54 Gy
227
Thymoma RT dose for clear/close margins
45-50
228
5 year freedom from failure rate for unresected thymoma getting chemo --> 54 Gy
54%
229
Appropriate CTV margin of adenocarcinoma
8mm
230
Appropriate CTV margin of SCC
6mm
231
Lambert eaton presentation
progressive muscle weakness of proximal lower extremities
232
What is 1 year OS with PCI on ES-SCLC slotman study
27%
233
What is 1 year OS without PCI on ES-SCLC slotman study
13%
234
PACIFIC trial - how long did patients get durva
1 year
235
PACIFIC trial 2 year OS with Durva
66%
236
PACIFIC trial 2 year OS without Durva
56%
237
PACIFIC trial PFS differences
17 vs. 6 months
238
Subsets potentially benefitted more from durva
PDL1 > 25%
| Starting durva within 2 weeks post CRT
239
V20 goal for contralateral lung after extrapleural pneumonectomy using IMRT
<7%
240
What levels should always be covered when doing PORT
level 7
ipsi level 4
level 5/6 for left sided N2 disease
241
0617 V45 heart goal
<2/3
242
0617 V60 heart goal
<1/3
243
0617 V40 heart goal
<100%
244
When should spinal cord be blocked when doing hemithoracic RT for meso
41.4
245
Max dose to plexus for SBRT
D3cc < 6 x 5
246
CONVERT trial median OS for 45 BID vs. 66 QD
30 months vs 25 months NSS
247
What chemo given with CONVERT
cis-etoposide
248
What is the preferred chemo regimen for mesothelioma
cis-pemetrexed +/- BEV
249
What is preferred chemo regimen for thymoma
cis, doxorubicin, cyclophosphamide
250
age range to get low dose CT
50-80
251
pack year history minimum to get low dose CT
20
252
smoking status to get low dose CT
active smoker or quit in past 15 years
253
Expected 5 year OS after neoadjuvant CRT and R0 resection of superior sulcus tumor
54%
254
Rate of severe toxicity for central tumors from Timmerman study
46%
255
Rate of severe toxicity for peripheral tumors from Timmerman study
17%
256
MTD of SBRT to ultracentral tumors from RTOG 0813 (Bezjak)
12 x 5
257
What was DLT rate for this treatment dose
7.5%
258
RTOG 0236 Timmerman study dose utilized
18 x 3
259
RTOG 0236 Timmerman study max size
5 cm
260
RTOG 0236 Timmerman study 3 year local control (primary tumor and involved lobe)
91%
261
RTOG 0236 Timmerman study dose 3 year distant met rate
22%
262
RTOG 0236 Timmerman study dose 3 year OS
56%
263
RTOG 0236 Timmerman study dose 5 year local failure
7%
264
RTOG 0236 Timmerman study dose 5 year local and involved lobe
20%
265
RTOG 0236 Timmerman study dose 5 year OS
40%
266
In Turrisi study, what was worse in BID treatment
Increased G3 esophagitis (27% vs. 11%)
267
Rate of local failure after lobectomy on Ginsburg study
6%
268
Rate of local failure after sublobar resection
18%
