Lung Cancer&nbsp;&nbsp;&nbsp;

What are your top takeaways in Thoracic Cancers from ASTRO 2024?

Is there any role for ctDNA testing after surgery or SBRT for Stage IB NSCLC to determine the need for adjuvant chemotherapy?

As consolidative thoracic radiation (cTRT) was prohibited on the seminal chemoimmunotherapy trials in ES-SCLC, how do you approach cTRT in practice?

Would you consider it for a patient who had bulky thoracic disease, with limited extrathoracic disease at diagnosis and achieved a CR after induction ...

Which patients with Stage II-III lung adenocarcinoma, in whom you are considering neoadjuvant chemoimmunotherapy, can you rely on liquid NGS to exclude driver mutations in lieu of repeat tissue biopsy?

Per NCCN exclusion of EGFR/ALK alterations at a minimum is recommended prior to consideration of neoadjuvant chemoimmunotherapy.

Aside from radiation, what is your approach to patients with EGFR-mutated or ALK-translocated metastatic NSCLC who have systemic disease control but fail in the CNS?

Do you increase the dosage of the TKI or switch to a different generation TKI? How does your answer differ for EGFR vs. ALK, and for discrete brain me...

What is your preferred first line therapy for ROS1 rearranged metastatic NSCLC without CNS mets?

How do you decide between entrectinib or crizotinib? Since no head-to-head comparison, can real-world datasets (such as Doebele et al., Journal of Cli...

Do you perform routine interval lung cancer screening in non-smokers who are 1st degree relatives of patients with non-smoking related lung cancers with known EGFR mutations?

Would you ever consider repeating chemoradiation for patients with locally recurrent small cell lung cancer after prior chemoradiation for LS-SCLC?

What is the quickest palliative regimen you have tried for obstructing lesions in the lung in patients with stage IV disease?

Anyone here doing 17 Gy in 2 fx?

Is S1800A data sufficient to adopt ramucirumab + pembrolizumab in your clinical practice immediately, or is phase 3 data needed?

How will you decide who to offer ramucirumab + pembro after progression on chemoimmunotherapy?

Are there specific patient factors for which you would more preferentially use this regimen?

Do you consider NSCLC with multistation N2 involvement appropriate for treatment with neoadjuvant chemoimmunotherapy followed by surgery?

How would you manage a patient with stage IV EGFR L858R mutation but with a debilitating drug rash from osimertinib?

Should we switch to a new TKI?

In patients with EGFR mutant L858R stage III NSCLC who are unresectable due to multistation N2 disease, would you consider upfront osimertinib over definitive intent CCRT?

If CCRT is pursued, would you move forward with durvalumab consolidation? Assume the patient with ECOG PS 0 and no co-morbidities. How might this chan...

Would you start any treatment for radiation pneumonitis if there is a large area of consolidation in the irradiated lung field but the patient is asymptomatic?

Would you consider pentoxifylline and vitamin E to mitigate fibrosis?

How many days do you hold osimertinib during or around SBRT for oligometastatic EGFR mutated advanced lung cancer?

Does the site of treatment factor into your decision?

Do you use immune checkpoint inhibitors in NSCLC patients with pre-existing, well-controlled autoimmune disease?

Does the type of autoimmune disease (ex IBD, rheumatoid arthritis, interstitial lung disease) matter?

How are you approaching patients with early-stage NSCLC who progress on neoadjuvant chemo-immunotherapy and are no longer surgical candidates?

Will you consider definitive concurrent chemoradiation for stage IV lung adenocarcinoma with metastasis limited to an internal mammary lymph node?

What is your approach for an RA patient with lung cancer who is starting immunotherapy?

When should SBRT be preferred in operative patients who cannot undergo a lobectomy?

In other words, if offered wedge or segmentectomy, should SBRT be preferred? Does size matter ie if the lesion is < 3 vs < 2 vs < 1 cm? Does ...

Is dyspnea without radiation pneumonitis a side effect of lung radiation?

Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?

For a patient with a lung tumor that is radiographically consistent with early-stage NSCLC but pathology with characteristics overlapping with upper GI origin, what additional diagnostic procedures would you consider before treating?

For example, there are no abnormalities on CT or PET in the upper GI and the pathology demonstrates strong CK7 staining and mucinous features with neg...

How would you manage a left sided triple negative breast cancer with a concurrent left sided locally advanced non-small cell lung cancer?

The left breast cancer is an ER-negative, PR-negative, HER2-negative cT2N0 invasive ductal carcinoma, while the left lung primary is a cT2N1 squamous ...

Is it acceptable to treat newly diagnosed small cell lung cancer with limited brain metastasis with upfront SRS?

This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...

12 Answers available

Would you offer a different ALK inhibitor to a patient receiving alectinib who had decompensation of liver function in the setting of preexisting cirrhosis?

In a patient with history of successfully treated locally advanced H&N cancer, how do you discern between a metachronous second primary locally advanced lung SCC vs. metastatic head and neck SCC?

What clinical or radiographic factors would lean you in either direction - ie. time since index diagnosis, distribution or appearance of lung and noda...

How would you treat active rheumatoid arthritis in a patient in complete response on loralatinib for stage IV ALK positive NSCLC?

Patient already on methotrexate and plaquenil.

Is there any role for re-biopsy and NGS for patients with NSCLC and KRAS G12C at time of progression after first line therapy before starting sotorasib, or after progression on sotorasib?

What are your top takeaways in Thoracic Cancers from ASCO 2023?

When offering PCI for SCLC patient, do you include C1 in the treatment field or do you stop at the base of the skull?

How do you schedule IV/PO Dexamethasone if giving immunotherapy concurrently with chemotherapy in patients with NSCLC?

How do you approach PORT for T3N0 NSCLC, which had chest wall invasion, now status post lobectomy with a microscopically positive margin?

Dose/fractionation? Concurrent v. sequential chemo? What literature do you use to backup PORT for a positive margin?

Would you offer post-operative SRS/SBRT in the case of a resected brain metastasis from metastatic NSCLC with an EGFR mutation?

With targeted therapies available, is there a utility for post-op SRS to the resection cavity?

When would you include treatment of the entire staple line for an NSCLC staple line recurrence?

Would you consider treating with conventional fractionation to the entire staple line with a boost to the gross disease?

Would you offer adjuvant immunotherapy to patients with stage II-III NSCLC who achieved a pathologic complete response from 3 cycles of neoadjuvant nivolumab + chemotherapy?

How do you define an adequate EBUS when staging NSCLC?

Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?

Would you use SBRT to treat a >5cm NSCLC with chest wall invasion in a medically inoperable patient?

Are there any data regarding safety or efficacy of osimertinib and concurrent chemotherapy in patients with metastatic NSCLC harboring sensitizing EGFR mutation?

For NSCLC patients with limited diagnostic tissue that is insufficient for genetic testing, do you offer repeat biopsy (of accessible site), blood based testing, or both to evaluate for actionable driver mutations?

What is the role for "liquid biopsy" for patients with newly diagnosed metastatic NSCLC?

What is your current practice for obtaining PD-L1 and mutation testing for newly diagnosed metastatic NSCLC?

What specific platforms do you use, individual biomarker/PD-L1 status vs NGS, tissue vs liquid or both? Must you wait for PD-L1 testing if mutation t...

Are PD-L1 and molecular markers from pleural fluid specimens reliable enough to guide decision making in metastatic NSCLC?

Or would you conduct tissue or blood testing if no actionable results are found?

Would you send a lung cancer patient for genetic counseling/germline mutation testing if they are harboring mutations in NGS with variation allele frequency between >=50%?

Ex. TP53, BRCA, T790M, or another? As of now, T790M mutation is one of the few de novo mutations found in treatment naïve patients that have been...

How do you manage stage III resectable NSCLC patients treated with neoadjuvant chemoimmunotherapy per CheckMate 816 with residual disease who subsequently refuse surgery?

Would you recommend standard definitive chemoradiation followed by adjuvant durvalumab? Would you treat pre- or post-systemic therapy volumes?

Do you consider the duration of lung/lobar atelectasis in your decision making while offering airway stents for malignant central airway obstruction?

Are patients with long standing malignant central airway obstruction poor candidates for central airway stents? What is considered to be an acceptable...

How do you approach a patient with discordant mutation testing in liquid vs tissue biopsy for mNSCLC?

What is the appropriate management of severe myalgia during atezolizumab infusion?

In a patient with a mediastinal recurrence following lobectomy for early stage NSCLC, what would be your treatment volume?

Would anyone consider elective mediastinal XRT to 45-50Gy then boost involved LN to 60-66? Or treat involved lymph node only? The patient will r...

When treating patients with immune checkpoint inhibitors, do you routinely check markers of endocrinopathies such as TSH/ACTH, or only when a patient has symptoms?

If so, how often do you check these labs?

Should consolidative RT for extensive stage SCLC be given before, after, or concurrently with PCI?

In the study published by Slotman et al (Lancet 2015), nearly all the patients in the thoracic RT arm started with PCI. For patients with gross diseas...

How would you treat a patient with oligometastatic disease to the lung for whom SBRT/SABR is not feasible?

How would you approach treatment if SBRT was not technically possible? How would you opt to treat if SBRT was instead not covered by insurance, and w...

How do you choose between neoadjuvant and adjuvant chemo-immunotherapy for patients with resectable stage II-IIIA NSCLC?

In light of CheckMate 816 and IMpower010 and FDA approval for neoadjuvant chemo-nivolumab and adjuvant chemo-atezolizumab, how do you decide which sys...

How would you approach adjuvant therapy for a patient with pT2N2 lung adenocarcinoma who underwent an R1 resection and is not amenable to further surgical intervention?

NGS without any actionable mutations and PD-L1 TPS 15%. Would you offer chemotherapy, radiation, or immunotherapy and, if so, in what order?

For patients with NSCLC on osimertinib who progress, would you continue osimertinib when moving onto chemotherapy for 2nd line therapy?

How do you modify your dose constraints when giving lung SBRT to a new lesion in a patient previously treated with lung SBRT?

How does your approach change for same lung but now a different lobe v. different lung? How do you adjust your constraints?

Would you still offer adjuvant osimertinib to patients who elect not to receive chemotherapy in resected EGFR mutated lung cancer?

Do you ever consider small vessel doses when determining your dose for SBRT?

For example, would you modify your SBRT dose next to the azygous vein? While we talk frequently about OAR constraints for the great vessels, it seems ...

Do you incorporate immunotherapy in your multi-modality treatment after chemoradiation for patients with potentially resectable stage III superior sulcus NSCLC?

How many missed fractions will you allow for a definitive lung CRT before recommending treatment on the weekend?

If a treatment machine is down for 3 days, would you do weekend treatment? Would you consider doing BID?

What do you view as the role for docetaxel+ramucirumab for patients with metastatic NSCLC in light of LUNG-MAP S1800a data?

Would you still use ram/doce in 3rd or later lines after ram/pembro?

Are there differences in efficacy of ramucirumab + pembrolizumab based on extent and duration of response to first line chemo/pembro?

Did S1800a stratify by prior treatment response? Would you choose different 2L treatment for a patient who progresses rapidlly on pembro + platinum do...

Are there any unique toxicity concerns with combination of ramucirumab/pembrolizumab as compared with other available treatments for metastatic NSCLC?

How do you counsel patients on the available second line options?

Are there any situations where you would consider neoadjuvant chemoradiation as opposed to chemoimmunotherapy for patients with resectable NSCLC prior to surgical resection?

What radiation dose is appropriate for patients receiving induction chemoradiation prior to surgery for superior sulcus tumors?

How do you choose between neoadjuvant chemotherapy alone vs neoadjuvant chemoradiation in patients with potentially resectable stage III NSCLC who are not upfront surgical candidates?

In a life-time non-smoker with stage IV lung adenocarcinoma presenting in visceral crisis, what therapy would you recommend to avoid organ failure while awaiting mutational status?

What are your top takeaways in Thoracic Cancers from ASCO 2022?

What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?

What is the optimal treatment strategy for patients with stage IV NSCLC who have an actionable molecular target identified after initiation of first-line systemic therapy?

What systemic therapy, if any, would you offer a patient after WBRT for an isolated CNS relapse of initially limited stage SCLC that received chemoRT without PCI?

Would the timing of the relapse (eg within 6 months) impact your decision making?

How would you approach treatment of a patient with metastatic NSCLC with PD-L1>1% and HER2-mutation?

Does this change for PDL1 1-49% vs >50%? Will you be more likely to employ other checkpoint inhibitors before use of HER2 targeting therapy? Or sta...

For a patient with metastatic NSCLC who had progression x2 at a single site treated w RT, would you switch systemic treatment?

Patient has been on pembrolizumab and had two symptomatic soft tissue mass treated with radiation.

Is it reasonable to treat a solitary plasmacytoma of the lung parenchyma with SBRT?

What dose/fractionation?

When would you add an extra radiation dose to compensate for treatment breaks?

Apart from H&N SCC, are there times where adding an extra dose of radiation due to a tx break is appropriate? Is there a decent equatio...

Do you perform PDL1 and molecular testing for patients with stages I-III NSCLC?

Do you recommend holding a TKI when treating brain metastases with SRS/WBRT?

Is there evidence that supports/refutes the safety of concurrent use?

How do you interpret efficacy of trastuzumab deruxtecan based on HER2 mutation type and/or level of HER2 overexpression?

How and when do you plan to perform HER2 testing in patients with NSCLC?

Do you find data from phase 2 DESTINY-LUNG01 study sufficient to change practice in HER2 mutant NSCLC or is a phase 3 study still needed?

How does trastuzumab deruxtecan compare to other HER2 targeted strategies?

How would you approach a patient with mediastinal-only recurrence of small cell lung cancer < 6 months after primary surgical resection and adjuvant platinum-etoposide for Stage I disease?

What is your approach to a patient with metastatic lung cancer with HER2 mutant NSCLC who is not a trial candidate?

How are you thinking about sequencing therapies for these patients (IO vs chemo vs T-Dxd)? Are the data from DESTINY-Lung01 strong enough to warrant e...

What strategies can be employed to manage interstitial lung disease seen with trastuzumab deruxtecan?

Can patients be re-challenged after developing ILD? Is the toxicity seen with T-Dxd a potential barrier to use? Do you feel the dosing used in...

Do you recommend postoperative radiation therapy for pathologic T1-2N1 small cell carcinoma of the lung?

If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?

Does concurrent brain and systemic progression alter your choice of systemic therapy for patients with metastatic SCLC with early progression on chemoimmunotherapy and WBRT?

Would you offer topotecan, lurbinectedin, or another agent given the CNS progression as well?

Is it reasonable to offer observation with MRI rather than immediate PCI for patients with limited stage SCLC?

7 Answers available

How do you incorporate PCI into your management of patients with extensive stage SCLC?

Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...

How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?

Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...

Can immunotherapy, alone or with chemo, be considered for ROS1+ NSCLC after exhausting ROS1 targeted therapy options?

Would you offer SBRT/hypofractionation for stage I NSCLC with positive margins after resection?

Assuming re-resection is not feasible. The NCCN guidelines for post-operative RT for Stage I lung cancer with positive margins is PORT to 54-60 Gy (in...

Would you use a hippocampal sparing technique when treating with PCI for a limited stage small cell lung cancer?

How would you treat a patient with squamous NSCLC with NRG1 amplification (no fusion) who has progressed on first-line treatment?

Would you consider afatinib? Afatinib has shown some activity in NRG1 fusion + patients but amplifications is unclear.

Is it acceptable to use once daily fractionation for small cell lung cancer?

If so, what dose is appropriate?

7 Answers available

Is there a preferred ALK targeting agent for patients with ALK+ mNSCLC presenting with CNS metastases?

Should we consider radiation therapy for patients with N2 EGFRm NSCLC who will receive osimertinib, though RT was excluded on ADAURA?

Conversely: In a patient with N2 EGFR+ NSCLC receiving radiation, would you still consider use of osimertinib?

How do you treat a patient with widely metastatic, non T790M mutated, EGFR exon 20 insertion mutated lung cancer?

Are there any data to support a specific TKI therapy for non-T790M exon 20 mutations/insertions?

How does the lack of mandated PET or brain MRI in the ADAURA trial impact your interpretation of the results?

Is data available regarding the percentages of patients in each arm who underwent staging PET or the breakdown of CNS imaging modalities?

When is it too far out from CRT to the chest to be considered for PCI for limited-stage SCLC?

When is the ideal window for delivering PCI for limited-stage SCLC?

How will the ADAURA study impact your use of adjuvant chemotherapy?

Are the rates of adjuvant chemotherapy used in ADAURA consistent with real-world practice?

Would you give immunotherapy to patient with metastatic NSCLC who had liver transplant for hepatocellular carcinoma and now is progressing on chemotherapy?

How would you treat oligometastatic NSCLC (brain and bone) with Non-V600E BRAF mutations?

SRS done to the single brain met, PD-L1 5%, BRAF G469A mutation

How would you treat a patient with metastatic NSCLC with repeated episodes of CNS brain metastases but otherwise with good systemic disease control on maintenance therapy?

The patient remains without evidence of systemic disease outside of the CNS on serial imaging. Would you continue treating with SRS as lesions appear,...

Do you use bevacizumab in patients with history of VTE (DVT/PE) who are stable on anticoagulation?

Would it make a difference if the VTE diagnosis occurs during bevacizumab therapy or whether it preceded the cancer diagnosis?

What is an acceptable distance between tumor and heart or aorta to treat a non-small cell lung cancer with SBRT?

Would close proximity to the heart/aorta affect your dose and fractionation?

What is the best treatment dose and fractionation for WBRT in a patient who has numerous brain mets and previously received PCI with 25Gy/10fx for small cell lung cancer?

Would you offer systemic therapy after rendered NED from SRS to isolated CNS metastases in a patient with prior curative intent treatment of lung adenocarcinoma and clear cell RCC?

Do you use minimum cutoff values for any PFTs below which you would not offer conventionally fractionated chemoradiation or SBRT for NSCLC?

Are pre-treatment PFTs actually correlated with treatment-related toxicity? If no absolute cutoff, do you have an ideal lower limit for PFTs...

What is your approach to mediastinal-only failure outside of the previous chemo/radiation field for SCLC?

Would you treat the nodes with margin, the nodal group, or the whole untreated mediastinum?

In patients with metastatic lung SCC who are on pembrolizumab maintenance after starting pembrolizumab/carboplatin/nab-paclitaxel, what is your treatment strategy if they progress while on pembrolizumab alone?

Would you continue pembrolizumab with a re-challenge with carboplatin/taxane or move to second line therapy?

How do you counsel patients with metastatic NSCLC who have a sustained response (> 2 years) to checkpoint inhibitors who wish to discontinue therapy?

How do you approach this given the limited # of patients this applies to? Checkmate 017 and 057 only had 5-7% of patients still on nivolumab at ...

Would you rather start radiation for Stage III NSCLC in the middle of a chemotherapy cycle or wait for the 2nd cycle if it could not be started on cycle 1 day 1?

How long do you continue surveillance imaging for NSCLC after definitive treatment?

NCCN recommends annual CT surveillance indefinitely after year 5, but I’m curious how many physicians continue and for how long?

How would you treat a patient with metastatic NSCLC >50% PDL-1 positive AND an EGFR or ALK gene mutation/rearrangement in the first-line setting?

1st-line pembrolizumab is supposed to be used AFTER failure of appropriate targeted agents in this setting, but would you consider the reverse sequenc...

What V5 dose constraint best correlates with late lung toxicity following definitive chemo-radiation for lung cancer?

Would you deliver SRS/XRT for isolated asymptomatic CNS metastasis before start of immunotherapy for stage IV lung cancer (negative for driver mutation) with high positive PDL1?

Do you consider additional chemotherapy or durvalumab after definitive concurrent chemo/RT for Stage II NSCLC for patients who are not surgical candidates?

Would PDL-1 status impact your decision?

At what point during first-line treatment with mono-immunotherapy for oligometastatic NSCLC is the ideal time to consider consolidative radiation/SBRT to the primary and oligometastatic sites?

Much of this approach was designed with cytotoxic chemotherapy in mind -- wait "x" cycles, assess response, deliver radiation after chemotherapy. How ...

For patients with metastatic NSCLC with MET amplification who respond well to first line crizotinib but develop hepatotoxicity, how do you decided whether to consider re-challenge or change therapy altogether?

What are the clear criteria for unresectability in locally advanced NSCLC patients, other than medical or anatomic?

Medical inoperability is clearly defined, anatomical resectability is also pretty much clear (invasion of trachea/carina/esophagus, etc). But what abo...

If you are treating a patient with palliative radiation for hemoptysis do you require chemotherapy to be held?

If you are using a standard 30/10 fractionation, is there a benefit to keeping chemo on board for radio-sensitization?

How are you treating patients who progress while on durvalumab after definitive chemoradiation for stage III NSCLC?

Is the timing of progression (in relation to chemoradiation) a factor, and is there any role for repeat PD-L1 testing at the time of progression?

Do you offer consolidation thoracic radiation after atezolizumab, carboplatin, and etoposide for extensive stage small cell lung cancer?

Do you ever consider a dose constraint to the spleen when treating lung tumors with stereotactic radiotherapy?

I am treating a left lower lobe NSCLC and my PTV is so close to the spleen that a small portion of the spleen is getting significant dose. I can...

What follow-up imaging do you recommend after SBRT/SABR for lung cancer?

And at what intervals?

How do you manage a patient who presents with a tracheoesophageal fistula from a lung or esophageal primary that is non-metastatic?

As a for instance, a centrally located primary tumor with mediastinal adenopathy that results in a TE fistula? Currently we would recommend esophagea...

When do you recommend broader molecular testing for clinical trials in stage IV NSCLC patients who have negative initial molecular testing for FDA-approved targetable mutations?

Would you resume durvalumab after several month hiatus due to IO unrelated medical comorbidities that has since resolved?

If it is still within the 12 month period and no disease recurrence?

Would you deliver SBRT to the adrenal gland if a patient has already undergone contralateral adrenalectomy for oligometastatic NSCLC?

What would you anticipate with regard to potential adrenal toxicity when the patient has only 1 functioning adrenal gland? There are no other sites of...

Does EGFR+ status influence your decision? What is the significance of this finding and its potential for progression? Is it simply occult disease con...

How would you approach treatment in patients with stage III non small cell lung cancer invading the atrium of the heart?

Do you recommend elective mediastinal nodal irradiation for an inoperable NSCLC patient with N1 disease who is unable to undergo mediastinal staging?

Does the T stage or location of malignancy affect your decision?

How do you decide between enrolling an oligometastatic NSCLC patient on LU-002 versus treating them with SBRT off trial?

Since the randomized phase II data from Gomez et al presented at ASTRO 2018 showed a survival benefit, is there concern about randomizing patients to ...

How important is a severely diminished diffusion capacity in determining whether to offer a lung cancer patient radiotherapy?

Does it factor into your decision making in the setting of restricted spirometry and normal lung volumes? Does this differ for SBRT v. chemoRT?

Is there a current 'standard of care' dose and fractionation in treating lung cancer with SBRT?

There seem to be a lot of different fractionation schemes in the literature. Is there one that is most standard?

Is there really substantial evidence to avoid central lesions for SBRT?

The Indiana report and RTOG published a "danger zone". There was a catastrophic "case report" for 50 Gy in 5 fractions. Are there alternat...

What is the role of upfront pembrolizumab in metastatic PD-L1 positive NSCLC presenting with SVC syndrome?

Would starting with chemotherapy be preferred in this situation and consider concurrent radiation, then switch over to Pembrolizumab once some control...

How do you manage a stage I LLL medically inoperable lung cancer in close proximity to the stomach?

In patients with aberrant anatomy due to previous surgery with lung PTV overlapping the stomach, how much would you dose de-escalate? Even conventiona...

What is your preferred first line approach to patients with good PS stage IV non-squamous NSCLC that is EGFR/ROS1/ALK/BRAF WT and PDL-1 < 1%?

Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?

Is surgery preferable over SBRT for peripheral NSCLC invading into ribs?

Is local control worse for SBRT when the tumor is invading into the bone (rib)?

Is it acceptable to treat patients with limited, asymptomatic brain metastases and EGFR-mutant NSCLC with upfront TKI?

Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?

8 Answers available

How do you decide on the sequence of systemic and local therapy for patients with oligometastatic NSCLC?

When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?

Would you treat a patient with HIV or hepatitis C with an anti-PD-1 agent?

These patients have been largely excluded from these trials. What if the infection is well controlled?

Does HIV/AIDS change your management of locally advanced NSCLC?

If you are considering chemotherapy and radiation in the definitive, postoperative, or nodal failure scenarios, would you prefer sequential treat...

Is is okay to offer SBRT for central lung tumors in direct contact with the esophagus?

If so, 50 Gy / 5 fx? 7.5 Gy / 8 fx? If so what dose constraints would you use to help determine fractionation?

When do you recommend induction chemotherapy prior to concurrent chemoradiotherapy for locally advanced NSCLC?

If you treat pre-chemotherapy volumes, is there a benefit to induction chemotherapy even in bulky disease. If so, how do you define disease that ...

Do you recommend concurrent or sequential radiation and chemotherapy for margin-positive, node negative NSCLC?

What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?

Would you recommend a cycle of chemotherapy prior to concurrent chemoradiation for a Stage III NSCLC patient who needs to start treatment sooner than allowed by the IMRT planning process?

Or would you rather treat with 3D-CRT in order to initiate chemoRT concurrently?

How do you approach a peripheral, T1 lung cancer with a positive mediastinal node by EBUS?

Is there a role for SBRT to the primary site? Is it required to treat the ipsilateral hilum if no adenopathy was seen on EBUS or PET?

Is 10 Gy x 5 an acceptable dose to use for lung SBRT in tumors with favorable location (eg. not central and not encroaching on the chest wall?)

Given the multiple retrospective studies showing benefit to higher BED fractionation schedules (most recently, http://www.redjournal.org/article/S0360...

How would you approach treatment of an early-stage lung cancer adjacent to a prior lung cancer previously treated with SBRT?

Is another course of SBRT possible? If so, what are the important planning considerations?

Do you treat adenocarcinoma in situ (AIS) or minimally invasive adenocarcinoma (MIA) of the lung with SBRT in medically inoperable patients?

Given the lepidic growth pattern, do you use similar margins as with frankly invasive lung tumors? Are there any challenges localizing the target with...

How would you approach a patient with simultaneously diagnosed stage IVA SCC of the head and neck and limited stage small cell lung cancer (neither is symptomatic)?

Would you recommend chemo alone first? Would you treat with definite chemo-RT to the lung then the head/neck or vice versa? How would this chan...

Is there a firm rib dose constraint when treating lung tumors abutting the visceral pleura/chest wall with SBRT?

When treating lung tumors abutting the visceral pleura/chest wall with SBRT, chest wall or rib pain sometimes occurs. In these cases, I try to avoid i...

How would you approach patients with EGFR mutation positive (exon 19) NSCLC who rapidly progress on front line EGFR inhibition with first generation TKI at first imaging?

Can T790M mutation develop within this early time frame, or are these perhaps patients who may benefit from switch to chemotherapy?

Should NSCLC with positive cervical nodes be managed with definitive chemoradiation?

Or do you recommend treatment with systemic therapy alone, as this represents Stage IV disease?

Is there a role in sending liquid biopsy for patients progressing on ALK inhibitors?

How are you using liquid biopsy in the routine management of your patients with metastatic NSCLC?

Are you using ctDNA blood tests for targetable mutations at the time of diagnosis, at the time of disease progression, or not at all?

Can ctDNA be used to evaluate response to checkpoint inhibitors in NSCLC when pseudoprogression is suspected on CT imaging?

How do you approach adaptive planning in lung cancer?

Are there any rules you follow? Do you shrink target volumes if you notice a significant response (via CBCT) in a bulky lung tumor with fractionated r...

How are you incorporating abscopal radiation into your practice for metastatic NSCLC?

What is the best evidence for what dose to use? When would you give it in relation to the checkpoint inhibitors? Which metastatic sites do you choose ...

Should density overrides for VMAT lung SBRT planning be utilized for small mobile tumors?

Recently, while planning a patient for lung SBRT it was suggested by the physicist that we change the density of the PTV to higher density to improve ...

When is postoperative radiation appropriate for a typical lung carcinoid tumor?

Would a postiive margin or extracapsular extension altar your recommendations? Does size play a role in your recommendation?

How do you manage anticoagulation for patients with DVT/PE who have brain metastases?

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is t...

When do you offer consolidation chemotherapy for patients receiving chemoradiation for locally advanced NSCLC?

How long do you typically wait before starting consolidation chemotherapy, and do you routinely perform re-staging scans prior to consolidation?

Do you offer memantine for patients undergoing PCI?

How do you manage immune-related toxicity from checkpoint inhibitors that is refractory to initial steroid therapy?

What immunosuppressive agents are used and in what order? Does your approach differ depending on the organ involved, e.g. colitis vs. pneumoniti...

How would you manage a patient with surgically resected T3N1 NSCLC who is found to have one small brain metastasis on staging MRI?

In addition to addresing the brain met (surgery vs. SBRT), would you proceed with systemic "adjuvant" chemotherapy, or would you treat the patient as ...

In patients with metastatic NSCLC, would you consider atezolizumab after failure of nivolumab or pembrolizumab?

Is there any data to support this approach? If not, are there trials you are aware of looking at "rescuing" these patients with a different chec...

Would you continue immune checkpoint inhibitor therapy in a metastatic NSCLC patient with CNS failure if the systemic disease is otherwise controlled?

Does the extent/duration of systemic disease control (complete response vs. stable disease, for example) influence your decision? What about whe...

Would you use immune checkpoint inhibitors in patients with well-compensated liver cirrhosis?

Does the risk of severe inflammation of the liver lead you to choose other therapies in in this population? What about in patients with mild liv...

How do you manage hematologic toxicities in solid tumor patients treated with immune checkpoint inhibitors?

If these are presumed to be immune-mediated (e.g. immune neutropenia or immune thrombocytopenia), do you treat with steroids?

When do you consider using ALK targeted systemic therapy in lieu of WBRT or SRS for patients with metastatic ALK-positive NSCLC?

The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib.

Do you use anti-PD-1/anti-PD-L1 therapies in lung cancer patients with a prior history of radiation pneumonitis?

What about patients who are still on steroids for radiation pneumonitis?

For lung cancer patients who experience grade 3/4 toxicity from a PD-1 inhibitor necessitating cessation of therapy, but whose tumor has responded to the treatment, do you consider restarting PD-1 inhibitor therapy at the time when they progress again?

Would you consider giving the therapy with concominant steroids, or with a dose reduction?

For the first-line treatment of metastatic lung adenocarcinoma without a targetable driver mutation, do you routinely add bevacizumab to the chemotherapy backbone in the absence of a contraindication to the drug?

Do you add bevacizumab regardless of whether you are using paclitaxel or pemetrexed with the platinum agent?

Are there any subgroups of patients with advanced/metastatic NSCLC for whom you are using PD-1 inhibitors in the first-line setting, either alone or in combination with platinum-based chemotherapy?

Also, are you testing for PD-L1 routinely prior to initiation of first-line systemic therapy?

Do you offer the addition of necitumumab to first-line chemotherapy for patients with advanced/metastatic squamous cell NSCLC?

For a patient with stage III NSCLC who is treated with chemoradiation followed by surgery, when do you offer additional "adjuvant" chemotherapy after surgery?

Are you routinely offering nivolumab for second-line treatment of small cell lung cancer?

Based on recently published data from CheckMate 032, do you now offer nivolumab to small cell patients who have progressed after first-line chemothera...

What are your criteria to determine if there is a local failure versus post treatment changes after SBRT for inoperable early stage NSCLC?

If a biopsy carries a high risk of morbidity what interventions would you recommend for the local failure?

In newly diagnosed metastatic non-squamous NSCLC patients, which (if any) genomic targets are you routinely testing for besides EGFR and ALK?

What about specifically in never-smokers?

When is it considered inappropriate to omit pathological mediastinal lymph node staging for non-small cell lung cancer?

The NCCN guidelines call for pathological mediastinal lymph node staging for all NSCLC except in solid tumors <1cm and non-solid lesions < ...

Do you ever offer adjuvant chemotherapy to patients with resected stage IB non-small cell lung cancer when the tumor is less than 4cm in size?

4cm has historically been used as the cutpoint for determining benefit from adjuvant chemotherapy in this population (Strauss et al, JCO 2008; Bu...

Is there a role for VeriStrat testing in determining when to use an EGFR TKI in previously treated squamous cell NSCLC?

Although PD-1 inhibitors are now standard of care for second-line therapy of advanced NSCLC, there remains the question of which therapy is best to us...

What is the standard RT dose in locally advanced NSCLC with concurrent chemotherapy?

Is it reasonable to dose escalate beyond 60 Gy if meeting all dosimetric criteria and with some room to spare? RTOG 0617 would suggest 60 Gy should be...

Would you offer adjuvant TKI to patients with Stage III, EGFR-mutant NSCLC after standard chemoradiation?

Would you offer adjuvant TKI following ADAURA data? Or proceed with durvalumab based on PACIFIC data?

What is the absolute maximum lung V20 that you will accept for patients undergoing chemoradiation for locally advanced lung cancer?

When do you start steroids for radiation pneumonitis?

Following lung RT, I have rarely seen patients present with pneumonia-like symptoms of radiation pneumonitis. I'm more likely to see a patient with wo...

For T1b or T2a NSCLC cancer, approached with SABR, should chemotherapy be considered in the adjuvant setting?

As it is suggested for larger tumors treated with surgery, based on post hoc CALGB analysis?

Given the recent pooled analysis of STARS and ROSEL trials, can we say SBRT for early stage NSCLC is equivalent to lobectomy based on level 1 evidence?

Will the NCCN guidelines change based on this study?

Should the incorporation of thoracic RT be standard in patients with extensive stage small cell lung cancer?

Based on the European data published in the Lancet (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961085-0/abstract), are you s...

For NSCLCa patients who are found to have N2 disease at time of surgery, what treatment volume do you use for PORT?

Do you treat the hilum and ipsilateral mediastinum? Just the lymph node levels that were positive at surgery? I have not found good guidel...

How long do you continue maintenance chemotherapy for metastatic non-small cell lung cancer in patients who have achieved a radiographic CR?

Other than part of a clinical trial or for its FDA-approved indication (second-line therapy for metastatic squamous-cell NSCLC), when do you offer nivolumab to your patients with NSCLC?

For example, should nivolumab be considered standard second-line therapy for adenocarcinoma patients? Can it be considered for first-line thera...

For 5 fraction lung SBRT, is 11 Gy per fraction superior to 10 Gy per fraction?

The BED10 for 50 Gy in 5 fractions is 100, which is significantly lower then the BED of the 54 Gy in 3 fractions regimen (151). Since the Kestin/Grill...

What is the clinical significance of R50 in lung SBRT?

Our dosimetrists rarely meet the RTOG constraint using a non-coplanar technique, especially for very small lesions. I haven't been able to find a corr...

How do you define involved field radiotherapy for lung cancer?

Does IFRT include only the involved lymph nodes + margin or the entire involved lymph node station as specified by the Michigan Atlas?

What is the best adjuvant treatment for resected NSCLC?

What are your dose constraints for lung (V20, V5, MLD, etc.) in patients receiving postoperative radiation therapy after lobectomy?

Are your constraints different than the standard constraints used for patients who have not had surgery?

Can chemotherapy be used instead of radiation therapy in a patient with extensive stage small cell lung cancer who presents with epidural spinal cord compression?

I am aware that chemotherapy can obviate the need for RT in patients with SVC syndrome, but I'm not sure if this can be extrapolated to spinal cord co...

What is an acceptable SBRT dose for a central lung cancer encasing a coronary artery bypass graft?

Would you consider placing a stent in this patent graft to minimize closure of the graft after SBRT?

When do you give treatment breaks for patients with NSCLC undergoing chemoradiation with serious toxicity?

For patients with advanced-stage NSCLC being treated with concurrent chemoRT who miss treatment days secondary to acute toxicities, do you add on fractions at the end of treatment to compensate for repopulation, as is done in head and neck cancers?

If so, how do you calculate the amount of fractions that are added?

How do you manage a peripheral NSCLC and a single positive contralateral lymph node?

Should elective mediastinal irradiation still be avoided? For example, if you have a T2 RLL lesion, and let's say, a positive AP window node, do you n...

How do you approach lung tumors with vessel encasement, especially in someone with active hemoptysis?

Is there any concern about hemorrhage from treatment effect on tumor? Would SABR worsen the chance of fatal hemorrhage/hemoptysis and if so, would you...

Would you treat a patient with small cell lung cancer (limited to lung and mediastinum) but also with a malignant pleural effusion with upfront definitive thoracic chemoradiation?

If so, what would you include in the target and what dose?

Is there a role for post-operative chemoradiation therapy in fully resected, margin-negative T3N1 NSCLC?

What mutational testing is considered the standard of care for NSCLC?

Should mutations other then EGFR and ALK be routinely tested for? Should next generation sequencing be routinely done?

Do you treat pre- or post-chemotherapy nodal volumes on a patient with NSCLC following induction chemotherapy?

Would you treat initially involved contralateral supraclavicular nodes?

How do you take tumor seeding into account when staging NSCLC?

In the case where there is a PET avid subpleural nodule in the exact same location as needle biopsy 3 months prior, is this considered a chest wall me...

How would you manage a patient with EGFR mutant adenocarcinoma of the lung on erlotinib with a single site of disease progression, but otherwise well-controlled disease?

Would you stop the Tarceva at this point?

How do you approach volumes and dosing when using SBRT for a biopsy-proven NSCLC lung nodule with a central solid component and surrounding ground glass opacity (GGO) appearance?

For small overall volumes (e.g. 0.5cm solid component, 1cm total lesion size when including GGO), I imagine treating the entirety of the abnormality i...

What are your criteria for treating a patient with lung SBRT in the absence of a biopsy?

Roughly what percentage of patients are treated without a biopsy?

In evaluating V20 for lung RT, how should the lung volume be defined?

Do you define it as whole lungs (inc. tumor) or whole lungs minus GTV, CTV, ITV, or PTV?

What dose-fractionation do you use when treating primary NSCLC with oligometastatic disease?

We've seen quite a few patients present with NSCLC with a single brain metastasis and a good performance status. Would you advocate for an aggressive ...

Is local failure following SABR higher then previously thought?

ASTRO 2014's lung session presented data from RTOG 0236, showing a 20% intralobar failure/recurrence despite only 7% local failure. How does one recon...

Is 3D non-coplanar conformal radiotherapy preferable over arc therapy for lung SBRT?

RTOG 0915 allows either technique, but I've heard people say that IMRT is not "technically" SBRT. Is there is a benefit to the non-coplanar 3D techniq...

Do you offer postoperative radiotherapy to patients with stage I-II small cell lung cancer after complete resection?

The patient underwent lobectomy and nodal staging for a presumed non-small cell lung cancer.

What is the best management for a local recurrence for a stage I NSCLC treated previously with SBRT?

Should fractionated EBRT be administered or can repeat SBRT be used?

In SBRT for lung tumors, does Monte Carlo dose calculation algorithm versus AAA dose calculation give a better representation of lung target dose and normal tissue dose?

In SBRT, it has been said that Pencil Beam dose calculation algorithm can overestimate the target dose and understimate the normal tiss...

Is it safe to give thoracic irradiation to a patient with lung cancer previously treated with a VEGF inhibitor?

I've read about patients who were treated with concurrent bevacizumab-RT who developed lethal tracheoesophageal fistulas. How long would you have to w...

What kind of motion control do you use when treating lung cancer?

I've found that very few patients have a regular breathing cycle, which makes respiratory gating very difficult. Any other solutions?

If a PET/CT scan is positive for mediastinal lymph node involvement, is a mediastinoscopy or EBUS still required for NSCLC staging?

In practice, do you send patients with N2/3 disease for mediastinal staging if not offered upfront?

What is the biggest mistake people make when performing lung SBRT?