Thoracic Malignancies
Questions discussed in this category
Would your approach change based off of the PDL1 level?
Is there objective evidence demonstrating a benefit of consolidative durvalumab or prophylactic cranial irradiation in patients with stage I small cel...
What factors prompt you to offer adjuvant RT? What would be included in your field? Is elective mediastinal RT still used? Assume initial imaging was ...
These mutations were not eligible in the LAURA trial. Afatinib has a more durable PFS than osimertinib in these patients. How would you choose be...
Would you consider nivolumab/ipilimumab?
USPTF and CMS guidelines differ in age criteria, and NCCN guidelines do not have an upper age limit.
Would you recommend concurrent chemoradiation or targeted therapy with lorlatinib?
Would you offer chemotherapy after radiation is completed?
Al-Ibraheem et al., PMID 33731050
Have you encountered changes in prolactin, testosterone, etc?
A series of 46 patients showed excellent local control with SBRT (91% at 9 years). Should SBRT only be offered to patients formally deemed inoper...
NCCN states that all operable NSCLC patients should be evaluated for pre-op therapy with strong consideration of nivolumab + chemotherapy for those wi...
Some consider T4N3 Stage IIIC to be a borderline case. None of these patients were included in either PACIFIC or KEYNOTE-024 for example. Would y...
How about for non-UIP vs UIP? Non-improvement of ILD with steroids? Specifically in O2-dependent patients? Does the volume of ILD sway your decision (...
If so, what safety precautions would you have?
Patient is not a candidate for ablation or resection. Would you consider induction systemic therapy to hopefully shrink the disease away from the pace...
Would the recurrence while already on the checkpoint inhibitor sway you from offering durvalumab?
E.g. higher central hotspot in solid lesions? Any data on differences in toxicity?
Would you consider it for a patient who had bulky thoracic disease, with limited extrathoracic disease at diagnosis and achieved a CR after induction ...
Do you perform NGS on all specimens? If so, how much do you rely on that alone to determine clonality?
Would you consider omitting local therapy?
What clinical factors do you take into consideration?
Would you recommend chemo-immunotherapy regimens for a fit patient who relapses at 6 mos post-t...
Per NCCN exclusion of EGFR/ALK alterations at a minimum is recommended prior to consideration of neoadjuvant chemoimmunotherapy.
For example, do you recommend RT for close margins or focal trans-capsular invasion?
What is the expected rate of pneumonitis with this approach?
What dose/fractionation, and constraints would you use?
How does the changing landscape of first-line treatment impact your decision making for second line therapy?
A female in her 60s who has been on afatinib for 6 years. Has been NED on CT, PET, and MRI for > 5 years. Had isolated T-spine mets (radiated) and ...
Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?
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...
With low #s of patients on the durvalumab PACIFIC trial with EGFR mutated disease, and LAURA trial design of osimertinib until progression, should we ...
Based on results from Zhang et al., PMID 38631536. Would we select patients based on planned lung V20 to avoid excess toxicity? Any further considerat...
And would your answer be different if you had used pre-op nivolumab (CM-816)?
Given that LU002 has failed to meet its progression free survival benefit in results presented at ASCO, will you offer consolidative radiotherapy for ...
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...
NCCN guidelines allow the heart to get 105% of PTV prescription for 5 fractions to 55 Gy, but Timmerman tables from 2021 state the heart should be bel...
Some references and papers suggest 8 mm for adenocarcinoma and 6 mm for squamous cell carcinoma (Giraud et al., PMID 11072158). RTOG 1308 used 8 mm bu...
If so, when and to what extent?
What if the patient is also quite elderly? SBRT was a few years ago.
Do you modify your volumes? What dose constraints do you use? How would you determine your dose/fraction regimen?
Would you include a CTV, and if so, how would you account for proximity to the heart?
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
How do you incorporate the considerations regarding the brachial plexus and proximity to the cord when treating to ~60 Gy?
2020 ASTRO SCLC guidelines state under KQ1 Table 3. For postoperative patients with LS-SCLC and R1 or R2 resection, postoperative RT is conditionally ...
Can you explain the expansion cohorts into larger trials and the current amendments to the the protocol?
Are there ones beyond the limited constraints given on the CONVERT and RTOG protocols you routinely use?
Are there specific patient factors for which you would more preferentially use this regimen?
Assume that the volume of the tumor is <10 cc (equivalent diameter of 2.7 cm). Assume there is not a significant amount of overlap of the PTV with ...
If so, how long would you hold? This medication is given for migraines as q3 month infusions and some data suggest that CGRP plays a role in immune-mo...
Do you consider dose escalating to 160 mg or do you add chemotherapy to osimertinib?
Would you provide pentoxyphylline and vitamin E prophylactically after treatment? Is there a role for Boswellia? ACE inhibitor?
Are you seeing this with increased BED regimens such as concurrent CRT to a dose of 60 Gy in 40 Fx BID?
When is SBRT appropriate? Do you approach dose and fractionation differently in this setting?
Should we switch to a new TKI?
Is standard chemoradiation the standard of care or conventional fractionation dose-escalated (>60 Gy) radiotherapy without chemotherapy or some for...
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 offer consolidative brain SRS, SRS + consolidative RT to the primary (e.g. lung), consolidative RT to the primary alone?
Does the site of treatment factor into your decision?
This post refers to the recently published RCT by Chang et al., PMID 37478883 investigating lung SBRT with vs. without 4 months of nivolumab for early...
If so, would you recommend adjuvant chemotherapy and PCI after?
Does the type of autoimmune disease (ex IBD, rheumatoid arthritis, interstitial lung disease) matter?
Does reducing the rate of infusion, or adding Montelukast reduce chances of future reactions?
Additionally, would you give elective nodal coverage or just the postop bed?
E.g. esophagus? If you crop the esophagus out of the ITV, then your ITV would not fully encompass the iGTV.
Do you treat pre-neoadjuvant volumes to full RT dose, or do you modify treatment volumes if there is tumor shrinkage?
For instance, do you factor availability of RNAseq, inclusion of normal blood controls, and QNS rates into your decision?
The patient is not pacemaker dependent.
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 ...
If so, what would be your approach to radiation? Could SBRT be an option?
Does tumor size, age, or performance status play a role in your decision-making?
Relevant pathology features: 7.5cm, grade 3 with a 5mm bronchial margin, negative nodes.
As SCLC in never smokers is extremely rare, do you consider NGS testing, or do you modify treatment in any way?
Does an EGFR mutation in a never-smoker change your radiation treatment recommendations for ES-SCLC?
Do you recommend that standard 30/10 TRT approach or a more aggressive non-small cell like approach (e.g. CRT of locally advanced thoracic disease or ...
Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?
Patient in question had PMRT 20 years ago.
If utilizing an 8-12 fraction regimen, would daily fractionation be appropriate?
Is there any role for immunotherapy?
How would you utilize radiation to address a 10 cm-sized tumor with rib erosion and tumor expanding past ribs? How do you manage pain? What is the rol...
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 ...
This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...
How would you integrate RT with molecular agents?
Is it safe to keep median dose to the brachial plexus to ≤69 Gy per NCCN guidelines and maximum D2cc <75 Gy per Amini et al.?
If so, what dose of radiation dose would you use?
Would it change if only one of the initially sampled positive stations was removed at surgery (eg both 4 and 7 positive pre-therapy, but only 7 sample...
How do you decide when to “pull the trigger” in these cases where the growth trajectory is slow?
If so, what is the highest dose per fraction you would feel comfortable delivering?
Is there any role for targeted therapy, or would you consider consolidation durvalumab for these patients?
If so, which substructures (LAD, left ventricle, etc.)?
While the RTOG protocol defines central in relation to the PBT, should distance to the trachea above the PBT, esophagus, heart, spinal cord, etc. be t...
Patient already on methotrexate and plaquenil.
Eg 10-20 fraction regimens. And how (hot spot %, mean, D99) do you prescribe the dosage?
I feel like it’s nearly impossible to take carafate QID and avoid food and medications for 1-2 hours before and after. How do you counsel patien...
The TROG 13.01 SAFRON-II trial used a single 28 Gy fraction. When is it appropriate to use this fractionation?
Based on subgroup analysis, do you have a preference for cisplatin over carboplatin?
Do you complete the originally prescribed RT course, add fractions, treat BID, offer no further TRT, or do something different?
If so what dose/fractionation would you use?
Is this an artifact of what agent prior clinical trials used or something to do with the mechanism of action (i.e., less mineralocorticoid effect of d...
Do you use the MIP to generate an ITV, contoured on the average scan, or do you contour on each time phase of the 4DCT and boolean the results togethe...
Do you ever consider bridging with chemotherapy, and if so for how long?
Dose/fractionation? Concurrent v. sequential chemo? What literature do you use to backup PORT for a positive margin?
Please specify how your institution is allocating resources now or will be soon.
Would you consider a 2x2 design incorporating immunotherapy?
How does previous radiation pneumonitis impact your decision making and treatment planning for a new lung cancer or metastasis in a patient who is oth...
Would you consider treating with conventional fractionation to the entire staple line with a boost to the gross disease?
IMPower110 data add further support to use of checkpoint monotherapy; however guidelines continue to support either I/O monotherapy vs chemo-immunothe...
Assuming the patient had no contraindications to immunotherapy and no other significant comorbidities.
Prior tumor was adenocarcinoma, new primary is squamous cell carcinoma.
If you would offer reirradiation, what dose constraints would you apply to th...
E.g SCV and/or paratracheal nodes? If so, what dose do you prescribe for elective coverage?
Is there a minimum standard for which stations to sample? Does lymph node size affect your recommendations?
For example, 5 PET-positive lesions, 2 lesions biopsied and both of the same histology.
I've been prescribing sucralfate as first line symptom management but I sometimes see zero benefit. The randomized data doesn't support its use either...
I.e. based on the findings of ADAURA in surgically managed patients.
Would you add any additional dose or fractions?
Lately I have seen patients with a concurrent gynecologic (requiring chemoRT), head and neck (requiring surgery), and early stage NSCLC (requiring SBR...
Are there scenarios in which you would proceed with checkpoint inhibitor for PDL1+ disease before having full molecular testing results?
If there is partial response after chemoimmunotherapy in the primary, would you consolidate the primary? If there is complete response in the metastat...
Is it possible to do SBRT?
Ipsilateral V20? MLD?
How do you decide between starting infliximab, MMF, or IVIG? If a patient presents in respiratory failure (nearing or requiring intubation), woul...
If so, how would you approach managing the increase in lung dose required to cover these? Would you consider this metastatic disease?
Is there a safe regimen that still delivers BED >100?
This would “combine” approaches from both CheckMate 816 and IMpower010.
I see the LungTECH trial dose constraints, but, they seem really conservative when you have something large and close the PBT resulting in use of 60 G...
Do you consider any neoadjuvant therapy or proceed to surgery followed by adjuvant chemotherapy and osimertinib? Does the type of mutation (ex a rare ...
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...
Or would you conduct tissue or blood testing if no actionable results are found?
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...
Would you recommend standard definitive chemoradiation followed by adjuvant durvalumab? Would you treat pre- or post-systemic therapy volumes?
Are patients with long standing malignant central airway obstruction poor candidates for central airway stents? What is considered to be an acceptable...
Given the substantial risks associated with transporting an intubated and ventilated patient to Radiation Oncology, is there any evidence to support t...
Does PET avidity factor in your decision?
And, for additional information, what are the differences in 5 year survival and disease specific survival for stage I NSCCA between lobectomy vs SBRT...
What treatment volumes do you target? What dose-fractionation scheme do you employ?
Do you think these patients are appropriate for SBRT? Is endobronchial laser ablation or cryoablation a better treatment approach? Is there a role for...
For example, EGFR-mutated de novo metastatic disease, do you offer adjuvant RT vs observation with targeted therapy alone?
If you treat with SBRT, how would you constrain the heart given the significant prior involvement of the pericardium in this area in the PTV, assuming...
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...
If so, how often do you check these labs?
Does your management change if symptomatic or asymptomatic?
E.g. If a patient had CR in the primary tumor but PR in the nodes, would you still treat the primary?
I've noticed that these patients have been having greater than expected fatigue that persists for months after SBRT. This is very different than the f...
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 approach treatment if SBRT was not technically possible?
How would you opt to treat if SBRT was instead not covered by insurance, and w...
In light of CheckMate 816 and IMpower010 and FDA approval for neoadjuvant chemo-nivolumab and adjuvant chemo-atezolizumab, how do you decide which sys...
NGS without any actionable mutations and PD-L1 TPS 15%.
Would you offer chemotherapy, radiation, or immunotherapy and, if so, in what order?
Are there specific clinical factors, efficacy, or treatment tolerability issues that lead you to favor one agent over another?
How do you compare or ...
Now that RTOG 0915 shows 5 year data with no difference in OS, DFS, and toxicity, should single tx be routinely offered? Are there specific pati...
If you use VMAT, do you take into account leaf interplay/leaves crossing PTV or potential overmodulation during planning?
In a non-surgical candidate, would you consider adding radiotherapy sequenced with chemotherapy at any point? Or do you reserve it for palliative purp...
Based on results of the recently published study.
What fractionation scheme would you use? Would you give SBRT to a hilar tumor that has N1 nodal involvement adjacent to the tumor but can be enc...
How does your approach change for same lung but now a different lobe v. different lung? How do you adjust your constraints?
When tumors come close to chest wall, how do you define skin contour?
Traditionally these patients may have received chemotherapy prior to chemoRT.
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 ...
How would your approach change given the prior RT?
NSCLC-style regimen of 60Gy/30fx daily or SCLC-style regimen of 45Gy/30fxBID?
Would you offer adjuvant atezolizumab, osimertinib, or neither? Both IMpower010 and ADAURA only had patients with EGFR exon 19 deletion or L858R mutat...
Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?
Apart from removing the latex balloon, do you employ any additional technical accommodations?
How reliable is somatic testing to detect an underlying germline predisposition?
If a patient clearly has N1 disease with high SUV on PET, do you routinely recommend EBUS or mediastinoscopy to evaluate for N2 disease?
Would you treat lung and HN at the same time vs sequentially?
Is skin testing advised prior to trialing alternative?
If so, what dose and what would you include in your field? Would the pre-chemotherapy extent/burden of nodal recurrence influence your decision?
Should one do pleurectomy/decortication?
Do you routinely offer post-operative adjuvant radiation in addition to chemotherapy? Are the results of the recently published negative phase II...
If a treatment machine is down for 3 days, would you do weekend treatment? Would you consider doing BID?
Does the dosimetry of the plan (e.g. exceeding V20 constraints) impact your decision?
What factors do you use to decide between weekly low-dose carboplatin and paclitaxel combination vs cisplatin based doublet, and do you routinelt...
E.g treating and SCLC after prior NSCLC.
Would you still use ram/doce in 3rd or later lines after ram/pembro?
Did S1800a stratify by prior treatment response? Would you choose different 2L treatment for a patient who progresses rapidlly on pembro + platinum do...
How do you counsel patients on the available second line options?
Is there anything to differentiate the two agents? CNS penetration reportedly with adagrasib, FDA accelerated approval has been given with sotorasib.&...
Eg peri-tumoral fibrotic changes noted on cone beam midway through their treatment course?
For example, would you offer a patient SBRT with 3-4 lung SCC nodules? If so, how do you approach planning?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
Do you use BID treatments toward the end? Do you add additional daily treatments to exceed the prescription dose? Would you alter systemic t...
No prior brain radiation. Is full dose whole brain radiation mandated? Would you consider PCI dose or brain surveillance?
What dose-fractionation would you recommend?
Assume the dissection cannot be treated yet due to greater urgency of treating the tumor. What dose-fractionation would you select, and any additional...
I recently saw a patient who had been treated with concurrent pembrolizumab-RT elsewhere. Is this an acceptable practice outside the setting of a clin...
How do you operationalize finding biomarker information in EHRs/testing portals, either for your own patients or if they have changed providers?
If a...
Sodium alginate, an ingredient found in ice cream, is now being used in Japan to reduce RT-induced esophagitis. Anecdotally, a daily quart of ice crea...
Would you consider this standard in asymptomatic patients for workup and treatment planning? Or do you reserve MRI for symptomatic patients only?
Is there evidence or experience to support use of targeted therapy for KRAS G12C mutated NSCLC as first line in place of chemotherapy?
Do you use specific PDL-1 assays for each approach?
For example, in a patient recovering from COVID pneumonia who is no longer a surgical candidate due to decline in pulmonary status, and still has clin...
Are there situations in which you would recommend dilation of stenotic airways after radiation? Is there a concern for increased complications of dila...
Are there data for using checkpoint inhibitors in this setting?
What if there was mediastinal nodal involvement?
Would you attempt targeted therapy or would you choose chemo-immunotherapy?
Would the timing of the relapse (eg within 6 months) impact your decision making?
How are your teams effectively evaluating and counseling patients to ensure they are prepared for potential extended adjuvant treatment approaches? Is...
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...
Patient has been on pembrolizumab and had two symptomatic soft tissue mass treated with radiation.
When treating a NSCLC with extensive bilateral mediastinal disease +/- supraclavicular nodes, would you recommend exceeding certain tissue constrains ...
E.g. One NSCLC with N2 disease, and additional ipsilateral small nodule that is a biopsy-proven second primary. When do you consider SBRT to a nodule ...
Can atezo be used even if patient has completed chemotherapy preoperatively?
If a patient is asymptomatic at presentation, how do you incorporate local treatment options (RT/surgery) and when?
Does the 2020 approval of Nivolumab and Ipilimumab for mNSCLC with PDL1 >1% impact your decision?
What is your threshold for irradiating a suspicious lung nodule?
Do you consider size > 2cm, visceral pleural invasion or vascular invasion as indications for cisplatin-based chemotherapy?
Would you consider chemoradiation to the supraclavicular region?
For medical oncologists, would you offer a PD-1/L1 inhibitor? For other subspecialties, how would you counsel the oncologist regarding the risk of usi...
Would you consider the immune suppressed status of the patient as a high risk factor to offer adjuvant therapy?
What dose would you recommend? Is SBRT needed?
Will degree of PD-L1 status impact your decision?
Would you ever offer to stage IB patients as per study enrollment? Do AJCC v8 staging guideli...
Would you consider second line nivo-ipi for patients with a specific histology or tumor PD-L1 expression?
When patients have a single site of progression while on systemic therapy is it reasonable to consider stereotactic and/or conventional radiation to d...
Is there a certain time interval where you would feel comfortable to rechallenge with immunotherapy at recurrence (6m vs 1y vs 2y?) Does degree of PDL...
Are the experts convinced by DFS when the OS is immature?
How many in BSC arm went on to receive immunotherapy and was that adequate?
What would you do for a patient with a non-EGFR actionable mutation?IMpower010 included EGFR and ALK mutated NSCLC. Is there any concern in the use of...
In elderly patients (>70-75) with a good performance status, does the risk of neurocognitive decline outweigh the benefit of PCI?
Do you initially start with systemic therapy alone or do you proceed directly to chemo-radiation?
Would you stop all treatment after 4 cycles, or proceed with pembrolizumab alone, and would PD-L1 expression factor into your decision?
Dose recommendations for NSCLC are to use at least 60 Gy, but for SCLC recommendations are for higher doses starting at 66 Gy.
Classicall...
Is there evidence that supports/refutes the safety of concurrent use?
What margin would you use? Does this differ based on free-breathing vs. motion-management techniques like abdominal compression?
How and when do you plan to perform HER2 testing in patients with NSCLC?
Recent Japanese guidelines recommend <10MV beams, heart rhythm society and AAPM suggest up to 10MV beams are safe, recommending ≤10MV beams. Giv...
What would be the treatment duration if using oral TKI?
How does trastuzumab deruxtecan compare to other HER2 targeted strategies?
Knowing the OS benefit with the Slotman data in patients who did not have upfront MRIs, and the fact that the Takahashi data would not apply in his ca...
E.g. A patient with station 4 and 5 nodal disease and arterial grafts.
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...
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...
Is extranodal extension of pN1 node by itself an indication to offer adjuvant radiation if there are no additional risk factors like R1/R2 or pN2? Wha...
What is your level of concern for chest wall toxicity? Any difference in your thought process between SCLC vs. NSCLC?
What is your general rationale for selecting from available options?
If yes, do you recommend it be given concurrently with chemotherapy or sequentially? What is your target volume and dose?
Would you offer topotecan, lurbinectedin, or another agent given the CNS progression as well?
How do you interpret the comparative efficacy in squamous cell subsets among the CM vs KN vs EMPOWER studies?
Do you choose Lorlatinib or brigatinib? Or do you try to add chemotherapy to alectinib?
Has the use of immunotherapy replaced the use of sequential chemo?
If so, how can we accomplish this advocacy?
SBRT? Do you change dose fractionation?
E.g. disease burden causing airway or vascular compression.
E.g. right hemithorax disease from lung apex to diaphragm, no response s/p 3 cycles of cis/pem.
Given that prophylactic cranial irradiation (PCI) has been shown to decrease the incidence of symptomatic brain metastases in patients with extensive ...
Would you prioritize the head and neck cancer or treat the lung cancer first with SBRT to take care of it first? How about if there is mediastinal inv...
Do you favor systemic therapy for X cycles followed by restaging and then consolidative radiation (SBRT or CRT)? Or do you prefer up front thoracic di...
Can the ipsilateral supraclavicular field and bilateral hilar nodes still be limited stage?
How do you balance the risk of an EGFR flare while holding osimertinib vs the risk of pneumonitis when continuing?
Are two negative pleurocentesis' adequate to conclude that the patient does not have metastatic disease? Do you routinely recommend VATS and pleural b...
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 offer SBRT over standard fractionation of smaller tumors?
E.g. SBRT 9 months ago.
Patient is <60 years old
If so, what dose fractionation would you recommend?
Would there be any benefit to surgery in a healthy/good PS patient? There is so little data on pulmonary atypical carcinoid and radiation respons...
E.g. for a 7cm central NSCLC, would you offer 8 fx SBRT or ChemoRT? Patient is not a surgical candidate.
One example of this scenario would be a patient receiving consolidative durvalumab after chemoRT for stage III NSCLC who develops a new peripheral lun...
How would you approach the lung constraints in a patient that received definitive RT doses >2 years ago and develops a new primary amenable to SBRT...
Can adjuvant durvalumab or other I/O or osimertinib (if EGFR+) be considered?
Although a small subset, do you generally move these patients directly on to chemotherapy +/- immunotherapy or does it depend on the specific mutation...
Patient has been treated with carbo/etop/atezo, WBRT, and maintenance atezo. Currently on high-dose steroids. Would you consider hospice or trial chem...
If starting with entrectinib would you still try crizotinib, or move to lorlatinib or another novel TKI? Or change entirely to chemotherapy, immunothe...
Is there any role of radiation therapy for these patient for symptomatic relief?
NCCN guidelines as of the May 2021 update state "In PORT, the CTV includes the bronchial stump and high-risk draining lymph nodes stations." Wou...
What dose is preferred for central stage III NSCLC without chemotherapy? Do you recommend higher dose hypofractionated RT or conventional RT?
The recent randomized Phase II Scandinavian trial (Gronberg et al.) showed a statistically significant increased 2-year and median overall survival in...
Would you consider afatinib? Afatinib has shown some activity in NRG1 fusion + patients but amplifications is unclear.
Is your decision swayed by RB1 status or by duration since platinum therapy?
If so, what dose is appropriate?
What is your approach for a symptomatic inpatient with locally advanced NSCLC who cannot have a PET?
Would you consider treating the full mediastinum or any mildly enlarged nodes, even contralateral? Do you have a strategy that transitions from a pall...
Given recent data in Blood (Moik et al, 2021), and the potentially overlapping risks with other clinical factors associated with NSCLC.
Will you alte...
Is local control with SBRT poorer in cystic lung tumors?
The ALTA and ALEX trials showed better PFS with brigatinib v. crizotinib and alectinib v. crizotinib. How do you choose your first...
Would you test for resistance mutations in this setting, using blood-based sample if no progression outside CNS?
Would inhaled steroids help reduce the PO dose and/or significantly accelerate tapering? If s, for what pneumonitis grade? What specific steroid...
What is the current data regarding acquired resistance mutations for ALK?
Should newer agents such as lorlatinib be reserved for later lines a...
Eg T2N2 who required management of cardiac comorbidities leading to months-long delay but scans are still clear.
Are you routinely performing molecular sequencing? Would you modify your treatment approach in first or later lines based on PDL1 status?
Such as dysgeusia, headache, rash, fatigue, etc
Would you consider SBRT and continue osimertinib?
If so, would you treat to full dose or lower elective dose?
Do you aim to give a total of 26 doses or do you stop at one year from first dose no matter how many were given?
If so, do you allow a period of "washout" between immunotherapy and radiation?
How do you decide between supportive care v. chemoimmunotherapy? Is there a threshold of disease burden that would push you towards recommending hospi...
Should patient be considered for definitive therapy or chemo alone if pleural cytology positive but no T4, N2, or sarcomatoid features?
SWOG 9416 did not include N2 patients in their superior sulcus trial.
Do you recommend definitive chemoRT followed by immunotherapy or preop chemoRT ...
I am considering every 6 week pembrolizumab dosing in patients >70 years old in whom I want to reduce clinic visits for, especially in the context ...
Conversely: In a patient with N2 EGFR+ NSCLC receiving radiation, would you still consider use of osimertinib?
If so, do you take any additional precautions with planning?
Are there any data to support a specific TKI therapy for non-T790M exon 20 mutations/insertions?
Would you differentiate between patients with measurable disease vs NED? Are there specific data to guide us?
E.g. chemo/durvalumab vs chemo/atezolizumab?
Would you deliver RT or not? If you would deliver RT, would you use PCI dosing or WBRT dosing?
What was the magnitude of benefit for patients with EGFRm NSCLC by stage?
Are you still considering adjuvant osimertinib for patients with earl...
If yes, do you re-biopsy for tissue, or perform blood-based sequencing?
Are you performing repeat molecular sequencing after progression on targeted therapy? If so, are you obtaining tissue biopsy vs liquid platform?
Is data available regarding the percentages of patients in each arm who underwent staging PET or the breakdown of CNS imaging modalities?
If patients do recur, do you perform these tests on the initial surgical specimen or on tissue from a fresh biopsy (or both?)
When is the ideal window for delivering PCI for limited-stage SCLC?
I've anecdotally been taught that RT rarely will help open up the lung, but we often will still offer a course of palliative treatment. How do you dec...
What are some appropriate dose fractionations? What about dose constraints for bronchial tree that previously got 70Gy?
Are the rates of adjuvant chemotherapy used in ADAURA consistent with real-world practice?
What is considered an acceptable dose to normal breast tissue? E.g. for thymoma, PMBCL, HL, etc.
Would you include any of the staple line or treat nodal stations at risk only? How would you view this situation in the context of the recently presen...
Is there concern for airway healing and hemorrhage if the area is irradiated too soon?
NCCN recommends chemoRT for unresectable, “locally advanced, advanced or recurrent disease” but is chemoRT necessary in a small (e.g. 2.5c...
What radiation dose should be used for definitive chemoradiation for an unresectable pancoast tumor?
What would be your brachial plexus and cord constraints?
For example, a patient with a large (>3cm), spiculated, FDG-avid lung lesion, who has poor lung function and is refusing a CT-guided biopsy?
What about for patients with hiatal hernia?
Assuming no clinical trial, no actionable mutation, and PD-L1 < 50%, do you consider the patient to be primary refractory to platinum and move to s...
Pathology is not carcinoid or small cell.
In the case of conventional fractionation or SBRT, would you constrain the implants? (No history of breast cancer.)
E.g. Recurrent one year out from neoadjuvant chemo-immunotherapy and margin-negative lobectomy. SBRT vs. larger-field chemoRT? Difference in approach ...
If so, what fields do you irradiate? The initially involved nodal regions? Do you offer after PR as well? If not, do you consolidate at any point...
For T2bN0 or T3N0 disease, you consider radiation alone, sequential radiation followed by chemotherapy, or concurrent chemoradiation?
After initiation of anti-TB treatment and 3 negative AFB smears, would you initiate concurrent chemoRT? Would you give sequential RT then chemo to giv...
Does the recent CROWN trial affect your first line treatment decision?
If there was a stage III adeno lung cancer and a contralateral SCC lung primary, what would be the best way to treat? What about a contralateral NSCLC...
E.g. 50 Gy/5fx 2 years ago. If so, what dose and what aorta and bronchus constraints do you use?
No primary thoracic mass identified. Knowing these often following an aggressive clinical course, would you consider concurrent chemo/RT, incorporate ...
What would be you field and margins?
Following chemoradiation, would you consider maintenance durvaluamb as for NSCLC even given the SCLC component?
Chemoradiation completed 1.5 years prior
Would your practice change if the patient had N2 disease?
Would you modify the radiation dose or field in this setting?
Would you pre-emptively dose reduce chemotherapy, or modify the dosing of ruxolitinib?
Would you offer SBRT to both sites, SBRT to the primary and standard fractionation to the node due to proximity to the main bronchus/proximal lobar br...
Would it matter the site of recurrence (ie lung nodule vs bone lesion)?
Under what circumstances would you treat elective nodal regions? Would you consider treating the ipsilateral hilum if it was not PET avid?
Does the reported positive endpoint in OS for Checkmate 743 change your practice?
SRS done to the single brain met, PD-L1 5%, BRAF G469A mutation
The patient remains without evidence of systemic disease outside of the CNS on serial imaging. Would you continue treating with SRS as lesions appear,...
If so, what sub-volumes and dose constraints do you use?
If there is hilar LN involvement only, could you consider hypofractionated RT?
I’ve noticed some patients develop worsening SOB and DOE months after RT and rather than interstitial diffuse pattern you would see with pneumon...
I have seen cited bronchus - smaller airways V32Gy<0.5cc and max point dose 40Gy for stenosis with atelectasis, but unsure sure if this is used in ...
What is your standard approach for patients with platinum and ICI refractory small cell lung cancer?
Topotecan, nivolumab/ipilimumab and others are listed within NCCN guidelines, and lurbinectedin was recently approved in this space. How do you decide...
Is there an advantage to early diagnosis and intervention versus observation until the nodules are amenable to percutaneous biopsy?
The recent NELSON trial evaluates screening in a slightly different population than the USPSTF/NLST criteria. Which will you follow?
How do you balance risk of chemo after surgery with risk of progression of disease while waiting for healing after surgery before starting chemo?
Do you cover the entire involved vertebral body with an elective dose volume (similar to spine mets)? How do you balance cord tolerances with coverage...
Any differences in the risks between SBRT vs. conventionally fractionation? Concurrent immunotherapy?
Would close proximity to the heart/aorta affect your dose and fractionation?
Do you worry about chest wall necrosis? Is surgery preferable? Does the previous RT affect your dose and fractionation? I am seeing more patients with...
Are you placing more weight on patient risk factors such as age >65 or co-morbidities?
Would you proceed with definitive chemoRT to ~60 Gy in 30 fractions?
Are there subsets of patients who will not benefit with addition of first line immunotherapy?
Would you hold treatment for patients who develop PE/DVT while on BRAF-directed therapy?
Is there a certain age beyond which it is not safe to do SBRT?
Would you treat with platinum-etoposide alone again, or would you add atezolizumab?
IMpower133
Are pre-treatment PFTs actually correlated with treatment-related toxicity? If no absolute cutoff, do you have an ideal lower limit for PFTs...
Does the availability of first line checkpoint inhibitor therapy affect your treatment decision?
The patient in question developed this new primary 3 years after prior chemoradiation. What dose constraints would you apply if treating with reirradi...
Would you treated with local therapies (RFA or SRS) and continue pembrolizumab or would you move to second line treatment?
Would you treat the nodes with margin, the nodal group, or the whole untreated mediastinum?
What would your dosing recommendation be?
What are the risks of infection with COVID-19 if using immunotherapy?
How do you prescribe a steroid taper? If it is grade 2, would you keep them on low dose prednisone while continuing? When do you feel comfortable re-c...
Are there specific mutations or co-mutations were you would consider use of this agent?
Is there data to guide treatment re: SBRT vs. concurrent chemoradiation vs. sequential therapy vs. systemic therapy alone? Does the nodal location imp...
Should staging and treatment decisions be made based on imaging alone?
How would you approach a patient who is receiving chemoRT but has confirmed COVID-19 with minor symptoms, as breaking treatment for 2 weeks quarantine...
Would you get repeat invasive mediastinal staging to confirm response?
Would you continue pembrolizumab with a re-challenge with carboplatin/taxane or move to second line therapy?
Are the specific Exon 18 mutations that are more sensitive to TKI?
If so, for how long would you expect this increased susceptibility to last? Our medical oncologists often tell patients that their lymphocyte counts m...
If so, how long is too long to wait?
Also, how would you handle immune modulators for rheumatoid arthritis during their treatment?
Many commercial testing assays report on EGFR gene amplification in addition to the known sensitizing mutations. Are there any data that this can be u...
Would you treat with chemotherapy (carboplatin/etoposide) vs anti-pd-1 monotherapy vs combination chemoimmunotherapy vs supportive care?
Would you proceed with maintenance atezolizumab or switch to second line therapy?
If a non-contrast CT is not performed at CT simulation or otherwise not useable, can you plan on the contrast CT or must you re-simulate for cancers n...
NCCN recommends achieving margins of 2.0cm or at least the size of the lesion, but assuming the patient did not have adequate lung function for lobect...
Assume the patient is medically inoperable.
Do you ever consider stopping if stable disease and good tolerance?
Patient does not want chemo but is tolerating these well otherwise.
Would you offer SABR in the setting of only two lesions? How would your recommendation change if this was NSCLC?
Most trials establishing CRT as standard of care for IIIB NSCLC excluded patients with separate ipsilateral lung nodules given that they were categori...
Does timing of recurrence (early vs late) factor into your decision and would you consider consolidation durvalumab?
Is your approach to simply calculate the EQD2 for specific lung constraints from the prior SBRT and add to the current plan to use cumulative standard...
How, if any, do you utilize genomic testing to guide systemic therapy?
If a patient was administered GM-CSF during concurrent chemoRT, would this be an indication to hold RT, regardless of cell counts (e.g. based on Bunn ...
Keynote 407 recently published data on pembrolizumab +/- chemo for metastatic squamous cell lung cancer. The confidence interval for the group w...
Does the degree of PD-L1 expression weigh into your decision?
Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?
Especially if you don't have trials available at the moment.
Would you try off-label erdafitinib (given recent data on bladder cancer) or 2nd line ge...
What dose constraints would you prioritize for the esophagus, given that a long segment of esophagus will be in PTV?
How (if at all) would you modify your target volume if the hemorrhage was present on immediate post-biopsy CT, but resorbed by time of CT sim? What ab...
Our medical oncology team wants to give a patient Vitamin B12 and Folate 1 week before chemo- do we need to push back the RT start date to start both ...
Would you offer adjuvant chemoRT?
Does tumor location play a role (central vs peripheral) in making the decision? The question stems from an oral presentation at ASTRO 2014 inves...
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 ...
(ie. surgery vs SBRT)
Would your choice of concurrent chemotherapy be impacted by this histologic finding?
PET-CT and Brain MRI are negative for other evidence of disease.
Would nivo + Ipi be appropriate in this situation, especially if high TMB?
In patients who have a mixed response or progression and are poor candidates for other systemic agents, would you consider consolidating the chest? Wo...
Would you consider single agent immunotherapy given recent exposure to platinum agent or chemoimmunotherapy?
For example, in a patient who is a poor surgical candidate with stage III NSCLC.
In the absence of a frontline clinical trial, would you treat with carboplatin+pemetrexed+pembrolizumab or consider IMPOWER 150 or other?
Are the other options of chemotherapy that can be used instead of platinum based doublets, including with paclitaxel?
Would you consider first line treatment with somatostatin analog or Lu 177 dotatate? Is observation an option for asymptomatic patients?
Would you give a more definitive dose (e.g. 60 Gy/30 fractions) or follow the CREST trial (30 Gy/10 fractions)?
Are there any data regarding response to checkpoint inhibitors for these patients?
RTOG 1308 uses 5mm, but is standard practice the same? Do you do daily CBCT?
In a patient with lung cancer with both NSCLC and SCLC components, would you offer carbo/pem/pembro or carbo/etoposide/atezolizumab? Or any other alte...
Would you treat this AP window node like small cell lung cancer with chemoRT?
Would you suspect progressive disease v. radiation necrosis vs optic neuritis due to immunotherapy. Eyes were within radiation field 8 months ago.&nbs...
The NCCN guidelines regard MET exon 14 skip mutation as an emerging biomarker but no formal recommendation to start crizotinib. If high P...
Is there any advantage of one regimen over the others?
Would tumor pathology affect your decision-making (e.g. angiosarcoma)?
Are there any biomarkers that would affect your decision for first line PD-1 therapy (including but not limited to STK11)?
1st-line pembrolizumab is supposed to be used AFTER failure of appropriate targeted agents in this setting, but would you consider the reverse sequenc...
How would you utilize PD-L1 expression to guide your decision making in this situation?
For instance, not chronic autoimmune diseases (eg RA, IBD) that may relapse/remit but events like Guillan Barre syndrome that is not likely to recur b...
Would you continue osimertinib after radiation therapy, switch to crizotinib, or consider chemotherapy +/- immunotherapy?
Is there a role for surgery? Assume early stage with negative nodes on EBUS and PET.
Given the potential high risk of developing pneumonitis with TKI post checkpoint inhibitor, do you avoid TKIs and try a different regimen (ex carbo/pa...
If so, what is your approach to sequencing and timing of targeted therapy and local therapy?
Should these patients be managed using small cell lung regimens?
ie renal dysfunction, hearing loss, neuropathy
I've been trained to treat the larger lesion, re-stage, and then treat the other lesion if there are no new lesions (to rule out the possibility of me...
Would PDL-1 status impact your decision?
With the recent finding of benefit of pembrolizumab and SBRT (PMID: 31294749), would you consider "adjuvant" pembrolizumab for PDL1 positive patients?...
Do you recommend or make any modifications in the PACIFIC regimen for patients > 75 years of age?
Would you offer definitive chemoradiation?
Would you reserve TKI for after standard of care chemotherapy and immunotherapy or consider earlier line of treatment?
Much of this approach was designed with cytotoxic chemotherapy in mind -- wait "x" cycles, assess response, deliver radiation after chemotherapy. How ...
If so do you favor repeat tumor biopsy or cfDNA?
How do you surveil or decide to biopsy and treat these additional lesions? Are there certain size, growth rate, or imaging criteria that are usef...
What if only site of progression was in the brain/CNS?
Do you offer consolidation chemotherapy prior to durvalumab in locally advanced, unresectable NSCLC?
In clinical practice, consolidation chemotherapy is sometimes used, though this was not implemented in the PACIFIC trial.Antonia et al., PMID 28885881...
Would this approach be different for a patient treated with tri-modality therapy (ie neoadjuvant chemoradiation followed by resection)?
Given the prior results of Keynote 189, how do you plan to utilize the data from Keynote 042 with pembrolizumab monotherapy?
Or do you reserve in case of oligo-progression or progressive/symptomatic disease?
Would the presence of high-titer antiphospholipid antibodies (for example) in the absence of a clot history alter your decision?
CT or PET? If so, how often?
What are the major factors that impact your decision? If you opt for surgery, what factors impact your decision to offer RT preoperatively vs. postope...
Is 30Gy/10fx from the CREST trial standard? Do you ever use a more/less protracted fractionation? Does a malignant pleural effusion at diagnosis affec...
Rate of pneumonitis was low in the PACIFIC trial but does it mirror the real world setting? We are seeing increased pneumonitis in our practice.
For example in a patient with a good performance status and a biologically favorable cancer (ER+ breast cancer, EGFR+ NSCLC, or prostate cancer), are ...
Is IO related pneumonitis in the radiation field or more diffuse?
SELECT trial
Do you feel it is important to start durvalumab within 14 days of completing cCRT? What real life challenges do you face in doing so and wh...
http://abstracts.asco.org/239/AbstView_239_262655.html
Medical inoperability is clearly defined, anatomical resectability is also pretty much clear (invasion of trachea/carina/esophagus, etc). But what abo...
Would you treat to the GEJ regardless of whether the positive node was identified in the upper portion of station 8? Do surgeons routinely dissect to ...
NCCN guidelines recommend adjuvant chemotherapy for patients with stage 2 or 3 R0 resected NSCLC including 4 cycles of platinum based chemotherapy, bu...
Is there a size or number of metastasis cut-off where you would consider SRS vs. WBRT?
If so, would you combine them vs monotherapy? Patient ECOG is 1
Do you consider specific pre-medications, an alternate checkpoint inhibitor, or abandon ICI altogether?
If so, how would you modify this regimen?
Retrospective studies (PMID: 29935305, PMID: 30125216) have shown a correlation between poorer outcome and baseline steroid use in patients treat...
If you are using a standard 30/10 fractionation, is there a benefit to keeping chemo on board for radio-sensitization?
If clinically node negative, would you add elective nodal radiation?Does it depend on location (upper vs. lower trachea)?
Retrospective data suggest clinically significant disease flare after tyrosine kinase inhibitor discontinuation in patients with EGFR-mutant lung canc...
Do you use crizotinib for first-line therapy?
First line pembrolizumab is only approved after progression on TKI - but would you ever offer chemo-immunotherapy prior to target therapy?
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?
Is there one drug that carries the least risk of pneumonitis?
The FDA has approved the new dosing schedule of Nivolumab 480 mg every 4 weeks for multiple disease sites (melanoma, RCC, urothelial carcinoma, SCC of...
Is there any correlation with dose in the area of the phrenic nerve and development of referred shoulder pain and/or diaphragm paralysis?
Is there an established benefit for this? For instance if your patient has cardiac calcifications on imaging but no history of cardiac disease are the...
If all other nodes were negative but the patient was pN2 due to a level 9 LN, what volume would you treatm?
For the first treatment day (during combined chemo/XRT courses), is it ok to give XRT first then send the patient for chemo or should the chemo be giv...
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...
Would the results effect your decision to offer PCI?
Is there a role for attempting to continue EGFR inhibition in addition to chemotherapy for small cell lung cancer?
And at what intervals?
Would you consider adding atezolizumab to a cisplatin/irinotecan regimen, or cisplatin instead of carboplatin?
As a for instance, a centrally located primary tumor with mediastinal adenopathy that results in a TE fistula?
Currently we would recommend esophagea...
In a stable patient, do you perform standard chemoRT in 2 Gy fractions with IMRT for urgently start with a few high dose fractions (ex 4Gy/fx) and bri...
If it is still within the 12 month period and no disease recurrence?
Would you give adjuvant chemotherapy or start osimertinib?
Would you consider treating 3-5mm lesions with SBRT or wait until they are a certain size? I am concerned I will not be able to see them adequately on...
Would you use a similar dose and fractionation as gastric MALT (30Gy in 1.5 Gy fractions)?
Would you recommend empiric diflucan? Would EGD be indicated? At what point would you consider hyperbaric oxygen?
Some retrospective data reports that STK11 (AKA LKB1) makes NSCLC resistant to immunotherapy.
No other site of metastatic disease. It is unclear if this situation should be managed as two separate primaries or metastatic disease.
This is a commonly used hypofractionated RT schedule in Canada, but the BED is lower than that for doses used in the US. If so, do you modify your dos...
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...
There is no primary and no distant disease seen on restaging PET. RTOG 0236 shows significant regional failure rate. Some have reported salv...
Do you routinely perform molecular testing?
Would you offer immunotherapy combination (nivo/ipi) in patients who have failed nivolumab mono-therapy?
Does EGFR+ status influence your decision? What is the significance of this finding and its potential for progression? Is it simply occult disease con...
Do you recommend or withhold influenza and pneumonia vaccines while on treatment with checkpoint inhibitors?
Does the T stage or location of malignancy affect your decision?
At what point (ie 8, 10, 12 weeks or more) would you no longer offer consolidation durvalumab?
Would an excellent KPS, LVSI+ or poorly differentiated histology change your decision? Would you base your decision on the ANITA trial where subset an...
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 ...
Does it factor into your decision making in the setting of restricted spirometry and normal lung volumes? Does this differ for SBRT v. chemoRT?
Does your practice differ based on limited or extensive stage disease?
If there is no other evidence of metastatic disease, would you offer thoracic radiation? Either upfront with chemo or after initial system therapy if ...
The NCCN guidelines suggest surgery can be considered for up to T3N2 NSCLC after a period of induction chemotherapy/chemo-radiation without progressio...
What chemotherapy and radiation doses/fractionation would you use once the airway has been stabilized to provide reasonably safe and effective palliat...
Would your answer differ based on whether the patient is receiving concurrent chemotherapy? Are there other factors that would influence this decision...
Is this recommended in a certain subset of patients (EGFR positive or 1 metastasis only)? Or should we await maturation of the MD Anderson/Colorado/On...
How common is hyperprogresion, and are there any strategies to mitigate it?
What if the patient has thymoma-associated myasthenia gravis?
There seem to be a lot of different fractionation schemes in the literature. Is there one that is most standard?
Do you prefer breath-hold techniques (ABC, DIBH) or abdominal compression regardless of tumor motion? Or do you use a general threshold number of cc's...
Carbo/pemetrexed/pembrolizumab, carbo/pemtrexed without immunotherapy or second line immunotherapy (Nivo, Pem or atezolizumab)?
The Indiana report and RTOG published a "danger zone". There was a catastrophic "case report" for 50 Gy in 5 fractions. Are there alternat...
Prior to the PACIFIC trial, patients were treated with definitive chemo/rads. With local recurrence <1yr after chemorads and definitive treatment f...
For a Stage III NSCLC looking to do definitive chemoRT who required IVIG and high-dose prednisone for paraneoplastic myopathy (mimicking dermatomyosit...
Has the publication of IMpower133 changed standard of care?
Does this vary based on whether the patient had a lobectomy v. wedge resection?
All tumors in this case were <2cm in size.
Would starting with chemotherapy be preferred in this situation and consider concurrent radiation, then switch over to Pembrolizumab once some control...
If so how would you select patients (ie. PS, histology, PD-L1 expression level)?
In a patient with a cavitated lesion with underlying chronic infection (identified as cocci) and SqCC, are there additional risks to SBRT? Should spec...
In patients with aberrant anatomy due to previous surgery with lung PTV overlapping the stomach, how much would you dose de-escalate? Even conventiona...
There is no evidence of disease outside the lung on PET, and the patient is completely asymptomatic with negative EGFR, ALK, ROS1, and BRAF and a PD-L...
If so, what constraint is most clinically relevant?
The EORTC LungTech trial (60Gy/8 fractions) does not specify a chest wall constraint. I have...
PD-L1 < 50% and no targetable mutations. Would you use carbo/pemetrexed/pembrolizumab or Nivolumab or pembrolizumab?
For example, would a + vascular margin, extranodal extension of N1 disease, translobar disease, or high risk histologies (large cell neuroendocrine, s...
Would you repeat PET or is it adequate to change to CT surveillance? Although surveillance PET/CT is not recommended by NCCN guidelines, these are oft...
Would you treat with localized therapy with chemoradiation or SBRT or consider ROS-1 directed therapies?
What dose and fractionation would you consider if surgery is not an option?
Do you discuss this at the first consultation? Is there strong evidence to suggest that risks are significantly increased compared to upfront lobectom...
Would you use the same schedule as early stage NSCLC primary?
The current NCCN guidelines reserves radiation for patients who are not resectable after induction chemotherapy. Does it make sense to offer concurren...
Lung primary is inaccessible for biopsy and metastatic sites are only 2 small bone lesions. In a non-smoker, a driver mutation is suspected but would ...
Would you offer adjuvant therapy post resection?
Would your choice of treatment change if the same patient was T790M negative and osimertinib was given as a first-line therapy?
Do you prefer carboplatin-paclitaxel-bevacizumab, carboplatin-pemetrexed-pembrolizumab, or chemotherapy alone?
Is local control worse for SBRT when the tumor is invading into the bone (rib)?
Does the more recent NEJ026 trial describing benefit from Bevacizumab plus Erlotinib over Erlotinib alone in patients with EGFR driver mutations ...
Certainly ovarian cancer will respond to carboplatin and paclitaxel and it sounds like a reasonable chemotherapy to give to a stage IV NSCLC, however ...
If there are 3 negative scans, do you continue annual screening?
A recent phase III trial published in JCO describes the NVALT-11/DLCRG-02 study, evaluating PCI vs observation in patients with stage III NSCLC s/p co...
Specifically, would carbo-taxol-bev-atezo (IMpower 150) be an attractive option given the activity of bev-atezo in sarcomatoid PDL1+ metastatic RCC (I...
Is there any data for the benefit for systemic chemo in such situation?
For the Impower 150 trial, is there data reported on PFS and OS for ABCP vs ACP (atezolizumab/bevacizumab/carboplatin/paclitaxel vs atezolizumab/carbo...
Or would you wait to start coincident with the start of cycle 2? If a shorter time from the start of any therapy to the end of radiation (SER) is sign...
How do you interpret the results of Checkmate 227 in light of Keynote 189 and Keynote 407?
Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?
Does the recent FDA approval based on PFS and response rate in KEYNOTE-021 warrant it's use?
Does the stage of the cancer affect this decision?
For example, a NSCLC of the LLL abutting and potentially involving the adventitia of the descending aorta?
For a patient with a new contralateral primary or recurrence and previous pneumonectomy, what lung constraints do you prioritize (ex mean lung dose, V...
By the definition this would be M1 disease, but would definitive treatment be appropriate? Is there clear data that a single pleural nodule has no cha...
Would you consider "aggressive" concurrent chemoradiation followed by SRS to the CNS lesion and possible consolidative immunotherpay (the PACIFIC...
Would you consider MS an absolute contraindication to this treatment?
What is your treatment approach in a patient with small cell lung cancer and a pericardial effusion?
In a patient with newly diagnosed small cell lung cancer with disease limited only to the thorax would you treat with definitive chemoRT in the presen...
In a patient with pain that does not respond well to narcotics what would be your treatment approach? Is there any data that suggests patients c...
Given the results of Keynote 189, is there any benefit of chemotherapy+pembrolizumab in specific subsets of patients in the first line setting?
Do you electively treat the tracheobronchial tree? Or a certain length of the trachea and bronchus? Does the volume and dose depend on location (...
In the absence of clinical trial, is there are role for dose-escalating alectinib, or would you consider brigatinib or chemotherapy?
When would you favor delivering local therapy (e.g. SBRT) prior to systemic therapy?
These patients have been largely excluded from these trials. What if the infection is well controlled?
If you are considering chemotherapy and radiation in the definitive, postoperative, or nodal failure scenarios, would you prefer sequential treat...
Assuming it is clinically indicated, would a checkpoint inhibitor be efficacious in a patient who has a concurrent autoimmune illness (PMR/TA) and is ...
Would you ever considering re-starting immunotherapy before completing the taper?
According to the new guildelines on managing immunotherapy related ...
If so, 50 Gy / 5 fx? 7.5 Gy / 8 fx? If so what dose constraints would you use to help determine fractionation?
What are some guidelines or principles that you use to recommend adjuvant radiation after complete resections of sarcoma?
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 ...
If so, what would be the regimen?
What factors influence your decision (R1 v. R2 resection? T stage?) If sequential, do you typically prefer radiation before or after chemotherapy?
Or would you rather treat with 3D-CRT in order to initiate chemoRT concurrently?
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 another course of SBRT possible? If so, what are the important planning considerations?
Given the lepidic growth pattern, do you use similar margins as with frankly invasive lung tumors? Are there any challenges localizing the target with...
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...
Would you treat if there is active infection? How much improvement would you expect?
Would you treat if the patient is asymptomatic? If you do treat with RT, what dose-fractionation would you use, and what volumes do you target?
Is a pleural effusion not oligometastatic by definition? The best evidence for consolidative RT was the MD Anderson/U Colorado/Western Ontario phase I...
Would you consider second line immunotherapy before considering chemotherapy?
What regimen do you prefer?
Can T790M mutation develop within this early time frame, or are these perhaps patients who may benefit from switch to chemotherapy?
Or do you recommend treatment with systemic therapy alone, as this represents Stage IV disease?
Any special dosing considerations or can you approach this like any other small peripheral 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?
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 does this approach change with mediastinal lymph node involvement? What are the indications for definitive or adjuvant radiotherapy +/- chemothera...
Would age or histology alter your decision if biospy proven N2 disease has a pCR after 4 cycles of chemotherapy?
Which imaging studies do you perform and what is the timing after treatment?
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 ...
How do you select between the available treatment options (gemcitabine, docetaxel, paclitaxel, nab-paclitaxel) in combination with platinum?
Up...
Would a large number of peribronchial nodes but negative nodes at the hilum and mediastinum (LN stations 7-10) affect decision making or volumes? What...
When there is biopsy proven mediastinal disease, do you offer definitive chemoradiation and monitor, or do you try to prove the presence/absence ...
Has the recent FDA approval of dabrafenib/trametinib changed your practice?
Are there specific conformality parameters you prioritize (105% dose volume outside of PTV, conformality index, ratio of 50% isodose volume to PTV, an...
Although elective nodal irradiation is not standard, what you treat lymph node stations that are adjacent to involved lymph nodes? For example, i...
Similarly, would SBRT be an option for a small central persistent node? What maximum total BED would you accept before no longer recommending addition...
Have the results of LUX-Lung 7 changed your routine practice? Are there promising up-front clinical trials that these patients may benefit from?
Do you incoprate Ki67% or mitotic rate into your treatment decision, and is there any use for somatostatin based imaging such as octreoscan or gallium...
In IB-IIIA cases?
Is there any role for a trageted agent with CNS penetration (such as second generation ALK inhibitors) after completion of postoperative brain radiati...
After sublobar resection and well dissected mediastinum, would you soley focus on the area of the positive margin or would you include ipsilateral hil...
Have you ever seen toxicity related to diaphragm dose with conventional fractionation?
Should we be routinely sequencing ALK to select an ALK inhibitor with the appropriate efficacy, matched to resistance patterns?
Does the site of oligometastasis matter (ex. brain v bone)? In this trial https://www.ncbi.nlm.nih.gov/pubmed/27789196 20% of patients were ...
What is the average healing time? What medications and/or procedures do you recommend for pain control? Does management differ for those with chest wa...
Do you specify an isodose line to prescribe to? Do you ask for a percent hot, and if so do you specify what percent or volume of the GTV/ITV should re...
Do you use V5, V30 (as per Dess, JCO 2017)? V50 (Speirs, JTO 2017)? Mean (Wang JCO 2017)? What is the most evidence based criteria? How do you b...
Is there any role for consolidative RT/CRT to the lung and mediastinum after initial chemo? What dose and fractionation would be most appropriate for ...
What factors influence your decisions to offer neoadjuvant chemotherapy?
Is there any role for either the addition of bevaciziumab or for maintanance pemetrexed?
Would a postiive margin or extracapsular extension altar your recommendations? Does size play a role in your recommendation?
Under what clinical circumstances would you consider prescribing them?
For instance with isolated progression at one metastatic site, with all other disease stable and clinically doing well.
How do the different assays compare when choosing a specific immunotherapy, and does this change for first vs second (or beyond) line of therapy?
How long do you typically wait before starting consolidation chemotherapy, and do you routinely perform re-staging scans prior to consolidation?
For example, there is a retrospective series out of MD Anderson (Kim, Acta Oncologica 2008) wherein 37 patients with gastric cancer were treated with ...
What immunosuppressive agents are used and in what order? Does your approach differ depending on the organ involved, e.g. colitis vs. pneumoniti...
In addition to addresing the brain met (surgery vs. SBRT), would you proceed with systemic "adjuvant" chemotherapy, or would you treat the patient as ...
There are varying reports in the literature which seem to suggest increased rates of Gr 4-5 pneumonitis in IPF patients. How do you manage these...
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...
Does the extent/duration of systemic disease control (complete response vs. stable disease, for example) influence your decision? What about whe...
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...
Would you give radiation after and if so would you give it with chemotherapy or alone?
These patients with brain metastases were excluded from the CREST study.
Does the presence of a sarcomatoid component influence this decision?
If these are presumed to be immune-mediated (e.g. immune neutropenia or immune thrombocytopenia), do you treat with steroids?
Based on JO25567 and the phase Ib trial of afatinib and cetuximab, for patients otherwise tolerating therapy would you consider adding these agents or...
The Phase III J-ALEX study and two phase II studies seem to suggest favorable intracranial response rates for alectinib.
For example, in a patient minimal brain and liver metastasis, would you treat all sites definitively?
What about patients who are still on steroids for radiation pneumonitis?
In my experience, it seems like the post-SBRT area of fibrosis is more than I would have otherwise expected with GGOs. I have usually advised wa...
What if there was a pT1aN0 invasive adenocarcinoma that was separate from the focus of adenocarcinoma in situ which resulted in the positive margin. &...
If so, what adjustments do you make? Does your recommendation change based upon how long the lobe has been collapsed and/or its presumed functionality...
Does recent data from the OAK study showing a survival benefit for atezolizumab over docetaxel even in non-smokers affect your decision making?
What is the role of PET?
Would you consider giving the therapy with concominant steroids, or with a dose reduction?
Or do you use standared involved nodal fields, as is done with concurrent chemoRT?
Do you add bevacizumab regardless of whether you are using paclitaxel or pemetrexed with the platinum agent?
Also, are you testing for PD-L1 routinely prior to initiation of first-line systemic therapy?
For fit patients, what regimen do you prefer outside of a clinical trial?
Our lung cancer screening program does not enroll anyone who has previously been deemed to be a nonsurgical candidate. I see that there is no ev...
I ask this question recognizing there is no great data here, and that "pseudo-progression" is rare, but I am looking for any guidance with regard to h...
If not what radiation fractionation regimen is preferred for otherwise good KPS patient?
Should surgery followed by adjuvant chemotherapy and radiation be considered for non-bulky single station N2 disease?
Based on recently published data from CheckMate 032, do you now offer nivolumab to small cell patients who have progressed after first-line chemothera...
Would adjuvant chemotherapy suffice, or would you also consider RT in a patient with a PS of 0-1? Would your recommendations change if it was N0...
If a biopsy carries a high risk of morbidity what interventions would you recommend for the local failure?
What about specifically in never-smokers?
The NCCN guidelines call for pathological mediastinal lymph node staging for all NSCLC except in solid tumors <1cm and non-solid lesions < ...
4cm has historically been used as the cutpoint for determining benefit from adjuvant chemotherapy in this population (Strauss et al, JCO 2008; Bu...
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...
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 following ADAURA data? Or proceed with durvalumab based on PACIFIC data?
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...
Would you do concurrent vs. sequential chemoradiation? What would be your preferred dose and fractionation?
How do you incorporate the pre-chemo vs post-chemo tumor volume into the treatment design?
As it is suggested for larger tumors treated with surgery, based on post hoc CALGB analysis?
If so, how? Or would you avoid SBRT in such a situation?
Will the NCCN guidelines change based on this study?
The NCCN guidelines discourage the use of PET/CT surveillance but the recent analysis of RTOG 0235 found post-CRT PET uptake to be associated with wor...
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...
Do you treat the hilum and ipsilateral mediastinum? Just the lymph node levels that were positive at surgery? I have not found good guidel...
Specifically from a GI primary?
For example, should nivolumab be considered standard second-line therapy for adenocarcinoma patients? Can it be considered for first-line thera...
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...
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...
Does IFRT include only the involved lymph nodes + margin or the entire involved lymph node station as specified by the Michigan Atlas?
Are your constraints different than the standard constraints used for patients who have not had surgery?
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...
Would you consider placing a stent in this patent graft to minimize closure of the graft after SBRT?
If so, how do you calculate the amount of fractions that are added?
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...
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...
If so, what would you include in the target and what dose?
Should mutations other then EGFR and ALK be routinely tested for? Should next generation sequencing be routinely done?
Would you treat initially involved contralateral supraclavicular nodes?
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...
Would you stop the Tarceva at this point?
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...
If so, what technique and dose would you suggest?
Roughly what percentage of patients are treated without a biopsy?
Do you define it as whole lungs (inc. tumor) or whole lungs minus GTV, CTV, ITV, or PTV?
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 ...
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...
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...
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, it has been said that Pencil Beam dose calculation algorithm can overestimate the target dose and understimate the normal tiss...
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 dose/fractionation is appropriate and does it differ between histology?
What are the primary data that drove organ at risk and conformality dose constraints?
Is a biopsy needed? Do you consider treatment palliative or curative?
I've found that very few patients have a regular breathing cycle, which makes respiratory gating very difficult. Any other solutions?
In practice, do you send patients with N2/3 disease for mediastinal staging if not offered upfront?
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