Non-small cell lung cancer&nbsp;&nbsp;&nbsp;

Would you ever consider definitive thoracic RT with concurrent immunotherapy in Stage III NSCLC?

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...

What dose constraints do you use for 60 Gy in 15-20 fraction lung treatments that are adjacent to the hilum?

Are there clinical features that would lead you to consider combining SBRT + immunotherapy in a high risk early stage NSCLC?

How do you approach EGFR mutated NSCLC with isolated progression in the chest who is planned for a course of radiation at least 3-4 weeks?

How do you balance the risk of an EGFR flare while holding osimertinib vs the risk of pneumonitis when continuing?

Do you have a maximum size cutoff for lung SBRT in central NSCLC?

E.g. for a 7cm central NSCLC, would you offer 8 fx SBRT or ChemoRT? Patient is not a surgical candidate.

6 Answers available

Is there ever a role for adjuvant chemotherapy and/or immunotherapy for early stage, N0 non-small cell lung cancer treated with SBRT alone?

5 Answers available

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?

How do you approach treatment for patients with ALK+ mNSCLC who have multifocal or leptomeningeal CNS progression while on first-line targeted therapy?

Would you test for resistance mutations in this setting, using blood-based sample if no progression outside CNS?

5 Answers available

In locally advanced EGFR-mutated NSCLC with initial good response to osimertinib, how do you manage local progression of the primary?

Would you consider SBRT and continue osimertinib?

How do you manage pneumonitis in patients with Stage III NSCLC receiving durvalumab?

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...

Should durvalumab consolidation still be offered to Stage III NSCLC patients with PD-L1< 1%?

Do the results of the unplanned subset analysis of the PACIFIC trial showing no OS benefit in this population lean you away from consolidation?

Should lung SBRT fractions be delivered on consecutive days, every other day, or perhaps an even more prolonged schedule?

Does tumor location play a role (central vs peripheral) in making the decision? The question stems from an oral presentation at ASTRO 2014 inves...

7 Answers available

Do patients with Stage III unresectable NSCLC with lepidic features require a different approach to chemo-radiation?

Would your choice of concurrent chemotherapy be impacted by this histologic finding?

Do you offer consolidative thoracic radiation for oligometastatic NSCLC following upfront immunotherapy?

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 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?

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?

How do you approach elderly patients with stage III NSCLC who have a reasonable performance status?

Do you recommend or make any modifications in the PACIFIC regimen for patients > 75 years of age?

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. https://www.ncbi.nlm.nih.go...

How do you monitor response for stage III NSCLC patients receiving consolidation immunotherapy?

CT or PET? If so, how often?

Does consolidation durvalumab increase the risk of pneumonitis in Stage III NSCLC?

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 patients with inoperable stage III NSCLC who are unable to receive or refuse definitive chemoradiation, how do you decide among radiation alone, pembrolizumab alone, or radiation followed by either pembrolizumab or durvalumab?

5 Answers available

How do you time re-staging studies and adjuvant durvalumab for stage III NSCLC treated with definitive cCRT?

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...

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...

Do you recommend adjustment of lung dose constraints in the setting of stage III lung cancer treated with definitive concurrent chemoradiation followed by planned consolidation immunotherapy?

Do you stop consolidative durvalumab after one year as per the PACIFIC trial or continue if the patient is otherwise tolerating well?

Would you offer the PACIFIC protocol to a patient with stage III lung cancer with performance status 2-3?

If so, how would you modify this regimen?

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?

For stage III NSCLC treated with definitive intent chemoRT, how do you decide to proceed with surgery vs consolidation immunotherapy?

Are you offering durvalumab to patients with Stage III NSCLC with known targeted mutations (ie ALK, EGFR, ROS1, BRAF) after completion of chemoradiation per PACIFIC?

The EGFR subgroup appeared not have benefited as much as other patients in the publication. However, recently it was reported that the PACIFIC study m...

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 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...

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...

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?

What dose constraint do you use for the proximal bronchial tree for when treating NSCLC to 60 Gy/8 fx?

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...

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?

Do you do recommend further mediastinal staging for patients with SCLC or inoperable NSCLC with N1 disease on PET?

If a patient clearly has N1 disease with high SUV on PET, do you routinely recommend EBUS or mediastinoscopy to evaluate for N2 disease?

Should radiotherapy be utilized in stage IVA NSCLC with a malignant pericardial effusion?

If there is no other evidence of metastatic disease, would you offer thoracic radiation? Either upfront with chemo or after initial system therapy if ...

Would you include any elective nodal stations for cases of T3/T4 node-negative NSCLC staged by PET/CT in which a patient cannot undergo nodal sampling?

Would your answer differ based on whether the patient is receiving concurrent chemotherapy? Are there other factors that would influence this decision...

For oligometastatic NSCLC that would be otherwise considered stage 3, would you consider consolidative immunotherapy with durvalumab after definitive treatment for both the primary and oligometastatic site?

When do you choose motion management over free-breathing techniques for lung SBRT?

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...

What lung constraint do you use when delivering SBRT for local failure of early stage NSCLC following surgery?

Does this vary based on whether the patient had a lobectomy v. wedge resection?

Would you offer immunotherapy after chemoradiotherapy for Stage III lung cancer given results of PACIFIC Trial?

If so how would you select patients (ie. PS, histology, PD-L1 expression level)?

What potential risks of SBRT do you counsel patients on when treating early stage lung cancer with an underlying chronic lung infection?

In a patient with a cavitated lesion with underlying chronic infection (identified as cocci) and SqCC, are there additional risks to SBRT? Should spec...

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...

Do you use a chest wall constraint when treating large lung cancers with 8 or 10 fraction SBRT?

If so, what constraint is most clinically relevant? The EORTC LungTech trial (60Gy/8 fractions) does not specify a chest wall constraint. I have...

Do you ever recommend PORT or chemoRT rather than chemotherapy alone for NSCLC with adverse features other than positive margins or N2 disease?

For example, would a + vascular margin, extranodal extension of N1 disease, translobar disease, or high risk histologies (large cell neuroendocrine, s...

Is there concern for hemorrhage after SBRT to a lung metastasis that directly involves a branch of the pulmonary artery?

What dose and fractionation would you consider if surgery is not an option?

How do you counsel patients in regards to the options and risks for salvage lobectomy/wedge after SBRT?

Do you discuss this at the first consultation? Is there strong evidence to suggest that risks are significantly increased compared to upfront lobectom...

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)?

How would you approach treatment for a patient with locally advanced NSCLC and systemic scleroderma if chemoradiation is their only curative option?

Does the presence of interstitial lung disease affect your decision to offer SBRT for early stage NSCLC?

Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?

6 Answers available

What factors do you use to decide between phase based vs. amplitude based gating for lung SBRT?

How do you fractionate SBRT for NSCLC abutting the chest wall or in which the PTV encompasses part of the chest wall?

Does proximity to or involvement of the aorta effect the dose and fractionation you use for an early stage NSCLC?

For example, a NSCLC of the LLL abutting and potentially involving the adventitia of the descending aorta?

How does your management of locally advanced NSCLC change in a patient with a previous contralateral pneumonectomy?

For a patient with a new contralateral primary or recurrence and previous pneumonectomy, what lung constraints do you prioritize (ex mean lung dose, V...

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?

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?

What dose constraint, if any, do you use for the diaphragm when treating liver or lung tumors with SBRT?

Have you ever seen toxicity related to diaphragm dose with conventional fractionation?