Lung Cancer   

Questions discussed in this category



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 ...

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

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

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

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

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

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

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?

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

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 ...

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...

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

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

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...

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?

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

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

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

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

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

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)?

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...

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

If so, what fields do you irradiate? The initially involved nodal regions? If not, do you consolidate at any point in the future (ie after a loca...

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

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

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?

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

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

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

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 ...

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

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?

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

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

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

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...

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

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

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?

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...

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 ...

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

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

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

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

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

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 ...

 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...

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

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

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...

Since results of the phase III J-ALEX study were reported at ASCO 2016, do you try to obtain alectinib in the first-line setting instead of crizotinib...

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

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

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

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...

It seems like the RADIANT trial, finding an 18 month DFS benefit for adjuvant erlotinib, would favor this, but the study calls this "not statistically...

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...

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

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...

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

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 ...

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?

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...

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

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...

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...

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.

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

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...

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


Papers discussed in this category


Cochrane Database Syst Rev, 2006-10-18

Clin Oncol (R Coll Radiol), 1996-01-01

J Thorac Oncol, 2007 Jul

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2014-03

Int J Radiat Oncol Biol Phys, 2002 Mar 15

The Lancet. Oncology, 2015-02

Radiat Oncol, 2007 Jun 7

International journal of radiation oncology, biology, physics, 2013-09-01

JAMA, 2010-03-17

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2009-07

Clinical oncology (Royal College of Radiologists (Great Britain)), 2007-09

Radiation oncology (London, England), 2014-01-03

Int. J. Radiat. Oncol. Biol. Phys., 2010-03-15

The New England journal of medicine, 2012-06-14

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2006-10-20

International journal of radiation oncology, biology, physics, 2012-08-01

International journal of radiation oncology, biology, physics, 2014-07-01

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2009-06

J Thorac Oncol, 2011 Dec

International journal of radiation oncology, biology, physics, 2013-08-01

International journal of radiation oncology, biology, physics, 2010-03-01

Cancer, 2006-05-01

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2006-11

Journal of thoracic disease, 2011-03

Lancet Oncol., 2006-09-01

The Journal of thoracic and cardiovascular surgery, 2013-03

Int. J. Radiat. Oncol. Biol. Phys., 2010-06-01

Medical physics, 2013-09

International journal of radiation oncology, biology, physics, 2010-06-01

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2009-08

International journal of radiation oncology, biology, physics, 2007-10-01

Int J Radiat Oncol Biol Phys, 2000 Nov 1

N Engl J Med, 2007 Aug 16

J Clin Oncol, 1999 Jul

Lancet, 2015 Jan 3

International journal of radiation oncology, biology, physics, 2011-11-01

Int. J. Radiat. Oncol. Biol. Phys., 2006-09-01

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2017-12

Lancet Oncol., 2017-05-01

The New England journal of medicine, 1999-08-12

BMC Cancer, 2015-08-15

Journal of cancer research and therapeutics, 2012

International journal of radiation oncology, biology, physics, 2012-05-01

Neurosurgery, 2013-10

Practical radiation oncology, 2015

J. Neurosurg., 2005-01-01

J Korean Neurosurg Soc, 2011-08-01

Radiat Oncol, 2014-07-08

BMC Cancer, 2015-03-04

Acta Neurochir (Wien), 2013-01-01

International journal of radiation oncology, biology, physics, 2010-03-01

American journal of clinical oncology, 2015-08

Radiother Oncol, 2011 Nov

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2001-01-01

Journal of the National Cancer Institute, 2011-10-05

International journal of radiation oncology, biology, physics, 2006-07-15

International journal of radiation oncology, biology, physics, 2010-06-01

J Natl Cancer Inst, 1991 Mar 20

International journal of radiation oncology, biology, physics, 2002-10-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2002-08-15

Journal of the National Cancer Institute, 2016-09

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017-01

Radiation oncology (London, England), 2013-01-03

N Engl J Med, 2014 Sep 27

International journal of radiation oncology, biology, physics, 2014-12-01

International journal of radiation oncology, biology, physics, 2014-04-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2006-07-01

International journal of radiation oncology, biology, physics, 2012-06-01

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2015-01

Lancet, 1998 Jul 25

Int. J. Radiat. Oncol. Biol. Phys., 1999-08-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-03-10

International journal of radiation oncology, biology, physics, 2015-06-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2010-01-10

J Natl Cancer Inst, 2014 Aug

Int. J. Radiat. Oncol. Biol. Phys., 2014-04-01

Radiat Oncol, 2015 May 27

International journal of radiation oncology, biology, physics, 2016-06-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017-04-01

The New England journal of medicine, 2016-11-10

The New England journal of medicine, 2018-01-11

N. Engl. J. Med.,

International journal of radiation oncology, biology, physics, 2005-09-01

Am. J. Clin. Oncol., 2007-06-01

Int J Radiat Oncol Biol Phys, 2008 Oct 1

The New England journal of medicine, 2015-10-22

The Lancet. Oncology, 2015-06

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-11-01

Semin Radiat Oncol, 2015 Oct

J Thorac Cardiovasc Surg, 2011 Mar

J. Clin. Oncol., 2008-07-20

Chest, 2007 Sep

Lancet Oncol., 2014 May 13

The Lancet. Oncology, 2015-08

International journal of radiation oncology, biology, physics, 2010-12-01

Frontiers in oncology, 2014

Radiother Oncol, 2013 Oct

International journal of radiation oncology, biology, physics, 2016-09-01

Radiother Oncol, 2012 Mar

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-11-01

The Lancet. Oncology, 2016-07

Lancet (London, England), 2009-08-01

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2013-07

Journal of the National Cancer Institute, 2007-03-21

The Lancet. Oncology, 2015-07

Annals of oncology : official journal of the European Society for Medical Oncology, 2013-09

JCO Precision Oncology, 2017 Sep 29

Sci Rep, 2014 Sep 09

Medicine (Baltimore),

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-10-01

Blood, 2015-07-23

Cancer Treat. Rev., 2016-04-01

Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 2015-01

Clin. Cancer Res., 2015-04-15

International journal of radiation oncology, biology, physics, 2016-06-01

Radiat Oncol, 2011-12-21

Eur. J. Cancer, 2016-02-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2007-01-20

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2005-09-01

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2007-05-01

Medical and pediatric oncology, 1990

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 1986-01

N Engl J Med, 2017 Nov 16

Immunotherapy, 2016-10

J Thorac Oncol,

Clin. Cancer Res., 2015 May 27

Lancet (London, England), 2017-01-21

Lancet (London, England), 2016-04-09

The New England journal of medicine, 2018-06-14

The Lancet. Respiratory medicine, 2019-05

Ann. Oncol.,

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2014-08-10

The Journal of thoracic and cardiovascular surgery, 2005-04

Radiographics : a review publication of the Radiological Society of North America, Inc, 2014-10

Oncotarget,

Nature, 2017-04-26

Cancer discovery, 2017-12

Cancer discovery, 2016-10

The Lancet. Oncology, 2016-11

The New England journal of medicine, 2018-05-31

International journal of radiation oncology, biology, physics, 2015-11-15

Int. J. Radiat. Oncol. Biol. Phys.,

J Thorac Oncol, 2016 Oct 07

Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-04-01

J. Natl. Cancer Inst.,

Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2017-10

International journal of radiation oncology, biology, physics, 2009-04-01

J. Clin. Oncol.,

International journal of radiation oncology, biology, physics, 2014-09-01

The New England journal of medicine, 2017-06-22

Clinical lung cancer, 2016-11

The New England journal of medicine, 2018-11-22

Lung Cancer,

Lancet Oncol., 2008 Jun 24

International journal of radiation oncology, biology, physics, 2013-03-01

Respir. Res., 2018 Apr 24

International journal of radiation oncology, biology, physics, 2011-10-01

JAMA oncology, 2017-05-01

The New England journal of medicine, 2018-12-13

Int. J. Radiat. Oncol. Biol. Phys., 2008 Jan 30

Thorac Surg Clin,

International journal of radiation oncology, biology, physics, 2013-04-01

International journal of radiation oncology, biology, physics, 2015-09-01

N. Engl. J. Med.,

PLoS ONE, 2015 Nov 24

J. Clin. Oncol., 2015 Nov 02

The Lancet. Oncology, 2009-05

Clin. Cancer Res., 2018 Oct 08

International journal of radiation oncology, biology, physics, 2018-03-15

J Thorac Oncol, 2019 Feb 16

The New England journal of medicine, 2011-08-04