Case study 120.3
A 75-year-old woman, an ex-smoker with significant medical problems that include mild chronic obstructive pulmonary disease, coronary artery disease, diabetes, and a recent mild stroke, was found to have a T2N1 large cell carcinoma, with a 3.5 cm primary tumor in the right lower lobe of the lung and a 2 cm right hilar lymph node. Both areas are fluoro-deoxyglucose (FDG) avid on positron emission tomography (PET) scan. The remainder of the metastatic work-up is negative. Her performance status is ECOG1; she has no respiratory symptoms and has not lost weight.
• How should she be managed?
This patient has a clinical stage II (T2N1M0) NSCLC. If she were medically operable, the standard treatment would be mediastinal nodal assessment, and, if that is negative for N2 disease, lobectomy with lymph node dissection followed by adjuvant chemotherapy. This patient, however, is at high risk for surgery, particularly due to the recent stroke. Her risk of perioperative and postoperative vascular events is significant. Thus, she should be considered for nonsurgical treatment with curative intent. This clinical scenario is not common, and thus treatment recommendations are not based on randomized trials specific to this question, but are extrapolations of evidence from nonsurgical treatments of N2 disease, and a known natural history of surgical N1 disease.
Radical radiotherapy would be the main local treatment, and discussion would be around whether the patient is fit enough for combined chemoradiotherapy. Her age, diabetes, and vasculopathy are risk factors that put her at a higher risk of chemotherapy complications, including arterial thrombotic events, although they are not absolute contraindications to chemotherapy. If the patient is deemed well enough to tolerate chemotherapy, it could be considered concurrently with radiation, or sequentially to minimize toxicity.
Radiation volumes would need to consider the risk of this patient having occult mediastinal nodal disease. Ideally, sampling of mediastinal lymph nodes through endobronchial ultrasound (EBUS) biopsy (which would avoid the risk of general anesthesia) would be performed prior to commencing treatment, and if they are indeed computed tomography (CT), PET, and EBUS negative, they may be excluded from the radiation field. However, in the presence of gross N1 disease, mediastinal nodes are at a risk of harboring microscopic disease, and consideration would be given to including at least first-eschalon nodes (e.g., the subcarinal and ipsilateral lower paratracheal nodes) in the RT volumes if pathological information was unavailable. Typical doses would be in the range of 60 Gy in 30 fractions to the known cancer, and lower doses to the areas thought to be at risk of microscopic disease. If chemotherapy is not being considered, more hypofractionated RT regiments (e.g., 60 Gy in 20 fractions) could be considered. Although SBRT could deliver a much higher dose, currently it is not a consideration for nodal disease, except as part of an experimental protocol.
It is likely that this patient would tolerate radical radiotherapy well, with some esophagitis, tiredness, and likely a relatively small risk of symptomatic radiation pneumonitis. Although local control with RT is considerably less than with surgery, the morbidity and mortality risks from treatment are also considerably less, and the potential for cure is probably around 50–60%.
17: Management of Therapy-Related Myeloid Neoplasms
36: Nodular Lymphocyte-Predominant Hodgkin Lymphoma
71: Secondary Brain and Spinal Cord Tumors
