Stereotactic radiation lung mass without biopsy

[NJPAIN]

I am a pain management physician who is active on another forum. While I know that SDN Is not a place for medical advice I hope you will answer a question in general terms. 91 year old former smoker with multiple medical problems including COPD on chronic oxygen therapy and low dose steroids. However she is cognitively 100% intact. Incidentally found on chest CT is left upper lobe mass approx 3 cm in size. Not present on CT one year prior. In younger healthier patient she would be candidate for surgical resection. Not in location for biopsy by bronchoscopy. Radiology opines that CT guided biopsy will almost certainly drop the lung. Oncology suggests doing nothing. When asked about stereotactic radiation without biopsy oncologist states " that's malpractice, no one will do that". She goes on to state that treating with radiation will only cause problems and do nothing else. Is this accurate? Will no one treat without tissue under these circumstances? What treatment associated morbidly is associated with stereotactic radiation of the lung?

Thanks


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[OliveTree]

I am a pain management physician who is active on another forum. While I know that SDN Is not a place for medical advice I hope you will answer a question in general terms. 91 year old former smoker with multiple medical problems including COPD on chronic oxygen therapy and low dose steroids. However she is cognitively 100% intact. Incidentally found on chest CT is left upper lobe mass approx 3 cm in size. Not present on CT one year prior. In younger healthier patient she would be candidate for surgical resection. Not in location for biopsy by bronchoscopy. Radiology opines that CT guided biopsy will almost certainly drop the lung. Oncology suggests doing nothing. When asked about stereotactic radiation without biopsy oncologist states " that's malpractice, no one will do that". She goes on to state that treating with radiation will only cause problems and do nothing else. Is this accurate? Will no one treat without tissue under these circumstances? What treatment associated morbidly is associated with stereotactic radiation of the lung?

Thanks


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Herder & Brock models can be used to estimate risk of malignancy. At our institution, we would offer SBRT in the above "general" situation after PET scan without biopsy.

https://www.uptodate.com/contents/c...k-brock-university-cancer-prediction-equation
http://spn.azurewebsites.net/Herder

 

[Phantom1]

If you do nothing the median survival is around 12 months. However in a 91 y/o with COPD on oxygen there are multiple competing risks of mortality, and median survival may be around 1-2 years irregardless, so this is not a simple decision. I usually try to avoid irradiating the lung in patients on oxygen.

Nevertheless, to answer your questions: treating without a biopsy is not malpractice and it is done in some of the top cancer centers in the US. Generally you would want to show evidence of a new and progressive PET positive mass in a smoker. On a PET/CT if there is 1) no evidence of distant metastatic disease 2) no lymphadenopathy, 3) no other clear medical reason for the mass, and 4) the mass is PET positive and growing, then we would consider SBRT for presumed early stage lung cancer in medically inoperable patient. Consensus opinion from a thoracic tumor board is also recommended. Lung SBRT is generally extremely well tolerated (depending on location). There are usually no acute effects, and low rate of long term side effects with exceptional local control. Sounds like you are getting some pretty biased and uninformed advice..

 

[OTN]

Not unreasonable to treat without biopsy if it's PET-avid. Decent data from Duke I think it was showed great LC with low morbidity.

 

[medgator]

Electro-navigational bronchoscopy (ENB) is performed by pulmonary or CT surgery and carries a much lower risk of pneumothorax, although I imagine with the pt on oxygen already, she may not tolerate the general anesthesia some places use for it.

Agree with others that it's reasonable to offer treatment in this scenario. I believe there is data from japan where they skip biopsy before sbrt in certain cases

 

[samysmiley]

I am not an attending, just a lowly resident, but one of my mentors was on the original team of the first big SBRT trial. He has done a great deal of work with lung cancer over the years, including studying the natural history. If this goes untreated, the patient does have a pretty decent likelihood of death due to lung cancer, median OS was 1.2 years in that study. I knew that needs to be taken with a grain of salt due to this patient's age. We would treat a new, PET+ lesion in this case, especially since SBRT has been shown to possibly lead to a decrement in PFTs, but not a long-term worsening of symptoms.

 

[Neuronix]

Get a second opinion from a radiation oncologist at an academic center. Where I trained we would radiate patients like this with regularity.

In Europe they frequently SBRT without a biopsy. The risks of the biopsy are likely higher than the risks of the SBRT in this patient.

The obvious question is whether this is really malignancy. Need PET/CT to confirm low stage disease if malignant, high SUV of primary, and I also request failure of antibiotics. I put these patients empirically on a fluoroquinolone for a month to make sure it's not an infection. When all of that is satisfied, I think it's very reasonable to treat.

 

[NJPAIN]

Thanks for the responses. With regard to navigational bronchoscopy, pulmonary feels she will not tolerate.
A few additional questions if I may:
1. Why avoid SBRT if on oxygen?
2. My concern is not only increasing length of survival but more Important quality of life. If SBRT is likely to improve the quality of life over the next 1-2 years it is worth it. My fear is the symptoms that will develop with disease progression. The oncologist flat out said the SBRT "would only make things worse". I'm not convinced that is a knowledge based statement.

Thanks again


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[Phantom1]

Thanks for the responses. With regard to navigational bronchoscopy, pulmonary feels she will not tolerate.
A few additional questions if I may:
1. Why avoid SBRT if on oxygen?
2. My concern is not only increasing length of survival but more Important quality of life. If SBRT is likely to improve the quality of life over the next 1-2 years it is worth it. My fear is the symptoms that will develop with disease progression. The oncologist flat out said the SBRT "would only make things worse". I'm not convinced that is a knowledge based statement.

Thanks again


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You can irradiate if on oxygen, but depends on situation, if chronic for years on oxygen and has COPD with significant emphysematous changes in the Upper lobes, then SBRT to an upper lobe tumor would likely have little effect on lung function. However, I think you are asking for specific advice on this patient which we obviously can't give here. By "oncologist" I think you are referring to a medical oncologist or chemotherapy doctor who is clearly biased and uninformed on this issue. Bottom line is that the patient needs to see a Radiation Oncologist for discussion and evaluation, because Lung SBRT is the Standard of care for medically inoperable early stage NSCLC. SBRT is extremely well tolerated with little to no side effects in the vast majority of patients.

 

[RSAOaky]

lowly resident here as well but in a hypothetical patient with a 3cm lung nodule that wasn't there a year ago we would get a PET/CT and rule out distant metastatic disease. If the lesion is PET+ and there is no distant disease we will treat. A lesion that size is unlikely to be PET negative if it is a primary lung cancer, but even so we would still have a conversation with the patient regarding the risks and benefits of treatment. As I see it, the treatment is well tolerated and while there may not be much of a survival benefit in someone with significant competing comorbidities, local progression of a tumor in that location has potential to be quite morbid.

 

[NJPAIN]

Thanks again for your replies. I must admit that I am disturbed that the medical oncologist instantly dismissed my idea of SBRT without biopsy. After briefly looking at some of the literature it just didn't make much sense thus my venture onto this forum.
We will proceed with PET and consult with radiation oncologist. We are in Northern NJ. I am told that there is a radiation oncologist with experience in SBRT at Overlook Medical Center that is not too far away.


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[evilbooyaa]

Agree with everyone else. PET/CT to make sure it's brightly FDG avid and no mediastinal/distant mets.

Lung toxicity with SBRT is quite minimal. There is a possible (low) risk of radiation pneumonitis but that's not generally something to preclude treatment.

Again, agree that patient should meet with a radiation oncologist. The question is her performance status. If the concern was that SBRT is going to be all toxicity without benefit, then perhaps the rad onc thinks the patient's co-morbidities will kill her before the lung cancer, which is a definite possibility. There are various shades of functionality for 91 year olds; obviously being on oxygen is a concern but shouldn't be the only factor stopping her from treatment.

If a radiation oncologist in the community balks, I'd consider referring for second opinion to the nearest academic center. There may be some defensiveness to 'not being blamed' for respiratory demise in a 91 year old COPD'er on oxygen in the community. Generally that defensiveness isn't a real factor in academic facilities.

 

[JahnTeller]

Not sure what others may think about getting a sputum cytology, but doing a few in hopes of catching malignant cells (depending on location of the tumor) may provide a diagnosis without risks of a biopsy. Sensitivity is not great, and if negative wouldn't use that by itself as a reason not to treat, but probably doesn't hurt to try.

 

[Neuronix]

This is not a simple case. I'd see a lung dedicated radiation oncologist at an academic medical center.

If there was going to be an operation, would you trust a surgeon who occasionally operates on this and typically in healthy patients? Or would you want to see the best around who only operates on lung cancer and has experience with patients with comorbidities like advanced age and decreased baseline lung function?

It's the same here. You're taking your family member's life into uncertain hands for convenience only. Your choice.

 

[vm26]

complex, interesting case...great discussion

 

[NJPAIN]

This is not a simple case. I'd see a lung dedicated radiation oncologist at an academic medical center.

If there was going to be an operation, would you trust a surgeon who occasionally operates on this and typically in healthy patients? Or would you want to see the best around who only operates on lung cancer and has experience with patients with comorbidities like advanced age and decreased baseline lung function?

It's the same here. You're taking your family member's life into uncertain hands for convenience only. Your choice.

Excellent point. I frequently shake my head when my patients seek out less than optimally qualified physicians for convenience. Obviously the treating physicians at the large community hospital are not offering guidance beyond their resources. How does one identify such a physician ? I have been out of academia for quite some time so my resources in that realm are limited. If anyone is willing to PM me with a suggestion that would be appreciated.


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[thecarbonionangle]

We routinely do SBRT without a biopsy. Ignore the chemotherapist. They sadly know very little, quite often. A few months ago I treated a patient with COPD without a biopsy, they were on 4-6L oxygen. Just saw them on follow up. Doing excellent. Proceed without fear, mate.

 

[Gfunk6]

This is not a simple case. I'd see a lung dedicated radiation oncologist at an academic medical center.

If there was going to be an operation, would you trust a surgeon who occasionally operates on this and typically in healthy patients? Or would you want to see the best around who only operates on lung cancer and has experience with patients with comorbidities like advanced age and decreased baseline lung function?

It's the same here. You're taking your family member's life into uncertain hands for convenience only. Your choice.

Why? I could do it and I'm sure many community guys do SBRT Lung on a very regular basis.


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[Neuronix]

Why? I could do it and I'm sure many community guys do SBRT Lung on a very regular basis.


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Without offending my private practice colleagues, I've seen a wide range of treatments within private practice that make me nervous about going to the nearest radiation oncologist for SBRT or other modern radiation treatments. It may just be Florida.

 

[RadOncDoc21]

Without offending my private practice colleagues, I've seen a wide range of treatments within private practice that make me nervous about going to the nearest radiation oncologist for SBRT or other modern radiation treatments. It may just be Florida.

Florida is a very different (and dangerous) place! I have noticed a lot of academic vs private groups outcomes research during the ASTRO annual meeting. I think it should focus more on ancient vs. modern practice techniques because there are great community practices out there and maybe not so great academic chairs who can't even use IMRT.

 

[medgator]

Florida is a very different (and dangerous) place! I have noticed a lot of academic vs private groups outcomes research during the ASTRO annual meeting. I think it should focus more on ancient vs. modern practice techniques because there are great community practices out there and maybe not so great academic chairs who can't even use IMRT.

Without offending my private practice colleagues, I've seen a wide range of treatments within private practice that make me nervous about going to the nearest radiation oncologist for SBRT or other modern radiation treatments. It may just be Florida.

Florida is a mixed bag unfortunately. I've also heard Texas has some craziness going on too. I think a lot of it is old timers who are grandfathered lifetime BC who didn't train in the 3D/imrt era. Many of them also own their practice/machine. I have heard stories of pts getting ridiculously long fractionation for mets, imrt for mets (without clear medical necessity) and pts getting treated bid at 1.05 Gy/fx etc.

I think bundled payments (which is coming at some point if you look at what has been happening with codes) and/or eventual retirement of these folks will address the problem but it may be awhile

 

[Haybrant]

just read a few of the opinions here, sounds like a lot of residents. The rad onc needs to present the data to the patient, let the patient and family decide with appropriate consent. Yep there is a chance of pneumonitis and there is a chance of worsening lung function, those risks are low but possible and permanent 02 supplement is a chance depending on baseline Lung fx. Let them balance this with the risk or progression (local vs distant), and the risk you're treating something that is not lung cancer. Whoever said it's malpractice sounds ridiculous and probably an old timer that is well past hanging up the cleats. I hope you will stop referring to that person.

 

[BobbyHeenan]

just read a few of the opinions here, sounds like a lot of residents. The rad onc needs to present the data to the patient, let the patient and family decide with appropriate consent. Yep there is a chance of pneumonitis and there is a chance of worsening lung function, those risks are low. Let them balance this with the risk or progression (local vs distant), and the risk you're treating something that is not lung cancer. Whoever said it's malpractice sounds ridiculous. I hope you will stop referring to that person.

Agree fully here. I practice in a fairly large multidisciplinary cancer center but not in academics.

You ask that family come to the appointment and lay out the options. I see about 2-3 cases like this a year. I've had one case I was about to treat where at the time of CT sim about 3 weeks after PET (SUV ~5) the 1-2 cm solid lesion looked a tad smaller to me. I did not treat and re-imaged in 2 months and it mostly resolved. Six months later it was gone.

I'd bet of the dozen or so cases I've treated like this (unbiopsied but very suspicious) over the past 5 years odds are I may have treated a non-cancerous lesion. However, with the natural history of untreated lung cancer and the relatively low chance of major morbidity of SBRT I still offer treatment as an option in these cases after we present them at our multidisciplinary chest conference with pulmonlogists, CT surgeons, radiology, and interventional radiologists going over the case. If I didn't have that conference/multiD approach I'd be a little more nervous, but would never consider it malpractice to treat an unbiopsied but suspicious lung nodule as long as radiology thinks it's malignancy and the appropriate providers have stated biopsy is too risky.

If it was me or my parent or grandparent and that 3 cm mass was solid on CT and FDG avid (SUV >3 at minimum) with no associated lymph nodes, I'd take SBRT.

 

[scarbrtj]

When asked about stereotactic radiation without biopsy oncologist states " that's malpractice, no one will do that".

Super wrong. Per Donald Rumsfeld (was he a radiation oncologist?), "You go to war with the army you have, not the army you want."
1) https://www.ncbi.nlm.nih.gov/pubmed/25001510, https://www.ncbi.nlm.nih.gov/pubmed/24334338, https://www.ncbi.nlm.nih.gov/pubmed/21377293
2) morbidity from SBRT is close to nil. Certainly involved with exceedingly minimal acute effects. Knock on wood: no clinically significant lung problems in patients after 10+ years of doing lung SBRT in my practice. Patient (and tumor) selection can be key here, obviously.
3) Lung SBRT is standard operating procedure for any modern BC rad onc. Please don't tell me you have to go to academic med centers for simple lung SBRT.

 

[NJPAIN]

Can a medical oncologist in a "cancer center" at a large well respected community hospital be so poorly informed? This discussion has really opened my eyes up to what you radiation oncologists do and perhaps how little we idiots in the remainder of the medical community know about what you do.


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[scarbrtj]

Can a medical oncologist in a "cancer center" at a large well respected community hospital be so poorly informed? This discussion has really opened my eyes up to what you radiation oncologists do and perhaps how little we idiots in the remainder of the medical community know about what you do.


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Of course you are not an idiot. People in my specialty, say perhaps relative to a surgeon e.g., are far too steeped in the medical traditions of equivocation and non-absolutism. Granted, these things have their place... but as you can see above... do you think a surgeon thinks as we do? No! (Fellow non-rad onc MDs, just like a horse or a wolf, can smell fear. Ha.) Plus, sometimes the rad oncs don't even show up to let horse or wolf to catch a whiff of anything. Fear of getting thrown or bit, I reckon.

Case-in-point. I practice at a community hospital. Large academic center rad oncs also practice alongside me (the rad oncs are not large--their academic center is). Fellow with history of bleomycin (it's a chemo which is tough on lungs) because of lymphoma a couple of years ago (in complete remission or "cure" since that time) shows up with growing RUL nodule. He smokes a lot. He's 60. He's not on O2. Lung PFTs look reasonable but DLCO is 40% which is LOW. His lung CTs look like total crap. Pulmonologist does biopsy: squamous non-small cell lung cancer; Stage I-A. Pulm sends him to med onc, who sends me a lot of SBRTs but not this time, who sends him to academic rad onc in community center. Academic rad onc is known "SBRT expert," I guess. Academic rad onc sends him to thoracic surgeon at academic med center 60 miles away! Pulm goes "what the heck?!" and presents him at tumor board to plead with rad oncs--any rad onc!--to give him SBRT. Pulm was very concerned not a good surgery candidate. After much gas money spent and confusion on patient's part, he is finally about to get SBRT.

Yeesh.

 

[scarbrtj]

Can a medical oncologist in a "cancer center" at a large well respected community hospital be so poorly informed? This discussion has really opened my eyes up to what you radiation oncologists do and perhaps how little we idiots in the remainder of the medical community know about what you do.


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Just as an aside, way off topic grant you, I once had a patient with a probable optic nerve sheath meningioma. No surgery, and due to location, no biopsy, so this was the probable diagnosis. He had been seeing the most famous, most respected neuro-opthalmologist (NO) in our state for almost 10 years as his vision in the right eye got worse and worse. The NO followed and followed him and tried to cajole him into neurosurgery, but the guy never went for the surgery because the risks for vision loss seemed too great in his estimation and the surgery a little too scary. The fellow basically walked into my clinic on his own after it became almost impossible for him to read the newspaper in the morning. So I offered him fractionated stereotactic radiation for the lesion. The NO wrote me what I would call a "screed" that I was going to blind the guy (and that she hated radiation in all shapes and forms for his condition). I was a young lad, only a year or so out of residency (about 2005), but I'd seen this thing, I knew the literature, etc. He and I forged ahead. In the year after the treatment, the lesion slowly shrank to nothing and vision became remarkably better. Vision was still good as of 2010, last time I saw him. I always made sure the transcriptionist of my followup notes cc'd the NO, to which the patient never wished to return despite my exhortations.

So yes, non-rad MDs can be very poorly informed re: radiation therapy. It's a thing.

 

[RadOncDoc21]

Super wrong. Per Donald Rumsfeld (was he a radiation oncologist?), "You go to war with the army you have, not the army you want."
1) https://www.ncbi.nlm.nih.gov/pubmed/25001510, https://www.ncbi.nlm.nih.gov/pubmed/24334338, https://www.ncbi.nlm.nih.gov/pubmed/21377293
2) morbidity from SBRT is close to nil. Certainly involved with exceedingly minimal acute effects. Knock on wood: no clinically significant lung problems in patients after 10+ years of doing lung SBRT in my practice. Patient (and tumor) selection can be key here, obviously.
3) Lung SBRT is standard operating procedure for any modern BC rad onc. Please don't tell me you have to go to academic med centers for simple lung SBRT.

I don't think the problem is with the experience in doing SBRT but more so the cut off point of when to initiate treatment. We all know of some folks who would treat all nodules they see on CT, which (I hope) we could all agree is the wrong thing to do.

 

[evilbooyaa]

Can a medical oncologist in a "cancer center" at a large well respected community hospital be so poorly informed? This discussion has really opened my eyes up to what you radiation oncologists do and perhaps how little we idiots in the remainder of the medical community know about what you do.


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People can be poorly informed regardless of how high up the ladder they are. Sometimes the people that are highest on the ladder and aren't routinely keeping up with the most recent literature ARE the most poorly informed.

Rad Oncs are frequently aware of the things that their surgeon (across various surgical subspecialties) and medical oncology colleagues frequently say to make radiation appear like a less tempting option. However, you still have to suck up to them because we rely on them for their referrals. I've seen people referred WAY too late in their treatment course for the first time to radiation oncology. It's not just palliative stuff either all the time (post-prostatectomy relapse of prostate cancer with progressively worsening PSA continuing on 'observation')

 

[seper]

On the topic of empiric lung SBRT, I've unfortunately noticed a fair amount of over-utilization and inappropriate treatment of clearly benign lung infiltrates (major metro area in Northeast).
The nature of the problem makes it hard to catch wrongdoers using data analysis.

 

[medgator]

On the topic of empiric lung SBRT, I've unfortunately noticed a fair amount of over-utilization and inappropriate treatment of clearly benign lung infiltrates (major metro area in Northeast).
The nature of the problem makes it hard to catch wrongdoers using data analysis.

Infiltrates? Not even nodules? Usually I hypofractionate the more ground glassy, indistinct stuff rather than 3-5 fx sbrt, of course after a biopsy.

Infiltrates are even a harder call to treat imo without a biopsy than an enlarging, spiculated PET+ nodule

 

[Phantom1]

Infiltrates should not be treated with SBRT if there is no biopsy. The differential diagnosis is so broad. Ground glass changes may be infectious/inflammatory, premalignant, or malignant, but they will generally progress to a distinct nodule/mass if malignant.

 

[Spiced Meats]

Infiltrates should not be treated with SBRT if there is no biopsy. The differential diagnosis is so broad. Ground glass changes may be infectious/inflammatory, premalignant, or malignant, but they will generally progress to a distinct nodule/mass if malignant.

Yeah I agree this is the situation that might be considered malpractice.
I also second or third the sentiment that lung SBRT is not the purview of academic centers. Advanced age and decreased baseline lung function are the norm in these patients. This is part of standard scope of practice for a radiation oncologist trained in this era.

That being said, the oversight is much better at most academic centers. You're far more likely to find someone who shouldn't even be treating a low risk prostate out in the private world.

 

[scarbrtj]

Infiltrates should not be treated with SBRT if there is no biopsy. The differential diagnosis is so broad. Ground glass changes may be infectious/inflammatory, premalignant, or malignant, but they will generally progress to a distinct nodule/mass if malignant.

It's interesting that the "pre-test likelihood" (ie pre-biopsy likelihood) based on the large PanCan study of a ground glass, upper lobe finding in a 91-year old female with severe COPD is ~76%... versus ~79% if the mass is solid... or 85% if the mass is semi-solid. Statistically speaking, the pre-test likelihood would be raised even much higher (I'd guesstimate 90+%) in an especially PET+ ground glass finding in an equal clinical scenario. So, "empiric SBRT" for a "ground glass" finding (in a 91 yo with 3 cm mass blah blah blah) would rest on seemingly similar footing as for empiric SBRT for a solid nodule, data-wise.

 

[nkmiami]

Anecdotally, I had one patient killed by the biopsy and 2 others end up in the icu over the past 10 years. With stereo, I have seen several rib fractures when I was giving 20 x 3 in 2007. Bascially, stereo may often carry less potential side effects than a biopsy in many of these patients. I recall that in some of the randomized trials -either here or in Japan, 1/3 of patients were not biopsied.
(Experience at a large northeast nccn center)

 

[seper]

there was also an ASTRO abstract a few years back comparing outcomes Bx confirmed vs. empiric SBRT at a single center. Does anyone remember?

 

[Phantom1]

It's interesting that the "pre-test likelihood" (ie pre-biopsy likelihood) based on the large PanCan study of a ground glass, upper lobe finding in a 91-year old female with severe COPD is ~76%... versus ~79% if the mass is solid... or 85% if the mass is semi-solid. Statistically speaking, the pre-test likelihood would be raised even much higher (I'd guesstimate 90+%) in an especially PET+ ground glass finding in an equal clinical scenario. So, "empiric SBRT" for a "ground glass" finding (in a 91 yo with 3 cm mass blah blah blah) would rest on seemingly similar footing as for empiric SBRT for a solid nodule, data-wise.

Yes, but the percentages you quoted are highly skewed by this specific scenario (91 y/o with a new 3cm lesion), yes that is highly likely to be cancer as 3cm is pretty big. However, using the same calculator and a different clinical scenario: 65 y/o man with a new 1.5cm lesion, the pre-biopsy likelihood of malignancy is ~16% for solid and ~14% for ground glass... these numbers are much more telling and in line with the PanCan and NLST data that the vast majority of lung nodules found on screening are benign. The percentages are similar between ground glass and solid, but a key distinction is that ground glass opacities largely represent non-invasive disease which can be monitored closely usually as a Lung-Rads 3 or 4A, while solid nodules if malignant represent invasive disease (which have an increased risk of metastasizing and thus require treatment), which is why I would not recommend SBRT for infiltrates or ground glass nodules in absence of pathology. One exception is patients with multi-focal ground glass opacities, where one lesion may have been resected or biopsied and proven malignant. In that case with a known history of lung cancer any growing lesions ground glass or otherwise are very likely to be malignant as well, for which you could do more surgery or SBRT. But having a known diagnosis of lung cancer is very different from the NEJM screening studies which excluded patients with any prior history of lung cancer.

 

[scarbrtj]

Yes, but the percentages you quoted are highly skewed by this specific scenario (91 y/o with a new 3cm lesion), yes that is highly likely to be cancer as 3cm is pretty big. However, using the same calculator and a different clinical scenario: 65 y/o man with a new 1.5cm lesion, the pre-biopsy likelihood of malignancy is ~16% for solid and ~14% for ground glass... these numbers are much more telling and in line with the PanCan and NLST data that the vast majority of lung nodules found on screening are benign. The percentages are similar between ground glass and solid, but a key distinction is that ground glass opacities largely represent non-invasive disease which can be monitored closely usually as a Lung-Rads 3 or 4A, while solid nodules if malignant represent invasive disease (which have an increased risk of metastasizing and thus require treatment), which is why I would not recommend SBRT for infiltrates or ground glass nodules in absence of pathology. One exception is patients with multi-focal ground glass opacities, where one lesion may have been resected or biopsied and proven malignant. In that case with a known history of lung cancer any growing lesions ground glass or otherwise are very likely to be malignant as well, for which you could do more surgery or SBRT. But having a known diagnosis of lung cancer is very different from the NEJM screening studies which excluded patients with any prior history of lung cancer.

No SBRT for ground glass in absence of pathology ever??? So what say you for NJPAIN's scenario were it a ground glass nodule. 91 yo COPD patient, 3 cm enlarging ground glass finding, solitary, no biopsy possible, and let's say PET SUV is 8.5. (Yours truly would say malignancy potential is ninety plus percent.)

Still recommend no treat? If no, what's your opinion of the rad onc who would?

 

[evilbooyaa]

3cm ground glass nodule (without any solid component), enlarging, with that level of FDG-avidity? I'm all for having guidelines but is that not kind of a unicorn? Is it common to see that description for a ground glass nodule?

 

[scarbrtj]

3cm ground glass nodule (without any solid component), enlarging, with that level of FDG-avidity? I'm all for having guidelines but is that not kind of a unicorn? Is it common to see that description for a ground glass nodule?

I don't know if it's a unicorn or not. I think I've surely seen a couple, but yes it's sure not common. I'm just wondering if we should be dogmatic: no SBRT for ground glass findings (without path), EVER.

 

[johnboy12]

there was also an ASTRO abstract a few years back comparing outcomes Bx confirmed vs. empiric SBRT at a single center. Does anyone remember?

This may be what you are looking for:
http://www.redjournal.org/article/S0360-3016(12)02425-X/abstract

However, this is what I have cited in the past. Data from VUMC in the Netherlands where biopsy is often omitted:
http://www.thegreenjournal.com/article/S0167-8140(11)00543-3/abstract

 

[Phantom1]

I never said never ever , there are always exceptions in oncology.. just in general I would not recommend SBRT for ground glass opacity in absence of any pathology. I haven't seen a malignant 3cm GGO without any solid component, but I'm sure its possible..

 

[NJPAIN]

Thank you all for your input several months ago regarding the 91 yo with a lung mass. She is in the midst of receiving SBRT, without a biopsy, at a major cancer center here in this area. The problem we are encountering now, only 1.5 weeks into treatment (third fraction received today) is profound fatigue starting after the first fraction. Baseline functional status was poor but now very fatigued, sleeping most of the day. Have any of you had experience using stimulants such as modafinil or methylphenidate in this type of situation in a patient with multiple medical comorbidities?

 

[evilbooyaa]

We generally warn of the possibility of some element of fatigue with radiation. Usually we say it's not something that will keep them in bed all day, but in a 91-year old with poor functional status it might be enough to do that on it's own. Can't say I have experience with what you're asking. I'd be way out of my comfort zone prescribing either of those two drugs.

 

[thecarbonionangle]

Had a patient who was in those meds, prescribed for adult ADD. Swore by it during XRT. I don't see why not. I don't think my attendings would let me do it, but it completely makes sense. For things like methylphenidate or amphetamine salts (Adderall, vyvanse), i'd start slow as these have other side effects like raising blood pressure and dry mouth, etc. Make sure they have a healthy heart. Modafinil could work but I don't think it works fast enough, unlike the classic ADD meds. Honestly though for SBRT,pt will be done soon and it will get better after therapy. Tell them to drink coffee and stay active.

 

[nkmiami]

I use steroids- decadron 4mg bid- for fatigue, and have tried Ritalin if the steroids failed, and it wasn't very helpful. The literature confirms this. There is actually extensive literature on fatigue, and it is mentioned in the nccn guidelines. Basically, to sum it up, other than steroids, nothing has proven to be helpful.

BTW, I have noticed quite a bit of disabling fatigue in elderly pts who had lung stereo- usually lasts 3 weeks. (re modafinil- it is very mild and usually won't get insurance approval, despite now being generic.)

 

[NJPAIN]

I use steroids- decadron 4mg bid- for fatigue, and have tried Ritalin if the steroids failed, and it wasn't very helpful. The literature confirms this. There is actually extensive literature on fatigue, and it is mentioned in the nccn guidelines. Basically, to sum it up, other than steroids, nothing has proven to be helpful.

BTW, I have noticed quite a bit of disabling fatigue in elderly pts who had lung stereo- usually lasts 3 weeks. (re modafinil- it is very mild and usually won't get insurance approval, despite now being generic.)

Have you seen onset this quickly? Within days of the first fraction?


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[nkmiami]

yes, also on a very elderly pt.

 

[NJPAIN]

How quickly do you generally see a response to steroids?


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[nkmiami]

if there is a response, it should be within several days of starting the steroid.