I often recommend caffeine (usually a cup of Starbucks)
Stereotactic radiation lung mass without biopsy
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Personally I would not prescribe stimulants to an elderly patient. Even with steroids I would be gentle and keep the course short. Want to avoid steroid myopathy (or psychosis). Elderly patients can be very sensitive to medications.
Just realized the thread was a month old. What happened to your patient and her fatigue?
Just realized the thread was a month old. What happened to your patient and her fatigue?
Still struggling with it to some extent. She responded well to 20mg/day. Was at that level nearly a month. Ok down to 10mg/day for a week but upon returning to her baseline 5mg/day (for COPD) she went back to sleeping nearly 24/7. So we were back to 10mg/day for a week and have just started alternating 5mg with 10mg daily. Trying to weigh safety against quality of life.
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New ASTRO lung SBRT guideline OKs treatment without biopsy:
"Non-biopsied patients: While biopsy should be used whenever possible to confirm malignancy of the tumor, SBRT can be considered for patients who are unable or unwilling to undergo biopsy but have appropriate imaging studies supporting a cancer diagnosis. These cases should be discussed at a multidisciplinary tumor board prior to treatment."
ASTRO issues guideline for use of stereotactic radiation in early-stage lung cancer
"Non-biopsied patients: While biopsy should be used whenever possible to confirm malignancy of the tumor, SBRT can be considered for patients who are unable or unwilling to undergo biopsy but have appropriate imaging studies supporting a cancer diagnosis. These cases should be discussed at a multidisciplinary tumor board prior to treatment."
ASTRO issues guideline for use of stereotactic radiation in early-stage lung cancer
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Except something to CYA with in PP. Valuable indeed
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You got NCCN for that, or any of the recent SBRT protocols, at least for OARs.
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Is it just me or all of these ASTRO white sheets clinically useless?
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I have a heavy smoker that has been followed for lung nodules. He had this RLL nodule that was first noted in December 2017 to be 0.8cm and a repeat in March w PET was 0.8cm, uptake is SUV 2.5. Looking back 2 years however this nodule was there then too but measured 0.6 cm.
They don't want to biopsy it and hes not a surgical candidate. 2 questions. First one is would you offer SBRT. Pulm loves asking us this question but ill be honest I don't know the answer sometimes. This patient in particular wants more confirmation that he has cancer and was asking about liquid biopsy. I mean it grew 0.2cm in 2 years. Talked about it at tumor board and the surgeon did not want to biopsy bc of the approximation to the branch of the pulm artery.
That brings me to the 2nd question. If you offered and the patient wanted to proceed with SBRT, is that branch of the PA an issue? At present the lesion is about 1.4 cm from the nearest airway. Included 2 images to show the lesion and the proximity to that vessel. Thanks all
They don't want to biopsy it and hes not a surgical candidate. 2 questions. First one is would you offer SBRT. Pulm loves asking us this question but ill be honest I don't know the answer sometimes. This patient in particular wants more confirmation that he has cancer and was asking about liquid biopsy. I mean it grew 0.2cm in 2 years. Talked about it at tumor board and the surgeon did not want to biopsy bc of the approximation to the branch of the pulm artery.
That brings me to the 2nd question. If you offered and the patient wanted to proceed with SBRT, is that branch of the PA an issue? At present the lesion is about 1.4 cm from the nearest airway. Included 2 images to show the lesion and the proximity to that vessel. Thanks all
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Thanks sep, any issues with the proximity to branch of pulm artery? Also, is there anything emerging for liquid biopsies in such cases or is that all locally advanced disease
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Do any of your pulmonologists do ENB? Might be worth seeing if that could be an option
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I think growth of 0.2cm over 2 years is minimal, and SUV is really low TBH. No role for liquid biopsy - it's a misnomer looking for histology when in reality it's looking for mutational status.
In regards to treat or not - shared decision making. Discuss slow growth, discuss minimal FDG-avidity, discuss could not treat now but continue with surveillance CTs. As stated previously in this thread, Europeans treat without biopsy all the time, but I think this is a more cautionary indication than what I'd feel comfortable slam dunk treating with. As an aside, if it's super bright, solitary nodule, showing some element of growth, I'd treat those all the time without biopsy after having discussion with patient about a chance that it's not cancer.
If patient wants to be aggressive and is OK with the risks of RT (should be minimal) then go for it. I would not worry about the artery whatsoever. Vessel toxicity data in the chest is from the aorta (a higher pressure system) and primarily in the re-irradiation (Std Fx or SBRT) setting. Whatever dose you want to pick for early stage lung cancer SBRT is fine. If you're concerned about the central location then 10Gy x 5 or the 60/8 from the dutch is fine. I personally would do 10Gy x 5 and call it a day. Cheat as necessary on your PTV to meet your bronchial tree constraints, especially the contralateral wall one as possible. Minimize motion with 4D/CT evaluation, gating if necessary, and abdominal compression if patient can tolerate (not sure what his medical co-morbidities are).
I'm not sure what the point of "dose-reduced" SBRT is. Either treat it properly or not at all, IMO. Don't just do some little dose that then burns bridges when the tumor recurs. This is a curative situation.
EBUS is going to be near impossible to go that distally.
I'd see what your local skilled EBUS pulmonologist thinks. I've been surprised before at what they've been able to reach. I agree with either full-dose SBRT or none, and also agree that liquid bx holds no value in this situation.
