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I have a 77 year old male, long time smoker with COPD (FEV1 ~35% of predicted, DLCO 20% of predicted, on O2 prn). Not a surgical candidate. He was diagnosed with what was initially thought to be a ~4 cm peripheral left upper lobe squamous cell. CT C/A/P negative for nodal or distant mets (non contrast).
For whatever reason he had EBUS before PET. All nodes "looked small" so none sampled. Then came PET and a small L hilar ?node? is hot (PET done without IV contrast, so no node was seen in the midst of vasculatuar) with primary tumor SUV 16, L hilar node SUV 9. Contrasted CT then shows node at 1 cm in greatest dimension...radiology says "suspicious" and anatomically correlates with where PET is hot.
I send him back for repeat EBUS and tell pulmonologist to try to get that L hilar node. They sampled 4L and "think" they got the right node in the L hilum but admittedly it was a very tough stick/angle through the vasculature. Both biopsies negative with lymphocytes in the specimen...
However, I'm not convinced. I'm not sure if I should SBRT the known cancer and watch this node or treat as T2N1. He is not a chemo candidate (not concurrent or sequential). If treating as T2N1 what dose/fractionation would you use?
I rarely go outside standard of care, but I'm thinking about maybe giving ~60 Gy in 10 fractions to the larger tumor and ~45 Gy in 10 to the L hilar area with a dose painting stereotactic fractionated approach. The lung tumor is about 6 cm from the hilum, so if alignment and motion is congruent on 4D ct sim. However with these odd hypofractionated techniques it's hard to know a lung constraint(s). I have a pretty good idea of esophagus, cord, etc at these doses, but lung toxicity data/dosimetry is more difficult.
Any input is appreciated.
For whatever reason he had EBUS before PET. All nodes "looked small" so none sampled. Then came PET and a small L hilar ?node? is hot (PET done without IV contrast, so no node was seen in the midst of vasculatuar) with primary tumor SUV 16, L hilar node SUV 9. Contrasted CT then shows node at 1 cm in greatest dimension...radiology says "suspicious" and anatomically correlates with where PET is hot.
I send him back for repeat EBUS and tell pulmonologist to try to get that L hilar node. They sampled 4L and "think" they got the right node in the L hilum but admittedly it was a very tough stick/angle through the vasculature. Both biopsies negative with lymphocytes in the specimen...
However, I'm not convinced. I'm not sure if I should SBRT the known cancer and watch this node or treat as T2N1. He is not a chemo candidate (not concurrent or sequential). If treating as T2N1 what dose/fractionation would you use?
I rarely go outside standard of care, but I'm thinking about maybe giving ~60 Gy in 10 fractions to the larger tumor and ~45 Gy in 10 to the L hilar area with a dose painting stereotactic fractionated approach. The lung tumor is about 6 cm from the hilum, so if alignment and motion is congruent on 4D ct sim. However with these odd hypofractionated techniques it's hard to know a lung constraint(s). I have a pretty good idea of esophagus, cord, etc at these doses, but lung toxicity data/dosimetry is more difficult.
Any input is appreciated.