SABR oligomets criteria
Dose/#
Metachronous metastasis (>6m post primary tx)
PS 0-2
Life expectancy >6m
Histological diagnosis
1-3 mets in 1-2 organs.
Max 5cm any single met (QART (except lung) say upto 6cm ok)
Bone, spine, adrenal, LN, liver, Lung
Bone (non-spine) incl. sacrum 30Gy/3# on alternate days.
Liver
Small oligomet (e.g. ≤ 4cm) & away from chest wall/visceral OAR. 45Gy/3#/alternate days.
Larger oligomet (> 4cm, ≤6cm) &/or PTV is within 1cm of small bowel/visceral OAR/bile duct or adjacent to chest wall/rib.
55Gy/5#/alternate days
Adrenal
30Gy/3# on alternate days
45Gy/5#/alternate days
Spine - I would follow the SABR consortium guidelines for delineation. 27Gy/3#/alternate days (EQD2 approx. 74Gy)
Pelvic LNs 30Gy/3#/alternate days.
Lung SABR Eligibility
Dose/#
</= 5cm, N0, not ultracentral
54Gy/3#/alternate days
55Gy/5#/alternate days - peripheral + PTV overlaps with chest wall
60Gy/8#/alternate days - central tumours*
*Central tumours: Motion adapted GTV (i.e. ITV) meets any of the following criteria
· 1-2cm from the proximal bronchial tree.
· ≤ 2cm from the central structures (major vessels, heart, oesophagus, spinal cord, phrenic & recurrent laryngeal nerve, brachial plexus, trachea) but not overlapping.
Ultracentral = <1cm PBT or overlapping central structures.
EXTRA: RT without tissue diagnosis sometimes ok. Chemo without tissue diagnosis = never ok.
Concurrent chemo-rad NSCLCa Headline?
I would offer 63Gy/30#/6 weeks with concurrent chemotherapy cisplatin D1 80mg/m2 IV, vinorelbine oral D1, D8 60mg/m2, 3 weekly cycle.
Followed by 2 more 3 weekly cycles of cisplatin/vinorelbine.
Alternative: e.g. high tumour, near to brachial plexus.
I would offer 55Gy/20#/4 weeks with concurrent chemotherapy cisplatin D1 80mg/m2 IV, vinorelbine oral D1, D8 60mg/m2, 3 weekly cycle. (In practice, I believe Vin is given D1, D8, D19, D26 = #1,#6,#15,#20).
Followed by 2 more, 3 weekly cycles of cisplatin/vinorelbine.
If there is no progression post-CRT, pdl1>/= 1%, and no CI, proceed with durvalumab 1500mg q28 IV, start within 42 days.
lung function - FEV 1 ≥ 1.0, DLCO ≥ 40%
Alternative chemo is cisP CI: weekly carbo AUC2/paclitaxel 40mg/m2.
WHO PS 0-1, selected PS2
Headline for Radical NSCLCa RT alone?
55Gy/20#/4weeks.
CHART 54Gy/36#/2.5 weeks, 3 #/day.
RCR, not QART - 66Gy/33#/6.5 weeks
QART not RCR hypofractionated 50, 52, 58 or 60/15#.
Headline for Sequential NSCLCa?
Non-SCC 4 cycles of carbo AUC5 and Pemetrexed 500mg/m2 IV D1, 21 day cycle.
SCC 4 cycles of carbo AUC5 IV D1 with gemcitabine 1250mg/m2 IV D1, D8, 21 day cycle.
Followed by radical radiotherapy:
55Gy/20#/4weeks.
CHART 54Gy/36#/2.5 weeks, 3 #/day.
RCR, not QART - 66Gy/33#/6.5 weeks
QART not RCR hypofractionated 50, 52, 58 or 60/15#.
Palliative Lung RT headline?
Good PS 0-2 36Gy/12#/2.5 weeks.
Poor PS 17Gy/2#/8days, 10Gy/1#.
Usuals 30/10, 20/5, 8/1.
Radical chemo-RT SCLCa headline?
Limited stage, PS 0-1, not for surgery (T1-T2 N0 -after extensive staging- for surgery).
4 cycles 3 weekly cisplatin, eptoposide. Cisplatin 80mg/m2, etoposide 100mg/m2 IVD1. Etoposide oral 200mg/m2 in divided doses, D2-D3.
Commence radiotherapy C2D1 45Gy/30#/3 weeks BD.
This would be followed by durvalumab 1500mg IV D1 every 4 weeks for upto 2 years.
I would consider PCI if good response to treatment (limited especially, also extensive stage). Caution if >70 or PS 2.
25Gy/10#/2weeks, delivered with a lateral POP.
Alternative OP regime 66Gy/33#/6.5weeks.
Sequential or Radical RT SCLCa headline?
4 cycles 3 weekly Carbo (or cis), etoposide. Carbo AUC5, etoposide 100mg/m2 IVD1. Etoposide oral 200mg/m2 in divided doses, D2-D3.
Radical radiotherapy 40Gy/15#/3weeks
50Gy/20#/4 weeks.
This would be followed by durvalumab 1500mg IV D1 every 4 weeks for upto 2 years.
Consolidation radiotherapy extensive small cell?
Consider if persistent disease or was bulky at presentation (not if CR).
30Gy/10#/2weeks.
IRL, if has extensive mets elsewhere, can wait and give pall RT if needed (WKM).
1L SACT
Carbo etop atezo vx carbo etop
PCI
Consider if good response to treatment (limited especially, also extensive stage). Caution if >70 or PS 2.
25Gy/10#/2weeks, delivered with a lateral POP.
Pancoast headline?
Pancoast tumours (T3–4 N0–1):
If resectable:
I would offer tri-modality therapy, 45Gy/25#/5 weeks with concurrent cisplatin (carbo if less fit) and etoposide. Cisplatin 80mg/m2, etoposide 100mg/m2 IVD1. Etoposide oral 200mg/m2 in divided doses, D2-D3.
Followed by surgery (if no PD) and 2 more cycles of cisplatin/etoposide.
If unresectable post CRT, straight to 2 more cis/etop.
If unresectable at outset, treat as standard NSCLCa.
If T1-T2N0-1(unusual), can be treated as per early NSCLCa i.e. surgery.
Thymoma management headline?
Resectable - upfront surgery.
Potentially resectable - 2-4 x CAP (cyclophos adriamycin, cisplatin) or cis/etop, then surgery +/- Adj RT.
If upfront or post chemo, unresectable, for rad CRT.
Chemo-radiotherapy 54Gy/30#/6 weeks with concurrent cisplatin etoposide, to complete 4 cycles. Cisplatin 80mg/m2, etoposide 100mg/m2 IVD1. Etoposide oral 200mg/m2 in divided doses, D2-D3.
Adjuvant radiotherapy 54Gy/30#/6 weeks.
Indications: All stage III, R1/R2 resection or thymic carcinoma (C).
PORT lung?
Indicated for R1, R2 resection (not indicated for nodal disease alone)
Adjuvant radiotherapy 50Gy/20#/4weeks.
Management of operable NSCLCa?
Definition, treatment options, peri-op/adjuvant tx.
Operable = stage I, II and selected 3a.
Upto T3N2a or T4(size criteria only)N2a max.
All PS 0-1.
eGFR and alk negative.
If operable stage II - IIIB, >4cm or N+
Neo-adjuvant chemotherapy-IO
3 cycles of Nivolumab 350mg, carbo AUC 5, paclitaxel 175mg/m2, all IV D1, 3 weekly cycles. No adjuvant chemo.
Alternative, no NACT-IO but >4cm or N+
4 cycles of Adjuvant cisplatin 80mg/m2 IV D1, vinorelbine 80mg/m2 PO D1 and D8, 3 weekly cycles.
If there’s no progression, followed by adjuvant pembrolizumab IV 400mg every 6 weeks for 1 year (no pdl1 requirement). Alternative = Atezo if pdl1 >50%.
eGFR positive -exon 19 deletions or exon 21 (L858R) substitution mutations.
Stage 1b (>3cm) to IIIA, after complete resection.
Adjuvant osimertinib 80mg OD oral for upto 3 years.
Given with or without adjuvant chemo.
alk positive
Complete resection, stage IB (>/=4cm) to IIIA.
Adjuvant alectinib upto 2 years 600mg BD PO.
No adjuvant chemo.
+/- PORT
Indicated for R1, R2 resection (not indicated for nodal disease alone)
Adjuvant radiotherapy 50Gy/20#/4weeks.
NSCLCa recurrence post surgery in treatable field, management?
If fit, can consider radicla RT alone.
55Gy/20#/4weeks.
CHART 54Gy/36#/2.5 weeks, 3 #/day.
RCR, not QART - 66Gy/33#/6.5 weeks
QART not RCR hypofractionated 50, 52, 58 or 60/15#.
Less fit, for pall RT.
Good PS 0-2 36Gy/12#/2.5 weeks.
Poor PS 17Gy/2#/8days, 10Gy/1#.
Usuals 30/10, 20/5, 8/1.
1L SACT SCLCa
1L PS 0-1 no IO CI = atezo1200mg, carbo AUC5/etoposide 100mg/m2 day 1 IV, 200mg/m2 D2-3 in divide doses oral. q21 x 4 followed by s.a atezo.
PS 2-3 chemo alone.
PS 4 BSC.
2L = rechallenge or 2L chemo e.g. topotrcan.
1L SACT NSCLCa
Actionable driver mutation? Treat this first.
If not, is pdl1 >/=50% = single agent pembro.
PS 0-1 and pdl1 0 < 50%:
Adeno - q21 x 4 carbo AUC 5/pemotex 500mg/m2/pem 200mg, then maint pem/pem upto 2 years
ASS - q21 x 4 Carbo AUC6/taxol 200mg/m2/pem 200mg, then maint pemb 400mg 6 weekly upto 2 years.
Chemo alone = carbo/pem + pem maint for Non-SCC or Carbo gem for SCC.
2L single agent IO e.g. atezo with any pdl1 if not had already and has had chemo
Chemo doce +/- nintedanib
