Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor

Transcription

1 Extensive-Stage Small Cell Lung Cancer Post Full-Course Chemotherapy with Residual Locoregional Cancer Disease: the Role and Treatment Consideration of Radiotherapy Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case with small cell lung cancer, extensive stage, post full course chemotherapy with residual intra-thoracic cancer disease, r-limited stage; to discuss the role and treatment consideration of radiotherapy Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 73 year-old male patient, 張 OO, was referred to us for radiotherapy assessment. S: <<Refer from CHE section for RT assessment>> 1. In 2007/08, a LUL lung mass was found in CXR. Mediastinum scope for biopsy was done. Pathology reported metastatic small cell carcinoma. The clinical stage, extensive stage, was defined by CHE section. 2. Since 2007/08, 6 cycles chemotherapy with EP regimen. 3. On 2008/02/13, he was referred to our RT section for RT assessment. Review of symptoms: mild cough, mild dyspnea, mild neck soreness; no body weight loss, no poor appetite Hx: 1. Heavy smoker, quitted since 68 Y/O, H/T(-), DM(-), denied Hx. of pul. TB 2. NDKA 3. Old trauma history with C-spine injury at 5-6 years ago O: 1. ECOG: 1, ambulatory status, speech: OK (no hoarseness) 2. HEENT: no SCF neck LNs 3. Ext: free movement; muscle power 4-5 on four limbs; no numbness 4. Back and spine: mild knocking pain on the right lower SI region; no knocking pain on the spine 5. *** Pathology in 2007/08, mediastinum LN biopsy: metastatic small cell carcinoma. 6. CHEST CT in 2007/08: a mass lesion with size about 5*4 cm over the LUL with multiple mediastinum LNs with size varied with 1-3 cm. 7. Bone scan in 2007/08: C-spine and L5 non-specific findings 8. CHEST CT in 2008/02: partial response of the LUL mass (size about 3 cm), and near complete response of the mediastinum LNs (all less than 1 cm) 9. Bone scan in 2008/01: multiple non-specific enhanced over bone and joints, favor benign course

2 Key Image(s): Fig. 1. Fig. 2. Fig. 3.

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: extensive stage (2007/08, suspect bone mets); r-limited stage (2008/02) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: no pathology stage can be defined in this case. Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Small cell carcinoma of the lung, extensive stage (2007/08, suspect bone mets), post 6 cycles chemotherapy (2007/ /01, EP), with clinical partial response (2008/02, a residual 3-cm LUL lung mass and multiple small mediastinum LNs), r-limited stage (2008/02) Q5: What is your Oncology Plan for this case? A5: Suggest Current Oncology Plan: (1). Arrange 3DCRT; (2). RTC 2 weeks later Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: residual disease after full course chemotherapy; r-limited stage (2). Goal: potential curative to prolong survival (3). Target & Volume: Residual LUL lung mass and mediastinum LNs (4). Technique: 3DCRT (5). Dose & Fractionation: 4500 cgy in 25 fractions to the CTV with 1440 cgy in 8 fractions boost dose to the GTV; total planned dose of 5940 cgy in 33 fractions. Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/04/25

5 Key Image(s): (with marked) Fig. 1. Fig. 1. Significant tumor volume reduction after chemotherapy was found (right CXR, 2007/08; left CXR, 2008/01; as the white arrows). Fig. 2. Fig. 2. Significant tumor volume reduction after chemotherapy was found (right CT, 2007/08; left CT, 2008/01; primary tumors as the long white arrows; nodal disease as the short white arrows). Fig. 3. Fig. 3. The C spine showed increase uptake in SPECT-CT, c/w old trauma history in this case (as the white arrow).