Workshop Case: Lung Cancer

58-year old male

Usus: active smoker, 15 pack years

Medical history:
Polymyalgia reumatica
Bleeding mesencephalon, no residual neurological deficits
Multiple resections of tubular adenoma’s with dysplasia, for which follow-up with CEA
COPD, Gold stage I
Incidental lung nodule on CXR

Clinical presentation:
No pulmonary complaints.
No weight loss.
Karnofsky Performance Status: 80
No clinical abnormalities:
normal lung auscultation, no palpable lymph nodes, no hepatomegaly, no bone percussion pain

Diagnostic work-up:
Chest X-ray: normal
Bronchoscopy: mucosal thickening in left lower lobe
Pathology: non-small cell lung cancer, NOS
PET-CT: Tumor left lower lobe.
Enlarged nodes, PET + in level 4R, 4L and 7; enlarged node left hilar region, PET –
No distant metastases.
EBUS: Confirmed positive nodes in level 4R, 4L, and 7, not in 10L
Invasive adenocarcinoma, EGFR negative.
Pulmonary function tests:
FEV1s: 2.8l, 102% of predicted; DLCO 76% of predicted

Treatment decision on external multidisciplinary tumor board:

Sequential chemo-radiotherapy.
Patient was referred to our department for radiotherapy after 3 cycles of chemotherapy.
PET-CT in treatment position is post-chemotherapy.
Questions
- What is the tumor stage?

- Would you have performed additional invasive or non-invasive procedures?

- Would you have proposed a different treatment approach?

- Define and draw the GTV primary lung tumor (use “GTV primary” structure) on the
planning CT-scan. Use the 18FDG PET scan.

- Discuss treatment of the mediastinum: elective lymph node irradiation or involved field
irradiation? Which lymph node areas?

- Define and draw the GTV lymph node(s) (use “GTV lymphnode” structure) on the planning
CT-scan. Use the 18FDG PET scan.

- Did the PET information influence your determination of the nodal GTV?

- Did the EBUS information influence your determination of the nodal GTV?

- Would you have defined the GTV differently in case of concurrent chemo-radiotherapy?

- Discuss the margin from GTV to CTV for both the primary tumor as well as the nodes. Do
you include additional nodes in the CTV?

- Discuss the margin from CTV to PTV for both the primary tumor as well as the nodes.

Appendix
IASLC Staging 2009