♪ Well, hello everyone. Let's not sit on that to keep us here for too long. My name's Max Didems, I'm the Interventional Pulmonary Fellow at UNC Chapel Hill and I'll be your introducer and moderator here for this case today. We'll see if we even actually get to see our slides here. Fantastic. So, I'd just like to introduce everyone in order for how far they have come to team up on Tumor Board. First of all, Dr. David Lamb, the Chief of Respiratory Medicine at HK Shenzhen Hospital who joins us from 5,547 miles away. Way to go. Myself, Max Didems, your moderator and MC at 4,759 miles. Dr. Gerard Silvestri from Professional Medicine from the Medical University of South Carolina at 4,755 miles. Strong work. Dr. Patricia Rivera, Professor of Medicine from the University of Rochester at 4,742 miles. Dr. Carolyn Presley, Assistant Professor, our Medical Oncologist from The Ohio State University who does have some disclosures listed here and is from 4,500 miles. Very even. Dr. Aaron Gillespie, Chief of Thoracic Surgery at CHI Health here from Omaha, Nebraska who has some disclosures there at a distance of 4,331 miles. And finally, last but certainly not least, Dr. Christina Spears at a whopping 7,563 meters away. I actually live two miles away. I will update it appropriately. This is your Tumor Board but also look around you and sit close because you all represent your own Tumor Boards together here and in this class we will be flipping the Tumor Board where you all will show to us the sort of answers that you think should come to these cases. So, we're going to start right into the first case here. I'm just blocking it out here because you all are intelligent. You've already done the homework beforehand. We have our first case we're going to jump into and you all are going to have some time in your own little Tumor Board. Yep, you're probably saying to yourself, I should have invited my Medical Oncologist to come with me to this course right now. It's always good to have a diverse Tumor Board team. Here's our first case we're going to go through and we're going to talk through what the imaging shows and then you will have a second to discuss with each other about what you see. So, case one we have a 57-year-old Caucasian male. He's a 50-pack year smoker, no other cancers. His CT chest has a 3-centimeter right upper lobe endobronchial mass. His pet is right upper lobe mass avid. There's a right peritracheal and subcentimeter subclavicular lymph nodes. We'll see that imaging in a second. On bronchoscopy he has an endobronchial mass with intrinsic and extrinsic obstruction of the right upper lobe ostium. An E-Bus is performed but is positive only at 4R. It's left to right staging complete. Ultrasound of those subclavicular nodes shows that they're all less than 5 millimeters and not amenable to a fine needle aspiration. Pathology of the E-Bus sample shows squamous cell carcinoma of the lung. This patient is asymptomatic. He's got an ECOG of zero. His MRI brain is within normal limits and his PFTs are excellent. So, here is the imaging because we all love to see the imaging. And we'll cycle through one more time. All right, and there you have it, our key slices, just for clarity. Here's the information and the question, as always with all of our board exams, is what is the best next step? Is it A, restage with excisional biopsy of the supraclavicular nodes, B, curative resection right now, C, chemotherapy plus checkpoint inhibitor now followed by re-imaging and resection, or D, chemoradiotherapy followed by checkpoint inhibitor, or E, resection now followed by chemo plus checkpoint inhibitor. So each of you in your tumor boards, join together or be alone and stand out of the crowd with your unanimous answers. Have a grab of one of these here, and you're going to hold up your answer after a three-minute timer here. So ready, set, go. Please introduce yourself. Whoever in your group has traveled the furthest is the spokesperson who's going to be holding up your answer. All right? Go ahead. The goal is to be a little bit gray, although if the supraclav node is positive, then you're And texting your colleagues back at home is totally not cheating. All right, this is your one-minute warning. All right, let's move on. This is what they came to see us like. All right. All right. Dr. Rivera, don't give away the answers before they get a chance to answer. All right. So I'm going to count down from three. And on three, has everyone got their answers? Has your spokesperson got your answer? And on three, we're all going to hold up our answers to this. All right. We'll do it together. Ready? One, two, three. All right. What do we got here? Ooh, A's. Blue's here. All right. We got a D. Okay. So can somebody from the – where's our little microphone here? Can somebody from the A group – ooh, A group. Can somebody from the A group, like as a spokesperson, what made you guys decide you wanted to go after A? We need to decide whether they are resectable or not resectable. I think that – yep. All right. And how would that change with this stage? What would it go from to? So you would possibly end up with – if you've got a superclavicular node, you're going to end up with at least a 3C, if not an H4, depending on how many nodes are there. Right? No? 3B. 3B. It's 3B. Okay. Yeah, sorry. Okay. And then we need to hear from our D friends. Thank you. Thank you. Can you offer here? So just now the PET-CT shows the right superclavicular lymph node. At least that area is quite FDGA fit. So despite – at least in this case we can't pursue FNA or BAPC of the right superclavicular lymph node, but it seems radiologically it is quite compatible with right superclavicular metastasis. So it should be a stage N3 disease. This is such a teachable moment right now because the false positive rate of PETs, it doesn't matter how hot it is, the false positive rate of PET is at least 20% even in this situation. So I think – I don't know about the folks here. Thank you. Thank you so much. All right. That's such a great – I'm so glad you brought this up. Because I will tell you one of the most common questions I ask a patient after PET or before I get a PET on them is have they had a COVID vaccine or recent COVID? Because the number of false positive lymph nodes we see these days I actually think might even be higher than that 20%. I also happen to live in the histobelt. You live in the histobelt. So we have a huge amount of lymph node pathology that is unrelated to cancer. And so it makes it really critically important to evaluate patients pathologically to make sure you very clearly understand their state. At least the first site of metastatic disease, right? Like if you have overwhelming bone metastasis and a liver met and a big mediastinal thing and you do EVIS and everything else is there, head CT, head MRI, that's one thing. But it also works in the opposite direction. Your willingness to accept this made the patient a surgical candidate potentially in this – made him an inoperable candidate. It works both ways. We see patients with mediastinal lymph node involvement with PET, that is, sarcoid, that is, infection, that is, post-obstructive pneumonia. And if you eliminate the ability for them to go to surgery, you maybe have done them a disservice. Dr. Rivera, your shoulder looks like it's about to fall off. I do the false positive rate of PET is 50 to 20%. But we also have to think about the probability of this superclavicular node being malignant. And the setting of the 3-centimeter mass and a right peritracheal node that has been biopsy-proven to be sclerosal carcinoma of the lung. So the likelihood, in my opinion, of the superclavicular node being a false positive, that's an odd place for a false positive node. It's not an axillary node where, you know. So I think I would not ignore it, eh? But the question is, can you confirm or not? And if you can't, then as Frankie's overstatement, you bet with the patient. And we've got someone here who potentially may be a stage 3B. But single node in the mediastinum, small node in the superclavicular fossa, possibly a candidate for resection. I mean, a candidate for resection based on PET. And in the era of neoadjuvant therapy, is there a role for treating and seeing what happens to that lymph node? Because I can't get to it. But I just, you know, I'm a big proponent of both positive and both negative. But in this setting, avoid. One other point, I think, if you're just going to go with a hemorrhage, you know, a checkpoint, it's going to change your radiation. Yeah. Right. Or it doesn't. Does everybody hear that? It changes. There's a bigger field now with that. I absolutely want to know if I should. I think one of the other key important things, endobronchial, you tend to have higher rates of post-obstructive pneumonia as if it's completely obstructed. And so that's a factor to consider as well. So you always have to look at sort of every piece of data that you have and how it could be impacting the patient, how it could be impacting the clinical imaging that you're getting. Patricia's point was good. Yeah. I think we're all kind of saying the same thing. All right. So tissue is the issue. We're going after that supraclavicular lymph node. I'll say that in this case there was not an amenable target that they didn't think they could get to, and that in this case the choice that was selected by the team was actually to go for neoadjuvant as the next step here. In proportion with the Keynote 671 trial, looking at resectable stage 2 to 3A and 3B and two-stage non-small cell lung cancer, these patients were all treated with neoadjuvant and adjuvant pembrolizumab and had significantly improved event-free survival compared to those with neoadjuvant chemo alone, with significant improvements in their major pathological response. This was thought the discussion ultimately came down with the patient and the team to consider it, to go for it, if you will, and see if this would be something that would not, that would be improved with neoadjuvant therapy beforehand. They also based this off of the Checkmate 816 trial, again looking at resectable stage 1B to 3A non-small cell lung cancer with checkpoint therapy, showing improved pathologic complete response, which we actually saw in this patient, who after they were treated had significant improvement in their tumor burden. The supraclavicular avidity disappeared on a repeat PET scan, which I did not have loaded up here, I'm sorry. But a robotic right upper lobe sleeve resection was performed with clear margins. 4R was still positive on resection, but all other nodes were negative. I did know it, and I don't know it right now. Dr. Rivera? Can you tell the audience why we are asking for the PD-L1 status? Yeah, so we know based on these neoadjuvant, right, and so neoadjuvant is before surgical resection. So I'd like everybody to be on the same page as, with our terms, right, because the words we use are important. So neoadjuvant is before surgery. 6.7.1 was perioperative, meaning they got it before and after surgery, right? But in both Checkmate 8.16 and Keynote 6.7.1, patients who had a higher PD-L1, greater than 50%, really benefited more, particularly in the Stage 3 setting, if they had a higher PD-L1. And so that's really consistent with what we're seeing with this patient. And so that's why we always want to know what their PD-L1 status is, because if they're PD-L1 negative, then, you know, we still give it to them, but they're less likely to have as robust of a response. But we know that giving immunotherapy in the neoadjuvant setting, so before surgery rather than just the adjuvant setting, we think it really exposes the T cells, right, because that's what we're trying to mobilize in the neoadjuvant setting, is the T cells are exposed to more neoantigens on the tumor. So you get greater expansion in number and in diversity of T cells. And that's really what you want in terms of post-surgical resection. If there's any, you know, three tumor cells left behind, you want that tumor cell to be recognized by that patient's T cells. And that's why neoadjuvants still appeal. Before you ask the question, the other thing is, just so you know, in Europe and in Canada, for PD-L1 of less than 1%, they will not use the checkmate protocol. Yep. And if you look at all the different factors for outcomes in checkmate 816 and checkmate 671, it does cross one. So some people are not giving this in other countries where actually money makes a difference. So in the Pacific trial, the same thing happened, right? Agreed. So we actually, our center, don't give DERVA after chemo-RAD if their PD-L1 is negative because, again, the hazard ratio, but we really have to dig for that hazard ratio Totally agree. I just wanted them to know that there is a different thought out there in other countries. It was greater than 1%, but I don't remember the exact number. Yeah, I think that would work. Thank you very much. So the positive node at the time of surgical infection then would make them a candidate for further adjuvant therapy that excludes radiation. Yeah, there's a lot of background. Right. If it's a Kenope 671, they'd get PEPRO. Mm-hmm. Pardon? I didn't hear what you said. We never sampled those two in the clinic. But no, it's something else. No, it was in the end-to-end. Even the 4R is still positive. Right, exactly. So before, that would have qualified them for course. Incomplete. But he would be, so he does have surgery, so he is a candidate for adjuvant. Yeah, this person would get a Pembroke for at least a year, right? There is one other nuance I'd ask our panel to consider, and then we probably need to move to the next case, because we can probably waste an hour on it. Yeah, just a second. Waste is the wrong word. Is the nuance of, you follow this patient up, and you have, forget the four-R, but one persistent area where everything else has gone away, and you have this sort of persistent, small, positive area, either out in the lung or anything else. Would you, I want to ask our radiotherapist, would you consider in that frame of mind doing some kind of oligos-metastatic radiotherapy in that? You mean later on? Yes, so we're out at a year, and what we see, just for the audience, what we see a lot with immunotherapy is these one single lesions that everything else has gone away, and you have this sort of persistent, slow-growing, small, positive lung lesion. And those patients we've been advocating without great evidence for an oligos-metastatic type, oligo-progressive type approach, so I would ask our radiotherapist if she'd be willing to do that in her practice. I would, and Dr. Pressley suggested that we bias it. You have to bias it. Yeah, you have to bias it. Agreed. Why the molecular, which we don't know the PD-L1 or the molecular profiling of this past case, which. Wait. I know, but still. Well, on that subject, we're gonna move on to our next case here. This is what a regular tumor board looks like, by the way. It's amazing. Time out, time out, don't call it time here. Everyone, clinic starts in half an hour. Go ahead. All right, case number two, we have a 74-year-old Caucasian male. He has a remote 15-pack year smoking history, no prior cancers. He has a PET CT with a six by four by five centimeter left upper lobe mass with some adjacent scarring extending to the pleura. There is no other avidity. Navigational bronchoscopy is performed before he is referred to you with poorly differentiated adenocarcinoma of that mass. There's insufficient tissue for genetics to be sent. The patient is asymptomatic, he has an ECOG of zero. He is a farmer. His PFTs are excellent. I need to know where you're finding these people for these PFTs. I don't know. I want all of you. I've never seen anyone with an MPB1 margin, not only you. Oh, he was. Well, the 14th percent. Truly, this man himself was amazing. All right, so here, everyone loves the imaging. So here we have the imaging. So, as always, what is the next best step for this gentleman? Would it be an E-Bus, an MRI, neoadjuvant therapy followed by resection, resection now, radiation now, or additional tissue biopsy? We'll give you just two minutes on this one. Because we blew 20 on the last one. We'll cut the rest of you off a little sooner. Moderator. Moderator, yes. The person only had a NAV bronc, there was no E-Bus performed. We should work together. 30 seconds. We've already got someone committing. I like it. I like it. All right. We're going to count on three. We'll raise our answers. On the count of three. One, two, three. Answers. All right. So, we've got some A's and then we've got a blank sheet for E. Very good. All right. Who has an A? Yes. All right. All right. So, let's have an A over here. What do you all think? Why A? Well, I felt like the case probably should have been a NAV E-Bus to start because it's over three centimeters. I think it was pretty central. So, I think chest guidelines say E-Bus for over three centimeter. Absolutely. Absolutely. The whole panel is very excited here. And I think that there are some nuances that people want to discuss, but this is sort of a stopgap along the way. I'll just take us here. So, I just want to make a point that's an excellent point. It's a large mass greater than three centimeters. It's central and it's an abnormal. So, three reasons why even if the CT and PET are negative, we need to sample the nose. And by the way, it's such a central tumor, we go back out and try to get repeat analysis for mutation, right? So, before you talk all the answers through, I'll just say that, yes, and up to a quarter of patients are receiving inadequate staging based off of surveys. Especially for this patient in particular, he had an MRI performed which showed metastasis to brain at the time of presentation. So, while his E-Bus was being scheduled, we determined that he had already achieved metastatic disease. So, now that he's stage 4A, what is the next best step? There's some subtle differences here. How many brain mats? He had one brain mat. Okay. There it is. It's a cute little one. Six millimeter metastatic disease with surrounding vasogenic edema. So, the question now becomes, what is the next best step? Is it further imaging? Is it neoadjuvant therapy followed by resection? Is it resection now? Is it platinum chemo and radiation now? Or is it additional tissue biopsy? Since you know the case, I'll give you a minute 30. The beach is calling. And by resection, you mean the main lung mass, not the brain mass? Correct. All right. That was interesting, right? So, the system means that there is lymph nodes, right? So, the thing that's one lymph node. We don't know. Okay. We don't know. It was said to have been knocked out. It was a brain MRI. That is correct. It is NX. All right. Are we about prepared? And E is if you just show the back of one of the sheets, you can pick your favorite color. Do we have an answer ready from everyone? On the count of three, we're going to hold up our answers. Ready? Three, two, one. Answer here. Everyone says E. All right. Very good. Can somebody justify why they're saying E? Dr. Diderich. All right. Well, I think a couple of reasons. I think you need to know the marker status for this. That's going to make a big difference, or you're going to go with targeted, you know, with immunotherapy, et cetera. It's going to get some chemo anyway. The other thing is that, you know, I think this qualifies for oligometastatic disease, and I think you should take an aggressive approach, but you need to know the status of the mediastinum. Thank you. And in sickness, oligometastatic disease is a brain medicine diagnosed at the time that the primary cancer was diagnosed. Very good. So do we have consensus from our board about the next step here? We were showing no sheets. We were showing no sheets? Wow, that much? It was the back of a sheet, I think. Oh, I see. Yes. So this patient in particular, while we were planning the bronchoscopy, we were going to do an E-bust, the liquid biopsy, and the blood mutational analysis came back positive for an EGFR mutation, and the patient was started on osimertinib. So yes, yes, further tissue, further tissue. No. Yeah. He's a hardworking farmer. Don't you say those things. In terms of treating aggressively oligometastatic disease, and that is, you know, synchronous oligometastatic disease is against him, because metacronins is better. N1 or N2 disease, right? We know from the few trials, including the Gomez trial, that that's a predictor, so, you know, we want to give him the benefit of the doubt. Be aggressive with his primary, aggressive with the metastatic leaving. I think there's no right answer to this one, Patricia. I think, you know, in the case of second-generation TKIs, so osimertinib, that I think it would be absolutely fair to give this patient osimertinib and do stereoradiotherapy to the brain and watch. I don't think that... And not consider him... I mean, I think they're both sort of reasonable. I think with the amount of incredible responses we're seeing with osimertinib in a white-haired never-smoker, I think a lot of people would choose to do OC and stereotactic brain radio therapy. You might not even need it, because... You might, because it crosses the brain barrier. That's so small. And I don't know whether he's symptomatic or not. I'm sorry. No, you didn't see me. You're talking about a palliative approach. It's me, and I got an IV 140. I want a curative, potentially curative approach. I want you to take that damn thing out of my chest if I have other immune systems. I don't want you to just give me a palliative approach. Yeah, I would say... I think a liquid biopsy in this patient isn't fair, because the patient's been inadequately staged. And then we can't make the right treatment decisions. This patient has... We have to stage patients thoroughly so we can help to make the right... guide them through the right treatment decisions and make sure they have their options available to them, right? We're not trying to force the patient down any pathway. We're just trying to make sure they understand their options. I have to agree, Dr. Detterbrick. Like this, as soon as I saw this, I know surgeons are ganging up on everybody. I love the representation. Yeah, yeah, two, two. I'm agreeing with her. So I think this patient, totally fair game to consider a section of the primary and to give a systemic treatment that compressive blood would vary. We have patients like this who are now five years out. It's three to one. Can I get some support? So I would say chemo XRT to the chest with SRS to the brain and then you actually hold on the OC would probably be the curative approach. I don't think I would necessarily resect that. I'm okay with that too, but I don't want just OC. You don't want just OC. So I think the hard part about Adora is that once you become metastatic, right, then what do you do? And that's the problem. And now we're adding in the metastatic setting, now, you know, FLORA2 was just presented at World Lung. Now we're adding chemo to OC in the first line. Metastatic setting. Oh, you don't have to tell me that. I read them the riot act, right? Because I'm like, you're making people feel super sick when you don't have an OS benefit. So you don't have to convince me. However, I think surgical resection, I think it would depend on their functional status, not their ECOG performance status. He has an FPV1 of 140% and a transverse fracture of 112%. You're hung up on that for sure. But I might give him chemo then, not chemo I.O. I would give him chemo in order to shrink that tumor, potentially, then resect, do SRS to the brain, plus-minus OC afterwards. But it would depend on... The only thing you don't want to do is do surgery on someone, make them super dysmech, post-op, right? That's not a problem. So left upper lobe, three segments, 15% of a lung problem. 15%. I don't know, let's include the lingua there, the little knuckle thing. Okay, 25%. He has an FPV1 of 140%. This man may potentially... You know, this is the patient that potentially can be alive 10 years from now, because you aggressively treated a primary cancer with a skip metastasis to the brain, he may not have N1 or N2 disease. We don't know. We got a question in the audience here. Oh, 100%. You need a stage. 100%. All right, let's go on. All the lymph nodes. Yes, yes. And here's the thing. When you're doing that Ebus, it's the perfect opportunity to go get additional tissue from that primary, because that allows you to immediately send it for molecular testing, PD-L1 testing. Make sure you have your wits about you to take care of the patient. I just want to admit, it's possible he may have had an Ebus. He had an Ebus bronze, let's just say, and the nodes, they couldn't find nodes, or they were really tiny, eh? So that's okay, too. But somebody with experience looked, eh? Yeah. We got a question in the audience. If I had suspicious lymph nodes on imaging that I didn't think I was going to be able to access adequately through my planned approach, yes. Otherwise, no. I can do a very, very aggressive lymphadenectomy through a robotic or minimally invasive approach. You can get fully cross-dressed. But you would still need to be assigned whether or not there's a problem with that. Yeah. So I'd say, at minimum, three and two lymph notations. And of course, if there's any residual concern or an inadequate EVIS or imaging that suggests I'm going to have to do, you can do it same setting. I will tell you, knowing who your proceduralist is also really important, so you can understand how thorough they are. So I'm really lucky. I worked with some brilliant IP docs. They wrote beautiful reports. And I've seen them do very, very thorough exams. I've watched them look at the lymph nodes. I've watched them sample lymph nodes. I also feel very confident going in and being able to trust their evaluation as well, which is really lovely. This is beautiful. Yes, last question for the audience. Um, I would not. I would not. I wouldn't either. Not really. You see so many changes related to retraction and... Yeah. That's a wonderful question. This patient did end up getting stereotactic surgery to the brain mat, and then was started on osimertinib and has been doing pretty well for the last year and a half until he had some progression of disease. Where did he progress, locally? It was locally. Actually, he had a, there was a new nodule in, I believe it was the left side. Whereas the previous disease actually stayed stable on osimertinib. Can I give you? I got creepers on the study evaluation and deemed that the patient is not resectable indeed and usually we discuss with the patients of the different options and the trial findings and a lot of time, if we open that option to patients, a lot of time they will choose OC-based treatment to try first. So in view of the age and the performance of the patient. So we may as well like this patient, what he has. Thank you so much. All right. For our third case here, we have a 58-year-old female, 60 pack years smoking, actively smoking. Stage three invasive squamous cell carcinoma of the cervix that has already been treated with chemoradiation four months prior and her oncologist has declared her looking excellent, that it is responding well. And during a follow-up CT scan, she was found to have a new lung lesion. Pet CT showed a 2.4 centimeter right upper lobe lesion with high levidity, which we will see. We will actually don't have the pet images, I apologize, but we'll see the CT. E-bus was performed and was left to right staging was positive for squamous cell carcinoma at 11R. The pathology was P40 positive, TTF1 negative, and P16 negative. Her ECOG is one. She has some coronary artery disease with a negative nuclear med stress test, but is a little dyspneic at times. Her PFTs, again, I don't know where we get these people, 107. Despite 60 pack year smoking, she was not able to perform her DLCO, which was likely at least a little bit abnormal, Dr. Gillespie, but she just wasn't able to participate with it appropriately. So everyone's favorite imaging. All right. So again, what is the next best step? Is it chemoradiation per gynonc, SBRT to the lung lesion, surgical resection of the lung lesion, or is it just direct to palliative care? You have three minutes in your groups. Consider wisely. Dr. Rivera. Can we talk about the lesion? Yes. It's beautiful. I just can't. So what is the next best step? Is it chemoradiation per gynonc, SBRT to the lung lesion, surgical resection of the lung lesion, or is it just direct to palliative care? You have three minutes in your groups. Thank you all for being here today, and I hope you have a great rest of your day. All right, you care to tell us why you like C? I wanted to go into a treatment mode here without really understanding what you're doing. Can I just go back? We have an e-bus? We're asking one of our audience members. How did we know it was a squamous cell from white tissue? It was positive from 11R. It was a left-to-right staging with nodal tissue found on each step along the way, but only 11R was positive. Okay, so we've got to write up a code. MRI brain negative. So right. So I think addressing this question of the MRI of the brain, making sure that the patient didn't have any metastatic disease that was occult. Once we understand that, I think given that the patient didn't seem to have metastatic excremental cell carcinoma and has been doing well after their initial set of surgical resections, you have a patient that has an N1 node and otherwise a resectable upper lobe lesion, FEV1 is, again, superhuman, and the DLCO, I'm assuming, is like 200% unpredicted. So I think that's the approach that I would consider. I want to talk about the lumen. Yes, you can talk about the lumen. Would you talk about the lumen? No, I think it's important. Think about it. So this one had a squamous cell carcinoma of the cervix. Squamous cell cancer is stage 3B, I think. They can metastasize to the lung. But lung metastases from a second primary are usually to the lower lobes. They're usually smaller and well demarcated lesions. This patient has a 2.5 centimeter irregular, it's an irregular lesion abutting the mediastinal pleura with a right hilar node. So the likelihood of that being metastatic squamous cell cancer of the cervix, I'm putting that really low. This is, I think, a synchronous primary. Not really synchronous, but metacritous primary, second primary of the lung. And I think those radiographic features can be very helpful in helping us think we're likely dealing with a primary lung and not metastatic squamous. I totally agree. And the other thing, too, get the pathology from her prior and compare it. I think it's so important, always ask for the prior pathology to take a look at things and give yourself more confidence that you're making the right treatment decisions and categorizing this as a new primary. I think that's really important. The prior... Sometimes we can't tell the difference between, for example... Squames. The head and squames and the head and neck. Yep. Which 50% met the lung and 50% are primaries. This lady has a 60-pack year history of smoking. I couldn't agree with Dr. Rivera more in that the presentation looks more like lung. Yeah. The presentation looks more like lung. So yes, get the path, see if you can compare it to... This is, again, one of those benefit of the doubt to the patient, right? So I like that approach. The other thing, too, when you're thinking about PFTs, I always ask the patient how it went, and if they potentially just struggled with the respiratory therapist who was taking them through or maybe the instructions were unclear, and then sometimes I'll just take them to a different room and repeat the PFTs with someone different, and then they can perform and we can get the numbers that we need to the DLCO. It's so important to ask your patient, hey, how do you think that went, especially if the numbers don't add up to what you think they should be or if you're not getting the numbers you think you should have been able to get. Or if you take the patient up two flights of stairs and they look great, like you can... We're not allowed to do that anymore. No. Because if they fall, apparently we're... Like they've made us stop doing it, yeah. So I walk them around the clinic instead. We're in South Carolina. They push people down the steps. That's how you get to the operating room. You survive, you get surgery. And I do think this is a lady with a 60-packs years of history of smoking. So she has got the true risk factors of having another primary of lung tumor. And with a 60-years of pack of smoking, the FEV1 of 100,000, the FEV1 of 100,000, the FEV1 of 100,000. I guess it depends on the dose of the prior platinum because if it was concurrent it might not have been full dose right so that's the first thing and how many doses they ended up getting but you're right if they have a second primary and they've already gotten a full dose platinum it's unlikely that that platinum will do much good which is why getting your PDL 1 status and your your tumor genomic testing is so critical but yeah we see that I mean I've had patients get chemotherapy for other cancers whether it's head and neck or esophageal and it makes it really hard to treat them actually right because you're not dealing with a naive bone marrow either right and so those are all things that you really have to make sure you get good records right from the prior doc but I'm wondering if they were treating that cervical cancer if like state you know getting or getting a low dose CT or whatever that probably wasn't even on their radar right so but I do think trying to make sure that we're keeping up with other screenings for other cancers even when we're treating a different cancer is really important I don't advocate for lung cancer screening and someone who's actively being treated for another cancer I don't think that that's there is no data to support that and you often get into a lot of problems with you know false positives that happens a lot with breast cancer and women who are getting radiated and get screened right after the radiation and then you go down the rabbit hole of the nodule the NLST four percent of individuals enrolled in the NLST were individuals who had a prior history of cancer in the Nelson trial nobody with a prior history of lung cancer was enrolled in in the trial in the NLST the that 4% because we've analyzed that data and reported on it were screened 5 to between 5 and 10 years after their cancer diagnosis so I think we have to be careful I'm a big proponent of lung cancer screening cancer survivors who are eligible for screening by USPSTF because I believe that they have a much higher risk for second primaries that's been shown for colon breast bladder head and neck of course and of course primary lung but there should be a window and that window is at least four if not five years after their first cancer diagnosis so do you think that tumor was like two and a half almost two and a half centimeters do you think they just didn't scan her chest probably I mean it's possible it seems unlikely with the stage three like why wouldn't they have scanned why wouldn't they have got that diagnosis yeah it's often they don't do CTs for many cancers pet you would think but then we don't that's why I asked right or you know it's so close to the media I wonder that it was in this that's one of the areas but I just I mean I just would not advocate for screening actively for screening what someone is getting routine surveillance right routine surveillance is important and then after they've five years I mean they wouldn't have scanned her chest for routine surveillance for cervical probably not for cervical for endometrial I feel like they catch the chest pretty decently I'm surprised you wouldn't because she was I just like that's a question is what was done So I'll let you answer that. Sure. So we are still doing adjuvant treatment. So we have to know their PD-L1. We always have the conversation about whether or not we're going to give chemo or not, depending on how big the tumor is. But I still think if their PD-L1 is positive, we have the Empower 010 data showing that we can give adjuvant atezolizumab if they're at least PD-L1 positive. So it's always a discussion. I think that some people, so I'm also a geriatric oncologist. So I think a lot of my, it's always a conversation about whether it's going to be chemo, IO, or IO, or just chemo. And you really need the PD-L1 in the molecular testing. But yes, it is still something that we talk a lot about. And you probably want to mention also that if they're EGFR positive, they'd get OCD. Oh, right. Yeah. But less beneficial if they're 1s. 1B, 2A, if they're EGFR positive, would get OC. If they're EGFR negative, but high PD-L1 status, they're probably going to get MEO out back. And if they're both negative, negative. Chemo. Lace meta-analysis still suggests that between a 5% and 13% benefit from straight chemo. And then don't forget, there was also the PEARLS data that came out. So that's keto-091 that was looking, and that is now approved 1% and greater. They also allowed people not to get chemo and just to get the pembrolizumab. To follow, the data's still more immature than the Empower 010. But there's several different treatment options that could be considered, with sort of the trends showing the best outcomes in the high PD-L1, so they're greater than 50%, slightly larger tumors, for the overall survival. Time. They need to be seen by a medical oncologist. They need to send them to a medical oncologist. Can I have a big round of applause for our tumor board and for all of our tumor boards in the audience? Thank you all for participating on this happy, sunny day. If you guys would all have a lovely day at the beach and enjoy your time in Hawaii. Thank you all very much. Thank you.

tumor board discussion

neoadjuvant therapy

surgical resection

chemotherapy

radiographic features

pathological response

metastasis

stage 3B

molecular testing

individualized treatment decisions