Lecture 13 - Lung Cancer

Question 1

Lung cancer is the ____ most common

Answer 1

2nd
#1 killer
survival rates have greatly improved

Question 2

Risk factors

Answer 2

tobacco, occupational/environmental exposure to asbestos, heavy metals, radon, polycyclic aromatic hydrocarbons, ionizing radiation, genetic predisposition

Question 3

Etiology

Answer 3

chronic exposure of epithelial cells to carcinogens results in chronic inflammation; induces genetic and cytologic changes which eventually lead to carcinogenesis

Question 4

Etiology - EGFR mutations

Answer 4

can predict sensitivity to tyrosine kinase inhibitor therapy
T790M mutations: resistance to therapies (osimertinib is drug for this mutation)

Question 5

Etiology - K-RAS mutations

Answer 5

predict resistance to TKIs
in adenocarcinomas, mutations are exclusive to smokers

Question 6

Etiology - ALK inhibition

Answer 6

less sensitive to EGFR inhibitors and chemo
present in no/light smokers, young age, adenocarcinoma

Question 7

Etiology - ROS-1 mutations

Answer 7

encodes a receptor kinase related to ALK
present in never/light smoker, young pts, adenocarcinomas

Question 8

Etiology - BRAF V600E

Answer 8

in current/former smokers
recommended to rest in 1st line metastatic setting for NSCLC

Question 9

Etiology - PD-L1 status

Answer 9

recommended to test status in 1st line metastatic setting

Question 10

Histologic classification

Answer 10

non-small cell (NSCLC): adenocarcinoma (non-smokers), squamous (smokers), large cell, and non-squamous
small cell (SCLC): small cell (related to smoking)

Question 11

Small cell lung cancer

Answer 11

clear relationship to smoking
paraneoplastic syndromes common
rapid cell growth fraction
highly sensitive to radiation and chemo
most common cancer to cause brain metastases

Question 12

Non-small cell lung cancer

Answer 12

slower growth fraction
moderately sensitive to radiation
marginal sensitivity to chemo

Question 13

Staging: SCLC

Answer 13

limited: tumor confined to hemithorax and contained in radiation port
extensive stage: tumor not confined to hemithorax of origin, not contained in radiation port, distant metastasis

Question 14

Small cell lung cancer highly sensitive to

Answer 14

radiation and chemo
chemo demonstrates 5-fold increase in median survival and is the mainstay of therapy
surgery is generally not a therapeutic option

Question 15

Limited stage disease

Answer 15

curative intent
combined modality: radiation + combo chemo - cisplatin + etoposide, radiation daily
maintenance chemo is of no value
prophylactic cranial radiation for pts obtaining a complete response

Question 16

Regimens for limited stage

Answer 16

cisplatin + etoposide
carboplatin + etoposide

Question 17

Extensive state

Answer 17

NO radiation!
rarely curable
platinum based combo chemo w/o radiation preferred: cisplatin or carbolatin based combo chemo - etoposide or irinotecan
chest radiation does not improve results
whole brain radiation therapy if brain metastases present
maintenance chemo is standard of care

Question 18

Immunotherapy: extensive stage

Answer 18

first line: atezolizumab + carboplatin + etoposide; durvalumab + carboplatin + etoposide; durvalumab + cisplatin + etoposide

Question 19

Complications of therapy for SCLC

Answer 19

most cisplatin-based regimens: serious chemo induced N/V, nephrotoxicity, ototoxicity, neuropathy
radiation therapy may cause fatigue, esophagitis, radiation pneumonitis, and cardiac toxicity

Question 20

PD-1 inhibitors

Answer 20

pembrolizumab: option for metastatic SCLC in pts who have progressed on or after platinum-based chemo and at least 1 prior line of therapy
regardless of PD-1 status

Question 21

Non-small cell lung cancer

Answer 21

moderately sensitive to radiation and low sensitivity to chemo
surgery is most efficacious!
radiation therapy may be given for early-stage NSCLC when surgery isn’t able to be performed

Question 22

Types of NSCLC

Answer 22

resectable
unresectable
advanced/metastatic

Question 23

Treatment of resectable NSCLC

Answer 23

neoadjuvant –> surgery –> chemo followed by immunotherapy or oral agent

Question 24

Neoadjuvant therapy NSCLC

Answer 24

nivolumab + a platinum doublet in tumors >/= 4 cm or node +
adjuvant chemo now a standard of care; chemo decided on histology