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FRCR2 > Lung > Flashcards

Lung Flashcards

1
Q

When is a PET-CT indicated in lung cancer

When is MRI indicated

A

In all those eligible for radical treatment
If LNs > 1cm seen on staging CT -> PET-CT, EBUS & Bx

MRI - Pancoast tumour to assess involvement of brachial plexus

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2
Q

What brain imaging is indicated in lung cancer and when

A

Stage 2 - CT head with contrast
Stage 3 - MRI head with contrast

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3
Q

What investigations are needed to manage lung cancer

A

Bloods
Chest imaging & staging
Brain imaging if appropriate
Biopsy result for histology

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4
Q

Where is nodal station 1 and what N stage does this indicate

A

Highest mediastinal nodes
Ipsilateral/contralateral low cervical / supraclavicular / sternal notch nodes

=N3

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5
Q

How is N1 status defined

A

Stations 10-14 positive
10 - ipsilateral hilar
11 - peribronchial - interlobar
12 - intrapulmonary - lobar
13 - intrapulmonary - segmental
14 - intrapulmonary - subsegmental

distal to carina

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6
Q

How is N2 status defined

A

Positive stations 2-9 - ipsilateral superior mediastinal, aortic or ipsilateral mediastinal
Same side mediastinal, and aortic nodes

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7
Q

How is N3 nodal disease defined

A

Either contralateral hilar nodes (station 10) or contralateral mediastinal nodes (stations 7-9)

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8
Q

Which nodal stations are the ipsilateral superior mediastinal nodes

A

Stations 2, 3 & 4
2 = upper paratracheal
3 = pre vascular / retrotracheal
4 = lower paratracheal

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9
Q

Which nodal stations are the aortic nodes

A

Stations 5 & 6
Station 5 = sub aortic
Station 6 = para-aortic
N2 disease

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10
Q

Which nodal stations are the ipsilateral mediastinal nodes

A

Sup mediastinal
2-4

inferior mediastinal
Stations 7, 8 & 9
Station 7 = subcarinal
Station 8 = para-oesophageal
Station 9 = pulmonary ligament

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11
Q

Which station are the ipsilateral hilar nodes

A

Station 10

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12
Q

Which nodes are station 2 and what N stage do they indicate

A

2 = upper paratracheal (part of ipsilateral superior mediastinal)
N2

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13
Q

Which nodes are station 3 and what N stage do they indicate

A

3 = prevascular / retrotracheal
Part of ipsilateral superior mediastinal nodes
N2

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14
Q

Which nodes are station 4 and what N stage do they indicate

A

4 = lower para-tracheal
Part of ipsilateral superior mediastinal nodes
N2

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15
Q

Which nodes are station 5 and what N stage do they indicate

A

5 = sub-aortic
Part of aortic group
N2

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16
Q

Which nodes are station 6 and what N stage do they indicate

A

6 = para-aortic
Part of aortic group
N2

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17
Q

Which nodes are station 7 and what N stage do they indicate

A

7 = subcarinal
Part of ipsilateral mediastinal group
N2 disease

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18
Q

Which nodes are station 8 and what N stage do they indicate

A

8 = para-oesophageal
Part of ipsilateral mediastinal group
N2 disease

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19
Q

Which nodes are station 9 and what N stage do they indicate

A

9 = pulmonary ligament
Part of ipsilateral inferior mediastinal group

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20
Q

Which nodes are station 10 and what N stage do they indicate

A

10 = ipsilateral hilar
N1 disease

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21
Q

Which nodes are station 11 and what N stage do they indicate

A

11 = interlobar / peribronchial nodes
N1 disease

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22
Q

Which nodes are station 12 and what N stage do they indicate

A

12 = intrapulmonary nodes - lobar
N1 disease

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23
Q

Which nodes are station 13 and what N stage do they indicate

A

13 = intrapulmonary nodes - segmental
N1 disease

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24
Q

Which nodes are station 14 and what N stage do they indicate

A

14 = intrapulmonary nodes - sub-segmental
N1 disease

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25
Q

Which nodal stations are the contralateral hilar /mediastinal nodes
What N stage do they indicate

A

As numbered according to above stations
But contralateral = N3 disease

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26
Q

Which nodal station are the low cervical / supraclavicular / sternal notch nodes
What N stage do they indicate

A

Station 1
N3 disease

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27
Q

How is M1 disease defined

A

M1a - contralateral lung nodule or malignant effusion (pleural or pericardial)
M1b - single extra-thoracic met
M1c - multiple extra-thoracic metastases

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28
Q

How is a T1 lung tumour defined

A

≤3cm

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29
Q

How is a T2 lung tumour defined

A

3-5cm

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30
Q

How is a T3 lung tumour defined

A

5-7cm or chest wall / pleural invasion
Or 2nd tumour in same lobe

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31
Q

How is a T4 lung tumour defined

A

> 7cm or direct invasion into mediastinal structures
Or second tumour on same side but different lobe

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32
Q

How is a stage 1A lung cancer defined

A

T1N0

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33
Q

How is a stage 1B lung cancer defined

A

T2a N0

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34
Q

How is a stage 2A lung cancer defined

A

T2b N0

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35
Q

How is a stage 2B lung cancer defined

A

T1-2 N1 or T3 N0
ie T3 disease or N1

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36
Q

How is a stage 3A lung cancer defined

A

T1-2 N2 or T3 N1 or T4 N0-1
ie N2 positive, T3N1 or T4 disease

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37
Q

How is a stage 3B lung cancer defined

A

T1-2 N3, T3-4 N2

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38
Q

How is a stage 3C lung cancer defined

A

T3-4 N3

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39
Q

How is a stage 4 lung cancer defined

A

M1

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40
Q

How does nodal positivity affect lung cancer staging

A

N1 = stage 2b
N2 = stage 3a at least (3b if also T3-4)
N3 = stage 3b at least (3c if also T3-4)

41
Q

What three things are optimised prior to lung treatment

A

Smoking
PT
Dietician for nutrition

42
Q

What information is required before being able to make a treatment decision

A

Staging CT CAP
MRI brain
PET
Histology
Pulmonary function

43
Q

What is the treatment of choice for a stage 1 (T1-2N0) lung cancer

A

Surgery
Lobectomy - if confined to one lobe (L) or two (RML/RLL)
Sub-lobar resection - segmentectomy or wedge resection

44
Q

What is the treatment of choice for a stage 2 (T2b-3 N0 / T1-2 N1) lung cancer

A

Presuming radical treatment:
Surgery (with NA-SACT or adj SACT)
CRT (concurrent or sequential)

45
Q

When is a pneumonectomy indicated over a lobectomy

A

When tumour is <2.5cm from carina

46
Q

What are the FEV1 requirements for surgery

A

FEV1 >1.5L - Lobectomy

FEV1 >2L - Pneumonectomy

47
Q

What are the options for neoadjuvant SACT ahead of radical surgery
And what are the criteria

A

Neo-adjuvant chemotherapy - cisplatin/paclitaxel SqCC; carbo/pemetrexed for adjuvant
Neo-adjuvant immunotherapy - nivolumab/Pt-based chemotherapy

NA nivolumab:
T2b or greater, or node positive (ie stage 2 or above), potentially resectable disease
Independent of PDL1 status
No actionable driver mutation - ALK/EGFR

48
Q

What are the options for adjuvant treatment after surgery for a lung cancer

A

Adjuvant chemotherapy

Adjuvant targeted therapy

Adjuvant immunotherapy

49
Q

When is adjuvant RT recommended following surgery for lung cancer
And at what dose
What is encompassed in the CTV
What is the CTV-PTV margin

A

R1 resection (microscopic disease) incl extracapsular spread
60Gy in 30# (or 50-55Gy/20#)

Not recommended for R0 resection as pts do worse

If R2 resection - tx as new lung cancer with CRT

CTV - tumour bed, incl clips. Resected positive nodal areas

PTV = CTV +1cm axially and 1.5cm sup/inf unless using 4D CT (use 1cm margin throughout)

50
Q

What are the indications for adjuvant chemotherapy?
What is the benefit
And what regimen

A

Node positive
T2b - stage IIB or unexpected stage III

Benefit - 4-5% OS improvement at 5yrs

Cisplatin/Vinorelbine (SqCC), carbo/pemetrexed (adeno)

51
Q

What is the indication for adjuvant osimertinib
When does it start
Duration
What is the benefit

A

Completely resected EGFR mutated NSCLC (exon 19 deletion or L858R substitution)
Stage 1B (T2a) or greater, up to N2 only stage 3
ie >T2a N0, T1-2 N2, T3-4 N2

to start within 10wks if no chemotherapy or within 26wks if following chemotherapy (indicated if node positive or stage T2a (4cm) or greater)

For 3yrs / disease recurrence / unacceptable toxicity

Greater benefit for greater disease stage
Adaura trial - mDFS not reached fornosimertinib, vs 19mths for placebo

52
Q

What are the resistance mechanisms to osimertinib

A

EGFR or non-EGFR mechanisms
Usually EGFR exon 20 C797X mutation or loss of T790M mutation
Alternatively MET amplification, HER2 amplification or non-EGFR pathway aberrations (RAS-MAPK, PI3K), cell cycle gene alterations, oncogenic fusions

53
Q

What is the indication for adjuvant atezolizumab

A

Following complete resection of a NSCLC, stage 2b or greater (ie T1-2 N1 - T3-4 N2)
with PDL1 >50%
For one year
and if no progression following Pt-based chemotherapy

54
Q

What are the two options for radical RT for an early lung cancer

A

Non-SABR RT
SABR RT

55
Q

When is non-SABR RT indicated for an early lung cancer
What is the dose

A

stage I-II (T1-2N1 or T3N0), non-resectable cancer within 1cm of the proximal bronchial tree (therefore not amenable to SABR) or overlaps critical structures

Dose:
54Gy/36# CHART - 3x/day over 12 days
Or 55Gy/20#

56
Q

When is SABR RT indicated
What is the dose

A

Tumour up to 5cm (T2), outside of proximal bronchial tree / exclusion zone (≥2cm away).
Node negative
Or T3 only due to chest wall invasion

Not suitable for surgery or declines surgery
PS0-2

Dose:
Peripheral tumours - 54Gy in 3# over 5-8 days, prescribed to 80% isodose
Tumours in contact with chest wall - 55Gy in 5# / 10-14 days (not compromised for chest wall tolerance)
Tumours adjacent to OAR - 60Gy in 8# /10-20 days

57
Q

What are the exclusion criteria for lung SABR

A

Pt unable to lie flat for 45min
PS >2
Tumour not definable on planning CT, ie associated with consolidation or atelectasis
Within 2cm of central exclusion zone
Previous RT within the planned treatment volume

58
Q

What are the outcomes from lung SABR

A

Improved local control rates
2-yr local control rate >90% (similar to surgery);
5-yr local control rate 86%
Nodal recurrence 4-11% post SABR
Improved OS cf to radical RT (40% v 20% at 5yrs)

59
Q

What are the OAR tolerances for lung SABR

A

Oesophagus - 1cc <24Gy
Lung - V20<10%
Heart - 1cc <24Gy

60
Q

How is lung SABR planned

A

4D CT
GTV - Tumour
CTV -> ITV - Outline tumour on MIP
ITV -> PTV - 5mm

61
Q

How is operable N2 disease (stage III) defined

A

No LN > 3cm
Must be free from major mediastinal structures: great vessels & trachea
Non-fixed, non-bulky, single zone N2

62
Q

What is the regimen for radical concurrent chemoRT?

A

55Gy/20#, or 60Gy/30# or 66Gy/33#

Cycles 1&2 of cisplatin (40mg/m2) and vinorelbine (15mg/m2) given alongside RT

Cycles 3&4 given following completion of RT
cisplatin (80mg/m2) and vinorelbine (35mg/m2)

63
Q

What is the indication for durvalumab?

A

No progression following concurrent chemoradiotherapy, good PS, PDL1 >1%

Given 2wkly for 12mths / disease progression / toxicity

Pacific trial (CRT +durvalumab / placebo) - Median survival benefit 47.5mths vs 29.1 months

64
Q

For concurrent CRT, what GTV-ITV & PTV margin is given

A

GTV +5mm
PTV = CTV/ITV +1cm radically and 1.5cm if no motion management, or CTV +5mm if motion management

65
Q

For sequential CRT, what GTV-ITV & PTV margin is given

A

GTV - post chemo lesion / tumour bed
CTV - GTV + pre-chemo LNs (no margin on primary lesions)
PTV - CTV + 10mm axially and 15mm sup/inf

66
Q

What dose constraints would be acceptable for a radiotherapy plan (4 organs)

A

Lung: V20Gy <35%
Spinal cord: Dmax <50Gy
Heart: V40Gy <30%
Oesophagus: V35Gy <50%

67
Q

What is the treatment algorithm for a pancoast tumour

A

If operable: Neo-adjuvant CRT - 45Gy/25# with cisplatin/etoposide, followed by surgery
If inoperable: Primary CRT - 45Gy/25# with cisplatin/etoposide

Or consider radical CRT - 60Gy/30#, followed by surgery if disease has become operable
If PDL1>1% and no progression after CRT, would be eligible for consolidation durvalumab

68
Q

What targetable mutations exist for metastatic NSCLC & corresponding txs (non EGFR & ALK)

A

Met - exon 14 skip mutation - tepotinib
B-raf - dabrafenib/trametinib - 1st line
K-ras - sotorasib if G12C mutation 2nd line after Pt-based ChT/IO
NTRK - larotrectinib/entrectinib - 2nd line after Pt-based chemo, IO and docetaxel
Ros1 - can use crizotinib or entrectenib both 1st line
HER2 - Trastuzumab-emtansine
RET fusion - selpercatinib - approved 1st line

69
Q

What are the commonest EGFR mutations in NSCLC

A

L858R and exon 19 deletion - confer sensitivity to osimertinib.
Exon 20 insertions (C797X) - confer resistance

70
Q

What is the response rate to osimertinib

A

> 60% RR for intracranial disease
80% for those with L858R mutation

71
Q

What is the workup for progression on non-osimertinib EGFRi

A

Rebiopsy if possible:
T790M mutation - osimertinib
Non T790M mutation - Pt-based chemotherapy doublet

72
Q

What are the first line options for an ALK-positive NSCLC
What are the typical side effects

A

Alectinib - LFTs/anaemia/constipation/oedema/weight gain
Brigatinib - htn/rash/CPK/ILD
Good CNS penetration

73
Q

What is the typical resistance mutation to first line ALK inhibition, and what is the 2nd line treatment

A

ALK G1202R
Retains sensitivity to 2nd line lorlatinib
PFS 6mths

74
Q

Brain mets common in those treated with ALK inhibitors. What is the recommended treatment

A

Avoid WBRT if possible, consider SRS

75
Q

What systemic treatment is given after progression on osimertinib (EGFR mutation) or alectinib & lorlatinib (ALK mutation)

A

Atezo, carboplatin, paclitaxel, bevacizumab
or Pt-doublet

76
Q

If no actionable mutation is present, what is the first line systemic treatment for a metastatic squamous cell carcinoma?

And 2nd line

A

If PDL1 >50% - single agent atezolizumab or pembrolizumab, or carboplatin/paclitaxel/pembrolizumab if a rapid response is required, followed by maintenance pembrolizumab

If PDL1 <50% - carboplatin/paclitaxel/pembrolizumab +/- bevacizumab
Followed by maintenance pembrolizumab (2yrs)
Addition of bevacizumab to carbo/paclitaxel/atezo improved mOS

2nd line:
If PDL1 >50% initially - Pt-based doublet ChT
If PDL1 <50% - single agent atezolizumab, nivolumab or pembrolizumab (PDL1 >1%)

77
Q

If no actionable mutation is present, what is the first line systemic treatment for a metastatic adenocarcinoma?

And 2nd line

A

If PDL1 >50% - single agent atezolizumab & bevacizumab, followed by atezolizumb/bev
Or single agent pembrolizumab, followed by maintenance pembro/pemetrexed
Or carboplatin/pemetrexed/pembrolizumab/bev if a rapid response is required, followed by atezolizumb/bev

If PDL1 <50% - carboplatin/pemetrexed/pembrolizumab +/- bevacizumab
Followed by maintenance pemetrexed/pembrolizumab (2yrs)

2nd line:
If PDL1 >50% initially - Pt-based doublet ChT or Pt/pemetrexed, followed by maintenance pemetrexed

If PDL1 <50% - single agent atezolizumab, nivolumab or pembrolizumab (PDL1 >1%)
Docetaxel +/- nintedanib

78
Q

How is limited vs extensive stage small cell lung cancer defined

A

Limited - can be encompassed in one 10x10cm field
Practically, disease confined to one hemithorax and regional nodes

Extensive stage (90% of presentations)
Multiple lung nodules, SCF nodes, effusion

79
Q

What is the management for an early small cell lung cancer

A

If T1/2 - surgery (lobectomy) + adjuvant chemotherapy (cisplatin/etoposide) +/- PCI

If found to be node positive after surgery - give adjuvant CRT

80
Q

Management for T3/4 or N+ small cell lung cancer

A

Concurrent ChemoRT, followed by surveillance if response, or 2nd line treatment if progression

Less intense if sequential ChemoRT - if pt less fit or disease is not encompassable / too extensive

81
Q

What is the regimen for sequential chemoRT

A

4 cycles cis/carboplatin & etoposide, followed by 40Gy/15# over 3wks

82
Q

What are the CRT regimes for small cell lung cancer

A

Either Turrisi regimen or Convert regimen
4x cisplatin and etoposide
RT starts with second cycle of chemo

Turrisi:
45Gy/30# treating bd, over 19 days
4% survival advantage to bd RT treatment - can instead treat daily

Convert
66Gy/33#, RT starting with cycle 2
45Gy/30# is SOC

Rescan 4-6wks after completion of cycle 4 chemotherapy, before considering PCI

83
Q

How should RT be planned for a small cell lung cancer

A

GTV = primary and nodes
CTV = GTV +5mm
PTV = CTV +10mm axillary and 15mm sup/inf, or 5mm throughout if planned using 4DCT

84
Q

What is the regimen for PCI in limited small cell lung cancer
Indications
What is the benefit

A

25Gy/10#/2wks

Indications:
Partial or complete response in limited disease, within 4-6wks of completing ChT
PS0-2 & age ≤70

Benefit:
Improves OS by 5% at 3yrs, from 15->20%
Reduces risk of CNS met by 50% (60->30%) at 3yrs

85
Q

What is the first line management of extensive stage small cell lung cancer

A

Carboplatin/etoposide + atezolizumab x6, followed by maintenance atezolizumab (needs PS 0-1)
Or cisplatin/carboplatin + etoposide + durvalumab x6, followed by maintenance durvalumab

If PS2-3 - consider platinum/etoposide only

86
Q

What is the mOS for extensive stage SCLC treated with carbo/etopo/atezo

and carbo/etopo/durvalumab

A

atezo: 12.3mths according to IMPower 133 trial

durval: 13mths - Caspian trial

87
Q

How should brain mets be managed as part of small cell lung cancer presentation

A

CNS RT, then wean off steroids before starting immunotherapy
Cannot use immunotherapy with uncontrolled / untreated intracranial disease

88
Q

How should a small cell cancer presenting as SVCO be managed

A

Stent only if doesn’t delay chemo
Urgent carboplatin/etoposide, and add ate once PS improves to 1.

89
Q

What are the indications for consolidation RT in SCLC?
What dose is given

What volumes
What was the benefit

A

Residual disease post chemotherapy / chemo-IO
Bulky mediastinal disease initially

Dose: 30Gy/10# / 20Gy/5#, 17/2, single 8 or 10

Volumes:
CTV lung - post chemo volume
CTV nodes - pre-chemo volume
PTV = CTV +15mm

Crest trial - 30Gy/10# - 2yr OS improved by 10% (13% vs 3%)

90
Q

When is PCI indicated in extensive stage SCLC
Dose?
Benefit
SE

A

If complete or partial response to treatment, age <75 and PS0-2
20Gy/5# or 25Gy/10# if fitter (same dose as limited stage)
And not already had WBRT

Increased mOS (27% vs 13%) and reduced occurrence of symptomatic brain mets (15% vs 40%)
based on Slotman trial, but no baseline imaging was done
Possible that MRI surveillance is as effective

SE: mild cognitive decline in 30%, headache, N/V. fatigue

91
Q

What is the risk of malignancy for lung nodule/mass:
<5mm
1-2cm
2-3cm
>3cm

A

nodules < 5mm - 1% malignant
nodules 1-2 cm 18% malignant
nodules 2-3 cm 50% malignant
masses >3cm 90% malignant

92
Q

What mass/nodule features on imaging would suggest malignancy

A

Size, spiculated appearance, thick walled, necrotic

93
Q

When does radiation pneumonitis typically occur

A

8wks post RT
treat with steroids

94
Q

What is the management of a lung nodule based on size

A

<8mm - CT surveillance
If <5-6mm -> CT at 1yr
>6mm - CT at 3mths

If >8mm - assess malignancy risk
<10% risk - CT surveillance (3mths)
10-70% risk - biopsy
>70% risk - excise

95
Q

who is eligible for lung screening

A

age 55-74, hx of smoking
low dose CT
20% reduction in lung cancer related death and 6.7% in overall all cause mortality vs CXR
70% were stage I-II

96
Q

what is the prognosis of NSCLC and the benefit of adj chemotherapy

A

5-year survival 7% men, 9% women
Adjuvant chemotherapy can increase absolute survival rates by 4%

97
Q

What are the numbers for lung T staging

A

3-5-7
T1 <3cm
T2 3-5cm
T3 5-7cm
T4 >7cm

98
Q

What is the risk of pneumothorax with RFA

A

40%

99
Q

what is the first line treatment for a metastatic NSCLC with exon 20 egfr mutation

A

Pt-based chemotherapy

FRCR2 (28 decks)

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