Lung Flashcards
What proportion of new cancer dx in 2018 were lung?
9%
What percentage of cancer deaths are from lung ca?
18%
What is the most important carcinogen in cigarettes?
Polycyclic aromatic hydrocarbons
What are other risk factors?
Occupation exposure Second-hand smoke Family history EGFR mutation Internal cooking
What screening is evidence based? Why isn’t it recommended in Aus?
Yearly low dose CT scan in high risk persons
- age 55-74
- > 30 pack years
- Smoking cessation <15years
False positive rate of 96%
What are some techniques for gaining tissue?
Cytology EBUS Mediastinoscopy Thorascopy Thoracentesis Pleural fluid
What is the SN and SP for mediastinal LNs?
91% and 86%
What tumour factors mean immediate stage IV?
Pleural effusion
Tumour in contra-lateral lung
Mean survival and Mx of stage 1
60-80%
Surgery if medically fit. Stereotactic surgery if not fit.
Mean survival and Mx of stage 2
40-50%
Surgery if medically fit. Radiotherapy if not fit
What is the standard surgery?
Lobectomy with mediastinal LN dissection
When is adjuvant chemo recommended?
Stage II and IIIA (stage IB controversial)
What chemotherapy is used?
Platinum based
When is radiotherapy best given in relation to chemo?
Concurrently
What is the role of durvalumab in stage III lung Ca?
Maintain post primary chemoradiation
What is the mean survival of stage IV?
4-5 months
What are the four tissue markers of importance for targeted therapy?
EGFR
ALK rearrangement
ROS 1
PDL-1
What is the classic pathological classification?
Small-cell (15%) and non-small-cell (85%)
Non-small-cell
- Squamous (30%)
- Non-squamous (70%)
Non-squamous
- Adenocarcinoma (90%)
- Large-cell carcinoma (10%)
Which pathological subtype has the worse prognosis?
Large-cell neuroendocrine
Which pathology types should be tested for what marker?
All NSCLC - PDL1
Adenocarcinoma
- EGFR, ALK rearrangement, ROS1
Which patients more commonly have EGFR mutant?
Asian
What drug targets the EGFR mutant Ca
1st gen: Erlotinib
2nd gen: Gefitinib
3rd gen: Osimertinib
What is the classic side effect of EGFR molecular therapy?
Acneiform rash - 80% get it
What is the benefit of Osimertinib?
Overcomes T790 mutation that commonly leads to resistance to erlotinib and gefinitib
How common is ALK rearrangement?
2-7% NSCLC
What drug targets ALK rearrangement
Crizotinib
Alectenib (replaced crizotinib as standard of care)
What are the side effects of ALK rearrangement targeting therapy?
Visual changes Neutropenia Altered bowel habit Pulmonary toxicity Fluid retention Hepatotoxicity Bradycardia Prolonged QT Fatigue Cytochrome p450 interactions
What is the benefit of alectenib over crizotinib?
Less toxic, better CNS penetration
Hazard ratio for disease progression or death 0.5
How common is ROA-1 rearrangement?
1% of NSCLCs
Which medication targets ROA-1?
Crizotinib
When are immunotherapies indicated?
1st line
2nd line
Adjuvant
What markers do you check for prior to immunotherapy?
PDL1 status
When is pemrolizumab alone first line?
When PDL1 is >50%
What was the trial median overall survival with first line pembrolizumab
30months
When is atezolizumab indicated?
Non-squamous for low PDL1 or progression on TKI for EGFR and ALK
What is the next stage in pembrolizumab use?
Combination with chemo for first line regardless of PDL1 status
When is a first line chemotherapy regimen is used?
Low PDL1
Not candidate for immunotherapy or not suitable
