Lung

Question 1

What proportion of new cancer dx in 2018 were lung?

Answer 1

9%

Question 2

What percentage of cancer deaths are from lung ca?

Answer 2

18%

Question 3

What is the most important carcinogen in cigarettes?

Answer 3

Polycyclic aromatic hydrocarbons

Question 4

What are other risk factors?

Answer 4

Occupation exposure
Second-hand smoke
Family history
EGFR mutation 
Internal cooking

Question 5

What screening is evidence based? Why isn’t it recommended in Aus?

Answer 5

Yearly low dose CT scan in high risk persons

• age 55-74
• > 30 pack years
• Smoking cessation <15years

False positive rate of 96%

Question 6

What are some techniques for gaining tissue?

Answer 6

Cytology
EBUS
Mediastinoscopy
Thorascopy
Thoracentesis 
Pleural fluid

Question 7

What is the SN and SP for mediastinal LNs?

Answer 7

91% and 86%

Question 8

What tumour factors mean immediate stage IV?

Answer 8

Pleural effusion

Tumour in contra-lateral lung

Question 9

Mean survival and Mx of stage 1

Answer 9

60-80%

Surgery if medically fit. Stereotactic surgery if not fit.

Question 10

Mean survival and Mx of stage 2

Answer 10

40-50%

Surgery if medically fit. Radiotherapy if not fit

Question 11

What is the standard surgery?

Answer 11

Lobectomy with mediastinal LN dissection

Question 12

When is adjuvant chemo recommended?

Answer 12

Stage II and IIIA (stage IB controversial)

Question 13

What chemotherapy is used?

Answer 13

Platinum based

Question 14

When is radiotherapy best given in relation to chemo?

Answer 14

Concurrently

Question 15

What is the role of durvalumab in stage III lung Ca?

Answer 15

Maintain post primary chemoradiation

Question 16

What is the mean survival of stage IV?

Answer 16

4-5 months

Question 17

What are the four tissue markers of importance for targeted therapy?

Answer 17

EGFR
ALK rearrangement
ROS 1
PDL-1

Question 18

What is the classic pathological classification?

Answer 18

Small-cell (15%) and non-small-cell (85%)

Non-small-cell

• Squamous (30%)
• Non-squamous (70%)

Non-squamous

• Adenocarcinoma (90%)
• Large-cell carcinoma (10%)

Question 19

Which pathological subtype has the worse prognosis?

Answer 19

Large-cell neuroendocrine

Question 20

Which pathology types should be tested for what marker?

Answer 20

All NSCLC - PDL1

Adenocarcinoma
- EGFR, ALK rearrangement, ROS1

Question 21

Which patients more commonly have EGFR mutant?

Answer 21

Asian

Question 22

What drug targets the EGFR mutant Ca

Answer 22

1st gen: Erlotinib
2nd gen: Gefitinib
3rd gen: Osimertinib

Question 23

What is the classic side effect of EGFR molecular therapy?

Answer 23

Acneiform rash - 80% get it

Question 24

What is the benefit of Osimertinib?

Answer 24

Overcomes T790 mutation that commonly leads to resistance to erlotinib and gefinitib

Question 25

How common is ALK rearrangement?

Answer 25

2-7% NSCLC

Question 26

What drug targets ALK rearrangement

Answer 26

Crizotinib | Alectenib (replaced crizotinib as standard of care)

Question 27

What are the side effects of ALK rearrangement targeting therapy?

Answer 27

``` Visual changes Neutropenia Altered bowel habit Pulmonary toxicity Fluid retention Hepatotoxicity Bradycardia Prolonged QT Fatigue Cytochrome p450 interactions ```

Question 28

What is the benefit of alectenib over crizotinib?

Answer 28

Less toxic, better CNS penetration | Hazard ratio for disease progression or death 0.5

Question 29

How common is ROA-1 rearrangement?

Answer 29

1% of NSCLCs

Question 30

Which medication targets ROA-1?

Answer 30

Crizotinib

Question 31

When are immunotherapies indicated?

Answer 31

1st line 2nd line Adjuvant

Question 32

What markers do you check for prior to immunotherapy?

Answer 32

PDL1 status

Question 33

When is pemrolizumab alone first line?

Answer 33

When PDL1 is >50%

Question 34

What was the trial median overall survival with first line pembrolizumab

Answer 34

30months

Question 35

When is atezolizumab indicated?

Answer 35

Non-squamous for low PDL1 or progression on TKI for EGFR and ALK

Question 36

What is the next stage in pembrolizumab use?

Answer 36

Combination with chemo for first line regardless of PDL1 status

Question 37

When is a first line chemotherapy regimen is used?

Answer 37

Low PDL1 | Not candidate for immunotherapy or not suitable