Lung ca Flashcards
Where does lung ca metastasise to
Brain
liver
Adrenals
Bone
3 most important genetic mutations to know in lung adenocarcinoma
EGFR (almost always happens in adenocarcinoma)
ALK
ROS1 (rare)
Can use targeted agents!
How do you get Horner’s syndrome in lung cancer?
Compression of sympathetic chain (apical tumour)
Which type of lung ca commonly presents with paraneoplastic syndrome?
Small cell
What is the most common type of mutation in NSCLC?
KRAS
But no targeted agents at the moment
What stage is the lung ca if there is also a pleural or pericardial nodule?
stage 4
What stage is the lung ca if there is tumour in the contra-lateral lung?
Stage 4
What needs to be done urgently with newly diagnosed small cell lung cancer?
Urgent chemotherapy
Urgent CT staging including brain (MRI preferred)
Brain radiotherapy if mets present
Treatment of stage 1 or 2 NSCLC
Lobectomy PLUS mediastinal LN resection with curative intent
PLUS adjuvant chemo (cisplatin) for stage 2
If unfit, sterotactic radiotherapy
Treatment of stage 3a (non-bulky) NSCLC
Lobectomy OR/AND radiotherapy PLUS chemotherapy
Treatment of stage 3a (bulky) NSCLC
Chemoradiotherapy followed by durvalumab (PD1 inhibitor)
Regardless of PD1 status
What investigations must you do in stage 4 NSCLC?
Test for driver mutations - EGFR, ALK, ROS1
AND PD1 status (if no driver mutation; comes second only!)
= Will direct therapy!
Treatment of stage 4 NSCLC with EGFR mutation
EGFR TKI - Erlotinib
2nd line: orsimertinib (if T790 mutation aka resistance)
Treatment of stage 4 NSCLC with ALK mutation
ALK TKI - Alectinib
Treatment of stage 4 NSCLC with ROS1 mutation
ALK TKI - crizotinib
Treatment of stage 4 NSCLC without EGFR, ALK or ROS1 mutation, but high PD1 status
PDL1 inhibitor - pembrolizumab
2nd line: platinum doublet chemo (cisplatin or carboplatin)
Treatment of stage 4 NSCLC without EGFR, ALK or ROS1 mutation, with low PD1 status
Platinum doublet chemo - cisplatin or carboplatin
2nd line: immunotherapy e.g. nivolumab, atezoizumab
OR pemetrexed or docetaxel
Treatment of stage 4 non-squamous NSCLC (mainly adenocarcinoma) with negative driver mutations, and low PD1
Atezolizumab
Bevalizumab
Carboplatin
Paclitaxel
= ABCP
Must be fit though. Tough treatment !
Treatment of limited small cell lung cancer
Platinum chemo (cisplatin) PLUS etoposide PLUS brain chemotherapy (prophylactic)
Treatment of extensive small cell lung cancer
Platinum chemo (cisplatin/carboplatin) PLUS etoposide plus brain and chest radiotherapy
Treatment of mesotheolioma
Palliative chemo (cisplatin + pemetrexed)
AE of erlotinib (EGFR TKI)
80% will get acneiform rash
62F incidental lung nodule (1.8cm). Biopsy adenocarcinoma of lung.
She’s fit and healthy.
Treatment?
Lobectomy
62F incidental lung nodule (1.8cm). Biopsy adenocarcinoma of lung.
She’s unfit and frail.
Treatment?
Sterotactic radiotherapy
62F with stage 4 lung ca
ECOG 1
No CI to immunotherapy
Biopsy: adenocarcinoma/squamous with high PDL1 (>50)
Treatment?
Pembrolizumab (PDL1 inhibitor)
62F with stage 4 lung cancer
ECOG 1
No CI to immunotherapy
Biopsy: adenocarcinoma with low PDL1 (<50)
Treatment?
Atezolizumab
Bevacizumab
Carboplatin
Paclitaxel
ABCP
62F with stage 4 lung ca
ECOG 1
No CI to immunotherapy
Biopsy: squamous with low PD1 (<50)
Treatment?
Doublet platinum chemo
62M Fit Ex smoker Adenocarcinoma Staging T3N2 Not surgical candidate as lymph nodes are too close to mediastinum and vascular structures
Chemoradiotherapy followed by durvalumab (Anti-PD1 ab)
Roughly describe each stage of NSCLC Stage 1 Stage 2 Stage 3 Stage 4
Stage 1: no nodal involvement
Stage 2: hilar nodes (N1 nodes) or very large primary tumour
Stage 3: mediastinal/supraclavicular fossa nodes (N2, N3 nodes)
Stage 4: metastatic disease including MPE
Investigations in staging of lung cancer
CXR/CT chest
PET scan
CTB or MRI Brain (PET is not good for the brain)
+/- invasive staging of mediastinum (generally not needed if PET negative)
Histological confirmation of primary cancer and any PET positive findings
