Lung ca

Question 1

Where does lung ca metastasise to

Answer 1

Brain
liver
Adrenals
Bone

Question 2

3 most important genetic mutations to know in lung adenocarcinoma

Answer 2

EGFR (almost always happens in adenocarcinoma)
ALK
ROS1 (rare)

Can use targeted agents!

Question 3

How do you get Horner’s syndrome in lung cancer?

Answer 3

Compression of sympathetic chain (apical tumour)

Question 4

Which type of lung ca commonly presents with paraneoplastic syndrome?

Answer 4

Small cell

Question 5

What is the most common type of mutation in NSCLC?

Answer 5

KRAS

But no targeted agents at the moment

Question 6

What stage is the lung ca if there is also a pleural or pericardial nodule?

Answer 6

stage 4

Question 7

What stage is the lung ca if there is tumour in the contra-lateral lung?

Answer 7

Stage 4

Question 8

What needs to be done urgently with newly diagnosed small cell lung cancer?

Answer 8

Urgent chemotherapy
Urgent CT staging including brain (MRI preferred)
Brain radiotherapy if mets present

Question 9

Treatment of stage 1 or 2 NSCLC

Answer 9

Lobectomy PLUS mediastinal LN resection with curative intent
PLUS adjuvant chemo (cisplatin) for stage 2

If unfit, sterotactic radiotherapy

Question 10

Treatment of stage 3a (non-bulky) NSCLC

Answer 10

Lobectomy OR/AND radiotherapy PLUS chemotherapy

Question 11

Treatment of stage 3a (bulky) NSCLC

Answer 11

Chemoradiotherapy followed by durvalumab (PD1 inhibitor)

Regardless of PD1 status

Question 12

What investigations must you do in stage 4 NSCLC?

Answer 12

Test for driver mutations - EGFR, ALK, ROS1

AND PD1 status (if no driver mutation; comes second only!)

= Will direct therapy!

Question 13

Treatment of stage 4 NSCLC with EGFR mutation

Answer 13

EGFR TKI - Erlotinib

2nd line: orsimertinib (if T790 mutation aka resistance)

Question 14

Treatment of stage 4 NSCLC with ALK mutation

Answer 14

ALK TKI - Alectinib

Question 15

Treatment of stage 4 NSCLC with ROS1 mutation

Answer 15

ALK TKI - crizotinib

Question 16

Treatment of stage 4 NSCLC without EGFR, ALK or ROS1 mutation, but high PD1 status

Answer 16

PDL1 inhibitor - pembrolizumab

2nd line: platinum doublet chemo (cisplatin or carboplatin)

Question 17

Treatment of stage 4 NSCLC without EGFR, ALK or ROS1 mutation, with low PD1 status

Answer 17

Platinum doublet chemo - cisplatin or carboplatin

2nd line: immunotherapy e.g. nivolumab, atezoizumab
OR pemetrexed or docetaxel

Question 18

Treatment of stage 4 non-squamous NSCLC (mainly adenocarcinoma) with negative driver mutations, and low PD1

Answer 18

Atezolizumab
Bevalizumab
Carboplatin
Paclitaxel

= ABCP

Must be fit though. Tough treatment !

Question 19

Treatment of limited small cell lung cancer

Answer 19

Platinum chemo (cisplatin) PLUS etoposide PLUS brain chemotherapy (prophylactic)

Question 20

Treatment of extensive small cell lung cancer

Answer 20

Platinum chemo (cisplatin/carboplatin) PLUS etoposide plus brain and chest radiotherapy

Question 21

Treatment of mesotheolioma

Answer 21

Palliative chemo (cisplatin + pemetrexed)

Question 22

AE of erlotinib (EGFR TKI)

Answer 22

80% will get acneiform rash

Question 23

62F incidental lung nodule (1.8cm). Biopsy adenocarcinoma of lung.
She’s fit and healthy.
Treatment?

Answer 23

Lobectomy

Question 24

62F incidental lung nodule (1.8cm). Biopsy adenocarcinoma of lung.
She’s unfit and frail.
Treatment?

Answer 24

Sterotactic radiotherapy

Question 25

62F with stage 4 lung ca
ECOG 1
No CI to immunotherapy
Biopsy: adenocarcinoma/squamous with high PDL1 (>50)

Treatment?

Answer 25

Pembrolizumab (PDL1 inhibitor)

Question 26

62F with stage 4 lung cancer
ECOG 1
No CI to immunotherapy
Biopsy: adenocarcinoma with low PDL1 (<50)

Treatment?

Answer 26

Atezolizumab
Bevacizumab
Carboplatin
Paclitaxel

ABCP

Question 27

62F with stage 4 lung ca
ECOG 1
No CI to immunotherapy
Biopsy: squamous with low PD1 (<50)

Treatment?

Answer 27

Doublet platinum chemo

Question 28

62M 
Fit
Ex smoker
Adenocarcinoma
Staging T3N2
Not surgical candidate as lymph nodes are too close to mediastinum and vascular structures

Answer 28

Chemoradiotherapy followed by durvalumab (Anti-PD1 ab)

Question 29

Roughly describe each stage of NSCLC
Stage 1
Stage 2
Stage 3
Stage 4

Answer 29

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

Question 30

Investigations in staging of lung cancer

Answer 30

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