Lung Cancer Flashcards
Are there any lung cancer screening programmes?
No
What are the risk factors for lung cancer?
Cigarette smoking, environment tobacco smoke (passive smoking), absestos, radon gas, diesel fumes, genetic predisposition, lung disease, previous malignancies
How does smoking cessation impact lung cancer treatment?
- patients should be advised that smoking increases the risk of pulmonary complications after surgery, and nicotine replacement should be offered.
- surgeries should not be postponed to allow patients to stop smoking
What are the signs and symptoms of lung cancer?
- tumour related, non specific systemic symptoms.
RESPIRATORY: cough, dysponea, chest pain, haemophysis, wheezing
signs: reduced breath sounds, clubbing, cracking anaemia
What are the complications of lung cancer?
- nerve compression
- superior vena cava obstruction
- pleural effusions
- dysphagia
- bone pain
What is non small cell lung cancer?
Squamos cell adenocarcinoma, large cell lung cancer. Central chest is where the symptoms present. It is the most common lung cancer present in the glandular cells within the periphery of the lungs. It develops quickly and often is not symptomatic until it has metastasised
What is small cell lung cancer?
Small cell relates to the shape of the cells. It is susceptible to chemotherapy but often returns.
Which cytogenetic mutations are associated with NSCLC?
EGFR, ALK, KRAS, ROS1, BRAF, PDL-1
What are the T stages related to NSCLC?
Tx - tumour in sputun
T0 - no evidence of tumour
Th - carcinoma in situ
T1 - less than 3cm surrounded by lung pleura, not involving the bronchus
T1a (mi) - minimally invasive
T1a - Less than 1cm
T1b - more than 1cm but less than 2cm
T1c - more than 2cm but less than 3cm
T2 - more than 3cm but less than 5cm, involves the bronchus or extends to ileum
T2a - more than 3cm but less than 4cm
T2b - more than 4cm but less than 5cm
T3 - more than 5cm but less than 7cm or tumour of any size than involves chest wall, pericardium or phenic nerve
T4 - more than 7cm and involvment of diaphragm, heart, great vessels, trachea, oesaphagus
What are the N stages related to NSCLC?
N1- nodes surrounding tumour
2 - nodes in bronchi
3 - nodes on the opposite side of the lung
What are the M stages of NSCLC?
M1 - distant metastases
M1A - Tumor in other lung
1b - single outer lung tumour
1c - multiple other lung tumour
What are the treatment options for NSCLC?
- Surgery - the bigger the tumour/further nodal involvement makes surgery less possible. If there is any distant metastases then surgery cannot happen
- Neoadjuvant chemo + surgery
- radical radiotherapy - potential curative
- radical chemo
- palliative chemo - in inoperable or metastatic disease
- symptomatic support
When is adjuvant chemotherapy indicated for NSCLC?
For stage 2 and 3 patients with surgically resectable disease, preferably within 8 weeks of surgery. The patient must have good performance status
Which agents are used for adjuvant chemotherapy for NSCLC?
Platinum based agents - cisplatin and carboplatin
Discuss cisplatin vs carboplatin
- increased overall survival with cisplatin
- equal responses when used with 3rd gen chemo agent
- cisplatin leads to more nausea and vomitting
- more thrombocytopenia and neurotoxicity with cisplatin
When is palliative chemotherapy indicated?
For patients with Stage 3b or stage 4 disease, to prolong survival
What are the treatment options for palliative chemotherapy in patients with non squamos NSCLC?
- EGFR tyrosine kinase targetted therapies if EGFR mutation present. First line is a platinum based combination
- if EGFR mutation not present, then PD- 1 on T cells indicated
What are the treatment options for palliative chemotherapy in patients with squamos NSCLC?
Start with a very targetted approach to PD1 as you don’t tend to see EGFR mutations and then revaluate, if no response then use traditional cytotoxic agents. Traditional platinum based chemo can be used alone
What is the epidermal growth factor receptor?
A receptor that controls cell proliferation and growth. It is a tyrosine kinase, and mutations in this receptor may lead to signalling activation.
Which patients are likely to have EGFR mutations?
- patients with adenocarcinomas, non smokers, females, asians
Give some examples of EGFR inhibitors
erlotinib, gefitinb, dacomitinb, afatinib, osmetanib
How are EGFR inhibitors metabolised?
By CYP450 so check interactions
What are the common side effects of EGFR inhibitors?
Skin rashes within the first few weeks of treatment, usually on head, chest and back. Managed by liberal application of emollients and avoiding sun exposure, pnuemonitis and other non specific side effects can occur
What is anaplastic lymphoma kinase and how are patients that are positive for this treated with palliative treatments?
- it is a fusion oncogene
- treated with ALK targetted therapy
Which patients are likely to have ALK1 mutations?
never/light smokers, younger, adenocarcinoma
Give some examples of ALK inhibitors
- crizotinib, ceritinib, alotinib
What is PD-1 and how is it targetted?
Tumors have a high level of the PDL-1 Ligand, which binds to receptors on T cells, and switches off the immune system so that T cells do not kill the cancer. PD-1 pathway inhibitors block the receptor, and prevent binding
Give examples of PD1 pathway inhibitors
Nivolumab, pembrolizumab
What is nintedanib and how does it work?
It is a tyrosine kinase inhibitor, and blocks 3 receptors that promote angiogenesis and tumour growth (VEGF, FGF, PDF). It is licensed in combination with docetaxel
What is small cell lung cancer?
A cancer which is relatively rare, but aggressive in nature, there is also a high risk of brain metastases, therefore prophylactic cranial irradiation is given.
How is small cell lung cancer staged?
Limited or extensive
How is limited small cell lung cancer with good performance status treated?
A combination of chemotherapy and thoracic radiotherapy
How is extensive small cell lung cancer treated?
Chemo, radiotherapy and prophylactic cranial irradiation
Is small cell lung cancer responsive to chemotherapy?
Yes, but it usually comes back
What are the usual cyototxic agents used for treatment of small cell lung cancer?
Carboplatin and etoposide 1st line
2nd line: topocetan, doxorubicin, cyclophosphamide, vincristine
Can you restart the same chemotherapy regimen again in small cell lung cancer?
Yes, if it has been more than 6 months since it was last used
What is carboplatin dose based on?
renal function
What elements are there to palliative care for small cell lung cancer?
It is a progressive disease with low cure rate
patients can be in significant pain
If the tumour presses on the superior vena cava, this is a medical emergency
breathlesness, haematopysis, stridor, bone metastasis and hypercalcaemia are all associated with end of life small cell lung cancer, and symptomatic relief can be provided
