Lung Cancer Flashcards
You are preparing a case to present at the Lung Cancer MDT. The patient had a chronic cough and weight loss and was referred on the 2 week wait pathway. They have had a CT chest. It shows findings suspicious for malignancy. There is a 3.3cm left upper lobe mass, with an additional 5mm nodule also in the left upper lobe. Ipsilateral hilar, subcarinal and ipsilateral scalene nodes are enlarged on CT. There is an enlarged left adrenal gland which the Radiologist says has features of a metastatic deposit.
Based On the CT findings which ONE of the following is the most accurate staging, assuming this is a non-small cell lung cancer
A. T1c N2 M1a
B. T2a N3 M1a
C. T2b N2 M1b
D. T3 N3 M1b
E. T4 N3 M1c
D. T3 N3 M1b
Lung cancer staging is based on the IASLC TNM8 system. In this case, the tumour would be T2a on size criteria (>3cm ≤4cm) but is upstaged to T3 as there is a satellite nodule in the same lobe. The nodal staging is N3 as any supraclavicular or scalene node involvement is N3 whether ipsilateral or contralateral. There is an adrenal metastasis which is a single extrathoracic metastasis, and therefore M1b.
A patient is worked up for a suspected diagnosis of Lung Cancer. They have an avid 14mm solid nodule which has grown over 3 months. It is not amenable to CT or navigational biopsy. They are PS 1 with good lung function and are being considered for surgical resection.
At the MDM the surgeon asks whether the PET is recent. What is the maximum length of time since the PET scan that would allow for a decision to be made on radical treatment?
BTS guidelines on the radical management of Lung Cancer state that contemporaneous imaging must be available for decisions regaridng radical treatment. This means a maximum of 4weeks.
A patient with a T3 N0 M0 adenocarcinoma of the LUL is being considered for lobectomy. BTS guidelines advocate a ‘tripartite risk assessment’ which considers operative mortality, risk of perioperative cardiac events, and risk of post-op dyspnoea. What post-op TLCO % is considered the threshold for a high risk of post-op dysnpnoea?
Patients who will end up with a post-op TLCO and FEV1 of <40% are considered high risk for post-op dyspnoea. The post-op TLCO will depend on the pre-op TLCO and the lobe being removed. Different lobes contribute different numbers of segments (eg LLL is 5 of possible 19). A pre-op TLCO of 40% will of course guarantee a post-op TLCO of <40%. In these patients sublobar resection may be considered. Such patients would all also require functional assessment eg CPET
A patient with a T3 N0 M0 adenocarcinoma of the LUL is being considered for lobectomy. The surgeon has some concerns about their peri-operative cardiac risk and asks for further information at the MDM. Which cardiac conditions are considered contraindications to lobectomy?
The American College of Cardiology guidelines state that any patient without an active cardiac conditions should be considered for surgery. In ‘active’ they include unstable angina, heart failure, arrythmias, and severe valvular heart disease. They also recommend that patients with </=2 risk factors should be considered for surgery. These include IHD, CCF, CVA, serum creat >177mmol/L and insulin dependant diabetes. In reality patients with these conditions may be optimised and further assessed with eg Cardiac MR before considering surgery if otherwise fit.
Other than tobacco smoking, what are the risk factors for non-small cell lung cancer?
Radon, heavy metals, air pollution, asbestos, poor quality diet, family history.
What is the 1 and 5 year survival for stage I Non-small cell lung cancer?
Based on data from people diagnosed between 2013 and 2017 (and followed up to 2022) overall 40% survive a year, 15% survive 5 years.
Stage I: 88% (1yr) 56% (5yr)
Stage II: 73% (1yr) 34% (5yr)
Stage III: 52% (1yr) 15% (5yr)
Stage IV: 19% (1yr) 5% (5yr)
Of course these are broad figures and prognosis is very dependant on age, comorbidities, treatments options and treatment response. Since 2013 there has also been great progress in the use of TKIs and immunotherapy.
What is the 1 and 5 year survival for stage IV Non-small cell lung cancer?
Based on data from people diagnosed between 2013 and 2017 (and followed up to 2022) overall 40% survive a year, 15% survive 5 years.
Stage I: 88% (1yr) 56% (5yr)
Stage II: 73% (1yr) 34% (5yr)
Stage III: 52% (1yr) 15% (5yr)
Stage IV: 19% (1yr) 5% (5yr)
Of course these are broad figures and prognosis is very dependant on age, comorbidities, treatments options and treatment response. Since 2013 there has also been great progress in the use of TKIs and immunotherapy.
What features of a pulmonary nodule would be consistent with an intrapulmonary lymph node and therefore not require imaging follow up?
Well defined, solid, non-calcified
Middle or lower lobes (below carina level)
Lentiform appearance
Oval, round, triangular, trapezoidal or polygonal
Subpleural or perifissural location
The BTS Guideline on the Investigation and Management of Pulmonary Nodules has a useful diagram of typical and atypical IPLNs and feaures associated with a higher risk of malignancy
In the TNM8 staging classification of lung cancer what T stage is a 3.5cm tumour?
T2a (>3cm</=4cm)
See https://radiologyassistant.nl/chest/lung-cancer/tnm-classification-8th-edition for more info.
In the TNM8 staging classification of lung cancer which features upstage from T2 to T3 regardless of size?
Involvement of chest wall, pericardium, phrenic nerve, or satellite nodules in the same lobe upstages from T2 to T3.
See https://radiologyassistant.nl/chest/lung-cancer/tnm-classification-8th-edition for more info.
In the TNM8 staging classification of lung cancer what T stage is a 14mm tumour?
T1a (<1cm)
In the TNM8 staging classification of lung cancer what T stage is a 7.3cm tumour?
T4 (>7cm)
In the TNM8 staging classification of lung cancer what T stage is a 42mm tumour?
T2b (>4cm </=5cm)
In the TNM8 staging classification of lung cancer which features upstage from T1 to T2 regardless of size?
Involvement of main bronchus without carina, invasion of visceral pleura, atelectasis or post obstructive pneumonitis extending to hilum all upstage from T1 to T2.
See https://radiologyassistant.nl/chest/lung-cancer/tnm-classification-8th-edition for more info.
In the TNM8 staging classification of lung cancer which features upstage from T3 to T4 regardless of size?
Invasion of medastinum, diaphragm, heart, great vessels, recurrent laryngeal nerve, carina, trachea, oesophagus, spine, or separate nodule in different lobe of ipsilateral lung all upstage from T3 to T4.
