Lung cancer Flashcards
What should you do for solid nodule <5mm (80mm^3)
Discharge
What should you do for solid nodule 7mm?
CT 3 months –> if volume doubling time <=400days or no evidence of growth, then 1 year CT
–> >=80mm^3 or >=6mm then 3 month CT
–> 5-6mm then 1 year CT
What should you do for solid nodule 200mm^3?
CT 3 months –> if VDT <=400mm^3 or no evidence of growth, then 1 year CT
–> >=80mm^3 or >=6mm then 3 month CT
–> 5-6mm then 1 year CT
What should you do for solid nodule 9mm?
Assess with Brock model - if <10% malignancy risk then 3 month CT. If >10% then PET-CT with Herber risk assessment model
What should you do with solid nodule 350mm^3?
Assess with Brock model - if <10% malignancy risk then 3 month CT. If >10% then PET-CT with Herber risk assessment model
What do you do with solid nodule 350mm^3 with Brock model 10% and PET-CT Herber assessment malignancy risk 20%?
Consider image-guided biopsy (excision biopsy and CT surveillance may be considered based on patient preference)
Note: PET-CT Herber risk <10% = 3 month surveillance CT, 10-70% = as above, >70% = excision or non-surgical treatment +/- biopsy
What do you do with solid nodule 350mm^3 with Brock model 20% and PET-CT Herber assessment malignancy risk 5%?
3 month surveillance CT
Note: PET-CT Herber risk <10% = 3 month surveillance CT, 10-70% = image-guided biopsy, >70% = excision or non-surgical treatment +/- biopsy
What do you do with solid nodule 350mm^3 with Brock model 20% and PET-CT Herber assessment malignancy risk 85%?
Excision or non-surgical treatment (+/- biopsy)
Note: PET-CT Herber risk <10% = 3 month surveillance CT, 10-70% = image-guided biopsy, >70% = excision or non-surgical treatment +/- biopsy
What do you do with solid nodule 5mm that is abutting the fissure?
Benign nodule - can discharge.
Harmatoma and peri-fissural nodule typically benign - ‘lentiform’ ‘homogenous’ within 1cm of fissure
What size solid nodule do you refer for surveillance CT scans?
5-8mm or 80-300mm^3 - or bigger but Brock Model score <10%
What do you do with solid nodule 5.9mm?
1 year CT surveillance
–> 5-6mm = 1 year CT
–> >=6mm or >=80mm^3 = 3 month CT
What do you do if solid nodule volume double time <= 400 days on 3 month CT?
Work up and consideration of definitive management
What do you do if solid nodule volume double time <= 400 days on 1 year CT?
Work up and consideration of definitive management
What do you do if solid nodule volume double time 500 days on 1 year CT?
Consider biopsy of further CT surveillance depending on patient preference
What do you do if solid nodule volume double time > 400 days on 3 months CT?
1 year CT
What do you do if solid nodule volume doubling time >600 days on 1 year CT?
Consider discharge
≤400 days then further work-up
400-600 then consider biopsy or further surveillance
>600 then consider d/c or ongoing surveillance
What do you do if solid nodule volume stable on 1 year CT?
Discharge
What do you do if solid nodule volume doubling time >600 days on 3 month CT?
1 year surveillance CT
What do you do if solid nodule size in mm stable on 1 year CT?
Another CT in 1 year unless volumetric assessment available and can be used to allow discharge at the 1 year category
What do you do with sub-solid nodule 4mm?
Discharge
What do you do with sub-solid nodule 7mm?
Repeat CT at 3 months (unless previous imaging available to show stability over 4 years)
What do you do with sub-solid nodule 5mm that on 3 month CT has not changed?
Brock model
- If <10% then CT and 1, 2 & 4 years from baseline
- If >10% then either CT monitoring, image-guided biopsy, or resection/non-surgical treatment
What do you do with sub solid nodule that resolves on 3 month CT?
Discharge
What do you do with sub solid nodule that has grown or has altered morphology on 3 month CT?
Consider resection/non-surgical treatment - this may entail PET-CT for staging if not yet had.
What surgical options are there for patients with nodule that have been considered high risk enough to want to excise?
- Wedge resection with on-table frozen section followed by completion lobectomy in same anaesthetic
- Anatomical segmentectomy if unfit for lobectomy
- Lobectomy (if image-guided biopsy already proven malignancy)
What non-surgical options are there for patients with nodule that have been considered high risk enough to want to excise but not fit for surgery?
- Image guided biopsy +/- SABR/RFA/radical radiotherapy
- SABR/RFA or radical radiotherapy if not fit for biopsy
What makes up the Brock Model?
Patient characteristics: age, gender, fhx lung cancer, emphysema
Nodule characteristics: size, count, type (e.g. GGO, solid etc), upper lobe, spiculated
What makes up Herder Model?
Patient characteristics: age, current or former smoker, personal hx of extra-thoracic cancer
Nodule characteristics: size, upper lobe, spiculation, PET-CT avidity findings
What are the T stages of lung cancer?
T1 –> ≤ 3cm (surrounded by lung or visceral pleura w/o involvement of main bronchus)
—-> T1a(mi) minimally invasive carcinoma
—-> T1a ≤1cm
—-> T1b 1 to ≤2cm
—-> T1c 2 to ≤3cm
T2 –> 3 to ≤5cm OR involving bronchus (not carina)/visceral pleura/atelectasis/post-obstructive pneumonitis extending to hilum
—-> T2a 3 to ≤4cm
—-> T2b 4 to ≤5cm
T3 –> 5 to ≤7cm OR chest wall/pericardium/phrenic nerve/satellite nodule in SAME lobe
T4 –> >7cm OR mediastinum/diaphragm/heart/great vessels/recurrent laryngeal nerve/carina/trachea/oesophagus/spine/nodule in same lung but different lobe
Tx = tumour in sputum/BAL but nt seen on imagine or bronchoscopy
T0 = no evidence of tumour
Tis - carcinoma in situ
What is the 5 year survival for a patient with lung cancer stage 1?
Stage 1 80%
2 60%
3a 46%
3b 26%
4a 10%
4b 0%
What is the 5 year survival for a patient with lung cancer stage 3a?
3a 46%
Stage 1 80%
2 60%
3a 46%
3b 26%
4a 10%
4b 0%
What upstages a tumour to T2?
Involves main bronchus but not carina, visceral pleural or atelectasis/obstructive pneumonitis extending to hilar
What upstages a tumour to T3
Invading: parietal pleura, chest wall, phrenic nerve or parietal pericardium
Or: separate tumour in same lobe
What upstages tumour to T4?
Invades: diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, oesophagus, vertebral body, carina
Or: nodule in ipsilateral lobe
What are n-staging?
N0 - no LNs
N1 - ipsilateral hilar (10 - hilar, 11 - interlobar)
N2 - ipsilateral mediastinal (2 - upper paratracheal, 4 - lower paratracheal, 5 - subaortic, 6 - para-aortic)
- subcarinal (7)
- ispsilateral para-oesophageal (8) or pulmonary ligament (9)
N3 - neck (1 - cervical/supraclavicular/sternal notch)
- contralateral mediastinal/hilar/para-oesophageal/pul ligament
Nb. N1 - ipsilateral double figure nodes
N2 - ipsilateral single figure node
N3 - contralateral nodes or neck
What are N1 nodes?
Ipsilateral hilar (10- hilar, 11 - interlobar)
https://radiologyassistant.nl/chest/mediastinum/mediastinum-lymph-node-map
Follow this link to see good review for nodes on CT:
https://radiologyassistant.nl/chest/mediastinum/mediastinum-lymph-node-map
What are N2 nodes?
Ipsilateral mediastinal (2 - upper paratracheal, 4 - lower paratracheal, 5 - subaortic, 6 - para-aortic)
Ipsilateral paraoesophageal (8) and pulmonary ligament (9)
Subcarinal (7)
https://radiologyassistant.nl/chest/mediastinum/mediastinum-lymph-node-map
What are N3 nodes?
Contralateral mediastinal (2,4,5,6)/hilar (10/11)/paraoesphageal(8)/pulmonary ligament(9)
Neck (1 - cervical, supraclavicular, stenal notch)
How might you recognise neck nodes on CT?
No/very little lung visible and anterior to ribs (otherwise superior mediastinal) –> remember that if have a bit of lung visible, then can see anterior and posterior rib (in front and behind lung)
How might you recognise that we are at mediastinum and therefore looking at mediastinal nodes?
Sternum
4L - continues until superior border of pulmonary artery
4R - continues until azygous vein (bottom left of trachea when looking (anatomical right)
Nb. don’t get confused with hilar nodes 10, which will start to appear when trachea begins to split
Nb. difference between 2 and 4 approx to do with appearance of aortic arch
What demarcates line between L&R of chest to determine LN sides?
L border of trachea
What is M staging for lung cancer?
M0 = no mets
M1a = nodule in contralateral lobe/pleural/pericardial or malignant pleural/pericardial effusion
M1b = single extrathoracic met (includes extra-thoracic LN)
M1c = multiple extrathoracic mets
What is stage M1b?
M1b = single extrathoracic met (includes extra-thoracic LN)
M0 = no mets
M1a = nodule in contralateral lobe/pleural/pericardial or malignant pleural/pericardial effusion
M1b = single extrathoracic met (includes extra-thoracic LN)
M1c = multiple extrathoracic mets
What is stage M1c?
M1c = multiple extrathoracic mets
M0 = no mets
M1a = nodule in contralateral lobe/pleural/pericardial or malignant pleural/pericardial effusion
M1b = single extrathoracic met (includes extra-thoracic LN)
M1c = multiple extrathoracic mets
What is stage M1a?
M1a = nodule in contralateral lobe/pleural/pericardial or malignant pleural/pericardial effusion
M0 = no mets
M1a = nodule in contralateral lobe/pleural/pericardial or malignant pleural/pericardial effusion
M1b = single extrathoracic met (includes extra-thoracic LN)
M1c = multiple extrathoracic mets
Draw the staging grid for lung cancer staging
Draw
What are the different diagnostic bundles for lung cancer?
1 - peripheral tumour (outer 2/3 of thorax - if draw circle inside CT image using approx 50% of whole radius as radius then exclude that bit) + normal mediastinum + no distant mets
2- central tumour OR N1 nodes + no distant mets
3 - tumour + mediastinal nodes (<3cm and not conglomerate) + no distant mets
4 - conglomerate/invasive nodes + no distant mets
5 - distant mets (stage 4 disease)
What investigations would you do for diagnostic bundle 1 in lung cancer?
Bundle 1 = peripheral tumour (outer 2/3 of thorax - if draw circle inside CT image using approx 50% of whole radius as radius then exclude that bit) + normal mediastinum + no distant mets
PET
Percutaenous biopsy or radial EBUS
OR Staging EBUS if PET +ve (not routine as for this group, N2/3 disease only 5-10% prevalence)
Physiological tests - lung function, echo (if cardiac hx or suspicion), bloods
What investigations would you do for diagnostic bundle 2 in lung cancer?
Bundle 2 = central tumour OR N1 nodes OR distant mets
PET
Staging EBUS +/- bronch (prevalence of N2/3 disease 20-25% and get false +ve (15%) and false -ve (25%) of nodes on PET)
Physiological tests - lung function, echo (if cardiac hx or suspicion), bloods
What investigations would you do for diagnostic bundle 3 in lung cancer?
Bundle 3 = tumour + mediastinal nodes (<3cm and not conglomerate) + no distant mets
PET
Staging EBUS (prevalence of N2/3 disease 60% and get false +ve (15%) and false -ve (25%) of nodes on PET)
Physiological tests - lung function, echo (if cardiac hx or suspicion), bloods
What investigations would you do for diagnostic bundle 4 in lung cancer?
Bundle 4 = conglomerate/invasive nodes + no distant mets
Need tissue (radiology diagnostic) e.g. US neck + FNA, EBUS (nb. N2/3 disease approx 100% therefore don’t need staging)
Physiological tests only if considering radical tx
What investigations would you do for diagnostic bundle 5 in lung cancer?
Bundle 5 = mets (stage 4 disease)
Nb. may need liver US/MRI, triple phase CT adrenal or PET to confirm metastatic disease if any doubt
Tissue - whatever is easiest but avoid bone unless soft-tissue component
Physiological tests only if considering radical tx
When should you image brain for lung cancer?
If stage 2 or 3 AND suitable for radical treatment
2 = contrast CT (cheaper)
3 = MRI (better)
Pt has peripheral nodule that lights up on PET. No other sites of disease. Current smoker. Old. What should you do next and why?
Refer for surgery - calculated Herder score >70% therefore consider excision (or biopsy but surgery better option)
Herder score:
Pt: age, smoking, personal hx cancer
Nodule: size, PET avidity, spiculation, upper lobe
How do you calculate post-op DLCO or FEV1?
Pre-op number/total segments x residual segements
LUL: 5
LLL: 4
RUL: 3
RML: 2
RLL: 5
How should you risk assess pt for thoracic surgery in lung cancer?
- Global risk score e.g. Thoracoscore
- Cardiac:
- avoid resection <30days after MI
- if ≥3 risk factors then get cardio r/v (thoracic surgery = 1, therefore 2 more out of: IHD, CCF, cerebrovascular disease, insulin for diabetes, Cr >177)
- if ≤2 RFs then can offer surgery w/o further investigation - Lung function:
- DLCO (regardless of other spirometric values)
- Consider VQ to predict post-of lung function (calculating segments)
- Consider shuttle walk (>400m = good function)
- Consider CPET (peak O2 consumption >15ml/kg/min = good function)
- Consider quantitative CT/MRI to predict post-op lung function
Should you offer surgical resection of lung cancer to pt with high risk of post-opSOB?
Yes if they are aware and accept the risk and complications of this (low risk = offer, mod/high = need to know risks)
(Predicted post op FEV1/TLCO <30%)
Mr B has lung cancer and is being considered for resection? He has IHD and diabetes (insulin-dependent). What does he need prior to surgery?
Cardio review
- avoid resection <30days after MI
- if ≥3 risk factors then get cardio r/v (thoracic surgery = 1, therefore 2 more out of: IHD, CCF, cerebrovascular disease, insulin for diabetes, Cr >177)
- if ≤2 RFs then can offer surgery w/o further investigation
Global risk score e.g. Thoracoscore
Lung function:
- DLCO (regardless of other spirometric values)
- Consider VQ to predict post-of lung function (calculating segments)
- Consider shuttle walk (>400m = good function)
- Consider CPET (peak O2 consumption >15ml/kg/min = good function)
- Consider quantitative CT/MRI to predict post-op lung function
When would you consider sub-lobar resection in pt with lung cancer?
If limited pulmonary reserve (i.e. high risk of post-op dyspnoea)
What is the difference between N2a and N2b disease?
N2a = single zone nodes
N2b = multi-zone nodes
Pt presents with rapidly progressive lung cancer. What is most likely subtype?
Small cell
- Almost always a smoker
- Metastasises early
- Can cause paraneoplastic syndromes (SIADH, Cushing)
- Worse prognosis
What are the associations of paraneoplastic syndromes with the different types of lung cancer?
Small cell - SIADH, Cushing, neuro e.g. Limbic encephalitis
Squamous: hypercalcaemia from PTH-related peptide, arthralgia/clubbing from hypertrophic pulmonary osteoarthropathy
Nb. remember can get hypercalcaemia from bone metastases but won’t have elevated PTHrH
Never smoker present with lung cancer. What is most likely subtype?
Adeno
Most common type of lung cancer
Most common in women
Most common in non-smokers (although most ppl are smokers)
Peripheral tumours
Which lung cancer is most strongly associated with smoking?
Squamous
What lung cancer patients could be considered for radical treatment?
Lobectomy:
- T1-3 N0-1 M0 (consider in T4 N0-1 M0) + systemic if N1 (consider systemic if T2-3)
- Also consider for T1-3 N2a M0 disease + systemic (nb. though if subcarinal, surgery not an option)
i.e. stages I+II+ some IIIa
Radical RT + systemic (chemo/immuno)
- T1-4 N2 M0
- N3 if locally advanced
Nb. if decline surgery/not suitable, then SABR if T1-2 NOMO or radical RT if T3
Nb2. chemo = carboplatin + venorelbine
Do you ever use pre-op chemo in lung cancer?
No
How do you treat SCLC?
Nb. tends to be rapidly progressive and present late, therefore often metastatic already
T1-4 N0-3 M0 = cisplatin or carboplatin + etoposide chemo + RT (together if fit)
Nb consider surgical resection if T1-3 N0-1 M0 i.e. stage I-IIA+some IIB
If respond then consider prophylactic whole brain irradiation
Who should be offered brain irradiation in lung cancer?
Consider whole brain in SCLC and >12 mets, or as prophylaxis if good response to treatment of the cancer
Stereotactic RT if <12
How should you manage endobronchial obstruction in lung cancer?
Radiotherapy and/or debulking or stent
How should you manage pleural effusion in lung cancer?
If symptomatic, aspriation +/- TALC
How should you manage SVC obstruction in lung cancer?
Radio or chemo
Consider stent for immediate relief or failure of earlier treatment
Dexamethasone for symptom control
If needed anticoag, would be with LMWH
How should you manage brain mets in lung cancer?
Dexamethasone
Stereotactic RT if <12
Whole brain if SCLC and >12
What is the best treatment for non-resectable mesothelioma?
Cisplatin + pemetrexed
Nb. no role for RT - only used for pain relief
Who should be referred on 2ww lung cancer pathway?
CXR suggestive of cancer
>=40 with unexplained haemoptysis
Nb. Urgent CXR in 2 weeks if 2 or more (1 or more if ever smoked or exposed to asbestos):
- cough, fatigue, SOB, chest pain, wt loss, appetite loss
Or if,
- persistent/recurrent chest infection, clubbing, neck lymphadenopathy, chest signs consistent with lung cancer, thrombocytosis
What is associated with EGFR mutations?
Adeno Ca (not exclusive though)
Female, never smoker, Asian
How do you manage metastatic spinal cord compression in lung cancer?
High dose dexamethasone (16mg)
If good performance status, then decompressive surgery and adjuvant RT
What is 30d mortality following lobectomy for lung cancer?
2.3% (5.8 if pneumonectomy)
What tumour markers do you see in adenocarcinoma?
Positive TTF-1, CK7 & Napsin A or E-cadherin
‘Glandular differentiation or mucin production’
Might be ‘lepidic, acinar, papillary, micropapillary or solid’
Nb. Sarcomatoid carcinoma = NSCLC with sarcoma or sarcoma like (spindle or giant cell) differentiation
Nb2. Large cell carcinoma = NSCLC that lacks features of any other type (diagnosis of exclusion)
What tumour markers do you see in squamous cell lung cancer?
Positive p63, CK5 & CK6
Negative TTF-1
‘Bizarre shaped, keratinised, nuclei with abundant cytoplasm’
What tumour markers do you see in small cell lung cancer?
Positive TTF-1 (nb. 10% are -ve), positive neuro endocrine markers E.g. CD56, synaptophysin, chromagranin
‘Round, oval and spindle shapes. Scant cytoplasm and ill-defined borders, chromatin, absent/inconspicuous nuclei’
What are the tumour markers for different types of lung cancer? (mesotheliomas, adenocarcinoma)
Mesothelioma: caretinin, CK5/6, Wilms tumour 1, D2-40
Adeno: TTF-1, CEA, Bee-EP4
Cherry red endobronchial lesions seen on bronch. What kind of tumour is this?
Carcinoid
What is crizotinib most useful for? (or Nivolumab)
ALK positive tumours
What is pembrolizuamb used for?
Untreated NSCLC if PDL1 >50% + negative EGFR
- stop at 2 years uninterrupted treatment or if disease progression
What is immuno treatment for EGFR positive NSCLC?
Tyrosine kinase inhibitors e.g. Gefitinib, Erlotinib
Nb. facial rash = common SE
What are some CT features of interpulmonary LNs and therefore don’t need nodule follow up?
Abut pleura/fissures.
Often 2xstraight edges (‘polygonal’)
Flattish shape
What kind of radiology might you see in GPA vasculitis?
Large nodules that cavitate
Pt has 7mm nodule. Has Brock score of 14%. What is next step?
3 month Ct
Any nodules <8mm, even if Brock ≥10%, enters nodule pathway
What is the target rate for thoracotomy by surgical centres?
What is resection rate target for NSCLC?
5%
17%
What risks does ongoing smoking confer on lung cancer surgery?
Increased risk of post-operative air leak, pneumonia, respiratory distress, atelectasis, bronchopulmonary fistula, reintubation and length of stay
Nb. doesn’t impact long term survival from surgery (although higher risks of other smoking-related reasons)
What is the difference between:
Adenoca in situ
Atypical adenomatous hyperplasia
Minimally invasive adenoca
Invasive adenoca
1 - pure GGO 5-30mm
2 - pure GGO <5mm
3 - part solid <5mm
4 - part solid >5mm
How is mesothelioma staged?
Nb. usually PET scan however if have had talc pleurodsis then need MRI for t-stage
T1 - ipsilateral pleura
T2 - ipsilateral pleura + visceral pleura OR diaphragm OR lung parenchyma
T3 - all ipsilateral pleura + endothoracic fascia OR mediastinal fat OR soft tissue of chest wall OR non-transmural invading pericardium
T4 - all ipsilateral pleura + rib OR peritoneum OR mediastinal organ OR contralateral pleura OR spine/brachial plexus OR pericardium
N1 - ipsilateral hilar or mediastinal nodes
N2 - contralateral hilar or mediastinal nodes, neck nodes
M1 - mets present
Stage 1A: T1NOMO
1B: T2/3NOMO
2: T1/2N1MO
3a: T3N1MO
3b: T1-3N2 OR T4NanyM0
4: anyM1
What is immunotherapy for VEGF-R2 tumours?
Ramucirumab (monoclonal Ab IgG1 against VEGF)
Some notes on radiotherapy (when used)
1 - CHART & external beam
2 - SABR & other stereotactic
3 - radiofrequncy ablation
4 - endobronchial radiotherapy
1 - need histological diagnosis
2 - SCLC or can be given if no histological diagnosis. Max tumour size 5cm
3 - SCLC (put probe into tumour though skin)
4 - palliative if tumour blocking bronchus
What are 1 year survival rates for lung cancer?
Stage
1 = 80%
2 = 60%
3 = 40%
4 = 15%
Pt has RUL nodule with enlarged paratracheal and subcarinal LNs of 12mm and 17mm respectively. He undergoes PET and there’s a weakly positive RUL nodule only. What should happen next?
EBUS - because any node >10mm on CT needs sampling, regardless of PET avidity
How should hypercalcaemia associated with malignancy be managed?
IV rehydration
Then IV bisphosphonate (zolendronic acid)
