Lung cancer Flashcards
What is the assessment for surgery?
LFTs- not for post procedure FEV1 40% cut off anymore as tumours can cause VQ mismatch and may be disproportionate emphysema. But if >40% and post procedure TLCO >40%- deemed low risk.
Shuttle walk >400m
CPET VO2 max >15ml/kg/min
cardio/neuro/pysch as appropriate
Who are the Group 1 patients? and what should we be doing? prevalance of N2/3 disease?
Peripheral tumour only
PET followed by biopsy unless PET pos nodes
N2/3 5-10%
Who are the Group 2 patients? and what should we be doing? prevalance of N2/3 disease?
central tumour or N1 adenopathy only
PET followed by staging EBUS, if neg need to be biopsy
N2/3 20-25%
Who are the Group 3 patients? and what should we be doing? prevalance of N2/3 disease?
1ary tumour with discrete mediastinal LNs on CT, no mets
PET, staging EBUS if neg need to be biopsy
N2/3 60%
Who are the group 4 patients? and what should we be doing? prevalance of N2/3 disease?
invasive/nodal malignancy with no distant mets
doesn’t need PET techinically- can go straight to biopsy- normally to neck US +/- diagnostic EBUS
N2/3 close to 100%
Who are the Group 5 patients? and what should we be doing? prevalance of N2/3 disease?
Distant mets on CT
go straight to tissue- easiest to obtain with needing further procedure
What is the incidence of brain disease? and who to image?
10-20%
CT = clinical stage II NSCLC having curative intent
MRI= stage III NSCLC having curative intent
In curative intent who needs to see a cardiologist? Who to include or exclude?
Cardiology: x3 RF or more, poor cardiac function or active disease
x2 or less RF can be offered surgery
optimised cardiac disease
avoid surgery <30days after MI
who to offer surgery to based on LFTs?
good ET with normal FEV1
need to work out function segments and work out post op DLCO
predicted postop FEV1 or TLCO below 30% IF they accept risks of SOB and associated comps
shuttle walk >400m
CPET VO2 max >15ml/kg/min
Who to offer SABR to?
decline surgery/too high risk in T1a-2b
lesions outside 2cm radius of main airways and proximal bronchial
tree. This is defined as 2cm from the bifurcation of the second order bronchus
What are the radiation fractions?
55 Gy in 20f over 4 weeks
60–66 Gy in 30–33f over 6–6½ weeks
Who do you offer chemorad to?
Stage II and III that aren’t fit/decline surgery
OFFER post op chemorad to Tany N1-2 disease
CONSIDER post op chemorad to T2b-4 N0 (ie tumours >4cm)
WITH surgery IIIA–N2
treatment consequence in SqCLC? which mutations matter and what is the treatment?
PDL1 <50% no mutations
Pembro+carbo+paclitaxel or platinum bichemo
FAILS pembro (>1%), nivolumab/atizolizumab or docetaxel
PDL1 >50% no mutations
Pembro+carbo+paclitaxel or pembro or atizolizumab
FAILS docetaxel
Mutations:
RET- above plus selpercatinib at any point
NTRK- if fails docetaxel- Entrectinib or larotrectinib
KRAS- sotorasib at any point
METex14- tepotinib at any point
EGFRexon20- mobocertinib at any point
treatment consequence in non-SqCLC? which mutations matter and what is the treatment?
PDL1<50% no mutations
pemetrexed and cisplatin, or Pembro+carbo or variation of with atizolizumab
PDL1>50% no mutations
Pembro+permetrexed or pembro or atizolizumab
FAILS docetaxel
MAIN THING IS IF MUTATION- MUTATION TARGET NORMALLY 2ND LINE
Mutations:
RET- above plus selpercatinib at any point
NTRK- if fails docetaxel- Entrectinib or larotrectinib
KRAS- sotorasib at any point
METex14- tepotinib at any point
EGFRexon20- mobocertinib at any point
ROS1 POS
crisotinib or entrectinib 1st line
EGFR-TK POS
afatinib, osimertinib etc 1st line
ALK POS
brigatinib, alectinib, certinib etc 1st line
A patient has a solid 7mm nodule with no previous imaging without typical benign features. What do you do?
Repeat at 3 months.
If VD time is <400days or clear growth procede to resection (+/- biospy)
if >400days CT at 1 yr from baseline
A patient has a solid 7mm nodule with no change on 1yr scan without typical benign features. What do you do?
What do you do if it has increased?
If VD time done- can be discharged, if not, repeat at 2yr- then consider discharge then if no change.
If VD <400days- resect/treat
if VD 400-600- CONSIDER biopsy or further scan (pt preference)
if VD >600 days- consider discharge or further scan (0.8% ca risk)
A patient has a sub-solid 6mm nodule without typical benign features. What do you do?
3 month CT unless previous imaging for 4 years shows stability- can consider discharge
A patient has a sub-solid 6mm nodule with no change at 3mo scan without typical benign features. What do you do?
What do you do if it has increased?
Brock score
If <10% risk of malignancy- for 1yr, 2yr and 4yr CT
If >10% or concerning morphology- OPTIONS to patient- 1/2/4yr survey, biopsy, treat/resect
Which cancers are likely to metastase?
based on liklihood:
1. Sq from head and neck
2. lymphoma/leukaemia
3. mets from bladder, breast, cervix, biliary tree, oesophagus, ovary, prostate or stomach
4. salivary, adrenal, colon, parotid, kidney, thyroid, thymus or uterus
5. melanoma, sarcoma or testicular carcinoma
what are the radiological predictors of malignancy for a nodule?
- diameter
- spiculation
- pleural indentation
- UL
What are the radiological predictors for a benign lesion?
- calcification
- smooth border
- cavitation
- satellite lesions
- lentiform/triangular within 1cm of pleura- tend to be IPLN
T in TNM for Lung ca?
T1- <3cm not involving main bronchus
0-1cm T1a
1-2cm T1b
2-3cm T1c
T2 3-5cm OR <3cm includes main bronchus or invades visceral pleura or obstructive atelectasis/pneumonitis
3-4cm T2a
4-5cm T2b
T3 5-7cm OR <5cm includes invasion of pericardium, chest wall, phrenic nerve or nodule in SAME LOBE
T4 >7cm OR invasion of mediastinum, oesophagus, spine, diaphragm, recurrent laryngeal, carina or trachea or nodule in DIFFERENT IPSILATERAL LOBE
N in TNM for Lung ca?
N1 ipsilateral S10,11,12
N2 ipsilateral S4 and 7
N3 any other chest nodes including contralateral and pericardial
M in TNM for Lung ca?
M1a nodule in contralateral lung, pericardium or malignant effusion
M1b SINGLE extrathoracic nodule or LN
M1c lots extrathoracic
What is the risk of PTX during CT guided biopsy?
15%
6.6% require drain
What is the mortality of a wedge resection?
0.4% for inpatients
2.1% 30 day 4.2% 90 day
when would you nav bronch/radial EBUS over CT guided biopsy?
Consider if lesion is >1/3 away from the periphery
If a patient requires a bronch, how soon should it be available?
within 7 days
when should an IPC be removed?
<50mL are drained on three consecutive occasions and there is an absence of symptoms of fluid reaccumulation and no substantial residual pleural effusion on imaging
when should anti-platelets and anti-coags be stopped pre-pleural procedure?
Xa inhibitors 24–48hours before the procedure
dabigatran- full 48hours-4days if high bleeding risk procedure
Aspirin therapy and LMWH continued
Clopidogrel and prasugrel 5days
ticagrelor 7 days
high bleeding risk procedures- restart anticoag day 2 rather than day 1
Is coag required for a pleural procedure?
not required if no history of coagulopathy and not on anticoagulant
What are the lights criteria?
► Pleural fluid protein is more than half the serum protein
► Pleural fluid LDH is more than 0.6 times the serum LDH
► Pleural fluid LDH is more than 2/3 the upper limit of normal of the serum LDH
chylothorax v pseudochylothorax? Causes?
chylo:
high triglycerides
low chol
chylomicron pos
pseudo:
low triglycerides
high chol
chylomicrons neg
Pseudo: TB and RA
Chylo: trauma, malignancy, LAM, TB, cirrhosis, idiopathic
T1c N0M0. What stage is is?
1a
T1a N1M0. What stage is is?
2b
T1b N2 M0. What stage is it?
3a
T1a N3 M0. What stage is it?
3b
T1b N0M1a. What stage is it?
4a
T2a N0M0. What stage is it?
1b
T2bN0M0. What stage is it?
2a
T2a N1M0. What stage is it?
2b
T2bN3M0. What stage is it?
3b
T3N0M0. What stage is it?
2b
T3N1M0. What stage is it?
3a
T3N2M0. What stage is it?
3b
T3N3M0. What stage is it?
3c
T4N0M0. What stage is it?
3a
T4N1M0. What stage is it?
3a
T4N2M0. What stage is it?
3b
T4N3M0. What stage is it?
3c
T2a N0M1c. What stage is it?
4b
T3 N3M1b. What stage is it?
4a
What are the cardiac risk factors for surgery and what do you do if you have them?
RF:
‘high risk surgery’- all thoracic surgery is high risk
IHD
CCF
Hx of stroke/TIA
Insulin controlled diabetes
creat >177
> 3 see a cardiologist or ifthey have ‘poor’ cardiac function
2 with good function - offer surgery
Cardiac complications in:
3 or more risk factors: 11%
2: 7%
1: 1%
Rank the most likely cause of anterior masses
Thymic hyperplasia and thymic Ca
Lymphoma
Germ Cell (50% Teratomas)
Endocrine (5%)
What does SMARCA4-deficiency tell you?
It relates to anterior lung/lung tumours that are sarcomatoid and generally have a poor prognosis. Usually male smokers
To be a adenocarcinoma it needs to be……positive or have mucin positive tumour cells (……. A).
TTF-1 and Napsin
Most common genes associated with adenoca of the lung?
EGFR
ROS-1
ALK
KRAS
TP 53
Most common targeted genes associated with adenoca of the lung?
EGFR
ROS-1
ALK
KRAS
BRAF
RET
Which gene mutations are commonly found in cigarette smokers?
KRAS
also TP53, NRAS, and MAP2K1
Which gene mutations are commonly associated with never/light smokers?
EGFR, ALK, ROS1, and RET
Which gene mutations are commonly associated younger patients and women?
EGFR
ALK, ROS1, and RET- all in young patients
Which gene is associated with predom solid adenoca?
KRAS
TTF positivity is associated with which gene mutation?
EGFR
Which NSCLC chemo doesn’t work in SqCLC
Pemetrexed
