lung cancer

Question 1

risk factor/causes of lung cancer

Answer 1

-(passive) smoking
-asbestos (plumber)
-radon ((uranium miner)
-chronic lung disease

Question 2

pathogenesis of lung cancer

Answer 2

1. inhaled carcinogens interact with epithelium of upper + lower airways

2.form DNA adducts: DNA pieces bound to cancer-causing chemical.

3. Persisting misrepaired DNA adducts-> mutation-> genomic alterations.

Question 3

types of lung cancers

Answer 3

Squamous cell carcinoma
-bronchial epithelium; centrally located

Adenocarcinoma
-mucus-producing glandular tissue; peripherally-locate

Large cell lung cancer

Small cell lung cancer
-pulmonary neuroendocrine cells

Question 4

important oncogenes

Answer 4

EGFR tyrosine kinase
-adenocarcinoma
-Asian women
-never-smokers

ALK tyrosine kinase// ROS1 receptor tyrosine kinase
-non-small cell lung cancer
-younger pts
-never smokers

BRAF
-non-small cell lung cancer
-smokers

Question 5

Signs in lung caner

Answer 5

-Horner’s syndrome
-clubbing
-cachexia
-Pemberton’s sign (superior vena cava obsruction)

Question 6

types of imaging

Answer 6

chest X-ray
staging CT (chest+abdo)
PET-CT- exclude occult metastases

Question 7

types of biopsy methods? For which type of tumour and can they stage/diagnose

Answer 7

-Bronchoscopy- central and segmental airways tumour.

-Endobronchial ultrasound and transbronchial-needle aspiration (EBUS [TBNA])= mediastinal lymph nodes. Stage+ diagnose

CT-guided lung biopsy- peripheral tumours

Question 8

what determines treatment

Answer 8

-Patient fitness
-Cancer histology/stage
-Patient preference

Question 9

Patient fitness – WHO performance status.
Radical treatment usually restricted to PS 0-2

Answer 9

0 – Asymptomatic

1 – Symptomatic but completely ambulatory

2 – Symptomatic, up and about >50% of waking hours

3 – Symptomatic, confined to bed or chair >50% of waking hours

4 – Completely disabled

5 – Death

Question 10

what/who is surgical resection for

Answer 10

early stages of disease.
-Lobectomy + lymphadenectomy usual approach
Sublobar resection if stage 1 (≤3 𝑐𝑚)

Question 11

Radical Radiotherapy

Answer 11

-Alt to surgery for early stage disease
- comorbidity

-Stereotactic ablative body radiotherapy (SABR)
High-precision targeting, multiple convergent beams

Question 12

what are the 3 types of systemic treatment and what are they first line for

Answer 12

oncogene-directed= for metastatic NSCLC with mutation

immunotherapy=
metastatic NSCLC with no mutation (PDL1 ≥50%)

cytotoxic chemotherapy=
metastatic NSCLC with no mutation and PDL1 ≤50% (in combination with immunotherapy)

Question 13

oncogene-directed systemic treatment
+side effects

Answer 13

tyrosine kinase inhibitor (TKI)
EGFR: erlotinib
ALK: crizotinib,
ROS-1: crizotinib

generally ok. Rash/diarrhoea

Question 14

immunotherapy systemic treatment and side effects

Answer 14

Pembrolizumab

SE: gen ok. Immune- related side effects (thyroid/ skin)

for metastatic NSCLC with no mutation (and PDL1 ≥50%)

blocks PDL-1 or PD-1
- allows T cells to kill tumour cells

Question 15

cytotoxic chemotherapy systemic treatment +SE

Answer 15

-Target any rapidly dividing cells
carboplatin

SE: fatigue, nausea

Question 16

benefits of palliative care and when to offer

Answer 16

all pts with advanced stage disease

at 12 weeks: improve QoL, lower depression

Question 17

how to treat early stage disease

Answer 17

Surgery or radiotherapy

Question 18

How to treat Locally advanced disease (involving thoracic lymph nodes)

Answer 18

Surgery + adjuvant chemotherapy
Radiotherapy + chemotherapy +/- immunotherapy

Question 19

how to treat Metastatic disease

Answer 19

With targetable mutation (e.g. EFGR, ALK, ROS-1): tyrosine kinase inhibitor

No mutation, PDL-1 positive: immunotherapy alone

No mutation, PDL-1 negative: cytotoxic chemotherapy + immunotherapy

Palliative care, alone or with the above