Lung cancer Flashcards
Epidemiology
1 killer in both men and women
2nd most common cancer in men and women
History of disease
Metastasis: BRAIN, bone, liver, lymph nodes, adrenal glands
Risk factors
Tobacco (85-90% of lung cancers)
-Risk decreases with smoking cessation but not to baseline
Radiation
Occupational/environmental exposure to asbestos
Heavy metals, radon, aromatic hydrocarbons
Genetics
Pathophysiology
Chronic exposure of epithelial cells to carcinogens results in chronic inflammation that can induce genetic and cytologic changes
Signs/symptoms
Local: cough, hemoptysis, dyspnea, rust-colored sputum, wheezing/stridor
Metastasis: bone pain, neurologic deficits, spinal cord compression, liver
Paraneoplastic:
SCLC: Cushing’s, SIADH, Myasthenic syndrome
NSCLC: hypercalcemia
Both: clubbing, edema, hyper-coagulability
Presentation
SCLC–> 67% present with metastases
NSCLC–>50% present with metastases
Mutations
EGFR–> sensitivity to TKI
-More common in females, Asians, and non-smokers
KRAS–> resistance to TKI
-Exclusive to smokers
ALK: more common in younger, andenocarinoma, and no/light smokers
ROS-1: more common in younger, adenocarcinoma, and no/light smokers
BRAF V600E: exclusive to current or former smokers
PDL-1: less common with EGFR, ALK, ROS-1
Screening
Spiral CT scan–> high risk only
55-74, 30-year pack history of smoking, current smoker or quit in past 15 years, good health, and willing to have curative lung surgery
False positives, multiple radiologists
Prevention
Smoking cessation
SCLC
Related to smoking
Rapid cell growth fraction
Paraneoplastic syndromes common
Treatment: chemo and radiation
NSCLC
Adenocarcinoma: common in non-smokers, located peripherally to lung
Squamous: related to smoking, located centrally in lung
Large cell: located peripherally to lung
Non-squamous
Staging (SCLC)
Limited–>tumor is confined to hemithorax and is contained in radiation port
Extensive–>tumor is not confined to hemithorax and not contained in radiation port (both lungs)
Limited stage
Highly sensitive to radiation and chemo
Without therapy:
Survival with limited: 12 weeks
Survival with extensive: 6 weeks
NO MAINTENANCE CHEMO OR SURGERY
Extensive stage
NO RADIATION
SCLC Limited stage treatment
Radiation + combination chemotherapy
EC: Cisplatin/Carboplatin + Etoposide every 21 days for 4-6 cycles
Radiation is daily (Mon-Fri) for 6-7 weeks
Prophylactic cranial radiation
SCLC Extensive stage treatment
Combination chemotherapy
Carboplatin + Etoposide + Atezolizumab every 21 x 4 cycles
Carboplatin + Etoposide + Durvalumab every 21 days x 4 cycles
Prophylactic cranial radiation:
If symptomatic: whole brain radiation prior to chemo
If asymptomatic: whole brain radiation after chemo
Maintenance chemo: Atezolizumab or Durvalumab until patient progresses or toxicities
If patient has progressed–> Pembrolizumab regardless of PDL-1 status
NSCLC
Surgery is the most efficacious treatment of NSCLC
Radiation may be used in early-stage when surgery is not able
NSCLC treatment (resectable)
Neoadjuvant chemo–> tumor > 4 cm or lymph node positive
-Platinum doublet + nivolumab x 3-4 cycles
Surgery
Adjuvant chemo
Non-squamous: Cisplatin + Pemetrexed every 21 days x 4 cycles
Squamous: Cisplatin + Gemcitabine every 21 days x 4 cycles
Cisplatin + Docetaxel every 21 days x 4 cycles
Targeted therapies after chemo
Early stage + ALK: Alectinib x 24 hours
Early stage + EGFR: Osimertinib x 3 years
Early stage + High risk + no mutation + PDL1 > 1%: Atezolizumab or Pembrolizumab
NSCLC treatment (unresectable)
Radiation
Chemotherapy
Non-squamous
Cisplatin + Pemetrexed every 21 days x 3
Carboplatin + Pemetrexed every 21 days x 4
Squamous
Cisplatin + Etoposide
Carboplatin + Pacletaxel
Targeted therapies after chemo
Durvalumab x 1 year
Osimertinib until disease progression
If unable for surgery, chemo, or radiation
PDL1 > 1%–> pembrolizumab
Adenocarcinoma (metastatic) NO MUTATION
Check PDL1 status
> 1-49%
1st line: Pembrolizumab +/- chemo
> 50%
1st line: Pembrolizumab +/- chemo
Atezolizumab
Cemiplimab +/- chemo
Negative:
1st line: Pembrolizumab/Atezolizumab + chemo
Chemo: Carboplatin + Pemetrexed
Adenocarcinoma (metastatic) MUTATION
EGFR (exon 19 deletion or exon 21 sub)
Osimertinib
BRAF
Dabrafenib + Treametinib
KRAS G12C
Sotorasib
Squamous
Check PDL-1 Status + Performance status
If not contraindications to immunotherapy
Pembrolizumab +/- chemo x 4 cycles
If contraindication to immunotherapy
Carboplatin + Paclitaxel/Docetaxel/Gemcitabine x cycles