Lung Cancer Flashcards
Categories of lung cancer
Small cell aggressive haem spread CX siadh
Non small cell
Squamous mass can cavitate, hyper ca
Adenoca smokers
Bronchoalveolar rare mutinous vs lipidic
Presentation of lung cancer
Local respiratory symptoms inc Haemoptysis
Mets
LN liver bone CNS oesophageal
Paraneoplastic
Squam hpoa (periosteal bone proliferation) hyper ca or hypercoag
Small siadh /acth /lems /limbic enc w anti hu/ dm and pm
Lems
Autonomic dysregulation
Prox myopathy
Myopathy
Ab vg cc
Repeated stimulation increased strength
Treat SCLC
IVIG and plasmaphoresis
Pred then aza/cyclophos
Lymphangitis carcinomatosis
Tumour infiltrates lymphatics
Sob cough systemic
HRCT infiltrates septal thickening
Methylpred then pred
Poor prognosis
TNM
Tx can’t assess
T0 no primary
T1a o <=1 t1b 1-2 t1c 2-3
T2a 3-4 T2b 4-5
T3 5-7
T4 above 7 cm
Nx can’t assess
No no LN involved
N1 il peribronchial or hilar or intrapulm LN
N2 subcarinal or mediastinal il
N3 CL peribronchial/hilar/med or scalene/supraclav
Mx can’t assess
Mo no mets
M1a controlateral nodule or effusion peric/pleural or pericardial/pleural nodule
M1b single extra thoracic met inc non regional LN
M1c distant mets
Upstaging
T2
Visceral pleura
Main bronchus less than carina
Obstructive atelectasis
T3
Same lobe nodule
Chest wall
Phrenic
Pericardium
T4
Pancoast
Med fat
Diaphragm
Carina
IL node
CT and PET
Have to be within 4 weeks
Pet for
curable disease
N2-3 disease
Limited SCLC
Uptake mediastinal LN then stage mediastinum with Ebus
S2 ct head with contrast and S3 mri head
Bronch indications Endobronchial or less than 4cm lobar bronch or segmental airway
Ct Bx more than 2cm tumour
Mediastinoscopy assess tumour and invasion or other LN aortopul sub aortic phrenic hilar
Surgical Bx under ga 98% specific and 93% sensitive
Thoracoscopy for effusion
Bone scan if bone pain
Ct guided Bx
Tumour more than 2cm or met
Bx met if able
Ind peripheral tumour or multiple nodules or multiple local infiltration
Fev1 > 1L
INR less than 1.4 and plt more than 100
Hugh risk admit
Alt flexible bronch
CX
20% Ptx and 3% need ICD
Haemoptysis
1% die
NSCLC management
T1-4N2MO radical RT or chemorad
T1-3N2M0 surgery then chemo
Occult N2 surgery resect N2 disease then chemo
Single N2 surgery
Multinidal N2 chemorad
N3 trials radical chemorad
S1 70% resectable
S2 surgery and adjuvant chemo
S3a N1 surgery then chemo
S3bN1 surgery chemorad
S3b radical rt to S4 chemorad
Stage 1B to 3A
Resection
R1 then chemorad
R0 then chemo cisplatin w vin/gemcitabine/docetaxel/pemtrexed
R0 and resected tumour more than 4cm carboplatin and pacletaxel
Need to have resectable disease for neo adjuvant no-1 or non bulky n2
Stage 3
Chemorad
If no progression and pdl1 less than 1% then durvalumab
S4 with PS 0-2 with PDL1 less than 50% and no other mutations
Carboplatin and paclitax OR pembro and pemtrexed OR pemtrexed carbo
T4 with good ps then multimodal
Types of surgery
Segmentectomy take out lung supplied by segmental bronchi
Peripheral with regional LN
Lobectomy
Tumour over one or two lobes with LN for path stage
Wedge
Not anatomical
Sleeve
Lobe of lung and part of bronchus with anastomosis
Macroscopic free margin 5cm
CX surgery
Fistula
Infection
Resp failure
Phrenic nerve injury
Recurrent laryngeal n injury
Chest wall pain
8% mortality
Post op fev1
Pre op fev1 x (19- resected /all over 19)
More than 60% ok
30-60 6wt
Less than 30% cost and vo2 less than 35% no sx
Contra indications for surgery
MI 30d
Discuss cardio more than 2 risk factors or mi 6m or stent or angina
Fev1 less than 40% and TLCO <30% high risk sob
Shuttle walk less than 400m cpet and less than 15ml per kg no sx
Upper lobe LVRS
Tia or stroke carotid Doppler
Smoke nrt
Nutrition supplement
Death risk calculator surgery
Thoracoscore
Non small cell management immuno
Locally advanced
Egfr positive w ps 0-2 and chemo naive erlotinib or geftinib
PDL1 over 50% w egfr/alk then pembro
Ros1 crizotinib
Squamous cell management
PDL less than 50% Pembro with paclit/ carboplatin
PDL more than 50% pembro
Or gemcitabine w carbo or cisplatin
S3
Cisplatin with etopiside
Then rad
Immune modulators
Molecular testing
Advanced nsclc so s4 with PS 0-2
Squamous cell no smoking history
Egfr erlotinib
17% nsclc
Non smoking Asian women
SE GI lft pneumonitis dry eyes
Alk ceritinib
Young non smokers
Ros crizotinib
PDL1 pembro or nivolumimab
Advanced disease with PS 0-2 no mutations but PDL1 over 50%
Itis
Hold
Steroid
Depending on grade may need steroid sparing agent
Radiotherapy indications
Indications
Early stage not for sx then radical rt
S3 some surgery then chemorad
Not for surgery chemorad
Post surgery microscopic disease
Combo less than 75 and ps 0-1
Alt sequential
Types radiotherapy
Radical
S1-3 respectable not for surgery
Good ps o-1
SABR
Less than 5cm to IIa and Not for surgery or pt declined
Indication ps 0-2, peripheral, over 18
CI fev1 less than 1.5, consolidation or GGO, pre rt, pregnant or lactating, not able to consent and consolidation
Fr 3-5 fr
Conventional
55 Gy in 20f over 4w
60 Gy in 33f over 6w
Low dose
Ps 2 and above with mets
Palliative
Good ps
39Gy in 13w
Survival by treatment
Adjuvant
SVCO
Obstruction blood svc by external compression or thrombosis
Cause
85% cancer lung lymphoma Thymoma
15% benign goitre lines ppm wire
Upper body swelling worse arms up with collateral vein
Syncope due to reduced venous return rh
Ct cap
Bx for cytology key try to hold off dex if able
Bronch if stable
Mx
O2 analgesia
Dex
Stent first line se migration 90% success
Radiotherapy second line as takes 10d plan
Small cell tx
Surgery
T1-2a MoNo
S2-3 or incomplete margins post op chemo
Limited and extensive
Etopiside and cisplatin or carboplatin (ind poor ps or poor renal function)
2nd anthracyclines eg doxirubicin w oral tapotocan
Radiotherapy
45Gy in 3 weeks
A T1-4No-3M0 to 1band ps 0-1 with cisplatin based chemo 6 cycles
Partial response thoracic rt and cranial proph 25gy in 10 fr
B relapse
Anthracycline based chemo limited evidence 6th
Palliative
RT symptoms
Pulmonary carcinoid
2% lung origin rare
40-50
Neuroendocrine associated men1
Anatomy central
Slow growing benign 82% or can met 18%
Typical no necrosis distant mets rare - 90% 10 y survival
Atypical focal necrosis ; 20% distant mets - 60% ten year survival
Symptom
Endobronchial Resp symptoms and infection
Parenchymal NIL
Syndrome sweaty tachy diarrhoea wheeze
Cushing
No avidity pet so dotatate scan
Bronch cherry red can bleed
Bloods chromograffin A or 5HIAA
Cushing cortisol /acth and 24hr urinary cortisol
Isolated sx lobectomy with nodal dissection
Bulky met then Ssa then embolise or rfa
Liver met resection vs embolise vs rfa
Other met octreotide
Metastatic disease chemo no set regimen
Hypercalcaemia
PTHrp
Ca above 2.75
Bone pain confusion constipation dehydration arrhythmia
Raised ca
Low pth
High pthrp
Low vit d
Renal function off
Long qtr
3L ivf then zolendronic acid
Furos helps excrete ca
Steroids
Siadh
Small cell
Low na
Serum Osm low and urinary osm high
Urinary na high
Screen tsh /vit d/ cortisol /lipids / paired osm /urinary na
Ct cap and ct head w contrast
Check drugs
Fluid restrict
Salt tabs
Demeclocycline blocks adh or vaptan blocks adh but lft deranged
Spinal cord compression
Sphincter symptoms hours until paraplegia
Weakness
Sensory level
Hyperreflexia
Saddle anaesthesia
Pathology
Direct compression due to vert met
Indirect pressure posterior med LN
Haematogenous spread rare
Analgesia
Dex 8mg bd
Nsx
Aos consider rt
Catheter /laxative /pressure area care / VTE
Nodule definition
Less than equal 3cm
Solid or sub solid
Benign intrapulomary LN or granuloma or hamartima or bronchial adenoma
Malignant lung cancer or met
Benign
Less than 5mm
Parafissural Subpleural
Smooth calcified triangular popcorn fat
Non smoker and young
Malignant
More than 1cm
Speculated /pleural indent / gg/ cavity / UL
Vdt less than 480, uptake or extra thoracic disease
Smoker older
Solid nodule
5-6mm ct at 1y
6-8mm ct at 3m- if vdt less than 400 then sx OR more than 400 repeat CT 1y
— 2y stable on 2d or 1year vdt w >600d discharge
- vdt 400 to 600 ct Bx
- vdt less than 400 sx
More than 8mm
Brock
Less than 10% then ct 3m then 1y then vdt stable 1y dc or 2y 2d
- vdt 400 to 600 ct Bx
- vdt less than 400 sx
More than 10% pet and herder
-Less than 10% then ct 3m then 1y then vdt stable 1y dc or 2y stable 2d dc
- vdt 400 to 600 ct Bx
- vdt less than 400 sx
10-70% Bx and fu
Over 70% sx
Subsolid
Ct 3m
Growth sx
Stable
Brock
Less than 10% ct 1-2-4y - stable stop
More than 10% Workup
Palliative tx
Endobronchial obstruction
External beam rt or Endobronchial debunk or stent
Pleural MPE
ICD with talc vc ipc
Sob fan opioid benzo psych
Hoarse ent
Svco Dex then stent then rt
Brain mets
Dex 8mg bd +- aed
Nsx and aos re rt
Bone mets single fraction radiotherapy
weight nutrition
Surgical mortality
Lobectomy 2-3%
Pneumonectomy 5-8%
Tumour markers
Adeno
Ttf1 ck7 e cadherin
Small cell
Cd56 synotophysin chromograffin ttf
Meso
Ck5/6 calretinin d20
Negative ttf1 ck7 p63
Squamous
P63 ck5/6 cea
TTF -ve
Smoking and surgery
Post op air leak due to bpf
Pneumonia
Resp distress
Atelectasis
Epidemiology lung cancer
40,000 new cases
S4 has 64%
Largest incidence at 85-89
Worse prog African or Pakistani as Dx later as 75% S3-4
Brock
Malignancy on CT
Emphysema
UL
Size spiculation gg
Fhx lung cancer
Age gender
Herder
Risk ca based on pet
Smoking
Hx of extrathoracic cancer
Nodule size n upper lobe and avidity
Post op TLCO
Pre op over 19 x (19-resected)
Less than 40% not acceptable
Non small cell survival
1 year vs 5 year
88% vs 56%
73% vs 36%
52% vs 13%
19% vs 3%
Lobe stage
Same lobe T3
IL but different lobe T4
CL lobe M1a
Worked examples
T3Nomo
Stage 2b
Ct with contrast then resection vs chemorad
T3n2m0
3b
T4n2m0 is 3b
Ps1
No targetable mutation
Chemorad
T3n3m0
Us supraclav node first
T1bn2m0
3a sclc
Concurrent chemorad with carboplatin and etopiside
Malignant Meso limited stage
Cisplatin and etopiside
Rt for pain at site
Meso prognosis
Survival 12m
3 year survival 10%
Age at diagnosis 73
MRI indication
Talk
Debate T stage
Change in management
Brain mets incidence
10-20%
Brain imaging
S2 ct with contrast
S3 mri with contrast
Stage 4
4a in M1a or m1b
4b in m1c
Variability nodule allowed
25%
Discharge nodule
Less than 5mm
Unfit
Nodule stable over 4y
Surgery nodule
Wedge resection with frozen section
Segmentectomy if not fit for lobectomy
Image guided Bx and
—if malignant lobectomy
— not malignant repeat Bx or sx resection
Not fit for surgery
Ct Bx if possible and safe and if malignancy sabr or rfa or radical rt
Undiagnostic ct Bx then repeat
Not able to Bx then sabr or rfa or radical rt
Good pre op function
Shuttle walk more than 400m
Cpet vo2 max more than 15ml/kg
Prognostic factors SCLC
Small cell
Older /smoker /low bmi /male /high Ldh /low na
Limited
Treated 1.5y
untreated 3m
Extensive
Treated a year
Untreated 6w
Management small cell
Stage 1-2 with T1-2
Resection offered
If p stage T1-2N0R0 then adjuvant chemo cisplatin and etopiside
If N2 or R1-2 then concurrent CRT — no progression and less than 70+ good ps then PCI
Stage 1-3 with T1-2 and N0-3
Good PS 0-1 concurrent CRT
PS 2 or worse then sequential crt
— no progression + less than 70 and ps 0-1 then PCI
Stage 4 or S3 not for curative intent
PS 2 or worse due to com BSC
Ps 0-1 carboplatin and etopiside and atezolizumab OR cisplatin and etop and durvalumab
Ps 0-1 contraindication PCI then carbo w etop or carbo w topotecan or cisplatin w irinotecan — response with ps 0-2 consolidate thoracic RT; less than 75 PCI with mri surveillance
Ps 0-1 no co pci then chemo (carboplatin w etop w atezolizumab) or (cis w etop w durvalumab)
Ps 0-1 with CI ici then carbo etop or carbo oral top or cisplatin irinotecan — response and ps 0-2 then thoracic RT and consider pci less than 75
Ps worse than or equal to 2: carbo etop or carbo gems— response and ps 0-2 then thoracic rt and if less than 75 pci with mri surveillance
Limited stage small cell
Chemo
Chemo cisplatin and etopiside 3 week cycles x4
Switch to carboplatin if low egfr
Radiotherapy
45Gy in 30fr over 3w or 66Gy in 33 fr over 6w
PCI
25 Gy over 10fr
Recurrence small cell
Platinum resistant
Worse PS lurbinectedin
Good ps oral or iv topecetan OR cyclophos Doxi vinc OR lurbinectedin
Platinum sensitive more than 3m
Plt etop or topotecan or cyclophos/dox/vincristine
Follow up small cell
Limited stage CT 3-6 M for 2y
Extensive CT 2-3m
MRI head 3m for a year then 6m if no pci
Indication screen NSCLC
55-74
Over 30py
Less than 15y since quit
Squamous cell lung cancer
Indication PS0-2 and minimal coM
Gemcitabine
Vinorelbine
Taxane
Lambert Eaton
Predate cancer 4y
Proximal limb weakness
Ans dry mouth constipation ED
Hypo reflex
Better w exercise
VGCC AB due to reduced ach release at motor terminal
Tx cancer
IVIG or plasmaphoresis short term benefit
Limbic encephalitis
Within 4y Dx
Personality change
Seizures
Confusion
Stml
Anti HU ab 50%
PET false
False positive
RA
Granuloma
False negative
Carcinoid
GG nodules
DM
Ebus indication
LN over 10mm short axis
Radical radiotherapy lung function
CI if FEV1 less than 1.5
Definition nodules
<5mm GGN atypical adenomatous hyperplasia
>5mm GGN adenocarcinoma in situ
Solid nodule
<5mm minimally invasive adeno
>5mm invasive adeno
Histology
Adeno
Mucin w gland formation
Squamous
Bridges w keratin pearls
Small cell
Almost all nucleus with crowding
Immune modulator side effects
Neuro per gbs mg men enc
Pneumonitis and pleuritis
MyoC peric vasculitis
Nephritis
Colitis gastritis pancreatitis hepatitis
Mss arthralgia
AIHA thrombocytopenia low neut
Psoriasis Vitiligo dermatitis sjs
Endo dam hypo or hypert adrenal insufficiency
Uveitis conjunctivitis ON
Mx
Grade one continue and symptomatic
Grade two po steroid and hold
Grade three iv steroid and discontinue
Grade four iv steroids and discontinue
Steroid 1-2mg/kg per day and taper over 4 weeks
Limited vs extensive
Limited tumour one area
Extensive N2 above or any M
Lung cancer Ix groups
Peripheral tumour with normal mediastinum on CT and no distant Mets
Pet then Ebus vs nav bronch
10% pet positive nodes are positive on Bx
Central tumour or N1 with normal staging ct and no distant mets
30% N2 or N3 with 15% FP rate on Pet
Staging Ebus if negative bx lesion
Primary tumour and discrete mediastinal adenopathy no distant Mets
60% N2/3 disease and 15% FP
Ebus negative then ct bx
Conglomerate and invasive nodal on staging no distant mets
For chemorad mostly
Us N3 nodes supraclav
Distant mets on staging CT
Bx most distant safest site of met
Brain imaging
Mets 20%
Pet picks up 60%
5 year survival
S1 a 92 83 77
S1b 68
S2 a 60 2b 53
S3 a 36 b 26 c 13
S4 a 10 or 4b 0
