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Lung Cancer Flashcards

1
Q

Categories of lung cancer

A

Small cell aggressive haem spread CX siadh

Non small cell
Squamous mass can cavitate, hyper ca
Adenoca smokers
Bronchoalveolar rare mutinous vs lipidic

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2
Q

Presentation of lung cancer

A

Local respiratory symptoms inc Haemoptysis

Mets
LN liver bone CNS oesophageal

Paraneoplastic inc cerebellar syndrome SCLC
Squam hpoa (periosteal bone proliferation) hyper ca or hypercoag
Small siadh /acth /lems /limbic enc w anti hu/ dm and pm

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3
Q

Lems

A

Autonomic dysregulation
Prox myopathy
Myopathy

Ab vg cc
Repeated stimulation increased strength

Treat SCLC
IVIG and plasmaphoresis
Pred then aza/cyclophos

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4
Q

Lymphangitis carcinomatosis

A

Tumour infiltrates lymphatics

Sob cough systemic

HRCT infiltrates septal thickening

Methylpred then pred

Poor prognosis

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5
Q

TNM

A

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 (10/11)
N2 subcarinal 7 or mediastinal il paratracheal 2/4
N3 CL peribronchial (10/11)/hilar/med (2/4) or scalene/supraclav (1)

Right tumour
- N3 also 5/6 around aorta, 8 oes, 9 pulm segment
Left tumour
- N2 will be 7/ IL 2n4/5/6/IL 8/9
-N3 any 1, all other controL

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

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6
Q

Upstaging

A

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

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7
Q

CT and PET

A

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

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8
Q

Ct guided Bx

A

Tumour more than 2cm or met
Bx met if able

Ind peripheral tumour or multiple nodules or multiple local infiltration

Fev1 > 1L or less than 35% predicted
INR less than 1.4 and plt more than 100

CI
Previous pneumonectomy
PAH

Hugh risk admit

Alt flexible bronch

CX
20% Ptx and 3% need ICD
Haemoptysis 5% and haemorrhage 15%
Rare tumour seeding/tamponade/chest infection
Rare air embolism presents as stroke or circulatory collapse often fatal
1% die

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9
Q

NSCLC management

A

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
S3AN2 consider chemorad a sx
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

Stage 3B onwards
Chemorad
If no progression and pdl1 less than 1% then durvalumab

S3B and 4
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

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10
Q

Types of surgery

A

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

Limited reserve sublobar resection

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11
Q

CX surgery

A

Air leak
Fistula
Infection
Resp failure
Phrenic nerve injury
Recurrent laryngeal n injury
Chest wall pain
2-4% mortality

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12
Q

Post op fev1

A

Ppo value is (pre op/no functioning segments left) x (19- lobes to go)

Pre in mL times (remainder /19)

FEV1
More than 60% ok
30-60 6wt
Less than 30% cost and vo2 less than 35% no sx

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13
Q

Contra indications for surgery

A

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

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14
Q

Death risk calculator surgery

A

Thoracoscore

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15
Q

Non small cell management immuno

A

Locally advanced
Egfr positive w ps 0-2 and chemo naive erlotinib or geftinib
PDL1 over 50% w egfr/alk then pembro
Ros1 crizotinib

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16
Q

Squamous cell management

A

PDL less than 50% Pembro with paclit/ carboplatin
PDL more than 50% pembro
Or gemcitabine w carbo or cisplatin

S3 radical chemorad
Cisplatin with etopiside
Then rad

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17
Q

Immune modulators

A

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 (TKI)
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

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18
Q

Radical Radiotherapy indications NSC

A

Indications
Early stage not for sx then radical rt stereotactic (or hyperfract)

-Locally advanced with good PS not for surgery then chemorad w. cisplatin based chemo + CHART
- locally advanced good PS not for chemo or surgery CHART (conventional or hyperfract)

S3
Chemorad or no chemo then CHART
some surgery then chemorad

Combo less than 75 and ps 0-1
Alt sequential

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19
Q

Types radiotherapy

A

Radical
S1-3 resectable 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

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20
Q

Survival by treatment

A

Adjuvant

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21
Q

SVCO

A

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

If they ask most appropriate initial management then chemo

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22
Q

Small cell tx

A

Surgery as part of multimodal
T1-2a MoNo-1
T1-3N2 as clinical trial

T1-4N0-3M0 chemorad
Good PS concurrent
-BD thoracic RT 45Gy in 3 weeks with cisplatin and etop and 40Gy once a day
Bad PS sequential
Good response and good PS PCI

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

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23
Q

Pulmonary carcinoid

A

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

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24
Q

Hypercalcaemia

A

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

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25
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
26
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
27
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
28
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
29
Subsolid
Ct 3m Growth sx Stable Brock Less than 10% ct 1-2-4y - stable stop More than 10% Workup
30
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
31
Surgical mortality
Lobectomy 2-3% Pneumonectomy 5-8%
32
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
33
Smoking and surgery
Post op air leak due to bpf Pneumonia Resp distress Atelectasis
34
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
35
Brock
Malignancy on CT Emphysema UL Size spiculation gg Fhx lung cancer Age gender
36
Herder
Risk ca based on pet Smoking Hx of extrathoracic cancer Nodule size n upper lobe and avidity
37
Post op TLCO
Pre op over 19 x (19-resected) Less than 40% not acceptable
38
Non small cell survival
1 year vs 5 year 88% vs 56% 73% vs 36% 52% vs 13% 19% vs 3%
39
Lobe stage
Same lobe T3 IL but different lobe T4 CL lobe M1a
40
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
41
Meso prognosis
Survival 12m 3 year survival 10% Age at diagnosis 73 MRI indication Talk Debate T stage Change in management
42
Brain mets incidence
10-20%
43
Brain imaging
S2 ct with contrast S3 mri with contrast
44
Stage 4
4a in M1a or m1b 4b in m1c
45
Variability nodule allowed
25%
46
Discharge nodule
Less than 5mm Unfit Nodule stable over 4y
47
Surgery nodule types
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
48
Good pre op function
Shuttle walk more than 400m Cpet vo2 max more than 15ml/kg
49
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
50
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
51
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
52
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
53
Indication screen NSCLC
55-74 Over 30py Less than 15y since quit
54
Squamous cell lung cancer chemo
Indication PS0-2 and minimal coM Gemcitabine Vinorelbine Taxane
55
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
56
Limbic encephalitis
Within 4y Dx Personality change Seizures Confusion Stml Anti HU ab 50%
57
PET false
False positive RA Granuloma False negative Carcinoid GG nodules DM
58
Ebus indication
LN over 10mm short axis
59
Radical radiotherapy lung function
CI if FEV1 less than 1.5
60
Definition nodules
<5mm GGN atypical adenomatous hyperplasia >5mm GGN adenocarcinoma in situ Solid nodule <5mm minimally invasive adeno >5mm invasive adeno
61
Histology
Adeno Mucin w gland formation Squamous Bridges w keratin pearls Small cell Almost all nucleus with crowding
62
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
63
Limited vs extensive
Limited tumour one area Extensive N2 above or any M
64
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
65
Brain imaging
Mets 20% Pet picks up 60%
66
5 year survival nsclc
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
67
Abnormal adrenal uptake on pet
Bx
68
Negative TBNA or EBUS on staging next steps
Mediastinoscopy
69
NSCL Mx subsets
T3N0Mo radical treatment T4N0-1M0 radical multimodal T4 clinical trials radical tx Most MDT N3 no sx N2 some surgery as multimodal N3 chemo +- radiotherapy M1a/b clinical trials
70
T1-4N2M0 NSCLC
Radical RT or chemorad
71
T1-3N2M0 non fixed non bulky NSC
Multimodal including consider surgery Bulky or fixed no sx Options chemo/radical RT or concurrent
72
T1-4N3M0 NSC
Clinical trials radical treatment
73
Bronchoalveolar lung Ca single site
Anatomical lung resection Limited then consider wedge
74
Lung cancer and heterogenous emphysema
Lung resection based on LVRS criteria
75
Pre op chemo
Not for resectable cancer
76
Post op chemo nSCLC
T1-3N1-2M0 T2-3N0M0 if more than 4cm Cisplatin based chemo
77
Post op RT NSC
Microscopic disease only R1
78
LN enlarged if
More than 1cm max short axis diameter in transverse plane
79
PET sensitivity
85%
80
Mediastinoscopy
EBUS negative to detect microscopic N2 disease
81
Risk assessment for surgery
Cardiac risk factors - NO if a) 3 or more RF b) 30D MI c) angina or HF or arrhythmia or severe heart disease — refer cardio PeriOp death thoracoscore Post op dyspnoea
82
Cardio discussion sx
Secondary prevention Continue anti anginals Discuss stents Stable angina refer stent
83
Lung function pre op
Spiro and TLCO Low risk post op sob then surgery Moderate or high risk if accept risk sx If mismatch suspected then scintigraphy
84
Exercise testing pre op
If shuttle walk less than 400m
85
High risk post op sob
Fev1 less than 40 Tlco less than 40 Functional ax poor
86
Lymph node management sx
Systematic dissection Min 6 nodes or stations to be removed
87
Alternative radical early NSC
RFA or radical brachytherapy
88
RF NSCLC
Prev RT
89
Small cell brain mets
Whole brain radiotherapy
90
Pollution and cancer
Interleukin 1B inflammation promoting egfr mutant cells
91
Cherio sign CT
Sign of lung adenoCA Ddx LCH
92
Cavitation and proximal airway causing atelectasis
Squamous cell
93
Post pneumonectomy syndrome
1 year after pneumonectomy Opposite side of aortic arch Sob, insp stridor and recurrent LRTI Ct distal trachea and mainstem bronchus narrowed Mx Silicone implant in post surgical space to reposition mediastinum
94
LN misc
Station 5 mediastinal n3 M1b Non regional LN eg descending aorta
95
CPFE lung cancer
Highest risk
96
N2 and surgery
Consider sx then chemorad in non fixed non bulky single zone N2
97
S3 NSCLC principles
Concurrent superior to sequential chemorad Chemorad for S2/3 when not suitable for surgery Elderly good PS can have chemorad concurrently cHART for locally advanced disease but risk oesophagitis

Resiratory SCE (13 decks)

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