Lung Cancer

Question 1

What are the types and freq of types of lung cancer?

Answer 1

Non small cell lung cancer (85%)

• adenocarcinoma (40%, typically peripheral)
• squamous (25%, typically central)
• large cell (10%, typically peripheral)

Small cell lung cancer (15%, typically central)

Question 2

What are some clinical features of lung cancer?

Answer 2

Cough, haemoptysis
Chest pain, sob
Hoarseness due to laryngeal nerve involvement (most freq on left side due to longer course of nerve)
HPOA (clubbing, joint swelling, periositis) = more common in adeno
SVCO
Pancoast tumour complications

Question 3

What is a pancoast tumour?

Answer 3

Apical mass (usually squamous) which causes pain in shoulder/arm, hornets syndrome, wasting of small muscles of hand, bony destruction of ribs

Question 4

Common metastatic sites of lung cancer?

Answer 4

Liver
Adrenal gland
Bone
Brain

Question 5

What are some examples of paraneolpastic syndromes seen in lung cancer?

Answer 5

Hypercalcaemia (most commonly squamous due to PTHrP)
SIADH (SCLC causes 75% of cancer related SIADH)
Neurological - lambert-eaton myasthenia syndrome, cerebellar ataxia

Question 6

When is PET scanning used for lung cancer?

Answer 6

In operable patients to detect unseen metastases and evaluate mediastinum (often upstages disease)

Question 7

Basic staging for NSCLC lung cancer?

Answer 7

Stage 1 - solitary tumour
Stage 2 - regional lymph node involvement (hilar) or tumour invading local structures
Stage 3 - mediastinal lymph node involvement
Stage 4 - distant mets

Question 8

Treatment for stage 1 NSCLC?

Answer 8

Surgical resection - ideally lobectomy
No role for adjuvant chemo
If not operable candidate - radical RT

Question 9

Treatment for stage 2 NSCLC?

Answer 9

Surgical resection and adjuvant chemotherapy (platinum doublet - best is cisplatin/vinorelbine

If unresectable or poor operative candidate treat with radical chemo-rad

Question 10

Treatment for stage 3 NSCLC?

Answer 10

Concurrent chemoradiation

Question 11

When should you test for a targetable mutation?

Answer 11

Advanced disease

Non-squamous lung cancer

Question 12

What is treatment of stage 4 NSCLC without targetable mutation?

Answer 12

Platinum doublet chemotherapy - 4 cycles
Pemetrexed best in non-squamous
Gemcitabine best in squamous

Role for maintainance pemetrexed in adenocarcincoma

Question 13

What is an eGFR mutation?

Answer 13

Mutation causes a constantly active tyrosine kinase receptor leading to increased signalling
Mutation in EGFR caused by a deletion in exon 19

Question 14

What are some risk factors for lung cancer?

Answer 14

Smoking - dose related
Environmental exposure - asbestos, radon, heavy metals
Radiation treatment - typically mantle RT for lymphoma or RT for breast cancer

Question 15

Who is EGFR mutation more common in?

Answer 15

Non smokers
Younger patients
Asian
Females
Adenocarcinomas

Occurs in 10% of Caucasian population

Question 16

What are drugs used for EGFR mutation?

Answer 16

Tyrosine kinase inhibitors compete for ATP for binding to tyrosine kinase domain
Erlotinib
Gefitinib

Question 17

What are some side effects of EGFR inhibitors?

Answer 17

Mucosal toxicities
Skin rash
Diarrhoea
Rare: hepatitis, pneumonitis
Resistance develops in all patients, 50% due to a point mutation in t790M

Question 18

What is ALK?

Answer 18

Anaplastic lymphoma kinase is a transmembrane receptor tyrosine kinase - mutation caused by breakpoint leads to aberrant signalling
Found in 5%
Higher in younger, non smokers and adenocarcinomas

Question 19

What is the drug used on ELK mutated lung cancer?

Answer 19

Crizotinib - dual ALK and MET tyrosine kinase inhibitor