Lung Cancer Flashcards
What is the overall 5-year survival rate for lung ca? Which one has the best survival rate?
15%. Worse for Small cell (5%), best for Bronchio-alveolar (~40%)
List 5 types of Lung Ca in order of frequency.
Adeno (32%)
Squamous (29%)
Small cell (18%)
Large cell (9%)
Bronchioalveolar (3%)
What are the risk factors for Lung cancer? (4)
Smoking (dose-dependent, includes passive smoking)
Occupational exposure (Asbestos - synergistic with smoking: risk 90-fold if concurrent smoking, uranium miners…etc)
Family history
Chronic scarring (TB, scleroderma, ILD - Adenocarcinoma)
What are the clinical features of local extension of Lung Ca? (8)
Pleural effusion
Pericardial effusion
SVC obstruction
Oesophageal obstruction
Bronchial obstruction
Lymphangitis
Rib involvement
Nerve involvement: Pancoast, Horner’s RLNP
What are the non-metastatic systemic features /manifestations of lung cancer? (5 categories)
Constitutional: weight loss, fever, cachexia
Endocrine: SIADH, Hypercalcaemia (PTHrP), Cushing’s (ACTH), Gyneocomastia (ectopic LH/FSH), Carcinoid syndrome, Insulin-like activity
Neurological: Eaton-Lambert, PN, autonomic neuropathy, cortical or cerebellar degeneration, dementia, acute transverse myelopathy
MSK: dermatomyositis / polymyositis
Haem: DVT/PE, BM infiltration
Primary Lung ca type for following ectopic secretions
ADH
ACTH
LH/FSH
PTH
Insilin-like
Carcinooids
Eaton-Lambert
ADH - small cell
ACTH - small cell
LH/FSH - all
PTH - squamous
Insulin-like- squamous
Carcinoids - small cell
Eaton-Lambert - small cell
Lung cancer examination findings
Cachexia, radiation tattoos, porta-cath
Clubbing, HPOA, small hand-muscle wasting
Pemberton’s sign, pallor, Horner’s, Hoarse voice (RLNP)
Tracheal deviation towards (collapse) or away (massive effusion)
Chest: fixed inspiratory wheeze, pleural effusion
What is your approach to investigating suspected Lung Cancer (e.g. large spiculated lung nodule on CXR)?
T: CT chest with contrast, sputum cytology, BAL lavage / bronchoscopy + biopsy, CT-guided biopsy. If pleural effusion: pleural fluid analysis + cytology. Consider VATS / thoracotomy
E: exclude
- Other malignancies: metastasis (with lung primary or lung mets from others) CT-CAP, PET scan, DOTATATE PET (NET)
- Infection: pneumonia work-up, sputum MCS, including fungal (e.g. Histoplasma) and AFB (TB), IGRA
- Inflammatory: Sarcoid (ACEi), GPA (ANCA), RA (RhF, CCP), Amyloid (electrophoresis)
S: FBC/film (BM involvement), EUC, CMP (Hypercalcaemia), LFT (liver mets), tumour markers (burden), LDH, CTB and CTAP, PET, Bone scan (small cell)
T: Tx baseline bloods & staging
S: complications - PE
Location of the lung tumour can suggest the cell type. Where are adeno, squamous, small cell, bronchoalveolar cell tumours typically found?
Adeno: peripheral nodule
Squamous: central + obstructive pneumonitis
Small cell: peri-hilar / mediastinal
Bronchoalveolar: alveolar infiltrate
Staging of small cell lung ca?
Limited: tumour confined to the ipsilateral hemithorax + regional lymph nodes able to be included in single tolerable radiotherapy port (corrensponding to TNM I-IIIB)
Extensive (70%): beyond boundaries of limited disease (e.g. mets, malignant pericdardial/pleural effusions, contralateral supraclavicular and hilar involvement )
What do you know about TNM staging of Non-small cell lung Ca?
(i.e. what is T, N and M)?
T (=size): T1 (≤1cm), T2 (≤5cm), T3 (≤7cm), T4 (≥7cm)
N: N1 (ipsilateral lung, peribronchial, hilar), N2 (all others - including ipsilateral mediastinal/subcarina)
M: M0, M1
So how would you convert TNM to stages in NSLCL?
Stage I: up to T2 (≤5cm) + no LN involvement
Stage II: up to T2 (≤5cm) + LN involvement
Stage III: T3-T4 +LN involvement
Stage IV: Mets
5-year survival rate for NSCLC depending on stages?
75% (I)
50% (II)
25% (III)
5% (IV)
Median survival rate for Small cell lung Ca?
Limited: 18 months
Extensive: 12 months
5-year survival
Limited: 10%
Extensive: 1%
SCLC treatment depending on stage?
Limited: Chemo + Radio + prophylactic cranial irradiation
Extensive: Chemo +/- Immuno. Only if responsive to Chemo then Radio + Cranial irradiation
NSCLC management depending on staging (except stage IV)?
Stage I-II:
Resection + adj chemo (except pathologic 1A)
RTx (no chemotherapy) if unfit for surgery
Stage III:
MDT discussion - options are
Surgery +/- Chemo +/- RTx
Chemo + RTx
Palliative RTx or Chemo
Best supportive care
Treatment option for Stage IV NSCLC?
Systemic therapy or symptom-based palliative therapy
Systemic therapy:
- If driver mutation present, targetted therapy
- PDL1 expression ≥50%: Pembrolizumab (if progresses then chemo). If very extensive or rapidly progressing → platinum doublet + pembrolizumab
- PDL1 <50%: platinum doublet chemotherapy + pembrolizumab
- Consider addition of Bevacizumab (VEGF-Ai - aka AVASTIN) in non-squamous
Consider palliative measures for symptom control:
- laser coagulation / bronchoscopic removal of tumour / stenting)
- Palliative RTx, draining pleural effusion (tunnelled pleural catheter)
Treatment options for those with driver mutations? (discuss 4 mutations)
EGFR: Osimertinib (1st line), Gefitinib, Erlotinib. Combinaiton of Chemo is not a standard option given toxicity.
ALK: Alectinib (1st line - better penetrate CNS), Crizotinib.
ROS 1: Crizotinib or Entrectinib.
If patient progressed on immuno and/or chemotherpy and has BRAF V600 mutation - dabrafenib + trametinib
Main side effects of EGFR inhibitors?
Gefitinib, Erlotinib, Osimertinib (T790 mutation)
Acneiform rash - also predicts response.
ALK inhibitors - give a few names. Main side effects?
ALKaline batteries are CERtified by ALEx, Lora and Cris in the quality control (QT) centre.
Alectinib
Ceritinib
Loratinib
Alectinib
Long QT / Bradycardia
Bevacizumab - what is it and 3 side effects?
VEGF inhibitor - MAB that interferes with angiogenesis
Side FX are therefore, bowel perforation, HTN and Bleeding.
Immunotherapy side effects in general? (many)
How would you MANAGE this patient with Cancer recurrence? (up to G-CA)
Goals: delay progression, minimise complication of therapies, symptom control and advanced care planning
Confirm the dx, staging, previous therapy profiles
A: screen & treat for depression, ETOH excess, infection, anaemia (fatigue)
How would you MANAGE this patient with Cancer recurrence? (T-ICE)
T: Non-pharm
- Educate prognosis, discuss Advanced Care Planning early
- Offer counseling & support, involve SW
- Early referral to palliative care, dietician
- Encourage health-promoting life-style changes: exercise (1A), mind-body intervention (Yoga - 2A) rather than alcohol and smoking
- CBT has 2C evidence for helping with fatigue (also depression)
T: Pharm
- Consider palliative RTx (or surgery, chemo) for symptom control
- Paracetamol + Opioid analgesia + Laxatives
- Consider steroids for severe fatigue
I: involve family, GP and AH for continued support and appropriate home modification
CE: ensure follow-up and monitor for complications of
Disease: progression (prompt for alternative Mx strategy), PE, depression
Chemo/Immunotherapy: immuno/chemo side effects
Pain therapy: adequate?, constipation, drowsiness, falls
Monitor for cognitive impairment that may affect driving or work safety
