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Respiratory (Long) > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

What is the overall 5-year survival rate for lung ca? Which one has the best survival rate?

A

15%. Worse for Small cell (5%), best for Bronchio-alveolar (~40%)

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2
Q

List 5 types of Lung Ca in order of frequency.

A

Adeno (32%)

Squamous (29%)

Small cell (18%)

Large cell (9%)

Bronchioalveolar (3%)

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3
Q

What are the risk factors for Lung cancer? (4)

A

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)

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4
Q

What are the clinical features of local extension of Lung Ca? (8)

A

Pleural effusion

Pericardial effusion

SVC obstruction

Oesophageal obstruction

Bronchial obstruction

Lymphangitis

Rib involvement

Nerve involvement: Pancoast, Horner’s RLNP

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5
Q

What are the non-metastatic systemic features /manifestations of lung cancer? (5 categories)

A

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

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6
Q

Primary Lung ca type for following ectopic secretions

ADH

ACTH

LH/FSH

PTH

Insilin-like

Carcinooids

Eaton-Lambert

A

ADH - small cell

ACTH - small cell

LH/FSH - all

PTH - squamous

Insulin-like- squamous

Carcinoids - small cell

Eaton-Lambert - small cell

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7
Q

Lung cancer examination findings

A

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

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8
Q

What is your approach to investigating suspected Lung Cancer (e.g. large spiculated lung nodule on CXR)?

A

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

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9
Q

Location of the lung tumour can suggest the cell type. Where are adeno, squamous, small cell, bronchoalveolar cell tumours typically found?

A

Adeno: peripheral nodule

Squamous: central + obstructive pneumonitis

Small cell: peri-hilar / mediastinal

Bronchoalveolar: alveolar infiltrate

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10
Q

Staging of small cell lung ca?

A

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 )

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11
Q

What do you know about TNM staging of Non-small cell lung Ca?

(i.e. what is T, N and M)?

A

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

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12
Q

So how would you convert TNM to stages in NSLCL?

A

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

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13
Q

5-year survival rate for NSCLC depending on stages?

A

75% (I)

50% (II)

25% (III)

5% (IV)

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14
Q

Median survival rate for Small cell lung Ca?

A

Limited: 18 months

Extensive: 12 months

5-year survival

Limited: 10%

Extensive: 1%

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15
Q

SCLC treatment depending on stage?

A

Limited: Chemo + Radio + prophylactic cranial irradiation

Extensive: Chemo +/- Immuno. Only if responsive to Chemo then Radio + Cranial irradiation

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16
Q

NSCLC management depending on staging (except stage IV)?

A

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

17
Q

Treatment option for Stage IV NSCLC?

A

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)
18
Q

Treatment options for those with driver mutations? (discuss 4 mutations)

A

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

19
Q
A
20
Q

Main side effects of EGFR inhibitors?

A

Gefitinib, Erlotinib, Osimertinib (T790 mutation)

Acneiform rash - also predicts response.

21
Q

ALK inhibitors - give a few names. Main side effects?

A

ALKaline batteries are CERtified by ALEx, Lora and Cris in the quality control (QT) centre.

Alectinib

Ceritinib

Loratinib

Alectinib

Long QT / Bradycardia

22
Q

Bevacizumab - what is it and 3 side effects?

A

VEGF inhibitor - MAB that interferes with angiogenesis

Side FX are therefore, bowel perforation, HTN and Bleeding.

23
Q

Immunotherapy side effects in general? (many)

A
24
Q

How would you MANAGE this patient with Cancer recurrence? (up to G-CA)

A

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)

25
Q

How would you MANAGE this patient with Cancer recurrence? (T-ICE)

A

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

Respiratory (Long) (11 decks)

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