Lung Cancer

Question 1

Immunohistochemistry markers suggestive of lung Adenocarcinoma (3):

Answer 1

• TTF-1
• Mucin
• Napsin-A

Question 2

Non small cell lung cancer staging

• Define Stage I
• Define Stage II
• Define Stage III
• Define Stage IV

Answer 2

Question 3

Non-small cell lung cancer treatment of stages I to II

Answer 3

Chemotherapy:

• Adjuvant chemotherapy in stage II and IIIA disease. ( stage IB controversial)
• Normally cisplatin based combination treatment

Question 4

NSCLC treatment Stage III

Answer 4

Most controversial

Stage III NSCLCA chemoradiotherapy vs sequential treatment - Concurrent radiotherapy preferred over sequential therapy

• Most widely used are cisplatin-etoposide OR cisplatin-vinorelbine
• Radiotherapy doses used are in the range of 60-66 Gy, delivered in once-daily doses of 2 Gy. Higher total radiation doses have led to improved survival

Question 5

Treatment of non-small cell lung cancer -metastatic

Answer 5

Stage IV NSCLCA

• Median survival 4-5 month with best supportive care without systemic treatment
• Significant change in landscape of treatment
• Immunotherapy is integral part as first line or second line for patients without actionable mutation

Factors to be consider:

• Presence of driver mutation (EGFR,ALK rearrangement, ROS 1)
• Presence of PDL-1 (high vs low)
• Squamous (central, haemoptysis and very radio sensitive) vs non-squamous histology
• Performance status (PBS restrict most drug for performance status 2 or less)

Question 6

Mutation to look for before starting Osimertinib?

Answer 6

T790M mutation

Question 7

Investigations in NSCLC

Answer 7

Question 8

EGFR

• what kind of receptor?
• What is the typical phenotype?
• Name 4 drugs that are EGFR inhibitors
• Most important SE and what does it signify?

Answer 8

EGFR is a transmembrane amino-acid receptor tyrosine kinase of the ErbB family of proteins

Question 9

Treatment of SCLC

Answer 9

Limited = chemo + radiotherapy

Extensive = chemo only

Treatment -URGENCY of treatment

• Strongly associated with smoking
• Very chemotherapy sensitive tumour and rapid progression
• Occasional present with variety of paraneoplastic syndrome
• CNS metastasis is frequent (MRI brain/CT recommended)
• Platinum(cisplatin or carboplatin) with etoposide is recommended.
• Classified according to radiotherapy field (limited vs extensive)
• Radiotherapy recommended for limited stage from cycle 2 onwards with chemotherapy

Question 11

Treatment of NSCLC

Answer 11

Question 12

ALK

Answer 12

ALK gene rearrangement

ALK is a novel receptor tyrosine kinase of which the chromosomal translocation is associated with approximately 60% anaplastic large-cell lymphomas –hence “ALK”

• NSCLC associated with the novel EML4- ALK fusion oncogene
• Inversion in chromosome 2 that fuses EML4 gene with ALK gene

Alectinib

PFS was also significantly longer with alectinib than with crizotinib

• Alectanib is become standard of care. (PBS listed for first line)
• Less toxic
• Better CNS penetration – used over radiation in those with brain mets

Question 13

Genotypes with approved targeted therapies in NSCLC

• Name the ALK inhibitors (members of the ALK family)
• Name of EGR inhibitors
• Which can target ROS1

Answer 13

Question 14

Risk Features of Solitary Pulmonary Nodule

Answer 14

Question 15

Small Cell Lung Ca
% of lung cancer
Association with smoking
Staging
Management
Prognosis

Answer 15

Question 16

Paraneoplastic antibodies - Anti-Ri

Answer 16

Associated cancer - breast, gynaecologic, SCLC
Syndrome - Cerebellar degeneration, brainstem encephalitis, opsoclonus-myoclonus

Question 17

Immunohistochemistry markers suggestive of Squamous Lung Ca (2):

Answer 17

• *p63**
• *CK5/6** (CK7 negative)