Lung Cancer

Question 1

What are the criteria for lung cancer screening?

Answer 1

1. Age 55-74 years
2. > or = 30 pack year hx smoking
3. Current smoker or quit within the past 15 years.

ONLY APPLIES if > 18 years old and NOT suspected of having lung CA. ONLY screen if reasonable life expectancy and suitable for tx of lung cancer.

Question 2

What is the work up for patients with lung cancer?

Answer 2

All patients get a CT C/A/P and either a CT or MRI brain.

If they do not have evidence of metastatic disease on CT/imaging, then:

• PET to look for occult metastasis
• Mediastinal staging (EBUS or mediastinoscopy)

Question 3

What is Stage I non-small cell lung cancer?

Answer 3

Tumour size < or = 4 cm, without lymph node involvement.

Question 4

What is Stage 2 non-small cell lung cancer?

Answer 4

Ipsilateral parenchymal or hilar lymph nodes

OR

Tumour size > or = 5 cm

Question 5

What is Stage 3 NSCLC?

Answer 5

Mediastinal or Supraclavicular lymph nodes involved.

Question 6

What is Stage 4 NSCLC?

Answer 6

Malignant effusion or distant metastases.

Question 7

What are the requirements on PFT for resection of early stage NSCLC?

Answer 7

Predicted post-op FEV1 AND DLCO > 60%

Question 8

What is the treatment of Stage I/II NSCLC?

Answer 8

Fit for Surgery -> Surgery + adjuvant chemotherapy with a platinum doublet (Cisplatin + pemetrexed/vinorelbine)

Unfit for Surgery -> Radiation +/- adjuvant chemotherapy.

Question 9

What is the treatment for Stage III (locally advanced) NSCLC?

Answer 9

These patients get discussed at multi-disciplinary rounds.

Respectable: Surgery + adjuvant chemo, assessment by rad onc.

Unresectable: Concurrent chemorads, followed by potential immunotherapy with a checkpoint inhibitor x 1 year (Durvalumab)

Question 10

What is the therapy for Stage IV EGFR + NSCLC?

Answer 10

EGFR Inhibitor (Osimertinib, gefitinib, erlotinib)

Question 11

What is the treatment for ALK + metastatic NSCLC?

Answer 11

ALK Inhibitor (Crizotinib, Alectinib)

Question 12

If there is no driver mutation, how do you treat Stage IV NSCLC?

Answer 12

PD-L1 Expression > or = 50%: immunotherapy 1st line (pembrolizumab)
PD-L1 < 50%: Chemo (plantinum + pemetrexed) +/- pembrolizumab

Question 13

What are the stages of small cell lung cancer?

Answer 13

Limited: Confined to 1 hemithorax or 1 radiation field.
Extensive: NOT confined to 1 radiation field or presence of a malignant effusion.

Question 14

How is limited stage small cell lung cancer treated?

Answer 14

Chemoradiotherapy + prophylactic cranial irradiation.

Curative intent.

Question 15

How is extensive stage small cell lung cancer treated?

Answer 15

Chemotherapy +/- prophylactic cranial irradiation (fallen out of favour)
Palliative intent.

Question 16

What are the paraneoplastic syndromes of small cell lung cancer?

Answer 16

1. SIADH
2. Lambert-Easton Myasthenic Syndrome (LEMS)
3. Encephalomyelitis & Sensory Neuropathy
4. Cushing’s Syndrome

Question 17

What are the paraneoplastic syndromes of NSCLC?

Answer 17

Hypertrophic Osteoarthropathy - Clubbing and new periosteal bone formation of tubular bones, with symmetrical, painful arthropathy of the ankles, knees, wrists and elbows.

Question 18

What is the paraneoplastic syndrome associated with squamous cell NSCLC?

Answer 18

Hypercalcemia due to PTHrP