Lung Oncology Flashcards
What are the risk factors for lung cancer?
cigarette smoking (10x risk) absbestos radon metals polycyclic aromatic hydrocarbons ionizing radiation
What are the two types of lung cancer?
non small cell (80%)
Small cell carcinoma (20%)
What pathology makes up non small cell lung cancer?
SCC (30%)
Adenocarcinomas (50%)
Large cell carcinomas
Upon clinical presentation what are the four areas that symptoms relate to?
primary lesion
intrathoracic spread
distant metastases
paraneoplastic syndromes
What are the symptoms for a primary lesion?
cough
breathlessness
haemoptysis
chest pain
What are the symptoms for intrathoracic spread?
pleural or percardial effusion
hoarseness of voice
brachial plexus involvement
compression of SVC
What are the symptoms for distant metastases?
pain (bone mets) weakness and weight loss headaches seizures neurological symptoms (cerebral mets)
What are paraneoplastic syndromes?
set of symptoms due to either a immune response to the cancer or by substances secreted by the cancer
(Hyperdalcemia, clubbing, hypertophic pulmonary osteopathy, SIADH- Syndrome of inappropriate antidiuretic hormone secretion)
What are the four steps of diagnostic evaluation of lung cancer?
- confirm the diagnosis of cancer
- determine what type of cancer (pathology, cytology, immunohistochemistry)
NSCLC vs SCC
NSCLC- adeno vs SCC - evaluate staging
- if localised determine if patient is fit for radicl or palliative RT
What are the other considerations in diagnostic evaluation?
symptoms other medical condition (heart disease, chronic lung disease) weightloss exercise tolerance full respiratory function tests (RFTs) (spirometry- FEV1/FVC) (measures of diffusion (DLCO))
What techniques can be used in diagnostic evaluation?
chest x-ray
CT scan (chest, abdomen +/- brain)
Biopsy (e.g. CT-guided fine needle aspiration biopsy, bronchoscopy)
What is the ‘resectability’ of the different stages of lung cancer
early stage (IA, IB, IIA, IIB)- potentially resectable locally advanced (IIIA, IIIB)- usually unresectable metastatic (IV)
What techniques can be used in diagnostic evaluation/ investigation of NSCLC?
NSCLC- positron emission tomography (PET) scan
EBUS- Endobronchial USS
Mediastinoscopy
(both considered where PET +ve mediastinum and want to exclude false +ve)
How would you treat Early stage NSCLC if resectable + acceptable lung & cardiac function + no other co-morbidities that would preclude surgery?
surgery +/- adjuvant chemotherapy (lobectomy, pneumonectomy, wedge resection)
How would you treat Early stage NSCLC if patient refused surgery or they had co-morbidities that precluded surgery + acceptable lung function?
Radical Radiotherapy
(50Gy/ 20# OR 60Gy/ 30#)
SBRT
How would you treat Early stage NSCLC if poor lung function - CI to high dose RT?
Observe or Palliative RT (depending on whether symptomatic)
SBRT
For treatment of early stage NSCLC would adjuvant treatment after surgery be used?
Chemo: improved survival (4%) in ≥iB disease, platinum based doublet
Radiotherpy: not indicated unless +ve margins. Evidence suggests worse survival when RT affed after complete resection for early disease
What does treatment of locally advance (Stage III) (usually unresectable) NSCLC depend on?
volume of disease
lung function
co-morbidities (fitness for chemo)
symptoms
What are the limitation for RT in lung cancer?
lung cancer is aggressive
normal lung radiosensitive (lungs are vital)
uninvolved lung often doesn’t work wll due to pre-existing smoking related lung disease (chronic obstructive pulmonary disease)
What is the typically treatment for locally advance NSCLC if:
volume of disease not too large
acceptable lung function
fit for chemo?
Radical Chemoradiotherapy
(concurrent platinum-based chemotherapy and 60Gy/30# radical RT)
(addition of chemo to RT gives better overall survival than RT alone although increases toxicity
What is the typically treatment for locally advance NSCLC if:
volume of disease not too large
acceptable lung function
unfit for chemo?
Radical Radiotherapy
60Gy/ 30#
What is the typically treatment for locally advance NSCLC if:
volume of disease not too large
acceptable lung function
Symptoms?
Palliative RT +/- chemo
OR
Chemo alone
What is the typically treatment for locally advance NSCLC if:
volume of disease not too large
acceptable lung function
No symptoms?
Observe
or chemo
Has concurrent or sequential chemoradiotherapy resulted in a better survival?
concurrent
What was the result of dose escalation trials for inoperable stage III NSCLC?
compared 60Gy/30# with concurrent chemotherapy with 74Gy/ 37#
worse survival with high dose (more treatment related deaths)
What is the process for the small % of stage III locally advanced disease that can receive surgery?
appropriate only for low volume or unexpected mediastinal node disease
Neoadjuvant chemotherapy to improve resectability for those borderline resectable
Adjuvant chemotherapy indicated