Neoplasm

Question 1

NSCLC Stage 1 treatment

Answer 1

Surgery or if inoperable SBRT

> 1a -> post op targeted therapy if +EGFR
OR
if EGFR- neoadjuvant chemo then surgery

Question 2

NSCLC Stage 2 treatment

Answer 2

Surgery with
adjuvant chemo
OR
EGFR+/ALK+ then targeted therapy
OR
If EGFR/ALK neg then neoadjuvant chemo + immunotherapy then surgery

Question 3

NSCLC Stage 3 Treatment

Answer 3

Chemo + radiation + adjuvant immunotherapy or targeted therapy

If EGFR+ then adjuvant osimertinib
Or
High PDL1–> immunotherapy
Or
if EGFR neg then neoadj chemo, immuno then surgeryN

Question 4

NSCLC Stage 4 or recurrent

Answer 4

Chemo
Targeted therapy (EGFR- erlotinib, ALK alectinib)
Immunotherapy
Supportive Care

Question 5

Treatment for Pancoast tumor

Answer 5

Induction chemoradiotherapy
- if resectable better if chemo/rad pre op
- If not or N2 then concurrent chem/rad

Question 6

NSCLC surveillance

Answer 6

CT every 6mo for 2 years
THEN yearly until 5 years
(if eligible for LDCT then yearly)

Question 7

Treatment for Extensive Small cell

Answer 7

Cisplatin + VP-16 (epoposide)
OR carboplatin + VP-16 (less toxic)
OR cisplatin + irinotecan

2 cycles for induction then:
- 2-4 more for consolidaation
- No benefit to >6 cycles

Can add immunotherapy

NO XRT survival benefit but can be palliative

Question 8

Treatment for limited small cell

Answer 8

XRT + treatment for extensive

Question 9

Endobronchial lesion with t(11;19)(q21;p13) chromosomal translocation

Answer 9

Mucoepidermoid salivary gland type carcinoma

Question 10

Presentation and testing of hypertrophic ostoarthropathy (HOA)

Answer 10

Mass in lung
pain and swelling over long bones

99mTc bone scan

Question 11

Which diseases cause hypertrophic osteoarthropathy?

Answer 11

Non-small cell lung cancer
(Mesothelioma and benign fibrous tumors of pleura)

pulmonary fibrosis and bronchiectasis, cyanotic CHF, GI tumors, cirrhosis and IBD

Question 12

Lung cancer with hypercalcemia

Answer 12

Squamous cell carcinoma

PTHrp

Question 13

When to get mediastinal lymph node sampling ?

Answer 13

If considering resection with curative intent with metastatic dz to only one organ – need to make sure there is not additional spread

Question 14

Additional testing needed to determine treatment for non-small cell lung cancer

Answer 14

molecular characterization (need enough tissue so likely EBUS)
Genetic alterations- Next gen sequencing
PDL-1 expression (core biopsy)

Question 15

What value of FEV1 and DLCO would not require additional work up prior to lung resection?

Answer 15

> = 80%

if less then need to get predicted postop (PPO) lung function data

Question 16

How to assess contribution of lung region to function?

Answer 16

Lung perfusion scintigraphy – pneumonectomy
Segment counting – better for lobectomy (use CT)

Question 17

How to calculated PPO lung function using perfusion scintigraphy?

Answer 17

PPO FEV1 = preoperative FEV1 x (1 – fraction of total perfusion in the resected lung measured on radionuclide perfusion)

same for DLCO

Question 18

How to calculate PPO lung function with segment counting?

Answer 18

PPO FEV1 = preoperative FEV1 x (1 – a/b) where “a” is the number of segments to be resected and “b” is the total number of unobstructed segments (total number of segments is 19 [typically 10 on the right and 9 on the left])

Question 19

Which patients need more work up based on PPO FEV1 and/or DLCO?

Answer 19

<60%

Question 20

Postoperative predicted FEV1 or DLCO <60 percent but both ≥30 percent, next steps?

Answer 20

need to get stair climb (<22m need CPET) or shuttle walk test (<400 m need CPET)

Question 21

Postoperative predicted FEV1 and DLCO <30 percent, next steps?

Answer 21

CPET to measure VO2max

Question 22

lung resection risk based on CPET results

Answer 22

> 20 ml/kg/min (>75% predicted) - low risk

10-20 – moderate risk.

<10 (<35% predicted) – high risk

Question 23

fibrolymphoplasmacytic infiltrate on path suggestive of …

Answer 23

inflammatory myofibroblastic tumor (IMT)

Question 24

anaplastic lymphoma kinase translocations associated with what mass

Answer 24

inflammatory myofibroblastic tumor

Question 25

somatostatin receptors associated with what lung lesion

Answer 25

Carcinoid

Question 26

Recommended surveillance of NSCLC treated with curative intent

Answer 26

6 mo after completion of therapy and every 6mo for first 2 years then yearly though 5 years

Question 27

How to tell if two nodules are same cancer or two primary cancers?

Answer 27

Need histological genomic testing.

Features suggestive of separate tumors:
- different appearance on imaging
- different behavior
- absence of regional spread
- presence of different molecular biomarkers

Question 28

Multiple lung nodules from same cancer staging if in same lobe

Answer 28

T3

Question 29

Multiple lung nodules from same cancer staging if in different lobes of same lung

Answer 29

T4

Question 30

Multiple lung nodules from same cancer staging if in different lungs

Answer 30

M1a