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Hematology, oncology > Small cell lung cancer > Flashcards

Small cell lung cancer Flashcards

1
Q

SCLC vs NSCLC in terms of doubling time, mets

A

SCLC = rapid doubling time, higher growth fraction, early widespread hematogenous metastases.

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2
Q

SCLC chemo and radiosensitivity

A

highly sensitive to initial chemo and radiation

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3
Q

typical clinical course

A

High initial response rates, but then most patients relapse within a few months of completing initial therapy and die (tumor rapidly develops resistance)

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4
Q

Driver mutations and SCLC?

A

No driver mutations amenable to currently available targeted drug therapies.

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5
Q

Impact on mortality from lung cancer screening.

A

None. All mortality reduction from screening is for NSCLC.

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6
Q

Common sites of mets

A

Brain, *liver, bone, *adrenal glands.

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7
Q

Most frequent cause of paraneoplastic syndromes

A

SCLC!

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8
Q

paraneoplastic syndromes associated with SCLC

A

1) *SIADH
2) ectopic adrenocorticotropic hormone (ACTH) production, Cushing syndrome
3) Lamber-Eaton syndrome
4) Subacute cerebellar degeneration
5) encephalomyelitis
6) Myoclonus-opsoclonus)

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9
Q

staging workup

A

MRI brain
PET/CT to confirm limited stage (especially if lymphadenopathy suspected)
IF PET/CT not done –> CT chest/abdomen/pelvis

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10
Q

basic staging classification

A

Limited stage and extensive stage

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11
Q

Median survival of limited stage

A

About 16 months

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12
Q

Median survival of extensive stage

A

About 10 months

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13
Q

Limited stage definition

A

Tumor confined to ipsilateral hemithorax and regional nodes able
- tumor must be be encompassed in a single tolerable radiotherapy port (for chemoradiotherapy)

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14
Q

Extensive stage definition

A

Tumor beyond ipsilateral hemithorax or metastatic disease.

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15
Q

Typical presentation

A
  • Typically disseminated at presentation
  • Rapid onset of symptoms (cough, SOB, wheezing, PNA)
  • Often with signs of metastatic disease (abdominal pain, bone pain, vomiting, headache)
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16
Q

Main chemotherapeutic agents

A
  • Cisplatin/carboplatin
  • etoposide
  • topotecan/irinotecan
  • atezolizumab
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17
Q

Goal of therapy for limited and extensive stage

A

Limited stage = cure
Extensive stage = palliative

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18
Q

Standard of care for limited-stage SCLC (including cycles + adjuvant treatment)

A
  • Concurrent chemoradiation ASAP w/ 4 to 6 cycles of cisplatin plus etoposide with concurrent radiation
  • followed by PCI for 4 to 6 weeks after completion of therapy
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19
Q

What is PCI?

A

prophylactic cranial irradiation

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20
Q

Treatment in general of extensive-stage SCLC

A

Palliative chemoimmunotherapy, followed by PCI

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21
Q

what is WBRT?

A

whole-brain radiation therapy

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22
Q

Complications of concurrent chemoradiation

A

Increased risk of esophagitis, dysphagia, odynophagia, oropharyngeal/esophageal candidiasis, pneumonitis

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23
Q

role for maintenance chemo in SCLC?

A

None (no survival benefit)

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24
Q

Definition of refractory

A

tumor progresses during the initial therapy or did not respond to initial therapy

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25
Q

Definition of sensitive relapse

A

Tumor progression occurs 90 days or more after last day of initial treatment

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26
Q

Definition of resistant relapse

A

Tumor progression occurs within 90 days or more of last day of initial treatment

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27
Q

Treatment of relapse if no clinical trial available

A

IF >6 months, repeat original regimen
If between 3 and 6 months, topotecan

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28
Q

Preferred management of refractory or relapsed disease

A

Clinical trial

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29
Q

Role for surgery?

A
  • In rare cases, SCLC is diagnosed at an early stage and surgery is recommended followed by adjuvant chemo
30
Q

Follow up imaging timeframe

A

CT chest q3 months during first 2 years

31
Q

most common lung cancer types/breakdown statistically

A

Non-small cell lung cancer (NSCLC) accounts for the majority (approximately 85 percent) of lung cancers with the remainder as mostly small cell lung cancer (SCLC).

32
Q

Evidence/utility for PET/CT for SCLC diagnosis

A

*Routinely used but has never shown a survival benefit.
- LIMITED STAGE: More accurate in detecting occult disease, so should really be used if concern for occult disease (patients with limited stage, potentially resectable disease, ie finding occult met would change management).
- More accurate in determining mediastinal disease.

33
Q

SUV criteria for determining what defines a malignant nodule

A

There are no standardized criteria defining what constitutes a positive PET result and no ideal cut-off point for the standardized uptake value (SUV).

34
Q

how to determine if lymph node is malignant based on SUV criteria

A

lymph nodes with FDG uptake greater than that observed in the mediastinal blood pool are highly suspicious for metastatic disease

35
Q

Where SCLC typically arises

A

Central airways, infiltrating the submucosa, and gradually narrowing the bronchial lumen through extrinsic or endobronchial spread.

36
Q

Most common radiographic presentation of SCLC

A

large hilar mass with bulky mediastinal adenopathy.

37
Q

Etoposide SE’s

A
  • myelosuppression
  • hypersensitivity reaction
  • pulmonary toxicity/ILD
  • nausea/vomiting
  • see others on package insert
38
Q

Preferred regimen for extensive stage SCLC

A
  • Cis or carboplatin + etoposide
    atezolizumab
39
Q

Histology of small cell lung cancer

A

neuroendocrine

40
Q

Typical clinical course of small cell

A

Responds rapidly to both chemotherapy and radiotherapy (RT), it commonly relapses within months despite treatment.

41
Q

Staging classification

A

limited-stage (LS) versus extensive-stage (ES) disease

42
Q

Preferred regimen for extensive stage

A

Carboplatin-etoposide and atezolizumab, followed by maintenance atezolizumab

43
Q

why carboplatin etoposide is preferrable if extensive stage

A

Less nephrotoxicity, neurotoxic, and less emetogenic, with comparable outcomes to cisplatin

44
Q

general term for irinotecan class of drugs

A

camptothecin analogues

45
Q

duration of induction chemotherapy for SCLC

A

The optimal duration of induction chemotherapy for patients with SCLC is not well defined; conventional approach is to give 4-6 cycles.

46
Q

Initial management of SCLC patient with brain mets

A

If asymptomatic – Upfront systemic therapy followed by WBRT.
IF symptomatic brain metastases – Upfront WBRT, followed by induction systemic therapy (no point in surgery going to come back)

47
Q

Why WBRT is used for SCLC and not SRS

A

WBRT is typically preferred for those with SCLC and any degree of intracranial disease, due to the propensity for SCLC to recur intracranially.

48
Q

Response assessment following induction chemo

A

Ct chest/abdomen/pelvis with contrast + brain MRI

49
Q

Treatment of SCLC relapse within 6 months

A

Topotecan OR
Lurbinectedin OR
Clinical trial

50
Q

What is intensification therapy?

A

Consolidation therapy, just another term

51
Q

Targeted agents approved for SCLC

A

None with proven benefit to date

52
Q

EP regimen is

A

Etoposide/cisplatin

53
Q

Standard of care chemo regimen for extensive stage + duration

A
  • EP (etoposide + cisplatin or carbon-latin doublet) + immunotherapy with a CPI
  • 4-6 cycles
54
Q

Why EP is standard of care in the US

A

Many regimens have been shown to be equally effective but EP is less toxic

55
Q

Role for maintenance chemotherapy

A

None, hasn’t been shown to be effective in SCLC (resistance)

56
Q

Common change in regimen when patients become extensive stage

A

Change from cisplatin to carboplatin (better tolerated, equal efficacy)

57
Q

FDA-approved IO drugs for SCLC

A
  • atezolizumab
  • durvalumab
58
Q

Evidence for PCI in extensive stage

A
  • controversial (conflicting data, including a study with shorter OS + a lot of people develop brain mets even with PCI)
59
Q

New FDA approved drug for relapsed SCLC

A

Lurbinectedin (“lure”)

60
Q

Treatment of relapsed SCLC depends on…

A

How long after from 1L therapy patient relapses

61
Q

Lurbinectidin MOA in general

A

Pro-apoptotic + alters the tumor microenvironment

62
Q

Preferred chemo regimen for limited stage

A

Cisplatin + etoposide

63
Q

initial branch point in management of extensive stage aside from brain mets

A

presence of localized symptomatic sites, which warrant RT before systemic therapy

64
Q

Preferred management of sensitive relapse

A

Repeat original regimen

65
Q

limited stage management in poor PS

A

Systemic therapy and RT often done sequentially rather than concurrently

66
Q

management of relapse in SCLC

A
  • if greater than 6 months out, rechallenge original regimen
  • if within 6 months, lurbinectidin
67
Q

fractionation schedule in limited stage SCLC

A

BID fractions

68
Q

first line for limited stage SCLC, followed by PCI

A
  • concurrent chemoRT with cisplatin-etoposide, followed by PCI
69
Q

Radiation fractonation for limited stage small cell

A

Twice daily

70
Q

adjuvant management of resected early stage SCLC

A

4 cycles of cisplatin, etoposide

Hematology, oncology (218 decks)

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