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Lung Cancer Flashcards

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1
Q

What are the features of a T1 tumour

A

Size: up to 3cm (T1a up to 1cm, T1b 1.1-2cm, T1c 2.1-3cm
Localised to the lung or visceral pleura (with no main bronchus involvement)

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2
Q

What are the features of a T2 tumour

A

Size: 3.1-5cm (T2a 3.1-4cm, T2b 4.1-5cm
Minimal invasion (MVP): main bronchus, visceral pleura
Other features: atelectasis or post-obstruction pneumonitis up to hilum

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3
Q

What are the features of a T3 tumour

A

Size: 5.1-7cm
Moderate invasion (PCP): pericardium, chest wall, phrenic nerve
Satellite nodule within the same lobe

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4
Q

What are the features of a T4 tumour

A

Size >7cm
Advanced invasion (MDLOSTHCG): mediastinum, diaphragm, recurrent laryngeal nerve, oesophagus, spine, trachea, heart, carina, great vessels)
Tumour in separate lobe (ipsilateral)

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5
Q

What are the features of N1 disease

A

Near nodal involvement (peribronchial and ipsilateral mediastinal/intrapulmonary)

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6
Q

What are the features of N2 disease

A

Midline involvement (ipsilateral mediastinal, subcarinal)

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7
Q

What are the features of N3 disease

A

Distal involvement (scalene and supraclavicular, contralateral hilar and mediastinal)

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8
Q

What are the features of M1a disease

A

Contralateral lung tumour
Malignant effusion (plerual/pericardial)
Nodules (plerural/pericardial)

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9
Q

What are the features of M1b disease

A

Solitary extrathoracic metastasis or lymph node

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10
Q

What are the features of M1c disease

A

> 1 extrathoracic met (in 1 or multiple organs)

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11
Q

What are the stages of lung cancer for the following:
1. T1aN3M1a
2. T2bN2M0
3. T4N3M0
4. T3N2M1b
5. T2aN1M0
6. T3N2M1c
7. T2bN0M0

A
  1. IVA
  2. IIIA
  3. IIIC
  4. IVA
  5. IIB
  6. IVB
  7. IIA
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12
Q

Lymphangitis Carcinomatosis: definition, sources, signs, imaging, management

A

Definition: tumour invasion of pulmonary lymphatics
Sources: lung, breast, prostate, stomach, pancreatic
Signs: dyspnoea, systemic signs of advanced malignancy
Imaging: CXR – fine linear shadowing, septal lines present.
Management: symptom control (steroids, diuretics)

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13
Q

5 year survival rates of lung caner stages

A

IA1 90%
IA2 85%
IA3 75%
IB 70%
IIA 60%
IIB 50%
IIIA 35%
IIIB 25%
IIIC 15%
IVA 10%
IVB 0%

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14
Q

Provide some key figures from NICE guidelines regarding fitness for lung surgery (NSCLC)

A

SWT (shuttle walk test) >400m
CPET VO2 max >15ml/kg/min on

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15
Q

Name the different types of thoracic oncological operations and what they are used for

A

Pneumonectomy – for tumour involving >1 or 2 lobes, sometimes if hilar nodes involved.

Lobectomy (or bi-lobectomy) – for localized tumour. Radical if hilar nodes involved.

Segmentectomy – for localised peripheral lesion with clear regional lymph nodes (especially if post-operative respiratory function is predicted to be borderline

Wedge resection – tumour removal with minimal surrounding lung parenchymal removal. For localised peripheral lesion, 23% recurrence rate.

Sleeve resection – lobectomy with removal of section of bronchus affected by tumour (to avoid pneumonectomy).

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16
Q

What are the mortality rates for wedge resections, lobectomies and pneumonectomies?

A

Wedge: 1-3.5%
Lobectomy: 2-4%
Pneumonectomy: 6-8%

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17
Q

Name some post-operative complications

A

Bronchopulmonary fistula
Respiratory failure
Infection
Phrenic nerve damage –> diaphragmatic paralysis
Recurrent laryngeal nerve damage –> hoarse voice
Prolonged chest wall pain

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18
Q

What are the features of the WHO PS?

A

WHO Performance Status
0 – fully active, able to carry out all pre-disease activities
1 – restricted in physically strenuous activities, ambulatory and able to carry out light work (house work, office job)
2 – ambulatory, able to self-care, unable to carry out work activities, mobile >50% of waking hours
3 – limited self-care, confined to bed >50% of waking hours
4 – completely disabled, unable to self-care, totally confined to bed/chair

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19
Q

Who is SACT for?

A

For patients with advanced disease as a palliative intervention (prolong life, minimise symptoms). Must have WHO-PS 0-2

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20
Q

What are the tumour markers on NSCLC and some of their associations?

A

PEAR:-
- PD-L1 expression (squamous and non-squamous)
- EGFR-TK (epidermal growth factor receptor tyrosine kinase mutation) – non-squamous
o Never smokers, women, Asians
- ALK (anaplastic lymphoma kinase) tyrosine kinase gene rearrangement – non-squamous
o Younger patients, light/never-smokers
- ROS1 (c-ROS oncogene 1) receptor tyrosine kinase gene rearrangement – non-squamous

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21
Q

Broadly speaking, what are the lung function cut-offs for different surgical options

A

FEV1 + DLCO >80% –> resection up to pneumonectomy
If either FEV1 or DLCO <80% –> CPET
If Peak VO2 >75% or >20ml/kg/min –> resection up to pneumonectomy
If Peak VO2 <75% or <10ml/kg/min –> lobectomy/pneumonectomy not recommended
In between, based on split function ppo-FEV1 and ppo-DLCO

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22
Q

Describe the options for tumour resection in patients with emphysema and stage 1 NSCLC

A

For stage 1 NSCLC
If FEV1 >65% –> lobectomy
If FEV1 <65% with evidence of emphysema –> consider level of lung function impairment
- Severe impairment (FEV1 <30%) –> non-surgical modalities (RFA (radiofrequency ablation) and SBRT (stereotactic body radiotherapy)).
- Moderate impairment (FEV1 30-65%) –> consider anatomy of emphysema, location of mass and LVRS candidacy
o Ideal LVRS candidate –> mass resection with LVRS
o Non-ideal candidate –> consider sublobar resection

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23
Q

Grossly, what nodal stations correspond to the significant nodal regions for staging

A

N1:
- Peri-bronchial and hilar = Stations 10-14
N2
- Mediastinal = Stations 2-4, 5-6(left only) 8-9
- Subcarinal = Station 7
N3
- Supraclavicular = Station 1
- Any contralateral

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24
Q

What criteria would be required to discharge a patient with a pulmonary nodule

Study These Flashcards
A

Size <5mm
Volume <80mm3
Clear features of benign disease
Unfit for treatment

25
What initial features of a pulmonary nodule require 3/12 surveillance CT?
Size 5-8mm Volume 80-300mm3 Size >8mm with <10% risk of malignancy (Brock model) Risk of malignancy <10% on PET-CT (Herder model)
26
What are the options available for a pulmonary nodule following PET-CT
Based on risk (using Herder model) - <10% (low) risk of malignancy --> surveillance CT in 3/12 - 10-70% (intermediate) risk of malignancy --> image-guided biopsy/excision biopsy or CT surveillance (guided by individual risk and patient preference) - >70% (high) risk of malignancy --> consider excision or non-surgical treatment (such as SABR) (+/- image-guided biopsy)
27
What is the surveillance algorithm for a solid pulmonary nodule that is between 5-6mm in diameter?
1. 5-6mm (or volumetry not possible) --> CT in 1 year - If stable (2D/diameter) --> CT in 1 year (2 years from baseline) i. If stable --> discharge - If stable (+/-25% of volumetry) --> discharge - Long VDT (>600 days) --> consider discharge or ongoing surveillance (depending on patient preference and age) - Intermediate VDT (400-600 days) --> consider biopsy or further CT surveillance based on patient preference - Short VDT (<400 days) or clear evidence of growth --> consideration of definitive management and further workup
28
What is the surveillance algorithm for a solid pulmonary nodule that is >6mm or >80mm3 on volumetry?
2. >6mm or >80mm3 --> CT in 3/12 - If VDT >400 days --> CT surveillance 9/12 (1 year after baseline) i. If stable (2D/diameter) --> CT in 1 year (2 years from baseline) - If stable --> discharge ii. If stable (+/-25% of volumetry) --> discharge iii. Long VDT (>600 days) --> consider discharge or ongoing surveillance (depending on patient preference and age) iv. Intermediate VDT (400-600 days) --> consider biopsy or further CT surveillance based on patient preference v. Short VDT (<400 days) or clear evidence of growth --> consideration of definitive management and further workup - If VDT <400 days or clear evidence of growth --> consideration of definitive management and further workup
29
What are the key cut-offs for VDT (volume doubling time) for solid pulmonary nodules?
Long VDT >600 days Intermediate VDT 400-600 days Short VDT <400 days
30
What is the algorithm for sub-solid pulmonary nodules?
1. Nodule <5mm, patient unfit for treatment or nodule stable over 4 years --> discharge 2. If previous imaging available, but <4 years - If stable --> assess risk of malignancy - If growth or altered morphology (developing solid component) --> favour resection or non-surgical treatment 3. If no previous imaging available --> repeat thin-section CT in 3/12 - If resolved --> discharge - If growth or altered morphology (developing solid component) --> favour resection or non-surgical treatment - If stable, assess risk of malignancy (Brock Score) 4. If low risk of malignancy (<10%) --> thin section CT at 1, 2 and 4 years (from baseline) 5. If high risk of malignancy (>10%) or concerning morphology --> discuss with patient - Monitor with thin section CT (1, 2 and 4 years from baseline) - Image-guided biopsy - Resection/non-surgical treatment
31
When would the brain be imaged as part of the staging for NSCLC?
Symptomatic --> MRI Brain Asymptomatic:- - Stage II disease --> CT with contrast - Stage III disease --> MRI
32
How many segments are there in each lobe of the lungs?
Remember:- - RUL and LUL (not including lingula) = 3 - RML and Lingula = 2 - RLL = 5 - LLL (little bit smaller because of the heart) = 4 RUL = 3 RML = 2 RLL = 5 LUL = 5 (3 UL, 2 Lingula) LLL = 4
33
How do you calculate the PPO, and which lung function values can be calculated using it? For example a patient with DLCO at baseline 70% requiring a RUL lobectomy for a T2 tumour causing obstruction to the RUL apical segment
PPO can be used for FEV1 and DLCO ppoValue = Pre-operative value % / Total segments (discounting any obstructed segments) X Residual Segments Example: 70 / 18 x 16 = 62% 18 (rather than 19) as the DLCO is based on a an obstructed non-ventilating segment.
34
When would a cardiology opinion be required when assessing surgical risk for cancer treatment?
When: 1. Active cardiac condition or 2. 3 or more risk factors or 3. Poor cardiac function capacity Risk factors: - All thoracic surgery - IHD - CCF - Cerebrovascular disease - IDDM - CKD with Cr >177
35
What respiratory physiological assessments should occur or be considered when assessing fitness for surgery
Always: 1. Spirometry (for FEV1) 2. DLCO Consider: 1. Form of V/Q scanning 2. Shuttle walk test 3. CPET
36
What are the side-effects of immunotherapy?
* CNS - GBS - MG - Encephalitis * Endocrine - Thyroid (hyper- or hypothyroidism) - Hypophysitis - Pancreas --> T1DM - Adrenal insufficiency * Lungs --> pneumonitis * Cardiac --> myocarditis * GI - AI hepatitis - Colitis * Skin - Vitiligo - Psoriasis - SJS/DRESS * Rheumatological - Vasculitis - Arthritis
37
How are immunotherapy-related adverse events treatetd?
Treatment of Immune-Related Adverse Events Grade 1 – treat symptoms, continue treatment Grade 2 – Steroids for some, withhold most Grade 3 – steroids, withhold/discontinue treatment Grade 4 – steroids, discontinue treatment Steroid dose: 1-2mg/kg/day of prednisolone or alternate - Slow taper ofver >4 weeks
38
What are the different treatment options for different stages of locally advanced NSCLC
Advanced T-Staging, Early N-Staging:- 1. T3N0-1(M0) --> offer radical treatment 2. T4N0-1(M0) --> consider radical multimodality treatment Advanced N-Staging:- 1. N2 disease (M0) a. T1-T4 -> consider radical radiotherapy or chemoradiotherapy b. T1-T4 single zone N2 -> consider surgery (as part of multimodality approach) 2. N3 disease (M0) a. Consider clinical trials of radical treatment Metastatic Disease 1. Consider clinical trials of radical treatment
39
What are the associations with the EGFR mutation
- Females - Never smokers - Asian-Pacific descent - NSCLC predominance (adenocarcinoma)
40
What are the general SACT regimens for NSCLC based on gene expression?
Non-Squamous 1. EGFR mutations – treat with TK-inhibitors (tinibs), eg Erlotinub, Gefitinib, Afatinib, Dacomitinib (EGAD) 2. ALK rearrangement – treat with TK-inhibitors (tinibs), eg Alectinib, Crezotinib, Ceritinub (ACC) 3. ROS-1 rearrangement – treat with TK-inhibtors (tinibs), eg Crizotinib 4. No mutation and PD-L1 expression ≥ 50% - treat with PD-L1 Ab eg pendrolizumab 5. No mutation and PD-L1 expression <50% - treat with PD-L1 Ab (eg Atezolizumab) and VEGF inhibitor (eg Bevacizumab) and Carboplatin and Paclitaxel (no P, treat with ABCP) Squamous 1. PD-L1 expression ≥ 50% - treat with PD-L1 Ab (pembrolizumab) 2. PD-L1 expression <50% - treat with pembrolizumab + paclitaxel + carboplatin
41
What stage of lung cancer is combined chemotherapy used (and for what outcome)? What are the common agents used?
Usage: Stage III disease (or lower not suitable for surgery) with curative intent Common agents: cisplatin and etoposide
42
What are the options for radiotherapy in NSCLC (indications, contraindications, requirements, options)
Indications - Curative intent – high dose - Palliative control – high dose - Symptom relief – low dose Contraindications - No benefit following complete primary resection Requirements - PFTs including TLCO, with FEV1 >1.5L Options - Radical radiotherapy (high dose with curative intent) o Requirements: localised chest disease, Stage I-III, PS 0-1, unresectable (or resectable but unfit/don’t want surgery) - SABR (stereotactic body radiation therapy) o Requirements: small (<5cm) early stage (up to IIA/T2N0M0)
43
Provide details of the paraneoplastic syndromes associated with SCLC
SIADH (10% of SCLC) Cushing’s syndrome from ectopic ACTH production (5% of SCLC) LEMS (Lambert-Eaton Myasthenic Syndrome) - Features: proximal limb and trunk weakness, autonomic involvement (dry mouth, constipation, erectile dysfunction), hyporeflexia - Treatment: IVIG/plasmapheresis, steroids Cerebellar syndrome Limbic encephalitis - Features: personality change, seizueres, depression, subacute confusion, short-term memory loss - Associations: Anti-Hu Ab
44
What are the surgical options for SCLC
Early disease only (rare) – T1-2aN0M0 Consider post-operative combination chemotherapy for micromets
45
What are the chemotherapy options, and survival benefits, for SCLC
Typically etoposide with cisplatin or carboplatin Survival benefits - Limited disease – increases median survival by 15-20 months - Extensive disease – increases median survival by 8-13 months
46
When is radiotherapy used in SCLC
Non-metastatic disease (T1-4N0-3M0) with PS 0-1 – consider chest radiotherapy Limited/extensive disease who have completed chemotherapy – prophylactic cranioradiotherapy Symptomatic relief of bone pain, MSCC, SVCO
47
What are the treatment options for SVCO
Stents - 1st line treatment, especially while awaiting diagnosis - May not be necessary in SCLC (which rapidly responds to radiotherapy) Radiotherapy - Usually works within 3-4 weeks Steroids - Limited data to support use - Most would start with dexamethasone 8mg BD - Ideally obtain tissue diagnosis pre-treatment - Problematic if underlying diagnosis is lymphoma Treating the underlying cause - SCLC – chemo - NSCLC – radiotherapy - Lymphoma - chemo
48
What are the features, investigations and management of hypercalcaemia (specifically in the context of cancer)
Features (seen with Ca >3) - Confusion - Weakness - Nausea - Constipation - Short QTC - Renal failure Investigations - Supressed PTH (in malignancy) - Normal/high phosphate (in metastatic bone disease, as well as sarcoidosis) Management - Crystalloid - Consider furosemide (increases calcium secretion) - Bisphosphinates
49
What station are the supraclavicular LNs
Station 1
50
What LNs are at station 1
Supraclavicular
51
What are the upper zone lymph nodes, including their stations and local anatomical landmarks
Station 2 - upper paratracheal - above aortic arch Station 4 - lower paratracheal - between aortic arch and trachea, includes azygous nodes Station 3A - anterior (prevascular) Station 3P - posterior (prevertebral)
52
What LNs are in the aortopulmonary zone, including some anatomical landmarks?
Station 5 - subaortic nodes - lateral to aorta and pulmonary trunk Station 6 - para-aortic nodes - anterolateral to ascending aorta/arotic arch
53
What station are the subcarinal LNs located
Station 7
54
What LNs are located at station 7
Subcarinal
55
What are the lower zone/inferior mediastinal lymph nodes, including their stations and local anatomical landmarks
Station 8 - para-oesophageal - below the carina Station 9 - pulmonary ligament
56
What LNs are within the hilar/interlobular zone?
Station 10 - Hilar Station 11 - Interlobular
57
What station are the interlobular LNs located
Station 11
58
What station are the hilar LNs located?
Station 10
59
What station are the pulmonary LNs located?
Stations 12-14

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