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Respiratory SCE > Lung cancer > Flashcards

Lung cancer Flashcards

1
Q

What is the assessment for surgery?

A

LFTs- not for post procedure FEV1 40% cut off anymore as tumours can cause VQ mismatch and may be disproportionate emphysema. But if >40% and post procedure TLCO >40%- deemed low risk.

Shuttle walk >400m
CPET VO2 max >15ml/kg/min

cardio/neuro/pysch as appropriate

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2
Q

Who are the Group 1 patients? and what should we be doing? prevalance of N2/3 disease?

A

Peripheral tumour only

PET followed by biopsy unless PET pos nodes
N2/3 5-10%

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3
Q

Who are the Group 2 patients? and what should we be doing? prevalance of N2/3 disease?

A

central tumour or N1 adenopathy only

PET followed by staging EBUS, if neg need to be biopsy
N2/3 20-25%

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4
Q

Who are the Group 3 patients? and what should we be doing? prevalance of N2/3 disease?

A

1ary tumour with discrete mediastinal LNs on CT, no mets

PET, staging EBUS if neg need to be biopsy
N2/3 60%

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5
Q

Who are the group 4 patients? and what should we be doing? prevalance of N2/3 disease?

A

invasive/nodal malignancy with no distant mets

doesn’t need PET techinically- can go straight to biopsy- normally to neck US +/- diagnostic EBUS

N2/3 close to 100%

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6
Q

Who are the Group 5 patients? and what should we be doing? prevalance of N2/3 disease?

A

Distant mets on CT

go straight to tissue- easiest to obtain with needing further procedure

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7
Q

What is the incidence of brain disease? and who to image?

A

10-20%
CT = clinical stage II NSCLC having curative intent
MRI= stage III NSCLC having curative intent

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8
Q

In curative intent who needs to see a cardiologist? Who to include or exclude?

A

Cardiology: x3 RF or more, poor cardiac function or active disease

x2 or less RF can be offered surgery
optimised cardiac disease
avoid surgery <30days after MI

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9
Q

who to offer surgery to based on LFTs?

A

good ET with normal FEV1
need to work out function segments and work out post op DLCO
predicted postop FEV1 or TLCO below 30% IF they accept risks of SOB and associated comps
shuttle walk >400m
CPET VO2 max >15ml/kg/min

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10
Q

Who to offer SABR to?

A

decline surgery/too high risk in T1a-2b
lesions outside 2cm radius of main airways and proximal bronchial
tree. This is defined as 2cm from the bifurcation of the second order bronchus

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11
Q

What are the radiation fractions?

A

55 Gy in 20f over 4 weeks
60–66 Gy in 30–33f over 6–6½ weeks

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12
Q

Who do you offer chemorad to?

A

Stage II and III that aren’t fit/decline surgery
OFFER post op chemorad to Tany N1-2 disease
CONSIDER post op chemorad to T2b-4 N0 (ie tumours >4cm)
WITH surgery IIIA–N2

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13
Q

treatment consequence in SqCLC? which mutations matter and what is the treatment?

A

PDL1 <50% no mutations
Pembro+carbo+paclitaxel or platinum bichemo
FAILS pembro (>1%), nivolumab/atizolizumab or docetaxel

PDL1 >50% no mutations
Pembro+carbo+paclitaxel or pembro or atizolizumab
FAILS docetaxel

Mutations:
RET- above plus selpercatinib at any point
NTRK- if fails docetaxel- Entrectinib or larotrectinib
KRAS- sotorasib at any point
METex14- tepotinib at any point
EGFRexon20- mobocertinib at any point

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14
Q

treatment consequence in non-SqCLC? which mutations matter and what is the treatment?

A

PDL1<50% no mutations
pemetrexed and cisplatin, or Pembro+carbo or variation of with atizolizumab

PDL1>50% no mutations
Pembro+permetrexed or pembro or atizolizumab
FAILS docetaxel

MAIN THING IS IF MUTATION- MUTATION TARGET NORMALLY 2ND LINE

Mutations:
RET- above plus selpercatinib at any point
NTRK- if fails docetaxel- Entrectinib or larotrectinib
KRAS- sotorasib at any point
METex14- tepotinib at any point
EGFRexon20- mobocertinib at any point

ROS1 POS
crisotinib or entrectinib 1st line

EGFR-TK POS
afatinib, osimertinib etc 1st line

ALK POS
brigatinib, alectinib, certinib etc 1st line

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15
Q

A patient has a solid 7mm nodule with no previous imaging without typical benign features. What do you do?

A

Repeat at 3 months.
If VD time is <400days or clear growth procede to resection (+/- biospy)
if >400days CT at 1 yr from baseline

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16
Q

A patient has a solid 7mm nodule with no change on 1yr scan without typical benign features. What do you do?
What do you do if it has increased?

A

If VD time done- can be discharged, if not, repeat at 2yr- then consider discharge then if no change.
If VD <400days- resect/treat
if VD 400-600- CONSIDER biopsy or further scan (pt preference)
if VD >600 days- consider discharge or further scan (0.8% ca risk)

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17
Q

A patient has a sub-solid 6mm nodule without typical benign features. What do you do?

A

3 month CT unless previous imaging for 4 years shows stability- can consider discharge

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18
Q

A patient has a sub-solid 6mm nodule with no change at 3mo scan without typical benign features. What do you do?
What do you do if it has increased?

A

Brock score
If <10% risk of malignancy- for 1yr, 2yr and 4yr CT
If >10% or concerning morphology- OPTIONS to patient- 1/2/4yr survey, biopsy, treat/resect

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19
Q

Which cancers are likely to metastase?

A

based on liklihood:
1. Sq from head and neck
2. lymphoma/leukaemia
3. mets from bladder, breast, cervix, biliary tree, oesophagus, ovary, prostate or stomach
4. salivary, adrenal, colon, parotid, kidney, thyroid, thymus or uterus
5. melanoma, sarcoma or testicular carcinoma

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20
Q

what are the radiological predictors of malignancy for a nodule?

A
  1. diameter
  2. spiculation
  3. pleural indentation
  4. UL
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21
Q

What are the radiological predictors for a benign lesion?

A
  1. calcification
  2. smooth border
  3. cavitation
  4. satellite lesions
  5. lentiform/triangular within 1cm of pleura- tend to be IPLN
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22
Q

T in TNM for Lung ca?

A

T1- <3cm not involving main bronchus
0-1cm T1a
1-2cm T1b
2-3cm T1c

T2 3-5cm OR <3cm includes main bronchus or invades visceral pleura or obstructive atelectasis/pneumonitis
3-4cm T2a
4-5cm T2b

T3 5-7cm OR <5cm includes invasion of pericardium, chest wall, phrenic nerve or nodule in SAME LOBE

T4 >7cm OR invasion of mediastinum, oesophagus, spine, diaphragm, recurrent laryngeal, carina or trachea or nodule in DIFFERENT IPSILATERAL LOBE

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23
Q

N in TNM for Lung ca?

A

N1 ipsilateral S10,11,12
N2 ipsilateral S4 and 7
N3 any other chest nodes including contralateral and pericardial

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24
Q

M in TNM for Lung ca?

A

M1a nodule in contralateral lung, pericardium or malignant effusion
M1b SINGLE extrathoracic nodule or LN
M1c lots extrathoracic

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25
Q

What is the risk of PTX during CT guided biopsy?

A

15%
6.6% require drain

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26
Q

What is the mortality of a wedge resection?

A

0.4% for inpatients
2.1% 30 day 4.2% 90 day

27
Q

when would you nav bronch/radial EBUS over CT guided biopsy?

A

Consider if lesion is >1/3 away from the periphery

28
Q

If a patient requires a bronch, how soon should it be available?

A

within 7 days

29
Q

when should an IPC be removed?

A

<50mL are drained on three consecutive occasions and there is an absence of symptoms of fluid reaccumulation and no substantial residual pleural effusion on imaging

30
Q

when should anti-platelets and anti-coags be stopped pre-pleural procedure?

A

Xa inhibitors 24–48hours before the procedure
dabigatran- full 48hours-4days if high bleeding risk procedure
Aspirin therapy and LMWH continued
Clopidogrel and prasugrel 5days
ticagrelor 7 days

high bleeding risk procedures- restart anticoag day 2 rather than day 1

31
Q

Is coag required for a pleural procedure?

A

not required if no history of coagulopathy and not on anticoagulant

32
Q

What are the lights criteria?

A

► Pleural fluid protein is more than half the serum protein
► Pleural fluid LDH is more than 0.6 times the serum LDH
► Pleural fluid LDH is more than 2/3 the upper limit of normal of the serum LDH

33
Q

chylothorax v pseudochylothorax? Causes?

A

chylo:
high triglycerides
low chol
chylomicron pos

pseudo:
low triglycerides
high chol
chylomicrons neg

Pseudo: TB and RA
Chylo: trauma, malignancy, LAM, TB, cirrhosis, idiopathic

34
Q

T1c N0M0. What stage is is?

A

1a

35
Q

T1a N1M0. What stage is is?

A

2b

36
Q

T1b N2 M0. What stage is it?

A

3a

37
Q

T1a N3 M0. What stage is it?

A

3b

38
Q

T1b N0M1a. What stage is it?

A

4a

39
Q

T2a N0M0. What stage is it?

A

1b

40
Q

T2bN0M0. What stage is it?

A

2a

41
Q

T2a N1M0. What stage is it?

A

2b

42
Q

T2bN3M0. What stage is it?

A

3b

43
Q

T3N0M0. What stage is it?

A

2b

44
Q

T3N1M0. What stage is it?

A

3a

45
Q

T3N2M0. What stage is it?

A

3b

46
Q

T3N3M0. What stage is it?

A

3c

47
Q

T4N0M0. What stage is it?

A

3a

48
Q

T4N1M0. What stage is it?

A

3a

49
Q

T4N2M0. What stage is it?

A

3b

50
Q

T4N3M0. What stage is it?

A

3c

51
Q

T2a N0M1c. What stage is it?

A

4b

52
Q

T3 N3M1b. What stage is it?

A

4a

53
Q

What are the cardiac risk factors for surgery and what do you do if you have them?

A

RF:
‘high risk surgery’- all thoracic surgery is high risk
IHD
CCF
Hx of stroke/TIA
Insulin controlled diabetes
creat >177

> 3 see a cardiologist or ifthey have ‘poor’ cardiac function
2 with good function - offer surgery

Cardiac complications in:
3 or more risk factors: 11%
2: 7%
1: 1%

54
Q

Rank the most likely cause of anterior masses

A

Thymic hyperplasia and thymic Ca
Lymphoma
Germ Cell (50% Teratomas)
Endocrine (5%)

55
Q

What does SMARCA4-deficiency tell you?

A

It relates to anterior lung/lung tumours that are sarcomatoid and generally have a poor prognosis. Usually male smokers

56
Q

To be a adenocarcinoma it needs to be……positive or have mucin positive tumour cells (……. A).

A

TTF-1 and Napsin

57
Q

Most common genes associated with adenoca of the lung?

A

EGFR
ROS-1
ALK
KRAS
TP 53

58
Q

Most common targeted genes associated with adenoca of the lung?

A

EGFR
ROS-1
ALK
KRAS
BRAF
RET

59
Q

Which gene mutations are commonly found in cigarette smokers?

A

KRAS
also TP53, NRAS, and MAP2K1

60
Q

Which gene mutations are commonly associated with never/light smokers?

A

EGFR, ALK, ROS1, and RET

61
Q

Which gene mutations are commonly associated younger patients and women?

A

EGFR

ALK, ROS1, and RET- all in young patients

62
Q

Which gene is associated with predom solid adenoca?

A

KRAS

63
Q

TTF positivity is associated with which gene mutation?

A

EGFR

64
Q

Which NSCLC chemo doesn’t work in SqCLC

A

Pemetrexed

Respiratory SCE (19 decks)

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