Lung Cancer

Question 1

At what size does a pulmonary nodule require a Brock Score Performing?

Answer 1

GREATER than or EQUAL TO 8mm or 300mm3 on volumetry

Question 2

What are the measurement criteria for a nodule to require follow up?

Answer 2

GREATER or EQUAL to 5mm or 80mm3. If 5-6mm then requires follow up scan at 1 year. If 6-8mm or 80mm3 then needs follow up at 3 months.

Question 3

What is the first line chemotherapy for patients with locally advanced/metastatic non-SCLC with EGFR+ mutations?

Answer 3

Gefitinib as per NICE recommendations.

Question 4

Which positive tumour markers would you expect to see in an adenocarcinoma?

Answer 4

TTF-1
CK 7
Napsin A

Question 5

Which positive tumour markers would you expect to see in a squamous cell lung cancer?

Answer 5

CK5
CK6
p63
TTF-1 negative

Question 6

Which positive tumour markers would you expect to see in a Small Cell lung cancer?

Answer 6

TTF-1
Neuroendocrine markers e.g.
CD56, synaptophysin, chromogranin

Question 7

When can Pembrolizumab be used as first line chemotherapy?

Answer 7

If confirmed NSCLC and PD-L1 expression is >50% with NEGATIVE ALK and EGFR mutations

Question 8

What is the median survival time of a patient with malignant mesothelioma following diagnosis?

Answer 8

9.5 months

Question 9

At what level of lidocaine usage during bronchoscopy may a patient develop toxicity?

Answer 9

> 9.6mg/kg
Although doses of up to 15.4 mg/kg may be used without adverse effects

Question 10

What is the treatment of choice for limited stage SMALL CELL lung cancer?

Answer 10

First line is cisplatin-based chemotherapy. This is usually with concurrent radiotherapy if it can be encompassed in a field and WHO 0-1.
If unfit for concurrent therapy then can consider sequential chemotherapy and radiotherapy if the tumour responds to chemo

Question 11

When is carboplatin used in treatment of mesothelioma?

Answer 11

Cisplatin-based combination chemotherapy is first line. If this cannot be tolerated then carboplatin can be substituted.
Usually if RENAL IMPAIRMENT, WHO 2+ or significant comorbidities

Question 12

When should prophylactic cranial irradiation be offered in small cell lung cancer? What is the dose?

Answer 12

If a patient has Performance Status 0-2 with LIMITED STAGE disease that has NOT PROGRESSED on first line treatment.
The dose is 25 Gy in 10 fractions

Question 13

In which demographics are EGFR mutations more common?

Answer 13

Females, non-smokers and those of Asian-Pacific descent.
Most common in non-small cell tumours with adenocarcinoma differentiation

Question 14

Which antibodies are associated with neurological syndromes in lung cancer patients?
Which type of lung cancer are they associated with?

Answer 14

Anti-Hu antibodies.
Associated with small cell lung cancer.
Can cause symptoms such as limbic encephalitis

Question 15

How many lung segments are there? How are they distributed?

Answer 15

19 in total
10 right, 9 left
3 RUL
2 RML
5 RLL
3 LUL
2 Lingula
4 LLL

Question 16

What are the components of the Lent score and how are they scored?

Answer 16

LDH- from pleural fluid
<1500 = 0, >1500 =1
ECOG Performance Status
0 = 0, 1 = 1, 2 = 2, 3/4 =3
Neutrophil:Lymphocyte Ratio (Pleural Fluid)
<9 = 0, >9 = 1
Tumour Type
Mesothelioma, Haematological = 0
Breast, Gynae, Renal = 1
Lung cancer, Other = 2

0-1 = Low Risk (319 day med survival)
2-4 = Medium Risk (130 days)
5-7 = High risk (44 day median)

Question 17

In what size of tumour can SABR be used?

Answer 17

LESS THAN OR EQUAL TO 5cm

Question 18

A patient has begun chemotherapy for metastatic lung cancer but developed an acneiform rash, what is the most likely causative agent?

Answer 18

Erlotinib- causes an acneiform rash in around 2/3 of patients
Development of rash is thought to be associated with better prognosis.

Question 19

At what predicted post-op FEV1 (%) would pre-op assessment with CPET be recommended?
What is a satisfactory CPET result?

Answer 19

If predicted post-op FEV1 is LESS THAN 30% then CPET and other investigations are required.
A CPET result of >15ml/kg/min is considered satisfactory

Question 20

What is the indication for pembrolizumab as 1st line immunotherapy?
What are common/possible side effects?

Answer 20

In NON-SMALL CELL cancers with
PD-L1 expression >50% and NEGATIVE EGFR and ALK mutations
Side effects include nausea, diarrhoea, fatigue and pyrexia but it can also cause immunotherapy-related hypophysitis (inflammation of the pituitary gland): Hypocortisolism, hypothyroidism and hypogonadism

Question 21

What is the first line treatment for non-squamous NSCLC with ROS-1 mutation?

Answer 21

Crizotinib is 1st line.

Question 22

When is osimertinib used in the treatment of lung cancer?

Answer 22

Indicated in EGFR T790M mutation cancer where there is disease progression after first line treatment with erlotinib or gefitinib

Question 23

What is Lambert-Eaton Myaesthenic syndrome? With which cancer and which antibodies is it associated?

Answer 23

Paraneoplastic phenomenon usually presenting with proximal muscle weakness that improves with repetition of the exercise.
Often associated with small cell lung cancer.
Associated with antibodies vs voltage-gated calcium channels

Question 24

What are the chemotherapy agents that may be used in ALK POSITIVE mutations?

Answer 24

Alectinib, Ceritinib and Crizotinib

Question 25

What is the median survival of limited stage SMALL CELL lung cancer treated with chemotherapy?

Answer 25

15-20 months

Question 26

What is the 30-day mortality rate for lobectomy and pneumonectomy respectively?

Answer 26

2.3% for lobectomy 5.8% for pneumonectomy Individual risk can be calculated with thoracoscore

Question 27

What is the recommended first line imaging in patients with localised signs or symptoms of bone mets?

Answer 27

X-ray should be the first line imaging. If inconclusive then can consider a bone scan or MRI. Urgent MRI is required if suspected spinal cord compression

Question 28

What is the most appropriate initial treatment in malignant spinal cord compression?

Answer 28

Dexamethasone (16mg if oral) or equivalent IV To continue with a dose of 16mg daily until surgery or other treatment can be initiated

Question 29

What are the Herder score cut off points in investigating lung cancer?

Answer 29

<10% should continue on the monitoring algorithm 10-70% should consider image-guided biopsy, excision biopsy or CT surveillance depending upon patient preference >70% should consider excision biopsy or non-surgical management

Question 30

What are the first-line options available for chemotherapy in malignant mesothelioma? What are the requirements?

Answer 30

First line options are either CISPLATIN-PERMETREXED chemotherapy or NIVOLUMAB-IPILIMUMAB in patients with performance status 0-1. Bevacizumab may be added in NIVOLUMAB-IPILIMUMAB is first line treatment of choice if good performance status

Question 31

Which type of mediastinal mass may show Antoni A and Antoni B regions on histology?

Answer 31

Schwannoma. May present as a posterior mediastinal mass

Question 32

What grading system is used in the classification of thymoma?

Answer 32

Masaoka-Koga classification system 3 main stages 1: Completely encapsulated tumour 2: Macroscopic invasion into surrounding fatty tissue or adhered to but not invading the mediastinum 3: Macroscopically invading into adjacent structures e.g. pericardium/great vessels/lung

Question 33

What grading system is used in the classification of teratoma?

Answer 33

Gonzalez-Crussi grading system

Question 34

What is the median survival for Stage IVA lung cancer?

Answer 34

100 days

Question 35

With which type of lung cancer are raised PTHrP most associated?

Answer 35

Squamous cell lung cancer Other cancers (esp small cell) may cause hypercalcaemia but squamous cell is most associated with PTHrP

Question 36

Which tumour types may demonstrate low FDG avidity on PET?

Answer 36

Lepidic adenocarcinoma Low-grade lymphoma Some carcinoid tumours

Question 37

What are the NICE recommended timeframes for recovery from pneumonia?

Answer 37

1 week- fever should have settled 4 weeks - chest pain and sputum production should have substantially reduced 6 weeks - cough and breathlessness should have substantially reduced 3 months - most symptoms should have resolved but fatigue may persist 6 months- all symptoms should have settled

Question 38

Which type of asbestos fibre has the highest potency for mesothelioma induction?

Answer 38

Crocidolite (blue asbestos)

Question 39

What is the best treatment for limited SCLC?

Answer 39

CONCURRENT chemoRtx with Carboplatin and Etoposide Limited SCLC can fit within a radiation field- treat with curative intent.