Lung Cancer Flashcards

Question

Lung cancer What histology of NSCLC is more common to have brain metastases? SCC? Adenocarcinoma? or anaplastic?

Answer 1

Adenocarcinoma

Answer 2

``` Cushing syndrome SIADH Hypercalcemia Lambert-Eaton myasthenic syndrome Hypertrophic Osteoarthropathy ```

Answer 3

SCLC carcinoid *note, SLC patients with Cushing syndrome appear to have worse prognosis than those without

Answer 4

squamous - 51% adeno - 22% SCLC - 15%

Answer 5

demeclocycline

Answer 6

True. In contrast to myasthenia gravis which worsens with repetition.

Answer 7

True Also, a positive PET should not be considered proof of lymph node metastasis, especially if such a conclusion would otherwise exclude surgery.

Answer 8

Mediastinoscopy Although considered the gold standard, mediastinoscopy does have a false-negative rate of approximately 10%. Furthermore, the role of mediastinoscopy for lung cancer has evolved recently. Less invasive techniques such as EBUS-TBNA or EUS-FNA are frequently utilized instead to sample lymph nodes found to be clinically suspicious on imaging. Mediastinoscopy should still be considered in situations where less invasive techniques are nondiagnostic.

Answer 9

Thoracoscopy

Answer 10

Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy

Answer 11

Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)

Answer 12

T1a Tumor is ≤1 cm in greatest dimension T1b Tumor >1 cm but ≤2 cm in greatest dimension T1c Tumor >2 cm but ≤3 cm in greatest dimension

Answer 13

Minimally invasive adenocarcinoma: adenocarcinoma (≤3 cm in greatest dimension) with a predominantly lepidic pattern and ≤5 mm invasion in greatest dimension

Answer 14

Tumor >3 cm but ≤5 cm or having any of the following features: involves the main bronchus but without involvement of the carina; invades the visceral pleura; or associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of the lung

Answer 15

T2a Tumor >3 cm but ≤4 cm in greatest dimension T2b Tumor >4 cm but ≤5 cm in greatest dimension

Answer 16

Tumor >5 cm but ≤7 cm in greatest dimension or directly invading any of the following: parietal pleura, chest wall (including superior sulcus tumors), phrenic nerve, parietal pericardium, or separate tumor nodule(s) in same lobe as the primary

Answer 17

Tumor >7 cm or tumor of any size of that invades diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, or carina; separate tumor nodule(s) in an ipsilateral lobe different from that of the primary

Answer 18

Involvement of ipsilateral intrapulmonary, or peribronchial, hilar lymph nodes

Answer 19

Involvement of mediastinal or subcarinal lymph nodes

Answer 20

Involvement of contralateral mediastinal or hilar lymph nodes. Involvement of ipsilateral or contralateral scalene or supraclavicular nodes

Answer 21

Separate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial nodule(s) or malignant pleural or pericardial effusion.

Answer 22

Single extrathoracic metastasis

Answer 23

Multiple extrathoracic metastases in one or several organs

Answer 24

All N0, M0 0 - Tis IA1 - T1(mi) IA2 - T1a IA3 - T1b

Answer 25

IVA is M1a and M1b | IVB is M1c

Answer 26

- paratracheal (stations 2R and 4R) - subcarinal (station 7) - hilar (station 10R) - interlobar lymph nodes (station 11R)

Answer 27

- aortopulmonary window (station 5) - ascending aorta (station 6) - subcarinal (station 7) - hilar (station 10L) - interlobar (station 11L) lymph nodes

Answer 28

pulmonary ligament lymph nodes (station 9)

Answer 29

At least 6 | 3 from mediastinal; 3 from hilar

Answer 30

(a) squamous cell carcinoma (b) adenocarcinoma of the lung (c) small cell carcinoma (d) large cell carcinoma

Answer 31

adenocarcinoma and large cell

Answer 32

adenocarcinoma

Answer 33

adenocarcinoma

Answer 34

baseline qol

Answer 35

operable - complete surgical resection ± chemotherapy inoperable - SBRT/SABR

Answer 36

select stage IIIA candidates for surgery - neoadjuvant chemo/chemoRT + surgery inoperable - concurrent chemoRT

Answer 37

FEV1 >60% | DLCO >60%

Answer 38

lobectomy The Lung Cancer Study Group performed a randomized trial of lobectomy versus limited surgical resection (either wedge resection or segmentectomy) in patients with T1N0 or T2N0 NSCLC. This trial randomized 276 patients and found a 17% risk of local recurrence with limited resection versus 6% with lobectomy (P = .008) and a trend toward an increase in all-cause and cancer-specific risk of death in patients randomized to limited resection (30% and 50% increased risk, respectively [P = .09], for both). Additionally, the report did not demonstrate any late functional advantages or decreased perioperative morbidity with limited resection. This study firmly established lobectomy as the standard of care for early-stage lung cancer.

Answer 39

ACOSOG Z4032 There was no difference between arms in time to local recurrence, LR (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.51, 1.98; P = .98), or type of LR. In subgroups of patients with potentially compromised surgical margin (margin < 1cm; margin:tumor ratio <1; positive staple line cytology; wedge resection, nodule size >2 cm), SRB did not reduce LR, although trends favored the SRB arm, especially in the 14 patients with positive staple line cytology (HR 0.11, P = .24). Overall 3-year survival was similar for SR (71%) and SRB (71%) (P = .97). They concluded that there was no impact of brachytherapy on oncologic outcome in these patients.

Answer 40

No. (ACOSOG) Z0030 trial was a randomized trial of 1,111 patients with N0 or N1 (less than hilar) early-stage NSCLC to either mediastinal lymph node sampling or complete lymphadenectomy during pulmonary resection. The 5-year disease-free survival was 69% in the mediastinal lymph node sampling group and 68% in the mediastinal lymph node dissection group (P = .92). There was no difference in local (P = .52), regional (P = .10), or distant (P = .76) recurrence between the two groups, suggesting that complete lymphadenectomy does not improve survival in patients with early-stage NSCLC

Answer 41

RTOG 0618 The RTOG (RTOG 0618) initiated a phase II study of SBRT in operable patients with early-stage NSCLC. Of 26 evaluable patients, 23 had T1 and 3 had T2 tumors. Four patients (16%) had SBRT-related grade 3 AEs, whereas 0 had grade 4 to 5 AEs. Median follow-up was 25 months. Two patients have been scored with in-field failure, INF (11.7 and 12.4 months post SBRT), and 1 with marginal failure, MF (32.5 months post SBRT), giving an estimated 2-year primary tumor failure rate of 7.7% (95% CI 0.0%, 18.1%). Two-year estimates of LF (primary tumor plus involved lobe failure), RF, and DF are 19.2% (95% CI 3.7%, 34.7%), 11.7% (95% CI 0.0%, 24.5%), and 15.4% (95% CI 1.2%, 29.6%), respectively. Only one patient was eligible for attempted surgical salvage and underwent lobectomy 1.2 years post SBRT complicated by a grade 4 cardiac arrhythmia. Two-year estimates of progression-free survival (PFS) and OS are 65.4% (95% CI 44.0%, 80.3%) and 84.4% (95% CI 63.7%, 93.9%), respectively. This study suggested that SBRT was associated with a high rate of tumor control, moderate treatment-related morbidity, and infrequent need for surgical salvage in operable early-stage lung cancer patients with peripheral lesions.

Answer 42

They are prospective studies that tried to compare surgery and SBRT in early-stage operable NSCLC patients. However, the trial closed early due to accrual, but retrospective matching of these two trials showed a promising outcome as possible noninvasive alternative to surgery in the future.

Answer 43

RT Median and 5-year OS for patients randomly assigned to resection versus radiotherapy were 16.4 versus 17.5 months and 15.7% versus 14%, respectively (HR 1.06, 95% CI 0.84 to 1.35). Rates of PFS were also similar in both groups. The authors concluded that radiotherapy is the preferred approach in these patients owing to lower rates of treatment-related morbidity and mortality.

Answer 44

potentially sterilize micrometastatic | disease beyond the thorax

Answer 45

Neoadjuvant versus Adjuvant Taxol/Carbo Hope trial (NATCH) Neoadjuvant arm had a trend toward better DFS than surgery alone arm, but results were not statistically significant (5-year DFS 38% vs. 34%, HR 0.92, P = .176). One possible explanation for the lack of benefit is due to the proportion of patients with early-stage disease in the trial (75% had clinical stage I disease). With subset analysis of only stage II-T3N1 patients, 5-year DFS was 36.6% in the neoadjuvant arm and 25% in the surgery arm (HR 0.81, P = .07). The adjuvant arm showed less benefit than the neoadjuvant arm, and more patients in the neoadjuvant arm were able to complete their planned chemotherapy (90.4% vs. 60.9% for neoadjuvant vs. adjuvant).

Answer 46

Chemotherapy for Early Stages Trial PFS and OS HRs were 0.70 (95% CI, 0.50 to 0.97; P = .003) and 0.63 (95% CI, 0.43 to 0.92; P = .02), respectively, both in favor of chemotherapy. When looking at just stage IIB/IIIA patients, a statistically significant impact of neoadjuvant chemotherapy was seen (3-year PFS rate: 36.1% vs. 55.4%; P = .002).

Answer 47

phase II by TROG Overall, this trial did not demonstrate a survival benefit for the addition of surgery to chemoradiotherapy in patients with stage IIIA NSCLC.

Answer 48

along surgical stump or in mediastinal nodes.

Answer 49

May have improved 5-year OS for pN2 patients but reduced OS for pN0 and pN1 (SEER) Decrease in survival for pN1 disease, no survival difference for pN2 -(PORT-meta-analysis) improved survival for pN2 disease with or without chemotherapy. improved survival for pN1 but detrimental effect with chemo. -(Adjuvant Navelbine International Trialist Association (ANITA) trial)

Answer 50

International Adjuvant Lung Cancer Trial (IALT) In this trial, 1,867 patients were randomized to cisplatin-based adjuvant chemotherapy or observation. With a median follow-up duration of 56 months, patients receiving chemotherapy had a significantly higher survival rate (44.5% vs. 40.4% at 5 years) and disease-free survival rate (39.4% vs. 34.3% at 5 years) compared with observation. However, after 7.5 years of follow-up, the survival curves started to converge and cross, the benefit of chemotherapy decreased over time, and there were more deaths in the chemotherapy group by 7.5 years (P = .10).

Answer 51

The National Cancer Institute of Canada JBR.10 trial Compared to observation, adjuvant chemotherapy significantly prolonged median OS (94 vs. 73 months) and median relapse-free survival (not reached in chemo arm vs. 46.7 months) compared to observation alone. Like the IALT trial, some of the benefit diminished with longer follow-up; however, unlike IALT, the survival difference remained statistically significant beyond 5 years. After 9 years of follow-up, adjuvant chemotherapy was found beneficial for stage II (median survival 6.8 vs. 3.6 years), although not for stage IB patients.

Answer 52

ECOG 3590 There was no difference in local recurrence or survival between the two arms

Answer 53

RTOG 9705 At a median follow-up of 56.7 months, median OS time was 56.3 months, with 1-, 2-, and 3-year survival rates of 86%, 70%, and 61%, respectively. The 1-, 2-, and 3- year PFS rates were 70%, 57%, and 50%, respectively. Toxicities were acceptable. When compared to previously reported studies, the RTOG concluded that these results might portend an improvement in OS and PFS with chemoradiotherapy in postoperative resected NSCLC patients

Answer 54

Definitive RT alone or SABR/SBRT

Answer 55

-poorer overall health of the medically inoperable patient -most of these patients are clinically, rather than surgically, staged -a higher dose (up to 100 Gy) is required for the sterilization of most NSCLC tumors which is not usually achievable without toxicities.

Answer 56

RTOG 0236 (Timmerman et al.)

Answer 57

increases long term survival The survival rate in the thoracic RT group was 58% at 1 year, 36% at 2 years, and 29% at 3 years, compared with 66%, 9%, and 3% at 1, 2, and 3 years, respectively, in the chemotherapy-alone group. The investigators concluded that thoracic RT “significantly increases the number of long-term survivors as compared with chemotherapy alone and that RT to bulky disease in the thorax is an important part of combined modality therapy, a necessary part of further studies in locally advanced disease.”

Answer 58

60 Gy/2/30

Answer 59

Yes. data suggest that IFRT can be employed in patients with locally advanced NSCLC without risk of significant compromise in clinical outcome

Answer 60

CCRT. Although this comes with greater esophageal toxicity.

Answer 61

Performance status and weight loss

Answer 62

Pemetrexed

Answer 63

Shoulder pain (which may radiate down the arm)

Answer 64

ptosis, pupillary miosis hemifacial anhidrosis

Answer 65

for small SSTs CCRT for extensive, chemotherapy. Assess for resectability MDACC good results with resection + PORT. Others RT+chemo... Can be CRT then assess for resectability.

Answer 66

clinically macroscopic disease, typically identified on any imaging modality.

Answer 67

If the tumor is near the hilum or mediastinum.

Answer 68

Lung window width 850 Hounsfield units length -750 Hounsfield units (-Harris et al.)

Answer 69

9mm pathologically derived correlative data have shown that a 9-mm margin would encompass all microscopic disease in approximately 90% of lung adenocarcinomas. Others have advocated the use of a differential margin based on histology of 8 mm for adenocarcinoma and 6 mm for squamous cell carcinomas to account for 95% of the microscopic extension of disease.

Answer 70

For nodal disease, surgical series have shown that a 3-mm margin will encompass 95% of the microscopic extranodal extension of disease in lymph nodes <2 cm. However, larger margins may be required for lymph nodes >2 cm.

Answer 71

The ITV is defined by the International Commission on Radiation Units and Measurements (ICRU) 62 as an expansion of the CTV to account for tumor motion.

Answer 72

when using stereotactic frame without CBCT 9-13 mm with CBCT 1-2 mm. For advanced-stage NSCLC, typical margins for the PTV are on the order of 5 to 10 mm if an ITV is used for motion compensation and daily image-guided RT is employed during treatment.

Answer 73

- 4D scans, - slow CT, - abdominal compression, - DIBH, - automatic breathing control, - respiratory gating, - tumor tracking, - MIP, - CIP

Answer 74

Osimertinib (third gen EGFR TKI)

Answer 75

Ceritinib and alectinib

Answer 76

False. SVC syndrome from SCLC are more responsive to chemotherapy than from NSCLC. Therefore, chemotherapy is initiated first and the post chemotherapy volume is treated with RT. With NSCLC, RT can be initiated right away.

Answer 77

Stage (limited vs. extensive) Other clinical factors consistently reported to correlate with improved survival include good performance status, female gender, and normal LDH levels at baseline.

Answer 78

1973 Veteran’s Administration Lung Group staging scheme. limited vs. extensive. In this system, limited stage is defined as disease confined to the ipsilateral hemithorax, which can be safely encompassed within a tolerable radiation portal. Virtually all studies in limited disease exclude malignant pleural effusions. From a practical standpoint, hemithoracic radiotherapy to encompass the entire ipsilateral pleura has little justification because it would confer a significant risk of pulmonary toxicity in a high-risk patient population with little chance of cure. As such, patients with malignant pleural effusions are classified as having extensive-stage disease.

Answer 79

distant dissemination

Answer 80

Choi - phase I RTOG 0239 CALGB 39808 CONVERT trial

Answer 81

limited | Auperin meta-analysis

Answer 82

RP may occur during fractionated treatment or up to 18 months afterward, with a peak incidence at 2 to 6 months posttreatment.

Answer 83

Chest x-ray or CT scan may be normal, or, depending on the time course, there may be ground-glass opacification (within 2 to 6 months), patchy consolidation (4 to 12 months), or fibrosis (10 months or more) that loosely corresponds to the radiation field.

Answer 84

MLD <20 Gy V20 <35% V5 <60% V20 remained the most accurate predictive metric of RP (RTOG 0617)

Answer 85

For bilateral lung, they recommend maximum dose to 10 and 15 cc of lung of 7.4 and 7 Gy for single-fraction SBRT, 12.4 and 11.6 Gy for three-fraction SBRT, and 13.5 and 12.5 for five-fraction SBRT.

Answer 86

The AAPM Task Group 101 recommends maximum doses to 4 cc and maximum point doses to the proximal tracheobronchial tree of 10.5 and 20.2 Gy for singlefraction SBRT, 15 and 30 Gy for three-fraction SBRT, and 16.5 and 40 Gy for five-fraction SBRT.

Answer 87

40 and 50 Gy

Answer 88

66 Gy (RTOG 0617) for SBRT: AAPM TG 101 recommends maximum dose to 3 cc and maximum point dose of 14 and 17.5 Gy for single-fraction SBRT, 20.4 and 24 Gy for three-fraction SBRT, and 27 and 30.5 Gy for five-fraction SBRT.

Lung Cancer Flashcards

(125 cards)