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FRCR2 > Lung - NSCLC > Flashcards

Lung - NSCLC Flashcards

1
Q

When is a PET-CT indicated in lung cancer

When is MRI indicated

A

In all those eligible for radical treatment
If LNs > 1cm seen on staging CT -> PET-CT, EBUS & Bx

MRI - Pancoast tumour to assess involvement of brachial plexus

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2
Q

What brain imaging is indicated in lung cancer and when

A

Stage 2 - CT head with contrast
Stage 3 - MRI head with contrast

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3
Q

What investigations are needed to manage lung cancer

A

Bloods
Chest imaging & staging
Brain imaging if appropriate
Biopsy result for histology

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4
Q

Where is nodal station 1 and what N stage does this indicate

A

Highest mediastinal nodes
Ipsilateral/contralateral low cervical / supraclavicular / sternal notch nodes

=N3

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5
Q

How is N1 status defined

A

Stations 10-14 positive
10 - ipsilateral hilar
11 - peribronchial - interlobar
12 - intrapulmonary - lobar
13 - intrapulmonary - segmental
14 - intrapulmonary - subsegmental

distal to carina

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6
Q

How is N2 status defined

A

Positive stations 2-9 - ipsilateral superior mediastinal, aortic or ipsilateral mediastinal
Same side mediastinal, and aortic nodes

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7
Q

How is N3 nodal disease defined

A

Either contralateral hilar nodes (station 10) or contralateral mediastinal nodes (stations 7-9)

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8
Q

Which nodal stations are the ipsilateral superior mediastinal nodes

A

Stations 2, 3 & 4
2 = upper paratracheal
3 = pre vascular / retrotracheal
4 = lower paratracheal

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9
Q

Which nodal stations are the aortic nodes

A

Stations 5 & 6
Station 5 = sub aortic
Station 6 = para-aortic
N2 disease

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10
Q

Which nodal stations are the ipsilateral mediastinal nodes

A

Sup mediastinal
2-4

inferior mediastinal
Stations 7, 8 & 9
Station 7 = subcarinal
Station 8 = para-oesophageal
Station 9 = pulmonary ligament

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11
Q

Which station are the ipsilateral hilar nodes

A

Station 10

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12
Q

Which nodes are station 2 and what N stage do they indicate

A

2 = upper paratracheal (part of ipsilateral superior mediastinal)
N2

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13
Q

Which nodes are station 3 and what N stage do they indicate

A

3 = prevascular / retrotracheal
Part of ipsilateral superior mediastinal nodes
N2

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14
Q

Which nodes are station 4 and what N stage do they indicate

A

4 = lower para-tracheal
Part of ipsilateral superior mediastinal nodes
N2

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15
Q

Which nodes are station 5 and what N stage do they indicate

A

5 = sub-aortic
Part of aortic group
N2

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16
Q

Which nodes are station 6 and what N stage do they indicate

A

6 = para-aortic
Part of aortic group
N2

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17
Q

Which nodes are station 7 and what N stage do they indicate

A

7 = subcarinal
Part of ipsilateral mediastinal group
N2 disease

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18
Q

Which nodes are station 8 and what N stage do they indicate

A

8 = para-oesophageal
Part of ipsilateral mediastinal group
N2 disease

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19
Q

Which nodes are station 9 and what N stage do they indicate

A

9 = pulmonary ligament
Part of ipsilateral inferior mediastinal group
N2

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20
Q

Which nodes are station 10 and what N stage do they indicate

A

10 = ipsilateral hilar
N1 disease

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21
Q

Which nodes are station 11 and what N stage do they indicate

A

11 = interlobar / peribronchial nodes
N1 disease

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22
Q

Which nodes are station 12 and what N stage do they indicate

A

12 = intrapulmonary nodes - lobar
N1 disease

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23
Q

Which nodes are station 13 and what N stage do they indicate

A

13 = intrapulmonary nodes - segmental
N1 disease

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24
Q

Which nodes are station 14 and what N stage do they indicate

A

14 = intrapulmonary nodes - sub-segmental
N1 disease

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25
Which nodal stations are the contralateral hilar /mediastinal nodes What N stage do they indicate
As numbered according to above stations But contralateral = N3 disease
26
Which nodal station are the low cervical / supraclavicular / sternal notch nodes What N stage do they indicate
Station 1 N3 disease
27
How is M1 disease defined
M1a - contralateral lung nodule or malignant effusion (pleural or pericardial) M1b - single extra-thoracic met M1c - multiple extra-thoracic metastases
28
How is a T1 lung tumour defined
≤3cm
29
How is a T2 lung tumour defined
3-5cm
30
How is a T3 lung tumour defined
5-7cm or chest wall / pleural invasion Or 2nd tumour in same lobe
31
How is a T4 lung tumour defined
>7cm or direct invasion into mediastinal structures Or second tumour on same side but different lobe
32
How is a stage 1A lung cancer defined
T1N0
33
How is a stage 1B lung cancer defined
T2a N0
34
How is a stage 2A lung cancer defined
T2b N0
35
How is a stage 2B lung cancer defined
T1-2 N1 or T3 N0 ie T3 disease or N1
36
How is a stage 3A lung cancer defined
T1-2 N2 or T3 N1 or T4 N0-1 ie N2 positive, T3N1 or T4 disease
37
How is a stage 3B lung cancer defined
T1-2 N3, T3-4 N2
38
How is a stage 3C lung cancer defined
T3-4 N3
39
How is a stage 4 lung cancer defined
M1
40
How does nodal positivity affect lung cancer staging
N1 = stage 2b N2 = stage 3a at least (3b if also T3-4) N3 = stage 3b at least (3c if also T3-4)
41
What three things are optimised prior to lung treatment
Smoking PT Dietician for nutrition
42
What information is required before being able to make a treatment decision
Staging CT CAP MRI brain PET Histology Pulmonary function
43
What is the treatment of choice for a stage 1 (T1-2N0) lung cancer
Surgery Lobectomy - if confined to one lobe (L) or two (RML/RLL) Sub-lobar resection - segmentectomy or wedge resection
44
What is the treatment of choice for a stage 2 (T2b-3 N0 / T1-2 N1) lung cancer
Presuming radical treatment: Surgery (with NA-SACT or adj SACT) CRT (concurrent or sequential)
45
When is a pneumonectomy indicated over a lobectomy
When tumour is <2.5cm from carina
46
What are the FEV1 requirements for surgery
FEV1 >1.5L - Lobectomy
 FEV1 >2L - Pneumonectomy
47
What is the regimen for neoadjuvant SACT ahead of radical surgery And what are the criteria
Neo-adjuvant chemotherapy - cisplatin/paclitaxel Neo-adjuvant immunotherapy - nivolumab/Pt-based chemotherapy NA nivolumab: T2b (>4cm) or greater, or node positive (ie stage 2 or above), potentially resectable disease Independent of PDL1 status No actionable driver mutation - ALK/EGFR
48
What are the options for adjuvant treatment after surgery for a lung cancer
Adjuvant chemotherapy Adjuvant targeted therapy Adjuvant immunotherapy
49
When is adjuvant RT recommended following surgery for lung cancer And at what dose What is encompassed in the CTV What is the CTV-PTV margin
R1 resection (microscopic disease) incl extracapsular spread 60Gy in 30# (or 50-55Gy/20#) Not recommended for R0 resection as pts do worse If R2 resection - tx as new lung cancer with CRT CTV - tumour bed, incl clips. Resected positive nodal areas PTV = CTV +1cm axially and 1.5cm sup/inf unless using 4D CT (use 1cm margin throughout)
50
What are the indications for adjuvant chemotherapy? What is the benefit And what regimen
Node positive T2b (>4cm) - stage IIA or unexpected stage III Benefit - 4-5% OS improvement at 5yrs Cisplatin/Vinorelbine
51
What is the indication for adjuvant osimertinib When does it start Duration What is the benefit
Completely resected EGFR mutated NSCLC (exon 19 deletion or L858R substitution) Stage 1B (T2a) or greater, up to N2 only stage 3 ie >T2a N0, T1-2 N2, T3-4 N2 to start within 10wks if no chemotherapy or within 26wks if following chemotherapy (indicated if node positive or stage T2a (t2b - 4-5cm) or greater) For 3yrs / disease recurrence / unacceptable toxicity Greater benefit for greater disease stage Adaura trial - mDFS not reached for osimertinib, vs 19mths for placebo
52
What are the resistance mechanisms to osimertinib
EGFR or non-EGFR mechanisms Usually EGFR exon 20 C797X mutation or loss of T790M mutation Alternatively MET amplification, HER2 amplification or non-EGFR pathway aberrations (RAS-MAPK, PI3K), cell cycle gene alterations, oncogenic fusions
53
What is the indication for adjuvant atezolizumab
Following complete resection of a NSCLC, stage 2b or greater (node positive or >T3N0) with PDL1 >50% For one year and if no progression following Pt-based chemotherapy
54
What are the two options for radical RT for an early lung cancer
Non-SABR RT SABR RT
55
When is non-SABR RT indicated for an early lung cancer What is the dose
stage I-II (T1-2N1 or T3N0), non-resectable cancer within 1cm of the proximal bronchial tree (therefore not amenable to SABR) or overlaps critical structures Dose: 54Gy/36# CHART - 3x/day over 12 days Or 55Gy/20#
56
When is SABR RT indicated What is the dose
Tumour up to 5cm (T2), outside of proximal bronchial tree / exclusion zone (≥2cm away). Node negative Or T3 only due to chest wall invasion Not suitable for surgery or declines surgery PS0-2 Dose: Peripheral tumours - 54Gy in 3# over 5-8 days, prescribed to 80% isodose Tumours in contact with chest wall - 55Gy in 5# / 10-14 days (not compromised for chest wall tolerance) Tumours adjacent to OAR - 60Gy in 8# /10-20 days
57
What are the exclusion criteria for lung SABR
Pt unable to lie flat for 45min PS >2 Tumour not definable on planning CT, ie associated with consolidation or atelectasis Within 2cm of central exclusion zone Previous RT within the planned treatment volume
58
What are the outcomes from lung SABR
Improved local control rates 2-yr local control rate >90% (similar to surgery); 5-yr local control rate 86% Nodal recurrence 4-11% post SABR Improved OS cf to radical RT (40% v 20% at 5yrs)
59
What are the OAR tolerances for lung SABR
Oesophagus - 1cc <24Gy Lung - V20<10% Heart - 1cc <24Gy
60
How is lung SABR planned
4D CT GTV - Tumour CTV -> ITV - Outline tumour on MIP ITV -> PTV - 5mm
61
How is operable N2 disease (stage III) defined
No LN > 3cm Must be free from major mediastinal structures: great vessels & trachea Non-fixed, non-bulky, single zone N2
62
What is the regimen for radical concurrent chemoRT?
55Gy/20#, or 60Gy/30# or 66Gy/33# Cycles 1&2 of cisplatin (40mg/m2) and vinorelbine (15mg/m2) given alongside RT Cycles 3&4 given following completion of RT cisplatin (80mg/m2) and vinorelbine (35mg/m2)
63
What is the indication for durvalumab?
No progression following concurrent chemoradiotherapy, good PS, PDL1 >1% Given 2wkly for 12mths / disease progression / toxicity Pacific trial (CRT +durvalumab / placebo) - Median survival benefit 47.5mths vs 29.1 months
64
For concurrent CRT, what GTV-ITV & PTV margin is given
GTV +5mm PTV = CTV/ITV +1cm radically and 1.5cm if no motion management, or CTV +5mm if motion management
65
For sequential CRT, what GTV-ITV & PTV margin is given
GTV - post chemo lesion / tumour bed CTV - GTV + pre-chemo LNs (no margin on primary lesions) PTV - CTV + 10mm axially and 15mm sup/inf
66
What dose constraints would be acceptable for a radiotherapy plan (4 organs)
Lung: V20Gy <35% Spinal cord: Dmax <50Gy Heart: V40Gy <30% Oesophagus: V35Gy <50%
67
What is the treatment algorithm for a pancoast tumour
If operable: Neo-adjuvant CRT - 45Gy/25# with cisplatin/etoposide, followed by surgery If inoperable: Primary CRT - 45Gy/25# with cisplatin/etoposide Or consider radical CRT - 60Gy/30#, followed by surgery if disease has become operable If PDL1>1% and no progression after CRT, would be eligible for consolidation durvalumab
68
What targetable mutations exist for metastatic NSCLC & corresponding txs (non EGFR & ALK)
Met - exon 14 skip mutation - tepotinib B-raf - dabrafenib/trametinib - 1st line K-ras - sotorasib if G12C mutation 2nd line after Pt-based ChT/IO NTRK - larotrectinib/entrectinib - 2nd line after Pt-based chemo, IO and docetaxel Ros1 - can use crizotinib or entrectenib both 1st line HER2 - Trastuzumab-emtansine RET fusion - selpercatinib - approved 1st line
69
What are the commonest EGFR mutations in NSCLC
L858R and exon 19 deletion - confer sensitivity to osimertinib. Exon 20 insertions (C797X) - confer resistance
70
What is the response rate to osimertinib
>60% RR for intracranial disease 80% for those with L858R mutation
71
What is the workup for progression on non-osimertinib EGFRi
Rebiopsy if possible: T790M or L858R mutation - osimertinib Otherwise - Pt-based chemotherapy doublet
72
What are the first line options for an ALK-positive NSCLC What are the typical side effects
Alectinib - LFTs/anaemia/constipation/oedema/weight gain Brigatinib - htn/rash/CPK/ILD Good CNS penetration
73
What is the typical resistance mutation to first line ALK inhibition what is the 2nd line treatment What is the benefit
ALK G1202R Retains sensitivity to 2nd line lorlatinib PFS 6mths
74
Brain mets common in those treated with ALK inhibitors. What is the recommended treatment
Avoid WBRT if possible, consider SRS
75
What systemic treatment is given after progression on targeted treatement (osimertinib (EGFR mutation) or alectinib & lorlatinib (ALK mutation)), for NSCLC
Atezo, carboplatin, paclitaxel, bevacizumab or Pt-doublet or Pt/pemetrexed
76
If no actionable mutation is present, what is the first line systemic treatment for a metastatic squamous cell carcinoma? And 2nd line
If PDL1 >50% - single agent atezolizumab or pembrolizumab, or carboplatin/paclitaxel/pembrolizumab if a rapid response is required, followed by maintenance pembrolizumab If PDL1 <50% - carboplatin/paclitaxel/pembrolizumab +/- bevacizumab Followed by maintenance pembrolizumab (2yrs) Addition of bevacizumab to carbo/paclitaxel/atezo improved mOS 2nd line: If PDL1 >50% initially - Pt-based doublet ChT If PDL1 <50% - single agent atezolizumab, nivolumab or pembrolizumab (PDL1 >1%)
77
If no actionable mutation is present, what is the first line systemic treatment for a metastatic adenocarcinoma? And 2nd line
If PDL1 >50%: - single agent atezolizumab or pembrolizumab, Or -carboplatin/pemetrexed/pembrolizumab if a rapid response is required (followed by pemetrexed/pembro maintenance) If PDL1 <50%: - carboplatin/pemetrexed/pembrolizumab Followed by maintenance pemetrexed/pembrolizumab (2yrs) 2nd line: If PDL1 >50% initially - Pt-based doublet ChT or Pt/pemetrexed, followed by maintenance pemetrexed If PDL1 <50%: - single agent atezolizumab, nivolumab or pembrolizumab (PDL1 >1%) - Docetaxel +/- nintedanib
78
What is the risk of malignancy for lung nodule/mass: <5mm 1-2cm 2-3cm >3cm
nodules < 5mm - 1% malignant nodules 1-2 cm 18% malignant nodules 2-3 cm 50% malignant masses >3cm 90% malignant
79
What mass/nodule features on imaging would suggest malignancy
Size, spiculated appearance, thick walled, necrotic
80
What is the management of a lung nodule based on size
<8mm - CT surveillance If <5-6mm -> CT at 1yr >6mm - CT at 3mths If >8mm - assess malignancy risk (Brock model) <10% risk - CT surveillance (3mths) >10% risk -> PET <10% risk - CT surveillance (3mths) 10-70% risk - biopsy >70% risk - excise
81
When does radiation pneumonitis typically occur
8wks post RT treat with steroids
82
who is eligible for lung screening
age 55-74, hx of smoking low dose CT 20% reduction in lung cancer related death and 6.7% in overall all cause mortality vs CXR 70% were stage I-II
83
what is the prognosis of NSCLC and the benefit of adj chemotherapy
5-year survival 7% men, 9% women Adjuvant chemotherapy can increase absolute survival rates by 4%
84
What are the numbers for lung T staging
3-5-7 T1 <3cm T2 3-5cm T3 5-7cm T4 >7cm
85
What is the risk of pneumothorax with RFA
40%
86
what is the first line treatment for a metastatic NSCLC with exon 20 egfr mutation
Pt-based chemotherapy
87
When is WBRT offered in lung cancer
Quartz trial - PS2 - no benefit vs BSC WBRT is not routinely offered for brain mets in NSCLC Except in Good PS (0-1), Age <60 & well controlled extracranial disease
88
when should sotorasib be taken relative to omeprazole
Sotorasib - take omeprazole 4hrs after, or 10hrs before
89
what treatment is indicated for a ros1+ NSCLC
crizotinib
90

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