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26 Cards in this Set
- Front
- Back
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Approximately what percentage of patients with NSCLC are never smokers or have minimal exposure to smoking (defined as <10 py's)?
What % of these are likely related to second-hand smoke? |
15% of patients with no reported smoking history of minimal smoking history
25% of patients with NSCLC were exposed to second-hand smoke |
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Hypercalcemia in Lung Cancer
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More common in patietns with NSCLC and is more likely due to Metastases than elevated PTH-rp
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Lung cancer type most commonly associated with hypertrophic osteoarthropathy
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Adenocarcinoma
-- leades to clubbing of digits, periostitis, and joint swelling |
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Myasthenic illness most often associated with small cell lung cancer and other cancers and is characterized by proximal weakness and absent deep tendon reflexes that typically improve with activity, as well as signs of autonomic insufficiency.
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Lambert-eaton Syndrome
- antibodies directed against presynaptic voltage-gated P/Q-type calcium channels. - 5% of patietns who have SCLC |
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Basic Staging in NSCLC
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Stage I = A solitary tumor without regional (peribronchial or hilar) or mediastinal lymph node involvement
-- A = <3 cm -- B = >3 cm Stage II = Regional lymph node invovlement or the presence of primary tumors that invade local structures such as the pleura or chest wall or are lcoated near the carina Stage III = mediastinal lymph node involvement Stage IV = metastatic disease, ipsilateral malignant pleural effusion |
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Primary therapy for patients with Stage I and II NSCLC
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Surgery (approximately 30% of cases)
Once advanced-stage IV disease is excluded, a thoracic surgeon should decide whether complete surgical resection is feasible, which is based on the presence or absence of mediastinal lymph node involvement. If positive lymph nodes are found by mediastinoscopy or bronchoscopic ultrasonography, surgery is not usually indicated for definitive therapy. A classic procedure involving a thoracotomy incision or a minimally invasive procedure such as video-assisted thoracoscopic surgery (VATS) can be used. The thoracoscopic procedure is associated with less discomfort because of the smaller incision and shorter hospitalizations. Patients with stage I NSCLC have the most favorable prognosis, but only 60% of these patients are cured following surgery. Cure rates for patients with stage II disease are approximately 30%. |
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Treatment of Stage III NSCLC with N2 lymph node invovlement (involvement of ipsilateral mediastinal or subcarinal lymph nodes)
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Patients with stage III non–small cell lung cancer with N2 lymph node involvement are usually treated with combined radiation therapy and chemotherapy rather than surgery.
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Adding a cisplatin-based chemotherapy regimen following attempted curative surgical resction improves survivial rates for patients with Stage II and III NSCLC by approximately how much
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5 year survival rates improved by ~10%
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Treatment of IV (Metastatic) NSCLC
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Goals of Tx are symptoms palliation and possible prolongation of survival (median survival despite best efforts usually 8-10 months)
First line tx us a 2-drug platinum-based combination. Tx is given for 4-6 cycles. A biologic agent such as bevacizumab (a VEGF inhibitor) or cetuximab (an EGF inhibitor) can be added Radiation therapy helps alleviate symptoms of superior vena cava syndrome and obstructive pneumonitis. Brain metastases and spinal cord compression are treated with radiation therapy and occasionally with surgery. Patients with bone metastases may benefit from radiation therapy for pain control and bisphosphonates to control pain and reduce fracture risk. |
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EGFR and NSCLC
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Although approximately 50% of patients with NSCLC have tumors expressing the epidermal growth factor receptor (EGFR), therapeutic agents that target this receptor provide only a modest response in patients with advanced disease. However, patients whose tumors have a mutation in the EGFR gene often benefit dramatically from such therapy. When testing a large unscreened patient population, approximately 10% of patients with adenocarcinoma of the lung will be found to have the EGFR gene mutation, whereas it is rarely found in patients with squamous cell or large call carcinoma. The typical clinical phenotype of a patient with this mutation is a woman with adenocarcinoma who has never smoked (or has a very limited smoking history) and is often of Asian descent. EGFR tyrosine kinase inhibitors such as erlotinib have a very high response rate in this subset of patients and have the potential for controlling advanced disease for many months. In patients without the EGFR gene mutation, these agents have some benefit as second- or third-line therapy but are associated with only very modest response rates and disease control.
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Staging in SCLC
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LIMITED = confined to one hemithorax, including the primary mass plus hilar, mediastinal and ipsilateral supraclavicular lymph nodes, and suggests that all known disease can be encompassed within a tolearble radiation portal during treatment
EXTENSIVE (most patients) = Overt spread fo disease beyond the hemithorax, including an ipsilateral malignant effusion and metastases to the brain, liver, or bone. |
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Treatment of Limited-Stage Small Cell Lung Cancer
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Combined Chemotherapy and Radiation therapy
ChemoTx: Cisplatin or Carboplatin + Etoposide x 4-6 cycles Radiation in the first or second cycle Prophylactic Cranial Radiation |
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Median survival of patients with limited stage SCLC
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14-18 months
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Treatment of Extensive-Stage SCLC
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Mainstay of tx is chemotherapy with cisplatin or carboplatin + Etoposide or Irinotecan
Response rates range from 60-80% with complete responses acheived in 10-20% Average response lasts 4-6 months Median survival is 8-10 months Salvage chemotherapy may benefit from ~30% Raditaion tx for symptom palliation Prophylactic cranial radiation for patients who have response to chemotx Palliative care consult |
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Prophylactic Cranial Radiation Tx in SCLC
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Patients with lmiited stage SCLC who complete combination chemotx and radiation tx have a 50-80% chance of developing CNS mets if they survive for 2 years
In 20% of patients, teh CNS is the initial site of systemic disease spread Prophylactic brain irration may reduce the likelihood of symptomatic brain metastases and slighly improve overall survival Patients with extensive SCLC who have a good response to systemic tx may also benefit, b/c this often results in a meaningful reduction in CNS mets and prevention of neurologic sequelae Benefits outweigh risks of cognitive impairment in long-term survivors. |
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Replacement descriptor of bronchoalveolar carcinoma
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"Lepdic-predominant pattern"
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RFs for Lung Cancer
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- 90% of all lung cancers are smoking related
- After controlling for smoking, evidence of airway obstruction on PFTs reflects a 4-6x increased risk for lung cancer - Smoking + Asbestos Exposure = 50-90x increased risk for lung cancer - Second hand smoke - Asbestos - Radon - Metals (Arsenic, Chromium, Nickel) - Ionizing Radiation - Polycystic Aromatic Hydrocarbons - Pulmonary fibrosis |
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Cost-effective preoperative imaging modality of choice prior to surgical biopsy or resection in lung cancer
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PET scanning and integrated PET-CT are valuable tools in the evaluation of NSCLC. Randomized controlled trials have shown the cost effectiveness of adding PET-CT to preoperative staging. Approximately one in five patients thought to have resectable disease prior to PET-CT will have evidence of mediastinal or distant spread and unnecessary surgery can be avoided. PET-CT is most often pursued in the preoperative staging of NSCLC; however, it is frequently also used by oncologists for treatment planning in nonresectable disease, and it may be helpful in determining limited versus extensive disease in SCLC.
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Use of ultrasound guidance in staging non-metastatic lung cancers
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Use of ultrasound guidance has greatly improved yields of bronchoscopic sampling of paratracheal, subcarinal, and hilar lymph nodes identified by CT or PET-CT. Endobronchial ultrasonography provides real-time imaging of the mediastinal nodes and enables the operator to see the needle in the node at the time of sampling. Yields of greater than 90% for the paratracheal and subcarinal nodes and negative predictive values of greater than 90% have been reported. Randomized trials have shown that the combination of ultrasound-guided endobronchial and esophageal needle aspiration is comparable if not superior to mediastinoscopy for preoperative staging of N2 (ipsilateral mediastinal) and N3 (contralateral mediastinal) nodes.
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Candidates for surgical resection in NSCLC
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- Stage I or II disease and can withstand surgery
- Good performance status - No major cardiovascular risk (recent MI, unstable angina, uncomplicated heart failure, or severe valvular disease) - FEV1 and DLCO at or above 80% of predicted For patients with an FEV1 of less than 80% of predicted, calculating the predicted postoperative pulmonary function helps identify which patients are otherwise acceptable surgical candidates. The postoperative predicted pulmonary function is calculated by subtracting the approximate percentage of lung function to be lost with surgical removal (segment, lobe, or pneumonectomy) from the preoperative function. If the postoperative predicted FEV1 and DLCO are greater than 40%, surgery is generally well tolerated. A quantitative perfusion scan or an exercise assessment, specifically measuring aerobic capacity, may help determine whether surgery is appropriate in patients who have a predicted postoperative FEV1 or DLCO of less than 40%. |
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The most important factors in the prognosis of a patient with lung cancer
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Stage at Presentation and Performance status
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Carcinoid Tumors
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- Low grade tumor consisting of cells of neuroendocrine origin
- 2% of all tumors - No association with smoking - Tendency to have an endobronchial location --> frequently present with hemoptysis or evidence of bronchial obstruction resulting in atelectasiss or focal bronchiectasis - Classification: Typical vs. Atypical -- Typical: 10 year survival >90% -- Atypical: high rate of mitosis and metastasis (5 y survival 50-60%) - Tx: surgical resection is treatment of choice for both and is often curative ***Carcinoid syndrome (flushing and diarrhea) rarely occurs with carcinoid tumor in the lung. |
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Histologic characteristics of mesothelioma
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Histologically, mesotheliomas are categorized as predominantly epithelial or sarcomatous (spindle cell morphology), but mixed variants are common.
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Neoplasms metastitic to the lung
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Frequent cancer sources:
- Head and neck - Colon - Breast - Thyroid - Kidney - Melanoma Presence of innumerable nodules, multiple nodules of 1 cm or larger, or multiple massess in a patient with a h/o malignancy suggests metastases |
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For which metastatic cancers does resection for a solitary pulmonary met show benefit in survival
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- Sarcomas
- Renal Cell Carcinoma - Breast Cancer - Colon cancer |
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NSCLC Tx based on staging
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Stage I - curative surgical resection, no chemorads
Stage II - curative surgical resection with adjuvant chemo +/- rads Stage III - chemorads Stage IV - chemotherapy |
