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WEEK 22:
Lung cancer treatment and prognosis:
| Question | Answer |
|---|---|
| predictors of survival (3) | tumour related factors (eg stage of disease, tumour size and location), patient related factors (etc age, smoking), and treatment related factors (eg treatment adherence or access to care) |
| types of treatment (2) | curative and palliative |
| curative treatment (3) | surgery, radical radiotherapy (including stereotactic ablative radiotherapy SABR), and radical chemotherapy |
| classification of LC (3) | SCLC, NSCLC (lung adenocarcinoma, squamous cell carcinoma, and large cell carcinoma), and pulmonary carcinoid tumours |
| palliative treatment (3) | radiotherapy, systemic anticancer treatment, and combinations |
| modalities of treatment (4) | radiotherapy, chemotherapy, chemo-radio, and surgery |
| adenocarcinoma | mutations in EGFR |
| squamous cell carcinoma | associated withTP53 |
| induction chemotherapy | aims to down stage tumour prior to an operation with curative intent |
| neo-adjuvant chemotherapy | pre-operation to reduce chance of metastases |
| adjuvant chemotherapy | post operation to reduce chance of metastasis |
| adjuvant immunotherapy | immunotherapy given after surgery to reduce risk of cancer coming back |
| targeted treatment | drugs designed to attack specific genetic mutations (driver mutations) to kill cancer cells and spare healthy cells |
| how is cancer treatment chosen | based on cancer type (NSCLC etc), stage, molecular profile (etc EGFR), and patient factor (etc age, comorbidities and preferences) |
| NSCLC treatment** | high prevalence of targetable mutations where stage strongly determines surgery vs systemic therapy |
| SCLC treatment | fast growing high grade neuroendocrine tumour where systemic therapy is MANDATORY and few actionable mutations -> chemo-immunotherapy dominates |
| carcinoid tumours treatment | slow growing neuroendocrine tumours where surgery first and low mutation burden -> limited role for targeted therapy |
| treatment for no driver mutation cancer tumours** | immunotherapy +/- chemotherapy when PDL1.. |
| primary treatment for carcinoid type lung cancer | surgical resection but lung preserving surgery preferred |
| role of PD1** | bind to PDL1 on the lung cancer cell become 'exhausted' and inhibits growth |
| SABR (stereotactic ablative body radiotherapy) or stereotactic body radiotherapy SBT | highly precise form of radiotherapy that delivers very high dose radiation to a tumour in a small number of treatments while minimising damage to surrounding normal tissue |
| No fly zone - complications | massive haemoptysis, penumonia, airway necrosis, and pericardial effusion |
| RATS (robotic assisted thoracic surgery) | minimally invasive surgical technique used o remove lung cancers using robotic surgical system |
| follow up care | crucial in monitoring patients recovering and detecting recurrence, managing side effects of treatment and improving long term outcomes |
| NSCLC | most common type of lung cancer (87% of cases) with 2 major subtypes (adenocarcinoma/ non squamous and squamous cell carcinoma) where treatments are different (with identification of mutations in tumours being important in adenocarcinomas) |
| SCLC | less common (12% cases), aggressive cancer which spreads at an early age and so is nearly always advanced at time of diagnosis leading to limited curative intent treatment options |
| pulmonary carcinoid tumours | well differentiated neuroendocrine tumours (much less aggressive than SCLC/ other high grade neuroendocrine cancers) and has 2 subtypes |
| clinical features of pulmonary carcinoid tumours (2) | arise from bronchial neuroendocrine cells and slow growing (usually central airway tumours) |
| 2 subtypes of pulmonary carcinoid tumours (2) | typical and atypical |
| typical carcinoid tumour | low grade, excellent prognosis |
| atypical carcinoid tumour | intermediate grade, higher mitotic rate, greater metastatic risk |
| low grade meaning | less aggressive |
| high grade meaning | more aggressive |
| local symptoms of lung cancer (5) | persistent cough, haemoptysis, dyspnoea, chest pain, and recurrent pneumonia (bronchial obstruction) |
| regional spread of lung cancer (3) | hoarse voice (recurrent laryngeal nerve), SVC obstruction, pancoast tumour sign (Horner's and shoulder pain) |
| how do carcinogens lead to mutations to cancer | repeated exposure to carcinogens eg tobacco smoke causes DNA breaks and mutations in bronchial epithelial cells and failure of DNA repair leads to accumulation of driver mutations and uncontrolled cell proliferation |
| adenocarcinoma includes mutations in | EGFR and KRAF leading to active growth pathways |
| squamous cell carcinoma includes mutations in | T53 |
| SCLC and carcinoid has an origin for | neuroendocrine origin |
| SCLC arises from | pulmonary neuroendocrine cells (rapid doubling time) with loss os TP53 and RB1 |
| carcinoids | well differentiated neuroendocrine tumours with slow proliferation |
| when tumour peentrates bronchial wall what happens | local obstruction -> collapse, consolidation, and recurrent pneumonia |
| when tumours invade nerves/ vessels what happens | chest pain, haemoptysis, hoarseness (RLN palsy) |
| how does SCLC metastasise | early and aggressively |
| initial investigations for lung cancer | CXR, CT of chest, and spirometry |
| chemotherapy | whole body treatment where drugs are used to kill cancer cells by disrupting their growth where in early stage cancer it is used to shrink tumour size before surgery but in advanced lung cancer it is used to stop cancer from spreading further |
| radiotherapy | high energy xrays destroy cancer cells to stop them growing and spreading. In early stage NSCLC for those who cannot have surgery, used after surgery if it wasnt possible to remove all cancerous tissue, and in late stage to manage symptoms |
| when is radiotherapy used in early stage | in early stage NSCLC for people who cannot have surgery |
| when is radiotherapy used after surgery | if it was not possible to remove all the cancerous tissue |
| when is radiotherapy used in late stage | to manage symptoms |
| chemoradiotherapy | combination of chemotherapy and radiotherapy offered to people with stage 2/3 NSCLC who are reasonably well as it can be difficult to tolerate the side effects of both treatments |
| surgery | effective |
| systemic anticancer treatment | include all treatments that are administered to the whole body eg chemotherapy, immunotherapy and other medicines that disrupt behaviour of cancer cells and are more oftenly used in advanced NSCLC |
| systemic anticancer treatments like chemotherapy are more often used to treat | advanced NSCLC |
| NSCLC treatment used in early stage I/II | surgery and or adjuvant therapy |
| NSCLC treatment used in locally advanced III | chemotherapy and or immunotherapy |
| NSCLC treatment used in stage IV | systemic therapy based on mutations |
| what is essential before first line therapy | molecular diagnostic are essential before first line therapy |
| how does SABR work | uses multiple small focused radiation beams aimed at the tumour from different angles where beams meet at tumour leading to high dose to cancer and low dose to normal tissue |
| SABR is used for | early stage NSCLC (small tumours), especially when patients are no surgical candidates, oligometastatic lung disease (eg metastases to lung, liver, spine) |
| treatment for limited stage SCLC | chemoradiotherapy |
| treatment for extensive stage SCLC | systemic therapy |
| role of chemotherapy on carcinoid type | not very effective and reserved for progressive atypical carcinoids |
Created by:
kablooey
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