Lung Cancer

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Lung Cancer
2010-03-16 22:25:26
Lung Cancer

Lung Cancer
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  1. predicts EGFR TKI sensitivity (erlotinib)
    EGFR exon 19 deletion/exon 21 L858R mutation
  2. poor survival and predictive of lack of benefit from platinum/vinorelbine chemotherapy or EGFR TKI thereapy
    K-ras mutations
  3. a very big risk after lung cancer
    development of a secondary malignancy
  4. rapidly growing cells with scant cytoplasm
    typically in central airways
    association with paraneoplastic syndromes
    strong dose response association with cigarettel smoking
    Small cell carcinoma
  5. arise in proximal segmental bronchi and present clinically in lung periphery
    tend to be slow growing
    strong dose response relation to tobacco exposure
    comprised of sheets of epithelial cells that frequently include keratin
    can be associated with a parathyroid hormone like factor -- hypercalcemia
    squamous cell
  6. types of non-squamos, non small cell carcinoma
    • adenocarcinoma
    • bronchioalveolar
    • large cells
    • others
  7. most frequent in US and in nonsmokers
    mostly in our area
  8. relatively uncommon
    found among nonsmoking females of asian descent that harbor unique EGFR mutations
    responds to erlotinib
    bronchioalveolar carcinoma -- subtype of adenocarcinoma
  9. peripheral tumors and lack definite evidence of squamous or glandular maturation
    large cell
  10. indicated by pleural or chest wall pain, cough, restrictive dyspenea
    Peripheral primary tumor growth
  11. indicated by dysphagia, nerve paralysis syndromes, SVC, pericardial tamponade, pleural effusion, paraneoplastic syndromes
    regional or metastatic tumor growth
  12. stage of localized advanced disease
    stage III
  13. advanced disease
    stage IV
  14. disease that is confined to ipsilateral hemithorax and can be encompassed by a single radiation port

    it is no necessary to radiate the whole lung area
    limited stage small cell carcinoma
  15. all other disease, including metastatic sites, pleural or cardiac effusion
    can spread quickly
    most people have it before they discover disease
    extensive disease small cell carcinoma
  16. improves delivery of external beeam radiotherapy and reduce toxicity
    3D-CRT, IMRT
  17. Adverse effects of radiation therapy
    • acute effects start 2nd or 3rd week
    • esophagitis, fatigue, nausea, pneumonitis, blood counts, superficial infections
  18. adverse effects: follicular rash, diarrhea, interstitial lung disease, conjuctivitis, keratitis, corneal ulcerations

    avoid concomitant 3A4 inducers

    potential increased risk of bleeding with warfarin and NSAIDS
    erlotinib and gefitinib
  19. adverse effects: follicular rash, diarrhea, hypomagnesia, hypersensitivity rxns, and interstitial lung disease
  20. criteria for cetuximab
    • EGFR positive disease, ECOG perfomance status 0-2, no known brain metastases, no prior chemo o ranti EGFR therapy
    • no k-ras
  21. folic acid needed
  22. 4 major treatment modalities
    • surgery
    • radiation therapy
    • EGFR inhibitors
    • Cytotoxic Agents
  23. For Non-small Cell Carcinomas resectable disease:

    Tx of choice for stage I and II
    Size of primary tumor adn extent of lymph node involvment is important
  24. chemo recommended as adjuvant therapy for Non-small Cell Carcinomas resectable disease
    • cisplatin based and XRT at discretion of investigator
    • paclitaxel/carboplatin only recommended if patients cannot tolerate cisplatin
  25. For Non-small Cell Carcinomas, postoperative __________ reduces local recurrences, increases toxicity, but controversial whether it improves OS
    adjuvant radiation therapy
  26. Tx options for Non-small Cell Carcinomas that is locally advanced
    • surgery
    • neoadjuvant -- radiation, chemo
    • adjuvant -- radiation, chemo
  27. when in radiation used for Non-small Cell Carcinomas with locally advanced disease as neoadjuvant therapy?
    with those who are not candidates for chemotherapy
  28. chemo for Non-small Cell Carcinomas with locally advanced disease as neoadjuvant therapy
    preoperative chemo and radiation recommended for patients with resectable tumors

    generally involves cisplatin and a second drug(etoposide, vinorelbine, vinblastine) or paclitaxel plus carboplatin
  29. radiation as adjuvant therapy for Non-small Cell Carcinomas with locally advanced disease?
    if surgical margins positive for tumor cells

    may improve control for patients who have been completely resected
  30. chemo for Non-small Cell Carcinomas locally advanced as adjuvant therapy?
    may reduce distant recurrence in those that have been completely resected

    administered to those who did not recieve preoperative radiation, or in pts with positive tumor margins
  31. tx options for Non-small Cell Carcinomas with advanced, unresectable, or metastatic disease
    • surgery
    • radiation -- palliation
    • controll of obstructed airways
    • concurrent chemo
    • EGFR inhibitors
  32. concurrent chemo for Non-small Cell Carcinomas that are advanced, unresectable, or metastatic
    platinum based chemo plus XRT provides a modest survival advantage
  33. chemo for Non-small Cell Carcinomas that are advanced, unresectable, or metastatic
    • overall: platinum based 2 drug chemo
    • chemo provides modest sruvival advantage and is cost effective
  34. indicated for tx of pts with locally advanced or metastatic NSCLC after failure of at least one prior chemo regimen

    data suggests it is limited to people harboring specific EGFR activating mutations and absence of K-ras mutations
  35. For NSCLC _______ showed improved OS vs vinorelbine an cisplatin +/- cetuximab, but increase in grade 3 or 4 neutropenia and grade 2 follicular rash
  36. associated with best survival outcomes for metastatic NSCLC
    platinum based combnation regimens
  37. 1st line therapy for chemo for Non-small Cell Carcinomas that are advanced, unresectable, or metastatic with a perfomance status of 0-1
    • - chemo + bevacizumab: if non squamous cell NSCLC, no untreated CNS metastases, and no history of hemoptysis
    • - cisplatin plus pemetrexed if non-squamous cell histology
    • - cetuximab/vinorelbine/cisplatin if meets criteria for cetuximab
  38. 1st line therapy for chemo for Non-small Cell Carcinomas that are
    advanced, unresectable, or metastatic with a perfomance status of 0-2
    cetuximab/vinorelbine/cisplatin if meets criteria for cetuximab
  39. what are the requirement for cetuximab?
    • EGFR positive disease
    • performance status of 0-2
    • no know brain metastases
    • no prior chemo or anti-EGFR therapy
  40. for what NSCLC patients is maintenance therapy an option?
    those who have recieved 4-6 cycles of chemo with stable non-progressive disease
  41. 2nd line and subsequent therapy for chemo for Non-small Cell Carcinomas that are
    advanced, unresectable, or metastatic
    • docetaxel: PS 0-2
    • pemetrexed: PS 0-2
    • erlotinib: PS 0-3
  42. Median survival with extensive disease without tx is about 5 weeks
    Dissemination of disease almost always has occured by diagnosis
    Brain metastasis common
    Small Cell Carcinoma
  43. Tumor regression occurs in approximately 90% witih newly diagnosed SCLC
    Adds to survival benefit in limited stage disease
    Radiation therapy
  44. SCLC is very sensitive to _______ _________. Can cure a small fraction of patients with _____ ______ disease
    • Combination chemo
    • Limited stage disease
  45. 1st line therapy of SCLC
    • Limited stage: chemo (x 4 cycles) plus chest radiotherapy
    • Exstensive stage: chemo
  46. preferred with cuncurrent radiation therapy in limited stage SCLC
    EP (cisplatin + etoposide)
  47. For SCLC, alternating non-cross resistant regimens is not ______ ______.
    ______ _______ may be acceptable for patients at increased risk for toxicity but do not yeild comparable results. Original regimen can be used if relapse is > than __ _______
    • proven superior
    • single agents
    • 6 months
  48. duration of tx of SCLC is limited to about ___ ______
    6 months
  49. For all lung cancer, _____ _________ can be used for brain metastases, SCLC, symptomatic local or weight bearing bone lesions, and hemoptysis
    radiation therapy