Given to Florida State University School of medicine medicine residents

1. Amit Jain, MD, MPH
TMH Cancer Center
May 2016
Lung Cancer Board Review for
Internal medicine residents

2. Case 1
A 57-year-old woman is evaluated in the ED for shortness of breath associated with
wheezing and pain with inspiration. She has a 25-pack-year smoking history of
cigarette smoking. She takes no medications.
On physical examination, temperature is normal, blood pressure is 138/82 mm Hg,
and respiration rate is 18/min. Wheezing is heard on pulmonary examination. The
remainder of the examination is normal.
Laboratory studies are normal. A chest radiograph is normal, and a spiral CT scan
reveals multiple bilateral pulmonary emboli in addition to several bilateral pulmonary
nodules, each measuring 2 to 4 mm.
The patient is admitted to the hospital, and heparin and warfarin therapy is begun.
Which of the following is the most appropriate next diagnostic step in the evaluation
of the patient’s pulmonary nodules?
 Bronchoscopy with cytologic analysis
 CT-guided biopsy of the largest nodule after withdrawal of anticoagulation
 Follow-up CT in 12 months
 PET/CT now

3. Lung cancer screening
 Sputum cytology, Chest X rays, other imaging
 All negative studies
 Recent NLST study
 Low dose screening spiral CT yearly
 Minimum 30-pack-years smoking
 20% reduction in lung cancer mortality
 Pulmonary nodules evaluation
 Non-calcified nodules >4mm require further evaluation
 High risk individuals with nodules < 4 mm require f/u imaging
 Low risk individuals with nodules < 4mm, no f/u imaging recommended
 PET/CT scan unlikely to detect lesions <1 cm in size

4. Answer
 Follow-up CT in 12 months

5. Case 2
A 65-year-old man is evaluated for a 3-week history of hemoptysis and a recent 10 lb weight
loss. He has a 90-pack year smoking history.
On physical examination, vital signs are normal. The pulmonary examination reveals occasional
crackles at the posterior right midlung field. The remainder of the examination is normal.
A chest radiograph demonstrates a large right hilar mass. A CT scan of the chest shows a 5-cm
right hilar mass with bulky mediastinal adenopathy. Bronchoscopic examination reveals small
cell lung cancer. Results of the staging studies with an MRI of the brain and a bone scan are
negative.
The patient receives six cycles of chemotherapy with cisplatin and etoposide with radiation to the
lung mass concurrently. A follow-up CT scan shows a residual 1.5 cm right hilar abnormality.
Which of the following is the most appropriate next step in this patient’s management?
 Biopsy of the residual mass
 Three additional cycles of chemotherapy
 Whole brain radiation
 Observation

6. Small cell lung cancer
 15% of all lung cancers
 Almost always in smokers
 Centrally located tumors
 Bronchoscopy for diagnosis
 Instead of TNM classification, two-category classification
 Limited stage: all disease in hemithorax and can be encompassed in one
radiation field
 Extensive stage: All others

7. Treatment of SCLC
 Limited stage (TNM Stages I/II/IIIA)
 Combined chemotherapy and radiation
 Concurrent
 Sequential (slightly inferior)
 High risk for CNS relapse
 Prophylactic cranial irradiation (PCI) if CR or very good response
 Extensive stage
 Palliative chemotherapy

8. Prognosis of SCLC
 Limited stage
 Median survival is 1.5 years
 5 year survival rate up to 20%
 Extensive stage
 Median survival is 9 months
 5 year survival is almost 0

9. Case 3
A 56-year-old woman is evaluated for a persistent cough of 2.5 months’ duration. She also notes
a 10-lb weight loss. The patient has no history of pulmonary disease and has never smoked
cigarettes. is otherwise healthy.
On physical examination, vital signs are normal. There is no peripheral lymphadenopathy, and
pulmonary and neurologic findings are normal.
A chest radiograph reveals a large peripheral right lung mass. Right hilar and subcarinal
lymphadenopathy, as well as several hepatic hypodensities consistent with metastatic disease,
are identified on CT scans of the chest and abdomen. MRI of the brain is normal. A radionuclide
bone scan notes uptake in several ribs.
A CT-guided needle lung biopsy demomstrates adenocarcinoma.
Which of the following is the most appropriate next step in the evaluation of this patient?
 CT-guided biopsy of the liver
 Epidermal growth factor receptor (EGFR) mutation tumor analysis
 Mediastinoscopy with biopsy
 Serum chromogranin measurement

10. Lung cancer in non-smokers
 Better outcome
 Higher response rate
 Long term progression free survival
 Better tolerance to treatment
 15% of all lung cancers
 Patient characteristics
 Non-smokers or remote smokers (quit more than 20 years ago and smoked
for less than 20 years)
 Predominantly adenocarcinoma
 Women
 Asian

11. Mutations in lung cancer
 Driver mutations identified
 EGFR
 EML4-ALK
 ROS1
 Others
 Targeted therapy based on mutations
 EGFR inhibitors
 Erlotinib, Geftinib, Afatinib
 ALK inhibitors
 Criztonib, Ceritinib
 MET inhibitors

12. Answer
 EGFR mutation analysis

13. Case 4
 A 44 year old fit female karate instructor, non-smoker, is diagnosed with
Stage IV adenocarcinoma of the lung with extensive liver mets. She is
keen on aggressive chemotherapy treatment and is started on oral
Erlotinib after her pathology report reveals an EGFR mutation from the
biopsy.
 Which of the following is not an expected side effect of Erlotinib?
 Fatigue and asthenia
 Acneiform rash on the face, trunk and extremities
 Diarrhea
 Systolic dysfunction and cardiomyopathy

14. Toxicity of targeted therapy in lung
cancer
 Skin rash
 Most common
 Acneiform
 Well tolerated
 Treatment with topical therapy
 Diarrhea
 Less common
 Easily treatable
 Fatigue
 Seen with most cancer treatments

15. Toxicity of TKI’s targeting VEGF
 Hypertension
 Preteinuria
 Cardiac dysfunction
 Examples
 Sunitinib
 Sorafenib
 Pazopanib
 Imatinib

16. Answer
 Systolic dysfunction and cardiomyopathy

17. Case 5
A 52-year-old man is evaluated for a 5-week history of hemoptysis and a 6-month history of cough occasionally
productive of sputum for which he did not seek medical attention. He also had a 10 lb weight loss during this
period. He has a 62-pack-year smoking history.
On physical examination, vital signs are normal. There is an expiratory wheeze localized to the left upper
pulmonary lobe. The remainder of the physical examination is normal.
A chext X ray demonstrates a large left upper lobe lung mass. A CT scan of thorax and abdomen reveals a 7-cm
pulmonary mass in the left upper lobe and some mediastinal lymph node enlargement. A CT-guided biopsy of a
lung lesion reveals squamous cell carcinoma. A PET/CT scan indicates extensive uptake in the mediastinal
lymph nodes. MRI of the brain is normal. Mediastinoscopy and lymph node sampling reveal no evidence of
cancer.
Which of the following is the most appropriate treatment for this patient?
 Combination radiation and chemotherapy
 Surgical resection
 Surgical resection followed by chemotherapy
 Systemic chemotherapy

18. Lung cancer staging and outcome
Stage T N M Survival at 5 years
IA T1 or tumor < 3cm N0 M0 50%
IB T2a or tumor 3-5 cm N0 M0 43%
IIA T2 or T1N1 (hilar
nodes)
M0 36%
IIB T2 or T3 (>7cm) N1 M0 25%
IIIA T1-T3 N2 (mediastinal
nodes) or T4N1
M0 19%
IIIB T1-T4 N3 (contralateral
mediastinal/hilar
nodes)
M0 10%
IV Any T Any N M1 <5%

19. Lung cancer staging
 Biopsy
 CT scan of chest and abdomen
 If surgical candidate, Stage IIIA or less
 PET/CT scan
 Mediastinoscopy if clinical positive lymph nodes
 Either CT or PET
 Bone scan
 If symptoms
 Small cell histology
 MRI brain
 20% incidence of occult brain mets on presentation

20. Early stage lung cancer treatment
 Stage I
 Surgical resection
 Adjuvant chemotherapy in highly selected St IB if poor prognostic features
 Stage II
 Surgical resection
 Adjuvant chemotherapy
 Cisplatin doublet
o Vinorelbine
o Etoposide
o Taxanes
 No role of adjuvant radiation
 multiple negative trials
 Stage III
 Surgical resection if feasible, often not
 Concurrent chemotherapy and radiation
 Platinum analogue doublet

21. Case 6
 A 56 year old male is evaluated 4 weeks after a pulmonary lobectomy for a
spiculated lesion in the RUL of the lung. Pathology reveals poorly differentiated
adenocarcinoma of the lung (TTF-1 +) with clear margins, no pleural or lympho-
vascular invasion and with 7 negative lymph nodes for metastatic cancer.

 A pre-op MRI brain was negative and a PET-CT revealed a 2.7 cm RUL
pulmonary lesion with a SUV of 8.5 but no distant disease.
 Which of the following is the appropriate next step in the management?
 Radiation treatment
 Platinum based doublet chemotherapy
 Concurrent chemotherapy and radiation
 Suveillance with periodic physical exam and imaging

22. Answer
 Surveillance with periodic imaging

23. Case 7
A 65-year-old man is evaluated for a 6-week history of weakness on climbing stairs, difficulty
raising his arms above his head, and the need to push off the arms of a chair to rise from a
seated position. The patient also has dry eyes and mouth and new-onset erectile dysfunction.
Medical history is significant for limited-stage small cell lung cancer for which he completed
treatment with cisplatin-etoposide and mediastinal radiation therapy, followed by prophylactic
cranial irradiation, 3 months ago.
On physical examination, temperature is normal, and BP is 136/74 mm Hg. There is no
lymphadenopathy. The cardiopulmonary and abdominal examinations are unremarkable. He
scores 30/30 on the Mini-Mental State Examination. Neurologic evaluation reveals no evidence
of muscle atrophy. There is bilateral ptosis and 4/5 proximal weakness of the upper and lower
extremities, mild weakness of the distal musculature, and absent reflexes. After a brief isometric
exercise involving the upper extremities, the triceps tendon reflex returns to normal, and
proximal arm strength returns to normal.
Laboratory studies are unremarkable.
Which of the following is the most likely diagnosis?
 Brain metastases
 Lambert-Eaton syndrome
 Radiation toxicity
 Spinal cord compression

24. Paraneoplastic syndromes in lung
cancer
 Hypercalcemia
 SIADH secretion (Hyponatremia)
 Neurologic
 Lambert Eaton syndrome
 Cerebellar ataxia
 Limbic encephalitis
 Encephalomyelitis
 Autonomic neuropathy
 Hematologic
 Leukocytosis
 Thrombocytosis
 Eosinophilia
 Hypercoagulable disorders
 Trousseau’s syndrome
 Hypertrophic osteoarthropathy
 Myositis
 Cushing’s syndrome

25. Answer
 Lambert Eaton

26. Case 8
A 63-year-old man is evaluated in the emergency department for facial swelling, cough and progressive
dyspnea. He reports no headache, change in vision or chest pain. HE has a 40-pack-year smoking history.
On physical examination, temperature is 37.0 C, BP is 160/95 mm Hg, pulse rate is 110/min, and respiration rate
is 24/min. Oxygen saturation is 90% with the patient breathing room air. He has facial plethora and cyanosis as
well as bilateral internal jugular venous distension. Wheezing is noted in the left upper lung field, but the lungs
are otherwise clear. Cardiac examination is normal without extra sounds or murmurs. There is no peripheral
edema and no cervical, supraclavicular, or axillary lymphadenopathy.
Chest X ray reveals a widened mediastinum and a left upper lobe infiltrate. CT scan of the chest demonstrates a
left upper lobe mass with impingement on the superior vena cava and mediastinal adenopathy.
Which of the following is the most appropriate next step in management?
 Chemotherapy
 Combination chemotherapy and radiation therapy
 Corticosteroids
 Mediastinoscopy and biopsy
 Radiation therapy

27.  What is it???
 Treatment before diagnosis
 Do steroids help?
 Does histology of lung cancer change front line
management

28. Answer
 Mediastinoscopy and biopsy

29. SVC syndrome: Causes
 Lung cancer
 Small cell
 Non-small cell
 Lymphoma
 Metastatic cancer
 Germ cell cancer
 Thymoma
 Mesothelioma
 Non-malignant causes
 Thromboembolic disease

30. Management of SVC syndrome
 Elevation
 Depending on etiology
 Chemotherapy
 SCLC, GCT, lymphoma
 Radiation
 NSCLC, metastatic cancer
 Surgery
 Thymoma
 Stent
 VTE
 Steroids
 Only as adjunct to primary treatment
 Not proven to help by itself

31. Case 9
A 54-year-old woman is evaluated for shortness of breath of 3 months’ duration and a 10-lb
weight loss over the preceding 2 months. She has a 35-pack-year smoking history.
On physical examination, vital signs are normal except pulse rate of 108/min and oxygen
saturation on room air is 92%. No palpable lymphadenopathy is noted. The patient has clubbing
of the fingertips. The lung fields are clear on the left, with diminished breath sounds and dullness
to percussion over the lower half of the right lung. The remainder of examination is normal.
A chest X ray reveals a large right pleural effusion. A thoracentesis demonstrates an exudate,
with cytologic evaluation indicating adenocarcinoma. A chest tube is placed, and talc pleurodesis
is performed. A CT scan reveals a 4-cm right peripheral lung mass with no obvious
lymphadenopathy. Bone scan and brain MRI are normal.
Which of the following is the most appropriate treatment?
 Combination chemotherapy and radiation
 Radiation
 Surgical resection of the lung mass
 Systemic chemotherapy

32.  What stage is this disease?
 What are the goals of treatment?
 Does she need local vs systemic treatment?
 Is this curative intent or palliative?

33. Answer
 Systemic chemotherapy

34. Thank you
Questions!!!