Lung Cancer

What are the risk factors that can put a patient at an increased risk of lung cancer?

·         Occupational hazards ( miners, heavy metal workers)

·         Smoking/tobacco

·         Second-hand smoke

·         Family history

·         Radon gas

·         Aging

·         Other illnesses ( COPD, tuberculosis, etc.)

·         Pollution

·         Exposure to radiation

What is the major cost of lung cancer that accounts for 80% of lung cancer deaths in the US?

·         Smoking/tobacco use.

What are the local symptoms associated with Lung Cancer?

·         Most common: Cough

·         Hemoptysis: 50-60%

·         Dyspnea

·         Chest pain/discomfort ( +/- hemoptysis)

·         Bronchitis

·         Hoarseness

·         Wheezing

·         Pneumonitis

·         Pleural or pericardial effusion

·         Dysphagia

What can be other signs and symptoms of Lung Cancer?

·         Bone pain: can see this when the cancer spreads to the bone.

·         Fatigue

·         Weight loss/ anorexia

·         Clubbing

·         Paraneoplastic and other syndromes 

This type of Lung cancer accounts for 15% of Lung Cancers:

Small-Cell Lung Cancer

How do you stage Small-Cell Lung Cancer?

§  Limited stage ( I-III)

§  Extensive  stage (IV)

Pathophysiology of Small-Cell Lung Cancer:

o   Has a clear relationship to smoking.

o   Likes to metastasize to the Brain.

o   Very aggressive and rapidly growing tumors.

This type of Lung Cancer accounts for 85% of Lung Cancers:

Non-Small Cell Lung Cancer

What are the types of Non-Small Cell Lung Cancers?

-Adenocarcinoma

-Large Cell Carcinoma

-Squamous Cell Carcinoma

Pathophysiology of Adenocarcinoma:

§  Mostly nonsmokers

§  Happens in the bronchoalveolar.

§  Can metastasize early.

Pathophysiology of Large Cell Carcinoma:

§  Poorly differentiated.

§  Happens in the periphery of lung.

§  Has a poor prognosis.

Pathophysiology of Squamous Cell Carcinoma:

§  Mostly smokers, males.

§  Tends to be centrally occurring.

§  Has a better prognosis.

How do you stage Non-Small Cell Lung Cancer?

§  TNM stages ( I-IV):

·         Localized (I-II)

·         Regional (II-IIII)

·         Distant (IV)

What are the platinum doublet treatment for Lung Cancer?

·         Cisplatin:

o   Vinorelbine

o   Vinblastine

o   Etoposide

o   Gemcitabine

o   Docetaxel

o   Pemetrexed

·         Carboplatin:

o   Paclitaxel

o   Gemcitabine

o   Pemetrexed

o   Etoposide

What is considered platinum sensitive?

o   Response to platinum doublet for 6+ months.

What is the first line treatment approach for a patient with advanced stage metastatic non-small cell lung cancer?

·         1^st: Assess for targetable genomic alterations:

o   This is recommended in squamous cell.

o   This is mandatory to do in adenocarcinoma.

·         2^nd: After assessing genomic alterations ; you assess PD-L 1 Status (TPS):

o   < 1%: negative

o   > 1:-49% :  positive

o   >50%:  it is for sure positive.

·         3^rd: The Patient is Biomarker negative:

o   They can only use a platinum-based regimen.

EGFR TKI medications:

Amivantimab:

o   This is a Bi-specific antibody to EGFR and MET.

o   This medication is an antagonist to EGFR mutations.

It also prevents receptor crosstalk with MET.

KRAS G12 Inhibitors:

What are some KRAS G12 phenotypes?

o   Adenocarcinoma

o   Smokers

o   Resistance to EGFR TKIs

ALK Inhibitors

What are some ALK phenotypes?

o   Adenocarcinoma

o   Younger patients ( med. Age= 52)

o   Nonsmokers or former light smokers

o   More likely to present with brain Mets.

Genomic Alteration Negative treatment plan:

No targetable genomic alterations ( PD-L1 testing)
PD-L 1 > 50%	PD-L 1 (1%-49%)
Pembrolizumab alone Atezolizumab alone Cemiplimab-rwlc alone or Platinum/pemetrexed + pembrolizumab	Adenocarcinoma large cell ( other non-squamous): Platinum/pemetrexed + pembrolizumab	Squamous cell: carboplatin _ nab-paclitaxel + pembrolizumab

What are the side effects of the EGFR inhibitors?

-acneiform rash

-diarrhea

-stomatitis

  If a patient has Grade 1 rash, what would  be the treatment?

§  Topical steroids or topical antibiotics

If a patient has  a Grade 2 rash, what would be the treatment?

§  Topical steroids + oral antibiotics.

If a patient has a Grade 3 rash, what would be the treatment?

§  Temporarily discontinue + ( grade 2 treatment)

If a patient has a Grade 4 rash, what would be the treatment?

§  Discontinue medication permanently.

   How would you treat a patient who experiences diarrhea from their EGFR Inhibitor?

§  Loperamide

§  IV fluids

§  Electrolyte replacement

How would you treat a patient who gets stomatitis from their EGFR inhibitor?

§  Triamcinolone dental paste

§  Oral erythromycin

§  Magic mouth wash

§  Clobetasol ointment