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Neoplasia
Lung Cancer: Staging, Workup & Treatment Overview
Added by Dr. Andrew · Last updated 2024-01-15
Overview
Lung cancer is the leading cause of cancer death in the US. NSCLC accounts for 85% of cases. Molecular profiling has transformed treatment, with targeted therapies available for EGFR, ALK, ROS1, KRAS G12C, BRAF V600E, MET exon 14, RET, and NTRK alterations.
Key Points
- 1NSCLC subtypes: adenocarcinoma (most common, 40%), squamous cell (25–30%), large cell (10%)
- 2SCLC: limited stage (one hemithorax + ipsilateral nodes) vs extensive stage
- 3Staging: CT chest/abdomen/pelvis + PET-CT + brain MRI for stage III-IV
- 4Molecular testing: all advanced NSCLC should have comprehensive molecular profiling (EGFR, ALK, ROS1, PD-L1, KRAS, BRAF, MET, RET, NTRK)
- 5Screening: annual LDCT for age 50–80, ≥20 pack-years, current or quit within 15 years (USPSTF 2021)
- 6EGFR mutation (~15% of NSCLC in US): osimertinib first-line (FLAURA trial)
Clinical Pearls
- Pancoast tumor (superior sulcus): Horner syndrome (ptosis, miosis, anhidrosis) + shoulder/arm pain
- SIADH: most common paraneoplastic syndrome in SCLC
- Lambert-Eaton: proximal muscle weakness, improves with repeated use — VGCC antibodies
- Osimertinib: crosses BBB — preferred for EGFR+ NSCLC with brain metastases
Board High-Yield
Exam Focus- NLST: LDCT reduced lung cancer mortality 20% vs CXR in high-risk smokers
- FLAURA: osimertinib superior to erlotinib/gefitinib for EGFR-mutant NSCLC (1st line)
- ALEX: alectinib superior to crizotinib for ALK+ NSCLC
- KEYNOTE-024: pembrolizumab superior to chemo for PD-L1 ≥50% NSCLC
- SCLC limited stage: concurrent chemoradiation (cisplatin + etoposide); prophylactic cranial irradiation
ABIM Exam Weight
9.5%
Neoplasia & Lung Cancer represents approximately 9.5% of the PCCM certification exam.