1b Lung Cancer Flashcards
What is the biggest modifiable risk factor for lung cancer?
Smoking (85%)
What can cause lung cancer other than smoking?
Chronic lung diseases (COPD, fibrosis)
Immunodeficiency
Familial/ genetic – several loci identified
passive smoking
asbestos
radon
indoor cooking fumes
air pollution
What is a DNA adduct?
pieces of DNA covalently bound to a cancer-causing chemical
How do DNA adducts form?
The interaction between inhaled carcinogens and the epithelium of upper and lower airways leads to the formation of DNA adducts
What do adducts lead to the formation of?
They can result in a mutation or genomic alteration
Which cancer originates from the bronchial epithelium and is generally centrally located?
Squamous Cell Carcinoma (30%)
Which lung cancer arises from the mucus producing glandular tissue, and is more peripherally located?
Adenocarcinoma (40%)
Which cancer type originates from pulmonary neuroendocrine cells and is highly malignant?
Small cell lung cancer (15%)
Which cancer type is from heterogenous group and is undifferentiated?
Large cell lung cancer (15%)
What is NSCLC?
Non Small Cell Lung Cancer
Mutations in which oncogene are important for directed treatment in women, asian ethnicity and never smokers?
epidermal growth factor receptor (EGFR) tyrosine kinase
Mutations in which oncogene are important for directed treatment in younger patients and never smokers?
Anaplastic lymphoma kinas3 (ALK) tyrosine kinase
c-ROS oncogene 1 (ROS1) receptor tyrosine kinase
Mutations in which oncogene are important for directed treatment in smokers especially?
BRAF
What are the clinical features of lung cancer?
Cough
Weight loss
Breathlessness
Fatigue
Chest pain
Haemoptysis
What are some features of advanced / metastatic disease?
Focal weakness
Seizures
Bone Pain
Paraneoplastic syndromes
What are some paraneoplastic symptoms?
clubbing, hypercalaemia, hyponatraemia, Cushing’s
What is pembertons sign?
Facial Redness and Congestion for One minute when the patient is asked to raise their hands above their head
What is horners syndrome?
constricted pupil (miosis)
drooping of the upper eyelid (ptosis)
absence of sweating of the face (anhidrosis), and sinking of the eyeball into the bony cavity that protects the eye (enophthalmos).
What imaging is done for a definitive staging process?
PET-CT (fluorodeoxyglucose)
When would a bronchoscopy be performed?
For tumours of the central airway, where staging the tissue is not important
Which biopsy technique is used to stage mediastinum and achieve tissue diagnosis?
Endobronchial ultrasound and transbronchial-needle aspiration of mediastinal lymph nodes (EBUS [TBNA])
Which biopsy technique is used to access peripheral lung tumours?
CT Guided Lung Biopsy
What is the TMN system?
Tumour
Nodes
Metastasis
What are some factors which determine how the cancer is treated?
Patient fitness
Cancer histology
Cancer stage
Patient preference
Health service factors
What are the five stages in the WHO Performance Status Test?
- Asymptomatic
- Symptomatic but ambulatory
- Symptomatic but in bed less than 50% of the day
- Symptomatic but in bed >50% of the day, but not bed bound
- Bed Bound
- Death
Which stages of the WHO PS is radical treatment restricted to?
PS 0-2
What is the standard of care for early stage lung cancer disease?
Surgical resection
What is the usual surgical approach for lung cancer?
Lobectomy + lymphadenectomy usual approach
sublobar resection if stage 1 (<= 3cm)
What is the alternative for surgery for early stage disease?
Radical Radiotherapy - particularly if the patient has co-morbidities
What is the technique of choice for radical radiotherapy?
SABR - Stereotactic ablative body radiotherapy (SABR)
High-precision targeting, multiple convergent beams
What is the first line treatment for metastatic NSCLC with mutation?
Oncogene directed Systemic treatment - targetted towards EGFR (erlotinib, gefitinib, afatinib, dacomitinib, and osimertinib)
ALK (crizotinib, ceritinib, alectinib, brigatinib, lorlatinib)
ROS-1 (crizotinib, entrectinib)
Tyrosine Kinase Inhibitor
What are the common side effects of oncogene directed systemic treatment?
rash, diarrhoea, and (uncommonly) pneumonitis
Binding of what inhibits T cells from killing cancer cells?
PD-L1/PD1 binding
What immunotherapy is used to treat lung cancer?
Blocking of PD-L1 or PD-1 allows the T cells to then kill the cancer cells
Pembrolizumab, atezolizumab, nivolumab
What cancer is immunotherapy the first line of treatment for?
First line for metastatic NSCLC with no mutation (and PDL1 ≥50%)
What are the side effects of immunotherapy to treat lung cancer?
Immune-related side-effects in 10-15% of cases (thyroid, skin, bowel, lung, liver)
Describe how cytotoxic chemo works?
Targets apidly dividing cells using platinum based regimens
carboplatin, cisplatin, paclitaxel, pemetrexed
What are the side effects of chemotherapy used to treat lung cancer?
Frequent: fatigue, nausea, bone marrow suppression, nephrotoxicity
quality of life poorly evaluated in trials
What should be offered as a standard to all patients with advanced stage lung cancer?
palliative and supportive care
What treatment is used for early stage disease?
Surgery or radiotherapy with curative intent
What treatment is used for advanced, but local disease?
- Surgery + adjuvant chemotherapy
- Radiotherapy + chemotherapy +/- immunotherapy
What treatment is used for metastatic disease with a targetable mutation?
tyrosine kinase inhibitor
What treatment is used for metastatic disease with no mutation but PDL-1 Positive?
Immunotherapy alone
What treatment is used for metastatic disease with no mutation but PDL-1 Negative ?
‘standard’ chemotherapy + immunotherapy
What is the most common type of Lung Cancer?
Adenocarcinoma
Why is it important to screen for lung cancer?
The tumour can get very large and develop very quickly before it starts to cause problems, by which point it might be too late
Why does metastatic lung cancer cause focal weakness?
Due to cardiac vegetations which embolize to main cerebral arteries
What causes the clubbing seen in metastatic lung cancer?
Due to increased blood flow to the area, leading to an accumulation of fluid in the soft tissues at the terminal portion of the finger
Why can lung cancer lead to cushings?
Small cell lung cancer canoccasionally be a source of ectopic ACTH secretion
Why does cachexia occur in lung cancer
Due to increased breakdown and depletion of skeletal muscle proteins
When pemberton’s sign is present, which vessel is obstructed?
Superior Vena Cava
What is PET most useful for in a diagnosis of lung cancer?
Detect occult metastasis and detects mediastinal lymph nodes
The TNM8 lung cancer staging system uses primary tumour site, tumour size, regional lymph node metastases and which other characteristic to score lung cancer progression
Extrathoracic Metastasis
What types of surgery is the usual approach to treat lung cancer?
Lobectomy + lymphadenectomy
