1b// Lung cancer

Question 1

how common is lung cancer in the UK?

Answer 1

3rd most common cancer

leading cause of cancer death

Question 2

who is most at risk of lung cancer?

Answer 2

age 75-90
male
lower socioeconomic status
smoking history

Question 3

what are the risk factors for lung cancer?

Answer 3

smoking and passive smoking
asbestos
radon
indoor cooking fumes
chronic lung diseases
immunodeficiency
familial

Question 4

what is the most common type of lung cancer?

Answer 4

adenocarcinoma

Question 5

what is squamous cell carcinoma?

Answer 5

centrally located lung cancer

originating from bronchial epithelium

Question 6

what is adenocarcinoma?

Answer 6

peripherally located lung cancer

originating from mucus producing glandular tissue

Question 7

what is large cell lung cancer?

Answer 7

undifferentiated heterogenous group lung cancer

Question 8

what is small cell lung cancer?

Answer 8

originates from pulmonary neuroendocrine cells

highly malignant!

Question 9

what oncogenes are important for adenocarcinomas?

Answer 9

epidermal growth factor receptor (EGFR) tyrosine kinase

more so in women, never-smokers, asian

Question 10

what oncogenes are important for small cell lung cancer?

Answer 10

anaplastic lymphoma kinase (ALK) tyrosine kinase - young patients, non-smokers
e-ROS oncogene 1 (ROS1) receptor tyrosine kinase - younger patients, non-smokers
BRAF (downstream cell-cycle signalling mediator) - esp in smokers

Question 11

what are the key symptoms of lung cancer?

Answer 11

cough
weight loss
breathlessness
fatigue
chest pain
haemoptysis
frequently asymptomatic!

Question 12

what are the features of advanced/metastatic lung cancer?

Answer 12

neurological features: focal weakness, seizures, spinal cord compression
bone pain
paraneoplastic syndromes: clubbing, hypercalcaemia, hyponatraemia, cushings
swelling lymph nodes

Question 13

where are the common metastases of lung cancers?

Answer 13

bone
liver
brain
lymph nodes
adrenal glands

Question 14

what are some signs of lung cancer?

Answer 14

cachexia
clubbing
horners syndrome
pembertons sign (superior VC obstruction)

Question 15

what is the diagnostic strategy for lung cancer?

Answer 15

establish most likely diagnosis
establish fitness for investigation/treatment
confirm diagnosis, specific type if treating
confirm staging

Question 16

how may lung cancer appear on a chest x ray?

Answer 16

white-grey masses

Question 17

how is CT scanning used in lung cancer diagnosis?

Answer 17

primarily for staging - invasion of other tissues, metastases
chest+abdo

Question 18

how may PET scans be used in lung cancer diagnosis?

Answer 18

to exclude occult metastases

Question 19

what are the biopsy methods available for lung cancer?

Answer 19

bronchoscopy
endobronchial ultrasound and transbronchial needle aspiration of mediastinal lymph nodes
CT-guided lung biopsy

Question 20

when is bronchoscopy biopsy used in lung cancer?

Answer 20

for tumours of central airway

+ tissue staging not important

Question 21

when is EBUS ((endobronchial US)) + (TBNA) biopsy used in lung cancer?

Answer 21

to stage mediastinum +/- achieve tissue diagnosis

Question 22

when are CT-guided lung biopsies used in lung cancer?

Answer 22

to access peripheral lung tumours

Question 23

how is lung cancer staged?

Answer 23

T1-4 size
N0-3 lymph node involvement
M0-1c metastases + no.

Question 24

what are the determinants of treatment for lung cancer?

Answer 24

patient fitness 
cancer histology
cancer stage
patient preference
health service factors

Question 25

what are the WHO performance status guidelines for patient fitness?

Answer 25

0 - asymptomatic
1 - symptomatic but ambulatory
2 - symptomatic <50%in bed during day
3 - symptomatic >50% in bed but not bedbound
4 - bedbound
5 - dead

Question 26

what treatment is standard for early stage lung cancer?

Answer 26

surgical resection - usually lobectomy + lymphadenectomy

Question 27

what surgical treatment is used for lung cancers in stage 1 (<3cm)

Answer 27

sub-lobar resection

Question 28

when is radical radiotherapy used in lung cancer?

Answer 28

early stage disease if no surgery

esp for comorbidities

Question 29

what is radical radiotherapy for lung cancer?

Answer 29

stereotactic ablative radiotherapy (SABR)

high precision targeting, multiple convergent beams

Question 30

what are the available systemic treatment types for lung cancer?

Answer 30

oncogene directed
immunotherapy
cytotoxic chemotherapy

Question 31

what is standard treatment for locally advanced disease (involving thoracic lymph nodes)

Answer 31

surgery + adjuvant chemotherapy

radiotherapy + chemotherapy +/- immunotherapy

Question 32

what is standard treatment for metastatic disease?

Answer 32

with targetable mutation tyrosine kinase inhibitors (EFGR, ALK, ROS-1)
no mutation but PDL-1 positive immunotherapy alone
no mutation but PDL-1 negative chemotherapy + immunotherapy
palliative care

Question 33

what are the NICE approved oncogene-directed systemic treatments?

Answer 33

EGFR - erlotinib, gefitinib, afatinib
ALK - crizotinib, ceritinib, alectinib
ROS-1 - crizotinib, entrectinib

Question 34

what are the NICE approved immunotherapies?

Answer 34

pembrolizumab, atezolizumab, nivolumab

Question 35

when is immunotherapy given for lung cancer?

Answer 35

first line for metastatic non small cell with no mutation

PDL1 >50%

Question 36

when is oncogene directed treatment given for lung cancer?

Answer 36

first line for metastatic non-small cell with mutation

Question 37

when is cytotoxic chemotherapy given for lung cancer?

Answer 37

first line for metastatic non-small cell with no mutation PDL1<50%
in combo with immunotherapy

Question 38

when should palliative/supportive care be offered to lung cancer patients?

Answer 38

all patients with advanced stage disease

Question 39

what is palliative and supportive care in lung cancer?

Answer 39

symptom control
psychological support
education
practical and financial support
planning for end of life

Question 40

What is the mechanism of action of immunotherapy?

Answer 40

Binds to PDL-1 on tumour cell or PD-1 on T cell (normally these cause inhibition of T cell killing tumour cell)
Therefore prevents PDL-1 or PD-1 from inhibiting T cell destruction of tumour cell - allows killing of tumour cell