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BRS 1b > 5.7 Lung Cancer > Flashcards

5.7 Lung Cancer Flashcards

1
Q

What is the leading cause of cancer death in men and women?

A

Lung

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2
Q

What does a typical lung cancer patient look like? (4)

A

age peak 75-90
more men than women
lower socioeconomic status
smoking history (when stopped, duration, intensity)

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3
Q

What % of patients with lung cancer have never smoked?

A

10-15%

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4
Q

What are other aetiological factors that could increase the risk of lung cancer? (7)

A

passive smoking
asbestos exposure 2x risk (plumbers, ship-builders etc)
radon (silver/uranium miners)
indoor cooking fumes (wood burning, frying fats)
chronic lung disease (COPD, fibrosis)
immunodeficiency
genetic

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5
Q

What are the four classes of lung cancer?

A
  1. Squamous cell carcinoma
  2. Adenocarcinoma
  3. Large cell
  4. Small cell

(1-3 sometimes known as non-small cell)

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6
Q

What % of cases of lung cancer are squamous cell carcinoma?

A

~30%

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7
Q

What % of cases of lung cancer are adenocarcinoma?

A

~40% - Most common

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8
Q

What % of cases of lung cancer are large cell lung cancer?

A

~15%

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9
Q

What % of cases of lung cancer are small cell lung cancer?

A

~15%

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10
Q

What is squamous cell carcinoma?

A
  • previously most common

- originating from bronchial epithelium; centrally located

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11
Q

What is adenocarcinoma?

A

originating from mucus-producing glandular tissue; more peripherally located

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12
Q

Why was adenocarcinoma the most common type of lung cancer from the 1980’s onwards?

A

low tar cigarettes, inhaled more deeply/retained longer

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13
Q

What is large cell lung cancer?

A

heterogenous group, undifferentiated

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14
Q

What is small cell lung cancer?

A

originates from pulmonary neuroendocrine cells

highly malignant

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15
Q

Why is small cell lung cancer grouped separately?

A

because it often presents very differently; much more aggressive than other types

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16
Q

What is metaplasia?

A

reversible change in which one adult cell type replaced by another adult cell type; adaptive

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17
Q

What is dysplasia?

A

abnormal pattern of growth in which some of the cellular and architecture features of malignancy are present; pre-invasive stage with intact basement membrane

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18
Q

What are the 6 stages in model of lung cancer development?

A 
normal epithelium
hyperplasia
squamous metaplasia
dysplasia
carcinoma in situ
invasive carcinoma
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19
Q

Why is dysplasia an important turning point in cancer development?

A

turning point from reversible to irreversible

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20
Q

What are the 4 important oncogenes in lung cancer?

A

EGFR tyrosine kinase
ALK tyrosine kinase
ROS1 receptor tyrosine kinase
BRAF

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21
Q

Why is it important to know the oncogenes that could play a role in lung cancer?

A

Targeting these proteins can have therapeutic benefit

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22
Q

What are the 6 key symptoms of lung cancer?

A 
cough
weight loss
breathlessness
fatigue
chest pain
haemoptysis (coughing up blood) --> rare
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23
Q

Why can it be hard to diagnose lung cancer?

A
  • frequently asymptomatic, lots of space for tumour to grow before symptoms develop
  • patients often have pre-existing lung conditions –> similar symptoms
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24
Q

What are the features of advanced lung cancer/ metastatic disease?

A

neurological features: focal weakness, seizures, headaches, spinal cord compression (weakness in arms and legs)
bone pain
paraneoplastic syndromes: clubbing, hypercalcemia, hyponatremia, Cushing’s
Horner’s syndrome
Superior vena cava obstruction (Pemberton’s sign)

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25
Q

What is Horner’s syndrome?

A

Apical lung tumour compresses thoracic outlet, affects sympathetic supply to face

  • ptosis
  • myosis (constriction of pupil)
26
Q

What is Pemberton’s sign?

A

Superior VC obstruction

causes facial swelling and redness when they lift arms up

27
Q

What is the diagnostic strategy for lung cancer? (4)

A

establish most likely diagnosis
establish fitness for investigation and treatment
confirm diagnosis
confirm staging

28
Q

Why do we establish fitness fir investigation and treatment?

A

Average patient very old with many comorbidities

29
Q

How do we confirm staging?

A

Staging CT (chest and abdomen)

30
Q

When is x ray used in the investigation of lung cancer?

A

Early, to confirm diagnosis (staging done by CT)

31
Q

When is a PET scan used in the investigation of lung cancer?

A

To exclude occult metastases (lymph node involvement) –> look for bright scan

32
Q

Why do we do CT of chest and abdomen when investigating lung cancer?

A

To look for mets (esp liver)

33
Q

What’s the ultimate way we mage a diagnosis and confirm type of cancer?

A

biopsy

34
Q

How do we choose what type of biopsy to confirm type of cancer?

A

choose method based on accessibility, availability and impact on staging

35
Q

When do we do bronchoscopy?

A

for tumours of central airway

where tissue staging not important

36
Q

When do we use endobronchial ultrasound and transbronchial-needle aspiration of mediastinal lymph nodes?

A

to stage mediastinum +/- achieve tissue diagnosis

37
Q

When do we use CT-guided lung biopsy

A

to access peripheral lung tumours

38
Q

What are the three options for biopsy for lung cancer?

A

bronchoscopy
endobronchial ultrasound and transbronchial needle aspiration
CT- guided lung biopsy

39
Q

What is the criteria for lung cancer staging?

A

TNM

40
Q

What does T stand for in lung cancer staging (TNM)?

A

T1-4: tumour size and loaction

41
Q

What does N stand for in lung cancer staging (TNM)?

A

N0-3: lymph node involvement - mediastinum and beyond

42
Q

What does M stand for in lung cancer staging (TNM)?

A

M0-1c: metastases + number

43
Q

How do we determine treatment? (4)

A

patient fitness
cancer history
cancer stage
patient preference

44
Q

What are the 5 levels of patient fitness according to WHO?

A

0-Asymptomatic
1- Symptomatic but completely ambulatory
2- Symptomatic <50% in bed during the day
3- Symptomatic >50% in bed but not bedbound
4- Bedbound
5- Death

45
Q

What level of patient fitness, according to the WHO patient fitness level, should radical treatment be restricted to?

A

0-2

46
Q

When is surgical resection the standard of care for lung disease?

A

Early stage disease
keyhole lobectomy + lymphadectomy usual approach
sublobar resection if stage 1 (<3cm)

47
Q

What is an alternative to surgery for early stage lung cancer?

A

radical radiotherapy
stereotactic ablative body radiotherapy (SABR)
- high precision, other structures less affected

48
Q

When is radical radiotherapy used instead of surgery in early stage lung cancer?

A

if patient has many comorbitities

49
Q

What are the 3 systemic treatment options for lung cancer?

A
  1. oncogene-directed
  2. immunotherapy
  3. cytotoxic chemotherapy
50
Q

When is oncogene directed drugs used?

A

metastatic NSCLC with mutation

51
Q

When are immunotherapy drugs typically used for treatment of lung cancer?

A

metastatic NSCLC with no mutation and PDL1 expression>50%

52
Q

When are chemotherapy drugs typically used for treatment of lung cancer?

A

first line for metastatic NSCLC with no mutation and PDL1> 50% and used in combination with immunotherapy

53
Q

Why do we get frequent side effects with chemo?

A

very non specific, many other cells affected

54
Q

When should palliative and supportive care be offered for lung cancer?

A

advanced stage disease

  • look to improve QoL
  • educate about disease
  • lower depression scores
55
Q

What are the treatment options for early stage disease? (2)

A

surgery
radiotherapy
–> both with curative intent

56
Q

What are the treatment options for locally advanced disease (involving thoracic lymph nodes)? (2)

A

surgery + adjuvant chemotherapy

radiotherapy + chemotherapy +/- immunotherapy

57
Q

What are the treatment options for metastatic disease? (4)

A

with targetable mutation (e.g. EFGR,ALK,ROS-1): tyrosine kinase inhibitor
no mutation, PDL-1 positive: immunotherapy alone
no mutation, PDL-1 negative: chemo + immunotherapy
palliative care

58
Q

What are the benefits of immunotherapy?

A

generally well tolerated

immune related side effects in 10-15%

59
Q

How does immunotherapy work?

A

blocks PD-L1, allows T cell killing of tumour cell

60
Q

What is the prognosis of lung cancer?

A

only 10% live > 10 years

survival decreases with worse staging

BRS 1b (25 decks)

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