Blue Book: Lung Cancer

Question 1

3 main risk factors: how many caused by smoking?

Answer 1

Age (0ver 40)
Smoking: 90%
Occupation: asbestos, uranium, ship building, petroleum.

Question 2

What type of cell do tumour form from?

2 main types of lung cancer used to manage treatment and their frequency.

Answer 2

Epithelium of large and medium bronchi.

Small cell (18%)

Non-Small cell (82%)

Question 3

Describe small cell lung cancers.

Answer 3

Derive from near-endocrine cells, associated with neuropeptide secretion. ADH or ACTH.

Metastasises extremely quickly. Sensitive to chemo.

Question 4

Name 3 types of non small cell lung cancer

Answer 4

Squamous cell carcinoma
Adenocarcioma: may arise in areas of lung damage, often peripheral and more frequent in women.
Large cell carcinoma

Question 5

How does lung cancer present?

Answer 5

Non-specific: cough, dysponea, haemoptysis, chest pain, recurrent infection.

Specific:

• Horner’s syndrome (pan coast tumours) + pain in distribution of the nerve routes.
• Recurrent laryngeal nerve palsy
• Superior vena cava obstruction (both mediastinal disease)
• Effects of neuroendocrine factors

Question 6

Investigations:

How to assess complications of tobacco-related problems.
COPD, vascular disease and general disability.

Answer 6

CXR: 95% lung tumours visible
Sputum cytology: 80% have detectable malignant cells in sputum. Identify type.
Bronchoscopy: Visualise bronchial tree and biopsy.
Other biopsy techniques: trans-thoracic or lymph nodes.
CT chest and upper abdo: assess local and distant disease: lungs, mediastinum, pleura, liver, adrenal glands.
PET scan: operable disease to check for distant mets.
Others:
- Head/isotope bone scan: metastasis
- Tumour marker: Neuron Specific Enolase (NSE) and lactate dehydrogenase (LDH) indicates tumour activity.

2) pulmonary function testing, echocardiogram, clinical assessment of performance status.

Question 7

Staging:
What investigations required?

Explain T1-T4

Answer 7

CT chest and abdo and sometimes bone/head scan.

T1: 3cm 2cm from carina)
- Invading visceral pleura
- causing atelectasis (lung collapse) of some of 1 lung.
T3: >7cm
- local invasion: chest wall, diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium, main bronchus with 2 cm of carina
-atelectasis of entire lung
- separate tumour nodule in same lobe
T4: Organ invasion (inoperable): mediastinum, great vessels, recurrent laryngeal nerve, oesophagus, vertebral body
- separate nodules in ipsilateral lobe

Question 8

N1-N3

Answer 8

N1: Ipsilateral bronchopulmonary and hilar nodes
N2: Ipsilateral mediastinal node
N3: Contralateral nodes or superclavicular nodes (inoperable)

Question 9

M0-M1b

Answer 9

M0: NO mets
M1a: Separate tumour in contralateral lung, malignant pleural or pericardial effusion
M1b: Distant mets

Question 10

What is stage based on? What is stage 4?

Answer 10

TNM score. Any M1

Question 11

Describe Treatments of Small Cell Lung Cancer.

3 indications for radiotherapy.

Answer 11

Chemotherapy: 90% will respond to combination chemo, most relapse, many within 12 months with chemo-resistant and die rapidly.
Radiotherapy: Highly radiosensitive
1. Treat primary: Limited stage, will follow or accompany chemo and improves overall survival.
2. Prophylactic cranial radiotherapy (PCI): Brain metastases are frequent in SCLC and cause mobility but radio causes memory impairment, functional deficit, dementia.
3. Palliative: Symptom control

Surgery: Often inappropriate (90%) as often systemic as presentation. Stage 1 can be considered alongside chemo and radio. Limited evidence for improved outcome.

Question 12

Prognosis of SCLC

Answer 12

Without treatment: 2-4 months.
With systemic chemo: 11 months

Prognostic factors: extent of disease, number of metastatic sites, performance status, degree of weight loss and biochemical abnormalities (LDH raised)

Question 13

Non-small cell lung cancer

Answer 13

Surgery: Stage 1 and 2: surgical resection - good prognosis. Mediastinal involvement contraindicates surgery. 30% suitable. Pneumonectomy, lobectomy, wedge reaction.
+/_ adjacent radio/chemo

Radiotherapy:
Radical: Stage 1/2 not suitable for surgery: 20% and 5 yrs.
Continous, hyperfractioned accelerated radiotherapy (CHART) 3 X a day for 12 days.

Chemo
Response rates of 30% in combination regimes. response duration is limited and survival advantage is limited. Used to shrink tumour before radio or adjuvant to surgery.

Targeted Therapy:
Tyrosine Kinase Inhibitors (erlotinib or gefitinib) targets EGFR. Used after progression in palliative setting. 1st line in mutations of EGFR.

Question 14

Prognosis: Stage and 5 yr survival

Answer 14

Stage 1: 50%
2: 40%
3a: 25%
3b: