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Respiratory > Bronchial Carcinoma > Flashcards

Bronchial Carcinoma Flashcards

1
Q

What are the features of cancer?

A

Malignant growth
Uncontrolled replication
Local invasion
Metastasis (lymphatic spread, blood, serous cavities)

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2
Q

What causes non metastatic systemic effects?

A

Biologically active molecules (hormones) released from tumour cells. These mimic the effect of naturally occuring hormones leading to paraneoplastic features

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3
Q

What percentage of lung cancers are incurable at the time of diagnosis?

A

90% and 50% of people are dead within 6 months

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4
Q

Why are lung cancer rates falling in men but rising in women?

A

Reflects the rates of smoking now and in the past

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5
Q

Lung cancer is the most common cause of cancer death. True or false?

A

True

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6
Q

How can a primary lung tumour present?

A

Haemoptysis
Recurrent pneumonia
Stridor
Short of breath

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7
Q

Why is every pneumonia CXR at 6 weeks?

A

Check pneumonia has resolved and there is no underlying cancer

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8
Q

Why does the lung effected by cancer usually shrink rather than grow?

A

Obstruction of proximal divisions of the bronchial tree. All air below obstruction is absorbed and lung shrinks to a smaller size

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9
Q

What is stridor?

A

Inspiratory sound- distressing

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10
Q

What can be the presentation of local invasion of lung cancer?

A

1) Recurrent laryngeal nerve palsy- horse vioce for >2 weeks as the tumour can grow and compress vocal chords
2) Atrial fibrillation or pericardial effusion- due to invasion for the pericardium
3) Dysphagia- if the oesophagus is compressed
4) Numbness and muscle wasting in the small muscles of the hand due to pancoast tumours compressing the brachial plexus
5) Pleural effusion- tumour invading pleural space
6) Headache, redness and puffy eyes- invasion of the SVC
7) Dilated vains on chest and abdomen- invasion of the IVC
8) pleuritic pain/ MSK pain- invasion of the chest wall

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11
Q

Presentation: Numbness and muscle wasting in the small muscles of the hand implies…?

A

Pancoast tumour in the lung apicies compressing the brachial plexus

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12
Q

Presentation: Recurrent laryngeal nerve palsy implies…?

A

Local invasion of the vocal chords

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13
Q

Presentation: Atrial fibrilation or pericardial effusion implies…?

A

Local invasion of the pericardium

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14
Q

Presentation: Dysphagia implies…?

A

Local invasion of the oesophagus

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15
Q

Presentation: Pleural effusion implies…?

A

Local invasion of the pleural space

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16
Q

Presentation: headache, redness and puffy eyelids implies…?

A

Local invasion of the SVC

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17
Q

Presentation: dilated blood vessels on neck and abdomen implies…?

A

Local invasion of the IVC

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18
Q

Presentation: Pleuritic pain/ MSK pain on twisting/ worse at night implies…?

A

Local invasion of the chest wall

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19
Q

Where are the sites of common metastases sites for lung tumours?

A

Brain, Liver, Bone, Adrenal gland

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20
Q

What are the signs f a cerebral metastasis?

A

insidious onset
One sided weakness/visual disturbances
Headaches- worse in the morning
Epileptic fit if met in cortex

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21
Q

What are the signs of liver metastasis?

A

Stretching pain- mets adjacent to liver capsule
Jaundice- mets obstructing the bilary duct
Abnormal liver function tests

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22
Q

What are the signs of bone metastasis?

A

Localised pain worse at night
Pathological fracture
Paralysis- met in the veterbrae

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23
Q

How are boney metastasis detected?

A

Isotope bone scan

PET scan

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24
Q

What are the signs if Adrenal metastasis?

A

Rarely any signs
Hormones are produced as normal
Incidental finding usually

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25
Q

Do paraneoplastic symptoms indicate metastatic disease?

A

Not necessarily- they are the result of hormones produced from the primary tumour initially

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26
Q

What are the paraneoplastic signs of bronchial carcinoma?

A 
Finger clubbing
Hypertrophic pulmonary osteoarthopathy HPOA
Thrombophlebitis 
Weight loss
Hypercalemia
Syndrome of inappropriate ADH (SIADH)
Eaton Lambert Syndrome
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27
Q

What is Hypertrophic pulmonary osteoarthopathy HPOA?

A

Rare pain and tenderness in the long bones due to elevation of the perioesteum away from the surface

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28
Q

What is thrombophlebitis and why do cancer patients get it?

A

Inflammation around a superficial vein due to hypercoaguable blood in cancer patients

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29
Q

What other lung diseases, other than bronchial Ca, cause weight loss?

A

Pulmonary fibrosis

Advanced COPD

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30
Q

Why do cancer patients get hypercalemia and what is the treatment?

A

Tumour excreates a substance that mimics the effect of the parathyroid hormone.
Leads to headaches, confusion, thirst and constipation
Treated by rehydration initially. If calcium >4 use IV bisphosphonate (increases bone turnover)

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31
Q

Hypercalemia is associated with which type of lung cancer?

A

Squamous cell carcinoma

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32
Q

What can hypercalemia cause?

A 
Stones- renal and bilary 
Bones- bone pain
Groans- abdo pain, constipation and D+V
Thrones- Polyuria
Psychiatric overtones- depression, anxiety and reduced GCS
cardiac arrythmias
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33
Q

What is Syndrome of inappropriate ADH (SIADH), how is it treated and what lung cancer is it associated with?

A

High sodium in the blood >120
Leads to nausea nad vomiting, lethargy, confusion, seizures, myoclonus (twitching/jerking)
Treated with fluid restriction and demeclocycline
Small cell lung cancer

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34
Q

What is Eaton Lambert Syndrome and what type of bronchial Ca is it associated with?

A

Weakness in the limbs similar to myaesthenia gravis

Usually small cell lung cancer

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35
Q

What are the detect lung cancer early signs?

A 
Cough > 3 weeks
Haemoptysis
Recurring/long standing lung infection 
Unexplained weight loss
Horse voice 
Chest or Shoulder pains 
Unexplained tiredness/loss of energy
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36
Q

What are the differentials for breathlessness?

A

PE, pleural effusion, pleural oedema, pericardial invasion

37
Q

What might you find on examination of a patient with bronchial Ca?

A 
Finger clubbing 
Stridor
Weight loss
Horse voice
Bloated face
enlarged liver 
Lymphadenopathy
Tracheal deviation 
Dull Percussion
38
Q

What investigations are important if you suspect bronchial Ca?

A 
FBC
Coagulation screen 
Na, K Ca and alkaline phosphate
Spirometry/ FEV1
CXR
CT thorax
PET scan
Bronchoscopy
EBUS- endobronchial ultrasound
39
Q

What is a PET scan

A

Positron Emission Tomography
Analysis of tissue uptake of radioactively labelled glucose
Tissues with a high metabolic rate will light up.
Assessment of function rather then structure

40
Q

How will you obtain a tissue diagnosis?

A 
Broncoscopy
CT guided biopsy
Lymphnode aspirate
Aspiration of pleural fluid 
EBUS
Thoracoscopy
41
Q

How is a broncoscopy carried out?

A

Local anathetic with IV sedation
Flexible bronchoscope passes through the nose to inspect the central part of the bronchial tree
Biopsies and brush cytology => diagnosis

42
Q

Can a bronchoscope see peripheral tissue?

A

No. Its limited by its 5mm diameter

43
Q

What does a broncoscope have?

A

2 light sources and camera and a suction channel

44
Q

What is a CT guided biopsy used for and what is the risk?

A

Obtaining a tissue sample from a peripheral tumour

Risk of pneumothorax

45
Q

Is anasthetic needed for a CT guided biopsy?

A

Yes local anasthetic is used

46
Q

What is an EBUS?

A

Endobronchial ultrasound
Bronchoscope with a ultrasound tip
Day case procedure

47
Q

What is EBUS used for?

A

To get a visualisation of hilar and mediastinal structures

Target and sample lymph nodes if they are involved

48
Q

What is a medical thoracoscopy?

A

Semi rigid scope inserted in the intercostal space
The lung is deflated to allow visualisation of the pleural surfaces
Sample pleural fluid and biopsies from pleura
Day case- sedation with local anaesthetic

49
Q

What is the mortality 1 year post diagnosis of Bronchial Ca?

A

90%

50
Q

What percentage of smokers will die from lung cancer? What other cancers do smokers commonly get?

A

20% will die from lung cancer

Also get larangeal, cervical, bladder, mouth, oesophageal and colon cancer

51
Q

What types of lung neoplasms are there?

A

Benign- rare

Malignant- common

52
Q

What are the other risk factors for bronchial Ca?

A

Asbestos, nickle, chromates, radiation and pollution

Genetics would be clearer if people didn’t smoke

53
Q

What are the 4 common smoking related types of lung cancer and the percentage occurrence?

A 
Adenocarcinoma- 35%
Squamous cell carcinoma- 30%
Small cell carcinoma- 25%
Large cell carcinoma- 10%
Grouped into small cell and non small cell
54
Q

What are the 2 non smoking related types of lung cancer?

A

Carcinoid- Neuroendocrine tumours

Bronchial gland tumours (adenoid cyctic carcinoma and mucopidermoid carcinoma)

55
Q

1 in 4 adenocarcinomas occur in never smokers. True or false?

A

True often younger women

56
Q

Rank the 4 lung cancers in order of prognosis?

A

Small cell- worse
Large cell
Adenocarcinoma
Squamous cell- best

57
Q

Why is it important to have a tissue diagnosis?

A

Prognosis and treatment mainly. Pathogenesis and epidemiology

58
Q

What are the characteristics of small cell lung cancer?

A 
Rapidly progressive 
Early metastasis
Few/no symptoms 
Rarely suitable for surgery
Chemosensitive but with rapidly emerging resistance
59
Q

What are the characteristics of non small cell lung cancer?

A

Now respond better to new chemo and radiotherapy regimens- palliative
New targeted treatments based on DNA mutations
Slower growing
Surgery and radical radiotherapy may cure it

60
Q

Is surgery an option if lymph nodes are involved?

A

Maybe. Only if its 1 or 2 together. Unlikely

61
Q

What are the molecular gene abnormalities in the oncogenes of small cell lung cancer which may be a therapeutic target?

A

MYC

62
Q

What are the molecular gene abnormalities in the tumour suppressor genes of small cell lung cancer which may be a therapeutic target?

A

p53, retinoblastoma (Rb) and 3p

63
Q

What are the molecular gene abnormalities in the oncogenes of non small cell lung cancer which may be a therapeutic target?

A

MYC, K-RAS, HER2

64
Q

What are the molecular gene abnormalities in the tumour suppressor genes of non small cell lung cancer which may be a therapeutic target?

A

p53, 1q, 3p, 9p, 11p, Retinoblastoma

65
Q

Is epithilial growth factor involved in signalling in lung epithilium?

A

Yes

66
Q

How can a mutation in the EGFR gene lead to cancer development?
What type of cancer are these found in?
How can these mutations be detected?
What treatment do these tumours respond to?

A

Specific point mutation in the EGFR gene can activate it in the absence of EGF ligand binding.
Found in adenocarcinomas of non smokers- often aisan
Detected in DNA from a biopsy and cytology.
Respond to Tyrosone Kinase Inhibators- Erltinib

67
Q

How can the immune response be targeted in non small cell lung cancers?

A

Some express PD-L1.
PDL1 binds to the PD (programmed death receptor) on T lymphocytes inactivating the cytotoxic immune response.
Targeted therapy can inhibit this effect and enhance the immune killing of a tumour.
Less toxic than chemo.

68
Q

How do bronchial tumours develop?

A

Squamous cell metaplasia- there is no normal squamous epithilium in the large airways
Dysplasia
Carcinoma in situ
Invasive malignancy

69
Q

How do peripheral adenocarcinomas develop?

A

Atypical andenomatous hyperplasia
Spread of neoplastic cells along alviolar walls- bronchioalviolar carcinoma
True invasive adenocarcinoma

70
Q

How are tumours stages

A

Tumour
Node
Metastasis

71
Q

What is immunohistochemistry and how can it be used to differentiate adenocarcinomas from squamous cell carcinomas?

A

Immunohistochemistry involves the process of selectively imaging antigens in cells of a tissue section by exploiting the principle of antibodies binding specifically to antigens in biological tissues.
Adenocarcinomas express TTF1 (thyroid transcription factor 1)
Squamous cell carcinomas express nuclear antigen p63 and high molecular weight cytokeratins

72
Q

What is the median survival for small cell and non small cell lung cancer?

A

Small cell = 6 months

Non small cell = 8 months

73
Q

What must you consider for before surgery?

A

Is the tumour localised? Single primary with a couple of lymph nodes
Will the patient survive the operation? 2-3% peri-opperative mortality
What will there residual lung function be? How will this impact on their quality of life

74
Q

What investigations must be carried out to check someone is a suitable candidate for surgery?

A

Broncoscopy- cell type, vocal chord palsy, proximity to carina
EBUS- lymph node involvement?
CT Brain and CT thorax
PET scan

75
Q

Is a tumour less than 2am from the carina fit for surgery?

A

No

76
Q

Does PET scanning up stage or down stage someones disease?

A

Up stage

Good thing as it prevents unnecessary operations

77
Q

What are the choices for types of surgery?

How is the surgery carried out?

A

Pneumonectomy- removal of a lung
Lobectomy- removal of a lung lobe

Thoracotomy- large incision into the chest wall. Long recovery with 10 days in hospital
VATS (Video assisted thoracic surgery)- key hole with 5 small incisions. Faster recovery. 5 days in hospital

78
Q

What staging must be performed to check someone is fit for chemotherapy?

A

Bronchoscopy for tissue diagnosis
CT scan for tumour size, lymph nodes, mets and local invasion
Performance Status ECOG score 0-2

79
Q

What is the ECOG score?

A

Performance status assessment
0 = fit 5= dead
Need 0-2 for chemotherapy (up and about for 50% of day)

80
Q

What are the common chemotherapy side effects?

A 
Nausea and vomiting 
Tiredness and loss of appetite 
Bone marrow suppression => opportunistic infections, anaemia and neutropenic sepsis
Hair loss
Pulmonary fibrosis
81
Q

When is radical radiotherapy used?

A

Early stage disease with curative intent

82
Q

When is palliative radiotherapy used?

A

To delay disease progression, to reduce pain and to shrink metastasis

83
Q

What are the drawbacks to radiotherapy?

A

1) Maximal cumulative dose that can be achieved
2) Collateral damage as the beam passes through other tissues (spinal cord, oesophagus and lung tissue)
Post radiation fibrosis in these areas
3) Only works where directed- subclinical mets not targeted

84
Q

What is SABR?

A

Stereotactic Ablative Radiotherapy
Reduces damage to surrounding tissue by having beams from lots of angles with a lower dose.
Requires 4D scanning because the patients are breathing.

85
Q

What are the advantages of SABR?

A

1) Less collateral damage
2) Very high cumulative dose delivered to the tumour
3) Less treatments required

86
Q

What therapies can be carried out with a bronchoscope?

A

Strent insertion for stridor

Photodynamic therapy

87
Q

What are the common comorbidities associated with lung cancer?

A

COPD and ischemic heart disease

88
Q

Why would you not do a CT guided biopsy on a patient with an FEV1 <1L?

A

There is a 10% risk of pneumothorax

Respiratory (26 decks)

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