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brs (phase 1b) > (cardioresp) lung cancer > Flashcards

(cardioresp) lung cancer Flashcards

1
Q

what is the epidemiology of lung cancer?

A

third most common cancer in UK

= 48,000 diagnoses/year

= 35,000 deaths/year

leading cause of cancer death

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2
Q

historically, when did lung cancer become more common and why?

A

prior to the 1930s lung cancer was rare

= smoking only popular from WW1 onwards

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3
Q

what are the risk factors for lung cancer?

A

age = peak 75-90

sex = M > F

lower socioeconomic status

smoking history (duration, intensity, when stopped)

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4
Q

what is the link between cigarettes and lung cancer deaths?

A

cigarettes cause approx 1.5 million deaths from lung cancer per year

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5
Q

what is the main cause of lung cancer?

A

smoking

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6
Q

what are other causes for lung cancer besides smoking?

A

passive smoking

asbestos exposure

radon exposure

indoor cooking fumes (wood smoke, frying fats)

chronic lung diseases (COPD, fibrosis)

immunodeficiency

familial/genetic

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7
Q

who is more commonly at risk of asbestos exposure?

A

plumbers, ship-builders, carriage workers, carpenters

risk is x2

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8
Q

what are the two broad categories of lung cancer?

A

small cell lung cancer (SCLC)

non-small cell lung cancer (NSCLC)

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9
Q

what cancers fall under NSCLC (non-small cell lung cancers)?

A

squamous cell carcinoma

adenocarcinoma

large cell lung cancer

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10
Q

of all lung cancer cases, how many are classified as squamous cell carcinomas?

A

30%

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11
Q

of all lung cancer cases, how many are classified as adenocarcinomas?

A

40%

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12
Q

of all lung cancer cases, how many are classified as large cell lung cancers?

A

15%

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13
Q

of all lung cancer cases, how many are classified as small cell lung cancers?

A

15%

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14
Q

what are squamous cell carcinomas in lung cancer?

A

second most common lung cancer

originate from the squamous (flat) cells that line the bronchial epithelium of the airways

centrally located

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15
Q

what are adenocarcinomas in lung cancer?

A

most common lung cancer

originate from the mucus-producing glandular tissue

peripherally-located, tend to develop in alveoli/outer edges of lungs

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16
Q

what are large cell lung cancers?

A

heterogenous group, undifferentiated

= grow rapidly and more aggressively than other forms of lung cancer AND can appear anywhere in the lungs

DIAGNOSIS OF EXCLUSION = ‘catch-all diagnosis’ for the lung cancers that cannot be classified as SCC, AC, SCLC

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17
Q

what are small cell lung cancers?

A

least common type of lung cancer

originates in the pulmonary neuroendocrine cells

highly malignant + cancer typically metastasises rapidly to outside the lung

AND is type that is most likely to relapse after treatment

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18
Q

why are large cell lung cancers called so?

A

due to the large size and abnormal-looking appearance of the cancer cells

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19
Q

what are squamous cell carcinomas, adenocarcinomas and large cell lung cancers often grouped into?

A

non-small cell lung cancers (NSCLC)

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20
Q

what are the three stages of lung cancer development?

A

early
intermediate
late

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21
Q

what do the three stages of lung cancer comprise?

A

early

  • normal epithelium
  • hyperplasia
  • squamous metaplasia

intermediate
- dysplasia

late

  • carcinoma in situ
  • invasive carcinoma
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22
Q

what does the early stage of lung cancer comprise?

A

normal epithelium
hyperplasia
squamous metaplasia

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23
Q

what does the intermediate stage of lung cancer comprise?

A

dysplasia

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24
Q

what does the late stage of lung cancer comprise?

A

carcinoma in situ

invasive carcinoma

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25
Q

define metaplasia

A

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

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26
Q

define dysplasia

A

abnormal pattern of growth in which some of the cellular and architectural features of malignancy are present

BUT pre-invasive stage with intact basement membrane

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27
Q

define oncogene

A

a mutated gene that contributes to the development of a cancer

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28
Q

what are the key symptoms of lung cancer?

A

persistent cough

unexplained weight loss

dyspnoea/shortness of breath

fatigue

chest pain

haemoptysis

repeated respiratory infection

(or frequently asymptomatic)

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29
Q

define haemoptysis

A

coughing up blood

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30
Q

what are the features of advanced/metastatic lung cancer?

A

neurological features (focal weakness, seizures, spinal cord compression)

bone pain

paraneoplastic syndromes (clubbing, hypercalcaemia, hyponatraemia, Cushing’s)

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31
Q

what are the most common sites of lung cancer metastases?

A 
bones
liver
brain
lymphnodes
adrenal glands
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32
Q

what are common signs of lung cancer?

A

clubbing

cachexia

Horner’s syndrome

Pemberton’s sign (superior vena cava obstruction)

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33
Q

define cachexia

A

“wasting” disorder that causes extreme weight loss and muscle wasting, and can include loss of body fat

usually seen in people in the late stages of serious diseases

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34
Q

what is Horner’s syndrome?

A

contracted pupil, drooping upper eyelid, and local inability to sweat on one side of the face

(miosis, ptosis & anhydrosis)

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35
Q

what is Pemberton’s sign?

A

development of facial plethora/swelling, distended neck and head superficial veins upon raising of the patient’s both arms above his/her head simultaneously, as high as possible = SVCS (superior vena cava syndrome)

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36
Q

why can Pemberton’s sign occur in lung cancer?

A

lung cancer can metastasise to chest

1) tumour can press on the superior vena cava
2) tumour can grow into the superior vena cava and block it

= Pemberton’s sign

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37
Q

how does lung cancer result in Horner’s syndrome?

A

growing tumour can cause compression of a brachiocephalic vein, subclavian artery, phrenic nerve, recurrent laryngeal nerve, vagus nerve or a sympathetic ganglion (at thoracic outlet) = symptoms

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38
Q

why is a PET scan done in lung cancer patients?

A

to rule out occult metastases

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39
Q

what are occult metastases?

A

tumour deposits that are initially undetected in the pathological examination and subsequently identified

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40
Q

why is a PET scan done in lung cancer patients?

A

to rule out occult metastases (tumour deposits that are initially undetected and then subsequently identified)

41
Q

what are occult metastases?

A

tumour deposits that are initially undetected and subsequently identified

42
Q

how is the type of biopsy to be carried out determined in lung cancer patients?

A

choose method based on accessibility, availability and impact on staging

43
Q

what types of biopsies can be done for lung cancer?

A

bronchoscopy

endobronchial ultrasound and transbronchial-needle aspiration - EBUS/TBNA

CT-guided lung biopsy

44
Q

when is a bronchoscopy chosen as the biopsy method?

A

for central airway tumours where staging does not matter

45
Q

when are EBUS/TBNA of mediastinal lymph nodes chosen as the biopsy methods?

A

to stage mediastimun +/- achieve tissue diagnosis

46
Q

when is a CT guided lung biopsy chosen as the biopsy method?

A

to access peripheral tumours

47
Q

what kind of biopsy is done for central airway tumours?

A

bronchoscopy

48
Q

what kind of biopsy is done for peripheral lung tumours?

A

CT-guided lung biopsy

49
Q

what kind of biopsy is done when the mediastinum needs to be staged?

A

EBUS/TBNA

endobronchial ultrasound/transbronchial needle aspirate

50
Q

what is the method used to stage lung cancer?

A

TMN staging

51
Q

what is TNM staging?

A

staging based on

1) tumour size + location
2) lymph node involvement
3) metastases

52
Q

how does TMN staging work?

A

T1-4
tumour size and location

N0-3
lymph node involvement (mediastinum + beyond)

M0-1c
metastases + number

53
Q

in TNM staging, how does the T work?

A

categorised T1-4 based on tumour size and location

54
Q

in TNM staging, how does the N work?

A

categorised N0-3 based on lymph node involvement (mediastinum + beyond)

55
Q

in TNM staging, how does the M work?

A

categorised M0-1c based on metastases and their number

56
Q

what is commonly seen when diagnosing lung cancer with TMN staging?

A

late stage is common at diagnosis

57
Q

how is lung cancer classified based on spread?

A

early
locally-advanced
metastatic

58
Q

what are the determinants of lung cancer treatment?

A 
patient fitness
cancer histology
cancer stage
patient preference
health service factors
59
Q

how is patient fitness graded 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

60
Q

how is surgery used to treat lung cancer?

A

surgical resection is the standard of care for early stage disease

lobectomy + lymphadenectomy = usual approach

but sublobar resection is stage 1 (≤ 3cm)

61
Q

what is the most common form of management for early-stage lung cancer?

A

surgical resection (usually lobectomy and lymphadenectomy)

62
Q

what type of surgeries are carried out to treat early-stage lung cancer?

A

lobectomy and lymphadenectomy

sublobar resection if stage 1 and less than or equal to 3cm

63
Q

what are the types of surgical resection for lung cancer?

A

wedge resection
segmental resection
lobectomy
pneumonectomy

64
Q

what is a wedge resection?

A

removal of a small section of lung that contains the tumour along with a margin of healthy tissue

65
Q

what is a segmental resection?

A

removal of a larger portion of lung than a wedge resection but not an entire lobe

66
Q

what is a lobectomy?

A

removal of the entire lobe of one lung

67
Q

what is a pneumonectomy?

A

removal of an entire lung

68
Q

what are the two surgical techniques that are used to treat lung cancers?

A

open thoracotomy

VATS (video-assisted thoracoscopic surgery)

69
Q

what are the two treatment options for early-stage lung cancer?

A

surgery

radical radiotherapy

70
Q

what is radical radiotherapy for lung cancer?

A

SABR (stereotactic ablative body radiotherapy) = high-precision targeting w multiple convergent beams from different angles

useful if comorbidity present

alternative to surgical treatment for early-stage

71
Q

why would radical radiotherapy be preferentially used over surgery for early-stage lung cancer?

A

if a comorbidity is present

72
Q

what systemic treatments are available to manage lung cancer?

A

oncogene-directed drugs

immunotherapy

cytotoxic chemotherapy

73
Q

what are the side effects of oncogene-directed systemic treatment?

A

generally well-tolerated but possible rash, diarrhoea and pneumonitis

74
Q

how does immunotherapy work in lung cancer treatment?

A

often numerous T cells will bind to tumour cells and eradicate them but some T cells are inhibited by binding to PDL-1 so immunotherapy can deactivate PDL-1 so T cells can carry out their eradication function

75
Q

how does cytotoxic chemotherapy work?

A

targets rapidly dividing cells

76
Q

what are the side effects of cytotoxic chemotherapy systemic treatment?

A

fatigue, nausea, bone marrow suppression, nephrotoxicity

+ poor quality of life

77
Q

what are the requirements for immunotherapy use in lung cancer treatment?

A

first line for metastatic NSCLC with no mutation and PDL >= 50%

78
Q

what are the requirements for cytotoxic chemotherapy use in lung cancer treatment?

A

first line for metastatic NSCLC with no mutation and PDL <= 50% (in combination w immunotherapy)

79
Q

what are the requirements for oncogene-directed drug use in lung cancer treatment?

A

first line for metastatic NSCLC with mutation

80
Q

what support should be offered to patients with advanced stage disease?

A

palliative and supportive care

81
Q

what is offered as part of palliative and supportive care for advanced stage lung cancer patients?

A

symptom control

psychological support,
financial and practical support

education,
planning for end of life

lung cancer specialist nurses

82
Q

what are the treatments available for early stage lung cancer?

A

surgery

radical radiotherapy

83
Q

what are the treatments available for locally-advanced stage lung cancer that involves the thoracic lymph nodes?

A

surgery + chemotherapy

radiotherapy + chemotherapy (+ maybe immunotherapy)

84
Q

what are the treatments available for late stage, metastatic lung cancer?

A

with targetable mutation = tyrosine kinase inhibitors (oncogene-directed therapy)

no mutation, PDL1 positive = immunotherapy

no mutation, PDL1 negative = chemotherapy + immunotherapy

(palliative care too)

85
Q

does lung cancer ever have an early presentation?

A

extremely rarely - late presentation on diagnosis is most common

86
Q

why does lung cancer never usually have an early presentation?

A

people who get lung cancer usually have pre-existing lung conditions too so write off symptoms as they may not be abnormal for them

87
Q

what stage of lung cancer is pleural effusion most commonly seen with?

A

metastatic lung cancer

88
Q

what stage of lung cancer are infected lymph nodes most commonly seen with?

A

locally-advanced lung cancer

89
Q

what are some important oncogenes in terms of lung cancer?

A

EGFR
ALK
ROS1
BRAF

90
Q

how does EGFR affect lung cancer?

A

= approx 15-30% of adenocarcinoma

more so in women, Asian ethnicity, never-smokers

91
Q

how does ALK affect lung cancer?

A

= approx 2-7% of non-small cell lung cancer

especially in younger patients and never smokers

92
Q

how does ROS1 affect lung cancer?

A

= approx 1-2% of non-small cell lung cancer

especially in younger patients and never smokers

93
Q

how does BRAF affect lung cancer?

A

= approx 1-3% of non-small cell lung cancer

especially in smokers

94
Q

define ‘undifferentiated’ cancers

A

a cancer in which the cells are very immature and do not look like cells in the tissue from it arose

= undifferentiated more malignant than a cancer of that type which is well differentiated

95
Q

where does the lung tumour metastasise to in order to cause Horner’s syndrome?

A

metastasises or originates in the apices of the lungs
e.g. Pancoast tumours
(rare form of lung cancer, locally advanced/invasive more quickly)

96
Q

where are pulmonary neuroendocrine cells found?

A

rare airway epithelial cells that also uniquely harbor neuronal and endocrine characteristics

= cells implicated in the formation of the highly malignant form of lung cancer (small cell lung cancer)

97
Q

which cigarette type are adenocarcinomas asociated with?

A

low tar cigarettes = inhaled more deeply & retained longer

98
Q

what is the diagnostic strategy for lung cancer?

A
  • establish most likely diagnosis
  • establish fitness for investigation and treatment
  • confirm diagnosis (specific type of cancer if considering systemic treatment)
  • confirm staging
99
Q

what imaging techniques are used to investigate lung cancer?

A

CXR
abdo + chest staging CT
PET scan

brs (phase 1b) (71 decks)

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