Clinical features of lung cancer and staging

Question 1

which is the leading cause of cancer death (both men and women)?

Answer 1

lung cancer

Question 2

what percentage of cancer deaths are lung cancer (in the UK)?

Answer 2

1 in 5

Question 3

smoking accounts for what percentage of lung cancers?

Answer 3

> 85% (most preventable cancer)

Question 4

what are the main risk factors for lung cancer?

Answer 4

smoking (>85%), passive smoking, exposure to asbestos, radon, air pollution and diesel exhaust

Question 5

what metastatic advanced diseases are there for lung cancer?

Answer 5

• bone pain
• spinal cord compression (limb weakness, paraesthesia, bladder/ bowel dysfunction)
• cerebral metastases (headache, vomiting, dizziness, ataxia, focal weakness)
• thrombosis

Question 6

what paraneoplastic advanced diseases are there for lung cancer?

Answer 6

• hyponatraemia (SIADH)
• anaemia
• hypercalcaemia (parathyroid hormone related protein, bone metastases)
• dermatomyositis/ polymyositis (proximal muscle weakness)
• Eaton/ Lambert syndrome (upper limb weakness)
• cerebellar ataxia
• sensorimotor neuropathy

Question 7

what clinical signs are there for lung cancer?

Answer 7

chest signs, clubbing, lymphadenopathy, Horner’s syndrome, Pancoast tumour, SVC obstruction, lymphadenopathy, hepatomegaly, skin nodules (metastases)

Question 8

what are the initial investigations for lung cancer (by GP)?

Answer 8

CXR, FBC, renal, liver functions and calcium, clotting screen, spirometry

Question 9

what “tissue diagnosis” investigations are there for lung cancer?

Answer 9

bronchoscopy, EBUS, image guided lung biopsy, image guided liver biopsy, FNA of neck node or skin metastasis, excision of cerebral metastasis, bone biopsy, mediastinoscopy/otomy, surgical excision biopsy

Question 10

what is a bronchoscopy?

Answer 10

looking down the airways with a bronchoscope

Question 11

what is an EBUS?

Answer 11

scanning outside the airways using a scan which goes down into the bronchi

Question 12

what factors does staging take into account?

Answer 12

diameter, invasion, atelectasis (partial or total lung collapse), nodules

Question 13

what characterises a T1 tumour?

Answer 13

under 3cm, no invasion, lobar bronchus

Question 14

what characterises a T2 tumour?

Answer 14

3-7cm, lobar atelectasis or obstructive pneumonia to hilus

Question 15

what characterises a T3 tumour?

Answer 15

> 7cm, whole lung atelectasis, invasion of chest wall, diaphragm, mediastinal pleural, pericardium, nodules in the same lobe

Question 16

what characterises a T4 tumour?

Answer 16

tumour in carina, invasion of heart great vessels, trachea, oesophagus, spine, nodules in other ipsilateral (= same side of body) lobes

Question 17

how else can you stage lung cancer?

Answer 17

nodal involvement (N0-N3), metastasis (M0-M1)

Question 18

what does M0 correspond to?

Answer 18

distant metastasis absent

Question 19

what does M1 correspond to?

Answer 19

distant metastasis present

Question 20

what does N0 correspond to?

Answer 20

no regional node involvement

Question 21

what does N1 correspond to?

Answer 21

involvement of ipsilateral hilar or ipsilateral peribronchial nodes

Question 22

what does N2 correspond to?

Answer 22

involvement of ipsilateral mediastinal or subcarinal nodes

Question 23

what does N3 correspond to?

Answer 23

involvement of contralateral mediastinal or hilar nodes OR ipsilateral or contralateral scalene or supraclavicular nodes

Question 24

TRUE/FALSE cancer staging combines these 3 staging-classification (tumour, nodal involvement, metastasis)

Answer 24

TRUE

Question 25

what stage does nodal involvement begin in?

Answer 25

2 or 3

Question 26

what state does presence of distant metastasis begin in?

Answer 26

4

Question 27

which two stages are fairly similar in terms of prognosis?

Answer 27

1 and 2

Question 28

what does the decision to treat depend on?

Answer 28

performance status, patient wishes, histological type and stage, multidisciplinary team, aims of treatment (radical/ palliative)

Question 29

how do you rank performance status?

Answer 29

``` 0= fully active 1= symptoms but ambulatory 2= "up and about" > 50%, unable to work 3= "up and about < 50%, limits self care 4= bed or chair bound ```

Question 30

what percentage of patients get surgery for lung cancer?

Answer 30

around 18%

Question 31

what three types of surgery can be given to patients with lung cancer?

Answer 31

wedge resection, lobectomy, pneumonectomy

Question 32

what three types of radiotherapy can be given to patients with lung cancer?

Answer 32

radical, palliative, stereotactic

Question 33

what available chemotherapies are there? what are the deciding factors for choosing a chemotherapy?

Answer 33

- part of radical or palliative treatment - alone, combined with radiotherapy, adjuvant (after surgery) - targeted areas (ex: tyrosine kinase inhibitors and monoclonal antibodies (erlotinib, gefitinib, etoposide)), adenocarcinoma (cisplatin/ permetrexed), squamous (cisplatin/ gemcitabine)

Question 34

what aspects are there to palliative care?

Answer 34

- symptom control (may include chemotherapy, radiotherapy, pain, haemoptysis, opiates, bisphosphonates, benzodiazepines, treatment of hypercalcaemia, dehydration, hyponatraemia) - quality of life - community support - decisions and planning, resuscitation status, end of life care - multidisciplinary team including lung cancer nurse and hospice