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Cardiorespiratory > Lecture 24: Lung cancer > Flashcards

Lecture 24: Lung cancer Flashcards

1
Q

definition of lung cancer?

A

The term lung cancer, or bronchogenic carcinoma, refers to malignancies that originate in the airways or pulmonary parenchyma

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2
Q

95 % of all lung cancers are classified as either

A
  • -Small cell lung cancer (SCLC) or

- -Non-small cell lung cancer (NSCLC)(80%)

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3
Q

what tumors commonly metastasize to lungs?

A

The lungs are a common site for metastatic disease; breast, thyroid, bowel, melanoma, renal etc.

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4
Q

None-small cell lung cancer (NSCLC) includes…

A
  • -Constitutes 80% of all lung cancers
  • -Adenocarcinoma
  • -Squamous cell
  • -Large cell
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5
Q

SCLC constitutes the majority of lung cancers. T/F

A

False

  • -Constitutes 20% of all lung cancers
  • -Endocrine in origin and often associated with paraneoplastic syndromes
  • -Can be diagnosed with EBUS-TNA
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6
Q

what is the epidemiology of lung cancer?

A

–1.8 million cases worldwide in 2012 and 1.6 million deaths
–An estimated 224,000 new cases of lung cancer in the U.S. in 2014
–Commonest cause of cancer mortality worldwide
–National Cancer Registry Ireland 2018
1)Lung cancer is the No 1 cause of cancer death in Ireland
2)2564 cases per year
3)Representing 19% of all female cancer deaths and 22% of all male cancer deaths
Incidence in women is increasing, slightly falling in men

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7
Q

what are the risk factors of lung cancer?

A

1) Smoking
- -Accounts for 90% of lung cancers
- -Risk dependent on duration and extent of smoking
- -1 in 8 smokers develop lung cancer
- -2/3 present with advanced disease
- -Passive smoking
2) Radiotherapy for other malignancies
- -Breast cancer
- -Hodgkin’s Lymphoma
3) Environmental Toxins
- -Radon (commonest cause of lung cancer in never smokers)
- -Asbestos
- -Heavy metals (arsenic, chromium, and nickel)
- -Ionizing radiation
- -Polycyclic aromatic hydrocarbons
4) Age
- -Median age at dx 71 years
5) Family History
6) Idiopathic Pulmonary Fibrosis
- -7 fold increased risk

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8
Q

what is the major risk factor of lung cancer?

A
  • -Smoking
  • -Accounts for 90% of lung cancers
  • -Risk dependent on duration and extent of smoking
  • -1 in 8 smokers develop lung cancer
  • -2/3 present with advanced disease
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9
Q

does passive smoking increase the risk of lung cancer?

A

Yes

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10
Q

what is the most common environmental toxin that increase the risk of lung cancer?

A
  • -Radon (the commonest cause of lung cancer in never smokers)
  • -others
    1) Asbestos
    2) Heavy metals (arsenic, chromium, and nickel)
    3) Ionizing radiation
    4) Polycyclic aromatic hydrocarbons
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11
Q

what is ht median age of lung cancer representation?

A

71

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12
Q

what is the impact of smoking on the risk of lung cancer:

A

The risk of developing lung cancer increases with the number of cigarettes smoked and decreases in proportion to the number of years after smoking cessation. Other factors that impact smoking-related risk include age that smoking begins, years of smoking duration, extent of smoke inhalation, tar and nicotine content of the cigarettes, and use of unfiltered cigarettes.

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13
Q

how patients with suspected lung cancer are assessed?

A

1) Clinical Assessment:
- -Symptoms and signs
- -Performance status (ECOG) and co-morbidities
2) Radiological Assessment: CT scan to suggest the diagnosis
3) Pathological Assessment: Bronchoscopy and tissue diagnosis - only confirmatory diagnostic test
4) Physiological Assessment: Pulmonary function
5) Staging - to determine the presence and degree of metastatic disease

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14
Q

what are the signs and symptoms of lung cancer?

A
  • -Most cases initially present to their GP
  • -Certain proportion present to ED as emergency
  • -Incidental finding on CXR (7-10%)
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15
Q

what are the symptoms of lung cancer – related to the location of the tumor and stage of disease?

A

1) Peripheral lesion
- -Incidental finding with no symptoms
2) Central lesion
- -Cough (irritative effect from the tumour),
- -Hemoptysis (friable tumor tissue/abnormal tumor vasculature)
- -Dyspnea (bronchial obstruction/collapse/effusion)
- -Hoarseness (laryngeal nerve palsy from tumor invasion)
3) Pleural/mediastinal involvement
- -Chest pain
- -SVC obstruction
5) Metastatic
- -Seizures
- -Headache
- -Cranial nerve defects
- -Confusion
- -Hepatomegaly
- -Bone pain
6) Systemic
- - Weight loss
- - Anorexia

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16
Q

symptoms of lung cancer are more due to peripheral or central location of tumors?

A

Central lesion

  • -Cough (irritative effect from the tumor),
  • -Haemoptysis (friable tumor tissue/abnormal tumor vasculature)
  • -Dyspnoea (bronchial obstruction/collapse/effusion)
  • -Hoarseness (laryngeal nerve palsy from tumor
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17
Q

what are the paraneoplastic syndromes commonly associated with lung cancer?

A
  • -Hypercalcaemia (SquamCCa)
  • -Syndrome of Inappropriate ADH secretion (Small Cell LC)
  • -Ectopic ACTH secretion (Small Cell LC)
  • -Cerebellar Syndrome (Small Cell LC)
  • -Lambert-Eaton Myasthenic Syndrome (Small Cell LC)
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18
Q

hypercalcemia is commonly seen with SCLC. T/F

A
  • -False

- -SCC

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19
Q

what are the signs that would prompt urgent CXR?

A
  • -Clubbing
  • -Lymphadenopathy
  • -Focal chest signs
  • -Hepatomegaly
  • -Horner’s syndrome
  • -Tracheal deviation
  • -Cachexia
  • -Positive Pemberton’s sign (SVC obstruction)
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20
Q

performance status by ECOG: eastern cooperative oncology group: clinical cancer research organization?

A
  • -0: Fully active, able to carry on all pre-disease performance without restriction
  • -1: Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light housework, office work
  • -2:Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours
  • -3:Capable of only limited self-care; confined to bed or chair more than 50% of waking hours
  • -4: Completely disabled; cannot carry on any self-care; totally confined to bed or chair
  • -5: dead
21
Q

what investigations should be performed in suspected lung cancer?

A

1) Chest radiograph (CXR)
2) CT Thorax/Liver/Adrenals
- -Staging (Normally Thorax, Abdomen and Pelvis in practice)
3) PET-CT
- -Assesses metabolic activity of primary lesion +/- clarifies/identifies sites of metastatic disease
4) Bronchoscopy
- -bronchial washings, bronchial brushings, bronchoalveolar lavage, endobronchial biopsy
5) Endobronchial Ultrasound and Trans-Bronchial Needle Aspiration of mass/lymph node (EBUS-TBNA)
- -Stages of mediastinal disease
6) US-guided pleural biopsy or pleural effusion aspiration.
7) CT-/U/S-guided biopsy of a peripheral lung/liver/adrenal/neck lesion
8) Sputum cytology
9) Radio-isotope bone scan for bone metastases

22
Q

what is the PET?

A

A diagnostic imaging technique that uses a radiotracer to provide information about blood flow and/or metabolic processes in the body. The most common radiotracer used is fluorodeoxyglucose (FDG).

  • -More accurate than CT at differentiating between benign and malignant nodules
  • -Performed prior to biopsy if the CT imaging is inconclusive, particularly for patients with a high probability of malignancy
  • -Good negative predictive value: high sensitivity for detecting malignancies, but moderate positive predictive value: does not distinguish malignant processes from other metabolically active processes (e.g., infections, inflammatory conditions).
23
Q

CT imaging for further evaluation indicated if…

A
  • -New lesion detected on chest x-ray
  • -Changes (e.g., enlargement) compared to previous chest x-ray are inconclusive
  • -No previous CXR/CT is available
24
Q

what is the confirmatory test of lung cancer?

A
  • -Bronchoscopy and biopsy
  • -Procedures
  • -Bronchoscopy with transbronchial biopsy: central nodules
  • -CT-guided transthoracic biopsy: peripheral nodules
  • -thoracoscopy: if bronchoschopy or CT-guided biopsy are inconclusive, or in small peripheral nodules (Simultaneous diagnostic and curative approach; if the lesion is found to be malignant in cryosection, immediate resection of the tumor may be considered.)
  • -Mediastinoscopy: to biopsy mediastinal nodes or masses
25
Q

what therapeutic investigations can be performed in lung cancer?

A
  • -Rigid bronchoscopy with bronchial stent insertion

- -CT Thorax +/- Stent insertion into SVC if SVC obstruction is present under fluoroscopic guidance.

26
Q

in lung cancer what can be found in CBC?

A

Anaemia of chronic disease, leucocytosis 20 to pneumonia

27
Q

in lung cancer what can be found in U/E

A

SIADH

28
Q

in lung cancer what can be found in CMP?

A

Hypercalcaemia, bone metastases (inc ALP, bone scan)

29
Q

CT Neck/Thorax/Brachial Plexus can reveal…

A

Pancoast tumor/Superior Vena Cava Obstruction

30
Q

ABG, CTPA can be done in suspected…

A

PE

31
Q

Bronchoscopy can reveal…

A

post-obstructive pneumonia

32
Q

The echocardiogram can reveal…

A

pericardial effusion

33
Q

CT/MRI Brain is done to find out…

A

Brain metastases/Cerebellar Syndrome

34
Q

how Lambert Eaton Myasthenic Syndrome (LEMS) is diagnosed?

A

EMG/Voltage-Gated Calcium Channel Antibodies

35
Q

Pemberton’s sign is suggestive of…

A

SVC obstruction

36
Q

Serum ACTH, Cortisol levels is performed to find out the source of…

A

Ectopic ACTH production

37
Q

major fissure of lung separates…

A

middle and lower lobes on righy and upper and lower on left.

38
Q

what system is used to stage lung cancer?

A

1) Non-small cell lung cancer
- -TNM staging system
2) Small cell lung cancer
- -Limited
- -Extensive

39
Q

how TNM staging is performed?

A

–T: Tumour ————- CT Thorax
–N: Nodes —————- CT: Mediastinum window
–M: Metastases ———- CT-PET,
Bone scan,
Brain CT/MRI etc.

STEP 1: The CT scan

40
Q

what is the importance of staging?

A

1) To define extent of disease and assess prognosis
2) To assign therapy
- -Select pts who would benefit from surgical resection
3) Compare across clinical trials

41
Q

does EBUS used for staging?

A

Yes

1) Meta-analysis of EBUS-TBNA in the staging of lung cancer
2) 11 studies with 1299 patients met criteria
- -Overall sensitivity 93%
- -Overall specificity 100%

42
Q

what are the issues of lung cancer management?

A
  • -Delay in presentation
  • -Symptoms; in common with chronic respiratory conditions (COPD)
  • -Delay in referral
  • -Delay in diagnosis
  • -Delay in treatment initiation
43
Q

lung cancer treatment depends on…

A
  • -Depends on STAGE of disease
  • -But also:
    1) Performance status of patient
    2) Co-morbidities
    3) PFT results (Degree of impairment)
44
Q

what are the components of lung cancer therapy?

A

1) Cardiothoracic surgery for excision of tumour
2) Radiation
- -External
- -Stereotactic body radiotherapy
3) Chemotherapy
- -Biologic therapy
- -Immunotherapy
4) Palliation (dyspnoea and pain)
- -Endobronchial treatment
- -Pleural fluid drainage
- -Radiotherapy

45
Q

how local control of cancer is achieved?

A

radiation

surgery

46
Q

how metastatic control is achieved?

A

chemotherapy

Brain XRT

47
Q

SCLC is mainly treated by surgery. T/F

A

False

  • -Limited stage: chemotherapy and RT
  • -Extensive: chemotherapy
  • -If response: prophylactic cranial irradiation
  • -Overall Chemotherapy and radiation has increased survival
    1) from 2 months to 10 months
    2) many complete remissions
    3) almost all patients relapse
48
Q

which mutations are commonly detected in lung cancers?

A

–KRAS
–EGFR
–EML4-ALK
–BRAF
no mutation detected in46%

49
Q

what are lung cancer prevention strategies?

A

1) Cessation of smoking
- -After cessation, the risk of lung cancer reduces by half within 5–10 years. After approx. 15–20 years, the risk decreases to the corresponding level in nonsmokers.
2) Screening with low-dose CT imaging in patients aged –55–74 years (USPSTF recommends 55–80 years) with either:
* A history of smoking (≥ 30 pack-years) and continue smoking or stopped within 15 years
* Or a history of smoking (≥ 20 pack-years) and another risk factor for lung cancer

Cardiorespiratory (24 decks)

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