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1
Q

State some factors affecting choice of treatment

A
  • Metastasis (staging)
  • Performance status
  • 0 = asymptomatic; well
  • 1= symptomatic; able to do light work
  • 2= has to rest but for 50% of the day
  • 4= bed bound
  • Tumour type
  • Patients wishes and options
  • Aims of therapy (curative/palliative-supportive care)
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2
Q

Causes of lung cancer

A 
¬	TOBACCO
¬	Asbestos 
¬	Environmental radon 
¬	Other occupational exposure 
¬	Chromates, Hydrocarbons, Nickel
¬	Air pollution and Urban environment
¬	Other radiation
¬	Pulmonary fibrosis
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3
Q

Symptoms of lung cancer; common and also less common symptoms

A
  • Cough (chronic, recurrent)
  • Fatigue
  • Weight loss
  • Short of breath
  • Haemoptysis
  • Chest pain
  • Recurrent/persistent chest infections
¥	Wheeze
¥	Hoarse voice
¥	Dysphagia
¥	Fever
¥	Face swelling
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4
Q

state the problems of primary lung cancer

A

¥ Probably grows ‘clinically silent’ for many years
¥ Presents LATE in its natural history
¥ May have few, if any, signs or symptoms until the disease is very advanced
¥ May be found incidentally, during investigation for something unrelated
¥ Generally speaking, symptomatic lung cancer is fatal. Too late to be treated.

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5
Q

name four oncogenes that are not induced by smoking

A

ALK, BRAF, HER2, EDFR

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6
Q

state some local effects of lung cancer

4 categories

A 
Bronchial Obstruction: 
¥	Collapse						      	      	       
¥	Endogenous Lipoid Pneumonia
¥	Infection / Abscess						
¥	Bronchiectasis – abnormal widening of airways which are at risk of infection.

Pleural
¥ Inflammatory
¥ Malignant

Direct Invasion
¥ Chest Wall
¥ Nerves
¥ Mediastinum (SVC, Pericardium)

Lymph Node Metastases

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7
Q

what is the prevalence of small cell lung cancers and non small cell lung cancers

A

Non-small cell lung cancer ~85%
o Squamous 30%; adenocarcinoma 55%; large cell undifferentiated ~5% and others ‘not otherwise specified’ or NOS

Small cell lung cancer - 15%

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8
Q

when is adjuvant therapy used?

A

¥ POSTOPERATIVE; to increase chance of cure
¥ Detrimental in stages I and II (better for more progressive tumours)
¥ Some benefits in later stages
¥ Cisplatin+vinorelbine 5-year survival improved by 15% at 5 years

ADjuvant - ADD on to the operation

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9
Q

When is neoadjuvant therapy used?

A

¥ Proven to be very beneficial in stage III
¥ Used before surgery to reduce size of tumour to increase chances of operability

NEOadjuvant - before surgery

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10
Q

What are targeted drugs?

A

Drugs that are used when a patient with lung cancer has a specific gene mutation.
These drugs can radically improve a patients situation even if they were late staged.
These drugs should only used on patients with the mutation as the drugs can decrease survival rates of lung cancer patients without the mutation.

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11
Q

Bone pain in lung cancer patients

  • what percentage of cancer patients experience this?
  • when is the pain worst?
  • what is the treatment?
A

¥ ~50% of cancer patients have tumors in bone.
¥ Often worse at night
¥ Pathological fracture will give symptoms.
¥ Vertebral metastasis can compress the spinal cord
¥ Treatment – palliative RT

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12
Q

What are the four factors which have to be considered when staging lung cancer?

A

¥ Clinical history/examination
¥ Performance status
¥ Pulmonary function
¥ TNM International system for staging Lung Cancer
- Stage of disease (I->IV)
- Classification: type of cancer
- markers/oncogenes/gene expression profiles

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13
Q

Briefly describe the four stages of cancer

A

¥ Stage 1usually means thata cancer is relatively small and contained within the organ it started in.
¥ Stage 2usually means the cancer has not started to spread into surrounding tissue but the tumour is larger than in stage 1. Sometimes stage 2 means that cancer cells have spread into lymph nodes close to the tumour. This depends on the particular type of cancer.
¥ Stage 3usually means the cancer is larger. It may have started to spread into surrounding tissues and there are cancer cells in the lymph nodes in the area.
¥ Stage 4means the cancer has spread from where it started to another body organ. This is also called secondary or metastatic cancer.

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14
Q

what do the following mean:
TX
T0
Tis

A

TX Primary tumour cannot be assessed (X means tumour is blocked and therefore can’t be assessed)
T0 no evidence of primary tumour (0 means no tumour)
Tis carcimona in situ

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15
Q 
T
What are the different size cut offs for the different stages.
1a, 1b, 1c
2a, 2b 
3
4
A

1a 7cm and/or invades one of the following mediastinum, diaphragm, pericardium, recurrent laryngeal nerve, great vessels, vertebral bodies, oesophagus, carina

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16
Q

What is primary cancer?

A

when the cancer starts in the lungs and hasn’t spread from somewhere else in the body

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17
Q

State an oncogene which is induced by smoking

A

KRAS

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18
Q

What are the two most common oncogene addictions

A

KRAS and EGRF

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19
Q

What percentage of patients have KRAS mutation

A

35%

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20
Q

What percentage of patients have the EGRF mutation?

A

15%

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21
Q

What percentage of patients have the ALK rearrangement, HER 2 and BRAF mutations?

A

2% each

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22
Q

Where in the lungs are adenocarcinomas and squamous cell carcinoma found?

A

adenocarcinomas - peripheral of lungs

squamous cell carcinomas - central airways of lungs

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23
Q

Who are most affected by adenocarcinomas ?

A

non smokers and women

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24
Q

Which oncogene mutation has a poor prognosis?

A

KRAS

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25
Name 6 causes of tumours in the lungs (including rare causes)
benign carcinoid tumour bronchial gland tumour lymphoma sarcoma metastasis
26
Name two other sources of opacities on CXR
infection (bacterial- TB, fungal) vascular haematoma
27
What treatment does ALK rearrangements usually respond to ?
EGFR treatment
28
What are the two main type of primary lung cancer ?
NSCLC and SCLC
29
Name the four nerves that tumours can directly invade in the thorax and the problems caused when these are invaded
- phrenic - diaphragmatic paralysis - brachial plexus - Pancoast T1 damage - recurrent laryngeal nerve - hoarse voice - cervical sympathetic - Horners syndrome
30
Name three distant effects that primary tumours can cause
distant metastases secondary to local effects non-metastatic effects
31
Name the seven non-metastasis effects of cancer
``` cutaneous neurological skeletal endocrine-hormone cardiovascular renal haematologic ```
32
What are the two skeletal non metastasis effects?
clubbing hypertrophic pulmonary oesteoarthropathy (HPOA) - inflamed joints and bones
33
What are the two cutaneous non metastasis effects?
Dermatomyositis - inflammation of skin and muscles resulting in upper limb weakness Acanthuses nigricans - areas of dark, velvetly discolouration in creases and body folds
34
What are the three haematologic non metastasis effects?
Granulocytosis - increase of granulocytes (WBC) in the blood Eosinophila - increase of eosinophils in the blood Disseminated intravascular coagulation (DIC) - overactive clotting
35
What are the one cardiovascular non metastasis effects?
Thrombophlebitis Migrans | - inflammation of a vein associated with thrombi which moves slowly for one vein to another
36
What are the one renal non metastasis effects?
nephrotic syndrome | - glomeruli become more leaky and therefore proteins can leak out in the urine
37
What are the five neurological non metastasis effects?
polyneuropathy encephalopathy cerebellar degeneration myasthenia (eaton-lambert) - rare disorder involving a problem with the NMJ which results in upper limb weakness, dry mouth, impotence and constipation Gynecomastia - male breast enlargement
38
What are the common symptoms with a neurological problem?
``` head ache vomiting ataxia dizziness focal weakness ```
39
Generally what is the prognosis of lung cancer?
dreadful | only 10% of patients are operated on
40
Is the prognosis better for NSCLC or SCLC ?
NSCLC - 5YS = 10-25% | SCLC - 5YS = 4%
41
How many days does it take NSCLC and SCLC to double in size?
NSCLC - 129 days | SCLC - 29 days
42
How are the cancers staged ? NSCLC SCLC
NSCLC - staged by TNM (stage 1 to 4) SCLC - staged by "limited" or "extensive" disease
43
SCLC | How is limited and extensive cancer treated?
limited - chemotherapy extensive - only 4 cycles of chemo or a single fraction of RT if the patient is too unwell for chemo
44
What are the two drugs used for chemo?
cisplatin and etoposide
45
Why is a blood test done in cancer patients?
- anaemia - abnormal bone profile (bone metastasis?) - abnormal liver function (liver metastasis?) - high WBC? - FBC
46
What investigations should be done for cancer patients?
``` CXR Bronchoscopy - biopsy - brushing and washing - endobronchial ultrasound guided aspiration (EBUS) Trans-thoracic fine needle aspiration Trans-thoracic core biopsy Pleural aspiration Advanced imaging technique - CT - MRI - PET - ECHO ```
47
Describe the N staging of cancer | 0-4
N0 - no lymphatic involvement N1 - ipsilateral peribronchial, hilar or intrapulmonary nodes N2 - ipsilateral mediastinum, sub carinal N3 - contralateral mediastinum, hilar, scalene or supraclavicular lymph nodes
48
Describe the M staging of cancer | 0, 1a, 1b, 1c
0 = no distant metastasis 1a = separate nodule in contralateral or pleural/mediastinum nodule 1b = single distant metastasis 1c -multiple distant metatstasis
49
Name the common sites for cancer to spread to
``` liver brain skin adrenal glands skeletal ```
50
What is the definition of nodule and mass?
nodule 3cm
51
State the structure of X ray analysis
``` name lines/metal heart mediastinum lungs (zones and opacities) bones diaphragm soft tissue review areas - hiliar - lung apices - behind heart - behind diaphragm ```
52
What are stages 3 and 4 classified as?
advanced disease
53
What are the different treatments available for stage 3 and 4?
stage 3 - radical therapy - chemo RT stage 4 - systematic therapy
54
describe radical therapy used to treat stage 3 NSCLC
- use high doses radio therapy (55Gy) | - 3 cycles are optimal
55
during radical therapy what organ function test is essential ?
pulmonary function test
56
Describe the benefit of using chemoRT for stage 3 instead of RT on its own?
chemo travels around the body killing cancer cells that have been undetected
57
By how long can maintenance chemo extend survival by?
3-5 months
58
What type of drugs are targeted drugs?
tyrosine kinase inhibitors and monoclonal antibodies
59
What does immune therapy do in the body?
prevents the T lymphocytes form being inactivated by the cancer cells therefore the immune system would be able to detect the cancer cells and destroy the cells
60
What are the issues surrounding immune therapy
very expensive
61
What are the four aims of palliative care?
- symptom control - maintaining quality of life - organising community support - help make decisions and planning for end of life care
62
In what ways can the symptoms be relieved in patients with cancer ?
DRUGS - chemo - radio therapy - opiates - bisphosphonates - benzodiazepines TREATMENT OF - hypercalaemia - dehydration - hyponatraemia
63
What four ways can cancer be prevented ?
- education - minimise waiting times - smoking ban - screening ?
64
Describe the PET scan
- nuclear medicine - half life of 60 mins so leaves body quickly - image will glow brightly where the most glucose consumption is occurring, therefore show where the most rapidly dividing cells are (cancer cells)
65
What is an MRI scan useful for detecting in relation to cancer patients?
vascular and neurological involvement in pancoast tumours
66
Fitness for surgery: what factors affect fitness related to the CVS ? what factors affect fitness related to the Resp.?
CVS angina, heart problems, previous CABG/PCI, smoker, previous stroke/TIA, heart murmurs, carotid bruits Resp. hyper inflated chest, COPD, smoker, asthmatic, recent URTI, on O2, exercise capacity
67
Name six fatal complications of surgery
- MI - Bronchopneumonia - Acute respiratory distress syndrome - pneumothorax - intrathoracic bleeding - PE
68
State some other less serious complications?
``` wound pain infection empyema AF MI respiratory insufficiency constipation ```
69
State 9 clinical signs for cancer
- hyperinflation - pan coast syndrome - Horners syndrome - clubbing - lymphadenopathy - hepatomegaly - SVC obstruction - skin nodules (metastasis) - pleural effusion
70
factors affecting accuracy of staging the cancer?
- collapsed lobe - presence of separate pulmonary nodule - retrosternal thyroid - adrenal nodule - head CT is not routinely done pre op

Lung Cancer (2 decks)

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