Lung Flashcards

1
Q

What are the types of lung cancer?

A

Small cell lung cancer

Non small cell lung cancer:
Adenocarcinoma
Squamous cell carcinoma
Large cell
Alveolar cell carcinoma
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2
Q

What is the difference between SCLC and NSCLC?

A

SCLC usually centrally located, more aggressive, treatment usually chemo

NSCLC 85-90% of cancers, can be fast or slow growing
Staging with TNM
Surgical, medical or radiation

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3
Q

What are the characteristics of adenocarcinomas?

A

Usually more peripheral
Most common type in non-smokers
Precursor is atypical alveolar hyperplasia

Histology shows cancer of bronchial mucosal tissue
Often early mets
Prognosis worse than squamous cell

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4
Q

What are the characteristics of squamous cell carcinoma?

A

Usually centrally located
Smoking
Cancer of squamous epithelial cells
Slow growing tumour

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5
Q

What are some of the known risk factors for the development of lung cancer?

A
Tobacco smoking, second hand smoke
Radon, asbestos
Occupational exposure
Personal or FH of LC
Personal history of lung disease e.g. COPD, TB
Radiation exposure
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6
Q

From what cells do small cell lung cancers originate?

A

Kulchitsky cells

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7
Q

How does squamous cell lung cancer commonly present?

A

Bronchial obstruction leading to recurrent infections

Finger clubbing

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8
Q

What are the characteristics of small cell lung cancer?

A

Small round blue cells on histologic staining, approx twice the size of lymphocytes

Centrally located lesions
Aggressive tumour spreads
More responsive to chemo but poor prognosis

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9
Q

What are the symptoms of lung cancer?

A

Frequently asymptomatic
When symptomatic, cough, malaise and WL predominate

Fever, malaise, nausea
Cough, haemoptysis
Features of SVCO, PNS
Hoarseness - involvement of recurrent laryngeal
Weight loss
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10
Q

What are the signs of lung cancer?

A
Lymphadenopathy
Stridor
Wheeze
Clubbing
Hypertrophic pulmonary osteoarthropathy
Signs of pleural effusion
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11
Q

What is hypertrophic pulmonary osteoarthropathy?

A

Fibrovascular proliferation
Results in periostitis (inflammation of periosteum) of the long bones, arthralgia, clubbing.

Lung cancer - paraneoplastic syndrome or in ovarian or adrenal malignancies

CT scan for diagnosis, NSAIDs for the pain

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12
Q

What are the signs of pleural effusion?

A

Dull - stony dull percussion
Reduced vocal remits
Reduced breath sounds

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13
Q

What is a Pancoast tumour?

A

Tumour of the pulmonary apex
Local spread may affect brachial plexus, cervical sympathetic trunk, stellate ganglion, subclavian vein

Can cause Horner’s - sympathetic ganglion
Pain in shoulder, radiates into arm and hand - brachial plexus
Atrophy of muscles of upper limb
Oedema of upper limb
Hoarse voice = recurrent laryngeal

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14
Q

What can be seen on CXR with Squamous cell lung cancer?

A

Cavitations so a CT is needed to rule out TB

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15
Q

What paraneoplastic syndromes are associated with squamous cell lung cancer?

A

PTHrP = hypercalcaemia
Ectopic TSH = hyperthyroid
Hypertrophic osteoarthropathy

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16
Q

Which type of lung cancer is most common in non-smokers?

A

Adenocarcinomas

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17
Q

Why do adenocarcinomas tend to present with fewer symptoms?

A

They are more likely to be located in the peripheries

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18
Q

What are signs/symptoms of Superior Vena Cava Obstruction?

A

Early morning headache
Arm and Face Oedema
Jugular distention

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19
Q

Describe the clinical features of lung cancer caused by mets

A
  • Fatigue
  • Weight loss
  • Night sweats
  • Lymph node enlargement (supraclavicular)
  • Liver mets- anorexia, mass, jaundice, abdo pain, ascites
  • Adrenals- addisons (bronze pigment, hypoglycaemia, postural hypotension, weight loss, GI disturbance, weakness, crises)
  • Bone- pathological fractures, bone pain
  • Pleura- effusions
  • CNS- cord compression, focal neurological signs
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20
Q

Describe the clinical features of lung cancer caused by the primary tumour

A
  • Cough (lasting >3 weeks)
  • SOB
  • Haemoptysis
  • Wheeze
  • SVC obstruction (SOB, distended neck veins and JVP, headache/ fullness, blurred vision, odema arms/ face, confusion, syncope)
  • Persistent/ recurrent infections
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21
Q

Describe the possible clinical features of lung cancer caused by paraneoplastic syndromes

A
  • Horners syndrome (partial ptosis, unilateral anhidrosis, miosis)
  • Clubbing
  • Hypercalcaemia
  • Anaemia
  • SIADH
  • Cushings
  • Lambert eaton myasthenic syndrome (muscle weakness, fatigue, pain, reduced reflexes, walking difficulty, speech impairment and swallowing problems)
  • VTE
  • Thrombocytosis
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22
Q

What occurs in hypercalcaemia due to paraneoplastic syndromes?

A

Due to bony mets
Or tumour secretion of
parathyroid hormone related protein - PTHrP
Calcitriol

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23
Q

When is SIADH seen in lung cancer?

A

SCLC
Hyponatraemia
In extreme cases cerebral oedema

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24
Q

What is Lambert Eaton syndrome?

A

Caused by antibodies to voltage gated calcium channels, seen in 1% of SCLC
Proximal and ocular muscle weakness

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25
What is hypertrophic osteoarthropathy?
Thought to be due to fibrovascular proliferation due to accumulation of megakaryocytes Clubbing Periostitis of small hand joints and metacarpophalangeal joints Distal expansion of long bones and painful swollen joints
26
What is the criteria for a two week wait referral?
Suggestive CXR findings Unexplained haemoptysis and aged over 40 Those with SVCO or stridor require urgent referral and emergency admission
27
When should an urgent CXR within 2 weeks be considered in those over 40?
``` Persistent or recurrent chest infection Clubbing Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy Chest signs indicative of lung cancer Thrombocytosis ``` Have two of these, or one and ever smoked: cough, fatigue, SOB Chest pain, weight loss Appetite loss
28
What are the investigations for lung cancer?
``` Bloods Imaging Bronchoscopy Lung function tests Histology and cytology ```
29
What does squamous cell carcinoma commonly secrete?
PTHrp causing hypercalcaemia
30
What does small cell carcinoma commonly secrete?
ACTH - Cushing's | ADH - SIADH
31
What are some differentials for lung cancer and features differentiating it from cancer?
TB - night sweats, sputum culture, cavitating lesion Mets to lungs from other sites - symptoms related to primary tumour Sarcoidosis - enlarged parotids, erythema nodosum, granulomas Wegener's - cANCA, saddle nose deformity, urinalysis Non-Hodgkin's - night sweats, hepatosplenomegaly
32
What are appropriate bedside investigations?
Pulse oximetry - aim for 94-98% | ECG performed pre-operatively
33
What are appropriate lab investigations?
FBC - anaemia LFTs - raised ALP, GGT hepatic mets, raised ALP bone mets U&Es Serum calcium, bone profile
34
What is appropriate imaging investigations?
CXR - opacities, pleural effusion or lung collapse CT chest-abdomen-pelvis Bronchoscopy and biopsy - confirms subtype, presence of targetable mutations PET-CT for staging CT/MRI brain can be ordered to exclude cerebral mets
35
How can tissue biopsies be obtained?
Bronchoscopy Image guided biopsy Video assisted thoracoscopic surgery Mediastinoscopy
36
How can cytology be obtained?
Aspirates, washings, pleural fluid | Obtained from the tumour, lymph node or mets
37
What is the TNM staging?
Tumour TX: Primary tumour cannot be assessed or tumour proven by presence of malignant cells in sputum or bronchial washings but not visualised by imaging or bronchoscopy T0: No evidence of a primary tumour Tis: Carcinoma in situ T1: Tumour measuring 3 cm or less in greatest dimension surrounded by lung or visceral pleura without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e. not in the main bronchus) T1a: tumor ≤1 cm T1b: tumor >1 cm but ≤2 cm T1c: tumor >2 cm but ≤3 cm T2: Tumour > 3 cm but ≤ 5 cm or tumour with any of the following features: Involves the main bronchus regardless of distance from the carina but without the involvement of the carina Invades visceral pleura Associated with atelectasis or obstructive pneumonitis that extends to the hilar region involving part or all of the lung T2a: tumour > 3 cm but ≤ 4 cm in greatest dimension T2b: tumour > 4 cm but ≤ 5 cm in greatest dimension T3: Tumour > 5 cm but ≤ 7 cm in greatest dimension or associated with separate tumour nodule(s) in the same lobe as the primary tumour or directly invades any of the following structure: Chest wall (including the parietal pleura and superior sulcus) Phrenic nerve Parietal pericardium T4: Tumour > 7 cm in greatest dimension or associated with separate tumour nodule(s) in a different ipsilateral lobe than that of the primary tumour or invades any of the following structures: diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, oesophagus, vertebral body or carina) Node Nx: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension N2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s) N3: Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s) Metastasis M0: no distant metastasis M1: distant metastasis present The above tumour, node and metastasis classification can then be grouped into stages: Stage I: IA: T1N0M0 IIB: T2aN0M0 Stage II: IIA: T2bN0M0 IIB: T1N1M0, T2N1M0, T3N0M0 Stage III: IIIA: T1N2M0, T2N2M0, T3N1M0, T4N0M0, T4N1M0 IIIB: T1N3M0, T2N3M0, T3N2M0 IIIC: T3N3M0, T4N3M0 Stage IV: Any T, Any N, M1
38
What is the I-IV cancer staging system?
I: One small tumour (<4cm) – localised to one lung II: Larger tumour (>4cm) – may have spread to nearby lymph nodes III: Tumour that has spread to contralateral lymph nodes, or grown into nearby structures (e.g. trachea) IV: Tumour that has spread to lymph nodes outside the chest, or other organs (e.g. liver)
39
What is the management of Stage I-III NSCLC?
Surgery - lobectomy/pneumonectomy in patients with intact lung function or wedge resection if reduced lung function e.g. elderly Pre-op chemo, post op chemo/radiotherapy Pneumonectomy is where an entire lung is removed
40
What is SABR?
Stereotactic ablative radiotherapy If unsuitable for surgery e.g. too frail Directs more intense and focused beam of radiation at the tumour Reduces number of sessions needed and minimises damage to surrounding tissue
41
What is the management of Stage IV NSCLC?
Targeted therapy - drugs target mutations Immunotherapy - targets immune checkpoints Chemotherapy Palliative care - radiotherapy for mets and symptom control
42
What are some examples of targeted therapy for NSCLC?
EGFR-TK - Gefitinib, Osimertinib (epidermal growth factor receptor tyrosine kinase) ALK - Alectinib (Anaplastic lymphoma kinase positive gene rearrangement) ROS1 - Crizotinib
43
What are examples of immunotherapy?
Immune checkpoint PD-L1 is targeted by pembrolizumab
44
What is the basis of lung cancer pathogenesis?
Initiation - due to exposure to a carcinogen, DNA damage leads to permanent mutation Promotion - subsequent or continued exposure, growth, proliferation and development into a tumour Progression - undergoes changes causing morphological changes and malignant features
45
What is the staging of small cell lung cancer?
Limited disease - cancer is only present in one side of the chest in a radioencompassable volume (single radiation treatment field) Extensive disease - cancer is present bilaterally in the chest, there is pleural effusion or there are distant metastases
46
What are indicators of a good outcome post surgery?
Lung function tests done to assess lung reserve FEV1 greater than or equal to 1.2 and diffusing capacity of the lung for CO greater than 60% predicted Fit for surgery with FEV 0.7
47
What are some of the indications for chemo?
Shrink tumour prior to surgery or radiation Kill cancer cells not removed during surgery, to reduce risk of recurrence Primary treatment for those unable to have surgery Relieve pain of advanced cancer Maintenance therapy for those with advanced cancer that is responsive to chemo
48
How can lung cancer cause anaemia?
Similar mechanism to anaemia of chronic disease: tumour causes macrophage activation, causing hepcidin release (directly and via cytokines acting on liver this reduces iron absorbtion and release from stores, idea is to starve bacteria in blood of iron) leading to functional iron deficiency
49
How can lung cancer cause VTE?
Inflammatory cytokines activate procoagulant pathways. | Ca cells can also produce procoagulant proteins, fibrinolysis inhibitors and microparticles also
50
What is the prognosis of SCLC?
Limited stage - 18-30 months | Extensive - 7-12 months
51
What are indications for adjuvant chemotherapy?
Potentially curative resection Final pathological stage of 2 or 3 Good post-op recovery No co-morbidities precluding chemo
52
What are the symptoms of Pancoast tumour?
Associated with non small cell lung cancer Compression of brachiocephalic vein, subclavian artery, phrenic nerve, vagus nerve, recurrent laryngeal, sympathetic ganglion Symptoms of lung cancer Pain/weakness in muscles of arm and hand Hoarse voice, bovine cough SVCO
53
What is Carcinoid syndrome?
Paraneoplastic syndrome Occurs secondary to carcinoid tumours Flushing, diarrhoea - due to serotonin, histamines and gastrin, heart failure, vomiting, bronchoconstriction, abdo pain due to hepatomegaly Endogenous secretion of serotonin and kvllikrein
54
Where is it important to examine upon investigating lung cancer?
Check axillary lymph nodes when suspecting lung cancer as metastasise to here early
55
What is the treatment of SCLC?
Nearly always metastasised, so palliative care with chemo Regimens include cyclophosphamide, doxorubicin, vincristine and etoposide or cisplatin and radiotherapy
56
What is a common chemotherapy treatment regimen?
Gemcitabine and Carboplatin - GemCarbo Bloods taken beforehand Anti-emetics given Each cycle takes 21 days/3 weeks: Day 1 - gemcitabine and carboplatin Day 8 - gemcitabine only Then rest period of no treatment for 13 days Then begin next cycle, pts tend to have 4 cycles
57
What is a performance assessment for chemotherapy?
Lower the number = fitter 0 - fit and active 1 - fit and active but unable to work, e.g. cannot do manual labour job 2 - not working, but able to be up and about for 50% of the day and self-care 3 - able to self care, but up and active for less than 50% of the day 4 - bed bound
58
What are complications of surgical management?
Pneumonia Atelectasis Chylothorax - lymphatic fluid from the thoracic duct in the pleuritic cavity Post-op haemorrhage leading to haemothorax Pneumothorax Bronchial stump insufficiency Mediastinal shift
59
What is prophylactic cranial irradiation?
Combat occurrence of mets, e.g. from SCLC | Either highly precise or therapeutic radiation
60
What are carcinoid tumours?
Slow growing type of neuroendocrine tumour originating in cells of the neuroendocrine system In the lung - is an uncommon low-grade malignant lung mass, typically present with cough or haemoptysis
61
What biomarkers are used to detect carcinoid tumours?
Chromogranin A and 5HIAA levels
62
How are carcinoid tumours managed?
-Surgery + adjuvant chemo is curative if localised but mets common at presentation so surgery often palliative - type of surgery depends on location of the tumour - Somatostatin analogues like octreotide can give symptom control if functional tumour interferon alpha inhibits protein, hormone synthesis and angiogenesis and stimulates immune system- is primary treatment for low proliferating tumours cytotoxic chemo for high proliferating tumours and large tumour burden radiotherapy only used if brain or bone mets
63
List some common causes of pneumonitis in patients undergoing treatment for lung cancer.
Radiation therapy Chemotherapy Viral infection Bronchial obstruction
64
What is radiation pneumonitis?
Loss of epithelial cells Oedema, inflammation Occlusion of airways Fibrosis
65
What is the presentation of pneumonitis?
History of precipitating cause SOB, cough, burning sensation Fatigue, cyanosis, clubbing
66
What are the investigations for pneumonitis?
``` Bloods - FBC, raised ESR and CRP Blood gases - hyperaemia Sputum cultures Serum precipitating antibodies CXR may be normal or may show micro nodular or reticular opacities CT scan Pulmonary function tests Lung biopsy ```
67
What are the complications of pneumonitis?
``` Recurrent pneumonia Pneumothorax Pulmonary fibrosis Cor pulmonale COPD ```
68
What is the management of pneumonitis?
Use of corticosteroids e.g. short course of oral prednisone or methylprednisolone
69
What is a pleural effusion?
Accumulation of fluid in the pleural space - between the visceral and parietal pleura Serous fluid within pleural membrane allows these to slide over each other and create surface tension
70
What is the classification of pleural effusion?
Transudative - <25g/l | Exudative - high protein level of >35g/L due to increased permeability
71
What are the causes of transudative pleural effusion?
Heart failure, liver failure | Hypoalbuminaemia, nephrotic syndrome, dialysis
72
What are the causes of exudative pleural effusion?
Infection - parapneumonic, TB, malignancy
73
What are other types of pleural effusion?
Haemothorax - blood in pleural space Empyema - pus in pleural space Chylothorax - chyle in pleural space due to disruption of thoracic duct e.g. neoplasms, trauma
74
What are the clinical features of pleural effusion?
Small - asymptomatic Breathlessness Cough Pleuritic chest pain Check for symptoms of cancer, heart failure, infection, smoking history, asbestos exposure
75
What is looked for on examination for pleural effusion?
Peripheral inspection Reduced chest movement Tracheal deviation away from affected side Reduced tactile remits over pleural effusion Stony dull on percussion Breath sounds and vocal resonance reduced
76
What are the differentials for pleural effusion?
Infection; pneumonia, TB Malignancy without effusion Pulmonary embolism Pneumothorax
77
What are the investigations for pleural effusion?
Bedside ECG, urine dip for protein Bloods FBC, CRP, cultures - infection ABG, d-dimer (PE?) LFTs U&Es, amylase TFTs CXR Unilateral - exudative Bilateral - transudative Look for consolidation, malignancy, cardiomegaly, pleural plaques (asbestos) CT, ECHO If thought to be exudative - pleural fluid aspiration under USS guidance
78
What is Light's criteria summary?
The fluid is an exudate if one or more of the following criteria are met: Pleural fluid protein divided by serum protein is >0.5 Pleural fluid LDH divided by serum LDH is >0.6 Pleural fluid LDH is >⅔ the upper limit of the laboratory normal value for serum LDH
79
What is the management of pleural effusion?
Treat underlying cause Diuretics heart failure Antibiotics for infection Therapeutic aspiration Chest drain insertion Long term indwelling chest drain Pleurodesis - mildly irritant drug into pleural space to stick lung to wall of chest Video assisted thoracic surgery
80
What are some complications of pleural effusion?
In parapneumonic effusions, complications include empyema and sepsis
81
What is a mesothelioma?
Malignant growth of mesothelial cells Most commonly affecting the pleura Strongly associated with prior exposure to asbestos Mesothelial cells line the body cavities e.g. pleura, peritoneum, pericardium, testis
82
What can cause the development of mesothelioma?
Secondary to asbestos exposure; shipbuilding, mining, plumbing, manufacturing Germline mutations in BAP1, NF2 genes
83
What is the pathophysiology of mesothelioma?
Asbestos fibres inhaled deeply into the lung Penetrate the pleural space Provoke persistent inflammatory reaction with mesothelial cells Parietal pleura affected
84
What is the presentation of mesothelioma?
Pleural - progressive dyspnoea, chest wall pain Chronic cough, malaise, fever, chills, weight loss Peritoneal - abdo swelling, pain due to ascites, WL, fever, chills etc Pericardial - chest pain, cough, orthopnoea, dyspnoea
85
How can a mesothelioma be diagnosed?
CT scan Shows pleural thickening, effusion or pneumothorax Pleurocentesis - exudative pleural effusion, cytology Biopsy - thoracoscopy or laparoscopy shows mesothelioma cells and psammoma bodies (calcium) Immunohistochemistry markers
86
What is the management of mesothelioma?
Generally resistant to radio and chemo Surgical resection Symptomatic treatment Survival 8-14 months
87
What are the signs of mets?
Liver - abdo pain, nausea, early satiety Brain - behavioural changes, aphasia, neurological deficits, nausea, vomiting, seizures Bone - pain, pathological fractures
88
What are the differentials for lung cancer?
``` PE TB Pneumonia Histoplasmosis Sarcoidosis - inflammatory condition, non caveating granulomas in organs COPD Mesothelioma ```