Lung Flashcards by Bekah Hanrey

What kind of lung cancer is most common?

Most lung cancers are from secondary mets, the mets can come from…

1) breast
2) colon
3) renal cell carcinoma

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What are the types of primary lung cancer?

Non small cell lung cancer (60-80%)

Small cell lung cancer (15-20%)

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What are the types of non small cell lung cancer?

Adenocarcinoma
Squamous
Large cell
Bronchial carcinoid

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If someone who is a non smoker and has lung cancer, what type of lung cancer do they likely have?

Non small cell- adenocarcinoma

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Lung cancer can metastasise quickly, where does ling cancer often metastasise to?

Mediastinum 
Hilar lymph nodes
Breast 
Liver 
Adrenal glands 
Brain 
bone

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What are the risk factors for lung cancer?

Family history 
Increasing age 
Being male 
Pre existing lung disease 
History of cancer
Occupational exposure- radon gas, asbestos 
HIV
Smoking

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What are the associations with adenocarcinoma non small cell lung cancer?

Hypertrophic osteoarthropathy
Hyperthyroid
Gynaecomastia

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What is the association with squamous cell carcinoma non small cell lung cancer?

It is associated with PTH related peptide
The release of PTH causes high levels of Ca2+ in the serum
Therefore patients with squamous cell carcinoma can present with signs of hypercalcaemia!

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What are the signs of hypercalcaemia?

Kidney stones
Abdo pain
Confusion
Constipation

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How might someone with squamous cell carcinoma present?

Signs of hypercalcaemia or hyperthyroidism (due to ectopic production of TSH)

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Small cell lung cancer is a neuroendocrine tumour, what can they secrete?

ADH to cause SIADH
ACTH to cause cushings
Antibodies to voltage gated Ca2+ channels which cause lambert eaton syndrome and weakness

These lung cancers develop fast, metastasise quickly and grow centrally

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Where do small cell lung cancers often metastasise to?

Brain/bone

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What symptoms do people with lung cancer present with?

Haemoptysis 
Dyspnoea 
Hoarseness 
Anorexia 
Persistent cough
Pleuritic pain 
Recurrent chest infections

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Why is it people with lung cancer get recurrent chest infections?

Obstruction of the bronchus due to a centrally located tumour

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What are the reasons that people with lung cancer get hoarseness/ voice changes?

This occurs if the tumour is located at the apex of the lung
Pancoast tumour- impinges on the recurrent laryngeal nerve which also gives signs of horners syndrome- miosis and ptosis

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What would patients with brain mets secondary to lung cancer present with?

Headache
N and V
Visual disturbance

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What are the signs of lung cancer?

Distended veins on neck and face
Swollen face and right arm

^SVCO obstruction

Neuro signs

Pallor

Supraclavicular lymphadenopathy

Cachexia

Plethoric complexion

Neuro signs

Clubbing

Dullness/ wheeze on auscultation

Pleural effusion- dullness to percussion

Pneumothorax- tracheal deviation, absent breath sounds

Pneumonia- consolidation,

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Specifically what lung cancer is associated with clubbing?

Non small cell lung cancer

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When should a patient with suspected lung cancer have a 2 week wait referall?

1) anyone with suspicious CXr findings
Or
2) >40 with haemoptysis

When should you get an urgent CXR for a patient?

If they are more than or equal to 40 and have 2 of the following features (or 1 if they are a smoker)...
. SOB 
. Fatigue 
. Persistent cough 
. Chest pain 
. Anorexia 
. Weight loss

Or if they are equal or more than 40 years old and have…
. persistent/ recurrent chest infections
. Finger clubbing
. Persistent supraclavicular/ cervical lymphadenopathy
. Chest signs consistent with lung cancer
. Thrombocytosis

What bloods should you request before referral for x ray?

FBC 
U and Es 
LFTs 
Bone profile 
CRP

Lung function tests should also be done before treatment

What would you see on a CXR of a patient with lung cancer?

Lung collapse
Mediastinal widening
mass
Hilar lymphadenopathy

What are the differentials for hilar lympgadenopathy?

TB 
Non hodgkins lymphoma 
Sarcoidosis 
Malignancy- more common in Hodgkin lymphoma than non Hodgkin  
Infection 
Heart failure

If malignancy is confirmed on CXR, what investigations are done next?

CT CAP for staging
Staging for non SCC is using the TNM staging while for SCC they are either classified as limited or extensive disease

PET- CT is done to look for mets and to show whether the patient is eligible for treatment

Histologically, how do you confirm the diagnosis of lung cancer?

If it is a peripheral tumour then trans thoracic needle biopsy can be used If it is a central tumour then endotrachial ultrasound can be used

When is a mediastinoscopy done in a patient with lung cancer?

This is done when the patient is suitable for surgery, a mediastinoscopy shows whether there is mediastinal lymph node involvement.

What is the management of lung cancer?

The management is guided by the cancer cell type, the stage, co-morbidities and patient status. Stop smoking!! Surgical options are used for non small cell- lobectomy, pneumonectomy, wedge resection (segment) Prophylactic cranioradiotherapy can sometimes be offered to prevent brain mets

What is the mainstay of treatment for small cell carcinoma?

Palliative chemo

What percentage of lung cancer cases in the UK are preventable?

79% 72% are caused by smoking 5% caused by ionising radiation 13% work exposure 8% air pollution

How do small cell lung cancers present?

Arise from endocrine cells As a result they secrete many poly peptides- ACTU Can also cause presentations like Addisons and cushing’s Small cell carcinoma spreads very early and is almost inoperable at presentation

What is the presentation of small cell lung cancer?

``` Cough Haemopytsis Dyspnoea Chest pain Weight loss Nausea and vomiting Anorexia ```

What investigations are done for lung cancer?

``` In order... CXR CT CAP Biopsy PET MRI head Spirometry Echo ```

What is limited stage small cell lung cancer?

When the tumour and nodes can be fit in a box that can be given radiotherapy.

What is the SCLC treatment?

If the tumour is less than 5cm= sugery If it is limited stage suitable for radiotherapy then give chemoradiotherapy and consider prophylactic cranial radiotherapy If extensive then give chemo followed by radiotherapy and also consider prophylactic cranial radiotherapy If it relapses then either palliative or secondary chemo

How does immunotherapy work?

Trys to turn the immune system on to recognise the tumour cell as a foreign body

What supportive care is given to patients with lung cancer?

Breathlessness- stent/radiotherapy Home O2 LOROS breathlessness service Medication- oramoprh, steroids Pain- analgesia, nerve blocks, radiotherapy Social- OT/PT/ dietician Psychosocial support- macmillan, support groups, psychONC, smoking cessation, financial support services.

What is the lung cancer associated with hypercalcaemia?

Squamous cell carcinoma (non small cell)

How do you manage SCLC if it is extensive disease?

Platinum based combination chemo

What do you offer people with limited stage disease SCLC (T1-4, N0, M0)?

Cisplatin based combination chemo Offer twice daily radiotherapy with concurrent chemoradiotherapy to people with limited stage disease SCLC and a who performanc pf 0 or 1

What is the management of NSCLC?

First-line: lobectomy Curative radiotherapy can also be offered to patients with stage I, II and III NSCLC. Chemotherapy should be offered to patients with stage III and IV NSCLC to control the disease and improve quality of life.

Does squamous cell carcinoma secrete parathyroid hormone?

No it secretes parathyroid hormone related peptide not PTH.

What is the difference between the location of non small cell and small cell lung cancers?

Squamous cell (non small cell)= usually in lobes Small cell= usually in bronchus

What paraneoplastic syndromes is small cell lung cancer associated with?

SIADH (euvolaemic hyponatraemia) | Cushings

What are the symptoms of a patient with SIADH?

N andV | Acutely confused

What is dermatomyositis?

New onset bilateral proximal muscle weakness which can often present before malignancy, lung cancer is one of the malignancies which is most highly associated with dermatomyositis.

What are the options on how you can obtain a sample in terms of lung cancer?

Endobronchial US transbronchial needle aspiration Bronchoscopy Contrast enhanced CT scan Sputum cytology

When is endobronchial ultrasound transbronchial needle aspiration done?

Most commonly, Endobronchial ultrasound-guided transbronchial needle aspiration is done to take samples from the central lymph glands in the centre of your chest (mediastinum) which may be enlarged for a variety of reasons. In 9 out of 10 cases, we would expect this test to give a helpful answer to the problem. Very occasionally, another test may be needed.