Lung

Question 1

Epidemiology of lung cancer

Answer 1

3rd most common cancer
Most common cause of cancer death
More common in men and over 75s

Question 2

Risk factors for lung cancer

Answer 2

Smoking
Lung disease - TB, COPD
Radiotherapy
Pulmonary fibrosis
HIV
FHx
Radon gas
Asbestos - mesothelioma

Question 3

Types of lung cancer

Answer 3

Small cell - 20%
- develop from APUD cells - produce hormones
- central, grow quick and metastases early
Non-small cell
- adenocarcinoma - 32% - arises from gland linging lungs - common in women and non-smokers
- squamous cell carcinomas - arises from flat cells of airways - 35% - central and metastasise later
- large cell - 10% - undifferentiated
- bronchoalveolar carcinoma - 1-2% - non invasive initially
Mesothelioma

Question 4

Presentation of lung cancer

Answer 4

Symptoms
- persistent cough
- SOB
- haemoptysis
- recurrent chest infections
- pain - tumour invades chest wall
Signs
- weight loss/cachexia
- clubbing - NSCLC
- effusion, lobe collapse, consolidation
- monophonic wheeze

Question 5

Ix of lung cancer

Answer 5

Bloods
- FBC, U+Es, LFTs, bone profile, CRP - baseline and signs of mets
Tumour markers
- CEA
Sputum cytology - malignant cells
CXR
- mass
- mediastinal widening
- hilar lymphadenopathy
- lobe collapse
CT
- extent of tumour and metastasis
- PET CT - light up area of metastasis
Biopsy
- bronchoscopy
- VATS - video assisted thoracoscopy surgery
- CT guided biopsy

Question 6

Mx of lung cancer

Answer 6

Surgery 
- NSCLC
- removal of affected lobe/lung
Radiotherapy
- SC + NSCLC
- prophylactic cranial if limited disease and good response after primary tx
Chemo
- SC
- adjuvant in NSCLC
- locally advanced and metastatic
Biological
- metastatic NSCLC

Question 7

NICE urgent CXR criteria

Answer 7

Age over 40 and 2 of the following or smoked and one of the following
- cough
- fatigue
- SOB
- chest pain
- anorexia
- weight loss
Age over 40 and any of the following
- persistent/recurrent chest infection
- finger clubbing
- persistent supraclavicular/cervical lymphadenopathy
- chest signs consistent with lung cancer
- thrombocytosis

Question 8

Staging of small cell lung cancer

Answer 8

Limited disease - within tolerable radiation field

Extensive disease - distant metastases

Question 9

Staging of NSCLC

Answer 9

1 - cancer is small (3-5cm) and not spread to lymph nodes
2 - tumour spread to nearby lymph nodes
3a - cancer extends to surrounding tissues and structures
- lining of lung and chest wall
- has spread to ipsilateral lymph nodes
3b - > 2 tumours present
- spread to contralateral lung and lymph nodes
4 - metastatic spread to other parts of body
- bone, brain, liver and adrenal gland

Question 10

TNM staging of lung cancer

Answer 10

T
1 < 3cm
2 3-7cm
3 > 7cm
4 - invasion of other organs/structures
N
0 = none
1 = ipsilateral
2 = ipsilateral mediastinal
3 = contralateral 
M
0 = none
1 = present

Question 11

Common sites of lung metastases

Answer 11

Liver
Adrenals
Lung
Lymph nodes
Pleural
Brain
Bone

Question 12

Mx of hypercalcaemia

Answer 12

IV normal saline

Bisphosphonates - IV Pamidronate

Question 13

Symptoms of hypercalcaemia

Answer 13

> 3 mmol/l usually symptomatic
Confusion
Weakness
Nausea
Constipation
Reduced fluid intake

Question 14

Define pneumonitis

Answer 14

Inflammation of lung tissue

Question 15

Causes of pneumonitis

Answer 15

Recurrent lung infections
Chemotherapy
Radiation treatments
Exposure to feathers or bird excrement

Question 16

Mx of pneumonitis

Answer 16

Reduced exposure
Corticosteroids
Oxygen therapy

Question 17

Symptoms of pneumontitis

Answer 17

SOB
Cough
Fatigue
Loss of appetite
Unintentional weight loss

Question 18

Features of recurrent laryngeal nerve palsy

Answer 18

Hoarse voice

Caused by cancer pressing on of affecting recurrent laryngeal nerve as it passes through the mediastinum

Question 19

Features of phrenic nerve palsy

Answer 19

Presents as SOB

Due to nerve compression causing diaphragm weakness

Question 20

Features of SVCO

Answer 20

Caused by direct compression on tumour on superior vena cava

Presents with facial swelling, difficulty breathing and distended veins over neck and upper chestf

Question 21

Features of horners syndrome

Answer 21

Partial ptosis, anhidrosis and miosis

Caused by Pancoast’s tumour (pulmonary apex) pressing on sympathetic ganglion

Question 22

Features of SIADH

Answer 22

Syndrome of inappropriate ADH
Caused by ectopic ADH secretion by SCLC
Presents with hyponatraemia

Question 23

Features of Cushing’s syndrome

Answer 23

Caused by ectopic ACTH secreted by small cell lung cancer
Presents as increased abdo fat with skinny arms/legs, buffalo hump, easy bruising, purple stretch marks, low libido and depression

Question 24

Define limbic encephalitis

Answer 24

SCLC causes immune system to make antibodies to tissues in the brain
- limbic system -> inflammation
A/w anti-Hu antibodies

Question 25

Features of limbic encephalitis

Answer 25

Causes short term memory impairment, hallucinations, confusion and seizures

Question 26

Define Lamber-Eaton Myasthenic syndrome

Answer 26

Result of antibodies produced against SCLC

Also target voltage-gated Na channels in presynaptic terminals of motor neurons

Question 27

Features of Lambert-Eaton Myasthenic syndrome

Answer 27

Weakness of proximal muscles
Diplopia (double vision)
Ptosis
Slurred speech
Dysphagia
Reduced tendon reflexes

Question 28

Define mesothelioma

Answer 28

Lung malignancy affecting mesothelial cells of pleura
Strongly a/w asbestos inhalation
- latent period of up to 45 years

Question 29

Mx of mesothelioma

Answer 29

Prognosis very poor

Palliative chemotherapy - improves survival

Question 30

Mx of lung cancer

Answer 30

Small cell
- chemoradiotherapy
- prophylactic cranial radiotherapy
NSCLC
- stage 1+2 - surgical resection/radical radiotherapy
- stage 2/3 - adjuvant chemo
- stage 3 - concurrent chemo/RT, RT alone, palliative
- metastatic - chemo, targeted, immunotherapy
- EGFR tyrosine kinase inhibitors - gefitinib
- monoclonal antibody - pembrolizumab