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Y3 Medicine: Respiratory > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

How common is lung cancer?

A

Lung cancer is the third most common cancer in the UK behind breast and prostate

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2
Q

What are the 2 different histological types of lung cancer?

A

Clinically the most important division is between small cell (sclc) (20%) and non-small cell (nsclc) (80%).

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3
Q

What are the 3 different types of non-small cell lung cancer?

A

Non-small cell lung cancer:

  • Adenocarcinoma (around 40%)
  • Squamous cell carcinoma (around 30%)
  • Large-cell carcinoma (around 10%)
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4
Q

What are small cell lung cancers?

A

Arise from endocrine cells (Kulchitsky cells), often secreting polypeptide hormones resulting in paraneoplastic syndromes (eg production of acth, Cushing’s syndrome).

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5
Q

What are the risk factors for lung cancer?

A

Includes cigarette smoking; exposure to tobacco smoke, radon gas, or asbestos; and the presence of COPD.

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6
Q

What are the signs of lung cancer?

A
  • Cachexia
  • Anaemia
  • Clubbing
  • Hpoa (hypertrophic pulmonary osteoarthropathy, causing wrist pain);
  • Supraclavicular or axillary nodes
  • Chest signs: none, or consolidation; collapse; pleural effusion
  • Metastases: bone tenderness; hepatomegaly; confusion; fits; focal cns signs; cerebellar syndrome; proximal myopathy and peripheral neuropathy
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7
Q

What are the symptoms of lung cancer?

A
  • Cough (80%)
  • Haemoptysis (70%)
  • Dyspnoea (60%)
  • Chest pain (40%)
  • Recurrent or slowly resolving pneumonia
  • Lethargy
  • Anorexia
  • Weight loss
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8
Q

What investigations should be ordered for lung cancer?

A
  • CXR
  • Contrast enhanced CT scan
  • PET-CT
  • Bronchoscopy with endobronchial ultrasound (EBUS)
  • Biopsy
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9
Q

Why investigate using CXR?

A

A standard posteroanterior (PA) chest x-ray is the first line investigation in suspected lung cancer.

Findings suggesting cancer include:

  • Hilar enlargement
  • “Peripheral opacity”- a visible lesion in the lung field
  • Pleural effusion- usually unilateral in cancer
  • Collapse
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10
Q

Why investigate using contrast enhanced CT?

A

A contrast-enhanced CT of the lower neck, chest, and upper abdomen is standard and helps to define the primary tumour and evaluate for regional spread.

Shows size, location and extent of primary tumour; evaluates for hilar and/or mediastinal lymphadenopathy and distant metastases.

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11
Q

Why investigate using PET-CT?

A

PET-CT (positron emission tomography) scans involve injecting a radioactive tracer (usually attached to glucose molecules) and taking images using a combination of a CT scanner and a gamma ray detector to visualise how metabolically active various tissues are. They are useful in identifying areas that the cancer has spread to by showing areas of increased metabolic activity suggestive of cancer.

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12
Q

Why investigate using bronchoscopy?

A

Bronchoscopy, typically performed with a flexible bronchoscope, is an endoscopic procedure in which the proximal bronchial tree can be directly visualised and suspicious areas biopsied.

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13
Q

Why investigate using bronchoscopy?

A

Pathological confirmation of malignancy is the only widely accepted method to make a definitive diagnosis of lung cancer. Tissue is sampled from bronchoscopy where possible

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14
Q

Briefly describe the staging of lung cancer

A

The TNM staging classification is first used, and then converted to the I-IV staging system which is used to guide management decisions.

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15
Q

Briefly describe the treatment of NSCLC

Note: stage I-III

A

Surgical management

  • Options include lobectomy/pneumonectomy in patients with intact lung function, or wedge resection in patients with reduced lung function (e.g. elderly, underlying respiratory conditions)

Medical management

  • Pre-operative chemotherapy
  • Post-operative chemotherapy and radiotherapy: may not be needed in some cases of stage I lung cancer

If unsuitable for surgery (e.g. too frail), patients may be offered stereotactic ablative radiotherapy (SABR). Compared to conventional radiotherapy, SABR involves directing a more intense and focused beam of radiation at the tumour. This reduces the number of radiotherapy sessions needed and minimises damage to surrounding tissue.

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16
Q

Briefly describe the treatment of NSCLC

Note: stage IV

A

Targeted therapy

  • These drugs target mutations which drive the pathogenesis of lung cancer .

Immunotherapy

  • These drugs target immune checkpoints, which prevent the patient’s immune cells from killing tumour cells. For example, the immune checkpoint PD-L1 is targeted by pembrolizumab. Immunotherapy is an emerging field in cancer management.

Chemotherapy

  • Especially important for patients who do not have any mutations which can be targeted by targeted therapies.

Palliative care

  • Includes palliative radiotherapy, for metastases and symptom control.
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17
Q

Briefly describe the treatment of SCLC

A

Chemotherapy and radiotherapy.

Surgery: rare in small cell lung cancer, as most patients present with advanced disease.

Prophylactic cranial irradiation: since small cell lung cancer is associated with a high risk of brain metastases, radiotherapy is directed at the brain to prevent brain metastases.

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18
Q

Give examples of drugs used in targeted therapy for NSCLC

A

Gefitinib and osimertinib→ EGR mutation

Alectinib→ ALK mutation

Crizotinib→ ROS1 mutation

19
Q

What is the role of endocronchial treatment with stents or debulking?

A

Endobronchial treatment with stents or debulking can be used as part of palliative treatment to relieve bronchial obstruction caused by lung cancer.

20
Q

What is the role of surgery in lung cancer?

A

Surgery is offered first line in non-small cell lung cancer to patients that have disease isolated to a single area with intention to cure the cancer.

Lobectomy (removing the lung lobe containing the tumour) is first line. Segmentectomy or wedge resection (taking a segment or wedge of lung to remove the tumour) is also an option.

21
Q

Who is involved in the MDT meeting of lung cancer?

A

All treatments are discussed at an MDT meeting involving various consultants and specialists, such as pathologists, surgeons, oncologists and radiologists. This is to make a joint decision about what is the most suitable options for the individual patient.

22
Q

What are the complications of lung cancer?

A
  • Horner’s Syndrome
  • Post-obstructive pneumonia or hypoxia
  • Superior vena cava syndrome
  • Paraneoplastic syndromes
23
Q

What differentials should be considered for lung cancer?

A
  1. TB
  2. Metastasis to the lungs from other sites
  3. Sarcoidosis
24
Q

How does lung cancer and TB differ?

A

Differentiating signs and symptoms:

  • Drenching night sweats

Differentiating investigations:

  • Positive sputum culture and microscopy
  • Chest X-ray: cavitating lesion/hilar lymphadenopathy
25
Q

How does lung cancer and metastasis to the lungs from other sites differ?

A

Differentiating signs and symptoms:

  • Symptoms relevant to the primary tumour (e.g. haematuria due to renal cell carcinoma)

Differentiating investigations:

  • CT head-abdomen-pelvis: shows primary tumour
  • FDG-PET: increased uptake at the primary tumour site
26
Q

How does lung cancer and sarcoidosis differ?

A

Differentiating signs and symptoms:

  • Enlarged parotids
  • kin signs: erythema nodosum and lupus pernio

Differentiating investigations:

  • Tissue biopsy: non-caseating granulomas
27
Q

What are the criteria for a 2 week wait referrel for lung cancer?

A

The NICE criteria for a 2-week wait referral for lung cancer are:

  • Chest X-ray findings suggestive of lung cancer, or
  • Over 40 years old and unexplained haemoptysis

Other patients may just need an urgent chest x-ray (within 2 weeks) before a decision to refer on a 2-week wait is made. These patients must be over 40 years old, and have two of the following unexplained symptoms (one if they have ever smoked):

  • Cough
  • Weight loss
  • Appetite loss
  • Dyspnoea
  • Chest pain
  • Fatigue
28
Q

What is shown in the CXR?

A

Chest x-ray showing lung cancer in the right upper zone .

29
Q

What are the complications of chemotherapy and radiotherapy?

A

Due to chemotherapy: alopecia, neutropaenia, bone marrow toxicity.

Due to radiotherapy: mucositis, pneumonitis, oesophagitis.

30
Q

What is smoking pack years? How is it calculated?

A

1 pack-year = smoking 20 cigarettes a day for a year

31
Q

Give examples of extrapulmonary manifestations of lung cancer

A
  • Recurrent laryngeal nerve palsy
  • Phrenic nerve palsy
  • Superior vena cava obstruction
  • Horner’s syndrome
  • Syndrome of inappropriate ADH (SIADH)
  • Cushing’s syndrome
  • Hypercalcaemia
  • Limbic encephalitis
  • Lambert-Eaton myasthenic syndrome
32
Q

Why is recurrent laryngeal nerve palsy a extrapulmonary manifestation of lung cancer?

A

Recurrent laryngeal nerve palsy presents with a hoarse voice. It is caused by the cancer pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.

33
Q

Why is phrenic nerve palsy a extrapulmonary manifestation of lung cancer?

A

Phrenic nerve palsy due to nerve compression causes diaphragm weakness and presents as shortness of breath.

34
Q

Why is supervior vena cava obstruction a extrapulmonary manifestation of lung cancer?

A

Superior vena cava obstruction is a complication of lung cancer. It is caused by direct compression of the tumour on the superior vena cava. It presents with facial swelling, difficulty breathing and distended veins in the neck and upper chest. “Pemberton’s sign” is where raising the hands over the head causes facial congestion and cyanosis. This is a medical emergency.

35
Q

Why is Horner’s syndrome a extrapulmonary manifestation of lung cancer?

A

Horner’s syndrome is a triad of partial ptosis, anhidrosis and miosis. It is caused by a Pancoast’s tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion.

36
Q

Why is syndrome of inappropriate ADH (SIADH) a extrapulmonary manifestation of lung cancer?

A

Syndrome of inappropriate ADH (SIADH) caused by ectopic ADH secretion by a small cell lung cancer and presents with hyponatraemia.

37
Q

Why is Cushing’s syndrome a extrapulmonary manifestation of lung cancer?

A

Cushing’s syndrome can be caused by ectopic ACTH secretion by a small cell lung cancer.

38
Q

Why is hypercalcaemia a extrapulmonary manifestation of lung cancer?

A

Hypercalcaemia caused by ectopic parathyroid hormone from a squamous cell carcinoma.

39
Q

Why is limb encephalitis a extrapulmonary manifestation of lung cancer?

A

Limbic encephalitis is a paraneoplastic syndrome where the small cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas. This causes symptoms such as short term memory impairment, hallucinations, confusion and seizures. It is associated with anti-Hu antibodies.

40
Q

What is Lambert-Eaton myasthenic syndrome?

A

Lambert-Eaton myasthenic syndrome is a result of antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones.

41
Q

How does Lambert-Eaton myasthenic syndrome present?

A

Weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia. Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.

Patients with Lambert-Eaton have reduced tendon reflexes. A notable finding is that these reflexes become temporarily normal for a short period following a period of strong muscle contraction. For example, the patient can maximally contract the quadriceps muscle for a period, then have their reflexes tested immediately afterwards, and display an improvement in the response. This is called post-tetanic potentiation.

42
Q

What is mesothelioma? What is it linked to? And what is its prognosis?

A

Mesothelioma is a lung malignancy affecting the mesothelial cells of the pleura. It is strongly linked to asbestos inhalation. There is a huge latent period between exposure to asbestos and the development of mesothelioma of up to 45 years. The prognosis is very poor. Chemotherapy can improve survival but it is essentially palliative.

43
Q

What is shown in the image?

A

Horner’s syndrome.

44
Q

What is shown in the image?

A

Superior vena cava obstruction (before treatment). After treatment there is resolution of the facial swelling.

Y3 Medicine: Respiratory (15 decks)

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