lung cancer

Question 1

offer urgent chest xray

Answer 1

40 and over 2 or more
smoker and one or more unexplained

cough
fatigue
shortness of breath
chest pain
weight loss
appetite loss.

> 40 unexplained haemoptysis

Question 2

types of lung cacner

Answer 2

non small cell

1. adenocarcinoma - most common in non-smoker
   - peripheral
2. sqaumous
   - PTHrp
   - Hypertrophic pulmonary osteoarthropathy (HPOA)
   - finger clubbing
   - central
   - strongest association with smoking

• large cell
• carcinoid
  bronchoalveolar
• > small cell lung cancer
• neuroendocrine tumours
• aggressive
• smoking related

Question 3

staging

Answer 3

Tumour
T0 - no sign of cancer
T1 cancer within the lung <3cm
T2 3-5 cm
T3 >5-7 cm
T4 >7cm 

N0 - no lymph nodes involved.
N1 - ipsilateral bronchopulmonary or hilar nodes involved.
N2 - ipsilateral mediastinal or subcarinal nodes.
N3 - contralateral mediastinal, hilar, any supraclavicular nodes involved.

M0 - no metastases.
M1 - metastases present.
M1a - separate tumour nodule(s) in contralateral lobe or tumour with malignant pleural (or pericardial) effusion.
M1b - distant metastasis.

Question 4

Ix for lung cancer

Diagnositc tests

Answer 4

Bloods – FBC, U&E, Calcium, LFT’s, INR
• CXR
• Staging CT – CT Thorax and Upper Abdo

Continuous scan from lung apices to midabdomen (liver or adrenal mets common)
• Can be used to calculate TNM stage

Histology
<10mm PET

> 10mm biopsy, bronchoscopy
PET
EBUS

Question 5

RFs of lung cancer

Answer 5

• smoking - large no of smoking pack years
• increased age
• long term lung diseases ie COPD
• previous Hx of cancer
• exposure to radon gas
• FH of lung cancer
• cacner Mx for other cancers
• exposure to certain chemicals in the workplace
  Industrial dust diseases, asbestos, chromium, arsenic, iron oxides and radiation.

Question 6

symptoms and signs of lung cancer

Answer 6

unexplained cough lasting more than 3 weeks 
Dyspnoea.
Weight loss.
Chest pain.
Haemoptysis.
Bone pain.
Fever.
Weakness.
Dysphagia.
Headache.
Nausea and vomiting.
Hoarseness (recurrent laryngeal nerve involvement).
Wheezing and stridor

• Superior vena cava obstruction.
• horners
• Metastatic disease – liver, adrenals (Addison’s),
  bone, pleural, CNS
  • Paraneoplastic – clubbing, hypercalcaemia,
  anaemia, SIADH, Cushing’s syndrome, LambertEaton myasthenic syndrome, thromboembolic
  disease

Question 7

Mx of lung cancer NSCLC

Answer 7

surgical intervention - stage I/II disease - curative intent

radiotherapy - stage I/III who are not suitable for surgery NSCLC

chemotherapy - stage II/III NSCLC
Durvalumab

Question 8

follow up of lung cacner

Answer 8

within 6 weeks of completing Mx

Question 9

Mx of SCLC

Answer 9

early stage surgery

extensive stage disease - platinum based combination chemotherapy

Question 10

complications of lung cancer

Answer 10

LOCAL

• Recurrent laryngeal palsy, phrenic nerve palsy, Horner’s syndrome, Pancoast’s syndrome.
• Cardiovascular: superior vena cava obstruction, pericarditis, atrial fibrillation.
• Rib erosion.

METASTATIC

• Brain: confusion, fits, focal neurological deficit, cerebellar syndrome.
• Bone: bone pain, hypercalcaemia.
• Liver: hepatomegaly.
• Adrenal: Addison’s disease.

Question 11

epidemiology of lung cancer

Answer 11

biggest cause of cancer related death

• 5 year survival approx. 12%
• 85% of LC occurs in smokers or ex-smokers

Question 12

commonest sites of metastases

Answer 12

• Liver
• Adrenals
• Lung
• Lymph Nodes
• Pleural
• Brain
• Bone

Question 13

NSCLC prognosis 5 year survival

Answer 13

All NSCLC – 10-13%
• Stage 1 following surgical resection – 60-70%
• Stage 2 following surgical resection – 30-55%
• Stage 3 – 7%
• Stage 4 – 1%

Question 14

malignant pleural effusions diagnose by

Answer 14

- Diagnosed by
Ultrasound Guided
Aspirate:
• Exudate
• Cytology may be
positive, but likely to
need pleural biopsy
(Thoracoscopy)
• Indicates advanced
disease (M1)

Question 15

DDx of a solitary pulmonary nodule

options Mx

Answer 15

• Primary bronchial carcinoma
• Infection – consider Tuberculosis / fungal
• Non infectious granuloma – Granulomatosis with
Polyangiitis (Wegener’s)
• Rheumatoid nodule
• Bronchial carcinoid
• Hamartoma
• Metastasis

• Sequential CT surveillance over 24
months
• If patient fit, they may wish to have nodule
removed – lobectomy

Question 16

Lung cancer complications

Answer 16

cord compression
- Upper motor neurone signs, possibly back pain, urinary retention/constipation, sensory loss in
the saddle area
• Urgent MRI spine & discussion with
neurosurgeon and oncologist
• High dose steroids IV or PO dexamethasone
• Radiotherapy +/- surgical decompression
• Urinary catheterisation
• Delay = paraplegia, loss of bowel & urinary
function

hypercalcaemia - (2.1-2.6) >3mmol/l
confusion, weakness, nausea,
constipation, reduced fluid intake
Mx
IV fluids + Pamidronate

SVCO
• Oxygen
• Analgesia
• Sit patient upright – reduces venous pressure
• Urgent CT
• Consider steroids if histology already confirmed
• Options of urgent radiotherapy, intraluminal
stenting or chemotherapy

SIADH
• Low Sodium & urine osmolality >100 mosmol/kg
• Symptoms – Headache, lethargy, confusion,
seizures
• Fluid Restriction
• Consider Demeclocycline (causes DI)

Brain mets
- • Dexamethasone IV or PO 8-12mg/day in
morning/early afternoon – avoid in
evenings (side effect of insomnia, agitation)
• Urgent Radiotherapy

Question 17

Performance status

Answer 17

• 0 Normal - Fully active without restriction

• 1 Restricted in physically strenuous activity but
ambulatory and able to carry out light work e.g., light
house work, office work

• 2 Ambulatory and capable of all self-care but unable to
carry out any work activities. Up and about more than
50% of waking hours

• 3 Capable of only limited self-care, confined to bed or
chair more than 50% of waking hours

• 4 Completely disabled. Cannot self-care. Totally
confined to bed or chair

• 5 Dead