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CR3 > Lung cancer > Flashcards

Lung cancer Flashcards

1
Q

What are the 2 main categories of lung cancer?

A

Small cell lung cancer

Non small cell lung cancer

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2
Q

What are the different types of Non small cell lung cancer?

A

Adenocarcinoma
Squamous cell carcinoma
Large cell

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3
Q

What are the 2 main risk factors for lung cancer and which type of lung cancer do they cause?

List 6 other causes of lung cancer

A

Smoking - risk factor in all types. Risk is still twice as much in a non smoker even after 30 years of stopping

Asbestos - mainly associated with mesothelioma but also adenocarcinoma of the lungs

Radiation (environmental radon)
Arsenic
Chromium
Coal tar and oils
Iron oxides
Recent study: pollution
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4
Q

Which lung cells are associated with adenocarcinomas? How does it relate to the 2 main risk factors and where in the lungs does it usually manifest?

A

Cancer of the mucus-secreting cells

appears proportionally more in non-smokers than squamous cell carcinoma

Smoking and asbestos exposure are both risk factors.

tends to occur in lung peripheries.

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5
Q

Which lung cells are associated with Squamous cell cancers? How does it relate to the 2 main risk factors and where in the lungs does it usually manifest?

A

Cancer of squamous cells

Occurs in central parts of lungs

often presents with pneumonia secondary to an obstructed bronchus.

Smoking is the most common cause

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6
Q

What is a significant feature of the histopathology for Squamous cell cancer?

A

histopathology shows keratin.

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7
Q

Which lung cells are associated with Large cell cancers?

A
  • undifferentiated neoplasms
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8
Q

Which type of Non-small cell lung cancer metastasis early and which metastasis late?

A

Early - Large cell

Late - Squamous cell

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9
Q

Which lung cells are associated with Small cell lung cancer? How does it relate to the 2 main risk factors and where in the lungs does it usually manifest?

A
  • APUD cells, a neuroendocrine cell
  • occurs almost exclusively in smokers
  • extremely poor prognosis,
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10
Q

Which type of cancer is the most aggressive?

A

Small cell lung cancer

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11
Q

What are the signs and symptoms of lung cancer?

A

frequently asymptomatic

Symptoms- 
Fever
Malaise
Nausea
Cough
Haemoptysis 
Hoarseness
Weight loss
Signs- 
 Lymphadenopathy 
Stridor
Wheeze
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA)
Signs of pleural effusion

features of superior vena cava obstruction (SVCO) or a paraneoplastic syndrome

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12
Q

Which type of pleural effusion is associated with lung cancer? What are the symptoms of pleural effusion?

A

Exudative pleural effusion

  • Dull (‘stony dull’) percussion
  • Reduced vocal fremitus
  • Reduced breath sounds
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13
Q

When a tumour causes compression of the superior vena cava. which symptoms present?

A

engorgement of vessels in the neck and face, shortness of breath and a ‘fullness’ of the head.
Symptoms exacerbated by bending forwards / lying down
Cough
Dysphagia
Upper limb oedema

Cyanosis
Cognitive dysfunction
Coma

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14
Q

What is a pancoast tumour? What can there location effect?

What are they known to cause?

A

What is it -
tumour of the pulmonary apex.

Location can affect-

  • Brachial plexus
  • Cervical sympathetic trunk and Stellate ganglion
  • Subclavian vein

Pancoast tumours are known to cause

  • Horner’s syndrome
  • Pain in the shoulder that radiates into the arm and hand
  • Atrophy of muscles of the upper limb
  • Oedema of the upper limb
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15
Q

Where can lung cancer metastasis to and what are the results of the metastasis?

A
  • Bone: bone pain, raised ALP
  • Brain: focal and non-focal neurology
  • Liver: abnormal LFTs
  • Adrenal glands: though a common site of metastasis, normally asymptomatic
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16
Q

What are Paraneoplastic syndromes?

A

Refers to remote effects of tumours unrelated to mass effect, invasion or metastasis.

17
Q

Describe the features associated with What are Paraneoplastic syndromes? (5)

A 
Hypercalcaemia - 
Stones, bones, groans thrones, and psychiatric moans.
- Renal calculi 
- Bone pain
- Abdominal pain
- Polyuria 
- Signs of altered mental status

SIADH (syndrome of inappropriate anti-diuretic hormone)

  • seen in 10% of small cell lung cancer
  • symptoms are those of hyponatraemia and in extreme cases, cerebral oedema

Cushing’s syndrome -

  • caused by exposure to high levels of glucocorticoids
  • Rarely lung cancers produce ectopic ACTH driving an increase in glucocorticoids.

Lambert-Eaton syndrome

  • caused by antibodies to voltage-gated calcium channels
  • Seen in 1-3% of small cell lung cancer
  • causes proximal and ocular muscle weakness.

Hypertrophic osteoarthropathy

  • characterised by clubbing and periostitis
  • symmetrical, painful arthropathy affecting the distal joints.
18
Q

Hypercalcemia can be caused in 2 ways in lung cancer, what are they?

A

Bony metastasis

Tumour secretion of:

  • Parathyroid hormone-related protein (PTHrP)
  • Calcitriol
19
Q

When should a patient be put on the two-week wait referral for malignancy? - before and after chest X ray

A

Before chest X ray -

  • Unexplained haemoptysis and aged over 40 smokers/ ex smoker
  • SVCO
  • stridor
    Last2 should be emergency referal

After X ray

  • Suggestive CXR of CT findings suggesting lung cancer
  • pleural effusion
  • Slowly resolving consolidation

Normal chest X ray but high clinical suspicion of lung cancer

20
Q

When should an urgent x ray (within 2 weeks) in those over 40 be considered? (12)

A

Haemoptysis

Any of the following for > 3 weeks unexplained

  • Persistent or recurrent chest infection
  • Clubbing
  • Supraclavicular lymphadenopathy or
  • persistent cervical lymphadenopathy
  • Chest signs indicative of lung cancer
  • Thrombocytosis
  • dyspnoea
  • chest/shoulder pain
  • weight loss
  • hoarseness
  • Features of metastasis
21
Q

When should you consider urgent CXR (within 2 weeks) in those aged over 40 with two of the following or have ever smoked and have one of the following

A
  • Cough
  • Fatigue
  • Shortness of breath
  • Chest pain
  • Weight loss
  • Appetite loss
22
Q

What are the bedside, blood, imaging and special test investigations are required in someone suspected of having lung cancer?

A

Bedside-

  • Observations
  • Blood pressure
  • Lung function tests

Blood

  • FBC
  • U&Es
  • LFTs

Imaging

  • CXR
  • CT scan
  • PET-CT
  • Bronchoscopy

Special tests -

Tissue biopsy - obtained using - Obtained from the tumour, lymph node or metastasis

Cytology

  • From aspirates, washings, pleural fluids.
  • Obtained from the tumour, lymph node or metastasis.
23
Q

What are the different methods which can be used to obtain a tissue biopsy for lung cancer?

A

bronchoscopy, image-guided biopsy, video-assisted thoracoscopic surgery (VATS) and/or mediastinoscopy.

24
Q

Which chest signs are associated with lung cancer?

A
  • Visible swelling
  • Facial swelling
  • Distended veins
  • Reduced expansion
  • Dullness, ↓TVF and VR
  • Wheeze – esp. unilateral
    Reduced breath sounds
25
Q

Which Paraneoplastic syndromes are directly associated with small cell carcinoma?

A 
Cushing’s syndrome (ectopic ACTH)
–
 SIADH
–
 Lambert Eaton myasthenic syndrome
–
Autoimmune Limbic encephalitis - inflammation of  the limbic system in the brain due to the cancer (e.g. short term memory loss, seizures,  psychiatric symptoms)
–
 Cerebellar syndrome - cerebellar defecits  (ataxia (issues with co-ordination, balance walking, soeech), nystagmus, dysmetria, dysarthria, vertigo, and diplopia)

Anny but more common in this type of cancer

  • Dermatomyositis - proximal muscle weakness and a typical cutaneous rash
26
Q

Which Paraneoplastic syndromes is directly associated with Squamous cell carcinoma?

A

Hypercalcaemia

27
Q

What are the main investigations used to help with the staging of lung cancer?

A

CT of chest -
includes upper
abdomen to cover liver, adrenals and kidneys

 Bronchoscopy
•
 CT guided biopsy
•
 PET scan
•
 MRI scan for Pancoast tumours
28
Q

What are the extra investigations used to help with the staging of lung cancer?

A 
Transbronchial “blind” FNA
•
 EBUS guided FNA
•
 EUS guided FNA
•
 Mediastinoscopy
•
 Bone scan
•
 Brain CT/MRI
29
Q

What are the main features of the TNM staging for lung cancer?

A

T – based on size and location of tumour.
– T1 is a small peripheral tumour which may be removed
surgically (Stage 1 or 2)
– T4 is an advanced large tumour invading e.g. heart (Stage 3)

N – depends on which lymph nodes are involved
– N1 – hilar (Stage 2), N2 – mediastinal, N3 – contralateral

(Stage 3)
M – if metastases are present: M1 (Stage 4)
– Common sites: liver, lungs, adrenals, brain, bones

30
Q

What is treatment option 1 for those with lung cancer?

A

Surgical

  • Localised tumours
  • No signs of spread
  • Only cure
  • 70% 5 year survival
31
Q

What is treatment option 2 for those with lung cancer

A

Radical Radiotherapy (RT)
- May be useful in squamous cell carcinoma where
surgery not possible

  • Palliative Radiotherapy
    To relieve pain, haemoptysis, neurological
    problems (brain or spinal metastases)
32
Q

List 2 complications of Radical Radiotherapy

A

post radiation pneumonitis

early) and fibrosis (late

33
Q

What is treatment option 3 for those with lung cancer

A

Chemotherapy - small survival advantage

Chemotherapy for non small cell cancer

  • Cisplatin, , gemcitabine
  • Oral therapy: EGFR- TK positive tumours = EGFR antagonists like gefitinib, erlotinib

EGFR- T790M positive = Osimertinib

ALK (anaplastic lymphoma kinase mutation) positive = ceritinib, alectinib, Crizotinib

If disease progresses after target therapy of ir there is no gene mutation offer - Pemextred + cisplatin or Pemextred + carbplatin (platinum double chemotherapy)

If disease continues to progress -

New agents - Atezolizumab, durvalumab

Docetaxel

Immunotherapy - pembrolizumab (for PD-L1 positive tumours)

Squamous cell cancer treatments-
PDL1 at 50% or above =

Pembrolizumab
If progresses - offer gemcitabine or vinorelbine and cisplatin or carboplatin chemotherapy
If progresses -
docetaxel monotherapy

PDL1 below 50%
offer gemcitabine or vinorelbine and cisplatin or carboplatin

If progresses -
atezolizumab, nivolumab and pembrolizumab, or offer docetaxel monotherapy

Small cell cancer chemotherapy -

Limited stage disease - cisplatin + radiotherapy

Extensive disease
platinum-based combination chemotherapy

34
Q

What is treatment option 4 for those with lung cancer

A

Adjuvant chemotherapy
- Chemotherapy given after surgery to try to reduce
chance of recurrence – usually if disease is found
in a hilar lymph node

Neo-adjuvant chemotherapy
Chemotherapy given before surgery to try to make
sure that the cancer is as well controlled as
possible

35
Q

What is treatment option 5 for those with lung cancer

A

Other Palliative Therapies
– Endobronchial laser to relieve obstruction,
breathlessness, haemoptysis
– Stenting to relieve breathlessness
– Endobronchial radiotherapy (brachytherapy)

General palliative treatments
–
 Painkillers
–
 Antitussives
–
 Oxygen
–
 Steroids
36
Q

What is treatment option 6 for those with lung cancer

A

Involvement of cancer nurse specialist
– Psychosocial support
– Counselling

DNAR and advance directives

37
Q

What are the complications of lung cancer?

A 
Recurrent laryngeal nerve palsy - Hoarseness.
Noisy breathing
Phrenic nerve palsy
SVC obstruction
Horner’s syndrome (Pancoast’s tumour)
 rib erosion
pericarditis
Atrial fibrillation

CR3 (10 decks)

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