Lung cancer Flashcards by Praise Tokode

What are the 2 main categories of lung cancer?

Small cell lung cancer

Non small cell lung cancer

How well did you know this?

Not at all

Perfectly

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

Adenocarcinoma
Squamous cell carcinoma
Large cell

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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?

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.

How well did you know this?

Not at all

Perfectly

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?

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

How well did you know this?

Not at all

Perfectly

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

histopathology shows keratin.

How well did you know this?

Not at all

Perfectly

Which lung cells are associated with Large cell cancers?

undifferentiated neoplasms

How well did you know this?

Not at all

Perfectly

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

Early - Large cell

Late - Squamous cell

How well did you know this?

Not at all

Perfectly

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?

APUD cells, a neuroendocrine cell
occurs almost exclusively in smokers
extremely poor prognosis,

How well did you know this?

Not at all

Perfectly

Which type of cancer is the most aggressive?

Small cell lung cancer

How well did you know this?

Not at all

Perfectly

What are the signs and symptoms of lung cancer?

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

How well did you know this?

Not at all

Perfectly

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

Exudative pleural effusion

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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

What are they known to cause?

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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

What are Paraneoplastic syndromes?

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

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

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.

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

Bony metastasis

Tumour secretion of:

Parathyroid hormone-related protein (PTHrP)
Calcitriol

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

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

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

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

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

Cough
Fatigue
Shortness of breath
Chest pain
Weight loss
Appetite loss

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

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.

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

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

Which chest signs are associated with lung cancer?

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

Which Paraneoplastic syndromes are directly associated with small cell carcinoma?

``` 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

Which Paraneoplastic syndromes is directly associated with Squamous cell carcinoma?

Hypercalcaemia

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

CT of chest - includes upper abdomen to cover liver, adrenals and kidneys ``` Bronchoscopy • CT guided biopsy • PET scan • MRI scan for Pancoast tumours ```

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

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

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

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

What is treatment option 1 for those with lung cancer?

Surgical - Localised tumours - No signs of spread - Only cure - 70% 5 year survival

What is treatment option 2 for those with lung cancer

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)

List 2 complications of Radical Radiotherapy

post radiation pneumonitis | early) and fibrosis (late

What is treatment option 3 for those with lung cancer

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

What is treatment option 4 for those with lung cancer

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

What is treatment option 5 for those with lung cancer

Other Palliative Therapies – Endobronchial laser to relieve obstruction, breathlessness, haemoptysis – Stenting to relieve breathlessness – Endobronchial radiotherapy (brachytherapy) ``` General palliative treatments – Painkillers – Antitussives – Oxygen – Steroids ```

What is treatment option 6 for those with lung cancer

Involvement of cancer nurse specialist – Psychosocial support – Counselling DNAR and advance directives

What are the complications of lung cancer?

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