Lung Cancer Flashcards
What is the first line investigation for suspected lung cancer
CXR
List the investigation carried out to diganose lung cancer
CXR - first line
CT chest, abdo, pelvis - for staging and checks for node involvement and mets
PET scan - good at identifying mets
Bronchoscopy - can take biopsy at ime this t
How do you tell if a CXR has appropriate inspiration
Should show at least the 10th or 11th posterior rib
How much of the chest should the heart take up on CXR
Less than 50% of the total diameter of the chest
What is the most common lung cancer
Adenocarcinoma
Followed by squamous cell
Which is more common small cell or non-small cell lung cancer
Non-small cell
Makes up 85% of lung cancer cases
Which lung cancers are associated with smokers
Adenocarcinoma - smoking and asbestos are risk factors
Squamous cell - smoking is main cause
Small cell - almost exclusively smokers
Which lung cancers tend to metastasise early
Small cell - poor prognosis as aggressive
Large cell
Which lung cancers tend to metastasise early
Small cell - poor prognosis as aggressive
Large cell
Squamous cell cancers tend to develop in which part of the lung
Central areas
What is the main treatment for small cell lung cancer
Chemotherapy with platinum-based drugs usually forms the mainstay of treatment
Surgery is usually not an option
Surgery is a treatment option in which lung cancer patients
Stage I or Stage II disease
Dependent on performance status, prognosis + likelihood of
success.
Can be used alongside chemo
Which type of immunotherapy is used in lung cancer
Immune checkpoint inhibitors
When these checkpoints are turned on they signal T cells to not mount an immune
response.
Checkpoint inhibitor immunotherapy works by blocking the binding of checkpoints to their partner proteins, thus preventing the ‘turning off’ of T cells.
This aids the immune system in mounting an immune response against the cancer
Immunotherapy can cause what side effects
Fatigue Nausea & vomiting Rash Diarrhoea Shortness of breath
Although typically better tolerated than traditional chemo
Which paraneoplastic syndrome is associated with squamous cell carcinoma of the lung
Ectopic parathyroid related peptide production
This acts like parathyroid hormone and leads to hypercalcaemia
What are the symptoms of hypercalcaemia
Stones, bones, abdominal moans
and psychic groans
Renal stones, and also diabetes insipidus.
Bone problems e.g. osteoporosis and pathological fractures.
Abdominal moans meaning abdominal pain, constipation,
nausea and vomiting.
Psychic groans referring to depression, anxiety, irritability
and psychosis.
Hypercalcaemia of malignancy can be caused by which cancers
Squamous cell lung cancer
Bone mets - common with lung, breast and prostate
How do you treat hypercalcaemia in malignancy
If severe or symptomatic, the patient can be admitted to hospital
and treated with IV fluids and IV bisphosphonate therapy.
If mild and asymptomatic the blood tests can just be monitored.
Which paraneoplastic syndromes are associated with small cell lung cancer
Lambert-Eaton Syndrome Cushing's Syndrome Syndrome of inappropriate ADH secretion Cerebellar ataxia Limbic encephalitis Dermatological
What are the unmodifiable risk factors for lung cancer
Age
Genetics - risk increases if 1st degree relative had it
List some modifiable risk factors for lung cancer
Smoking - mainly small cell and squamous Occupational exposure Air pollution Ionising radiation exposure Poor diet
List some of the intrathoracic symptoms of lung cancer
Cough Dyspnoea Chest pain Haemoptysis Chest infection Hoarseness Pleural effusion Superior Vena Cava Obstruction Pancoast tumour/syndrome
List the common sites of mets from lung cancer and their symptoms
Liver - can cause pain if capsule stretched
Bone - lytic lesions, pain, can cord compression
Adrenal - asymptomatic
Brain - mass symptoms (ICP)
List some of the paraneoplastic syndromes associated with lung cancer
Hypercalcaemia SIADH secretion Neurologic manifestations Haematological manifestations Hypertrophic osteoarthropathy Dermatomyositis, polymyositis Cushing’s syndrom
What surgical treatments are available for lung cancer
Wedge resection
Segmentectomy
Lobectomy
Pneumonectomy
Can also do hilar and mediastinal node sampling
Palliative procedures such as stenting and debulking
What is the prupose of adjuvatn chemo and radiotherapy following lung surgery
Chemo = improves survival Radio = prevents local recurrence
What is the best option for cure in lung cancer
Surgery - treatment of choice if curative
Radiotherapy is the next best
How is radiotherapy used palliatively in lung cancer
Used to treat bony mets and cord compression
Palliative radiotherapy is at a lower dose and fewer fractions
What is the typical dose for conventional external beam radiotherapy for lung cancer
55 Gray in 20 fractions
What prophylactic treatment is used in small cell lung cancer
Prophylactic cranial irradiation due to high risk of brain mets
20% have them at diagnosis, 80% by time of death
It halves the incidence
List some of the temporary side effects of lung radiotherapy
Fatigue Shortness of breath Cough Oesophagitis Skin changes After prophylatoc cranial radio - Headaches, nausea, hair loss
Side effects from radiation tend to peak when
After the completion of treatment
List some of the permanent effects of radiotherapy toxicity following lung treatment
Breathlessness due to fibrosis
After Stereotactic ablative body radiotherapy (SABR)
- Brachial plexopathy
- Myelopathy
- Rib fractures
After prohylactoc cranial - memory/cognitive impairment
Secondary malignanc
Which type of lung cancer is usually most chemo responsive
Small cell
Are targeted therapies and immunoherapies used for curative or palliative treatment
They have no established role in curative regimes
Some targeted ones can be used as 1st line palliative
Targeted therapies are mainly used for which types of lung cancer
Non-small cell
A number of mutations have been found in the molecular pathways which are involved in its development - EGFR, ALK, ROS1
Targeted therapies are usually tolerated better than traditional chemotherapies - true or false
True
List some of the adverse effects of targeted lung cancer therapy
Rash
Diarrhoea
Pulmonary toxicity
Hepatotoxicity
List some of the adverse effects of lung cancer immunotherapy
Immunosuppression Fatigue Skin changes Mucositis Diarrhoea Colitis, Hepatotoxicity Pneumonitis Endocrinopathies
What is the basis of immunotherapy
Based upon premise of immune system playing key role in defence against malignancy
Drugs act on the immune system to help it fight cancer cells
What happens to the trachea position in lung consolidation
Nothing - it remains central
What happens to the trachea position in lung collapse
It shifts towards the site of collapse
What happens to the trachea position in pleural effusion
It moves away from the side of effusion
What happens to the trachea position in pneumothorax
It moves away from the side of pneumothorax
What happens to the trachea position in pulmonary fibrosis
Nothing - it remains central
Which conditions can lead to decreased chest expansion
Lung consolidation, collapse, plueral effusion and pneumothorax will all lead to decreased expansion over the affected area
In pulmonary fibrosis expansion is decreased symetrically
Which conditions can lead to dull percussion
Consolidation
Lung collapse
Will be stony and dull over an effusion
What is percussion like over a pneumothorax
It is resonant
What is percussion like over pulmonary fibrosis
It is normal
How is air entry affected by lung consolidation
Reduced - bronchial sounds
How is air entry affected by lung collapse
It is absent or reduced
How is air entry affected by pleural effusion
It will be absent over the fluid
Bronchial sounding above
How is air entry affected by pneumothorax
It is reduced
How is air entry affected by pulmonary fibrosis
It is normal
What are the features of Horner’s syndrome
Miosis
Enopthalmos - sunken eye
Ptosis - droopy eyelid
Unilateral loss of sweating
What causes Horner’s syndrome
Invasion of cervical sympathetic plexus.and shoulder/arm pain-brachial invasion c8-t2
Can be cause by a pancoast lung tumour
What causes Horner’s syndrome
Invasion of cervical sympathetic plexus.and shoulder/arm pain-brachial invasion c8-t2
Can be cause by a pancoast lung tumour
What are the indication for CXR
Unexplained/persistent haemoptysis (urgent)
3 week history of the following unexplained: Cough Chest or shoulder pain Dyspnoea Weight loss Hoarseness Chest signs or finger clubbing Persistent lymphadenopathy (cervical/supraclavicular) Features suggestive of metastases
List features which suggest lung cancer mets
Confusion Weight loss Bone pain Headache Unsteady gait
Which CXR abnormalities may be caused by an underlying lung cancer
Mass lesions Consolidation Collapse Pleural effusion Pulmonary metastases Erosion of ribs
A normal chest x-ray excludes lung cancer - true or false
FALSE
Should still be referred to resp
Which methods can be used to obtain a tissue biopsy/sample for lung cancer diagnosis
Image guided percutaneous biopsy (CT-guided biopsy)
Bronchoscopy
Mediastinoscopy - sample from mediastinum and hilum
Thoracoscopy - keyhole with ports through chest wall
What checks are done prior to bronchoscopy
Make sure there is informed consent Oxygen saturation on air Hb or platelets Coagulation (note, if LFT abnormal check coag) FEV1 - should be >40% ideally
Warfarin should be stopped prior to bronchoscopy - true or false
True
Patients should be switched to heparin 1 week before procedure
When is sputum cytology used in the diagnosis of lung cancer
Only used in patients with large central lesions where bronchoscopy and other tests are unsafe
Which technique is used for the diagnosis of peripheral lung tumours
Percutaneous CT-guided biopsy
Which technique is used for the diagnosis of peripheral lung tumours
Percutaneous CT-guided biopsy
Pneumothorax is a complication of percutaneous CT-guided biopsy - true or false
True
How is lung cancer staged
Based on CT scans, MRI, US and PET
Non-small cell lung cancer is staged according to the TNM system
Small cell lung cancer is categorised as either limited disease (confined to a single radiation field) OR
Extensive disease
According to T staging (from TNM) which lung cancers are resectable
T1 and 2 are
T3 tumours sometimes can be
However, T4 tumours invade vital structures and are non-resectable
Describe the different N stages in lung cancer
N1 – ipsilateral hilar tumour spread
N2 – ipsilateral mediastinal tumour spread; not resectable
N3 – contralateral mediastinal tumour/ supraclavicular tumour spread; not resectable
What is the best scan for detecting metastatic bone disease
Bone scan
This involves injection of radionuclides
Increased uptake at sites of metastases leading to ‘Hot spots’
What is the most common cancer in non-smokers
Adenocarcinoma
Smoking cessation is still beneficial in patients who already have lung cancer - true or false
True!
Continued smoking in lung cancer reduces life expectancy, increases risk of recurrence/metastases, reduces treatment efficacy and exacerbates treatment side-effects
Which factors are taken into account when deciding if a patient can go for curative surgery
Stage and type of cancer Age - morbidity increases with age Pulmonary function Co-morbidity Performance status
Patients of which performance status are eligible for surgery
0, 1 and 2
Which factors would make a lung cancer patient inoperable
Stage III or stage IV lung cancer
Poor respiratory reserve, i.e. poor FEV1
Multiple co-morbidities making them a high risk surgical candidate
WHO performance status 3 or 4
Which type of chemo is used for NSCLC
Platinum-based combination chemotherapy is recommended for patients with stage IIIb and IV
Maximum of 4 cycles in patients with advanced NSCLC
Which type of chemo is used for SCLC
A platinum agent and etoposide
Duration of 3-6 cycles of chemotherapy in SCLC
Radiotherapy may be curative in some cases of NSCLC - true or false
True
If in stage 1 or 2 and not medically fit for or refusing surgery
