Lung Cancer

Question 1

Epidemiology of lung cancer?

Answer 1

3rd common cancer
Leading cause of cancer death
in both male + female

Question 2

What factors affect who gets lung cancer?

Answer 2

Age (75-90)
Male > Female
Smoking history - affected by duration, intensity, when stopped
Lower socioeconomic (healthcare access)

Question 3

What may cause lung cancer in the 10-15% of ppl with lung cancer who have never smoked

Answer 3

Passive smoking
Aetiological causes
10-15% of ppl with lung cancer have never smoked

Question 4

What are Aetiological causes of lung cancer?

Answer 4

Asbestos - exposure increases risk X2
Radon - miners in germany
Indoor cooking fumes - e.g. indian wood smoke + poor ventilation
Chronic lung diseases
immumodefiency
familial

Question 5

What pathophysiologies of lung cancer are there?

Answer 5

Squamous cell carcinomas
Adenocarcinomas (mucous secreting)
Large cell lung cancer
Small cell lung cancer

Question 6

Where does squamous cell carcinoma originate?

Answer 6

Bronchial epithelium - centrally located

Question 7

Where does adenocarcinomas originate?

Answer 7

Most common now due to low tar cigarettes, inhaled more deeply and retained longer

Mucus produding glandular tissue, periperally located

Question 8

Describe the stages from normal epithelium to invasive carcinoma?

Answer 8

Normal epithelium -->
hyperplasia -->
squamous metaplasia-->
( becomes non reversible from there )
dysplasia-->
carcinoma in situ
invasive carcinoma

Question 9

What mutations in specific oncogenes are involved (and can be targeted for directed treatment)

Answer 9

• Epidermal growth factor receptor (seen in adenocarcinomas)
• anaplastic lymphoma kinase (in non smokers)
• c-ROS oncogene 1 (non-small cell lung cancer)
• BRAF

Question 10

What are the symptoms of lung cancer?

Answer 10

Cough
weight loss
breathlessness
fatigue
chest pain
haemoptysis

Question 11

Why does lung cancer kill so many?

Answer 11

• frequently asymptomatic *ppl who have other lung diseases may not go to dr for these symptoms

Question 12

What are the features of advanced or metastatic lung cancer?

Answer 12

Neurological features : focal weakness, seizures, spinal cord compression

Bone pain

Paraneoplastic syndromes

Question 13

What are paraneoplastic syndromes?

Answer 13

Clubbing, hypercalcaemia, hyponatraemia, cushings

Because lungs can secrete hormones

Question 14

What is the pembertons sign?

Answer 14

lung cancer sign

shows superior vena cava obstruction, reduces veous return

• redness and swelling in face, if px put arms up this makes it worse

Question 15

What is Horner’s syndrome?

Answer 15

Lung cancer sign

compresses thoracic outlet, reducing sympathetic supply to face. present with ptosis, myosis, hydrosis

Question 16

What clinical signs are there of lung cancer?

Answer 16

Clubbing ( most ppl will die before it presents this advanced
cachexia
horners
pembetons

Question 17

What imaging is done to exclude occult metastases?

Answer 17

PET (tumour will show up brightly to show active tumour)

and also shows normal but active lymph nodes

Question 18

What is a bronchoscopy?

Answer 18

for tumours of central airway
where tissue staging is not important

biopsy method

Question 19

What is an endobronchial ultrasound and transbronchial needle aspiration used for?

Answer 19

Done on the mediastinal lymph nodes as a biopsy

To stage mediastinum/get a tissue diagnosis

Question 20

What is a CT-guided lung biopsy?

Answer 20

Through chest wall
tissue sample

biopsy method

Question 21

How are lung cancer stages determined with TNM?

Answer 21

T1-4 = tumour size and location

N0-3 = lymph node involvement

M0-1c = metastases

• late stage at diagnosis if common

Question 22

What is a three fold way of staging lung cancer?

Answer 22

Early
Locally-advanced
Metastatic

Question 23

What factors affect treatment given?

Answer 23

px fitness
cancer histology
cancer stage
px preference
health service factors

Question 24

How does the WHO summarises performance status? from 0-5

Answer 24

0 - asymptomatic
1 - symptomatic but completey ambulatory
2 - symptomatic <50% bed during the day
3 - 0 symptomatic >50% bed 
4 -  bed bound
5 - death

Question 25

What surgery is offered for lung cancer?

Answer 25

Surgical resection is standard of care for early stage disease

lobectomy + lymphadenectomy

Sublobar resection if stage 1 (<3cm)

Question 26

what is an alternative to surgery for early stage disease?

Answer 26

radical radiotherapy
particulaly if there is. comorbidity
Stereotactic ablative body radiotherapy - SABR
- technique of choice
- high precision targeting, multiple convergent beams

Question 27

What systemic treatment drugs are offered?

for SCLC with mutations

Answer 27

crizotinib

First line for metastatic Non small cell lung cancer (SCLC) with mutations:

EGFR
ALK
ROS-1

efficacy : improvements in progression free survival, but not overall vs standard chemo

Side effects : well tolerated tablets
Rash
Diarrhoea
uncommon pneumonitis

Question 28

What immunotherapy drugs are available?

Answer 28

PD-L1/PD-1 receptor in tumour cells binding inhibits T cell killing of tumour cell

SO

blocking PD-Lq or PD-1 allows T cell killing of tumour cells

given when PDL1 is >50%
can give pembrolizumab / atezolizumab / nivolumab

improvements compared to chemo

generally well tolerated
Immune related side effects e.g. thyroid, skin, bowel in small percentage

Question 29

What is cytotoxic chemotherapy treatment?

Answer 29

Targets rapidly dividing cells
Platinum based regimes = carboplastin / cisplatin / paclitaxel / pemetrexed

When used alone, small improvements but in combination with other drugs e.g. PDL1 blockers increased survival

Side effects

Fatigue, nauseam bone marrow suppression
…