Lung cancer Flashcards
how common is lung cancer in the UK?
3rd most common cancer
leading cause of cancer death
who is most at risk of lung cancer?
age 75-90
male
lower socioeconomic status
smoking history
what are the risk factors for lung cancer?
smoking and passive smoking asbestos radon indoor cooking fumes chronic lung diseases immunodeficiency familial
what is the most common type of lung cancer?
adenocarcinoma
what is squamous cell carcinoma?
centrally located lung cancer
originating from bronchial epithelium
what is adenocarcinoma?
peripherally located lung cancer
originating from mucus producing glandular tissue
what is large cell lung cancer?
undifferentiated heterogenous group lung cancer
what is small cell lung cancer?
originates from pulmonary neuroendocrine cells
highly malignant!
what oncogenes are important for adenocarcinomas?
epidermal growth factor receptor (EGFR) tyrosine kinase
more so in women, never-smokers, asian
what oncogenes are important for small cell lung cancer?
anaplastic lymphoma kinase (ALK) tyrosine kinase - young patients, non-smokers
e-ROS oncogene 1 (ROS1) receptor tyrosine kinase - younger patients, non-smokers
BRAF (downstream cell-cycle signalling mediator) - esp in smokers
what are the key symptoms of lung cancer?
cough weight loss breathlessness fatigue chest pain haemoptysis frequently asymptomatic!
what are the features of advanced/metastatic lung cancer?
neurological features: focal weakness, seizures, spinal cord compression
bone pain
paraneoplastic syndromes: clubbing, hypercalcaemia, hyponatraemia, cushings
swelling lymph nodes
where are the common metastases of lung cancers?
bone liver brain lymph nodes adrenal glands
what are some signs of lung cancer?
cachexia
clubbing
horners syndrome
pembertons sign (superior VC obstruction)
what is the diagnostic strategy for lung cancer?
establish most likely diagnosis
establish fitness for investigation/treatment
confirm diagnosis, specific type if treating
confirm staging
how may lung cancer appear on a chest x ray?
white-grey masses
how is CT scanning used in lung cancer diagnosis?
primarily for staging - invasion of other tissues, metastases
chest+abdo
how may PET scans be used in lung cancer diagnosis?
to exclude occult metastases
what are the biopsy methods available for lung cancer?
bronchoscopy
endobronchial ultrasound and transbronchial needle aspiration of mediastinal lymph nodes
CT-guided lung biopsy
when is bronchoscopy biopsy used in lung cancer?
for tumours of central airway
+ tissue staging not important
when is EBUS ((endobronchial US)) + (TBNA) biopsy used in lung cancer?
to stage mediastinum +/- achieve tissue diagnosis
when are CT-guided lung biopsies used in lung cancer?
to access peripheral lung tumours
how is lung cancer staged?
T1-4 size
N0-3 lymph node involvement
M0-1c metastases + no.
what are the determinants of treatment for lung cancer?
patient fitness cancer histology cancer stage patient preference health service factors
what are the WHO performance status guidelines for patient fitness?
0 - asymptomatic 1 - symptomatic but ambulatory 2 - symptomatic <50%in bed during day 3 - symptomatic >50% in bed but not bedbound 4 - bedbound 5 - dead
what treatment is standard for early stage lung cancer?
surgical resection - usually lobectomy + lymphadenectomy
what surgical treatment is used for lung cancers in stage 1 (<3cm)
sub-lobar resection
when is radical radiotherapy used in lung cancer?
early stage disease if no surgery
esp for comorbidities
what is radical radiotherapy for lung cancer?
stereotactic ablative radiotherapy (SABR)
high precision targeting, multiple convergent beams
what are the available systemic treatment types for lung cancer?
oncogene directed
immunotherapy
cytotoxic chemotherapy
what is standard treatment for locally advanced disease (involving thoracic lymph nodes)
surgery + adjuvant chemotherapy
radiotherapy + chemotherapy +/- immunotherapy
what is standard treatment for metastatic disease?
with targetable mutation tyrosine kinase inhibitors (EFGR, ALK, ROS-1)
no mutation but PDL-1 positive immunotherapy alone
no mutation but PDL-1 negative chemotherapy + immunotherapy
palliative care
what are the NICE approved oncogene-directed systemic treatments?
EGFR - erlotinib, gefitinib, afatinib
ALK - crizotinib, ceritinib, alectinib
ROS-1 - crizotinib, entrectinib
what are the NICE approved immunotherapies?
pembrolizumab, atezolizumab, nivolumab
when is immunotherapy given for lung cancer?
first line for metastatic non small cell with no mutation
PDL1 >50%
when is oncogene directed treatment given for lung cancer?
first line for metastatic non-small cell with mutation
when is cytotoxic chemotherapy given for lung cancer?
first line for metastatic non-small cell with no mutation PDL1<50%
in combo with immunotherapy
when should palliative/supportive care be offered to lung cancer patients?
all patients with advanced stage disease
what is palliative and supportive care in lung cancer?
symptom control psychological support education practical and financial support planning for end of life
What is the mechanism of action of immunotherapy?
Binds to PDL-1 on tumour cell or PD-1 on T cell (normally these cause inhibition of T cell killing tumour cell)
Therefore prevents PDL-1 or PD-1 from inhibiting T cell destruction of tumour cell - allows killing of tumour cell
