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Y4 Cancer Care: Oncology > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

How many cases of lung cancers are diagnosed in the UK per year?

A

Over 43,000 new lung cancers are diagnosed each year in the UK.

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2
Q

What are the 2 different types of lung cancers?

A

Lung cancers can be divided into small-cell and non-small cell tumours.

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3
Q

Briefly describe the classification of lung cancer

A
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4
Q

Briefly differentiate between small cell lung cancer and non-small cell lung cancer

A
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5
Q

Which type of lung cancers are more aggressive? SCLC or NSCLC?

A

SCLC is generally more aggressive, growing and metastasizing rapidly compared to NSCLC.

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6
Q

What is the most common risk factor for cancer?

A

Cigarette smoking is the most important risk factor, being associated with causation in up to 90% of cases

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7
Q

What are the risk factors for lung cancer?

A
  • Smoking (tobacco and cannabis)
  • Passive smoking
  • Occupation exposure (asbestos, silica, welding fumes, coal)
  • HIV
  • Organ transplantation
  • Radiation exposure (X-ray, gamma rays)
  • Beta-carotene supplements in smokers
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8
Q

Which cancers commonly metastasise to the lung?

A

Bone, breast, colon, skin, and testicular cancer are the common tumours that metastasise to the lung.

However, almost any tumour can metastasise to the lungs through hematogenous spread.

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9
Q

Within the NSCLC what are the 3 main types of cancer?

A

Within the NSCLC category, there are three main subtypes of lung cancer: squamous cell carcinoma, adenocarcinoma, and large-cell carcinoma.

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10
Q

Briefly differentiate between the 3 NSCLC: squamous cell carcinoma, adenocarcinoma and large-cell carcinoma

Note: prevalence, incidence, location, risk factors, histologiccal features and prognosis

A
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11
Q

Briefly describe the important freatures of squamous cell carcinoma

A
  • Most common type of lung cancer in the UK
  • Usually present as obstructive lesions of the bronchus leading to infection
  • Occasionally cavitates (10% at presentation)- lung cancer that most commonly cavitates
  • On X-ray it is not possible to tell whether it is an abscess or a cancer (the border’s definition cannot be easily seen) but on the CT there is obviously a jagged border- indicating cancer.
  • Local spread is common but metastasis are normally late (but frequent)
  • Often causes hypercalcaemia– by bone destruction or production of PTH analogues (PTHrp)
  • Also associated with clubbing and HPOA (Hypertrophic pulmonary osteoarthropathy)
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12
Q

Briefly describe important features of adenocarcinoma

A
  • Arises from mucous cells in the bronchial epithelium
  • Commonly invades the mediastinal lymph nodes, the pleura and spreads to the brain and bones
  • Does not usually cavitate
  • Proportionally more common in non-smokers, women and in the far East least likely to be related to smoking
  • Most likely to cause pleural effusion (as are mesotheliomas)
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13
Q

Briefly describe important features of small cell lung cancer

A
  • Accounts for about 10-15% of lung cancers
  • Characterised by small, round and blue cells (on histologic staining) that are approximately twice the size of lymphocytes
  • Lesions usually centrally located
  • Arise from endocrine cells (Kulchitsky cells)
    • These are APUD cells, and as a result, these tumours will secrete many poly-peptides mainly ACTH
  • They can also cause various presentations such as Addison’s and Cushing’s disease
  • Small cell carcinoma spreads very early and is almost always inoperable at presentation
  • These tumours do respond to chemotherapy, but the prognosis is generally poor
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14
Q

What are the symptoms of lung cancer?

A
  • Cough
  • Haemoptysis
  • Dyspnoea
  • Chest Pain
  • Weight loss
  • Nausea and vomiting
  • Anorexia
  • Hoarseness of voice
  • Headache, swelling of face, arms and/or neck
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15
Q

Why does hoarseness of voice occur in lung cancer?

A

This symptom arises when the tumour compresses the recurrent laryngeal nerve around the trachea that innervates the vocal cords.

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16
Q

What are the signs of lung cancer?

A
  • Cachexia
  • Finger Clubbing
  • Hypertrophic pulmonary osteoarthropathy
  • Anaemia
  • Horner’s syndrome (if the tumour is apical)
  • Examination of the chest:
    • Consolidation (pneumonia)
    • Collapse (absent breath sounds
    • Ipsilateral tracheal deviation)
    • Pleural effusion (stony dull percussion, decreased vocal resonance and breath sounds)
  • Enlargement of supraclavicular and axillary lymph nodes
  • Paraneoplastic syndromes
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17
Q

What are paraneoplastic syndromes?

Give examples

A

Paraneoplastic symptoms and signs are caused by the release of substances by the tumour rather than by direct tumour effects. Symptoms are a result of hormonal or electrolyte alterations.

Examples of hormonal and electrolyte abnormalities include:

  • Hypercalcemia
  • Syndrome of inappropriate ADH
  • Cushing syndrome
  • Lambert Eaton syndrome (suggests small cell lung cancer)
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18
Q

How does hypercalcaemia present?

A

Weakness, fatigue, nausea and vomiting and confusion.

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19
Q

How does syndrome of inappropriate ADH present?

A

Muscle weakness and cramping, restlessness, confusion, fatigue, nausea and vomiting.

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20
Q

How does Cushing’s Syndrome present?

A

Hypertension, hyperglycemia, round face, muscle weakness and striae.

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21
Q

How does Lambert Eaton syndrome present?

A

Muscle weakness and loss of movement.

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22
Q

What are the non-metastatic complications of bronchial carcinoma?

A
  • Shortness of breath
  • Haemoptysis
  • Pain
  • Pleural effusion
  • Superior vena cava obstruction
  • Pneumothorax
  • Atelectasis (collapse of a lung or lobe)
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23
Q

What investigations should be ordered for lung cancer?

A
  • Sputum cytology
  • Chest X-ray
  • Contrast-enhanced CT scan
  • Bronchoscopy
  • Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA)
  • Cardiovascular review and lung function tests should also be performed to assess patient’s suitability for treatment options
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24
Q

What signs are present on blood tests in lung cancer?

A

Aigns of lung cancer including anemia, leukocytosis, thrombocytosis or hypercoagulable disorders.

25
Q

What is the role of chest X-ray in diagnosing lung cancer?

A

Abnormalities that may be seen include nodules, lung collapse, pleural effusion, consolidation and bony metastases.

26
Q

What is the role of contrast-enhanced CT scan in diagnosing lung cancer?

A

This is used to further confirm the diagnosis and stage (TNM classification) the disease. The CT scan should also include both the adrenals and liver to look for sites of metastases.

27
Q

Briefly describe how lung cancer is diagnosed

A

Lung cancer diagnosis is done by complete history, physical examination, and relevant tests.

Imaging tests include X-ray and CT scan with confirmation by biopsy.

28
Q

What is the role of PET scans in diagnosing lung cancer?

A

PET scans may be used to assess lymph node involvement and search for metastases.

29
Q

What imaging is used to stage cancer?

A

Staging investigations will vary depending on the extent and type of disease and may include CT, PET scan and/or MRI.

Contrast enhanced CT of the chest and upper abdomen including the liver and adrenal glands is the most appropriate for most patients suspected of having lung cancer.

30
Q

What may a CXR of lung cancer show?

A

Chest xray is the first line investigation in suspected lung cancer. Findings suggesting cancer include:

  • Hilar enlargement
  • “Peripheral opacity”- a visible lesion in the lung field
  • Pleural effusion- usually unilateral in cancer
  • Collapse
31
Q

Briefly describe the use of staging CT

A

Staging CT scan of chest, abdomen and pelvis to establish the stage and check for lymph node involvement and metastasis. This should be contrast enhanced using an injected contrast to give more detailed information about different tissues.

32
Q

Briefly describe the use of PET-CT

A

PET-CT (positron emission tomography) scans involve injecting a radioactive tracer (usually attached to glucose molecules) and taking images using a combination of a CT scanner and a gamma ray detector to visualise how metabolically active various tissues are.

They are useful in identifying areas that the cancer has spread to by showing areas of increased metabolic activity suggestive of cancer.

33
Q

Briefly describe the use of bronchoscopy with endobronchial ultrasound (EBUS)

A

Bronchoscopy with endobronchial ultrasound (EBUS) involves endoscopy of the airways (bronchi) with ultrasound on the end of the scope. This allows for detailed assessment of the tumour and ultrasound guided biopsy.

34
Q

Briefly describe the use of endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA)

A

EBUS-TBNA allows biopsy of lymph nodes, paratracheal and bronchial lung lesions for histology.

35
Q

Who is involved in the MDT for lung cancer?

A

All treatments are discussed at an MDT meeting involving various consultants and specialists, such as pathologists, surgeons, oncologists and radiologists. This is to make a joint decision about what is the most suitable options for the individual patient.

36
Q

Briefly describe the treatment for NSCLC

A

Surgery is the primary treatment modality for NSCLC if the disease is localised. Chemotherapy and radiation, alone or in combination, may be used for patients who are not surgical candidates or as adjuvant therapy. Immunotherapy and targeted therapies are available for more advanced staged cancers not responsive to standard treatments.

37
Q

Briefly describe the treatment for SCLC

A

Chemotherapy is the main therapy used, with radiotherapy being used as an adjuvant therapy in some situations.

Surgery is not a standard treatment option for SCLC.

38
Q

What % of patients with NSCLC are suitable for surgery?

A

Only 20% suitable for surgery.

39
Q

What is the most common surgery for NSCLC?

A

A lobectomy is the most common surgery for lung cancer.

Segmentectomy or wedge resection (taking a segment or wedge of lung to remove the tumour) is also an option.

40
Q

When should surgery be offered to patients with NSCLC?

A

Surgery is appropriate for patients with tumours that can be completely resected, and are in a location suitable for resection. Surgical resection is indicated when the disease has not spread beyond one lung, the tumour is small enough to ensure resection will be feasible, there is limited spread to local lymph nodes, and patient and other tumour factors are favourable

41
Q

When is radiotherapy offered to patients with NSCLC?

A

Radiotherapy can also be curative in non-small cell lung cancer when early enough and can also be offered to patients with stage I, II and III NSCLC.

42
Q

When is chemotherapy offered to patients with NSCLC?

A

Chemotherapy can be offered in addition to surgery or radiotherapy in certain patients to improve outcomes (“adjuvant chemotherapy”) or as palliative treatment to improve survival and quality of life in later stages of non-small cell lung cancer.

It should be offered to patients with stage III and IV NSCLC.

43
Q

What chemotherapeutic agents are used to treat SCLC?

A

SCLC is usually treated with combinations of chemotherapy agents.

Platinum-based chemotherapy agents (cisplatin or carboplatin) are used in conjunction with etoposide as first line therapy.

44
Q

When is radiotherapy offered to patients with SCLC?

A

Radiation is also not the primary treatment modality of choice for extensive-stage SCLC disease. However, for both extensive-stage and limited-stage disease, radiation used in conjunction with chemotherapy resulted in decreased mortality.

45
Q

Does NSCLC or SCLC carry better prognosis?

A

Prognosis is generally worse from small cell lung cancer than non-small cell lung cancer.

46
Q

What treatment should be offered to patients with bronchial obstruction due to lung cancer?

A

Endobronchial treatment with stents or debulking can be used as part of palliative treatment to relieve bronchial obstruction caused by lung cancer.

47
Q

What are the extra-pulmonary manifestations of lung cancer?

A
  • Recurrent laryngeal nerve palsy
  • Phrenic nerve palsy
  • Superior vena cava obstruction
  • Horner’s syndrome
  • Syndrome of inappropriate ADH (SIADH)
  • Cushing’s syndrome
  • Hypercalcaemia
  • Limbic encephalitis
  • Lambert-Eaton myasthenic syndrome
48
Q

How does recurrent laryngeal nerve palsy present?

A

Recurrent laryngeal nerve palsy presents with a hoarse voice. It is caused by the cancer pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.

49
Q

How does phrenic nerve palsy present?

A

Phrenic nerve palsy due to nerve compression causes diaphragm weakness and presents as shortness of breath.

50
Q

How does superior vena cava obstruction present?

A

Superior vena cava obstruction is a complication of lung cancer. It is caused by direct compression of the tumour on the superior vena cava. It presents with facial swelling, difficulty breathing and distended veins in the neck and upper chest. “Pemberton’s sign” is where raising the hands over the head causes facial congestion and cyanosis. This is a medical emergency.

51
Q

How does Horner’s syndrome present?

A

Horner’s syndrome is a triad of partial ptosis, anhidrosis and miosis. It is caused by a Pancoast’s tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion.

52
Q

Syndrome of inappropriate ADH (SIADH):

  1. What causes it?
  2. Which lung cancer is it commonly linked to?
  3. How does it present?
A

Syndrome of inappropriate ADH (SIADH) caused by ectopic ADH secretion by a small cell lung cancer and presents with hyponatraemia.

53
Q

Cushing’s syndrome:

  1. What causes it?
  2. Which lung cancer is it commonly linked to?
A

Cushing’s syndrome can be caused by ectopic ACTH secretion by a small cell lung cancer.

54
Q

Hypercalcaemia:

  1. What causes it?
  2. What type of lung cancer is it commonly linked to?
A

Hypercalcaemia caused by ectopic parathyroid hormone from a squamous cell carcinoma.

55
Q

What is limbic encephalitis?

A

Limbic encephalitis. This is a paraneoplastic syndrome where the small cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas. This causes symptoms such as short term memory impairment, hallucinations, confusion and seizures. It is associated with anti-Hu antibodies.

56
Q

Briefly describe Lambert-Eaton Myasthenic Syndrome

A

Lambert-Eaton myasthenic syndrome is a result of antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones.

57
Q

How does Lambert-Eaton Myasthenic Syndrome present?

A

Lambert-Eaton Myasthenic Syndrome presents with weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.

Patients with Lambert-Eaton have reduced tendon reflexes.

58
Q

Briefly describe the reflexes of patients with Lambert-Eaton Myasthenic Syndrome

A

Patients with Lambert-Eaton have reduced tendon reflexes. A notable finding is that these reflexes become temporarily normal for a short period following a period of strong muscle contraction. For example, the patient can maximally contract the quadriceps muscle for a period, then have their reflexes tested immediately afterwards, and display an improvement in the response. This is called post-tetanic potentiation.

Y4 Cancer Care: Oncology (7 decks)

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