lung cancer

Question 1

epidemiology of cancer

Answer 1

3rd most commpn cancer in uk
48000 diagnoses/yr
35000 deaths/ yr
leading cause of cancer death

Question 2

what are some risk factors for lung cancer

Answer 2

age peak 75-90
sex m>f
lower socioeconomic status
smoking - duration, intensity, how long ago stopped

Question 3

what are some other causes of cancer besides smoking

Answer 3

passive smoking
asbestos exposure
radon
indoor cooking fumes
chronic lung disease e.g copd, fibrosis
immunodeficiency
familial/genetics

Question 4

what % of lung cancer cases are caused by smoking

Answer 4

approx 85%

Question 5

what are the 4 types of lung cancer

Answer 5

squamous cell carcinoma
adenocarcinoma
large cell lung cancer
small cell lung cancer§

Question 6

what % of cases does squamous cell carcinoma cause

Answer 6

30%
originates from bronchial epithelium
centrally located

Question 7

what % of cases does adenocarcinoma cause

Answer 7

40%
most common from 1980s
originates from mucus producing glandular tissue
more peripherally located

Question 8

what % of cases does large cell lung cancer cause

Answer 8

15%
heterogenous group - undifferentiated
everything else

Question 9

what % of cases does small cell lung cancer cause

Answer 9

originates from neuroendocrine cells
highly malignant
very aggressive

Question 10

stages of lung cancer development

Answer 10

normal epithelium - hyperplasia - squamous metaplasia - dysplasia - carcinoma in situ - invasive carcinoma

Question 11

what are some important oncogenes involved in lung cancer

Answer 11

egfr tyrosine kinase
alk tyrosine kinase
ros1 receptor tyrosine kinase
braf

Question 12

what are some key symptoms of lung cancer

Answer 12

cough,
weight loss
breathlessness
fatigue
chest pain
haemoptysis
or frequently asymptomatic

Question 13

what are some features of advanced/metastatic cancer?

Answer 13

neurological features ; focal weakness, seizures, spinal cord compression
bone pain
paraneoplastic syndromes - clubbing, hypercalcaemia
hyponatraemia, cushings

Question 14

what are some clinical signs of advanced lung cancer

Answer 14

cachexia
horners syndrome - tumour presses on thoracic outlet, reduces sympathetic supply to face
superior vena cava obstruction - pembertons sign

Question 15

what is diagnostic strategy

Answer 15

establish most likely diagnosis
establish fitness for treatment and investigation
confirm diagnosis
specifically what type of cancer
confirm staging

Question 16

what are some investigations you can do for lung cancer

Answer 16

chest x ray
staging ct
pet - most useful tp exclude occult metastases
biopsy

Question 17

what are some methods of biopsy for lung

Answer 17

bronchoscopy
endobronchial ultrasound and transbronchial - needle aspiration of mediastinal lymph nodes (ebus(tbna))
ct guided biopsy - for peripheral tumours

Question 18

how to stage cancer

Answer 18

tumour size
lymph node involvement
metastases and number
early vs locally advanced vs metastatic

Question 19

what are some determinants of treatment

Answer 19

patient fitness
cancer histology
cancer stage
patient preference
health service factors

Question 20

what do we use to classify patient fitness for treatment

Answer 20

who performance status
0 - asymptomatic
1 - symptomatic but ambulatory
2 -symptomatic but <50% in bed
3 - symptomatic >50% in bed
4 - bedbound
5 - death

comorbidity and lung function is also very important

Question 21

what is the standard of care for early stage disease

Answer 21

surgical resection
lobectomy and lymphadenectomy usual approach
sublobar resection if stage 1 <3cm
pneumonectomy
VATS
open thoracotomy

Question 22

what is an alternative for surgery for early stage

Answer 22

radical radiotherapy
- particulary if comorbid
stereotactic ablative radiotherapy (sabr):
high precision targeting using multiple convergent beams

Question 23

first line systemic treatment for nsclc with mutation

Answer 23

for egfr - erlotinib,gefitinib,dacomitinib and osimertinib
for alk - crizotinib, certinib, alectinib, brigatinib, lorlatinib
ros 1 - crizotinib,entrectinib

Question 24

first line systemic treatment for metastatic nsclc with no mutation

Answer 24

immunotherapy

e.g pembrolizumab, atezolizumab,nivolumab

Question 25

first line systemic treatment for metastatic nsclc with no mutation
with immunotherapy

Answer 25

cytotoxic chemotherapy

Question 26

what is another key part of treatment for lung cancer

Answer 26

Pallative care

supportive care

Question 27

treatment for locally advanced disease

Answer 27

surgery and adjuvant chemotherapy

radiotherapy and chemotherapy