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CARDIORESPIRATORY 2 > LUNG CANCER > Flashcards

LUNG CANCER Flashcards

1
Q

How prevalent is lung cancer?

A

3rd most common cancer in UK

Leading cause of cancer death

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2
Q

What demographic is most likely to get lung cancer?

A

Male of age 75-90 who has lower social economic status and has been smoking for a long time intensely

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3
Q

What percentage of patients who have lung cancer have smoked?

A

85-90%

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4
Q

What are the causes of lung cancer other than smoking?

A 
Passive smoking
Asbestos (now banned)
Radon (from mining)
Indoor cooking fumes - wood smoke/frying fats...
Chronic lung diseases (COPD, fibrosis)
Immunodeficiency e.g from HIV
Genetic (several loci)
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5
Q

Name the different stages of lung cancer development

A 
Normal epithelium
Hyperplasia
Squamous metaplasia
Dysplasia
Carcinoma in situ
Invasive carcinoma
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6
Q

What is metaplasia?

A

Reversible change in which one adult cell type replaced by anther adult cell type as an adaptive mechanism

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7
Q

What is dysplasia?

A

Abnormal growth where some of the cellular and architectural features of malignancy are present

Pre-invasive stage with intact basement membrane

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8
Q

What are oncogenes?

A

Mutated genes which contribute to the development of cancer

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9
Q

What are the key symptoms of lung cancer?

A 
Cough
Weight loss
Breathlessness
Fatigue
Chest pain
Haemoptysis (coughing of blood)

Frequently asymptomatic

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10
Q

Why does lung cancer have such a high mortality?

A

Symptoms often present late and non-specific which delays patients from seeing a doctor

There is a lot of space in the lungs for the tumour to grow before impacting any vital structures unlike other cancers

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11
Q

What are the common sites of lung cancer metastases?

A 
Liver
Brain
Lymph nodes
Adrenal glands
Bones
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12
Q

What are the features of advanced/metastatic disease?

A

Neurological features:

  • Focal weakness
  • Seizures
  • Spinal cord compression

Paraneoplastic syndromes:

  • Clubbing
  • Hypercalcaemia
  • Hyponatraemia
  • Cushing’s

Bone pain

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13
Q

What is Horner’s syndrome and why might lung cancer cause this?

A

Ptosis and meiosis of an eye

Apical lung tumour on top of lungs compressing the thoracic outlet and thus sympathetic chain. Reduced SNS supply to face

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14
Q

What is Pemberton’s sign and why might lung cancer cause this?

A

Facial swelling and redness which gets worse when arms are lifted.

Superior vena cava is obstructed by tumour which reduces venous return.

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15
Q

What are the stages for diagnosis of lung cancer?

A

Establish most likely diagnosis
Establish fitness for investigation and treatment
Confirm diagnosis e.g. biopsy
Confirm staging

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16
Q

What imaging can you carry out on a patient with lung cancer?

A

Chest X-ray
Staging CT of chest and abdomen
PET scan for staging too

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17
Q

What does opacification of the lungs suggest in a patient with lung cancer?

A

Pleural effusion meaning the cancer has metastasised to the pleural membrane

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18
Q

What are the black boles seen in a lung CT suggestive of?

A

Emphysema which is caused by smoking

Many lung cancer patients will have this

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19
Q

What does a PET scan show and why do it?

A

Parts of the body using a lot of glucose. Can be used to exclude potential metastases that you aren’t too sure of

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20
Q

What 3 types of biopsy can you carry out on lung cancer patients?

A

Bronchoscopy

Endobronchial ultrasound and transbronchial needle aspiration of mediastinal lymph nodes (EBUS[TBNA])

CT guided lung biopsy

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21
Q

When is a bronchoscopy done?

A

For tumours of central airway

When tissue staging not important

22
Q

When is EBUS[TBNA] done?

A

To stage mediastinum and/or achieve tissue diagnosis

Mediastinum contains lymph nodes in chest

23
Q

When is CT-guided lung biopsy done?

A

To access peripheral lung tumours not close to the airways

24
Q

How are cancers staged?

A

T1-4: tumour size and location
N0-3: lymph node involvement - mediastinum + beyond
M0-1c: metastases and number

25
Q

What factors do you have to analyse before determining if a patient can undergo a treatment?

A 
Patient fitness
Cancer histology
Cancer stage
Patient preference
Health service factors
26
Q

How does WHO measure patient fitness and which patients are good for radical treatment?

A

WHO performance status
0 - asymptomatic
1 - symptomatic but completely ambulatory
2 - symptomatic < 50% in bed during day
3 - symptomatic > 50% in bed but not bedbound
4 - bedbound
5 - death

Also take into account comorbidity/lung function

Radical treatment usually only for PS 0-2

27
Q

For early stage lung cancer what is the standard of care?

A

Surgical resection - usually lobectomy + lymphadenectomy

28
Q

If a patient has stage 1 lung cancer and the tumour is =< 3cm what type of surgery can be done?

A

Sublobar resection

29
Q

What are the two methods of carrying out a lung resection?

A

Video assisted thorascopic surgery (VATS) - keyhole

Open thoractomy - used to do this, very invasive

30
Q

When is radical radiotherapy done for patients with cancer?

A

Alternative to surgery in early stage disease particularly if patient has a comorbidity

31
Q

What technique of radiotherapy is usually used for patients with cancer?

A

Sterotactic ablative body radiotherapy (SABR)
- High-precision targeting with multiple beams from
different directions all converging on the tumour

32
Q

What are the 3 systemic treatments for cancer?

A

Oncogene-directed
Immunotherapy
Cytotoxic chemotherapy

33
Q

List the different types of lung cancer

A

Squamous cell carcinoma (30%)
Adenocarcinoma (40%)
Large cell lung cancer (15%)
Small cell lung cancer (15%)

34
Q

Which types of cancer does non-small cell lung cancer encompass?

A

Squamous cell carcinoma
Adenocarcinoma
Large cell lung cancer

35
Q

Where does squamous cell carcinoma originate from?

A

Originating from bronchial epithelium, centrally located

36
Q

What is adenocarcinoma?

A

Originating from mucus producing glandular tissue; more peripherally located
Often due to low tar cigarettes inhaled more deeply/retained longer

37
Q

What is large cell lung cancer?

A

Heterogenous group, undifferentiated

38
Q

What is small cell lung cancer?

A

Originates from pulmonary neuroendocrine cells (produces ACE)
Highly malignant and aggressive with patients already having metastases when presenting

39
Q

When are oncogene-directed treatments done and how do they work?

A

First line for metastatic NSCLC with mutation

Blocks defective protein produced by the oncogenes

40
Q

What are the side effects of oncogene-directed treatments?

A

Generally well tolerated

Rash, diarrhoea and uncommonly pneumonitis

41
Q

When is immunotherapy done and how does it work?

A

First line for metastatic NSCLC with no mutation and PD-L1 >= 50%

Blocks PD-L1/PD-1 allowing T cell to kill tumour cell

42
Q

What are the side effects of immunotherapy?

A

Generally well tolerated

Immune-related side effect in 10-15%

43
Q

How does the efficacy of immunotherapy compare with chemotherapy?

A

Immunotherapy has greater progression free survival and overall survival

44
Q

How does the efficacy of oncogene directed drugs compare with chemotherapy?

A

Oncogene directed drugs has greater progression free survival but non necessarily overall survival

45
Q

When cytotoxic chemotherapy done and how does it work?

A

First line for metastatic NSCLC with no mutations and PD-L1 =< 50% (in combo with immunotherapy)

Targets and kills any rapidly dividing cell

46
Q

What is the efficacy of chemotherapy?

A

When used alone:
- modest improvements in overall survival compared to
supportive care
- with immunotherapy much increased survival rate

47
Q

What are the side effects of chemotherapy?

A

Frequent:

  • Fatigue
  • Nausea
  • Bone marrow suppression
  • Nephrotoxicity
48
Q

When should palliative and supportive care be offered?

A

All patients with advanced stage disease

49
Q

What does palliative and supportive entail?

A

Symptom control, psychological support, education. practical and financial support, planning for end of life

50
Q

What is the prognosis of lung cancer?

A

Only 10% live > 10 years

Worse prognosis in patients who are less fit

51
Q

What are the important oncogenes of lung cancer?

A

Epidermal growth factor receptor (EGFR) tyrosine kinase

  • 15-30% adenocarcinoma
  • women, asian, never smokers

Anaplastic lymphoma kinase (ALK) tyrosine kinase

  • 2-7% of NSCLC
  • young patients and never smokers

c-ROS oncogene 1 (ROS1) receptor tyrosine kinase

  • 1-2% of NSCLC
  • young patients and never smokers

BRAF (downstream cell-cycle signalling mediator)

  • 1-3% of NSCLC
  • esp in smokers

CARDIORESPIRATORY 2 (8 decks)

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