lung cancer

Question 1

Demographics of lung cancer?

Answer 1

Age peak 75-90. M > F. lower socioeconomic status. Smoking history. 3rd most common cancer in UK, leading cause of cancer death

Question 2

What are causes other than smoking for lung cancer?

Answer 2

Passive smoking, asbestos, radon, indoor cooking fumes, genetic/familial, chronic lung diseases (COPD, pulmonary fibrosis), immunodefiency

Question 3

What are the 4 types of lung cancer?

Answer 3

1. non-small cell carcinoma: squamous cell carcinoma, adenocarcinoma, large cell lung cancer. 2. small cell lung cancer

Question 4

Where does squamous cell carcinoma originate from and how common is it?

Answer 4

Originates from bronchial epithelium (centrally located) - 30%

Question 5

Where does adenocarcinoma originate from and how common is it?

Answer 5

Originates from glandular mucus producing tissue (peripherally located) - most common (40%)

Question 6

What does large cell lung cancer present as? How common is it?

Answer 6

Heterogenous, undifferentiated. 15%

Question 7

Where does small cell lung cancer originate from? How malignant is it?

Answer 7

Pulmonary neuroendocrine cells. Highly malignant

Question 8

which is the most malignant out of the lung cancer types?

Answer 8

Small cell lung cancer

Question 9

What is a model of lung cancer development?

Answer 9

Normal epithelium –> hyperplasia –> metaplasia –> dysplasia –> carcinoma in situ –> invasive carcinoma

Question 10

What is the difference between metaplasia and dysplasia?

Answer 10

Metaplasia is a reversible change where 1 cell type is replaced by another. Dysplasia is abnormal growth with some cellular/architectural features of malignancy (but pre-invasive, intact basement membrane)

Question 11

Why are oncogenes important in lung cancer? What are they?

Answer 11

Oncogenes are genes that when mutated can lead to cancer. Treatment can be directed at them.

Question 12

Which oncogene contributes to about 15-30% cases of adenocarcinoma, more in women, asians, that have never smoked?

Answer 12

EGFR - Epidermal growth factor receptor tyrosine kinase.

Question 13

Which oncogene contributes to 2-7% of non-small cell cancers, young patients & never smokers?

Answer 13

ALK - anaplastic lymphoma kinase tyrosine kinase

Question 14

Which oncogene contributes to about 1-2% of non-small cell cancer mostly in young people and never smokers?

Answer 14

ROS-1) ROS oncogene 1 receptor tyrosine kinase

Question 15

Which oncogene implicated in 1-3% cases of non-small cell cancer especially in smokers?

Answer 15

BRAF (downstream cell cycle signalling mediator)

Question 16

What are the key symptoms of lung cancer?

Answer 16

Cough, haemoptysis, weight loss, fatigue, breathlessness, chest pain. Can present asymptomatic and non-specific and late.

Question 17

What are features of advanced/metastatic disease?

Answer 17

Neurological symptoms (focal weakness, spinal cord compression, seizures), bone pain, paraneoplastic syndromes (clubbing, cushings, hypernatraemia)

Question 18

What are common sites of lung cancer metastases?

Answer 18

Bone, liver, brain, adrenal glands, lymph nodes

Question 19

What are some signs of lung cancer?

Answer 19

Clubbing of nails, cachexia, horner’s syndrome, SVC obstruction (pemperton’s sign)

Question 20

What is diagnostic strategy for lung cancer?

Answer 20

Most likely diagnosis, fitness for investigations/treatment, staging

Question 21

What imaging used in lung cancer?

Answer 21

Chest x-ray, staging CT (chest abdomen), PET scan

Question 22

What imaging is used for staging lung cancer?

Answer 22

Staging CT (chest + abdomen)

Question 23

What are the uses of PET scan in lung cancer?

Answer 23

occult metastases (light up areas using glucose) + LN involvement (mediastinal)

Question 24

What are the different types of biopsies for lung cancer? Their uses and how do you choose which method?

Answer 24

1. bronchoscopy: for tumours of central airway where staging not important 2. EBUS/TBNA (endobronchial ultrasound/ transbronchial needle aspiration): needle aspiration of mediastinal lymph nodes to stage mediastinum and tissue diagnosis 3. CT guided lung biopsy: for peripheral lung tumours.

Question 25

How do you stage a lung tumour? What can they be divided in?

Answer 25

t1-4 tumour size and location. N0-3: lymph node involvement mediastinum and beyond. M0-1c: metastases and number. Stages divided into early, locally advanced, metastatic

Question 26

What factors determine treatment?

Answer 26

Cancer stage, patient fitness, patient wishes, comborbidities, health service factors

Question 27

How is patient fitness determined for lung cancer? When do you usually do radical treatment?

Answer 27

WHO performance status: 0-asymtomatic. 1-symtomatic but ambulatory (normal daily activities good, maybe on exertion not). 2-symptomatic but <50% of time bedbound. 3-symptomatic but >50% of time bedbound. 4- bedbound 5. death. Radical treatment usually limited to 0-2.

Question 28

What are the surgical options for lung cancer and when are they used?

Answer 28

Standard care for early lung cancer. 1. Lobectomy + lymphadenectomy 2. sublobar if stage 1 less than 3cm.

Question 29

When is radical radiotherapy used and what is the technique of choice? What does it involve?

Answer 29

Used when cant have surgery in early stage disease (eg comborbities). SABR (stereo-ablative body radiotherapy) technique of choice. Involved high presicion radiotherapy with mutliple convergent beam

Question 30

What are some systemic treatments used in lung cancer?

Answer 30

Oncogene directed treatment, immunotherapy, cytotoxic chemotherapy, palliative/supportive care

Question 31

What is oncogene directed treatment, how does it work? When is it used? Which drugs approved? Efficacy? Side effects?

Answer 31

Drugs directed towards mutated oncogenes to block defective protein produced by them. 1st line for metastatic NSCLC with mutation. For EGFR (erlotinib), ALK (crizotinib,) ROS-1. improvement in progression-free survival but not nevessarily overall survival compared to standard. Side effects well tollerated - rash, diarrhpea, penumonitis

Question 32

What is immunotherapy, how does it work? When is it used? Which drugs approved? Efficacy? Side effects?

Answer 32

Normally, T cells can kill early cnacer cells but many tumours bypass this system via PDL1 receptor allowing immune evasion. These drugs block PDL1 receptor. 1st line for metastatic NSCLC without mutation & PDL1>50%. Drugs include pembrolizumab, atezolizumab, nivolumab. Improves progression-free survival and overall survivial. Side effects tolerated - immune side effects in some (thyroid, skin, bowel, lung , liver)

Question 33

What is cytotoxic chemotherapy, how does it work? When is it used and how? Reginems approved? Efficacy? Side effects?

Answer 33

Targets any rapidly dividing cell. 1st line for metastatic NSCLC with no mutation & PDL1 <50%. Used in combination with immunotherapy. Platinum based regimens eg. Carboplatin, cisplatin, paclitaxel. When used allone modest improvement but with pembrolizumab better. Side effects frequent, fatigue, nausea, bone marrow suppresion, nephrotoxicity.

Question 34

What is palliative and supportive care, what does it involve? When offered? Efficacy?

Answer 34

Symptom control, psych support, education, financial support, planning end of life (lung cancer specialist nurses). Survival and symptomatic benefit - improves quality of life and depression scores. All with advanced stage disease

Question 35

What treatment for early stage lung cancer?

Answer 35

Surgery or radical radiotherapy curative intent

Question 36

What treatment for locally advanced disease (involving thoracic lymph nodes)?

Answer 36

Surgery + adjuvant chemotherapy, radiotherapy + chemotherapy +/-immunotherapy

Question 37

Treatment for metastatic disease with targetable mutation or with no mutation, PDL-1 + or negative?

Answer 37

With mutation oncogene directed treatment (tyrosine kinase inhibitor). No mutation PDL1 positive immunotherapy. No mutation PDL1 negative chemotherapy + immunotherapy.