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2. Respiratory Medicine (Lectures) > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

Another name for lung cancer

A

Pulmonary neoplasia

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2
Q

Causes of lung cancer

A

Tobacco
Asbestos
Environmental radon
Other occupational exposure
- chromates
- hydrocarbons
- nickel
Air pollution and urban environment
Other radiation
Pulmonary fibrosis

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3
Q

What % of lung cancer is attributable to smoking?

A

> 85%

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4
Q

What % of smokers get lung cancer?

A

10%

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5
Q

What is a pack year?

A

Packs per day per year

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6
Q

Two main pathways of carcinogenesis in the lungs

A

Lung periphery
- bronchioalveolar epithelium stem cell transformation
- adenocarcinoma
Central lung airways
- bronchial epithelial stem cells transform
- SCC

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7
Q

Which process is strongly associated with smoking in the lungs?

A

Squamous dysplasia -> CIS -> invasive bronchogenic carcinoma

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8
Q

What is peripheral lung adenocarcinogensis and what is it associated with?

A

Atypical adenomatous hyperplasia AAH to adenoma in situ to invasive adenocarcinoma
Assosiated less strongly with smoking however does occur in non smokers

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9
Q

Adenocarcinogensis and molecular biology

A

KRAS ; 35% - smoking induced
EGFR ; 15% - not related to tobacco carcinogenesis
BRAF, HER2 ; 2% - not related to smoking
ALK rearrangements ; 2% - not related to smoking carcinogenesis

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10
Q

What % of lung neoplasms are a carcinoid tumour?

A

< 5%

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11
Q

What is a carcinoid tumour?

A

Low grade malignancy

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12
Q

What are the tumours of the bronchial glands and are they common?

A

Adenoid cystic carcinoma
Mucoepidermoid carcinoma
Benign adenomas

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13
Q

Tumours of the lung

A

Benign causes of a mass lesion
Tumours of the bronchial glands
Carcinoid tumour
Lymphoma
Sarcoma
Mets to lungs
Carcinoma

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14
Q

4 main types of lung carcinoma

A

Squamous cell 40%
Adenocarcinoma 41%
Small cell 15%
Large cell 4%

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15
Q

Histological types of lung carcinoma

A

15% - small cell carcinoma (SCLC)
85% - non small cell carcinomas (NSCLC)

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16
Q

What are the NSCLCs?

A

Adenocarcinoma
SCC
Large cell carcinomas

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17
Q

When does a primary lung cancer present?

A

Late - few or no symptoms or signs until the disease is very advanced

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18
Q

Local effects of lung cancer

A

Bronchial obstruction
- collapse
- endogenous liquid pneumonia
- infection/abscess
- bronchiectasis
Pleural
- inflammatory
- malignant
Direct invasion
- chest wall
- nerves
Mediastinum (SVC, pericardium)
Lymph node mets

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19
Q

What nerves can be effected by direct invasion of lung cancer?

A

Phrenic
L recurrent pharyngeal
Brachial plexus
Cervical sympathetic

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20
Q

What would damage to the phrenic nerve cause?

A

Diaphragmatic paralysis

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21
Q

What would damage to the L recurrent laryngeal nerve cause?

A

Hoarse, bovine cough

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22
Q

What would damage to the brachial plexus cause?

A

Pancoast T1 damage

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23
Q

What would damage to the cervical sympathetic chain cause?

A

Horners syndrome

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24
Q

Distant effects of lung cancer

A

Distant mets
Secondary to local effects
- neural
- vascular
Non met effects

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25
Where does lung cancer metastasise to?
Liver Adrenals Bone Brain Skin
26
What are the non metastatic paraneoplastic effects of lung cancer?
Clubbing HPOA ACTH, siADH, PTH Carcinoid syndrome Gynaecomastia Polyneuropathy Encephalopathy Cerebellar degeneration Myasthenia Acanthosis nigricans Dermatomyositis Granulocytosis Eosinophilia DIC Thrombophlbeitis migrans Nephrotic syndrome
27
Investigations for lung cancer
CXR FBC RFTs, LFTs, calcium Clotting screen Spirometry Bronchoscopy - bronchial bronchoscopy - bronchial brushings and washings - endobronchial US guided aspiration (EBUS) Image guided lung biopsy Trans thoracic FNA Trans thoracic core biopsy CT MRI PET
28
Prognostic factors in lung cancer
Stage of disease Classification Markers/oncogenes/gene expression profiles Growth rate Cell proliferation DNA aneuploidy (abnormal number of chromosomes) Immune cell infiltration
29
What may prognostic markers be used to select?
Patients for adjuvant therapy
30
Prognosis in lung cancer
< 7% 5 year survival
31
What stages of lung cancer are generally operable?
I and II
32
5 year prognosis of Stage I lung cancer
> 60%
33
5 year prognosis of Stage II lung cancer
35%
34
Genes involved in adenocarcinomas
EGFR KRAS HER2 BRAF ALK translocations
35
Genes involved in SCCs
FGFR1 gene copy number DDR2 FGFR2
36
3 top killers in the world
Cancer Heart disease COPD
37
Presentation of lung cancer
Chronic cough Haemoptysis Wheeze Chest and bone pain Chest infections Difficulty swallowing Rapsy, hoarse voice SOB Unexplained weight loss Nail clubbing
38
What is nail clubbing?
Increased curvature of fingernails
39
Presentation of advanced lung cancer disease
Mets - Bone pain - spinal cord compression - cerebral mets - thrombosis Paraneoplastic - hyponatraemia - anaemia - hypercalcaemia - dermatomyositis / polymyositis Eaton-Lambert syndrome Cerebellar ataxia Sensorimotor neuropathy
40
Presentation of spinal cord compression
Limb weakness Paraesthesia Bladder/bowel dysfunction
41
Presentation of cerebral mets
Headache Vomiting Dizziness Ataxia Focal weakness
42
What is thrombosis?
Blood clot
43
What does dermatomyositis cause?
Proximal muscle weakness
44
What does eaton lambert syndrome cause?
Upper limb weakness
45
Signs of lung cancer
Chest signs Clubbing Lymphadenopathy Horners syndrome Pancoast tumour SVC obstruction Hepatomegaly Skin nodules (mets)
46
What Is a Pancoast tumour?
Tumour of pulmonary apex
47
What has to be damaged to cause horners syndrome?
Sympathetic trunk
48
What type of lung cancer are smokers more likely to have?
SCCs
49
What type of lung cancer are non smokers more likely to have?
Adenocarcinoma
50
What is T staging based on?
Size and proximity to chest and vessels
51
What is N staging based on?
Nodal involvement
52
What is M staging based on?
Metastases
53
How many stages are there of TNM?
4
54
Stage 1 lung cancer
Localised to lung No other organ involvement 90% will be alive end of year 1
55
Stage 2 lung cancer
85% will be alive at end of year 1
56
Stage 4 lung cancer
24% will be alive at end of year 1
57
How does a PET scan show neoplasm?
Cancer cells are hungry for food as they multiply very fast Radionucleotide contrast taken up by the cancer cells which light up
58
Performance status scale
0 = fully active 1 - symptoms but ambulatory (walking). Likely to respond to treatment 2 = "up and about" > 50%, unable to work. Likely to respond to treatment 3 = Up and about < 50%, limited self care, unlikely to respond to treatment 4 = bed or chair bound, unlikely to respond to Tx
59
Treatment for lung cancer
Surgery (18% of patients) - wedge resection - lobectomy - pneumonectomy Radiotherapy Chemotherapy
60
What is a pneumonectomy?
Surgical removal or lung / part of lung
61
Palliative management of lung cancer
Symptom control - chemo - radio - opiates - bisphosphonates - benzodiazepines Tx of - hypercalcaemia - dehydration - hyponatraemia
62
What is hyponatraemia?
Low sodium
63
Where is the aorta-pulmonary window?
Between the pulmonary trunk and arch of the aorta
64
What may lung cancer look like on CXR?
Pleural effusion (tumour in pleural space) Chest wall invasion Collapsed lung or lobe
65
Blood results in lung cancer
Anaemia Abnormal LFTs - high ALP High calcium Low haemoglobin
66
Reasons for perioperative death in the Tx of lung cancer
ARDS Bronchopneumonia (esp if have COPD) MI PTE Pneumothorax Intra thoracic bleeding
67
What is ARDS?
Adult respiratory distress syndrome
68
Complications of surgery for lung cancer
Post thoracotomy wound pain Empyema BPF (bronchopleural fistula) Wound infection AF MI Post op resp insufficiency Gastroparesis/constipaton
69
What is empyema?
Pus in pleural space
70
Mortality of pneumonectomy
8 - 12%
71
Mortality of lobectomy
3 - 5%
72
Mortality of wedge resection
2 - 3%
73
What is a thoracotomy?
Incision into the pleural space of the chest
74
Causes of pulmonary mass
Lung cancer Metastases TB Lung abscess Fungal infection Benign tumour (hamartoma, carcinoid) Granuloma (sarcoid, wegeners, rheumatoid nodule) Fibrosis Paraffinoma (chronic granuloma produced by prolonged exposure to paraffin) Vascular haematoma AVM
75
How to look at a CXR
1. Name / marker / rotation / penetration 2. Lines / metal work 3. Heart 4. Mediastinum - hilar vascular structures crisply defined - no widening of mediastinum - central trachea 5. Lungs - compare zones (upper/middle/lower) - look between ribs for lung detail - behind heart 6. Bones 7. Diaphragm 8 Soft tissues
76
What should you be aware of that would indicate a central lung cancer?
Lobar collapse which fails to resolve in 2 - 3 weeks in a smoker over the age of 45
77
What is a pulmonary mass?
An opacity (lacking transparency) in the lung > 3cm with no mediastinal adenopathy or atelectasis
78
What should lung cancer be diagnosed by?
CXR +ve bronchoscopy
79
Features of bone pain caused by metastases
Any site Worse at night Pathological fracture
80
What is small cell lung cancer associated with?
ECTOPIC ADH and ACTH SECRETION SiADH - inappropriate ADH production leading to a dilutional hyponatraemia Cushings syndrome - due to ACTH production
81
What can the ACTH production in SCLC lead to?
Cushings syndrome Bilateral adrenal hyperplasia which leads to a hypokalaemic metabolic acidosis
82
Where does renal cell carcinoma metastasise to and what is it called?
Lungs - 'cannonball mets' - multiple, large, round, well circumscribed masses in both lungs
83
Contraindications to lung cancer surgery
SVC obstruction FEV < 1.5 Malignant pleural effusion Vocal cord paralysis
84
Patients with known or suspected lung cancer are offered what?
Contrast enhanced CT of - chest - liver - adrenals
85
What is adenocarcinoma of the lung associated with?
Gynaecomastia Hypertrophic pulmonary osteoarthropathy
86
Associations of SCC of the lung
PTH related protein (PTH-rp) secreting causing hypercalcaemia Clubbing Hypertrophic pulmonary osteoarthropathy Hyperthyroidism due to ectopic TSH
87
What can Pancoast tumours result in?
Suppressing the recurrent laryngeal nerve causing hoarseness of the voice
88
What may a large cell lung carcinoma secrete?
B-hCG

2. Respiratory Medicine (Lectures) (50 decks)

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