lung cancer Flashcards
What age range has the highest instance of lung cancer?
75-90
Are males or females more likely to be diagnosed with lung cancer?
males
what is the epidemiological relevance of lung cancer in the UK?
third most common cancer and leading cause of cancer death
what percentage of those with lung cancer have never smoked?
10-15%
Other than smoking what are the main causes of lung cancer?
asbestos, radon, indoor cooking fumes, chronic lung diseases, immunodeficiency, familial/ genetic
what are the 4 categories of lung cancers and what percentage of cases do they account for?
squamous cell carcinoma (30%), adenocarcinoma (40%), large cell lung cancer (15%), small cell lung cancer (15%)
where do squamous cell carcinoma lung cancers originate from?
bronchial epithelium, centrally located
where do adenocarcinoma lung cancers originate from?
mucus-producing glandular tissue
where do small cell lung cancers originate from?
pulmonary neuroendocrine cells, are highly malignant
outline the general pathogenesis of lung cancers
may arise from all differentiated and undifferentiated cells. interaction between inhaled carcinogens and the epithelium of the upper and lower airways leads to the formation of DNA adducts (pieces of DNA covalently bound to a cancer-causing chemical. if DNA adducts persist or are mis-repaired they result in a mutation and cause genomic alterations - these are key events particularly if they occur in critical oncogenes or tumour suppressor genes
What are the four most important oncogenes for directed treatments?
epidermal growth factor receptor (EGFR) tyrosine kinase. anaplastic lymphoma kinase (ALK) tyrosine kinase. c-ROS oncogene 1 (ROS1) receptor tyrosine kinase. BRAF ( downstream cell-cell signalling mediator)
which oncogene is most important for directed treatments in smokers?
BRAF (downstream cell-cycle signalling mediator)
What are the key symptoms associated with lung cancer?
cough, weight loss, breathlessness, fatigue, chest pain, haemoptysis. frequently asymptomatic
what is haemoptysis?
coughing up blood
what are the features of advanced/ metastatic lung cancer?
neurological features such as focal weakness, seizures, spinal cord compression. bone pain. paraneoplastic symptoms such as clubbing, hypercalcaemia, hyponatraemia, Cushings. horners syndrome, cachexia
what are the signs of Horners syndrome ?
Horner syndrome is characterized by a constricted pupil (miosis), drooping of the upper eyelid (ptosis), absence of sweating of the face (anhidrosis), and sinking of the eyeball into the bony cavity that protects the eye (enophthalmos).
what is cachexia?
weakness and wasting of the body due to severe chronic illness.
what are some of the common differentials associated with lung cancer?
pulmonary fibrosis, pneumonia, bronchiectasis, TB, bronchitis
what are the common sites of lung cancer metastases?
liver, brain, lymph nodes, bones, adrenal glands
outline the diagnostic strategy for lung cancer
establish most likely diagnosis, establish fitness for investigation and treatment (older patients may not benefit from invasive treatment, confirm diagnosis (imaging, biopsy) confirm staging
What is the ultimate test to confirm diagnosis of lung cancer? What tests are done prior?
Biopsy, should be done after a chest x-ray, CT chest and PET scan
What determines the type of biopsy used to diagnose lung cancer?
Accessibility, availability of test and impact of staging
What are the three types of biopsy that can be used to investigate lung cancers?
Bronchoscopy, EBUS, CT guided lung biopsy
What is an EBUS?
Endobronchial ultrasound and transbronchial-needle aspiration of mediastinal lymph nodes, used to access mediastinum and access lymph nodes to stage the mediastinum and achieve tissue diagnosis
When would a bronchoscopy be used?
For tumours of the central airway where tissue staging is not important
When would a CT-guided lung biopsy be used?
To access peripheral lung tumours
What is the staging system used for lung cancers?
TNM, tumour size, lymph nodes, metastases
What are the determinants of treatment for lung cancer patients?
Patient fitness, cancer histology, cancer stage, patient preference, health service factors
What is the WHO performance status for patients?
0 to 5 scale for assessing patient fitness (for treatment)
What are the parameters for the 0-5 scale of the WHO performance status?
0 - asymptomatic
1 - symptomatic but completely ambulatory.
2 - symptomatic, <50% in bed during the day
3 - symptomatic, >50% in bed, but not bedbound
4 - bedbound
5 - death
Radical treatment is normally restricted to which WHO performance status patients?
PS 0-2
What are the treatment options for lung cancer?
Surgical, radiological, pharmacological and supportive
What are the surgical treatment options for lung cancer?
Wedge resection, segmental resection, lobectomy, pneumonectomy
What is a wedge resection (lung)?
Removal of a small section of lung that contains tumour along with a margin of healthy tissue
What is a segmental resection (lung)?
Removes a larger portion of the lung but not an entire lobe
What is a lobectomy?
Removal of an entire lobe of the lung
What is a pneumonectomy?
Removal of an entire lung
When is surgical resection offered?
In early stager lung cancer
In early stage lung cancer, what can also be offered as an alternative to surgical resection?
Radical radiotherapy, especially is comorbidities
What is an NSCLC?
Non-small cell lung cancer
Oncogene directed systemic treatments are first line treatment for which type of lung cancers?
Metastatic NSCLC with mutation. Are tyrosine kinase inhibitors that improve side effects and progression-free survival.
Immunotherapy systemic treatments are first line treatments for which type of lung cancers?
Metastatic NSCLC with no mutation and PDL1>50%
How do immunotherapy systematic treatments work against lung cancer?
uses bodies own immune cells to attack cancer by blocking PD-L1/Pd-1 receptor to T cell (allows evasion from immune system)
What is the efficacy of immunotherapy treatments for lung cancer?
Improvements in progression-free survival and overall survival vs standard chemotherapy
Cytotoxic chemotherapy is first line treatment for which type of lung cancer?
Metastatic NSCLC with no mutations and PDL1<50%
What treatment should be offered to a patient with locally advanced lung cancer (involving thoracic lymph nodes)
Surgery and adjuvant chemotherapy.
Radiotherapy and chemotherapy and immunotherapy
What treatments should be offered to a patient with metastatic lung cancer?
With a targetable mutation = tyrosine kinase inhibitor.
With no mutation, PDL1 positive = immunotherapy
With no mutation, PDL1 negative = standard chemotherapy and immunotherapy.
Palliative care either alone or with above
What is the general prognosis for lung cancer?
Relatively poor, survival much lower as stage at diagnosis increases. Usually late age at presentation, reducing survival
list three targetable mutations
EFGR, ALK, ROS-1
what is the radical radiotherapy technique of choice?
SABR - stereotactic ablative body radiotherapy
when would a sublobar resection be offered?
stage 1 (<3cm)
what is an EBUS used for?
To stage mediastinum +/- achieve tissue diagnosis
