Lung Cancer Flashcards
What is lung cancer?
It is defined as the proliferation of malignant epithelial cells in the lungs
How common is lung cancer in the UK?
It is the third most common cancer
What is the mortality rate of lung cancer in the UK?
It has the highest cancer mortality rate
What are the two main classifications of lung cancer?
Small Cell Lung Cancer (SCLC)
Non-Small Cell Lung Cancer (NSCLC)
What is SCLC?
It is defined as lung cancer that results in abnormal proliferation of small epithelial cells
Where are SCLC’s located?
They are located centrally in the bronchi
Which patient group tends to be affected by SCLC?
Older smokers
How quickly does SCLC metastasise?
It metastasises early during disease progression
SCLC is associated with what syndromes? How?
Paraneoplastic syndromes
Small cells contain neurosecretory granules, which release neuroendocrine hormones – such as ACTH and ADH
What percentage of lung cancer cases are SCLC?
15%
What is the prognosis of SCLC in comparison to NSCLC?
The prognosis is worse for these patients
What is NSCLC?
It is defined as lung cancer that results in abnormal proliferation of epithelial cells – other than small cells
What percentage of lung cancer cases are NSCLC?
85%
What is the prognosis of NSCLC in comparison to SCLC?
The prognosis is better for these patients
What are the three subclassifications of NSCLC?
Adenocarcinoma
Squamous Cell Carcinoma
Large Cell Carcinoma
What is the most common classification of lung cancer?
Adenocarcinoma
What is adenocarcinoma?
It is defined as the abnormal proliferation of glandular cells within the epithelial tissue of the lung
Where are adenocarcinomas located?
They are located peripherally in the bronchioles
Which two patient groups do adenocarcinomas tend to affect?
Non-smokers
Asian females
How quickly do adenocarcinomas metastasise?
It metastases early during disease progression
What is squamous cell carcinoma?
It is defined as the abnormal proliferation of squamous cells within the epithelial tissue of the lung
Where are squamous cell carcinomas located?
They are located centrally in the bronchi
Which patient group tend to be affected by squamous cell carcinoma?
Smokers
How quickly does squamous cell carcinoma metastasise?
It metastases late during disease progression
What is a characteristic feature of squamous cell carcinoma on CXR?
Cavitating lesions
What is large cell carcinoma?
It is defined as an undifferentiated malignant tumour that lacks the characteristic cytologic features of squamous cell carcinoma, adenocarcinoma and small cell carcinoma
Where are large cell carcinomas located?
They are located both peripherally in the bronchioles and centrally in the bronchi
Which patient group tends to be affected by large cell carcinomas?
Smokers
How quickly does large cell carcinoma metastasise?
It metastasises early in disease progression
What are the five risk factors of lung cancer?
Smoker
Male Gender
Family History
Air Pollution
Radon Gas Exposure
What is the main risk factor of lung cancer?
Smoking
What genetic mutation is associated with lung cancer? What induces this mutation?
KRAS
Smoking
What are the nine clinical features associated with lung cancer?
Chronic Cough > 3 Weeks
Haemoptysis
Dyspnoea
Pleuritic Chest Pain
Recurrent Pneumonia
Weight Loss
Fixed Monophonic Wheeze
Supraclavicular Lymphadenopathy
Finger Clubbing
What weight loss is deemed as significant?
> 5% in 6 months
Which clinical feature is specifically associated with adenocarcinomas?
Gynaecomastia
What are the four investigations used to diagnose lung cancer?
Blood Tests
Chest X-Ray (CXR)
Contrast CT Scan
Bronchoscopy
What two blood tests are conducted to diagnose lung cancer? Why?
FBC = Increased Plts, Increased Calcium Levels Indicate SSC, Increased ADH Levels Indicate SCLC
LFTs = Increased ALP & GGT Levels Indicate Hepatic/Bone Metastases
What is the first line investigation used to diagnose lung cancer?
CXR
What are the four signs of lung cancer on CXR?
Hilar Enlargement
Peripheral Opacities
Unilateral Pleural Effusion
Lung Collapse
In what two ways are contrast CT scans used to investigate lung cancer?
They are used to confirm the findings established on CXR
They are used to determine the staging of lung cancer
What is bronchoscopy?
It involves the insertion of a small camera into the bronchi
This enable direct visualisation of the lung cancer and a biopsy of the tumour to be obtained
What can bronchoscopy be conducted with? What is this? Why is it advantageous?
Endobronchial ultrasound (EBUS)
It involves the attachment of ultrasound equipment to the bronchoscope
This enables detailed assessment of the cancer and an ultrasound guided biopsy
How do we stage lung cancer?
It is initially staged with the TMM classification system and then converted to the I-IV staging system
What is stage I lung cancer?
It is defined as a small tumor (<4cm) localised to one lung
What is stage II lung cancer?
It is defined as a large tumour (>4cm)
There may be metastasis to nearby lymph nodes within the same lung
What is stage III lung cancer?
It is defined as lung cancer that has metastasised to contralateral lymph nodes or nearby respiratory structures (eg. trachea)
What is stage IV lung cancer?
It is defined as lung cancer that has metastasised to extra pulmonary structures
What are the five management options for NSCLC?
Surgical Management
Stereotactic Ablative Radiotherapy (SABR)
Chemotherapy
Targeted Therapies
Immunotherapy
When is surgery recommended to manage NSCLC?
It is the first line option in individuals with stage I – III NSCLC
What three surgeries can be used to treat NSCLC?
Lobectomy
Pneumonectomy
Wedge Resection
What is lobectomy?
It involves the surgical removal of the lung lobe containing the tumour
When is lobectomy recommended?
It is the first line surgical management option in individuals with intact lung function
What is pneumonectomy?
It involves the surgical removal of the whole lung containing the tumour
When is pneumonectomy recommended?
It is the second line surgical management option in individuals with intact lung function
What is wedge resection?
It involves the surgical removal of a wedge shaped segment of lung that contains the tumour
When is wedge resection recommended?
It is the first line surgical management option in individuals with reduced lung function – such as the elderly or those with underlying respiratory conditions
What are the six contraindications of the surgical management of non-small cell lung cancer?
Stage IIIb/IV Cancer
FEV1 < 1.5L
Malignant Pleural Effusion
Tumour Near Hilum
Vocal Cord Paralysis
Superior Vena Cava Obstruction
When is SABR recommended to manage NSCLC?
It is the second line option in individuals with stage I – III non-small cell lung cancer, who are unsuitable for surgery
What is SABR?
In comparison to conventional radiotherapy, SABR involves directing a more concentrated, focused beam of radiation at the tumour
What are the two advantages of SABR?
It reduces the number of radiotherapy sessions needed
It minimises damage to surrounding tissue
How is chemotherapy used to manage lung cancer?
It can be administered neoadjuvantly or adjuvantly, in combination with surgical or radiotherapy management techniques to improve the likelihood of success
When are targeted therapies recommended to manage NSCLC?
It can be used in individuals with stage IV non-small lung cancer
What are targeted therapies?
These drugs target mutations which drive the pathogenesis of lung cancer
What two targeted therapies are used to target EGFR mutations in lung cancer?
Gefitinib
Osimertinib
What targeted therapy is used to target ALK mutations in lung cancer?
Alectinib
What targeted therapy is used to target ROS1 mutations in lung cancer?
Crizotinib
When is immunotherapy recommended to manage NSCLC?
It can be used in individuals with stage IV non-small cell lung cancer
What is immunotherapy?
These drugs target immune checkpoints, which prevent the patient’s immune cells from targeting tumour cells
What are the three management options for SCLC?
Chemotherapy
Radiotherapy
Prophylactic Cranial Irradiation
What is prophylactic cranial irradiation? Why is recommenced in SCLC?
It involves the use of radiotherapy to prevent brain metastases
There is a high risk of brain metastases with small cell lung cancer
Why is surgery not usually recommended in SCLC?
It is usually metastatic by the time of presentation
What are the four common locations of lung cancer metastasis?
Brain
Bones
Adrenal glands
Liver
What are the eleven extrapulmonary complications of lung cancer?
Recurrent Laryngeal Nerve Palsy
Phrenic Nerve Palsy
Superior Vena Cava Obstruction
Horner’s Syndrome
Syndrome of Inappropriate ADH Secretion (SIADH)
Cushing’s Syndrome
Limbic Encephalitis
Lambert Eaton Myasthenic Syndrome
Hypercalcaemia
Hyperthyroidism
Hypertrophic Pulmonary Osteoarthropathy (HPOA)
How can lung cancer cause recurrent laryngeal nerve palsy?
When the tumour compresses the recurrent laryngeal nerve as it passes through the mediastinum
What is the additional clinical feature associated with recurrent laryngeal nerve palsy?
Hoarseness
How can lung cancer cause phrenic nerve palsy?
When the tumour compresses the phrenic nerve as it passes anterior to the lung root
What are the two additional clinical features associated with phrenic nerve palsy?
Diaphragm weakness
Dyspnoea
How can lung cancer cause superior vena cava obstruction?
When the tumour compresses the superior vena cava, which prevents venous drainage from the head and neck
What are the three additional clinical features associated with superior vena cava obstruction?
Facial swelling
Breathing difficulties
Vein distention in the neck and chest
What sign indicates that superior vena cava obstruction has become a medical emergency?
Pemberton’s sign
What is Pemberton’s sign?
This is when the raising of hands over the head causes facial congestion and cyanosis
How can lung cancer cause Horner’s syndrome?
When the tumour is present in the pulmonary apex, therefore compressing the sympathetic ganglion
What specific tumour is associated with Horner’s syndrome?
Pancoast
What are the three additional clinical features of Horner’s syndrome?
Partial ptosis
Anhidrosis
Miosis
Which classification of lung cancer is associated with SIADH? How?
SCLC
It stimulates ectopic ADH secretion due to neuroendocrine hormone release
What is the additional clinical feature associated with SIADH?
Hyponatraemia
Which classification of lung cancer is associated with Cushing’s syndrome? How?
SCLC
It stimulates ectopic ACTH secretion due to neuroendocrine hormone release
What are the additional five clinical features associated with Cushing’s syndrome?
Moon face
Central obesity
Abdominal striae
Buffalo hip
Skin changes
Which classification of lung cancer is associated with limbic encephalitis? How?
SCLC
It causes the immune system to produce anti-Hu antibodies against the limbic tissues of the brain – resulting in inflammation of this area
What are the four additional clinical features associated with limbic encephalitis?
Short term memory impairment
Hallucinations
Confusion
Seizures
What is Lambert Eaton myasthenia syndrome?
It is defined as an autoimmune condition, in which the immune system produces antibodies against small cell lung cancer cells
These antibodies specifically target the voltage gated calcium channels of these cells, located on the presynaptic terminals in motor neurones
When can Lambert-Eaton syndrome present?
It may precede the cancer diagnosis by a number of years
What is the characteristic clinical feature of Lambert Eaton myasthenic syndrome?
Muscle fatiguability
It results in the characteristic features of myasthenia gravis, in which muscles become progressively weaker during periods of activity and slowly improve after periods of rest
This usually means that clinical features are minimal in the morning and worse at the end of the day
What are the six clinical features of Lambert Eaton myasthenic syndrome?
Proximal Muscle Weakness
Diplopia
Ptosis
Facial Muscle Weakness
Dysphagia
Slurred Speech
Which classification of lung cancer is associated with hypercalcaemia? How?
Squamous cell
It stimulates ectopic parathyroid hormone (PTH-rp) secretion due to neuroendocrine hormone release
How are PTH levels affected by hypercalcaemia secondary to malignancy?
Decreased
Which classification of lung cancer is associated with hyperthyroidism? How?
Squamous cell
It stimulates ectopic TSH hormone secretion due to neuroendocrine hormone release
Which two classifications of lung cancer is associated with HPOA? How?
Squamous cell
Adenocarcinoma
They cause fibrovascular proliferation of the organs, lungs, bones and joints
What are the three additional clinical features associated with HPOA?
Periostitis
Finger clubbing
Large joint arthropathy
What is mesothelioma?
It is defined as a lung malignancy affecting the mesothelial cells of the pleura
What is the most common risk factor of mesothelioma?
Asbestos exposure
What is the management of mesothelioma?
Palliative care
