Lung Cancer

Question 1

What are the common clinical symptoms of lung cancer?

Answer 1

Cough
Haemoptysis
Dyspnoea
Chest pain
Weight loss
Nausea and vomiting
Anorexia

Question 2

What are the common clinical signs of lung cancer?

Answer 2

Cachexia
Finger clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA).
Anaemia
Horners syndrome (if the tumour is apical)
Lymphadenopathy
Skin nodules (metastases)
Superior vena cava obstruction
Chest signs
Paraneoplastic syndromes

Question 3

What is paraneoplastic syndrome?

Answer 3

Sings or symptoms occurring in a patient with cancer that results from antibodies or ectopic hormones produced by the cancer and are not due directly to local effects of cancer cells.
Removal of the cancer usually resolves the problem.

Question 4

What are some paraneoplastic symptoms of advanced disease?

Answer 4

Neurological:
- polyneuropathy
- cerebellar degeneration
- lambert-eaton syndrome

Finger clubbing
anaemia
HPOA
carcinoid syndrome
inappropriate ADH secretion > hyponatraemia.
Ectopic ACTH secretion causing Cushing’s syndrome.
Hypercalcaemia due to the secretion of parathyroid hormone related peptides.

Question 5

What are some metastatic symptoms of advanced disease?

Answer 5

Bone pain
Spinal cord compression: limb weakness, paraesthesia and bladder/bowel dysfunction.
Cerebral metastases: headache, vomiting, dizziness, ataxia, focal weakness.
Thrombosis.

Question 6

What is the pathology of squamous cell carcinoma?

Answer 6

Usually present as obstructive lesions of the bronchus leading to infection.
Associated with smoking.

Question 7

What paraneoplastic syndromes are associated with squamous cell carcinoma?

Answer 7

-Often causes hypercalcaemia by bone destruction or production of PTH analogues (PTHrp).
-Also often associated with clubbing and HPOA.

Question 8

What is the pathology of adenocarcinoma?

Answer 8

Arises from mucous cells in the bronchial epithelium.
Commonly invades the mediastinal lymph nodes and the pleura and spreads to the brain and bones.
Most likely to cause pleural effusion (as are mesotheliomas).

Question 9

What is the pathology of small cell carcinoma?

Answer 9

-Arise from endocrine cells (Kulchitsky cells). These are ADUP cells, and as a result, these tumours will secrete many poly-peptides mainly ACTH.

Question 10

What paraneoplastic syndromes are associated with small cell carcinoma?

Answer 10

Due to inappropriate ACTH secretion, it can cause Cushing’s syndrome.
Addison’s disease.
Lambert-eaton syndrome.

Question 11

Describe the management of non-small cell lung cancer.

Answer 11

• First-line: lobectomy.
• Curative radiotherapy can also be offered to patients with stage I, II and III NSCLC.
  -Chemotherapy should be offered to patients with stage III and IV NSCLC to control the disease and improve quality of life.

Question 12

Small-cell lung cancer management

Answer 12

-Can be combined chemotherapy and radiotherapy.
-However SCLC is usually disseminated on presentation, so generally palliative chemotherapy is the treatment.

Question 13

What are the risk factors of lung cancer?

Answer 13

Smoking (more than 85%).
Passive smoking.
Exposure to asbestos, radon, air pollution and diesel exhaust.

Question 14

What are the initial investigations?

Answer 14

CXR.
FBC.
Renal, liver functions and calcium.
Clotting screen.
Spirometry.

Question 15

What main investigations can be used for a tissue diagnosis?

Answer 15

Bronchoscopy.
EBUS.
Ct biopsy.

Question 16

What investigations are used to stage the lung cancer?

Answer 16

CT thorax and abdomen.
CT-PET.

Question 17

Describe the TNM staging system used to stage lung cancer.

Answer 17

How big is it and how far it has spread/size and position of the tumour (T).
Whether cancer cells have spread into lymph nodes (N).
Whether the tumour has spread anywhere else in the body i.e. metastases (M).

Question 18

What is the difference between a pulmonary nodule/mass?

Answer 18

A pulmonary mass is an opacity in the lung over 3 cm with no mediastinal adenopathy or atelactasis.
A pulmonary nodule is an opacity in the lung up to 3cm with no mediastinal adenopathy or atelectasis.

Question 19

Describe the other treatment strategies which are important in the palliation of lung cancer.

Answer 19

Chemotherapy.
Immunotherapy.
TKI.
Palliative radiotherapy.
Combination of above.

Question 20

Describe he pathology of malignant mesothelioma.

Answer 20

Malignant pleural mesothelioma is a rare and aggressive disease and is caused by inhaled asbestos fibres reaching the pleura and causing inflammation, thereby provoking tumour formation.

Question 21

What is pleural effusion?

Answer 21

Pleural effusion is the collection of fluid in the pleural space when there is an imblance between production and absorption.

Question 22

What are the types of effusion?

Answer 22

Transudate and exudate.

Question 23

Describe transudative effusion.

Answer 23

Non-inflammatory, very commonly caused by left ventricular and liver cirrhosis.

Question 24

Describe exudative effusion.

Answer 24

Inflammatory > protein content 3g/dl or more. Common causes include malignancy (pulmonary and non-pulmonary), parapneumonic effusions, empyema and tuberculosis.

Question 25

Define the approach used to investigate pleural effusion.

Answer 25

US: more sensitive han CXR, mark site for aspiration, assess pleura, bedside.
CXR: accessible, easy to interpret.
CT thorax: complete effusions, visualising the pleura, vascular and mediastinal structures.
Pleural fluid analysis .

Question 26

Describe the management of common causes of pleural effusion.

Answer 26

PH less than 7.2 with pneumonia, pus or blood may need a chest drain.
Transudate: treat the underlying cause, may not need CT imaging.
Exudate: unless the cause is identified will neeed further investigation, e.g., further imaging, and/or pleural biopsy.

Question 27

Definition of small cell lung cancer.

Answer 27

High grade neurodendocrine tumour that arises in the hilum of smokers, with a poor prognosis and no current targeted therapy.