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Phase 1b - Cardiovascular & Respiratory Medicine > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

Outline the epidemiology of lung cancer (6).

A
  • 3rd most common cancer in UK
    • 48,000 diagnoses/ year
  • Leading cause of cancer death
    • 35,000 deaths/ year
  • Age: peak 75-90
  • Sex: M>F
  • Lower socioeconomic status
  • Smoking history
    • Duration, intensity, when stopped
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2
Q

What are the risk factors of lung cancer (8)?

A
  • Smoking
    • 10-15% patients with lung cancer never smoked
  • Passive smoking (~15% of these)
  • Asbestos - exposure (plumbers, ship-builders, carriage workers, carpenters, etc) - risk up to x2
  • Radon – e.g. silver miners in Germany late 19th century; 1950s uranium mining in Colorado
  • Indoor cooking fumes – wood smoke, frying fats
  • Chronic lung diseases (COPD, fibrosis)
  • Immunodeficiency
  • Familial / genetic – several loci identified
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3
Q

Outline the general pathogenesis of lung cancer (2).

A
  1. The interaction between inhaled carcinogens and the epithelium of upper and lower airways leads to the formation of DNA adducts
    -> DNA adducts: Pieces of DNA covalently bound to a cancer-causing chemical
  2. If DNA adducts persist or are misrepaired, they result in a mutation and can cause genomic alterations
    -> These are key events in lung cancer pathogenesis, especially if they occur in critical oncogenes and tumour suppressor genes.
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4
Q

What what are the main 2 types of lung cancer?

A
  • Small cell lung cancer (SCLC) (~15%)
  • Non-small cell lung cancer (NSCLC) (~85%)
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5
Q

What are are the subtypes of non-small cell lung cancer (NSCLC) (3)?

A
  • Squamous cell carcinoma (~30%)
  • Adenocarcinoma (~40%)
  • Large cell lung cancer (~15%)
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6
Q

Where does squamous cell carcinoma (~30%) originate? Where is it usually located?

A
  • Bronchial epithelium
  • Centrally located
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7
Q

Where does adenocarcinoma (~40%) originate? Where is it usually located?

A
  • Mucus-producing glandular tissue
  • More peripherally-located
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8
Q

Where does large cell lung cancer (~15%) originate?

A
  • Heterogenous group, undifferentiated
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9
Q

Where does small cell lung cancer (~15%) originate?

Small cell cancer is highly malignant.

A
  • Pulmonary neuroendocrine cells
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10
Q

What important oncogenes are related to lung cancer (4)?

A
  • Epidermal growth factor receptor (EGFR) tyrosine kinase
    • 15-30% of adenocarcinoma
    • More so in women, Asian ethnicity, never-smokers
  • Anaplastic lymphoma kinase (ALK) tyrosine kinase
    • 2-7% of non-small cell lung cancer
    • Especially in younger patients and never smokers
  • c-ROS oncogene 1 (ROS1) receptor tyrosine kinase
    • 1-2% of non-small cell lung cancer
    • Especially in younger patients and never smokers
  • BRAF (downstream cell-cycle signalling mediator)
    • 1-3% of non-small cell lung cancer
    • Especially in smokers
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11
Q

What is the clinical presentation of unmetastasised lung cancer (6)?

Frequently asymptomatic

A
  • Cough
  • Weight loss
  • Breathlessness
  • Fatigue
  • Chest pain
  • Haemoptysis
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12
Q

What is the (possible) clinical presentation of metastasised lung cancer (6)?

A

Neurological features:
* Focal weakness (Horner’s syndrome)
* Seizures
* Spinal cord compression

Bone pain

Pemberton’s sign (Superior vena cava obstruction)

Paraneoplastic syndromes:
* Clubbing
* Hypercalaemia
* Hyponatraemia
* Cushing’s
* Cachexia

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13
Q

What are the recommended investigations in suspected lung cancer?

A

Imaging:
* CXR
* Staging CT (chest + abdomen)
* PET-CT (fluorodeoxyglucose)
* Definitive imaging for staging

Biopsy:
* Bronchoscopy
* Endobronchial ultrasound and transbronchial-needle aspiration of mediastinal lymph nodes (EBUS [TBNA])
* CT-guided lung biopsy

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14
Q

What imaging is recommended in suspected lung cancer (3)?

A
  • CXR
  • Staging CT (chest + abdomen)
  • PET-CT (fluorodeoxyglucose)
    • Definitive imaging for staging
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15
Q

What biopsy methods is recommended in suspected lung cancer (3)?

A
  • Bronchoscopy
    • For tumours of central airway
    • Where tissue staging not important
  • Endobronchial ultrasound and transbronchial-needle aspiration of mediastinal lymph nodes (EBUS [TBNA])
    • To stage mediastinum +/- achieve tissue diagnosis
  • CT-guided lung biopsy
    • To access peripheral lung tumours
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16
Q

When is bronchoscopy used as an investigation to diagnose lung cancer (2)?

A
  • For tumours of central airway
  • Where tissue staging not important
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17
Q

When is Endobronchial ultrasound and transbronchial-needle aspiration (EBUS [TBNA]) of mediastinal lymph nodes used as an investiation to diagnose lung cancer (2)?

A
  • To stage mediastinum and / or achieve tissue diagnosis
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18
Q

When is CT-guided lung biopsy used as an investigation to diagnose lung cancer (2)?

A
  • To access peripheral lung tumours
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19
Q

What does T1 stand for in TNM 8th edition lung cancer?

A

≤ 3 cm surrounded by lung / visceral pleura, not involving main bronchus

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20
Q

What does T1a(mi) stand for in TNM 8th edition lung cancer?

A

Minimally invasive carcinoma

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21
Q

What does T1a stand for in TNM 8th edition lung cancer?

A

≤ 1 cm

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22
Q

What does T1b stand for in TNM 8th edition lung cancer?

A

> 1 to ≤ 2 cm

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23
Q

What does T1c stand for in TNM 8th edition lung cancer?

A

> 2 to ≤ 3 cm

24
Q

What does T2 stand for in TNM 8th edition lung cancer?

A

> 3 to ≤ 5 cm surrounded by lung / visceral pleura, not involving main bronchus

OR

Involvement of main bronchus without criteria, regardless of distance from carina or invasion visceral pleura

OR

Atelectasis or post obstructive pneumonitis extending to the hilum

25
Q

What does T2a stand for in TNM 8th edition lung cancer?

A

> 3 to ≤ 4 cm

26
Q

What does T2b stand for in TNM 8th edition lung cancer?

A

> 4 to ≤ 5 cm

27
Q

What does T3 stand for in TNM 8th edition lung cancer?

A

> 5 to ≤ 7 cm in greatest dimension

OR

Tumour of any size that involves the chest wall, pericardium or phrenic nerve

OR

Satellite nodules in the same lobe

28
Q

What does T4 stand for in TNM 8th edition lung cancer?

A

> 7 cm in greatest dimension

OR

Tumour of any size that invades the mediastinum, diaphragm, heart, great vessels, recurrent laryngeal nerve, carina, trachea, oesophagus, spine

OR

Separate tumour in different lobe of ipsilateral lung

29
Q

What does N1 stand for in TNM 8th edition lung cancer?

A

Ipsilateral periobranchial and / or hilar nodes and intrapulmonary nodes

30
Q

What does N2 stand for in TNM 8th edition lung cancer?

A

Ipsilateral mediastinal and / or subcarinal nodes

31
Q

What does N3 stand for in TNM 8th edition lung cancer?

A

Contralateral mediastinal or hilar

OR

Ipsilateral nodes

OR

Contralateral scalene

OR

Supraclavicular

32
Q

What does M1 stand for in TNM 8th edition lung cancer?

A

Distant metastasis

33
Q

What does M1a stand for in TNM 8th edition lung cancer?

A

Tumour in contralateral lung or pleura / pericardial nodule / malignant effusion

34
Q

What does M1b stand for in TNM 8th edition lung cancer?

A

Single extrathoracic metastasis, including single non-regional lymph node

35
Q

What does M1c stand for in TNM 8th edition lung cancer?

A

Multiple extrathoracic metastasis in one or more organs

36
Q

What are the determinants of lung cancer treatment (5)?

A
  • Patient fitness
  • Cancer histology
  • Cancer stage
  • Patient preference
  • Health service factors

WHO performance status:

  • 0 - Asymptomatic (Fully active, able to carry on all predisease activities without restriction)
  • 1 - Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work)
  • 2 - Symptomatic, < 50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours)
  • 3 - Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)
  • 4 - Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)
  • 5 - Death
37
Q

What is the recommended treatment of early stage lung cancer (2)?

A
  • Surgery

OR

  • Radiotherapy with curative intent
38
Q

What is the recommended treatment of locally advanced lung cancer (involving thoracic lymph nodes) (2)?

A
  • Surgery
    • Adjuvant chemotherapy

OR

  • Radiotherapy
  • Chemotherapy and / or immunotherapy
39
Q

What is the recommended treatment of metastatic lung cancer (With targetable mutation [e.g. EFGR, ALK, ROS-1]) (1)?

A
  • Tyrosine kinase inhibitor
40
Q

What is the recommended treatment of metastatic lung cancer (No mutation, PDL-1 positive) (1)?

A
  • Immunotherapy
41
Q

What is the recommended treatment of metastatic lung cancer (No mutation, PDL-1 negative) (1)?

A
  • Chemotherapy and Immunotherapy
42
Q

What are the 2 surgical options for lung cancer treatment?

A
  • Lobectomy and Lymphadenectomy usual approach

OR

  • If stage 1 (≤ 3 cm): Sublobar resection
43
Q

What are the systemic treatment options for lung cancer (3)?

A
  • Oncogene-directed therapy
  • Immunotherapy
  • Cytotoxic chemotherapy
44
Q

What are the NICE approved oncogene directed therapy options for EGFR mutation lung cancer (know 2)?

A
  • Erlotinib
  • Gefitinib
  • Afatinib
  • Dacomitinib
  • Osimertinib
45
Q

What are the NICE approved oncogene directed therapy options for ALK mutation lung cancer (know 2)?

A
  • Crizotinib
  • Ceritinib
  • Alectinib
  • Brigatinib
  • Lorlatinib
46
Q

What are the NICE approved oncogene directed therapy options for ROS-1 mutation lung cancer (know 2)?

A
  • Crizotinib
  • Entrectinib
47
Q

Outline the efficacy of oncogene directed therapy compared to cytotoxic chemotherapy.

A
  • Improvements in progression-free survival, but not necessarily overall survival

  • e.g. erlotinib PFS 14 vs 5 months, OS 23 vs 29 months compared to chemo
  • e.g. crizotinib PFS 8 vs 3 months, OS 20 vs 23 months
48
Q

What are the side effects of oncogene directed therapy for lung cancer (3)?

Generally well tolerated.

A
  • Rash
  • Diarrhoea
  • (Uncommonly) Pneumonitis
49
Q

What are the NICE approved immunotherapy options for lung cancer (know 2)?

A
  • Pembrolizumab
  • Atezolizumab
  • Nivolumab
50
Q

Outline the efficacy of immunotherapy compared to cytotoxic chemotherapy.

A
  • Improvements in progression-free survival and overall survival

e.g. pembrolizumab PFS 10 vs 6 months, OS >30 vs 14 months

51
Q

What are the side effects of immunotherapy for lung cancer?

Generally well tolerated.

A
  • Immune-related side-effects in 10-15% (thyroid, skin, bowel, lung, liver)
52
Q

What are the NICE approved cytotoxic chemotherapy options for lung cancer (know 2)?

A
  • Carboplatin
  • Cisplatin
  • Paclitaxel
  • Pemetrexed

Platiunum-based regimens

53
Q

Outline the efficacy of cytotoxic chemotherapy comparred to best supportive care.

A
  • When used alone (old data, pre-2000) modest improvements in overall survival vs best supportive care
    • With pembrolizumab (Keynote 189), a lot better (23% 2y survival vs 5% for standard chemo alone)

e.g. pembrolizumab PFS 10 vs 6 months, OS >30 vs 14 months

54
Q

What are the side effects of cytotoxic chemotherapy for lung cancer (4)?

A

Frequent:
* Fatigue
* Nausea
* Bone marrow suppression
* Nephrotoxicity

Quality of life poorly evaluated in trials; no evidence for improvement

55
Q

When is palliative and supportive care offered to lung cancer patients?

Paliative care:
* Symptom control
* Psychological support
* Education
* Practical and financial support
* Planning for end of life

A
  • Should be offered as standard to all patients with advanced stage disease
56
Q

What is the prognosis of lung cancer?

A
  • Only 10% live > 10 years

Phase 1b - Cardiovascular & Respiratory Medicine (21 decks)

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