Lung cancer Flashcards
1
Q
What are some risk factors of lung cancer?
A
Smoking
Asbestos
Nickel
Chromates
Radiation
Atmospheric pollution
Genetics
2
Q
What are some components of tobacco smoke that increased the risk of lung cancer?
A
Polycyclic hydrocarbons
Aromatic amines
Phenols
Nickel
Cyanates
3
Q
What percentage of smokers will die of lung cancer?
A
Around 20%
4
Q
How might lung cancer cause symptoms?
A
Via the primary tumour, local invasion, metastases or via its paraneoplastic syndromes
5
Q
What are some symptoms of lung cancer?
A
Persistent cough
Haemoptysis
Shortness of breath
Dysphagia
Dysphonia
Cachexia (Weight loss)
6
Q
How does lung cancer cause haemoptysis?
A
Invasion of the chest wall can erode blood vessels
7
Q
How can lung cancer cause dysphonia?
A
The tumour can obstruct the recurrent laryngeal nerve
8
Q
What are some red flag symptoms that people should go to the GP with, that may be suggestive of lung cancer?
A
For for ≥3 weeks
Breathlessness for no reason
Chest infection that doesn’t clear
Haemoptysis (Most likely chest infection)
Unexplained weight loss
Chest or shoulder pain
Unexplained tiredness or lack of energy
Hoarse voice
Recurrent pneumonia
Stridor
9
Q
What are some clinical signs suggestive of lung cancer?
A
Fixed, monomorphic wheeze
Supraclavicular lymphadenopathy
Cervical lymphadenopathy
Finger clubbing
10
Q
What are the 4 main types of lung tumour?
A
Adenocarcinoma (35%)
Squamous cell carcinoma (30%)
Small cell carcinoma (25%)
Large cell carcinoma (10%)
11
Q
What type of cells do adenocarcinomas effect?
A
Glandular cells
12
Q
What type of cell is affected by squamous cell carcinoma?
A
Keratinising, squamous epithelial cells
13
Q
What type of cell is affected by small cell carcinoma?
A
Neuroendocrine cells
14
Q
What type of cell is affected by large cell carcinoma?
A
Any cell type (Causes large cell formation)
15
Q
What are some common secondary lung cancers in primary lung cancer?
A
Neuroendocrine tumours
Bronchial gland tumours
16
Q
What is the most basic classification of lung cancer?
A
Small cell vs non-small cell
17
Q
What are some common characteristics of small cell carcinoma?
A
They are usually rapidly progressing, metastasise early and is usually very chemosensitive early on
18
Q
What are some common characteristics of large cell carcinoma?
A
They are usually slower growing and can sometimes be cured using surgery or radical radiotherapy
19
Q
What is an example of a neuroendocrine neoplasm?
A
Carcinoid tumours
20
Q
What are some examples of bronchial gland neoplasms?
A
Adenoid cystic carcinomas
Mucoepidermoid carcinoma
21
Q
What is the usual pathogenesis of lung cancer?
A
Squamous metaplasia
Then dysplasia
Then carcinoma in situ
Then invasive malignancy
Then metastases
22
Q
What is a common pathogenesis of peripheral adenocarcinomas?
A
Atypical adenomatous hyperplasia
Then spread of neoplastic cells along alveolar walls
Then true invasive adenocarcinoma
23
Q
What is the most basic staging for lung cancer?
A
Stage I - Tumour <3cm, No spread
Stage II - Tumour 3-5cm, Local lymph node involvement
Stage III - Tumour >5cm, Central lymph node involvement
Stage IV - Tumour >7cm, Metastasis
24
Q
What is the clinical method of tumour staging?
A
TNM staging
T = Tumour
N = Nodes
M = Metastasis
25
What can occur due to local invasion of the recurrent laryngeal nerve in lung cancer?
Paralysis of the vocal cords and hoarse voice
26
What can occur due to local invasion of the pericardium in lung cancer?
Breathlessness, atrial fibrillation and risk of pericardial effusion (The fluid from which can be used to diagnose cancer)
27
What can occur due to local invasion of the oesophagus?
Dysphagia
28
What can occur due to local invasion of the brachial plexus of nerves?
muscle weakness and wastage in the arm
29
What can occur due to local invasion of the pleural cavity and ribs?
Chest pain and pleural effusion
30
What can occur due to local invasion of the superior vena cava?
Congestion in the jugular and subclavian veins can lead to swelling and erythema in the head, as well as a distended internal jugular vein and superficial, visible anastomoses across the chest
31
How can local invasion and obstruction of the SVC be treated?
Stent implantation and palliative chemotherapy or radiotherapy
32
What can occur due to local invasion of the pulmonary arteries?
Increased risk of pulmonary embolism or decreased blood supply to the lungs
33
What is a Pancoast tumour?
A form a non-small cell tumour that invades through the chest wall of the apices and invades the brachial plexus, causing muscle wastage in the arm and hand
34
What is a common presentation of a Pancoast tumour?
The patient will often complain of dropping a lot of things such as cups of tea
35
What is a possible complication of a Pancoast tumour?
Horner's syndrome
36
What is Horner's syndrome?
A syndrome in which a Pancaost tumour compresses the sympathetic chains that supply the head
37
What are the 3 signs of Horner's syndrome?
Unilateral mitosis, ptosis and anhidrosis
38
What is miosis?
Pupil constriction
39
What is ptosis?
Eyelid drooping
40
What is anhydrosis?
Lack of sweating
41
What are the 6 main areas to which lung cancer can metastasise?
Brain
Liver
Bone
Adrenal glands
Skin
Contralateral lung
42
What are some symptoms and complications of brain metastases?
Brain metastases will often have an insidious onset, resulting in weakness, fits, visual disturbances and headaches which are worse in the morning and are not photophobic
43
How can liver metastases present?
Liver metastases don't often cause symptoms, however, it can cause a dull abdominal ache
44
What are some complications of bone metastases?
Bone weakness and descruction, leading to weakness and easy bone fracturing
45
What are paraneoplastic syndromes?
These are symptoms and effects of cancers that are not directly caused by tumour production, but are caused by genetic abnormalities, leading to production of hormones and chemicals that therefore cause effects
46
What type of cells are affected by small cell lung cancer?
Neuroendocrine cells
47
What are some possible paraneoplastic syndromes of small cell lung cancer?
SIADH
Cushing's syndrome
Lambert-Eaton syndrome
48
What is meant by SIADH?
Syndrome of Inappropriate Anti-Diuretic Hormone
49
What occurs in SIADH?
This is a complex paraneoplastic syndrome in which a tumour secretes large amounts of ADH, resulting in hyponatraemia as the kidneys increase excretion of sodium?
50
What are some common symptoms of SIADH?
Nausea
Myoclonus (Sudden, brief muscle twitching)
Lethargy
Confusion
Seizures
Coma
51
How can SIADH be treated?
Using fluid restriction and possible demeclocycline
52
What occurs in Lambert-Eaton syndrome?
This is a condition in which the body produces antibodies against Ca2+ receptors, leading to muscle weakness
53
What occurs in Cushing's syndrome?
This is a condition in which there is an abnormal production of adrenocorticotrophic hormone
54
What are some symptoms of Cushing's syndrome?
Trunkal obesity
Thin limbs
Rounded face
Shoulder humping
Fatigue
Weakness
55
What type of cell is affected in squamous cell carcinoma?
The keratinising squamous cells of the lungs
56
Which form of cancer can cause cavitating lesions?
Squamous cell carcinoma
57
What are some some paraneoplastic syndromes that can occur in squamous cell carcinoma?
Hypercalcaemia
Hypertrophic Pulmonary Osteoarthropathy (HPOA)
58
How does hypercalcaemia occur in squamous cell carcinoma?
This occurs due to the production of parathyroid hormone-related protein, which mimics an anti-diuretic and causes calcium retention by the kidneys
59
What are the symptoms of hypercalcaemia as a paraneoplastic syndrome in squamous cell carcinoma?
Stones - Renal/Biliary calculi
Bones - Bone pain
Groans - Abdominal pain, constipation
Thrones - Polyuria (Lots of urine)
Psychiatric Overtones - Depression, anxiety
60
What is the treatment regime in hypercalcaemia as a paraneoplastic syndrome
Initial: rehydration
If calcium >4 : IV Bisphosphate (Pamidronate) to decrease Ca2+ levels
61
What is meant by Hypertrophic Pulmonary Osteoarthropathy?
Inflammation and lifting of the periosteum surrounding the bone
62
What are some clinical presentations of hypertrophic pulmonary osteoarthropathy?
Periostitis
Bone pain
Digital clubbing
Arthropathy of large joints
63
Which cancer is the most common in non-smokers?
Adenocarcinoma
64
What type of cell is affected in adenocarcinoma?
Mucus secreting glandular cells
65
What are some paraneoplastic syndromes of adenocarcinoma?
Gynaecomastia
Hypertrophic pulmonary osteoarthropathy
66
What is the first line investigation in suspected lung cancer?
Chest X-ray
67
What investigation will be used for screening and further suspicion in a clear CXR?
Contrast-enhanced CT scan
68
When is PET scanning useful in cancers?
If the cancer cannot be fully staged via contrast CT scanning
69
How does PET scanning work?
PET scanning detects the intake of radio-labelled glucose and so measures areas of greatly increased respiration and glucose metabolism
70
What are some ways in which tissue samples can be taken to give a full diagnosis of lung cancer?
Bronchoscopy
CT guided biopsy
Lymph node aspiration
Aspiration of pleural fluid
EndoBrachial UltraSound (EBUS)
Thoracoscopy
71
What are the advantages and disadvantages of CT guided lung biopsy in lung cancer?
It is useful in tumours that invade the chest or in healthy patients, however, it does carry a risk of pneumothorax
72
What occurs in a thoracoscopy?
The lung is deflated and a camera and sampling tool is inserted through the chest wall, and a sample of the chest wall is taken
73
What is an example of an immunohistochemical marker of adenocarcinomas?
TTF1 (Thyroid Transcription Factor 1)
74
What is an example of an immunohistochemical marker of squamous cell carcinoma?
Nuclear antigen p63 and high molecular weight cytokeratins
75
What are some normal tests that should be carried out in lung cancer, not for staging or diagnosis, but to show the effects
Full blood counts
Sodium levels
Calcium levels
Alkaline phosphatase
Spirometry
76
How are bone metastases shown in lung cancer?
Using radionucleotide bone scanning (99M Tc)
77
What are some examples of lung cancer mimics?
Tuberculosis
Vasculitis
Pulmonary embolism
Secondary cancer
Lymphoma
Bronchiectasis
78
Which treatment does small cell carcinoma have a very good initial response to?
Chemotherapy
79
What is meant by radical treatment?
Treatment delivered with the intent of long term disease control
80
What is meant by palliative treatment?
Treatment delivered without intention of cure, for the control or relief of symptoms
81
What is meant by neo-adjuvent treatment?
Treatment delivered before the definitive treatment e.g. chemo before surgery
82
What is meant be adjuvant treatment?
Treatment delivered after the definitive treatment to reduce the risk of recurrence e.g. chemo after surgery
83
What is meant by concurrent treatment?
Chemotherapy and radiotherapy together
84
What is meant by sequential treatment?
Chemotherapy then radiotherapy
85
What is a gray in radiotherapy?
This is the unit of measurement for radiotherapy dosing
Dose delivered ÷ Dose absorbed by tissue
(Joules per kilogram)
86
What is meant by a fraction in lung cancer treatment?
The number of daily treatments
87
Which treatment is the preferred choice in lung cancer?
Surgery
88
What is the 1 year survival rate after surgery in lung cancer?
81%
89
How is staging for surgery carried out?
Bronchoscopy
Mediastinoscopy
CT scanning of brain, thorax and abdomen
PET scanning of abdomen
90
What are the uses of bronchoscopy in staging for surgery in lung cancer?
It can check for vocal cord palsy, proximity to the carina and cell type
91
What are the uses of mediastinoscopy in screening for lung cancer?
Check lymph node involvement
92
What are some available surgical procedures in lung cancers?
Pneumonectomy - Lung removal
Lobectomy - Lobe removal
Lymph node removal
VATS - Video Assisted Thoracic Surgery
RATS - Robotics Assisted Thoracic Surgery
93
Which form of lung cancer is more susceptible to chemotherapy?
Small cell lung cancers as it targets rapidly dividing cells and small cell lung cancers develop quickly
94
What are some methods of screening for chemotherapy?
Tissue sampling
CT scanning
95
What scoring system is used to calculate chemotherapy risk?
ECOG score
96
How is the ECOG score calculated?
This is a scoring system from 1-5:
0 - Fully active, able to carry on all pre-disease performance without restriction
1 - Restricted in physically strenuous activity but able to carry out light work
2 - Ambulatory for >50% waking hours and capable of self care but unable to carry out work
3 - Capable of only limited self care and confined to bed or chair for >50% waking hours
4 - Completely disabled and cannot carry out any self care
5 - Dead
97
What are some common side effects of chemotherapy?
Nausea and vomiting
Tiredness
Bone marrow suppression so infection or anaemia
Hair loss (Not in lung cancer regimes)
Pulmonary fibrosis
98
What is meant by systemic therapy in lung cancer?
This is a combination of chemotherapy and targeted, personalised medicine
99
What are some common targetable mutations in lung cancer?
EGFR and ALK1
100
How are EGFR mutations targeted in lung cancer treatment?
By tyrosine kinase inhibitor (erlotinib), which is taken as a tablet
Tumours can become resistant however, but some of the more common mutations can be targeted now
101
How are ALK1 mutations in brain metastases of lung cancer treated?
By tyrosine kinase inhibitors, which cause the brain metastases to "Melt away"
102
How can EML4-ALK fusion oncogenes be targeted?
Crizotinib
103
What is the main target of immunotherapy in lung cancer?
This targets PD-L1 (Programmed Death Ligand) which binds to PD receptors on T lymphocytes, which usually inactivate the cytotoxic immune response, and thus blocking this allows an immune response to be mounted
104
What occurs in radiotherapy?
Radiotherapy involves the use of ionising radiation, usually X-rays, via a linear accelerator, to destroy or shrink the tumour
105
Why is radiotherapy not classed as curative?
It does not remove lymph nodes, so there is always the chance that lymph node involvement is missed
106
What are some structures that are at risk from radiotherapy in lung cancer?
The spinal cord
Oesophagus
Adjacent lung tissue
107
From how many angles is radiotherapy usually given?
4-5 angles
108
What is meant by SABR?
Stereotactic ablative radiotherapy
This involves targeting the tumour from many angles, giving higher dose radiation to the tumours core, while a 4D CT scan is used to tract the tumours movement while the person breaths
109
What are some early symptoms of radiation toxicity after radiotherapy?
Nausea
Diarrhoea
Mucositis (Inflamed mouth or gut)
Skin reactions
110
What are some late symptoms of radiation toxicity after radiotherapy?
Skin scarring
Cardiac events
Insufficiency fractures
Pulmonary fibrosis
111
What are some methods of palliative care in lung cancer?
Endobrachial therapy
Stent implantation
Pain management
Sickness management
Anxiety management
112
What is an example of endobrachial therapy?
Photodynamic therapy
113
What occurs in photodynamic therapy?
A drug is given which induces photosensitivity in the tumour, before a bright light is shone on the tumour, causing a degree of apoptosis and shrinkage, allowing opening of the airways
114
What are some disadvantages of photodynamic therapy?
This makes the person highly sensitive to light so patients may be trapped indoors during their final weeks of life
