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Year 4 Oncology > Lung cancer > Flashcards

Lung cancer Flashcards

1
Q

What are the three types of non-small cell lung cancer?

A

Squamous cell cancer

Adenocarcinoma

Lung cell carcinoma

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2
Q

In what type of lung cancer are caveating lesions more common in?

A

Squamous cell cancer

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3
Q

Typical location of squamous cell lung cancer?

A

Central

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4
Q

What peripheral clinical sign is lung SCC strongly associated with?

A

Finger clubbing

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5
Q

What electrolyte disturbance is SCC lung cancer associated with?

A

HYPERCALCEMIA

Associated with parathyroid hormone-related protein (PTHrP) secretion → hypercalcaemia

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6
Q

What type of lung cancer is associated with hypercalcemia and why?

A

SCC
Associated with parathyroid hormone-related protein (PTHrP) secretion → hypercalcaemia

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7
Q

What lung cancer is associated with hypertrophic pulmonary osteoarthropathy (HPOA)?

A

SCC

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8
Q

What type of lung cancer is most common in non-smokers?

A

Adenocarcinoma

(although the majority of patients who develop lung adenocarcinoma are smokers)

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9
Q

Typical location of adenocarcinoma type lung cancer?

A

Peripheral

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10
Q

Typical location of large cell lung carcinoma?

A

Peripheral

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11
Q

What type of lung cancer may secrete β-hCG?

A

Large cell lung cancer

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12
Q

What might large cell lung cancer secrete?

A

B-hCG

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13
Q

Characteristics of large cell lung cancer tumours?

A

anaplastic, poorly differentiated tumours with a poor prognosis

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14
Q

What type of cancer is most commonly associated with superior vena cava obstruction?

A

Lung cancer

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15
Q

Small vs non-small cell lung cancer - which is more common?

A

Non small cell, adenocarinoma most common subtype

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16
Q

What is the most common subtype of non-small cell cancer

A

Adenocarcinoma

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17
Q

Lung cancer - general risk factor

A

Smoking (tobacco and cannabis)

Passive smoking

Occupation exposure (asbestos, silica, welding fumes, coal)

HIV

Organ transplantation

Radiation exposure (X-ray, gamma rays).

Beta-carotene supplements in smokers (convert to vit A in body)

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18
Q

Lung cancer - general SYMPTOMS

A

Cough

Haemoptysis

Dyspnoea

Chest Pain

Weight loss

Nausea and Vomiting

Anorexia

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19
Q

Lung cancer - general SIGNS

A

Cachexia

Finger Clubbing

Hypertrophic pulmonary osteoarthropathy

Anaemia

Horner’s syndrome (if the tumour is apical)

Examination of the chest: consolidation (pneumonia); collapse (absent breath sounds, ipsilateral tracheal deviation); pleural effusion (Stony dull percussion, decreased vocal resonance and breath sounds)

Enlargement of supraclavicular and axillary lymph nodes

Paraneoplastic syndromes: Cushing’s syndrome, SIADH, and Lambert-Eaton syndrome (suggest small-cell), hyperparathyroidism (suggests squamous cell)

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20
Q

Lung cancer: O/E - auscultation

A

Absent breath sounds - lung collapse

Decreased vocal resonance and bronchial breath sounds - pleural effusion

Pleural firction rub (Nonmusical, explosive, usually biphasic sounds; typically heard over basal regions) - pleural tumour or pleural inflamation

Corase crackle (indicates intermittent airway opening, may be related to secretions) - pneumonia

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21
Q

Lung cancer: O/E - percussion

A

Stony dull percussion - pleural effucsion

Dull percussion - consolidation

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22
Q

If lymphadenopathy is present in lung cancer, which lymph nodes may be elarged?

A

Supraclavicular
Axillary

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23
Q

What paraneoplastic syndromes may be present in small cell lung cancer?

A

Cushing’s syndrome (ectopic ACTH)
SIADH (ectopic ADH)
Lambert-Eaton syndrome

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24
Q

What non-metastatic complications of bronchial carcinoma, which can arise due to local invasion, may be present and why?

A

DYSPONEA
People with lung cancer can experience shortness of breath if the cancer invades major airways.

HAEMOPTYSIS
The invasion of cancer into the airways which is friable tissue may lead to bleeding.

PAIN
Advanced lung cancer may cause local invasion affecting the lining of pleural cavity or bone causing pain.

PLEURAL EFFUSION
Lung cancer can cause inflammatory reactions which lead to the accumulation of fluid in the pleural space.

SUPERIOR VENA CAVA OBSTRUCTION
The cancer may invade into surrounding tissues leading to compression of the drainage of the superior vena cava leading to dyspnea and facial plethora due to venous congestion.

PNEUMOTHORAX
Invasion of the tumour may lead to a communication between the lung parenchyma and the pleural cavity resulting in the collapse of the lung.

ATELECTASIS
The invasion of a tumour may lead to total obstruction of the airway leading to collapse of that lobe

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25
Q

What is the most common presentation of lung squamous cell carcinoma and why?

A

Infection, due to obstructive lesions of the bronchus

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26
Q

Differentiating between a lung abscess or SCC on imaging

A

Hard to differentiate on CXR as the border’s definition cannot easily be seen

Jagged border in SCC is obvious on CT

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27
Q

Spread pattern of lung SCC?

A

Local spread common

Mets frequent, but normally LATE

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28
Q

By what two mechanisms can lung SCC cause hypercalcemia?

A

by bone destruction or

production of PTH analogues (PTHrp)

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29
Q

What paraneoplastic syndromes are lung SCCs associated with?

A

HPOA (Hyper trophic pulmonary osteoarthropathy)

Hypercalcemia - PTHrP-producing

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30
Q

From which cells does lung adenocarcinoma arise?

A

Mucous cells in the bronchial epithelium

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31
Q

From which cells does the most common type of lung cancer arise?

A

Adenocarcinoma -

Mucous cells in the bronchial epithelium

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32
Q

Where does adenocarcinoma of the lung tend to invade?

A

Invades the mediastinal lymph nodes and the pleura

Spreads to the brain and bones

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33
Q

Which types of lung cancer are most likely to cause pleural effusion

A

Adenocarcinoma and mesotheliomas

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34
Q

Which type of lung cancer is least likely to be related to smoking?

A

Adenocarcinoma

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35
Q

What type of lung cancer is proportionally more common in women?

A

Adenocarcinoma

36
Q

What type of lung cancer is proportionally more common in the Far East?

A

Adenocarcinoma

37
Q

From what cells does small cell carcinoma of the lung arise, and what is the signficance of this?

A

Arise from endocrine cells (Kulchitsky cells).

These are APUD cells, and as a result, these tumours will secrete many poly-peptides mainly ACTH.

38
Q

What endocrine presentations might small cell carcinoma of the lung cause?

A

CUshing’s disease
Addison’s disease

39
Q

Why is the prognosis of lung small cell carcinoma generally poor?

A

Small cell carcinoma spreads very early and is almost always inoperable at presentation
.
These tumours do respond to chemotherapy, but the prognosis is generally poor.

40
Q

What management do small cell carcinoma lung tumour tend to respond well to?

A

Chemotherapy

41
Q

Neurological paraneoplastic syndromes in lung cancer?

A

Polyneuropathy (Antibodies against the myelin sheath)

Cerebellar degeneration

Lambert-Eaton Syndrome

42
Q

Vascular and haematological paraneoplastic syndromes in lung cancer?

A

Anaemia

Thrombophlebitis migrans

43
Q

Features of Hypertrophic pulmonary osteoarthropathy?

A

Joint stiffness

Join pain: severe in wrist and ankles

Sometimes, gynaecomastia

XR: proliferative periostitis at the ends of the long bones, which have an ‘onion skin’ appearance

Finger clubbing (if cancer the cause)

44
Q

What are 30% of finger clubbing cases caused by?

A

Non-small cell carinoma of the lung

45
Q

What is though to cause HPOA in lung cancer and why?

A

It is thought to be caused by a blood borne factor released by the tumour – when patients have the primary tumour removed, the pain goes away

46
Q

Which features does carcinoid syndrome present with?

A

hepatomegaly
flushing
diarrhoea

47
Q

Why might lung cancer cause hyponatremia?

A

Paraneoplastic syndrome of SIADH (inappropriate ADH secretion)

Particularly associated with SMALL CELL lung cancer

48
Q

Why might lung cancer be associated with Cushing’s syndrome?

A

Secretion of ectopic ACTH.

Small cell lung cancer is the most common cause.

Ectopic ACTH stimulates excessive cortisol release from the adrenal glands.

49
Q

Cushingoid features on inspection of patient

A

Features on inspection (round in the middle with thin limbs):

Round face (known as a “moon face”)

Central obesity

Abdominal striae (stretch marks)

Enlarged fat pad on the upper back (known as a “buffalo hump”)

Proximal limb muscle wasting (with difficulty standing from a sitting position without using their arms)

Male pattern facial hair in women (hirsutism)

Easy bruising and poor skin healing

Hyperpigmentation of the skin in patients with Cushing’s disease (due to high ACTH levels)

50
Q

Where does lung cancer commonly metastesise to and how?

A

BRAIN
BREAST
ADRENALS
BONE

The most likely mechanism by which brain metastases spread is via the bloodstream.

51
Q

What CXR abnormalities may be seen in lung cancer?

A

Nodules
Lung collapse
Pleural effusion
Consolidation
Bony metastases

(image A chest x-ray of an individual with a left sided lung cancer)

52
Q

Lung cancer: investigations

A

Sputum cytology

CXR - first line

Contrast-enhanced CT scan: this is used to further confirm the diagnosis and stage The CT scan should also include both the adrenals and liver to look for sites of metastases.

PET-CT (positron emission tomography) scans involve injecting a radioactive tracer (usually attached to glucose molecules) and taking images using a combination of a CT scanner and a gamma ray detector to visualise how metabolically active various tissues are. They are useful in identifying areas that the cancer has spread to by showing areas of increased metabolic activity suggestive of cancer.

Bronchoscopy with endobronchial ultrasound (EBUS) involves endoscopy of the airways (bronchi) with ultrasound on the end of the scope. This allows for detailed assessment of the tumour and ultrasound guided biopsy - Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA - allows biopsy of lymph nodes, paratracheal and bronchial lung lesions for histology

HISTOLOGY - to check the type of cells in the cancer requires a biopsy. This can be either by bronchoscopy or percutaneously (through the skin).

Cardiovascular review and lung function tests should also be performed to assess patient’s suitability for treatment options.

53
Q

Roles of endobronchial transbronchial needle aspiration in investigating lung cancer (EBUS-TBNA)

A

Allows biopsy of the following for histology:

Lymph nodes
Paratracheal lung lesions
Bronchial lung lesions

54
Q

What should be included in the contrast-enhanced CT scan performed when investigating pts with lung cancer?

A

Both adrenals and liver, to look for sites of mets

55
Q

What is the first line management of non-small cell lung cancers (NSCLC) if pt is suitable?

A

Lobectomy

56
Q

NSCLC management

A

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.

57
Q

Which stages of NSCLC can be offered curative radiotherapy?

A

Stages I-III

58
Q

What stages of NSCLC should be offered chemotherapy to control the disease and improve quality of life?

A

Stages III and IV

59
Q

How is small cell lung cancer managed (generally)

A

Generally palliative chemotherapy, as tumours are disseminated on presentation.

60
Q

What is Pancoast’s syndrome?

A

Symptoms are caused by an apical malignant neoplasm of the lung.

These include ipsilateral invasion of the sympathetic cervical plexus leading to Horner’s syndrome with shoulder and arm pain due to Brachial Plexus invasion.

Association with smoking

61
Q

What signs may be seen on CXR in lung cancer?

A

Hilar enlargement

“Peripheral opacity” – a visible lesion in the lung field

Pleural effusion – usually unilateral in cancer

Collapse

62
Q

Extra-pulmonary manifestations of lung cancer?

A

Recurrent laryngeal nerve palsy

Superior vena cava obstruction

Horner’s syndrome (Pancoast’s tumour)

SIADH (small cell lung cancer)

Cushing’s syndrome (small cell lung cancer)

Hypercalcaemia (squamous cell carcinoma)

Limbic encephalitis (small cell lung cancer)

Lambert-Eaton myasthenic syndrome.

63
Q

What might make a patient with lung cancer present with a hoarse voice and why?

A

Recurrent laryngeal nerve palsy

It is caused by the cancer pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum.

64
Q

What extrapulmonary manifestation of lung cancer might cause SOB and why?

A

Phrenic nerve palsy due to nerve compression causes diaphragm weakness and presents as shortness of breath.

65
Q

What specific syndrome (inc symptoms) might you see in a patient with a Pancoast’s tumour, and why?

A

Horner’s syndrome

Triad of
PARTIAL PTOSIS
ANHIDROSIS
MIOSIS

It is caused by a Pancoast’s tumour (tumour in the pulmonary apex) pressing on the sympathetic ganglion (PRE-GANGLIONIC LESION)

66
Q

Where is a Pancoast tumour situated?

A

Pulmonary apex

May press on the sympathetic ganglion and cause Horner’s syndrome

67
Q

What is limbic encephalitis?

A

Limbic encephalitis. This is a paraneoplastic syndrome where the small cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas.

This causes symptoms such as short term memory impairment, hallucinations, confusion and seizures.

It is associated with anti-Hu antibodies.

68
Q

What type of lung cancer is limbic encephalitis associated with?

A

Small cell

69
Q

What antibodies is limbic encephalitis associated with?

A

Anti-Hu

70
Q

What are the signs/symptoms of limbic encephalitis?

A

Short term memory impairment

Hallucinations

Confusion

Seizures

71
Q

In what type of lung cancer does Lambert-Eton myasthenic syndrome occur and why?

A

SMALL CELL LUNG CANCER

Lambert-Eaton myasthenic syndrome is a result of antibodies produced by the immune system against small cell lung cancer cells.

72
Q

Basic pathophysiology of Lambert-Eaton myasthenic syndrome?

A

Antibodies produced by the immune system against small cell lung cancer cells.

These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones

This leads to weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing).

Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.

73
Q

Signs/symptoms of Lambert-Eaton Myasthenic Syndrome?

A

Proximal muscle weakness

Diplopia (intraocular muscle weakness)

Ptosis (levator muscles in the eyelids)

Slurred speech (pharyngeal muscle weakness)

Dysphagia (pharyngeal muscle weakness)

Post-tetanic potentiation - reduced tendon reflexes that become temporarily normal for a short period following a period of strong muscle contraction.

74
Q

What is mesothelioma?

A

Mesothelioma is a lung malignancy affecting the mesothelial cells of the pleura.

75
Q

What is mesothelioma highly linked to and what is notable about this association?

A

Asbestos inhalation.

There is a huge latent period between exposure to asbestos and the development of mesothelioma of up to 45 years.

76
Q

Management/prognosis of mesothelioma?

A

The prognosis is very poor.

Chemotherapy can improve survival but it is essentially palliative.

77
Q

What is a pleural effusion?

A

A pleural effusion is a collection of fluid in the pleural cavity.

This can be exudative meaning there is a high protein count (>3g/dL) or transudative meaning there is a relatively lower protein count (<3g/dL).

Whether it is exudative or transudative helps determine the cause.

78
Q

What protein count would you expect in a pleural effusion due to lung malignancy?

A

Exudative pleural effusion -

meaning there is a HIGH protein count

(>3g/dL)

79
Q

Is pleural effusion due to lung cancer exudative or transudative?

A

EXUDATIVE

80
Q

When might a TRANSUDATIVE pleural effusion be seen in a patient with cancer?

A

Meig’s syndrome - (right sided pleural effusion with ovarian malignancy)

Lung cancer would cause an EXUDATIVE pleural effusion

81
Q

Why does lung cancer cause pleural effusion?

A

The cancer itself or and opportunistic pneumonia causes inflamation.

The inflammation results in protein leaking out of the tissues in to the pleural space

Fluid collects in the pleural cavity - the potential space between the visceral and parietal pleura (which normally contains a small amount of lubricating serous fluid)

82
Q

What are the signs/symptoms of pleural effusion?

A

Shortness of breath
Dullness to percussion over the effusion
Reduced breath sounds
Tracheal deviation away from the effusion if it is massive

83
Q

CXR signs in pleural effusion?

A

Blunting of the costophrenic angle

Fluid in the lung fissures

Larger effusions will have a meniscus. This is a curving upwards where it meets the chest wall and mediastinum.

Tracheal and mediastinal deviation if it is a massive effusion

Taking a sample of the pleural fluid by aspiration or chest drain is required to analyse it for protein count, cell count, pH, glucose, LDH and microbiology testing.

84
Q

Potential complications of pleural effusion

A

Complications vary depending on the cause of the pleural effusion.

Larger pleural effusions may cause increasing respiratory compromise. In parapneumonic effusions, complications may include empyema and sepsis.

Complications, such as pneumothoraces, may relate to pleural procedures carried out during the diagnosis and treatment of a pleural effusion.

Patients with malignancy or pneumonia have a poorer prognosis if a pleural effusion develops.

85
Q

Management of pleural effusion?

A

Conservative management may be appropriate as small effusions will resolve with treatment of the underlying cause. Larger effusions often need aspiration or drainage.

Pleural aspiration involves sticking a needle in and aspirating the fluid. This can temporarily relieve the pressure but the effusion may recur and repeated aspiration may be required.

Chest drain can be used to drain the effusion and prevent it recurring.

86
Q

Empyema

A

Empyema is where there is an infected pleural effusion.

Suspect an empyema in a patient who has an improving pneumonia but new or ongoing fever.

Pleural aspiration shows pus, acidic pH (pH < 7.2), low glucose and high LDH. Empyema is treated by chest drain to remove the pus and antibiotics.

Year 4 Oncology (15 decks)

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