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BRS YR2 > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

How common is lung cancer?

A
  • 3rd most common (UK)
  • leading cause of cancer death
  • 48000 diagnoses per year
  • 35000 deaths per year
  • 10-15% never smoked
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2
Q

Who is most likely to have lung cancer?

A
  • 75-90yrs old
  • males
  • low socioeconomic status
  • smoking
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3
Q

What are the causes of lung cancer?

A
  • smoking
  • passive smoking
  • asbestos (x2)
  • radon
  • indoor cooking fumes
  • chronic lung disease (COPD, Fibrosis)
  • Immunodeficiency
  • genetics/family history
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4
Q

What are the 4 different types of lung cancer?

A
  • squamous cell carcinoma
  • adenocarcinoma
  • large cell lung cancer
  • small cell lung cancer
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5
Q

What is squamous cell carcinoma?

A
  • 30% of cases
  • originates in bronchial epithelium
  • centrally located
  • used to be the most common
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6
Q

What is adenocarcinoma?

A
  • 40% of cases
  • possible link to low tar cigarettes which are inhaled more deeply
  • originates from mucus producing glandular tissue
  • located peripherally
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7
Q

What is large cell lung carcinoma?

A
  • 15%
  • heterogenous composition
  • large pleomorphic cells
  • peripherally located
  • originated from epithelial cells
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8
Q

What is small cell lung cancer?

A
  • 15%
  • originates at pulmonary neuroendocrine cells
  • highly malignant
  • centrally located
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9
Q

What cancers make up Non-Small Cell Lung Cancer?

A
  • squamous cell carcinoma
  • adenocarcinoma
  • large cell lung cancer
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10
Q

What histology can be seen in early lung cancer development?

A

hyperplasia, followed by squamous metaplasia

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11
Q

What histology can be seen in intermediate lung cell cancer development?

A

dysplasia

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12
Q

What histology can be seen in late lung cell cancer development?

A

carcinoma in situ followed by an invasive carcinoma

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13
Q

What is metaplasia?

A

reversible change in which one adult cell type replaced by another adult cell type; adaptive

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14
Q

What is dysplasia?

A

abnormal pattern of growth in which some of the cellular and architectural features of malignancy are present; pre-invasive stage with INTACT basement membrane

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15
Q

What is an oncogene?

A

genetic mutations that predisposes someone to a particular cancer, important to inform treatment/prevention

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16
Q

What is impact of Epidermal Growth Factor Receptor (EGFR) Tyrosine Kinase mutation?

A 
- 15-30% adenocarcinoma
seen in:
- women 
- asian ethnicity
- never-smokers
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17
Q

What is the impact of Anaplastic Lymphoma Kinase (ALK) Tyrosine Kinase mutation?

A
  • 2-7% of non-small cell lung cancer
    seen in:
  • youth
  • never-smokers
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18
Q

What is the impact of a mutation in c-ROS Oncogene 1 (ROS-1) Receptor Tyrosine Kinase?

A
  • 1-2% of non-small cell lung cancer
    seen in:
  • youth
  • never-smokers
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19
Q

What is the impact of a mutation in BRAF (downstream cell-cycle signalling mediator)?

A
  • 1-3% of non-small cell lung cancer
    seen in:
  • smokers
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20
Q

What are the key symptoms of lung cancer?

A
  • cough
  • weight loss
  • breathlessness
  • fatigue
  • chest pain
  • haemoptysis
    OFTEN ASYMPTOMATIC
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21
Q

What are the features of advanced/metastatic disease?

A 
neurological features
- focal weakness
- seizures
- spinal cord compression
bone pain 
paraneoplastic syndromes:
- clubbing 
- hypercalcaemia
- hyponatraemia
- cushing's
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22
Q

What are the common signs seen with lung cancer?

A
  • clubbing
  • cachexia
  • Horner’s syndrome
  • Pemberton’s sign
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23
Q

What is the most useful form of imaging to see occult metastases?

A

PET scan

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24
Q

What types of imaging are used to diagnose lung cancer?

A
  • Chest x-ray
  • Staging CT (chest+abdomen)
  • PET scan
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25
Q

When should a bronchoscopy be used in lung cancer?

A
  • tumours of the central airway
  • no need for tissue staging
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26
Q

How do you choose the method of primary biopsy?

A

Choose based on:

  • accessibility
  • availability
  • impact on staging
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27
Q

What is the aim of an Endobronchial US and Transbronchial-needle aspiration of the mediastinal lymph nodes?

A

stage mediastinum +/- achieve tissue diagnosis

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28
Q

Why would you do a CT-guided lung biopsy?

A

to access peripheral lung tumours

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29
Q

What does T1-4 represent in staging?

A

tumour size and location

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30
Q

What does N0-3 represent in staging?

A

lymph node involvement - mediastinum and beyond

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31
Q

What does M0-1c represent in staging?

A

metastases and the number of them

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32
Q

What are the determinants of treatment?

A
  • patient fitness
  • cancer histology
  • cancer stage
  • patient preference
  • health service factors
33
Q

What are the different classifications in the WHO performance status?

A

0 - Asymptomatic
1 - Symptomatic, completely ambulatory
2 - symptomatic, < 50% in bed during the day
3 - symptomatic, >50% in bed, not bedbound
4 - bedbound
5 - death

34
Q

Which WHO performance statuses is radical treatment restricted to?

A

PS 0-2

35
Q

What should also be taken into account with the WHO performance status?

A
  • comorbidity
  • lung function
36
Q

What is the standard of care for early stage lung cancer?

A
  • surgical resection
  • radiotherapy with curative intent
37
Q

What is the most common surgical resection done in lung cancer?

A

lobectomy (+/-) lymphandectomy

38
Q

What is the surgical resection done if the cancer is stage I (<3cm)?

A

sublobar resection

39
Q

What is a wedge resection?

A
  • removal of a small part of the lung
  • removes tumour + a margin of healthy tissue
40
Q

What is a segmental resection?

A

removing a large part of the lung, but NOT an entire lobe

41
Q

What is a pneumonectomy?

A

removal of an entire lung.

42
Q

What is an alternative to surgery for early stage lung cancer due to comorbidities?

A

radical radiotherapy

43
Q

What is Radical Radiotherapy?

A

Stereotactic Ablative Body Radiotherapy (SABR)

  • high precision targeting
  • multiple, convergent beams
44
Q

What is the first line treatment for metastatic non-small cell lung cancer with mutation?

A

Oncogene-directed treatments

45
Q

What is treatment of Epidermal Growth Factor Receptor (EGFR) Tyrosine Kinase mutation?

A
  • tyrosine kinase inhibitors
  • erlotinib
  • gefitinib
  • afatinib
  • dacomitinib
  • osimertinib
46
Q

What is the treatment of Anaplastic Lymphoma Kinase (ALK) Tyrosine Kinase mutation?

A
  • crizotinib
  • ceritinib
  • alectinib
  • brigatinib
  • lorlatinib
47
Q

What is the treatment of a mutation in c-ROS Oncogene 1 (ROS-1) Receptor Tyrosine Kinase?

A
  • cirzotinib
  • entrectinib
48
Q

What is the efficacy of oncogene-directed treatment?

A
  • increase progression-free survival
  • modest overall survival when compared to chemotherapy
49
Q

What are the side effects on oncogene-directed treatment?

A
  • generally well tolerated (tablets)
  • rash
  • diarrhoea
    UNCOMMON:
  • pneumonitis
50
Q

How does immunotherapy to treat lung cancer work?

A

blocks PD-L1/PD-1 to allow T-cell killing of the cell

51
Q

What is the first line treatment for NSCLC with NO mutation (PDL1>50%)?

A

immunotherapy

  • prembrolizumab
  • atezolizumab
  • nivolumab
52
Q

What is the efficacy of immunotherapy?

A

greater progression-free survival and overall survival in comparison to chemotherapy

53
Q

What are the side effects of immunotherapy?

A
  • generally well tolerated
  • (10-15%) immune-related side effects (thyroid, skin, bowel, lung and liver)
54
Q

What is the first line treatment for metastatic NSCLC with NO mutation and PDL1 <50%?

A

cytotoxic chemotherapy (+ immunotherapy)

55
Q

What is cytotoxic chemotherapy?

A
  • targets rapidly dividing cells by interfering with RNA and DNA synthesis
  • long established
  • paltinum-based regimens (carboplatin, cisplatin, paclitaxel, premetrexed)
56
Q

What is the efficacy of cytotoxic chemotherapy?

A
  • modest survival improvements when used alone
  • significantly better when combined with immunotherapy
57
Q

What are the side effects of cytotoxic chemotherapy?

A
  • fatigue
  • nausea
  • bone marrow suppression
  • nephrotoxicity
  • poor quality of life
58
Q

What is palliative and supportive care?

A
  • symptom control
  • psychological support
  • education
  • practical and financial support
  • end-of-life planning
59
Q

When is palliative care given?

A

all patients with advanced stage disease

60
Q

What is key for successful palliative care?

A

lung cancer specialist nurses

61
Q

What is the impact of palliative care (+standard oncology care)?

A
  • improved quality of life
  • lower depression scores
  • increased survival (2.5 months)
62
Q

What is the expected treatment of locally advanced treatment (involving thoracic lymph nodes)?

A
  • surgery and adjuvant chemotherapy
  • radiotherapy and chemotherapy (+/- immunotherapy)
63
Q

What is the treatment for metastatic lung disease with a targetable mutation?

A
  • tyrosine kinase inhibitor
  • palliative care
64
Q

What is the treatment for metastatic lung disease with NO mutation, PDL-1 positive (>50%)?

A
  • immunotherapy, ALONE
  • palliative care
65
Q

What is the treatment for metastatic lung disease with NO mutation, PDL-1 negative (<50%)?

A
  • immunotherapy + chemotherapy
  • palliative care
66
Q

What is the prognosis of lung cancer?

A
  • only 10% live longer than 10 years
  • little change in the last 40 years
67
Q

What is the pathogenesis of lung cancer?

A
  • can arise from differentiated or undifferentiated cells
  • inhaled carcinogens lead to DNA adducts in the epithelium of the upper and lower airways
  • persisting DNA adducts cause genomic alterations
68
Q

What is a DNA adduct?

A

pieces of DNA covalently bound to a cancer-causing chemical

69
Q

What is this sign?

A

Clubbing

70
Q

What is this sign?

A

Cachexia (loss of muscle mass)

71
Q

What is this sign?

A

Horner’s syndrome

72
Q

What is this sign?

A

Pemberton’s sign (superior vena cava obstruction)

73
Q

How does prognosis change with stage?

A

The later the stage at diagnosis the shorter the survival

74
Q

How does prognosis change with performance status?

A

The better the performance status the longer the survival

75
Q

Who is part of the lung cancer MDT?

A
  • Patient
  • respiratory
  • radiology
  • pathology
    -thoracic surgery
  • oncology
  • palliative care
76
Q

What is the diagnostic strategy for lung cancer?

A
  • Establish most likely diagnosis
  • Establish fitness for investigation and treatment
  • Confirm diagnosis and histological type - genomic testing key if considering systemic treatment in NSCLC
  • Confirm staging
77
Q

What sort of imaging is this?

A

Chest X-ray

78
Q

What sort of imaging is this?

A

Staging CT (chest and abdomen)

79
Q

What sort of imaging is this?

A

PET-CT

BRS YR2 (67 decks)

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