Lung Cancer

Question 1

what are the risk factors for lung cancer?

Answer 1

Smoking is the biggest risk factor.
Environmental tobacco smoke,
Ionising radiation,
air pollution
Asbestos,
Others, eg, fibrosing conditions of the lung

Question 2

What are the signs and symptoms of lung cancer?

Answer 2

Cough,
Haemoptysis,
Shortness of breath,
Chest pain,
Weight loss/anorexia,
General malaise,
Signs - Clubbing, hypertrophic pulmonary osteoarthritis

Question 3

What are the signs and symptoms of central lung cancer vs peripheral lung cancer?

Answer 3

Central - Ulceration of bronchus (haemoptysis) and can cause bronchial obstruction (pneumonia, wheeze, bronchiectasis, SOB)

Peripheral - Can have few symptoms. Can have pleural involvement which can cause pain and effusions

Question 4

What are the effects of a local spread of malignancy?

Answer 4

If invades pleura then can cause haemorrhagic effusion.
Invasion of hilar lymph nodes,
Invasion of adjacent tissue (which if invades BVs then causes haemoptysis)
Invasion of pericardium which can cause pericardial effusion
Invasion of mediastinum which can cause SVC obstruction, RL nerve obstruction and phrenic nerve obstruction.
Pancoast tumours

Question 5

What are the paraneoplastic syndromes associated with lung cancer?

Answer 5

Cushing Syndrome - Suggests small (opposite to cushing which is big)
SIADH - small cell
Lambert Eaton syndrome - small cell. Antibodies to voltage gated calcium channels causing myasthenic like syndrome/
Hyperparathyroidism - squamous cell
HPOA - ends of long bones have onion skin appearence

Question 6

What are the different types of lung cancer?

Answer 6

Small cell - Only accounts for 15% but has worse prognosis
Non small cell lung cancer which includes: Adenocarcinoma, squamous carcinoma, large cell, alveolar cell carcinoma and bronchial adenoma

Question 7

Describe features of adenocarcinoma of the lung

Answer 7

Most common type of lung cancer which is often seen in non smokers.
Arises from mucus cells in bronchial epithelium.
Commonly invades mediastinal lymph nodes and spreads to brain and bones.
Most likely to cause pleural effusion. Associated with gynaecomastia and hypertrophic pulmonary oesteoarthropathy

Question 8

Describe features of squamous lung cancer

Answer 8

Usually presents with an obstructive lesion of the bronchus leading to infection.
Causes cavitating lesions.
Associated with hypercalcaemia due to production of PTHrp.

Question 9

Describe features of small cell carcinoma

Answer 9

Arises from endocrine cells so tumours secrete many hormones, mainly ACTH.
Usually central and usually metastatic by time of diagnosis

Question 10

What are the effects of SVC obstruction?

Answer 10

Facial oedema, headaches and a raised JVP

Question 11

What are the effects of a phrenic nerve paralysis?

Answer 11

Raised right hemi diaphragm

Question 12

What are the likely tumours if central or peripheral in lung?

Answer 12

Central tumours are likely to be squamous or small cell carcinomas.
Peripheral are adenocarcinomas

Question 13

Describe features of large cell lung carcinoma

Answer 13

Typically peripheral. It is anaplastic, poorly differentiated so has a poor prognosis. May secrete beta-HCG

Question 14

What are the investigations for suspected lung cancer?

Answer 14

1. Chest X ray
2. CT
3. Bronchoscopy - allows for biopsy to be taken
4. PET scanning - typically in non-small cell to establish eligibility for curative treatment
5. Bloods - may see raised platelets, and signs of paraneoplastic syndrome

Question 15

What is the management of non small cell lung cancer?

Answer 15

First line = lobectomy
Other options = Curative radiotherapy (stages I, II and III) or chemotherapy which is offered to stages III and IV to control disease and improve quality of life

Question 16

What is the management of small cell lung cancer?

Answer 16

Palliative chemotherapy

Question 17

What is a carcinoid tumour of the lung?

Answer 17

Tumour of neuroendocrine cells which can be central or peripheral.
Typical or atypical

Question 18

Describe features mesothelioma

Answer 18

It is a primary pleural tumour associated with asbestos.
Long lag period
Epithelial or sarcomatoid appearance or mixture

Question 19

What are the contraindications for surgery?

Answer 19

Stage IIIb or IV (i.e, mets present)
FEV1 < 1.5L for lobectomy,
Malignant pleural effusions,
Tumour near hilum,
Vocal cord paralysis,
SVC obstruction

Question 20

What are the lung cancer referral guidelines?

Answer 20

Referral for 2 week wait in patients with: Chest x ray findings that suggest lung ca, age 40+ with unexplained haemoptysis.
Urgent chest x ray for patients > 40 with two of following (or one if they have smoked): cough, fatigue, SOB, chest pain, weight loss, appetite loss. Or >40 with any of: persistent/recurrent chest infections, finger clubbing, supraclavicular lymphadenopathy, chest signs or thombocytosis.

Question 21

What is seen on the following chest x ray?

Answer 21

Pleural plaques. These are benign and do not undergo malignant change

Question 22

What are the features of asbestosis and the management?

Answer 22

Features - dyspnoea, reduced exercise tolerance, clubbing, bilateral end-inspiratory crackles, restrictive spirometry.
Treatment - conservative. No interventions offer benefit

Question 23

what does the following image show?

Answer 23

Mesothelioma in left upper zone.