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cardio and resp yr 2 > lung cancer > Flashcards

lung cancer Flashcards

1
Q

are all lung cancer patients smokers?

A

no. 10-15 % of smokers have never smoked

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2
Q

where is cancer in rank of types of cancer death causes?

A

its the first

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3
Q

risk factors of lung cancer (age, sex and 2 others?

A

age - peak 75-90
sex M>F
lower socioeconomic status
smoking (biggest single factor- duration, intensity, when stopped)

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4
Q

causes other than smoking

A

Passive smoking (~15% of never smokers)
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)
Air pollution
Familial/ genetic – several loci identified

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5
Q

what cells can lung cancer arise form?

A

ALL differentiated and undifferentiated cells

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6
Q

describe the pathogenesis of lung cancer: (how does it arise in a cell)

A

1) interaction between inhaled carcinogens and the epithelium of upper AND lower airways

2) formation of DNA adducts: DNA pieces covalently bound to a cancer-causing chemical
(note: specifically oncogenes- tumour suppressor genes- key to pathogenesis of lung canc)

3) persisting DNA adducts/ misplaced lead to mutation causing

4) GENOMIC ALTERATIONS

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7
Q

what factor distinguishes different types of lung cancer diseases?

A

cell type form which cancer originates

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8
Q

2 broadest categories of lung cancer diseases and which is more aggressive

A

Non small cell lung cancer (includes: squamous cell carcinoma, adenocarcinoma, large cell lung cancer)
and
small cell lung cancer (more serious / dangerous/ highly malignant )

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9
Q

what is the positive thing about small cell lung cancer?

A

responds well to chemo

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10
Q

what cells does small cell lung cancer originate from

A

pulmonary neuroendocrine cells

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11
Q

what cells does large cell lung cancer originate form

A

heterogenous group of cells that are undifferentiated

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12
Q

cell origin of adenocarcinoma and location in pulmonary system

A

mucus producing glandular tissue - more peripherally located

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13
Q

squamous cell carcinoma : what part of pulm epithelium does it arise form? location in resp system ?

A

bronchial epithelium, centrally located

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14
Q

prevalence of each type of cancer cell diseases and how has this recently changed

A

40% adenocarcinoma most prevalent from 1980s onwards due to low tar cigarettes, inhaled more deeply / retained longer

30% squamus cell carcinoma (used to be most prevalent)

large cell lung cancer 15% = small cell lung cancer 15%

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15
Q

why do we care to know the relevant oncogenes?

A

for directed treatments

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16
Q

what is tyrosine kinase?

A

enzyme that regulates growth, proliferation and differenciation

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17
Q

what are some important oncogenes in non smokers

A

epidermal growth factor RECEPTOR (EGFR) tyrosine kinase
(women, asian)

anaplastic lymphoma KINASE (ALK) tyrosine kinase
(younger)

c-ROS oncogene 1 (ROS1) RECEPTOR to tyrosine kinase
(Younger)

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18
Q

oncogene for smokers

A

BRAF (downstream cell- cycle signalling mediator)

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19
Q

what type of lung cancer is each oncogene associated with

A

EGFR: 15-30% of adenocarcinomas

the rest are

2-7% ALK
1-2% c-ROS
1-3% BRAF
:non small lung caners

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20
Q

KEY SYMPOTMS OF LUNG CANCER

A

weight loss
cough
breathless
fatigue
chest pain
haemoptysis

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21
Q

common or uncommon to have asymptomatic lung canc?

A

common

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22
Q

features of advanced metastatic disease (3 categories and specifics) (features: diseases in the body)

A

1) neurological features a) focal weakness, b) seizures c) spinal cord compression

2) bone pain

3) paraneoplastic syndromes
a) clubbing (fingers thing) b) hypercalaemia c) hyponatraemia d) cushings

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23
Q

signs of lung cancer

A

cachexia: (loss of muscle and fat- skeleton looking)

horners syndrome : one eyelid dropped: (happens bc lung cancer compresses sympathetic nerve going up)

clubbing: fingers tips big and weird nails

pemberton’s sign (superior vena cava obstruction - red face when raise hans)

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24
Q

diagnostic strategy of lung cancer

A

1) establish mokst likely diagnosis

2) establish fitness for investigation and treatment

3) confirm diagnosis and histological type (alse genomic test it consideringn systemic treatment in nsclc- all these tests also gelp tetermine treatment)

4) confirm staging

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25
Q

what has changed in terms of lung cancer screening?

A

people at high risk (basically smokers 55-74- age group younger than actual peak of disease prevalence bc balance tryna be found with quality of life- more life for younger) invited for screening

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26
Q

what scan do you see lung cancer?

A

x ray

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27
Q

what scan do you stage lung cancer and what specific area?

A

ct- chest and abdomen

28
Q

when is PET- ct used and why is it appropriate for that use

A

to exclude occult (hidden) metastases ex in lymph nodes ect ]

Metabolic scans, patients get fdg, glucose, glucose goes to areas of high metabolic activity – higher uptske of gluc light up – so tumours light up

29
Q

what determines what type of biopsy you do?

A

accessibility, availability and impact on staging

30
Q

what are the 3 types of biopsy and when do you do each?

A

bronchoscopy using a fibrotic ENDOSCOPE - useful for tumours of central and segmental airways (also useful to visualise tumour before surgery)

stage mediastinum +/- achieve tissue diagnosis

CT guided lung biopsy - to access peripheral lung tumours

31
Q

3 components/ scales of IASLC (International Association for the Study of Lung Cancer) 8th edition lung cancer staging system

A

TNM

T1-4: size and location
N: 0-3: lymph node involvement mediastinum and beyond
M0-1c: metastases + number (= M1a, 1b, 1c)

32
Q

what is M0, M1A, M1B, M1C?

A

m0: No distant metastases
m1a: malignant pleural pericardial effusion or nodules
m1b: single extrathoracic metastasis
m1c: multiple extrathoracic metastasis

33
Q

what are N0, N1, N2, N3

A

0: no regional node metastasis
n1: ipsilateral pulmonary or hilar nodes
n2: ipsilateral mediastinal/ subcranial nodes
n3: contralateral mediastinal/ hilar or supraclavicular nodes

34
Q

what is t1 t2 t3 t4

A

t1: </= 3 cm

t2 is either: 5 >/= t2: > 3
OR involves visceral pleura / main bronchus

t3: either 7>/=tumor >5
OR invading chest wall, pericardium, phrenic nerve
OR if theres separate tumor nodule in same lobe

t4: >7 cm
OR invading MEDIASTINUM, diaphragm, heart, great vessels, reccurent larengeal nerve, carina, trachea, oesophagus, spine

35
Q

what are the T1a T1b T1C and T2a T2b

A

is you remember the large range, they are the splits of each cm so

t1a</= 1
1<b</=2
c: 2-3(=)

t2a 3-4(=)
t2b 4-5(=)

36
Q

what dimension of the tumour counts or tumour size?

A

the biggest dimension

37
Q

check slife 22 with images

A
38
Q

detemrinants of treatment

A

disease related:
cancer stage, histology

patient related:
patient fitness, patient preference

resource related:
health service factors

39
Q

0-5 scale of patient fitnes based on who - perofrmance status

A

0: asymptomatic, completely capable of pre-disease activities

1: symptomatic but completely ambulatory, only thing they cant do is strenus exercise

2: sumpotmatic but more than 50% of the time mobile, can do all self care but not some extra work

3: sympotmatic more than 50% chair or bed bound, difficulty in self care

4: totally disabled and completely confined to bed or chair

5: death

40
Q

is surgery resection standard care approach for any stage in disease?

A

yes, for early stage

41
Q

what is the usual parts rmeoved in surgery of early stage?

A

lymphadenectomy and lobectomy or sublobar resection if stage 1

42
Q

what is an alternative that patients can choose other than surgery for early disease? when is it particularly prefered? explain that method a bit

A

radical radiotherapy - stereotactic (σκέψου τον κρατάμε στερεό και ατακ) ablative body radiotherapy

when there are comorbidities

high percision targeting with multiple convergent beams (v high radioactive dose)

43
Q

why is surgery still more effective than radical radiotherapy?

A

because you also remove lymph nodes whereas in radiotherapy u dont adress lymph nodes that may have microcancer

44
Q

what are the types of systemic treatment?

A

immunotherapy, oncogene directed treatment, cytotoxic chemotherapy

45
Q

when are oncogene directed treatments given?

A

when there is
1) no SCLC
2) theres metastasis
3) theres mutation

46
Q

when do you give immunotherapy?

A

when there is
1) NO SCLC
2) theres metastasis
3) no mutation
4) PDL1>/= 50% (you stain for this)

47
Q

when do you give cytotoxic chemotherapy?

A

same criteria as immunotherapy and you give it along with immunotherapy

48
Q

NICE approved medications for EGFR mutation?

A

erlotinib, gefitinib, afatinib, dacomitinib, and osimertinib

49
Q

ALK approved meds

A

ALK: crizotinib, ceritinib, alectinib, brigatinib, lorlatinib

50
Q

ros-1 targeted meds

A

ROS-1: crizotinib, entrectinib

51
Q

What is the effect of oncogene targeted treatment compared to chemotherapy in terms of progression free survival and overall survival?

A

oncogene targeted therapy is more effective in terms of progression free survival but less in overall survival (trials for erlotinib and crizotinib showed same trend)

52
Q

side effects of oncogene targeted therapy

A

rash, diarrhoea and uncommonly pneumonitis

generally tablet is well tolerated though

53
Q

NICE approved immunotherapy drugs

A

Pembrolizumab, atezolizumab, nivolumab

53
Q

efficacy compared to chemotherapy ?

A

better progression free survival AND overall survival

54
Q

side effects of immunotherapy

A

generally well tolerated
immune related side effects in 10-15 % 9THYROID, SKIN, BOWEL, lung, liver)

55
Q

what is the mechanism of immunotherapy?

A
  • theres the PD-L1 receptor in tumour cells that binds PD-1 on T cells and inhibits t cell from killing tumor cell
  • treatment is anti-PD-1 and anti PD-L1 so antibodies bind on both sides of this interaction and the t cell is now allowed to kill the tumour cell
56
Q

what chemical element are cytotoxic chemotherapies all based on? give drug examples

A

platinium- based regiments
eg carboplatin, cisplatin, paclitaxel, pemetrexed

57
Q

which immunotherpay drug have there been trials about/ evidence

A

pembrolizumab

58
Q

efficacy of chemotherapy

A

when sued alone MODEST imporvements in ONE YEAR survival compared to best SUPPORTIVE CARE

however much worse than pembrolizumab which has 23% surv rate for 2 yrs vs 5% chemo

59
Q

side effects of chemo

A

fatigue
nausea
bone marrow supression
nephrotoxicity

quality of life poorly rate din trials…

60
Q

palliative supportive care when is it given and what it involves?

A

Should be offered as standard to all patients with advanced stage disease
Symptom control, psychological support, education, practical and financial support, planning for end of life

61
Q

key group of specialists in palliative care

A

lung cancer nurses

62
Q

efficacy of palliative care?

A

1) survuval rates improved
2) quality of life imporved (less depression
3)

63
Q

what is the difference between chemo given in early stage disease vs locally advanced?

A

first is curative intent instead of surgery, second is ADJUVANT, meaning given along with surgery (after)

64
Q

what is another treatment plan for locally adv dis other than surg and chemo

A

radiotherapy and chemotherapy and maybe also immuno

65
Q

categories of metastatic disease based on treatment

A

with targetable mutation (tyrosine kinase inhibitor)

no mutations and PDL-1 positive or negative

palliative care alone or with the above (patient wishes)

cardio and resp yr 2 (10 decks)

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