Lung cancer

Question 1

Lung carcinomas

Answer 1

• adenocarcinoma - peripheral, non-smokers, Asians, early mets
• SCC - central, smokers, PTHrP secretion, hypercalcaemia, late mets
• large cell carcinoma - peripheral or central, smokers, early mets
• small cell lung carcinoma - central, older smokers, early mets, ACTH, Cushing’s, ADH (SIADH), Lambert-Eaton

Question 2

Lung cancer risk factors

Answer 2

• smoking (associated with 80%)
• check second hand smoking!
• air pollution
• family history of (lung) cancer
• male sex
• radon gas in miners
• check occupation!

Question 3

Lung cancer presentation

Answer 3

• unexplained cough +/- haemoptysis for at least 3 weeks
• unintended weight loss - >5% in 6m
• new-onset dyspnoea
• pleuritic chest pain (invasion of pleura)
• bone pain (mets to spine, pelvis etc)
• fatigue - anaemia of chronic disease
• Pancoast tumour - Horner’s, stridor, hoarse voice

Question 4

Lung cancer examination findings

Answer 4

• cachexia
• finger clubbing
• dullness to percussion
• cervical lymphadenopathy
• wheeze on auscultation

Question 5

2 week wait referral for lung cancer

Answer 5

• CXR findings suggestive of lung cancer
• over 40 with unexplained haemoptysis

Question 6

2 week wait X-ray for lung cancer

Answer 6

• over 40 and two of these symptoms (or 1 + smoking history):
• cough
• weight loss
• appetite loss
• dyspnoea
• chest pain
• fatigue

Question 7

Lung cancer differentials

Answer 7

• tuberculosis - drenching night sweats, cavitating lesions, positive sputum
• lung mets - check CT and PET scan
• GPA - saddle nose, cANCA, epistaxis and haematuria
• non-Hodgkin’s lymphoma - drenching night sweats, hepatosplenomegaly, lymph node biopsy

Question 8

Lung cancer investigations

Answer 8

• pulse oximetry and ECG
• FBCs for anaemia
• LFTs - hepatic or bony mets
• U&Es - baseline and SIADH
• serum calcium - PTHrP
• CXR first line - opacities, pleural effusion, lung collapse
• CT TAP to confirm
• bronchoscopy and biopsy to diagnose
• PET scan for staging

Question 9

Lung cancer staging

Answer 9

• TNM and then 1-4 staging
• stage 1 - small tumour <4cm, one lung
• stage 2 - large tumour >4cm, may spread to local lymph nodes
• stage 3 - spread to contralateral lymph nodes or surrounding structures
• stage 4 - spread to lymph nodes outside chest or distant organs

Question 10

Non small cell lung cancer management

Answer 10

• stage 1 - 3
• surgery - lobectomy or pneumonectomy if intact lung function, wedge resection if reduced
• preop/postop chemo (postop radio)
• if unsuitable for surgery, stereotactic ablative radiotherapy (SABR)
• stage 4
• targeted therapy, immunotherapy, chemotherapy, palliative care

Question 11

Small cell lung cancer managment

Answer 11

• managed with chemo + radiotherapy
• surgical management is rare as most present with advanced disease
• prophylactic cranial irradiation as high risk of brain mets

Question 12

Lung cancer complications

Answer 12

• Horner’s syndrome due to Pancoast tumour infiltrating brachial plexus
• SVC obstruction
• paraneoplastic - SIADH, Lambert-Eaton
• chemo complications - hair loss, neutropenia, bone marrow toxicity
• radio complications - mucositis, pneumonitis, oseophagitis