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Lung Cancer Flashcards

1
Q

What are the 3 most common cancers in order?

A

Breast
Prostate
Lung

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2
Q

What is the biggest cause of lung cancer?

A

Smoking, 80%

Radon gas exposure also causes a small % of cases

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3
Q

Outline the thoracic anatomy

A

Trachea
Splits into left and right main bronchi

Bronchi then split into lobar bronchi
Segmental bronchi
Bronchioles
Alveoli

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4
Q

How many lobes does each lung have?

A

Right - 3 lobes
Left - 2 lobes

Not enough space on left for 3 lobes due to heart

Both have oblique fissure
Right also has horizontal fissure

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5
Q

What is the membrane called that surrounds the lungs?

A

Visceral pleura

Parietal pleura is the chest wall

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6
Q

Where is the pleural cavity?

A

Potential space between the visceral and parietal pleura

Negative pressure pulls the pleural layers close together

As the chest expands, negative pressure in the pleural cavity pulls the lungs towards the chest wall causing them to expand

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7
Q

What does a pleural effusion do to the pleural pressures?

A

Inward pressure on the lungs, reducing lung volume

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8
Q

How is lung cancer broadly divided?

A

Small cell lung cancer (20%)
Non-small cell lung cancer (80%)

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9
Q

How is non-small cell lung cancer divided?

A

Adenocarcinoma (40%)
Squamous cell carcinoma (20%)
Large cell carcinoma (10%)
Other types (10%)

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10
Q

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

A

Adenocarcinoma

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11
Q

What type of cancer is most common in smokers?

A

Squamous cell

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12
Q

Where do squamous cell carcinomas and adenocarcinomas develop in the lung?

A

Squamous
Develop centrally from epithelial cells lining airways
Take longer to metastasise
Cavitating lesions

Adenocarcinomas
Develop from peripheral mucous secreting cells
Bronchial or alveolar wall
More common in women than men

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13
Q

What are squamous cell cancers more likely to do?

A

Lobar collapse or infection due to blockage of airways

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14
Q

Where do large cell carcinomas develop?

A

Throughout the lung
Undifferentiated structure
Centrally or peripherally

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15
Q

Where do Small cell cancers arise from?

A

APUD cells
Central carcinomas
Fast growing and metastasise early

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16
Q

Why do small cell lung cancers cause paraneoplastic syndromes?

A

They contain neurosecretory granules which can release neuroendocrine hormones

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17
Q

What are the 5 paraneoplastic syndromes asscoiated with lung cancer?

A

Small cell
SIADH
- Ectopic ADH secretion so hyponatraemia

Cushing’s Syndrome
- Ectopic ACTH secretion so more glucocorticoids made

Lambert Eaton Syndrome
- Antibodies to voltage gated calcium channels
- Similar to myasthenia gravis

Squamous cell carcinoma
Hypercalcaemia
- Stones, bones, groans
- Due to bony metastases and secretion of PTHrP and calcitriol

Hypertrophic osteoarthropathy
- Clubbing and periostitis
- Symmetrical, painful arthropathy affecting the distal joints

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18
Q

What happens to PTH in hypercalcaemia related to SCC?

A

Low PTH

Due to negative feedback from hypercalcaemia, raised PTHrP

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19
Q

What are some differential diagnoses for symptoms of lung cancer?

A

Pneumonia
Pulmonary TB
PE
Heart failure

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20
Q

What is a mesothelioma?

A

Lung malignancy affecting mesothelial cells of the pleura

Strongly linked to asbestos

Latent period of up to 45 years

Poor prognosis, chemotherapy can improve survival but mainly palliative

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21
Q

How does lung cancer present?

A

SOB
Cough
Haemoptysis
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy- supraclavicular nodes

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22
Q

What causes haemoptysis and coughing in lung cancer?

A

Unstable tumours cause blood vessels to break and bleed

Tumour irritates airways activating cough reflex

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23
Q

What type of wheeze is heard in lung cancer?

A

Monophonic wheeze
Tumour causes narrowing of single airway

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24
Q

What extrapulmonary manifestation is indicated by a hoarse voice?

A

Recurrent laryngeal nerve palsy

Tumour presses on the recurrent laryngeal nerve as it passes through the mediastinum

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25
What causes a phrenic nerve palsy in lung cancer?
Nerve compression by tumour Causes diaphragm weakness and SOB
26
What happens in a SVC obstruction?
Direct compression of the tumour on the SVC Facial swelling Difficulty breathing Distended neck veins and upper chest veins
27
What is Pemberton's sign?
Raising hands over head causes facial congestion and cyanosis This is because there is increased obstruction to SVC drainage due to mass pushing against the SVC
28
What causes Horner's syndrome?
**Pancoast tumour** (adenocarcinomas) Ptosis Anhidrosis Miosis Tumour presses on the sympathetic ganglion
29
What causes SIADH?
Ectopic ADH secreted by small cell lung cancer Hyponatraemia
30
What causes Cushing's syndrome in lung cancer?
Ectopic ACTH by small cell lung cancer
31
What causes hypercalcaemia in lung cancer?
Ectopic PTH by **squamous cell carcinoma**
32
What is limbic encephalitis?
Paraneoplastic syndrome Small cell lung cancer causes immune system to make antibodies which attack the limbic system in the brain Leads to : - Short term memory loss - Hallucinations - Confusion - Seizures **anti-Hu antibodies**
33
What happens in Lambert-Eaton myasthenic syndrome?
Antibodies produced by immune system against **small cell lung cancer** Antibodies also target and damage **voltage-gated calcium channels** on presynaptic terminals in motor neurones Weakness in proximal muscles, intraocular muscles and pharyngeal muscles - Diplopia - Ptosis - Slurred speech - Dysphagia - Proximal muscle weakness Other symptoms - Dry mouth - Blurred vision - Impotence - Dizziness
34
What is the referral criteria for lung cancer?
CXR within 2 weeks to patients over 40 with : - **Clubbing** - Lymphadenopathy (**supraclavicular**) - Recurrent or persistent chest infections - Thrombocytosis - Chest signs of lung cancer
35
When should patients also be given a CXR?
Over 40 with : - Two or more unexplained symptoms that have never smoked - One or more unexplained symptoms that have smoked
36
What are unexplained symptoms in relation to lung cancer?
Cough SOB Fatigue Chest pain Weight loss Loss of appetite
37
What is the first line investigation in suspected lung cancer?
**Chest x-ray** Hilar enlargement Peripheral opacity (visible lesion in lung field) Pleural effusion (unilateral usually) Diaphragm collapse or lung collapse FBC and CRP - exclude infectious causes U&Es and bone profile
38
How does lobar collapse present on CXR?
* Tracheal deviation towards side of collapse * Mediastinal shift towards side of collapse * Elevation of the hemidiaphragm
39
What other investigations can be used in confirmed lung cancer?
**CT CAP with contrast** - Assess TNM status - Using contrast gives more information about different tissues **PET-CT** - Radioactive tracer, images taken with a CT scanner and gamma-ray detector - Useful to see if cancer has spread by showing increased metabolic activity **Bronchoscopy with endobronchial USS (EBUS)** - Endoscopy with USS on scope - Allows details tumour assessment and USS guided biopsy **Histological diagnosis** - Biopsy to check type of cells in tumour - By bronchoscopy or percutaneous biopsy
40
How is lung cancer treated?
**MDT meeting** **Surgery** First-line in non-small cell lung cancer Disease isolated in single area Entire tumour removed **Radiotherapy** Can be curative in non-small cell lung cancer when diagnosed early **Chemotherapy** Can be offered in addition to surgery or radiotherapy in certain patients to improve outcomes Or palliative to imrpove survival and QoL in later stages of non-small cell lung cancer **Endobronchial stenting or debulking** Can be used as part of palliative to relieve bronchial obstruction from lung cancer
41
How is small cell lung cancer treated?
Chemotherapy and radiotherapy Prognosis is worse than non-small cell
42
What gene mutations present in lung cancer are favourable for treatment?
EGFR-TK ALK ROS-1 **On T-Cells** PD-L1 at 50% or above if no above mutations
43
What is **Systemic anti-cancer therapy (SACT)** used in non-squamous NSCLC?
If these mutations are present checkpoint inhibitors are used **Epidermal growth factor receptor tyrosine kinase (EGFR-TK) mutation:** Afatinib, erlotinib and gefitinib **Anaplastic lymphoma kinase-positive (ALK) gene rearrangement:** Crizotinib, ceritinib and alectinibs
44
If NSCLC has no gene mutations so cannot have systemic anti cancer therapy, what chemotherapy are they offered instead?
Usually platinum based
45
What is the prognosis in lung cancer?
One year survival - 40% Five year survival - 15%
46
What is the prognosis of small cell lung cancer?
1-3 months if untreated 15 months with chemotherapy
47
What is done prophylactically in SCLC?
Prophylactic cranial radiotherapy as 50% develop brain mets
48
How is small cell lung cancer staged?
**VALSG staging** **Limited disease**: tumour not spread beyond hemithorax, regional nodes that may be treated with single radiotherapy field **Extensive disease**: tumour spread beyond hemithorax or extensively through the hemithorax, distant metastasis, malignant effusions or contralateral hilar/supraclavicular involvement TNM used for NSCLC
49
Before thoracic surgery what should be done in all patients?
Peak flow and spirometry Calculate predicted post-operative respiratory capacity to guide the type or resection Pneumonectomy - 50% reduction in FEV1 Lobectomy - 20% reduction Therefore >1L in lobectomy >2L in pneumonectomy
49
When is lung cancer surgery contraindicated?
Stage IIIb or IV FEV < 1.5 Malignant pleural effusion Tumour near hilum SVCO
50
What options are there for removing a lung tumour?
**Segmentectomy or wedge resection** **Lobectomy** Entire lobe containing tumour removed (most common) **Pneumonectomy** Removing entire lung **Sleeve resection** Removing one lobe and part of the bronchi
51
What are the different types of **surgery** for lung cancer?
**Thoracotomy** Open surgery, incision and separation of rib to access thoracic cavity **Video-assisted thorascopic surgery (VATS)** Keyhole surgery **Robotic surgery**
52
What type of surgery is preferred in lung cancer?
Minimally invasive e.g. VATS or robotic Faster recovery and fewer complications
53
What are the main thoracotomy incisions?
**Anterolateral thoractomy** Incision around front and side **Axillary thoracotomy** **Posterolateral thoracotomy** Incision around back and side (most common)
54
What is the done differently between thorascopic surgery and laparosopic?
Thorascopic is done by deflating the lung Laparoscopic the abdomen is inflated
55
What indicates a pneumonectomy vs lobectomy on examination?
If there is a thoracotomy scar and there is no breath sound on that side Indicates entire lung removal rather than lobectomy If absent lung sounds in a specific area, indicates a lobectomy
56
Why is a chest drain left in after thoracic surgery?
Allows air and fluid to leave the thoracic cavity and lungs to expand Chest drain pump can be used to suck fluid and air out of chest
57
How does a chest drain work?
External end placed underwater Creates a seal to prevent air going back through drain into chest Air can still exit chest and bubble through water, but water prevents air re-entering Water in drain will rise and fall due to changes in chest pressure - **swinging**
58
What are the symptoms of pneumonitis?
* Shortness of breath * Low sats * Fever * Cough * Chest pain with breathing Do CXR, Chest CT, Lung function tests and bloods/sputum to rule out infection
59
How is radiation pneumonitis treated?
Prednisolone long-term Oxygen therapy NSAIDs Bronchodilators Treat the same as pulmonary fibrosis

Haematology (16 decks)

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