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Lung Cancer Flashcards

1
Q

give some aetiological factors of lung cancer

A 
> tobacco
> asbestos
> environmental radon
> occupational exposure (chromates, nickels, hydrocarbons)
> air pollution 
> pulmonary fibrosis
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2
Q

what is the safe smoking threshold?

A

there is no safe smoking threshold is risk is related to consumption

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3
Q

describe the multi hit theory that leads to carcinogenesis

A

there needs to be between three and twelve molecular changes happening in a particular order in stem cells to create a malignant tumour. the host may activate pro-carcinogens, or inherit polymorphisms that predispose an individual (metabolism of pro-carcinogens and nicotine addiction).

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4
Q

what sort of carcinogenesis occurs in the lung periphery?

A

bronchiolalveolar epithelium stem cells transform creating an adenocarcinoma

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5
Q

describe carcinogenesis occurring in the central lung airways

A

here bronchial epithelial stem cells transform crating squamous cell carcinomas

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6
Q

what is a smoking induced mutation in adenocarcinogenesis?

A

KRAS 35%

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7
Q

name some genetic mutations that are not induced by smoking that lead to carcinogenesis

A

> EGFR 15%
BRAF, HER2 2% (each)
ALK rearrangements 2%

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8
Q

name some tumours in the bronchial glands

A

> adenoid cystic carcinoma
mucoepidermoid carcinoma
benign adenomas

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9
Q

what are the four main cell types in a carcinoma?

A

> squamous cell 40%
adenocarcinoma 41%
large cell carcinoma 4%
small cell carcinoma 15%

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10
Q

why is primary lung cancer often only diagnosed late in its history?

A

it grows silently for many years and can have few signs and symptoms

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11
Q

what effects can a lung cancer have on bronchial obstruction?

A

> collapse
endogenous lipoid pneumonia
infection/ abscess
bronchectasis

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12
Q

what effect can cancer have on the nerves?

A

> it can degrade the phrenic nerve paralysing the diaphragm
L recurrent laryngeal innervating the voice box, this causes a bovine cough
brachial plexus
cervical sympathetic causing horners syndrome

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13
Q

describe horners syndrome

A

there is a tiny pupil and he inability to open ones eyelid properly. this is caused by cancer affecting the cervical sympathetic nerves.

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14
Q

what happens when the superior vena cava is blocked by a cancer?

A

the veins in the head cannot drain, they dilate to compensate for this but still cant drain.

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15
Q

what sort of lung cancer would cause limb weakness, paraesthesia and bladder dysfunction?

A

metastatic cancer that is compressing the spinal cord

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16
Q

what symptoms would a cerebral metastasis cause?

A 
> headache
> vomiting
> dizziness
> ataxia
> focal weakness
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17
Q

name some paraneoplastic symptoms of advanced lung cancer

A

> hyponatraemia: low Na conc. in the blood
anaemia
hypercalcaemia (bone metastasis, parathyroid hormone related problem)
dermatomyositis
eaton-lambart syndrome (upper limb weakness)
cerebellar ataxia
sensorimotor

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18
Q

what is dermatomyositis?

A

inflammatory disorder in which the skin and underlying tissues (including the muscles) are affected by a purple skin eruption.

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19
Q

what is polymyositis?

A

the absence of dermatomyositis

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20
Q

what are the initial investigations for suspected lung cancer?

A 
> CXR
> full blood count (they may also have anaemia
> renal and liver functions
> clotting screen
> spirometry
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21
Q

what cancer s are associated with smokers?

A

squamous and small cell

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22
Q

what does T staging involve?

A

T staging is based on the size of the tumour and its proximity to the chest wall.

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23
Q

what does N staging look at?

A

N staging looks at metastasis to the lymph glands. N0 has no regional lymph node involvement.

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24
Q

what does M staging involve?

A

this is staging based on the metastasis of the cancer, M0 has no distant metastasis while M1 does.

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25
to what stages is creative treatment given to?
stages one and two
26
describe how the patient is given a performance status
``` 0= fully active 1= symptomatic 2= up and about > 50% of the time 3 = up and about < 50% of the time 4 = bed/chair bound ```
27
name three types of surgery given to patients with lung cancer
> wedge resection > lobectomy > pneumonectamy
28
after a CXR has been carried out confirming that the lesion is intrapulmonary what do you do?
do a CT scan and evaluate size, border, density, whether it is solid
29
define a pulmonary mass
an opacity in the lung over 3cm with no mediastinal adenopathy or atelectasis
30
what is a pulmonary nodule?
an opacity in the lung up to 3cm with no mediastinal adenopathy or atelectasis
31
what could a solitary mass or nodule seen on a CXR be?
> lung cancer > metastasis > benign neoplasm > infection (bacterial, fungal)
32
what would you do to find out how close to the carina the cancer is?
a bronchoscopy
33
what is the labelled analogue used in FDG PET?
18F-FDG
34
what is the half body time of 18FDG?
60 minutes
35
what does it mean: >TX >T0
> that a primary tumour could not be assessed | > no evidence of a primary tumour
36
describe a T1 tumour
it is less than 3cm in greatest dimension and is surrounded by lung or visceral pleura, there is no bronchoscopic evidence of involvement with the main bronchus
37
what is the difference between a T1a, a T1b and a T1c tumour?
> T1a is a minimally invasive adenocarcinoma <= 1cm at its greatest dimension > T1b tumour is <= 2cm > T1c tumour is <= 3cm
38
describe a T2 tumour
it is more than 3cm in length but less than 5. it has one of the following features: > involvement with the main bronchus > invasion of the visceral pleura > associated with atelectasis or obstructive pneumonitis that extends to the hilar region involving all or part of the lung
39
which is bigger a T2a tumour or a T2b tumour?
a T2b tumour which is between 4 and 5 cm (a T2a is between 3 and 4cm)
40
describe a T3 tumour
it is more than 5cm but less than 7cm that directly invades either the chest wall, phrenic nerve or parietal pericardium. or if it is a separate tumour nodule in the same lobe as the primary
41
if a tumour invades the oesophagus what T staging is it given?
T4
42
If a tumour nodule is in a different ipsilateral lobe what staging is it given?
T4
43
A tumour with N1 staging has spread to which nodules?
ipsilateral peri-bronchial, hilar or intrapulmonary nodes (including by direct extension)
44
what can a CT scan tell us about metastasis to nodes?
it can tell you the prevalence of metastasis via the size of the nodes
45
what does an M1a staging of a tumour tell us?
that there is a separate tumour nodule in a contralateral lobe or that the tumour is with the pleural or pericardial nodes, or a malignant/pericardial effusion.
46
What does a M1b staging tumour tell us?
that there is a single distant metastasis
47
what does M1c staging of a tumour tell us?
that there are multiple distant metastasis
48
a patient with a tumour that is T2, N1 and M1 has a survival chance of what?
1%
49
a patient with a T1, N0, M0 tumour has a survival chance of what?
67%
50
what lymph node metastasis can be resected with the lung?
N1, the metastasis to the hilar lymph nodes. N2 resection is a separate surgery.
51
where does the pharyngeal nerve pass through in the thorax?
the aortic-pulmonary window, the area between the aortic arch and pulmonary vein.
52
what is phrenic nerve palsy?
this is when a tumour has degraded the phrenic nerve, paralysing the hemi diaphragm.
53
what can a collapsed lobe make more difficult when looking at a CXR?
it can make it hard to discriminate between the lung and the cancer. leading to an open and close surgery where they cannot operate on the lung.
54
what blood tests would you carry out when staging a cancer for surgery?
> full blood count to check for anaemia > Liver function tests > Bone profile (this can be altered to due to disease
55
why is an MRI useful for staging cancer for surgery?
it determines the degree of vascular and neurological involvement in pancoast tumour
56
describe mediastinoscopy
By making a cut behind the breast bone and going down the trachea looking at the tracheal nodes.
57
what do you need to assess clinically when deciding if a patient is fit for surgery?
> cardiovascular system > respiratory system > mental health > others, such as arthritis, pulmonary hypertension
58
how is the respiratory system tested when deciding if a patient is fit for surgery?
> spirometry > diffusion study (inhalation of CO2) > arterial blood gases on air > fractionated V/Q scan
59
what investigations are carried out in cardiac assessment when deciding if a patient is fit enough to under go surgery?
> ECG > ECHO > CT scan > coronary angiogram
60
what problems may be encountered when staging lung cancer?
> collapse of a lobe/ lung making it difficult to assess the tumour size > presence of another pulmonary nodule > retrosternal thyroid > adrenal nodule
61
what are some fatal complications in surgery?
``` > adult respiratory syndrome, accumulation of fluid in the lung > bronchopneumonia > myocardial infarction > pneumothorax > intrathoracic bleeding ```
62
what are some non-fatal complications of surgery?
``` > pain > empyema > wound infection > broncho pulmonary fistula (the broncho stump gets a hole in it and the fluid in the pleural space is coughed up) > MI > post op respiratory insufficiency > constipation ```
63
how aggressive is small cell lung cancer?
very, it doubles in size every 29 days
64
what do the therapeutic options for non-small cell lung cancer depend on?
> stage > eastern cooperative group performance status > patients wishes
65
what is the surgical 5 year survival in non-small cell lung cancer?
40%
66
what is adjuvant therapy?
this is post operative therapy to increase the chance of a cure.
67
what stages on NSC lung cancer is adjuvant radiotherapy detrimental?
in stage one and two (though there can be some benefit in N2 metastasis or if there is marginal involvement)
68
when is neo-adjuvant therapy given in NSC lung cancer and why?
in stage 3 as preoperative chemotherapy demonstrates a very significant survival advantage
69
what are treatment decisions of advanced NSC lung cancer affected by?
co-morbid diseases such as angina
70
what is the dose of radical chemotherapy given to stage 3 NSC lung cancer patients?
the dose is 55Gy+
71
what is the main side effect of radical chemotherapy given to stage 3 NSC lung cancer patients?
inflammation and fibrosis
72
what is the survival rate of stage 3 NSCLC patients given radical radiotherapy?
5 year survival rate is 20%
73
what treatment is given to stage 4 NSCLC?
palliative only as it is incurable. chemotherapy is given for systematic benefit and increase in survival. medial survival is >12 months with chemo alone.
74
what are the affects of bone metastasis?
> pain > pathological fracture > cord compression in the thoraco-lumbar spine can create weak legs and effect bowel movements
75
name driver mutations in an adenocarcinoma?
> 15% EGFR mutation > 5% ALK translocation > 2% BRAF mutation > 1% ROS alteration
76
what is the concept of tyrosine kinase inhibitors?
targeted therapy for a broad range of common solid tumours.
77
how is the cancer cell rendered invisible to the immune system?
tumour cells contain a pdl1 antigen that interacts with the T cell rendering it invisible
78
how does immune therapy "wake up" the immune system?
monoclonal antibodies attach to the tumour activating the t cell which can then see and destroy the tumour.
79
what is the effect of nivolumab BMS on the activity of T lymphocytes?
this blocks the interaction of PD-1 to PDL-1 and PD-L2. this potentiates the activity of t cells by preventing them from being inactivated.
80
what is the difference in presentation of small cell lung cancer?
it can cause secretory syndromes such as SIADH (low sodium confusion) and ACTH.
81
what treatment is given to SCLC patients with limited disease?
high dose alternating maintenance chemo
82
what is the medial survival of limited disease small cell lung cancer with treatment compared with no treatment?
without is 8 months and with is 16 months
83
what is the 2 year survival of limited disease small cell lung cancer?
25%
84
what is the treatment for extensive small cell lung cancer?
> 4 cycles of combination treatment therapy > single fraction radiotherapy to palliate if they are not fit for chemo > if there is a brain metastasis they are given RT and steriods
85
what is the difference in survival of extensive small cell lung cancer with treatment compared with no treatment?
without: 8 weeks with: 8 months

Respiratory system (19 decks)

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