Lung Cancer

Question 1

What is primary lung cancer?

Answer 1

Malignant carcinoma which may obstruct bronchi, cause pleural inflammation/malignancy or invade the chest wall

Question 2

What are the four types of lung cancer?

Answer 2

Small cell carcinoma
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma

Question 3

What kind of tumour is small cell carcinoma?

Answer 3

Neuroendocrine - secretes abnormal hormones

Question 4

Where in the lung do adenocarcinomas commonly occur?

Answer 4

In the peripheries as they affect bronchioles and alveoli

Question 5

Where in the lung does squamous cell carcinoma commonly develop?

Answer 5

Central airways (bronchi)

Question 6

Aetiology

Answer 6

Smoking
Passive smoking
Exposure to asbestos, radon, air pollution, diesel exhaust
Genetics

Question 7

How does tobacco cause lung cancer?

Answer 7

Epithelial effects and activation of pro-carcinogens

Question 8

Name 2 biomarkers of lung cancer

Answer 8

KRAS

EGFR

Question 9

Symptoms

Answer 9

Chronic coughing
Haemoptysis
Wheezing sound
Chest and bone pain
Chest infections
Difficulty swallowing
Raspy hoarse voice
Dyspnoea

Question 10

Name 4 nerves which may be compressed by lung cancer and the effects of this

Answer 10

Left recurrent laryngeal - raspy hoarse voice
Cervical sympathetic - Horner’s syndrome
Brachial plexus - pancoast tumour
Phrenic - diaphragmatic paralysis

Question 11

Signs

Answer 11

Unexplained weight loss
Clubbing
Chest signs
Lymphadenopathy (palpable lymph nodes)
Horner's syndrome (droopy eye)
Pancoast tumour
Superior vena cava obstruction (prominent veins when hand raised)
Hepatomegaly
Skin nodules

Question 12

What are the initial investigations for lung cancer (often by GP)

Answer 12

Chest x-ray
Full blood count
Renal and liver functions
Calcium
Clotting screen
Spirometry

Question 13

What do you look for in a chest x-ray?

Answer 13

Key areas - apex, hilum, behind heart, mediastinum, costophrenic angles
Pleural effusion
Chest wall invasion
Collapsed lobe/lung
Phrenic nerve palsy

Question 14

What further imaging would you do for staging etc?

Answer 14

CT thorax and abdomen
MRI
PET CT

Question 15

What are you looking for in a CT?

Answer 15

Size
Mediastinal nodes
Metastatic disease
Effusion
Diaphragmatic involvement

Question 16

What investigations for tissue diagnosis?

Answer 16

Bronchoscopy
EBUS (endobronchial ultrasound)
Image guided lung biopsy
Image guided liver biopsy
FNA (fine needle aspiration) of neck node or skin metastases
Excision of cerebral metastases
Bone biopsy
Mediastinoscopy
Surgical excision biopsy

Question 17

What three things is the treatment of lung cancer decided upon?

Answer 17

Histological type and stage
Performance status of patient
Patient wishes

Question 18

Name 3 procedures that could potentially be done surgically to remove a tumour

Answer 18

Pneumonectomy (removal of lung)
Lobectomy (removal of a lobe)
Wedge resection (removal of tumour)

Question 19

What are the non-operative options for lung cancer?

Answer 19

Radiotherapy - radical or palliative
Chemotherapy
Best supportive care
Targeted drugs
Immunotherapy

Question 20

What is the first choice of treatment for small cell cancer?

Answer 20

chemotherapy

Question 21

What drugs in chemotherapy for small cell carcinoma, adenocarcinoma and squamous cell carcinoma?

Answer 21

Small cell - cisplatin and etoposide
Adeno - cisplatin and pemetrexed
Squamous - cisplatin and gemcibatine

Question 22

Differential diagnosis

may cause similar looking opacities, masses or nodules on chest x-ray or similar symptoms

Answer 22

Benign tumour - hamartoma, teratoma, granuloma
Bacterial infection
Tuberculosis
Fungal infection
Lung abscess
Fibrosis

Question 23

What does the T, N and M tell you in TNM staging?

Answer 23

T - how big it is and how far it has spread
N - lymph node involvement
M - metastases

Question 24

Tx, T0, Tis ?

Answer 24

Tx - primary tumour cannot be assessed
T0 - no evidence of primary tumour
Tis - carcinoma in situ

Question 25

T1

Answer 25

Tumour <3cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of involvement of the main bronchus

Question 26

T2

Answer 26

Tumour 3-5cm with any of the following features:

• involves main bronchus but not carina
• invades visceral pleura
• associated with atelectasis (collapse of lobe/lung) or obstructive pneumonitis that extends to the hilar region involving part of all the lung

Question 27

T3

Answer 27

Tumour 5-7cm or directly invades one of the following:
- chest wall
- phrenic nerve
- parietal pericardium
Or separate tumour nodules in same lobe as primary

Question 28

T4

Answer 28

Tumour >7cm or invades any of the following:
- diaphragm
- mediastinum
- heart
- great vessels
- trachea
- recurrent laryngeal nerve
- oesophagus
- vertebral body
- carina
Separate tumour nodules in a different ipsilateral lobe

Question 29

N0

Answer 29

No regional lymph node metastases

Question 30

N1

Answer 30

Ipsilateral peribronchial, hilar or intrapulmonary nodes including by direct extension

Question 31

N2

Answer 31

Ipsilateral mediastinal, subcarinal

Question 32

N3

Answer 32

Contralateral mediastinal, contralateral hilar, scalene or supraclavicular

Question 33

M0

Answer 33

No distant metastasis

Question 34

M1

Answer 34

Distant metastasis