Lung cancer

Question 1

Most common type of lung cancer?

Answer 1

Squamous cell (NSCLC) - typically central, can secrete PTHrP (–> hypercalcaemia)

NSCLC = 82% of which squamous cell is 32%

Question 2

1st line management of NSLCL for stage 1/2 without chest wall invasion?

Answer 2

Surgery + adjuvant chemo

80% 5 year survival

Question 3

Management of NSLCL if surgery is not possible?

Answer 3

Radiotherapy + concurrent chemo

Question 4

What metastases would palliative radiotherapy be indicated for?

Answer 4

Brain mets, SVCO, SCC

Question 5

Chemotherapy options for NSCLC

Answer 5

Carboplatin + gemcitabine/paclitaxel

Question 6

Targeted therapy option for NSCLC

Answer 6

TKI - erlotimab

Often used in a palliative setting

Question 7

5 year survival of different stages of NSCLC

Answer 7

1 = 50%
2 = 40%
3a = 25%
3b = <5%

(4 = 6 months to live)

Question 8

Proportion of lung cancers that are small cell in origin?

Answer 8

20%

Question 9

What treatment options are SCLC particularly responsive to?

Answer 9

Radio and chemotherapy

Question 10

Paraneoplastic syndromes of SCLC?

Answer 10

ADH –> hyponatremia

ACTH –> cushings –> muscle weakness, hypokalemia, HTN, oedema

Lambert-eaton syndrome - antibodies for voltage gated calcium channel –> myasthenia like syndrome

Question 11

Usual presentation of SCLC? (i.e. local or disseminated)

Answer 11

Usually metastasised at presentation (poor prognosis)

Question 12

Management of limited SCLC (i.e. fairly localised)

Answer 12

If tumour is at very ealry stages (12a, N0, M0) then can do surgery

Most patients = Chemo + concurrent radial radiotherapy

Question 13

Management of extensive SCLC?

Answer 13

Chemo (palliative)

90% responsive but high relapse rates

Question 14

Risk factors for LC?

Answer 14

Age>40
Smoking
occupation (asbestos, uranium mining, ship building etc)

Question 15

Causes of lung cancer?

Answer 15

TSG inactivation via chromosomal deletions
Oncogene overexpression - RAS, myc
EGFR activation (common in adenocarcinoma)

Question 16

Clinical presentation?

Answer 16

Non-specific:
Persistent cough +/- haemoptysis 
Dyspnoea
Recurrent chest infections
Chest pain

Syndromal (dependent on tumour location):

• Apical tumours –> horner’s, pancout’s syndrome
• Paraneoplastic
• Mediastinal –> SVCO, recurrent laryngeal nerve palsy (voiceless)

Question 17

Investigations?

Answer 17

1. CXR - 95% tumours visible at presentation
2. Sputum cytology - can detect and analyse malignant cells
3. Bronchoscopy - take biopsy
4. Trans-thoracic biopsy if peripheral tumour
5. CT chest + upper abdomen + head - metastases/staging
6. PET scan - for patients with operable disease to check for distant mets
   (7. tumour markers - NSE and LDH, not routinely used)

Also: Function test e.g. spirometry

Question 18

T, N and M

Answer 18

T1 = <3cm (surrounded by pleura)
T2 = <7cm (invades main bronchus)
T3 = >7cm (Local invasion e.g. chest wall)
T4 = organ invasion (inoperable)

N1 = I/L Bronchopulmonary and hilar LN
N2 = I/L mediastinal or subcarinal LN
N3 = Supraclavicular or contralateral LN

M1a - C/L lung
M1b - distant metastases

Question 19

Staging

Answer 19

Stage 1 = T1/T2, N0, M0
Stage 2 = T1/T2, N1, M0 or T3, N0, M0
Stage 3a = T1/T2/T3, N2, N0 or T3/T4, N1, M0
Stage 3b = T4, N2, M0 or any N + M0
Stage 4 = M1 (any)

Question 20

At what stage does lung cancer become inoperable?

Answer 20

Stage 3b

Question 21

Definition of limited disease?

Answer 21

one hemithorax (I/L mediastinal and supraclavicular LN)