Lung Cancer

Question 1

How many new cases of lung cancer in the UK each year?

Answer 1

44,000

Question 2

Describe the epidemiology of lung cancer

Answer 2

Higher cancer related deaths world wide.

35,000 death per year in the UK

500 deaths per year in Leicester

Question 3

Describe a typical patient with cancer

Answer 3

75 year old male, ex-smoker

Peristant cough

Tried antibiotics and steroids

CXR - abnormal

Then referred to rapid access lung (RAL) clinic

Question 4

What does smoking cause in relation to lung cancer?

Answer 4

90% of lung cancer deaths in men

80% of lung cancer deaths in women 2

0% of lung cancer cases in non-smokers

Question 5

What are the risk factors for lung cancer other than smoking?

Answer 5

• Asbestos
• Radon
• “Occupational carcinogens”
  
  • chrominum,
  • nickel,
  • arsenic
• Genetic factor

Around 5000 cases a year are never smokers.

Question 6

Why don’t we screen for lung cancer?

Answer 6

Because it has not shown a big increase in specific disease mortality.

BUT, they have started a low dose CT screening program in Manchester for people who smoke which may be decreasing mortality so, it may eventually become a thing.

Question 7

What are the different stages of lung cancer?

Answer 7

Uses TNM staging

Question 8

What imaging can you use to stage cancer?

Answer 8

• CXR
• CT Scan
• PET Scan
• MRI
• USS
• Bone scan
• ECHO

Question 9

What tissue samples can you do to stage lung cancer?

Answer 9

• Bronchoscopy
• USS -neck node, lung/chest wall mass, pleural fluid, liver
• CT biopsy - lung, pleura
• Thorocoscospy - medical
• Surgical - mediastinoscopy ect..

Question 10

Where could lung cancer spread to?

Answer 10

• Brain
• Draining lymph nodes
• Pericardium
• Lung
• Pleura
• Liver
• Adrenals
• Bone

Question 11

What are the symptoms of a primary lung cancer tumour?

Answer 11

• Cough
• Dyspnoea
• Wheezing
• Haemoptysis
• Lung infection
• Chest / shoulder pain
• Weight loss
• Lethargy / Malaise
• NO SYMPTOMS

Question 12

What symptoms can you get from regional metastasis of lung cancer?

Answer 12

• Bloated face (SVC obstruction)
• Hoarsness (left recurrent laryngeal nerve palsy)
• Dyspnoea (anaemia, pleural or pericardial effusion)
• Dysphagia (oesophageal compression)
• Chest pain (parietal pleural)

Question 13

What symptoms can you get from distant metastasis?

Answer 13

• Bone pain / fractures
• CNS symptoms (headache, double vision, confusions)

Question 14

What metabolic symptoms can you get?

Answer 14

• Thirst (hypercalcaemia)
• Constipation (hypercalcaemia)
• Seizures (hyponatraemia - SIADH, small cell)

Question 15

What are some signs of lung cancer?

Answer 15

• Cachexia
• Pale conjuctiva
• Cervical lymphadenopathy
• Horner’s syndrome
• Consolidation
• Signs of pleural effusion
• Muffled heart sounds
• Liver enlargement
• Skin metastases
• Neurological long tract signs
• NO SIGNS

Question 16

What are the symptoms of paraneoplastic syndromes?

Answer 16

• Endocrine
  
  • Hypercalcaemia
  • Cushing’s syndrome
  • SIADH
• Neurological
  
  • Encephalopathy
  • Peripheral neuropathy
  • Eaton-Lambert syndrome
  • Pancoast syndrome
• Haematological
  
  • Anaemia
  • Thrombocytosis
• Cutaneous
  
  • Dermatomyositis
• Skeletal
  
  • Finger clubbing

Question 17

What imaging do you do on all with suspected lung cancer and what do you only do on some?

Answer 17

All:

• Chest X-Ray
• Staging chest CT

Some:

• PET-CT
• Head CT
• Pelvic CT
• MRI
• Bone Scan
• Ultrasound

Question 18

What are the different types of biopsy?

Answer 18

• Bronchoscopy
• Cervical lymph node fine needle aspiration
• Pleural fluid aspiration
• CT guided lung biopsy
• CT guided pleural biopsy
• CT / USS guided liver biopsy
• Adrenal biopsy
• Skin biopsy
• Bone biopsy
• Brain biopsy
• Lymph node biopsies (axillary, abdominal)

Question 19

What are the different types of lung cancer?

Answer 19

Non-small cell lung cancer:

• Squamous cell carcinoma (40%)
• Adenocarcinoma (35%)
• Large cell carcinoma (5%)

Small cell carcinoma (12%)

Rare tumours (12%)

Question 20

What are the molecular markers of lung cancer?

Answer 20

• EGFR mutations
• ALK mutation
• KRAS mutations
• PD1 mutations
• PDL1 mutations

Question 21

How do you decide what treatment people with lung cancer get?

Answer 21

• Take into account:
  
  • Staging
  • Performace status (how active they are)
  • Co-morbidities

Question 22

What treatment options are available for people with lung cancer?

Answer 22

• Surgery
  
  • Mostly for NSCLC (20-25% operable). The best chance of cure
• Radiotherapy
  
  • ‘Radical’ - with curative intent
  • ‘Palliative’ - symptom control
• Combination chemotherapy
  
  • Small cell -potentially curative in a minority
  • Non-small cell- modest survival increase, symptom control
  • ‘neoadjuvant’ therapy -chemo just beofre surgery (to ‘downstage’ the tumour to allow subsequent surgery)
  • ‘Adjuvant’ -chemo after surgery
• Combination therapy
  
  • Combination chemo-radiotheray -potentially curative
• Biological (‘Targetted’) therapies
  
  • Based on muational analysis (EGFR, ALK, RAS, PD1, PDL1)
• Palliative care and other treatments
  
  • Active symptom control