Lung Cancer Flashcards by Eilidh Seaton

What are the two types of lung cancer

Small cell

Non-small cell

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What can non-small cell be further differentiated into

SCC
Adenocarcinoma
Large cell undifferentiated

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What are the RF for lung Ca
What is specific to SCC
What is specific to adenocarcinoma

What is smoking most related too
What is least related to smoking

Smoking - most related to SCC (least to adenocarcinoma)
Asbestos
Environmental radon 
Air pollution
Pulmonary fibrosis 
SCC - polycyclic aromatic carbons
Adeno - N-nitroxamines

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What are the symptoms of lung cancer

If central = tend to get chest symptoms
If peripheral e.g. adenocarcinoma = present late (may not see on bronchoscopy) 
SOB 
Chronic cough
Haemoptysis
B symptoms 
Wheezing
Chest + bone pain
Chest infection - slow resolving + recurrent 
Abscess 
Hoarse voice - pancoast compressing laryngeal nerve
Lymphadenopathy - often supraclavicular

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What are the signs of lung cancer

Anaemia - haemolytic
Weight loss 
Clubbing 
Dysphagia + stridor if compress 
Trachea deviation
Horner's 
Hypercalcaemia 
Vena cava obstruction 
HSM
Skin nodules 
Thromboplebitis migrans
DIC

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What is Horner’s and what causes

Pancoast tumour - in apex pressing on sympathetic ganglion 
Miosis
Ptosis 
Anhidrosis 
Enopathalmus

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What are signs of hypercalacameia

Constipation
Abdominal pain
Confusion
Renal

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What are local complications of lung C

Lung collapse
Pneumothorax
Bronchial obstruction - lung collapse, pneumonia, bronchiectasis
Direct invasion of chest wall + nerves
Phrenic = diaphragm paralysis = SOB
L recurrent palsy = bovine cough / hoarse voice
Brachial plexus + ribs
Superior vena cava obstruction - distended veins and swelling
Rib erosion
Pericarditis

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What is squamous associated with

Clubbing
PTH increased = high Ca
Ectopic TSH = hyperthyroid
Osteoarthropathy

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What is adenocarcinoma associated with

Clubbing
Gynaecomastia due to HCG
Pulmonary osteoarhtropathy

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What is suggestive of mets

Bone pain
Anaemia
Hepatomegaly
Adrenal = Addison’s
CNS - Confusion / fits / cerebellar / encephalopathy
Peripheral neuropathy
Lambert eaton - autoimmune attack on own tissues

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Urgent cancer pathway

If >40 + haemoptysis

>40 and CXR suggest cancer

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When do you do CXR

>40 + 2 of or smoker +1 of
Cough
Fatigue
SOB
Chest pain
Weight loss
Anorexia

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What symptoms = immediate CXR

Recurrent chest infection
Clubbing
Cervical LN
Thrombocytosis
Chest signs

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What are initial investigation by GP and when do you admit straight away

CXR
FBC, U+E - if contast, LFT, Ca 
Clotting screen in case biopsy 
Spirometry
Sputum cytology
Blood culture

Admit if

Stridor
SVC obstruction

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What does FBC / LFT / Ca show

Anaemia (cancer in bone marrow)
Thrombocytosis
Abnormal LFT if liver mets
High Ca suggest bone mets

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What does CXR show

Pleural effusion - usually unilateral 
Peripheral opacity 
Invasion
Collapsed lung
Hilar enlarged
Consolidation

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What do you do after CXR

Staging CT CAP contrast enhanced

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Depending what CT shows what are options

Bronchoscopy + biopsy = most common
EUS aspiration
Trans thoracic FNA / biopsy
Surgical excision biopsy

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What is advanced imaging options

CT
ECHO - pericardial effusion
MRI
PET CT - if curative intent
Biomarkers

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What biomarkers have drugs to target

EGFR

ALK

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How do you do T staging

CT
PET
Bronchoscopy

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N staging

PET
CT
EBUS
Mediastinoscopy - always do before surgery to look for LN

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M staging

PET CT

Bone scan

Differential of cancer / consolidation

``` TB Abscess Carcinoid Hamartoma AV malformation Foreign body Skin tumoru Fibrosis ```

Where does lung metastasis too

``` Liver Adrenal Renal - cannon ball Bone Brain Skin LN ```

When is surgery CI

``` Not fit Stage IIIb or IV FEV1 <1.5l Pleural effusion Tumour near hilum Vocal cord affected SVC obstruction ```

What is palliation options

``` Control symptoms - analgesia + anti-emetic Chemo RT - Obstruction - Bone + brain mets SVC stent Analgesia Biphosphonates – treat hypercalcaemia Fluids DNACPR END OF LIFE CARE ```

What does Novulumab do

Attack check points Switch on immune system to attack Cancer switches of immune by binding to PD1 / PDL1 / CTLA4

When is surgery possible

Stage 1 and 2 onl | Only 10% of people

What is best chance of cure in NSC

Surgery RT can be curative if early enough Adjuvant chemo to improve chance of survival or for palliation Nivolumab

Where does small cell cancer arise and what is prognosis

Fast growing so usually have mets by the time Dx | Arise from neuroendocrine cells

Sx Small cell

``` Same as above Ectopic hormone production common ACTH SIADH Lambert Eaten common Limbic encephalitis - short term memory, hallucination, seizure ```

What does SIADH cause

Hyponatraemia

What does ACTH cause

Cushing's High BP High blood glucose Hypokalaemic acidosis due to high cortisol

How do you treat

Chemo + RT = Rx of choice | No surgery in most cases

Prognosis

Poor

What is adenocarcinoma associated with

KRAS

What is SCC associated with

FGFR1 DDR2 FGFR2

What mutations have no relation to smoking

EGFR – target drug BRAF HER2 ALK rearrangement – target drug

What can RT be used for

``` Palliation Obstruction Haemoptysis Lobe collapse Chest pain ```

What does staging for RT require

PT test

Radcical RT Stages

``` 0 = asymptomatic 1 = symptomatic with light work 2 = rest for <50% day 3 = rest for >50% 4 = bed bound (incurable) ```

What are options for nicotine replacement therapy

Varencline | Bupropion

When do you prescribe NRT

2 weeks before target stop date | If high dependence prescribe patch + another form

SE of NRT

N+V Headache Flu Insomnia

What is Varencline

Nicotine partial agonist | 12 week coarse

Common SE

N+V Headache Insomnia

When is it CI

Pregnancy Breast feed Depression

What is Bupropion

Norenephrine and dopamine reuptake inhibitor

When is it CI

Pregnancy | Epilepsy as small risk of seizure

What do you do if smoking during pregnancy

``` Refer to services CO to test CBT / motivation interview Nicotine replacement Patch = 1st Line NRT if all else fails ```

What is Lambert and what are Sx

Ab from SCLC targeted against Ca gated channels Weakness - worse in legs / proximal muscles Diplopia if extra-ocular Ptosis if LPS Slurred speech / dysphagia if pharyngeal muscles Like myasthenia gravis Improves muscle use

What should you consider in cancer patient with weakness

Spinal cord compression Cauda equina - back pain / saddle Lambert Eaton

What is large cell associated with

Poor prognosis as poor differentiated | Secrete b-HCG

Rx NSCLC

Surgery

RX SCLC

RT | CANT operate

What can cause breathlessness in lung cancer

Pleural effusion Pneumothorax Lymphangitis carcinomatosa