Lung Cancer

Question 1

What are the two main categories of lung cancer?

Answer 1

Small Cell Lung Cancer

Non small Cell Lung Cancer

Question 2

What is the most aggressive type of lung cancer?

Answer 2

Small Cell Lung Cancer is more aggressive, cells divide quickly and it is more prone to metastasise early

Question 3

What are the different types of non-small cell lung cancer?

Answer 3

Adenocarcinoma (most common type of lung cancer)
Squamous cell carcinoma
Carcinoid tumour
Large cell tumours (haven’t differentiated to either of above)

Question 4

What are some of the symptoms of lung cancer?

Answer 4

Haemoptysis
Chronic cough
Chest pain
Breathlessness
Fatigue
Weight loss
Recurrent lobar pneumonia (due to reduced ventilation distally)

Symptoms due to compression of other tumours:
Pancoast’s Tumour- Horner’s, Upper limb weakness, SVC obstruction
Hoarse voice- laryngeal nerve compression

Paraneoplastic symptoms (more common with SCLC)-
Cushings features
PTH release- hyperparathyroid features
Lambert eaton myasthenic syndrome

Question 5

What are some differentials for haemoptysis?

Answer 5

Lung malignancy
Tuberculosis
Pulmonary infarct
Pulmonary oedema (pink frothy sputum)
Bleeding from elsewhere- e.g. pharynx

Question 6

Why could an apical lung tumour cause upper limb weakness?

Answer 6

Invasion or compression of the brachial plexus. This could also cause sensory abnormalities.

Question 7

What are some risk factors for lung cancer?

Answer 7

Smoking
Radon exposure
Radiation exposure- e.g. previous radiotherapy
Genetics

Question 8

What initial investigations should be done for lung cancer?

Answer 8

CXR
Bloods- FBC, U&Es, Ca, PTH, ALP, CRP, ESr,
TB?- Sputum culture, TBT, AFB staining, HIV check too
Sputum cytology- if effusion send for analysis

Question 9

What further investigations should be done for lung cancer after basic ones?

Answer 9

CT Scanning- can assess the extent of spread, local invasion, or be used to guide a biopsy

Bronchoscopy- Can be used to visualize the tumour, take a biopsy but is limited by anatomical location of the tumour. EBUS can be used to sample mediastinal lymph nodes as well.

If any bony metastases are suspected radio-isotope bone scanning should be done.

If considering surgery lung function tests need to be done to assess suitability.

PET scanning (marked glucose) will also show up metastases and the primary tumour

Question 10

How is lung cancer staged?

Answer 10

TNM staging system like every other cancer

Question 11

What is a Pancoast’s tumour?

Answer 11

This is an apical lung tumour, due to its location it causes additional symptoms:

• Compression of brachial plexus = Upper limb weakness
• Compression of SVC= SVC obstruction
• Compression of cervical sympathetic chain = Horner’s Syndrome (Ptosis, Meiosis, Anhidrosis)

Question 12

What is Lambert Eaton Myasthenic Syndrome?

Answer 12

This occurs due to lung cancers which stimulate production of autoantibodies which target the calcium channels of presynaptic neurons. Unlike myasthenia repetitive action causes increasing strength (myasthenia demonstrates fatigability)

Question 13

What are the treatment option for lung cancer?

Answer 13

Depends upon the TNM stage

Surgery if localised
Chemotherapy
Radiotherapy
Targeted therapies for specific mutations

Question 14

What should you always remember to ask about in a lung cancer history?

Answer 14

Smoking status
Passive smoking (i.e. did parents or anyone in your home smoke)

Question 15

What are some differentials for nodules on a CXR?

Answer 15

Malignancy
Granuloma
TB
Abscess
Hamartoma
Foreign body
Cysts
Tumour not in the lung- e.g skin, breast

Question 16

What is the prognosis for lung cancer?

Answer 16

It’s not great.

NSCL- 50% at 2 years without spread, 10% with spread

SCLC- Medical survival is 3 months if untreated, 1-1.5 years if treated.

Question 17

Where does lung cancer often metastasis to?

Answer 17

Brain
Bone
Liver
Adrenal Glands

Question 18

What type of lung cancer causes elevated PTH?

Answer 18

Squamous cell lung cancer

Question 19

What type of lung cancer secretes Beta HCG? What features does this cause?

Answer 19

Large cell carcinoma

Causes galactorrhoea in females or gynaecomastia in males

Question 20

What might carcinoid tumours secrete? What symptoms can this cause?

Answer 20

Carcinoid tumours can cause carcinoid syndrome where they secrete serotonin. This can cause flushing, nausea and diarrhoea. 5-HIAA can be detected in the urine if serotonin elevated.

Question 21

What might be seen on a CXR for lung cancer?

Answer 21

Nodule/ Lesion
Hilar lymphadenopathy
Pleural effusion- do a pleural tap if seen
Collapse or consolidation (due to poor ventilation distally)

Question 22

How does CT how biopsies are obtained?

Answer 22

If within the lumen of the airway- transbronchial biopsy can be done

If within the parenchyma- endobronchial ultrasound can be used to obtain a biopsy, can also sample lymph nodes

If located peripherally- CT guided biopsy or VATS

Question 23

When is surgery suitable for lung cancer?

Answer 23

For a localised solitary nodule that has not metastasised. Metastatic disease can only be treated with chemotherapy.

Question 24

What scans can help to identify metastatic disease?

Answer 24

CT scan
PET Scan
Isotope Bone Scanning

Question 25

When should people with suspected lung cancer be referred under a 2WW?

Answer 25

CXR with suspicious features
Aged 40 or over with unexplained haemoptysis

Do an urgent CXR if chronic cough, fatigue, SOB, chest pain, weight loss, low appetite and over 40.