Lung cancer

Question 1

3 causative factors of lung cancer

Answer 1

tobacco
radon
asbestos

Question 2

Clinical features of lung cancer leads to?

Answer 2

Urgent referral for a CXR

Question 3

What are clubbing of fingers?

Answer 3

In late clubbing the angle is greater than 180 degrees and the proximal edge of the nail elevates.

Question 4

All Non Small Cell Lung Cancers

Molecular phenotype

Answer 4

PDL-1 Status

Over 50% consider immunotherapy

Question 5

Adenocarcinoma

Molecular phenotype

Answer 5

EGFR
ALK gene
ROS-1
kRAS

Question 6

What is FDG-PET-CT? Cons?

Answer 6

A FDG PET/CT Scan is a diagnostic procedure which uses a small amount of a tracer (FDG) to help physicians identify abnormal from normal functioning organs and tissues.

Only imaging
No tissue diagnosis
Additional specimen collection procedure is required to confirm diagnosis

Question 7

Bronchoscopy & Endobronchial Ultrasound (EBUS) used for?

Answer 7

Small cell carcinoma

Question 8

Trans-thoracic CT biopsy

Pros and cons

Answer 8

Advantage:
Real time
Sensitivity 70-100%

Disadvantage:
Risk of pneumothorax (25-30%)
Small sample size
In case of bleeding no immediate intrabronchial treatment possible

Question 9

Treatment of lung cancer is based on?

Answer 9

Treatment Based on:
Diagnosis
Cell Type
Subgroup
Molecular Phenotype

Staging
Disease extent

Fitness

Question 10

What is the airway conductive system?

Answer 10

Asymmetrical dichotomous branching tubular system
(up to) 24 divisions

Bronchi > ~ 1mm
Bronchioli < 1mm
“Small airways” < 2mm

Question 11

Development of carcinoma

Answer 11

Multistep accumulation of mutations resulting in:
Disordered growth
Loss of cell adhesion
Invasion of tissue by tumour
Stimulation of new vessel formation around tumours

Mutations occur in epithelial cells and stem cells.
Pathways different for different tumour types
Reflected in histology of tumours

Question 12

Lung tumour types

Answer 12

Tumours arise from a variety of cell types: Epithelial, mesenchymal (soft tissue), lymphoid.

Question 13

What are Benign lung tumours

Answer 13

Do not metastasise

Can cause local complications
Airway obstruction

E.g. chondroma

Question 14

What are Malignant lung tumours

Answer 14

Potential to metastasise, but variable clinical behaviour from relatively indolent to aggressive

Commonest are epithelial tumours : “carcinomas”

Question 15

What is squamous cell carcinoma?

Answer 15

25-40% pulmonary carcinoma
Closely associated with smoking
Traditionally central arising from bronchial epithelium, but recently increase in peripheral SqCC
Local spread, metastasise late.

Question 16

Adeocarcinoma development

Answer 16

Atypical adenomatous hyperplasia - proliferation of atypical cells
Lining the alveolar walls. Increases in size and eventually can become
Invasive.

Question 17

Progression of AAH

Answer 17

acquires invasive phenotype

Question 18

Small cell Ca vs Non small cell Ca

Answer 18

Small cell lung carcinoma
Survival 2-4 months untreated
10-20 months with current therapy
chemoradiotherapy (surgery very rarely undertaken as most have spread at time of diagnosis)

Non small cell lung carcinoma
Early Stage 1: 60% 5 yr survival
Late Stage 4: 5% 5 yr survival
20-30% have early stage tumours suitable for surgical resection. 
Less chemosensitive

Question 19

TNM staging- define what it does and each section

Answer 19

TUMOUR (T1-4)
Size, Invasion pleura, invasion other structures e.g. pericardium

N LYMPH NODE METASTASIS (N0-3)
N0 – lymph node not involved by tumour
N1 or N2 or N3 - lymph nodes involved by tumour

M DISTANT METASTASIS (M0 or 1)
M1 – tumour has spread to distant sites
E.g. tumour in liver, bones, brain (includes separate tumour nodule in different lobe of lung)

It is a measure of how advanced a tumour is:
Each patient given T N and M stage and together these give information about prognosis and operability.

Can be clinical, radiological or pathological (the latter is most accurate)

Question 20

Local effects of lung cancer

Answer 20

bronchial obstruction
invasion of local structures
inflammation/irritation/invasion of pleura or pericardium

Question 21

Bronchial obstruction is ?

Answer 21

Collapse of distal lung
Shortness of breath

Impaired drainage of bronchus
Chest infection
Pneumonia, abscess

Question 22

Invasion of local structures is?

Answer 22

Invasion of local airways and vessels
Haemoptysis, cough
Invasion around large vessels
Superior vena cava syndrome- venous congestion of head and arm oedema and ultimately circulatory collapse
Oesophagus
Dysphagia
Chest wall
Pain
Nerves
Horners syndrome

Question 23

Inflammation/irritation/ invasion of pleura or pericardium is?

Answer 23

Pleuritis or pericarditis, with effusions
Breathlessness
Cardiac compromise

Question 24

Systemic Effects of Bronchogenic Carcinoma

Answer 24

Physical effects of distant spread
brain (fits)
skin (lumps)
liver (liver pain, deranged LFTs)
bones (bone pain, fracture)

Paraneoplastic Syndromes: Systemic effect of tumour due to abnormal expression by tumour cells of factors (e.g. hormones and other factors) not normally expressed by the tissue from which the tumour arose
Endocrine e.g. “Syndrome of inappropriate antidiuretic hormone” causing hyponatremia (especially small cell carcinoma)
Non-endocrine e.g. Haematologic/coagulation defects