Lung Cancer

Question 1

How common is lung caner.

Answer 1

It is the most common cause of death from cancer worldwide.

Question 2

How many deaths occur per year due to lung cancer. (2)

Answer 2

1.4million worldwide.

27% of cancer deaths.

Question 3

What percentage of deaths due to malignant disease are due to lung cancer.

Answer 3

18%.

Question 4

How many deaths due to lung cancer occur in the UK per annum.

Answer 4

40,000.

Question 5

What are the risk factors for lung cancer. (6)

Answer 5

Smoking is the biggest risk factor. 
Asbestos. 
Chromium. 
Arsenic. 
Iron oxides. 
Radiation (radon gas).

Question 6

How many lung cancer cases are estimated to be due to smoking.

Answer 6

90% of lung carcinomas.

Question 7

What are the histological types of lung cancer. (5)

Answer 7

Squamous cell (35%). 
Adenocarcinoma (27%). 
Small (oat) cell (20%).
Large cell (10%).
Alveolar cell carcinoma (rare,

Question 8

What is the most important clinical distinction when it comes to lung cancer. (2)

Answer 8

Between small cell and non-small cell.

Question 9

What are the most common blood-borne sites of metastasis in lung cancer. (5)

Answer 9

Liver. 
Bone. 
Brain. 
Adrenals. 
Skin.

Question 10

What subset of lung cancer is prone to distant metastases.

Answer 10

Small cell lung cancers.

Question 11

What local structures tend to be invaded by lung cancers. (6)

Answer 11

May involve the pleura directly or by lymphatic spread.
It may extend into: the chest wall, invading the intercostal nerves or the brachial plexus and causing pain.
There may be lymphatic spread to mediastinal and supraclavicular lymph nodes (often before diagnosis).

Question 12

What are the symptoms of lung cancer. (9)

Answer 12

Cough (80%).
Haemoptysis (70%).
Dyspnoea (60%). 
Chest pain (40%). 
Recurrent or slowly resolving pneumonia. 
Lethargy. 
Anorexia. 
Weight loss.
Pain and nerve entrapment (eg pleuritic pain usually indicated malignant pleural invasion).

Question 13

What are the clinical signs of lung cancer.

Answer 13

Cachexia.
Anaemia.
Finger clubbing.
Hypertrophic pulmonary ostearthropathy (HPOA) causing wrist pain (painful periostitis of the distal tibia, fibula, radius, and ulne, with local tenderness and sometimes pitting oedema over the anterior shin).
Supraclavicular or axilliary node enlargement.
Chest: none, colsolidation, collapse, pleural effusion.
Metastatic: bone tenderness, hepatomegaly, confusion, fits, focal CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy.

Question 14

What may a carcinoma in the lung apex cause.

Answer 14

Horner’s syndrome.

Question 15

What is Horner’s syndrome characterised by. (4)

Answer 15

Ipsilateral partial ptosis.
Enophthalmos.
Miosis.
Hypohidrosis of the face.

Question 16

What is Pancoast’s syndrome.

Answer 16

Pain in the inner aspect of the arm, sometimes with small muscle wasting in the hand.

Question 17

What does Pancoast’s syndrome indicate.

Answer 17

Indicates malignant destruction of the T1 and C8 roots in the lower part of the brachial plexus by an apical lung tumour.

Question 18

What occurs in SVC obstruction by a malignant node. (4)

Answer 18

Causes suffusion and swelling of the neck and face.
Conjunctival oedema.
Headache.
Dilated veins on the chest wall.

Question 19

What is the most common cause of a SVC obstruction (in lung cancer).

Answer 19

Bronchial carcinoma.

Question 20

What are some common non-metastatic extrapulmonary effects of lung cancer. (4)

Answer 20

Syndrome of inappropriate ADH secretion and ectopic adrenocorticotrophic hormone secretion are associated with small cell lung cancer.
Hypercalcaemia may indicate malignant bone destruction or production of hormone-like peptides by a tumour.
Associated neurological syndromes may occur with any type of bronchial carcinoma.

Question 21

What causes the typical ‘bovine’ cough (lacking the normal explosive character) often seen in lung cancer.

Answer 21

Involvement of the left recurrent laryngeal nerve by tumours at the left hilum.

Question 22

What are the local complications of lung tumours. (8)

Answer 22

Recurrent laryngeal nerve palsy. 
Phrenic nerve palsy. 
SVC obstruction. 
Horner's syndrome (Pancoast's tumour). 
Rib erosion. 
Pericarditis. 
AF.

Question 23

What are the metastatic complications of lung cancer. (4)

Answer 23

Brain.
Bone (bone pain, anaemia, raised calcium).
Liver.
Adrenals (Addison’s).

Question 24

What are the endocrine complications of lung cancer. (2)

Answer 24

Ectopic hormone secretion (eg SIADH = low sodium, raised ADH; ACTH = Cushing's) by small cell tumours. 
Raised PTH (raised serum calcium) by squamous cell tumours.

Question 25

What are the non-metastatic neurological complications of lung cancer. (7)

Answer 25

Confusion. 
Fits. 
Cerebellar syndrome. 
Proximal myopathy. 
Neuropathy. 
Polymyositis. 
Lambert-Eaton syndrome.

Question 26

What are the other complications of lung cancer. (5)

Answer 26

Clubbing. 
HPOA. 
Dermatomyositis. 
Acanthosis nigricans. 
Thrombophlebitis migrans.

Question 27

What are the common causes of large bronchus obstruction. (5)

Answer 27

Bronchial carcinoma or adenoma.
Enlarged traceobronchial lymph nodes (malignant or tuberculosis).
Inhaled foreign body.
Bronchial casts or plugs consisting of inspissated mucus or blood clot (especially asthma, CF, haemoptysis, debility).
Collections of mucus or mucopus retained in the bornchi as a result of ineffective expectoration (especially postoperative following abdominal surgery).

Question 28

What are the rare causes of large bronchus obstruction. (5)

Answer 28

Aortic aneurysm. 
Giant left atrium.
Pericardial effusion. 
Congenital bronchial atresia. 
Fibrous bronchial stricture.

Question 29

What are the common radiological presentations of bronchial carcinoma. (8)

Answer 29

Unilateral hilar enlargement. 
Peripheral pulmonary opacity. 
Lung, lobe or segmental collapse. 
Pleural effusion. 
Broadening of mediastinum, enlarged cardiac shadow, elevation of a hemidiaphragm. 
Rib destruction.

Question 30

How are lung tumours staged.

Answer 30

CT.

Question 31

What is the prognosis for lung cancer. (4)

Answer 31

Non-small cell: 50% 2 year survival without spread, 10% with spread.
Small cell: median survival is 3 months if untreated, 1-1.5years if treated.