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Respiratory Pathology > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

Another name for lung cancer

A

Pulmonary neoplasia

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2
Q

Causes of lung cancer

A 
Tobacco 
Asbestos
Environmental radon 
Other occupational exposure
- chromates
- hydrocarbons
- nickel 
Air pollution and urban environment
Other radiation 
Pulmonary fibrosis
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3
Q

What % of lung cancer is attributable to smoking?

A

> 85%

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4
Q

What % of smokers get lung cancer?

A

10%

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5
Q

What is a pack year?

A

Packs per day per year

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6
Q

Two main pathways of carcinogenesis in the lungs

A

Lung periphery
- bronchioalveolar epithelium stem cell transformation
- adenocarcinoma
Central lung airways
- bronchial epithelial stem cells transform
- SCC

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7
Q

Which process is strongly associated with smoking in the lungs?

A

Squamous dysplasia -> CIS -> invasive bronchogenic carcinoma

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8
Q

What is peripheral lung adenocarcinogensis and what is it associated with?

A

Atypical adenomatous hyperplasia AAH to adenoma in situ to invasive adenocarcinoma
Assosiated less strongly with smoking however does occur in non smokers

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9
Q

Adenocarcinogensis and molecular biology

A

KRAS ; 35% - smoking induced
EGFR ; 15% - not related to tobacco carcinogenesis
BRAF, HER2 ; 2% - not related to smoking
ALK rearrangements ; 2% - not related to smoking carcinogenesis

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10
Q

What % of lung neoplasms are a carcinoid tumour?

A

< 5%

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11
Q

What is a carcinoid tumour?

A

Low grade malignancy

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12
Q

What are the tumours of the bronchial glands and are they common?

A

Adenoid cystic carcinoma
Mucoepidermoid carcinoma
Benign adenomas

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13
Q

Tumours of the lung

A 
Benign causes of a mass lesion 
Tumours of the bronchial glands
Carcinoid tumour
Lymphoma
Sarcoma
Mets to lungs
Carcinoma
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14
Q

4 main types of lung carcinoma

A

Squamous cell 40%
Adenocarcinoma 41%
Small cell 15%
Large cell 4%

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15
Q

Histological types of lung carcinoma

A

15% - small cell carcinoma (SCLC)

85% - non small cell carcinomas (NSCLC)

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16
Q

What are the NSCLCs?

A

Adenocarcinoma
SCC
Large cell carcinomas

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17
Q

When does a primary lung cancer present?

A

Late - few or no symptoms or signs until the disease is very advanced

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18
Q

Local effects of lung cancer

A 
Bronchial obstruction 
- collapse
- endogenous liquid pneumonia
- infection/abscess
- bronchiectasis 
Pleural 
- inflammatory
- malignant 
Direct invasion 
- chest wall 
- nerves
Mediastinum (SVC, pericardium)
Lymph node mets
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19
Q

What nerves can be effected by direct invasion of lung cancer?

A

Phrenic
L recurrent pharyngeal
Brachial plexus
Cervical sympathetic

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20
Q

What would damage to the phrenic nerve cause?

A

Diaphragmatic paralysis

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21
Q

What would damage to the L recurrent laryngeal nerve cause?

A

Hoarse, bovine cough

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22
Q

What would damage to the brachial plexus cause?

A

Pancoast T1 damage

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23
Q

What would damage to the cervical sympathetic chain cause?

A

Horners syndrome

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24
Q

Distant effects of lung cancer

A 
Distant mets
Secondary to local effects
- neural 
- vascular
Non met effects
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25
Q

Where does lung cancer metastasise to?

A 
Liver
Adrenals
Bone
Brain 
Skin
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26
Q

What are the non metastatic paraneoplastic effects of lung cancer?

A 
Clubbing
HPOA
ACTH, siADH, PTH
Carcinoid syndrome
Gynaecomastia
Polyneuropathy 
Encephalopathy 
Cerebellar degeneration 
Myasthenia
Acanthosis nigricans
Dermatomyositis
Granulocytosis
Eosinophilia
DIC
Thrombophlbeitis migrans
Nephrotic syndrome
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27
Q

Investigations for lung cancer

A 
CXR
FBC
RFTs, LFTs, calcium 
Clotting screen
Spirometry 
Bronchoscopy 
- bronchial bronchoscopy
- bronchial brushings and washings
- endobronchial US guided aspiration (EBUS)
Image guided lung biopsy 
Trans thoracic FNA
Trans thoracic core biopsy 
CT
MRI 
PET
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28
Q

Prognostic factors in lung cancer

A

Stage of disease
Classification
Markers/oncogenes/gene expression profiles
Growth rate
Cell proliferation
DNA aneuploidy (abnormal number of chromosomes)
Immune cell infiltration

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29
Q

What may prognostic markers be used to select?

A

Patients for adjuvant therapy

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30
Q

Prognosis in lung cancer

A

< 7% 5 year survival

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31
Q

What stages of lung cancer are generally operable?

A

I and II

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32
Q

5 year prognosis of Stage I lung cancer

A

> 60%

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33
Q

5 year prognosis of Stage II lung cancer

A

35%

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34
Q

Genes involved in adenocarcinomas

A 
EGFR
KRAS
HER2
BRAF
ALK translocations
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35
Q

Genes involved in SCCs

A

FGFR1 gene copy number
DDR2
FGFR2

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36
Q

3 top killers in the world

A

Cancer
Heart disease
COPD

37
Q

Presentation of lung cancer

A 
Chronic cough 
Haemoptysis 
Wheeze
Chest and bone pain
Chest infections
Difficulty swallowing
Rapsy, hoarse voice
SOB
Unexplained weight loss
Nail clubbing
38
Q

What is nail clubbing?

A

Increased curvature of fingernails

39
Q

Presentation of advanced lung cancer disease

A 
Mets
- Bone pain
- spinal cord compression 
- cerebral mets 
- thrombosis 
Paraneoplastic
- hyponatraemia
- anaemia
- hypercalcaemia
- dermatomyositis / polymyositis
Eaton-Lambert syndrome
Cerebellar ataxia
Sensorimotor neuropathy
40
Q

Presentation of spinal cord compression

A

Limb weakness
Paraesthesia
Bladder/bowel dysfunction

41
Q

Presentation of cerebral mets

A 
Headache
Vomiting
Dizziness
Ataxia
Focal weakness
42
Q

What is thrombosis?

A

Blood clot

43
Q

What does dermatomyositis cause?

A

Proximal muscle weakness

44
Q

What does eaton lambert syndrome cause?

A

Upper limb weakness

45
Q

Signs of lung cancer

A 
Chest signs
Clubbing
Lymphadenopathy 
Horners syndrome
Pancoast tumour
SVC obstruction 
Hepatomegaly 
Skin nodules (mets)
46
Q

What Is a Pancoast tumour?

A

Tumour of pulmonary apex

47
Q

What has to be damaged to cause horners syndrome?

A

Sympathetic trunk

48
Q

What type of lung cancer are smokers more likely to have?

A

SCCs

49
Q

What type of lung cancer are non smokers more likely to have?

A

Adenocarcinoma

50
Q

What is T staging based on?

A

Size and proximity to chest and vessels

51
Q

What is N staging based on?

A

Nodal involvement

52
Q

What is M staging based on?

A

Metastases

53
Q

How many stages are there of TNM?

A

4

54
Q

Stage 1 lung cancer

A

Localised to lung
No other organ involvement
90% will be alive end of year 1

55
Q

Stage 2 lung cancer

A

85% will be alive at end of year 1

56
Q

Stage 4 lung cancer

A

24% will be alive at end of year 1

57
Q

How does a PET scan show neoplasm?

A

Cancer cells are hungry for food as they multiply very fast

Radionucleotide contrast taken up by the cancer cells which light up

58
Q

Performance status scale

A

0 = fully active
1 - symptoms but ambulatory (walking). Likely to respond to treatment
2 = “up and about” > 50%, unable to work. Likely to respond to treatment
3 = Up and about < 50%, limited self care, unlikely to respond to treatment
4 = bed or chair bound, unlikely to respond to Tx

59
Q

Treatment for lung cancer

A 
Surgery (18% of patients) 
- wedge resection 
- lobectomy
- pneumonectomy
Radiotherapy
Chemotherapy
60
Q

What is a pneumonectomy?

A

Surgical removal or lung / part of lung

61
Q

Palliative management of lung cancer

A 
Symptom control 
- chemo
- radio 
- opiates
- bisphosphonates
- benzodiazepines
Tx of
- hypercalcaemia
- dehydration 
- hyponatraemia
62
Q

What is hyponatraemia?

A

Low sodium

63
Q

Where is the aorta-pulmonary window?

A

Between the pulmonary trunk and arch of the aorta

64
Q

What may lung cancer look like on CXR?

A

Pleural effusion (tumour in pleural space)
Chest wall invasion
Collapsed lung or lobe

65
Q

Blood results in lung cancer

A

Anaemia
Abnormal LFTs - high ALP
High calcium
Low haemoglobin

66
Q

Reasons for perioperative death in the Tx of lung cancer

A 
ARDS
Bronchopneumonia (esp if have COPD)
MI
PTE
Pneumothorax
Intra thoracic bleeding
67
Q

What is ARDS?

A

Adult respiratory distress syndrome

68
Q

Complications of surgery for lung cancer

A 
Post thoracotomy wound pain 
Empyema
BPF (bronchopleural fistula)
Wound infection 
AF
MI
Post op resp insufficiency 
Gastroparesis/constipaton
69
Q

What is empyema?

A

Pus in pleural space

70
Q

Mortality of pneumonectomy

A

8 - 12%

71
Q

Mortality of lobectomy

A

3 - 5%

72
Q

Mortality of wedge resection

A

2 - 3%

73
Q

What is a thoracotomy?

A

Incision into the pleural space of the chest

74
Q

Causes of pulmonary mass

A 
Lung cancer
Metastases 
TB
Lung abscess
Fungal infection 
Benign tumour (hamartoma, carcinoid)
Granuloma (sarcoid, wegeners, rheumatoid nodule)
Fibrosis
Paraffinoma (chronic granuloma produced by prolonged exposure to paraffin)
Vascular haematoma
AVM
75
Q

How to look at a CXR

A
  1. Name / marker / rotation / penetration
  2. Lines / metal work
  3. Heart
  4. Mediastinum
    - hilar vascular structures crisply defined
    - no widening of mediastinum
    - central trachea
  5. Lungs
    - compare zones (upper/middle/lower)
    - look between ribs for lung detail
    - behind heart
  6. Bones
  7. Diaphragm
    8 Soft tissues
76
Q

What should you be aware of that would indicate a central lung cancer?

A

Lobar collapse which fails to resolve in 2 - 3 weeks in a smoker over the age of 45

77
Q

What is a pulmonary mass?

A

An opacity (lacking transparency) in the lung > 3cm with no mediastinal adenopathy or atelectasis

78
Q

What should lung cancer be diagnosed by?

A

CXR

+ve bronchoscopy

79
Q

Features of bone pain caused by metastases

A

Any site
Worse at night
Pathological fracture

80
Q

What is small cell lung cancer associated with?

A 
ECTOPIC ADH and ACTH SECRETION 
SiADH 
- inappropriate ADH production leading to a dilutional hyponatraemia
Cushings syndrome
- due to ACTH production
81
Q

What can the ACTH production in SCLC lead to?

A

Cushings syndrome

Bilateral adrenal hyperplasia which leads to a hypokalaemic metabolic acidosis

82
Q

Where does renal cell carcinoma metastasise to and what is it called?

A

Lungs - ‘cannonball mets’

- multiple, large, round, well circumscribed masses in both lungs

83
Q

Contraindications to lung cancer surgery

A

SVC obstruction
FEV < 1.5
Malignant pleural effusion
Vocal cord paralysis

84
Q

Patients with known or suspected lung cancer are offered what?

A

Contrast enhanced CT of

  • chest
  • liver
  • adrenals
85
Q

What is adenocarcinoma of the lung associated with?

A

Gynaecomastia

Hypertrophic pulmonary osteoarthropathy

86
Q

Associations of SCC of the lung

A

PTH related protein (PTH-rp) secreting causing hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy
Hyperthyroidism due to ectopic TSH

87
Q

What can Pancoast tumours result in?

A

Suppressing the recurrent laryngeal nerve causing hoarseness of the voice

88
Q

What may a large cell lung carcinoma secrete?

A

B-hCG

Respiratory Pathology (16 decks)

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