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Lung Cancer Flashcards

1
Q

What are the two types of lung cancer

A

Small cell

Non-small cell

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2
Q

What can non-small cell be further differentiated into [5]

A

Adenocarcinoma 45%
SCC 15%
Large cell undifferentiated
Alveolar cell carcinoma
Bronchial adenoma

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3
Q

What are the RF for lung Ca
What is specific to SCC?
What is least related to smoking?) [6]
What is most related to SCC?
What is most related to adenocarcinoma?

A

Smoking - most related to SCC (least to adenocarcinoma)
Asbestos exposure
Radon (environment)
Chromium, iron oxides
Air pollution
Pulmonary fibrosis
Cryptogenic fibrosing alveolitis

SCC - polycyclic aromatic carbons
Adeno - N-nitroxamines

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4
Q

What are the symptoms of lung cancer? [7]

A

Chronic cough, SOB
Haemoptysis
Pleuritic pain + bone pain
Chest infection (slow resolving + recurrent)
Cancer B-symptoms
Wheezing
Dysphagia
Hoarseness

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5
Q

Lung signs of malignancy [4]
Systemic signs [4]
Local complications of malignancy [5]

A

Lung signs:
* Stridor
* Consolidation
* Collapsed lung
* Pleural effusion, Pneumothorax

Systemic signs:
* Anaemia - haemolytic
* Clubbing
* Lymphadenopathy (supraclav)
* B symptoms
* DIC

Local complications:
* Hoarseness (laryngeal nerve palsy)
* SOB, orthopnoea (phrenic n. palsy)
* SVC obstruction
* Horner’s syndrome
* Rib erosion, pericarditis, AF

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6
Q

What is Horner’s and what causes [5]

What are skin complications of lung cancer? [2]

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

Skin:

  • Acanthosis nigricans
  • Thrombophlebitis migrans
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7
Q

What are signs of bone metastatic complications of lung cancer? [4]

What other metastases are common in lung cancer? [3]

A

Bony tenderness
Bone marrow invasion causing anemia
Hypercalcemia

Adrenal mets (Addison’s)
Liver mets (HSM)
Neurological complications

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8
Q

What is squamous associated with [4]

A
  • Parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
  • Ectopic TSH = hyperthyroid
  • Clubbing
  • hypertrophic pulmonary osteoarthropathy (HPOA)
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9
Q

What is adenocarcinoma associated with [3]

A

Clubbing
Gynaecomastia due to HCG
Pulmonary osteoarhtropathy

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10
Q

Initial investigations for suspected lung cancer

A
  1. Chest x-ray + CT TAP with contrast (?mets)
    CXR may not show anything if mass is central or very small
  2. CT-PET is considered for accurate staging
  3. MRI thorax for ?chest wall involvement
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11
Q

What is required to achieve a histiological diagnosis in suspected lung cancer?

85% patients presenting with lung cancer should have a histiological dx

A

EBUS - LN >10mm
Neck US and sampling
Sputum cytology (more dx for central tumours)
Flexible fibro-optic bronchoscopy - for endobronchial and central tumours
CT guided fine needle aspiration if lesion >2cm
Lymph node sampling done by TBNA or EBUS

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12
Q

Flexible vs rigid bronchoscopy
Requirements for CT guided biopsy

A

Rigid bronchoscopy done under general anaesthetic, gives operator more control and may increase dx yield with difficult cases esp if tumour near carina
Requirements for CT guided biopsy - spirometry, normal sats, can hold breath and lie down flat, FEV1<1L is contraindicated, severe emphysematous lung (high pneumothorax)
20% risk of pneumothorax in CT guided biopsy

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13
Q

CXR nodules differentials [6]

A
  • Malignancy: primary or secondary
  • Abscess, Granuloma, encysted effusion, FB
  • Carcinoid tumour
  • Pulmonary hamartoma
  • AV malformation
  • Skin tumour e.g. seborrheic wart
  • Rounded atelectasis secondary to infection or pleural fibrosis (if attached to chest wall on CT), comet-tail appearance
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14
Q

What does CXR show that suggests malignancy [6]

A

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

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15
Q

What investigation is indicated if there is pleural involvement?

A

Pleural involvement - VATS for tissue diagnosis

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16
Q

What is needed for accurate staging?
What is the purpose of staging a disease and how does it affect the treatment plan?

A

CT-PET and LN sampling is key to accurately stage lung cancer.
Poor for detection of slow growing cancer like adenoca and carcinoid tumours
False positive for infective or inflammatory pathology
Sampling of paratracheal and peribronchial LN, mediastinal LN can be taken by mediastinoscopy.

Deciding on treatment plan is either RADICAL (CURATIVE INTENT) or PALLIATIVE

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17
Q

What biomarkers have drugs to target [2]

A

EGFR
ALK

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18
Q

How do you do T staging [3]

A
  • CT with positron emission tomography (CT-PET)
  • Bronchoscopy
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19
Q

N staging [4]

A

PET
CT
EBUS
Mediastinoscopy

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20
Q

M staging [2]

A

PET CT

Bone scan

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21
Q

How do you determine fitness for surgery i.e. lobectomy, pneumonectomy? [4]

A

Co-morbidities
PFT, V/Q - High FEV1 predicts better survival if pneumonectomy is considered.
Cardiopulmonary exercise testing

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22
Q

Where does lung cancer metastasise to [7]

A 
Liver
Adrenal
Renal - cannon ball
Bone
Brain
Skin
LN
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23
Q

When is surgery contraindicated in non small cell lung ca [7]

A

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

24
Q

What stage will you consider palliative management?

Palliative management [4]

A 
Stage IV PS 0-2
Control symptoms with:
- Chemo, RT
- Analgesia, Fluids
- Biphosphonates – treat hypercalcaemia
- DNACPR, END OF LIFE CARE
25
What does Nivolumab do? | Form of immunotherapy for lung cancer
blockade of PDL1 action blocks the tumour cells’ defence against the host immune response
26
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
27
Presentation of SCLC
Usually central mass arising from APUD cells * Amine - high amine content * Precursor Uptake - high uptake of amine precursors * Decarboxylase - high content of the enzyme decarboxylase
28
What clinical features are specific to Small cell [3]
ACTH SIADH = hyponatraemia Lambert Eaton syndrome Limbic encephalitis - short term memory, hallucination, seizure
29
Prognosis between SCLC and NSCLC
* NSCLC: 10% 2y survival without mets, 10% with mets | * SCLC: median survival if untreated 3m, treated 1-1.5y
30
What is adenocarcinoma associated with
KRAS
31
What is SCC associated with [3]
FGFR1 DDR2 FGFR2
32
What mutations have no relation to smoking [4]
EGFR – target drug BRAF HER2 ALK rearrangement – target drug
33
What offers best cure in NSC [2]
Surgery | Lobectomy = curative
34
What can RT be used for [5]
``` Palliation Obstruction Haemoptysis Lobe collapse Chest pain ```
35
**ECOG performance status in lung cancer determines treatment [5]** Performance status (PS) e.g. the ECOG score is the next most significant factor in defining a patient’s potential therapy. Late presentation and poor performance status is a major factor in limiting treatment options.
``` 0 = asymptomatic 1 = symptomatic with light work 2 = rest for <50% day 3 = rest for >50% 4 = bed bound (incurable) ```
36
What should you consider in cancer patient with weakness [3]
Spinal cord compression Cauda equina - back pain / saddle Lambert Eaton
37
What is large cell associated with [2]
Poor prognosis as poorly differentiated | Secretes b-HCG
38
How does adenocarcinoma tend to present compared to other types of lung cancers?
If central cancer = tend to get chest symptoms If peripheral e.g. adenocarcinoma = present late (may not see on bronchoscopy)
39
Stage 1: TisN0M0 T1N0M0 T2N0M0 [3]
TisN0M0 (carcinoma in situ) T1N0M0 (<3cm in lobar or more distal airway) T2N0M0 >3cm and >2cm distal to carina or any size of pleural involvement or obstructive pneumonitis extending to hilum but not all lung)
40
Stage 2: T1/2N1M0 T3N0M0 [3]
T1/2N1M0 (peribronchial or ipsilateral hilum) T3N0M0 - involves chest wall, diaphragm, mediastinal pleura, pericardium o - >2cm but not at carina or - >7cm in diameter and nodules on same lobe
41
Stage 3a = T3N1M0 or T1-3N2N0 [2] | Stage 3b = T1-4N3M0 [2] or T4N0M0 [2]
a = T3N1M0 or T1-3N2N0 (ipsilateral mediastinum or sub carinal LN) b = T1-4N3M0: contralateral mediastinum or hilum, scalene or supra-clavicular T4N0M0: involves mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina, malignant effusion or nodules on other lobe)
42
Stage 4a/b
``` a = T1-4N0-2M1a (nodule in other lung, pleural lesions or malignant effusion) b= T1-4N0-2M1b (distant metastases present) ```
43
Mx NSCLC Stage 1/2 [3] Stage 3/4 [3]
Stage 1-2: T1-2a,N0,M0 - surgical excision, only 20% of all NSCLC are suitable. - with adjuvant or neoadjuvant chemotherapy +/- adjuvant RT Stage III/IV PS 3-4: - chemotherapy e.g. CISPLATIN 4-6 cycles - with monoclonal antibody e.g. CETUXIMAB (targets EGFR) +/- RT
44
Mx SCLC - Limited disease [3] - Advanced disease [4] | Surgery rarely used, only in early stage of disease ## Footnote but usually at presentation disease is disseminated
o Limited disease: - chemotherapy e.g. CISPLATIN - with RT - and prophylactic cranial RT o Advanced disease: - CYCLOPHOSPHAMIDE - VINCRISTINE - and ETOPOSIDE (responds well but always relapses) - with prophylactic cranial RT
45
# HHH How does CT-PET identify metastases?
identifies lesions with high glucose uptake as a surrogate of increased metabolic activity typical of cancer to give more sensitive/specific tumour, node, metastasis (TNM) staging information.
46
# Surgical options in lung cancer Lobectomy Pneumonectomy Wedge resection
* Lobectomy * Pneumonectomy - hilar lymph node +ve * Wedge resection - poor performance status + peripheral tumour
47
Lung cancer: carcinoid | Epidemiology, natural history, pathognomic finding on ix
* typical age = 40-50 years * smoking not risk factor * slow growing: e.g. long history of cough, recurrent haemoptysis * often centrally located and not seen on CXR * 'cherry red ball' often seen on bronchoscopy | carcinoid syndrome itself is rare (associated with liver metastases)
48
Lung cancer: carcinoid tumours | Prognosis, management
surgical resection if no metastases then 90% survival at 5 years
49
# Mesothelioma Risk factor Describe how this would present.
Risk factor: strongly associated with asbestos exposure Features * Dyspnoea, weight loss, chest wall pain
50
# Mesothelioma Investigations
suspicion is normally raised by a chest x-ray showing either a pleural effusion or pleural thickening the next step is normally a pleural CT if a pleural effusion is present fluid should be sent for MC&S, biochemistry and cytology (but cytology is only helpful in 20-30% of cases) local anaesthetic thoracoscopy is increasingly used to investigate cytology negative exudative effusions as it has a high diagnostic yield (around 95%) if an area of pleural nodularity is seen on CT then an image-guided pleural biopsy may be used
51
# NSCLC management not suitable for surgery Radiotherapy Chemotherapy
* Radiotherapy - Stage 1-3 disease, curative = radical RTX, SABR, palliative * Chemotherapy -Is offered to those with stage III or IV disease to improve survival and quality of life. Four weekly treatments, up to 6 cycles.
52
# Chemotherapy in Lung cancer What is the difference between adjuvant and neo-adjuvant chemotherapy?
* Adjuvant chemotherapy is combined with radical treatment i.e. lung resection or radical radiotherapy * Neo-adjuvant chemotherapy is for patients who cannot be treated radically and you want to give them a shot by 'downgrading' the tumour.
53
Assessing response to chemotherapy with radiology - 4 classifications
* Disease progression - development of new lesions or increase in tumour size 20% or more * Partial response - 30% decrease in tumour size * Stable disease - 19-29% decrease in tumour size * Complete response - resolutio nof all previously visible tumour and tumour markers
54
Palliative options
Palliative chemo, palliative radiotherapy Endobronchial stenting or debulking for bronchial obstruction Pleural drainage of effusions Brain mets - dexamethasone
55
Pulmonary nodules vs mass Which nodules require urgent surveillance
Pulmonary mass >3cm Nodule <5mm, or clear benign features, or unsuitable for treatment: can be discharged Nodule =>8mm and high risk*: then CT-PET, and if CT-PET shows high uptake then biopsy Nodule 5-6mm, or =>8mm and low-risk*: then CT surveillance CT surveillance: if 5-6mm then at 1 year, if =>6 then in three months

Respiratory (14 decks)

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