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Y4 Respiratory > Lung cancer > Flashcards

Lung cancer Flashcards

1
Q

What is the mortality rates of lung cancer?

A
  • 90% after 1 year in Scotland
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2
Q

List the risk factors for lung cancer development:

A
  • Tobacco smoke
  • Asbestos
  • nickel
  • chromates (chromium)
  • radiation (radon gas)
  • atmospheric pollution
  • (genetics)
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3
Q

How is lung cancer classified histologically?

A
  • As being either small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC)
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4
Q

List the different types of NSCLC’s:

A
  • squamous: c. 35%
  • adenocarcinoma: c. 30%
  • large cell: c. 10%
  • alveolar cell carcinoma: not related to smoking, ++sputum
  • bronchial adenoma: mostly carcinoid
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5
Q

Which category of lung cancers account for most cases – NSCLC or SCLC?

A
  • NSCLC
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6
Q

Which type of lung cancer classification carries with it the worst prognosis?

A
  • SCLC - almost all dead in one year
  • Note - Large cell worse than squamous or adenocarcinoma
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7
Q

What are the 4 types of smoking associated lung cancers?

A
  • adenocarcinoma (35%)
  • squamous carcinoma (30%)
  • small cell carcinoma (25%)
  • large cell carcinoma (10%)
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8
Q

What are the symptoms of lung cancer?

A
  • Persistent cough
  • Haemoptysis
  • Dyspnoea
  • Chest pain
  • Recurrent or slowly resolving pneumonia
  • Constitutional symptoms – lethargy, weight loss, loss of appetite (anorexia)
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9
Q

What are the signs of lung cancer?

A
  • Finger clubbing
  • Hypertrophic pulmonary osteoarthropathy (HPOA)
  • Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
  • Cachexia (weakness and wasting of the body)
  • Anaemia
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10
Q

What complications can develop because of lung cancers?

A
  • Superior vena cava obstruction
  • Recurrent laryngeal nerve palsy – hoarseness
  • Phrenic nerve palsy – difficulty breathing
  • Stridor
  • Horner’s syndrome (due to Pancoast tumours)
  • Chest – collapse, pleural effusions
  • Paraneoplastic features
  • Metastases – bone tenderness, hepatomegaly, confusion, fits, focal CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy
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11
Q

List some of the common sites for metastasis of lung cancer:

A
  • Mediastinum & hilar lymph nodes
  • Lung pleura
  • Heart
  • Breasts
  • Liver
  • Adrenal glands
  • Brain
  • Bone
  • Skin
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12
Q

List the main structures lung cancer can locally invade and state the symptoms/signs of these invasions:

A
  • Recurrent laryngeal nerve – hoarsness
  • Pericardium – SOB, AF, pericardial effusion
  • Oesophagus – dysphagia
  • Brachial plexus – weakness etc
  • Pleural cavity – pleural effusion (causing SOB)
  • Chest wall invasion +/- bone erosion (ribs) – pain worse on movement, if bone erosion then pain described worse at night
  • Superior vena cava – SVC obstruction
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13
Q

What is HPOA?

A
  • It is a syndrome characterized by the triad of periostitis, digital clubbing, and pain and tenderness of the long bones near the adjacent joints, especially involving the lower limbs particularly in the distal part of the tibia and fibula. It is not due to metastatic disease.
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14
Q

What causes hoarseness in lung cancer and which tumours cause this?

A
  • Invasion of the recurrent laryngeal nerve – seen in Pancoast tumours
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15
Q

What is SVC obstruction and what is it most associated with?

A
  • It is an oncological emergency caused by compression of the SVC. It is most associated with lung cancer.
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16
Q

List the potential causes of SVC obstruction:

A
  • common malignancies: non-small cell lung cancer, lymphoma
  • other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
  • aortic aneurysm
  • mediastinal fibrosis
  • goitre
  • SVC thrombosis
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17
Q

What are the features of SVC obstruction?

A
  • dyspnoea is the most common symptom
  • swelling of the face, neck and arms - conjunctival and periorbital oedema may be seen
  • headache: often worse in the mornings
  • visual disturbance
  • pulseless jugular venous distension
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18
Q

What is the management of SVC obstruction?

A
  • general: dexamethasone, balloon venoplasty, stenting
  • small cell: chemotherapy + radiotherapy
  • non-small cell: radiotherapy
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19
Q

What features would potential suggest cerebral metastases in someone with lung cancer?

A
  • Insidious onset of symptoms
  • Weakness
  • Visual disturbance
  • Headaches - Worse in the morning & Not photophobic
  • Fits
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20
Q

What can be done in the short term for treating the symptoms of cerebral metastases in lung cancer?

A
  • High dose corticosteroids e.g. IV dexamethasone (Unfortunately this benefit is short lived and within a few weeks the symptoms will return)
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21
Q

How do bone metastases in someone with lung cancer tend to present?

A
  1. Localised pain which is worse at night. Or
  2. Pathological fracture. The bone may fracture following a trivial mechanical stress.
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22
Q

What should be done for people to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms:

  • Cough ≥ 3 weeks
  • fatigue
  • shortness of breath
  • chest pain
  • weight loss
  • appetite loss
A

Offer an urgent chest x-ray (to be performed within 2 weeks)

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23
Q

What should be considered to assess for lung cancer in people aged 40 and over with any of the following:

  • persistent or recurrent chest infection
  • finger clubbing
  • supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
  • chest signs consistent with lung cancer
  • thrombocytosis
A

Consider an urgent chest x-ray (to be performed within 2 weeks)

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24
Q

What should be done if someone has CXR findings that suggest lung cancer or are aged 40 and over with unexplained haemoptysis?

A
  • Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer
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25
Q

Describe the histology of squamous cell lung carcinomas

A

Form square-shaped cells which produce keratin (may see keratin pearls), desmosomes also seen.

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26
Q

In what part of the lungs do squamous cell carcinomas tend to arise ?

A

They arise more centrally in large bronchi than peripherally

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27
Q

What are squamous cell carcinomas strongly associated with ?

A

Smoking

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28
Q

What paraneoplastic features can squamous cell lung carcinomas cause and how ?

A
  1. Classically tumour can produce parathyroid hormone (PTH) (causing hypercalcaemia and brittle bones).
  2. Can cause hypertrophic pulmonary osteoarthropathy (HPOA).
  3. Ectopic TSH production which can cause hyperthyroidism.
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29
Q

What clinical sign which can suggest lung cancer is more strongly with specifically squamous cell carcinoma?

A

Finger clubbing

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30
Q

Describe the histology of adenocarcinomas of the lung

A
  • They form glandular structures and produce mucin
31
Q

Where in the lungs do adenocarcinomas tend to arise ?

A

More commonly arise peripherally rather than centrally

32
Q

What is it important to remember about who is affected by lung adenocarcinomas ?

A

Its important to remember that adenocarcinomas are the most common lung cancer in non-smokers, BUT 80% of adenocarcinomas still arise in smokers

33
Q

What paraneoplastic features are associated with adenocarcinomas of the lung ?

A
  • HPOA
  • Gynaecomastia
34
Q

What protein do adenocarcinomas of the lung express ?

A
  • TTF (thyroid transcription factor) 1
35
Q

Describe the histology of large cell carcinomas of the lung

A

They are poorly differentiated tumours which lack glandular & squamous differentiation. No desmosomes, no keratin & no mucin staining

36
Q

Where in the lungs do large cell carcinomas tend to arise ?

A

They can present throughout the lungs, but typically peripherally

37
Q

What hormone may large cell carcinomas of the lung secrete ?

A

β-hCG

38
Q

What histologically do carcinoid tumours of the lung arise from ?

A

Arise from mature neuroendocrine cells

39
Q

Where in the lung do carcinoid tumours arise ?

A

They can arise throughout the lung

40
Q

What clinical syndrome can carcinoid tumours of the lung result in ?

A
  • Tumour can release serotonin and result in carcinoid syndrome (see GI notes)
41
Q

What cells do small cell carcinomas of the lung arise from ?

A

Immature neuroendocrine cells

42
Q

Describe the histology of small cell carcinomas of the lung

A

Histologically seen there is:

  • High N/C ratios
  • Frequent mitotic figures
  • High % of cells in division
  • Salt & pepper chromatin
43
Q

What are small cell carcinomas of the lung strongly associated with ?

A

Smoking

44
Q

Where in the lungs do small cell carcinomas typically develop?

A

Centrally

45
Q

In terms of disease progression what is it typical to find on diagnosis with small cell carcinoma of the lung ?

A

Common for the patient to already have developed metastatic spread - this is due to the fast growth rate and rapid development of metastases in lung cancer

46
Q

Describe what is meant by the terms limited and extensive disease when used in relation to small cell lung cancers

A
  • If disease found within one lung then it is considered ‘limited’ disease. If spread beyond one lung into the other it is considered ‘extensive’ disease
47
Q

SCLC’s can secrete hormones resulting in paraneoplastic syndromes, what hormones and syndromes are they associated with causing ?

A
  • Adrenocorticotropic hormone (ACTH) production causing cortisol production and resulting in cushings syndrome (hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc in terms of Cushing features)
  • ADH production causing SIADH
  • Tumour can also cause the body to produce autoantibodies resulting in Lambert-eaton syndrome
48
Q

Describe the features suggestive of hypercalacemia

A
  • Stones - (Renal/biliary calculi)
  • Bones - (Bone Pain)
  • Groans - (Abdominal pain, Constipation, N+V)
  • Thrones - (Polyuria)
  • Psychiatric overtones - (Depression, anxiety, reduced GCS, Coma)
  • ALSO - Cardiac arrhythmias
49
Q

What is the treatment of hypercalaemia ?

A
  • 1st line = rehydration
  • 2nd line = If Calcium is very high on admission (>4) or does not correct with fluid then also use IV Bisphosphonate (Pamidronate)

Main aim is to treat underlying cancer – usually Squamous cell

50
Q

What causes the symptoms in SIADH – Syndrome of inappropriate antidiuretic hormone and what are the symptoms?

A

Low sodium concentration, resulting in ggeneralised nonspecific symptoms:

  • Nausea/vomiting
  • Myoclonus
  • Lethargy/confusion
  • Seizures/coma
51
Q

What is the treatment of SIADH ?

A
  • Treat underlying cause + Fluid restriction – 1.5L/day
  • Sometimes need Demeclocycline
52
Q

What is a Pancoast tumour?

A
  • It is a tumour of the pulmonary apex, which typically spreads to nearby tissues which can result in compression of the blood vessels & nerves.
  • Pancoast tumours can be formed by squamous or adenocarcinomas
53
Q

What in particular can Pancoast tumours damage and what can this lead to?

A
  • Thoracic inlet, brachial plexus & cervical sympathetic nerves.
  • Damage to these can cause Horner’s syndrome
54
Q

What are the signs of Horner’s syndrome?

A
  • Ptosis (drooping of upper eyelid)
  • Miosis (constriction of pupil)
  • Anhidrosis (absence of sweating of the face on the side of damage)
  • enophthalmos* (sunken eye)
55
Q

Besides pancoast tumours what are some of the other causes of horners syndrome?

A
  • Carotid/Aortic aneurysms
  • Lesions of neck
  • Congenital
  • Idiopathic
56
Q

How is lung cancer diagnosed ?

A
  • Generally 1st line = CXR (even if this is normal however further investigation is done in those with suspected LC)
  • 2nd line = contrast CT of chest & abdomen (including liver, adrenals & lower neck) - this is recommended in all patients with suspected LC, regardless of CXR) it provides diagnosis and staging of LC
57
Q

Following diagnosis of LC on CT what then needs to be done ?

A

Histological/ tissue diagnosis:

  • For central LC lesions do flexible bronchoscopy - sometimes aided by endobronchial U/S
  • For peripheral LC lesions do percutaneous FNA biopsy

Note - sputum cytology only ever used in patients with large central lesions where bronchoscopy or other tests are deemed unsafe

58
Q

What investigations should most patients with LC undergo for intra-thoracic lymph node assessment or whom are aimed to be treated curativley ?

A
  • 1st = PET-CT
  • 2nd = EBUS-TBNA or EUS-FNA done either after PET-CT if patient has enlarged intrathoracic lymph nodes (≥ 10mm on CT) or done without PET-CT if clinical suspicion of nodal malignancy is high
59
Q

When may mediastinotomy/ mediastinoscopy be done in the investigation of LC’s?

A

It is considered in patients with hilar & mediastinal masses where histological or cytological confirmation has not been achieved by less invasive means

60
Q

What additional investigations should be done in all LC patients being considered for treatment with curative intent (surgery or radiotherapy)?

A

Spirometry & transfer factor (TCLO) - if FEV1 within normal limits & good exercise tolerance then perform surgery

61
Q

How is lung cancer staged?

A
  • TNM staging
62
Q

What advice should be provided to patients with a suspected or confirmed diagnosis of lung cancer and why even when the diagnosis has been confirmed is this of benefit to the patient?

A
  • To stop smoking – it is still of benefit for the patient to stop smoking even if they have confirmed lung cancer because stopping reduces the risk of developing pulmonary complications
63
Q

What is the treatment of stage I-IIA (T1a-2b, N0, M0) NSCLC?

A
  • 1st line = curative surgery (resection should be as limited as possible with lobectomy being the procedure of choice over pnuemoectomy) + hilar & mediastinal lymph node sampling or en bloc resection
  • 2nd line = radical radiotherapy (stereotactic alblative radiotherapy) - for those who are medically inoperable or whom refuse surgery
64
Q

List the contraindications to surgical treatment of NSCLC

A
  • stage IIIb or IV (i.e. metastases present)
  • FEV1 < 1.5 litres is considered a general cut-off point*
  • malignant pleural effusion
  • tumour near hilum
  • vocal cord paralysis
  • SVC obstruction
65
Q

What is the treatment of more advanced NSCLC ?

A
  • Chemotherapy (cisplantin based) +/- radiotherapy

Note - this is no longer curative treatment I believe

66
Q

What additional treatments may be used for patients with stage IIIB & IV NSCLC ?

A
  • If EGFR-TK mutation pos then give tyrosine kinase inhibitor e.g. afatimb
  • If ALK gene or ROS1 pos give crizotinib
  • If PDL1 ≥ 50% give pembrolizumab
67
Q

What small group of patients may be eligable for curative treatment for SCLC and what is the treatment ?

A

Patients with very early stage disease (T1-2a, N0, M0) may be considered for surgical resection + consider adjuvant chemo

68
Q

What is the main treatment of SCLC for patients with limited disease (T1-4, N0-3, M0) ?

A

Give combo chemoradiotherapy

69
Q

What is the treatment of extensive disease SCLC ?

A

Chemo +/- radiotherapy (radio done if they have a partial or complete response to the chemo)

70
Q

What is typical for SCLC’s patinets response to chemo ?

A

Patients may initially respond well to chemo, but they invariably relapse

71
Q

If someone has symptomatic bone metastases from LC, what palliative treatment can be provided ?

A

Biphosphonates

72
Q

If someone with LC develops a malignant pleural effusion what is the 1st and 2nd line treatment options ?

A
  • 1st line = pleural aspiration
  • 2nd line = talc pleurodesis
73
Q

If someone with LC develops endobronchial obstruction what palliative treatment can be provided ?

A

External beam radiotherapy &/or endobronchial debulking or stenting

Y4 Respiratory (27 decks)

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