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Lung Cancer Flashcards

1
Q
  1. What are the different types of lung neoplasms?
A

Primary - Benign or malignant

Metastatic

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2
Q
  1. Why is metastatic cancer tin the lung very common?
A

Because the lungs get the entire vascular supply, therefore there is an increased chance of spreading.

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3
Q
  1. What is the most common visceral malignancy?
A

Trachea, Bronchus and Lung Cancer

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4
Q
  1. What is the mortality rate of patients with lung cancer within a year?
A

90%

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5
Q
  1. Name some of the potent carcinogens in tobacco smoke
A 
Polycyclic hydrocarbons
Aromatic amines
Phenols
Nickel
Cyanates
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6
Q
  1. What other cancers can smokers get?
A

Laryngeal, Cervical, Bladder, Mouth, Oesophageal, Colon

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7
Q
  1. Name some other risk factors for cancer.
A 
Asbestos
Nickel
Chromates
Radiation
Atmosphere Pollution
Genetics
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8
Q
  1. Name the local effects of lung cancer in clinical presentation.
A

a. Obstruction of the airway causing pneumonia
b. Invasion of the chest wall causing pain
c. Ulceration causing haemoptysis

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9
Q
  1. Why does obstruction of the airway lead to pneumonia or chest infection?
A

The blockage in the lung will lead to inadequate drainage of the lung which can promote infection.

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10
Q
  1. Name some of the metastases of lung cancer in clinical presentation.
A

Nodes
Bones
Liver
Brain

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11
Q
  1. Name some of the systemic effects of lung cancer in clinical presentation.
A

Weight loss
Ectopic hormone production
(it is important to remember that these are common to many malignant tumours)

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12
Q
  1. What is ectopic hormone production?
A

This is where there are hormones produced that are not native to the lung and are instead produced by the tumour.

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13
Q
  1. Give some examples of ectopic hormones arising from lung cancer
A

PTH (from squamous cancer) - causes hypercalcaemia

ACTH (from small cell cancer) - causes increased cortisol secretions

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14
Q
  1. What is the respiratory acinus?
A

Functional unit of the lung, where gas exchange takes place

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15
Q
  1. Name the 4 simplified classifications of lung cancer
A

Adenocarcinoma - most common
Squamous carcinoma
Small cell carcinoma
Large cell carcinoma

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16
Q
  1. Name some methods of histological diagnosis of lung cancer.
A
  1. Usually done by getting a tissue sample
    a. Bronchoscopy and biopsy of the tumour if able
    b. Biopsy or needle aspiration of metastases -s especially in lymph nodes (EBUS)
  2. We then need a microscopic diagnosis and sufficient tissue for identification of molecular predictors of response to treatment.
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17
Q
  1. Describe Adenocarcinoma
A

A type of cancer the starts in the mucous producing glands
It can secrete mucin (a constituent of mucus)
It is non-small cell lung cancer

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18
Q
  1. Describe Squamous Cell Carcinoma
A

It arrises as a result of keratinisation of the epidermal cells.
It is a non-small cell lung cancer.

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19
Q
  1. Describe Small Cell Carcinoma
A

This usually develops in the bronchi.
It spreads faster than NSCLC.
It also has the ability to metastasise rapidly

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20
Q
  1. Describe Large Cell Carcinoma
A

This usually develops in the outer regions of the lung and tends to grow rapidly.
It is a non-small cell lung cancer.

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21
Q
  1. Why do we classify lung cancers?
A

It helps us determine PROGNOSIS
It can help select for the correct TREATMENT
It allows us to understand the PATHOGENESIS and BIOLOGY which ultimately feeds back to deciding treatment
It indicates the EPIDEMIOLOGY

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22
Q
  1. What is the epidemiology of lung cancer?
A

The distribution of the type of lung cancer within the population.

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23
Q
  1. Describe the prognosis for different types of lung cancer.
A

Small cell is the worst, almost all are dead within a year.

Large cell is worse than adenocarcinoma or squamous cell carcinoma.

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24
Q
  1. What is the most simple classifications of lung cancer/?
A

Small cell lung cancer OR Non-small cell lung cancer

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25
Q
  1. Describe treatment options for small cell lung cancer
A

It is chemosensitive but will rapidly gain resistance.

The chemotherapy is therefore used to buy patients time.

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26
Q
  1. Describe treatment options for non-small cell lung cancer
A

Surgery is the treatment of choice in non-metastatic NSCLC.
There are also NSCLC regimens for chemotherapy and radiotherapy
There are also targeted treatments that are based on pathologically identified abnormal DNA or other tumour markers

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27
Q
  1. Describe chemotherapy use in NSCLC.
A

There are differing regimens for adenocarcinoma and squamous cell carcinoma.
PEMETREXED shouldn’t be used for squamous carcinoma but should be used for adenocarcinoma

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28
Q
  1. Describe the immunohistochemistry of NSCLC
A

Adenocarcinoma expresses TNF 1 (thyroid transcription factor 1)
Squamous cell carcinoma expresses antigen p63 and hy molecular weight cytokeratins

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29
Q
  1. Name some molecular genetic abnormalities in SCLC
A

myc oncogene
p53, Rb and 3p tumour suppressor genes
These are potential therapeutic targets

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30
Q
  1. Name some molecular genetic abnormalities in NSCLC
A

myc, K-ras and EGFR oncogenes
p53, 1q, 3p, 9p, 11p, Rb tumour suppressor genes
These are potential therapeutic targets

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31
Q
  1. Describe how targeted treatment to the EGFR gene can work
A
  1. Specific point mutations render the EGFR gene active in the absences of the ligand binding.
  2. These mutations can be identified in DNA extracted from biopsy etc.
  3. This mutation is seen almost exclusively in adenocarcinoma.
  4. These tumours respond to tyrosine kinase inhibitors.
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32
Q
  1. Name some other targetable oncogenes for treatment.
A

EML4-ALK fusion oncogene also identifies a target for treatment.
ROS1 is another target for fusion rearrangement.

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33
Q
  1. How can the immune response be targeted in NSCLC?
A
  1. The lung cancer must be shown to express PD-L1.
  2. PD-L1 binds to the PD receptor on T lymphocytes, inactivating the cytotoxic immune response.
  3. Targeted therapy can inhibit this effect and enhance immune killing of the tumour.
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34
Q
  1. Describe the pathogenesis towards malignancy.
A
  1. Squamous metaplasia (change from glandular type epithelium to squamous epithelium)
  2. Dysplasia
  3. Carcinoma in situ
  4. Invasive malignancy
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35
Q
  1. Describe the pathogenesis of peripheral adenocarcinomas
A
  1. Atypical adenomatous hyperplasia
  2. Spread of neoplastic cells along the alveolar walls.
  3. True invasive adenocarcinoma.
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36
Q
  1. What does the T relate to in TNM staging?
A

T relates to the tumour staging. There are 4 stages and they relate to the size of the tumour.

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37
Q
  1. What does the N relate to in TNM staging?
A

N relates to the node staging. Each number relates to a different lymph node. There are three stages.

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38
Q
  1. What does the M relate to in TNM staging?
A

This indicates if there is metastases or not. The is only M0 means no metastases and M1 means there is metastases.

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39
Q
  1. Name some other lung neoplasms.
A

Carcinoid - neuroendocrine neoplasms of low grade malignancy.
Bronchial gland neoplasms

40
Q
  1. Describe pleural neoplasia.
A

Benign tumours are rare.
Primary malignant neoplasm = mesothelioma
Metastatic cancers are common to invade.

41
Q
  1. Describe the prognosis for lung cancer.
A

90% of lung cancers are incurable.

42
Q
  1. Describe symptoms that help to detect lung cancer early.
A 
Cough lasting 3+ weeks.
Breathlessness for no reason.
Chest infection that doesn't clear up (e.g. recurrent pneumonia)
Haemoptysis.
Unexplained weight loss
Chest or shoulder pains
Unexplained tiredness or lack of energy
Hoarse voice.
43
Q
  1. Why would a lung cancer patient get haemoptysis?
A

The tumour will develop its own blood supply, but this is very fragile and disordered and will therefore be prone to rupture.

44
Q
  1. Why would a lung cancer patient get recurrent infection or pneumonia?
A

The tumour can block part of the airway, therefore there isn’t proper cleaning and it is hard to remove bacteria.

45
Q
  1. What is stridor?
A

This is a wheezing sound upon inspiration. It is usually caused by a large airway obstruction.

46
Q
  1. Name some places where there can be local invasion by a lung cancer tumour.
A 
Recurrent laryngeal nerve
Pericardium
Oesophagus
Brachial plexus
Pleural cavity
Superior vena cava
47
Q
  1. Why would we be worried if a patient presents with a hoarse voice?
A

We would worry about a tumour invading into the mediastinum and therefore affecting the laryngeal nerve and vocal cords.

48
Q
  1. What can result from local invasion of the tumour into the pericardium (heart)? ❤️
A

Breathlessness
Atrial Fibrillation
Pericardial effusion

49
Q
  1. What is atrial fibrillation?
A

Irregular and often rapid heartbeats due to disrupted electrical signals.

50
Q
  1. What is pericardial effusion?
A

Fluid build up around the heart.

51
Q
  1. What can result from local invasion of the tumour into the oesophagus?
A

Dysphagia

52
Q
  1. What is dysphagia?
A

Difficulty swallowing, the patient may even regurgitate.

53
Q
  1. What is a pancoast tumour?
A

A tumour of the pulmonary apex (apex of the lung). It typically spreads to nearby tissues such as the ribs or vertebrae. It can also cause muscle wasting due to disruption of the brachial plexus.

54
Q
  1. What is the brachial plexus?
A

A network of nerves formed by the arterial rami of the lower four cervical nerves and first thoracic nerve.

55
Q
  1. What is pleural effusion?
A

A build up of fluid in the pleural cavity. This is relatively commons and can be drained.

56
Q
  1. Describe superior vena cava obstruction.
A

This can result in swelling of the head and headaches.

This also causes engorged blood vessels.

57
Q
  1. Describe cerebral metastases.
A

They have an insidious onset, meaning it is gradual and slow growing.
Patients will experience weakness, visual disturbance, headaches and fits.

58
Q
  1. Describe liver metastases.
A

This will result in abdominal swelling and hardness, also a lower liver function.

59
Q
  1. Describe metastases to the adrenal gland.
A

This very rarely causes any symptoms.

This is also a very common place to find metastatic deposits therefore we always check them.

60
Q
  1. Describe some paraneoplastic features of lung cancer.
A 
Finger clubbing
Hypertrophic pulmonary osetoarthropathy - HPOA
Weight loss
Thrombophlebitis
Hypercalcaemia
Hyponatraemia - SIADH
Weakness - Eaton Lambert Syndrome
61
Q
  1. What have we to remember in hypercalcaemia?
A 
Stones
Bones
Groans
Thrones
Psychiatric overtones
62
Q
  1. What causes hypercalcaemia in lung cancer?
A

This is usually caused by squamous cancers.

It is due to a hormonal expression by the tumour and is not secreted by the tumour itself.

63
Q
  1. How is hypercalcaemia treated?
A

This initial treatment is rehydration by IV fluids.
If calcium is v high we can use IV biphosphonate which alters bone turnover and breaks down calcium.
We will also want to treat the underlying cancer.

64
Q
  1. What is syndrome of inappropriate antidiuretic hormone?
A

Usually caused by small cell lung cancer.
It results in low sodium concentration (hyponatraemia)
It has general symptoms - nausea, myoclonus, lethargy, seizures.

65
Q
  1. How is SIADH treated?
A

The underlying cause must be treated.
There will also be fluid restriction because the sodium is diluted therefore reducing water will increase sodium.
Sometimes we need demeclocycline which is an antibiotic that increases Na.

66
Q
  1. What investigations should we do on an individual with lung cancer?
A 
Full blood count
Coagulation screen
Na, K, Ca, Alk Phos
Spirometry to give an idea of fitness
Chest X-Ray
CT scan of thorax
PET scan
Bronchoscopy
Endobronchial Ultrasound
NOT sputum cytology
67
Q
  1. What is a PET scan?
A

A scan to assess function rather than structure. It will show the metabolic activity as the tissue uptake of radio-labelled glucose is levels. Tissues with high metabolic activity light up, therefore cancers will be shown.
This test is more saved for patients we believe can have curative treatment.

68
Q
  1. How can we make a tissue diagnosis for lung cancer?
A 
Tissue diagnosis is the gold standard and cannot always be achieved.
Bronchoscopy
CT guided biopsy
Lymph node aspirate
Aspiration of pleural fluid
Endobronchial ultrasound
Thoracoscopy
69
Q
  1. Describe the initial treatment of Small Cell Lung Cancer
A

Rarely suitable for surgery

Good initial response to chemotherapy but it isn’t curative

70
Q
  1. Describe the initial treatment of Non Small Cell Lung Cancer.
A

Curative options are surgery or radical radiotherapy

Palliative chemotherapy and new targeted treatments are also an option.

71
Q
  1. What is the gold standard treatment for a lung cancer?
A

Surgery

72
Q
  1. What must we consider when selecting surgery as a treatment option for a lung cancer patient?
A

Can we cut it out?
Is the disease localised?
Will the patient survive the operation? Are they healthy?
What will the residual lung function be?

73
Q
  1. What are the procedures and tests carried out before lung cancer surgery?
A 
Bronchoscopy
Mediastinoscopy/EBUS
CT scan of the brain
CT scan of the thorax
PET scan
74
Q
  1. What is bronchoscopy used for prior to lung cancer surgery?
A

To detect - vocal chord palsy and proximity of the tumour to the carina. (cant do the surgery in these cases)
To determin the cell type.

75
Q
  1. What are mediastinoscopy/EBUS used for prior to lung cancer surgery?
A

They can be used to detect if the cancer has spread to the lymph nodes.

76
Q
  1. What is a CT scan of the brain used for prior to lung cancer surgery?
A

To detect metastases to the brain.

77
Q
  1. What is a CT scan of the thorax used for prior to lung cancer surgery?
A

Mainly used for TNM staging and also to detect local invasion of the tumour.

78
Q
  1. What is a PET scan used for prior to lung cancer surgery?
A

This is also to detect metastases in the body.

79
Q
  1. What are different surgery options for lung cancer patients?
A

Pneumonectomy

Lobectomy

80
Q
  1. What is a pneumonectomy?
A

The removal of the whole lung. This is essentially a whole lung transplant.

81
Q
  1. What is a lobectomy?
A

This is the removal of a cancerous lobe of lung and the associated lymph glands.

82
Q
  1. What is a thoracotomy?
A

This is where the chest surgery involves a large incision in the chest with a rib spreader.

83
Q
  1. What is a minimal access VATS
A

This is a video assisted thoroscopic surgery. This will reduce a patients recovery time after surgery and is essentially keyhole surgery.

84
Q
  1. What are the procedures and tests carried out before lung cancer chemotherapy?
A

Bronchoscopy/other tissue sampling
CT scan
ECOG score

85
Q
  1. What is bronchoscopy used for prior to lung cancer chemotherapy?
A

This is used to obtain a tissue sample for biopsy.

It is also used to differentiate between small cell and non small cell lung cancer.

86
Q
  1. What is CT scanning used for prior to lung cancer surgery?
A

This is again used for TNM staging and to detect local invasion.

87
Q
  1. What is ECOG score used for prior to lung cancer surgery?
A

This is to determine how fit the patient is before chemotherapy. It is relatively subjective.

88
Q
  1. Describe cytotoxic chemotherapy.
A

This is rarely a curative treatment for lung cancer and a balanced should be drawn between quality and quantity of life.
There are better responses in small cell lung cancer.
There are major side effects.
It is delivered by intravenous injection every 3-4 weeks in an outpatient clinic.

89
Q
  1. Describe the method of cytotoxic chemotherapy.
A

This is a whole body treatment, therefore doesn’t specifically target the lungs.
It targets rapidly dividing cells.
It is able to cross the blood brain barrier and can therefore also help with metastases in the brain.

90
Q
  1. What are the side effects of cytotoxic chemotherapy?
A

Nausea and vomiting
Tiredness
Immunosuppression
Hair loss - not generally for lung cancer
Pulmonary fibrosis
Patients can generally get medications alongside their chemotherapy to help with side effects.

91
Q
  1. Name some new targets for cancer treatments.
A

Genetic mutations - EGFR, ALK!

Immune Therapy - PD-L1

92
Q
  1. Describe radiotherapy for lung cancer treatment
A

Ionising radiation is used.
This can either be a radical or palliative treatment.
It is usually well tolerated by patients.

93
Q
  1. What are the negatives to using radiotherapy to treat lung cancer?
A

There is a maximum cumulative dose therefore we can only give so much.
There may also be collateral damage e.g . to the spine or oesphagus.
It is very speicific therefore not good for subclinical metastases.

94
Q
  1. What is stereotactic ablative radiotherapy?
A

This uses several beams of X-ray to target the tumour more specifically. This means that less frequent treatment is required.

95
Q
  1. What is endobronchial therapy?
A

This is particularly useful for carcinoma in situ.

It can involve the placing of a stent, photodynamic therapy with a fibre optic cable or other laser therapies.

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