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Lung cancer (RESP) Flashcards

1
Q

What is lung cancer the leading cause of?

A

Leading cause of cancer death worldwide

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2
Q

Describe the epidemiology of lung cancer. (2)

A
  • M>F
  • peak incidence 65-75y
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3
Q

What are some causes of lung cancer? (3)

A
  • tobacco smoking
  • exposure to carcinogens e.g. radon, asbestos
  • family history
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4
Q

Describe the typical steps involved in cancer development.

A

Metaplasia –> dysplasia –> carcinoma in situ –> invasive carcinoma

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5
Q

How can lung cancer be divided into categories? (2)

A
  • small cell lung cancer (SCLC)
  • non-small cell lung cancer (NSCLC) - >80%
    • adenocarcinoma
    • squamous cell carcinoma
    • large cell carcinoma
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6
Q

Describe small cell lung cancer (SCLC). (5)

A
  • central
  • originate from pulmonary neuroendocrine cells and highly malignant
  • strong association with smoking
  • associated with several paraneoplastic syndromes (SIADH, Cushing’s, Lambert-Eaton Syndrome AKA LEMS)
  • also causes superior vena cava obstruction (SVCO)
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7
Q

How does superior vena cava obstruction present in small cell lung cancer? (6)

A
  • dyspnoea
  • swelling of face, neck and arms
  • headache worse in mornings
  • visual disturbance
  • raised JVP
  • positive Pemberton’s test - raising arms causes facial redness
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8
Q

What is the immediate management for superior vena cava obstruction in small cell lung cancer?

A

Oral dexamethasone

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9
Q

What are the three types of NSCLC?

A
  • adenocarcinoma
  • squamous cell carcinoma
  • large cell carcinoma
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10
Q

Describe adenocarcinomas - NSCLC. (3)

A
  • most common lung cancer
  • peripheral (mucus-producing glandular tissue)
  • non-smokers
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11
Q

Describe squamous cell carcinomas - NSCLC. (5)

A
  • central (bronchial epithelium)
  • associated with smoking
  • PTHrP causes hypercalcaemia
  • finger clubbing, wheeze, obstruction
  • associated with cavitating lesions - upper lobe
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12
Q

Describe large cell carcinomas (NSCLC).

A

Heterogenous group of undifferentiated cells that are frequently aggressive

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13
Q

What is the SSS rule of lung cancer?

A

Squamous cell and Small cell lung cancers are both Sentrally located

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14
Q

What is epidermal growth factor receptor (EGFR) tyrosine kinase (lung cancer)?

A
  • 15-20% adenocarcinoma
  • more in women, Asians, never-smokers
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15
Q

What is anaplastic lymphoma kinase (ALK) tyrosine kinase (lung cancer)?

A
  • 2-7% NSCLC
  • younger patients and never-smokers
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16
Q

What is c-ROS oncogene 1 (ROS1) receptor tyrosine kinase?

A
  • 1-2% of NSCLC
  • younger patients and never-smokers
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17
Q

What is BRAF (downstream cell signalling mediator)?

A
  • 1-3% NSCLC
  • especially in smokers
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18
Q

What is a Pancoast tumour (lung cancer)?

A

Apical lung carcinoma, may cause Horner’s syndrome

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19
Q

What can a Pancoast tumour lead to? (1+5)

A

Horner’s syndrome:

  • ipsilateral miosis
  • ptosis
  • anhidrosis (no sweat)
  • laryngeal nerve damage (in some cases) –> hoarseness
  • SVC obstruction
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20
Q

What is another cause of Horner’s syndrome, apart from a Pancoast tumour?

A

Carotid artery dissection

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21
Q

How does lung cancer often present?

A

Asymptomatic until late stages

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22
Q

What are the clinical features of lung cancer? (11)

A
  • persistent cough
  • haemoptysis
  • progressive dyspnoea
  • weight loss, fever, weakness
  • chest pain
  • hoarseness - Pancoast tumours pressing on recurrent laryngeal nerve
  • neurological features - focal weakness, seizures, SC compression, dysphagia, arrhythmias
  • bone pain
  • recurrent pneumonia / pleural effusions
  • SVC syndrome - head and neck oedema, arm swelling, distorted vision, headache, nasal stiffness, nausea, light-headedness
  • hyperpigmentation (in SCLC - due to ectopic ACTH –> increased MSH)
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23
Q

What might you see on examination in lung cancer? (8)

A
  • clubbing
  • cachexia
  • palpable mass
  • supraclavicular or persistent cervical lymphadenopathy
  • Horner’s syndrome (ptosis, miosis, anhidrosis, hoarseness, SVCO)
  • SVC obstruction - dyspnoea, headache, swelling, raised JVP, vision, Pemberton’s
  • Pemberton’s sign - SVC obstruction –> facial flushing when arms raised
  • paraneoplastic syndrome
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24
Q

What sign is seen in superior vena cava obstruction (lung cancer)?

A

Positive Pemberton’s sign - raising arms causes facial redness

(Immediate management is oral dexamethasone)

25
What metastatic features of lung cancer may we see?
Brain, bone, liver, adrenals: - headaches - seizures - bone pain - jaundice - hepatomegaly
26
What paraneoplastic syndrome features would you see in adenocarcinoma (lung cancer)?
Gynaecomastia
27
What paraneoplastic syndrome features would you see in SCLC (lung cancer)? (3)
- SIADH - hyponatraemia, high urine osmolality, high urine sodium - Cushing's (ACTH) - Lambert-Eaton Syndrome (LEMS): - difficulty walking (waddling gait) - muscle tenderness - hyporeflexia - muscle weakness that improves with exercise (as opposed to myasthenia gravis)
28
What are the features of Lambert-Eaton Syndrome (paraneoplastic syndrome, SCLC)? (4)
- difficulty walking (waddling gait) - muscle tenderness - hyporeflexia - muscle weakness that improves with exercise (as opposed to myasthenia gravis)
29
What antibodies do you find in Lambert-Eaton Syndrome (SCLC)?
Antibodies against pre-synaptic voltage-gated calcium channels at NMJ
30
What paraneoplastic syndrome features would you see in squamous cell carcinoma (lung cancer)? (2)
- **PTH-releasing peptide** - - hypercalcaemia (constipation, myopathy, polydipsia, polyuria, low mood, bone pain) - clubbing - cavitating lesions - hyperthyroidism - **hypertrophic pulmonary osteoarthropathy** - clubbing, periostitis of small hand joints
31
What are the features of PTH-releasing peptide (paraneoplastic syndrome in SCC of the lung)? (4)
- hypercalcaemia (constipation, myopathy, polydipsia, polyuria, low mood, bone pain) - clubbing - cavitating lesions - hyperthyroidism
32
What are some risk factors for lung cancer? (8)
- cigarette smoking - environmental tobacco exposure - COPD - family history - radon gas exposure - asbestos exposure - older age - male
33
What are the first-line investigations for lung cancer? (2)
- 1st: CXR - then: contrast-enhanced CT (chest, liver, adrenals) should be performed before a fibreoptic bronchoscopy/endobronchial ultrasound needle aspiration as allows you to identify and localise the lesion
34
What other imaging can we do in lung cancer? (4)
- PET-CT to look for metastases and lymph node involvement - bronchoscopy - central lesion (e.g. SCC/SCLC); biopsy and TNM staging - CT-guided lung biopsy - peripheral lesion (e.g. adenocarcinoma) - endobronchial ultrasound and transbronchial-needle aspiration (EBUS-TBNA) of mediastinal lymph nodes
35
What bloods do we look for in lung cancer? (5)
- raised platelets - thrombocytosis - hyponatraemia - SCLC - hypercalcaemia - bone metastases or PTHrP in SCC - ALP - bone metastases - LFTs - liver metastases
36
What are some differential diagnoses for lung cancer? (8)
- abscess - granuloma - carcinoid tumour - pulmonary hamartoma - A/V malformation - cyst - foreign body - skin tumour
37
What are some determinants for treatment of lung cancer? (5)
- patient fitness - WHO scale 0-5, radical treatment limited to PS 0-2, comorbidity and lung function also considered - cancer histology - cancer stage - patient preference - health service factors
38
How is patient fitness in lung cancer classified by WHO performance status?
- 0 - asymptomatic (fully active, able to carry out all predisease activities without restriction) - 1 - symptomatic but completely ambulatory (restricted in physically strenuous activity but ambulatory and able to carry out any light/sedentary work activities) - 2 - symptomatic, up and about >50% of waking hours (ambulatory and capable of all self-care but unable to carry out any work activities) - 3 - symptomatic, confined to bed or chair >50% of waking hours (capable of only limited self-care) - 4 - completely disabled (cannot carry on any self-care, fully confined) - 5 - death
39
Which levels of WHO performance status are usually required for treatment of lung cancer?
0-2 as 3/4 will not benefit much (supportive care instead)
40
What are the surgical options for lung cancer? (4)
- **lobectomy and lymphadenectomy** - sublobar resection if stage 1 lung cancer <3cm - video-assisted thoracoscopic surgery (VATS) more modern - pneumonectomy in more severe cases
41
What is radical radiotherapy in lung cancer?
- stereotactic ablative body radiotherapy (SABR) - 10 sessions once a day over 2 weeks - early stage disease where patient has comorbidity
42
What are some contraindications to surgery in lung cancer? (4)
- SVC obstruction - malignant pleural effusion - vocal cord paralysis - FEV<1/5
43
How do we manage SVC syndrome in lung cancer? (4)
- supplemental oxygen - tilt head upwards - oral dexamethasone 8mg BD - emergency Rx: steroids, SVC balloon dilatation, stent insertion - indicated when brain oedema, decreased CO, upper airway compression
44
How do we manage Horner's syndrome in lung cancer? (2)
- apraclonidine - cocaine eye drops
45
What is the management plan for NSCLC (adenocarcinoma, SCC, large cell carcinoma)? (4)
- 1st line: lobectomy - stages I, II, III: curative radiotherapy also offered - stages III, IV: chemotherapy should be offered to control disease and improve QoL - advanced NSCLC: targeted therapy - EGFR inhibitors, ALK tyrosine kinase inhibitors
46
What is an alternative treatment (rather than surgery) for early stage lung cancer?
- stereotactic ablative body radiotherapy (SABR) - technique of choice, high-precision targeting, multiple convergent beams - particularly useful if you have a comorbidity
47
When is systemic oncogene-directed treatment used in lung cancer?
First-line for metastatic NSCLC with mutation (blocks mutated protein)
48
What are the NICE approved systemic-oncogene directed treatments for metastatic NSCLC?
- EGFR - erlotinib, gefitinib, afatinib, dacomitinib, osimertinib - ALK - crizotinib, ceritinib, alectinib, brigatinib, lorlatinib - ROS-1 - crizotinib, entrectinib
49
How good is the efficacy of systemic oncogene-directed treatments in metastatic NSCLC?
Improvements in progression-free survival, modest overall survival vs standard chemotherapy
50
What are some side effects of systemic oncogene-directed treatment for metastatic NSCLC? (3)
Generally well-tolerated (tablets), but: - rash - diarrhoea - uncommonly pneumonitis
51
How does systemic immunotherapy work against metastatic NSCLC?
- T cells can mop up and kill early cancer cells - many tumours bypass this system through PD-1 (protein on T cells) that binds to PD-L1 receptor on tumour cell and blocks T cell from working - immunotherapy blocks PD-L1 receptor or PD-1 allowing T cell to kill tumour cell
52
Describe systemic immunotherapy as a treatment for metastatic NSCLC.
- first-line for metastatic NSCLC with no mutation and PD-L1>50% - pembrolizumab, atezolizumab, nivolumab - improves progression-free survival and overall survival vs standard chemotherapy - generally well-tolerated - immune-related side effects in 10-15% (thyroid, skin, bowel, lung, liver)
53
Describe systemic cytotoxic chemotherapy as a treatment for metastatic NSCLC. (4)
- first-line for metastatic NSCLC with no mutation and PD-L1<50% (in combination with immunotherapy to boost outcomes) - targets rapidly dividing cells and kills - platinum-based regimens e.g. carboplatin, cisplatin, paclitaxel, pemetrexed - side effects: fatigue, nausea, BM suppression, nephrotoxicity
54
Summarise the three systemic therapies used for metastatic NSCLC. (4)
- targetable mutation (e.g. EGFR, ALK, ROS-1) - tyrosine kinase inhibitor (systemic oncogene-directed treatment) - no mutation, PDL1 positive - immunotherapy alone - no mutation, PDL1 negative - cytotoxic ‘standard’ chemotherapy + immunotherapy - palliative care alone or with the above
55
What is the management for SCLC (lung cancer)? (2)
- palliative chemotherapy - correct SIADH slowly - fluid restriction, demeclocycline (reduces responsiveness of collecting tubule cells to ADH), ADH receptor antagonists
56
What do you need to check in a lung cancer patient before putting in a chest drain for pleural effusion?
INR for bleeding risk
57
Summarise the treatments for different types of lung cancer. (3)
- NSCLC: lobectomy, SABR/curative radiotherapy - metastatic NSCLC: systemic oncogene-directed therapy (mutation), immunotherapy (PD-L1>50%), cytotoxic chemotherapy - SCLC: palliative chemotherapy
58
What is a complication of lung cancer?
Lobar collapse
59
What is the prognosis of NSCLC compared to SCLC?
NSCLC has better prognosis than SCLC Only 10% of lung cancer patients survive beyond 10y

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