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Year 3 > Lung cancer (RESP) > Flashcards

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
Q

What metastatic features of lung cancer may we see?

A

Brain, bone, liver, adrenals:

  • headaches
  • seizures
  • bone pain
  • jaundice
  • hepatomegaly
26
Q

What paraneoplastic syndrome features would you see in adenocarcinoma (lung cancer)?

A

Gynaecomastia

27
Q

What paraneoplastic syndrome features would you see in SCLC (lung cancer)? (3)

A
  • 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
Q

What are the features of Lambert-Eaton Syndrome (paraneoplastic syndrome, SCLC)? (4)

A
  • difficulty walking (waddling gait)
  • muscle tenderness
  • hyporeflexia
  • muscle weakness that improves with exercise (as opposed to myasthenia gravis)
29
Q

What antibodies do you find in Lambert-Eaton Syndrome (SCLC)?

A

Antibodies against pre-synaptic voltage-gated calcium channels at NMJ

30
Q

What paraneoplastic syndrome features would you see in squamous cell carcinoma (lung cancer)? (2)

A
  • 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
Q

What are the features of PTH-releasing peptide (paraneoplastic syndrome in SCC of the lung)? (4)

A
  • hypercalcaemia (constipation, myopathy, polydipsia, polyuria, low mood, bone pain)
  • clubbing
  • cavitating lesions
  • hyperthyroidism
32
Q

What are some risk factors for lung cancer? (8)

A
  • cigarette smoking
  • environmental tobacco exposure
  • COPD
  • family history
  • radon gas exposure
  • asbestos exposure
  • older age
  • male
33
Q

What are the first-line investigations for lung cancer? (2)

A
  • 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
Q

What other imaging can we do in lung cancer? (5)

A
  • 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
  • bloods
35
Q

What bloods do we look for in lung cancer? (5)

A
  • raised platelets - thrombocytosis
  • hyponatraemia - SCLC
  • hypercalcaemia - bone metastases or PTHrP in SCC
  • ALP - bone metastases
  • LFTs - liver metastases
36
Q

What are some differential diagnoses for lung cancer? (8)

A
  • abscess
  • granuloma
  • carcinoid tumour
  • pulmonary hamartoma
  • A/V malformation
  • cyst
  • foreign body
  • skin tumour
37
Q

What are some determinants for treatment of lung cancer? (5)

A
  • 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
Q

How is patient fitness in lung cancer classified by WHO performance status?

A
  • 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
Q

q
Which levels of WHO performance status are usually required for treatment of lung cancer?

A

0-2 as 3/4 will not benefit much (supportive care instead)

40
Q

What are the surgical options for lung cancer? (4)

A
  • lobectomy and lymphadenectomy
  • sublobar resection if stage 1 lung cancer <3cm
  • video-assisted thoracoscopic surgery (VATS) more modern
  • pneumonectomy in more severe cases
41
Q

What is radical radiotherapy in lung cancer?

A
  • stereotactic ablative body radiotherapy (SABR)
  • 10 sessions once a day over 2 weeks
  • early stage disease where patient has comorbidity
42
Q

What are some contraindications to surgery in lung cancer? (4)

A
  • SVC obstruction
  • malignant pleural effusion
  • vocal cord paralysis
  • FEV<1/5
43
Q

How do we manage SVC syndrome in lung cancer? (4)

A
  • 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
Q

How do we manage Horner’s syndrome in lung cancer? (2)

A
  • apraclonidine
  • cocaine eye drops
45
Q

What is the management plan for NSCLC (adenocarcinoma, SCC, large cell carcinoma)? (4)

A
  • 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
Q

What is an alternative treatment (rather than surgery) for early stage lung cancer?

A
  • stereotactic ablative body radiotherapy (SABR) - technique of choice, high-precision targeting, multiple convergent beams
  • particularly useful if you have a comorbidity
47
Q

When is systemic oncogene-directed treatment used in lung cancer?

A

First-line for metastatic NSCLC with mutation (blocks mutated protein)

48
Q

What are the NICE approved systemic-oncogene directed treatments for metastatic NSCLC?

A
  • EGFR - erlotinib, gefitinib, afatinib, dacomitinib, osimertinib
  • ALK - crizotinib, ceritinib, alectinib, brigatinib, lorlatinib
  • ROS-1 - crizotinib, entrectinib
49
Q

How good is the efficacy of systemic oncogene-directed treatments in metastatic NSCLC?

A

Improvements in progression-free survival, modest overall survival vs standard chemotherapy

50
Q

What are some side effects of systemic oncogene-directed treatment for metastatic NSCLC? (3)

A

Generally well-tolerated (tablets), but:

  • rash
  • diarrhoea
  • uncommonly pneumonitis
51
Q

How does systemic immunotherapy work against metastatic NSCLC?

A
  • 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
Q

Describe systemic immunotherapy as a treatment for metastatic NSCLC.

A
  • 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
Q

Describe systemic cytotoxic chemotherapy as a treatment for metastatic NSCLC. (4)

A
  • 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
Q

Summarise the three systemic therapies used for metastatic NSCLC. (4)

A
  • 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
Q

What is the management for SCLC (lung cancer)? (2)

A
  • palliative chemotherapy
  • correct SIADH slowly - fluid restriction, demeclocycline (reduces responsiveness of collecting tubule cells to ADH), ADH receptor antagonists
56
Q

What do you need to check in a lung cancer patient before putting in a chest drain for pleural effusion?

A

INR for bleeding risk

57
Q

Summarise the treatments for different types of lung cancer. (3)

A
  • NSCLC: lobectomy, SABR/curative radiotherapy
  • metastatic NSCLC: systemic oncogene-directed therapy (mutation), immunotherapy (PD-L1>50%), cytotoxic chemotherapy
  • SCLC: palliative chemotherapy
58
Q

What is a complication of lung cancer?

A

Lobar collapse

59
Q

What is the prognosis of NSCLC compared to SCLC?

A

NSCLC has better prognosis than SCLC

Only 10% of lung cancer patients survive beyond 10y

Year 3 (110 decks)

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