Lung Cancer Tutorial

Question 1

Case Study:

Mr PJ is 72 and visits his GP because of cough and lethargy for 6 weeks

Past medical history: COPD, benign prostatic hypertrophy, ischaemic heart disease – NSTEMI with coronary stents 2007

Social history: retired plumber, ex-smoker (10-15 cigarettes/ day from age 15-59). Lives with wife, independent. Can walk around 100 yards / 1 flight stairs. Does gardening and simple DIY

Give at least 3 differential diagnoses for the symptoms

Answer 1

Lung cancer 
COPD inflammation / exacerbation 
Bronchitis
Pulmonary fibrosis
pneumonia
Bronchiectasis
TB

Question 2

What is this man’s WHO performance status?

Answer 2

PS1 - symptomatic but completely ambulatory, restricted in physically strenuous activity

Question 3

What are the possible risk factors for lung cancer in this case

Answer 3

Ex-smoker (10-15 cigarettes/day between ages 15-59)

COPD

Plumber = exposure to toxins e.g. asbestos

Possible family history of cancer

Question 4

What does Mr PJ’s chest x-ray and CT imaging show?

Answer 4

CT scan shows tumour on the right lung - right upper lobe tumour

Black holes at the edges of the lungs = emphesyma

Enlarged heart and aorta - suggestive of cardiac disease

35 mm = tumour width

Classified as T2A (3-4 cm sized tumour)

Question 5

Assuming there is no abnormality seen in the mediastinal, hilar or other lymph nodes, with no evidence of metastatic disease on the staging CT scan, what is the provisional staging?

Answer 5

T2A N0 M0

Question 6

What imaging would help confirm this staging?

Answer 6

PET - area where radioactive glucose is used lights up

Question 7

What would be the likely histology?

Answer 7

Adenocarcinoma

Question 8

What would be the way to confirm the diagnosis histologically?

Answer 8

Take a biopsy

CT guided lung biopsy for peripheral lesions

Question 9

What treatment should be offered?

Answer 9

Surgery - lobectomy

Radical radiotherapy - if co-morbidities significant or patient declines surgery

Question 10

Is there any other information is necessary before deciding treatment?

Answer 10

Patient fitness
Patient preference
Complete medical history with details of co-morbidities
Medication history
Lung function
Echocardiogram and cardiology assessment

Question 11

Case Study:

Mrs FG is 57 and visits her GP because of persistent right-sided chest pain.

Past medical history: none, no regular medication.

Social history: never smoker. Works full-time as a cleaner/ house keeper

What is the performance status?

Answer 11

PS0 - asymptomatic

Question 12

What does Mrs FG’s imaging show – early, locally advanced or metastatic disease?

Answer 12

Metastatic - tumour in the lung, mediastinal node enlargement, liver metastasis, pleural effusion

Enlargement of the lymph nodes

Question 13

How could a tissue diagnosis be made?

Answer 13

Ultrasound guided liver biopsy - biopsying the liver is most straight forward as it it closer to the surface

CT guided lung biopsy = higher risk of pneumothorax and other complications

Question 14

The biopsy shows adenocarcinoma with PDL1 10%, EGFR mutation positive

What treatment modalities could be offered?

Answer 14

PDL1 was slightly high

Tyrosine kinase inhibitor

Platinum based regimens e.g. carbeplatin

Palliative / supportive care

Question 15

Case Study:

Gladys is 87 with dementia. Has carers 3 times a day, walks with a Zimmer, and needs help with personal care, poor short-term memory. Hypothyroid, hypertension. Ex-smoker.

Reduced appetite and weight loss for 6 weeks with worsening confusion.

Admitted with a fall.

Chest x-ray shows a mass. Bloods show hyponatraemia and hypercalcaemia.

Has a CT – mediastinal node enlargement, sclerotic foci in pelvis suspicious of metastatic disease (i.e. likely stage 4 lung cancer)

What is her performance status?

Answer 15

PS3

Question 16

If this is cancer what is Gladys’s likely prognosis?

Answer 16

Very poor prognosis - old, many co-morbidities

Weeks - short months

Question 17

How would you determine the appropriate course of action?

Answer 17

Supportive and palliative care
Systemic treatment rarely given to PS 3-4
Decision making involves patient and family
MDT

Question 18

Comparing lung cancer to other types of cancer (e.g. breast, colon), why is it frequently only diagnosed at a late stage?

Answer 18

Lung cancer can be asymptomatic for a considerable amount of time before diagnosis

Early symptoms are vague and non-specific, often dismissed or misattributed to other (e.g. smoking related) conditions

Symptoms can overlap with other things e.g. most smokers have coughs and wheezes

Generic symptoms, coughs, wheezes can be caused by many different conditions

Gradual onset of symptoms = hard to notice

Question 19

What are other reasons for poor prognosis with this disease?

Answer 19

Mainly elderly patients are diagnosed with lung cancer, less likely to be offered radical treatments to improve prognosis

Lungs = more difficult / dangerous to remove compared to other cancers e.g. breasts

Smokers have higher rates of co-morbidities e.g. heart disease, peripheral vascular disease etc.

Possible nihilism

Question 20

What interventions might help reduce deaths from lung cancer?



Answer 20

Introducing lung cancer screening for smokers, COPD patients etc.

Educate patients on the symptoms of lung cancer

Introduce smoking cessation - VBA

Tackle causes of smoking

Faster hospital referrals, diagnoses and treatment pathways in secondary care