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Respiratory Medicine > Lung Cancers > Flashcards

Lung Cancers Flashcards

1
Q

What is angiosarcoma?

A

Malignancy of vascular endothelial cells
Of skin, heart, liver, etc
UK annual incidence 1.5 cases per million

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2
Q

What is the prevalence of cardiovascular cancer?

A

Incredibly rare

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3
Q

What are the features of cardiac tumours?

A

E.g. myxoma, tumour of connective tissue

Annual incidence <1 case per million

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4
Q

Why are cardiac cancers so rare?

A

Low exposure of cells to carcinogens

Turnover rate: cardiac myocytes divide very rarely

Strong selective advantage against anything which could compromise function

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5
Q

Why might other organs be exposed more too carcinogens?

A

Lung- inhaled particles, smoking etc

Kidney/Liver - exposed to toxins

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6
Q

Why is the shape of cardiac cells relevant to low incidence of cancer?

A

Shape in cells is highly specialised

Any change will prevent the cardiovascular system from working

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7
Q

What is the scale of lung cancer?

A

3rd most common cancer in UK

~48,000 diagnoses/ year

~35,000 deaths/ year

Leading cause of cancer death

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8
Q

What are risk factors for lung cancer?

A

Age, peak 75-90
Sex, M>F
Lower socioeconomic status
Smoking history

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9
Q

What is relevant in a smoking history?

A

Duration
Intensity
When stopped

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10
Q

What are other causes of lung cancer other than smoking?

A

Passive smoking

Asbestos – exposure (plumbers, ship-builders, carriage workers, carpenters, etc) – risk up to x2

Radon – e.g. silver miners in Germany late 19th century; 1950s uranium mining in Colorado

Indoor cooking fumes – wood smoke, frying fats

Chronic lung diseases (COPD, fibrosis)

Immunodeficiency

Familial/ genetic – several loci identified

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11
Q

What are the different types of lung cancer?

A

Squamous cell carcinoma
Adenocarcinoma
Large cell lung cancer
Small cell lung cancer

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12
Q

What are the features of squamous cell carcinomas?

A

Squamous cell carcinoma (~30% of cases).
– previously the most common
– originating from bronchial epithelium; centrally located

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13
Q

What are the features of adenocarcinomas?

A

Adenocarcinoma (~40%)
– most common from 1980s onwards – low tar cigarettes, inhaled more deeply / retained longer
– originating from mucus-producing glandular tissue; more peripherally-locate

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14
Q

What are the features of large cell lung cancer?

A

Large cell lung cancer (~15%)

heterogenous group, undifferentiated

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15
Q

What are the features of small cell lung cancer?

A

Small cell lung cancer (~15%)
originate from pulmonary neuroendocrine cells
highly malignant

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16
Q

What is NSCLC?

A

Non small cell lung cancer

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17
Q

Describe the model of lung cancer development?

A 
Normal Epithelium
Hyperplasia
Squamous metaplasia
Dysplasia
Carcinoma in situ
Invasive carcinoma
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18
Q

What is metaplasia?

A

reversible change in which one adult cell type replaced by another adult cell type; adaptive

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19
Q

What is dysplasia?

A

abnormal pattern of growth in which some of the cellular and architectural features of malignancy are present; pre-invasive stage with intact basement membrane

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20
Q

What are some oncogenes?

A

epidermal growth factor receptor (EGFR) tyrosine kinase

anaplastic lymphoma kinase (ALK) tyrosine kinase

c-ROS oncogene 1 (ROS1) receptor tyrosine kinase

BRAF (downstream cell-cycle signalling mediator)

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21
Q

What do genetic kinase defects cause?

A

Lung cancer most common in those who have never smoked

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22
Q

What are the key symptoms of lung cancer?

A 
Cough
Weight loss
Breathlessness
Fatigue
Chest pain
Haemoptysis
Or frequently asymptomatic
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23
Q

Why is lung cancer often diagnosed late?

A

Nature of lung
Lots of space in the thoracic cavity
Does not impede on other structures quickly
Non-specific symtoms

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24
Q

What are features of advanced/metastatic disease?

A

Neurological features:
focal weakness, seizures, spinal cord compression

Bone pain

Paraneoplastic syndromes:

clubbing, hypercalaemia, hyponatraemia, Cushing’s

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25
Q

What is Pemberton’s sign indicative of?

A

Superior vena cava obstruction

Engourgement of the face due to decreased blood flow
Redness
Facial swelling
Distention of veins of neck and chest

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26
Q

What is Horner’s syndrome caused be?

A

Apical lung tumour
Loss of sweating on side of face
Ptosis
Pupillary reconstruction

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27
Q

What is cachexia?

A

Muscle wastage

Weight loss

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28
Q

What is the diagnostic strategy for lung cancer?

A

Establish most likely diagnosis

Establish fitness for investigation and treatment

Confirm diagnosis
specific type of cancer if considering systemic treatment

Confirm staging

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29
Q

What imaging can be used to diagnose lung cancer?

A

Chest X-ray
Tumours appear white
Might show unilateral pleural effusion

Staging ST (chest and abdomen)

PET

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30
Q

What is unilateral pleural effusion often indicative of?

A

Malignancy

Likely metastasised to pleura from lung

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31
Q

What is PET useful for?

A

To exclude occult metastases

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32
Q

What are tests use to confirm diagnosis?

A

Biopsy

via bronchoscopy
via endobronchial ultrasound and trans bronchial needle
via CT guided lung biopsy

33
Q

How do you stage lung cancer?

A

T1-4: tumour size and location

N0-3: lymph node involvement – mediastinum + beyond

M0-1c: metastases + number

34
Q

How is biopsy conducted via bronchoscopy?

A

Tube passed down
for tumours of central airway
where tissue staging not important

35
Q

How is biopsy conducted via endobronchial ultrasound?

A

Endobronchial ultrasound and transbronchial-needle aspiration of mediastinal lymph nodes (EBUS [TBNA])
To stage mediastinum +/- achieve tissue diagnosis

36
Q

How is biopsy conducted via CT guided biopsy?

A

CT-guided lung biopsy

To access peripheral lung tumours

37
Q

What determines treatment selection?

A 
Patient fitness
Cancer histology
Cancer stage
Patient preference
Health service factors
38
Q

What are the treatment options?

A

Surgical
Radiological
Pharmacological
Supportive

39
Q

How do assess patient fitness?

A

WHO performance status

0-5 scale

40
Q

What does 0 on the fitness scale mean?

A

Asymptomatic (Fully active, able to carry on all predisease activities without restriction)

41
Q

What does 1 on the fitness scale mean?

A

– Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work)

42
Q

What does 0 on the fitness scale mean?

A

Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours)

43
Q

What does 0 on the fitness scale mean?

A

Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)

44
Q

What does 0 on the fitness scale mean?

A

Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)

45
Q

What does 0 on the fitness scale mean?

A

Death

46
Q

Which numbers on the scale are radical treatments restricted to?

A

0-2

47
Q

How is surgery used to treat lung cancer?

A

Surgical resection is standard of care for early stage disease

Lobectomy + lymphadenectomy usual approach

Sublobar resection if stage 1 (≤3 𝑐𝑚)

48
Q

How is radical radiotherapy used to treat lung cancer?

A

Alternative to surgery for early stage disease

Particularly if comorbidity

Stereotactic ablative body radiotherapy (SABR)

  • Technique of choice
  • High-precision targeting, multiple convergent beams
49
Q

How is surgery conducted?

A

Open thoracotomy

now VATS

50
Q

When is radiotherapy used instead of surgery?

A

Not fit enough for surgery

Refuse surgery

51
Q

When are oncogene systemic pharmacological treatments used?

A

First line for metastatic NSCLC with mutation

52
Q

What are some NICE approve drug treatments?

A

EGFR: erlotinib, gefitinib, afatinib, dacomitinib, and osimertinib

ALK: crizotinib, ceritinib, alectinib, brigatinib, lorlatinib

ROS-1: crizotinib, entrectinib

53
Q

What is the efficacy of drug treatments?

A

improvements in progression-free survival, but not necessarily overall survival vs standard
chemotherapy:

e.g. erlotinib PFS 13 vs 5 months, OS 23 vs 27 months compared to chemo (OPTIMAL trial)

54
Q

What are the side effects of the drug treatments?

A

generally well-tolerated (tablets)

rash, diarrhoea, and (uncommonly) pneumonitis

55
Q

What is the desired effect for drug treatments?

A

Not always to cure
But to improve QoL
Alleviate some symptoms
Palliative

56
Q

What is PFS?

A

Progression free survival

57
Q

What is immunotherapy?

A

New, progressive field, radical approach

Harnesses own immune system to attack cancer cells

58
Q

What are NICE approved immunotherapy drugs?

A

Pembrolizumab, atezolizumab, nivolumab

59
Q

When is immunotherapy used?

A

First line for metastatic NSCLC with no mutation (and PDL1 ≥50%)

60
Q

What is the efficacy of immunotherapy?

A

improvements in progression-free survival and overall survival vs standard chemotherapy:
e.g. pembrolizumab PFS 10 vs 6 months, OS 30 vs 14 months (KEYNOTE-024 trial)

61
Q

What are side effects of immunotherapy?

A

generally well-tolerated

Immune-related side-effects in 10-15% (thyroid, skin, bowel, lung, liver)

62
Q

When is cytoxic chemotherapy used?

A

First line for metastatic NSCLC with no mutation and PDL1 ≤50% (in combination with immunotherapy)

63
Q

What are the features of chemo?

A

Target any rapidly dividing cells

Platiunum-based regimens, e.g. carboplatin, cisplatin, paclitaxel, pemetrexed

64
Q

What is the efficacy of chemo?

A

Modest improvements in overall survival vs best supportive care:
e.g. 29 vs 20% one year survival in clinical trials

65
Q

What are the side effects of chemo?

A

Frequent: fatigue, nausea, bone marrow suppression, nephrotoxicity
Quality of life poorly evaluated in trials; no evidence for improvement

66
Q

What is the fourth dimension in cancer care?

A

Palliative care

Supportive care

67
Q

What are the features of palliative care?

A

Should be offered as standard to all patients with advanced stage disease
Symptom control, psychological support, education, practical and financial support, planning for end of life

68
Q

Who is key in palliative care?

A

Lung cancer specialist nurses key

69
Q

What does palliative care result in?

A

Improve QoL
Lower depression scores
Mean survival can increase

70
Q

What treatment is used for early stage disease?

A

Surgery or radiotherapy with curative intent

71
Q

What treatment is used for locally advances disease? (involving thoracic lymph nodes)

A

Surgery + adjuvant chemotherapy

Radiotherapy + chemotherapy +/- immunotherapy

72
Q

What is the treatment for metastatic lung cancer?

A

With targetable mutation (e.g. EFGR, ALK, ROS-1): tyrosine kinase inhibitor

No mutation, PDL-1 positive: immunotherapy

No mutation, PDL-1 negative: ‘standard’ chemotherapy

Palliative care, alone or with the above

73
Q

Via what two methods can you perform a lung biopsy?

A

Bronchoscopy - more deep

Transthoracic needle - more superficila

74
Q

What blood results might be seen in lung cancer?

A 
High Calcium (bone mets)
High ALP (bone mets)
Derranged LFTs (liver mets)
75
Q

What is seen on a CXR in secondary lung cancer?

A

Coin-shaped lesions

Cannonball mets

76
Q

What cancer is caused by asbestos exposure?

A

Mesothelioma

Hear a pleural friction rub on ausculatation

77
Q

What is mesothelioma?

A

Malignant neoplasm of mesothelial cells of the pleura

78
Q

What is thoracentesis?

A

Pleural tap

Aspiration of pleural fluid

79
Q

What might be see on a CXR in mesothelioma?

A

Pleural thickening

Pleural plaques - due to asbestos

Respiratory Medicine (12 decks)

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