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Respiratory System (Year 1) > Neoplasia (Lung Cancer) > Flashcards

Neoplasia (Lung Cancer) Flashcards

1
Q

What is the aetiology of lung cancer?

A
  • TOBACCOO
  • asbestos
  • environmental radon
  • other occupational exposure (chromates, hydrocarbons, nickel)
  • air pollution and urban environment
  • other radiation
  • pulmonary fibrosis
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2
Q

What percentage of lung cancer is attributed to tobacco?

A

> 85%

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3
Q

What percentage of smokers get lung cancer?

A

10%

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4
Q

What are the two main pathways of carcinogenesis in the lung?

A
  • in the lung periphery
  • bronchioloalveolar epithelial stem cells transform
  • adenocarcinoma
  • in the central lung airways
  • bronchial epithelial stem cells transform
  • squamous cell carcinoma
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5
Q

What are the different types of “tumours” of the lung?

A
  • benign causes of mass lesion
  • carcinoid tumour
    –> <5% of lung neoplasms
    –> low grade malignancy
  • tumours of bronchial glands (VERY RARE)
    –> adenoid cystic carcinoma
    –> mucoepidermoid carcinoma
    –> benign adenomas
  • lymphoma
  • sarcoma
  • METASTASES to lung are common
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6
Q

What are the local effects of lung cancer, due to bronchial obstruction?

A
  • collapse
  • endogenous lipid pneumonia
  • infection/abscess
  • bronchiectasis
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7
Q

What are the local effects of lung cancer, in relation to pleural?

A
  • inflammatory
  • malignant
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8
Q

What are the local effects of lung cancer for direct invasion?

A
  • chest wall
  • nerves
    • phrenic –> diaphragmatic paralysis
    • L recurrent laryngeal –> hoarse, bovine cough
    • brachial plexus –> pancoast T1 damage
    • cervical sympathetic –> horner’s syndrome
  • mediastinum (SVC, pericardium)
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9
Q

What are the local effects of lung cancer for lymph node metastases?

A
  • mass effect
  • lymphangitis carcinomatosa
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10
Q

What are the distant effects of lung cancer for distant metastases?

A
  • liver
  • adrenals
  • bone
  • brain
  • skin
  • potential for neural and vascular
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11
Q

What are the different non-metastatic paraneoplastic effects of lung cancer?

A

Skeletal
- clubbing
- HPOA

Endocrine
- ACTH, siADH, PTH
- carcinoid syndrome
- gynecomastia

Neurological
- polyneuropathy
- encephalopathy
- cerebellar degeneration
- myasthenia (Eaton-Lambert)

Cutaneous
- acanthosis nigricans
- dermatomyositis

Haematologic
- granulocytosis
- eosinophilia
- DIC

Cardiovascular
- thrombophlebitis migrans

Renal
- nephrotic syndrome

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12
Q

What are the different investigations used for lung cancer?

A
  • chest xray
  • sputum cytology rarely used
  • bronchoscopy
    –> bronchial biopsy
    –> bronchial brushings and washings
    –> endobronchial US-guided aspiration (EBUS)
  • trans-thoracic fine needle aspiration
  • trans-thoracic core biopsy
  • pleural effusion cytology and biopsy
  • advanced imaging techniques
    –> CT scanning
    –>MRI, PET scanning
    –> other imaging
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13
Q

What are 10 basic symptoms of lung cancer?

A
  • chronic coughing
  • coughing up blood
  • wheezing sound
  • chest and bone pain
  • chest infections
  • difficulty swallowing
  • raspy, hoarse voice
  • SOB
  • unexplained weight loss
  • nail clubbing
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14
Q

What are the symptoms of lung cancer (metastatic)?

A
  • bone pain
  • spinal cord compression
    –> limb weakness
    –> paraesthesia
    –> bladder/bowel dysfunction
  • cerebral metastases
    –> headache
    –> vomiting
    –> dizziness
    –> ataxia
    –> focal weakness
  • thrombosis
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15
Q

What are the symptoms of lung cancer (paraneoplastic)?

A
  • hyponatraemia
    –> siADH
  • anaemia
  • hypercalcaemia
    –> parathyroid hormone related protein
    –> bone metastases
  • dermatomyositis/polymyositis
    –> proximal muscle weakness
  • cerebellar ataxia
  • sensorimotor neuropathy
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16
Q

What are the clinical signs of lung cancer?

A
  • chest signs
  • clubbing
  • lymphadenopathy
  • horner’s syndrome
  • pancoast tumour
  • superior vena cava obstruction
  • hepatomegaly
  • skin nodules (metastases)
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17
Q

What are the first investigations to be done?

A
  • CXR
  • FBC
  • renal, liver functions and calcium
  • clotting screen
  • spirometry
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18
Q

What are the different scores for performance status?

A

0 = fully active
1 = symptoms but ambulatory
2 = “up and about” > 50%, unable to work
3 = “up and about” < 50%, limited self care
4 = bed or chair bound

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19
Q

What are the different treatments for lung cancer?

A

SURGERY - 18% of patients
- wedge resection
- lobectomy
- pneumonectomy

RADIOTHERAPY
- radical
- palliative
- stereotactic

CHEMOTHERAPY
- part of radical or palliative treatment
- alone, combined with radiotherapy, adjuvant (after surgery)
- targeted agents e.g. Tyrosine Kinase Inhibitors and monoclonal antibodies
- small cell e.g. cisplatin/pemetrexed
- squamous e.g. cisplatin/gemcitabine

BEST SUPPORTIVE CARE

CO-ORDINATION - lung cancer specialist nurse

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20
Q

What palliative care is put into place for people with end-stage lung cancer?

A

SYMPTOM CONTROL
- may include chemotherapy
- may include radiotherapy
- opiates, bisphosphonates, benzodiazepines
- treatment of hypercalcaemia, dehydration, hyponatraemia

QUALITY OF LIFE

COMMUNITY SUPPORT

DECISIONS AND PLANNING, RESUSITATION STATUS, END OF LIFE CARE

MULTIDISCIPLINARY TEAM INCLUDING LUNG CANCER NURSE AND HOSPICE

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21
Q

What is a pulmonary mass?

A

An opacity in lung over 3cm with no mediastinal adenopathy or atelectasis

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22
Q

What is a pulmonary nodule?

A

An opacity in lung up to 3cm with no mediastinal adenopathy or atelectasis

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23
Q

What is TNM staging?

A

T –> how big it is and how far has it spread/size and position of the tumour

N –> whether cancer cells have spread into the lymph nodes

M –> whether the tumour has spread anywhere else in the body i.e. metastases

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24
Q

What different scans should be done for each part of TNM staging?

A

T –> CT, PET-CT, bronchoscopy

N –> PET-CT, mediastinoscopy, CT, EBUS/EUS

M –> PET-CT, CT, bone scan

25
Q

What is Tx/T0/Tis?

A

Tx –> primary tumour cannot be assessed

T0 –> no evidence of primary tumour

Tis –> carcinoma in situ

26
Q

What is a T1 (a/b/c)?

A

Tumour <= 3cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of involvement of the main bronchus

T1a –> minimally invasive adenocarcinoma tumour <= 1cm in greatest dimension

T1b –> tumour <= 2cm

T1c –> tumour <= 3cm

27
Q

What is a T2 (a/b)?

A

Tumour > 3cm but 5cm or tumour with any of the following features (T2 tumours with these features are classified T2a if <= 5cm)
- involves main bronchus, but not carina
- invades visceral pleura
- associated with atelectasis or obstructive pneumonitis that extends to the hilar region involving part or all the lung

T2a –> tumour > 3cm but < 4cm in greatest dimension

T2b –> tumour > 4cm but < 5cm in greatest dimension

28
Q

What is a T3?

A

tumour > 5cm but < 7cm or one that directly invades any of the following:
- chest wall (including superior sulcus tumours)
- phrenic nerve
- parietal pericardium

Or separate tumour nodule(s) in the same lobe as the primary

29
Q

What is a T4?

A

Tumour > 7cm or invades any of the following:
- diaphragm
- mediastinum
- heart
- great vessels
- trachea
- recurrent laryngeal nerve
- oesophagus
- vertebral body
- carina

Separate tumour nodule(s) in a different ipsilateral lobe

30
Q

What is N0-3?

A

N0 –> no regional lymph node metastases

N1 –> ipsilateral peribronchial, hilar or intrapulmonary nodes including by direct extension

N2 –> ipsilateral mediastinal, subcarinal

N3 –> contralateral mediastinal, contralateral hilar, scalene or supraclavicular

31
Q

What is M0/1?

A

M0 –> no distant metastasis

M1 –> distant metastasis

32
Q

What is M1 (a/b/c)?

A

M1a –> separate tumour nodule(s) in a contralateral lobe, tumour with pleural or pericardial nodules or malignant pleural or pericardial effusion

M1b –> single distant metastasis

M1c –> multiple distant metastases

33
Q

What does a PET/CT do in staging?

A
  • performs whole body staging in a single study excluding cerebral disease
  • discloses metastases and other pathology not detected by other means
    –> unexpected metastases in 10-20%
  • excludes metastases where structural imaging abnormal
  • non invasive
34
Q

What are the limitations of a PET/CT?

A
  • false negative results
  • false positive results
  • cost
35
Q

What can be present in a CXR for someone with lung cancer?

A
  • pleural effusion
  • chest wall invasion
  • phrenic nerve palsy
  • collapsed lobe or lung
36
Q

What can be present in blood tests for someone with lung cancer?

A
  • anaemia
  • abnormal LFTs
  • abnormal bone profile
37
Q

What can be present in a CT for someone with lung cancer?

A
  • size of tumour
  • mediastinal nodes
  • metastatic disease –> other parts of lungs, liver, adrenals, kidneys
  • proximity to mediastinal structures
  • pleural/pericardial effusion
  • diaphragmatic involvement
38
Q

What does a MRI do for testing for lung cancer?

A

Useful in determining the degree of vascular and neurological involvement in pancoast tumour

39
Q

What does a bone scan do for testing for lung cancer?

A

Good test for chest wall invasion and for bony metastases

40
Q

What does a ECHO do for testing for lung cancer?

A

Will demonstrate presence or absence of significant pericardial effusion

41
Q

What are cardiovascular factors which influence the patients fitness for surgery?

A
  • angina
  • heart problems
  • high blood pressure
  • DM
  • PVD
  • smoking
  • stroke/TIA
  • carotid bruits
  • previous CABG/angioplasty
  • heart murmurs
42
Q

What are respiratory factors which influence the patients fitness for surgery?

A
  • barrell-chested
  • COAD
  • still smoking
  • asthmatic
  • recent URTI
  • on oxygen
  • exercise capacity
  • previous thoracotomy or ICD
43
Q

What are the psychiatric factors which influence the patients fitness for surgery?

A
  • pH of mental illness
  • severe anxiety
  • social background
  • chronic pain problems
44
Q

What are other factors which influence the patients fitness for surgery?

A
  • pulmonary hypertension
  • permanent tracheostomy
  • rheumatoid arthritis
  • the immobile patient
  • cirrhosis
  • h/o radiotherapy to chest
45
Q

What respiratory testing is done to assess the patients fitness for surgery?

A
  • spirometry
  • diffusion studies
  • ABG on air/SLV
  • fractionated V/Q scan
46
Q

What cardiovascular testing is done to assess the patients fitness for surgery?

A
  • ECG
  • ECHO
  • CT scan
  • ETT
  • coronary angiogram
47
Q

What is the surgical treatment for lung cancer?

A
  • curative resection is the goal
  • remove the minimum amount of lung tissue
  • resection of parietal structures is feasible
  • firm diagnosis of malignancy is highly desirable before lung resection
48
Q

What are the reasons for peri-operative death?

A
  • ARDS
  • bronchopneumonia
  • myocardial infarction (MI)
  • PTE
  • pneumothorax
  • intrathoracic bleeding
49
Q

What are the non-fatal complications of surgery for lung cancer?

A
  • post thoracotomy wound pain
  • empyema
  • BPF
  • wound infection
  • AF
  • MI
  • post-op respiratory insufficiency
  • gastroparesis/constipation
50
Q

What are the most common problems with staging of lung cancer?

A
  • collapse of a lobe or lung makes tumour size difficult to assess
  • presence of another (usually small) pulmonary nodule
  • retrosternal thyroid
  • adrenal nodule
  • CT head is not routinely performed pre-op
51
Q

What is the operative mortality for a pneumonectomy?

A

5-10%

52
Q

What is the operative morality of a lobectomy?

A

3-5%

53
Q

What is the operative morality for a wedge resection?

A

2-3%

54
Q

What is the operative morality for an open/close thoracotomy?

A

5%

55
Q

What are the different types of non-small cell lung cancer and what percentage of of lung cancer is this?

A

85% total

adenocarcinoma - 55%
squamous - 30%
large cell undifferentiated ~ 5%
others ‘not otherwise specified’ or NOS < 10%

56
Q

What are the different levels of the Eastern Cooperative Group (ECOG) performance status measurement?

A

0 = asymptomatic; well
1= symptomatic; able to do light work
2 = has to rest but for <50% of the day
3 = has to rest for >50% of the day
4 = bedbound
5 = dead

57
Q

What are the side effects of chemotherapy?

A
  • marrow suppression (+ risk of life threatening infection)
  • nausea, vomiting, GI upset, mucositis, fatigue, lethargy
  • neuropathy, increased risk MI/stroke, renal impairment
  • hair loss, nail changes
58
Q

What are the side effects of radiotherapy?

A

general - lethargy, risk to surrounding organs

acute - pneumonitis, dysphagia

late - fibrosis, stricture, increased risk MI, 2nd malignancies

59
Q

What are the side effects of immunotherapy?

A

(anything-itis)

  • colitis
  • pneumonitis
  • dermatitis
  • endocrinopathies

Respiratory System (Year 1) (12 decks)

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