Non small cell lung cancer (NSCLC)

Question 1

What are the red flag symptoms suggesting a disease underlying a chest infection?

Answer 1

Haemoptysis
Weight loss
Persistent cough
Breathlessness
Pain
Changes in fingers suggesting clubbing
Pain in the limbs indicating Hypertrophic osteoarthropathy.

Question 2

What do you understand by Skill mix?

Answer 2

This is the use of different grades of staff trying to use skilled personnel at the right level.
For doctors, this originally meant trying to avoid clerical duties but now includes training non-medics to do work to keep costs down and provide a resilient workforce.

Question 3

What is NSCLC?

Answer 3

NSCLC accounts for more than 80% of all lung cancers.

Lung cancer is divided into NSCLC and small cell lung cancer.

Question 4

What is lung cancer?

Answer 4

This comprises a group of indignant epithelial tumours arising from the cells lining the respiratory tract.

Question 5

How many types of NSCLC are there?

Answer 5

3.
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma

Question 6

Causes of NSCLC

Answer 6

Cigarette smoking is the most important cause.
Lung cancer also linked to radon gas.
Exposure to asbestos.

Question 7

Pathophysiology of NSCLC

Answer 7

45% of NSCLC are adenocarcinomas which tend to be located more peripherally in the lung.
Squamous cell carcinoma tend to be in the central airways.
Large cell carcinomas (10%) tend to arise centrally and are undifferentiated tumours.

Question 8

Typical patient with NSCLC

Answer 8

>65 year old man. 
Dry persistent cough 
4-5kg unintentional weight loss 
COPD and HTN 
20 pack history

Question 9

Risk factors of NSCLC

Answer 9

Cigarette smoking 
Environmental tobacco exposure 
Positive FHx 
COPD 
Radon gas exposure 
Older age

Question 10

Investigations of NSCLC

Answer 10

CXR (can detect pulmonary nodules ), mass, lung collapse, pleural effusion.
Contrast-enhanced CT scan- shows size, location and extent of primary tumour
Sputum cytology- malignant cells in sputum
Bronchoscopy- endobronchial lesions
Biopsy- specimen for pathological diagnosis

Question 11

Differentials of NSCLC

Answer 11

Small cell lung cancer 
Metastatic cancer 
Pulmonary TB 
Rheumatoid arthritis 
Pneumonia/bronchitis 
Organising pneumonia 
Sarcoidosis 
Carcinoid tumour 
Actinomycosis 
Nocardiosis 
Amyloidosis 
Non-Hodgkin’s lymphoma

Question 12

The most common cause of lung cancer

Answer 12

Smoking causes 90% of all lung cancers

Question 13

Signs & symptoms of NSCLC

Answer 13

Cough 
Dyspnoea 
Haemoptysis 
Chest and/or shoulder pain 
Weight loss 
Fatigue 
Wheeze 
Crackles 
Decreased breath sounds 
Dullness to percussion
Facial swelling 
(From weeks to months)

Question 14

Signs of bronchial carcinoma

Answer 14

weight loss
 finger clubbing 
lymphadenopathy 
chest assymmetry 
focal chest signs
consolidation
hepatomegaly
neuropathy

Question 15

Approach to the management of NSCLC

Answer 15

History
Examination
Chest radiograph / CT Scan 
Bloods (FBC, LFTs, Calcium)
Fibreoptic bronchoscopy ~ 60% Percutaneous needle biopsy
Node biopsy
Mediastinoscopy / mediastinotomy 
Thoracotomy- this has been replaced with EBUS

Question 16

Which tumours are not operable?

Answer 16

Tumours invading the atrium
Tumours invading the chest wall
Metastasis in the femur

Inoperable if:
Distant metastasis 
Mediastinal spread eg
Recurrent laryngeal nerve palsy 
Phrenic nerve palsy
Poor pulmonary function 
Frequent angina / heart failure 
Psychological failure

Question 17

Link between egfr and lung cancer

Answer 17

Epidermal growth factor receptor (EGFR) is a protein found in abnormally high levels on the surface of many types of cancer cells, particularly non-small cell lung cancer (NSCLC) cells.

A patient‘s EGFR mutation status
(positive or negative) can be confirmed using a sample of tumour tissue.

EGFR mutation-positive cells predict response to specific chemotherapy
- gefitinib.
Gefitinib only used if mutation present

Question 18

Complications of NSCLC

Answer 18

-Post-obstructive pneumonia/hypoxia

-Superior vena cava syndrome:
The most common cause is lung cancer 
Bulky mediastinal adenopathy or medial extension of a right upper lobe tumour can compress the SVC. 
Physical examination show: 
Facial plethora 
Distended neck and chest wall. 

-Paraneoplastic syndromes:
Neo-metastatic manifestations.

Question 19

what are the red flag symptoms of lung cancer?

Answer 19

Cough (dry/productive) 
Haemoptysis 
Dyspnoea 
Hoarse voice- recurrent laryngeal nerve involvement 
Chest pain 
Fatigue 
Appetite loss 
Weight loss