Primary Lung Cancer (Resp)

Question 1

Define primary lung cancer and the histological types

Answer 1

It refers to a primary malignancy arising from the lung parenchyma or the bronchi. They are classified histologically as small cell (SCLC) or non-small cell (NSCLC), with 80% being non-small cell. The main subtypes of NSCLC are squamous cell cancers and adenocarcinomas.

Question 2

What is the most common type (subtype) of lung cancer?

Answer 2

adenocarcinoma

Question 3

What are the two types of primary lung cancer?

Answer 3

Lung cancer is classified histologically as being either small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC) due to them having different features, management and prognosis in the two groups.

Question 4

Which type of lung cancer is more common?

Answer 4

NSCLC is the most common with a better prognosis (less aggressive)

Question 5

Which primary lung cancer is more aggressive?

Answer 5

SLCL is more aggressive and worse prognosis and more incurable. Fast growing cancer

Question 6

Why is the epidemiology of lung cancer significant?

Answer 6

Lung cancer makes up the largest proportion of cancer deaths (21% of all cancer deaths). It is the second most common cancer in both males and females (after prostate and breast respectively). Third most common after prostate and breast.

Question 7

What are the risk factors of lung cancer?

Answer 7

Tobacco smoking (e.g. cigarettes, pipes, cigars)
Passive smoke exposure
Occupational exposures (e.g. beryllium, cadmium, arsenic, asbestos, silica)
Radon exposure
Family history of lung cancer
Radiation to the chest (e.g. in lymphoma treatment)
Air pollution
Immunosuppression (e.g. HIV, medications)
Increasing age

Question 8

Biggest risk factor for lung cancer and its epidemiology?

Answer 8

Incidence is strongly related to age, with the highest rates in people aged over 75 years old. Although non-smokers can also get lung cancer, 86% of cases are linked to smoking and so the majority of cases are potentially preventable.

Question 9

What are the differential diagnoses for lung cancers?

Answer 9

Lung metastases from another primary cancer (e.g. breast or colorectal cancer)
Mesothelioma (cancer of the pleura, strongly related to asbestos exposure)
Tuberculosis
Bronchiectasis

Question 10

What are the symptoms of lung cancer?

Answer 10

Persistent cough
Haemoptysis
Dyspnoea especially on exertion
Chest pain
Weight loss and anorexia
Hoarseness is seen with Pancoast tumours pressing on the recurrent laryngeal nerve
Recurrent chest infections, or infections resistant to treatment
Superior vena cava syndrome

Question 11

What are clinical signs of lung cancer?

Answer 11

Cachexia
Finger clubbing
Lymphadenopathy (supraclavicular or persistent cervical)
If there is lung collapse due to an obstructing tumour - absent breath sounds, trachea deviated towards side of collapse
If there is a malignant pleural effusion - stony dull on percussion, decreased breath sounds over affected area

Question 12

What are paraneoplastic syndromes?

Answer 12

Paraneoplastic syndromes are a group of rare disorders that occur when the immune system has a reaction to the cancerous tumor or when tumour produces certain substances

Question 13

What are the paraneoplastic features/syndromes of small cell?

Answer 13

SCLC - ADH causing SIADH , Lambart eaten syndrome (antibodies), ACTH (cushing’s but not typical)

Question 14

What are the paraneoplastic features/syndromes of squamous cell?

Answer 14

Humoral hypercalcaemia of malignancy bc PTH related protein (PTH-rp) secretion causing hypercalcaemia.
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA)
Hyperthyroidism due to ectopic TSH

Question 15

What are the paraneoplastic features/syndromes of adenocarcinoma?

Answer 15

Gynecomastia
Hypertrophic pulmonary osteoarthropathy (HPOA)

Question 16

What are the investigations done for diagnosing lung cancer?

Answer 16

Chest X ray - first investigation done if suspecting lung cancer (not definitive bc can’t differentiate w/ other conditions)
CT with contrast - done after chest x ray, localises and stages the cancer
PET CT - after ct scan if show cancer, it is more sensitive way to stage the cancer, assesses eligibility for curative treatment
If CT shows sus cancer in central chest, may do bronchoscopy with EBUS to see inside and take biopsy (either mass or LNs). If CT shows peripheral tumour then biopsy done percutaneously.

Question 17

When should patients be referred from GP to specialist for sus lung cancer?

Answer 17

In primary care, patients should be referred on a 2 week wait pathway in the following situations:

• Aged 40+ with unexplained haemoptysis
• Chest X-ray findings suspicious for lung cancer

Question 18

What symptoms mean that an urgent chest x ray should be offered to check for lung cancer?

Answer 18

To be done within 2 weeks, should be done for pts 40+ who have one of these symptoms and have ever smoked (or two symptoms if they are never smokers): Cough
Fatigue
Shortness of breath
Chest pain
Weight loss
Anorexia

Question 19

When should an urgent chest x ray be considered to check for lung cancer?

Answer 19

in patients aged 40+ with any of:

Persistent/recurrent chest infection
Finger clubbing
Supraclavicular or persistent cervical lymphadenopathy
Thrombocytosis
Chest signs consistent with lung cancer (e.g. reduced breath sounds, dullness to percussion)

Question 20

Describe the management of NSCLC lung cancer

Answer 20

MDT approach (as for any cancer)
If healthy and restricted to one area, first line is surgery (if early stage = lobectomy, if in middle of lung or spreaded =pneumonectomy, if small and v early = wedge resection
Curative or palliative radiotherapy can be used otherwise (may be combined with chemo), however if late stage then adjuvant or palliative chemo offered

Question 21

Management of SCLC lung cancer?

Answer 21

Chemo (either on its own or combined with radio/immuno) - this is with palliative intent (not for curing but to prolong life/improve symptoms), however if found very early surgery may be used

Question 22

What are tests that need to be done before surgery for lung cancer?

Answer 22

ECG, Spirometry, exercise test

Question 23

Non medical management of lung cancer?

Answer 23

Holistic support e.g. palliative care for symptoms, end of life care, smoking cessation