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Year 3: Respiratory > Respiratory: Lung Cancer > Flashcards

Respiratory: Lung Cancer Flashcards

1
Q

What difference does quitting smoking have on prognosis of lung cancer? [2]

A

At any stage of lung cancer, stopping smoking will increase prognosis.

Stopping smoking does not lower risk back down to non-smoking levels, but does increase life expectancy

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2
Q

State some causes of lung cancer [7]

A

Smoking
asbestos
radiation
Arsenic
Chromium
Coal tar and oils
Iron oxides
Pollution

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3
Q

What are the different classifications of lung cancer? [4]

A

Small cell (oat cell) lung cancer (SCLC)

Non small cell lung cancer (NSCLC) - more common
- Squamous cell carcinoma (20-30%)
- Adenocarcinoma (40-50%)
- Large cell carcinoma (10-15%)

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4
Q

What is the most common type of lung cancer? [1]

A

Adenocarcinoma lung cancer

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5
Q

Which type of lung cancers is most commonly seen in non-smokers? [1]

A

Adenocarcinoma

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6
Q

Which type of lung cancers is most commonly seen in smokers? [2]

A

Small cell
Squamous cell

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7
Q

Which type of lung cancer is most likely to cause paraneoplastic syndromes? [1]

Explain why [1]

A

Small-cell lung cancer cells contain neurosecretory granules that release neuroendocrine hormones.

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8
Q

Desribe the features of small cell carcinoma [4]

A
  • Aggressive & early spread
  • Usually inoperable
  • May respond to chemotherapy (due to rapid dividing nature of the cells)
  • Endocrine cells: hormones produced - paraneoplastic syndromes
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9
Q

Which type of lung cancer often cavitates? [1]

A

Squamous cell carcinoma

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10
Q

What does this CXR show? [1]
Which type of lung cancer does this commonly occur in? [1]

A

Cavitation
Commonly in squamous cell carcinoma

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11
Q

Explain is what meant by mesothelioma [1]

What is a common cause of mesothelioma? [1]

Describe when it commonly presents [1]

What is the prognosis like? [1]

A

Mesothelioma:
- lung malignancy affecting the mesothelial cells of the pleura

  • . It is strongly linked to asbestos inhalation.
  • There is a substantial latent period between exposure to asbestos and the development of mesothelioma of up to 45 years.
  • The prognosis is very poor. Chemotherapy can improve survival, but it is essentially palliative.
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12
Q

Describe the differentiation level of large cell lung cancer [1]

Is it early or late metastasis? [1]

A

Undifferentiated

Early metastasis / spread quickly

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13
Q

Which type of lung cancer may resemble pneumonia on CXR? [1]

A

Bronchoalveolar cell (used to be know as adenomcarcinoma in situ)

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14
Q

Name some indicators of lung cancer that patients may present with [5]

A

Haemopytsis
Any of the following for > 3 weeks unexplained:
- Cough
- Chest / shoulder pain
- Dysopnea
- Weight loss
- Chest signs

Hoarse voice (tumour in left side of chest in RLN)

Finger clubbing

Feature of metastasis

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15
Q

What is meant by superior vena cava obstruction syndrome? [1]

Decribe the typical presentation of SVC Obstruction [7]

A

Superior vena cava obstruction is a complication of lung cancer.

It is caused by direct tumour compression on the superior vena cava.

It presents with:
- facial swelling
- difficulty breathing
- distended neck and upper chest veins.
- Reduced TVF and VR
- Reduced expansion
- Dullness
- Unilateral wheeze
- Reduced breath sounds

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16
Q

What is Pemberton’s sign? [1]

What complication of lung cancer does it indicate? [1]

A

Pemberton’s sign:

  • where raising the hands over the head causes facial congestion and cyanosis.
  • SVC obstruction is a medical emergency.
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17
Q

How would you expect this patient to present? [1]

A

Sore throat, cough and hoarseness due to left recurrent laryngeal nerve compression

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18
Q

State another nerve palsy (asides from RLN) that lung cancer can cause [1]

How does this present? [1]

A

Phrenic nerve palsy, due to nerve compression, causes diaphragm weakness and presents with shortness of breath.

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19
Q

What is the name for this tumour? [1]

How will it present? [3]

What type of cancer is it usually masde from? [1]

A

Pancoast tumour: causes compression of sympathetic ganglion at the pulmonary apex

Causes Horner’s syndrome:
- Ptosis
- Anhidrosis
- Miosis

Due to non-small cell lung carcinomas: close to 50% are adenocarcimoas

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20
Q

How can lung cancer affect ADH? [1]

What type of lung cancer causes this? [1]

A

Syndrome of inappropriate ADH (SIADH) can be caused by ectopic ADH secreted by a small-cell lung cancer. It presents with hyponatraemia.

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21
Q

Which type of lung cancer causes ectopic PTH secretion? [1]

Which type of lung cancer causes ectopic ACTH secretion? [1]

A

small-cell lung cancer:
- Cushing’s syndrome can be caused by ectopic ACTH secretion

Squamous cell carcinoma
- Hypercalcaemia caused by ectopic PTH

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22
Q

Explain what is meant by limbic encephalitis [1] and how this presents [3]

Which type of cancer causes this? [1]

A

Limbic encephalitis:

  • paraneoplastic syndrome where small-cell lung cancer causes the immune system to make antibodies to tissues in the brain, specifically the limbic system, causing inflammation in these areas.
  • This causes symptoms such as short-term memory impairment, hallucinations, confusion and seizures.

Caused by small cell lung cancer

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23
Q

Limbic encephalitis is associated with which type of antibodies? [1]

A

It is associated with anti-Hu antibodies.

24
Q

Which syndrome is caused by antibodies against small-cell lung cancer cells? [1]

A

Lambert-Eaton myasthenic syndrome

25
Q

Describe the pathophysiology of Lambert-Eaton myasthenic syndrome [5]

A
  • antibodies against small-cell lung cancer cells.
  • antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones.
  • Voltage-gated calcium channels are responsible for assisting in the release of acetylcholine into the synapse of the neuromuscular junction.
  • Acetylcholine travels across the synapse and attaches to receptors on the postsynaptic membrane, simulating muscle contraction
  • This leads to weakness, particularly in the proximal muscles.
26
Q

Describe the presentation of Lambert-Eaton myasethenic syndrome [6]

How do you differentiate between MG? [1]

A

Proximal muscle weakness
- causing difficulty climbing stairs, standing from a seat or raising the arms overhead

intraocular muscles weakness
- causing diplopia (double vision)

levator muscles weakness in the eyelid
- causing ptosis

pharyngeal muscles effected
- causing slurred speech and dysphagia (difficulty swallowing).

Autonomic dysfunction
- causing dry mouth, blurred vision, impotence and dizziness

Reduced or absent tendon reflexes

Unlike myasthenia gravis, LEMS symptoms often start in the limbs

27
Q

What clinical presentations of lung cancer would cause an urgent referral to A&E and not a two week pathway? [3]

A

Persistent haemopytsis in smokers / ex smokers who are 40+

SVC obstruction signs (swelling of face and neck with fixed elevation of JVP)

Stridor

28
Q

Referral Criteria

The NICE guidelines on suspected cancer (updated December 2021) recommend offering a chest x-ray, carried out within 2 weeks, to patients over 40 with: [5]

A
  • Clubbing
  • Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
  • Recurrent or persistent chest infections
  • Raised platelet count (thrombocytosis)
  • Chest signs of lung cancer

TOM TIP finger clubbing and supraclavicular lymphadenopathy = urgent CXR

29
Q

Referral Criteria

NICE also recommend offering a chest x-ray to patients over 40 years old who have [2]

A

Two or more unexplained symptoms in patients that have never smoked

One or more unexplained symptoms in patients that have ever smoked or had asbestos exposure

30
Q

Referral criteria

The unexplained symptoms that the NICE guidelines list are what? [6]

A

Cough
Shortness of breath
Chest pain
Fatigue
Weight loss
Loss of appetite

They’re vague! So have a low threshold for CXR

31
Q

Describe the investigations used for lung cancer [5]

A

Chest x-ray is the first-line investigation in suspected lung cancer

Staging CT scan of the chest, abdomen and pelvis to include liver, adrenals and kidneys

Bronchoscopy

CT guided biopsy

PET scan (detects metabolic activity: so if similar levels found in tumour are found elsewhere, this indicates metastasis)

MRI for pancoast tumours

32
Q

What is an EBUS? [1]

A

Endobronchial Ultrasound (EBUS) and
lymph node sampling procedure

A small
flexible camera fitted with ultrasound is carefully passed through your mouth into your lung.

The doctor will use an ultrasound scanner to look at the glands (lymph nodes) in the area and maytake samples using a needle

33
Q

Describe the CXR findings common to lung cancer [4]

A

Hilar enlargement
Peripheral opacity (a visible lesion in the lung field)
Pleural effusion (usually unilateral in cancer)
Collapse

34
Q

What is often offered first line treatment for non-small cell lung cancers? [1]

What investigation do you do prior to this treatmetn? [1]

A

Surgery: if disease is isolated to a single area

Undergo a PET scan before to ensure no metastasis

35
Q

Describe how radiotherapy can be used to treat lung cancer [2]

A

Radical radiotherapy:
- Useful for squamous cell carcinoma when surgery not possible

Palliative RT:
- to relieve pain, haemopytsis or neurological problems (brain or spinal met.)

36
Q

State three complications of high dose / radical radiotherapy to treat lung cancers [3]

A

Pneunomonitis (early)
Fibrosis (late)
Oesophagitis

37
Q

Describe how chemotherapy is used in treating lung cancers

A

Small survival advantage

Traditional chemotherapy includes

38
Q

Name the immunotherapy that can be used in treating lung cancer? [1]

A

Pembrolizumab: if have PD-L1 positive tumours

39
Q

NSCLC Management

Describe the treatment algorithm for NSCLC [4]

A

Surgical resection:
* Lobectomy (with hilar and mediastinal lymph node resection/sampling) is first-line treatment for those with stage I or II cancer who are medically fit for surgery. This surgery is done with curative intent.

Radiotherapy:
- Is first-line for those with stage I-III disease who are not suitable for surgery.
This treatment is given with curative intent.

Chemotherapy:
- Is offered to those with stage III or IV disease to improve survival and quality of life.
- First line regimes use a combination of:
Third-generation chemotherapy agent: e.g. docetaxel, paclitaxel or gemcitabine AND
Platinum agent: e.g. carboplatin or cisplatin

40
Q

How are the majority of SCLCs treated? [2]

A

Surgery is only considered in very early stage I and II disease due to its limited success.

The majority of SCLC patients are treated with chemotherapy in combination with radiotherapy

41
Q

State what is meant with regards to TNM for:

Limited-stage SCLC [1]
Extensive-stage SCLC [1]

Describe the treatment regime for SCLC management for

Limited-stage SCLC [3]
Extensive-stage SCLC [3]

A

Limited-stage SCLC:
- Limited-stage disease is defined as SCLC without distant metastasis (T1-4, N0-3, M0).
-First line treatment involves: 4-6 cycles of Cisplatin-based combination chemotherapy
- Concurrent or adjunct thoracic radiotherapy is only considered if there has been a good response to chemotherapy

Extensive-stage SCLC:
- Extensive-stage disease is defined as SCLC with distant metastasis (T1-4, N0-3, M1).
- First line treatment involves:
Platinum-based combination therapy where the patient is reassessed for a response after each cycle (up to a maximum of 6 cycles)
- Concurrent or adjunct thoracic radiotherapy can be considered if there has been a good response to chemotherapy at both the primary and metastatic sites.

42
Q

What treatment can be given fro all stages of SCLC second-line therapy can be considered in those who have relapsed? [2]

A

Further chemotherapy (maximum 6 cycles)

Palliative radiotherapy to control local symptoms

43
Q

Describe the different surgical options used for removing lung tumours [3]

A

Segmentectomy or wedge resection:
- involves removing a segment or wedge of lung (a portion of one lobe)

Lobectomy
- involves removing the entire lung lobe containing the tumour (the most common method)

Pneumonectomy
- involves removing an entire lung

44
Q

Describe the 3 types of surgery used for lung cancers [3]

A

Thoracotomy – open surgery with an incision and separation of the rib to access the thoracic cavity

Video-assisted thoracoscopic surgery (VATS) – minimally invasive “keyhole” surgery

Robotic surgery

45
Q

Which locations are the three main thoractomy incisions? [3]

A

Anterolateral thoracotomy with an incision around the front and side

Axillary thoracotomy with an incision in the axilla (armpit)

Posterolateral thoracotomy with an incision around the back and side (the most common approach to the thorax)

46
Q

Chemotherapies mentioned in lecture?????

A
47
Q

Under which situations is adjuvent chemotherapy most commonly given? [1]

A

Found if disease is found in hilar lymph node

48
Q

State the ideal pathway for patient care with lung cancer

A
49
Q

Which type of lung cancer causes clubbing

Small cell
Large cell
Squamous cell
Adenocarcinoma

A

Which type of lung cancer causes clubbing

Small cell
Large cell
Squamous cell
Adenocarcinoma

50
Q

Which type of lung cancer causes Lambert-Eaton syndrome

Small cell
Large cell
Squamous cell
Adenocarcinoma

A

Which type of lung cancer causes Lambert-Eaton syndrome

Small cell
Large cell
Squamous cell
Adenocarcinoma

51
Q

Which type of lung cancer causes increase in ADH

Small cell
Large cell
Squamous cell
Adenocarcinoma

A

Which type of lung cancer causes increase in ADH

Small cell
Large cell
Squamous cell
Adenocarcinoma

52
Q

Which type of lung cancer causes gynaecomastia due to paraneoplasia

Small cell
Large cell
Squamous cell
Adenocarcinoma

A

Which type of lung cancer causes gynaecomastia due to paraneoplasia

Small cell
Large cell
Squamous cell
Adenocarcinoma

53
Q

Which type of lung cancer causes hypertrophic pulmonary osteoarthropathy (HPOA) due to paraneoplasia [2]

Small cell
Large cell
Squamous cell
Adenocarcinoma

A

Which type of lung cancer causes hypertrophic pulmonary osteoarthropathy (HPOA) due to paraneoplasia

Small cell
Large cell
Squamous cell
Adenocarcinoma

54
Q

Which type of lung cancer causes hyperthyroidism due to ectopic TSH due to paraneoplasia

Small cell
Large cell
Squamous cell
Adenocarcinoma

A

Which type of lung cancer causes hyperthyroidism due to ectopic TSH due to paraneoplasia

Small cell
Large cell
Squamous cell
Adenocarcinoma

55
Q

Which type of lung cancer causes excess ACTH due to paraneoplasia

Small cell
Large cell
Squamous cell
Adenocarcinoma

A

Which type of lung cancer causes excess ACTH due to paraneoplasia

Small cell
Large cell
Squamous cell
Adenocarcinoma

56
Q

A 71-year-old smoker with a pack-year history of 80 years was admitted to hospital with haemoptysis and weight loss. A chest X-ray demonstrates a 4-cm cavitating lung lesion within the right middle lobe.

What is the most likely diagnosis?

Squamous cell carcinoma

Small-cell carcinoma

Bronchoalveolar carcinoma

Adenocarcinoma

Large-cell carcinoma

A

A 71-year-old smoker with a pack-year history of 80 years was admitted to hospital with haemoptysis and weight loss. A chest X-ray demonstrates a 4-cm cavitating lung lesion within the right middle lobe.

What is the most likely diagnosis?

Squamous cell carcinoma - most associated with cavitations

Year 3: Respiratory (42 decks)

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