Respiratory - Tobacco Smoking and Lung Cancer Flashcards
When do most people start smoking
While still children and become addicted to nicotine
How much more likely are those whose parents smoke to start smoking than those w/ non-smoking parents
3x
Which group of people finds it harder to give up smoking
Children who start smoking at younger ages
Why has the prevalence of smoking decreased in the 21st century
Smoking is no longer associated w/ Hollywood glamour and its social acceptability has decreased
Habitus
The body of tacit knowledge that we each carry with us that either enables us to feel comfortable on certain social settings or out of place
Models explaining mechanisms of health inequality
Behavioural
Material
Psychosocial
Life-course
Behavioural model of health inequality
Involve class differences in behaviour that are damaging or health promoting which are subject to individual choice
Material model of health inequality
Involve hazards that are inherent in the present form of social organisation and to which some people have no choice but to be exposed
Which model of health inequality is most important in accounting for social class differences in health
Material model
Psychosocial model of health inequality
Feeling affect behaviours
Incl helath-related stigma
Feelings that arise because of inequality, subordination and lack of social support may directly affect biological processes
Life-course model of health inequality
Disadvantages in their various forms are likely to accumulate through childhood and adulthood and into old age
Lifestype drift
The idea that govts start w/ policies designed to address the social of health e.g. poverty but due to complexity of this work they end up, endorsing narrow lifestyle interventions or individuals
What will habitus influence
The social acceptability of certain health practices
Social and cultural context plays a role in whether we smoke, drink, what food we eat
The rise of surveillance medicine
The idea that med has become much more about monitoring healthy bodies that it used to be
How common is lung cancer on the UK
130 dx daily
3rd most common cancer in UK
Lung cancer risk factors
Cigarette smoking Occupational exposure Genetics Low level radiation Smoking and low intake of beta carotene Lung disease hx Fhx
Symptoms seen in lung cancer
Persistent cough Change in cough SOB Haemoptysis Ache/ pain in chest or shoulder Unexplained wt loss Hoarse voice Swollen face
Signs seen in lung cancer
Pyrexia Recurring infections e..g bronchitis snd pneumonia Clubbing Swollen lymph nodes in neck Pleural effusion Dysphasia
Where do lung cancer pts px initially
76% in primary care
24% in secondary care
Why do we need a timely dx in lung cancer
To detect disease at an asymotomatic stage
In really stages, treatment is most successful
Earlier dx can increase survival
Why don’t we screen for lung cancer
High no. pts needed to screen
Cost effectiveness uncertain
Risk of over dx and invasive tests for benign sounds
What is likely to be more cost effective then screening for lung cancer
Smoking cessation snd tobacco control
Profile of a pt that should be referred urgently for a CXR (suspected lung cancer)
Unexplained haemoptysis or persistent lung cancer symptoms (>3/52) or <3/52 in pts w/ known risk factors
Profile of a pt that should be referred urgently to a lung cancer specialist
Persistent haemoptysis and are smokers or ex smoker 40+ CXR suggestive of lung cancer Finger clubbing Severe wt loss SVC obstruction - medical emergency Neck nodes - smokers
CXR suggestive of lung cancer
Lung nodules
Inca pleural effusion and slowly resolving consolidation
Why do we stage cancers
Treatment decision
Prognosis refinement
Communication between Drs
Stratification for clinical trials
Types of cancer staging
Clinical
Surgical
Pathological
What modalities are involved in clinical staging of lung cancer
CXR CT scan +/- bx MRI PET csan Bone scan
What is involved in surgical staging of lung cancer
Bronchoscopy EBUS-TBNA - best dx accuracy Mediastinoscopy Thoracoscopy (VATS) Thoracotomy
Pathological staging of lung cancer
After complete resection and LN (lymph node) staging
VATS in lung cancer
Can identify +ve or -ve LN stations
Staging lung cancer in metastatic disease
When the disease is metastatic the biopsy is obtained from the easiest site
CT/ USA guided needle aspiration - thoracocentTesis, cervical lymph node, liver bx
EBUS - L adrenal metastasis
TMN system of staging
T - tumour (0, 1A - 1C, 2A - 2B, 3, 4)
N - regional lymph nodes (0 - 3)
M - distant metastasis (0, 1A, 1B, 1C)
Pathological stating in the TMN system - T
Clinical size - size of solid component
Pathological size - size of invasive component
Implications of T component - TMN staging
Every cm counts; careful follow-up
Worse prognosis of larger tumours
Better prognosis for endobronchial location and total atelectasis and pneumonitis
Implications of N component - TMN staging
Amount of +ve LN has prognostic impact
Treatment decision regarding surgery
Prognosis refinement
Staging cancers w/ metastatic lesions
Multiple primary tumours - 1 TMN for each tumour
Implication of M component
No. metastasis is more important than their location
o M1a: pleural effusion, nodules in the unilateral or contralateral lung
o M1b: baseline definition of oligometastases and oligoprogression
Types of cancer cells (in order from highest to lowest frequency)
Adenocarcinoma Squamous cell carcinoma Small cell Large cell (undifferentiated) Carcinoid
What are the two manor classes of lung cancer
Small cell
Non small cell
Traits of NSCLC
Most common lung cancer
Gross more slowly than SCLC
Traits of SCLC
Usually begin in bronchi and nearly always caused by smoking
Spread more quickly than that of NSCLC
Frequently metastasises to mediastinal lymph nodes or distant sites at px
Main types of NSCLC
Adenocarcinoma - 40%
Squamous - 25-30%
Large cell - 10-15%
Features of adenocarcinomas
Slow growing cancers that can take years to develop into invasive cancer
Tend to be located in the periphery of the lung
Most common type of lung cancer among women and in non-smokers
Features of squamous cell carcinoma
Commonly starts in the bronchi and may not spread as rapidly as other lung cancers
Treatment is typically more difficult than other types
Dx in its initial state is v important
Features of large cell carcinoma
Named for the large, round cells seen in this cancer
Grow quickly and spread so usually are diagnosed in later stages
Good prognostic factors in NSCLC
Early stage disease at dx
Good performance status (ECOG 0, 1, 2)
No significant wt loss (5% or less)
Female gender
Biomarkers in lung cancer
Pts w/ spp gene mutations or rearrangements had better prognosis - lived longer and improved therapeutic efficacy
Common biomarkers in lung cancer
EGFR
K-ras oncogene
EML4-ALK fusion oncogene
PDL1
Immunohistochemical staining in SCC
TTF-1 -ve
P63 +ve
Cytokeratin 5/6 +ve
Immunohistochemical staining in adenocarcinoma
TTF-1 +ve
What does SCLC typically present with
Large hilar mass - bulky mediastinal lymphadenopathy that causes cough and dyspnoea
Paraneoplastic syndromes
What type of lung cancer has earlier development of widespread metastases
SCLC
Paraneoplastic syndromes in SCLC
SIADH Ectopic ACTH production - cushingoid Eaton-Lambert myasthenic syndrome Hypercalcaemia Peripheral neuropathy Increases risk of DVT/ PE
SIADH
Secretion of Inappropriate ADH
Causes hyponatraemia
Eaton-Lambert myasthenic syndrome
Proximal muscle weakness that improves on repetition
Signs and symptoms in SCLC
Smokers (almost exclusively) Cough Haemoptysis Dyspnoea and chest pain Clubbing Pneumonia Wt loss and constitutional symptoms
Best ix for SCLC
Labs - FBC, LFTs, LDH CT chest/abdo/pelvis Brain imaging (CT or MRI) - esp if symptomatic
Why do we image the brain in SCLC ix
Up to 30% have brain metastases at px
Common SCLC metastasis
BALLS
Brain (30%) Adrenal (20-40%) Liver (25%) Lung Skeletons (bones)
What kind of factors strongly influence whether or not someone smokes
Psychological
Micro social
Macro social
Psychological factors affecting whether or not people smoke
Beliefs
Coping resources
Risk factors e.g. stress
Micro social factors affecting whether or not people smoke
Background
School and area - peer group initiation
Culture, identity
Macro social factors affecting whether or not people smoke
Advertising
Wider society
In which groups do >75% people smoke
Homeless
Severe mental illness
Substance misuse
Criminal justice system
Public health interventions for smoking
Solution must be wider than individual smoking cessation
Plain packaging Harm reduction - E-cigarette Tax Advertising Smoke-free space
Why do we need smoke free public spaces
Importance of passive smoking
Increased risk of IHD and lung cancer by 25%
Increased risk of stroke >40%
WW estimation of 600,000 lives lost to 2nd hand smoke
NHS Stop Smoking services
Offers effective combined behavioural and pharmacological support to stop smoking
Lung cancer avg 5 year survival
5-10% survival
What % of lung cancer pts are dead within 12/12 of dx
80%
Mean time from dx to death in lung cancer pts
6/12
Bone pain in lung cancer
HPOA - hypertrophic pulmonary osteoarthropathy
Types of large cell cancers
Adenocarcinoma
SCC
Undifferentiated large cell
Bronchoalveolar
What do all lung cancer pts for radical therapy need
PET-CT
How do we dx lung cancer
Hx and examination CXR Bronschoscopy CT chest Lung function tests Biopsy MDT discussion
The role of surgery in lung cancer
Dx
Staging
Treatment
What do you need to consider in treatment of NSCLC
Is the disease localised?
Is the ot well enough to have potentially, curative treatment?
What should ideally be considered for treatment of NSCLC
Surgery - more likely to kill all tumour cells
If surgery is not feasible - radiotherapy
What can be considered in localised NSCLC
Surgery or radiotherapy
When is surgery not feasible for NSCLC
Tumour to closer to other structures of pt not well enough
What influences selection for surgery in NSCLC
Disease features (resectability) Pt features (operability)
Disease features affecting selection for lung cancer surgery
Histology (NSCLC)
Stage (I/ II/ IIA)
Pt features affecting selection of surgery for lung cancer
PMH/ co-morbidities
Pulmonary function
Contraindications to surgery for lung cancer
Malignant pleural effusion SVC obstruction Horner’s syndrome Vocal cord paralysis Phrenic nerve paralysis
Surgical resection procedures for lung cancer
Wedge excision
Segmentectomy
Lobectomy - chest wall excision
Pneumonectomy - intra/ extra pericardial, chest wall excision
When is chemotherapy indicated in lung cancer
To improve results of RT
SCLC
When are biological agents used in lung cancer
Advanced or metastatic disease
What extra modalities can be used in lung cancer in infancy
Immunotherapy
Gene therapy
How is RT given
Radically - curative intent, given daily over 4-6 weeks
Palliatively - relief of symptoms in shorter courses
Purpose of palliative RT for lung cancer
To relieve symptoms: Haemoptysis Breathlessness due to obstruction Pain Short term fatigue
Post-operative RT
Given only when tumour is known to extended to the surgical margins
Endobronchial RT
Placing radioactive isotope in the bronchus
Placed via a bronchoscope
Effective palliative for symptom relief
Overcoming tumour motion in NSCLC
Resp gating is a way of reducing the amount of normal lung irradiated
The RT is given in one Lhasa of breathing cycle
Gating in RT
Linking the treatments witch to the breathing cycles
Chemotherapy for lung cancer
Systemic treatment
Not curative except in lymphoma or leukaemia
Can reduce bulk of tumour by killing dividing cells
Difficult side effects
Chemo drugs for lung cancer
Cisplatin and carboplatin
Gemcitabine and vinorelbine
In which cancers can biological agents be very effective
NSCLC, eso if they have an EGFR mutation
Works well in non-smokers, Asians, females and BAC pts
BAC
Bronchiolo-alveolar cell carcinoma
How is the risk of post-operative dyspnoea after lung cancer surgery assessed
By spiro
Predicted post-op FEV1 or TLCO <40% predicted is considered moderate-high risk of dyspnoea
General stages of operation in lung cancer surgery
Inspection to confirm no disease progression
Define anatomy
Divide vein, artery, bronchus (typically)
Lymphadenectomy
When would adjuvant chemo be considered after lung cancer surgery
Unexpected higher staging
Confirmed nodal involvement
Large tumour size
A/c side effects of radiotherapy
Oesophagitis
Pneumonitis
N & V
Bone marrow suppression
Longer term side effects of radiotherapy
Pneumonitis and pulmonary fibrosis
Rib fractures
Cardiac fibrosis and dysfunction
Hypothyroidism
Stigma (Monaghan & Williams)
Meaning imposed on an attribute via -ve images, stereotypes and attitudes that potentially discredits a member of a particular category
‘Virtual social identity’
What a person ‘ought’ to be according to social norms
Linked to the idea of stereotype
‘Actual social identity’
The attributes the person actually possesses
‘Discredited’ - stigma
Stigmatised attribute is known by others
‘Discreditable’ - stigma
Concealed attribute that could be a source of stigma
Graham Scrambler’s theories of stigma
Felt stigma - fear of discrimination
Enacted stigma - enactments of discrimination
Possible reasons why condns are stigmatised
Perception of infection/ contamination e.g, HIV
Perception that the condn devalues QoL e.g. wheelchair users
Perception that condn is ‘self inflicted’ e.g. obesity, lung cancer
Sense of social embarrassment e.g. speech impediment
Perception that someone living w/ a condn cannot live independently
Why is haemoptysis seen in lung cancer
Bronchial tissue is friable
Sign of infection
Why is SOB seen in lung cancer
Space occupying lesion affecting alveoli
Pleural effusion
Why is chest pain seen in lung cancer
Invasion of pleura
Rib metastasis
Why is hypercalcaemia seen in lung cancer
PTHrP or metastatic bone cancer
What is HPOA
Triad of periostitis, digital clubbing and painful arthropathy of large joints
Lung cancer referral pathway
Urgent referral in 2/52
Which cancers cause thrombocytosis
LEGO
Lung
Oesophageal
Gastric
Ovarian
Clotting screen must be performed
Pharmacological smoking cessation agents
Bupropion
Varenicline
NRT
How is SVCO obstruction treated
Stent and radiotherapy
Where does the oblique fissure begin
At level of T3 spinous process and lies anteriorly at 6th costal cartilage
Course of horizontal fissure
Comes from meeting point with oblique and runs anteriorly to follow line of 4th rib
Which lobe of the lung is above 4th rib
Upper
Which lobe of the lung is found between 4th to 6th rib
Middle
Which lobe of the lung is found below the 6th lung
Lower
Surfaces of the lungs
Anterior (costal)
Posterior (costal)
Diaphragmatic
Where is the lingula found
L lung
Where does the primary bronchus enter the hilum
Posteriorly
Most posterior element in hilum
Structure of L hilum
Pulmonary artery is most superior structure
Below and posterior is airway, then pulmonary veins
Structure of R hilum
Pulmonary artery enters R lung anteriorly at same level as airway
Pulmonary veins enter inferiorly and anteriorly
Pulmonary ligament
Found inferiorly
Fold of mediastinal pleura
Specific features on L lung
Lingula
Cardiac notch
Function of sympathetic chain
Carries sympathetic outflow from CNS
Where is the sympathetic chain
T1 to L2 in thorax
Where does the sympathetic chain run
On lateral aspect of vertebral bodies
Where are ventral rami of the sympathetic chain found
IC spaces
Where are the ganglions in the sympathetic chain found
At each vertebral level
Largest ganglion in the sympathetic chain
Stellate ganglion - goes to head and neck, part of upper L8IQMY
Rami communicantes
Connections between rami
White rami of sympathetic chain
Delivers signal from spinal nerve into sympathetic chain
Splanchnic nerves
Pre synaptic fibres (myelinated - go through diaphragm into abdominal cavity to innervate abdominal viscera
Common places for space occupying lesions in lung
Hilum (adenocarcinoma)
Apex (small cell, Pancoast’s)
Which lesions may compromise the azygous vein
Lesion in R main bronchus - hilum tumour
What structures may be compressed by apical tumours
Sympathetic chain - Horner’s syndrome
Vagus nerve
What might a hilar tumour affect on the L lung
Recurrent branch of vagus nerve
Why can lung tumours cause a hoarse voice
Apical tumours may compress recurrent laryngeal nerve around R lung ——> unilateral vocal cord paralysis ——> hoarse voice
Divisions of the Bronchial tree
Trachea - both lungs
Main bronchus - single lung
Secondary bronchus - lobe
Tertiary bronchus - bronchopulmonary segment
Bronchopulmonary segment
Discrete portion of the lung that has its own individual bronchus, arterial supply and venous drainage
Contain alveoli - site of gaseous exchange
What are bronchopulmonary segments separated by
Connective tissues
What property allows the resection of bronchopulmonary segments without affecting each other
Having its own bronchus, arterial supply and venous drainage allows each segment to function semi-independently
What is the main difference in the layout of structures in the L and R hilum
On the L, the artery is superior to the bronchus
On the R, the bronchus is superior to the artery
If someone stops breathing after inhaling a foreign object, where is the item most likely to be
Trachea - obstructing whole airway
Where is an inhaled foreign body most likely to be
R main bronchus or R lower 2’ bronchus
R main is wider, shorter & more vertically orientated. May continue to lower 2’ bronchus if small enough
