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Medicine - Year 2 > The respiratory system - Tobacco smoking and lung cancer > Flashcards

The respiratory system - Tobacco smoking and lung cancer Flashcards

1
Q

Name 6 harmful substances in tobacco and their effect

A

Tar - carcinogenesis

Polycyclic aromatic hydrocarbons - carcinogenesis

Nicotine - Ganglionic stimulation and depression; tumour promotion

Benzo(a)pyrene - Carcinogenesis

Carbon monoxide - Impaired oxygen transport and utilization

Formaldehyde - Toxicity to cilia; mucosal irritation

Nitrogen oxides -Toxicity to cilia; mucosal irritation

Nitrosamine - Carcinogenesis

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2
Q

Describe the 3 patterns of emphysema

A

Centrilobular (also known as centriacinar)
- Central/proximal apolar until invollved
- Distal alveoli spared
- More severe in the upper lobes

Panacinar (pan lobular)
- Whole of the alveolar unit involved
- More commonly in the lower lobes
- Associated with alpha 1 antitrypsin deficiency

Paraseptal (distal acinar)
- Proximal alveolar unti normal
- Emphysematous change more evident near the pleura, along septa and markings of lobules

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3
Q

Describe the cellular transformation of the respiratory tract in smokers. What is this transformation known as?

A

Columnar epithelium becomes squamous epithelium

This is known as metaplasia

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4
Q

Describe the advantages and disadvantages of tracheobronchial squamous metaplasia in smokers

A

Advantages
- Squamous epithelium is more resistant to thermal and chemical damage

Disadvantages
- Reduced function
- Increase propensity for malignant transformation

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5
Q

Describe the role of the pathologist in the lung cancer pathway

A

Diagnosis
- Bronchial washings and brushings
- Endobronchial ultrasound guided transbronchial (finde) needle aspirations (EBUS TBNA)
- Lung biopsy
- Bronchial biopsy

Staging and reporting of lung excision
- Type of tumour
- Size
- Margins
- Pleural involvement
- Vascular invasion involvement of adjacent structures
- Lymph node involvement

Aiding personalised oncological treatment with molecular markers/analysis

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6
Q

Give the two main categories of lung cancer

A

Non-small cell lung cancer

Small-cell lung cancer

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7
Q

Give the 3 types of non-small cell lung cancer

A
  • Adenocarcinoma
  • Squamous cell carcinoma
  • (Undifferentiated) Large cell
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8
Q

Risk factors of lung cancer

A
  • Cigarette smoking
  • Occupational exposure (asbestos, motor vehicle emissions, pollutants, radon gas)
  • Genetics/family history of cancer
  • Low level radiation
  • Smoking and low intake of beta carotene
  • Lung disease history
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9
Q

Describe the features of adenocarcinoma

A
  • Localisation: lung peripheries
  • Cancer of mucus-secreting cells
  • Most common form of lung cancer
  • Most common lung cancer in non-smokers
  • Risk factors: smoking and asbestos
  • Commonly invades the mel lymph nodes and the pleura and spreads to the broad and bones
  • Non-invasive subtype: brochioalveolar carcinoma
  • Does not usually cavitate
  • Most likely cause of pleural effusions
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10
Q

Describe the features of squamous cell carcinoma

A
  • Localisation: central airways
  • Second most common form of lung cancer
  • Smoking is the most common cause
  • Metastases tend to occur late, histopathology classically shows keratin
  • Occasionally cavities (10% at presentation)
  • Can cause neoplastic syndrome: associated with ectopic produced of parathyroid hormone-related peptide (PTHrP) leading to hypercalcaemia and hypertrophic osetoarthopathy
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11
Q

Describe the features of undifferentiated (large cell)

A
  • Undifferentiated neoplasms accounting for 5% of lung cancers
  • Grow quickly and tend to metastasise early so usually diagnosed in later stages
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12
Q

good prognostic factors of NSCLC

A
  • Early-stage disease at diagnosis
  • Good performance status
  • No significant weight loss
  • Female gender
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13
Q

Describe the features of small cell lung cancer

A
  • Considered separately due to its fast-doubling time, aggressive nature, and early metastasis
  • It is a cancer of the APUD cells, a neuroendocrine cell found in the lungs
  • Occurs also exclusively in smokers
  • Associated with paraneoplastic syndromes: SIADH, ectopic ACTH production (Cushing’s syndrome), Lambert-Eaton myasthenia syndrome, ectopic PTHrP (hypercalcaemia), hypertrophic osteoarthropathy
  • Metastasises to:
    Brain, adrenal, lung and skeleton
  • Has an extremely poor prognosis, by the time of diagnosis curative therapy is rarely possible
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14
Q

Where does SCLC commonly metastasises to?

A

“BALS”

  • Brain
  • Adrenal
  • Lung
  • Skeleton
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15
Q

Symptoms of lung cancer

A
  • Cough
  • Chest pain
  • Fever
  • SOB
  • Malaise
  • Nausea
  • Haemoptysis
  • Hoarseness (due to involvement of the recurrent laryngeal nerve)
  • Loss of appetite/weight loss
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16
Q

Signs of lung cancer

A
  • Lymphadenopathy
  • Stridor
  • Wheeze
  • Clubbing
  • Pain under ribcage: swollen liver
  • Hypertrophic pulmonary osteoarthropathy
  • Signs of pleural effusion (exudative): stony dull percussion, reduced vocal fremitus, reduced breath sounds
  • SVC obstruction: facial swelling, engorgement of vessels in the neck and face, SOB, and headache
  • Pan-coast tumour (tumour of pulmonary apex): Horner’s syndrome (mitosis, ptosis and enophthalmos) pain in shoulder that radiates into the arm and hand, atrophy of muscles of the upper limb, oedema of the upper limb
  • Metastasis
    1. Bone: Bone pain, raised ALP
    2. Brain: Focal and non-focal neurology
    3. Liver: abnormal LFTs
    4. Adrenal glands: though a common site of metastasis, normally asymptomatic
17
Q

Describe the paraneoplastic syndromes (commonly associated with SCLC)

A

Ectopic production of parathyroid hormone-related protein (PTHrP)
- Hypercalcaemia: renal calculi, bone pain, abdominal pain, polyuria and signs of altered mental state

Syndrome of inappropriate anti-diuretic hormone (SIADH)
- Hyponatraemia, Cerebral oedema (extreme cases)

Ectopic adrenocorticotrophic hormone (ACTH) secretion
- Cushing’s syndrome: hyperpigmentation, weight gain, purple striae, depression, impaired blood glucose, hypertension

Lamber-Eaton syndrome
- Caused by antibodies to voltage-gated calcium channels
- Characterised by proximal and ocular muscle weakness (e.g., ptosis and double vision)
- Limb weakness initially improving with movement although the weakness will return when exertion is sustained
- Reports of autonomic symptoms such as dry mouths, impotence, and difficulty urinating

Hypertrophic osteoarthropathy
- Characterised by clubbing, periostitis, painful arthropathy (symmetrical and affecting the distal joints

18
Q

What are the indications for a two-week wait referral to specialists in patients

A
  • Suggestive CXR findings
  • Unexplained haemoptysis and are aged over 40
19
Q

What are the indications to consider an urgent CXR 9within 2 weeks) in those aged over 40

A

Unexplained haemoptysis

OR

  • Chest and/or shoulder pain
  • SOB
  • Weight loss/loss appetite
  • Abnormal chest signs
  • Hoarseness
  • Finger clubbing
  • Cervical and/or supraclavicular lymphadenopathy
  • Cough
  • Features suggestive of metastasis from a lunger cancer (e.g., in brain, bone, liver or skin)
20
Q

Describe the investigations for lung cancer

A

Bloods - FBC, U&Es, LFTs, bone profile

Imaging
-CXR
- Contrast enhanced CT chest: to localise lesion before bronchoscopy/EBUS-TBNA
- PET-CT
- CT/MRI of brain

Special
- Bronchoscopy
- Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA)
- Lung function tests

Histology and cytology
- Tissue biopsy
- Cytology

21
Q

What system is used to stage lung cancer?

A

TNM staging

22
Q

What do the following letters in TNM staging represent?

a) T

b) N

c) M

A

a) Size and extent of the the tumour

b) Extent of spread to lymph nodes

c) Presence of metastasis

23
Q

SCLC may be staged in a simpler two stage system. What is this called?

A

VASLG staging

24
Q

SCLC may be staged in a simpler two stage system named VALSG staging.

Describe the categories

A

Limited disease: tumour not spread beyond hemithorax, regional nodes that may be treated with single radiotherapy field

Extensive disease: tumour spread beyond hemithorax or extensively through the hemithorax, distant metastasis, malignant effusions, or contralateral hilar/supraclavicular involvement

25
Q

Describe the management of lung cancer

A
  1. Smoking cessation
  2. Surgical - surgical resection/thoracotomy
    - For early disease (stage I, II, IIIA)
  3. Radiotherapy
    - For locally advanced disease
    - Can be used as a combination with chemotherapy
  4. Chemotherapy
    - Can be used as neoadjuvant therapy and palliative
  5. Biologic agents
    - Can be very effective in NSCLC, especially if they have an EGFR mutation
    - Especially in non-smokers, asians, females, bronchioles-alveolar cell carcinoma

Systemic anti-cancer therapy (SACT)
- Specific therapies used in non-squamous NSCLC

Palliative care
- Where anticancer therapy is not appropriate

26
Q

Describe the management of NSCLC

A

Curative ( Stage I, II and stage IIIA)
- Surgical resection +/- adjuvant chemotherapy
- If surgery is not possible: polychemotherapy + radiation therapy

Curative (Pancoast tumours up to stage IIIB)
- Neoadjuvant radiation therapy + polychemotherapy
- Surgery therapy

Palliative (Stage IIIB and IV)
- Polychemotherapy +/- targeted therapy
- Alternative: symptom-orientated palliative supply
- Radiation therapy may be considered for management of metastases and complications

Systemic anti-cancer therapy (SACT) used in non-squamous NSCLC

27
Q

Describe the management of SCLC

A

Early disease
- Polychemotherapy (cisplatin-based) and/or radiotherapy
- Usually unresectable, consider surgery in patients with very small, resectable lesions

Extensive stage disease
- Polychemotherapy alone

+/- prophylactic cranial irradiation in patients who respond to the initial chemotherapy treatment

28
Q

Contraindications to surgery in lung cancer

A
  • Malignant pleural effusion
  • Superior vena cava obstruction
  • Horner’s syndrome
  • Vocal cord paralysis
  • Phrenic nerve paralysis
29
Q

Surgical complications of lung cancer

A
  • Displacement of the heart towards the operated side
  • Bronchial pump insufficiency leading to respirator failure
  • Chylothorax (damage to the thoracic duct)
  • Ateclectasis (Partial collapse or incomplete inflation of the lung)
  • Pneumonia
30
Q

smoking is a choice. However what other factors is it strongly influenced by?

A

Psychological factors - beliefs, coping response, risk factors e.g., stress

Micro-social - background, school and area, culture, and identity

Macro-social factors - advertising, wider society

31
Q

What social groups do those who smoke commonly belong to?

A
  • Homeless
  • Severe mental illness
  • Substance misuse
  • Criminal justice system
32
Q

Describe the legislistaions involved in tobacco control

A
33
Q

Describe the legislations involved in tobacco control

A
  • Tobacco tax
  • Tobacco advertising an promotion act (TAPA) 2022 - Ban of all tobacco advertising in UK
  • Legal age of smoking change from 16 to 18 in 2007
  • Against law to smoke in public (2007): Smoke-free public spaces
  • Illegal to smoke in car with children (2015): smoke free private vehicles
  • Vending machine ban: Cannot sell tobacco in vending machine (2011)
  • EU tobacco products directive (2016)
  • Plain packaging - mush show graphic images of smoke related disease (2016)
34
Q

What tobacco harm reduction is offered to addicted smokers (when conventional methods to stop smoking have not worked)?

A

E-cigarettes

35
Q

Name two drugs that can be taken aid in smoking cessation

A

Varenicline (champix)

Bupropion (Zyban or Wellbutrin)

Medicine - Year 2 (27 decks)

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