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Year 4 Cancer Care and Haem > Thoracic Cancers > Flashcards

Thoracic Cancers Flashcards

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1
Q

Lung cancer is the second most common cancer in the UK. Name four linked aetiologies

A

Cigarette smoking (particularly unfiltered and high nicotine)
Passive smoking
Asbestos
Chest Radiotherapy

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2
Q

Discuss screening and prevention of Lung Cancer

A

Screening with CXR and sputum cytology doesn’t reduce mortality

Trial with Spiral CT in smokers

2007 smoking ban in public places will reduce rates in future

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3
Q

Describe the histological subtypes of Lung Cancer

A

Small Cell Carcinoma (15-20%)

Non Small Cell Carcinoma (Squamous 30%, Adenocarcinoma 40%, Large Cell, Adenosquamous)

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4
Q

How does Small Cell Carcinoma present on histology?

A

Small Purple Cells

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5
Q

Describe the characteristics of Small Cell Carcinoma of the Lung

A 
Derived from Neuroendocrine cells (normally in the large airways)
Very aggressive (90% metastasise)
Associated with paraneoplastic syndromes
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6
Q

Describe the characteristics of Adenocarcinomas of the Lung

A

Usually peripheral but even small tumours metastasise

Commonly metastasising to: Liver, Adrenals, Other Lung, Pleura, Bone

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7
Q

Describe the characteristics of Squamous Cell Carcinoma of the Lung

A

Arise in proximal bronchi and grow slowly, disseminating in late course

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8
Q

What can a Pancoast Tumour compress?

A 
Braciocephalic Vein
Subclavian
Phrenic Nerve
Vagus Nerve
RLN
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9
Q

How does a Pancoast Tumour present?

A

Hoarse Voice
Bovine Cough
SVCO
Hand muscle wasting

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10
Q

Give four genetic mutations that are potentially associated with Lung Cancer

A 
EGFR Overexpression (Oncogene)
p53 Inhibition (Tumour Supressor)
Increased VEGF (Angiogenesis)
Telomerase Activation
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11
Q

Lung Cancer normally presents late as symptoms are often attributed to smoking. Give 5 symptoms

A 
Persistent Cough (>3 weeks)
Haemoptysis
Recurrent Chest Infections
Chest Pain
Hoarse Voice
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12
Q

What is the criteria for a 2ww referral along the lung cancer pathway?

A

CXR showing Lung Cancer or Mesothelioma
OR
Over 40 with unexplained haemoptysis

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13
Q

Describe some different referral criterias for a 2ww CXR for Lung Cancer

A

Over 40 with: Recurrent chest infection/Finger Clubbing/Cervical LN/Consistent Chest Signs/Thrombocytosis

Over 40 and never smoked with atleast two/used to smoke with atleast one of: Fatigue, Cough, Dyspnoea, Weight Loss, Chest Pain

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14
Q

What are the three main investigations for suspected Lung Cancer?

A

CXR
CT Staging with Contrast
Biopsy (If central then ideally via bronchoscopy, then if not via sputum, peripheral via needle biopsy)

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15
Q

Give four potential features seen on CXR of Lung Cancer

A

Circular Opacity
Hilar Enlargement
Consolidation
Pleural Effusion

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16
Q

Describe the WHO Performance Status

A 
0 - Asymptomatic
1 - Symptomatic but ambulatory
2 - In bed < 50% but unable to work
3 - In bed > 50%, no self care
4 - Bedridden
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17
Q

Who is involved in the MDT Lung Cancer team?

A 
Physician
Specialist Nurse
Radiologist
Thoracic Surgeon
Oncologist
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18
Q

What investigation can be done to specifically look for Liver and Bone metastases from the Lung?

A

FDG PET CT

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19
Q

Lung Cancer is staged via TNM. Describe Tx - T2

A 
Tx - Positive malignant cytology, no lesion
T0 - No evidence of primary tumour 
T1a - <2cm
T1b -2 to 3 cm
T2a - 3 to 5cm
T2b - 5 to 7cm
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20
Q

Lung Cancer is staged via TNM. Describe T3 - T4

A

T3 - >7cm invading, assoicated atelectasis, separate nodules in same lobe

T4 - Invasion of mediastinal organs, malignant effusion, RLN

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21
Q

How is suitability for surgical management of Lung Cancer assessed?

A

Thoracoscore

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22
Q

What are the surgical options for management of Lung Cancer?

A

Lobectomy
Pneumonectomy
Wedge resection for small tumours

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23
Q

Patients post op from surgical Lung Cancer management are managed in ICU/HDU, what are further treatment options?

A

Adjuvant Cis Platin if good performance score

Radiotherapy if incomplete resection

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24
Q

Give two early and two late complications of surgical management of Lung Cancer?

A

Early - Haemorrhage, Resp Failure

Late - Post Thoracotomy Pain, Late Bronchopulmonary FIstula

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25
Q

Name a biological treatment option for Lung Cancer

A

Afatinib (eGFR Tyrosine Kinase Inhibitors)

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26
Q

Name an immunotherapy treatment option for Lung Cancer

A

Pembidizumab (prevents inhibition of T cell response)

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27
Q

What is the preferred Chemotherapy regime for Adenocarcinoma of the lung?

A

Pemetrexed
Cisplatin (also a radiosensitiser)
Carboplatin

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28
Q

Lung Cancer can also be managed by radical radiotherapy if unsuitable for surgery. Give three disadvantages of this

A 
Frequent hospital attendance
Acute toxicities (oesophagitis)
Late toxicities (lung fibrosis)
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29
Q

Lung Cancer can also be managed by radical radiotherapy if unsuitable for surgery. Describe the CHART regimen

A

54Gy in 36 fractions over 12 days (8am, 12pm, 8pm)

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30
Q

Give three prognostic factors of Small Cell Carcinoma of the Lung

A

Performance Status
LDH
Na+ (SIADH = poor prognosis)

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31
Q

Small Cell Carcinoma of the Lung is staged slightly differently. Describe it

A

Limited Stage - confined to one hermithorax, ipsilateral hilar LN, supraclavicular and mediastinal nodes

Extensive Stage - Metastatic lesions in contralateral lung, distant metastatic involvment

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32
Q

Surgery is generally not recommended in Small Cell Carcinoma of the lung, describe the use of chemotherapy

A

Limited Stage: 4-6 cycles of cisplatin combination

Extensive Stage: Maximum 6 cycles of above

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33
Q

Surgery is generally not recommended in Small Cell Carcinoma of the lung, describe the use of radiotherapy

A

Limited: Thoracic irratiation alonside/after chemotherapy
Extensive: Offered if complete response at distant sites and good response in thorax

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34
Q

Give two local complications of Lung Cancer

A

Horners Syndrome

RLN Palsy

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35
Q

Give two metastatic complications of Lung Cancer

A

Confusion

Bone Pain

36
Q

Give two non metastatic complications of Lung Cancer

A

SIADH

Lambert Eaton Syndrome

37
Q

What is Lambert Eaton Syndrome?

A

Autoimmune targeting of voltage gated sodium channels causing muscular weakness
Associated with Small Cell Carcinoma

38
Q

Define Mesothelioma

A

Aggressive tumour arising from serosal lining of chest

Strong association with asbestos exposure

39
Q

Describe the pathology of Mesotheliomas

A

Grows diffusely in pleural space

Associated with pleural effusion

3 histological subtypes (epithelioid, sarcomatous, mixed)

40
Q

What is seen on CXR of Mesothelioma?

A

Pleural effusion/thickening

41
Q

What is seen on CT and MRI of Mesothelioma?

A

CT - Pleural mass and effusion encasing lung

MRI - definition of tissue planes

42
Q

How is Histology taken for suspected Mesothelioma?

A

US/CT guided biopsy
OR
Thoracoscopy and Biopsy

(risk of seeding into chest wall)

43
Q

How are Mesotheliomas staged?

A

Brigham staging

I - One side of the pleura
II - Intrapleural adenopathy
III - Extension into chest wall/ribs/spine/peritoneum/pericardium
IV - Distant metastatic disease

44
Q

Surgical management is ideal for Mesothelioma, but only applicable in certain cases, such as:

A

Stage I if medically fit
Stage II and III as part of multimodal therapy

Extrapleural pneumonectomy

45
Q

Describe the use of Radiotherapy/Chemotherapy for Mesothelioma

A

Radiotherapy - short course for painful chests

Chemotherapy - Pemetrexed in combination with Cisplatin/Carboplatin

46
Q

What is different about the management and paperwork of Mesotheliomas as opposed to other cancers?

A

Patients are entitiled to compensation

All deaths must be notified to coroner

47
Q

How does the incidence of Breast Cancer increase with age?

A

Incidence doubles every decade until menopause

After 50y there is a slower increase

48
Q

Give 5 risk factors for Breast Cancer

A 
Early Menarche and Late Menopaus
Exogenous Oestrogens (COCP, HRT)
Obesity
Previous breast surgery (eg augmentation)
Radiation
49
Q

How should a family history of breast cancer be managed?

A
  • 45-65% of those who inherit BRCA1/2 will get breast cancer before the age of 70
  • Prophylactic mastectomy (+/- Oophorectomy)
  • Annual MRI for BRCA1/2 carriers (aged 30-50)
50
Q

What is the most common type of Breast Cancer?

A

Ductal Carcinoma

More common in left breast

51
Q

Define DCIS

A
  • Atypical proliferation of ductal epithelium that eventually plugs ducts with neoplasm
  • Remains within basement membrane
  • Progression to invasive disease is 30-50%
52
Q

How does DCIS present on mammography?

A

Microcalcification

53
Q

How is LCIS different from DCIS?

A

Neither palpable nor showing microcalcifcations on mammography

54
Q

Invasive Ductal Carcinoma accounts for 75% of breast cancers , and is graded from I-III. How is the grade calculated?

A

Tubule Formation
Nuclear Pleomorphisms
Mitotic Frequency

55
Q

Name two prognostic markers of Breast Cancer and a score

A

ER receptor status
HER2 receptor status

Nottingham Prognostic Score

56
Q

What is a ‘Triple Negative’ Breast Cancer?

A

ER, PR and HER2 negative

15% of breast cancers

57
Q

What is Paget’s Disease?

A

Ductal carcinoma with involvement of nipple skin and areola (presents like nipple eczema)

58
Q

What are Breast Cysts?

A

Epithelial lined fluid filled cavities formed when lobules become distended due to blockage
Normally affects perimenopausal age group

59
Q

How are Breast Cysts investigated?

A 
Mammography (classic halo shape)
Needle Aspiration (cytology)
60
Q

What is Mammary Duct Ectasia?

A

Dilation and shortening of the lactiferous ducts

Common in the peri-menopausal age group

61
Q

How does Mammary Duct Ectasia present?

A

Green/Yellow nipple discharge
Palpable mass
Retracted nipple

62
Q

How is Mammary Duct Ectasia investigated?

A

Mammography (dilated calcified ducts)

Biopsy (multiple plasma cells)

63
Q

Name 5 types of benign breast lumps

A 
Fibroadenoma
Adenoma
Papilloma
Lipoma
Phyllodes
64
Q

How does a Papilloma present?

A

Typically in sub-areolar region

Clear/bloody nipple discharge

65
Q

What are Phyllodes tumours?

A

Rare fibroepithelial tumours that grow rapidly

Should be excised as a 1/3 have malignant potential

66
Q

Give five presentations of Breast Cancer

A 
Breast Lump 
Axillary Lump
Breast Skin Changes (dimpling, puckering, erythema)
Nipple Changes (inversion, discharge)
Abnormal mammogram
67
Q

Name four possible criteria for a 2ww Breast Cancer referral

A
  • Any age with discrete hard lump that is fixated
  • > 30 with lump persisting after period
  • Unilateral eczematous changes unresponsive to steroids
  • Persistent axillary swelling
68
Q

Name three possible criteria for a routine Breast referral

A

<30y with a lump (no other concerning features)
<50y with intermittent nipple discharge (non bloody)
Mastalgia and no palpable abnormality

69
Q

What is a Triple Assessment for Breast Cancer

A

Examination
Imaging
Biopsy

70
Q

What is the radiographical choice for Breast Cancer?

A

Mammography if over 35y (two views - caudiocranial, mediolateral)
USS in younger patients (due to denser tissue)

71
Q

When would you use an MRI to image breasts?

A

Familial Cancer Screening

Breast Implants

72
Q

What is involved in the clinical examination of suspicious Breasts?

A

Calliper measurement of any lumps
Assessment of fixicity
Lymphadenopathy

73
Q

Describe the biopsy options for Breast Cancer

A

Impalpable Lesions use US guided FNA (quicker and less painful)
Ideally use Core Biopsy (allows more information about tumour grade and receptor sensitivity)

74
Q

What is a Sentinel Node Biopsy?

A

Removing the first lymph node that the breast tissue drains to, found by injecting radioactive blue dye

75
Q

Name three adverse effects of Axillary Clearance

A

Lymphoedema
Arm Pain
Stiff Shoulder

76
Q

Describe the T of TNM Breast Cancer Staging

A 
T0 - in situ
T1 - <2cm
T2 - 2-5cm
T3 - >5cm
T4a  - Involvement of chest wall
T4b - Involvement of skin
T4c - Involvement of chest wall and skin
T4d - Inflammatory
77
Q

What are the management options for In Situ Breast Cancer?

A

Mastectomy
Wide Excision Alone
Wide Excision and whole Breast Irradiation

78
Q

What is the role of Adjuvant Hormone Therapy in Breast Cancer?

A

Aims to eradicate micrometastatic disease
Generally given for 10y

Premenopausal - Tamoxifen
Post menopausal - Anastrazole

79
Q

Adjuvant chemotherapy for Breast Cancer has a good response in Pre-Menopausal Women. Describe a typical regime

A

Doxorubicin
Fluorouracil
Cyclophosphamide

80
Q

What are the key treatments for Advanced Breast Cancer?

A 
Endocrine therapy (if ER positive)
Chemotherapy
81
Q

Give a benefit and disadvantage to immediate breast reconstruction in Breast Cancer

A

Preserves native skin so more symmetrical outcome

Can delay adjuvant therapy if any post op complications

82
Q

Give a benefit and disadvantage to delayed breast reconstruction in Breast Cancer

A

Allows focus on cancer treatment

Extra skin needs to be gathered from other site or donor

83
Q

Give three reconstructive options post Mastectomy

A

Lat Dorsi - for smaller breasts, can be free or pedicled
TRAM - Transverse Rectus Abdominus Muscle
DIEP - Deep Inferior Epigastric Perforator

84
Q

Give an advantage and disadvantage to adjuvant treatment in Breast Cancer

A

Immediate surgical removal of disease

Can’t assess full efficacy of treatment

85
Q

Give an advantage and disadvantage to neoadjuvant treatment in Breast Cancer

A

Allows visualisation of tumour response

Risk of over treatment

Year 4 Cancer Care and Haem (16 decks)

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