Week 4 formative quiz questions

Question 1

Ultrasound is the only imaging modality that allows a site for drainage of a pleural effusion to be marked.

Answer 1

True – ultrasound imaging allows the fluid to be visualised and quantified with the patient in a seated position, and a marking can be made on the skin to show a safe site for needle insertion and fluid drainage. This cannot be done from a CXR because it is a 2D image, and a CT scan is performed in a supine position, so fluid would move as soon as the patient sits up!

Question 2

Regarding Light’s Criteria: If the ratio of pleural fluid LDH/Serum LDH is greater than 0.6, the effusion is exudative.

Answer 2

True. Light’s Criteria help us decide whether an effusion is transudative or exudative, and therefore helps us determine the cause. The criteria (one or more required) for an exudative effusion are:

Pleural fluid protein/Serum protein >0.5

Pleural fluid LDH/Serum LDH >0.6

Pleural fluid LDH >2/3 the upper limit of the lab reference range for serum LDH

Question 3

PET/CT shows metabolic activity of a lesion.

Answer 3

True – in addition to showing cross-sectional CT imaging, PET imaging involves injection of a radio-labelled glucose analogue. High uptake of glucose (i.e. a high metabolic activity) will therefore show up on the scan as a bright spot, and this may identify metastatic deposits (as cancers typically have high metabolic activity due to their rapid growth).

Question 4

Lung cancer commonly metastasizes to the thyroid gland.

Answer 4

False – lung cancer commonly metastasizes to the adrenal glands.

Question 5

Lung cancer has the highest mortality of any cancer, worldwide.

Answer 5

True – in the UK, it is the joint most common cancer (with breast cancer), but the mortality is significantly higher.

Question 6

A pneumothorax can resolve without treatment.

Answer 6

True – not all pneumothoraces require treatment. Small pneumothoraces in well patients can simply be monitored, as the air will eventually be absorbed by the pleura.

Question 7

Liver failure causes a transudative pleural effusion.

Answer 7

True – liver failure alters the protein composition of blood, and therefore alters the balance in oncotic pressure that maintains constant volume in the pleural cavity. This is therefore a process of fluid accumulation due to a change in filtration rather than inflammation, so causes a transudative effusion.

Question 8

10% of smokers will develop lung cancer.

Answer 8

True – the risk of developing lung cancer is relative to consumption (quantified in terms of pack-years, where 20 cigarettes a day for 1 year is 1 pack-year) but there is no safe smoking threshold.

Question 9

Adenocarcinoma of the lung is more likely to arise centrally.

Answer 9

False - bronchioalveolar epithelial stem cells transform and undergo atypical adenomatous hyperplasia, developing into adenocarcinoma in situ and then invasive adenocarcinoma of the lung. This epithelium is found in small airways, so this cancer is more likely to arise peripherally.

Question 10

Patients with small cell lung cancer are only given radiotherapy to the brain if there are cranial metastases.

Answer 10

False – radiotherapy to the brain is given prophylactically (“prophylactic” treatment is anything that is given to prevent something) as it is known that SCLC frequently spreads to the brain.

Question 11

Lung cancer which has spread to mediastinal lymph nodes can often be successfully surgically resected.

Answer 11

False – the finding of malignant lymph nodes on mediastinoscopy means a lung cancer is not surgically resectable.

Question 12

Putting sterile talcum powder into the pleural cavity can help treat recurrent malignant pleural effusion.

Answer 12

True – this provokes an inflammatory reaction, which causes the visceral and parietal pleura to fuse, preventing recurrence of pleural effusion.

Question 13

Very high dose radiotherapy can be used instead of surgery in some patients with lung cancer, to remove tumours by ablation.

Answer 13

True – SABR (stereotactic ablative radiotherapy) can have similar results to surgery in carefully selected patients with small tumours, who would not be fit for surgery. It involves a short course of very high dose radiation.

Question 14

A pneumothorax which occurs without prior injury in a patient with a pre-existing lung condition is called a primary spontaneous pneumothorax.

Answer 14

False – primary pneumothoraces occur in people with no pre-existing lung disease. The description above is of a secondary spontaneous pneumothorax.

Question 15

Patients with mesothelioma are entitled to compensation.

Answer 15

True – it is an occupational lung disease, and patients (or their families) are entitled to compensation.

Question 16

Small cell lung cancers are much faster-growing than non-small-cell lung cancers.

Answer 16

True – non-small-cell lung cancers have an average doubling time of 129 days, whereas in small cell lung cancers it is 29 days.

Question 17

Lung cancer can cause bronchiectasis.

Answer 17

True – small airway obstruction by a lung tumour can cause the abnormal dilatation of airways known as bronchiectasis.

Question 18

Lung cancer can be staged from a chest x-ray.

Answer 18

False – the “stage” of a cancer refers to its spread, therefore cross-sectional whole-body imaging is required. This will normally be a CT scan.

Question 19

T4 lung tumours are usually not surgically resectable.

Answer 19

True – T4 tumours are locally advanced – i.e. invading into surrounding structures such as the aorta or the trachea, and so generally are not suitable for surgical resection.

Question 20

Small cell lung cancer tends to have a faster response to treatment than non-small-cell lung cancer.

Answer 20

True – because these cancers grow quickly and are highly metabolically active, they are also vulnerable to treatment and respond quickly.

Question 21

In cancer staging, “TNM” stands for “Tumour, Nodes, Metastasis”

Answer 21

True – TNM staging is widely used to describe the staging (i.e. the extent of spread) of many cancers. It looks at the size and/or direct invasion of the primary tumour, the involvement of local and distant lymph nodes, and the presence or absence of distant metastases. You do not need to know the exact details, but it is important to know what the components of TNM staging refer to, and how this corresponds to overall cancer stage.

Question 22

Parathyroid Hormone (PTH) secretion is a feature of small cell lung cancer.

Answer 22

False – this is typically a feature of squamous cell lung cancer.

Question 23

Regarding chest x-rays: A pulmonary mass is classed as an opacity over 1cm.

Answer 23

False – the cut-off is 3cm. Anything smaller than this is classed as a nodule.

Question 24

Regarding Light’s Criteria: If the pleural fluid protein concentration is more than half the serum protein concentration, the effusion is exudative.

Answer 24

True. Light’s Criteria help us decide whether an effusion is transudative or exudative, and therefore helps us determine the cause. The criteria (one or more required) for an exudative effusion are:

Pleural fluid protein/Serum protein >0.5

Pleural fluid LDH/Serum LDH >0.6

Pleural fluid LDH >2/3 the upper limit of the lab reference range for serum LDH

Question 25

Ectopic ACTH secretion and SIADH are endocrine effects of small cell lung cancer.

Answer 25

True. ACTH = adrenocorticotropic hormone SIADH = Syndrome of Inappropriate Antidiuretic Hormone secretion

Question 26

Prevalence of smoking correlates positively to economic deprivation.

Answer 26

True – adults in the most deprived postcodes are three times more likely to smoke than adults in the least deprived postcodes.

Question 27

In lung collapse, you will see the mediastinum shift towards the abnormal side on a chest x-ray.

Answer 27

True – collapse involves loss of volume, so it creates a pulling force on the mediastinum, causing it to deviate towards the side of the collapsed lung.

Question 28

A person who has to rest less than 50% of their day due to their cancer symptoms and is unable to work has a performance status of 3.

Answer 28

False – this describes a performance status of 2. A person who is PS3 has to sit or lie down for more than 50% of their day due to their cancer symptoms, and is likely to struggle with self-care. Performance status will be considered while deciding treatment options with a patient and a multidisciplinary team.

Question 29

Any lung cancer with distant metastases is termed Stage IV.

Answer 29

True – Stage IV designates the development of distant metastases.

Question 30

The only treatment for pleural effusion is drainage by a chest drain.

Answer 30

False – many transudative pleural effusions can be managed by treating the underlying cause, and will eventually resorb without drainage (as will many exudative effusions). Effusions require drainage when the pH is low (indicating high likelihood of empyema), when there is frank pus, or when they are of a volume that breathing is severely impacted.

Question 31

Paraneoplastic syndromes occur due to direct metastatic invasion of endocrine glands by lung cancer.

Answer 31

False – paraneoplastic syndromes are hormonal or chemical changes that occur in the body due to lung cancer, often as a result of the secretion of hormones by the primary tumour itself, or through immune system stimulation.

Question 32

Compression of the phrenic nerve by enlarged lymph nodes leads to voice hoarseness.

Answer 32

False – the phrenic nerve innervates the diaphragm, so phrenic nerve damage will cause paralysis of the affected hemidiaphragm. Recurrent laryngeal nerve damage leads to voice hoarseness.

Question 33

Following pneumonectomy, the patient will have an air-filled cavity for the rest of their life.

Answer 33

False – the space left by the resected lung will fill with fluid.

Question 34

Generally, fluid from a transudative effusion contains 3g/dL of protein or more

Answer 34

False – this describes the protein content of an exudative effusion, which is caused by inflammation.

Question 35

Radiotherapy can be used to treat the symptoms of lung cancer.

Answer 35

True – symptoms such as bony pain (from metastases) and haemoptysis can be improved by palliative radiotherapy.

Question 36

By law, cigarette packets cannot contain more than 20 cigarettes.

Answer 36

False – cigarette packets must contain at least 20 cigarettes. This is to prevent the sale of small, inexpensive packets of cigarettes that people buy for fun and then become addicted!

Question 37

CT screening for lung cancer is now widely offered to people who smoke.

Answer 37

False – this has not yet been established, but is in development.

Question 38

Exudative pleural effusions are inflammatory in nature.

Answer 38

True – examples include pleural effusion secondary to cancer or to pneumonia. Pleural fluid sampled from an exudative effusion will have a high protein content, which can help make the diagnosis.§

Question 39

After PET/CT scan, up to 15% of patients will have the stage of their cancer downgraded, i.e. it will be found to be at an earlier stage than originally thought.

Answer 39

False – up to 15% of patients will have their cancer UPstaged. This is because PET/CT can detect small foci of high metabolic activity (likely metastases) that may have been missed on CT imaging.

Question 40

Adult patients must have an estimated post-operative FEV1 of at least 1L for resective surgery to be considered.

Answer 40

True – a post-op FEV1 of less than this is likely to cause severe breathlessness.