week 4 in person lectures Flashcards by Emily Brown

lung cancer kills more than breast and prostate cancer combines

true

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other factors aside from tobacco/smoking that causes lung cancers?

asbestos, environmental radon e.g. from granite, air pollution and urban environment

other occupational exposure, other radiation, pulmonary fibrosis

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which two carcinogenic chemicals in tobacco smoke are the most toxic

polyclyclic aromatic hydrocarbons
n-nitrosamines

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Effect of carcinogenic chemicals?

Epithelial effects
there is a multi-hit theory of carcinogenesis, genomic damage, in a numbers game

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what are the two major tissue pathways of lung carcinogenesis?

invasive adenocarcinoma and invasive squamous cell carcinoma

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how does invasive adenocarcinoma occur

atypical adenomatous

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’’ ‘’ of squamous

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oncogene addiction

a signular molecukar abnormlaity, is the primary driver to the evolution of the cancer
adeno

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Is oncogene addiction more likely to occur in invasive adenocarcinoma or squamous cell/small cell

adenocarcinoma???

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squamous cell/small cell
everything to do with tobacco, less so with the other

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Are the oncogenic drivers suitable for targeting by drugs?

most are, but only like 4 approved in UK. Most not approved by NHS Scotland

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In particular for squamous cell carcinoma, are the oncogenic drivers suitable for targeting by drugs?

not really

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Metastases to the lung are uncommon

false

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4 main histological types of lung cancer:

squamous cell
adenocarcinoma
small cell carcinoma
large cell carcinoma

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Binary distinction between small cell carcinoma and otherwise?

There is NSCLC vs small cell carcinoma SCLC

However NSCLC, it’s important to distinguish between squamous cell and adenocarcinoma

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Primary lung cancers are often asymptomatic

yes, they grow clinically silent for many years- symptoms present late in natural history

‘Symptomatic lung cancer is fatal lung cancer’
Most cured is incidentally found lung cancer

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squamous cell carcinoma frequently cavitate, so it may look like:

a hole in the lung

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bronchial tumors bleed, yes or no

yes hence coughing up blood

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local effects of lung cancer?

bronchial obstruction (collapse)
endogenous lipoid pneumonia
infection/abscess
bronchiectasis

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lung infection more common when blockage of bronchus

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Local effect of lung cancer on pleura?

inflammatory, and from pleura to chest wall/mediastinum (malignant)

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Radiological change to pleura may not be due to malignancy, but just inflammation

true

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Would a surgeon ever take some rib?

in certain conditions

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Direct invasion of nerves due to lung cancer, name the 4 symptoms:

diaphragmatic paralysis
hoarse, bovine cough
pancoast T1 damage
horner’s syndrome

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damage to phrenic nerve due to cancer leads to what

diaphragmatic paralysis

damage to l recurrent laryngeal nerve due to cancer leads to what

hoarse, bovine cough SO IMPORTANT TO RECOGNIZE BOVINE COUGH

don't sweat on one side of their face=

horners. Potentially due to lung cancer

damage to recurrent plexus (perhaps due to lung cancer metastasis) is what

pancoast T1 damage

damage to cervical sympathetic nerves is called what syndrome

horner's

Small cell secrete hormones like

ACTH

Squamous cell secrete hormones like

P.H see lecture slide

Small cell carcinoma is the worst, true or false

true

Can oncogenic drivers be targeted for therapy?

yes

In squamous cell, there is little or no effective molecular therapy

Immunotherapy: recogmises PD1/PD-L1 interaction, allows cancer cells to flourish. It's an immune checkpoint in NSCLC. True or false

true. It's a therapeutic target

immune checkpoints are adopted by tumours to avoid immune destruction. so we need what

immune checkpoint inhibitors are gaining increased use in lung and other cancer therapy

What do we see on a full blood count?

neutrophils, macrophages

What causes the pus in COPD?

acute inflammatory cell (neutrophil polymorph) causes pus

haemoptysis- what's the first disease you think of, for an elderly smoker

lung cancer

Elderly smoker with many pack years cough up blood. What do you do next?

CT for bone CXR MRI for the soft tissue

When tumours outgrow blood supply, what happens?

necrosis blood vessels burst leading to blood in sputum also can cough up necrotic tissue, and blood from cavity

What causes cavitation?

Main complications of a cavity

also can cough up necrotic tissue, and blood from cavity get bacteria or fungi in cavity and this causes infection

What's dysphagia?

difficulty swallowing

Why might someone have difficulty swallowing?

Is oesophagus narrowed? Or problem with larynx? Pharynx? Stomach?

Difficulty swallowing, think oesophagus is narrowed, what do we do next

barium swallow, could see mass

Treatment for flashcard 45?

too old for surgery, so have radiotherapy

Tumour shrinks, vomits=

aspiration

Endoscopy, ulcertaion

place stent oesophagus down so she can swallow

still vomits, then develops final illness: fever, cough with cream-coloured sputum, breathlessness (dysnoea)

check sputum, positive culture. Then chest x ray, patchy white areas in the lung fields diagnosis: pneumonia, possibly secondary to aspiration of food

Why fever?

We're not actually sure why. Bacteria like 37. But the physiology behind a fever is cytokines (produced by wbc like neutrophils , macrophages) You feel cold, so that you get hot. Temp regulation goes up.

What colour is sputum normally?

translucent

If someone gets pneumonia, *why* do they get pneumonia?

Possibly upper respiratory tract infection, e.g. covid Possibly *aspiration*- and it's the larynx that stop stuff getting in the lungs Flu, usually non-severe You can have predisposition to bacterial infection by aspirating anything Anyone with pre-existing lung disease IV drug users

Anything that affects cough reflex, therefore higher incidence of aspiration

Treatment of pneumonia,

antibiotics, keep comfortable

Green sputum, that's dead bacteria, if sputum goes clear again, that's a good sign

Simple case of aspiration: anyone with blockage of oesophagus can aspirate food into larynx, and then lungs

pneumonia could have lead to septicemic shock

Why slice the tongue during an autopsy

epilectics bite their tongue

Why black lungs

pollution

purpose of stent

stop food from ulcerating the mucosa

There is a decreasing prevalence in non-smokers for lung cancer

false, increasing- pollution?

Who get's more lung cancer, women or men

women

Ten symptoms of lung cancer

chronic coughing coughing up blood wheezing sound (particularly new) chest and bone pain chest infections difficulty swallowing hoarse voice (recurrent laryngeal nerve) sob unexplained weight loss nail clubbing

What do I mean by 'paraneoplastic' symptoms

Of the liver, due to cancer you're secreting hormones

If coughing for how long, get a CXR?

three weeks

5 initial investigations due to GP

CXR, FBC, Renal, liver functions, and calcium, clotting screen, spirometry

Sometimes lung cancer can present as anemia, true or false

true

practice looking at x-ray's, and your technique

EBUS

taking sample

Bronchoscopy and EBUS are the most common investigations

true

what type of lung cancer is most common

Both adenocarcinoma and squamous cell carcinoma

If not radical treatment, it must be what

palliative (just improve quality of life) radical is with curable intent

PET scan is initial or further staging

for further staging 0-4 (4 is basically chair/bed bound) 3= 'up and about' < 50%

Explain prognosis, and conditions of prognosis?

yes be very honest

Is chemotherapy radical or palliative?

both

confirm cancer after imaging how

have tissue confirmation of malignancy

what's reflex testing

crack on and get results whether we need the results or not, for efficiency and time sensitivity

If metastatic disease, with a large tumour burden, what type of treatment?

incurable disease, consider palliative treatments

PE and hyponatraemia as complications of cancer are poor prognostic markers?

true hyponatraemia = high calcium

If PS3, largely housebound, frail, what treatment:

unsuitable for systemic anti cancer treatment too frail to withstand toxicities of treatment let them know they're not just discarded, for the scrapyard. Consider explaining why qol

Why might you consider an indwelling pleural catheter for palliation of breathlessness?

for 'symptom directed care'/ palliative for quality of life

Anticoagulate plus haemoptysis, concern?

Could increase- it's a risk vs benefit judgement call. Anticoagulate was for the pulmonary embolism- which might contribute to breathlessness. So they were tryna ease sob. But capacity to reverse decision if need be.

What to do next: 78F general malasise looks 'well' and 'fit', PS1 Palpable L supraclavicular lymph node Ex-smoker of 22 years, used to be 20 a day

Take CXR Take FNA from that lymph node to see if there is evidence of malignancy

22 years ex smoker, has lung cancer, what type of cancer most likely?

adenocarcinoma so the odds that there is an oncogenic carcinoma is high, vs if she was a life long smoker, where the odds would be low

Patient with adenocarcinoma is fit, what treatment and what next

Potentially suitable for aggressive concurrent chem/rad, if no metastasis Take PET scan to confirm Also EBUS, and molecular analysis of EGFR mutation

What's the drawback of a PET scan?

Inflam vs malignancy

Incurable disease, but has EGFR mutation?

consider palliative treatments EGFR mutation- wouldn't respond well to chemo. So suitable for systemic anti-cancer therapy, taken orally. Response to these meds potentially up to 3 years of a normal qol TKI targeted therapy

57M joiner, haemoptysis, mild dysponea, smoker 36 pack years, family history of lung cancer, had been in hospital for rib/trauma issue where cavity was incidental finding

take bronchoscopy

Squamous cell carcinoma locally aggressive, fit and well, what next

take PET scan Surgery likely to give best chance of cure, may require adjuvant treatment had completed left lower lobe lobectomy

Shoulder pain and background of cancer, why is that worrying

potential of recurrent disease

chemo and sepsis

don't bode well together edit card: why not

What treatment might be super helpful for pain

radiotherapy

82F very fit never smoked mild sob on exertion incidental finding of hiatus hernia, and lung nodule on CT prev breast cancer, mastectomy what next

Take CT, is this lung or breast? So take PET scan

Early-stage adenocarcinoma, consider what

radical treatment, debate surgical resection vs radiotherapy patient should have first refusal over this matter, as surgery really is best option

small cell lung cancer has a propensity to spread where

the brain and obviously brain metastasis would change the treatment intent

smoking and radiotherapy:

radiotherapy relies on free radicals, so the more oxygen the better

CT scan, every 6 months for about 5 years: for a check-up following an all-clear from lung cancer, does this sound about right?

yes

Chemo doesn’t cross blood brain barrier, true or false

True

Does lung cancer screening exist

Not YET