week 4 in person lectures Flashcards
lung cancer kills more than breast and prostate cancer combines
true
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
which two carcinogenic chemicals in tobacco smoke are the most toxic
polyclyclic aromatic hydrocarbons
n-nitrosamines
Effect of carcinogenic chemicals?
Epithelial effects
there is a multi-hit theory of carcinogenesis, genomic damage, in a numbers game
what are the two major tissue pathways of lung carcinogenesis?
invasive adenocarcinoma and invasive squamous cell carcinoma
how does invasive adenocarcinoma occur
atypical adenomatous
’’ ‘’ of squamous
oncogene addiction
a signular molecukar abnormlaity, is the primary driver to the evolution of the cancer
adeno
Is oncogene addiction more likely to occur in invasive adenocarcinoma or squamous cell/small cell
adenocarcinoma???
squamous cell/small cell
everything to do with tobacco, less so with the other
Are the oncogenic drivers suitable for targeting by drugs?
most are, but only like 4 approved in UK. Most not approved by NHS Scotland
In particular for squamous cell carcinoma, are the oncogenic drivers suitable for targeting by drugs?
not really
Metastases to the lung are uncommon
false
4 main histological types of lung cancer:
squamous cell
adenocarcinoma
small cell carcinoma
large cell carcinoma
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
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
squamous cell carcinoma frequently cavitate, so it may look like:
a hole in the lung
bronchial tumors bleed, yes or no
yes hence coughing up blood
local effects of lung cancer?
bronchial obstruction (collapse)
endogenous lipoid pneumonia
infection/abscess
bronchiectasis
lung infection more common when blockage of bronchus
yh
Local effect of lung cancer on pleura?
inflammatory, and from pleura to chest wall/mediastinum (malignant)
Radiological change to pleura may not be due to malignancy, but just inflammation
true
Would a surgeon ever take some rib?
in certain conditions
Direct invasion of nerves due to lung cancer, name the 4 symptoms:
diaphragmatic paralysis
hoarse, bovine cough
pancoast T1 damage
horner’s syndrome
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
