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(Emily) semester 2 > week 4 lung cancer and smoking also pleural effusion and asbestos > Flashcards

week 4 lung cancer and smoking also pleural effusion and asbestos Flashcards

1
Q

what are the survival rates for cancer?

A

quite poor, in 2009 less than 10%

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2
Q

How does surgical intervention affect survival curve?
How many patients are suitable for this?

A

Huge effect, however 2/3 patients present with advanced disease

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3
Q

Pulmonary nodule vs mass?

A

Mass: opacity in lung over 3cm, with no mediastinal adenopathy or atelectasis
Nodule: opacity in lung up to 3cm with with no mediastinal adenopathy or atelectasis

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4
Q

Causes of localised opacity in X-ray?

A
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5
Q

Approx method for reviewing a CXR?

A

Look at:

Name/marker/penetration
Metal work

Mediastinum contours and heart first ( no widening, trachea central, hilar vascular structures crisply defined)

Central airways (any area of increased density? Distorted? Pulled in an inappropriate direction?)

Both lungs: compare upper, middle then lower zones for nodules and mass

Both lungs: anything that indicates lung collapse? (E.g. may be loss of volume, costophrenic angles for blunting which might mean pleural thickening of fluid).

Bones and soft tissues

Final look at apices, hila behind heart, and below hemidiaphragms

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6
Q

What might cause a white out of a hemithorax?

A

large pleural effusion?
complete collapse of lung?
pneumectomy

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7
Q

pleural effusion or complete collapse of lung?

A

pleural effusion: mediastinal shift away from that side, pushed away by the fluid

lung collapse: loss of volume on lung collapse side, so mediastinum will be pulled towards that
*same with pneumectomy

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8
Q

If we see a collapsed lung on an x-ray, and they haven’t had a CT for us to discount it, what is the assumptive diagnosis?

A

central tumour

especially in an older patient, who is a smoker

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9
Q

main bronchus divides into what bronchi sub types

A

lobar, segmental, sub-segemental

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10
Q
A

lungs divided into lobes, and then bronchopulmonary segments- remove one, others remain unaltered in their function (good for a surgeon to know)
right = 10, left = 8-10 (some may fuse)

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11
Q

on a chest x-ray, do you define lobes?

A

No use zones not lobes:
upper, middle, lobar

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12
Q

how could you guess where the pulmonary arteries are

A

follow the bronchopulmonary segments to find out where the pulmonary arteries are

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13
Q

which ventricle pumps blood into the main pulmonary artery

A

divides into right and left pulmonary arteries before subdividing into lobar, segmental, and sub-segmental branches.

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14
Q

CT pulmonary angiogram used why

A

to find a pulmonary embolus

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15
Q

Lymph nodes shown in a CT scan?

A

potential malignancy, potentially from lung cancer? Or infection? It’s a broad differential

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16
Q

why might we beware the lobar collapse which fails to resolve in 2-3 weeks of a smoker aged over 45

A

central lung cancer?

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17
Q

can you get more than one lobe collapsing

A

yes

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18
Q

where might lesions be in particular more subtle and difficult to spot in a CXR

A

Beware of lesions behind the heart and hila.

(compare with previous films, always look at review areas)

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19
Q

why might you compare with previous films

A

easier to spot abnormality when you have something to compare to

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20
Q

4 places an abnormality may hide on CXR

A

Hila, lung apices, behind the heart, behind the diaphragm

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21
Q

which hilum is a bit higher normally, and if they’re not is it okay

A

left
its okay
but right should never be higher

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22
Q

why is the left hilum usually higher

A

because the left main pulmonary artery arches over the left main bronchus

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23
Q

should the density behind the heart and below the diaphragm be comparable?

A

yes

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24
Q

should both hilum’s be equal ‘bulkiness’?

A

yes otherwise perhaps a mass e.g. ‘left hilar mass’

(unrelated, but remember the name ‘mass, left costophrenic angle)

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25
Q

As well as actually looking at the CXR, what else is important in the diagnosis and staging of lung cancer?

A

looking at the clinical history

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26
Q

What key info from a clinical history might be useful for staging lung cancer?

A

Increasing SOB in smoker, history of pulmonary fibrosis, recent haemoptysis

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27
Q

Would the lesion ever be on the breast?

A

Yes. Important to confirm that lesion is intrapulmonary.

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28
Q

What’s the next step after an X-RAY if there is an uncertainty?

A

CT

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29
Q

What’s one reason you might see a breast implant in CXR?

A

If patient has had a mastectomy

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30
Q

What is a pulmonary nodule/mass? (not vs)

A

opacity in lung with no mediastinal adenopathy or atelectasis

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31
Q

difference between a mass vs nodule

A

mass = over 3cm
nodule= up to 3cm

so basically it’s a mass if it’s over 3cm

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32
Q

Most common reason for CXR

A

Diagnosis for pneumonia

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33
Q

You can only asses heart/mediastinum width etc on PA view

A

True

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34
Q

Why aren’t CXR good for looking for rib fractures

A

Can’t see 50% of rib fractures in CXR

Pneumothorax- related to rib fractures (air in pleural place)

Subcutaneous emphysema (looks like air outside lung)

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35
Q

Border of heart lost? Might conclude?

A

Suggests something is in the lung, abutting the left side of the heart

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36
Q

If we can see bronchus?

A

Usually cant see bc it’s air filled, surrounded by air filled lung. But if:
Surrounded by dense, consolidated lung, full of pus eg due to pneumonia.

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37
Q

No lung markings?

A

Maybe pneumothorax?

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38
Q

Which hemidiaphragm should be slightly higher than the other?

A

Right

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39
Q

Pneumoperitanium might look like

A

Free gas under diaphragm- perforated the bowel.

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40
Q

In lung cancer. Would it often be one or multiple nodules/masses

A

In the context of lung cancer usually solitary, unless metastatic (could metastasise to another part of the lung).

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41
Q

Could you get benign nodules can you think of four things

A

Hematoma’s- which have fat/calcium in, or carcinoid tumours, or vascular malformations, foci of calcification.

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42
Q

Is TB a cavitating illness?

A

Yes

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43
Q

Would the formation of fungal ball or aspergilloma within the cavity be a complication of what type of illness?

A

Cavitating illness eg
TB

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44
Q

What’s a pulmonary cavitation?

A

Thick-walled abnormal gas filled spaces within the lung, usually associated with a nodule, mass, or area of consolidation
A fluid level within the space may be present.

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45
Q

What could commonly present with hemoptysis?

A

Pulmonary cavities

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46
Q

Staging of lung cancer, 4 key stages:

A

Clinical history/ exam
Performance status
Pulmonary function
TNM International system for staging lung cancer

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47
Q

What’s TNM staging?

A

Three parts:

  1. How big / how far spread / size and position of Tumour (T)
  2. Whether cancer cells have spread to lymph nodes (N)
  3. Whether rumour has spread anywhere else in body (M)
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48
Q

What’s typical progression of metastasis of lymph nodes from the lungs?

A

Contra lateral mediastinal nodes
Clavicular nodes

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49
Q

For assessing lymphatic metastasis from the lungs, what three tools could you use?

A

PET-CT
Mediastinoscopy
CT

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50
Q

What’s a PET/CT for diagnosing lung cancer?

A

Metabolic assessment of the patient and the disease, using a label glucose analogue FDG, which is attached to fluorine 18, which is taken up most by cells in particular that are metabolically active

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51
Q

Metabolically active cells shown by PET/CT scan could be:

A

Inflammatory
Malignant

(FDG uptake)

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52
Q

N2 disease means what

A

2 nodes

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53
Q

What’s the ‘T’ stage of TNM about?

A

Size when we can’t assess eg because it’s in a collapsed lung or something

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54
Q

What are the measurements/staging of the ‘T’ stage of TNM?

A

T1 through to T4
T1 up to 3cm

If involvement of chest wall, T3 regardless of size, or separate nodule in same node as primary

T4, 7 cm or more, or invading a structure incl. mediastinum, or separate tumour nodule in different ipsilateral node

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55
Q

Meaning of N1-3 of ‘N’ stage?

A

N1= ipsilateral peribronchial, hilar, or intrapulmonary nodes
N2=

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56
Q

How do we know if the node is metastatic?

A

Not if less than 1cm (tho that is an arbitrary cut off)

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57
Q

If not sure if node is malignant?

A

Node can be targeted for tissue sampling

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58
Q

Could the brain be a common site of metastasis for lung cancer?

A

Yes

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59
Q

M1 staging?

A

Metastasis within the thorax

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60
Q

Where is normal FDG uptake?

A

Heart, GI tract, brain

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61
Q

Limitations of PET CT?

A

False pos/neg
Cost

Eg nodule too small, inflam, or slow growing malignancy bc it has low metabolic rate

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62
Q

Is it important or not important to get a tissue sample for lung cancer and how?

A

Yes
Guided by CT or also by PET/CT
Or bronchoscopy
Mediastinoscopy to sample mediastinal nodes

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63
Q

Could CT have a role in screening?

A

Maybe in the future

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64
Q

what’s the principal reason for undertaking thoracic surgery?

A

lung cancer

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65
Q

how many patients with lung cancer are operable?

A

like 10%

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66
Q

if at risk of ischemic heart disease, and COPD, are you as a patient suffering from lung cancer, operable for thoracic surgery?

A

Chronic obstructive pulmonary disease (COPD) increases the chances of surgical complications, such as infections and respiratory crises. In fact, long-term survival rates for people with severe COPD who have surgery are lower than that of people who do not have COPD.1

 Given this, a pre-operative evaluation that screens for lung disease is done in preparation for any surgical procedure.

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67
Q

why not thoracic surgery when you have both lung cancer and COPD?

A

mucus plugs
brochospasm
pneumothorax
hyperventitlation

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68
Q

How effective is thoracic surgery?

A

Of the 10% who can actually get operated on, about half are permanently cured of lung cancer

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69
Q

lymph node involvement in lung cancer is sometimes responsible for what?

A

recurrent laryngeal nerve palsy, or phrenic nerve palsy

Paralysis of the larynx (voice box) caused by damage to the recurrent laryngeal nerve or its parent nerve, the vagus nerve

These nerves are at risk of being destroyed by incoming tumor cells, e.g. those lying between the aortic arch and left pulmonary artery

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70
Q

where is the aortic pulmonary window

A

Between the aortic arch and left pulmonary artery

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71
Q

Why might clinical staging give a clue as to metastesis?

A

Because metastesis is often painful, especially if in the bones or the brain, headaches

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72
Q

Why the phenomenon of personality change?

A

CT scan the norm for lung cancer management.
If personality change, may be a feature of cerebral metastesis.

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73
Q

What do we look for, when doing a radiograph for cerebral metastesis?

A

Evidence for:
nerve palsy (phrenic nerve) - see in X-Ray

(if hearing hoarseness, it’s recurrent laryngeal nerve palsy)

brachial plexus palsy (from tumor at apex of lung) pancoast syndrome

74
Q

If tumor is compressing the superior vena cava, what may they have signs of

A

distended neck veins, and obstruction of the superior vena cava

75
Q

If a patient has supraclavicular lymph nodes or soft tissue nodules (when possible lung cancer), what does it suggest?

A

inoperable disease

76
Q

If there is a malignant pleural effusion present, will surgery get rid of the disease?

A

no

77
Q

If chest wall invasion, is it possible to resect invaded ribs and intervening soft tissues?

A

yes
then reconstruct chest wall with pericardial patch

78
Q

If phrenic nerve palsy, is it operable situation?

A

no

79
Q

Purpose of PET scan with collapsed lung during clinical staging?

A

help us to evaluate how much of collapsed lung is actually a tumor

80
Q

Why might it be worth doing a bone scan in a patient with lung cancer?

A

to see if there is abnormal uptake in the skeleton consistent with metastatic disease

81
Q

Why might it be worth doing a bone profile in a patient with lung cancer?

A

bc alkaline phosphate goes up when liver metastasis or bone metastasis

82
Q

Are mediastinal nodes N1 or N2

A

N2

83
Q

Would malignant effusion make the case inoperable?

A

yes

84
Q

Can the diaphragm be resected?

A

yes
but difficult to resect in the costodiaphragmatic recesses

85
Q

Where are the costodiaphragmatic recesses?

A

they are ‘potential spaces’, the sharp gutter at the junction of the costal and diaphragmatic pleurae in each pleural cavity

86
Q

For lung cancer patients, who do you perform an ECHO on?

A

everyone

87
Q

What’s the ECHO test?

A

to determine fitness for surgery. Will demonstrate presence or absence of significant pericardial effusion.

88
Q

You might do isotope bone scanning to demonstrate invasion of what?

A

The chest wall

e.g. increased isotope uptake in appropriate bones

89
Q

can you resect the scapula

A

not really

90
Q

tumor in main bronchus, limitations?

A

hopefully not at carina, wanna see a couple cm before we reach tumor

91
Q

tumor in lobar bronchus?

A

need to consider space before carefully resecting

92
Q

whats a mediastinoscopy

A

telescope placed to a small incision above the sternum near sternal notch, pass down adjacent to the trachea to take biopsies of the lymph nodes there

93
Q

do you operate on patients with major mental illness

A

no, lots of pain after surgery, don’t want to aggravate mental disorder

94
Q

Why look out for pulmonary hypertension when considering lung cancer operations?

A

(Pick up on ECHO scan). Fragile arteries, well known cause of death

95
Q

Would you consider immobility and rheumatoid arthritis for lung cancer operations?

A
96
Q

Would you consider a patient with cirrhosis as fit for surgery?

A

NO WAY HOSE

see week 4 ‘assessment and surgical treatment of lung cancer’

97
Q

What routine lung function testing would you do on our lung cancer patients?

A

spirometry and diffusion studies on ALL patients and franctionated V/Q scan

98
Q

4 fitness for surgery cardiac assessment scans?

A

ECG
CT (all patients)
ECHO (all patients)

if coronary arteries very calcified, coronary angiogram

99
Q

How many patients coming in for lung cancer surgery have confirmed lung cancer?

A

Only like 1/2

need to be clear that they MIGHT NOT NEED TO HAVE LUNG REMOVED so that they don’t sue surgeon

100
Q

If not confirmed lung cancer, but doing operation anyway, what might you consider doing?

A

frozen sections during operation to confirm the malignancy is present

101
Q

Would you consider doing frozen sections during a lobectomy/pneumonectomy?

A

not essential for lobectomy, certainly consider during pneumonectomy

102
Q

COPD is not associated with clubbing of the fingers. Is lung cancer?

A

yes
also of toes
e.g. ‘have you noticed recently it has become more difficult to cut their toe nails?’ as club toenails are more difficult to cut than non-clubbed ones.

103
Q

What’s a wedge resection/ segmentectomy?

A

just tryna chop actual tumour out, not even whole lobe

if segmental, ‘dividing up’ surgically,
or if use staple guns, then use wedge resection

104
Q

Most common reason of peri-operative death?

A

ARDS, adult respiratory death syndrome

never really know aetiology, but usually had interstitial lung disease alongside cancer, and this was activated by stress of the operation

105
Q

mortality for ADRS after lung resection?

A

50%

106
Q

mycardial infarction and chest infection, occur due to lung resection peri-operational deaths?

A

yes

107
Q

What’s post-pneumonectomy empyema?

A

whole chest cavity is full of pus, very serious

108
Q

BPF, bronchopleural fistula is what

A

large space
negative pressure
chest wall partially collapses
But fluid in space where lung was, negative pressure still there causes air to be sucked in through staple lines

109
Q

whats the commonest type of bronchopleural fistula?

A

post-pneumonectomy, becomes very difficult to eradicate once established

110
Q

Why might someone with BPF have repeated chest infections?

A

Because material in the empyema space leaks into the trachea, and then that infected material can be aspirated into the good lung

111
Q

What does aspirated mean

A

can refer to accidental breathing in of food or fluid into the lungs, can cause pneumonia and other lung problems

food’d would need to be removed

112
Q

If large bronchopleural fistula, inefficient what

A

inefficient ventilation, because a lot of what they breathe in goes to this dead space , so not much getting to the good lung

113
Q

would you remove non-functioning adrenal nodules

A

not really if they’re benign

114
Q

‘must be fairly central because it’s causing collapse of the lung’ is referring to what

A

a tumour, get a PET scan now plz

115
Q

mortality for pneumonectomy

A

5-10%

116
Q

They might develop another lung cancer, right? So how often do you follow up with X-Rays

A

5 years, once a year maybe

117
Q

What’s the most common thing for what we thought was lung cancer but actually wasn’t?

A

TB, lung abscess (tho infected lung abscesses can be associated with lung cancer)

then benign tumours
then granulomas
then fibrosis

118
Q

most common cancer in world?

A

lung and breast together

119
Q

Once you see an opacity in a chest X-Ray, what do you do next?

A

Get tissue sample via Biopsy: Bronchoscopy/EBUS
CT guided
US guided

120
Q

Once we have a tissue sample from biopsy for lung, what are the two categories we can put them into

A

non-small cell lung cancer (85%)- adenocarcinoma and squamous mainly
small cell lung cancer (15%)

121
Q

Is adenocarcinoma and squamous non-small cell or small cell

A

non-small cell

122
Q

When would you move onto doing a PET scan?

A

When we think we need to move the patient onto curative treatment, as a PET scan is more sensitive.

123
Q

What happens at a MDT meeting?

A

Discuss new cancer diagnosis (staging, history, wishes and fitness)
Therefore discuss therapeutic options, surgery or not, pallaitive or not, combo etc, or supportive care

124
Q

ECOG performance status management 0-5 meaning

A

symptomatic, light work, rest for less than half the day, rest for more than half the day, bedbound, dead.

125
Q

Doubling time for non-small cell lung cancer

A

129 days

126
Q

Remember what the TNM means

A

size of tumor, nodes involvement, metastasis

127
Q

Would you other surgery if you have disease elsewhere?

A

No because it’s a curative treatment option only

128
Q

Can chemo be given post-operatively or not

A

yes to reduce chance of recurrence

129
Q

Is neo-adjuvant therapy pre or post op.

A

Adjuvant therapy given before the main treatment is called neoadjuvant therapy. This type of adjuvant therapy can also decrease the chance of the cancer coming back, and it’s often used to make the primary treatment — such as an operation or radiation treatment — easier or more effective.

130
Q

is neo-adjuvant therpy used in lung cancer clinical practice

A

no, may in future, we’ll see

131
Q

Why is radical radiotherapy given

A

With intent to cure

132
Q

For radical radiotherapy, what type of test is essential?

A

pulmonary function test is essential

133
Q

What is concurrent chemotherapy?

A

It is systemic treatment, RT and chemo (tho addition of chemo increases toxicity, therefore patients have to be quite fit for that)
chemo goes in via drip (more systemic you see)

134
Q

chemotherapy can radio sensitize, what does that mean?

A

make cancer cells more sensitive to radiotherapy

135
Q

Is there a standard chemo regime in the UK?

A

no

136
Q

when combining chemotherapy and radiotherapy, is the radiotherapy planning the same as before

A

yes

137
Q

To whom is adjuvant immunotherapy available to?

A

Those who have stage three non-small cell lung cancer, or who have had chemotherapy

138
Q

Why SABR? (stereotactic ablative radiotherapy)

A

high dose, so if the lung cancer is quite small and peripheral, useful if not fit for surgery, more peripheral the better, only up to 4cm

139
Q

Options in palliative treatment?

A

chemotherapy
immunotherapy
palliative radiotherapy

combo of the above

140
Q

How is palliative chemotherapy given?

A

Given as doublet regime, two drugs given as IV infusion every 3 weeks- 3 is as good as 6 months

strike balance, improve quality of life over length of life

141
Q

Palliative immunotherapy, do patients need to be fit

A

not as fit as for chemo

142
Q

How does palliative immunotherapy ‘unmask’ cancers

A

Cancers are good at masking themselves via PDL1 expression, PDL1 is a protein that prevents immune system attacking cells in the body.
Immunotherapy however upregulates immune cells to unmask cancers

143
Q

Immunotherapy drug example

A

nivolumab

144
Q

What are TKI’s

A

Tyrosine Kinase Inhibitors, for those who have a targetable mutation.

145
Q

Example of driver mutation for palliative TKI’s

A

EGFR, and also BRAF

146
Q

TKI’s are often for smokers

A

nah, usually younger non-smokers who weren’t expecting lung cancer, they do well on this

147
Q

IRESSA specifically targets what type of driver mutation

A

EGFR

148
Q

Doubling time of nsclc is 129 days, what is the doubling time of small cell lung cancer?

A

29 days

149
Q

Similar or dissimilar symptoms in small cell lung cancer vs not?

A

similar, but more association with secretory syndromes eg SIADH, Cushing’s
also more often, a shorter duration

150
Q

is surgery offered for small cell lung cancer?

A

Not generally unless caught very very early

151
Q

Curative treatment for SCLC?

A

CRT, chemo and radiotherapy combo, slightly differnt to nsclc but still doublets

152
Q

Is there an advantage to high dose chemo therapy in SCLC?

A

no, nor for alternating chemo

153
Q

Role of prophylactic cranial radiation?

A

Prevent development of brain metastases

154
Q

What type of cell does chemotherapy target?

A

Cells that are dividing quickly e.g. cancer cells, hair, bone marrow

therefore bone marrow suppression, neutrophils can be low

155
Q

why neutrophenic sepsis

A

neutrophils low due to chemotherapy

156
Q

Immunotherapy side effects:

A

pretty much anything itis, colitis, pneumonitis, dermatisis (downregulate immune system with steroids)

157
Q

With either chemotherapy or radiotherapy, is there increased risk of 2nd malignancies?

A

with radiotherapies eg breast cancers etc

158
Q

How many patients are diagnosed too late to cure?

A

80%

159
Q

Patients on chemotherapy are at risk of neutropaenic sepsis

A

true

160
Q

Neo-adjuvant treatment is given after a definitive procedure

A

false, neo is before

161
Q

any questions about non surgical management of lung cancer ask:
andrew.duncan@nhs.scot

A

yeah

162
Q

What’s in a fag?

A

Highly engineered products:
tobacco
filter
filler
additives
paper
smoke

163
Q

Cigarette smoke contain approx 3000 chemicals

A

more than 4000 actually

164
Q

Is arsenic, cadmium and hydrogen cyanide in cigarette smoke?

A

yes all three

165
Q

Is there CO in cigarette smoke?

A

yes

166
Q

Is there acetone in cigarette smoke?

A

yes

167
Q

In Scotland, how many deaths a year from smoking?

A

10,000 deaths a year

168
Q

On average, how many years of life do patients who smoke lose? Top three causes?

A

7.5 years (from Lung cancer, COPD, heart disease)

169
Q

What other cancers could you get from smoking?

A

upper resp
bladder
pancreas
oesophagus
kidney

170
Q

Cardiovascular diseases from smoking?

A

coronary artery disease
peripheral vascular disease

171
Q

Gastroenterology diseases from smoking?

A

peptic ulceration
crohn’s disease

172
Q

Could you get type II diabetes mellatis from smoking?

A

yes

173
Q

What dermatology illness could you get from smoking?

A

psoriasis

174
Q

You’re less likely to get uterine carcinoma if you smoke

A

yes

175
Q

You’re less likely to get peptic ulceration if you smoke

A

wrong, def more likely

176
Q

You’re less likely to get ulcerative colitis if you smoke

A

true

177
Q

People in deprived areas are how many times more likely to smoke

A

3 x

178
Q

Second hand smoke increases the risk of bronchitis, bronchiolitis, cot death true or false

A

true

179
Q

How much nicotine do you get from vaping compared to a cig puff

A

nicotine hit is about 25-50%

180
Q

Which is worse, second hand smoking or maternal smoking for sudden infant death?

A

maternal = 3x more likely, 2nd hand = 45% more likely

181
Q

Stopping smoking: risk of heart attack falls how much after 15 years?

A

The same as someone who has never smoked

182
Q

After ten years quitting, risk of lung cancer falls to what?

A

About half that of a continuing smoker

(Emily) semester 2 (7 decks)

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