Lung Cancer Flashcards

1
Q

What are some risk factors of lung cancer?

A
  • Age, peak 75-90
  • Lower socioeconomic status
  • Smoking history
  • duration, intensity, when stopped
  • Passive smoking
  • Asbestos – exposure (plumbers, ship-builders, carriage workers, carpenters, etc) – risk up to x2
  • Radon – e.g. silver miners in Germany late 19th century; 1950s uranium mining in Colorado
  • Indoor cooking fumes – wood smoke, frying fats
  • Chronic lung diseases (COPD, fibrosis)
  • Immunodeficiency
  • Familial/ genetic – several loci identified
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2
Q

Describe the pathogenesis of lung cancer

A
  1. Lung cancer may arise from all differentiated and undifferentiated cells
  2. The interaction between inhaled carcinogens and the epithelium of upper and lower airways leads to the formation of DNA adducts: pieces of DNA covalently bound to a cancer-causing chemical
  3. If DNA adducts persist or are misrepaired, they result in a mutation and can cause genomic alterations.
  4. These are key events in lung cancer pathogenesis, especially if they occur in critical oncogenes and tumour suppressor genes.
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3
Q

What are the different types of lungs cancers?

A
  1. Squamous cell carcinoma (~30% of cases).
    – previously the most common
    – originating from bronchial epithelium; centrally located [relates to smoking]
  2. Adenocarcinoma (~40%)
    – most common from 1980s onwards – low tar cigarettes, inhaled more deeply / retained longer
    – originating from mucus-producing glandular tissue; more peripherally-locate
  3. Large cell lung cancer (~15%)
    heterogenous group, undifferentiated [difficult to treat because it’s not well understood]

1-3 often grouped together: non-small cell lung cancer (NSCLC)

  1. Small cell lung cancer (~15%)
    originate from pulmonary neuroendocrine cells
    highly malignant [most aggressive- grows v. quick BUT also responds to treatment quickly]
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4
Q

What mutations/ genes are targetted in the treatment of lung cancer?

A

“driver mutations”
MAIN ONE:
1. epidermal growth factor receptor (EGFR) tyrosine kinase
* 15-30% of adenocarcinoma
* more so in women, Asian ethnicity, never-smokers

OTHER GENES ALSO TARGETED:
2. anaplastic lymphoma kinase (ALK) tyrosine kinase
* 2-7% of non-small cell lung cancer
* especially in younger patients and never smokers
3. c-ROS oncogene 1 (ROS1) receptor tyrosine kinase
* 1-2% of non-small cell lung cancer
* especially in younger patients and never smokers
4. BRAF (downstream cell-cycle signalling mediator)
* 1-3% of non-small cell lung cancer
especially in smokers

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5
Q

What are the key symptoms of lung cancer?

A

(Or frequently asymptomatic- symptoms usually arise after the cancer has already advanced)
- Cough
- Weight loss
- Breathlessness
- Fatigue
- Chest pain
- Haemoptysis

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6
Q

What are the features of advanced/ metastatic disease

A
  1. Neurological features: (cancer spreads outside of thorax)
    * focal weakness, seizures, spinal cord compression
  2. Bone pain
  3. Paraneoplastic syndromes:
    * clubbing, hypercalaemia, hyponatraemia, Cushing’s
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7
Q

What are the clinical signs of lung cancer?

A
  1. Clubbing (swollen fingers/ nails- non specific sign)
  2. Horner’s syndrome (constriction of pupil= droopy eye- usually associated with pancreas tumors)
  3. Cachexia (“wasting” disorder that causes extreme weight loss and muscle wasting, and can include loss of body fat.)
  4. Pemberton’s sign (Superior vena cava obstruction= when the patient lifts their arm’s there is reduced venous return due to the block- their face turns red)
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8
Q

What is wrong with lung cancer screenings as a diagnostic tool?

A

Diagnoses the lung cancer only after the patinet becomes symptomatic (too late)

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9
Q

What is the diagnostic strategy used for suspected lung cancer?

A
  1. Establish most likely diagnosis
  2. Establish fitness for investigation and treatment (e.g. if they’re too fragile, have irreversible cognitive decline, etc)
  3. Confirm diagnosis (tissue sample)
    * specific type of cancer if considering systemic treatment (histologically)
  4. Confirm staging (v. important as this will influence the treatment they receive)
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10
Q

What are some features seen on an X-ray of a lung cancer patient?

A
  • Lung tumor
  • Mass in the lungs
  • Fluid “pleural effusion” could be caused by a mass
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11
Q

What are some features seen on a CT scan of a lung cancer patient?

A
  • Irregular masses
  • Lymph nodes infiltrated with carcinoma’s
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12
Q

What are some features seen on a PET scan of a lung cancer patient?

A

“radioactive drug to show up areas of your body where cells are more active than normal”
(definitive imaging for staging)
- Drug used= fluorodeoxyglucose (isotope of glucose)
- Goes to abnormal areas/ areas of rapid cell growth (tumors are areas that require high amounts of energy; attract the fluorodeoxyglucose)

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13
Q

Based on what features, do you choose the type of biopsy you conduct?

A

Choose method based on accessibility, availability and impact on staging

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14
Q

What are the types of biopsy you might consider to diagnose lung cancer? When would you choose each one?

A
  1. Bronchoscopy: [give sedation, place 5mm of flexible endiscope into airway, add saline +suck out+ study the sample, take out 5/6 pieces from lesions]
    - for tumours of central airway
    - where tissue staging not important
  2. Endobronchial ultrasound and transbronchial-needle aspiration of mediastinal lymph nodes (EBUS [TBNA]) [look at the lymph glands not masses- checks for metastases]
    - To stage mediastinum +/- achieve tissue diagnosis
  3. CT-guided lung biopsy: [need to ensure patient has good lung function
    - To access peripheral lung tumours
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15
Q

What are the different stages of lung cancer in accordance to IASLC (International Association for the Study of Lung Cancer) TNM 8th edition lung cancer staging system

A

TNM= tumor, nodes and metastases

Tx= tumour in sputum/ bronchial washings but not asses in imaging or bronchoscopy
T0= No evidence of tumor
T1= ≤ 3 cm surrounded by lung/ visceral pleura, not involving main bronchus
T2= >3 to ≤5 cm or involvement of main bronchus with carnia, regardless of distance from carina
T3= >5 to ≤7 cm in greatest dimension
N1,2 or 3
M1= distant metastases

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16
Q

How can lung cancer be staged (other than the IASLC TNM system)?

A

Early vs locally-advanced vs metastatic

17
Q

what are the Determinants of treatment for lung cancer?

A
  1. Patient fitness
  2. Cancer histology [drives choice of treatment]
  3. Cancer stage
  4. Patient preference
  5. Health service factors (how quickly can we see patients/ get a CT/ PET scan- health inequality or inequity)
18
Q

How is patient fitness test according to the WHO performance status?

A

0 – Asymptomatic (Fully active, able to carry on all predisease activities without restriction)
1 – Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work)
2 – Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours)
3 – Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)
4 – Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)
5 – Death

Radical treatment usually restricted to PS 0-2

Comorbidity + lung function also very important

19
Q

What is the surgical approach for lung cancer?

A
  • Surgical resection is standard of care for early stage disease
  • Lobectomy + lymphadenectomy usual approach
  • Sublobar resection/ wedge resection if stage 1 (≤3 𝑐𝑚)
  1. “Wedge resection” removes a small section of lung that contains the tumor along with a margin of healthy tissue (usually used for diagnosis if tumor has advanced quite far)
  2. “Segmental resection” removes a larger portion of the lung, but not the entire lobe (need to ensure clear margines to avoid future growths- if tumor is quite large whole lobes can be removed- risk of future resp issues)
  3. “Lobectomy” removes the entire lobe of one lung
  4. “Pneumonectomy” removes an entire lung
20
Q

When is radical radiotherapy used for treatment of lung cancer?

A
  • Alternative to surgery for early stage disease
  • Particularly if comorbidity
  • Stereotactic ablative body radiotherapy (SABR):
  • Technique of choice
  • High-precision targeting, multiple convergent beams
21
Q

Explain the systemic treatment for lung cancer that is oncogene directed

A

First line for metastatic NSCLC with mutation