17. Lung Cancer

Question 1

What is the most common disease that you would see in the apex of a CXR

Answer 1

TB

Question 2

How would you calculate the risk of someone having lung cancer

Answer 2

use a bayesian calculator or use Brock calculator (on medical it is called solitary pulmonary nodule SPN)

Question 3

The SPIKES model is used for breaking bad news

what does SPIKES stand for

Answer 3

• Setting
• Patients perception
• invitation to continue with the explanation
• knowledge in small chunks
• empathy for the shock or other emotions
• strategy what you and the patient are going to do

Question 4

What are the two main categories of lung cancer

Answer 4

none small cell lung cancer which includes;
- squamous cell carcinoma (35%)
- adenocarcinoma (25%)
Small cell lung cancer (20%)

Question 5

which of the lung cancers tend to release neuroendocrine hormones

Answer 5

small cell lung cancer

Question 6

what are the signs and symptoms of lung cancer

Answer 6

SOB
cough 
Haemoptysis (coughing up blood)
finger clubbing 
recurrent pneumonia 
weight loss 
lympathadenopathy- often supraclavicular nodes

Question 7

What findings on a CXR would be suggestive of lung cancer

Answer 7

Hilar enlargement
“Peripheral opacity” – a visible lesion in the lung field
Pleural effusion – usually unilateral in cancer
Collapse

Question 8

What and Why would you use a PET-CT

Answer 8

inject a radioactive tracer (usually attached to glucose molecules) and take images
metabolically active areas are identified and so this could indicate cancer

Question 9

Why is a bronchoscopy with end-brachial ultrasound (EBUS) used

Answer 9

allows detailed assessment of the tumour and ultrasound guided biopsy

Question 10

Which kind of lung cancer would be offered surgery as first line

Answer 10

non-small cell lung cancer

note that radiotherapy can also be used to treat this kind of cancer when early enough

Question 11

what is the treatment of small cell lung cancer

Answer 11

chemotherapy and radiotherapy

Question 12

prognosis is generally worse for which kind of patient

Answer 12

the ones with small cell lung cancer

Question 13

What endobronchial treatments can be used as part of palliative treatment to relieve bronchial obstruction caused by lung cancer

Answer 13

stents or debulking

Question 14

Extra-pulmonary manifestations and paraneoplastic syndromes:
- why would you get a hoarse voice

Answer 14

recurrent laryngeal nerve palsy as cancer is pressing one it as it moves through the mediastinum

Question 15

Extra-pulmonary manifestations and paraneoplastic syndromes:
- why would you get SOB

Answer 15

phrenic nerve palsy due to nerve compression so diaphragm weakness

Question 16

Extra-pulmonary manifestations and paraneoplastic syndromes:
-why would someone present with facial swelling and distended veins in neck and upper chest

Answer 16

superior vena cava obstruction

Question 17

Extra-pulmonary manifestations and paraneoplastic syndromes:
- why would someone get corners syndrome (partial ptosis, anhydrous and myosis)

Answer 17

Pancoast tumour (tumour in pulmonary apex) pressing on the sympathetic ganglion

Question 18

Extra-pulmonary manifestations and paraneoplastic syndromes:
- if the tumour is causing syndrome of inappropriate ADH (SIADH) then what does this cause and what kind of lung cancer do they have

Answer 18

ectopic ADH secretion by a small cell lung cancer and presents with hyponatraemia

Question 19

Extra-pulmonary manifestations and paraneoplastic syndromes:
- if the small cell lung cancer releases ectopic ACTH then what condition can this cause

Answer 19

Cushings

Question 20

Extra-pulmonary manifestations and paraneoplastic syndromes:
- Hypercalcaemia is caused by ectopic parathyroid hormone released from which kind of lung cancer

Answer 20

squamous cell carcinoma

Question 21

Extra-pulmonary manifestations and paraneoplastic syndromes:
- can cause limbic encephalitis. What is it

Answer 21

small cell lung cancer causes immune system to make antibiotics to tissues in the brain (limbic system) causing inflammation
results in short term memory impairment, hallucinations, confusion and seizures
associated with anti-Hu antibodies

Question 22

What is Lambert-eaton myasthenia syndrome

Answer 22

result of antibodies produced against small cell lung cancer cells

also target and damage VG calcium channels on motor neurones

leads to weakness in proximal muscles but also intraocular muscle, elevator muscles and pharyngeal muscles so symptoms similar to myasthenia gravis

Question 23

What is mesothelioma

Answer 23

lung malignancy affecting mesothelial cells of the pleura
strongly linked to asbestos
huge latency period with very poor prognosis
chemo can improve survival but is essentially palliative

Question 24

what is a carcinoma

Answer 24

begins in the skin or the tissue that covers the surface of internal organs and glands

Question 25

what are the common primary sites for secondary lung cancers

Answer 25

breast kidney bladder testis

Question 26

what are the 2 types of primary lung cancers

Answer 26

small cell | non small cell - Squamous and adenocarcinoma

Question 27

what is an adenocarcinoma

Answer 27

cancer that begins in the glandular cells

Question 28

Name some other differentials to lung cancer which also show CXR changes

Answer 28

``` TB pneumonia lung metastases from other primary cancers benign lung tumours rarities eg Wegeners granulomatosis ```

Question 29

Name some criteria for which lung cancer is no operable

Answer 29

``` o There is distant metastasis o Mediastinal spead eg recurrent laryngeal nerve palsy o Phrenic nerve palsy o Poor pulmonary function o Frequent angina/heart failure o Psychological failure ```

Question 30

What drug is licensed to treat lung cancer if there is a epidermal growth factor receptor (EGFR) mutation

Answer 30

Gefitinib

Question 31

In the cell cycle what protein is the guardian of the genome which controls the cell cycle by blocking cell cycle progression

Answer 31

P53 gene

Question 32

what is the role of the p21 proteins

Answer 32

inhibit CDK

Question 33

Complications of lung cancer: | - what does non small cell lung cancer produce which causes for increased calcium

Answer 33

parathyroid related protein

Question 34

complications with lung cancer; | - what kind of hormones can a small cell lung cancer release and what problems do these cause

Answer 34

ADH which increase blood pressure and can lead to low potassium ACTH will increase corticosteroids so reduce immune function

Question 35

what is the commonest cause of high calcium

Answer 35

malignancy

Question 36

which gland helps to regulate calcium ions

Answer 36

parathyroid gland by releasing parathyroid hormone which increases calcium  In kidney cause tubules in nephron to increase reabsorption of calcium  In bones it stimulates osteoblasts to release RANKL and then this stimulates osteoclasts which break down bone into calcium in the blood stream  Stimulates gut to increase absorption of calcium

Question 37

tumour cells from which cancers can release parathyroid related proteins which leads to an increase in calcium

Answer 37

o Anxiety, depression, cognitive changes, lethargy (neurones) o Cramping of muscles, N/V and GI symptoms(smooth muscles) o Sinus arrythmias or ventricular arrythmias (cardiac)

Question 38

What are the main treatments for high calcium

Answer 38

there are many different options but some main ones include Iv fluids and diuretics but can also consider bisphosphonates if the high calcium is due to cancer

Question 39

What CXR finding is suggestive of exposure to asbestos and name some other problems with asbestos inhalation

Answer 39

thickening/pleural plaques * Lung fibrosis * Pleural thickening and pleural plaques * Adenocarcinoma * Mesothelioma

Question 40

What is asbestosis

Answer 40

lung fibrosis related to inhalation of asbestos