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systems: resp > Lung cancer > Flashcards

Lung cancer Flashcards

1
Q

What is the 5 year survival rate for lung cancer?

A

The second worst of all cancers, first in pancreatic. This is mainly due to most patients being unfit for treatment.

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2
Q

Name the 2 main causes of lung cancer.

A

Smoking (80ish%) and asbestos exposure (4% mesothelioma - cancer of the pleura). Other causes (6%) include: environmental radon, occupational exposure (excluding asbestos), air pollution and pulmonary fibrosis.

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3
Q

What % of smokers get lung cancer?

A

10% - more males than females. Over 50% of patients with lung cancer are ex-smokers.

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4
Q

What is the risk of passive smoking?

A

Increases risk 50-100% in a non-smoker, but this is risk from a very low level.

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5
Q

What are the 2 main pathways of carcinogenesis in the lungs?

A

Adenocarcinoma and squamous cell carcinoma.

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6
Q

Describe adenocarcinoma.

A

Cancer of the lung periphery. Bronchioalveolar stem cells become transformed. Associated with newer cigarette formulations and non-smokers. AAH (atypical adenomatous hyperplasia) –> adenocarcinoma in situ –> invasive adenocarcinoma.

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7
Q

Describe squamous cell carcinoma.

A

Occurs in the central lung airways. Bronchial epithelial stem cells transform. This is the classical pathway and is VERY associated with smoking. Squamous dysplasia –> CIS (carcinoma in situ) –> invasive bronchogenic carcinoma.

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8
Q

Why is it important to differentiate between adenocarcinoma and squamous cell carcinoma?

A

They have different therapeutic implications.

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9
Q

Define oncogene addiction.

A

Oncogenes that drive growth of the cancer due to mutation. Most lung cancers are not caused by these.

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10
Q

Give examples of oncogenes found in lung cancer.

A

KRAS (smoking induced, 35% lung cancers), EGFR (15% lung cancers) –> both good targets for drug therapy. BRAF, HER2 and ALK rearrangements –> 2% prevalence each, not related to tobacco carcinogenesis.

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11
Q

What are the different types of tumours of the lung?

A

Benign causes (organising pneumonia), carcinoid tumours (low grade malignancy), bronchial gland tumours (very rare), lymphoma and sarcoma. Mets in the lung are common.

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12
Q

What are the 4 main types of carcinoma?

A

Squamous cell, adenocarcinoma (most), small cell (oat cell) and large cell.

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13
Q

What are the 2 histological types of carcinoma?

A

NSCLC’s (non-small cell 85%) and SCLC (small cell 15%).

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14
Q

Can lung cancers be surgically resected?

A

Only 10% can, but resection cures 50% on these. Generally, symptomatic lung cancer is fatal.

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15
Q

Describe local effects of lung cancer.

A

1) Bronchial obstruction (endogenous lipid pneumonia, abscess, bronchiectasis, haemoptysis), 2) Pleural (inflammatory), 3) Direct invasion (chest wall, nerves: phrenic - diaphragmatic paralysis, L recurrent laryngeal - hoarse, bovine cough as this supplies the larynx, brachial plexus - pancoast T1 damage, cervical sympathetic - Horner’s syndrome, mediastinum - SVC), 4) Lymph node mets (lymphangitis carcinomatosa - tumour spreading throughout the lymphatics of the lung)

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16
Q

Describe distant effects of lung cancer.

A

Distant mets (liver, adrenals, bone skin), neural effects, vascular effects. Paroneoplastic effects: clubbing, endocrine disorders, neurological, cutaneous (dermatomyositis), CV, renal.

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17
Q

Which investigations are used in lung cancer?

A

CXR, bronchoscopy, trans-thoracic fine needle aspiration or core biopsy, pleural effusion and advanced imaging techniques (CT, MRI, PET).

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18
Q

Name the prognostic factors for lung cancer.

A

Stage, classification, gene expression, growth rate, DNA aneuploidy, immune cell infiltration. Prognostic markers may be used to select patients for adjuvant therapy.

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19
Q

What is the prognosis for lung cancer?

A

Less than 9-9% 5YS in Scotland. If cancer is operable at stage 1, 60% 5YS. If cancer is operable at stage 2, 35% 5YS. If cancer is inoperable, treatment is always palliative.

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20
Q

Describe the different prognoses with different lung cancer types.

A

Pure bronchioalveolar carcinoma - 100% 5Ys. NSCLC - between 10 and 25%. SCLC - worst prognosis, 4% 5YS, responds to chemo but always comes back.

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21
Q

What are the predictive biomarkers for adenocarcinoma?

A

KRAS, EGFR, ALK rearrangements, BRAF and HER2 (drugs against ALK and EGFR approved in Scotland).

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22
Q

What are the predictive biomarkers for squamous cell carcinoma?

A

FRFR1 copy number, DDR1 and FGFR2 (no good drugs - use cytotoxic chemo).

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23
Q

Why is lung cancer so important?

A

Most common malignancy. More people die from LC than breast, colorectal and prostate cancers combined. NSCLC doubling time is 129 days, SCLC doubling time is 29 days.

24
Q

Describe TNM staging.

A

T - tumour size. N - nodal involvement. M - distant metastases. Tx: primary tumour cannot be assessed. T0: distant mets found but no evidence of primary tumour. Tis: carcinoma in situ. T1: no invasion or involvement of main bronchus, 3cm 5cm 7cm, tumour in carina, diaphragm, heart etc. No: no regional node involvement. N1: ilselateral hilar/peribronchial. N2: ipselateral mediastinal/subcarinal (on same side). N3: contralateral mediastinal/ hilar/scalene/supraclavicular (different side) (N STAGING BEST SEEN ON PET CT). M0: no mets. M1: mets. M1A: intrapulmonary mets/malignant pleural effusion. M1B: single distant mets. M1C: multiple distant mets.

25
Q

Describe ECOG (Eastern Co-operative group) performance measurement.

A

Measures the patients ability to care for themselves. 0 - asymptomatic, well. 1 - symptomatic, can do light work. 2 - has to rest for less than 50% of the day, cannot work. 3 - has to rest for over 50% of the day, limited self-care. 4 - bed bound. Over stage 2?Most of the time cannot give chemotherapy.

26
Q

What is adjuvant therapy?

A

A therapy given post-operatively to increase the change of cure/reduce risk of cancer coming back.

27
Q

What is neoadjuvant therapy?

A

Administration of therapeutic agents before a main treatment to increase survival - eg. pre-operative chemotherapy.

28
Q

What defines advanced disease in NSCLC?

A

Around 80% present with advanced disease. Stage 3: locally advanced, mediastinal/major vessel invasion or mediastinal lymph node involvement. Stage 4: 60% have distant metastases.

29
Q

What is the benefit of chemoradiotherapy for NSCLC?

A

Increases survival. For stage 4 NSCLC RT and chemo give 70% symptom benefit. Need to measure QOL - bone pain can occur from distant mets which is often worse at night (pathological fractures).

30
Q

What is the 1YS for stage 3 & 4 NSCLC?

A

40%.

31
Q

Name new treatments for NSCLC.

A

Premetrexed (maintenance chemotherapy), TK inhibitors (mAb, BR21 (in patients unfit for chemo), PD1 inhibitor (nivolumab BMS).

32
Q

What is different in presentation of SCLC?

A

Secondary syndromes: SIADH (low Na which causes confusion), ACTH (Cushings) etc.

33
Q

What is the treatment of choice for SCLC?

A

Chemotherapy (cisplatin and etoposide), thoracic RT or prophylactic cranial radiation (PCI). For limited disease: response rate to treatment 90%, complete remission 60%, 2YS 25%. For extensive disease: brain mets RT and steriods, survival with treatment is 8 months.

34
Q

What is the major challenge of lung cancer?

A

80% of patients are diagnosed too late to cure. Survival rate has not changed much since 1970.

35
Q

What are the common causes of a solitary pulmonary nodule?

A

Primary LC’s, mets, infection (TB or pneumonia) or pseudotumours (pulmonary fluid that looks like a tumour).

36
Q

What are less common causes of a solitary pulmonary nodule?

A

Lymphoma, mesothelioma, carcinoid (slow growing neuroendocrine tumour) (malignant), hamartoma (focal malformation) or chondroma (cartilaginous) (benign).

37
Q

What are the most common symotoms of LC?

A

SOB, chronic cough, haemoptysis, weight loss, fatigue, chest pain (recurrent and persistent).

38
Q

What are less common symptoms of LC?

A

Wheeze, dysphagia, hoarse voice, fever and facial swelling.

39
Q

What are common symptoms of metastatic LC?

A

Bone pain, spinal cord compression (limb weakness, paraesthesia), cerebral symptoms (headache, vomiting).

40
Q

Name some paraneoplastic syndromes associated with LC.

A

SIADH (low Na - hyponatraemia), hypercalcaemia, dermatomyositis (VERY associated with malignancy), Eaton-Lambert (upper limb weakness). Patient showing these symptoms? Worse prognosis.

41
Q

What is a pancoast tumour?

A

Tumour of the pulmonary apex. Present as Horner syndrome sometimes and can affect the brachial plexus.

42
Q

Name common clinical signs of LC.

A

Reduced breath sounds on 1 side, chest infections, dullness of percussion, finger clubbing, Horner’s (damage to sympathetic nerves on 1 side of neck), pancoast, SVC obstruction, lymphoadenopathy, hepatomegaly (enlarged liver), skin nodules etc.

43
Q

Describe paraneoplastic syndromes associated with certain LC’s.

A

SMALL CELL: SIADH, Cushings, Eaton-Lambert, SVC and carcinoid. NON-SMALL CELL - squamous: hypercalcaemia, pancoadt, Horner’s. Adenocarcinoma: hypertrophic osteoarthropathy (bone pain in arms and legs). Large cell: gynecomastia SVC syndrome.

44
Q

What is the most important first line investigation?

A

CT scan. Others are CXR, PET, isotope bone scan and head CT (usually CXR then CT).

45
Q

What is stereotactic RT?

A

Targeted RT.

46
Q

Name 3 red-flag symptoms of LC.

A

Smoker/ex-smoker, weight loss, haemoptysis.

47
Q

What is the difference between a pulmonary nodule and a pulmonary mass?

A

Nodule: opacity less than 3cm with no mediastinal adenopathy or atelectasis (incomplete inflation or partial collapse of lung). Mass: opacity over 3cm with no mediastinal adenopathy or atelectasis.

48
Q

When deciding to give treatment, what needs to be taken into consideration?

A

Performance status and pulmonary function.

49
Q

Describe FDG-PET.

A

FDG is a labelled glucose analogue. Tumour cells take it up as they are very metabolically active but cannot expel it.

50
Q

Where are the most common places for LC’s to metastasise?

A

Cerebral, skeletal (symptoms), adrenal and liver (no symptoms).

51
Q

What may blood test results show on a patient with LC?

A

Anaemia, abnormal LFT’s and abnormal bone profile.

52
Q

Name 4 pulmonary function tests that would be be performed before surgery.

A

Spirometry, diffusion studies, ABG and fractioned V/Q scan.

53
Q

Which cardiac tests would be performed to determine if the patient is fit for surgery?

A

ECG, ECHO, CT and corinary angiogram.

54
Q

What is the most common post-op cause of death from LC surgery?

A

Bronchopneumonia.

55
Q

What is the operative mortality from LC surgery?

A

Pneumonectomy: 8-12%. Lobectomy: 3-5%. Wedge resection: 2-3%. Open/close thoracotomy: 5%

systems: resp (19 decks)

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