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Respiratory system > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

give some aetiological factors of lung cancer

A 
> tobacco
> asbestos
> environmental radon
> occupational exposure (chromates, nickels, hydrocarbons)
> air pollution 
> pulmonary fibrosis
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2
Q

what is the safe smoking threshold?

A

there is no safe smoking threshold is risk is related to consumption

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3
Q

describe the multi hit theory that leads to carcinogenesis

A

there needs to be between three and twelve molecular changes happening in a particular order in stem cells to create a malignant tumour. the host may activate pro-carcinogens, or inherit polymorphisms that predispose an individual (metabolism of pro-carcinogens and nicotine addiction).

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4
Q

what sort of carcinogenesis occurs in the lung periphery?

A

bronchiolalveolar epithelium stem cells transform creating an adenocarcinoma

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5
Q

describe carcinogenesis occurring in the central lung airways

A

here bronchial epithelial stem cells transform crating squamous cell carcinomas

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6
Q

what is a smoking induced mutation in adenocarcinogenesis?

A

KRAS 35%

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7
Q

name some genetic mutations that are not induced by smoking that lead to carcinogenesis

A

> EGFR 15%
BRAF, HER2 2% (each)
ALK rearrangements 2%

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8
Q

name some tumours in the bronchial glands

A

> adenoid cystic carcinoma
mucoepidermoid carcinoma
benign adenomas

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9
Q

what are the four main cell types in a carcinoma?

A

> squamous cell 40%
adenocarcinoma 41%
large cell carcinoma 4%
small cell carcinoma 15%

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10
Q

why is primary lung cancer often only diagnosed late in its history?

A

it grows silently for many years and can have few signs and symptoms

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11
Q

what effects can a lung cancer have on bronchial obstruction?

A

> collapse
endogenous lipoid pneumonia
infection/ abscess
bronchectasis

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12
Q

what effect can cancer have on the nerves?

A

> it can degrade the phrenic nerve paralysing the diaphragm
L recurrent laryngeal innervating the voice box, this causes a bovine cough
brachial plexus
cervical sympathetic causing horners syndrome

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13
Q

describe horners syndrome

A

there is a tiny pupil and he inability to open ones eyelid properly. this is caused by cancer affecting the cervical sympathetic nerves.

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14
Q

what happens when the superior vena cava is blocked by a cancer?

A

the veins in the head cannot drain, they dilate to compensate for this but still cant drain.

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15
Q

what sort of lung cancer would cause limb weakness, paraesthesia and bladder dysfunction?

A

metastatic cancer that is compressing the spinal cord

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16
Q

what symptoms would a cerebral metastasis cause?

A 
> headache
> vomiting
> dizziness
> ataxia
> focal weakness
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17
Q

name some paraneoplastic symptoms of advanced lung cancer

A

> hyponatraemia: low Na conc. in the blood
anaemia
hypercalcaemia (bone metastasis, parathyroid hormone related problem)
dermatomyositis
eaton-lambart syndrome (upper limb weakness)
cerebellar ataxia
sensorimotor

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18
Q

what is dermatomyositis?

A

inflammatory disorder in which the skin and underlying tissues (including the muscles) are affected by a purple skin eruption.

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19
Q

what is polymyositis?

A

the absence of dermatomyositis

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20
Q

what are the initial investigations for suspected lung cancer?

A 
> CXR
> full blood count (they may also have anaemia
> renal and liver functions
> clotting screen
> spirometry
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21
Q

what cancer s are associated with smokers?

A

squamous and small cell

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22
Q

what does T staging involve?

A

T staging is based on the size of the tumour and its proximity to the chest wall.

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23
Q

what does N staging look at?

A

N staging looks at metastasis to the lymph glands. N0 has no regional lymph node involvement.

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24
Q

what does M staging involve?

A

this is staging based on the metastasis of the cancer, M0 has no distant metastasis while M1 does.

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25
Q

to what stages is creative treatment given to?

A

stages one and two

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26
Q

describe how the patient is given a performance status

A 
0= fully active
1= symptomatic
2= up and about > 50% of the time
3 = up and about < 50% of the time
4 = bed/chair bound
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27
Q

name three types of surgery given to patients with lung cancer

A

> wedge resection
lobectomy
pneumonectamy

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28
Q

after a CXR has been carried out confirming that the lesion is intrapulmonary what do you do?

A

do a CT scan and evaluate size, border, density, whether it is solid

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29
Q

define a pulmonary mass

A

an opacity in the lung over 3cm with no mediastinal adenopathy or atelectasis

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30
Q

what is a pulmonary nodule?

A

an opacity in the lung up to 3cm with no mediastinal adenopathy or atelectasis

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31
Q

what could a solitary mass or nodule seen on a CXR be?

A

> lung cancer
metastasis
benign neoplasm
infection (bacterial, fungal)

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32
Q

what would you do to find out how close to the carina the cancer is?

A

a bronchoscopy

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33
Q

what is the labelled analogue used in FDG PET?

A

18F-FDG

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34
Q

what is the half body time of 18FDG?

A

60 minutes

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35
Q

what does it mean:
>TX
>T0

A

> that a primary tumour could not be assessed

> no evidence of a primary tumour

36
Q

describe a T1 tumour

A

it is less than 3cm in greatest dimension and is surrounded by lung or visceral pleura, there is no bronchoscopic evidence of involvement with the main bronchus

37
Q

what is the difference between a T1a, a T1b and a T1c tumour?

A

> T1a is a minimally invasive adenocarcinoma <= 1cm at its greatest dimension
T1b tumour is <= 2cm
T1c tumour is <= 3cm

38
Q

describe a T2 tumour

A

it is more than 3cm in length but less than 5.
it has one of the following features:
> involvement with the main bronchus
> invasion of the visceral pleura
> associated with atelectasis or obstructive pneumonitis that extends to the hilar region involving all or part of the lung

39
Q

which is bigger a T2a tumour or a T2b tumour?

A

a T2b tumour which is between 4 and 5 cm (a T2a is between 3 and 4cm)

40
Q

describe a T3 tumour

A

it is more than 5cm but less than 7cm that directly invades either the chest wall, phrenic nerve or parietal pericardium. or if it is a separate tumour nodule in the same lobe as the primary

41
Q

if a tumour invades the oesophagus what T staging is it given?

A

T4

42
Q

If a tumour nodule is in a different ipsilateral lobe what staging is it given?

A

T4

43
Q

A tumour with N1 staging has spread to which nodules?

A

ipsilateral peri-bronchial, hilar or intrapulmonary nodes (including by direct extension)

44
Q

what can a CT scan tell us about metastasis to nodes?

A

it can tell you the prevalence of metastasis via the size of the nodes

45
Q

what does an M1a staging of a tumour tell us?

A

that there is a separate tumour nodule in a contralateral lobe or that the tumour is with the pleural or pericardial nodes, or a malignant/pericardial effusion.

46
Q

What does a M1b staging tumour tell us?

A

that there is a single distant metastasis

47
Q

what does M1c staging of a tumour tell us?

A

that there are multiple distant metastasis

48
Q

a patient with a tumour that is T2, N1 and M1 has a survival chance of what?

A

1%

49
Q

a patient with a T1, N0, M0 tumour has a survival chance of what?

A

67%

50
Q

what lymph node metastasis can be resected with the lung?

A

N1, the metastasis to the hilar lymph nodes. N2 resection is a separate surgery.

51
Q

where does the pharyngeal nerve pass through in the thorax?

A

the aortic-pulmonary window, the area between the aortic arch and pulmonary vein.

52
Q

what is phrenic nerve palsy?

A

this is when a tumour has degraded the phrenic nerve, paralysing the hemi diaphragm.

53
Q

what can a collapsed lobe make more difficult when looking at a CXR?

A

it can make it hard to discriminate between the lung and the cancer. leading to an open and close surgery where they cannot operate on the lung.

54
Q

what blood tests would you carry out when staging a cancer for surgery?

A

> full blood count to check for anaemia
Liver function tests
Bone profile (this can be altered to due to disease

55
Q

why is an MRI useful for staging cancer for surgery?

A

it determines the degree of vascular and neurological involvement in pancoast tumour

56
Q

describe mediastinoscopy

A

By making a cut behind the breast bone and going down the trachea looking at the tracheal nodes.

57
Q

what do you need to assess clinically when deciding if a patient is fit for surgery?

A

> cardiovascular system
respiratory system
mental health
others, such as arthritis, pulmonary hypertension

58
Q

how is the respiratory system tested when deciding if a patient is fit for surgery?

A

> spirometry
diffusion study (inhalation of CO2)
arterial blood gases on air
fractionated V/Q scan

59
Q

what investigations are carried out in cardiac assessment when deciding if a patient is fit enough to under go surgery?

A

> ECG
ECHO
CT scan
coronary angiogram

60
Q

what problems may be encountered when staging lung cancer?

A

> collapse of a lobe/ lung making it difficult to assess the tumour size
presence of another pulmonary nodule
retrosternal thyroid
adrenal nodule

61
Q

what are some fatal complications in surgery?

A 
> adult respiratory syndrome, accumulation of fluid in the lung
> bronchopneumonia
> myocardial infarction
> pneumothorax
> intrathoracic bleeding
62
Q

what are some non-fatal complications of surgery?

A 
> pain
> empyema
> wound infection
> broncho pulmonary fistula (the broncho stump gets a hole in it and the fluid in the pleural space is coughed up)
> MI
> post op respiratory insufficiency
> constipation
63
Q

how aggressive is small cell lung cancer?

A

very, it doubles in size every 29 days

64
Q

what do the therapeutic options for non-small cell lung cancer depend on?

A

> stage
eastern cooperative group performance status
patients wishes

65
Q

what is the surgical 5 year survival in non-small cell lung cancer?

A

40%

66
Q

what is adjuvant therapy?

A

this is post operative therapy to increase the chance of a cure.

67
Q

what stages on NSC lung cancer is adjuvant radiotherapy detrimental?

A

in stage one and two (though there can be some benefit in N2 metastasis or if there is marginal involvement)

68
Q

when is neo-adjuvant therapy given in NSC lung cancer and why?

A

in stage 3 as preoperative chemotherapy demonstrates a very significant survival advantage

69
Q

what are treatment decisions of advanced NSC lung cancer affected by?

A

co-morbid diseases such as angina

70
Q

what is the dose of radical chemotherapy given to stage 3 NSC lung cancer patients?

A

the dose is 55Gy+

71
Q

what is the main side effect of radical chemotherapy given to stage 3 NSC lung cancer patients?

A

inflammation and fibrosis

72
Q

what is the survival rate of stage 3 NSCLC patients given radical radiotherapy?

A

5 year survival rate is 20%

73
Q

what treatment is given to stage 4 NSCLC?

A

palliative only as it is incurable. chemotherapy is given for systematic benefit and increase in survival. medial survival is >12 months with chemo alone.

74
Q

what are the affects of bone metastasis?

A

> pain
pathological fracture
cord compression in the thoraco-lumbar spine can create weak legs and effect bowel movements

75
Q

name driver mutations in an adenocarcinoma?

A

> 15% EGFR mutation
5% ALK translocation
2% BRAF mutation
1% ROS alteration

76
Q

what is the concept of tyrosine kinase inhibitors?

A

targeted therapy for a broad range of common solid tumours.

77
Q

how is the cancer cell rendered invisible to the immune system?

A

tumour cells contain a pdl1 antigen that interacts with the T cell rendering it invisible

78
Q

how does immune therapy “wake up” the immune system?

A

monoclonal antibodies attach to the tumour activating the t cell which can then see and destroy the tumour.

79
Q

what is the effect of nivolumab BMS on the activity of T lymphocytes?

A

this blocks the interaction of PD-1 to PDL-1 and PD-L2. this potentiates the activity of t cells by preventing them from being inactivated.

80
Q

what is the difference in presentation of small cell lung cancer?

A

it can cause secretory syndromes such as SIADH (low sodium confusion) and ACTH.

81
Q

what treatment is given to SCLC patients with limited disease?

A

high dose alternating maintenance chemo

82
Q

what is the medial survival of limited disease small cell lung cancer with treatment compared with no treatment?

A

without is 8 months and with is 16 months

83
Q

what is the 2 year survival of limited disease small cell lung cancer?

A

25%

84
Q

what is the treatment for extensive small cell lung cancer?

A

> 4 cycles of combination treatment therapy
single fraction radiotherapy to palliate if they are not fit for chemo
if there is a brain metastasis they are given RT and steriods

85
Q

what is the difference in survival of extensive small cell lung cancer with treatment compared with no treatment?

A

without: 8 weeks
with: 8 months

Respiratory system (19 decks)

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