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CCC > Oncology - Lung > Flashcards

Oncology - Lung Flashcards

1
Q

How common is lung cancer?

What is the prognosis of lung cancer?

A
  • lung cancer is the 3rd most common cancer in the UK
  • 2nd most common WORLDWIDE

-only 10% of patients who are diagnosed with lung cancer live for 5 years or more

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2
Q

What are the different types of lung carcinoma?

What is the most common type?

A
  1. Small cell lung carcinoma (15%)
  2. Non-small cell lung carcinoma (85%)
    a) Squamous cell
    b) Adenocarcinoma MOST COMMON
    c) Large cell carcinoma
    d) Adenocarcinoma in situ
  3. Mesothelioma
  4. Sarcoma
  5. Lymphoma
  6. Carcinoid
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3
Q

What is the most common lung carcinoma?

A

Non small cell, specifically adenocarcinoma

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4
Q

What does small cell lung cancer arise from?

A

Endocrine cells called Kulchitsky cells

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5
Q

What type of lung cancer is more aggressive? What is the treatment?

A
  • Small cell lung cancer
  • Grows rapidly and is highly malignant
  • 70% have metastasised at presentation so often cannot be treated by surgery

Treatment
-They can be very responsive to chemotherapy initially, but often relapse quickly. Overall, prognosis is generally poor

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6
Q

What gene mutations are commonly found in lung adenocarcinomas?

If they have these mutations how does that effect treatment?

A

Adenocarcinoma

  • EGFR
  • ALK
  • ROS1

Most likely to respond to immunotherapy

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7
Q

Which patients is the EGFR mutation more common in?

A

EGFR mutation

East Asian, Young, Females who are non smokers

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8
Q

What are the main causes of lung cancer?

A

Smoking - 90% (most in small cell, then squamous cell)

Occupation:

  • asbestos exposure
  • uranium mining
  • ship building
  • petroleum refining
  • arsenic
  • chromium
  • iron oxide
  • radiation
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9
Q

How does lung cancer usually present in order of most common symptoms?

A

Cough - 80%
Haemoptysis - 70%
Dyspnoea - 60%
Chest pain - 40%

Weight loss, anorexia, lethargy
Recurrent pneumonia

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10
Q

How does an apical/pancoast tumour present? (4)

A

Most pancoast tumours are NSCLC (normally squamous)

Pancoast syndrome

  • Hoarseness of voice (compress on RLN)
  • Horner’s syndrome-ptosis, miosis, anhidrosis
  • Shoulder and arm pain (ipsilateral)
  • Abnormal sensation (paresthesias), muscle weakness (paresis) and wasting (atrophy) of the arm and hand muscles
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11
Q

How can a mediastinal tumour present?

A
  • Hoarseness of voice due to recurrent laryngral nerve palsy (urgent Ent referral)
  • SVC obstruction
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12
Q

What type of lung cancer can cause paraneoplastic syndromes?

A

Small cell lung carcinomas can present with non-respiratory symptoms due to tumours secreting hormones

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13
Q

Give examples of paraneoplastic syndromes caused by SMALL CELL CARCINOMA

A

-Excess ACTH - Cushing’s
-Excess HCG - gynaecomastia
-Excess ADH - SIADH (causes low sodium)
-Lambert-Eaton Syndrome
•Weakness of PROXIMAL lower limbs (difficulty climbing stairs)
•swallowing problems, drooping eye lids, erectile dysfunction)

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14
Q

What are some skin manifestations of lung cancer?

A

Lung cancer-skin manifestations

  • Dermatomyositis
  • Herpes zoster
  • Acanthosis nigricans
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15
Q

What signs might be seen on inspection of the hands in lung cancer?

A
  • Clubbing (more common in squamous cell carcinoma)
  • Anaemia - pale palmar creases
  • Pain in the wrist - hypertrophic pulmonary osteoarthropathy
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16
Q

On auscultation of the chest, what sounds would be heard in lung cancer?

A

Monophonic wheeze due to partial airway obstruction

17
Q

Biggest risk factor for squamous cell carcinoma?

What factors of the investigations would indicate squamous cell carcinoma? (bloods and chest x ray)

A
  • squamous cell carcinoma is especially linked with cigarette smoking
  • SQUAMOUS CELL causes HYPERCALCEAMIA - they secrete PTH-related peptide
  • squamous cell carcinomas often found centrally, close to bronchi-cause bronchial obstruction
18
Q

What factors of the history would indicate adenocarcinoma?

What would the investigations show? (chest x ray and mutations)

A 
Adenocarcinoma (39% of NSCLC) 
History:
- Woman
- Non-smoker
- Asbestos exposure

Investigations:

  • Peripheral tumour
  • EGFR, ALK, ROS1 mutations
19
Q

What might be seen on a chest x-ray in lung cancer?

A

Chest X ray lung cancer
-Nodule
•central = small cell, squamous cell;
•peripheral = adenocarcinoma, large cell
-Hilar enlargement
-Consolidation (due to post-obstructive pneumonia)
-Pleural effusion UNILATERAL
-Lung collapse (atelectasis)
-Bony mets

20
Q

If there is suspicion of lung cancer from a CXR, what following investigations should be carried out?

A

Imaging

  1. Chest X-Ray - is it central or peripheral?
  2. CT TAP with contrast - signs of distant disease (also scan brain)
  3. PET scan -mets not seen on CT

Biopsy
-Bronchoscopy and biopsy
○Endo-bronchial Ultrasound (EBUS) for central nodes
○Trans-thoracic biopsy for peripheral nodes

Lung function
-pulmonary function tests (underlying lung function)
cardiopulmonary exercise testing (are they fit enough for lobectomy)

21
Q

What is the histopathology for squamous cell lung carcinoma?

A

Squamous cell

  • Small blue oval-shaped cells
  • Absent nucleoli
  • Decreased cytoplasm
22
Q

What is the TNM staging for lung cancer?

A

T1-4: tumour size and invasion

N0:lymph nodes don’t contain cancer cells.
N1: same lung as tumour
N2: nodes in mediastinum on same side as tumour
N3: lymph nodes on other side from tumour or at top of lung/collarbone

M1a: mets to other lung; pleural/pericardial effusion
M1b: single distant met outside thorax (e.g. liver)
M1c: multiple mets in different organs (e.g. liver and brain)

23
Q

What is the mainstay treatment for small cell lung cancer? What is the response?

A
  • Chemotherapy (SCLC is considered a systemic disease at diagnosis)
  • SCLC is one of the most chemo-sensitive solid tumours. Radiotherapy often given at the same time to make more radiosensitive
  • Responce is good however most patients will sadly relapse with a chemo resistant disease (within 12 months)
24
Q

When is radiotherapy used in Small cell lung cancer SCLC?

A
  • Chemo is mainstay for SMALL CELL
  • SMALL CELL is also highly radiosensitive
  1. Treatment of primary tumour
    -After or alongside chemo improves survival and makes body more sensitive to chemo
    (tumour will relapse, however in different place)
  2. Prophylactic cranial irradiation - brain mets are common. SE of PCI include tiredness, headaches, skin redness, nausea + vomiting, memory
  3. Palliative- help with symptoms of advance disease when unresponsive to other treatments.
25
Q

What are the different options for treatment of non-small cell lung carcinoma?

A

Early stage: surgery and radiotherapy
Late stage: palliative radiotherapy

Stage I and 2 –SURGERY (lobectomy/pneumonectomy) (~80% 5-year survival)

  • adjuvant chemo for nodal disease
  • adjuvant radiotherapy if resection margins are not tumour free

Stage 3 and 4-PALLIATIVE
Stage III + IV (palliative) - chemotherapy +/- immune targeted therapy

Patients with early disease who can’t have surgery

  • Continuous, hyperfractionated accelerated radiotherapy (CHART) – 3times/day for 12 days straight. 20% 5 year survival
  • Ablation- stereotactic ablative body radiotherapy (SABR) good for peripheral tumours in patients who aren’t fit for surgery
26
Q

What is the untreated life expectancy for SCLC? What does chemotherapy increase this to?

A

Untreated life expectancy = 2-4 months

Chemotherapy increases it to 6-12 months

27
Q

What are the features of large cell carcinoma

A

Large cell carcinoma (8% of NSCLC)

-These are less differentiated than other NSCLCs and tend to metastasise early.

28
Q

Whats the different between palliative care for SCLC and NSCLC?

A

Treatment of complications e.g. superior vena cava obstruction or spinal cord compression
The opposite of curative treatment:
-NSCLC- chemotherapy (immunotherapy if suitable)
-SCLC- radiotherapy

29
Q

What is the mainstay treatment for locally advanced/metastatic NSCLC?

A 
Chemotherapy 
Combination regimens are used:
- either Carboplatin and Gemcitabine 
-or Carboplatin/Cisplatin and Pemetrexed
- Docetaxel can be used as a 2nd line option.
30
Q

What is the treatment for advanced NSCLC with positive ALK/EGFR?

A

TARGETED THERAPY
Patients with EGFR and ALK positive adenocarcinoma are
treated with tyrosine kinase inhibitors (TKIs) can be used
- Afatinib/Erlotinib/Gefitinib for EGFR mutations
- Crizotinib for ALK mutations

31
Q

What is the treatment for advanced NSCLC with PLD1 expression?

A

IMMUNOTHERAPY- Pembrolizumab
-used either before or after chemotherapy

-PDL1 is a molecule involved in controlling the normal immune response

32
Q

Prognosis of NSCLC?

A

NSCLC

  • Immunotherapy and targeted therapy has greatly improved outcomes
  • WITHOUT TREATMENT = 3-6/12
  • WITH CHEMO - extend for a few more months possible to a year
  • WITH IMMUNOTHERAPY - prognosis of 2 years in some cases
33
Q

When would you refer for ?lung cancer

A

Organise urgent 2 week chest X-ray if:

  • aged 40+ if they have 2 symptoms (only need 1 symptom if they have EVER smoked):
  • Cough.
  • Fatigue.
  • Shortness of breath.
  • Chest pain.
  • Weight loss.
  • Appetite loss.

CCC (15 decks)

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