A2- Lung cancer

Question 1

There three ways in which lung cancer present what are they?

Answer 1

Symptoms

Incidental pickup

Screening programme

Question 2

What are the symptoms of lung cancer?

Answer 2

lung

Systemic

Metastases

Paraneiplastic syndromes

Complications

Question 3

What are some lung related symptoms

Answer 3

Wheeze

Chest pain

Breathlessness

Hamoptysis

Cough

Question 4

Systemic symptoms?

Answer 4

Weight loss

Lethargy

Loss of appetite

Question 5

Symptoms of metastases?

Answer 5

Pain

confusion

weakness

balance problems

Question 6

Symptoms of paraneoplastic syndromes?

Answer 6

Confusion

lethargy

pain

nausea and vomiting

thirst

Question 7

There are two types of paraneoplastic syndromes?

What are they?

Answer 7

• Lung cancer can produce pTH related peptide which leads to hypercalcaemia
• SiADH syndrome leading to hyponatremia

Question 8

Symptoms related to complications with lung cancer?

Answer 8

SVC obstruction could lead to:

Face swelling

Arm swelling

Dilated chest wall veins

Question 9

WHat is the horners syndrome

Answer 9

Horner syndrome is a combination of signs and symptoms caused by the disruption of a nerve pathway from the brain to the face and eye on one side of the body. Typically, Horner syndrome results in a decreased pupil size, a drooping eyelid and decreased sweating on the affected side of your face

Question 10

Horners syndrome triad?

Answer 10

• Mitosis (constricted pupils)
• partial ptosis
• Loss of hemifacial sweating (anhidrosis)

Question 11

What kind of lung tumours are related to horners syndrome?

Answer 11

Apical

Question 12

WHat imaging do you use to help diagnose lung cancer?

Answer 12

• CXR
• CT staging (chest + abdomen)
• MRI- brain/adrenal/liver

PET positron emission tomography- FDG uptake (fluorodeoxyglucose)

Question 13

How do you tissue diagnose depending on the lesion?

Answer 13

If lesion is:

Central in airways- bronchoscopy

Lymph nodes- US guided FNA/biopsy OR EBUS

Peripheral- CT guided lung biopsy

Lesion distal from the centre- miniprobe bronchoscopy (radial EBUS)

Mediastinal lymph nodes- mediastinoscopy

Question 14

WHat is EBUS

Answer 14

EBUS (endobronchial ultrasound) bronchoscopy

Question 15

Which biopsy type is the least invasive

Answer 15

US guided FNA pf lymph node

Question 16

Why is tissue diagnoses important?

Answer 16

Primary lung cancer vs metastases

small cell vs non small cell

adenocarcionoma vs squamous cell carcinoma

^all these tumours will be tested for PDL-1 (helps to assess when tumour will respond to immunotherapy) +adeno testing eg eGFR,ALK,ROS-1

Question 17

An MDT meeting can be split into two?

Answer 17

Diagnostic MDT- looking at imaging

Treatment MDT

Question 18

Who are the members of a lung MDT?

Answer 18

Question 19

Role of resp physician in MDT

Answer 19

• present new patients/diagnostic phase
• Sumarise case so they:
• present key symptoms
• pmhx
• smoking history/other risk factors
• performance status
• lung function
• results of other key tests such as echo/CPEX

Question 20

Role of Clinical Nurse Specialist in MDT

Answer 20

• Patients voice
• patients advocacy
• holistic needs
• updates and communication with patietns and familes in between OPA (outside outpaitent appointments)

Question 21

Role of Radiologists in MDT

Answer 21

Interpret scans

• CXR
• CT
• US (eg supraclavicular LN)
• PET-CT
• MRI

Radiological staging

Advice regarding feasibilty of biopsy

Question 22

Which of these factors would be a relative contraindication to CT guided lung biopsy?

• Peripheral lung lesion
• FEV1 0.75 litres
• Platelet count 160
• Haemoglobin 110 g/L

Answer 22

FEV1 0.75 litres

Question 23

Role of Pathologists in MDT

Answer 23

• cytology + histology specimens
• pathologist specialises in one area
• cell type
• origin- immunohistochemistry
• Receptor status:
• eGFR/ALK/ROS-1?PDL-1
• NGS panel

Question 24

Role of Clinical oncologists in MDT

Answer 24

• Advice on radiotherapy
• convention fractionated
• SABR (stereotactic Ablative Body Radiotherapy)
• Technical factors

Question 25

Role of **Medical oncologists** in MDT

Answer 25

- Subspecialty in chemo and immunotherapy - particular expertise in patients with driver mutairons eg eGFR, ALK - Disccusion (with clinical oncologists) about combined or sequential Tx - Trial opportunites e.g new treatments or new pathways such as adjuvant chemotherapy

Question 26

Which of these MDT members would give radiotherapy? * Radiologist * Medical oncologist * Clinical oncologist

Answer 26

Clinical oncologist

Question 27

Role of **Thoracic surgeons** in MDT

Answer 27

- Technical factos- is the lesion resectable - fitness for surgery - high risk MDT - Risk of postoperative complication - Staging for some patients- mediastinoscop y - diagnostic wedge biopsy

Question 28

Role of Palliative Care Team in MDT

Answer 28

- Consultant - Clinical Nurse specialits - Management of symtoms in parallel with active treatment - Palliation of symtoms- patients - Support with end of life care and planning for that.

Question 29

Role of Specialist Pharmacists in MDT

Answer 29

- Suport with chemo and immunotherapy - patient information and advice about their medications - Lead patient consultationas part of oncology team

Question 30

Role of **Holistic Care** in MDT

Answer 30

- Treating the whole and not just part of it - Care for the whole person - Centres on the patient - Holistic Needs Assessment (HNA)

Question 31

What is the holistic needs Assessment?

Answer 31

Can be done by CNS or Community Team * Simple patient questionnaire * Done at any stage of the cancer pathway * Helps identify a patient's concerns * Starts a conversation about needs * Helps develop a Personalised Care and Support Plan * Facilitates signposting to relevant services

Question 32

What are the different aspects of holistic needs assessment?

Answer 32

* Physical concerns (symptom management) * Emotional concerns (such as anxiety, guilt) * Practical concerns (such as benefits, care, transport) * Family or relationship concerns * Spiritual concerns * Information and support (such as exercise advice)

Question 33

What does palliative care involve?

Answer 33

-Symptom control * Related to the illness * Related to treatment - Emotional support - Patient & supporters such as family, friends - Medical and complementary therapies - Any stage of treatment

Question 33

What does palliative care involve?

Answer 33

•Symptom control * Related to the illness * Related to treatment * Emotional support * Patient & supporters such as family, friends * Medical and complementary therapies * Any stage of treatment

Question 34

Palliative care also discusses end of life care. What does this involve?

Answer 34

* Discussions about uncertainty * Recognising when patient is approaching end of life * Personalised planning (end of life care plan) * Gold Standards Framework: evidence based systematic approach to formalising best practice through improving the organisation and coordination of care for all people with any condition in any setting in the final year or so of life

Question 35

Which of these is used to plan and formalise best practice in a patient's final year of life? * End of Life Care Planclose * Holistic Needs Assessment * Gold Standards Framework

Answer 35

Gold Standards Framework

Question 36

What is the largest study for lung screening?

Answer 36

MELSON Trial published 2020

Question 37

What is the headline results from MELSON Trial published in 2020

Answer 37

* Screening group: 2.50 deaths per 1000 person-years * Control group: 3.30 deaths per 1000 person-years

Question 38

What is the Lung Health Check Programme

Answer 38

* Nationwide – NHS Long Term Plan * 55-74 year olds with history of smoking * Letter sent to patients – call to make appointment * 30-45 min conversation with specialist nurse * Questions assess risk of lung cancer * If at risk, a CT is performed