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(cardioresp) lung cancer Flashcards

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1
Q

what is the epidemiology of lung cancer?

A

third most common cancer in UK

= 48,000 diagnoses/year

= 35,000 deaths/year

leading cause of cancer death

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2
Q

historically, when did lung cancer become more common and why?

A

prior to the 1930s lung cancer was rare

= smoking only popular from WW1 onwards

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3
Q

what are the risk factors for lung cancer?

A

age = peak 75-90

sex = M > F

lower socioeconomic status

smoking history (duration, intensity, when stopped)

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4
Q

what is the link between cigarettes and lung cancer deaths?

A

cigarettes cause approx 1.5 million deaths from lung cancer per year

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5
Q

what is the main cause of lung cancer?

A

smoking

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6
Q

what are other causes for lung cancer besides smoking?

A

passive smoking

asbestos exposure

radon exposure

indoor cooking fumes (wood smoke, frying fats)

chronic lung diseases (COPD, fibrosis)

immunodeficiency

familial/genetic

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7
Q

who is more commonly at risk of asbestos exposure?

A

plumbers, ship-builders, carriage workers, carpenters

risk is x2

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8
Q

what are the two broad categories of lung cancer?

A

small cell lung cancer (SCLC)

non-small cell lung cancer (NSCLC)

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9
Q

what cancers fall under NSCLC (non-small cell lung cancers)?

A

squamous cell carcinoma

adenocarcinoma

large cell lung cancer

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10
Q

of all lung cancer cases, how many are classified as squamous cell carcinomas?

A

30%

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11
Q

of all lung cancer cases, how many are classified as adenocarcinomas?

A

40%

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12
Q

of all lung cancer cases, how many are classified as large cell lung cancers?

A

15%

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13
Q

of all lung cancer cases, how many are classified as small cell lung cancers?

A

15%

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14
Q

what are squamous cell carcinomas in lung cancer?

A

second most common lung cancer

originate from the squamous (flat) cells that line the bronchial epithelium of the airways

centrally located

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15
Q

what are adenocarcinomas in lung cancer?

A

most common lung cancer

originate from the mucus-producing glandular tissue

peripherally-located, tend to develop in alveoli/outer edges of lungs

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16
Q

what are large cell lung cancers?

A

heterogenous group, undifferentiated

= grow rapidly and more aggressively than other forms of lung cancer AND can appear anywhere in the lungs

DIAGNOSIS OF EXCLUSION = ‘catch-all diagnosis’ for the lung cancers that cannot be classified as SCC, AC, SCLC

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17
Q

what are small cell lung cancers?

A

least common type of lung cancer

originates in the pulmonary neuroendocrine cells

highly malignant + cancer typically metastasises rapidly to outside the lung

AND is type that is most likely to relapse after treatment

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18
Q

why are large cell lung cancers called so?

A

due to the large size and abnormal-looking appearance of the cancer cells

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19
Q

what are squamous cell carcinomas, adenocarcinomas and large cell lung cancers often grouped into?

A

non-small cell lung cancers (NSCLC)

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20
Q

what are the three stages of lung cancer development?

A

early
intermediate
late

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21
Q

what do the three stages of lung cancer comprise?

A

early

  • normal epithelium
  • hyperplasia
  • squamous metaplasia

intermediate
- dysplasia

late

  • carcinoma in situ
  • invasive carcinoma
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22
Q

what does the early stage of lung cancer comprise?

A

normal epithelium
hyperplasia
squamous metaplasia

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23
Q

what does the intermediate stage of lung cancer comprise?

A

dysplasia

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24
Q

what does the late stage of lung cancer comprise?

A

carcinoma in situ

invasive carcinoma

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25
define metaplasia
reversible change in which one adult cell type replaced by another adult cell type, adaptive
26
define dysplasia
abnormal pattern of growth in which some of the cellular and architectural features of malignancy are present BUT pre-invasive stage with intact basement membrane
27
define oncogene
a mutated gene that contributes to the development of a cancer
28
what are the key symptoms of lung cancer?
persistent cough unexplained weight loss dyspnoea/shortness of breath fatigue chest pain haemoptysis repeated respiratory infection (or frequently asymptomatic)
29
define haemoptysis
coughing up blood
30
what are the features of advanced/metastatic lung cancer?
neurological features (focal weakness, seizures, spinal cord compression) bone pain paraneoplastic syndromes (clubbing, hypercalcaemia, hyponatraemia, Cushing's)
31
what are the most common sites of lung cancer metastases?
``` bones liver brain lymphnodes adrenal glands ```
32
what are common signs of lung cancer?
clubbing cachexia Horner's syndrome Pemberton's sign (superior vena cava obstruction)
33
define cachexia
“wasting” disorder that causes extreme weight loss and muscle wasting, and can include loss of body fat usually seen in people in the late stages of serious diseases
34
what is Horner's syndrome?
contracted pupil, drooping upper eyelid, and local inability to sweat on one side of the face (miosis, ptosis & anhydrosis)
35
what is Pemberton's sign?
development of facial plethora/swelling, distended neck and head superficial veins upon raising of the patient's both arms above his/her head simultaneously, as high as possible = SVCS (superior vena cava syndrome)
36
why can Pemberton's sign occur in lung cancer?
lung cancer can metastasise to chest 1) tumour can press on the superior vena cava 2) tumour can grow into the superior vena cava and block it = Pemberton's sign
37
how does lung cancer result in Horner's syndrome?
growing tumour can cause compression of a brachiocephalic vein, subclavian artery, phrenic nerve, recurrent laryngeal nerve, vagus nerve or a sympathetic ganglion (at thoracic outlet) = symptoms
38
why is a PET scan done in lung cancer patients?
to rule out occult metastases
39
what are occult metastases?
tumour deposits that are initially undetected in the pathological examination and subsequently identified
40
why is a PET scan done in lung cancer patients?
to rule out occult metastases (tumour deposits that are initially undetected and then subsequently identified)
41
what are occult metastases?
tumour deposits that are initially undetected and subsequently identified
42
how is the type of biopsy to be carried out determined in lung cancer patients?
choose method based on accessibility, availability and impact on staging
43
what types of biopsies can be done for lung cancer?
bronchoscopy endobronchial ultrasound and transbronchial-needle aspiration - EBUS/TBNA CT-guided lung biopsy
44
when is a bronchoscopy chosen as the biopsy method?
for central airway tumours where staging does not matter
45
when are EBUS/TBNA of mediastinal lymph nodes chosen as the biopsy methods?
to stage mediastimun +/- achieve tissue diagnosis
46
when is a CT guided lung biopsy chosen as the biopsy method?
to access peripheral tumours
47
what kind of biopsy is done for central airway tumours?
bronchoscopy
48
what kind of biopsy is done for peripheral lung tumours?
CT-guided lung biopsy
49
what kind of biopsy is done when the mediastinum needs to be staged?
EBUS/TBNA | endobronchial ultrasound/transbronchial needle aspirate
50
what is the method used to stage lung cancer?
TMN staging
51
what is TNM staging?
staging based on 1) tumour size + location 2) lymph node involvement 3) metastases
52
how does TMN staging work?
T1-4 tumour size and location N0-3 lymph node involvement (mediastinum + beyond) M0-1c metastases + number
53
in TNM staging, how does the T work?
categorised T1-4 based on tumour size and location
54
in TNM staging, how does the N work?
categorised N0-3 based on lymph node involvement (mediastinum + beyond)
55
in TNM staging, how does the M work?
categorised M0-1c based on metastases and their number
56
what is commonly seen when diagnosing lung cancer with TMN staging?
late stage is common at diagnosis
57
how is lung cancer classified based on spread?
early locally-advanced metastatic
58
what are the determinants of lung cancer treatment?
``` patient fitness cancer histology cancer stage patient preference health service factors ```
59
how is patient fitness graded according to WHO?
0 – asymptomatic 1 – symptomatic but completely ambulatory 2 – symptomatic, <50% in bed during the day 3 – symptomatic, >50% in bed, but not bedbound 4 – bedbound 5 – death
60
how is surgery used to treat lung cancer?
surgical resection is the standard of care for early stage disease lobectomy + lymphadenectomy = usual approach but sublobar resection is stage 1 (≤ 3cm)
61
what is the most common form of management for early-stage lung cancer?
surgical resection (usually lobectomy and lymphadenectomy)
62
what type of surgeries are carried out to treat early-stage lung cancer?
lobectomy and lymphadenectomy | sublobar resection if stage 1 and less than or equal to 3cm
63
what are the types of surgical resection for lung cancer?
wedge resection segmental resection lobectomy pneumonectomy
64
what is a wedge resection?
removal of a small section of lung that contains the tumour along with a margin of healthy tissue
65
what is a segmental resection?
removal of a larger portion of lung than a wedge resection but not an entire lobe
66
what is a lobectomy?
removal of the entire lobe of one lung
67
what is a pneumonectomy?
removal of an entire lung
68
what are the two surgical techniques that are used to treat lung cancers?
open thoracotomy VATS (video-assisted thoracoscopic surgery)
69
what are the two treatment options for early-stage lung cancer?
surgery radical radiotherapy
70
what is radical radiotherapy for lung cancer?
SABR (stereotactic ablative body radiotherapy) = high-precision targeting w multiple convergent beams from different angles useful if comorbidity present alternative to surgical treatment for early-stage
71
why would radical radiotherapy be preferentially used over surgery for early-stage lung cancer?
if a comorbidity is present
72
what systemic treatments are available to manage lung cancer?
oncogene-directed drugs immunotherapy cytotoxic chemotherapy
73
what are the side effects of oncogene-directed systemic treatment?
generally well-tolerated but possible rash, diarrhoea and pneumonitis
74
how does immunotherapy work in lung cancer treatment?
often numerous T cells will bind to tumour cells and eradicate them but some T cells are inhibited by binding to PDL-1 so immunotherapy can deactivate PDL-1 so T cells can carry out their eradication function
75
how does cytotoxic chemotherapy work?
targets rapidly dividing cells
76
what are the side effects of cytotoxic chemotherapy systemic treatment?
fatigue, nausea, bone marrow suppression, nephrotoxicity | + poor quality of life
77
what are the requirements for immunotherapy use in lung cancer treatment?
first line for metastatic NSCLC with no mutation and PDL >= 50%
78
what are the requirements for cytotoxic chemotherapy use in lung cancer treatment?
first line for metastatic NSCLC with no mutation and PDL <= 50% (in combination w immunotherapy)
79
what are the requirements for oncogene-directed drug use in lung cancer treatment?
first line for metastatic NSCLC with mutation
80
what support should be offered to patients with advanced stage disease?
palliative and supportive care
81
what is offered as part of palliative and supportive care for advanced stage lung cancer patients?
symptom control psychological support, financial and practical support education, planning for end of life lung cancer specialist nurses
82
what are the treatments available for early stage lung cancer?
surgery radical radiotherapy
83
what are the treatments available for locally-advanced stage lung cancer that involves the thoracic lymph nodes?
surgery + chemotherapy radiotherapy + chemotherapy (+ maybe immunotherapy)
84
what are the treatments available for late stage, metastatic lung cancer?
with targetable mutation = tyrosine kinase inhibitors (oncogene-directed therapy) no mutation, PDL1 positive = immunotherapy no mutation, PDL1 negative = chemotherapy + immunotherapy (palliative care too)
85
does lung cancer ever have an early presentation?
extremely rarely - late presentation on diagnosis is most common
86
why does lung cancer never usually have an early presentation?
people who get lung cancer usually have pre-existing lung conditions too so write off symptoms as they may not be abnormal for them
87
what stage of lung cancer is pleural effusion most commonly seen with?
metastatic lung cancer
88
what stage of lung cancer are infected lymph nodes most commonly seen with?
locally-advanced lung cancer
89
what are some important oncogenes in terms of lung cancer?
EGFR ALK ROS1 BRAF
90
how does EGFR affect lung cancer?
= approx 15-30% of adenocarcinoma more so in women, Asian ethnicity, never-smokers
91
how does ALK affect lung cancer?
= approx 2-7% of non-small cell lung cancer especially in younger patients and never smokers
92
how does ROS1 affect lung cancer?
= approx 1-2% of non-small cell lung cancer especially in younger patients and never smokers
93
how does BRAF affect lung cancer?
= approx 1-3% of non-small cell lung cancer especially in smokers
94
define 'undifferentiated' cancers
a cancer in which the cells are very immature and do not look like cells in the tissue from it arose = undifferentiated more malignant than a cancer of that type which is well differentiated
95
where does the lung tumour metastasise to in order to cause Horner's syndrome?
metastasises or originates in the apices of the lungs e.g. Pancoast tumours (rare form of lung cancer, locally advanced/invasive more quickly)
96
where are pulmonary neuroendocrine cells found?
rare airway epithelial cells that also uniquely harbor neuronal and endocrine characteristics = cells implicated in the formation of the highly malignant form of lung cancer (small cell lung cancer)
97
which cigarette type are adenocarcinomas asociated with?
low tar cigarettes = inhaled more deeply & retained longer
98
what is the diagnostic strategy for lung cancer?
- establish most likely diagnosis - establish fitness for investigation and treatment - confirm diagnosis (specific type of cancer if considering systemic treatment) - confirm staging
99
what imaging techniques are used to investigate lung cancer?
CXR abdo + chest staging CT PET scan

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