CVR cancers of the lung, heart and vasculature

Question 1

Are cardiovasc cancers common?

Answer 1

no - very rare

Question 2

what is angiosarcoma?

Answer 2

malignancy of vascular endothelial cells; (of skin, heart, liver)
-> incidence 1.5 case per mil

Question 3

Example of a cardiac tumour

Answer 3

myxoma (cancer of connective tissue)

-> incidence <1 cases per mil

Question 4

Why are cardiac cancers so rare

Answer 4

1. Low exposure of cells to carcinogens
2. turnover rate is low as cardiac myocytes rarely divide
3. Strong selective adv against anything which could compromise function

Question 5

what is the 3rd most common cancer in the UK?

Answer 5

lung

Question 6

when did lung cancer start becoming a problem?

Answer 6

WW1

Question 7

what is the age peak for lung cancer?

Answer 7

75-90yrs

Question 8

do more men or women get lung cancer?

Answer 8

men

Question 9

what type of status can increase risk of lung cancer?

Answer 9

• lower socioeconomic

- smoking history

Question 10

what percentage of people who get lung cancer never previously smoked?
Passively smoked?

Answer 10

Never: 10- 15%
Passively: 15%

Question 11

aetiological factors other than smoking (passive/non-passive) that can cause lung cancer?

Answer 11

• asbestos
• Radon
• Indoor cooking fumes
• Chronic lung diseases
• Immunodeficiency
• Familial/genetic

Question 12

types of lung cancers

Answer 12

1. squamous cell carcinoma
2. adenocarcinoma
3. large cell lung cancer
4. small cell lung cancer

Question 13

what is the most common type of lung cancer?

Answer 13

• adenocarcinoma (40%)

- originating from mucus-producing glandular tissue: more peripherally located

Question 14

Features of squamous cell carcinomas? (30%)

Answer 14

(30%)

• originating from bronchial epithelium
• centrally located

Question 15

features of small cell lung cancer? (15%)

Answer 15

• originate from pulmonary neuroendocrine cells

- highly malignant

Question 16

umbrella term for squamous cell carcinoma, adenocarcinoma, large cell lung cancer

Answer 16

non-small cell lung cancer

Question 17

Are small cell lung cancers aggressive?

Answer 17

yes

Question 18

early stages of lung cancer

Answer 18

• normal epithelium
• hyperplasia
• squamous metaplasia

Question 19

intermediate stages of lung cancer

Answer 19

• dysplasia

Question 20

late stages of lung cancer

Answer 20

• carcinoma in situ

- invasive carcinoma

Question 21

What are oncogene directed treatments for lung cancer?

Answer 21

First line for metastatic non-small cell LC with mutation

1. EGFR tyrosine kinase (seen in adenocarcinoma, more common in asian women who never smoked)
2. ALK tyrosine kinase (see in non-small cell lung cancer in young children who never smoked)
3. ROS1 receptor tyrosine kinase (some non-small cell lung cancer in young non-smoker patients)
4. BRAF (non-small cell lung cancer for smokers)

S/E: generally well tolerated. Rash, diarrhoea, pneumonitis

Question 22

key symptoms of lung cancers (7)

Answer 22

1. cough
2. weight loss
3. breathlessness
4. fatigue
5. chest pain
6. haemoptysis
7. asymptomatic

Question 23

clinical signs of advanced/metastatic disease

Answer 23

1. neurological features (focal weakness, seizures, spinal cord compression)
2. Bone pain
3. Paraneoplastic syndromes (caused by production of hormones/cytokines by tumor) (hypercalcaemia, hyponatraemia, cushing’s)

Question 24

cause of hypercalaemia in lung cancer

Answer 24

tumours releasing parathyroid hormone related peptide

Question 25

cause of hyponatraemia in lung cancer

Answer 25

inappropriate ADH secretion (paraneoplastic syndrome) Often in small cell cancer

Question 26

cause of cushings in lung cancer

Answer 26

overstimulation of the adrenals (ectopic ACTH)

Question 27

signs of lung cancer (generally seen in late stages)

Answer 27

1. pemberton's sign- arm elevation causes red face (sign of venous obstruction) 2. Horner's syndrome- miosis and ptosis 3. clubbing- changes in areas near nails (e.g. bulging, colour change) (often sign of chronic low o2 sats) 4. cachexia- muscle wasting

Question 28

what causes horner's syndrome in lung cancer?

Answer 28

lung tumour impinges on the sympathetic chain -> ptosis, pupillary constriction and hydrosis (lots of sweating on the side of the face)

Question 29

diagnosing lung cancer

Answer 29

- establish most likely diagnosis - establish fitness for investigation and treatment - confirm diagnosis (specific type of cancer if considering systemic treatment) - --> confirm staging

Question 30

imaging for lung cancer

Answer 30

chest x ray

Question 31

differentials for shadows on chest x ray

Answer 31

pneumonia | tumour

Question 32

imaging for confirming lung cancer and metastases and staging.

Answer 32

CT abdo and chest

Question 33

what is the most useful imaging to exclude occult metastases?

Answer 33

PET scan

Question 34

only way to be certain of cancer diagnosis?

Answer 34

- biopsy | - also determines histology

Question 35

when is bronchoscopy chosen?

Answer 35

- for tumour of the central airway | - where tissues staging is not important

Question 36

type of biopsy used to investigate the mediastinum

Answer 36

endobronchial ultrasounds and transbronchial needle aspiration of mediastinal lymph nodes - stages mediastinum +/- achieve tissue diagnosis

Question 37

type of biopsy for tumours peripherally located in lung

Answer 37

CT-guided lung biopsy | - small risk of pneumothorax

Question 38

staging uses what system

Answer 38

TNM (I->IV) tumour nodes metastases + number

Question 39

When is surgery used for lung cancer?

Answer 39

Surgical resection is standard of care for early stage disease

Question 40

What types of surgery are used for lung cancer?

Answer 40

Lobectomy (remove entire lobe) and lymphadenectomy usual approach Sublobar resection if stage 1 (= 3cm) Other techniques: Wedge resection- remove small section of lung with tumor and a little healthy tissue Segmental resection- remove large part of lung but not entire lobe Pneumonectomy- remove entire lung

Question 41

What is radical radiotherapy?

Answer 41

Alternative to surgery for early stage disease Particularly if comorbidity Stereotactic ablative radiotherapy (SABR) is used- highly focused/precise radiation using multiple converging beams

Question 42

What immunotherapy treatments are there to treat lung cancer?

Answer 42

Blocking PD-L1/PD-1 to allow T cell killing of tumour cell First line for metastatic non-small cell LC with no mutation and PDL1 >/= 50% Drugs: pembrolizumab, atezolizumab, nivolumab S/E: Generally well-tolerated, immune related side-effects om 10-15%

Question 43

What cytotoxic chemotherapy treatments are there to treat lung cancer?

Answer 43

First line for metastatic non-small cell LC with no mutation and PDL1 = 50% Targets any rapidly dividing cell S/E: fatigue, nausea, bone marrow suppression, nephrotoxicity, poor QoL

Question 44

When should palliative care be given?

Answer 44

Standard for all patients with advanced stage disease Symptom control, psychological support, education, practical and financial support, planning for end of life Gives an improved QoL and lowers depression risk

Question 45

What are the stages of lung cancer?

Answer 45

Occult stage: Cancer cells can be picked up in the mucus you cough up. Your tumor can’t be seen on imaging scans or a biopsy. It’s also called hidden cancer. Stage 0: Your tumor is very small. Cancer cells haven’t spread into your deeper lung tissues or outside your lungs. Stage I (“stage 1”): Cancer is in your lung tissues but not your lymph nodes. Stage II (“stage 2”): The disease may have spread to your lymph nodes near your lungs. Stage III (“stage 3”): It has spread further into your lymph nodes and the middle of your chest. (In stage IIIa its 1 lung, on IIIb its both lungs) Stage IV (“stage 4”): Cancer has spread widely around your body. It may have spread to your brain, bones, or liver.