Lung cancer

Question 1

Lung cancer symptoms

Answer 1

persistent new cough or change in character of pre-existing cough
persistent LRTIs
chest/shoulder pain
dyspnoea
haemoptysis
lethargy, weight loss, anorexia (constitutional symptoms)
hoarseness

Question 2

Lung cancer signs

Answer 2

often none
clubbing
signs of lung collapse, consolidation, pleural effusion
localised persistent wheeze (monophonic)
stridor
supraclavicular lymphadenopathy
hoarseness
SVC obstruction
Horner’s syndrome
features of paraneoplastic syndromes

Question 3

SVC obstruction symptoms/signs

Answer 3

dyspnoea
orthopnoea
facial plethora
dilated/engorged veins
raised JVP
arm/face swelling

Question 4

What causes Horner’s syndrome?

Answer 4

compression of sympathetic chain at roughly the level of C1

Question 5

Features of Horner’s syndrome

Answer 5

miosis (constricted pupil)
ptosis (upper eyelid drooping)
anhidrosis (no sweat produced on one side of face/forehead)
enophthalmos (sunken in eye)

Question 6

What are 2 lung cancer medical emergencies?

Answer 6

SVC obstruction
spinal cord compression

Question 7

What investigations should be done if lung cancer is suspected?

Answer 7

CXR
CT staging (contrast) +/- biopsy
Bronchoscopy
Pulmonary function tests
6-minute-walk test
PET-CT scan
Bone scan
Cardiac investigations

Question 8

What is WHO performance status 0?

Answer 8

fully active and able to carry out pre-disease activities without restriction

Question 9

What is WHO performance status 1?

Answer 9

restricted in strenuous activity but ambulatory and able to carry out light work

Question 10

What is WHO performance status 2?

Answer 10

ambulatory and self-caring, but unable to do light work
up and about more than 50% of the time

Question 11

What is WHO performance status 3?

Answer 11

limited self care
in bed more than 50 % of the time

Question 12

What is WHO performance status 4?

Answer 12

unable to self care
confined to bed or chair

Question 13

Non-small cell lung cancer subtypes

Answer 13

squamous cell carcinoma
adenocarcinoma
large cell carcinoma

Question 14

What are the 4 mesothelioma subtypes and which is the most common?

Answer 14

epithelioid (most common)
biphasic
sarcomatoid
desmoplastic

Question 15

Where in the lung are small cell lung cancers normally located?

Answer 15

central

Question 16

Where in the lung are adenocarcinomas normally located?

Answer 16

peripheral

Question 17

Where in the lung are squamous cell carcinomas normally located?

Answer 17

central airways

Question 18

Where in the lung are large cell carcinomas normally located?

Answer 18

peripheral

Question 19

What factors are considered when staging a lung cancer?

Answer 19

location of primary tumour
tumour size and extent
lymph node involvement
presence of distant metastases

Question 20

Why is ist important to stage lung cancer?

Answer 20

common language for communicating the severity of a person’s cancer
prognostic information
determines treatment options

Question 21

What do TNM stand for in lung cancer staging?

Answer 21

T = tumour size
N = extent of spread to lymph nodes
M = presence of metastasis

Question 22

What invasive options are available for staging of a lung cancer?

Answer 22

EBUS-TBNA (endobronchial ultrasound-guided transbronchial needle aspiration - central nodules

thoracoscopy - small peripheral nodules

mediastinoscopy - mediastinal nodes or masses

Question 23

What imaging methods can be used to help stage a cancer?

Answer 23

CT
PET-CT

Question 24

What is the aim of biopsying the primary lesion?

Answer 24

Histological diagnosis

Question 25

Who is in the MDT for lung cancer?

Answer 25

respiratory physicians thoracic surgeons oncologists radiologists histopathologists lung cancer specialist nurses palliative care team

Question 26

Lung cancer management options (general)

Answer 26

surgery chemotherapy radiotherapy palliation

Question 27

When is surgical management indicated for lung cancer?

Answer 27

stage 1 and 2 disease (and some stage 3 disease)

Question 28

Define resectability

Answer 28

ability to completely excise the tumour at surgery

Question 29

Define operability

Answer 29

risk of mortality/morbidity from surgery

Question 30

What are the 3 main factors considered when assessing operability in lung cancer

Answer 30

risk of post-operative cardiac event risk of peri-operative death risk of post-operative dyspnoea

Question 31

What are the 4 types of resection that can be done to remove lung cancers surgically?

Answer 31

wedge resection segmental resection lobectomy (most common) pneumonectomy

Question 32

What does VATS stand for?

Answer 32

video-assisted thoracoscopic surgery

Question 33

Complications of surgery to remove lung cancer

Answer 33

displacement of heart towards operated side bronchial stump insufficiency pneumothorax (potentially tension pneumothorax) postoperative haemorrhage (hemothorax) chylothorax (damage to thoracic duct) atelectasis pneumonia

Question 34

Acute side effects of radiotherapy

Answer 34

oesophagitis pneumonitis nausea/vomiting bone marrow suppression

Question 35

Longer term side effects of radiotherapy

Answer 35

pneumonitis and pulmonary fibrosis rib fractures cardiac fibrosis and dysfunction hypothyroidism

Question 36

What cell functions can chemotherapy target?

Answer 36

DNA replication/repair cytoskeleton nucleotide synthesis hormones specific receptors (eg. herceptin)

Question 37

Is chemotherapy curative in lung cancer?

Answer 37

no

Question 38

Lung cancer risk factors

Answer 38

smoking (tobacco + cannabis) passive smoking occupation exposure (asbestos, silica, coal) HIV organ transplantation radiation exposure

Question 39

Squamous cell carcinoma important features

Answer 39

usually obstructive lesions of bronchus can cavitate local spread common, often late metastasis PTHrp production leading to hypercalcaemia associated with clubbing and HPOA

Question 40

What is HPOA?

Answer 40

hypertrophic pulmonary osteoarthropathy

Question 41

What cells do adenocarcinomas arise from?

Answer 41

mucous cells in bronchial epithelium

Question 42

Adenocarcinoma important features

Answer 42

can invade mediastinal lymph nodes and pleura can metastasise to brain and bones does not usually cavitate if a non-smoker has lung cancer it will be adenocarcinoma most likely to cause pleural effusions

Question 43

Small cell carcinoma important features

Answer 43

cause paraneoplastic syndromes (eg. Cushing's, Addison's) spreads early - almost always inoperable do respond to chemotherapy but have a poor prognosis

Question 44

What cells do small cell carcinomas arise from?

Answer 44

endocrine cells (Kulchitsky cells)

Question 45

Contraindications to surgery for lung cancer

Answer 45

malignant pleural effusion SVCO Horner's syndrome Vocal cord paralysis Phrenic nerve paralysis

Question 46

What is radical chemotherapy?

Answer 46

given with the aim of cure accept the likely side effects, longer course than palliative which is for symptom control

Question 47

What are 3 types of staging?

Answer 47

clinical staging (scans) surgical staging (biopsies) pathological staging

Question 48

NSCLC good prognostic factors

Answer 48

early stage disease at diagnosis good performance status no significant weight loss (<4%) female

Question 49

Common biomarkers in lung cancer

Answer 49

EGFR (epidermal growth factor receptor) K-ras oncogene EML4-ALK Fusion oncogene PDL1

Question 50

Squamous cell carcinoma immunohistochemical staining

Answer 50

TTF-1 negative p63 positive cytokeratin 5/6 positive

Question 51

Adenocarcinoma immunohistochemical staining

Answer 51

TTF-1 positive

Question 52

Small cell lung cancer paraneoplastic syndromes

Answer 52

SIADH Ectopic ACTH production (Cushing's) Eaton-Lambert myasthenic syndrome Hypercalcaemia Peripheral neuropathy PE/DVT risk

Question 53

Where does SCLC metastasise to?

Answer 53

BALLS Brain Adrenal Liver Lung Skeleton

Question 54

SCLC biomarkers

Answer 54

nearly all immunoreactive for keratin, epithelial membrane antigen and thyroid transcription factor-1 (TTF-1) most also stain positive for markers of neuroendocrine differentiation (eg. chromogranin A)