Lung Cancer

Question 1

What does tobacco smoke contain?

Answer 1

• polycyclic hydrocarbons • aromatic amines • phenols • nickel • cyanates

Question 2

What is the clinical presentation of lung cancer?

Answer 2

Local: • Obstruction of airway (pneumonia) • Invasion of chest wall (pain) • Ulceration (haemoptysis) Systemic: • Weight loss • Ectopic hormone production • PTH • ACTH

Question 3

What are the 4 different types of lung cancer?

Answer 3

• adenocarcinoma (35%)
• squamous carcinoma (30%)
• small cell carcinoma (25%)
• large cell carcinoma (10%)

Question 4

Which type of cancer is most common in non-smokers?

Answer 4

Adenocarcinoma

Question 5

What is characteristic about squamous cell lung cancer?

Answer 5

• Very common despite there being no squamous cells in the lung
• Produces keratin

Question 6

What is characteristic about adenocarcinoma?

Answer 6

Produces mucous

Question 7

What is characteristic about small cell carcinoma?

Answer 7

Not much cytoplasm but lots of nuclei - this is what makes them look like small cells

Question 8

What is characteristic about large cell carcinoma?

Answer 8

• Large cells with large nuclei
• Diagnosis made on surgical excision

Question 9

What is the prognosis of the 4 types of lung cancer in order of worst to best?

Answer 9

• Small cell lung cancer - Large cell lung cancer - Squamous cell lung cancer - Adenocarcinoma

Question 10

What 2 classifications are the 4 types of lung cancer normally divided into?

Answer 10

Small cell lung cancer (SCLC) vs. Non-small cell lung cancer (NSCLC)

Question 11

What is the treatment of choice of small cell lung cancer?

Answer 11

Chemotherapy (though growing resistance)

Question 12

What is the treatment of choice for non-small cell lung cancer?

Answer 12

Surgery or radical radiotherapy

Question 13

What do adenocarcinoma express?

Answer 13

Thyroid transcription factor 1 (TTF1)

Question 14

Which oncogene abnormalities are associated with SCLC?

Answer 14

myc

Question 15

Which tumour suppressor gene abnormalities are associated with SCLC?

Answer 15

P53, Rb, 3p

Question 16

Which oncogene abnormalities are associated with NSCLC?

Answer 16

Myc, K-ras, her2(neu)

Question 17

Which tumour suppressor gene abnormalities are associated with NSCLC?

Answer 17

P53, 1q, 3p, 9p, 11p, Rb

Question 18

Which mutation is seen almost exclusively in adenocarcinomas and what targeted treatment can therefore be used?

Answer 18

Specific point mutations render the EGFR gene active in the absence of ligand (epidermal growth factor) binding. These tumours respond to tyrosine kinase inhibitors (erlotinib).

Question 19

What is the pathogenesis of bronchial tumours?

Answer 19

• Squamous metaplasia • Dysplasia • Final stage before invasive cancer • Carcinoma in situ • Invasive malignancy

Question 20

What is the pathogenesis of peripheral adenocarcinomas?

Answer 20

• Atypical adenomatous hyperplasia • Spread of neoplastic cells along alveolar walls (bronchioloalveolar carcinoma) • True invasive adenocarcinoma

Question 21

What are the other, less common neoplasms?

Answer 21

• Carcinoid: Neuroendocrine neoplasms of low grade malignancy - Bronchial gland neoplasms: tumours more often seen in salivary glands - Pleural Neoplasia: mesothelioma

Question 22

What investigations are done to stage lung cancer?

Answer 22

• CT scan of thorax
  
  • Tumour size - want clear margins
  • Lymph nodes
  • Metastases
• CT scan of brain - Metastase
• PET scan - Metastase

Then use following to get sample:

• Bronchoscopy
  
  • Vocal cord palsy
    
    • Cant operate because we know its spread to laryngeal nerve
  • Proximity to carina
    
    • Cannot operate, would leave a huge hole
  • Cell type
• Mediastinoscopy/EBUS

Question 23

What are the surgical options for lung cancer?

Answer 23

• Pneumonectomy or lobectomy
  
  • Thoracotomy: Major surgery involving a long incision around the length of the sixth rib to gain access to the lung in question
  • Minimal access VATS (Video Assisted Thoracic Surgery)
    
    • This is far less traumatic and has the benefit of a much faster recovery.

*

Question 24

What performance staging system is used for chemotherapy?

Answer 24

Performance status ECOG score - determines if patients are fit enough to withstand chemotherapy

Question 25

What are the disadvantages of radiotherapy?

Answer 25

* Maximum cumulative dose * Too much can give you another cancer * And if that happens, then is hard to treat because they are at their max dose already * Collateral damage * Spinal cord * Oesophagus - Temporary oesophagitis is a common side effect of radiotherapy * Adjacent lung tissue - Normal lung tissue can undergo post radiation fibrosis. * Only goes where you point the beam

Question 26

Endobronchial therapy

Answer 26

* Patient receives a photo-sensitising drug a few days before this bronchoscopy. * Then recieves phototherapy to the tumour in the bronchus with laser light down a fibreoptic bundle. * Only works for tumours in the bronchial mucosa

Question 27

Incidence

Answer 27

number of new cases eg. 1 in 100

Question 28

Prevalence

Answer 28

Total number of people that actually have it

Question 29

Why does lung cancer have such a poor prognosis?

Answer 29

One reason for the poor prognosis is that lung cancer tends not to cause any symptoms until the disease has become too advanced for any hope of cure

Question 30

How can lung cancer cause lobar pneumonia?

Answer 30

If there is a tumour in a lobe of the lung then it can cause a partial obstruction. This means that is doesn’t get cleared so once the antibiotics finish, it just comes back - leading to recurrent episodes of pneumonia

Question 31

True or False: With growing lung cancer, the affected lung shrinks

Answer 31

When a lobe becomes obstructed, all of the air beyond the obstruction is absorbed and the lung tissue shrinks down to a much smaller size. The net effect is a reduction in size.

Question 32

Stridor

Answer 32

Wheeze on inspiration (wheeze on expiration is normal in COPD and asthma etc)

Question 33

Pancoast tumour

Answer 33

If a lung tumour is high in the apex of the lung and encroaches on the brachial plexus, T1 nerve root affected and causes wasting of the small muscles of the hand and also weakness

Question 34

What does localised joint pain which is worse at night suggest?

Answer 34

Possible bone metastases

Question 35

Paraneoplastic Syndromes

Answer 35

All of these features result from the effects of biochemically active products from the primary tumour. They are NOT indicative of metastatic disease.

Question 36

What parasneoplastic syndromes are associated with lung cancer?

Answer 36

* Finger clubbing * Hypertrophic pulmonary osteoarthropathy (HPOA) -Occurs with expansion of the superficial layers of the bone * Weight loss * Thrombophlebitis * Hypercalcaemia * Hyponatraemia – SIADH * Weakness - Eaton Lambert syndrome (Mimics myaesthenia gravis)

Question 37

How does lung cancer cause a cough?

Answer 37

the sensation which triggers a desire to cough is distortion of the normal bronchial mucosa by the tumour.

Question 38

How does lung cancer cause haemoptysis?

Answer 38

When the tumour ulcerates through the mucosa, it is prone to bleed

Question 39

How does lung cancer cause breathlessness?

Answer 39

Breathlessness in lung cancer is usually due to obstruction of a major branch of the bronchial tree by the tumour

Question 40

What techniques are used to make a definitive diagnosis of lung cancer?

Answer 40

* Bronchoscopy (with biopsy and brush-cytology) * Video bronchoscopy or Endobronchial Ultrasound * CT guided biopsy * Lymph node aspirate * Aspiration of pleural fluid

Question 41

What are the 3 most important questions when determining treatment for lung cancer?

Answer 41

1. Which cell type of lung cancer is it? 2. What stage is it? 3. How fit is the patient?

Question 42

How do you assess the fitness of the patient for treatment?

Answer 42

* Spirometry * WHO performance status scale