Lung Cancer

Question 1

Decide the epidemiology of lung cancer.

Answer 1

3rd most common cancer.
Affects people usually over age 75.
Men > women

Question 2

List the risk factors for lung cancer

Answer 2

Smoking
Family history
Radiotherapy
Occupational/toxins - asbestos, radon gas, arsenic
Lung disease - TB, COPD, pulmonary fibrosis
HIV

Question 3

What is the most common type of lung cancer?

Answer 3

Non small cell lung cancer (NSCLC) - 87%

Question 4

What are the main types of lung cancer?

Answer 4

Non small cell lung cancer

Small cell lung cancer

Question 5

What are the subtypes of NSCLC?

Answer 5

Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma

Question 6

Which lung cancer is most common in smokers?

Answer 6

Squamous cell

Question 7

Which lung cancer is most common in non-smokers?

Answer 7

Adenocarcinoma

Question 8

Which type of cancer (NSCLC or SCLC) is more metastatic?

Answer 8

SCLC

Question 9

Which cancer has surgical resection as an option?

Answer 9

NSCLC

Question 10

What are the NICE criteria for urgent 2ww referral for lung cancer?

Answer 10

Age 40+ with unexplained haemoptysis or CXR findings suggestive of lung cancer.

Question 11

How is SCLC staged/classified?

Answer 11

Limited disease

Extensive disease

Question 12

How is NSCLC staged?

Answer 12

I - 3cm - 5cm
II - spread to lymph nodes
IIIa - cancer extends into surrounding tissues and structure e.g. lining of the chest wall
IIIb - 2 or more tumours present, spread to contralateral lung and lymph nodes
4 - metastatic spread - bone, brain, liver, adrenal gland

Question 13

What investigation would you order if a patient aged 44 came into your GP practise complaining of fatigue and SOB? He is not a smoker but smoked in his 20s. No Fx.

Answer 13

Urgent CXR

Question 14

What is the first line treatment for stage I or II NSCLC?

Answer 14

Surgical resection

Question 15

Why is surgical resection first line treatment for NSCLC?

Answer 15

Less responsive to chemotherapy

Question 16

What oncological emergency is Squamous cell carcinoma of the lung associated with?

Answer 16

Hypercalcaemia

Question 17

What type of lung cancer is associated with hypertrophic osteoarthropathy?

Answer 17

Adenocarcinoma of the lung

Question 18

Which lung cancer is more associated with SIADH?

Answer 18

SCLC

Question 19

Which lung cancer is more associated with Pancoasts tumour?

Answer 19

NSCLC

Question 20

What receptor testing is done on NSCLC?

Answer 20

EGFR sensitising mutation

Question 21

What targeted therapy can be used to treat NSCLC?

Answer 21

Erlotinib

Question 22

How does Erlotinib work?

Answer 22

Inhibits tyrosine kinase inside tumour cell. Inhibiting epidermal growth factor, thereby stopping growth and reproduction of cancer cell.

Question 23

What drug therapy can be offered for relapsed NSCLC?

Answer 23

Pembrolizumab

Question 24

How does Pembrolizumab work?

Answer 24

Highly selective monoclonal IgG antibody that binds to the PD-1 receptor on the cell surface. Blocks brining and activity on of PD-L1 which causes activation of T-cell mediated immune responses against tumour cells.

Question 25

When might surgery be considered for SCLC?

Answer 25

Tumour is 5cm or less

Question 26

What is the mainstay treatment option for SCLC?

Answer 26

Chemoradiotherapy | Or chemotherapy followed by radiotherapy

Question 27

What preventative treatment should be considered for patients after undergoing treatment for SCLC? Why?

Answer 27

Prophylactic cranial radiotherapy. | 10% of patient’s present with cranial brain mets. 40-50% develop brain mets.

Question 28

What are the symptom someone might complain of who had brain mets?

Answer 28

Headache Nausea/vomiting Focal neurology Visual disturbances

Question 29

What is the prognosis for someone with SCLC?

Answer 29

Limited stage: 18-30 months | Extensive stage: 7-12 months

Question 30

What is associated with ectopic Cushing’s syndrome?

Answer 30

SCLC

Question 31

What is meant by ‘limited’ Disease?

Answer 31

Within a tolerable radiation field

Question 32

What is meant by extensive disease?

Answer 32

Distant metastases

Question 33

List the symptoms of lung cancer

Answer 33

``` Cough Haemoptysis Dyspnoea Chest pain Recurrent chest infections Weight loss Anorexia Fatigue ```

Question 34

What are the signs of lung cancer?

Answer 34

``` Cachexia Anaemia Clubbing Supraclavicular/cervical lymphadenopathy Pleural effusion SVOC Horner’s Syndrome ```

Question 35

Outline the pathophysiology of humoral hypercalcaemia of malignancy

Answer 35

Tumour secretes PTH-Related peptide which binds to commoN PTH receptor

Question 36

What happens to the serum osmolality and serum sodium level in SIADH?

Answer 36

Both reduced (hypo)

Question 37

What are the symptoms of SIADH?

Answer 37

``` Fatigue Headache Muscle weakness Memory loss Loss of consciousness Seizures ```

Question 38

What causes ectopic Cushing syndrome?

Answer 38

Uncontrolled secretion of ACTH from SCLC

Question 39

What investigations would you consider for a patient with lung cancer?

Answer 39

Bloods CXR CT scan - lobar masses, mediastinal lymphadenopathy, liver lesions, Thrombocytosis, PE DEXA scan

Question 40

What is the first line treatment for medically inoperable stage 1 or stage 2 NSCL cancer?

Answer 40

Radical radiotherapy

Question 41

What conditions must be met if a patient with NSCLC is to receive radical radiotherapy?

Answer 41

PS: 0-1 Medically inoperable or declining surgery Stage 1 or 2 or PET-CT Adequate lung function e.g. FEV1 > 1litre

Question 42

Is chemotherapy used in NSCLC stage 1 or 2 disease?

Answer 42

No - no current evidence for it

Question 43

Why does erlotinib not work in all patients?

Answer 43

Some have mutation in KRAS gene - downstream of EGFR tyrosine kinase so downstream events still occur allowing tumour to continue to proliferate. Erlotinib only works for wild type KRAS.