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AIP: Shortness of breath > Lung cancer > Flashcards

Lung cancer Flashcards

1
Q

What proportion of lung cancer cases are smoking related?

A

90%

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2
Q

In addition to smoking, what are 3 further risk factors for lung cancer?

A
  1. HIV
  2. Previous radiotherapy
  3. Pulmonary fibrosis
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3
Q

What proportion of cases of lung cancer are cured?

A

5.5% (UK bottom of league tables across Europe)

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4
Q

What would be a potential benefit for lung cancer patients of screening, despite the absence of an established screening programme?

A

Early stage cancer has a better prognosis, and more treatment options available for it

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5
Q

What would be a potential screening tool for lung cancer in the future?

A

Low dose CT scanning

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6
Q

What is a diagnostic/ screening blood test for lung cancer that is still undergoing trials?

A

EarlyCDT-Lung: test that measures levels of 7 autoantibodies to tumor-associated antigens

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7
Q

What are 9 features that mean a patient should be referred for early chest x-ray, due to suggesting lung malignancy?

A
  1. Haemoptysis
  2. >3 week cough
  3. >3 week chest/shoulder pain
  4. >3 week hoarse voice
  5. >3 week dyspnoea
  6. >3 week weight loss
  7. Features suggestig metastases on examination: stroke symptoms, pain from bony metastases
  8. Finger clubbing
  9. Cervical/ supraclavicular lymphadenopathy
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8
Q

If a patient has one of the 9 red flag symptoms and the early chest x-ray appears normal, what should be done?

A

Still refer to a respiratory physician

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9
Q

What type of presenting symptom requiers urgent referral to a physician?

A

Superior vena cava obstruction

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10
Q

What does the chest x-ray show?

A
  • Can’t see diaphragm on the left
  • no clear line to suggest pleural effusion - suggests lower lobe collapse
  • (difficult to exclude effusion)
  • warrants further investigation: CT thorax
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11
Q

What is the next step for investigation if the results of CXR are unclear?

A

CT thorax (?with IV contrast)

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12
Q

What does the CT thorax with IV contrast show?

A

Left lower lobe tumour and collapse; no nodes, no metastases

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13
Q

What are 5 important parts of the history in suspected lung cancer and why?

A
  1. Smoking history
  2. Employment history (especially asbestos): be thorough i.e. day 1 of career to final job
  3. Drug history - safe for further investigations? e.g. aspirin, warfarin, clopidogrel (anti-platelet)
  4. Previous imaging & where (can compare old and new, may develop nodules as a result - benign or malignant)
  5. General fitness
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14
Q

What is a way of assessing a patient’s general fitness and what does it comprise of?

A
  • WHO performance status
    • 0 fully active
    • 1 cannot carry out heavy physical work, but can do anything else
    • 2 up and about more htan half the day, can look after self, not well enough to work
    • 3 in bed or sitting in chair more than half of day, need some help looking after yourself
    • 4 in bed or a chair all time, need a lot of looking after
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15
Q

What are 2 groups that diagnosis and staging can be classed into?

A
  1. Imaging
  2. Tissue diagnosis
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16
Q

What are 2 key types of imaging for suspected lung cancer?

A
  • CT with IV contrast: to include liver and adrenals, first test always done
  • PET imaging: usually after tissue diagnosis
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17
Q

What is the role of PET imaging for lung cancer?

A
  • Done after tissue diagnosis generally, but gives more information about spread of disease, so know whether we can go on with invasive/ potentially curative surgery
  • important to establish whether any distant disease before patient undergoes radical radiotherapy
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18
Q

Why is a tissue diagnosis needed in lung cancer?

A

Even if lesion suspicious on CT, not definitely cancer until histological confirmation

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19
Q

What are 5 forms of tissue diagnosis for suspected lung malignancy?

A
  1. Bronchoscopy
  2. Endobronchial ultrasound (EBUS)
  3. Endoscopic ultrasound (EUS)
  4. CT-guided lung biopsy
  5. Biopsy of metastases (e.g. lymph nodes)
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20
Q

Which method for obtaining tissue diagnosis is often first line?

A

Bronchoscopy

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21
Q

What type of lesions is bronchoscopy not appropriate for?

A

Not appropriate for more peripheral lesions - not wihtin reach of bronchoscope (with needle)

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22
Q

What is EBUS (endobronchial ultrasound)?

A

Form of bronchoscopy in which the ultrasound tip is used as a bronchoscope

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23
Q

What can EBUS perform, and what is the limitation?

A

Can find lymph nodes and take needle biopsies; need to be within reach of major airways so bronchoscope can reach easily

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24
Q

What is endoscopic ultrasond?

A

Endoscope combined with ultrasound to look at images of internal organs of the chest and abdomen; goes into oesophagus rather than trachea and bronchi

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25
Q

What is the function of endoscopic ultrasound (EUS) for suspected lung malignancy?

A

For obtaining tissue from lymph nodes

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26
Q

What is the benefit of CT-guided lung biopsy for suspected lung malignancy?

A

Allow access to tissue which is more peripheral

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27
Q

Why is biopsy of metastases from lung primaries e.g. lymph nodes helpful?

A
  • Often most accessible lesions are those from metastases; if someone has lymph nodes, these should be targeted first
  • Will confirm diagnosis and also degree of spread
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28
Q

What are the 3 key groups of lung cancers in terms of pathology, and their relative proportions?

A
  1. Non-small cell lung cancer (NSCLC) - 81%
  2. Small cell - 13%
  3. Others- 6%
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29
Q

What are the 5 key groups of non-small cell lung cancer (NSCLC) and how much does each contribute to the 81% of all lung cancers?

A
  1. Adenocarcinoma - 38%
  2. Squamous cell - 20%
  3. Large cell - 5%
  4. Alveolar cell carcinoma​
  5. Broncial adenoma: mostly carcinoid
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30
Q

Why is it helpful to divide lung cancers into small cell and non-small cell?

A

Both staging and treatment are different for each group

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31
Q

Why is it useful to stage lung cancers?

A

good survival rate in earlier stages, e.g. for NSCLC IA median survival is 5 yeras, for IV it’s 6 months

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32
Q

What do the stages of NSCLC relate to?

A

TNM staging

IA/B - based on T size only, no nodes or mets

IIA/B - may have up to 1 node or T3

IIIA/B - up to 2 nodes or T4

IV mets present

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33
Q

What are the 2 treatment options for curative intent for NSCLC?

A
  1. Surgery
  2. Radiotherapy
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34
Q

What are the 2 key conditions for surgery for NSCLC?

A
  • if medically fit i.e. no significant co-morbidities that would make surgery more risky, e.g. damage to lungs from other conditions meaning pt would be too breathless after taking out part/whole of lung
  • If tumour is amenable to surgery (resectable)
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35
Q

Which range of NSCLC tumour classifications are usually amenable to surgery?

A

Stage I to IIIa

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36
Q

Who should be present when deciding if surgery is appropriate for a patient with NSCLC?

A

MDT, must have thoracic surgeon present

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37
Q

What NSCLC treatment offers the best prognosis?

A

Surgery

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38
Q

What is another name for radiotherapy with curative intent?

A

Radical radiotherapy

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39
Q

How does the success of radical radiotherapy compare with surgery with curative intent for NSCLC?

A

RR less successful than surgery (but no RCTs)

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40
Q

What is the name of the type of radiotherapy used for NSCLC with curative intent?

A

CHART: continuous hyperfractionated accelerated radiotherapy

41
Q

What is CHART (continuous hyperfractionated accelerated radiotherapy)?

A
  • Radiotherapy given in more than one fraction on each day, ideally at weekends too
  • In contrast to standard radiotherapy where single fraction is given daily, Monday to Friday, for several weeks
  • CHART proven to be more effective - maybe as reduces time between doses, less chance for cancer cells to recover
42
Q

What are the 5 key criteria for patients with NSCLC to receive CHART rather than surgery?

A
  • Indicated if not fit for surgery but
    • WHO performance status or 0 or 1
    • accepable lung function
    • Stage I to III disease
    • Disease within suitable radiotherapy field
43
Q

Why is it important that a NSCLC is within a suitable radiotherapy field if it is to receive CHART?

A

If too large or too close to major organs, radiation may cause too much damage for radical radiothearpy to be considered

44
Q

Why must a patient have acceptable lung function to undergo CHART for NSCLC?

A

Radiotherapy can cause fibrosis and breathlessness - patient’s lung function must be acceptable

45
Q

What reasons might a patient still require radiothearpy even if they’re not suitable for radiotherapy with curative intent?

A

Symptom control; can be used for range of problems including significant pain from metastases, or significant haemoptysis

46
Q

Who helps decide if radiotherapy should be used to treat NSCLC, both with and without curative intent?

A

Whole MDT, oncologist must be present

47
Q

When is chemotherapy used for NSCLC?

A
  • it is NOT a cure on its own, but may be used in conjunction with surgery/radiotherapy to improve survival; is a PART of the cure
  • palliative
48
Q

Which patient classifications of NSCLC can chemotherapy as part of a cure be used for?

A
  • can be used for stage II or III if not suitable for surgery
  • Can be used in patients WHO PS 0 or 1 wikth T1-3, N1-2, M0 stages
  • done on individual basis to improve disease free survival
49
Q

Which patient classifications of NSCLC can chemotherapy as palliation be used for?

A
  • stage III or IV
  • WHO PS 0 or 1 (must still be relatively fit)
50
Q

Why can chemotherapy be useful to use for palliation in NSCLC?

A

to improve survival and quality of life; demonstrated in a number of trials

51
Q

What is a newer therapy being developed currently for NSCLC and how does it work?

A
  • Antibodies targeting epidermal growth factor receptors (EGFR): Iressa and Tarceva
  • 10-20% NSCLC express EGFR on cell surface
  • shown clinically improved responses if EGFR mutation present in tumour cells
52
Q

What proportion of NSCLC cases have the epidermal growth factor receptor on their cell surface, and are therefore potentially amenable to newer therapies targeting these receptors?

A

10-20%

53
Q

What 4 groups of NSCLC is the EGFR mutation more common in?

A
  1. Adenocarcinomas
  2. never smokers
  3. females
  4. Asian ethnicity
54
Q

What is the staging of small cell lung carcinoma?

A
  1. Limited: ipsilateral hemithorax and supraclavicular lymph nodes
  2. Extensive: everything else
55
Q

What are the 3 treatment options for small cell carcinoma and which is the most useful treatment?

A
  1. Surgery
  2. Chemotherapy - most useful treatment of choice
  3. Radiotherapy
56
Q

When may surgery be of benefit for small cell carcinoma (SCC) and how often is it used?

A

May benefit if no evidence of metastases; generally surgery very rare, normally only when someone goes straight to surgery without biopsy

57
Q

If surgery for small cell carcinoma does occur, what should be done following it and why?

A

Post-op chemotherapy for risk of micro-metastases/ mets that haven’t shown up on pre-operative imaging

58
Q

How should the chemotherapy for small cell carcinoma be altered if the patient has a poor performance status?

A

Less intensive course

59
Q

What is the response of patients with small cell carcinoma to chemotherapy?

A
  • Good response - 80-90% response if limited, 60% if extensive
  • Survival increased from 3 months to 14 months in limited disease
    • but prognosis restricted even in limited disease with chemotherapy
60
Q

When do patients with small cell lung cancer receive radiotherapy?

A
  • Should also receive it in addition to chemotherapy if have demonstrated response to chemotherapy - consolidation treatment
  • Palliative sometimes offered for symptomatic problems
61
Q

In what region specifically should patients with small cell lung cancer receive adjuvant radiotherapy following chemo and why?

A
  • prophylactic cranial radiotherapy after chemotherapy increases survival by 5%
  • people have micrometastases that can’t be picked up with current imaging techniques; if treat empirically, can prevent these from progressing further
62
Q

What are 5 key things to remember regarding communication and lung cancer?

A
  1. Assess patient’s level of knowledge about their cancer (do not assume)
  2. Many patients may feel stigmatised - widely known it’s smoking related (still advise on benefit of stopping smoking, still beneficial with advanced cancer)
  3. Always invovle lung cancer specialist nurse
  4. Record discussions and communicate to all HCPs - ensure consistent info given
  5. Discuss end-of-life care appropriately - don’t wait until near end of life
63
Q

An MDT member trained in what is increasingly involved for lung cancer support?

A

Psychological support - psychologist, specialist nurse etc, to provide this to patient

64
Q

What are 5 palliative treatment aspects in lung cancer?

A
  1. Drain pleural effusions if symptomatic; offer appropriate pleurodesis to ensure doesn’t come back
  2. Opiates for cough
  3. Effective pain control
  4. ENT for hoarseness
  5. Dexamethasone for symptomatic brain metastases - reduce symptoms
65
Q

What are 7 potential symptoms of all types of lung cancer?

A
  1. Persistent cough
  2. Haemoptysis
  3. Dyspnoea
  4. Chest pain
  5. Weight loss and anorexia
  6. Hoarseness
  7. Superior vena cava syndrome
66
Q

What can cause hoarseness in lung cancer?

A

Pancoast tumours (tumour of pulmonary apex) pressing on the recurrent laryngael nerve

67
Q

What are 3 possible examination findings in lung cancer?

A
  1. Fixed, monophonic wheeze on auscultation
  2. Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
  3. Clubbing
68
Q

What are 3 possible para-neoplastic features of small cell lung cancer?

A
  1. ADH - SIADH
  2. ACTH - in appropriate secretion, not typical features
  3. Lambert Eaton myasthenic syndrome: immune system attacks neuromuscular junctions, antibodies to voltage-gated calcium channels
69
Q

What are 6 features of Lambert Eaton syndrome, seen with small cell lung cancer?

A
  1. Muscle weakness
  2. Walking difficulty
  3. Tingling
  4. Eyelid drooping
  5. Fatigue
  6. Dry mouth
70
Q

What are 5 of the commonest features of inappropriate ACTH secretion seen with small cell lung carcinoma?

A
  1. Hypertension
  2. Hyperglycaemia
  3. Hypokalaemia
  4. Alkaosis
  5. Muscle weakness
71
Q

What abnormality may be seen in blood tests in patients with small cell lung carcinoma?

A

Thrombocytosis (Raised platelets)

72
Q

In what proportion of patients subsequently diagnosed with lung cancer was the chest x-ray reported as normal?

A

10%

73
Q

How does PET scanning for lung cancer work?

A
  • uses 18-fluorodeoxygenase, preferentially taken up by neoplastic tissue
  • improves diagnostic sensitivity of both local and distant metastasis spread in NSCLC
74
Q

What proportion of patients with NSCLC are suitable for surgery?

A

only 20%

75
Q

What investigation should be performed prior to surgery for NSCLC and why?

A

Mediastinoscopy: CT doesn’t always show mediatinal lymph node involvement

76
Q

What is the response of NSCLC like to chemotherapy?

A

Poor response (hence used palliatively or alongside curative therapy)

77
Q

What are 7 contraindications to surgery in NSCLC?

A
  1. Poor general health
  2. Stage IIIb or IV i.e. mets present
  3. FEV1 <1.5 L considered cut off (but if <1.5 for lobectomy or <2.0 for pneumonectomy then some authorities advocate further lung function tests as operations may still go ahead based on results)
  4. Malignant pleural effusion
  5. Tumour near hilum
  6. Vocal cord paralysis
  7. SVC obstruction
78
Q

What are 4 paraneoplastic features of squamous cell (NSCLC) lung carcinomas?

A
  1. Parathyroid hormone-related protein (PTH-rp) secretion causing hypcalcaemia
  2. Clubbing
  3. Hypertrophic pulmonary osteoarthropathy (HPOA)
  4. Hyperthyroidism due to ectopic TSH
79
Q

What are 2 paraneoplastic features of adenocarcinoma (form of NSCLC)?

A
  1. Gynaecomastia
  2. Hypertrophic pulmonary osteoarthropathy (HPOA)
80
Q

What is hypertrophic pulmonary osteoarthropathy? Which lung cancer types cause it?

A
  • Proliferative periostitis (inflammation of periosteum) typically involving the long bones; often painful
  • Traditionally taught it’s most common with squamous cell carcinoma, but some studies indicate adenocarcinoma is most common cause
  • See x-ray
81
Q

What are the 2 causes for referring patients using a suspected cancer referral (2 week wait) for lung cancer?

A
  1. Have chest x-ray findings that suggest lung cancer
  2. Are aged 40 and over with unexplained haemoptysis
82
Q

What are 6 features that should lead to URGENT chest-x ray (within 2 weeks) and what are the criteria?

A

2 OR MORE OF THE FOLLOWING (unexplained) OR 1+HAVE EVER SMOKED:

  1. cough
  2. fatigue
  3. shortness of breath
  4. chest pain
  5. weight loss
  6. appetite loss
83
Q

When should an urgent chest x-ray (2 weeks) be considered to assess for lung cancer? 5 features

A

OVER 40 AND WITH ANY OF THE FOLLOWING:

  1. Persistent or recurrent chest infection
  2. Finger clubbing
  3. Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
  4. Chest signs consistent with lung cancer
  5. Thrombocytosis
84
Q

What are 2 key features of alveolar cell carcinoma?

A
  • Not related to smoking
  • Lots of sputum production
85
Q

What is the typical location of small cell cancers?

A

Usually central

86
Q

Which cells des small cell lung cancer arise from?

A

APUD cells:

  • Amine - high amine content
  • Precursor Uptake - high uptake of precursors
  • Decarboxylase - high content of enzme decarboxylase
87
Q

What effect on electrolytes does ADH secretion by small cell cancers present with?

A

Hyponatraemia

88
Q

What anatomical and electrolyte effects can ACTH secretion by small cell lung cancer have?

A
  • ACTH secretion can cause bilateral adrenal hyperplasia
  • High levels of cortisol can lead to hypokalaemic alkalosis
89
Q

What does the CT scan show?

A

Small cell lung cancer with multiple pulmonary nodules and extensive mediastinal nodal metastases

90
Q

Where is the typical location of squamous cell lung cancer?

A

Central

91
Q

What feature of examination is squamous cell lung cancer strongly associated with?

A

Finger clubbing

92
Q

Where is the typical location of adenocarcinoma, a form of NSCLC?

A

Peripheral

93
Q

What can be said about smokers and adenocarcinoma?

A

Most common type of lung cancer in non-smokers, BUT majority of patients with it are smokers

(alveolar cell carcinoma - another type, not related to smoking at all)

94
Q

What is the typical location of large cell lung carcinomas?

A

Typically peripheral

95
Q

What is the histology of large cell lung carcinomas?

A

Anaplastic, poorly differentiated

96
Q

What is the prognosis of large cell lung carcinomas like?

A

Poor

97
Q

What hormone may be secreted by large cell lung carcinomas?

A

ß-hCG

98
Q

What 2 types of lung cancer are typically centrally located?

A
  1. Small cell lung cancer
  2. Squamous cell cancer (NSCLC)
99
Q

What 2 types of lung cancer are typically peripherally located?

A
  1. Adenocarcinoma
  2. Large cell lung carcinoma

AIP: Shortness of breath (12 decks)

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