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Year 2 Cardio > Lung Cancers > Flashcards

Lung Cancers Flashcards

(74 cards)

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1
Q

What is angiosarcoma?

A

Malignancy of vascular endothelial cells
Of skin, heart, liver, etc
UK annual incidence 1.5 cases per million

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2
Q

What is the prevalence of cardiovascular cancer?

A

Incredibly rare

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3
Q

What are the features of cardiac tumours?

A

E.g. myxoma, tumour of connective tissue

Annual incidence <1 case per million

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4
Q

Why are cardiac cancers so rare?

A

Low exposure of cells to carcinogens

Turnover rate: cardiac myocytes divide very rarely

Strong selective advantage against anything which could compromise function

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5
Q

Why might other organs be exposed more too carcinogens?

A

Lung- inhaled particles, smoking etc

Kidney/Liver - exposed to toxins

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6
Q

Why is the shape of cardiac cells relevant to low incidence of cancer?

A

Shape in cells is highly specialised

Any change will prevent the cardiovascular system from working

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7
Q

What is the scale of lung cancer?

A

3rd most common cancer in UK

~48,000 diagnoses/ year

~35,000 deaths/ year

Leading cause of cancer death

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8
Q

From when has lung cancer become more common?

A

After the 1930s

Smoking was only really popular after WW1

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9
Q

Who linked smoking habits with lung cancer?

A

Doll and Hill

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10
Q

What are risk factors for lung cancer?

A

Age, peak 75-90
Sex, M>F
Lower socioeconomic status
Smoking history

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11
Q

What is relevant in a smoking history?

A

Duration
Intensity
When stopped

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12
Q

What are other causes of lung cancer other than smoking?

A

Passive smoking

Asbestos – exposure (plumbers, ship-builders, carriage workers, carpenters, etc) – risk up to x2

Radon – e.g. silver miners in Germany late 19th century; 1950s uranium mining in Colorado

Indoor cooking fumes – wood smoke, frying fats

Chronic lung diseases (COPD, fibrosis)

Immunodeficiency

Familial/ genetic – several loci identified

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13
Q

What are the different types of lung cancer?

A

Squamous cell carcinoma
Adenocarcinoma
Large cell lung cancer
Small cell lung cancer

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14
Q

What are the features of squamous cell carcinomas?

A

Squamous cell carcinoma (~30% of cases).
– previously the most common
– originating from bronchial epithelium; centrally located

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15
Q

What are the features of adenocarcinomas?

A

Adenocarcinoma (~40%)
– most common from 1980s onwards – low tar cigarettes, inhaled more deeply / retained longer
– originating from mucus-producing glandular tissue; more peripherally-locate

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16
Q

What are the features of large cell lung cancer?

A

Large cell lung cancer (~15%)

heterogenous group, undifferentiated

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17
Q

What are the features of small cell lung cancer?

A

Small cell lung cancer (~15%)
originate from pulmonary neuroendocrine cells
highly malignant

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18
Q

What is NSCLC?

A

Non small cell lung cancer

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19
Q

Describe the model of lung cancer development?

A 
Normal Epithelium
Hyperplasia
Squamous metaplasia
Dysplasia
Carcinoma in situ
Invasive carcinoma
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20
Q

What is metaplasia?

A

reversible change in which one adult cell type replaced by another adult cell type; adaptive

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21
Q

What is dysplasia?

A

abnormal pattern of growth in which some of the cellular and architectural features of malignancy are present; pre-invasive stage with intact basement membrane

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22
Q

What are some oncogenes?

A

epidermal growth factor receptor (EGFR) tyrosine kinase

anaplastic lymphoma kinase (ALK) tyrosine kinase

c-ROS oncogene 1 (ROS1) receptor tyrosine kinase

BRAF (downstream cell-cycle signalling mediator)

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23
Q

What do genetic kinase defects cause?

A

Lung cancer most common in those who have never smoked

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24
Q

What are the key symptoms of lung cancer?

A 
Cough
Weight loss
Breathlessness
Fatigue
Chest pain
Haemoptysis
Or frequently asymptomatic
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25
Why is lung cancer often diagnosed late?
Nature of lung Lots of space in the thoracic cavity Does not impede on other structures quickly Non-specific symtoms
26
What are features of advanced/metastatic disease?
Neurological features: focal weakness, seizures, spinal cord compression Bone pain Paraneoplastic syndromes: clubbing, hypercalaemia, hyponatraemia, Cushing’s
27
What is Pemberton's sign indicative of?
Superior vena cava obstruction Engourgement of the face due to decreased blood flow Redness Facial swelling Distention of veins of neck and chest
28
What is Horner's syndrome caused be?
Apical lung tumour Loss of sweating on side of face Ptosis Pupillary reconstruction
29
What is cachexia?
Muscle wastage | Weight loss
30
What is the diagnostic strategy for lung cancer?
Establish most likely diagnosis Establish fitness for investigation and treatment Confirm diagnosis specific type of cancer if considering systemic treatment Confirm staging
31
What imaging can be used to diagnose lung cancer?
Chest X-ray Tumours appear white Might show unilateral pleural effusion Staging ST (chest and abdomen) PET
32
What is unilateral pleural effusion often indicative of?
Malignancy | Likely metastasised to pleura from lung
33
What is PET useful for?
To exclude occult metastases
34
What are tests use to confirm diagnosis?
Biopsy via bronchoscopy via endobronchial ultrasound and trans bronchial needle via CT guided lung biopsy
35
How do you stage lung cancer?
T1-4: tumour size and location N0-3: lymph node involvement – mediastinum + beyond M0-1c: metastases + number
36
How is biopsy conducted via bronchoscopy?
Tube passed down for tumours of central airway where tissue staging not important
37
How is biopsy conducted via endobronchial ultrasound?
Endobronchial ultrasound and transbronchial-needle aspiration of mediastinal lymph nodes (EBUS [TBNA]) To stage mediastinum +/- achieve tissue diagnosis
38
How is biopsy conducted via CT guided biopsy?
CT-guided lung biopsy To access peripheral lung tumours
39
What determines treatment selection?
``` Patient fitness Cancer histology Cancer stage Patient preference Health service factors ```
40
What are the treatment options?
Surgical Radiological Pharmacological Supportive
41
How do assess patient fitness?
WHO performance status 0-5 scale
42
What does 0 on the fitness scale mean?
Asymptomatic (Fully active, able to carry on all predisease activities without restriction)
43
What does 1 on the fitness scale mean?
– Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work)
44
What does 0 on the fitness scale mean?
Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours)
45
What does 0 on the fitness scale mean?
Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours)
46
What does 0 on the fitness scale mean?
Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)
47
What does 0 on the fitness scale mean?
Death
48
Which numbers on the scale are radical treatments restricted to?
0-2
49
How is surgery used to treat lung cancer?
Surgical resection is standard of care for early stage disease Lobectomy + lymphadenectomy usual approach Sublobar resection if stage 1 (≤3 𝑐𝑚)
50
How is radical radiotherapy used to treat lung cancer?
Alternative to surgery for early stage disease Particularly if comorbidity Stereotactic ablative body radiotherapy (SABR) - Technique of choice - High-precision targeting, multiple convergent beams
51
How is surgery conducted?
Open thoracotomy | now VATS
52
When is radiotherapy used instead of surgery?
Not fit enough for surgery | Refuse surgery
53
When are oncogene systemic pharmacological treatments used?
First line for metastatic NSCLC with mutation
54
What are some NICE approve drug treatments?
EGFR: erlotinib, gefitinib, afatinib, dacomitinib, and osimertinib ALK: crizotinib, ceritinib, alectinib, brigatinib, lorlatinib ROS-1: crizotinib, entrectinib
55
What is the efficacy of drug treatments?
improvements in progression-free survival, but not necessarily overall survival vs standard chemotherapy: e.g. erlotinib PFS 13 vs 5 months, OS 23 vs 27 months compared to chemo (OPTIMAL trial)
56
What are the side effects of the drug treatments?
generally well-tolerated (tablets) | rash, diarrhoea, and (uncommonly) pneumonitis
57
What is the desired effect for drug treatments?
Not always to cure But to improve QoL Alleviate some symptoms Palliative
58
What is PFS?
Progression free survival
59
What is immunotherapy?
New, progressive field, radical approach Harnesses own immune system to attack cancer cells
60
What are NICE approved immunotherapy drugs?
Pembrolizumab, atezolizumab, nivolumab
61
When is immunotherapy used?
First line for metastatic NSCLC with no mutation (and PDL1 ≥50%)
62
What is the efficacy of immunotherapy?
improvements in progression-free survival and overall survival vs standard chemotherapy: e.g. pembrolizumab PFS 10 vs 6 months, OS 30 vs 14 months (KEYNOTE-024 trial)
63
What are side effects of immunotherapy?
generally well-tolerated | Immune-related side-effects in 10-15% (thyroid, skin, bowel, lung, liver)
64
When is cytoxic chemotherapy used?
First line for metastatic NSCLC with no mutation and PDL1 ≤50% (in combination with immunotherapy)
65
What are the features of chemo?
Target any rapidly dividing cells | Platiunum-based regimens, e.g. carboplatin, cisplatin, paclitaxel, pemetrexed
66
What is the efficacy of chemo?
Modest improvements in overall survival vs best supportive care: e.g. 29 vs 20% one year survival in clinical trials
67
What are the side effects of chemo?
Frequent: fatigue, nausea, bone marrow suppression, nephrotoxicity Quality of life poorly evaluated in trials; no evidence for improvement
68
What is the fourth dimension in cancer care?
Palliative care | Supportive care
69
What are the features of palliative care?
Should be offered as standard to all patients with advanced stage disease Symptom control, psychological support, education, practical and financial support, planning for end of life
70
Who is key in palliative care?
Lung cancer specialist nurses key
71
What does palliative care result in?
Improve QoL Lower depression scores Mean survival can increase
72
What treatment is used for early stage disease?
Surgery or radiotherapy with curative intent
73
What treatment is used for locally advances disease? (involving thoracic lymph nodes)
Surgery + adjuvant chemotherapy | Radiotherapy + chemotherapy +/- immunotherapy
74
What is the treatment for metastatic lung cancer?
With targetable mutation (e.g. EFGR, ALK, ROS-1): tyrosine kinase inhibitor No mutation, PDL-1 positive: immunotherapy No mutation, PDL-1 negative: ‘standard’ chemotherapy Palliative care, alone or with the above

Year 2 Cardio (10 decks)

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