Surgical Management of Lung Cancer

Question 1

What two factors are took into account when assessing a lung cancer patient for surgical treatment?

Answer 1

• staging of LC

- fitness of patient

Question 2

How many T stages are there within the TNM staging?

Answer 2

4

Question 3

What does a staging of N1 mean?

Would a surgeon consider operating on this?

Answer 3

cancer has spread to lymph nodes within lung and/or hilum

Yes - survival rate would be around 40% depending on size of tumour.

Question 4

What does a staging of N3 mean?

Would a surgeon consider operating on this?

Answer 4

cancer has spread to opposite side of chest wall, or to lung apex.

Normally not operable as cancer has spread too far.

Question 5

If cancer spreads to lymph nodes, which surrounding structures tend to be affected?

What can this lead to?

Answer 5

phrenic/laryngeal nerves

phrenic nerve palsy

Question 6

What happens with phrenic nerve palsy?

Answer 6

unilateral raised diaphragm

Question 7

What can tumour compression on laryngeal nerve result in?

Answer 7

voice box affected, hoarseness in voice

Question 8

Where does lung cancer commonly metastasise to?

5

Answer 8

B BALL

Bone
Brain
Adrenal glands
Liver
Lymph nodes

Question 9

What are the signs from a history that can help stage lung cancer?

(3)

Answer 9

• pain (bony pain)
• neurological (headache, personality changes)
• haematuria

Question 10

What are the signs from an examination that can help stage lung cancer?

(5)

Answer 10

• Recurrent laryngeal nerve palsy
• supraclavicular LNs
• Chest wall masses
• Pleural/pericardial effusion
• Hepatomegaly

Question 11

What are red flags for all cancers?

4

Answer 11

• weight loss
• loss of appetite
• fatigue
• night sweats

Question 12

Which type of cancer is usually treatable by surgery?

Answer 12

NSCCLC

60% adenocarcinoma
40% squamous

Question 13

What are the most common symptoms of lung cancer?

4

Answer 13

• persistent cough
• SOB
• haemoptysis
• malignant pleural effusion

Question 14

What can be looked for in a CXR to stage lung cancer?

4

Answer 14

• Pleural effusion (malignancy?)
• Chest wall invasion (mets)
• Phrenic nerve palsy (nodal spread)
• Collapsed lobe or lung

Question 15

What blood tests can be used to stage cancer and what do they show?

(3)

Answer 15

• anaemia (ca causing blood loss)
• abnormal LFTs (liver mets)
• abnormal bone profile (bone mets)

Question 16

How can a CT scan be useful in lung cancer staging?

6

Answer 16

• tumour size
• nodal spread (mediastinal)
• mets (BBALL)
• proximity to mediastinal structures
• pleural/pericardial effusion
• diaphragmatic involvement

Question 17

Which organs have a high glucose uptake on a PET scan?

3

Answer 17

Brain
kidney
heart

Question 18

What is an isolated uptake indicative of on a PET scan?

Answer 18

tumour

Question 19

What is MRI useful for when staging lung cancer?

Answer 19

determining the degree of vascular and neurological involvement in pancoast tumour

Question 20

What is a bone scan useful for when staging lung cancer?

2

Answer 20

• chest wall invasion

- bone mets

Question 21

what is an ECHO useful for when staging lung cancer?

Answer 21

pericardial effusion

Question 22

What is a pancoast tumour?

2

Answer 22

• tumour of pulmonary apex

- most are non-small cell cancers

Question 23

what invasive/surgical methods are used to stage lung cancer?

(2)

Answer 23

bronchoscopy

mediastinoscopy

Question 24

What CVS conditions may affect a patients fitness for surgery?

(5)

Answer 24

• angina
• hypertension
• peripheral vascular disease
• angioplasty/CABG
• stroke/TIA

Question 25

What respiratory conditions may affect a patient's fitness for surgery? (5)

Answer 25

- COPD - smoker - recent URTI - oxygen use - exercise capacity

Question 26

What psychological conditions may affect a patient's fitness for surgery? (3)

Answer 26

- PMH mental illness - severe anxiety - chronic pain problems

Question 27

What are some 'other' conditions that will affect a patient's fitness for surgery? (3)

Answer 27

- pulmonary hypertension - permanent tracheostomy - rheumatoid arthritis

Question 28

What are some respiratory function tests used to assess fitness for surgery? (4)

Answer 28

- spirometry - diffusion studies e.g. CO study - fractionated V/Q scan - ABG

Question 29

Which tests can be done to test fitness for surgery (in terms CVS)? (4)

Answer 29

- ECG - ECHO - CT scan – calcification of aorta - ETT – exercise tolerance test

Question 30

What is the ultimate goal of surgical treatment of lung cancer?

Answer 30

curative resection by removing the minimum amount of lung

Question 31

Is resection of the parietal structures feasible?

Answer 31

yes

Question 32

What is highly desirable before resection? Why?

Answer 32

firm diagnosis of malignancy Infections and TB can look like cancer

Question 33

What (guided) diagnostic technique might be used to confirm whether a tumour is malignant or benign?

Answer 33

CT guided tumour biopsy

Question 34

What are the reasons for post-operative deaths? | 4

Answer 34

- ARDS - Bronchopneumonia - MI - PE

Question 35

How can pulmonary thromboembolism be prevented?

Answer 35

- heparin s/c | - stockings

Question 36

What are some non-fatal complications of lung cancer? | 5

Answer 36

- empyema - wound infection - AF - MI - Post-op respiratory insufficiency

Question 37

What are common problems associated with staging lung cancer? (3)

Answer 37

- lung collapse masking tumour - adrenal nodule - retrosternal thyroid

Question 38

What are some conditions that can be mistaken for lung cancer? (5)

Answer 38

- Infection (TB, Lung abscess_ - Benign tumour - Granuloma (e.g. Sarcoidosis) - Fibrosis - Aspergilloma

Question 39

Which type of tumour removal surgery has the highest mortality? Which has the least?

Answer 39

pneumonectomy (or thoracotomy) wedge resection