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Year 4 CCC > Thoracic cancers > Flashcards

Thoracic cancers Flashcards

1
Q

Lung cancer accounts for % of all cancers?

A

14%

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2
Q

What are the 5-year survival rates of lung cancer in the UK?

A

6-7%

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3
Q

What % of lung cancers are due to smoking?

A

80-90%

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4
Q

Which types of cigarettes correlate to a higher risk of developing lung cancer?

A

Unfiltered

High-nicotine

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5
Q

In addition to smoking, what are the other causes/risk factors for lung cancer?

A

Passive smoking
Asbestos
Previous radiotherapy to the chest
Rarely, inhalation of radon gas, polycyclic aromatic hydrocarbons, nickel, chromate or inorganic arsenicals

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6
Q

What does recent evidence suggest in terms of the development of mixed histology commonly seen in lung cancer?

A

Lung cancers may arise in pluripotent stem cells in the bronchial epithelium

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7
Q

What are the pathological classifications of lung cancer?

A
  1. Squamous cell carcinoma (30%)
  2. Small cell carcinoma
  3. Adenocarcinoma - acinar, papillary, bronchioalveolar, mutinous, mixed
  4. Large-cell neuroendocrine carcinoma
  5. Mixed carcinoma (e.g. adenosquamous)
  6. Giant cell carcinoma
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8
Q

For the purposes of management, how are lung cancers classified?

A

Non-small cell (NSCLC) and small cell (SCLC)

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9
Q

What are the common sites of metastatic spread in lung cancer? (6)

A
  1. Regional lymph nodes
  2. Bone
  3. Liver
  4. Adrenal
  5. CNS
  6. Skin
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10
Q

Which lung cancer classification - NSCLC or SCLC has the highest risk of metastasising?

A

SCLC (estimated 90% will have mets as presentation)

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11
Q

Which genes are involved in the development and progression of lung cancer?

A

Oncogene activation:
1. Epidermal growth factor receptor (EGFR) overexpression (70% SCLCs and 40% adenocarcinomas)
2. Point mutation of RAS or MYC
Tumour suppressor gene inactivation:
1. p53 alteration
2. BCL2 high expression in SCLC protects against apoptosis
Angiogenesis - tumour progression and metastasis:
1. Vascular endothelial growth factor (VEGF) receptor
2. Telomerase activation occurs in 100% of SCLCs and 80% of NSCLCs.

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12
Q

A family history of lung cancer increases risk by how many times, even when smoking is taken into account?

A

2.5X

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13
Q

Germaine mutation of which two tumour suppressor genes can mean a genetic predisposition to the development of lung cancer?

A

p53 and Rb

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14
Q

How can lung cancer typically present?

A
  1. Recurrent chest infections
  2. Haemoptysis
  3. Dyspnoea
  4. Persistent cough
  5. Pleural effusion
  6. Chest pain
  7. Hoarse voice
  8. Wheeze, stridor
  9. Horner’s syndrome
  10. Weight loss
  11. Fatigue
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15
Q

What investigations are/can be carried out in suspected lung cancer? (at least 5)

A 
CXR
Respiratory examination
Fine needle aspiration 
Sputum cytology 
Bronchoscopy
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16
Q

What assessments are required in order to stage a NSCLC?

A
  1. Clinical examination (particular attention to lymph nodes, soft tissue masses)
  2. Bronchoscopy - movement of vocal chords, site of endobronchial tumour, bronchial divisions, extrinsic compression of bronchi
  3. CT chest and abdomen - size and site of primary tumour, relationship to lung fissures, mediastinum and chest wall, lymphadenopathy, metastatic disease
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17
Q

What does FDG-PET stand for?

A

Fluorodeoxyglucose positron emission tomography

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18
Q

Why is PET scanning recommended more than CT scanning for staging NSCLC?

A

FDG-PET scanning has a greater sensitivity and specificity than CT scanning for staging of NSCLC, and is recommended for pre-operative assessment. It is also used to exclude metastatic disease in patients being considered for radical non-surgical treatment

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19
Q

In people with lung cancer, who is surgery most appropriate for in terms of staging?

A

In people with stages I - II lung cancer, who are fit for surgery

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20
Q

In TNM staging of lung cancer, what does T1 refer to?

A

A tumour of 3cm or less in diameter, surrounded by lung and visceral pleura, distal to the main bronchus

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21
Q

What does T2 refer to?

A

Tumour 3 - 7cm diameter; or involving main bronchus 2cm or more distal to carina; or invading visceral pleura; or associated with atelectasis which extends to the hilum but does not involve the whole lung

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22
Q

What does T3 refer to?

A

Tumour >7cm; or invading chest wall, diaphragm, mediastinal pleura, or pericardium; or tumour in main bronchus <2cm distal to carina; or atelectasis of the whole lung

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23
Q

What does T4 refer to?

A

Tumour invading mediastinum, heart, great vessels, trachea, oesophagus, vertebra, or carina

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24
Q

What does N0 refer to?

A

No regional node metastases

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25
Q

What does N1 refer to?

A

Ipsilateral peribronchial or hilar node involvement

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26
Q

What does N2 refer to?

A

Ipsilateral mediastinal or subcarinal nodes

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27
Q

What does N3 refer to?

A

Contralateral mediastinal nodes; scalene; or supraclavicular nodes

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28
Q

M0?

A

No distant metastases

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29
Q

M1?

A

Metastatic disease either malignant pleural effusion or distant metastasis

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30
Q

What does stage I in lung cancer refer to in terms of TNM staging?

A

T 1-2 , N0

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31
Q

What does stage II refer to in terms of TNM staging?

A

T 1-2 N1 OR T3 N0

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32
Q

What does stage IIIa refer to?

A

T 1-2 N2 OR T3 N 1-2

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33
Q

What does stage IIIb refer to?

A

T4 any N M0 OR any N3 M0

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34
Q

What does IV refer to?

A

Any M1

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35
Q

What treatment offers the best possibility of cure in NSCLC?

A

Surgery

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36
Q

Which patients with NSCLC should be considered for surgery?

A

Any patient with non-metastatic NSCLC

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37
Q

Before the possibility of surgery, what assessments must be carried out to confirm the diagnosis of stage I or II NSCLC? (4)

A
  1. No evidence of metastases on PET scan
  2. Mediastinoscopy and lymph node biopsies
  3. Lymph nodes that appear a normal size on CT (<1cm diameter)
  4. Fitness for surgery; including co-morbidities and pulmonary function tests, spirometry etc.
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38
Q

What are the post-operative complications associated with removal of NSCLC (and possibly in many major thoracic surgeries..) (5)

A
  1. Haemorrhage
  2. Respiratory failure - opiate induced, or pneumothorax
  3. Cardiac arrhythmias, particularly AF
  4. Sepsis - chest infection, wound infection, empyema
  5. Broncho-pleural fistula
39
Q

What is the 5-year survival rate in people with stage I NSCLC?

A

60 - 80%

40
Q

Stage II 5-year survival?

A

25 - 40%

41
Q

Stage III 5-year survival?

A

10 - 30%

42
Q

Stage IV 5-year survival?

A

<5%

43
Q

In terms of radiotherapy, what does CHART stand for?

A

Continuous hyper fractionated accelerated radio therapy

44
Q

What is the standard international dose for radiotherapy?

A

60-66Gy in 30-33 fractions over 6 weeks

45
Q

What % of lung cancers are small cell? (SCLCs)

A

15-20%

46
Q

Why is staging and management of SCLCs different to NSCLCs?

A

Because SCLCs almost always demonstrate rapid growth and early dissemination and >90% have systemic disease at presentation

47
Q

What % of SCLCs are operable?

A

10%

48
Q

What is the key primary treatment for SCLCs?

A

Chemotherapy

49
Q

What are the two categories of SCLCs?

A
  1. Limited-stage disease

2. Extensive-stage disease

50
Q

What falls under the limited-stage disease category?

A

Tumour confined to one hemi-thorax and regional lymph nodes, and can be covered by tolerable radiotherapy fields

51
Q

What falls under the extensive-stage disease category?

A

Disease beyond the ‘limited-stage’ bounds.

52
Q

What are the other prognostic factors involved in staging or grouping the SCLC? (5)

A
  1. Performance status
  2. Sex (females have a better prognosis)
  3. Lactate dehydrogenase (LDH)
  4. Alkaline phosphatase
  5. Serum Na+ (hyponatraemia carries a poor prognosis)
53
Q

What does MPM stand for?

A

Malignant pleural mesothelioma

54
Q

Where does it arise from?

A

The serosal lining of the chest

55
Q

How many cases of mesothelioma are there a year in the UK?

A

Around 2200, although the incidence is expected to rise to 2500 in the next decade and fall thereafter

56
Q

What is the prognosis like for mesothelioma?

A

It is characterised by poor survival rates and is an aggressive tumour

57
Q

What is the peak age of incidence of mesothelioma?

A

60-70 years of age

58
Q

What is the male to female ratio of MPM?

A

5:1

59
Q

What % of people with MPM have an occupational history of exposure to asbestos?

A

90%

60
Q

Other than asbestos, what can more rarely cause mesothelioma? (2)

A
  • Erionite fibres (Turkey)

- thorium dioxide

61
Q

Where does the mesothelioma arise in the thorax?

A

It arises from the parietal or visceral pleura and grows diffusely within the pleural space

62
Q

What sign is commonly associated with mesothelioma?

A

Pleura effusion

63
Q

How does the tumour tend to spread?

A

It invades directly into the lung and mediastinum, and may cross the diaphragm to involve peritoneum

64
Q

What are the 3 distinct histological subtypes of malignant mesothelioma? (3)

A
  1. Epithelial (50%) - better prognosis with this pathology
  2. Sarcomatous
  3. Mixed
65
Q

What signs/symptoms are associated with malignant mesothelioma? (8)

A
  1. Chest pain
  2. Dyspnoea
  3. Systemic symptoms - fatigue, weight loss, sweating and fever
  4. Palpable chest wall mass
  5. Hoarse voice
  6. SVC obstruction
  7. Horner’s syndrome
  8. Ascites
66
Q

What is the name of the tumour in the lung associated with Horners syndrome?

A

Pancoast tumour

67
Q

What is the name of the staging system used in MPM?

A

Brigham

68
Q

What is the average survival rate in someone with untreated MPM?

A

Less than 1 year

69
Q

What are the treatment options for MPM? (4)

A
  1. Pleurodesis - Talc pleurodesis is effective in many patients in delaying the reaccumulation of pleural effusion
  2. Radiotherapy
  3. Chemotherapy
  4. Palliative care
    - surgery is very rarely an option (5%)
70
Q

Thyme tumours account for what % of all mediastinal tumours?

A

20%

71
Q

What tumours arise in the anterior mediastinum? (3)

A
  1. Thymic
  2. Lymphoma
  3. Teratoma
72
Q

In what ages does the incidence of thymomas peak?

A

Between 40-60 years of age

73
Q

Are thymomas typically fast or slow growing?

A

Slow growing

74
Q

What does thymomas typically retain the capacity to produce?

A

T-cells. The T-cells are generally of normal phenotype

75
Q

In terms of predicting prognosis and outcome, what is particularly important in a resected thymoma?

A

The presence or absence of an intact capsule and local invasion

76
Q

There are three classifications of thymoma, what are they?

A
  1. Encapsulated thymoma - benign cytology and biological behaviour (50%)
  2. Invasive thymoma - benign cytology but capable of local invasion and, rarely, distant metastases (40%)
  3. Thymic carcinoma (10%) - demonstrates cytological and biological features of cancer
77
Q

Where is metastatic spread most likely to occur with a thymoma?

A

Pleura, lung, lymph nodes and other viscera.

78
Q

What is the commonest paraneoplastic disease/effect, that occurs in approximately 15-25% if patients with thymoma?

A

Myasthenia gravis

79
Q

What investigations are carried out in people with suspected thymoma?

A
  1. Imaging by CT or MRI

2. CT-guided core biopsy preferred to FNA cytology

80
Q

What is the most common treatment of thymomas?

A

90% present with localised disease, for which surgery is best

81
Q

What is the prognosis like for people with thymoma?

A

Generally good, early stages of the disease = 10-year survival rate 70-90%. Late stage 10-year survival rate 38 - 57%

82
Q

In stage I thymoma, what is the % recurrence rate?

A

4%

83
Q

In stage IV thymoma, what is the % recurrence rate?

A

46%

84
Q

What is the pathology of 50% of lung cancers?

A

Adenocarcinoma

85
Q

What is the name of a lung cancer causing Horner’s syndrome?

A

Pancoast tumour

86
Q

If there was no spread of the pancoast tumour, what would be the treatment plan?

A

Radical treatment

87
Q

What predictive markers would help to aid treatment and prognosis in lung cancer?

A

EGFR
ALK
PDL-1

88
Q

What is the histology/characteristic of small cell lung cancer? (6)

A
  1. Cancer cells are small and oval
  2. Scanty cytoplasm
  3. Fine granular neoplasm
  4. Absent nuceoli
  5. Frequent mitosis
  6. Dense neurosecretory granules
89
Q

Which paraneoplastic syndromes are associated with small cell lung cancer? (3)

A
  1. Ectopic ACTH production
  2. Syndrome of inappropriate ADH
  3. Eaton Lambert syndrome
90
Q

Why is it important to test for oncogene presence in NSCLC?

A

As for example 15% of adenocarcinomas have EGFR and can therefore be treated really effectively with the ‘-tinib’ drugs (immunotherapy)

91
Q

Which lung cancer is most closely linked with smoking?

A

Squamous cell carcinoma

92
Q

Which lung cancer is more commonly found near the larger airways as opposed to peripherally?

A

Squamous cell carcinoma

93
Q

Which lung cancer tends to be more peripheral?

A

Adenocarcinoma

Year 4 CCC (17 decks)

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