1- Lung cancer Flashcards
prevalence
- Third most common cancer in UK (behind breast and prostate)
categorisation
- Non-small cell lung cancer (80%)
- Small cell (Oat cell)lung cancer (SCLC) (20%)
- Others: bronchial gland carcinoma, carcinoid tumour)
Non-small cell lung cancer (80%)
- Adenocarcinoma (most common- 40%)
- Squamous cell carcinoma (20%)- smoking (SS)
- Large-cell carcinoma (10%)
Small cell (Oat cell)lung cancer (SCLC) (20%)
Release neurosecretory granules which release neuroendocrine hormones -> paraneoplastic syndromes
- smoking (SS)
Others
bronchial gland carcinoma, carcinoid tumour
where does lung cancer metastatise to
Metastasis
- Liver
- Bone
- Brain
- Adrenal gland
- Pleura
Risk factors for lung cancer
- Cigarette smoking (72%)
- Airflow obstruction
- Increasing age
- Family history
- Exposure to carcinogens e.g. asbestos
presentation of lung cancer general
SoB
Cough
Haemoptysis
Finger clubbing
Recurrent pneumonia
Weight loss
Lymphadenopathy (supraclavicular nodes often first to be found)
presentation of small cell lung cancer (oat)
- Extrapulmonary manifestation and Paraneoplastic syndromes
- SIADH, Cushings, limbic encephalitis
presentation squamous cell cancer
hypercalcaemia
Red flags for lung cancer
- Cough which gets worse doesn’t go away
- Chest pain
- Shortness of breath
- Coughing up blood
- Fatigue
- Weight loss
- Anorexia
Referral criteria for lung cancer
Recommend offering a chest x-ray, carried out within 2 weeks, to patients over 40 with:
- Clubbing
- Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
- Recurrent or persistent chest infections
- Raised platelet count (thrombocytosis)
- Chest signs of lung cancer
investigations for lung cancer
- Bloods: FBC, U&Es, calcium, LFTs, INR (clotting important VTE)
- Chest Xray
- Staging CT CAP with contrast
- PET - CT using radioactive tracer (good for finding metastases)
- Bronchoscopy with endobronchial US (EBUS)–> allows detailed assessment of tumour and US guided biopsy
- Histological diagnosis (biopsy) -> via bronchoscopy or percutaenously (if peripheral tumour)
- if pleural effusion could drain effusion and send off cytology
chest X-ray findings
- Hilar enlargement
- Peripheral opacity – visible lesions in the lung field
- Pleural effusion- usually unilateral in cancer
- Collapse
Staging systems:
TNM staging
Extrapulmonary manifestations of lung cancer and paraneoplastic syndrome
Sometimes the first evidence of a lung cancer in otherwise asymptomatic patients
Extrapulmonary manifestation
1) Recurrent laryngeal nerve palsy
2) Phrenic nerve palsy
3) Superior vena cava obstruction
4) Horner’s syndrome
Recurrent laryngeal nerve palsy
- Hoarse voice
- Cancer pressing on recurrent laryngeal nerve as it passes through mediastinum
Phrenic nerve palsy
- SoB
- Nerve compression causes diaphragm weakness
Superior vena cava obstruction
- Facial swelling, difficulty breathing, distended veins in the neck and upper chest
- Pembertons sign- raising hands over head causes facial congestion and cyanosis
- Causes by direct compression of tumour on superior vena cava
- Emergency
Horner’s syndrome
- Partial ptosis, anhidrosis and miosis
- Pancoast tumour (pulmonary apex)
- Presses on sympathetic ganglion
what is paraneoplastic syndrome
Not caused by direct compression by tumour (Hormones and cytokines)
paraneoplastic syndrome
5) Syndrome of inappropriate ADH (SIADH)
6) Cushings syndrome
7) Hypercalcaemia
8) Limbic encephalitis
9) Lambert Eaton myasthenic syndrome
Syndrome of inappropriate ADH (SIADH)
- Ectopic ADH
- Small cell lung cancer
Cushings syndrome
- Ectopic ACTH
- Small cell lung cancer
Hypercalcaemia
- Ectopic parathyroid hormone
- Squamous cell carcinoma
Limbic encephalitis
- Memory problems, hallucinations, confusions and seizures – Anti-Hu antibodies
- Small cell lung cancer
- Tumour causes immune system to make antibodies to tissues in the brain – limbic system- inflammation
Lambert Eaton myasthenic syndrome
Lambert-Eaton myasthenic syndrome has a similar set of features to myasthenia gravis. It causes progressive muscle weakness with increased use as a result of damage to the neuromuscular junction. The symptoms tend to be more insidious and less pronounced than in myasthenia gravis.
Lambert-Eaton syndrome typically occurs in patients with small-cell lung cancer. It is a result of antibodies produced by the immune system against voltage-gated calcium channels in small cell lung cancer (SCLC) cells. These antibodies also target and damage voltage-gated calcium channels in the presynaptic terminals of the neuromuscular junction where motor nerves communicate with muscle cells.
These voltage-gated calcium channels are responsible for assisting in the release of acetylcholine into the synapse of the neuromuscular junction. This acetylcholine then binds to the acetylcholine receptors and stimulates a muscle contraction. When these channels are destroyed, less acetylcholine is release into the synapse.
management of lung cancer
MDT approach
Lung Cancer Treatment Summary
- Curative surgery for stages I & II – assuming fit for surgery
- Surgery & adjuvant chemotherapy clinical trial for stage IIIa – assuming fit for surgery & chemo
- Chemotherapy – consider in patients with stage III/IV disease and PS 0-2
- Radiotherapy – curative (CHART = continuous hyperfractionated accelerated radiotherapy) for people not fit for surgery OR palliative
- Palliative Care
- Do nothing / watch & wait
management of Non-small cell lung cancer
Surgery
- First line: Lobectomy
Non-small cell lung cancer which is isolated to a single area with intention to cure the cancer
- Segmentectomy or wedge resection also an option
Radiotherapy
Can also be curative in early non-small cell lung cancer
Chemotherapy
Offered as an adjunct to surgery or radiotherapy (adjuvant chemo) or as a palliative treatment to improve quality of life in later stages of non-small cell lung cancer
Management of Small cell lung cancer
- Rapid growth rate and almost always too extensive for surgery at time of diagnosis
- Mainstay of treatment is chemotherapy
- Also palliative radiotherapy
- immunotherapy
- Untreated – median survival is 8-16 weeks
- Combination chemotherapy – median survival 7- 15 months
Palliative management
- Endobronchial treatment with stents or debulking
Prognosis
- Small cell lung cancer worse prognosis than non-small cell lung cancer
Lung cancer surgery
There are several options for removing a lung tumour:
- Segmentectomy or wedge resection involves taking a segment or wedge of lung (a portion of one lobe)
- Lobectomy involves removing the entire lung lobe containing the tumour (the most common method)
- Pneumonectomy involves removing an entire lung
The types of surgery that can be used are:
- Thoracotomy – open surgery with an incision and separation of the rib to access the thoracic cavity
- Video-assisted thoracoscopic surgery (VATS) – minimally invasive “keyhole” surgery
- Robotic surgery
Minimally invasive surgery (i.e., VATS or robotic surgery) is generally preferred as it has a faster recovery and fewer complications.
There are three main thoracotomy incisions:
- Anterolateral thoracotomy with an incision around the front and side
- Axillary thoracotomy with an incision in the axilla (armpit)
- Posterolateral thoracotomy with an incision around the back and side (the most common approach to the thorax)
Lambert-Eaton myasthenic syndrome
Background
In older smokers with symptoms of Lambert-Eaton syndrome consider small cell lung cancer.
Lambert-Eaton myasthenic syndrome pathophysiology
- Is a result of antibodies produced by the immune system against small cell lung cancer cells
- These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones.
- This leads to weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia (difficulty swallowing). Patients may also experience dry mouth, blurred vision, impotence and dizziness due to autonomic dysfunction.
- Patients with Lambert-Eaton have reduced tendon reflexes.
A notable finding is that these reflexes become temporarily normal for a short period following a period of strong muscle contraction. For example, the patient can maximally contract the quadriceps muscle for a period, then have their reflexes tested immediately afterwards, and display an improvement in the response. This is called post-tetanic potentiation.
Mesothelioma background
- Lung malignancy affecting mesothelial cells of the pleura
mesothelioma risk factors
- Asbestos inhalation e.g. occupational – building, factory, mining
presentation of mesothelioma
Presentation
- Huge latent period between exposure to asbestos and development of mesothelioma -> 45 years
- Chest pain
- SoB
- Unusual lumps of tissue under skin
- Unexplained weight loss
Management of mesothelioma
- Chemotherapy can improve survival
- Palliative
prognosis of mesothelioma
Prognosis
- Very poor
immunotherapy in lung cancer
About immunotherapy for lung cancer
Immunotherapy and targeted therapy drugs are used to treat non-small cell lung cancer (NSCLC) that has spread outside the lung or to other parts of the body.
They are not commonly used for small-cell lung cancer (SCLC). Sometimes a combination of immunotherapy and chemotherapy for SCLC may be given.
brain metastasis
management of brain metastasis
supportive care
