BRONCHIAL CARCINOMA Flashcards
What % of primary lung tumours?
95%
What % of cases are SCLCs?
15%
What type of cells in SCLCs?
• Arise from Kulchitsky cells – part of amine precursor uptake and decarboxylation (APUD) endocrine system
What prognosis of SCLC?
Highly malignant, usually inoperable at presentation
Poor prognosis
What is SCLC also called?
Oat-cell carcinoma
What % are NSCLCs?
85%
What 5 types of NSCLCs?
- Squamous
- Adenocarcinoma
- Large-cell
- Carcinoid tumours
- Bronchialveolar cell
Describe squamous NSCLC
o Obstructive lesions of bronchus
o Local spread common, widespread metastases occur late
Describe adenocarcinoma NSCLC
o Arises from mucous cells in bronchus epithelium
o Invasion of leura and mediastinal lymph nodes common
o Often metastasises to brain and bones
Describe large-cell NSCLC
o Less differentiated forms of squamous cell and adenocarcinomas
o Metastasise early
Describe carcinoid tumours NSCLC
o Neuroendocrine tumours
o Arise predominantly from Kulchitsky cells
Describe bronchoalveolar cell NSCLC
o Occurs as peripheral solitary nodule or as diffuse nodular lesions
How long does it take to develop from initial malignant change to presentation of adenocarcinoma?
15
How long does it take to develop from initial malignant change to presentation of squamous carcinoma?
8
How long does it take to develop from initial malignant change to presentation of SCLC?
3
What other tumours can you get which are benign?
Which one is…
- very poor prognosis
- slow-growing
- benign?
Tracheal, bronchial, hamartoma
Describe mesothelioma?
usually occurs in pleura, rarely metastasises, associated with asbestos
Where do secondary tumours normally originate?
common, often asymptomatic, common primary sites include kidney, prostate, breast, bone, GI, cervix, ovary
What is the biggest risk factor?
Smokers
Which age group is it more prominent?
Older people
Is it more common in women or men?
Men
How common it is?
Most common malignant tumour world-wide with 1.3 million death/year.
3rd most common death after heart disease and pneumonia in UK.
In UK 32,000 die/year.
What are other risk factors?
EGFR-TK mutation
Hx of cancer
Age
Occupational risk: Arsenic, Coal tar/ combustion processes, asbestos, chromium, radiation, iron oxide
What are the symptoms?
- Cough (80%)
- Haemoptysis (70%)
- Dyspnoea (60%)
- Chest pain (40%)
- Recurrent or slowly resolving pneumonia
- Lethargy
- Anorexia
- Weight loss
- Hoarseness – due to recurrent laryngeal nerve involvement
- Finger clubbing
- Bone pain - metastasis
What are the signs?
- Cachexia
- Anaemia
- Clubbing
- HPOA (hypertrophic pulmonary osteoarthropathy) - Causes wrist pain; combines clubbing and periostitis of small hand joints; especially associated with NSCLCs
- Supraclavicular or axillary nodes
- Bone tenderness - metastasis
- Hepatomegaly - metastasis
- Confusion/fits/focal CNS signs/cerbeallar syndrome - metastasis
- Proximal myopathy/peripheral neuropathy - metastasis
What investigations would you do?
Cytology CXR (PET)-CT Bronchoscopy Bone scan Bloods Lung function tests
Why do you do cytology?
Sputum and pleural fluid - send at least 20mls. Test cells
Why do you of CXR?
- If cancer is causing symptoms, it will be visible on CXR
- Asymptomatic tumour visible if >1cm diameter
- Lateral views used to assess hilum and behind heart
- May cause 2° pneumonia (consolidation), pleural effusions and collapsed lobes
- peripheral nodule, hilar enlargement, consolidation, lung collapse, pleural effusion, bony secondary’s
Why do you do CT?
- Detecting small tumours esp of the mediastinum
- Staging the tumour – done by contrast-enhanced CT; done using TNM for NSCLCs; two stage system used for SCLCs
- Scanning should also include liver, brain and adrenal glands for mets
- MRI is not useful
Why do you do bronchoscopy?
- to give histology and assess operability
- To define anatomy, obtain biopsy and cytological samples
- To assess operability - if tumour involves first 2cm of either main bronchus then it is inoperable
- Widening and loss of sharp angle of carina suggests enlarged mediastinal lymph nodes
Why do you do bone scan?
If you suspect mets
Why do you do Peripheral aspiration and biopsy?
• For peripheral lung lesions that can not be seen by bronchoscopy
What bloods would you do?
- FBC (anaemia)
- LFT (liver mets)
- U+E (hypercalcaemia, hyponatraemia) – hypercalcaemia due to decreased bone resorption; hypernatraemia due to consequential changes in calcium excretion in kidneys which affects Na
Why would you do lung function tests?
to assess suitability for lobectomy
What is the biggest management interventions?
Quit smoking
Describe the treatment options for Stages 1-4?
Surgical resection – for stage I or II tumours; lobar resection is treatment of choice
Radiotherapy – for stage I-III unsuitable for surgery
Chemotherapy – for stage III-IV
When would you use Erlotinib?
second line treatment after chemotherapy fails
When would you use Gefinitb?
first line treatment for those with EGFR-TK mutations
When would you use multidrug regimes??
first line treatment for SCLCs; cisplatin-based combination chemotherapy; second-line chemotherapy offered only if first line was responded to but failed; thoracic irradiation after that
What palliative care options are there?
opiates; symptomatic pleural drainage/pleurodesis; radiotherapy, steroids, brochodilators
What is Endobronchial therapy?
- Tracheal stenting
- Cryotherapy
- Laser
- Brachytherapy – radioactive source placed close to tumour
How do you treat non-small cell tumours?
- Excision if stage ½
- Curative radiotherapy = alternative if resp reserve is poor
- Chemo +/- radio for more advanced disease
- Regimes may be platinum based eg with monoclonal Ab targeting epidermal GF receptor (cetuximab)
How do you treat small-cell tumours?
- Nearly always disseminated at presentation
- May respond to chemo but invariably relapse
- (cyclophosphamide + doxorubicin + vincristine + etoposide; OR cisplatin + radio if limited disease)
When do you do pleural drainage?
For symptomatic pleural effusions
What other drugs might you consider?
- Analgesia
- Steroids
- Antiemetics
- Cough linctus (codeine)
- Bronchodilators
- Antidepressants
What are the differentials?
- Secondary malignancy
- Arteriovenous malformation
- Pulmonary hamartoma – rare benign tumour
- Bronchial adenoma – rare slow-growing tumour; majority carcinoids
- Abscess
- Granuloma
- Encysted effusion – fluid, blood, pus
- Cyst
- Foreign body
- Pneumonia
- TB
What are the complications?
Local • Recurrent laryngeal nerve palsy • Phrenic nerve palsy • SVC obstruction • Horner’s syndrome (Pancoast’s tumour) – tumour of pulmonary apex; involvement of sympathetic ganglion • Rib erosion • Pericarditis • AF Metastatic • Brain • Bone --> bone pain, hypercalcaemia, anaemia • Liver • Adrenals --> addison’s Endocrine • Ectopic hormone secretion o SIADH and ACTH by small cell o PTH by squamous cell Non-metastatic neurological • Confusion • Fits • Cerebellar syndrome • Proximal myopathy • Neuropathy • Polymyositis • Lambert-Eaton syndrome Other • Clubbing • HPOA • Dermatomyositis • Acanthosis Nigricans – hyperpigmentation of the skin • Thrombophlebitis migrans – phlebitis related to a thrombus
What is the general prognosis?
20% alive at 1 year after diagnosis; 6-8% after 5 years (NB 50% for breast and cervix).
What is the prognosis for NSCLC?
50% 2yr survival without mets, with mets 10%.
What is the prognosis for SCLC?
Median survival = 3 months untreated, 1-1.5yrs treated.
