Bronchial Carcinoma Flashcards
What are the features of cancer?
Malignant growth
Uncontrolled replication
Local invasion
Metastasis (lymphatic spread, blood, serous cavities)
What causes non metastatic systemic effects?
Biologically active molecules (hormones) released from tumour cells. These mimic the effect of naturally occuring hormones leading to paraneoplastic features
What percentage of lung cancers are incurable at the time of diagnosis?
90% and 50% of people are dead within 6 months
Why are lung cancer rates falling in men but rising in women?
Reflects the rates of smoking now and in the past
Lung cancer is the most common cause of cancer death. True or false?
True
How can a primary lung tumour present?
Haemoptysis
Recurrent pneumonia
Stridor
Short of breath
Why is every pneumonia CXR at 6 weeks?
Check pneumonia has resolved and there is no underlying cancer
Why does the lung effected by cancer usually shrink rather than grow?
Obstruction of proximal divisions of the bronchial tree. All air below obstruction is absorbed and lung shrinks to a smaller size
What is stridor?
Inspiratory sound- distressing
What can be the presentation of local invasion of lung cancer?
1) Recurrent laryngeal nerve palsy- horse vioce for >2 weeks as the tumour can grow and compress vocal chords
2) Atrial fibrillation or pericardial effusion- due to invasion for the pericardium
3) Dysphagia- if the oesophagus is compressed
4) Numbness and muscle wasting in the small muscles of the hand due to pancoast tumours compressing the brachial plexus
5) Pleural effusion- tumour invading pleural space
6) Headache, redness and puffy eyes- invasion of the SVC
7) Dilated vains on chest and abdomen- invasion of the IVC
8) pleuritic pain/ MSK pain- invasion of the chest wall
Presentation: Numbness and muscle wasting in the small muscles of the hand implies…?
Pancoast tumour in the lung apicies compressing the brachial plexus
Presentation: Recurrent laryngeal nerve palsy implies…?
Local invasion of the vocal chords
Presentation: Atrial fibrilation or pericardial effusion implies…?
Local invasion of the pericardium
Presentation: Dysphagia implies…?
Local invasion of the oesophagus
Presentation: Pleural effusion implies…?
Local invasion of the pleural space
Presentation: headache, redness and puffy eyelids implies…?
Local invasion of the SVC
Presentation: dilated blood vessels on neck and abdomen implies…?
Local invasion of the IVC
Presentation: Pleuritic pain/ MSK pain on twisting/ worse at night implies…?
Local invasion of the chest wall
Where are the sites of common metastases sites for lung tumours?
Brain, Liver, Bone, Adrenal gland
What are the signs f a cerebral metastasis?
insidious onset
One sided weakness/visual disturbances
Headaches- worse in the morning
Epileptic fit if met in cortex
What are the signs of liver metastasis?
Stretching pain- mets adjacent to liver capsule
Jaundice- mets obstructing the bilary duct
Abnormal liver function tests
What are the signs of bone metastasis?
Localised pain worse at night
Pathological fracture
Paralysis- met in the veterbrae
How are boney metastasis detected?
Isotope bone scan
PET scan
What are the signs if Adrenal metastasis?
Rarely any signs
Hormones are produced as normal
Incidental finding usually
Do paraneoplastic symptoms indicate metastatic disease?
Not necessarily- they are the result of hormones produced from the primary tumour initially
What are the paraneoplastic signs of bronchial carcinoma?
Finger clubbing Hypertrophic pulmonary osteoarthopathy HPOA Thrombophlebitis Weight loss Hypercalemia Syndrome of inappropriate ADH (SIADH) Eaton Lambert Syndrome
What is Hypertrophic pulmonary osteoarthopathy HPOA?
Rare pain and tenderness in the long bones due to elevation of the perioesteum away from the surface
What is thrombophlebitis and why do cancer patients get it?
Inflammation around a superficial vein due to hypercoaguable blood in cancer patients
What other lung diseases, other than bronchial Ca, cause weight loss?
Pulmonary fibrosis
Advanced COPD
Why do cancer patients get hypercalemia and what is the treatment?
Tumour excreates a substance that mimics the effect of the parathyroid hormone.
Leads to headaches, confusion, thirst and constipation
Treated by rehydration initially. If calcium >4 use IV bisphosphonate (increases bone turnover)
Hypercalemia is associated with which type of lung cancer?
Squamous cell carcinoma
What can hypercalemia cause?
Stones- renal and bilary Bones- bone pain Groans- abdo pain, constipation and D+V Thrones- Polyuria Psychiatric overtones- depression, anxiety and reduced GCS cardiac arrythmias
What is Syndrome of inappropriate ADH (SIADH), how is it treated and what lung cancer is it associated with?
High sodium in the blood >120
Leads to nausea nad vomiting, lethargy, confusion, seizures, myoclonus (twitching/jerking)
Treated with fluid restriction and demeclocycline
Small cell lung cancer
What is Eaton Lambert Syndrome and what type of bronchial Ca is it associated with?
Weakness in the limbs similar to myaesthenia gravis
Usually small cell lung cancer
What are the detect lung cancer early signs?
Cough > 3 weeks Haemoptysis Recurring/long standing lung infection Unexplained weight loss Horse voice Chest or Shoulder pains Unexplained tiredness/loss of energy
What are the differentials for breathlessness?
PE, pleural effusion, pleural oedema, pericardial invasion
What might you find on examination of a patient with bronchial Ca?
Finger clubbing Stridor Weight loss Horse voice Bloated face enlarged liver Lymphadenopathy Tracheal deviation Dull Percussion
What investigations are important if you suspect bronchial Ca?
FBC Coagulation screen Na, K Ca and alkaline phosphate Spirometry/ FEV1 CXR CT thorax PET scan Bronchoscopy EBUS- endobronchial ultrasound
What is a PET scan
Positron Emission Tomography
Analysis of tissue uptake of radioactively labelled glucose
Tissues with a high metabolic rate will light up.
Assessment of function rather then structure
How will you obtain a tissue diagnosis?
Broncoscopy CT guided biopsy Lymphnode aspirate Aspiration of pleural fluid EBUS Thoracoscopy
How is a broncoscopy carried out?
Local anathetic with IV sedation
Flexible bronchoscope passes through the nose to inspect the central part of the bronchial tree
Biopsies and brush cytology => diagnosis
Can a bronchoscope see peripheral tissue?
No. Its limited by its 5mm diameter
What does a broncoscope have?
2 light sources and camera and a suction channel
What is a CT guided biopsy used for and what is the risk?
Obtaining a tissue sample from a peripheral tumour
Risk of pneumothorax
Is anasthetic needed for a CT guided biopsy?
Yes local anasthetic is used
What is an EBUS?
Endobronchial ultrasound
Bronchoscope with a ultrasound tip
Day case procedure
What is EBUS used for?
To get a visualisation of hilar and mediastinal structures
Target and sample lymph nodes if they are involved
What is a medical thoracoscopy?
Semi rigid scope inserted in the intercostal space
The lung is deflated to allow visualisation of the pleural surfaces
Sample pleural fluid and biopsies from pleura
Day case- sedation with local anaesthetic
What is the mortality 1 year post diagnosis of Bronchial Ca?
90%
What percentage of smokers will die from lung cancer? What other cancers do smokers commonly get?
20% will die from lung cancer
Also get larangeal, cervical, bladder, mouth, oesophageal and colon cancer
What types of lung neoplasms are there?
Benign- rare
Malignant- common
What are the other risk factors for bronchial Ca?
Asbestos, nickle, chromates, radiation and pollution
Genetics would be clearer if people didn’t smoke
What are the 4 common smoking related types of lung cancer and the percentage occurrence?
Adenocarcinoma- 35% Squamous cell carcinoma- 30% Small cell carcinoma- 25% Large cell carcinoma- 10% Grouped into small cell and non small cell
What are the 2 non smoking related types of lung cancer?
Carcinoid- Neuroendocrine tumours
Bronchial gland tumours (adenoid cyctic carcinoma and mucopidermoid carcinoma)
1 in 4 adenocarcinomas occur in never smokers. True or false?
True often younger women
Rank the 4 lung cancers in order of prognosis?
Small cell- worse
Large cell
Adenocarcinoma
Squamous cell- best
Why is it important to have a tissue diagnosis?
Prognosis and treatment mainly. Pathogenesis and epidemiology
What are the characteristics of small cell lung cancer?
Rapidly progressive Early metastasis Few/no symptoms Rarely suitable for surgery Chemosensitive but with rapidly emerging resistance
What are the characteristics of non small cell lung cancer?
Now respond better to new chemo and radiotherapy regimens- palliative
New targeted treatments based on DNA mutations
Slower growing
Surgery and radical radiotherapy may cure it
Is surgery an option if lymph nodes are involved?
Maybe. Only if its 1 or 2 together. Unlikely
What are the molecular gene abnormalities in the oncogenes of small cell lung cancer which may be a therapeutic target?
MYC
What are the molecular gene abnormalities in the tumour suppressor genes of small cell lung cancer which may be a therapeutic target?
p53, retinoblastoma (Rb) and 3p
What are the molecular gene abnormalities in the oncogenes of non small cell lung cancer which may be a therapeutic target?
MYC, K-RAS, HER2
What are the molecular gene abnormalities in the tumour suppressor genes of non small cell lung cancer which may be a therapeutic target?
p53, 1q, 3p, 9p, 11p, Retinoblastoma
Is epithilial growth factor involved in signalling in lung epithilium?
Yes
How can a mutation in the EGFR gene lead to cancer development?
What type of cancer are these found in?
How can these mutations be detected?
What treatment do these tumours respond to?
Specific point mutation in the EGFR gene can activate it in the absence of EGF ligand binding.
Found in adenocarcinomas of non smokers- often aisan
Detected in DNA from a biopsy and cytology.
Respond to Tyrosone Kinase Inhibators- Erltinib
How can the immune response be targeted in non small cell lung cancers?
Some express PD-L1.
PDL1 binds to the PD (programmed death receptor) on T lymphocytes inactivating the cytotoxic immune response.
Targeted therapy can inhibit this effect and enhance the immune killing of a tumour.
Less toxic than chemo.
How do bronchial tumours develop?
Squamous cell metaplasia- there is no normal squamous epithilium in the large airways
Dysplasia
Carcinoma in situ
Invasive malignancy
How do peripheral adenocarcinomas develop?
Atypical andenomatous hyperplasia
Spread of neoplastic cells along alviolar walls- bronchioalviolar carcinoma
True invasive adenocarcinoma
How are tumours stages
Tumour
Node
Metastasis
What is immunohistochemistry and how can it be used to differentiate adenocarcinomas from squamous cell carcinomas?
Immunohistochemistry involves the process of selectively imaging antigens in cells of a tissue section by exploiting the principle of antibodies binding specifically to antigens in biological tissues.
Adenocarcinomas express TTF1 (thyroid transcription factor 1)
Squamous cell carcinomas express nuclear antigen p63 and high molecular weight cytokeratins
What is the median survival for small cell and non small cell lung cancer?
Small cell = 6 months
Non small cell = 8 months
What must you consider for before surgery?
Is the tumour localised? Single primary with a couple of lymph nodes
Will the patient survive the operation? 2-3% peri-opperative mortality
What will there residual lung function be? How will this impact on their quality of life
What investigations must be carried out to check someone is a suitable candidate for surgery?
Broncoscopy- cell type, vocal chord palsy, proximity to carina
EBUS- lymph node involvement?
CT Brain and CT thorax
PET scan
Is a tumour less than 2am from the carina fit for surgery?
No
Does PET scanning up stage or down stage someones disease?
Up stage
Good thing as it prevents unnecessary operations
What are the choices for types of surgery?
How is the surgery carried out?
Pneumonectomy- removal of a lung
Lobectomy- removal of a lung lobe
Thoracotomy- large incision into the chest wall. Long recovery with 10 days in hospital
VATS (Video assisted thoracic surgery)- key hole with 5 small incisions. Faster recovery. 5 days in hospital
What staging must be performed to check someone is fit for chemotherapy?
Bronchoscopy for tissue diagnosis
CT scan for tumour size, lymph nodes, mets and local invasion
Performance Status ECOG score 0-2
What is the ECOG score?
Performance status assessment
0 = fit 5= dead
Need 0-2 for chemotherapy (up and about for 50% of day)
What are the common chemotherapy side effects?
Nausea and vomiting Tiredness and loss of appetite Bone marrow suppression => opportunistic infections, anaemia and neutropenic sepsis Hair loss Pulmonary fibrosis
When is radical radiotherapy used?
Early stage disease with curative intent
When is palliative radiotherapy used?
To delay disease progression, to reduce pain and to shrink metastasis
What are the drawbacks to radiotherapy?
1) Maximal cumulative dose that can be achieved
2) Collateral damage as the beam passes through other tissues (spinal cord, oesophagus and lung tissue)
Post radiation fibrosis in these areas
3) Only works where directed- subclinical mets not targeted
What is SABR?
Stereotactic Ablative Radiotherapy
Reduces damage to surrounding tissue by having beams from lots of angles with a lower dose.
Requires 4D scanning because the patients are breathing.
What are the advantages of SABR?
1) Less collateral damage
2) Very high cumulative dose delivered to the tumour
3) Less treatments required
What therapies can be carried out with a bronchoscope?
Strent insertion for stridor
Photodynamic therapy
What are the common comorbidities associated with lung cancer?
COPD and ischemic heart disease
Why would you not do a CT guided biopsy on a patient with an FEV1 <1L?
There is a 10% risk of pneumothorax
