Bronchial Carcinoma Flashcards
What are the key subcategories of lung cancers?
Small-cell
Non-small-cell (SCC, adeno and large-cell)
What is the most common type of lung cancer?
Non-small-cell
Which of the following is true of Small Cell Lung Cancer:
A. Most common type of lung cancer
B. Metastasis is rare
C. Arise from Kulchitsky cells
D. Not associated with smoking
C. Arise from Kulchitsky cells
SCLC:
- Neuroendocrine Tumour
- 80% present with advanced disease V. chemosensitive but v. poor prog
- Ectopic hormone secretion, ADH or ACTH (arise from endocrine Kulchitsky cells)
- Rapid growth and early metastasis
- May cause Eaton-Lambert syndrome (paraneoplastic syndrome)
Who is most at risk of lung cancers?
Smokers, over 60, male, family history
90% of lung cancer is in smokers; passive smoking also increases risk by 1.5
Occupational exposures (asbestos, radon, arsenic, coal tar) tend to lead to which type of lung cancer?
Adenocarcinoma
Which lung cancer is being described:
Most common lung cancer in non-smokers and overall (except for metastases)
Activating mutations include KRAS, EGFR and ALK
Adenocarcinoma
Which lung cancer is being described:
- Hilar mass from bronchus
- Cavitation
- Hypercalcemia (produced PTHrP)
Squamous cell carcinoma
Which lung cancer is being described:
- Rapid growth and early metastasis
- May produce ADH or ACTH or cause Eaton-Lambert syndrome (paraneoplastic syndrome)
Small cell carcinoma
What symptoms are likely to be reported by a patient with lung cancer?
Cough (80%)
Haemoptysis (70%)
Dyspnoea (60%)
Chest pain (40%)
Recurrent or slowly resolving pneumonia
Lethargy
Anorexia
Weight loss
What signs might you expect to find in a patient with lung cancer?
Cachexia; Anaemia; Clubbing
Hypertrophic Pulmonary Osteoarthropathy (HPOA)
Supraclavicular or axillary nodes.
[Hoarseness]
[Horner’s Syndrome: Pancoast’s tumour compresses sympathetic chain; Features: Miosis, Ptosis, Anhidrosis]
Chest Sx: None/consolidation; Collapse; Pleural effusion.
Metastases:
- Bone tenderness; hepatomegaly
- Confusion; fits; focal CNS signs; cerebellar syndrome.
- Proximal myopathy; peripheral neuropathy
What differentials would you consider alongside lung cancer?
Secondary malignancy
Arteriovenous malformation; Abscess; Cyst
Bronchial adenoma: Rare, slow-growing. 90% are carcinoid tumours; 10% cylindromas.
Hamartoma: Rare, benign; CT: lobulated mass +/- flecks of calcification
Granuloma
Encysted effusion: fluid, blood, pus
Foreign body; Pneumonia; TB
How is lung cancer staged?
TMN
What investigations may help you diagnose lung cancer?
Initial Diagnosis
Imaging:
- CXR: peripheral nodule; hilar enlargement; consolidation; lung collapse; pleural effusion; bony secondaries. [If cancer is causing symptoms, it will be visible on CXR]
Cytology
- Cytology: sputum and pleural fluid (send at least 20mL).
Biopsy
- Bronchoscopy: to give histology and assess operability ± endobronchial ultrasound for assessment and biopsy.
- Fine needle aspiration or biopsy: peripheral lesions / lymph nodes.
Other tests
- Lung function tests: help assess suitability for lobectomy.
Staging Workup
Imaging:
- CT: to stage the tumour and guide bronchoscopy
- 18F-deoxyglucose PET or PET/CT EBUS scan: to help in staging
- Radionuclide bone scan: if suspected metastases
What treatment options would you suggest for non-small-cell lung cancer?
Key points:
- Surgical resection in early stages.
- Supplement surgery with radiation or chemotherapy (depending on the stage).
- Palliative radiation and/or chemotherapy is appropriate for symptomatic but unresectable disease.
Lobectomy (open or thoracoscopic) is the treatment of choice if medically fit.
Radical radiotherapy for patient with stages I-III NSCLC.
Chemotherapy +/- radiotherapy for more advanced disease.
Regimens may be platinum based, e.g. with monoclonal antibodies targeting the epidermal growth factor receptor (cetuximab).
What treatment options would you suggest for small-cell lung cancer?
Key points:
- Unresectable
- Often very sensitive to chemo and radiation but usually recurs
- Poor survival rates
Consider surgery with limited stage disease.
Chemotherapy +/- radiotherapy if well enough.
Palliation:
- Radiotherapy is used for bronchial obstruction, SVC obstruction, haemoptysis, bone pain, and cerebral metastases.
- SVC stent + radio therapy and dexamethasone for SVC obstruction.
Endobronchial therapy: tracheal stenting, cryotherapy, laser, brachytherapy (radioactive source is placed close to the tumour).
Pleural drainage/ pleurodesis for symptomatic pleural effusions.
Drugs: analgesia; steroids; antiemetics; cough linctus; bronchodilators; antidepressants.
What is the average prognosis for the main types of lung cancer?
Non-small cell:
- 50% 2yr survival without spread; 10% with spread
Small cell:
- Median survival is 3 months if untreated; 1–1½yrs if treated
What complications are associated with lung cancers?
Local: Invasion of local structures
- Recurrent laryngeal nerve palsy (hoarseness)
- Phrenic nerve palsy
- SVC obstruction (SVC syndrome: supraclavicular venous engorgement and facial swelling)
- Horner’s syndrome (Pancoast’s tumour; miosis, ptosis, anhidrosis)
- Rib erosion
- Pericarditis
- AF
Metastatic: can met to any site, commonly LABBs (liver, adrenals, brain, bone)
- Brain
- Bone (bone pain, anaemia, Increase Ca2+)
- Liver
- Adrenals (Addison’s).
Non-metastatic neurological:
- Confusion
- Fits
- Cerebellar syndrome
- Proximal myopathy
- Neuropathy
- Polymyositis
- Lambert–Eaton syndrome
Which type of lung cancer can result in cushing’s syndrome?
Small cell (neuroendocrine tumour: ACTH secretion)
Which type of lung cancer can result in dilutional hyponatraemia?
Small cell (neuroendocrine tumour: SIADH)
Which lung cancer is associated with hypercalcaemia?
Squamous cell (secretion of PTHrP)
PTHrP = parathyroid hormone-related protein
PTHrP is a normal gene product expressed in a wide variety of neuroendocrine, epithelial, and mesoderm-derived tissues.
Which lung cancer is associated with gynaecomastia?
Large cell (Ectopic hCG secretion)
Which lung cancer is associated with skeletal paraneoplastic syndromes (including hypertrophic pulmonary osteoarthropathy and clubbing)?
Non-small cell
Which lung cancer is associated with peripheral neuropathy?
Small cell
Which lung cancer is associated with dermatomyositis?
All
Which lung cancer is associated with anaemia?
All
Which lung cancer is associated with DIC?
All
