Bronchial Carcinoma Flashcards
1
Q
When talking about “lung cancer” what does this usually refer to?
A
it generally refers to a tumour of the bronchus
95% of lung cancers are carcinoma of the bronchus
2% are alveolar tumours
3% are benign or less invasive malignant tumours
2
Q
What is the prognosis like for bronchial carcinoma?
What is 1 year and 5 year survival like?
A
prognosis is extremely poor
1 year survival is about 20%
5 year survival is about 5%
these values vary depending on the type of tumour that is present
3
Q
How common is bronchial carcinoma?
In what groups is the incidence increasing?
A
it is the most common cancer worldwide
it causes 32,000 deaths in the UK annually with 40,000 new cases each year
incidence is increasing in women, particularly in northern Europe
it causes more deaths in women than any other malignant tumour
4
Q
What is the male:female ratio in bronchial carcinoma?
What is mortality like in England?
A
the male to female ratio is 3 : 1
it accounts for 19% of all cancers and 27% of all cancer deaths in the UK
it is the third most common cause of death in the UK, following heart disease and pneumonia
5
Q
What is the major risk factor for bronchial carcinoma?
A
SMOKING
it causes 90% of cases
the strength of association between cigarette smoking and bronchial carcinoma overshadows any other aetiological factors
6
Q
How can place of living influence chance of developing bronchial carcinoma?
What other habit has a large influence?
A
there is a higher incidence of BC in urban, as opposed to rural areas
passive smoking increases the risk of bronchial carcinoma by 1.5 times
7
Q
What is the major occupational factor that is linked to bronchial carcinoma?
A
ASBESTOS EXPOSURE
there are 3 types of asbestos - white, blue and brown
blue is the worst
you are only at risk when the asbestos is broken up as this releases the fibres
this usually causes a specific type of tumour - mesothelioma
8
Q
What other occupational factors can increase risk of bronchial carcinoma?
What type of tumours usually are these?
A
- arsenic (in paint, batteries & fertilisers)
- iron oxide
- chromium
- petroleum products
- oil
- radiation / radon
- coal tar and products of coal combustion
tumours associated with occupational factors tend to be adenocarcinomas
9
Q
What is the relative risk of a non-smoker and a smoker contracting bronchial carcinoma?
How does risk change if someone stops smoking?
A
- someone who has never smoked has a relative risk of 1%
- a smoker has a relative risk of 43%
- after 10 years of stopping smoking, risk is greatly reduced, but it never reaches that of non-smokers
10
Q
How are bronchial carcinomas divided?
A
they are divided based on the characteristics of the disease and its response to treatment
it is divided into small cell carcinoma and non-small cell carcinoma
11
Q
What are the subcategories of non-small cell carcinoma?
A
- adenocarcinoma
- squamous cell carcinoma
- large cell carcinoma
12
Q
What is the development time, survival and common location for small cell carcinoma?
A
- development time from initial malignant change to presentation is about 3 years
- doubles in 30 days
- survival is around 5%
- common location is around the hilum / central
13
Q
What is the development time and common location of adenocarcinoma?
A
- development time from initial malignant change to presentation is 15 years
- doubles every 200 days
- more often found in the periphery
- more likely to present late as it is less likely to cause obstruction symptoms
14
Q
What is the development time for squamous cell carcinoma?
A
8 years
15
Q
What is meant by large cell carcinoma?
Where do they tend to be found?
A
large cell carcinomas are less differentiated forms of squamous cell carcinoma and adenocarcinoma
they are commonly found more centrally
16
Q
What % of tumours are in the lobar bronchi?
Tumours in which type of bronchi will present earlier?
A
80% of tumours are in lobar bronchi - the rest are in larger bronchi
tumours arising in a main bronchus tend to present earlier than those arising in a small bronchus
this is because they cause far greater symptoms at an early stage
17
Q
How can a squamous cell carcinoma that has cavitated by identified through imaging?
A
- on X-ray, it tends to have the appearance of an abscess or TB cavity
- on CT, you can clearly see the jagged edge of the cavity and possible infiltration of other structures (such as the pleura)
- the jagged edge seen on CT tells you that it is definitely cancer, and not just an abscess
18
Q
How common is squamous cell carcinoma and how does it usually present?
A
it is the most common type of bronchial carcinoma, accounting for 40% of cases
most present as obstructive lesions of the bronchus, leading to infection
it tends to arise more centrally than in the peripheral lung
19
Q
What % of squamous cell carcinomas will cavitate?
What does this mean?
A
SCCs will occasionally cavitate - around 10% at presentation
this occurs when the central part of the tumour undergoes necrosis
20
Q
How can CT be used to tell apart cavities caused by cancer and infection?
How about an abscess?
A
- cancer is likely to have a thicker wall than a cavity caused by infection
- cavities are more likely to be infective if the cavity has appeared quickly
- a smooth border and the presence of fluid makes it more likely to be an abscess
21
Q
How does squamous cell carcinoma tend to spread?
A
local spread is common but widespread metastases tend to occur relatively late
22
Q
What do the cells look like in squamous cell carcinoma?
A
the cells are usually well differentiated but occasionally anaplastic
it develops from squamous cells - the flat cells that cover the surface of the airways
23
Q
What does squamous cell carcinoma usually cause systemically?
A
HYPERCALCAEMIA
this is either due to bone destruction or production of PTH analogues
24
Q
A
25
From which cells does adenocarcinoma arise from?
How common is it?
Adenocarcinoma accounts for **10%** of all bronchial carcinomas
it arises from **_mucous cells_** in the **bronchial epithelium**
26
Where does adenocarcinoma typically spread to?
it commonly invades the **_pleura_** and the **_mediastinal lymph nodes_**
it commonly metastasises to the **_brain_** and **_bones_**
27
Where does adenocarcinoma tend to be found in the lungs?
it tends to develop in **_smaller airways_**, such as the alveoli
it tends to be found in the **_periphery_** of the lungs, rather than centrally
it tends to grow **_more slowly_** than other forms of lung cancer
28
What is known to cause many cases of adenocarcinoma?
In which groups is it proportionally more common?
* it is the most common bronchial carcinoma associated with **_asbestos_**
* it is proportionally more common in **non-smokers**, the **elderly**, **women** and in the **far east**
* it is the **_least likely_** to be **associated with _smoking_**
29
Does adenocarcinoma cavitate?
What other symptoms can it cause?
it does not usually cavitate
it can cause **_excessive mucous secretion_**
30
What can adenocarcinoma often be confused with?
it can be confused with **_mesothelioma_**
it is the most likely to cause **_pleural effusions_** (as are mesotheliomas)
31
What are large cell carcinomas?
How common are they?
they are **_less well-differentiated_** versions of **adenocarcinoma** and **squamous cell carcinoma**
if SCCs and adenocarcinomas have a ***longer time to develop before presentation***, they will present as large cell carcinomas
accounts for **_25%_** of all large cell carcinomas
32
What is the prognosis of large cell carcinomas like and why?
they tend to **_metastasise early_** and are associated with **_poor prognosis_**
33
Where are most large cell carcinomas found?
Who tends to be affected?
the cells do not look like squamous cell carcinoma or adenocarcinoma and are a **larger size** than small cell carcinoma
it is more common in **_men_**
can be found **_anywhere_** in the lungs but are **more common in the _periphery_**
34
What is bronchoalveolar cell carcinoma and how common is it?
it is a type of **non-small cell carcinoma** that is **very rare**
it is a **variation of _adenocarcinoma_**
it accounts for **1-2%** of all lung carcinomas
35
How does bronchoalveolar cell carcinoma tend to present?
usually presents as a **_peripheral single nodule_** or **many small nodular lesions**
this appears like **consolidation** on a chest X-ray
it typically arises in the **_periphery_** and grows along alveolar walls, without destroying lung parenchyma
36
What symptom is bronchoalveolar cell carcinoma associated with?
**_"bronchorrhoea"_** - diarrhoea of the bronchus
this is the production of **large amounts of mucous**, which is coughed up as **_white sputum_**
37
What is an alternative name for small cell lung cancer?
How common is it?
also known as ***"oat cell carcinoma"***
it accounts for **20-30%** of all lung cancers
38
What type of cells does small cell carcinoma arise from?
Arises from **endocrine cells** called **_Kulchitsky cells_**
These are **_APUD cells_** (amine precursor uptake & decarboxylation)
which have a role in **hormone synthesis and secretion**
39
What is the result of small cell lung cancer developing from Kulchitsky cells?
As they develop from APUD cells, many **_polypeptide hormones_** are released from these tumours
Some of these polypeptides work in an **_autocrine fashion_**
They will **feedback on the cells** and **induce further _cell growth_**
40
How quickly does small cell carcinoma grow?
What is the prognosis like?
* small cell carcinoma spreads **_early_** and **_very quickly_**
* it is almost always **inoperable** at presentation
* the tumour is **rapidly growing** and **highly malignant**, so therefore presents a **_poor prognosis_**
41
What are the 2 different types of APUD cells?
**_OPEN:_**
* secrete products in response to **_lumnial contents_**, as well as nervous and hormonal stimuli
**_CLOSED:_**
* have no luminal receptors
* only respond to nervous and hormonal stimuli
42
Where else in the body can primary small cell carcinoma develop?
* oesophagus
* stomach
* cervix
43
Where does bronchial carcinoma often spread to?
the tumour may spread to the **_pleura_**, either **directly**, or by **lymphatic drainage**
44
Where does bronchial carcinoma spread to by direct spread?
the tumour can directly involve the **_pleura_** and the **_ribs_**
45
What is a Pancoast's tumour?
Where can this spread to and what symptoms does it cause?
it is carcinoma in the **_apex_ of the lung**
it can **erode the ribs** and involve the **lower part of the _brachial plexus_** (C8, T1 and T2)
this causes **_severe pain in the shoulder_** and down the **_inner surface of the arm_**
there is also **_weakness of the hand_**
46
What structure can be lost through a Pancoast's tumour?
it can lead to loss of the **_first rib_** - the tumour consumes it
47
What happens if the tumour involves the sympathetic ganglion?
if the sympathetic ganglion is damaged, this can lead to **_Horner's syndrome_**
48
How does Horner's syndrome result from a lung tumour?
What type of tumour must it be to cause this?
Horner's syndrome results from **damage to the _sympathetic nervous system_**
In this case, it results from damage to the **sympathetic chain** **_at or above the stellate ganglion_**
these ganglion are on the **outside of the thoracic vertebrae** - so it would have to be a **_central posterior tumour_** to cause this
49
What are the clinical features of Horner's syndrome?
**_PTOSIS:_**
* a ***_drooping eyelid_*** resulting from improper innervation of the ***superior tarsal*** muscle
**_MIOSIS:_**
* ***_constriction of the pupil_*** (and dilation lag)
**_ANHYDROSIS:_**
* ***_decreased sweating_***
**_ENOPHTHALMOS:_**
* an impression that the eye has ***_sunken in_*** on the affected side of the face
* there can also be dilation of blood vessels on the affected side resulting in ***_flushing***_ and a _***blood shot eye_***
50
What nerve can be directly invaded by the bronchial carcinoma and what is the result of this?
bronchial carcinoma can directly invade the **_phrenic nerve_**
this causes **paralysis of the _ipsilateral hemidiaphragm_**
51
What other organs / structures can be locally invaded by the brochial carcinoma?
What symptoms does this produce?
the bronchial carcinoma can invade the **_oesophagus_**, producing **_progressive dysphagia_**
it can also invade or compress the **_pericardium_**, producing **_pericardial effusion_** and **_malignant arrhythmias_**
52
What are the symptoms associated with the bronchial carcinoma invading the superior vena cava?
* **early morning headache**
* **facial congestion** and **oedema** involving the **upper limbs**
* distension of the **jugular veins**
* distension of the **veins on the chest** that form collateral circulation with veins arising from the abdomen
53
Which nerve may hilar tumours involve and what symptoms does this produce?
hilar tumours may involve the **_recurrent laryngeal nerve_**
this produces **_unilateral vocal cord paresis_** with **hoarseness** and a **bovine cough**
54
55
Which lymph nodes tend to be affected when bronchial carcinoma spreads?
it tends to spread to the **_mediastinal_** and **_supraclavicular_** nodes
56
Where are the most common places for bronchial carcinoma to spread via the bloodstream?
* bony metastases
* liver
* brain
* adrenal glands (this is often a post-mortem finding as it is asymptomatic)
57
What are the consequences of metastases in the brain?
secondary deposits in the brain result in **change in personality**, **epilepsy** or as a **focal neurological lesion**
58
What are the consequences of bony metastases?
These tend to cause **_pain_** and **_pathological fractures_**
they can also result in **_spinal cord compression_**, which requires emergency surgery
59
How is size of the primary tumour in bronchial carcinoma related to the extent of spread?
Even a **very small** primary tumour can result in **wide-spread metastasis**
This is particularly true of **_small cell carcinomas_**
60
What % of bronchial carcinomas produce ectopic hormones?
What is the result of this?
**10%** of **small-cell tumours** produce ectopic hormones at some stage
however, **clinical extrapulmonary findings are rare**, except from **_finger clubbing_**
61
What are the main non-metastatic manifestations of bronchial carcinoma?
What type of bronchial carcinoma are these associated with?
* inappropriate **_ADH_** secretion
* ectopic **_ACTH_** secretion - causing **Cushing's syndrome**
* **_Hypercalcaemia_**
endocrine disturbances are typically associated with **_small cell carcinoma_**
62
What can inappropriate ADH secretion lead to?
How can this be treated clinically?
inappropriate ADH secretion can cause **_hyponatraemia_**
this is **NOT due to lack of sodium**, but by **_"dilation" of body fluids_** due to excess secretion of ADH - not enough water is being secreted
by **_denying the patient fluids_**, this can help to bring the sodium back to normal
63
What can ectopic ACTH secretion cause?
**_Cushing's syndrome_**
this produces symptoms similar to those on **steroids**
these patients, unlike those on steroids, will be **_heavily pigmented_**
64
Why does hypercalcaemia occur in bronchial carcinoma?
What type does this tend to be associated with?
it occurs due to the secretion of **_parathyroid hormone related peptides_** (PTH)
this mostly occurs with **_squamous cell carcinoma_**
65
What is a paraneoplastic syndrome?
When do they tend to present and how common are they?
***a _non-endocrine_, _non-metastatic_ complication of cancer***
they can present **_several years before_** the tumour itself presents
they are generally **_rare_** in comparison to local and metastatic spread
66
What are the potential neurological complications that present as paraneoplastic syndromes?
* **polyneuropathy**
* **cerebellar degeneration** (and other encephalopathies)
* **Lambert-Eaton syndrome** (and other muscular conditions)
67
What causes polyneuropathy and how does it present?
caused by **_antibodies against the myelin sheath_**
it involves damage to **_multiple peripheral nerves_**
it can present with **virtually any neurological symptom**, but the **damage is irreversible**
68
What is Lambert-Eaton syndrome?
it is essentially myasthenia gravis secondary to lung carcinoma
it is an **autoimmune** disorder that affects the **_neuromuscular junction_**
there are autoantibodies against **pre-synaptic voltage-gated calcium channels**
this leads to **_decreased acetylcholine release_**
69
What are the symptoms of Lambert-Eaton syndrome?
**_proximal muscle weakness_** that **improves with repeated use**
70
What are the potential vascular and haematological paraneoplastic syndromes?
these are rare
* **thrombophlebitis migrans**
* **anaemia** - microcytic or normocytic
71
What is another name for thrombophlebitis migrans?
What is it?
**_Trousseau syndrome_**
episodes of **vessel inflammation** due to blood clots (thrombophlebitis) that are **recurrent** or **appearing in different locations** over time
72
What is HPOA as a paraneoplastic syndrome and how common is it?
**_hypertrophic pulmonary osteoarthropathy_**
it occurs in **3%** of all bronchial carcinomas
particularly **squamous cell carcinomas** and **adenocarcinomas**
73
What are the symptoms of hypetrophic pulmonary osteoarthropathy (HPOA)?
* **joint stiffness**
* severe pain in the **ankles and wrists**
* **gynaecomastia** (sometimes)
* also associated with **finger clubbing**
74
What is gynaecomastia?
a condition in which **_males develop breast tissue_** as a result of imbalanced ratio of oestrogen and androgen activity
75
What does HPOA look like on X-ray?
there is **_proliferative periostitis_** at the **_ends of long bones_**, which have a characteristic ***_"onion skin" appearance_***
76
What is HPOA thought to be caused by and why?
it is thought to be caused by a bloodborne factor released by the tumour
when the primary tumour is removed, the pain often goes away
77
What % of cases of bronchial carcinoma are associated with finger clubbing?
30%
it is caused by **_non-small cell carcinoma_**
it is thought to be a result of ectopic hormone production
78
What is carcinoid syndrome and what causes it?
a paraneoplastic syndrome secondary to carcinoid tumours that presents as:
* **hepatomegaly**
* **flushing**
* **diarrhoea**
* (heart failure, vomiting, bronchoconstriction) - less common
it is caused by endogenous secretion of **_serotonin_** and **_kallikrein_**
79
How is carcinoid syndrome diagnosed?
using 24 hour urine 5-HIAA tests
80
What are the most common symptoms associated with bronchial carcinoma?
* **cough**
* **chest pain**
* **cough and pain**
* **haemoptysis** (coughing up blood)
* chest infection
* malaise
* weight loss
* shortness of breath
* hoarseness
81
What co-existing condition is present in many patients with bronchial carcincoma?
Many patients have co-existing COPD
82
What is the pain like in bronchial carcinoma?
initally the pain is described as a feeling of **_"fullness"_** and **_pressure_** in the chest
later, it may develop into a **_severe persistent pain_**
pain can also be **_pleuritic_**, owing to invasion of the **pleura or ribs**
83
What is the cough like in bronchial carcinoma?
What can sometimes be a telltale sign to look out for?
* cough is usually the **earliest symptom**
* the cough is often **_dry_**
* there may be **purulent sputum** if there is an **associated infection**
* infection is often the result of **_bronchial obstruction_**
* a telltale sign is a **_change in character of a "smokers cough"_** - particularly if associated with other respiratory symptoms
84
In which types of tumour is haemoptysis more common?
When can it be fatal and why is it sometimes missed?
* haemoptysis is common with tumours arising in the **_central bronchi_**
* occasionally these tumours can **invade large blood vessels**, causing a **_massive haemoptysis_** that can be fatal
* it may only present as the **_taste of blood_ in the back of the mouth** - particularly in the **_morning_**
85
When does haemoptysis need to be investigated?
a single episode, particularly in the background of infection, does not need to be investigated
typically, smokers may present with bronchial carcinoma with ***several episodes of small amounts of haemoptysis*** - this needs to be investigated
86
When is pneumonia suggestive of bronchial carcinoma?
Why does this occur?
it is suggestive of bronchial carcinoma when there is **recurrent pneumonia at the _same site_**, or it is **_slow to respond to treatment_**
tumours that block the bronchi prevent the proper functioning of the **mucociliary escalator**
this means that bacteria are **_retained behind the blockage_**
87
When does shortness of breath occur in bronchial carcinoma?
this only occurs when there is **obstruction of a large bronchus**
88
When might stridor be present in bronchial carcinoma?
What characteristic does it tend to have?
stridor may be present if there is a **_large tumour_**, either in the **trachea**, or in one of the **large bronchi**
stridor tends to be present when there is an **obstruction _ABOVE_ the main carina**
this tends to be **_monophonic_**
89
What is the difference between the causes of monophonic and polyphonic wheeze?
How can it be heard?
**monophonic wheeze** indicates that there is **_only one obstruction_**
this is an ominous sign as the likely cause is **carcinoma**
**polyphonic wheeze** is more suggestive of **_many airway blockages_**
stridor is often audible by the **_naked ear_**
90
What is pleuritic chest pain and what does it suggest?
chest pain that may be present all the time, but is **far more pronounced on _movement of the lungs_**
its presence indicates **_invasion of the pleura_**
91
What does hoarseness of the voice suggest?
Why is this not a good sign?
it suggests involvement of the **_left recurrent laryngeal nerve_**
(particularly if there is also a ***bovine cough***)
if this involvement is present, then the tumour is **inoperable**
92
Why are the mortality rates for lung cancer the same as they were 10 years ago?
lung cancer presents very late
93
How does someone with bronchial carcinoma typically present?
they typically present with **_persistent respiratory symptoms_** that **_do not respond_ to other standard treatments**
* change in nature of the smokers cough
* history of smoking
* isolated incidences of haemoptysis
* weight loss and decreased appetite
* HPOA
* hoarseness of the voice
* pancoasts syndrome
94
Why does someone with bronchial carcinoma also have a reduced appetite?
as a result of the inflammatory reaction that the tumour induces
(particularly the TNF that is released)
95
What findings are usually seen on examination of someone with bronchial carcinoma?
examination is usually **_normal_**
there may be enlargement of the **supraclavicular lymph nodes**
it is only abnormal if there is **_significant bronchial obstruction_** or the **_tumour has spread_**
96
What are more severe signs that may be seen on examination?
tumours in large bronchi may lead to **_lobar collapse_** or **_obstructive emphysema_**
there may be signs of an unresolved pneumonia or of associated underlying disease (e.g. pulmonary fibrosis in asbestos)
97
What signs are seen on examination when there is phrenic involvement?
* **_absent breath sounds_**
* **_dullness to percussion at the lung bases_**
* this is because phrenic involvement leads to **unilateral raising of the diaphragm**
98
What signs might be present on examination if there is involvement of the pleura?
* there will be pleuritic chest pain
* there will also be a **_pleural rub_** and signs of **_pleural effusion_**
99
Which lymph nodes should always be checked when you suspect lung cancer?
**_AXILLARY_** LYMPH NODES
lung cancer often metastasises here early
100
When can bronchial carcinoma be seen on X-ray?
**_Symptomatic tumours_** will usually be visible on X-ray
Asymptomatic tumours can be seen on X-ray when they are **_greater than 1cm_ in diameter**
101
Why are lateral X-ray views useful when looking at the lungs?
What type of tumours are not seen on X-ray?
lateral views are useful to assess areas of the lungs **behind the heart** and in the **hilar region**
a small number of tumours confined to the **_central airways_** are not visible on X-ray **because of the heart**
they are seen on **bronchoscopy** and **CT** though
102
Should a normal chest X-ray deter further investigation?
Why?
a normal chest X-ray should **_NOT_** be a sign to deter further investigation
especially in **_smokers over the age of 40_**
in many cases of **isolated haemoptysis**, the chest X-ray is normal
103
What % of lung cancers present as a mass on chest X-ray?
How can the different types be differentiated?
70% of lung cancers present with a mass
* virtually all **_small cell carcinomas_** and **_squamous cell carcinomas_** will present as a **_visible mass_**
* **_adenocarcinomas_** tend to occur more around the **_periphery_** of the lung than other tumours
* bronchial carcinoma can appear as a **_round shadow_** on X-ray that typically has a **jagged edge**
* it can also appear as a **cavity**
104
What is lymphangitis carcinomatosa?
What does this look like on X-ray?
bronchial carcinoma not only spreads to the mediastinal lymph nodes, but also to the **_lymphatic channels_**
this causes **dyspnoea** and **_streaky shadowing_** on X-ray that is usually **_unilateral_**
105
What does it suggest if there is streaky shadowing on the chest X-ray that is BILATERAL?
the spread of the tumour through the **lymphatics of the lung** due to **_lung metastases_** from other **primary cancers**
these are usually from below the diaphragm - e.g. stomach or colon
106
What features of lung cancer are looked for on a chest X-ray?
* peripheral circular opacities
* hilar enlargement
* lung collapse
* consolidation
* pleural effusion
* bony secondaries
if any of these are seen, a lateral X-ray should then be taken
107
When is CT scan particularly useful?
it is useful for looking at disease in the **_mediastinum_**
it can also detect masses that are **too small to be seen on chest X-ray** (**_\< 1cm diameter_**)
a normal CT of nodes before surgery excludes the need for mediastinoscopy and node biopsy
108
What is involved in performing a "staging CT"?
How accurate is this when looking at lung mets?
a staging CT should involve the **_liver,_** **_adrenal glands_** and the **_brain_** to check for **mets**
* it should look at the **chin to the kidneys** (includes liver and adrenal glands)
* one scan must be performed **with** **_contrast_** and **one without** - the contrast shows whether it is a ***lesion or just a blood vessel***
this is accurate for 60% of mets as it does not always pick up nodes if they are **less than 10mm**
109
Why might a PET scan be performed?
it is useful for **staging**
there is no point performing a PET scan if there is no plan for surgery
it tells you whether the **_cancer has spread_**, and therefore if the patient is **_suitable for surgery_**
110
What scan is usually performed before a PET scan?
How accurate is the PET scan at picking up mets and what value is read from this scan?
**_staging CT_** is done first and if it is clear, then a PET scan is used to look for **more distant spread**
if the PET scan is clear, then you can operate
PET scan is **90%** accurate for mets
the **_SUV value_** (from 1 to 9) tells you how likely a lesion is to be metastatic spread
111
When is bronchoscopy useful?
it is most useful to obtain cytology and biopsy
**_!!! tumours that involve the first 2cm on either main bronchus are inoperable !!!_**
112
What does widening of the angle of the carina on bronchoscopy suggest?
suggests involvement of the **_mediastinal lymph nodes_**
this is either due to **metastasis** or they may be **reactive**
they can be biopsied on bronchoscopy by passing a needle through the bronchial wall
113
What is cytology and how is it performed on bronchoscopy?
What type of tumours is this useful for?
the study of cells that are no longer in their natural environment
cells are obtained from a **bronchial washing**
this is only useful for tumours in an area about **_10cm square around the hilum_**
114
When is a percutaenous aspiration and biopsy (CT guided biopsy) a useful investigation?
this is useful for **_peripheral lesions_** that cannot be seen by bronchoscopy
it is done through the chest wall and usually guided by CT (or X-ray)
it is able to reach **75% of peripheral lesions** that **_cannot be reached by bronchoscopy_**
115
What is the main risk associated with percutaneous aspiration and biopsy?
there is a very high chance of **_pneumothorax_** ( between 1 - 25%) so patient has to be fit enough to survive one of these if this is performed
**haemoptysis** also occurs in **5%** of patients
116
How useful is a positive or negative result on percutaneous aspiration and biopsy?
positive result is useful
a negative result is useless as it could just mean that you missed the part of the lesion you wanted
117
What blood tests are also performed as part of the investigation for bronchial carcinoma?
* **full blood count** to look for **_anaemia_**
* **LFTs** to check for **_liver involvement_**
* biochemistry - look for **_hypercalcaemia_** and **_hyponatraemia_**
118
Why are hypercalcaemia and hyponatraemia present in bronchial carcinoma?
* ***hypercalcaemia*** occurs as a result of **_bone metastases_**
can also be the result of secretion of parathyroid hormone
* ***hyponatraemia*** occurs as a result of **_adrenal involvement_** (addisonianism)
119
What other cytology may be performed?
What is the problem with this?
**sputum & pleural fluid**
* at least 20ml of each needs to be sent
* this is not very accurate as there is a **_high false negative rate_**
120
What is a mediastinoscopy and what are the benefits to this procedure?
a cut is made just above the sternal notch and a camera is inserted
this helps to see into the **mediastinum** as it can't be seen well on x-ray
it also checks for nodes in cases of peripheral tumours
121
When is mediastinoscopy typically performed?
What can the results determine about surgery?
It is only done in patients who have had a PET scan and it cannot be decided whether there is spread or not
**presence of mediastinal disease is a _contraindication_ for surgery**
the procedure requires general anaesthetic, so many patients will not be fit for it
122
What are 2 important questions to ask at the end of any investigations into bronchial carcinoma?
* has the cancer spread?
* is the patient fit for surgery? (must have a FEV of 0.7)
123
Before deciding what treatment to give, what 3 things do you want to know about the lung cancer?
* the **_type_** of tumour
* the **_location_** of the tumour
* the **_performance status_**
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How are small cell and non-small cell lung cancers staged?
* **non-small cell carcinoma** is staged using the **_TNM system_**
* **small cell carcinoma** is generally **very aggressive** and is staged as either ***_limited_*** or ***_extensive_***
125
What is meant by Tx and Tis when staging the primary tumour for non-small cell lung cancer?
**Tx:**
* malignant cells found in bronchial secretions, but no evidence of tumour mass
**Tis:**
* carcinoma in situ
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What are T1 and T2 as descriptions of the primary tumour in non-small cell lung cancer?
**T1:**
* tumour is ***\<3cm*** in a ***lobar*** or ***more distal airway***
**T2:**
* tumour is ***\>3cm*** and ***at least 2cm away from the carina***
* or **_any size_** with **_pleural involvemen_**t
* or ***obstructive pneumonitis*** (generally inflammation of lung tissue) ***extending to the hilum***, but not in all of lung
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What are stages T3 and T4 in the TNM staging system of the primary tumour in non-small cell carcinoma?
**T3:**
* involves the chest wall, diaphragm, mediastinal pleura, pericardium or \<2cm from, but not involving, the carina
**T4:**
* involves mediastinum, heart, great vessels, trachea, oesophagus, vertebral body
* or malignant pleural effusion is present
128
What does Nx and N0 mean when looking at lymph node involvement?
**Nx:**
* the lymph nodes can't be assessed
**N0:**
* there is no sign of malignant cells in the lymph nodes
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What does N1 mean in terms of lymph node involvement?
there is metastasis in **_ipsilateral peribronchial_** and/or **_ipsilateral hilar_** lymph nodes and **_intrapulmonary nodes_**
this includes involvement by direct extension
there is cancer in the lymph nodes ***within the lung*** or in lymph nodes ***around the hilum***
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What does N2 mean in terms of lymph node involvement?
metastasis in **_ipsilateral mediastinal_** and/or **_subcarinal_** lymph nodes
cancer is present in lymph nodes in the ***centre of the chest*** (mediastinum) on the same side as the affected lung or ***just under the carina***
131
What is meant by N3 in terms of lymph node involvement?
metastasis in **_contralateral mediastinal_**, **_contralateral hilar_**, ipsilateral or contralateral **_scalene_** or **_supraclavicular_** lymph ndoes
there is cancer on the ***opposite side of the chest*** from the affected lung, ***above the clavicle*** or at the ***top of the lung***
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What does M0 and M1 mean in terms of metastasis?
**M0:**
* there is no distant metastasis
**M1:**
* distant metastasis present
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What does M1a mean?
* there is cancer in both lungs - nodule(s) in **_contralateral lobe_**
* tumour with **_pleural_** or **_pericardial_** nodule (s)
* **_malignant pleural or pericardial effusion_**
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What does M1b mean?
**_single extrathoracic metastasis_** involving a **single organ** or **single distant (nonregional) lymph node**
there is a single area of cancer outside of the chest in an organ or lymph node
135
What does M1c mean?
there are **_multiple extrathoracic metastases_** in one or more organs
136
What is the difference between limited and extensive small cell carcinoma?
**_Limited:_**
* confined to one lung / hemithorax
* may have spread to lymph nodes on the same side
**_Extensive:_**
* distant metastasis
* may have spread to the liver, bone, adrenal glands, brain and skin
137
Typically what % of tumours are operable at presentation?
What types of tumours tend to be operable?
only **15-20%** of cancers are suitable for surgery at presentation
operable tumours are the ones that tend to be **_asymptomatic_** and are **_discovered incidentally_**
usually lung cancer presents with a **complication** (e.g. pleural effusion, metastatic pain) and surgery is no longer suitable
138
What are the survival rates for stage 1, stage 2 and 2a NSCLC and what treatment is usually used?
**_STAGE 1:_**
* this is operable with 70% survival at 5 years after surgery
**_STAGE 2:_**
* survival drops to 40% after surgery
* there are often tiny metastases that cannot be seen
**_STAGE 2a:_**
* 25% survival after surgery, although these are often not operated on
* adjuvant chemotherapy, given after surgery, improves survival by 5%
139
What is the survival rate after radical radiotherapy for NSCLC?
whatever the stage of the tumour, the survival rate after 5 years is 20%
140
What is the only treatment available for stage 4 NSCLC?
How can this prolong lifespan and how many patients respond to it?
**_chemotherapy_** is the only treatment offered
with no treatment, there is a 6% chance of being alive after 1 year
with chemotherapy, there is a 12% chance of being alive after 1 year
generally, chemotherapy **extends lifespan by about 2 months** (but only **1/2 patients respond** to chemo)
141
What is the only treatment type offered in small cell carcinoma?
there is **_no curative treatment_**
the cancer has **nearly always metastasised** at the time of presentation, so only **_palliative treatment_** (usually **chemotherapy**) is available
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What is the life expectancy for limited and extensive small cell carcinoma?
How can this be improved with chemotherapy?
**Limited disease:**
* life expectancy is around 3 months from presentation
* with chemotherapy, this can be up to 1 year
**Extensive disease:**
* life expectancy is around 1 month at presentation
* with chemotherapy, this can be up to 8 months
143
What is the difference in response to chemotherapy in small cell and non-small cell lung cancers?
Around **90%** of **small cell carcinoma** will respond to chemotherapy
only **50%** of **non-small cell carcinoma** will respond to chemotherapy
144
What are the current chemotherapy drugs used in the treatment of small cell carcinoma?
**cyclophosphamide + doxorubicin + vincristine + etoposide**
or
**cisplatin + radiotherapy** if the disease is limited
5-year survival is only 10% with treatment
145
What is the common chemotherapy treatment for bronchial carcinoma?
Why do many patients choose not to do this?
**_gemcitabine_** and **_carboplantin_**
it can prolong life, but chemotherapy is also associated with **extensive side effects** and reduced quality of life
146
What is performance status and how is it measured?
it is a WHO classification that is scored from 0 - 4
* 0 - fit and active
* 1 - fit and active but unable to work
* e.g. can move around the home unaided, but cannot do their normal manual labour job
* 2 - not working, but able to be up and active for 50% of the day or more and able to self care
* 3 - able to self care but active for less than 50% of the day
* 4 - bed bound (probably hospitalised or cared for)
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Why is performance status evaluated before giving chemotherapy?
chemotherapy is only available for those in **_0 - 2_** and **_under the age of 80_**
148
What is the treatment of choice for non-small cell carcinoma?
Who is not suitable for this treatment and how can outcome be improved?
**_surgical excision_** is the treatment of choice for tumours at the **periphery** with **no metastatic spread**
surgery is **not suitable** for anyone **_aged \>65_** as operative mortality exceeds survival rate
**_adjuvant chemotherapy_** is beneficial and can down-stage a tumour before treatment and improve 5-year survival
149
When is radiotherapy typically used as a treatment for non-small cell carcinoma?
What is the main contraindication?
it is given when surgery is declined, or in cases where surgery is not suitable
it can be curative in some patients, particularly those with **slow-growing squamous carcinoma**
**poor lung function** is a contraindication for this type of treatment
150
What is radiation pneumonitis and why does it occur?
it develops in 10-15% of patients who have radiotherapy for NSCLC
it is an **_acute infiltrate_** that is **_confined_ to the area treated with radiotherapy**, and occurs **_within 3 months_** of therapy
it is **_inflammation of the lung tissue_** that is treated with **_steroids_**
151
When may radiotherapy be given for symptomatic relief?
suitable targets include bone pain, haemoptysis and SVC obstruction
152
What happens when asbestos fibres are inhaled?
How long does it take to develop problems from this?
they are inhaled and then become lodged in the lung
the properties of the fibres means they are **particularly difficult to destruction** by normal body mechanisms (e.g. enzymes)
it takes **_20-40 years_** to develop **_mesothelioma_** after inhalation of asbestos fibres
153
What is the relationship between smoking, asbestos exposure and development of bronchial carcinoma?
smoking and asbestos fibres have a **_synergistic effect_**
the risk of bronchial carcinoma when having worked with asbestos and having smoked is greater than the sum of the 2 individual risks
154
What is asbestosis?
How long does it take to present?
**_fibrosis of the lung tissue_** **secondary to exposure to _asbestos_**
it is a progressive condition that presents **5 - 10 years** after exposure
155
What are the signs and symptoms associated with asbestosis?
it causes ***severe reduction in lung function*** and ***progressive dyspnoea***
it has a **restrictive pattern**
there may also be ***finger clubbing*** and **_bilateral end-inspiratory crackles_**
156
What are the X-ray findings and treatments for asbestosis?
X-ray shows dark streaks with a honeycomb appearance - **_"honeycomb lung"_**
there is no curative treatment, although steroids are often prescribed (little evidence for their use)
157
What usually causes mesothelioma?
How does it usually present?
it can result from only **light exposure to asbestos fibres**
it is **progressive** and patients have a **restrictive pattern** on pulmonary function tests
it often presents with **_pleural effusion_** and **_progressive dyspnoea_**
there may also be **chest wall pain** and **ascites** due to abdominal involvement
158
How does the tumour begin in mesothelioma and how does it develop?
What structures are often invaded?
the tumour begins as **pleuritic nodules** that **gradually grow** and **extend** around the whole surface of the lung, and even into the **fissures**
this leads to chest wall pain
**intercostal nerves** and **hilar lymph nodes** may be invaded
159
What is the median survival for mesothelioma?
What is the treatment?
the median survival is around 2 years from presentation
there is no treatment
