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Core Conditions - Respiratory > Bronchial Carcinoma > Flashcards

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

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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

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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

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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

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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

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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

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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

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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

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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
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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

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11
Q

What are the subcategories of non-small cell carcinoma?

A
  • adenocarcinoma
  • squamous cell carcinoma
  • large cell carcinoma
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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
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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
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14
Q

What is the development time for squamous cell carcinoma?

A

8 years

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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

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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

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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
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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

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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

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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
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21
Q

How does squamous cell carcinoma tend to spread?

A

local spread is common but widespread metastases tend to occur relatively late

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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

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23
Q

What does squamous cell carcinoma usually cause systemically?

A

HYPERCALCAEMIA

this is either due to bone destruction or production of PTH analogues

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24
Q
A
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25
Q

From which cells does adenocarcinoma arise from?

How common is it?

A

Adenocarcinoma accounts for 10% of all bronchial carcinomas

it arises from mucous cells in the bronchial epithelium

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26
Q

Where does adenocarcinoma typically spread to?

A

it commonly invades the pleura and the mediastinal lymph nodes

it commonly metastasises to the brain and bones

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27
Q

Where does adenocarcinoma tend to be found in the lungs?

A

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

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28
Q

What is known to cause many cases of adenocarcinoma?

In which groups is it proportionally more common?

A
  • 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
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29
Q

Does adenocarcinoma cavitate?

What other symptoms can it cause?

A

it does not usually cavitate

it can cause excessive mucous secretion

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30
Q

What can adenocarcinoma often be confused with?

A

it can be confused with mesothelioma

it is the most likely to cause pleural effusions (as are mesotheliomas)

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31
Q

What are large cell carcinomas?

How common are they?

A

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

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32
Q

What is the prognosis of large cell carcinomas like and why?

A

they tend to metastasise early and are associated with poor prognosis

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33
Q

Where are most large cell carcinomas found?

Who tends to be affected?

A

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

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34
Q

What is bronchoalveolar cell carcinoma and how common is it?

A

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

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35
Q

How does bronchoalveolar cell carcinoma tend to present?

A

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

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36
Q

What symptom is bronchoalveolar cell carcinoma associated with?

A

“bronchorrhoea” - diarrhoea of the bronchus

this is the production of large amounts of mucous, which is coughed up as white sputum

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37
Q

What is an alternative name for small cell lung cancer?

How common is it?

A

also known as “oat cell carcinoma”

it accounts for 20-30% of all lung cancers

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38
Q

What type of cells does small cell carcinoma arise from?

A

Arises from endocrine cells called Kulchitsky cells

These are APUD cells (amine precursor uptake & decarboxylation)

which have a role in hormone synthesis and secretion

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39
Q

What is the result of small cell lung cancer developing from Kulchitsky cells?

A

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

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40
Q

How quickly does small cell carcinoma grow?

What is the prognosis like?

A
  • 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
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41
Q

What are the 2 different types of APUD cells?

A

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
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42
Q

Where else in the body can primary small cell carcinoma develop?

A
  • oesophagus
  • stomach
  • cervix
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43
Q

Where does bronchial carcinoma often spread to?

A

the tumour may spread to the pleura, either directly, or by lymphatic drainage

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44
Q

Where does bronchial carcinoma spread to by direct spread?

A

the tumour can directly involve the pleura and the ribs

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45
Q

What is a Pancoast’s tumour?

Where can this spread to and what symptoms does it cause?

A

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

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46
Q

What structure can be lost through a Pancoast’s tumour?

A

it can lead to loss of the first rib - the tumour consumes it

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47
Q

What happens if the tumour involves the sympathetic ganglion?

A

if the sympathetic ganglion is damaged, this can lead to Horner’s syndrome

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48
Q

How does Horner’s syndrome result from a lung tumour?

What type of tumour must it be to cause this?

A

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

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49
Q

What are the clinical features of Horner’s syndrome?

A

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
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50
Q

What nerve can be directly invaded by the bronchial carcinoma and what is the result of this?

A

bronchial carcinoma can directly invade the phrenic nerve

this causes paralysis of the ipsilateral hemidiaphragm

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51
Q

What other organs / structures can be locally invaded by the brochial carcinoma?

What symptoms does this produce?

A

the bronchial carcinoma can invade the oesophagus, producing progressive dysphagia

it can also invade or compress the pericardium, producing pericardial effusion and malignant arrhythmias

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52
Q

What are the symptoms associated with the bronchial carcinoma invading the superior vena cava?

A
  • 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
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53
Q

Which nerve may hilar tumours involve and what symptoms does this produce?

A

hilar tumours may involve the recurrent laryngeal nerve

this produces unilateral vocal cord paresis with hoarseness and a bovine cough

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54
Q
A
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55
Q

Which lymph nodes tend to be affected when bronchial carcinoma spreads?

A

it tends to spread to the mediastinal and supraclavicular nodes

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56
Q

Where are the most common places for bronchial carcinoma to spread via the bloodstream?

A
  • bony metastases
  • liver
  • brain
  • adrenal glands (this is often a post-mortem finding as it is asymptomatic)
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57
Q

What are the consequences of metastases in the brain?

A

secondary deposits in the brain result in change in personality, epilepsy or as a focal neurological lesion

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58
Q

What are the consequences of bony metastases?

A

These tend to cause pain and pathological fractures

they can also result in spinal cord compression, which requires emergency surgery

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59
Q

How is size of the primary tumour in bronchial carcinoma related to the extent of spread?

A

Even a very small primary tumour can result in wide-spread metastasis

This is particularly true of small cell carcinomas

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60
Q

What % of bronchial carcinomas produce ectopic hormones?

What is the result of this?

A

10% of small-cell tumours produce ectopic hormones at some stage

however, clinical extrapulmonary findings are rare, except from finger clubbing

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61
Q

What are the main non-metastatic manifestations of bronchial carcinoma?

What type of bronchial carcinoma are these associated with?

A
  • inappropriate ADH secretion
  • ectopic ACTH secretion - causing Cushing’s syndrome
  • Hypercalcaemia

endocrine disturbances are typically associated with small cell carcinoma

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62
Q

What can inappropriate ADH secretion lead to?

How can this be treated clinically?

A

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

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63
Q

What can ectopic ACTH secretion cause?

A

Cushing’s syndrome

this produces symptoms similar to those on steroids

these patients, unlike those on steroids, will be heavily pigmented

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64
Q

Why does hypercalcaemia occur in bronchial carcinoma?

What type does this tend to be associated with?

A

it occurs due to the secretion of parathyroid hormone related peptides (PTH)

this mostly occurs with squamous cell carcinoma

65
Q

What is a paraneoplastic syndrome?

When do they tend to present and how common are they?

A

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
Q

What are the potential neurological complications that present as paraneoplastic syndromes?

A
  • polyneuropathy
  • cerebellar degeneration (and other encephalopathies)
  • Lambert-Eaton syndrome (and other muscular conditions)
67
Q

What causes polyneuropathy and how does it present?

A

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
Q

What is Lambert-Eaton syndrome?

A

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
Q

What are the symptoms of Lambert-Eaton syndrome?

A

proximal muscle weakness that improves with repeated use

70
Q

What are the potential vascular and haematological paraneoplastic syndromes?

A

these are rare

  • thrombophlebitis migrans
  • anaemia - microcytic or normocytic
71
Q

What is another name for thrombophlebitis migrans?

What is it?

A

Trousseau syndrome

episodes of vessel inflammation due to blood clots (thrombophlebitis) that are recurrent or appearing in different locations over time

72
Q

What is HPOA as a paraneoplastic syndrome and how common is it?

A

hypertrophic pulmonary osteoarthropathy

it occurs in 3% of all bronchial carcinomas

particularly squamous cell carcinomas and adenocarcinomas

73
Q

What are the symptoms of hypetrophic pulmonary osteoarthropathy (HPOA)?

A
  • joint stiffness
  • severe pain in the ankles and wrists
  • gynaecomastia (sometimes)
  • also associated with finger clubbing
74
Q

What is gynaecomastia?

A

a condition in which males develop breast tissue as a result of imbalanced ratio of oestrogen and androgen activity

75
Q

What does HPOA look like on X-ray?

A

there is proliferative periostitis at the ends of long bones, which have a characteristic “onion skin” appearance

76
Q

What is HPOA thought to be caused by and why?

A

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
Q

What % of cases of bronchial carcinoma are associated with finger clubbing?

A

30%

it is caused by non-small cell carcinoma

it is thought to be a result of ectopic hormone production

78
Q

What is carcinoid syndrome and what causes it?

A

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
Q

How is carcinoid syndrome diagnosed?

A

using 24 hour urine 5-HIAA tests

80
Q

What are the most common symptoms associated with bronchial carcinoma?

A
  • cough
  • chest pain
  • cough and pain
  • haemoptysis (coughing up blood)
  • chest infection
  • malaise
  • weight loss
  • shortness of breath
  • hoarseness
81
Q

What co-existing condition is present in many patients with bronchial carcincoma?

A

Many patients have co-existing COPD

82
Q

What is the pain like in bronchial carcinoma?

A

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
Q

What is the cough like in bronchial carcinoma?

What can sometimes be a telltale sign to look out for?

A
  • 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
Q

In which types of tumour is haemoptysis more common?

When can it be fatal and why is it sometimes missed?

A
  • 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
Q

When does haemoptysis need to be investigated?

A

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
Q

When is pneumonia suggestive of bronchial carcinoma?

Why does this occur?

A

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
Q

When does shortness of breath occur in bronchial carcinoma?

A

this only occurs when there is obstruction of a large bronchus

88
Q

When might stridor be present in bronchial carcinoma?

What characteristic does it tend to have?

A

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
Q

What is the difference between the causes of monophonic and polyphonic wheeze?

How can it be heard?

A

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
Q

What is pleuritic chest pain and what does it suggest?

A

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
Q

What does hoarseness of the voice suggest?

Why is this not a good sign?

A

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
Q

Why are the mortality rates for lung cancer the same as they were 10 years ago?

A

lung cancer presents very late

93
Q

How does someone with bronchial carcinoma typically present?

A

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
Q

Why does someone with bronchial carcinoma also have a reduced appetite?

A

as a result of the inflammatory reaction that the tumour induces

(particularly the TNF that is released)

95
Q

What findings are usually seen on examination of someone with bronchial carcinoma?

A

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
Q

What are more severe signs that may be seen on examination?

A

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
Q

What signs are seen on examination when there is phrenic involvement?

A
  • absent breath sounds
  • dullness to percussion at the lung bases
  • this is because phrenic involvement leads to unilateral raising of the diaphragm
98
Q

What signs might be present on examination if there is involvement of the pleura?

A
  • there will be pleuritic chest pain
  • there will also be a pleural rub and signs of pleural effusion
99
Q

Which lymph nodes should always be checked when you suspect lung cancer?

A

AXILLARY LYMPH NODES

lung cancer often metastasises here early

100
Q

When can bronchial carcinoma be seen on X-ray?

A

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
Q

Why are lateral X-ray views useful when looking at the lungs?

What type of tumours are not seen on X-ray?

A

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
Q

Should a normal chest X-ray deter further investigation?

Why?

A

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
Q

What % of lung cancers present as a mass on chest X-ray?

How can the different types be differentiated?

A

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
Q

What is lymphangitis carcinomatosa?

What does this look like on X-ray?

A

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
Q

What does it suggest if there is streaky shadowing on the chest X-ray that is BILATERAL?

A

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
Q

What features of lung cancer are looked for on a chest X-ray?

A
  • 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
Q

When is CT scan particularly useful?

A

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
Q

What is involved in performing a “staging CT”?

How accurate is this when looking at lung mets?

A

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
Q

Why might a PET scan be performed?

A

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
Q

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?

A

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
Q

When is bronchoscopy useful?

A

it is most useful to obtain cytology and biopsy

!!! tumours that involve the first 2cm on either main bronchus are inoperable !!!

112
Q

What does widening of the angle of the carina on bronchoscopy suggest?

A

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
Q

What is cytology and how is it performed on bronchoscopy?

What type of tumours is this useful for?

A

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
Q

When is a percutaenous aspiration and biopsy (CT guided biopsy) a useful investigation?

A

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
Q

What is the main risk associated with percutaneous aspiration and biopsy?

A

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
Q

How useful is a positive or negative result on percutaneous aspiration and biopsy?

A

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
Q

What blood tests are also performed as part of the investigation for bronchial carcinoma?

A
  • full blood count to look for anaemia
  • LFTs to check for liver involvement
  • biochemistry - look for hypercalcaemia and hyponatraemia
118
Q

Why are hypercalcaemia and hyponatraemia present in bronchial carcinoma?

A
  • 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
Q

What other cytology may be performed?

What is the problem with this?

A

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
Q

What is a mediastinoscopy and what are the benefits to this procedure?

A

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
Q

When is mediastinoscopy typically performed?

What can the results determine about surgery?

A

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
Q

What are 2 important questions to ask at the end of any investigations into bronchial carcinoma?

A
  • has the cancer spread?
  • is the patient fit for surgery? (must have a FEV of 0.7)
123
Q

Before deciding what treatment to give, what 3 things do you want to know about the lung cancer?

A
  • the type of tumour
  • the location of the tumour
  • the performance status
124
Q

How are small cell and non-small cell lung cancers staged?

A
  • 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
Q

What is meant by Tx and Tis when staging the primary tumour for non-small cell lung cancer?

A

Tx:

  • malignant cells found in bronchial secretions, but no evidence of tumour mass

Tis:

  • carcinoma in situ
126
Q

What are T1 and T2 as descriptions of the primary tumour in non-small cell lung cancer?

A

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 involvement
  • or obstructive pneumonitis (generally inflammation of lung tissue) extending to the hilum, but not in all of lung
127
Q

What are stages T3 and T4 in the TNM staging system of the primary tumour in non-small cell carcinoma?

A

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
Q

What does Nx and N0 mean when looking at lymph node involvement?

A

Nx:

  • the lymph nodes can’t be assessed

N0:

  • there is no sign of malignant cells in the lymph nodes
129
Q

What does N1 mean in terms of lymph node involvement?

A

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

130
Q

What does N2 mean in terms of lymph node involvement?

A

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
Q

What is meant by N3 in terms of lymph node involvement?

A

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

132
Q

What does M0 and M1 mean in terms of metastasis?

A

M0:

  • there is no distant metastasis

M1:

  • distant metastasis present
133
Q

What does M1a mean?

A
  • there is cancer in both lungs - nodule(s) in contralateral lobe
  • tumour with pleural or pericardial nodule (s)
  • malignant pleural or pericardial effusion
134
Q

What does M1b mean?

A

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
Q

What does M1c mean?

A

there are multiple extrathoracic metastases in one or more organs

136
Q

What is the difference between limited and extensive small cell carcinoma?

A

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
Q

Typically what % of tumours are operable at presentation?

What types of tumours tend to be operable?

A

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
Q

What are the survival rates for stage 1, stage 2 and 2a NSCLC and what treatment is usually used?

A

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
Q

What is the survival rate after radical radiotherapy for NSCLC?

A

whatever the stage of the tumour, the survival rate after 5 years is 20%

140
Q

What is the only treatment available for stage 4 NSCLC?

How can this prolong lifespan and how many patients respond to it?

A

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
Q

What is the only treatment type offered in small cell carcinoma?

A

there is no curative treatment

the cancer has nearly always metastasised at the time of presentation, so only palliative treatment (usually chemotherapy) is available

142
Q

What is the life expectancy for limited and extensive small cell carcinoma?

How can this be improved with chemotherapy?

A

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
Q

What is the difference in response to chemotherapy in small cell and non-small cell lung cancers?

A

Around 90% of small cell carcinoma will respond to chemotherapy

only 50% of non-small cell carcinoma will respond to chemotherapy

144
Q

What are the current chemotherapy drugs used in the treatment of small cell carcinoma?

A

cyclophosphamide + doxorubicin + vincristine + etoposide

or

cisplatin + radiotherapy if the disease is limited

5-year survival is only 10% with treatment

145
Q

What is the common chemotherapy treatment for bronchial carcinoma?

Why do many patients choose not to do this?

A

gemcitabine and carboplantin

it can prolong life, but chemotherapy is also associated with extensive side effects and reduced quality of life

146
Q

What is performance status and how is it measured?

A

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)
147
Q

Why is performance status evaluated before giving chemotherapy?

A

chemotherapy is only available for those in 0 - 2 and under the age of 80

148
Q

What is the treatment of choice for non-small cell carcinoma?

Who is not suitable for this treatment and how can outcome be improved?

A

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
Q

When is radiotherapy typically used as a treatment for non-small cell carcinoma?

What is the main contraindication?

A

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
Q

What is radiation pneumonitis and why does it occur?

A

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
Q

When may radiotherapy be given for symptomatic relief?

A

suitable targets include bone pain, haemoptysis and SVC obstruction

152
Q

What happens when asbestos fibres are inhaled?

How long does it take to develop problems from this?

A

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
Q

What is the relationship between smoking, asbestos exposure and development of bronchial carcinoma?

A

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
Q

What is asbestosis?

How long does it take to present?

A

fibrosis of the lung tissue secondary to exposure to asbestos

it is a progressive condition that presents 5 - 10 years after exposure

155
Q

What are the signs and symptoms associated with asbestosis?

A

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
Q

What are the X-ray findings and treatments for asbestosis?

A

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
Q

What usually causes mesothelioma?

How does it usually present?

A

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
Q

How does the tumour begin in mesothelioma and how does it develop?

What structures are often invaded?

A

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
Q

What is the median survival for mesothelioma?

What is the treatment?

A

the median survival is around 2 years from presentation

there is no treatment

Core Conditions - Respiratory (10 decks)

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