Cancers or lung, heart and vasculature Flashcards
What is cardiovascular cancer?
Primary cancer of blood vessels and heart very rare
What is the most common cardiovascular cancer?
Angiosarcoma
What is angiosarcoma?
- Malignancy of vascular endothelial cells
- Of skin, heart, liver etc
- Annual incidence 1.5 cases per million
What are cardiac tumours?
- E.g. myxoma, tumour of connective tissue
- Annual incidence <1case per million
What are cardiac cancers so rare?
- Low exposure of cells to carcinogens
- Turnover rate: cardiac myocytes divide very rarely - increase size of myocytes is how it grows (not like in lungs)
- Strong selective advantage against anything which could compromise function, shape of cells is specialised and any change in shape would impact change in cardiovascular system
How many deaths and diagnoses are in lung cancer?
- Around 48,000 diagnoses/year
- Around 35,000 deaths/year
How common is lung cancer with other cancers?
- 3rd most common cancer in UK
- Leading cause of cancer death - in men and women
When did lung cancer become less rare?
smoking only popular WW1 Onwards (1930s onwards)
What were the other suggested causes of lung cancer?
- Air pollution
- Asphlated roads
- Road traffic
- Gas exposure. In WW1
- Influenza pandemic 1918
- Working with petroleum
Who found that smoking causes lung cancer?
- Doll + Hill - 1950s, classic prospective case control study of >40,000 British doctor’s smoking habit and development of lung cancer
- Strong influence of tobacco companies
What demographic tends to get lung cancer?
- age, peak 75-90
- Sex M>F
- Lower socioeconomic status
- Smoking history
What affects lung cancer risk with smoking history?
- Duration
- Intensity
- When stopped - if stopped 30 years then risk lower than 10 years
What is the worldwide tobacco use like?
- Cigarettes cause around 1.5million deaths from lung cancer per year (1 lung cancer death per 3 or 4 million smoked
- Developing world e.g china
What percentage of patients with lung cancer never smoked?
- 10-15% patients with lung cancer never smoked
2. Passive smoking (around 15% of these)
What are the other etiological causes of lung cancer?
- Asbestos: exposure (plumbers, ship-builders, carriage workers, carpenters, etc) - risk up to 2x
- Radon: e.g. silver miner in Germany later 19th centres; 1950s uranium mining in Colorado
- Indoor cooking fumes: wood smoke, frying fats
- Chronic lung disease (COPD, fibrosis) independent effect of smoking
- Immunodeficenciey
- Familial/genetic - several loci identified
What are four pathophysiologies of lung cancer?
- Squamous cell carcinoma
- Adenocarcinoma
- Large cell lung cancer
- Small cell lung cancer
- 1-3 often grouped together (non-small cell lung cancer (NSCLC)
What is squamous cell carcinoma?
- around 30% of cases
- previously the most common
- originating form bronchial epithelium; centrally located
What is adenocarcinoma?
- around 40% of cases
- Most common from 1980s onwards: low tar cigarettes, inhaled more deeply/retained longer
- Originating from mucus-producing glandular tissue; more peripherally located
What is large cell lung cancer?
- around 15% of cases
- heterogenous group
- undifferentiated
What is small cell lung cancer?
- around 15% of cases
- originate from pulmonary neuroendocrine cells
- highly malignant
What is metaplasia?
- reversible change in which one adult cell type replaced by another adult cell type
- adaptive
What is dysplasia?
- abnormal pattern of growth in which some of the cellular and architectural features of malignancy are present
- pre-invasive stage with intact basement membrane
Which genes are mutated and are important for directed treatments?
- epidermal growth factor receptor (EGFR) tyrosine kinase
- anaplastic lymphoma kinase (ALK) tyrosine kinase
- c-ROS oncogene 1 (ROS1) receptor tyrosine kinase
- BRAF (downstream cell-cycle signalling mediator)
When are there EGFR tyrosine kinase mutations?
- 15-30% of adenocarcinoma
2. more so in women, Asian ethnicity, never-smokers
When are there ALK tyrosine kinase mutations?
- 2-7% of non-small cell lung cancer
2. especially in younger patients and never smokers
When are there ROS1 receptor tyrosine kinase mutations?
- 1-2% of non-small cell lung cancer
2. especially in younger patients and never smokers
When are there BRAF mutations?
- 1-3% of non-small cell lung cancer
2. especially in smokers
What are the key symptoms of lung cancer?
- Cough
- Weight loss
- Breathlessness
- Fatigue
- Chest pain
- Haemopytsis - coughing up blood
Why is lung cancer frequently asymptomatic?
non specific symptoms and lung big so a lot of space to grow before notice any symptoms
What are the features of metastatic disease?
- Neurological features
- Bone pain / liver failure
- Paraneoplastic. syndromes
What are the neurological features of advanced disease?
- Focal weakness
- Seizures
- Spinal cord compression
What are some paraneoplastic syndromes?
- (proteins/substances secreted by tumour)
- clubbing
- hypercalaemia: PTH related protein
- hyponatraemia: ADH secretion
- Cushing’s : stimulation of adrenal glands
What are some other signs?
- Clubbing
- Horner’s syndrome
- Cachexia
- Superior vena cava obstruction (Pemberton’s sign)
What is the diagnostic strategy for lung cancer?
- Establish most likely diagnosis
- Establish fitness for investigation and treatment
- Confirm diagnosis: specific type of cancer if considering systemic treatment
- Confirm staging
What imaging techniques are used?
- Chest X ray
- Staging CT (chest + abdomen)
- PET: most useful to exclude occult metastases
What do you choose biopsy based off?
- accessibility
- availability
- impact on staging
When is bronchoscopy used?
- For tumours of central airway
2. Where tissue staging not important
When do you use EBUS?
- Endobronchial ultrasound and trans bronchial-needle aspiration of mediastinal lymph nodes (EBUS[TBNA])
- To stage mediastinum +/- achieve tissue diagnosis
When do you do CT guided lung biopsy?
to access peripheral lung tumours
Risk of pneumothorax
What are the different types of staging? What do they stand for?
- T1-4: tumour size and location
- N0-3: lymph node involvement - mediastinum + beyond
- M0-1c: metastases + number
Late stage at diagnosis is common
What determines treatment?
- Patient fitness
- Cancer histology
- Cancer stage
- Patient preference
- Health service factors
What is 0 on WHO patient fitness?
- Asymptomatic
- Fully active, able to carry on all predisease activities without restriction
What is 1 on WHO patient fitness?
- Symptomatic but completely ambulatory
- Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature
- For example, light housework, office work
What is 2 on WHO patient fitness?
- Symptomatic, <50% in bed during the day
- Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours
What is 3 on WHO patient fitness?
- Symptomatic, >50% in bed, but not bedbound
2. Capable of only limited self-care, confined to bed or chair 50% or more of waking hours
What is 4 on WHO patient fitness?
- Bedbound
- Completely disabled
- Cannot carry on any self-care
- Totally confined to bed or chair
What is 5 on WHO patient fitness?
Death
In what patient fitness can you do radical treatment?
usually restricted to PS 0-2
What else is important in determining patient fitness?
-Comorbidity
lung function also very important
What is the standard of care for early stage of disease?
Surgical resection
What is the usual surgical resection?
- Lobectomy
2. lymphadenectommy
