CSI 20: Lung Cancer Flashcards
outline the WHO performance status
0 – Able to carry out all pre-disease activities without restriction.
1 – Restricted in physically strenuous activity, but ambulatory and able to carry work of a light and sedentary nature (e.g., light housework, office work).
2 – Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about >50% of waking hours.
3 – Capable of only limited self-care, confined to bed or chair more than 50% of waking hours.
4 – Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair.
5 - Dead
what factors go into thoracoscore (mortality from lung surgery)
Age (years)
Sex
ASA Classification
Performance Status Classification
Dyspnea score
Priority of surgery
Procedure class
Diagnosis group
Comorbidity Score
what does this biopsy show and give features
Adenocarcinoma
Most common lung tumour type in non-smokers.
o Glandular differentiation with mucin-containing elements.
o Most express thyroid transcription factor-1 and napsin A.
o A precancerous lesion is described, known as adenocarcinoma in situ. o
Gland-forming adenocarcinoma; inset shows thyroid transcription factor 1 (TTF-1) expression, as detected by immunohistochemistry.
what does this biopsy show and give histological features
Squamous cell carcinoma
Strongly associated with smoking.
Occurs more centrally than other types.
May grow into the lumen and cause obstruction and infection, or out into the lung parenchyma.
Characterised by the production of keratin, which may take the form of squamous pearls or cells with very eosinophilic cytoplasm.
Characteristic protein markers are p63 and p40.
A precancerous lesion is known as squamous carcinoma in situ.
what does this biopsy show and give histological features
Small cell lung cancer
Strong link to smoking.
May arise in the major bronchi or the periphery of the lung.
The most aggressive of lung tumours, usually metastasised by diagnosis.
Demonstrates small round or spindle-shaped cells with scanty cytoplasm, ill-defined borders, and finely granular nuclear chromatin (salt-and-pepper pattern). Shows areas of necrosis.
Likely precursor is neuroendocrine progenitor cells that line the bronchial epithelium:
No in-stu
what does this biopsy show and give histological features
Large cell carcinoma (3%)
Undifferentiated malignant epithelial tumour. Lacks the features of other forms of lung cancer.
Cells have large nuclei, prominent nucleoli, and a moderate amount of cytoplasm.
Diagnosis of exclusion; negative for all characteristic markers.
Pleomorphic cells, i.e. cells with various forms in large cell carcinoma. No evidence of squamous or glandular differentiation.
Staging of lung cancer
Outline nodal status
Nx: regional lymph nodes cannot be assessed -
N0: no regional lymph node metastasis -
N1: involvement of ipsilateral intrapulmonary, peribronchial, or hilar lymph nodes -
N2: involvement of ipsilateral mediastinal or subcarinal lymph nodes -
N3: involvement of contralateral mediastinal or hilar nodes, or scalene or supraclavicular nodes on either side
Staging of lung cancer
Outline metastasis status
M0: no distant metastasis -
M1: distant metastasis present
- M1a: nodules in a contralateral lobe, the pleura or the pericardium, or effusions in the pleural cavity or pericardium
- M1b: single extrathoracic metastasis
- M1c: multiple extrathoracic metastases in one or more organs
Ixs for lung cancer
give overall Ixs principles
Choose least risky Ixs
offer CT-PET to those with potential curative treatment
Prioritise biopsy of high-risk intrathoracic lymph nodes (i.e., >1 cm on CT or PET-CTpositive) over the primary lesion if nodal status would affect the treatment plan.
Central lesions are those located within 3 cm of the proximal bronchial tree, heart, great vessels, trachea, or other mediastinal structures.
Ixs for lung cancer
give relative Ixs for central and peripheral tumour
Central primary tumour or node
- Offer flexible bronchoscopy to people with central lesions on CT.
- Offer endobronchial ultrasound-guided transbronchial needle aspiration (EBUSTBNA) for paratracheal and peri-bronchial intra-parenchymal lung lesions.
Peripheral primary tumour
- Offer image-guided (CT-guided) biopsy to people with peripheral lung lesions.
Staging of lung cancer
Outline T size
Tx: primary tumour cannot be assessed -
T0: no evidence of a primary tumour -
Tis: carcinoma in situ – tumour measuring <3 cm with no invasive component -
T1: invasive tumour measuring <3 cm, without invasion in the main bronchus o -
T2: tumour size 3-5 cm, or tumour which
- invades the main bronchus (but not the carina)
- invades visceral pleura
- associates with atelectasis or obstructive pneumonitis that extends to the hila
T3: tumour 5-7 cm, or tumour which:
- associates with separate tumour nodules in the same lobe
- invades the chest wall o invades the parietal pericardium
- invades the phrenic nerve -
T4: tumour >7 cm, or tumour which:
associates with separate tumour nodules in a different ipsilateral lobe o invades any of the following: ▪ carina ▪ diaphragm ▪ great vessels ▪ heart ▪ mediastinum ▪ oesophagus ▪ recurrent laryngeal nerve ▪ trachea ▪ vertebral body
outline local complications of advanced cancer
Breathlessness is common and caused by multiple factors, e.g., pleural effusions, anaemia, anxiety.
Cough due to airway irritation can make breathlessness and pain worse.
Haemoptysis may be caused by erosion of the tumour into blood vessels.
Pancoast tumours can produce neuropathic pain by invading the brachial plexus.
Pleuritic pain may be due to local spread or inflammation or due to metastases.
Superior vena cava obstruction can occur, leading to upper limb and facial plethora, as well as breathlessness.
outline systemic complications of advanced cancer
Anorexia and altered taste are common.
Bone metastases cause pain and increase the risk of fractures and cord compression.
Brain metastases should be suspected with persistent headaches, unexplained vomiting, or behaviour change. There is a risk of seizures.
Hypercalcaemia (ONCOLOGICAL EMERGENCY) presents with vague symptoms of nausea, altered mood, and confusion, as well as thirst and constipation. It may relate to bone metastases or to parathyroid hormone-related peptide release from squamous cancers.
Hyponatraemia (SIADH).
Palliative care :
explain how you would provide treatment for radiotherapy and endobronchial obstruction
Use specialist care
Palliative radio: offer it as symptoms arises or immediately for people who can’t have curative treatment
Endobronchial obstruction:
- Monitor for it
- Offer external beam radio +/- endobronchial debulking or stenting for people with impending obstruction
- Every cancer alliance team should have a specialist that can provide this care
Palliative care :
explain how you would provide treatment for:
- brain metastesis
- Bone metastesis
- FLAWS
Brain:
- Dex for those with symptoms and recude to minimum maintenace
Bone:
- Administer single-fraction radiotherapy to people with bone metastasis who need palliation and for whom standard analgesic treatments are inadequate
FLAWS:
- MDT and palliative care specialist should take care of it
Palliative care:
How would you manage other symptoms
Perform pleural aspiration or drainage (pleural effusion).
- Patients who benefit symptomatically from aspiration or drainage of fluid should be offered talc pleurodesis for longer-term benefit.
Consider non-drug interventions based on psychosocial support, breathing control and coping strategies for people with breathlessness.
Non-drug interventions for breathlessness should be delivered by a multidisciplinary group
Consider opioids, such as codeine or morphine, to reduce cough.
Refer people with hoarseness due to recurrent laryngeal nerve palsy to ENT for advice.
SVC Obstruction:
- Offer people chemotherapy and radiotherapy according to the stage of disease and performance status.
- Consider stent insertion for the immediate relief of severe symptoms of superior vena caval obstruction or following failure of earlier treatment.
what are all the components of palliative care and give any pertinent points
Physical symptoms
- Don’t add unneccessary med that won’t relieve symptoms
- Symptoms may be made worse by insomnia, depression, etc
Cultural
Spiritual
Family : address concerns and involve them whenever possible and appropriate
Psychological
- emergency psych interventions should be sought for those with severe mental health problems
Social
What is the mitotic index and appearance of small cell lung cancer?
- Highly malignant and appears round
- Neuroendocrine cells are origin
- Not suitable for surgery
Ones general for invasive cancer
- High mitotic index
- High nuclei-cytoplasmic ration
- Invade Basement membrane
what was Mr Craven thoracoscore ?
8.24%
why isnt PET-CT used to look for brain metastasis and give alternatives
marker is flourodeoxy-glucose
brain is highly metabolic and hence not feasible
Use Brain MRI instead
draw out areas of central and peripheral lung tumours , what are the possible sites of metastasis
bone, brain, liver and adrenals
what are the complications of EBUS and SABR
EBUS:
- bleeding
- Infection
- Pneumothorax
- Scarring
SABR
- pleurisy
- fibrosis
outline the TNM system (f2f session)
what specific complications did Mr Craven have ?
cough
SOB
Bony mets and nausea
dehydration
pleural effusion
Give GENERAL comparisions between large cell cancer and squamous cell
Squamouse:
- smoking
- central
- metastesis later than the rest
- cavitation is common
- PTHrp
Large:
- Central or peripheral
- Hard to diagnose (in terms of technique)
- Undifferentiated
Give GENERAL comparisions between Adenocarcinoma and Small cell
Adenocarcinoma:
- most common
- Non smoking
- peripheral
- women
Small:
- Metastsis v early
- Central and aggressive
- Neuroendocrine
outline all the treatment options for lung cancer
Surgery (lobectomy with lymph node sampling), no chemotherapy or radiotherapy
- Surgery (lobectomy), no chemotherapy or radiotherapy
- Chemotherapy, no surgery or radiotherapy
- Chemotherapy prior to surgery, no radiotherapy
- Chemotherapy following surgery, no radiotherapy
- Radiotherapy (conventional), no surgery or chemotherapy
- Radiotherapy (stereotactic ablative radiotherapy), no surgery or chemotherapy
draw and outline how target immunotherapy may be relevant in cancer
Nivolumab
