CVR cancers of the lung, heart and vasculature Flashcards
Are cardiovasc cancers common?
no - very rare
what is angiosarcoma?
malignancy of vascular endothelial cells; (of skin, heart, liver)
-> incidence 1.5 case per mil
Example of a cardiac tumour
myxoma (cancer of connective tissue)
-> incidence <1 cases per mil
Why are cardiac cancers so rare
- Low exposure of cells to carcinogens
- turnover rate is low as cardiac myocytes rarely divide
- Strong selective adv against anything which could compromise function
what is the 3rd most common cancer in the UK?
lung
when did lung cancer start becoming a problem?
WW1
what is the age peak for lung cancer?
75-90yrs
do more men or women get lung cancer?
men
what type of status can increase risk of lung cancer?
- lower socioeconomic
- smoking history
what percentage of people who get lung cancer never previously smoked?
Passively smoked?
Never: 10- 15%
Passively: 15%
aetiological factors other than smoking (passive/non-passive) that can cause lung cancer?
- asbestos
- Radon
- Indoor cooking fumes
- Chronic lung diseases
- Immunodeficiency
- Familial/genetic
types of lung cancers
- squamous cell carcinoma
- adenocarcinoma
- large cell lung cancer
- small cell lung cancer
what is the most common type of lung cancer?
- adenocarcinoma (40%)
- originating from mucus-producing glandular tissue: more peripherally located
Features of squamous cell carcinomas? (30%)
(30%)
- originating from bronchial epithelium
- centrally located
features of small cell lung cancer? (15%)
- originate from pulmonary neuroendocrine cells
- highly malignant
umbrella term for squamous cell carcinoma, adenocarcinoma, large cell lung cancer
non-small cell lung cancer
Are small cell lung cancers aggressive?
yes
early stages of lung cancer
- normal epithelium
- hyperplasia
- squamous metaplasia
intermediate stages of lung cancer
- dysplasia
late stages of lung cancer
- carcinoma in situ
- invasive carcinoma
What are oncogene directed treatments for lung cancer?
First line for metastatic non-small cell LC with mutation
- EGFR tyrosine kinase (seen in adenocarcinoma, more common in asian women who never smoked)
- ALK tyrosine kinase (see in non-small cell lung cancer in young children who never smoked)
- ROS1 receptor tyrosine kinase (some non-small cell lung cancer in young non-smoker patients)
- BRAF (non-small cell lung cancer for smokers)
S/E: generally well tolerated. Rash, diarrhoea, pneumonitis
key symptoms of lung cancers (7)
- cough
- weight loss
- breathlessness
- fatigue
- chest pain
- haemoptysis
- asymptomatic
clinical signs of advanced/metastatic disease
- neurological features (focal weakness, seizures, spinal cord compression)
- Bone pain
- Paraneoplastic syndromes (caused by production of hormones/cytokines by tumor) (hypercalcaemia, hyponatraemia, cushing’s)
cause of hypercalaemia in lung cancer
tumours releasing parathyroid hormone related peptide
cause of hyponatraemia in lung cancer
inappropriate ADH secretion
(paraneoplastic syndrome)
Often in small cell cancer
cause of cushings in lung cancer
overstimulation of the adrenals (ectopic ACTH)
signs of lung cancer (generally seen in late stages)
- pemberton’s sign- arm elevation causes red face (sign of venous obstruction)
- Horner’s syndrome- miosis and ptosis
- clubbing- changes in areas near nails (e.g. bulging, colour change) (often sign of chronic low o2 sats)
- cachexia- muscle wasting
what causes horner’s syndrome in lung cancer?
lung tumour impinges on the sympathetic chain -> ptosis, pupillary constriction and hydrosis (lots of sweating on the side of the face)
diagnosing lung cancer
- establish most likely diagnosis
- establish fitness for investigation and treatment
- confirm diagnosis (specific type of cancer if considering systemic treatment)
- –> confirm staging
imaging for lung cancer
chest x ray
differentials for shadows on chest x ray
pneumonia
tumour
imaging for confirming lung cancer and metastases and staging.
CT abdo and chest
what is the most useful imaging to exclude occult metastases?
PET scan
only way to be certain of cancer diagnosis?
- biopsy
- also determines histology
when is bronchoscopy chosen?
- for tumour of the central airway
- where tissues staging is not important
type of biopsy used to investigate the mediastinum
endobronchial ultrasounds and transbronchial needle aspiration of mediastinal lymph nodes
- stages mediastinum +/- achieve tissue diagnosis
type of biopsy for tumours peripherally located in lung
CT-guided lung biopsy
- small risk of pneumothorax
staging uses what system
TNM (I->IV)
tumour
nodes
metastases + number
When is surgery used for lung cancer?
Surgical resection is standard of care for early stage disease
What types of surgery are used for lung cancer?
Lobectomy (remove entire lobe) and lymphadenectomy usual approach
Sublobar resection if stage 1 (= 3cm)
Other techniques:
Wedge resection- remove small section of lung with tumor and a little healthy tissue
Segmental resection- remove large part of lung but not entire lobe
Pneumonectomy- remove entire lung
What is radical radiotherapy?
Alternative to surgery for early stage disease
Particularly if comorbidity
Stereotactic ablative radiotherapy (SABR) is used- highly focused/precise radiation using multiple converging beams
What immunotherapy treatments are there to treat lung cancer?
Blocking PD-L1/PD-1 to allow T cell killing of tumour cell
First line for metastatic non-small cell LC with no mutation and PDL1 >/= 50%
Drugs: pembrolizumab, atezolizumab, nivolumab
S/E: Generally well-tolerated, immune related side-effects om 10-15%
What cytotoxic chemotherapy treatments are there to treat lung cancer?
First line for metastatic non-small cell LC with no mutation and PDL1 = 50%
Targets any rapidly dividing cell
S/E: fatigue, nausea, bone marrow suppression, nephrotoxicity, poor QoL
When should palliative care be given?
Standard for all patients with advanced stage disease
Symptom control, psychological support, education, practical and financial support, planning for end of life
Gives an improved QoL and lowers depression risk
What are the stages of lung cancer?
Occult stage: Cancer cells can be picked up in the mucus you cough up. Your tumor can’t be seen on imaging scans or a biopsy. It’s also called hidden cancer.
Stage 0: Your tumor is very small. Cancer cells haven’t spread into your deeper lung tissues or outside your lungs.
Stage I (“stage 1”): Cancer is in your lung tissues but not your lymph nodes.
Stage II (“stage 2”): The disease may have spread to your lymph nodes near your lungs.
Stage III (“stage 3”): It has spread further into your lymph nodes and the middle of your chest. (In stage IIIa its 1 lung, on IIIb its both lungs)
Stage IV (“stage 4”): Cancer has spread widely around your body. It may have spread to your brain, bones, or liver.
