Lung Flashcards
What are the types of lung cancer?
Small cell lung cancer
Non small cell lung cancer: Adenocarcinoma Squamous cell carcinoma Large cell Alveolar cell carcinoma
What is the difference between SCLC and NSCLC?
SCLC usually centrally located, more aggressive, treatment usually chemo
NSCLC 85-90% of cancers, can be fast or slow growing
Staging with TNM
Surgical, medical or radiation
What are the characteristics of adenocarcinomas?
Usually more peripheral
Most common type in non-smokers
Precursor is atypical alveolar hyperplasia
Histology shows cancer of bronchial mucosal tissue
Often early mets
Prognosis worse than squamous cell
What are the characteristics of squamous cell carcinoma?
Usually centrally located
Smoking
Cancer of squamous epithelial cells
Slow growing tumour
What are some of the known risk factors for the development of lung cancer?
Tobacco smoking, second hand smoke Radon, asbestos Occupational exposure Personal or FH of LC Personal history of lung disease e.g. COPD, TB Radiation exposure
From what cells do small cell lung cancers originate?
Kulchitsky cells
How does squamous cell lung cancer commonly present?
Bronchial obstruction leading to recurrent infections
Finger clubbing
What are the characteristics of small cell lung cancer?
Small round blue cells on histologic staining, approx twice the size of lymphocytes
Centrally located lesions
Aggressive tumour spreads
More responsive to chemo but poor prognosis
What are the symptoms of lung cancer?
Frequently asymptomatic
When symptomatic, cough, malaise and WL predominate
Fever, malaise, nausea Cough, haemoptysis Features of SVCO, PNS Hoarseness - involvement of recurrent laryngeal Weight loss
What are the signs of lung cancer?
Lymphadenopathy Stridor Wheeze Clubbing Hypertrophic pulmonary osteoarthropathy Signs of pleural effusion
What is hypertrophic pulmonary osteoarthropathy?
Fibrovascular proliferation
Results in periostitis (inflammation of periosteum) of the long bones, arthralgia, clubbing.
Lung cancer - paraneoplastic syndrome or in ovarian or adrenal malignancies
CT scan for diagnosis, NSAIDs for the pain
What are the signs of pleural effusion?
Dull - stony dull percussion
Reduced vocal remits
Reduced breath sounds
What is a Pancoast tumour?
Tumour of the pulmonary apex
Local spread may affect brachial plexus, cervical sympathetic trunk, stellate ganglion, subclavian vein
Can cause Horner’s - sympathetic ganglion
Pain in shoulder, radiates into arm and hand - brachial plexus
Atrophy of muscles of upper limb
Oedema of upper limb
Hoarse voice = recurrent laryngeal
What can be seen on CXR with Squamous cell lung cancer?
Cavitations so a CT is needed to rule out TB
What paraneoplastic syndromes are associated with squamous cell lung cancer?
PTHrP = hypercalcaemia
Ectopic TSH = hyperthyroid
Hypertrophic osteoarthropathy
Which type of lung cancer is most common in non-smokers?
Adenocarcinomas
Why do adenocarcinomas tend to present with fewer symptoms?
They are more likely to be located in the peripheries
What are signs/symptoms of Superior Vena Cava Obstruction?
Early morning headache
Arm and Face Oedema
Jugular distention
Describe the clinical features of lung cancer caused by mets
- Fatigue
- Weight loss
- Night sweats
- Lymph node enlargement (supraclavicular)
- Liver mets- anorexia, mass, jaundice, abdo pain, ascites
- Adrenals- addisons (bronze pigment, hypoglycaemia, postural hypotension, weight loss, GI disturbance, weakness, crises)
- Bone- pathological fractures, bone pain
- Pleura- effusions
- CNS- cord compression, focal neurological signs
Describe the clinical features of lung cancer caused by the primary tumour
- Cough (lasting >3 weeks)
- SOB
- Haemoptysis
- Wheeze
- SVC obstruction (SOB, distended neck veins and JVP, headache/ fullness, blurred vision, odema arms/ face, confusion, syncope)
- Persistent/ recurrent infections
Describe the possible clinical features of lung cancer caused by paraneoplastic syndromes
- Horners syndrome (partial ptosis, unilateral anhidrosis, miosis)
- Clubbing
- Hypercalcaemia
- Anaemia
- SIADH
- Cushings
- Lambert eaton myasthenic syndrome (muscle weakness, fatigue, pain, reduced reflexes, walking difficulty, speech impairment and swallowing problems)
- VTE
- Thrombocytosis
What occurs in hypercalcaemia due to paraneoplastic syndromes?
Due to bony mets
Or tumour secretion of
parathyroid hormone related protein - PTHrP
Calcitriol
When is SIADH seen in lung cancer?
SCLC
Hyponatraemia
In extreme cases cerebral oedema
What is Lambert Eaton syndrome?
Caused by antibodies to voltage gated calcium channels, seen in 1% of SCLC
Proximal and ocular muscle weakness
What is hypertrophic osteoarthropathy?
Thought to be due to fibrovascular proliferation due to accumulation of megakaryocytes
Clubbing
Periostitis of small hand joints and metacarpophalangeal joints
Distal expansion of long bones and painful swollen joints
What is the criteria for a two week wait referral?
Suggestive CXR findings
Unexplained haemoptysis and aged over 40
Those with SVCO or stridor require urgent referral and emergency admission
When should an urgent CXR within 2 weeks be considered in those over 40?
Persistent or recurrent chest infection Clubbing Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy Chest signs indicative of lung cancer Thrombocytosis
Have two of these, or one and ever smoked:
cough, fatigue, SOB
Chest pain, weight loss
Appetite loss
What are the investigations for lung cancer?
Bloods Imaging Bronchoscopy Lung function tests Histology and cytology
What does squamous cell carcinoma commonly secrete?
PTHrp causing hypercalcaemia
What does small cell carcinoma commonly secrete?
ACTH - Cushing’s
ADH - SIADH
What are some differentials for lung cancer and features differentiating it from cancer?
TB - night sweats, sputum culture, cavitating lesion
Mets to lungs from other sites - symptoms related to primary tumour
Sarcoidosis - enlarged parotids, erythema nodosum, granulomas
Wegener’s - cANCA, saddle nose deformity, urinalysis
Non-Hodgkin’s - night sweats, hepatosplenomegaly
What are appropriate bedside investigations?
Pulse oximetry - aim for 94-98%
ECG performed pre-operatively
What are appropriate lab investigations?
FBC - anaemia
LFTs - raised ALP, GGT hepatic mets, raised ALP bone mets
U&Es
Serum calcium, bone profile
What is appropriate imaging investigations?
CXR - opacities, pleural effusion or lung collapse
CT chest-abdomen-pelvis
Bronchoscopy and biopsy - confirms subtype, presence of targetable mutations
PET-CT for staging
CT/MRI brain can be ordered to exclude cerebral mets
How can tissue biopsies be obtained?
Bronchoscopy
Image guided biopsy
Video assisted thoracoscopic surgery
Mediastinoscopy