Lung Flashcards
What kind of lung cancer is most common?
Most lung cancers are from secondary mets, the mets can come from…
1) breast
2) colon
3) renal cell carcinoma
What are the types of primary lung cancer?
Non small cell lung cancer (60-80%)
Small cell lung cancer (15-20%)
What are the types of non small cell lung cancer?
Adenocarcinoma
Squamous
Large cell
Bronchial carcinoid
If someone who is a non smoker and has lung cancer, what type of lung cancer do they likely have?
Non small cell- adenocarcinoma
Lung cancer can metastasise quickly, where does ling cancer often metastasise to?
Mediastinum Hilar lymph nodes Breast Liver Adrenal glands Brain bone
What are the risk factors for lung cancer?
Family history Increasing age Being male Pre existing lung disease History of cancer Occupational exposure- radon gas, asbestos HIV Smoking
What are the associations with adenocarcinoma non small cell lung cancer?
Hypertrophic osteoarthropathy
Hyperthyroid
Gynaecomastia
What is the association with squamous cell carcinoma non small cell lung cancer?
It is associated with PTH related peptide
The release of PTH causes high levels of Ca2+ in the serum
Therefore patients with squamous cell carcinoma can present with signs of hypercalcaemia!
What are the signs of hypercalcaemia?
Kidney stones
Abdo pain
Confusion
Constipation
How might someone with squamous cell carcinoma present?
Signs of hypercalcaemia or hyperthyroidism (due to ectopic production of TSH)
Small cell lung cancer is a neuroendocrine tumour, what can they secrete?
ADH to cause SIADH
ACTH to cause cushings
Antibodies to voltage gated Ca2+ channels which cause lambert eaton syndrome and weakness
These lung cancers develop fast, metastasise quickly and grow centrally
Where do small cell lung cancers often metastasise to?
Brain/bone
What symptoms do people with lung cancer present with?
Haemoptysis Dyspnoea Hoarseness Anorexia Persistent cough Pleuritic pain Recurrent chest infections
Why is it people with lung cancer get recurrent chest infections?
Obstruction of the bronchus due to a centrally located tumour
What are the reasons that people with lung cancer get hoarseness/ voice changes?
This occurs if the tumour is located at the apex of the lung
Pancoast tumour- impinges on the recurrent laryngeal nerve which also gives signs of horners syndrome- miosis and ptosis
What would patients with brain mets secondary to lung cancer present with?
Headache
N and V
Visual disturbance
What are the signs of lung cancer?
Distended veins on neck and face
Swollen face and right arm
^SVCO obstruction
Neuro signs
Pallor
Supraclavicular lymphadenopathy
Cachexia
Plethoric complexion
Neuro signs
Clubbing
Dullness/ wheeze on auscultation
Pleural effusion- dullness to percussion
Pneumothorax- tracheal deviation, absent breath sounds
Pneumonia- consolidation,
Specifically what lung cancer is associated with clubbing?
Non small cell lung cancer
When should a patient with suspected lung cancer have a 2 week wait referall?
1) anyone with suspicious CXr findings
Or
2) >40 with haemoptysis
When should you get an urgent CXR for a patient?
If they are more than or equal to 40 and have 2 of the following features (or 1 if they are a smoker)... . SOB . Fatigue . Persistent cough . Chest pain . Anorexia . Weight loss
Or if they are equal or more than 40 years old and have…
. persistent/ recurrent chest infections
. Finger clubbing
. Persistent supraclavicular/ cervical lymphadenopathy
. Chest signs consistent with lung cancer
. Thrombocytosis
What bloods should you request before referral for x ray?
FBC U and Es LFTs Bone profile CRP
Lung function tests should also be done before treatment
What would you see on a CXR of a patient with lung cancer?
Lung collapse
Mediastinal widening
mass
Hilar lymphadenopathy
What are the differentials for hilar lympgadenopathy?
TB Non hodgkins lymphoma Sarcoidosis Malignancy- more common in Hodgkin lymphoma than non Hodgkin Infection Heart failure
If malignancy is confirmed on CXR, what investigations are done next?
CT CAP for staging
Staging for non SCC is using the TNM staging while for SCC they are either classified as limited or extensive disease
PET- CT is done to look for mets and to show whether the patient is eligible for treatment
Histologically, how do you confirm the diagnosis of lung cancer?
If it is a peripheral tumour then trans thoracic needle biopsy can be used
If it is a central tumour then endotrachial ultrasound can be used
When is a mediastinoscopy done in a patient with lung cancer?
This is done when the patient is suitable for surgery, a mediastinoscopy shows whether there is mediastinal lymph node involvement.
What is the management of lung cancer?
The management is guided by the cancer cell type, the stage, co-morbidities and patient status.
Stop smoking!!
Surgical options are used for non small cell- lobectomy, pneumonectomy, wedge resection (segment)
Prophylactic cranioradiotherapy can sometimes be offered to prevent brain mets
What is the mainstay of treatment for small cell carcinoma?
Palliative chemo
What percentage of lung cancer cases in the UK are preventable?
79%
72% are caused by smoking
5% caused by ionising radiation
13% work exposure
8% air pollution
How do small cell lung cancers present?
Arise from endocrine cells
As a result they secrete many poly peptides- ACTU
Can also cause presentations like Addisons and cushing’s
Small cell carcinoma spreads very early and is almost inoperable at presentation
What is the presentation of small cell lung cancer?
Cough Haemopytsis Dyspnoea Chest pain Weight loss Nausea and vomiting Anorexia
What investigations are done for lung cancer?
In order... CXR CT CAP Biopsy PET MRI head Spirometry Echo
What is limited stage small cell lung cancer?
When the tumour and nodes can be fit in a box that can be given radiotherapy.
What is the SCLC treatment?
If the tumour is less than 5cm= sugery
If it is limited stage suitable for radiotherapy then give chemoradiotherapy and consider prophylactic cranial radiotherapy
If extensive then give chemo followed by radiotherapy and also consider prophylactic cranial radiotherapy
If it relapses then either palliative or secondary chemo
How does immunotherapy work?
Trys to turn the immune system on to recognise the tumour cell as a foreign body
What supportive care is given to patients with lung cancer?
Breathlessness- stent/radiotherapy
Home O2
LOROS breathlessness service
Medication- oramoprh, steroids
Pain- analgesia, nerve blocks, radiotherapy
Social-
OT/PT/ dietician
Psychosocial support- macmillan, support groups, psychONC, smoking cessation, financial support services.
What is the lung cancer associated with hypercalcaemia?
Squamous cell carcinoma (non small cell)
How do you manage SCLC if it is extensive disease?
Platinum based combination chemo
What do you offer people with limited stage disease SCLC (T1-4, N0, M0)?
Cisplatin based combination chemo
Offer twice daily radiotherapy with concurrent chemoradiotherapy to people with limited stage disease SCLC and a who performanc pf 0 or 1
What is the management of NSCLC?
First-line: lobectomy
Curative radiotherapy can also be offered to patients with stage I, II and III NSCLC.
Chemotherapy should be offered to patients with stage III and IV NSCLC to control the disease and improve quality of life.
Does squamous cell carcinoma secrete parathyroid hormone?
No it secretes parathyroid hormone related peptide not PTH.
What is the difference between the location of non small cell and small cell lung cancers?
Squamous cell (non small cell)= usually in lobes
Small cell= usually in bronchus
What paraneoplastic syndromes is small cell lung cancer associated with?
SIADH (euvolaemic hyponatraemia)
Cushings
What are the symptoms of a patient with SIADH?
N andV
Acutely confused
What is dermatomyositis?
New onset bilateral proximal muscle weakness which can often present before malignancy, lung cancer is one of the malignancies which is most highly associated with dermatomyositis.
What are the options on how you can obtain a sample in terms of lung cancer?
Endobronchial US transbronchial needle aspiration
Bronchoscopy
Contrast enhanced CT scan
Sputum cytology
When is endobronchial ultrasound transbronchial needle aspiration done?
Most commonly, Endobronchial ultrasound-guided transbronchial needle aspiration is done to take samples from the central lymph glands in the centre of your chest (mediastinum) which may be enlarged for a variety of reasons. In 9 out of 10 cases, we would expect this test to give a helpful answer to the problem. Very occasionally, another test may be needed.
