Lung cancer

Question 1

Types of lung cancer?

Answer 1

1. SCLC (15%) - smoking, early mets, more responsive to treatment
2. NSCLC (85%) -
   
   • squamous
   • Adenocarcinoma = most common, best prognosis
   • Large cell
   • alveolar cell carcinoma
3. Mesothelioma - pleural tumour, asbestos, no Tx
4. Mets in lungs

Question 2

History PC

Answer 2

Cough, haemoptysis, dyspnoea, chest pain, anorexia and weight loss

regional spread = dysphagia, hoarness - RLN
met = fatigue, low appetite, weight loss, paraneoplastic endocrone sx -(high Ca, cushings, SIADH)

Question 3

diagnosis and relevant PMHx and SHx

Answer 3

Investigations: CXR, CT, bronchoscopy, sputum cytology needle biopsy, thoracotomy

PMHx - slow resolving Pnx, Pleural effusion, lung abscess, conditions that cause scarring (TB, scleroderma, ILD)

SHx - exposure (smoke, asbestos, radiation, toxic gasses)

Question 4

Examination findings

Answer 4

General

• chachexia, fever, gynaecomastia, hoars voice
• cushingoid features (SCLC)

Peripheries/face

• clubbing (NSCLC)
• Hypertrophic pulmonary osteoarthropathy (HPOA) causing wrist pain
• Superclavicular/axillary nodes
• horners syndrome, SVC compression

Chest
inspection = dilated veins
palpation = boney pain
A/P = consolidation, collapse, P.Effusion

Neuro
confusion (cortical degeneration), peripheral/autonomic neuropathy

Skin
DIC, migrating thrombophlebitis, acanthosis nigricans, purpura, scleroderma

signs of mets
= bone tenderness, hepatomegaly, focal neurology or confusion, cerebellar syndrome(ataxia, overshooting)

Question 5

Complications of LC

Answer 5

local

• recurrent laryngeal nerve palsy
• phrenic nerve palsy
• SVC obstruction
• Horner’s syndrome
• Rib erosion
• pericarditis
• AF

Metastatic
- Brain, bone (>anaemia, inc Ca), Liver, Adrenals (>addison’s)

Endocrine
Ectopic hormone secretion
SCLC = SIADH and ACTH = low Na, high ADH, cushingoid
SSC = PTH = high Ca

Neuro
Eaton-lambert sundrome = proximal weakness + decreased reflexes
Confusion, fits, cerebellar syndrome

Other
Clubbing, HPOA, Dermatomyositis, Acanthosis nigricans, Thrombophelbitis migranes

Question 6

Ix for diagnosis

Answer 6

Cytology

• sputum if centeral
• pleural fluid if effusion

CXR
Adenocarcinoma = peripheral node
SCLC = hilar enlargement
Consolidation, collapse, pleural effusion, bony secondaries

Bronchoscopy
biopsy/FNA
Assess operability

Question 7

Ix for staging and Ix for treatment

Answer 7

STAGING
bloods - FBC, Ca, LFTs, ACTH, ADH, Na
imaging - CT, PET, +/- bone scan

TX
Lung function tests
FEV1 > 1.5L could tolerate pneumonectomy
Can climb 3 flights is positive predictor

Question 8

Management NSCLC and prognosis

Answer 8

excision if localised and no mets (1/3 of cases)
Curative radiotherapy
Chemo + radiotherapy if more advanced

50% at 2 years if no spread
10% at 2 years if spread

Question 9

Management SCLC and prognosis

Answer 9

Immunotherapy
Chemotherapy with platinum based drugs
cranial irratiation
…paliation

median survival 3/12 without treatment
8-13/12 with < 5% at 2 years with treatment