Lung Cancer Flashcards
What are the 2 categories of lung cancer?
non-small cell carcinoma (85%) and small cell carcinoma (15%)
How can Non-small cell lung carcinomas be further classified?
Adenocarcinoma
Squamous cell carcinoma
Large cell carcinoma
Describe the clinical features of adenocarcinomas of the lung.
More common in non-smokers and Asian females
Metastasise early
Responds well to immunotherapy
Describe the clinical features of squamous cell carcinomas of the lung.
More common in smokers
Secrete PTHrP, causing hypercalcaemia
Metastasise late (via lymph nodes)
Describe the clinical features of large cell carcinomas of the lung.
More common in smokers
Metastasise early
Describe the clinical features of SCC of the lung.
More common in older smokers
Metastasise early
Secrete ACTH (Cushing’s syndrome) and ADH (SIADH)
Associated with Lambert-Eaton syndrome
Describe the pathology of adenocarcinomas of the lung.
Located peripherally (in the smaller airways)
Describe the pathology of squamous cell carcinomas of the lung.
Located centrally (in the bronchi)
Describe the pathology of large cell carcinomas of the lung.
Located peripherally and centrally
Describe the pathology of SSC of the lung.
Located centrally
Describe the histology of adenocarcinomas of the lung.
Histology: glandular differentiation
Describe the histology of squamous cell carcinomas of the lung.
Histology: squamous differentiation (keratinisation)
Describe the histology of large cell carcinomas of the lung.
Histology: large and poorly-differentiated
Describe the histology of SSC of the lung.
Histology: poorly-differentiated
Name some risk factors of developing lung cancer.
The main risk factor is tobacco smoking, which is associated with 80% of lung cancer cases.
Other important risk factors include:
Air pollution (indoor and outdoor)
Family history of cancer, especially lung cancer
Male sex
Radon gas (typically affects miners)
Name some typical symptoms of lung cancer.
Typical symptoms of lung cancer include:
Unexplained cough for at least 3 weeks (with or without haemoptysis)
Unintended weight loss (>5% in 6 months)
New-onset dyspnoea
Pleuritic chest pain (due to the tumour invading the pleura or the chest wall)8
Bone pain (due to metastases – commonly the spine, pelvis and long bones)9
Fatigue (due to anaemia of chronic disease)
Name some typical clinical findings of lung cancer.
Cachexia: cancer can cause increased resting energy expenditure and lipolysis.12
Finger clubbing (Figure 1): the exact mechanism is unknown, but it may be due to increased secretion of growth factors, leading to the growth of the extracellular matrix in the nails.13
Dullness to percussion: due to the tumour (solids are less resonant than gases).
Cervical lymphadenopathy (Figure 2): due to metastasis to the lymphatic system.
Wheeze on auscultation: due to the tumour obstructing an airway.
What are the NICE criteria for a 2WW referral for lung cancer?
Chest X-ray findings suggestive of lung cancer, or
Over 40 years old and unexplained haemoptysis
Describe the criteria for sending patients for an urgent X-ray before a decision to refer via a 2WW.
Other patients may just need an urgent chest x-ray (within 2 weeks) before a decision to refer on a 2-week wait is made. These patients must be over 40 years old, and have two of the following unexplained symptoms (one if they have ever smoked):
Cough Weight loss Appetite loss Dyspnoea Chest pain Fatigue
What is stage one of the TNM staging for lung caner?
One small tumour (<4cm) – localised to one lung
What is stage two of the TNM staging for lung caner?
Larger tumour (>4cm) – may have spread to nearby lymph nodes
What is stage three of the TNM staging for lung caner?
Tumour that has spread to contralateral lymph nodes, or grown into nearby structures (e.g. trachea)
What is stage four of the TNM staging for lung caner?
Tumour that has spread to lymph nodes outside the chest, or other organs (e.g. liver)
What is the appropriate management of stage 1-3 of NSC lung cancer?
Surgery: options include lobectomy/pneumonectomy in patients with intact lung function, or wedge resection in patients with reduced lung function (e.g. elderly, underlying respiratory conditions).
Pre-operative chemotherapy
Post-operative chemotherapy and radiotherapy: may not be needed in some cases of stage I lung cancer
What is the appropriate management of stage 4 of NSC lung cancer?
Targeted therapy: these drugs target mutations which drive the pathogenesis of lung cancer (Table 3). Medical students should be aware that these targeted therapies exist and are used for stage IV lung cancer, but do not need to know much more detail than this.
Immunotherapy: these drugs target immune checkpoints, which prevent the patient’s immune cells from killing tumour cells. For example, the immune checkpoint PD-L1 is targeted by pembrolizumab. Immunotherapy is an emerging field in cancer management.
Chemotherapy: especially important for patients who do not have any mutations which can be targeted by targeted therapies.
Palliative care: includes palliative radiotherapy, for metastases and symptom control.
Name a drug used in the management of NSC lung cancer with the EGFR mutation.
Gefitinib
Osimertinib
Name a drug used in the management of NSC lung cancer with the ALK mutation.
Alectinib
Name a drug used in the management of NSC lung cancer with the ROS1 mutation.
Crizotinib
Name the management of small cell lung cancer.
Chemotherapy and radiotherapy
Surgery: rare in small cell lung cancer, as most patients present with advanced disease.
Prophylactic cranial irradiation: since small cell lung cancer is associated with a high risk of brain metastases, radiotherapy is directed at the brain to prevent brain metastases.
Describe Horner’s syndrome.
Due to a Pancoast tumour in the lung apex infiltrating the brachial plexus. Features include ptosis, miosis, anhidrosis (reduced sweating) and enophthalmos (posterior displacement of the eyeball into the orbit).
Describe superior vena cava obstruction.
tumour compresses the superior vena cava, preventing venous drainage from the head and neck, leading to facial swelling and distended neck/chest veins.
Name 2 types of paraneoplastic syndromes.
SIADH and Lambert-Eaton syndrome.
Name 3 treatment- related complications of chemotherapy.
alopecia, neutropaenia, bone marrow toxicity
Name 3 treatment- related complications of radiotherapy.
mucositis, pneumonitis, oesophagitis
