Lung Cancer Flashcards
Lung cancer is the ____ most common cancer in the UK
It affects _____ (gender) more than _____ (gender) in the UK
Lung cancer is the ______ most common cause of cancer-related death in the world (in 2020)
Lung cancer usually presents affects those aged ____
- 3rd most common in UK
- Affects slightly more men than women (52% male, 48% female); incidence in men has increased and incidence in women has decreased (due to changes in smoking habits in recent decades)
- Lung cancer is the MOST common cause of cancer-related death in the world (WHO 2020)
- 60-80yrs
State some risk factors for lung cancer- highlighting the most common
- Smoking- including passive smoking (due to the hydrocarbon carcinogens which cause metaplasia of bronchial epithelium from columnar to squamous. 80-90% lung cancers attributable to smoking)
- Air pollution- particularly from diesel engines
- Asbestos exposure
- Previous radiotherapy to chest
- Radon gas exposure
- Nickel exposure (used in alloys, stainless steel manufacture, pigments for paints etc)
- Arsenic exposure (used in industrial production as alloying agent and for production of other materials e.g. glass. Also present in ground water in some countries)
- Silica exposure
- Previous TB
- Family history
- Underlying lung disease e.g. COPD, interstitial lung disease
- Use of Beta-carotene in those who smoke or have been exposed to asbestos
State the different types of lung cancer; for each state what % of lung cancers they make up
- Small cell lung cancer (SCLC) = 15-20%
- Non-small cell lung cancer (NSCLC) = 80%
- Adenocarcinoma = 40%
- Squamous cell carcinoma = 35%
- Large cell carcinoma = 10%
- Other types = 10% (e.g. carcinoid)
What % of pts with lung cancer experience paraneoplastic syndromes?
10%
For small cell lung carcinoma, discuss:
- Central or peripheral
- What cells they arise from
- Differentiation
- Whether it metastasises late or early
- Whether cavitation is common
- What neoplastic syndromes are seen
- Central
- APUD cells
- Poorly differentiated
- Metastasises early (usually metastatic at time of diagnosis)
- Cavitation rare
- Paraneoplastic syndromes:
- Ectopic ADH secretion → hyponatraemia
- Ectopic ACTH secretion → cushing’s syndrome, bilateral adrenal hyperplasia, hypokalaemic alkalosis (due to high cortisol)
- Lambert-Eaton syndrome
For adenocarcinoma, discuss:
- Central or peripheral
- Differentiation
- Whether it metastasises late or early
- Who common in
- What extrapulmonary manifestations common
- What therapy it responds well to
- Peripheral
- Glandular differentiation
- Metastasise early
- Most common type seen in non-smokers (although most of people with it are smokers)
- Thrombophlebitis, gynaecomastia
- Responds well to immunotherapy
For squamous cell carcinoma discuss:
- Central or peripheral
- Differentiation
- Whether it metastasises late or early
- Whether cavitation is common
- What neoplastic syndromes & extrapulmonary manifestations are seen
- Central
- Squamous differentiation
- Metastasise late
- Most likely to have cavitation
- Neoplastic:
- PTHrP secretion → hypercalcemia
- Ectopic TSH → hyperthyroidism
- Extra-pulmonary:
- Hypertrophic pulmonary osteoarthropathy (triad of periostitis, digital clubbing and painful arthropathy of the large joints. Can also occur in other types e.g. adenocarcinoma)
For large cell carcinoma discuss:
- Central or peripheral
- Differentiation
- Whether it metastasises late or early
- Whether cavitation is common
- What neoplastic syndromes & extrapulmonary manifestations are seen
- Peripheral
- Large, anaplastic, poorly differentiated
- Metastasises early
- May secrete B-HCG
- Extra-pulmonary manifestations:
- SVC syndromes
- Hoarseness
Summary table for types of lung cancer
Passmed says both squamous and adenocarcinoma can have hypertrophic pulmonary osteoarthropathy
State some common sites for metastases in lung cancer
- Liver
- Skeleton
- Brain (especially SCLC)
- Adrenal glands (may present with Addison’s)
- Lymph nodes
- Skin
- Other areas of lungs (including contralateral lung)
- Pleura
State some symptoms of lung cancer
Some will be asymptomatic and have been diagnosed as CXR for screening or as part of an investigation of another disease. Up to 20% can present with non-respiratory symptoms.
- Persistent cough >3 weeks
- Haemoptysis
- Dyspnoea
- Chest pain
- Recurrent infections
- Hoarseness of voice (compression of recurrent laryngeal nerve)
- Neck/arm pain (invasion of T1 nerve root)
- Bone pain
- Weight loss
State some signs of lung cancer
- Finger clubbing
- Nicotine staining
- Lymphadenopathy (often supraclavicular)
- Dullness to percussion over tumour
- Wheeze
- SVC obstruction/swelling of face/neck/arms
- Horner’s syndrome (**partial ptosis, anhidrosis and miosis)
- Cachexia
State some differential diagnoses for lung cancer and how you would differentiate these from lung cancer
Discuss the 2WW referral for lung cancer
-
Refer for 2WW appointment if:
- CXR findings suggestive of lung cancer
- >/=40yrs with unexplained haemoptysis
-
Refer for urgent CXR (within 2 weeks) if >/=40yrs and have 2 or more of the following or if they have ever smoked and have 1 or more of the following:
- Cough.
- Fatigue.
- Shortness of breath.
- Chest pain.
- Weight loss.
- Appetite loss
-
Consider urgent CXR (within 2 weeks) to assess for lung cancer in people >/=40yrs with any of the following:
- Persistent or recurrent chest infection.
- Finger clubbing.
- Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy.
- Chest signs consistent with lung cancer.
- Thrombocytosis.
What are the government/department of health targets relation to the lung cancer screening/diagnostic pathways
What might you see on a CXR of a pt with lung cancer?
- Discrete opacity (may be cavitating)
- Hilar lymphadenopathy
- Pulmonary collapse
- Pleural effusion
What staging is used for lung cancer?
*Be sure to be specific about how this staging is interpreted in terms of lung cancer
TNM
In SCLC, a two category staging system is also used alongside TNM staging; describe this two category staging system
- Limited (30% pts): confined to ipsilateral hemithorax and fits in/can be treated in one radiation field (may include ipsilateral supraclavicular nodes)
- Extensive (70%): disease other than limited
Discuss the management of SCLC
SCLC is usually metastatic disease at time of diagnosis. Management depends on extent of disease. All pts should be advised to stop smoking. Chemotherapy is the mainstay of treatment.
- Very early stage disease (T1-2a, N0, M0): considered for surgery and then adjuvant chemotherapy- RARE AS OFTEN PRESENT METASTASES
- Limited disease: combination of chemotherapy (with platinum based chemotherapy agents) and radiotherapy to the chest. Prophylactic cranial irradiation to prevent brain metastases if show good response to initial treatment.
- More extensive disease: chemotherapy + immunotherapy (Immunotherapy offered to those with extensive disease and performance status 0-1). Prophylactic cranial irradiation to prevent brain metastases if show good response to initial treatment. (May give radiotherapy if show complete extra thoracic and partial intrathoracic response to chemo or may use to palliate symptoms)
*Immunotherapy treatments targeting PDL-1 (check Dr Chauhan’s slide when available)
*SCLC very chemo sensitive however there is a high relapse rate. Immunotherapy can help extend overall survival by ~2months
Discuss the treatment of NSCLC
Management depends on extent of disease. NSCL has poorer response to chemotherapy than SCLC. All should be advised to stop smoking. Options include:
- Early stage (I-IIIa):
- Surgical resection (wedge resection, lobectomy, pneumonectomy)
- May have neoadjuvant or adjuvant chemotherapy if higher stage (platinum based- may be adjuvant or neoadjuvant dependent on tumour)
- If not suitable for surgery, either radiotherapy alone or combination chemoradiotherapy with curative intent
- Later stage (IIIb-IV):
- Concurrent chemoRT
- Chemo followed by RT
- Radical RT alone
- Palliative chemo
- Palliative RT
- Targeted therapy (targets mutations that drive cancer)
- Immunotherapy: targets immune checkpoints
- **Will often tell pts we can offer then SACT (systemic anticancer treatment) which includes chemotherapy, targeted therapy & immunotherapy*
- **Examples of targeted therapies:*
- EGFR → gefitinib
- ALK → alectinib
- ROS1 → crizotinib
- **Examples of immunotherapy:*
- PDL-1 inhibitors → pembrolizumab, Nivolumab
Discuss the pathophysiology of pleural mesothelioma
- Arises from mesothelial cells of pleura (mesotheliomas can arise from mesothelial cells in other parts of body e.g. peritoneum, pericardium etc…)
- Slightly more common on R side (probably because there is a greater SA of pleura on the R)
- Tumour nodules are present, on both parietal and visceral pleura, and then coalesce to form plaques
- These plaques encase the lungs and infiltrate into fissures & interlobular septa
- Eventually pleural space is obliterated
- May be associated pleural effusion which is blood-stained & rich in protein
