Lung Cancer Flashcards
Another name for lung cancer
Pulmonary neoplasia
Causes of lung cancer
Tobacco
Asbestos
Environmental radon
Other occupational exposure
- chromates
- hydrocarbons
- nickel
Air pollution and urban environment
Other radiation
Pulmonary fibrosis
What % of lung cancer is attributable to smoking?
> 85%
What % of smokers get lung cancer?
10%
What is a pack year?
Packs per day per year
Two main pathways of carcinogenesis in the lungs
Lung periphery
- bronchioalveolar epithelium stem cell transformation
- adenocarcinoma
Central lung airways
- bronchial epithelial stem cells transform
- SCC
Which process is strongly associated with smoking in the lungs?
Squamous dysplasia -> CIS -> invasive bronchogenic carcinoma
What is peripheral lung adenocarcinogensis and what is it associated with?
Atypical adenomatous hyperplasia AAH to adenoma in situ to invasive adenocarcinoma
Assosiated less strongly with smoking however does occur in non smokers
Adenocarcinogensis and molecular biology
KRAS ; 35% - smoking induced
EGFR ; 15% - not related to tobacco carcinogenesis
BRAF, HER2 ; 2% - not related to smoking
ALK rearrangements ; 2% - not related to smoking carcinogenesis
What % of lung neoplasms are a carcinoid tumour?
< 5%
What is a carcinoid tumour?
Low grade malignancy
What are the tumours of the bronchial glands and are they common?
Adenoid cystic carcinoma
Mucoepidermoid carcinoma
Benign adenomas
Tumours of the lung
Benign causes of a mass lesion
Tumours of the bronchial glands
Carcinoid tumour
Lymphoma
Sarcoma
Mets to lungs
Carcinoma
4 main types of lung carcinoma
Squamous cell 40%
Adenocarcinoma 41%
Small cell 15%
Large cell 4%
Histological types of lung carcinoma
15% - small cell carcinoma (SCLC)
85% - non small cell carcinomas (NSCLC)
What are the NSCLCs?
Adenocarcinoma
SCC
Large cell carcinomas
When does a primary lung cancer present?
Late - few or no symptoms or signs until the disease is very advanced
Local effects of lung cancer
Bronchial obstruction
- collapse
- endogenous liquid pneumonia
- infection/abscess
- bronchiectasis
Pleural
- inflammatory
- malignant
Direct invasion
- chest wall
- nerves
Mediastinum (SVC, pericardium)
Lymph node mets
What nerves can be effected by direct invasion of lung cancer?
Phrenic
L recurrent pharyngeal
Brachial plexus
Cervical sympathetic
What would damage to the phrenic nerve cause?
Diaphragmatic paralysis
What would damage to the L recurrent laryngeal nerve cause?
Hoarse, bovine cough
What would damage to the brachial plexus cause?
Pancoast T1 damage
What would damage to the cervical sympathetic chain cause?
Horners syndrome
Distant effects of lung cancer
Distant mets
Secondary to local effects
- neural
- vascular
Non met effects
Where does lung cancer metastasise to?
Liver
Adrenals
Bone
Brain
Skin
What are the non metastatic paraneoplastic effects of lung cancer?
Clubbing
HPOA
ACTH, siADH, PTH
Carcinoid syndrome
Gynaecomastia
Polyneuropathy
Encephalopathy
Cerebellar degeneration
Myasthenia
Acanthosis nigricans
Dermatomyositis
Granulocytosis
Eosinophilia
DIC
Thrombophlbeitis migrans
Nephrotic syndrome
Investigations for lung cancer
CXR
FBC
RFTs, LFTs, calcium
Clotting screen
Spirometry
Bronchoscopy
- bronchial bronchoscopy
- bronchial brushings and washings
- endobronchial US guided aspiration (EBUS)
Image guided lung biopsy
Trans thoracic FNA
Trans thoracic core biopsy
CT
MRI
PET
Prognostic factors in lung cancer
Stage of disease
Classification
Markers/oncogenes/gene expression profiles
Growth rate
Cell proliferation
DNA aneuploidy (abnormal number of chromosomes)
Immune cell infiltration
What may prognostic markers be used to select?
Patients for adjuvant therapy
Prognosis in lung cancer
< 7% 5 year survival
What stages of lung cancer are generally operable?
I and II
5 year prognosis of Stage I lung cancer
> 60%
5 year prognosis of Stage II lung cancer
35%
Genes involved in adenocarcinomas
EGFR
KRAS
HER2
BRAF
ALK translocations
Genes involved in SCCs
FGFR1 gene copy number
DDR2
FGFR2
3 top killers in the world
Cancer
Heart disease
COPD
Presentation of lung cancer
Chronic cough
Haemoptysis
Wheeze
Chest and bone pain
Chest infections
Difficulty swallowing
Rapsy, hoarse voice
SOB
Unexplained weight loss
Nail clubbing
What is nail clubbing?
Increased curvature of fingernails
Presentation of advanced lung cancer disease
Mets
- Bone pain
- spinal cord compression
- cerebral mets
- thrombosis
Paraneoplastic
- hyponatraemia
- anaemia
- hypercalcaemia
- dermatomyositis / polymyositis
Eaton-Lambert syndrome
Cerebellar ataxia
Sensorimotor neuropathy
Presentation of spinal cord compression
Limb weakness
Paraesthesia
Bladder/bowel dysfunction
Presentation of cerebral mets
Headache
Vomiting
Dizziness
Ataxia
Focal weakness
What is thrombosis?
Blood clot
What does dermatomyositis cause?
Proximal muscle weakness
What does eaton lambert syndrome cause?
Upper limb weakness
Signs of lung cancer
Chest signs
Clubbing
Lymphadenopathy
Horners syndrome
Pancoast tumour
SVC obstruction
Hepatomegaly
Skin nodules (mets)
What Is a Pancoast tumour?
Tumour of pulmonary apex
What has to be damaged to cause horners syndrome?
Sympathetic trunk
What type of lung cancer are smokers more likely to have?
SCCs
What type of lung cancer are non smokers more likely to have?
Adenocarcinoma
What is T staging based on?
Size and proximity to chest and vessels
What is N staging based on?
Nodal involvement
What is M staging based on?
Metastases
How many stages are there of TNM?
4
Stage 1 lung cancer
Localised to lung
No other organ involvement
90% will be alive end of year 1
Stage 2 lung cancer
85% will be alive at end of year 1
Stage 4 lung cancer
24% will be alive at end of year 1
How does a PET scan show neoplasm?
Cancer cells are hungry for food as they multiply very fast
Radionucleotide contrast taken up by the cancer cells which light up
Performance status scale
0 = fully active
1 - symptoms but ambulatory (walking). Likely to respond to treatment
2 = “up and about” > 50%, unable to work. Likely to respond to treatment
3 = Up and about < 50%, limited self care, unlikely to respond to treatment
4 = bed or chair bound, unlikely to respond to Tx
Treatment for lung cancer
Surgery (18% of patients)
- wedge resection
- lobectomy
- pneumonectomy
Radiotherapy
Chemotherapy
What is a pneumonectomy?
Surgical removal or lung / part of lung
Palliative management of lung cancer
Symptom control
- chemo
- radio
- opiates
- bisphosphonates
- benzodiazepines
Tx of
- hypercalcaemia
- dehydration
- hyponatraemia
What is hyponatraemia?
Low sodium
Where is the aorta-pulmonary window?
Between the pulmonary trunk and arch of the aorta
What may lung cancer look like on CXR?
Pleural effusion (tumour in pleural space)
Chest wall invasion
Collapsed lung or lobe
Blood results in lung cancer
Anaemia
Abnormal LFTs - high ALP
High calcium
Low haemoglobin
Reasons for perioperative death in the Tx of lung cancer
ARDS
Bronchopneumonia (esp if have COPD)
MI
PTE
Pneumothorax
Intra thoracic bleeding
What is ARDS?
Adult respiratory distress syndrome
Complications of surgery for lung cancer
Post thoracotomy wound pain
Empyema
BPF (bronchopleural fistula)
Wound infection
AF
MI
Post op resp insufficiency
Gastroparesis/constipaton
What is empyema?
Pus in pleural space
Mortality of pneumonectomy
8 - 12%
Mortality of lobectomy
3 - 5%
Mortality of wedge resection
2 - 3%
What is a thoracotomy?
Incision into the pleural space of the chest
Causes of pulmonary mass
Lung cancer
Metastases
TB
Lung abscess
Fungal infection
Benign tumour (hamartoma, carcinoid)
Granuloma (sarcoid, wegeners, rheumatoid nodule)
Fibrosis
Paraffinoma (chronic granuloma produced by prolonged exposure to paraffin)
Vascular haematoma
AVM
How to look at a CXR
- Name / marker / rotation / penetration
- Lines / metal work
- Heart
- Mediastinum
- hilar vascular structures crisply defined
- no widening of mediastinum
- central trachea - Lungs
- compare zones (upper/middle/lower)
- look between ribs for lung detail
- behind heart - Bones
- Diaphragm
8 Soft tissues
What should you be aware of that would indicate a central lung cancer?
Lobar collapse which fails to resolve in 2 - 3 weeks in a smoker over the age of 45
What is a pulmonary mass?
An opacity (lacking transparency) in the lung > 3cm with no mediastinal adenopathy or atelectasis
What should lung cancer be diagnosed by?
CXR
+ve bronchoscopy
Features of bone pain caused by metastases
Any site
Worse at night
Pathological fracture
What is small cell lung cancer associated with?
ECTOPIC ADH and ACTH SECRETION
SiADH
- inappropriate ADH production leading to a dilutional hyponatraemia
Cushings syndrome
- due to ACTH production
What can the ACTH production in SCLC lead to?
Cushings syndrome
Bilateral adrenal hyperplasia which leads to a hypokalaemic metabolic acidosis
Where does renal cell carcinoma metastasise to and what is it called?
Lungs - ‘cannonball mets’
- multiple, large, round, well circumscribed masses in both lungs
Contraindications to lung cancer surgery
SVC obstruction
FEV < 1.5
Malignant pleural effusion
Vocal cord paralysis
Patients with known or suspected lung cancer are offered what?
Contrast enhanced CT of
- chest
- liver
- adrenals
What is adenocarcinoma of the lung associated with?
Gynaecomastia
Hypertrophic pulmonary osteoarthropathy
Associations of SCC of the lung
PTH related protein (PTH-rp) secreting causing hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy
Hyperthyroidism due to ectopic TSH
What can Pancoast tumours result in?
Suppressing the recurrent laryngeal nerve causing hoarseness of the voice
What may a large cell lung carcinoma secrete?
B-hCG
