Lung cancer Flashcards
Lung cancer symptoms
persistent new cough or change in character of pre-existing cough
persistent LRTIs
chest/shoulder pain
dyspnoea
haemoptysis
lethargy, weight loss, anorexia (constitutional symptoms)
hoarseness
Lung cancer signs
often none
clubbing
signs of lung collapse, consolidation, pleural effusion
localised persistent wheeze (monophonic)
stridor
supraclavicular lymphadenopathy
hoarseness
SVC obstruction
Horner’s syndrome
features of paraneoplastic syndromes
SVC obstruction symptoms/signs
dyspnoea
orthopnoea
facial plethora
dilated/engorged veins
raised JVP
arm/face swelling
What causes Horner’s syndrome?
compression of sympathetic chain at roughly the level of C1
Features of Horner’s syndrome
miosis (constricted pupil)
ptosis (upper eyelid drooping)
anhidrosis (no sweat produced on one side of face/forehead)
enophthalmos (sunken in eye)
What are 2 lung cancer medical emergencies?
SVC obstruction
spinal cord compression
What investigations should be done if lung cancer is suspected?
CXR
CT staging (contrast) +/- biopsy
Bronchoscopy
Pulmonary function tests
6-minute-walk test
PET-CT scan
Bone scan
Cardiac investigations
What is WHO performance status 0?
fully active and able to carry out pre-disease activities without restriction
What is WHO performance status 1?
restricted in strenuous activity but ambulatory and able to carry out light work
What is WHO performance status 2?
ambulatory and self-caring, but unable to do light work
up and about more than 50% of the time
What is WHO performance status 3?
limited self care
in bed more than 50 % of the time
What is WHO performance status 4?
unable to self care
confined to bed or chair
Non-small cell lung cancer subtypes
squamous cell carcinoma
adenocarcinoma
large cell carcinoma
What are the 4 mesothelioma subtypes and which is the most common?
epithelioid (most common)
biphasic
sarcomatoid
desmoplastic
Where in the lung are small cell lung cancers normally located?
central
Where in the lung are adenocarcinomas normally located?
peripheral
Where in the lung are squamous cell carcinomas normally located?
central airways
Where in the lung are large cell carcinomas normally located?
peripheral
What factors are considered when staging a lung cancer?
location of primary tumour
tumour size and extent
lymph node involvement
presence of distant metastases
Why is ist important to stage lung cancer?
common language for communicating the severity of a person’s cancer
prognostic information
determines treatment options
What do TNM stand for in lung cancer staging?
T = tumour size
N = extent of spread to lymph nodes
M = presence of metastasis
What invasive options are available for staging of a lung cancer?
EBUS-TBNA (endobronchial ultrasound-guided transbronchial needle aspiration - central nodules
thoracoscopy - small peripheral nodules
mediastinoscopy - mediastinal nodes or masses
What imaging methods can be used to help stage a cancer?
CT
PET-CT
What is the aim of biopsying the primary lesion?
Histological diagnosis
Who is in the MDT for lung cancer?
respiratory physicians
thoracic surgeons
oncologists
radiologists
histopathologists
lung cancer specialist nurses
palliative care team
Lung cancer management options (general)
surgery
chemotherapy
radiotherapy
palliation
When is surgical management indicated for lung cancer?
stage 1 and 2 disease (and some stage 3 disease)
Define resectability
ability to completely excise the tumour at surgery
Define operability
risk of mortality/morbidity from surgery
What are the 3 main factors considered when assessing operability in lung cancer
risk of post-operative cardiac event
risk of peri-operative death
risk of post-operative dyspnoea
What are the 4 types of resection that can be done to remove lung cancers surgically?
wedge resection
segmental resection
lobectomy (most common)
pneumonectomy
What does VATS stand for?
video-assisted thoracoscopic surgery
Complications of surgery to remove lung cancer
displacement of heart towards operated side
bronchial stump insufficiency
pneumothorax (potentially tension pneumothorax)
postoperative haemorrhage (hemothorax)
chylothorax (damage to thoracic duct)
atelectasis
pneumonia
Acute side effects of radiotherapy
oesophagitis
pneumonitis
nausea/vomiting
bone marrow suppression
Longer term side effects of radiotherapy
pneumonitis and pulmonary fibrosis
rib fractures
cardiac fibrosis and dysfunction
hypothyroidism
What cell functions can chemotherapy target?
DNA replication/repair
cytoskeleton
nucleotide synthesis
hormones
specific receptors (eg. herceptin)
Is chemotherapy curative in lung cancer?
no
Lung cancer risk factors
smoking (tobacco + cannabis)
passive smoking
occupation exposure (asbestos, silica, coal)
HIV
organ transplantation
radiation exposure
Squamous cell carcinoma important features
usually obstructive lesions of bronchus
can cavitate
local spread common, often late metastasis
PTHrp production leading to hypercalcaemia
associated with clubbing and HPOA
What is HPOA?
hypertrophic pulmonary osteoarthropathy
What cells do adenocarcinomas arise from?
mucous cells in bronchial epithelium
Adenocarcinoma important features
can invade mediastinal lymph nodes and pleura
can metastasise to brain and bones
does not usually cavitate
if a non-smoker has lung cancer it will be adenocarcinoma
most likely to cause pleural effusions
Small cell carcinoma important features
cause paraneoplastic syndromes (eg. Cushing’s, Addison’s)
spreads early - almost always inoperable
do respond to chemotherapy but have a poor prognosis
What cells do small cell carcinomas arise from?
endocrine cells (Kulchitsky cells)
Contraindications to surgery for lung cancer
malignant pleural effusion
SVCO
Horner’s syndrome
Vocal cord paralysis
Phrenic nerve paralysis
What is radical chemotherapy?
given with the aim of cure
accept the likely side effects, longer course than palliative which is for symptom control
What are 3 types of staging?
clinical staging (scans)
surgical staging (biopsies)
pathological staging
NSCLC good prognostic factors
early stage disease at diagnosis
good performance status
no significant weight loss (<4%)
female
Common biomarkers in lung cancer
EGFR (epidermal growth factor receptor)
K-ras oncogene
EML4-ALK Fusion oncogene
PDL1
Squamous cell carcinoma immunohistochemical staining
TTF-1 negative
p63 positive
cytokeratin 5/6 positive
Adenocarcinoma immunohistochemical staining
TTF-1 positive
Small cell lung cancer paraneoplastic syndromes
SIADH
Ectopic ACTH production (Cushing’s)
Eaton-Lambert myasthenic syndrome
Hypercalcaemia
Peripheral neuropathy
PE/DVT risk
Where does SCLC metastasise to?
BALLS
Brain
Adrenal
Liver
Lung
Skeleton
SCLC biomarkers
nearly all immunoreactive for keratin, epithelial membrane antigen and thyroid transcription factor-1 (TTF-1)
most also stain positive for markers of neuroendocrine differentiation (eg. chromogranin A)
