Lung Cancer Flashcards
What percentage of lung cancer cases do NSCLCs account for in the UK?
87% (most common type of lung cancer)
What are the 4 main histological types?
Squamous cell carcinoma
Adenocarcinoma
Large cell carcinoma
Mixed histologies
What is a squamous cell carcinoma?
This type develops in the flat cells that cover the surface of the airways.
Most arise proximally in large bronchi.
What is the most common histological type of NSCLCs?
Squamous cell carcinomas
What is a adenocarcinoma?
Starts in the goblet cells that produce mucus and are found in the epithelial lining.
Tend to be slow growing and in the peripheral part of the lung - often invade pleura
Most lung cancers in people who have never smoked are adenocarcinomas.
What is the most common form of lung cancer?
Lung adenocarcinoma is the most common form of lung cancer, accounting for 30 percent of all cases overall and about 40 percent of all non-small cell lung cancer occurrences.
What are large cell carcinomas?
10-15% of all lung cancers.
Tend to grow very quickly and spread.
More difficult to treat.
This type of lung cancer is around 20x more likely in smokers.
Where do NSCLCs typically locally invade?
Local invasion – mediastinum, bronchial wall, lung parenchyma, pleural space, chest wall
Apical (top of lungs) tumours – brachial plexus (lower part of neck into apex of lung), upper thoracic ribs, local nerves
Hilar tumours – tumour can cause damage to phrenic of left recurrent laryngeal nerve
Where can NSCLCs spread to lymphatic ally?
Lymphatic spread – mediastinal, hilar, sub-carinal, tracheobronchial and paratracheal nodes
Where can NSCLCs spread to haematogenously (blood)?
More common in SCLC (bone, brain, liver and adrenals) – still relatively common with NSCLC aswell
What does FEV1 stand for?
Forced expiration volume (over 1 second)
What does DLCO stand for?
Diffusion rate of carbon monoxide over respiratory membrane
What stages can be radically managed?
Early and locally advanced disease (stage 1 and 2)
What is the treatment of choice for stage 1-2?
Surgery (with curative intent)
Other options:
Radiotherapy
Rdaiofrequency ablation (RFA)
What are the 3 types of resection?
Lobectomy
Segmentectomy
Wedge resection
What is a wedge resection?
Removal of a small wedge shaped piece of tissue
What is a limitation of wedge resections?
Higher recurrence rate of cancer returning than lobectomy due to margins
What is the percentage of candidates unable to have surgery?
40%
What does Radiofrequency Ablation (RFA) do?
“Microwave” the tumour – ablation through heating
What stage is SABR often used? What other factors are considered?
Stage 1-2
Low toxicity profile
Elderly / COPD
2 year survival 90%
What percentage of locally advanced diseased patients have radical surgery?
2%
What percentage of locally advanced diseased patients have radical radiotherapy?
14%
What percentage of locally advanced diseased patients have palliative radiotherapy?
44% (22% is + chemo)
What percentage of locally advanced diseased patients have best supportive care?
39%
What so-called advance disease can be potentially resected?
Single staged N2 disease – and T4N0
Particularly when down-staged after induction chemotherapy.
If no resection what treatment pathway is used for located advanced disease?
Concurrent chemo-RT gold standard
What does SABR stand for?
Stereotactic Ablative Radiotherapy
How does SABR different conventional radiotherapy?
High radiation dose per fraction
Hypofractionated
Different image guidance protocols
Monitoring of tumour motion
What percentage of all reported lung cancer cases do SCLC patients represent?
Around 15-20% (rarer than non-small cell lung cancer)
Does SCLC tend to spread early?
Yes
Do majority of patients present with minimal or extensive disease?
Extensive
What does extensive SCLC disease look like?
This can be thoracic disease involving more than one hemiplorax or it can be more distant metastatic spread (approximately 2/3rds of patient present with extensive disease)
Where do malignant cells originate from?
Primate neuroendocrine cells (neuroendocrine-cell precursors)
What are 3 things SCLC’s are characterised by?
Rapid growth – high mitotic rate
High response rates to both chemotherapy and radiotherapy
Development of treatment resistance in patients with metastatic disease
Do patients with SCLC have a good or poor prognosis?
Poor
What is the median survival time length (months)
15-20
What is the percentage survival for 2 years?
20-40%
What is the percentage survival for 5 years?
20-25%
How many patients have T1-2 disease?
Less than 5%
What percentage of T1-2 could have surgery alone?
5%
What do the majority of localised disease have?
T3-4 node positive disease
What treatment can the majority of localised disease have?
Concurrent chemo-radiotherapy (bi-daily) (CONVERT Trial) or sequential for those who are not fit enough
What do NICE suggest to offer for treatment of limited-stage disease SCLC?
Offer 2 x day radiotherapy with concurrent chemotherapy
Performance Status 0 – 1,
or if present with disease that can be encompassed in a radical thoracic RT volume.
RT to commence during 1st of 2nd chemo cycle
Once daily if patient declines / unable to have twice daily RT
Patients not well enough for concurrent chemoRT, but who respond to chemo - offer sequential radical thoracic radiotherapy
Offer PCI (prophylactic cranial irradiation)– patients whose disease has not progressed on first line treatment (2019 amendment)
What do NICE suggest to offer for treatment of extensive-stage disease SCLC?
Chemotherapy, or Molecular or targeted therapies
Per NICE, chemotherapy – platinum-based chemotherapy if fit enough
Assessment prior to each cycle – maximum of six cycles, dependent on response and toxicity.
Consider thoracic radiotherapy with PCI
where there has been partial or complete response to chemotherapy within thorax and at distant sites
Whole brain radiotherapy (PCI) if response to CT
Palliation – RT (symptom management)
Best supportive care (no active therapy but more of a palliative approach)
What is the dose/fractionation for Prophylactic Cranial Irradiation (PCI) for SCLC?
NICE – 25Gy/10#/2 weeks (Mon-Fri)
What does Prophylactic Cranial Irradiation (PCI) for SCLC require?
Whole brain
Limited stage
PS WHO 0-2
No progression after 1st line treatment
Risks of PCI?
Neurocognitive decline (verbal fluency, memory)
Decreased QOL
What percentage of lung cancer treatments does palliative EBRT make up?
20-30%
What are the 2 fractionation/doses for palliative EBRT?
10Gy in 1# or 30Gy in 10#
What metastases can receive RT?
Brain, bone and adrenal
What are the response rate percentages for each side effect?
54.1% for cough,
68%for haemoptysis,
51.1% for thoracic pain,
38.3% for dyspnoea,
12% for hoarseness, and
8% for dysphagia
What is the aim for palliative EBRT?
Minimal acute/late toxicity
What is Haemoptysis?
Coughing up of blood from lung
What is Dyspnoea?
Difficult or laboured breathing
What is Dysphagia?
Painful swallowing
What is Oesophagitis?
Inflammation of oesophageal lining
What is Neutropenia?
Low number of white blood cells called neutrophils in your blood
What is Anaemia?
A condition in which the body does not have enough healthy red blood cells
What are some signs of RT induced toxicity? (first 24 hours)
Acute chest pain, rigors, sweating and fevers
What are some signs of RT induced toxicity? (acute)
Lung, oesophageal and skin
What are some signs of RT induced toxicity? (late)
Lung oesophageal (and cardiac)
What is breathlessness in medical terms?
Dyspnoea
What is the definition of breathlessness?
Breathlessness is the distressing sensation of a deficit between the body’s demand for breathing and the ability of the respiratory system to satisfy that demand.
What are the 2 types of breathlessness?
Acute breathlessness: develops over minutes, hours, or days.
Chronic breathlessness: develops over weeks or months
When can breathlessness occur pathologically?
Can occur with little to no exertion. (Affects 50-70% cancer patients at some point)
After pain what is the most common symptom patients person to their GP with?
Breathlessness is the most common symptom for which patients seek help and relief from their doctor.
What percentage of patients with advanced lung cancer does breathlessness affect?
90%
Signs and symptoms of breathlessness
Difficulty catching breath
Noisy breathing
Very fast, shallow breaths
An increase in pulse rate
Wheezing
Chest pain
Skin that looks pale and slightly blue, especially around your mouth
Cold, clammy skin
Flaring nostrils when you breathe in
To use your shoulders and the muscles in your upper chest to help you breathe
Anxiety or panicky feelings
What should be done first when a patient presents with breathlessness?
Find the reason for breathlessness then management (should be both clinician and patient led)
What are the 2 management options for breathlessness?
Pharmaceutical and non-pharmaceutical
What are potential causes for breathlessness?
Anaemia
Side effect of treatment
Heart problems
Chest infection
Pleural effusion
Tumour growth
Blood vessel blockage
