Lung Cancer Flashcards
How to classify lung cancers?
- non-small cell carcinoma (85%)
- small cell carcinoma (15%).
This distinction is based on the size of the malignant cells seen on microscopy.
How is non-small cell carcinoma further classified?
- adenocarcinoma (40% of all lung cancer)
- squamous cell carcinoma (30%)
- large cell carcinoma (10%)
Non small cell: Adenocarcinoma
- location
- histology findings ?
- clinical features?
Located peripherally (in the smaller airways)
Histology: glandular differentiation
Clinical features:
* More common in non-smokers and Asian females
* Metastasise early
* Responds well to immunotherapy
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Squamous cell carcinoma:
* location?
* histology findings ?
* clinical features?
CF: assoicated with / more common in
Located centrally (in the bronchi)
Histology: squamous differentiation (keratinisation)
Clinical features:
* More common in smokers
* Secrete PTHrP, causing hypercalcaemia
* Metastasise late (via lymph nodes)
Large cell carcinoma:
* location?
* histology findings ?
* clinical features?
CF: more common in
Located peripherally and centrally
Histology: large and poorly-differentiated
Clinical features:
* More common in smokers
* Metastasise early
Small cell carcinoma:
* location?
* histology findings ?
* clinical features?
CF: assoicated with / more common in
Located centrally
Histology: poorly-differentiated
Clinical features:
* More common in older smokers
* Metastasise early
* Secrete ACTH (Cushing’s syndrome) and ADH (SIADH)
* Associated with Lambert-Eaton syndrome
Risk factors for lung cancer
- TOBACCO SMOKING - 80% lung cancer cases
other:
* Air pollution (indoor and outdoor)
* Family history of cancer, especially lung cancer
* Male sex
* Radon gas (typically affects miners)
History: what are typical symptoms of lung cancer?
- 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)
- Bone pain (due to metastases – commonly the spine, pelvis and long bones)
- Fatigue (due to anaemia of chronic disease)
- Note that up to 20% of patients present with non-respiratory symptoms (such as fatigue).
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What are other areas important to cover in history if you suspect lung cancer ?
- Family history: lung cancer in a first-degree relative increases risk
- Smoking history: (remember passive smoking) quantify smoking in pack-years (1 pack-year = smoking 20 cigarettes a day for a year).
- Occupation: indoor air pollution or radon gas (e.g. miners)
What are some physical findings on clinical examination of a patient with lung cancer?
- Cachexia: cancer can cause increased resting energy expenditure and lipolysis.
- Finger clubbing
- Dullness to percussion: due to the tumour (solids are less resonant than gases).
- Cervical lymphadenopathy: mets to the lymphatic system.
- Wheeze on auscultation: due to the tumour obstructing an airway.
When to refer urgently: NICE RED FLAG symptoms for 2 WW?
- Chest X-ray findings suggestive of lung cancer
or - Over 40 years old and unexplained haemoptysis
Note: pt also needs a CXR in 2 weeks
Lung cancer: When to refer urgently for a CXR (within 2 weeks)…..?
urgent CXR (w/in 2 weeks) before a decision to refer on a 2-WW is made
Patient >40 yrs
AND have 2 of the following unexplained symptoms ( 1 if never smoked):
* Cough
* Weight loss
* Appetite loss
* Dyspnoea
* Chest pain
* Fatigue
Patient >40 yrs and ANY of the below :
* Clubbing
* Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes)
* Recurrent or persistent chest infections
* Raised platelet count (thrombocytosis)
* Chest signs of lung cancer
What are some differencial diagnosis for Lung cancer?
Will expand later on differenciating features
- TB
- Mets to the lung from other sites
- Sarcoidosis
- Granulomatoiss with polyangitis
- Non-Hodgkins lymphoma
Features differenciating TB from lung cancer
- Drenching night sweats
- Positive sputum culture and microscopy
- Chest X-ray: cavitating lesion/hilar lymphadenopathy
Features differenciating cancer that has metastaised TO THE lungs FROM (primary) Lung cancer
i.e. its not lung cancer
Symptoms relevant to the primary tumour (e.g. haematuria due to renal cell carcinoma)
CT head-abdomen-pelvis: shows primary tumour
FDG-PET: increased uptake at the primary tumour site
fluorodeoxyglucose (FDG) (PET) detects metabolically active malignant le
features differenciating sarcoidosis from lung cancer ?
Enlarged parotids
Skin signs: erythema nodosum and lupus pernio
Tissue biopsy: non-caseating granulomas
Features differenciating Non-hodgkins lymphoma from lung cancer?
Drenching night sweats
Hepatosplenomegaly
Positive lymph node biopsy (anti-CD20 stain)
Dr Tom loves which 2 physical findings which would suggest lung cancer and need urgent CXR?
Finger clubbing
supraclavicular lymphadenopathy
Bedside investigations for lung cancer?
- Pulse oximetry: aim for 94-98% (88-92% if the patient also has COPD
- ECG: always performed pre-operatively.
Lab investigations for lung cancer?
- FBC: may show anaemia.
- LFTs: raised ALP and GGT may indicate hepatic metastases, raised ALP may indicate bone metastases.
- U&E: i-baseline before treatment, hyponatraemia due to SIADH (small cell carcinoma.)
- Serum calcium: elevated with PTHrP (squamous cell carcinoma).
Imaging for lung cancer
- CXR:
Hilar enlargement, multiple opacities, pleural effusion and/or lung collapse. - CT chest-abdomen-pelvis WITH CONTRAST
confirm chest X-ray findings/ assesses for metastases. - Bronchoscopy with EBUS and biopsy
small camera into the airways to visualise, biopsy, pathologist confirms (cells, subtype e.g. adenocarcinoma and targetable mutations (e.g. EGFR mutation). - (PET-CT):
radioactive tracer - stages cancer by showing if spread - areas of increased metabolic acitivity light up.
endobronchial ultrasound (EBUS) involves endoscopy with ultrasound equipment on the end of the scope.
TNM staging of lung cancer
Lecture induction week : lung cancer symptoms?
Intro week lecture:
What do so if suspect lung cancer?
assess, who talk to, biopsy? bloods? imaging?
What are common places lung cancer metastasises to?
Liver
adrenals
bone
lung (elsewhere)
Brain
Complication of lung cancer- what is this? what do you need to do next?
malignant pleural effusion
Bloods:
* FBC / U&E, CRP / INR/ LFT
* US guided aspirate - send for protein, LDH, cytology, microbiology
* if cytology negative - medical thorascopy
* Pleural effusion - non curative treatment
If you find incidental nodules in the lung e.g. on CT - what is the likelihood they will be cancer? WHat scores are there to evaluate?
CLUE: think sizes
- BROCK score
- HERDER score
- see BTS nodule guidleines
A 78 year old female with known Lung Cancer (stage IV) presents with leg weakness. On examination there are upper motor neuron signs and sensory loss in the saddle area.
What would do next?
what worreid about?
MRI spine - worried about MSCC
An 81 year old male patient with LC (stage IV) presents with confusion, nausea and weakness.
What urgent blood test would you do?
What should you give her?
Bloods: calcium level
Give: IV fluids and Pamidronate
Pamidronate- treat moderate or severe hypercalcemia of malignancy
What is this? How is it treated?
SVCO (superior vena cava obstruction) - due to Lung cancer mets
Why might a pt with lung cancer have low sodium>
How investigate ? How treat?
rarely give tolvaptan - ask endocrinologist as expensive
A pt with advanced lung cancer has brain mets -
investigations?
Treatments - for raised ICP, for seizures?
What does pt need to be told?
investigations:
* CT and MRI brain
treatment:
* Dexamethasone 4 mg BD (8am and 12 noon) with weaning plan
* Keppra for seizures
Tell patient:
* CANNOT DRIVE
Lung cancer and MDT?
How long until a pt must be seen?
Who is part of the lung cancer MDT?
What are important parameters to assess with a pt with lung cancer?
Clue: WHO ____ used to see how fit they are, guides treatment etc.
What are the three types of lung cancer surgery?
Non small cell lung cancer:
tratment for stage I-III
see GM
Surgery:
* lobectomy/pneumonectomy in patients with intact lung function,
* wedge resection in patients with reduced lung function (e.g. elderly, underlying respiratory conditions).
medical:
* Pre-operative chemotherapy
* Post-operative chemotherapy and radiotherapy: may not be needed in some cases of stage I lung cancer.
* If unsuitable for surgery (e.g. too frail), patients may be offered stereotactic ablative radiotherapy (SABR)
Non small cell lung cancer: treamtment for stage IV
Targeted therapy
* target mutations that drive lung cancer - see image
Immunotherapy:
* targets immune checkpoints which are not killing cancer cells e.g. immune checkpoint PD-L1 is targeted by pembrolizumab
Chemotherapy:
* important for pts who do not have mutations that can be targeted
Palliative care:
* includes palliative radiotherapy, for metastases and symptom control.
Small cell lung cancer: treatment optioins
Medical:
* 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.
What are some disease related complications of lung cancer?
Horner’s syndrome
* Pancoast tumour in the lung apex infiltrating the brachial plexus.
Superior vena cava obstruction
* tumour compresses the SVC, preventing venous drainage from the head and neck, leading to facial swelling and distended neck/chest veins. Pembertons signs
Paraneoplastic syndromes:
* e.g. SIADH and Lambert-Eaton syndrome.
Reccurent laryngeal nerve palsy:
* hoarse voice as cancer presses as LRLN passes mediastinum
Phrenic nerve palsy
* nerve compression causes diaphragm weakness and presents as SOB
Syndrome of SIADH
* ectopic ADH bu small cell lung cancer- hyponatraemia
Cushings
* ectopic ACTH - small cell lung cancer
Hypercalcaemia
* ectipic PTH from squamous cell carcincoma
Lambert-Eaton myasthenic syndrome
- new slides
What are some treatment related complications of lung cancer?
Due to chemotherapy:
* alopecia
* neutropaenia
* bone marrow toxicity.
Due to radiotherapy
* mucositis
* pneumonitis
* oesophagitis.
What are some palliative interventions for lung cancer?
What is mesothelioma? where does it affect? causes? prognosis?
What and where?
* lung malignancy affecting the mesothelial cells of the pleura.
Cause:
* strongly linked to asbestos inhalation. There is a huge latent period between exposure to asbestos and the development of mesothelioma of up to 45 years.
Prognosis:
* very poor. Chemotherapy can improve survival but it is essentially palliative.
Lambert-Eaton myasthenic syndrome can be a manifestation of small cell lung cancer. Explain pathophysiolgy? What signs / symptoms?
- antibodies produced by the immune system against voltage-gated calcium channels in small cell lung cancer (SCLC) cells.
Why is this a problem? There are also VGCC in presynaptic terminals in motor neurones - these also get targetted.
- target VG calcium channels on presynaptic terminals in motor neurones.
leads to weakenss in:
* proximal muscles
* intraocular muscles - diplopia
* levator muslcles - ptosis
* pharyngeal muscles - dysphagia / slurred speech
AND
* autonomic dysfunction - dry mouth / blurred vision / impotence dizziness
AND
* reduced tendon refelxes (temporarily imporve after strong muscle contractions = ‘post tetanic potentiation”
Great lung cancer test question on capsule is
Oncology 704
pt is disovered to have lung cancer. what factors influence treatment options
- staging of lung cancer
- performance status
- patient wishes
- lung functino
- tumour testing for specific genetic mutations
Outline / recall performance status
(Performance status is a measure of activity. It has been correlated with outcome in cancer patients. The higher the number on the performance status scale, the less active the patient:)
0= no symptoms, fully active, able to perform all pre-disease activity
1= some symptoms but able to carry out light work, able to carry out office work/light house work
2= in bed or resting less than 50% of the day, capable of all self care
3= in bed or resting more than 50% of the day, capable of limited self care
4= in bed/resting all day, cannot carry out any self care
5= patient died
