Lung cancer Flashcards
Lung cancer : Aetiology
- Smoking - increases risk by 10x
- Asbestos exposure - increases risk by 5x
- Radon gas - radioactive decay product of uranium
Lung cancer : Criteria for 2 week Lung ca referral pathway
- have chest X‑ray findings that suggest lung cancer
OR - are *aged 40 and over with *unexplainedhaemoptysis
Lung cancer : Criteria for 2ww CXR
Offer *CXR *within 2 weeks if aged over 40 AND
- Smoker with 1> symptom
OR
- Non smoker with > 2 of the following sx
- New chronic cough
- Fatigue
- SOB
- Chest pain
- Weight loss
- Appetite loss
Lung cancer : Criteria to consider a CXR
Consider CXR if >40 and any 1 symptom
- *persistent or recurrent chest infection
- *fingerclubbing
- *supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- *chest signs consistent with lung cancer
- *thrombocytosis : raised platelets secondary to inflammatory immune response and cytokine/growth factor release by lung cancer tumours.
Lung cancer : Clincal symptoms
- *persistentcough
- *haemoptysis
- *dyspnoea
- *chest pain
- *weight lossandanorexia
Lung cancer : Clinical signs
- a fixed, monophonic wheeze may be noted
- supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- clubbing
- Horner’s syndrome
- Distended neck veins from vena cava obstruction
Lung cancer : Investigations - Blood tests
- FBC : Thrombocytosis, anaemia secondary to cancer,
- Raised LFTs - liver mets
- Hyponatremia - ADH from SIADH
- Hyperglycaemia, hypokalaemia : Excess ACTH
- ALP raised : Bone metastases
Lung cancer : Investigations - Imaging
- Chest XR : well defined consolidation
- CT chest and adrenal glands : Check for metastasis
- Flexible bronchoscopy : histology and biopsy
What are the different types of lung cancer?
- Non small cell lung cancer
- Adenocarcinoma
- Squamous cell carcinoma - Small cell lung cancer
- Large cell lung cancer
Which is the most common type of lung cancer?
Non small cell carcinoma : accounts for 80% of all lung cancers
Lung cancer: NSCC : Adenocarcinoma : Histology
- form from glandular structures and can generate mucin
Lung cancer: NSCC : Adenocarcinoma - causes
Most common lung cancer in never smokers
Lung cancer: NSCC : Adenocarcinoma - location in the lungs
- Arise peripherally in the lungs
Lung cancer: NSCC : Adenocarcinoma - Clinical features
Paraneoplastic syndrome
-
Gynaecomastia :
* Due to release of oestrogen which can increase breast tissue development in males -
Hypertrophic pulmonary osteoarthropathy
* Clubbing of the fingers and toes
* Secondary to release of cytokines and growth factors stimulating osteoblast production
Lung cancer: NSCC : Squamous cell carcinoma - location in the lungs
Arises centrally in the lungs
Lung cancer: NSCC : Squamous cell carcinoma - causes
Very strongly associated with smoking
Lung cancer: NSCC : Squamous cell carcinoma - Histology
Squamous square shaped and can produce keratin
Lung cancer: NSCC : Squamous cell carcinoma - Clinical features
Paraneoplastic syndrome
- Hypercalcaemia;
Secondary to parathyroid hormone released from tumour - Hyperthyroidism:
Secondary to ectopic TSH release - Hypertrophic pulmonary osteoarthropathy :
- Clubbing of the fingers and toes
- Secondary to release of cytokines and growth factors stimulating osteoblast production
Lung cancer: NSCC : Horner’s syndrome - Pathophysiology
Adenocarcinoma and Squamous cell cancer can cause pan coast tumours
* Pancoast tumours cause compression of brachial plexus
* leading to the due to dysfunctional sympathetic nerve.
Lung cancer: NSCC : Horner’s syndrome - Symptoms
Triad of of symptoms are;
* Constricted pupils,
* Drooping upper eye lid
* Loss of ability to sweat of that side of the face
Lung cancer: NSCC : Recurrent laryngeal nerve palsy
Compression of the recurrent laryngeal nerve due to tumour
*Sx *: Hoarseness of voice
Lung cancer: NSCC : Stage 1-4
- Stage 1 - small tumour and no spread
- Stage 2 - >4cm and with local lymph nose spread
- Stage 3 - Extensive lymphoid spread
- Stage 4 - metastasises 1 area other than lung
Lung cancer: NSCC : Stage 1-2} Management
Curative intent
* Surgical lobectomy with lymph node resection
* Adjuvant chemotherapy or radiotherapy
Lung cancer: NSCC : Stage 3-4} Management
Chemotherapy to improve survival and quality of life
Lung cancer : Small cell lung cancer : Incidence
- 15% of lung cancer
- Strong association with smoking
Lung cancer : Small cell lung cancer : Prognosis
- Aggressive malignancy, 2/3 of patient have evidence of distal metastasis at presentation
- Develops and metastasis quickly
Lung cancer : Small cell lung cancer : Histology
- Malignant epithelial tumor arising from cells lining the lower respiratory tract
- Tumor cells are small and densely packed
Lung cancer : Small cell lung cancer : Location in the lungs
- Arise central lung with mediastinal involvement
Lung cancer : Small cell lung cancer : Paraneoplastic syndrome
-
Excess ACTH release
* Triggers excess release of cortisol from the adrenal glands causing Cushing’s like symptoms
* Hypertension, hyperglycaemia, hypokalaemia } -
Lambert - Eaton myasthenia syndrome
* neurological symptoms from type 2 hypersensitivity reaction caused by the production of auto antibodies which bind and destroy neurone
Lung cancer : Small cell lung cancer : Management
-
Limited stage - confined to ipsilater hemithorax
* Radiotherapy + chemotherapy ; can be encompassed within radiation field -
Extensive stage - systemic metastasis
* Chemotherapy and immunotherapy - Surgery : only 20% of patients are suitable due to advanced nature of the disease
Lung cancer : Large cell lung cancer : features
- Lack both glandular and squamous differentiation
- Can arise centrally
Mesothelioma : Definition
Cancer of the mesothelial layer of the pleural lining that is strongly associated with asbestos exposure
Mesothelioma : Clinical features
- Dyspnoea, weight loss, chest wall pain
- Clubbing
- 30% present as painless pleural effusion
- Hx of Asbestos exposure
- Metastasis to contralateral lung and peritoneum
Mesothelioma : Investigation
- CXR : Pleural effusion or thickening
- Second line : Pleural CT
- Pleural fluid aspiration or biopsy of pleura
Asbestosis : Definition
chronic lung condition caused by prolonged exposure to asbestos fibers.
the severity of asbestosis is related to the length of exposure.
Asbestosis : Clinical features
- dyspnoea and reduced exercise tolerance
- clubbing
Asbestosis : Investigations
- CXR
* lower lobe fibrosis - bilateral end-inspiratory crackles
* Pleural plaques are benign and do not undergo malignant change. They, therefore don’t require any follow-up.
* 2. lung function tests show a restrictive pattern with reduced gas transfer
Asbestosis : Management
It istreated conservatively- no interventions offer a significant benefit.
Nicotine replacement therapy : SE
- adverse effects include nausea & vomiting, headaches and flu-like symptoms
Varenicline : MOA
- a nicotinic receptor partial agonist
- should be started 1 week before the patients target date to stop
- the recommended course of treatment is 12 weeks
- nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams
- varenicline should be used with caution in patients with a history of depression or self-harm.
- contraindicated in pregnancy and breast feeding
Bupropion : MOA
- a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
- should be started 1 to 2 weeks before the patients target date to stop
- small risk of seizures (1 in 1,000)
- contraindicated inepilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
