Lung cancer Flashcards
What % of death by lung cancer are caused by smoking?
Men - 90%
women - 80%
1/3 of all cancer deaths
What are the risk factors of lung cancer?
Smoking COPD Asbestos Radon Other occupational carcinogens Diet Genetic/familial factors Social class Around 5000 cases a year in never smokers
What are the symptoms of a primary lung tumour?
Cough Dyspnoea Wheezing Hemoptysis Chest pain Postobstructive pneumonia Weight loss Lethargy/malaise
What are the symptoms of lung cancer regional metastases?
Superior vena caval obstruction
Hoarseness (left recurrent laryngeal nerve palsy)
Dyspnoea (phrenic nerve palsy)
Dysphagia
What are the symptoms of lung cancer distant metastases?
Bone pain/fractures CNS symptoms (headache, double vision, confusion etc)
What investigations are carried out to diagnose and stage lung cancer?
Plain chest x-ray - does NOT have to appear abnormal
Serum biochemistry (Sodium, LFT, calsium
Imaging (cross sectional)- CT and PET-CT scans. Isotope bone scan etc
Bronchoscopy, CT guided needle biopsy, lymph node biopsy, mediastinoscopy, pleural biopsy/cytology
How many people with non-small cell lung cancer have inoperable disease at presentation?
2/3rds
In small cell lung cancer, how many people have metastatic disease at presentation?
75%
What is the incidence of the various types of lung cancer?
Small/oat cell - 20-25%
Squamous cell - 30-35%
Adenocarcinoma - 30-35%
Large cell undifferentiated - 15-20%
What do the letters of TNM classification mean?
T - Primary tumour (<3 cm, surrounded by lung and visceral pleura, no invasion proximal to lobar bronchus at bronchoscopy)
N - Regional lymph node
M - Distant metastasis
What is the role of imaging in lung cancer?
Diagnosis Staging Treatment plan Response to treatment Complications Intervention Recurrence Screening
What does ultrasonography show?
Metastases - liver, adrenal
Pleural effusion
Aspiration-PI fluid
Chest wal invasion
What is the abbreviation for metastases?
MO - No known distant metastasis
M1a - lung nodules, pleural effusion
M1b - distant metastases
Explain the abbreviations of nodal staging
N1 - peribronchial ipsilateral hilar
N2 - ipsilateral mediastinal and subcranial nodes
N3 - Contralateral mediastinal, contralateral mediastinal hilar, scalene, supraclavicular
What are the cellular histological factors of malignancy?
Nuclei of irregular shape (pleomorphic)
Nucleic dark staining (hyper chromatic)
Increased size of nuclei compared to cytoplasm
Frequent/abnormal mitoses (cell division)
Prominent/multiple nucleoli
What architectural histological features suggest malignancy?
Ulceration Necrosis Infiltrative margins Vascular invasion Poorly circumscribed Reaction in the surrounding tissue (stroma) Little resemblance to normal tissue
What is a lung carcinoma?
Invasive malignant epithelial tumour
How are NSCLC further subclassified?
Use additional pathology stains - immunocytochemistry and mucin
Describe squamous carcinoma
Often central tumours Angulate cells Eosinophilic cytoplasm Keratinisation Intercellular bridges - 'prickles' Keratin pearls
Immunos: CK5/6 and P63 +
Describe adenocarcinoma.
Often peripheral tumours Columnar/cuboidal cells Form glands (acini) Papillary structures May line alveoli Some produce mucin
Immunos: Most TTF-1+
Describe small cell carcinoma.
"Oat cell carcinoma" Very cellular tumour Small nuclei - c.f. size of lymphocyte Little cytoplasm Nuclear moulding Often necrosis and lots of mitoses
Immunos: CD56, Synaptphysin
What local complications can result from lung cancer?
Necrosis =/- cavitation
Ulceration - haemoptysis
Infection - abscess formation
Bronchial obstruction - lung collapse, consolidation
Where might lung cancer metastasise to locally (within the thorax)?
Direct spread or metastasis pleural/pericardial effusions
Mediastinal structures - SVCO, dysphagia
Recurrent laryngeal nerve - vocal cord palsy and hoarseness
Phrenic nerve - diaphragm palsy
Where does lung cancer commonly metastasise to?
Other lung Liver Adrenals Bone Brain
What is the survival rate for lung cancer?
10% live to 5 years
Overall median survival around 6 months
Worse in the UK than most other western countries
What is survival of lung cancer dependent on?
Cell type Stage of disease Performance status Biochemical markers Co-morbidities
What is the treatment for lung cancer?
Surgery - mostly for non - small cell
Radiotherapy - ‘radical’ with curative intent or ‘pallative’ - symptom control
Chemotherapy - small cell, potential curvature in minority, non-small cell modest survival increase, symptom control
Combination therapy - combination chem-radiotherapy
Biological (targeted) therapies
Palliative care
What % of lung cancer is operable?
20%
Surgical survival = 50% at 5 years
What treatment is used for people with “operable” tumours who aren’t fit for surgery?
Radiotherapy
What is the management for small cell carcinoma?
A systemic disease in >80% of cases
Rarely operable
3 month median survival untreated
85-90% respond to combination chemo (Approx 1 year of added survival)
10-15%s urvive 2 year; less than 8% survive 5 years
Good symptom palliation with chemo
Death from cerebral metastases common
Describe the palliative care involved in Lung cancer management.
A disease with multiple symptoms and often poor survival - need for prompt treatment of symptoms
Need for early involvement of palliative care services
Specific palliation usually best done by appropriate specialist
Communication betwen and coordination of various treatment agencies is vital. Patient held records may be useful
What is the problem with treatment of lung cancer?
Late diagnosis Overall poor prognosis Very symptomatic Professional nihilism Variable standards of care Lack of public pressure
