Lung cancer Flashcards
Risk factors lung cancers
Smpking - 10 fold
Asbestos - x 5
synergistic - together = 50 x risk
exposure to arsenic, Radon, Nicke, Chromate , Aromatic hydrocarbon, Cryptogenic fibrosing alveolitis
Radiotheraoy to breast or chest, exposure in workpleace, medical imaging tests ef CT, atomic bomb radiation
Air pollution
FH
HIV
beta carotene supplements
What is more common type of lung cancer
Non samll cell - 80%
What types of cancer is included in non small cell lung cancer
SCC - 25%
Adenocarcinoma - 40% - most common in smokers
Large cell carcinoma - 10%
What are small lung cell cancers
Neuro endocrine differntiation
Large AWs strong smoking ass
Primary lung cancer tumour symptoms
Cough - progresisive
Haemoptysis
Dysponiea
Chest pain - dull and persistent, shar if pleuritic involvement
Wheezing or stridor
Recurrent chest infections
Anorexia and weight loss
Symptoms of regional lung cancer spread
Hoarseness
Dysphagia
SVC obstruction
Pancoast tumour
What causes hoarseness in lung cancer
recurrent laryngeal nerve involvement.
Distance metastatsis related symptoms
Bone pain esp spine, pelvis, long bones
Neurological symptoms - brain mets
Abdo pain or jaundice - liver mets
Adrenal insufficiency - adrenal mets
Paraneoplastic symptoms
Hypercalcemia
Cushigns syndrome - ACTH production
SIADH -> hyponatremia
Lambert Eaton myasthenic syndrome - LEMS - neuromuscular disorder antibodies against voltage gated calcium channels in presynaptic
Clubbing
when refer for 2 week wait lung cacner
CXR suggestive
>40 unexplained haemoptysis
When offer an urgent CXR lung cancer
> 40 + 2 or more following or if ever smoked and 1 or more of -
Cough
Fatigue
SOB
Chest pain
Weight loss
Appetite loss
When do you consider an urgent CXR for lung cancer
Persistent or recurrent chest infection
Finger clubbing
supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
Chest signs consistent with lung cnacer
Thrombocytosis
Investigation of choice for suspected lung cancer
CT chest
Investigations for lung cancer
CXR first line
CT chest
Bronchoscopy - biopsy, endo US
PET scan - non small lung cacner - curative or palleative
How does PET scan work
18-fluorodeoxygenase taken up preferentially by neoplastic tissue seen on scan
Epidemiology of sage of lung cancer at presentation
75% stage III/IV
First line treatment for stage I or II lung cancer
Surgical resection - lobectomy with hilar and mediastinal lymph node resection and sampling
Curative intent
First line for lung cancer stage I-III if unfit for surgery
Radiotherapy
Curative intent
What is offered for lung cancer stage III or IV
Chemotherapy - improve survival and QOL
3rd gem chemo eg docetael, paclitacel, gemcitabine
Platinum agent - carboplatin or cisplatin
Alos consider for chemoradiotherapy
Which lung cancer paitents are offered adjuvant chemotherapy
Complete resection
Which lung cancer paitents are offered adjuvant Radidotherapy
Incoplete resection of tumour
What is limited stage small cell lung cancer
SCLC without distant mets
First line for SCLC limited disease
4-6 cycles of cispltin based combination therapy
Radiotherapy adjunct or concurrent only considered if good response
What is extensive stage SCLC
Distant mets
First line treatment for extensive SCLC
Platinum based combo therapy - reassess for response after each cycle - up to a maximum of 6 cycles
Concurrent or adjunct radio if good response to chemo at primary and metastatic sites
Relapsed lung cancer treat
6 cycles max of chemo
Palliatuive radiotherapy symptom control
Complications of local spread of lung cancer
Nerve plasy
SVC
Pericarditis
Metastatic spread of lung cancer
Brain, spina cord, bone, liver, adrenal glands
Palliative therapy in lung cnacer
Radiotherpay - symptom control
Endobrachial stenting or debulking for bronchial obstruction
Pleural drainage or aspiration for pleural effusion
Dexamethasone therapy for symptomatic brain mets
Opioid therapy relieve cough and SOB
Survival rate small cell LC
5 year surival of 30-40% very early stage - v rare
10-15% IIIA
5-10% IIIB
IV - 1-3%
NSCLC surivval 5 years
IB - 45-55%
IIA - 40-50%
IIB - 30-40%
IIIA - 20-30%
IIIB - 10-15%
IV -<5%
Factors affecting lung prognosis
Age - older = poorer
Overall health - cormorbidites
Tumour size and location - near vital strucutres etc
Molecular markers - EGFR mutations, ALK rerrangements - impact treatment options
What is pancoasts syndrome
Chest wall pain
Horners syndrome
Pain in T1 dermatome - apical tumour invading chest wall
Horners syndrome symptoms
Miosis
Anhydrosis
Partial ptosis and enophtalmos
Gender epidemiology lung cancer
3:1
How does lung cancer spread
Spread is circumferential and longitudinal along the bronchus of origin
Tumours frequently involve regional lymphatics
Spread is to ipsilateral peribronchial and hilar nodes, followed by mediastinal, contralateral hilar and supraclavicular nodes
There is a propensity to disseminate widely via the bloodstream and virtually any site may be involved
Where are SCLCs more common
Central tumour
Larger AWs
Mutations in SCLC
RB1 and TP53
Abnormal DNA methylation of cyclin D2 gene
Types of lung cancer with higher metatastic spread vs less
Adrenocarcinoma - peripherally occuring from bronchial muscosal glands - high risk metatastic spread often to mediastinal lymph and pleura -> effusion
Large cell - can be paraneoplastic features - high risk mets poor differentiate
SCC spead locally, less likely mets
Investigations for radical treatment in SCLC
pulmonary function tests
contrast CT scan of the thorax and upper abdomen
V/Q scan
MRI scan
ultrasound scan
mediastinoscopy, laryngoscopy, PET-CT
additional investigation if clinical, biochemical or radiological suspicion of metastatic disease.
Investigations for lung cncare
Bronchoscopy
Fine needle aspirate from lympg node or CT guided transthoracic biopsy
Fluid cytology from pleural effusion
MRI OR PET/CT to determine operability
Adverse prognostic factors lung cancer
Pulmonary symptoms
Large tumour size >3cm
Nonsquamous histology
Mets to multiple lymph nodes
Vascular invasion
Low risk adverse prognostic factors
Poor performance status
Any site metastasis
Increased serum LDH
Medium adverse prognostic factors
Bone metastasis
Liver metastasis
Male gender
> 5% weight loss
High risk adverse prohnostic factors
Brain mets
>65 years
Non squamous tyoe
Prev RT
Where does squamous cell carcinoma originate
Near a bronchus
Mutations of subsets of adrenocarcinoma of lung
MAPK
EGFR
P13K
Core biopsy vs FNA
Core biopsy provides more tissue to pathologise - larger and more resprecsenative smaple
Best approach biopsy specimen lung cancer
Biopsy from R supraclavicular fossa mass
Most likley cause of confusion in lung cancer
Calcium
What can be offered as treatment if EGFR mutations present
EGFR tyrosine kinase inhibitors - gefitinib, erlotinib
Curative radiotherapy for lung cacner
f continuous hyperfractionated accelerated radiotherapy (CHART), delivered in 3 fractions per day for 12 days
Genetics in NSCLC
EGFR mutations strongly predict the improved response rate and progression-free survival of inhibitors of EGFR. Fusions of ALK with EML4 and other genes form translocation products that occur in ranges from 3% to 7% in unselected NSCLC and are responsive to pharmacological inhibition of ALK by agents such as crizotinib. The MET oncogene encodes hepatocyte growth factor receptor. Amplification of this gene has been associated with secondary resistance to EGFR tyrosine kinase inhibitors. Recurrent fusions involving the ROS1 gene are observed in up to 2% of NSCLCs and are responsive to treatment with crizotinib and entrectinib. NTRK gene fusions can occur in up to 1% of NSCLCs and can be treated with the TRK inhibitors, larotrectinib and entrectinib.”1
Disease related complications in NSCLC
Local invasion
SVC obstruction
Pleural effusion
Distant metastasis
Brain, liver, bone
Non-metastatic
Hypercalcaemia
Cushing syndrome
SIAD
Neurological syndromes
What is caused by SVC obstruction
Compression, invasion, thrombosis in superior mediastinum
symptoms of SVC obstruction
Dyspnoea
Facial swelling
Head fullness
Cough
Arm swelling
Chest pain
Venous distention of neck or chest wall
Facial oedema
Cyanosis
Plethora of face
Oedema of arms
Causes of SVC obstruction
Lung cancer
Lymphoma
Other malignancies - primary or secondary
nonneoplastic
Undiagnosed
CXR findings on SVC obstruction
15% normal
Supreior mediastinal widening
Pleural effusion
R hilar mass
Bilateral diffuse infiltrates, cardiomegaly, calcified paratrahceal nodes, ant mediastinal mass
Brain mets presentation
Headache (70-80%)
Cognitive dysfunction (40%)
Neurological deficit (40%)
Seizures (15-20%)
How do steroids treat brain mets
Decrease peritumoral oedema
Minimal mineralcorticoid actiit
Can double surival
10 mg stat iv, followed by 16 mg per 24 hours
Treatment for brain mets
Dexamethasone
Anticonvulsants eg phenyotin if seizures
Surgery - limited ecisend
Radiotherapy
Chemoterhapy - often doesnt cross BBB
