Lung Cancer Flashcards
What is the primary structure found in the anterior mediastinum?
The thymus and connecting ligaments
The thymus is responsible for T cell production.
How does the anterior mediastinum change during development?
In childhood, the anterior mediastinum contains the large thymus which transitions into a smaller structure and also has fat and lymph nodes.
What are the common anterior mediastinal masses referred to as the 4 Ts?
- Teratomas
- Thymoma
- Terrible lymphoma
- Thyroidal goitre
These masses can present various symptoms and complications.
What are teratomas?
Germ cell tumours that include mature teratomas from at least 2 germ cell layers, typically benign. They may contain ectodermic tissue like hair and hair and teeth those that contain nostalgia or neuroendocrine tissue are immature and have a poor prognosis. They have a slower onset generally and insidious symptom progression.
Immature teratomas contain neuroendocrine tissue and have a poor prognosis.
What is a diagnostic marker for teratomas on blood test?
beta-HCG is elevated
What characterizes a thymoma?
Most common anterior mediastinal mass in adults, linked to myasthenia gravis, encapsulated, and slow-growing.
A thymoma is where the cancer cells resemble the normal cells of the thymus, are typically encapsulated, growing slowly and rarely spread beyond the thymus. Symptoms are generally a chronic cough, hoarseness voice, shortness of breath and swelling in the face and neck.
Symptoms include chronic cough, hoarseness, shortness of breath, and swelling in the face and neck.
What is the role of the thymus gland?
Thymus gland is a primary lymphoid organ which is responsible for the production of T cells.
What is terrible lymphoma?
Typically Hodgkin’s lymphoma rich in Reed-Sternberg cells, characterised into subtypes. nodular sclerosing which is the most common, lymphocyte rich, lymphocyte depleted and mixed cellular.
Non-Hodgkin lymphoma is least common and these cause rapidly progressing symptoms.
Non-Hodgkin lymphoma is less common and progresses rapidly.
What are the features of thyroidal goitre?
Thyroidal goitre is retrosternal, and the most common subtype is papillary carcinomas and least common are follicular carcinoma and medullary carcinoma. Typically in men and women older than 40 and is very common.
What is the typical age demographic for thyroidal goitre?
Men and women older than 40
Commonly presents as papillary carcinomas.
What symptoms do patients with anterior mediastinal masses typically present with?
- Cough
- Chest pain
- Dyspnoea
- Hoarseness of voice
- Haemoptysis
- Dysphagia
Patients may also experience constitutional symptoms like night sweats and unintentional weight loss.
Which imaging modality is best for anterior mediastinal masses?
CT scan due to observing soft tissue structure.
It is effective for observing soft tissue structures.
What are PET scans best for?
PET scans can be used to distinguish between benign and malignant lesions due to visualising the shape fo the tumour, where benign tumour have smooth edges and reaction to the radiotracer where cancerous cells have more activity
What is the Masoka-Koga staging system used for?
Staging thymoma
It ranges from Stage 1 (encapsulated) to Stage 4b (distant metastases).
What are the stages of a thymoma?
Stage 1: thymus is encapsulated
Stage 2: primarily contained with some microscopic extension
Stage 3: macroscopic invasion into the surrounding tissues like the pericardium, pleura or lng
Stage 4a: pleural or pericardial metastases
Stage 4b: distant metastases in liver or bones
How is a thymoma treated?
Thymoma is treated with surgical resection for early stage and for advanced disease, radiotherapy or chemotherapy.
How is a teratoma treated?
Teratoma is treated with combination of surgical resection, chemotherapy and radiation therapy.
What is the treatment for Hodgkin lymphoma?
AVBD (doxorubicin, neomycin, vinblastine, and dacarbazine)
May also include bone marrow/stem cell transplant or targeted therapy.
What are the alternatives for chemotherapy for treatment of Hodgkin lymphoma?
Bone marrow and stem cell transplant.
What are common complications of anterior mediastinal masses?
- Compression of nearby structures (trachea, bronchi, oesophagus, SVC)
- Respiratory compromise With respiratory failure
- Cardiovascular complications (cardiac tamponade, arrhythmia)
These complications can lead to respiratory distress or failure.
What does the middle mediastinum contain?
The heart, trachea, and bronchi
Masses here can include bronchial and tracheal tumours.
What are the middle mediastinum tumours?
Bronchial tumours
Tracheal tumours
Lymphoma
What does the posterior mediastinum contain?
Posterior mediastinum contains the oesophagus, vertebrae and arteries/veins/lymphatic masses.
What are the masses in the posterior mediastinum?
Lymphoma
Oesophageal tumours
Nerve sheath tumours
Multiple myeloma
What is the most common cause of tumours in the mediastinum?
Lung cancer
It can manifest in various forms and stages.
What are the two main types of lung cancer?
- Small cell lung cancer
- Non-small cell lung cancer
Small cell accounts for 25% of all cancers.
What characterizes small cell lung cancer?
Forms a neuroendocrine tumour, typically centrally located in the airways. Prognosis is typically poor when presenting symptomatically due to high rate of metastasis and has a strong association with paraneoplastic syndrome SIADH with dilutional hyponatremia and is chemo/radiosensitive.
It arises from amine precursor uptake decarboxylase (APUD) cells.
What is the histology of small cell lung cancer?
It arises from amine precursor uptake decarboxylase cells (APUD) that are endocrine cells found in the bronchial glands and surface epithelium of the lungs. They contain hyperchromatic nuclei
It is undifferentiated with little cyptoplasm typicallly in airways
What is the most common type of non-small cell lung cancer?
Adenocarcinoma, involving the mucinar cells which is peripherally located and typically assoicated with productive cough with excessive sptutum. It is undetectable by imaging and causes trousseau’s syndrome. It has no association with smoking and is linked to genetics and family history and can occur in scar tissue or sites of fibrosis
It is linked to genetics and can occur in scar tissue.
What is Trousseau’s syndrome?
Blood clotting disorder called migratory thrombophlebitis which is inflammation of the vein due to a blood clot that occurs in cancer malignancy due to tumour cells inducing thrombin activation. It causes:
->Acanthosis nigiricans: dark brown velvety lesion
This tends to occur in adenocarcinomas of the lung.
What is squamous cell carcinoma?
Squamous cell carcinoma which is centrally located and causes extensive central necrosis and cavitation, and may present as pan coast tumours, located in the superior sulcus of the lung with hypercalcaemia.
What is the histology of squamous cell carcinoma?
Cells are abundant with eosniophilic cyptoplasm, with keratinisation and intercellular desmosomes.
What are the features of large cell carcinoma?
Large cell carcinoma are typically peripheral and and cells are large with abundant cyptoplasm that lack defining features. It is diagnosed via exclusion of other histological lung cancer types.
What size is classified as a solitary pulmonary nodule?
Less than 3 cm and surrounding lung tissue is normal and absence of lymphadenopathy.
Surrounding lung tissue is normal and there is an absence of lymphadenopathy.
What are the common causes of benign pulmonary nodule?
Majority are benign and caused by a granuloma (collection of macrophages) due to tuberculosis, fungal infection (histoplasmosis or coccidomycoses).
A minority occur due to hamartoma, where it is surrounded by the same type of tissue found in the surrounding tissue.
What are the typical cases of malignant nodules?
Malignant nodule is 30% and typically bronchogenic carcinoma tha is squamous, adenocarcionoma or large cell. A minority are metastatic where there are typically multiple nodules.
What are indicators for malignant pulmonary nodules?
- Size over 1 cm
- Smokers
- Older age
- Enhanced with contrast
These factors increase the likelihood of malignancy.
What are the indicators for benign nodules?
Indicators for benign nodules is a non-smoker, smooth and well defined margins, younger age, cavitations with smooth walls
What is the aetiology of lung cancer?
- Cigarette smoking (excluding adenocarcinoma)
- Asbestos exposure
- Radon exposure
These factors are typically linked to lung cancer development.
What are common specific symptoms of lung cancer?
- Haemoptysis
- Dyspnoea
- Cough due to bronchial compression
- Wheezing
*Symptoms of hypercalcaemia with kidney stones, dehydration and confusion
These symptoms are often due to tumour obstruction.
Why does pleural effusion occur in lung cancer?
There may be recurrent pleural effusion due to lymphatic obstruction, post obstructive pneumonitis or atelectasis.
How should hypercalcaemia be managed?
Hypercalcaemia should be managed with isotonic saline infusion to manage dehydration and bisphosphonate to reduce osteoporosis.
What are the clinical signs of lung cancer?
Clinical signs may include supraclavicular lymphadenopathy or persistent cervical lymphadenopathy and a monophonic wheeze (continuous sounds throughout the respiratory cycle.)
Unilateral chest expansion
Decreased pulses
Paraesthesia and weakness of upper limb
Which symptom is assoicated with central tumours?
Post-obstructive pneumonia due to obstruction of mucus to be expelled.
What is a common site of metastasis of lung cancer?
BLAB:
Bones
Liver
Adrenal gland
Brain
What are the features of SVC syndrome?
Dilated neck veins, dyspnoea, facial and neck oedema and symptoms worsen when raising the arms. Headache may be worse on leaning forwards or lying down, syncope, hoarse voice and dysphagia.
There may be increased risk of thrombosis.
How does SVC syndrome manifest on imaging?
CXR will show widening of mediastinum with right hilar mass. It is managed with steroids ideally in the morning except for SVC caused by lymphoma.
What is the features of Horner’s syndrome?
Horner’s syndrome: ptosis, miosis and anhydrosis
Why does pleural effusion occur in lung cancer?
Pleural effusion due to increased capillary permeability due to a mass near the peripheries which could compress the lymph nodes and reduce clearance
Why does pneumothorax occur in lung cancer?
Pneumothorax due to destruction of the visceral pleural, creating a fistula with the pleural cavity, creating a tension pneumothorax
What is Pancoast syndrome?
Occurs due to a tumor in the superior sulcus, occurring in the apices of the lungs and is most susceptible at T1, where sympathetic nerves supply head, neck and eyes for pupil dilation, raising eyelid and stimulating sweat glands. It leads to:
*shoulder pain
* Horner’s syndrome
* compression of reccurent laryngeal nerve
* atrophy of hand muscles due to C5/6 and T1 motor loss
* evidence of bony destruction
* compression of brachial plexus
It is associated with adenocarcinoma and squamous cell carcinoma.
How does brachial plexus compression present?
occurs with Pancoast tumour with paraesthesia and weakness of upper arm, shoulder pain
How does phrenic nerve compression manifest?
Hemiparesis of right hemidiaphragm causing unilateral decreased chest expansion
What cancer is Pancoast syndrome associated with?
adenocarcionma
Squamous cell carcinoma
What is carcinoid syndrome?
Excessive serotonin due to neuroendocrine tumours, causing systemic vasodilation, leading to flushing, hypotension and increased gut motility, causing diarrhoea, bronchoconstriction, leading to wheezing.
Symptoms include flushing, hypotension, increased gut motility, and bronchoconstriction.
What is a feature of carcinoid syndrome specific to the lungs?
In the lungs, it typically produces histamine, which causes atypical flushing and pruritis.
What is a complication of high serotonin in carcinoid syndrome?
The high levels of serotonin causes excessive metabolism of tryptophan, resulting in high levels of 5-HIAA In urine which is a precursor of tryptophan and leading to low vitamin B3 and resulting in pellagra.
What is Pellagra?
Pellagra is a triad of dermatitis, dementia and diarrhoea, caused by low levels of Niacin (vitamin B3)
How is carcinoid syndrome treated?
It is treated with surgical resection and Somatostatin analogue such as ocreotide to inhibit serotonin.
What is Lambert-Eaton myasthenia syndrome?
A neuromuscular junction disorder associated with reduced acetylcholine release which causes proximal muscle weakness that improves with activity and is associated with small cell lung cancer.
It causes proximal muscle weakness and is linked to small cell lung cancer.
What is the aetiology of lambert-Eaton myasthenia syndrome?
Paraneoplastic syndrome: associated with small cell lung cancer and there is immune mediated destruction of voltage gated Ca2+ channels to prevent acetylcholine release. It is the most common cause of lambert-Eaton myasthenia syndrome.
Non-paraneoplastic syndrome: associated with Graves’ disease and type 1 diabetes
What are the features of Lambert Eaton myasthenia syndrome?
*Proximal muscle weakness that causes difficulty moving from a seated position
*absent reflexes prior to exercise
* autonomic disorder affecting sympathetic and parasympathetic function, causing sluggish pupils with ptosis and diplopia (double vision), dry mouth and erectile dysfunction.
It is managed with acetylcholinesterase inhibitors and treating the underlying cause.
What is limbic encephalitis?
Paraneoplastic syndrome causing inflammation in the limbic system, leading to memory loss, personality change and seizures
It can be associated with various cancers.
Which type of lung cancer is associated with the paraneoplastic syndrome PTH?
Squamous cell carcinoma: PTH-related peptide, that increases reabsorption of calcium ad phosphate diuretics, causing osteoclasts resorption.
It causes hypercalcaemia characteristic features are hypertrophic pulmonary osteoarthropathy with CLUBBING (due to TGF-beta and hyperthyroidism due to ectopic TSH.)
Which type of lung cancer is associated with the paraneoplastic syndrome Lambert Eaton myasthenia syndrome?
small cell carcinoma
Which type of lung cancer is associated with the paraneoplastic syndrome SIADH?
small Cell carcinoma where there is excessive release of ADH, leading to dilutional hyponatremia with high urine osmolality and low serum osmolality.
Which type of paraneoplastic syndrome is assoicated with adenocarcinoma?
- There is increased production of plasma cells which infiltrate skeletal muscle tissue, causing inflammatory myopathy called dermatomyocytis, causing proximal muscle weakness, gottron’s papules on the joints and shawl sign (widespread reddened area over the back.)
- Production of TGF-beta which causes hypertrophic osteoarthropy, gynaecomastia.
- Increases production of pro-coagulants, causing a hypercoagulable state that increases risk of DVT, PE, Stroke, and MI.
What is lymphangitis carcinomatosa?
Lymphangitis carcinomatosa is where tumour spread to the lymph vessels causes inflammation and results in shortness of breath and cough.
What are common indicators of metastatic lung cancer?
- Brain: neurological sequelae (impaired consciousness, memory disturbance and ataxia)
- Liver: palpable liver edge
- Adrenal glands
- Bones: bone pain and pathological fracture
Symptoms include neurological sequelae and bone pain.
What is the management for SIADH caused by lung cancer?
Fluid restriction, demeclocycline, and salt tablets. Hypertonic saline can be avoided to avoid rapid changes in osmolality and osmotic demyelination.
Hypertonic saline should be avoided to prevent rapid changes in osmolality.
What autoimmune condition may decrease acetylcholine production due to damage of voltage gated calcium channels?
Lambert-Eaton myasthenia syndrome
Myasthenia Gravis is characterized by weakness and rapid fatigue of voluntary muscles.
What are the features of spinal cord compression?
Spinal cord compression can occur with back pain or neurological symptoms like weak legs, constipation and urinary incontinence.
Loss of bladder and bowel function is a late sign. There will be upper motor neurone signs like increased tone, weakness, brisk reflexes and extensor plantars.
What are the typical sites of metastasis for lung cancer?
- Brain: neurological sequelae
- Liver: palpable liver edge
- Adrenal glands
- Bones: bone pain and pathological fracture
These sites are commonly affected due to the vascularization of the lungs.
What symptoms can indicate spinal cord compression?
- Back pain
- Weak legs
- Constipation
- Urinary incontinence
Late signs include loss of bladder and bowel function.
What imaging methods are used to identify spinal cord compression?
- Bone scan
- CT
- MRI
- CXR shown blunting of the costophrenic angle
MRI is often the preferred method due to its detailed imaging capabilities.
What is the preferred imaging for diagnosing mediastinal invasion of a tumor?
CT scan with contrast, also for identifiying metastatic lymph nodes
This helps differentiate between tumor invasion and metastatic lymph nodes.
What is the use of PET scan?
PET scan is ideal for assessing distant metastasis and active cancer areas and mediastinal involvement
What are the limitations of PET scans in lung cancer diagnosis?
- False positives can occur with active infections and inflammation
- False negatives can occur in low metabolic activity tumors
PET scans have higher sensitivity and specificity than CT scans but are not infallible.
What is a PAN-CT scan?
PAN-CT scan for the head, chest, abdomen and pelvis
What is essential for the diagnosis of lung cancer?
Biopsy
A biopsy is crucial for confirming the presence of cancer cells.
What types of biopsy methods are used for lung cancer?
- CT guided transthoracic biopsy
- Bronchoscopy
- Needle aspiration
- Thoracentesis
Each method is chosen based on the location and type of tumor.
What is a CT guided transthroacic biopsy used for?
Peripheral lesions with a low risk of pneumothorax
Bronchoscopy for tumours in the lumen
What is needle aspiration used for?
to assess the lymph node
What is thoracentesis used for?
cytology of pleural fluid
What is radiologically guided lung biopsy indicated for?
patients with a new mass, multiple chest nodules and multiple focal infiltrates
What factors indicate suspicion for malignant pulmonary nodules?
- Age over 50
- Smoking history
- Irregular borders
- Asymmetric calcifications
- Enlarged lymph nodes
These factors help determine the likelihood of malignancy.
What is the treatment protocol for non-small cell lung cancer stage 1?
Surgery for resection with lobectomy or pneumonectomy
Early-stage lung cancer is often treated with surgical intervention.
What is the treatment protocol for non-small cell lung cancer stage 2?
surgery with adjuvant chemotherapy -> can includes a Pancoast tumour which should be treated with neoadjuvant chemotherapy (cisplatin and etoposisde)
What is the treatment protocol for stage 3 lung cancer?
spread to lymphadenopathy
-> stage 3a is possible with resection
->3b: chemotherapy only
What is the treatment protocol for stage 4 lung cancer?
metastasis has occurred therefore only chemotherapy or monoclonal antibody therapy and is considered incurable
What is the chemotherapy regimen for lung cancer?
Chemotherapy is Etoposide with cisplatin/carboplatin 3 weekly for 6 cycles.
Second line is combination cyclophosphamide, doxorubicin and vincristine.
When is radiotherapy indicated?
Radiotherapy may be indicated for NSCLC for stage 1-2 with patients that have localised chest disease of stage 1-2 but can be given for allocative radiotherapy.
What is the indication for serial CXR?
30 year or more pack year history or former smoker les than 15 years ago, aged 55-80 year old
What is the treatment for small cell lung cancer?
- Prophylactic chemotherapy
- Radiation to the brain
Small cell lung cancer has a high rate of metastasis and requires aggressive treatment.
What are the contraindications for surgery in lung cancer patients?
- Age over 80
- Low cardiovascular function
- Higher mortality risk with right pneumonectomy
These factors can significantly impact surgical outcomes.
What immunotherapy agents are used for lung cancer?
- PD-1 receptor antagonists (e.g., Nivolumab)
- EGFR inhibitors (e.g., Gefitinib, Erlotinib)
These therapies aim to enhance the immune response against cancer cells.
What is the TNM classification for lung cancer staging?
- T: Tumor size and extent
- N: Node involvement
- M: Metastasis
This classification system provides a standardized way to describe the extent of cancer.
What are common complications of lung cancer?
- Thrombosis
- Paraneoplastic syndromes
- Chemotherapy-induced nausea and vomiting
These complications can significantly affect patient quality of life and treatment outcomes.
What are side effects of chemotherapy for lung cancer?
- Nausea
- Myelosuppression
- Ototoxicity
- Peripheral neuropathy
- Nephropathy
These side effects can vary based on the specific chemotherapeutic agents used.
What is the follow-up protocol for benign pulmonary nodules?
Follow up after a few months
This is to monitor for any changes that may indicate malignancy.
What is the significance of a lung cancer being 1cm in diameter?
It is a criterion for lung cancer screening
Early detection is crucial for improving treatment outcomes.
What is T1?
1= minimal invasive
1A=1cm or less
1B- 1-2 cm
1C=2 to 3cm
What is T2?
2= size between 3cm to 5cm: involves the main bronchus and the visceral pleura with some atelectasis due to inflammation.
2A=3cm to 4cm size
2b= 4cm to 5cm
What is T3?
3= size between 5cm to 7cm, OR the cancer is in more than one lung lobe, chest wall involves the parietal pleura, pericardium or phrenic nerve.
What is T4?
4= size greater than 7cm OR may involve heart, esophagus, diaphragm or trachea
What is N1?
1= involvement of ipsilateral hilar or peribronchial lymph node.
What is N2?
2= involvement of mediastinal lymph node
What is N3?
3= involvement of contralateral mediastinal or hilar lymph nodes
What is M1a?
1a= cancer in both lungs/ pleural lining or pericardial lining
What is M1b?
1b=single area fo cancer in an organ (e.g liver, brain or lymph node)
What is M1c?
1c= multiple organs
