Lung cancer Flashcards
Symptoms suspicious of lung cancer
- • Cough - that doesn’t go away or a long standing cough gets worse
- • Recurrent infections
- Breathlessness – lobar/lung collapse (co-existing COPD)
- Haemoptysis
- Unexplained weight loss
- Chest and/or shoulder pains
- Hoarse voice
Risk factors
Smoking in 85% Passive smoking, occupational asbestos, silica and nickel exposure, pulmonary fibrosis
Investigations
Aims of Investigation
- To make a diagnosis – NSCLC or SCLC
- Stage the disease
- Assess fitness to undergo treatment
Most Common Investigations
- Routine bloods – FBC, U+E, LFTs, serum calcium, CRP
- Imaging
- • CXR
- CT chest and upper abdomen – look for lymph nodes, evidence of liver or adrenal metastases
- CT / Positron emission tomography (CT-PET) - combined imaging to look for metastases
- Tissue diagnosis
- Bronchoscopy – will detect more central lesions
- Percutaneous needle aspiration and biopsy – CT guided – for peripheral lesions
- Other techniques
- Endobronchial ultrasound – to visualize and guide needle biopsy of mediastinal lymph nodes
- Ultra-sound guided aspiration of supraclavicular lymph nodes
- VATS (video-assisted thoracoscopic surgery) – to diagnose and treat pleural effusions
Assessing fitness for treatment
Lung function tests – need full PFTs if considering surgery (for surgery generally need an FEV1 > 1.5 litres)
CXR changes in lung cancer
• Mass lesion • Pleural effusion • Lobar or lung collapse • Slowly resolving consolidation • Mediastinal widening or hilar lymph nodes • Normal
Histological classification
Non small cell carcinoma - better prognosis Small cell carcinoma
Non small cell carcinoma subtypes
• Squamous cell (40-60%) - closely linked to smoking history, keratinization and/or intercellular bridges on histology, central airways, high frequency of p53 mutations • Adenocarcinoma (10 -20%) - arises from mucus producing cells within bronchial epithelium,, most common form in women and non-smokers, more peripherally located, TTF-1 positive, if EGFR mutations present may benefit from treatment with EGFR inhibitors • Large cell (5-15%) - undifferentiated epithelial tumour
Staging of non small cell carcinoma
• T – tumour size • N – regional lymph node involvement • M – presence or absence of distant metastases TNM used together to give stage of disease
histology of small cell carcinoma
- usually central -Arise from APUD cells (amine - high amine content, Precursor uptake- high uptake of amine precursors, decarboxylase - high content of enzyme decarboxylase) - associated with ectopic ADH, ACTH secretion
Staging of SCC
Staged as Limited or Extensive disease Limited disease – confined to one hemithorax and the ipsilateral supraclavicular fossa (30%) Extensive disease – all other patients (70%)
prognosis of SCC
Without treatment: survival 2-3 months in limited disease, 4 weeks in extensive disease With treatment: Limited disease survival 15 – 20 months, 10 -13 % 5 year survival Extensive disease – 8 -13 months median survival, 1-2% survive 5 years
Treatment of non small cell carcinoma
Surgery - early stages (Stage I or II)
Radiotherapy
- Curative intent (radical radiotherapy) in some with early stages if not thought to be fit for surgery
- Side effects – radiation pneumonitis in 10 – 15 %, radiation fibrosis around oneyear after
- symptom control (palliative radio) - good for bone chest and chest wall pain, haemoptysis, occluded bronchi and SVCO
Chemotherapy
- platinum based chemo (cisplastin/carboplastin) in combination with pacilatxel
- can be used to down stage tumours for surgery or to palliate symptoms
Small cell carcinoma treatment
Limited Stage – chemotherapy (cisplatin and etoposide/irinotecan) and radiotherapy
Extensive disease - chemotherapy (carboplatin and etoposide or irinotecan) 4-6 cycles of etopside + ciplatin or carboplatin
Other Treatments
- Endobronchial treatments – laser, stents to deal with tumour obstructing large airways
- Palliative care – opiates to treat pain and breathlessness (important as lung cancer often diagnosed at an advanced stage in patients with other health problems e.g. COPD, IHD
Metastatic lung cancer common sites
- Lymph nodes – mediastinal (causing superior vena caval obstruction),cervical, axillary
- Pleural effusion
- Liver
- Bone - bone pain, may cause spinal cord compression
- Brain
- Adrenals
Common non-metstatic manifestations of lung cancer (paraneoplastic syndromes)
Disease or symptoms cause by cancer but not due to local presence of cancer cells.
Mediated by the hromones or cytokines produced by cancer cells or by an immune response against the tumour.
- Metabolic – weight loss, anorexia, lassitude
- Endocrine -
- SIADH -small cell - concentrated urine, no hypovolaemia, oedema or diuretics
- ACTH (cushings) - small celll -PTH- squamous cell - Hypercalcaemia - parathyroid-related peptide, bony metastases
- Neurological - Eaton Lambert syndrome-affects proximal limbs and trunk with autonmic involvement (dry mouth, constipation) (pre-synaptic calcium channel absence)
- -Neuropathy (antibodies against the myelin sheath)
- Dermatological dermatomyositis (heliotrope rash on eye lids, purple papules on knuckles)
- Cutaneous -Finger clubbing -Hypertrophic osteoarthropathy
- Gynaecomastia -acanthosis nigricans -Erythema gyratum repens
- Rarely – vascular, haematological and cutaneous effects
