Lung cancer Flashcards
What is the 5 year survival rate for lung cancer?
The second worst of all cancers, first in pancreatic. This is mainly due to most patients being unfit for treatment.
Name the 2 main causes of lung cancer.
Smoking (80ish%) and asbestos exposure (4% mesothelioma - cancer of the pleura). Other causes (6%) include: environmental radon, occupational exposure (excluding asbestos), air pollution and pulmonary fibrosis.
What % of smokers get lung cancer?
10% - more males than females. Over 50% of patients with lung cancer are ex-smokers.
What is the risk of passive smoking?
Increases risk 50-100% in a non-smoker, but this is risk from a very low level.
What are the 2 main pathways of carcinogenesis in the lungs?
Adenocarcinoma and squamous cell carcinoma.
Describe adenocarcinoma.
Cancer of the lung periphery. Bronchioalveolar stem cells become transformed. Associated with newer cigarette formulations and non-smokers. AAH (atypical adenomatous hyperplasia) –> adenocarcinoma in situ –> invasive adenocarcinoma.
Describe squamous cell carcinoma.
Occurs in the central lung airways. Bronchial epithelial stem cells transform. This is the classical pathway and is VERY associated with smoking. Squamous dysplasia –> CIS (carcinoma in situ) –> invasive bronchogenic carcinoma.
Why is it important to differentiate between adenocarcinoma and squamous cell carcinoma?
They have different therapeutic implications.
Define oncogene addiction.
Oncogenes that drive growth of the cancer due to mutation. Most lung cancers are not caused by these.
Give examples of oncogenes found in lung cancer.
KRAS (smoking induced, 35% lung cancers), EGFR (15% lung cancers) –> both good targets for drug therapy. BRAF, HER2 and ALK rearrangements –> 2% prevalence each, not related to tobacco carcinogenesis.
What are the different types of tumours of the lung?
Benign causes (organising pneumonia), carcinoid tumours (low grade malignancy), bronchial gland tumours (very rare), lymphoma and sarcoma. Mets in the lung are common.
What are the 4 main types of carcinoma?
Squamous cell, adenocarcinoma (most), small cell (oat cell) and large cell.
What are the 2 histological types of carcinoma?
NSCLC’s (non-small cell 85%) and SCLC (small cell 15%).
Can lung cancers be surgically resected?
Only 10% can, but resection cures 50% on these. Generally, symptomatic lung cancer is fatal.
Describe local effects of lung cancer.
1) Bronchial obstruction (endogenous lipid pneumonia, abscess, bronchiectasis, haemoptysis), 2) Pleural (inflammatory), 3) Direct invasion (chest wall, nerves: phrenic - diaphragmatic paralysis, L recurrent laryngeal - hoarse, bovine cough as this supplies the larynx, brachial plexus - pancoast T1 damage, cervical sympathetic - Horner’s syndrome, mediastinum - SVC), 4) Lymph node mets (lymphangitis carcinomatosa - tumour spreading throughout the lymphatics of the lung)
Describe distant effects of lung cancer.
Distant mets (liver, adrenals, bone skin), neural effects, vascular effects. Paroneoplastic effects: clubbing, endocrine disorders, neurological, cutaneous (dermatomyositis), CV, renal.
Which investigations are used in lung cancer?
CXR, bronchoscopy, trans-thoracic fine needle aspiration or core biopsy, pleural effusion and advanced imaging techniques (CT, MRI, PET).
Name the prognostic factors for lung cancer.
Stage, classification, gene expression, growth rate, DNA aneuploidy, immune cell infiltration. Prognostic markers may be used to select patients for adjuvant therapy.
What is the prognosis for lung cancer?
Less than 9-9% 5YS in Scotland. If cancer is operable at stage 1, 60% 5YS. If cancer is operable at stage 2, 35% 5YS. If cancer is inoperable, treatment is always palliative.
Describe the different prognoses with different lung cancer types.
Pure bronchioalveolar carcinoma - 100% 5Ys. NSCLC - between 10 and 25%. SCLC - worst prognosis, 4% 5YS, responds to chemo but always comes back.
What are the predictive biomarkers for adenocarcinoma?
KRAS, EGFR, ALK rearrangements, BRAF and HER2 (drugs against ALK and EGFR approved in Scotland).
What are the predictive biomarkers for squamous cell carcinoma?
FRFR1 copy number, DDR1 and FGFR2 (no good drugs - use cytotoxic chemo).
Why is lung cancer so important?
Most common malignancy. More people die from LC than breast, colorectal and prostate cancers combined. NSCLC doubling time is 129 days, SCLC doubling time is 29 days.
Describe TNM staging.
T - tumour size. N - nodal involvement. M - distant metastases. Tx: primary tumour cannot be assessed. T0: distant mets found but no evidence of primary tumour. Tis: carcinoma in situ. T1: no invasion or involvement of main bronchus, 3cm 5cm 7cm, tumour in carina, diaphragm, heart etc. No: no regional node involvement. N1: ilselateral hilar/peribronchial. N2: ipselateral mediastinal/subcarinal (on same side). N3: contralateral mediastinal/ hilar/scalene/supraclavicular (different side) (N STAGING BEST SEEN ON PET CT). M0: no mets. M1: mets. M1A: intrapulmonary mets/malignant pleural effusion. M1B: single distant mets. M1C: multiple distant mets.
Describe ECOG (Eastern Co-operative group) performance measurement.
Measures the patients ability to care for themselves. 0 - asymptomatic, well. 1 - symptomatic, can do light work. 2 - has to rest for less than 50% of the day, cannot work. 3 - has to rest for over 50% of the day, limited self-care. 4 - bed bound. Over stage 2?Most of the time cannot give chemotherapy.
What is adjuvant therapy?
A therapy given post-operatively to increase the change of cure/reduce risk of cancer coming back.
What is neoadjuvant therapy?
Administration of therapeutic agents before a main treatment to increase survival - eg. pre-operative chemotherapy.
What defines advanced disease in NSCLC?
Around 80% present with advanced disease. Stage 3: locally advanced, mediastinal/major vessel invasion or mediastinal lymph node involvement. Stage 4: 60% have distant metastases.
What is the benefit of chemoradiotherapy for NSCLC?
Increases survival. For stage 4 NSCLC RT and chemo give 70% symptom benefit. Need to measure QOL - bone pain can occur from distant mets which is often worse at night (pathological fractures).
What is the 1YS for stage 3 & 4 NSCLC?
40%.
Name new treatments for NSCLC.
Premetrexed (maintenance chemotherapy), TK inhibitors (mAb, BR21 (in patients unfit for chemo), PD1 inhibitor (nivolumab BMS).
What is different in presentation of SCLC?
Secondary syndromes: SIADH (low Na which causes confusion), ACTH (Cushings) etc.
What is the treatment of choice for SCLC?
Chemotherapy (cisplatin and etoposide), thoracic RT or prophylactic cranial radiation (PCI). For limited disease: response rate to treatment 90%, complete remission 60%, 2YS 25%. For extensive disease: brain mets RT and steriods, survival with treatment is 8 months.
What is the major challenge of lung cancer?
80% of patients are diagnosed too late to cure. Survival rate has not changed much since 1970.
What are the common causes of a solitary pulmonary nodule?
Primary LC’s, mets, infection (TB or pneumonia) or pseudotumours (pulmonary fluid that looks like a tumour).
What are less common causes of a solitary pulmonary nodule?
Lymphoma, mesothelioma, carcinoid (slow growing neuroendocrine tumour) (malignant), hamartoma (focal malformation) or chondroma (cartilaginous) (benign).
What are the most common symotoms of LC?
SOB, chronic cough, haemoptysis, weight loss, fatigue, chest pain (recurrent and persistent).
What are less common symptoms of LC?
Wheeze, dysphagia, hoarse voice, fever and facial swelling.
What are common symptoms of metastatic LC?
Bone pain, spinal cord compression (limb weakness, paraesthesia), cerebral symptoms (headache, vomiting).
Name some paraneoplastic syndromes associated with LC.
SIADH (low Na - hyponatraemia), hypercalcaemia, dermatomyositis (VERY associated with malignancy), Eaton-Lambert (upper limb weakness). Patient showing these symptoms? Worse prognosis.
What is a pancoast tumour?
Tumour of the pulmonary apex. Present as Horner syndrome sometimes and can affect the brachial plexus.
Name common clinical signs of LC.
Reduced breath sounds on 1 side, chest infections, dullness of percussion, finger clubbing, Horner’s (damage to sympathetic nerves on 1 side of neck), pancoast, SVC obstruction, lymphoadenopathy, hepatomegaly (enlarged liver), skin nodules etc.
Describe paraneoplastic syndromes associated with certain LC’s.
SMALL CELL: SIADH, Cushings, Eaton-Lambert, SVC and carcinoid. NON-SMALL CELL - squamous: hypercalcaemia, pancoadt, Horner’s. Adenocarcinoma: hypertrophic osteoarthropathy (bone pain in arms and legs). Large cell: gynecomastia SVC syndrome.
What is the most important first line investigation?
CT scan. Others are CXR, PET, isotope bone scan and head CT (usually CXR then CT).
What is stereotactic RT?
Targeted RT.
Name 3 red-flag symptoms of LC.
Smoker/ex-smoker, weight loss, haemoptysis.
What is the difference between a pulmonary nodule and a pulmonary mass?
Nodule: opacity less than 3cm with no mediastinal adenopathy or atelectasis (incomplete inflation or partial collapse of lung). Mass: opacity over 3cm with no mediastinal adenopathy or atelectasis.
When deciding to give treatment, what needs to be taken into consideration?
Performance status and pulmonary function.
Describe FDG-PET.
FDG is a labelled glucose analogue. Tumour cells take it up as they are very metabolically active but cannot expel it.
Where are the most common places for LC’s to metastasise?
Cerebral, skeletal (symptoms), adrenal and liver (no symptoms).
What may blood test results show on a patient with LC?
Anaemia, abnormal LFT’s and abnormal bone profile.
Name 4 pulmonary function tests that would be be performed before surgery.
Spirometry, diffusion studies, ABG and fractioned V/Q scan.
Which cardiac tests would be performed to determine if the patient is fit for surgery?
ECG, ECHO, CT and corinary angiogram.
What is the most common post-op cause of death from LC surgery?
Bronchopneumonia.
What is the operative mortality from LC surgery?
Pneumonectomy: 8-12%. Lobectomy: 3-5%. Wedge resection: 2-3%. Open/close thoracotomy: 5%
