Lung Cancer Flashcards
General features of cancer
malignant growth, uncontrolled replication, local invasion, metastases, non-metastatic effects
Another name for non-metastatic effects?
paraneoplastic syndrome
What are non-metastatic effects?
rare, non-metastatic manifestations of malignancy mediated by hormones, cytokines or antibodies
Prognosis of lung cancer?
90% incurable at the time of lung cancer diagnosis
50% dead after 6 months
Potential reasons for poor lung cancer prognosis
Poor health at the time of diagnosis prevents treatment
Co-morbidities
Tends not to cause symptoms until advanced or metastatic
Potential Red Flags for Lung Cancer (8)
cough for 3 weeks or more haemoptysis breathless for no reason recurrent or unresolved chest infections unexplained weight loss chest or shoulder pain unexplained tiredness or lack of energy hoarse voice
Differential diagnosis of haemoptysis
TB, Pneumonia, Aspergillus, Lung Cancer
Haemoptysis presents in around 70% of patients with lung cancer - true or false?
true
Patients presenting with haemoptysis should be _______ and sent for _____
referred, CT scan
Any ___ patient with pneumonia has a repeated xray after ______. If this is not resolved then the patient should be referred to CT.
50+, 6 weeks
On an xray, the affected lung may…
lose volume and appear smaller
Stridor (in context of lung cancer)
swelling in the airway due to tumour pressing on bronchioles
Common sites of local invasion in lung cancer (6)
recurrent laryngeal nerve pericardium oesophagus brachial plexus pleural cavity SVC
What is the result of a tumour pressing on the recurrent laryngeal nerve?
hoarse voice
may cause the vocal cord not to move
What are the issues surrounding pericardial invasion by a tumour?
breathlessness atrial fibrillation pericardial effusion dysrhythmias - tamponade poor cardiac output
Tumour invasion of the oesophagus causes…
dysphagia
Pancoast tumour
apical lung cancer invading the brachial plexus
Symptoms of pancoasts tumour
pain, muscle wasting, sensory loss, weakness - occurring gradually in ipsilateral arm
Invasion of the pleural cavity causes…
pleural effusion - could contain answer if this is first presentation
Presentation of pleural effusion on examination
dull percussion
low - no breath sounds
white xray
Presentation of SVC obstruction due to lung cancer?
distension of jugular vein
pressure headaches and blurry vision
superficial veins
How might SVC obstruction be relieved in lung cancer?
stent or chemotherapy
Chest wall invasion can cause…
erosion of ribs, nerves and arteries
type of pain associated with chest wall invasion?
neuropathic burning sensation,
worsened by movement
localised
often described as worse at night
The patient is at risk of _______ _______ if the tumour starts to invade the pulmonary artery. This type of tumour may erode through the artery and the ________ to cause a sudden death due to massive _______.
Pulmonary embolis
bronchus
haemoptysis
Common sites of metastases in lung cancer (6)
liver brain bone adrenal skin Lung
Features of cerebral metastases in lung cancer
Gradual onset of: Weakness visual disturbance headaches fits
Features of headaches due to metastases?
worse in the morning
worse with sneezing
not photophobic
due to increase in ICP
Treatment for cerebral metastases?
high dose corticosteroids i.e. dexamethasone (ICP)
radiotherapy (tumour)
chemotherapy (tumour)
Particularly abnormal in Liver Metastases?
Alkaline Phosphatase
Clinical presentation of bone metastases?
non-specific ache away from joint
unusual pain
fracture during trivial mechanical stress
localised pain worse at night
Metastases in the adrenal glands ______ cause symptoms but are indicators of ________ disease
don’t
advanced
A CT is unable to determine if a growth on the adrenal gland is a benign adenoma or cancer. In lung cancer patients, why is it important to determine whether it is?
It is important to establish whether they can undergo further treatment.
Non-metastatic signs of lung cancer (7)
finger clubbing hypertrophic pulmonary osteoarthropathy weight loss thrombophlebitis hypercalcaemia hyponatraemia weakness
Other causes of finger clubbing (not lung cancer)
liver disease - hep C
congenital cyanotic heart disease
bacterial endocarditis
bronchiectasis
What is hypertrophic pulmonary osteoarthropathy?
inflammation and expansion of the outer layer of bone
Presentation of hypertrophic pulmonary osteoarthropathy?
pain and tenderness of long bones due to elevation of the periosteum away from the bone surface
Weight loss is very non-specific. What histories are required to understand weightloss in the context of lung cancer?
GI
Resp.
Bones
Age
What is thrombophlebitis?
inflammation of the veins - very common
What is the cause of thrombophlebitis?
increased coagulability of blood
What is hyponatreamia and how does it present?
low sodium causing confusion
Weakness is presented as Eaton Lambert Symdrome. This mimics…
myaethenia gravis which resolves if primary tumour is resected
I have a history of a cough, you ask…
How long has this occured? Do you produce sputum? What colour is the sputum? Do you always have a cough? Is there anything else associated with the cough?
Patients rarely volunteer information about…
haemoptysis
I come to you having coughed up some blood, what do you ask?
How much blood was it?
Has this happened before?
What colour is it, fresh red or dark red?
You are taking a history and I reveal I am a cigarette smoker, what questions might you ask?
How long have you smoked?
How many a day?
Am I thinking of stopping?
If you have stopped, how long and how many did you smoke?
Differential diagnosis for breathlessness?
PE, Pleural effusion, pericardial invasion, COPD, infection, lung cancer
On examination in a patient you might be concerned about lung cancer, what are you look, listening and feeling for?
finger clubbing cough bloated face lymphadenopathy dull percussion enlarged liver breathlessness weightloss hoarse voice tracheal deviation stridor
What investigations are common when investigating a potential lung cancer?
FBC Spirometry - FEV1 CXR CT of thorax PET scan Bronchoscopy Endobronchial Ultrasound
What do you not test for when looking for lung cancer?
sputum cytology
Which FBCs and bloods do you need in lung cancer suspect?
FBC
Na, K, Ca, Alk Phos
LFTs
Coagulation screen
What areas do you expect to light up in a PET scan?
Bladder and brain
highish in liver and spleen
Differential diagnosis in a smoker with haemoptysis and abnormal CXR
Lung cancer TB Vasculitis PE Secondary cancer Lymphoma Bronchiectasis
What needs to be considered with CT guided biopsy?
if lung is healthy enough to withstand 10% chance of pneumothorax
Options for obtaining a tissue diagnosis?
bronchoscopy CT guided biopsy Lymph node aspirate aspiration of pleural fluid EBUS Thoracoscopy
Benign neoplasm in the lung
hamartoma
Why are metastases in lung cancer very common?
the lungs get all the blood so it is easy for the cells to get around the body
What are common clinical presentations of patients experiencing the local effects of lung cancer?
obstruction of the airway (pneumonia)
invasion of the chest wall (pain)
Ulceration (haemopytsis)
4 common types of lung cancer
adenocarcinoma
squamous carcinoma
small cell carcinoma
large cell carcinoma
TNM staging is used for lung cancer…what does this stand for?
Tumour
Nodes
Metastases
What role does immunohistochemistry have to play in identifying cancer?
can identify specific expression of tumour suppression factors or oncogenes for targeting via drugs
What is mutated in the marjority of adenocarcinomas particularly in non-smokers and asian populations?
EGFR
What is Lambert-Eaton Syndrome?
Paraneoplastic syndrome - weakness that mimics myaesthenia gravis but resolves if primary tumour is resected.
How much fluid does the pleura normally contain?
4ml
How much pleural fluid is needed to be visualised on an x-ray?
200ml
What type of pleural effusions should cause concern?
large unilateral effusions
Investigates for a pleural effusion might be?
PA CXR Pleural Aspirate Biochemistry Cytology Culture ?CT chest
If you are unusure if the opacity is fluid on the CXR what can you do?
repeat CXR while patient is on their side, the fluid will move and create a straight line at the top
What might you suspect with straw-coloured effusion?
heart failure or hypoalbunaemia
What might you suspect with blood in the effusion?
malignancy, trauma, infection, infarction
What might you suspect with a milky or turbid effusion?
empyema, chylothorax
Transudates are…
protein <30g/L
Exudates are…
protein >30g/L
Transudates are associated with…(5)
HF Liver Cirrhosis Hypoalbuminaemia Atelectasis Peritoneal dialysis
Exudates are associated with…(4)
Malignancy
Infection incl. TB
Pulmonary infarct
Asbestos
A pH of less than 7.3 suggests…
pleural inflammation i.e. malignancy or RA
A pH of less than 7.2 must…
be draind
Where would glucose be expected to be low in an effusion?
Infection, RhA, Malignancy, oesophageal rupture, SLE
What two types of non-malignant cell type may be present in an effusion?
lymphocytes - TB, malignancy
Neutrophils - acute onset
apart from asbestos workers, who may also get mesothelioma?
people associated with those who worked with asbestos
how long does mesothelioma take to develop?
30-40 years post exposure
Symptoms that may present with mesothelioma (6)
breathlessness; chest pain; weight loss; fever; sweating; cough
Investigations in mesothelioma?
Imaging
Pleural fluid aspiration
Biopsy
Treatment options include:
Pleurodese effusions; radiotherapy; chemotherapy; surgery; palliative care
What might be done to relieve pleural effusions as a result of mesothelioma?
Talc slurry
Long term pleural catheters
Complications in the use of talc slurry (6)
pleuritic pain; fever; pneumonia; resp. failure; talc pneumonitis; secondary empyema
Complications of long-term pleural catheters (3)
incorrect placement; bleeding; infection
Which cancers particularly metastasise to the pleura?
lung; breast; upper GI; lymphoma; melanoma; ovarian
Median survival for mesothelioma
3-12 months
What score is used for predicting survival in mesothelioma?
LENT
L in LENT…
LDH in pleural fluid
<1500 = 0
>1500 = 1
E in LENT…
ECOG PS - functioning in daily life 0=0 1=1 2=2 3-4=3
N in LENT
Neutrophil to lymphocyte ratio
<9 = 0
>9 = 1
T in LENT
Tumour type Lowest Risk (0); meso, haematological Medium risk (1); breast, gynae, renal HIgh risk (2); lung, other types
