Lung Cancer Flashcards
What percentage of lung cancer is attributable to smoking?
> 85%
10% of smokers get lung cancer
Risk factors for lung cancer?
Tobacco Asbestos Environmental radon Occupational exposures - chromates, hydrocarbons, nickel Air pollution Radiation Pulmonary fibrosis
Tobacco
- epithelial effects
- multi-hit theory
- host activation of pro-carcinogens
What are the different types of lung cancer?
Small cell (15%) and non small cell (85%)
Non small cell:
- adenocarcinoma (41%)
- squamous cell carcinoma (40%)
- large cell carcinoma (4%)
Often hard to distinguish between non-small cell typers
What are the general symptoms of lung cancer?
Chronic cough Haemoptysis Wheeze Chest/bone pain Chest infections Difficulty swallowing Raspy, hoarse SOB Weight loss
What symptoms may suggest metastatic disease?
Bone pain Thrombosis Nerve symptoms (from spinal cord compression) - limb weakness, paraesthesia - bladder/bowel dysfunction
Cerebral metastases
- headache
- vomiting
- dizziness, ataxia
- focal weakness
Symptoms of paraneoplastic syndrome?
Hyponatraemia - siADH (syndrome of inappropriate ADH secretion) Anaemia Hypercalcaemia - PTH related protein, bone metastases Dermatomyositis/polymyositis - proximal muscle weakness Eaton-Lambert syndrome - upper limb weakess Cerebellar ataxia Sensorimotor neuropathy
Clinical signs of lung cancer?
Chest signs Clubbing Lymphadenopathy Horner's syndrome Pancoast tumour SVC Obstruction Hepatomegaly Skin nodules (metastases)
Beware lobar collapse that fails to resolve in 2-3 weeks in a smoker >45
SCLC has neuroendocrine symptoms and doubles every 29 days (vs 129 days in NSCLC)
What investigations might you do in suspected lung cancer?
CXR (then CT) FBC Sputum cytology rarely Spirometry Tissue diagnosis - broncoscopy with biopsy - EBUS - bone biopsy - mediastinoscopy/otomy - VATS - surgical excision biopsy
Renal/liver function and calcium
Trans-thoracic fine needle aspiration
Trans-throacic core biopsy
Advanced imaging
- CT, MRI, PET
How is cancer staged?
Tumour
Nodes
Metastases
Tumour relates to size
Nodes relates to lymph node involvement
Metastases absent (0) or present (1)
Overall stage grouping into stage 0, I, II, III, IV
0 - carcinoma in situ
I - cancer localised and small-medium
II - locally advanced, local node involvement
III - distal node involvement and increased size/direct invasion
IV - metastases
What type of treatments are available in lung cancer?
Surgery
Radiotherapy
Chemotherapy
Palliative
What surgical procedures are used in lung cancer?
Performed in 18% of patients. Survival much better if possible.
Wedge resection
Lobectomy
Pneumonectomy
Curative resection is the goal
Firm diagnosis of malignancy highly desirable before resection
What radiotherapeutic options are there in lung cancer?
Radical radiotherapy
Palliative radiotherapy
Stereotactic radiotherapy
Adjuvant RT detrimental in stage I/II
What chemotherapeutic options are there in lung cancer?
As part of radical or palliative treatment.
Alone or combined, adjuvant
Targeted cells e.g. with TKIs, monoclonal Abs
Adenocarcinoma - cisplatin/pemetrexed
Squamous - cisplatin/gemcitabine
Small cell - cisplatin/etoposide
Survival in NSCLC better than with RT alone.
In stage III/IV, 3 rounds of chemo are as good as 6
All about QOL
Maintenance therapy with pemetrexed improves survival by 3-5 months
What factors affect treatment in chemotherapy in lung cancer?
Performance status
Patient’s wishes
Histological type and stage
Aims e.g. radical or palliative
What are the details of palliative care in lung cancer?
Symptom control May include chemo or radiotherapy Opiates, Benzodiazepines Treatment of cancer side effects QOL, community support
What factors are considered in determining if a patient is fit for surgery?
CVS - any heart problems? or PMH of stroke, angina etc.
Respiratory issues - asthma? barrel-chested, O2 treatment? recent URTI?
Psych - mental illness? social background?
Other - PAH, permanent tracheostomy, RA, immobile?
What prognostic makers might be used to select patients for adjuvant therapy in lung cancer?
Adenocarcinoma - EGFR, Kras, BRAF, ALK translocations
Squamous cell - FGFR1 gene copy number, DDR2 and FGFR2 mutations
What factors are considered in prognosis of lung cancer?
Stage Classification Markers/oncogenes/gene expression Growth rate DNA aneuploidy Immune cell infiltration
NSCLC Stage IV is incurable
RT to primary tumour has 70% symptom benefit
What are some reasons for peri-operative death in lung cancer?
ARDS Bronchopneumonia MI PE PTX Intrathoracic bleeding
What are some non-fatal complications in surgery for lung cancer?
Post-thoracotomy wound pain Empyema Bronchopleural Fistula Wound infection AF MI Post-op respiratory insufficiency Gastroparesis/constipation
What are the two main pathways of carcinogenesis in the lung?
In the lung periphery
- bronchialveolar epithelial stem cells transform into adenocarcinoma
- this process is less strongly (but still) associated with smoking
In the central airway
- bronchial epithelial stem cells transform
- squamous cell carcinoma
What are some local effects of tumours in the lungs?
Bronchial obstruction
- collapse, lipoid pneumonia, infection/abscess, bronchiectasis
Pleural inflammation/malignancy
Direct invasion of chest wall/mediastinum/lymph node metastases
Effects on nerves
- phrenic = diaphragmatic paralysis
- L recurrent pharyngeal = hoarse, bovine cough
- brachial plexus = pancoast, T1 damage
- cevical sympathetic = Horner’s syndrome
Pleural effusion
What are some distant effects of lung cancer?
Distal metastases - liver, adrenals, bone, brain, skin
Clubbinb Cutaneous (dermatomyositis) Endocrine - small cell especially for ACTH, siADH - squamous especially for PTH Haematologic (granulocytosis, eosinophilia) CV issues Nephrotic syndrome Neurological
