Lung Cancer Flashcards
What are the histological types of lung cancer?
Squamous Cell (40%) Adenocarcinoma (41%) Small cell (15%) Large Cell (4%) [So NSCLC 85%] Adeno tends to be peripheral & squamous central
What other less common types of lung cancer are there?
Sarcoma Lymphoma Carcinoid Tumour Bronchial Tumour Metasteses from elsewhere
What are the causes/risk factors for lung cancer?
85% attributable to Smoking Asbestos Enviromental Radon Other Radiation Air Pollution Pulm. Fibrosis
Where does Lung Cancer commonly metastasise to?
Bones Lymph tissue Adrenals Liver Brain Skin
What are the symptoms of Lung CanceR?
Haemoptysis Dyspnoea Chest & Bone Pain Wheezing Dysphagia Weight Loss Chronic Cough Recurrent Chest Infections Shoulder Pain (Pancoast Tumour)
What are the clinical signs of Lung Cancer?
Hoarse Raspy Voice (L recurrent laryngeal nerve compression)
Clubbing (distinguishes LC from TB)
Lymphadenopathy
Horner’s Syndrome (Cervical Ganglion compression)
Hepatomegaly
Skin Nodules (Metastases)
SVC Obstruction (Face/neck swelling + pumped veins)
What are the possible complications of lung cancer? (warning: lots ahead)
Bronchial Obstruction:
- Lobar Collapse
- Bronchiectasis
- Infection/Endogenous Lipid Pneumonia)
- Abscess
Pleural:
- Pleurisy
- Malignant Invasion
- Effusions/Empyema
Mediastinal:
- SVC obstruction
- Phrenic compression (diaphragm paralysis)
- L recurrent Laryngeal Nerve (Hoarse voice & bovine cough)
- Brachial Plexus (loss of sensation/function in limb)
- Cervical Ganglion (Horner’s Syndrome)
Paraneoplastic Syndromes (Neuroendocrine)
Explain Neuroendocrine complications of Lung Cancer?
Some tumours can release hormones.
Squamous:
Parathyroid Hormone (PTH) -> Decrease in bone calcium & increase in blood calcium -> Fractures, hepatopathy (abdominal pain), constipation, confusion etc
Small Cell:
ADH (antidiuretic) -> Decrease Diuresis plus bodt loses more Na to cope -> Hypertension & diabetes insipidus
ACTH (Adrenocorticotropic) -> Excess CCS -> Immunesuppression -> Ectopic Cushings Syndrome
How is Lung cancer investigated?
Initial Investigations - GP:
CXR - FBC - Serum Calcium (Squamous paraneoplastic) - Bone profile - Clotting Screen - Spirometry - U&E + LFT
Tissue Diagnosis: Bronchoscopy EBUS Lung & liver biopsy FNA Bone Biopsy Explorative Thoracotamy Mediastinoscopy/otomy (smaple mediastinal nodes) Aspiration of pleural effusion
Cardiac Assessment:
CT - MRI - ECHO - ETT - ECG - Coronary Angiogram -
PET(metastases, normally pre-surgery)
What factors affect prognosis?
Stage
Class/Type
Biomarkers
Performance Status
What do we do to assess fitness for surgery?
Spirometry V/Q Scan ABG Diffusion studies Cardiac Assessment PET scan to check for metastases (using FDG glucose analogue)
What predictive biomarkers are there?
Adenocarcinoma - EGFR/KRAS/HER2/BRAF
Squamous - FGFR1/DDR2/FGFR2
What complications are there from surgery?
Empyema Pleural Effusion Pneumothorax Intra-thoracic Bleeding Wound Pain & Infection ARDS Bronchopneumonia MI Pulmonary Thromboembolism
How is a cancer staged?
T = Size and degree of invasion
N = Lymph Node involvement
M = Metastases
Performance status & pulm function are also involved
What difficulties are there with staging?
Other nodules due to TB, abscess, granuloma, fibrosis, paraffinama, benign tumour
Lobar collapse can make the tumour hard to see
What factors influence treatment?
Performance Status Wishes Stage & Type Radical vs Palliative Co-morbidities
What is performance status?
0 - No symptoms and fully mobile 1 - Symptomatic but mobile 2 - Up an about >50% of day -- cant work 3 - Up an about <50% of day -- Limited self care 4 - Bed or chair bound
What are the possible treatments for lung cancer?
Surgery
Radiotherapy
Chemotherapy
Best Supportive & palliative
What types of radiotherapy are there?
Radical (curative)
Palliative (control spread & symptoms)
Stereotactic (targeted brain radiotherapy)
What types of chemo are there?
Different for different cancer:
Adeno- and Small cell = cisplatin/pemetrexed
Squamous = cisplatin/gemcitabine
Targeted Agents:
EGFR (adenocarcinoma mutation) inhibitors:
Monoclonal Antibodies e.g. Cetuximab
Tyrosine Kinase Inhibitors e.g. Erlotinib
ALK translocation inhibitor (Adenocarcinoma):
Crizotinib
Whats involved in palliative care?
Suppressive Chemo & radiotherapy
Treatment of complications e.g. hypercalcaemia & hyponatramia
Community Support
Planning for end of life
What are the levels of N and T?
N1- Hilar/intrapulmonary/contralateral mediastinal
N2- ipsilateral mediastinal/subcarinal
N3- supraclavicular/contralateral hilar or mediastinal/scalene
Tis - abnormal cells Tx - Primary tumour cant be assessed T0 - No primary tumour T1 - <3cm T2 - <5cm T3 - <7cm T4 - 7cm
How is NSCLC treated in stage 1-3?
- Neo-Adjuvant chemo or radiotherapy to shrink the tumour pre-op
- Adjuvant chemo or RT as a insurance policy against any tumour cells that might have been left behind
- Radical RT, can cause fibrosis & inflammation so need good Pulm Function Results to do it
- Chemo, usually + RT gives better survival rate
How is stage 4 NSCLC treated?
Incurable
Palliative RT - Reduces symtpoms & complications from primary tumour. Useful for bone metastasis too.
Palliative Chemo - Does same thing, ideally give pemetrexed and RT if the pateint is healthy enough
Surgery - remove metastasis pressing on spinal cord and prevent paraplegia
Targeted treatment - Certain mutations can be targeted specifically e.g. EGFR = Erlotinib and ALK translocation = crizotinib
Immunotherapy
How is small cell lung cancer treated?
With combination chemo as palliative care
