Lung Cancer Flashcards
What percentage of lung cancer is incurable at time of diagnosis?
90%.
What can lung cancer present by (symptoms/signs)?
Haemoptysis (tumour blood supply chaotic and often breaks down), recurrent pneumonia (x-ray 6 weeks after pneumonia), stridor, shortness of breath (due to tumour taking up alveolar space or blocking airway).
Where can a lung cancer locally invade?
Recurrent laryngeal nerve (gives hoarse voice), pericardium (breathless, atrial fibrillation, pericardial infusion), oesophagus (dysphagia [cant swallow]), pancoast tumour invades branchial plexus (causes muscle wasting and heavy weak arm), pleural effusion, superior vena cava obstruction (veins pop out and dilate, treated with stent), chest wall (causes pain [mix between pleuritic and MSK] and lump), encasing left pulmonary artery (sometimes tumour erodes into artery and major bronchus, causing sudden death due to massive haemoptysis).
Where are the most common sites for metastases in bronchial carcinoma?
Liver, brain, bone, adrenal, skin and other parts of lung.
What kind of onset of cerebral metastases, what are some of the symptoms or cerebral metastases and how long does it take to develop?
Insidious onset. Weakness, visual disturbance, headaches that are worse when intra-cranial pressure is greater [worse in the morning, not photophobic], fits). Some weeks.
When do liver metastases cause symptoms and what sort of pain do they cause and where?
When they are quite large, stretching pain, in right upper quadrant.
What can bone metastases cause symptoms wise and where are they really bad to occur?
Pain. In spine as they can damage the spinal cord.
Is it understood why lung cancer metastases are common in the adrenal gland and what symptoms or functional changes do they cause?
No, and none.
What paraneoplastic (non-metastatic) changes can lung cancer cause?
Finger clubbing, hypertrophic pulmonary osteoarthropathy - HPOA (relatively rare, expansion of periosteum on long bones, causes pain and finger clubbing).
What is thrombophlebitis?
Inflammation of a vein where there is a blood clot at the site of inflammation. Common manifestation of many cancers and is not confined to lung cancer.
What other than cancer is weight loss a symptom of?
Advanced COPD.
What ‘ones’ does hypercalcaemia cause?
Stones (renal/biliary calculi), bones (bone pain), groans (abdominal pain, constipation, N+V), thrones (polyuria [needs to pee a lot]), psychiatric overtones (depression, anxiety, reduced GCS [glasgow coma scale], coma).
How does lung cancer cause hypercalcaemia and what can hypercalcaemia do to the heart?
Due to hormone release from the tumour. Can cause cardiac arrhythmias.
What are the treatments for hypercalcaemia?
Initial treatment is rehydration. If very high calcium or does not correct with fluid then IV biphosphate. Treat underlying cancer - usually squamous cell.
What does SIADH stand for and what type of lung cancer usually causes it?
Symptom of inappropriate antidiuretic hormone. Small cell.
What does SIADH result in and what are the symptoms?
Low sodium concentration. Generalised non-specific symptoms (nausea/vomiting, myoclonus [shock-like contractions of part of a muscle], lethargy/confusion, seizures/comas)
What is the treatment for SIADH?
Treat underlying cause, fluid restriction - 1.5L/day, sometimes need demeclocycline.
What should you ask about when you’re taking a history for lung cancer?
Cough, haemoptysis, cigarette smoker (uncommon to have lung cancer without having smoked), breathless, weight loss, chest wall pain, tiredness, recurrent infection, other smoking related disease, “is there anything you are worried about?”
What are you looking for in an examination that could show lung cancer?
Finger clubbing, breathless, cough, weight loss, bloated face, hoarse voice, lymphadenopathy, tracheal deviation, dull percussion, stridor, enlarged liver.
What investigations should you order when looking for lung cancer?
Full blood count, coagulation screens, Na K C Alk phosphates, spirometry and FEV1, CXR, CT scan or thorax PET scan, bronchoscopy, endobronchial ultrasound, NOT sputum cytology (bronchoscopy is done regardless of result).
How does positron emission tomography (PET) work?
Scan assesses function rather than structure, analysis of tissue uptake of radiolabelled glucose, tissues with high metabolic activity light up.
What techniques can we use to get a sample of tissue?
Bronchoscopy, CT guided biopsy, lymph node aspirate, pleural fluid aspirate, endobronchial ultrasound (bronchoscope with ultrasound tip to target and sample lymph nodes), thoracoscopy (looks into pleural space).
What are the other possible differential diagnoses for people with lung cancer?
TB, vasculitis, PE, secondary cancer, lymphoma, bronchiectasis.
What in tobacco smoke causes lung cancer?
Polycyclic hydrocarbons, aromatic amines, phenols, nickel, cyanates.
What other cancers can smoking cause?
Laryngeal, cervical, bladder, mouth, oesophagus, colon.
What other risk factors are there for lung cancer?
Asbestos, nickel, chromates, radiation, atmospheric pollution, genetics.
What ectopic hormones (hormones not native to organ in which they arise) can lung cancers produce?
Squamous cancer: parathyroid hormone (PTH). Small cell: adrenocorticotropic hormone (ACTH).
What types of lung cancer are there (from highest to lowest prevalence)?
Adenocarcinoma, squamous carcinoma, small cell carcinoma, large cell carcinoma.
A quarter of people who get what type of lung cancer are non-smokers?
Adenocarcinoma.
Give the histological characteristics of each type of lung cancer.
Squamous: defined by keratin formation. Adenocarcinoma: gland-forming epithelium, mucus also produced. Small cells: lots of tightly packed undifferentiated cells with not much cytoplasm. Large cell: very large undifferentiated cells.
What is the classification of lung cancer important for?
Prognosis, treatment, pathogenesis/biology and epidemiology.
What is the survival time like for the different types of lung cancer?
Small cell worst, then large cell, then squamous or adenocarcinoma.
What can help with subtyping tumours on small biopsies?
Immunohistochemistry.
What does adenocarcinoma express that squamous cell carcinoma doesn’t and vice versa?
Adenocarcinoma expresses TTF1 (thyroid transcription factor). Squamous cell cancer expresses nuclear antigen p63 and high molecular weight cytokeratins.
What are the common molecular genetic abnormalities in SCLC?
Oncogene: myc. Tumour suppressor genes: p53, Rb, 3p.
What are the common molecular genetic abnormalities in NSCLC?
Oncogene: myc, K-ras, her2. Tumour suppressor genes: p53, 1q, 3p, 9p, 11p, Rb.
What mutation is seen almost exclusively in adenocarcinoma and what does this respond to?
Specific point mutations rendering the EGFR gene active in the absence of ligand binding. Tyrosine kinase inhibitors (erlotinib).
What would be used to treat a lung cancer with an EML4-ALK fusion oncogene?
Crizotinib.
What will inhibiting the effect of PD-L1 on lung cancer do?
Enhance the immune killing of cancer cell as the PD-L1 binds to the PD receptor on T cells inactivating them.
Describe the formation of bronchial tumours.
Squamous metaplasia -> dysplasia -> carcinoma in situ -> invasive malignancy
Describe the formation of peripheral adenocarcinoma.
Atypical adenomatous hyperplasia -> spread of neoplastic cells along alveolar walls (bronchioalveolar carcinoma) -> true invasive carcinoma (pattern is becoming more common).
What are some other lung neoplasms?
Carcinoid: neuroendocrine neoplasms of low grade malignancy. Bronchial gland neoplasms (more often seen in salivary glands: adenoid cystic acrcinoma, mucoepidermoid carcinoma.
Where do the pleura combine?
Around the hila of the lung.
When would pleural effusion not require drainage or sampling?
Cardiac failure
What investigations would you do for a pleural effusion?
PA CXR, pleural aspirate, biochemistry (transudate or exudate), cytology, culture.
What would straw coloured pleural fluid indicate?
Cardiac failure, hypoalbuminaemia
What would bloody pleural fluid be caused by?
Trauma, malignancy, infection, infarction
What would turbid/milky pleural fluid indicate?
Empyema, chylothorax
What would a foul smelling pleural effusion indicate?
Anaerobic empyema.
What would food particles in a pleural effusion indicate?
Oesophageal rupture
What would a bilateral pleural effusion be caused by?
LVF, pulmonary embolism, drugs, systemic path
What is the difference between a transudate and an exudate?
Transudates have less than 30 g/L of protein whereas exudates have more than 30.
If the pleural effusion is a transudate, what could have caused it?
Heart failure, liver cirrhosis, hypoalbuminaemia, atelectasis (collpase), peritoneal dialysis.
If the pleural effusion is an exudate, what could have caused it?
Malignancy, infection including TB, pulmonary infarction or asbestos (always look for serious pathology).
What would the pH of pleural fluid tell you about the condition?
Normal is around 7.6, less than 7.3 suggests pleural inflammation, less than 7.2 requires drainage in the setting of infection.
What would the glucose levels of the pleural fluid tell you about the condition?
It is low in infection, TB, rheumatoid arthritis, malignancy, oesophageal rupture, SLE.
What are you looking for with cytology and cell counts?
Malignant cells, lymphocytes (TB or malignancy) or neutrophils (acute process).
What fraction of malignant effusions will be diagnosed with 2 samples?
2/3rds.
What microbiological tests should you carry out for pleural effusions?
Gram stain and microscopy, culture, PCR, AFB stain and liquid culture.
What effect does the volume of aspirate in a thoracentesis have on the yield of positive findings for malignancy?
It does not increase yield.
What ways could you take a pleural biopsy?
Blind percutaneous pleural biopsy (Abrams needle), CT guided cutting needle pleural biopsy, thoracoscopy.
Why would a pleural biopsy not contain malignant cells?
The technique is wrong so biopsies don’t contain pleura, the involvement of pleural disease is discontinous, or the effusion is ancillary to malignancy but not malignant.
What systemic tumour effects can ancillary effusions be caused by?
Embolism, hypoalbuminaemia.
What local tumour effects can ancillary effusions be caused by?
Postobstructive infection, lymphatic obstruction, atelectasis.
How long does mesothelioma take to develop?
Often 30-40 years.
What are the symptoms of mesothelioma?
Breathlessness, chest pain, weight loss, fever, sweating and cough.
What are the treatment options for mesothelioma?
Pleurodese effusions, radiotherapy, surgery, chemotherapy, palliative care, report deaths to fiscal.
What cancers are most likely to metastasise to the pleura?
Lung cancer and breast cancer.
What is the median survival rate for malignant pleural effusions?
3-12 months.
What are the 2 forms of talc used in treating pleural effusions?
Slurry and poudrage.
What are the complications of using talc?
Minor pleuritic pain and fever (common), pneumonia, respiratory failure, talc pneumonitis/ARDS, secondary empyema, local tumour implantation at port site in mesothelioma (all rare).
How long are long term pleural catheters designed to remain in place for?
For life.
What provides the suction to drain the pleural fluid in a long term catheter?
Vacuum in drainage bottle.
What are the complications of a long term pleural catheter?
Incorrect placement, bleeding, infection, not recommended to bath or swim and flying can be tricky.
What is the LENT score used for?
Predicting survival in malignant pleural effusion.
What does each part of the LENT score mean?
LDH, ECOG PS, (serum) neutrophil to lympocyte ratio, tumour type.
What is the treatment for pleural effusion?
Depends on the underlying cause.
