Lung cancer Flashcards
Describe the epidemiology of lung cancer
3rd commonest cancer in the UK
Largest cause of cancer-related mortality in UK and worldwide. 5-year survival is only 13%.
3rd commonest cause of death after CAD and CVD
85% occur in smoker or ex-smokers
44% are diagnosed aged 75 and older
Higher incidence in urban areas
Name 5 risk factors for lung cancer
Smoking*
Increasing age
FHx
Environmental: radon gas, asbestos, radiation and chemicals, air pollution
Host: pre-existing lung disease, previous radiation therapy, HIV, immunosuppression, genetics
Categorise the different types of primary lung cancer
Small cell lung cancer (12%) Non-small cell lung cancer (87%) -Adenocarcinoma: commonest -Squamous cell carcinoma -Large cell carcinoma
Name 3 cancers related to the lungs
Pancoast tumours: pulmonary apex
Mesothelioma: pleura
Metastatic lung cancer
Where does metastatic lung cancer commonly originate from?
Breast Bowel Kidney: cannonball metastases Testicle Bladder Melanoma Bone
Describe the features of small cell lung cancer
Accounts for 12% of lung cancers Arises from neuroendocrine cells 10% paraneoplastic: ACTH (Cushing's), ADH (SIADH) Often arises centrally Metastasises early
Describe the features of squamous cell carcinoma
Arises from epithelial cells
Associated with keratin production
May secrete PTHrP (hypercalcaemia)
Occasional cavitation with central necrosis
Obstructing lesions of bronchus with infection
Local spread common
Metastasise relatively late
Describe the features of adenocarcinoma
Commonest lung cancer in UK Originate from mucus-secreting glandular cells Most common type in non-smokers Often peripheral lesions on CXR/CT Subtype: bronchoalveolar cell carcinoma Commonly metastasises
Describe the features of large cell carcinoma
Often poorly differentiated
Metastasises relatively early
Name 5 local effects of lung cancer
Lung cancer is often asymptomatic, and presents late.
Cough*: 3-week cough merits CXR
Dyspnoea
Haemoptysis
Monophonic wheeze: partial obstruction
Chest pain:
-pleuritic: invasion of chest wall or pleura
-dull central ache: large-volume mediastinal nodes
Recurrent infection: post-obstructive pneumonia
Hoarse voice: recurrent laryngeal nerve compression
Nerve compression: pancoast tumour
-Klumpke’s paralysis (C8/T1): claw hand
-Horner’s syndrome: anhidrosis, ptosis, miosis
Direct invasion of phrenic nerve
SVC obstruction
Tracheal tumour: progressive dyspnoea and stridor
How does superior vena cava obstruction present?
Dyspnoea +/- dysphagia
Swollen oedematous facies and arms
Raised JVP
Dilated veins in upper chest and arms
Name 2 clinical features that can be caused by pancoast tumours
Hoarse voice: recurrent laryngeal nerve compression
Klumpke’s paralysis (C8/T1): claw hand
Horner’s syndrome: anhidrosis, ptosis, miosis
What cancer is known to secrete PTH-rp?
Squamous cell lung cancer
What cancer is known to secrete ADH and ACTH?
Small cell lung cancer
What paraneoplastic syndromes are associated with small cell lung cancer?
Cushing’s syndrome from ACTH secretion
SIADH from ADH secretion
Eaton-Lambert syndrome
What paraneoplastic syndrome is associated with squamous cell lung cancer?
Hypercalcaemia from PTHrP secretion
What sign is associated with metastatic lung cancer originating from the kidneys?
Cannonball metastases
Where do primary lung cancers often metastasise?
Mediastinal, cervical, axillary, intra-abdominal lymph
Liver: anorexia, nausea, weight loss, epigastric pain
Bone: bony pain, pathological fractures, spinal cord collapse*
Adrenal glands: usually asymptomatic
Brain: raised intracranial pressure
Malignant pleural effusion: dyspnoea and pleurisy
Name 5 non-metastatic extra-pulmonary manifestations of lung cancer
Weight loss, lethargy, anorexia Clubbing (30%) Small cell: SIADH, Cushing's Squamous cell: Hypercalcaemia Neuro: encephalitis, motor neurone disease, peripheral sensorimotor neuropathy, Eaton-Lambert syndrome
What tests should be ordered for lung cancer?
FBC, U&E, LFTs, INR, calcium
CXR
Staging contrast CT of chest, liver and adrenal glands
MRI spine: assess if at risk of cord compression
PET scan: detect mediastinal nodes and small mets
Bronchoscopy + biopsy
How is spinal cord compression secondary to lung cancer treated?
High dose steroids
Radiotherapy
Surgical decompression
What CXR findings may be seen with lung cancer?
Mass lesion if >1cm diameter
Pleural effusion: associated pleurisy
Lymphadenopathy or mediastinal widening
Slow-resolving consolidation: post-obstructive pneumonia
Lung collapse: endoluminal tumour
Reticular shadowing: lymphatic involvement
Normal: if confined to central airways and mediastinum
What must be done prior to commencing treatment of lung cancer?
WHO performance status: fitness for treatment
0-1: tolerate all forms of treatment
2: applicable for curative chemotherapy
3+: palliative care
Summarise the management of non-small cell lung cancer
Applicable for non-small cell lung cancer*
Ipsilateral tumour + good performance score: surgery
Good staging + performance score: chemotherapy
Stage I/II: curative surgery
Stage IIIa: surgery + adjuvant chemotherapy
Stage III/IV: curative chemo if performance score 0-2
Curative radiotherapy if unfit for surgery or curative chemotherapy
Palliative care
Watch and wait
What system is used to stage lung cancer?
TNM
Why is small-cell lung cancer generally unfit for curative surgery? How is this managed?
Rapid growth and early metastases
Curative: cisplatin chemotherapy
-Adjuvant radiotherapy given in limited disease
Palliative: radiotherapy
Combined chemo improves survival from 4-12wk to 6-15 months.
Outline the WHO performance status
0: Fully active, able to carry out predisease performance without restriction
1: Restricted in physically strenuous activity, but ambulatory and able to carry out work in a light or sedentary nature.
2: Ambulatory and capable of all self-care. Unable to carry out any work activities. Up and about more than 50% of waking hours.
3: Capable of only limited self-care. Confined to bed or chair more than 50% of waking hours.
4: Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
5: Death
