Lung cancer Flashcards
causes
1- smoking: 85% of cases 2- environmental radon 3- air radiation 4-pulmonary fibrosis 5-genetic susceptibility 6-occupation
Investigations
1-Assessment
CXR/MRI/PET
CT- shows staging 2-Biopsy: Bronchoscopy Mediastinoscopy 3-Cytology: FBC Liver function tests Calcium tests Lung function tests: Spirometry CT guided fine needle aspiration
Signs
Horners: affects sympathetic nerves between brain and face- in squamous Lymphadenopathy Pancoast tumour Nail clubbing Hepatomegaly Skin nodules Asthma Diarrhea
Symptoms
Explanation for symptoms
1-cough: 3 weeks 2-SOB 3-wheeze 4-raspy voice 5-haemoptysis 6-unexplained weight loss 7-fever 8-night sweats
1-3 tumour obstructing airway
5 tumour obstructing blood vessels and nerves
6-8 body response to tumour- releases IL8, tnk-ALPHA AND IL6 which lead to an inflammatory response
Treatment: how to assess who is fit for surgery based on history?
Staging: TNM Fitness: 1-Respiratory: -asthma -smoker -URTI -obstructive disease- -barrell chest 2-CVS -murmur -HBP -angina -Stroke/TIA/MI -Carotid bruits 3-psychological: -mental health -social background -chronic pain conditions 4-OTHER: -Cirrhosis -Rheumatoid arthritis
Tests:
CVS- ECHO, ECG, ETT, angiogram
Respiratory: V/Q scan, arterial blood gas, spirometry, diffusion studies- involves administering small amounts of CO
Complications with staging and surgery (fatal and non fatal)
Post surgery death:
- MI
- Intra-thoracic bleed
- Pneumothorax
- PTE
- Acute respiratory distress syndrome- waterlogged lungs
- Bronchopneumonia
Non-fatal:
- AF
- MI
- empyema
- broncho-pleural fistula
- wound infection
- respiratory insufficiency
Complications in staging:
- Other Nodules e.g, adrenal
- collapsed lung
Definition?
The uncontrolled division of epithelial cells.
Depending on the epithelium involved it is divided into 2 major groups:
-Small cell carcinoma
-non-small cell carcinoma
Different types of non-small cell carcinoma and characteristics
- adenocarcinoma: peripheral- not associated with smoking
- bronchial- general-associated with smoking
- Large cell- general
- Squamous cell: central, associated with smoking
Pancoast tumour:
- what is it
- which types of tumour is it associated with
Mass of carcinogens cells which form on the upper lobes of the lungs and compress against blood vessels and nerves
Associated with squamous
Affects central nervous system and can lead to Horner’s- constricted eyelid and drooping eye
Characteristics of small cell carcinoma
- associated with smoking
- found centrally in the main bronchus
- grows and metastasises very quickly- when it is diagnosed it is very advanced
- known as limited when found in 1 lung and extended when found in both
- cells divide so quickly they have little/no cytoplasm
Adenocarcinoma gene mutations and approved FDA treatments
-ALK rearrangement
-EGFR
-BRAF, HER2
-KRAS
treatments approved for-NIVOLUMAB
-ROS1
-BRAF
-EGFR
-ALK
Squamous cell gene mutations and treatment
No addictive oncogenes recognised
Mainly tumour suppressor gene inhibitors
Not much option for treatment
What is an addictive oncogene?
pathway which a tumour heavily depends on for progression
What are immune checkpoint inhibitors?
Example
Immune checkpoints are used by tumour cells to overcome the immune system response
Immune checkpoint inhibitors prevent the tumour cells from using these
e.g. Nivolumab
Advanced symptoms
- Bone pain
- Spinal cord compression: limb weakness, paraestesia, bladder and bowel problems
- cerebral: headache, dizziness, vomiting, ataxia
- Thrombosis
Paraneoplastic syndromes
Hormonal -ADH release-increased BP, concentrated urine due to water retention -Hypercalcemia -Cushing's- associated with weight gain and obesity Skeletal: -Finger clubbing -Hypertrophic pulmonary osteoarthropathy Neurological: -Eaton-lambert myasthenia -Horner's- related to central nervous system -polyneuropathy -encephalopathy Haematologic: -granulocytosis -Eosonophilia
What leads to hypercalcemia
Which type of cancer leads to it?
Squamous cell carcinoma:
Release of Parathyroid hormone
Deplets calcium supply from the bones
Leads to brittle bones
What leads to Diarrea and asthma
Which type of cancer leads to it?
Bronchial:
Releases serotonin which:
-causes bronchioles-constriction
-increases peristalsis
TNM staging
Used to diagnose how severe the tumour is
T0-T4
N0-3
M0-1
T staging
T1<3cm- no involvement of the main bronchus,lobar
T2<5cm-invasion of visceral pleura, main bronchus, hilarity lymph nodes
T3<7cm- invasion of mediastinum, parental pleura, phrenic nerve
T4>7cm- invasion of carina,invasion of heart, great vessels, trachea/oesophagus, vertebra
Ipsilateral nodules
M staging
Mo- no distant metastases
M1- distant metastases
staging based on performance status
0- fully active 1- symptomatic but mobile 2- at rest <50% of day 3- at rest >50% of day 4- bed bound
General staging?
- history/ clinical examination
- performance status
- Pulmonary function
- TNM staging
Areas to consider in radiology
Mediastinum: - hilar region -Trachea should be central and there should be no widening Lungs: -compare lobes -check behind the heart Lesions Lung apices Behind the diaphragm
Non surgical management of NSCLC
stage 1/2: surgery
stage 3: chemotherapy- radiation
stage 4: inoperable- palliative care
Median survival with our treatment: 8 months
Median survival with treatment: 16 months
Non surgical management of SCLC
When limited: chemo is first line of therapy with a combination of drugs
When extended: 4 rounds of chemo or radiation if not responsive
Median survival: 8 months with or without treatment
How to improve treatment of cancer
Education on possible symptoms
Screening programmes
Multidiscplinary team meetings
Specialist nurses
How long does it take an NSCLC to double/ SCLC to double
NSCLC: 129 days
SCLC: 29 days
Fiberoptic bronchoscopy
flexible tube is used
What is thoracotomy?
First incision into the chest to gain access to the pleural space- lungs
What is a lobectomy
Removal of a lobe of the lungs
Not performed in patients that that have tumours which have metastasised
Which cancer is associated with ADH increase, Eaton Lambert syndrome and Cushing’s
Small cell carcinoma:
- Relases cortisol- leads to Cushing’s
- Autoimmune disease- leads to Eaton lamber syndrome
- release of ADH associated with water retention, increased BP and increased oedema
Which type is associated with Horner’s?
Squamous cell
Pancoast tumour presses against central sympathetic nerve
Leads to pupil constriction and dropping eyelid
Eaton Lambert syndrome
Muscle weakness which worsens at rest
