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Theme 4 > Lung cancer > Flashcards

Lung cancer Flashcards

1
Q

Poor survival rates

A

Patients present late with advanced stage

Early symptoms similar to common smokers symptoms

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2
Q

Causes

A

90% are caused by smoking

Deaths in men have reduced by more than a quarter

Lung cancer deaths in women are increasing

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3
Q

Symptoms

A

Usually in a smoker of more than 20 years:
Respiratory
Metastatic- from spread to distant sites
Paraneoplastic/systemic

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4
Q

Common symptom presentation - respiratory

A 
Cough
haemoptysis
dyspnoea
wheeze
chest pain
hoarseness
recurrent pneumonia
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5
Q

Common systemic and metastatic presenting symptoms in lung cancer

A 
Weight loss
Anorexia, nausea
Malaise
Fatigue
From secondary sites eg CNS, bone, skin
Metastases - brain/bone
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6
Q

Paraneoplastic syndromes in lung cancer

A

Hyponatraemia (due to SIADH)- small cell carcinoma

Hypercalcaemia (due to PTH like activity)- squamous cell carcinoma

Less commonly- gynaecomastia, pruritis, cerebellar degeneration, peripheral neuropathy
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7
Q

Lung cancer presentation

A

Presenting symptoms = highly variable and may involve sites distant from the chest, or be very non-specific

The approach is to have a high index of suspicion in any (ex) smoker

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8
Q

Hyponatraemia

A

due to SIADH - small cell carcinoma

Paraneoplastic syndrome

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9
Q

Hypercalcaemia

A

due to PTH like activity - squamous cell carcinoma

Paraneoplastic syndrome

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10
Q

Subtypes

A 
Non-small cell (NSCLC) 
squamous 
adenocarcinoma 
large cell 
undifferentiated

Small cell - central, early lymphatic spread - paraneoplastic syndrome

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11
Q

Squamous lung cancer

A

Non small cell

central; invade locally; frequent cavitation; hypercalcaemia common (20%)

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12
Q

Adenocarcinoma

A

peripheral lung; more common in non-smokers Most common (40%)

non small cell

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13
Q

Common signs on examination

A

clubbing
cachexia
supraclavicular, cervical lymphadenopathy
Stridor due to large airway disease or vocal cord palsy (hoarse voice)
focal chest signs of lung collapse, fixed wheeze
pleural effusion

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14
Q

Investigations reasons

A

Confirm diagnosis
Determine tumour cell type
Stage extent

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15
Q

Types of investigation

A

CT
Bronchoscopy
Endobronchial Ultrasound Needle aspiration
Other biopsy procedure eg percutaneous CT thorax, peripheral lymph node/liver
PET scanning- a nuclear medicine scan, utilising the high uptake of a glucose analogue (2,3 FDG) in tumour cells

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16
Q

TNM staging in lung cancer

A

Important factor in determining treatment and prognosis in lung cancer (general fitness and patient wishes being the others)

It takes into account tumour size, involvement of local structures, lymph and blood metastases

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17
Q

Management of newly diagnosed lung cancer

A

Small cell or non-small cell lung cancer
If NSCLC is resectable

Otherwise, other radical treatment appropriate
- high dose radiotherapy, stereotactic radio/microwave ablation

18
Q

Role of surgery in NSCLC

A

Consider surgery for all patients with stage 1 and 2 disease
Usually involves lobectomy (pneumonectomy sometimes performed)
In practice around 10% in UK undergo potentially curative resection for lung cancer

19
Q

Other radical treatment

A

Radical (high dose) radiotherapy
+/- chemotherapy
Usually reserved for those with stage 1 or 2 disease who are unfit (or unwilling) for surgery

20
Q

Palliative radiotherapy/chemotherapy in NSCLC

A

Offers good symptom relief for haemoptysis, intractable cough or dyspnoea from bronchial or tracheal obstruction, chest and skeletal pain
Not expected to cure

Chemotherapy regimens can improve quality of life
Also offer a modest improvement in survival (measured in weeks)
May be used in conjunction with radiotherapy

21
Q

Differential diagnosis of lung mass

A 
Neoplastic vs non-neoplastic 
Benign vs malignant 
Primary vs secondary 
Site of origin 
Histological type 
Prognostic and predictive features 
Carcinoma, sarcoma and lymphoma
22
Q

Pathological diagnosis of lung cancer

A

Clinical history & examination
Distribution, gross appearance (number, shape and size)
Growth pattern at margin of tumour
Histological type, prognostic and predictive features
All requires a MDT approach

23
Q

Main histological types of lung cancer

A

Small Cell (AKA Oat Cell) Carcinoma (10-15%)

Non Small Cell Carcinoma (85-90%)
Squamous Cell Carcinoma 20-30%
Adenocarcinoma 40%
Undifferentiated / Large Cell Carcinoma 10- 5%
Mixed and others
24
Q

Small cell carcinoma

A

Widespread bulky disease

Small, dark, delicate cells with little cytoplasm

‘Salt and pepper’ chromatin in the nuclei

25
Q

Squamous cell carcinoma

A

Central origin often

Cigarette smoke provoking squamous metaplasia, then dysplasia of bronchial epithelium

Thought to arise from squamous metaplasia & dysplasia of bronchial epithelium

26
Q

Adenocarcinoma

A

May first begin with malignant cells lining alveolar spaces

Typically peripheral, contains fibrous tissue and shows variable differentiation which correlates with prognosis

27
Q

Difficult to distinguish between SCC and AC

A

Looking for specific proteins can help

eg TTF1 expression is typical of adenocarcinoma

28
Q

Molecular pathology of adenocarcinoma

A

Adenocarcinomas are subdivided according to key driver mutations
EGFR mutations may be targeted with tyrosine kinase inhibiting agents (eg erlotinib, gefitinib)
ALK fusion proteins may be targeted with crizotinib
Tissue is prioritized for testing to permit rational therapy

29
Q

Pattern of spread of lung cancer

A

local and direct spread
lymphatic
system spread

30
Q

Pattern of spread of lung cancer - local and direct spread

A

Adjacent lung, Intrapulmonary metastasis

Pleura and Pleural Cavity

31
Q

Pattern of spread of lung cancer - lymphatic

A

Lymphatics within Lung

Lymph Nodes – Hilar, Mediastinal

32
Q

Pattern of spread of lung cancer - system spread

A

Liver, Bone, Brain, Adrenal

33
Q

Making a diagnosis

A

Multidisciplinary Effort
Clinical Features, Imaging

Histological type
Small cell carcinoma
Non small cell carcinoma
Squamous cell carcinoma
Adenocarcinoma

Confirm by looking for proteins
Prognostic and predictive molecular pathology
Increasingly diagnosis is made on tiny specimens obtained by minimally invasive procedures (e.g. EBUS)

34
Q

Lung cancer associations

A

Smoking
Fibrosis alveolitis
Ionising radiation, air pollution and diesel engine exhaust

Chromium
Iron oxide, nickel

Mesothelioma - asbestos exposure

35
Q

Surgical considerations

A 
Operative mortality
Cardiovascular mordidity
Lung function
Post-operative quality-of-life/dyspnoea
Surgical approach
Chemotherapy – pre or post-op
Post-operative radiotherapy
36
Q

Outcome for surgery

A

5 year survival approx 50%

(only approx 15% of pts are suitable for resection)

37
Q

Radiation damage

A 
Base damage
Protein-protein cross-links
DNA-protein cross-links
Intra-strand cross-links
Inter-strand cross-links
intercalation
38
Q

Cell death

- chromosomal breaks and abberations

A

Chromosomal breaks -> early apoptosis

Chromosomal -> mitotic death, reproductive death and late apop

39
Q

Locally advanced lung cancer treatments

A

Radiotherapy + chemotherapy

Chemo and/or radiotherapy with surgery

Chemo followed by consolidation RT for small cell

40
Q

Outcomes from radical treatment

A

Locally advanced disease - median survival = 18-24 months

Outcome worse if: performance status poor or weight

41
Q

Chemotherapy

A

Cochrane review (52 trials, 9387 pts)

Surgery + chemo vs surgery alone
Tumours >4cm +/- nodes involved
absolute benefit 5% at 5 yrs

RT + chemo vs RT alone
absolute benefit 4% at 5 yrs (Cisplatin based)

Theme 4 (16 decks)

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