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lung cancer Flashcards

1
Q

types

A

Lung cancer is initially classified histologically as being either small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC) due to the different features, management and prognosis see in the two groups.

🥨 SCLC accounts for around 15% of cases and generally carries a worse prognosis.

🥨 NSCLC can be broken down into (percentages refer to total lung cancer cases, not just NSCLC:

  • squamous: c. 35%
  • adenocarcinoma: c. 30%
  • large cell: c. 10%
  • alveolar cell carcinoma: not related to smoking, ++sputum
  • bronchial adenoma: mostly carcinoid

Differentiating between NSCLC is now important than before due to the different drugs available treat the subtypes.

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2
Q

Small cell cancer aka ‘oat cell carcinoma’

epidemiology

A

20%

smokers

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3
Q

Small cell cancer aka ‘oat cell carcinoma’

pathology

A

central location

near bronchi

HISTO: small, poorly differential cells

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4
Q

Small cell cancer aka ‘oat cell carcinoma’

behaviour

A

80% present w/ advanced disease

v chemosensitive but v poor prognosis

ectopic hormone secretion:

  • associated with ectopic ADH, ACTH secretion
  • ADH → hyponatraemia
  • ACTH → Cushing’s syndrome
  • ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis
  • Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome
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5
Q

Small cell cancer aka. oat cell carcinoma

mx

A

Management

  • usually metastatic disease by time of diagnosis
  • patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery. NICE support this approach in their 2011 guidelines
  • however, most patients with limited disease receive a combination of chemotherapy and radiotherapy
  • patients with more extensive disease are offered palliative chemotherapy
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6
Q

NSCC: squamous cell carcinoma

epidemiology

A

35%

M>F

smoking

radon gas

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7
Q

NSCC: squamous cell carcinoma

pathology

A

centrally located

histo: evidence of squamous differentiation, keratinisation

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8
Q

NSCC: squamous cell carcinoma

behaviour

A

locally invasive

metastasize late [via LN]

cancer cells release parathyroid related protein= cause hypercalcemia

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9
Q

NSCC: adenocarcinoma

epidemiology

A

25%

females

non smokers

far-east

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10
Q

NSCC: adenocarcinoma

pathology

A

peripherally located

histo: glandular differentiation [gland/mucin formation]

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11
Q

NSCC: adenocarcinoma

behaviour

A

extrathoraic mets common and early

80% present with mets

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12
Q

NSCC: large cell

epidemiology

A

10%

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13
Q

NSCC: large cell

pathology

A

peripheral/central

histo: large, poorly differentiated cells

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14
Q

lung cancer symptoms

A

cough and hemoptysis

dyspnoea

chest pain

recurrent/slow resolving pneumonia

anorexia/wt loss

hoarseness

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15
Q

lung cancer: chest signs

A

consolidation

collapse

pleural effusion

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16
Q

lung cancer: general signs

A

cachexia

anemia

clubbing + HPOA [hypertrophic pulmonary osteoarthropathy]

supraclavicular +/ axillary LNs

17
Q

lung cancer: metastatic signs

A

bone tenderness

hepatomegaly

confusion, fits, focal neuro

addisons

18
Q

lung cancer RFs

A

smoking

asbestos

occupational exposures [chromium, aresnic, iron oxide,]

radiation [radon gas]

19
Q

local complications of lung ca

[RRASH]

A

Recurrent larnygneal n palsy

phrenic n palsy

svc obstruction

horner’s syndrome: ptosis, miosis, anhydrosis, enopthalmos [pancoast tumour]

AF

20
Q

lung ca: paraneoplastic features

A

Small cell

  • ADH
  • ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
  • Lambert-Eaton syndrome

Squamous cell

  • parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
  • clubbing
  • hypertrophic pulmonary osteoarthropathy (HPOA)
  • hyperthyroidism due to ectopic TSH

Adenocarcinoma

  • gynaecomastia
  • hypertrophic pulmonary osteoarthropathy (HPOA)
21
Q

Lung cancer: investigation

A

Chest x-ray

  • this is often the first investigation done in patients with suspected lung cancer
  • in around 10% of patients subsequently diagnosed with lung cancer the chest x-ray was reported as normal

CT

  • is the investigation of choice to investigate suspected lung cancer

Bronchoscopy

  • this allows a biopsy to be taken to obtain a histological diagnosis sometimes aided by endobronchial ultrasound

PET scanning

  • is typically done in non-small cell lung cancer to establish eligibility for curative treatment
  • uses 18-fluorodeoxygenase which is preferentially taken up by neoplastic tissue
  • has been shown to improve diagnostic sensitivity of both local and distant metastasis spread in non-small cell lung cancer
22
Q

Curative treatment for localised non-small cell carcinoma (NSCLC) i.e. squamous, adenocarcinoma or large cell carcinoma,

A

🍜 is surgical excision - lobectomy or pneumonectomy.🍜

1. surgery with curative intent for non-small-cell lung cancer

  • open or thoracoscopic lobectomy as the treatment of first choice
  • if it is not possible to do a complete resection, consider segmentectomy or wedge resection for patients with smaller tumours and borderline fitness
  • more extensive surgery (bronchoangioplastic surgery, bilobectomy, pneumonectomy) is only required when needed to obtain clear margins
  • hilar and mediastinal lymph node sampling or en bloc resection should be undertaken for all patients undergoing surgery with curative intent

2. radiotherapy with curative intent for non-small-cell lung cancer

lung function should be assessed before offering radiotherapy with curative intent

3. combination treatment for non-small-cell lung cancer

consider chemoradiotherapy for patients with stage II or III NSCLC who are not suitable for surgery

4. chemotherapy for non-small-cell lung cancer

chemotherapy should be offered to patients with stage III or IV NSCLC and good performance status

23
Q

small cell cancer mx

A

Management

  • usually metastatic disease by time of diagnosis
  • patients with very early stage disease (T1-2a, N0, M0) are now considered for surgery. NICE support this approach in their 2011 guidelines
  • however, most patients with limited disease receive a combination of chemotherapy and radiotherapy
  • patients with more extensive disease are offered palliative chemotherapy
24
Q

?Asbestos and the lung- what pathology would you see

A

Asbestos can cause a variety of lung disease from benign pleural plaques to mesothelioma.

Pleural plaques

Pleural plaques are benign and do not undergo malignant change. They are the most common form of asbestos related lung disease and generally occur after a latent period of 20-40 years.

Pleural thickening

Asbestos exposure may cause diffuse pleural thickening in a similar pattern to that seen following an empyema or haemothorax. The underlying pathophysiology is not fully understood.

Asbestosis

The severity of asbestosis is related to the length of exposure. This is in contrast to mesothelioma where even very limited exposure can cause disease. The latent period is typically 15-30 years. Asbestosis typically causes lower lobe fibrosis. As with other forms of lung fibrosis the most common symptoms are shortness-of-breath and reduced exercise tolerance.

Mesothelioma

Mesothelioma is a malignant disease of the pleura. Crocidolite (blue) asbestos is the most dangerous form.

Possible features

  • progressive shortness-of-breath
  • chest pain
  • pleural effusion

Patients are usually offered palliative chemotherapy and there is also a limited role for surgery and radiotherapy. Unfortunately the prognosis is very poor, with a median survival from diagnosis of 8-14 months.

Lung cancer

Asbestos exposure is a risk factor for lung cancer and also has a synergistic effect with cigarette smoke.

25
Q

lung ca prognosis

A

nsclc: 50% 5yrs w/o spread’ 10% w/stpread
sclc: 1-1.5yr median survival: 3mo if unrx’d

26
Q

what does lobar collapse look like on cxr?

A

Common causes of lobar collapse include:

  1. lung cancer (the most common cause in older adults)
  2. asthma (due to mucous plugging)
  3. foreign body

The general signs of lobar collapse on a chest x-ray are as follows:

  • tracheal deviation towards the side of the collapse
  • mediastinal shift towards the side of the collapse
  • elevation of the hemidiaphragm
27
Q

when to refer pts onto suspected cancer pathway?

A

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:

  • have chest x-ray findings that suggest lung cancer
  • are aged 40 and over with unexplained haemoptysis
28
Q

when to OFFER urgent cxr to peeps >40y/o

A

Offer an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and over if they have 2 or more of the following unexplained symptoms, or if they have ever smoked and have 1 or more of the following unexplained symptoms:

  • cough
  • fatigue
  • shortness of breath
  • chest pain
  • weight loss
  • appetite loss
29
Q

when to CONSIDER urgent cxr to peeps

A

Consider an urgent chest x-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 and over with any of the following:

  • persistent or recurrent chest infection
  • finger clubbing
  • supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
  • chest signs consistent with lung cancer
  • thrombocytosis

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