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- Y6 Respiratory > Lung Cancer > Flashcards

Lung Cancer Flashcards

1
Q

What are the types of lung cancer?

A
  • Small cell lung cancer
  • Non-small cell lung cancer e.g. SCC or adeno
  • Other: Mesothelioma, Pancoast tumours, Secondary lung cancer.
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2
Q

Which lung cancer is more common?

A

NSCLC (80% of all lung cancers)

SCLC (20%) →smokers, central, Lambert Eaton myasthenic syndrome

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3
Q

Name a benign tumour of the lung.

A

Chondroma

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4
Q

What are the types of non small cell lung cancer?

A

Adenocarcinoma(30%) - most common.

Squamous cell carcinoma (30%)

Large cell carcinoma (20%)

Undifferentiated non small cell lung carcinoma - e.g. sarcomatoid carcinoma

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5
Q

Where are adenocarcinomas usually located in the lung? Where are squamous cell carcinomas located?

A

Adenocarcinomas - located peripherally in the lungs but early metastases

Squamous cell carcinomas - central airways (metastasise later in the disease course), late metastases PTHrP

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6
Q

What are the risk factors for developing lung cancer?

A
  • Tobacco (passive too)- aromatic hydrocarbons, aromatic amines, N-nitrosamines, organic and inorganic compounds.
  • Family history
  • COPD
  • Radon gas - radioactive decay product of uranium which can decay into progeny that emit alpha particles which damage DNA
  • Old age
  • Asbestos(weak for NSCLC)
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7
Q

What are the most common symptoms associated with lung cancer?

A
  • Cough
  • Dyspnoea
  • Haemoptysis
  • Chest /shoulder pain
  • Weight loss
  • But may present with symptoms of metastases the most common of which is brain → confusion, personality change, seizures, weakness, focal neurological deficits, nausea and vomiting, and headaches.
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8
Q

What signs are associated with lung cancer?

A
  • Cachexia (weakness+wasting due to chronic illness)
  • Anaemia
  • Clubbing
  • Hypertrophic pulmonary osteoarthropathy - painful arthropathy with periosteal new bone formation. More common in adenocarcinoma.
  • Supraclavicular or axillary nodes

Chest signs: none or consolidation/collapse/pleural effusion

Metastases: bone tenderness, hepatomegaly, confusion, fits, local CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy

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9
Q

What complications are associated with lung cancer?

A

Local:

  • recurrent laryngeal nerve palsy
  • phrenic nerve palsy
  • SVC obstruction
  • Horner’s syndrome(Pancoast tumour)
  • rib erosion
  • pericarditis
  • AF

Metastatic:

  • brain
  • bone (bone pain, anaemia, increased Ca)
  • liver
  • adrenals (Addison’s)

Non-metastatic:

  • confusion
  • fits
  • cerebellar syndrome
  • proximal myopathy
  • neuropathy
  • polymyositis
  • Lambert-Eaton syndrome

Other:

  • Horner’s syndrome
  • Facial swelling
  • Dilated neck or abdominal wall veins
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10
Q

Why is there sometimes shoulder pain in lung cancer?

A

Lungs have no pain nerve fibres but sometimes tumours invade the pleura or chest wall which can cause chest discomfort early on.

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11
Q

What is the cause of hoarseness in lung cancer?

A

Recurrent laryngeal nerve paralysis

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12
Q

What is the cause of

  • Horner’s syndrome
  • Facial swelling

in lung cancer?

A

Horner’s syndrome (triad of ptosis, miosis and ipsilateral anhydrosis) - in patients with superior sulcus tumours which can invade the sympathetic plexus.

Facial swelling - compression of the vena cava due to mediastinal adenopathy or right upper lobe tumour extending into the mediastinum. Chest/abdominal veins may also be distended due to compression of the vena cava.

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13
Q

Which type of lung cancer is clubbing more common in?

A

More common in NSCLC than in small cell lung carcinoma.

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14
Q

What is the origin of these cancers?

Adenocarcinoma

Squamous cell carcinoma

A

Adenocarcinoma - tumour of the glandular epithelial cells (Pappiloma = epithelial)

Squamous cell carcinoma - squamous cells (found in respiratory and digestive tracts, skin, vagina, cervix)

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15
Q

Which type of lung cancer is associated with hypercalcaemia?

A

Any that cause paraneoplastic syndromes

Squamous cell carcinoma - secretes PTH like compound –> hypercalcaemia .

But paraneoplastic syndrome is more commonly associated with small-cell lung cancer.

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16
Q

What is the most common type of lung cancer in a patient who hasn’t smoked?

A

ADENOCARCINOMA (the bronchioalveolar subtype being more common in females who have never smoked)

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17
Q

What is the hypertrophic osteoarthritis triad?

A

Clubbing, long bone swelling, arthritis

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18
Q

What is the patttern of growth in an adenocarcinoma?

A

Lepidic growth pattern - replaces type I pneumocytes ( but no invasion of interstitium)

Can be multifocal and bilateral

19
Q

Which paraneoplastic syndromes are associated with small cell carcinoma?

A
  • ACTH –> Cushing’s. ACTH can cause bilateral adrenal hyperplasia and high levels of cortisol can also lead to hypokalaemic alkalosis.
  • ADH –> hyponatraemia
  • Lambert-Eaton myasthenic syndrome (LEMS) - immune system antibodies attack calcium channels causing myasthenic like syndrome
20
Q

Where in the lung do SCLC arise?

A

Centrally or periperally

21
Q

What are the pros and cons of a small-cell carcinoma?

A

Cons:

  • Fast-growing
  • Rapidly progression and early metastases
  • Often high stage (spread. NB: grade=differentation)

BUT

  • Highly responsive to chemo/rad treatment
  • Exclusively in smokers
22
Q

Where are large cell lung carcinomas typically found? What can they secrete? What is the prognosis?

A
  • typically peripheral
  • anaplastic, poorly differentiated tumours with a poor prognosis
  • may secrete β-hCG
23
Q

What are the features of small-cell lung cancer?

A
  • Usually central
  • Arise from APUD cells
  • Associated with ectopic ADH(vasopressin), ACTH
24
Q

Which type of lung cancer would you rather have and why?

A

Non small cell because small-cell is usually (in 2/3) metastatic by the time of diagnosis

25
Q

What are APUD cells?

A

An acronym for

  • Amine - high amine content
  • Precursor Uptake - high uptake of amine precursors
  • Decarboxylase - high content of the enzyme decarboxylase

These are the cells that small cell lung cancers usually arise from.

26
Q

What is the origin of a mesothelioma? Which lung is most often affected? Where does it metastasise to?

A

Malignancy of the mesothelial cells of the pleura

Metastases to contralateral lung and peritoneum

Right lung affected more than left

27
Q

How does a mesothelioma present?

A
  • Dyspnoea, weight loss, chest wall pain
  • Clubbing
  • Painless pleural effusion (30%)
  • History of asbestos exposure (in 85-90% with latency of 20-40 years)
  • It is rare but has a poor prognosis
28
Q

What are the risk factors for mesothelioma?

A
  • Asbestos exposure
  • Radiotherapy
  • Genetic predisposition e.g. BAP1 gene and simian virus 40 (SV-40), also BRCA1
29
Q

How does asbestos exposure lead to cancer?

A

Asbestos fibres lead to recruitement and activation of macrophages, neutrophils → generation of iron-catalysed reactive oxygen and nitrogen species

Chronic inflammation + oxidative stress -→ DNA damage –> alterations in gene expression –> malignancy

Variants:

  • Pleural (90%)
  • Peritoneal (5-10%)
  • Pericardial (<1%)
  • Testicular<1%)
30
Q

Which cells do small cell carcinomas arise from?

A

Kulchitsky cells (endocrine cells) and they often release polypeptide hormones resulting in paraneoplastic syndromes.

31
Q

What tests would you do if you suspect lung cancer?

A
  • CX - peripheral nodule, hilar enlargement, consolidation, lung collapse, pleural effusion, bony secondaries
  • Cytology - sputum and pleural fluid ( at least 20mL)
  • Fine needle aspiration/biopsy - peripheral lesions, lymph nodes
  • CT to stage the tumour and guide bronchoscopy
  • Bronchoscopy - to give histology and assess operability +/- endobronchial US for assessment and biopsy
  • 18F-deoxyglucose PET or PET/CT EBUS scan to help staging
  • Radionucleotide bone scan - for metastases
  • Lung function tests - help assess suitability for lobectomy
32
Q

What are some non-metastatic extrapulmonary manifestations of bronchial cancer?

A

Endocrine - Cushings (ACTH), ADH(dilutional hyponatraemia), PTH (hypercalcaemia), HCG (gynaecomastia)

Neurological - cerebellar degeneration, myopathy, myasthenic syndrome

Vascular- thrombophlebitis migrans, anaemia, DIC

Cutaneous - dermatomyositis, herpes zoster, acanthosis nigricans

Skeletal - clubbing, HPOA (hypertrophic osteoarthropathy)

33
Q

Which NSCLC is more common in non-smokers?

A

Adenocarcinoma which is more likely periphral than central - might see glands or mucin production

34
Q

What % of lung cancer in smokers is due to passive smoking?

A

25%

35
Q

What are the steps leading to development of carcinoma?

A
  • Metaplasia –> Dysplasia –> Carcinoma in situ –> Invasive carcinoma
  • Due to an accumulation of gene mutations
36
Q

What are the histological features of adenocarcinoma of the lung?

A
  • Gland formation
  • Papillae formation
  • Mucin
  • Histology shows evidence of glandular differentiation
  • Kras an P53 common, EGFR in non smokers
37
Q

Why is small cell lung cancer prognosis poor?

A

Often poorly differentiated and grow quickly so outgrow their blood supply and develop a necrotic core

P53 and RB1 mutation

2-4 month survival untreated, 10-20 months on treatment usually by chemotherapy

38
Q

Why is it important to distinguish between type of NSCLC i.e. adeno or SCC, for treatment purposes?

A

​If SCC is treated with biologics used for adenocarcinoma e.g. bebevacizumab, it can cause fatal haemorrhage

Adenocarcinoma targets:

  • EGFR mutation (responder or resistance) - TKi
  • ALK translocation (responds to Crizotinib)
  • Ros1 translocation
  • PD-L1 expression

SCC targets:

  • PDL1 expression (expression inhibits immune response)
39
Q

What investigations would you do for lung cancer?

A

2WW referral

CXR then CT contrast - neck, thorax, upper abdomen

Bronchoalveolar lavage:

  • Cytology – looking at cells:
    • Sputum
    • Bronchial washings and brushings
    • Pleural fluid or effusion fluid
    • Endoscopic fine needle aspiration of tumour/enlarged lymph nodes
  • Histology – looking at tissue:
    • Biopsy at bronchoscopy – central tumours
    • Percutaneous CT guided biopsy – peripheral tumours
    • Mediastinoscopy and lymph node biopsy – for staging
    • Open biopsy at time of surgery if lesion not accessible otherwise - frozen section
    • Resection specimen - confirm excision and staging

Staging: PET-CT to assess for metastases; VATS; bone scan; CT head

Bloods: FBC, clotting, LFTs, chemistry panel, ALP

40
Q

What are the endocrine/non-endocrine features of paraneoplastic syndrome?

A

Endocrine:

  • (1) ADH –> hyponatremia (SCC)
  • (2) ACTH –> Cushing’s syndrome (SCC)
  • (3) PTH –> hypercalcaemia (SCC)
  • (4) Other:
    • Calcitonin –> hypocalcaemia
    • Gonadotropins –> gynecomastia
    • Serotonin –> “carcinoid syndrome” (especially carcinoid tumours; rarely SCC)

Non-endocrine:

  • Haematological/coagulation defects, skin, muscular, miscellaneous
41
Q

What is the management of lung cancer?

A

Stage I to IIIA are potentially curable

  • MDT management
  • Surgical resection e.g. lobectomy or pneumonectomy is preferred over wedge resection
  • +/- Adjuvant chemo/radiotherapy - e.g. atezolizumab (PD1), platinum based chemotherapy

Other

  • Stereotactic radiosurgery or radiotherapy - for brain metastases
  • Palliative radiotherapy - relieves symptoms like haemoptysis, chest pain, SOB
42
Q

What are the complications of treatment with lung cancer?

A

Intraoperative and postoperative:

  • haemorrhage,
  • infection,
  • cardiac ischaemia,
  • stroke,
  • cardiac arrhythmia,
  • pneumonia,
  • prolonged air leak,
  • chylothorax,
  • pulmonary oedema,
  • bronchopleural fistula.
43
Q

What is the prognosis with lung cancer?

A

5yr survival based on stage:

  • Stage I - 90%
  • Stage II - 65%
  • Stage III - 41%
  • Stage IV - <10%

- Y6 Respiratory (23 decks)

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