Lung Cancer Flashcards
-Pathology -Patterns of spread -Staging -Management
What is the epidemiology of lung cancer?
- 3rd most commone cancer in UK
- 1 in 13 men
- 1 in ever 15 women
- Account for 22% or cancer related deaths
- 10% of patients diagnosed with lung cancer live for 5 years or more
- M 3x> F, however rates amognst men declining but women increasing
What are the risk factors for devloping lung cancer?
- Genetic predisposition
- Cigarette smoking
- Increasing age
- Hx of COPD
- Industrial exposure to absbestos, chromium, arsenic and iron oxide
- Coal tar/combustion production
- Exposure to radiation
- Smoking -90% of lung cancers is in smokers, passive smoking also increases risk by 1.5
What are the histology sub-types of lung cancer?
- Small cell lung cancer (15%)
- Non-small cell lung cancer (85%)
- Squamous cell carcinoma
- Adenocarcinoma
- Large cell carcinoma
How can bronchial carcinoma be devided? Which is more common?
- Small cell lung carcinoma 15%
- Non-small cell lung carcinoma 85%
What are features of small cell lung carcinomas?
- 15% of lung cancer
- Arise from Kulchitsky cells -part of amine precursor uptake and decarboxylation (APUD) endocrine system
- Highly malignant and highly aggressive
- Usually inoperable at presentation
- Poor prognosis
- also associated with paraneoplastic syndromes causing:
- cushings syndrome
- lambert eaton myesthaenic syndrome
- SIADH
What are the histological subtypes of non-small cell carcinomas? Which is the most common to least?
- Adenocarcinoma 50%
- Squamous Cell Carcinoma 30%
- Large Cell Carcinoma 5%
What are the features of squamous cell lung carcinoma?
- 42% of non-small cell lung cancers
- Often obstructive lesions of the bronchus
- Local spread common, widespread metastases occurs late
- Most related to smoking
- Found centrally, close to bronchi, and can present with bronchial obstruction
- Can also secrete PTH relate peptide which can lead to malignancny-related hypercalcaemia
What are the features of lung adenocarcinoma?
- 39% of non-small cell lung cancers
- arises from mucous cells in bronchus epithelium
- invasion of pleura and mediastinal lymph nodes common
- often metastasises to brain and bones
- 10% related to non-smokers
- often peripheral
- more frequent in women
- commonly associate dwith activating mutations in EGFR and ALK
What are the features of large cell carcinoma?
- Less differentiated forms of squamous cell and adenocarcinoma
- Metastasises early
What are the symptoms a patient who has lung carcinoma would present with?
- Chronic cough (80%)
- Haemoptysis (70%)
- Dyspnoea (60%)
- Chest pain (40%)
- Weight loss
- Bone pain
- Right upper quadrant pain
- Headaches/Nausea/Neurological symptoms
- Recurrent or slowly resolving pneumonia
- Lethargy
- Anorexia
- Finger clubbing
What are some signs you might find on examination of a patient with lung carcinoma?
- Cachexia
- Anaemia
- Clubbing
- Hypertrophic pulmonary osteoarthropathy (NSCLCs)
- Supraclavicular or axillary nodes
- Bone tenderness -metastasis
- Hepatomegaly -metastasis
- Confusion/fits/focal CNS signs/cerebellar symptoms
What investigations should be done in suspected lung cancer?
- CXR -more than 95% of lung tumours are visiable on a plain CXR at presentation
- CT chest and upper abdo
- PET scan
- used in patients who are throught to have operable disease ot check for distant metastases
- Bronchoscopy
- tumour biopsy
- Tumour markers
- neurone specific enolase and lactate dehydrogenase
- Pulmomnary function tests
- Cardiopulmomnary exercise testing
- important in patients being considered for surgical resection to ensure they are fit enough to undergo an operation
When do you offere an urgent chest X-Ray (2 weeks) to assess for lung cancer in people aged 40 and over?
2 or more of the following unexplained symptoms or if they have ever smoked, 1 or more of the following unexplained symptoms:
- cough
- fatigue
- SOB
- Chest pain
- weight loss
- appetite loss
Or if they have any of the following:
- persistent or recurrent chest infection
- finger clubbing
- supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- chest signs consistent with lung cancer
- thrombocytosis
When to you make an urgent chest X-Ray referral to assess for mesothelioma in people age 40 or over?
2 or more of the following unexplained symptoms or
1 or more and have ever smoked or
1 or more and have been exposed to asbestos
- cough
- fatigue
- SOB
- chest pain
- weight loss
- appetite los
- finger clubbing
- chest signs compatible with pleural disease
A diagnosis of lung cancer is made from a CXR. Why and when is a CT scan used?
- Contrast-enhances chest CT to further the diagnosis and stage the disease
- Include the liver, adrenals and lower neck in the scan
Name some other investigations and when they would be appropriate in lung cancer?
- Fibreoptic bronchoscopy
- define anatomy, obtain biopsy and cytological samples
- Sputum cytology in people who have centrally placed nodules or massess who decline or cannot tolerate bronchoscopy
- Endobronchial USS or transbronchial needle aspiration for biopsy
- for peripheral lesions that cannot be seen by bronchoscopy
- PET-CT offered before treatment
- Bloods
- FBC (anaemia)
- LFT (liver mets)
- U&Es (hypercalcaemia, hyponatraemia)
What is offered for people with clinical features of intracranial pathology, and lung cancer?
- CT of head, followed by MRI if normal
- Investigating for brain metastases
What are the some of the different managements for lung cancer?
- Smoking cessation
- Surgical resection -stage I-II tumours or lobar resection treatment of choice
- Radiotherapy -stage I-III unsuitable for surgery
- Chemotherapy -stage III-IV
- Multidrug regimes
- Palliative care -opiates, symptomatic pleural drainage/pleurodesis,sterids, radiotherapy, bronchodilators
What is the usual management of small cell lung cancer?
Chemo
- generally considered a systemic disease at presentation so vast majority receive palliative chemotherapy
- SCLC most chemo-sensitive solid tuour
- Most relapse 12months after chemo
Radiotherapy
- is disease apprearse ‘limited stage’ at diagnosis may try radical radiotherapy. Indications are:
- Treatment of primary tumours
- Prophylactic cranial irradiation (brain metastases are frequent in SCLC)
- Palliative for symptom relief
Surgery
- considered inappropriate for majority due to it being systemic disease
What is the prognosis of small cell lung cancer? Prognostic factors?
- Poor
- Without treatment, median survival 2-4months
- Median survival with systemic chemo is 6-12months
- Prognostic factors
- extent of disease at presentation
- number of metastatic sites
- performance status
- degree of weight loss
- biochemical abnormalities
What are the treatment options with curative intent for non-small-cell lung cancers?
Surgery
- Stage 1 and 2 managed with surgical resention =good prognosis
- Mediastinal involvement contraindication
- 30% cases suitable
- Hilar & mediastinal lymph node sampling
- Lobectomy who are well enough
- Offer more extensive surgery when needed to obtain clean margins
Radiotherapy
- Early stage unsuitable for surgery, radical radiotherapy given
- for people stage I-IIa, 20% 5 year survival
- 55 Gy in 20 fractions over 4 wks of 60-66Gy in 30-33 fractions in 6wks
- CHART: Contnuous Hyperfractionated Accerlerated Radiotherpy given2 times a day for 12 days
- Or can use SABR for early peripheral tumours
- Palliative therapy can be given
Chemoradiotherapy
- Mainstay of treatment for patients with metastatic or locally advanced disease
- Combination regimens are used: Carboplatin and Gemcitabine or Caboplatin/Cisplatin and Pemetrexed
Immunotherapy
- recently approved for patients with advanced NSCLC with high PDL1 expression
- used either before or after chemo and small percentage of patients have prolonged benefit
- stage II or III
What is the prognosis of non-small cell lung cancer?
- without treatment, prognosis short 3-6months
- with chemo extends life by months to possibly over a year
- if suitable for targeted treatment or immunotherapy, substantially longer and prognosis may be around 2 years in some cases
