Lung Cancer Flashcards
Lung cancer is the second biggest cause of cancer related deaths in the world; true or false?
FALSE
It is biggest cause of cancer related death in world.
What % of lung cancers occur in people who are smokers or ex-smokers?
85%
What is the 5 year survival rate for lung cancer?
13%
Discuss the types of lung cancer
- Small cell (12%): arise from neuroendocrine cells (amine precursor uptake decarboxylase cells) in. Central mass with lymph node enlargement
-
Non-small cell
- Adenocarcinoma (35%): peripheral nodule. More common in non-smokers
- Squamous cell (40%): arise from bronchial epithelium. Central mass
- Large cell (5%): large peripheral mass with metastases
For each of the 4 main types of lung cancer (small cell, adenocarcinoma, squamous cell, large cell) state:
- Central or peripheral
- Cavitation
- Metastases (early or late)
- Common neoplastic syndromes/exta-pulmonary complications
Although the different types of lung cancers have common symptoms, some symptoms (in particular the extra-pulmonary/paraneoplastic syndromes) are different. For small cell and squamous cell cancer, state some extra-pulmonary/paraneoplastic symptoms or syndromes you might find
- Small cell:
- SIADH (Hypertension)
- ACTH (Cushing’s)
- Lambert-Eaton syndrome
- Squamous cell
- PTH-rp (hypercalcaemia)
- TSH (hyperthyroidism)
Briefly outline how you would go about diagnosing and determining the management of lung cancer
- History & examination
- Investigations: bedside, bloods, imaging
- CXR
- Staging Ct
- Biopsy to confirm type of cancer and grade of cancer
- Determine stage of cancer
- Assess pts performance status & co-morbidities alongside factoring in pts wishes
- Decide treatment
State some risk factors for lung cancer
- Smoking
- Passive smoking
- Asbestos
- Radiation (radon gas)
- Family history
- Other cancers (mets to lung)
What are the symptoms of lung cancer?
For this flaschard think about symptoms due to the actual lung tumour e.g. actual respiratory system and local compression effects
- Cough
- Haemoptysis
- Dyspnoea
- Chest pain
- Malaise
- Weight loss
- Anorexia
- Asymptomatic (found accidentally)
- Horner’s syndrome (anhydrosis, miosis, partial ptosis)
- Facial oedema & egorgement of neck/facial veins due to obstruction of SVC
- Hoarsness of voice (recurrent laryngeal nerve)
- Weakness of muscles in hand (brachial plexus involvement)
State some symptoms/syndromes someone with lung cancer present may present with (that aren’t respiratory symptoms/are due to spread/paraneoplastic)
- Paraneoplastic:
- Clubbing
- Hypercalcaemia- stones, moans, groans, bones
- Anaemia- fatigue
- SIADH- hypertension
- Cushings syndrome- striae, bufalo hump, moon face etc…
- Lambert-Eaton myasthenic syndrome
- Thrombo-embolic diseae- e.g. PE, DVT
- Metastatic disease
- Liver
- Adrenal
- Bone
- Pleura
- CNS
What is Lambert-Eaton Myasthenia sydnrome?
Autoimmune condition in which autoantibodies attack neuromuscular junction leading to:
- Weakness in leg, arms, face and neck
- Problems controlling autonomic functions of body e.g blood pressure
- Aching muscles
- Constipation
- Erectile dysfunction
- Strenght that temporarily improves when exercising but then decreases as exercise continues
Discuss what you might find on clinical examination of someone with lung cancer
- Clubbing
- Dullness on percussion (if percussing over a mass)
- Increased vocal resonance (if over mass)
- Stony dullness to percussion (if pleural effusion present)
- Enlarged suprclavicular or axillary lymph nodes
- Hepatomegaly (liver mets)
*
For lung cancer state what investigations you would want, include:
- Bedside
- Bloods
- Imaging
*
Bedside
- Sputum culture: rule out infection
- Sputum cytology: cytology for abnormal cells
Bloods
- FBC
- U&Es: get idea of baseline. Also SIADH will cause hyponatraemia
- LFTs: raised ALP & gammaGT may suggest liver mets. Raised ALP may also suggest bone mets
- Calcium: thinking about PTH-rp
- INR: lung cancer can increase coagulability
Imaging
- CXR: check for tumours
- Staging CT: check for tumours and metastases
- PET scan: helps determine small metastases not seen on CT
What order would you do your imaging investigations if you susepct lung cancer?
EVERY PT GETS:
- CXR
- CT Staging
Then may consider further imaging e.g. PET scan etc..
Once you have identifed lung cancer on imaging, you want to confirm what type of lung cancer it is; there are multiple methods of doing this- state some
- US guided neck node fine needle aspiration if lymphadenopathy
- Bronchoscopy
- CT biopsy
- Thoracoscopy (if pleural effusion present)
What might you see on CXR of someone with lung cancer?
- Area of consolidation (tumour)
- Pleural effusions
What does this image show?
Cannon ball metastases to lungs
Whath might you see on staging CT of someone with lung cancer?
- Mass
- Pleural effusion
Calculating a pts performance score is an integral part of determining their lung cancer treatment. Describe the WHO performance scale
WHO performance scale gives an indication of pts level of fitness:
- 0= normal. Fully active without restriction
- 1= restricted in physically strenous activity but ambulatory & able to carry out light work e.g. light house work, office work
- 2= ambulatory and capable of all self-care but unable to carry out any work activities. Up and about >50% waking hours
- 3= capable of limited self-care, confined to bed or chair more than 50% of waking hours
- 4= completely disabled. Cannot self care. Totally confied to bed or chair
- 5= dead
What staging classification is used to stage lung cancer?
TNM staging is used first:
- T= size of primary tumour (1-4)
- N= spread via lymph nodes (0-3)
- M= spread to distant sites via blood (0-1)
Then the TNM staging is converted into the I-IV staging system as seen in the image
Discuss the management of small cell lung cancer
- Chemotherapy & radiotherapy
- Prophylactic cranial irradiation: pts with small cell are highly likely to get brain metastases hence radiotherapy directed at brain to reduce risk
- Surgery is rare in pts with small cell are most pts present with advanced disease
Discuss the management of non-small cell lung cancer
Treatment and it’s benefits depend on stage of cancer:
- I= surgery will be curative
- II and fit for surgery= surgery will be curative
- II and not fit for surgery= radiotherapy or stereotactic ablation therapy
- IIIa= surgery and chemotherapy
- IIIb or IV with PS 0-2= chemotherapy
- IV= dugs that target mutations or immune checkpoints, chemotherapy or palliative
*NOTE: palliative care includes radiotherapy for metastases and symptom control
What is stereotactic ablation chemotherapy
Compared to normal radiotherapy it involves a more intense and focused beam of radiation at tumour. Reduces damage to surrounding tissues and also reduces number of sessions needed.
State some complications of chemotherapy
State some complications of radiotherapy
- Due to chemotherapy: alopecia, neutropaenia, bone marrow toxicity.
- Due to radiotherapy: mucositis, pneumonitis, oesophagitis.
Discuss the prognosis of non-small cell lung cancer in terms of 5 year survival
- All 10-13%
- S1 following surgery: 60-70%
- S2 following surgery: 30-55%
- S3: 7%
- S4: 1%
Discuss the prognosis of small cell lung cancer
- Untreated mean survival is 4-12 weeks
- Combination chemotherapy median survival is 6-15 months
Small cell & non-small cell lung cancer accounts for about 95% of cases; state some other types of lung cancer that make up the remaining percentage
- Carcinoid tumour
- Bronchial gland tumour
