Lung Cancer Flashcards
What is the second most common cancer in the UK?
Lung cancer (carcinoma of the bronchus)
Risk factors of lung cancer.
Cigarette smoking
Passive smoking
Asbestos
Chromium
Arsenic
iron oxides
Radiation (radon)
Pre-existing lung diesease
Pulmonary fibrosis
HIV
Genetics
How can lung cancer be classified?
By histology
By molecular types
Histological classifications of lung cancer.
Small cell lung cancer (20%)
Non-small cell lung cancer (~80%)
Carcinoid tumours (~1%)
What subclasses of non-small cell lung cancer exist?
Adenocarcinoma (27-30%)
Squamous cell carcinoma (35%)
Large cell carcinoma (10-15%)
What do small cell lung cancers arise from?
Endocrine (Kulchitsky cells)
Molecular types of lung cancer.
EGFR (epidermal growth factor receptor) - commonly encountered in non-smokers, females and asian origin.
ALK (anaplastic lymphoma kinase) - commonly encountered in non-smokers, ex-smokers, young patients and male.
PDL1 - found in e.g. squamous cell carcinoma.
The molecular classifications guide treatment of the cancer.
Local symptoms of lung cancer.
Cough (80%)
Haemoptysis (70%) - fresh or old blood
Dyspnoea (60%)
Chest pain (40%)
Recurrent or slowly resolving pneumonias
Monophonic wheeze
Hoarse voice
Nerve compression
SVCO
Systemic symptoms of lung cancer.
Lethargy
Anorexia
Weight loss
Paraneoplastic syndromes
Signs of lung cancer.
Cachexia
Anaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy causing wrist pain.
Supraclavicular or axillary lymphadenopathy
Consolidation, collapse or pleural effusion
Bone tenderness
Heaptomegaly
Confusion
Fits
Focal CNS signs
Complications of lung cancer.
RLN palsy
Phrenic nerve palsy
SVCO
Honrer’s syndrome
Rib erosion
Pericarditis
Atrial fibrillation
Metastatic
Non-metastatic neurological
Investigations of lung cancer.
CXR -> CT -> PET CT -> Biopsy -> Histology
Cytology - sputum and pleural fluid
Fine needle aspiration
Biopsy
CT
Bronchoscopy
PET/CT EBSU scan
Radionuclide bone scan
MRI
CXR findings in lung cancer.
Peripheral nodules
Hilar enlargement
Consolidation
Lung collapse
Pleural effusion
Bony secondaries
Reticular shadowing
Or completely normal…
What is the gold standard of lung cancer diagnosis?
Standard biopsy
Why is a CT scan done in lung cancer?
To stage the cancer or guide bronchoscopy.
The bronchoscopy can give histology and assess operability.
What is EBUS?
Endobronchial ultrasound for assessment and biopsy.
What can be done to assess staging in lung cancer?
PET
PET/CT EBUS
MRI
Why might a radionuclide bone scan be done in lung cancer?
If metastases are suspected
When might an MRI be done in lung cancer?
Usually only done in Pancoast tumours to assess involvement of nerves and arteries.
Other lung tumours
Bronchial adenoma
Hamartoma
Malignant mesothelioma
What is the staging system of lung cancer?
TNM
N-staging of lung cancer.
N0 - no involvement
N1 - Peribronchial and/or ipsilateral hilum
N2 - Ipsilateral mediastinum or subcarinal involvement
N3 - Contralateral medistinum or hilum, scalene or supraclavicular.
What does pleural effusion mean in terms of staging?
Pleural effusion counts as metastatic disease
Paraneoplastic syndromes of lung cancer.
Lambert-Eaton syndrome - SmCC
Cushing’s (ACTH) - SmCC
SIADH - SmCC
Hypercalcaemia (PTHrP) - SqCC and adenocarcinoma
Hypertrophic pulmonary osteoarthropathy - adenocarcinoma
Clubbing - all lung cancer
Peripheral sensory neuropathy - SmCC
Stiff person syndrome - SmCC
Dermatomyosistis/polymyositis - all
What is Lambert Eaton syndrome?
Similar to Myasthenia gravis but antibodies are to voltage-gated Ca2+ channels on pre-synaptic membrane instead.
There gait difficulty, autonomic involvement
Hyporeflexia and weakness
Lambert-Eaton is similar to MG except amplitude increases greatly post-exercise.
Why does finger clubbing happen in lung cancer?
The mechanism is unclear.
Platelet theory;
Megakaryocytes are normally fragmented into platelets in the lungs. If the lungs are not working correctly the megakaryocytes might not be cleaved and traeol to periphery and become lodged in capillaries of fingers and toes.
This releases platelet-derived growth factor and vEGF which lead to tissue growth, vasuclar permeability and recruitment of inflammatory cells.
This does not explain all clubbing however and is just a theory.
Why is PET scan superior to CT in staging?
It detects small metastases that are not seen on CT staging.
Diagnostic tests of lung cancer (according to workbook)
Bloods - FBC, U&Es, Calcium, LFTs, INR
CXR
Staging CT - spiral CT thorax and upper Abdo
Treatment of lung cancer.
Curative surgery for stages I and II assuming they are fit for surgery
Surgery and adjuvant chemotherapy clinical trial for stage IIa assuming their fit for it.
Chemo - III/IV disease and PS 0-2 (performance status)
Radiotherapy - curative (CHART - continuous hyperfractionated accelerated radiotherapy) in people not fit for surgery or palliative care.
Palliative care
Prognosis of Non-small cell lung cancer.
10-13% 5 year survival
Stage 1 with resection - 60-70%
Stage II with resection - 30-55%
Stage III - 7%
Stage IV - 1%
Treatment of small cell lung cancer.
Rapid growth rate makes surgery difficult.
Chemotherapy and palliative radiotherapy.
Left untreated the median survival is 4-12 weeks.
Combination chemotherapy the median survival is 6-15 months.
What is mesothelioma?
A malignant tumour arising from the parietal or visceral mesothelial lining of the lung.
It occurs in the pleura.
What is mesothelioma associated with?
Asbestos
Latent period between exposure and development of mesothelioma.
Can be up to 45 years.
Clinical features of mesothelioma.
Chest pain
SOB
Weight loss
Finger clubbing
Recurrent pleural effusion
Lymphadenopathy
Hepatomegaly
Bonepain
Abdo pain
Investigations of mesothelioma.
CXR/CT
Pleural thickening and effusion.
Bloody pleural fluid.
Biopsy/thoracoscopy
Diagnosis of mesothelioma.
Made by history and histology.
It is however commonly diagnosed post-mortem
Management of mesothelioma.
Pemetrexed and cisplatin chemotherapy.
