lung cancer Flashcards
definition of non-small cell lung cancer
primary malignant neoplasm of lung
WHO classification of bronchocarcinoma: small cell 20%, non-small cell 80%
Histological types of non-small cell lung cancer include: Squamous cell carcinoma, adeno-carcinoma, large cell carcinoma and adenosquamous carcinoma, adenocarcinoma in situ
definition of small cell carcinoma
Malignant neoplasm of neuroendocrine Kulchitsky cells of the lung with early dissemination. Also known as oat cell carcinoma.
often secrete polypeptide hormones = paraneoplastic syndromes eg production of ACTH, Cushing’s syndrome
most SCLC are disseminated at presentation
definition of rarer lung cancer
bronchial adenoma - rare, slow growing. 90% are carcinoid tumours, 10% cylindromas
hamartoma - rare, benign. CT = lobulated mass +- flecks of calcification
aetiology of lung cancer
smoking = genetic alterations = neoplastic transformation
RF:
- smoking
- passive smoking
- occupational exposures - polycystic hydrocarbons, asbestos, nickle, chromium, cadmium, radon, arsenic, iron oxides
- atmospheric pollution
tumours generally in main or lobar bronchi
adenocarcinomas more peripheral
epidemiology of non-small lung cancer
Most common fatal malignancy in the West (18% of cancer mortality worldwide), 35000 deaths per year (UK), 3x more common in men (but increasing in women).
epidemiology of small cell lung cancer
20% of the lung cancers
epidemiology of carcinoma of the bronchus
2nd most common cancer in UK, 13% of all new cancer cases and 27% of cancer deaths (40000 cases/yr in UK)
incidence increasing in women
only 5% cured
sx of non-small cell lung cancer
may be asymptomatic with radiographic abnormality found - 5%
due to primary: cough, haemoptysis, chest pain, recurrent pneumonia
due to local invasion:
- brachial plexus (pancoast tumour) - shoulder/arm pain
- L recurrent laryngeal nerve - hoarseness and bovine cough
- oesophagus - dysphagia
- heart - palpitations/arrhythmias
due to metastatic disease or paraneoplastic phenomonia: weight loss, fatigue, fits, bone pain or fractures, neuromyopathies
sx of small cell lung cancer
may be asymptomatic with radiographic abnormality found
due to primary - cough, haemoptysis, dyspnoea, chest pain
due to metasatic disease - anorexia,m weight loss, fatigue, bone pain
due to paraneoplastic syndrome - weakness, lethargy, seizures, muscle fatiguability
Non-metastatic extrapulmonary manifestations of bronchial cancer
endocrine - ectopic secretion: ACTH (Cushing’s), ADH (dilutional hyponatraemia), PTH(hypercalcaemia), HCG (gynaecomastia)
neurological - Cerebellar degeneration, myopathy, polyneuropathy, myasthenic syndrome
vascular - thrombophlebitis migrans, anaemia, DIC
cutaneous - dermatomyositis, herpes zoster, acanthosis nigricans
skeletal - clubbing, HPOA
signs of non-small cell lung cancer
may be no signs
fixed monophonic wheeze
signs of collapse, consolidation or pleural effusion
due to local invasion
due to paraneoplastic phenomena
due to met
signs of non-small cell lung cancer due to local invasion
superior vena cava compression - facial congestion, distension of neck veins, upper limb oedema
brachial plexus - wasting of small muscles of the hand
sympathetic chain - Horner’s (pupillary miosis, ptosis, facial anhydrosis)
signs of non-small cell lung cancer due to paraneoplastic phenomena
hypertrophic osteoarthropathy: clubbing, painful swollen wrists/ankles (periosteal new bone formation)
dematological signs
- Acanthosis nigricans(pigmented thickened skin in axilla or neck),
- herpes zoster,
- dermatomyositis,
- thrombophlebitis migrans.
signs of non-small lung cancer due to metastasis
Supraclavicular lymphadenopathy,
hepatomegaly.
signs of small cell lung cancer
May be no signs or a fixed wheeze on auscultation of the chest.
signs of lobar collapse/pleural effusion
signs of met eg supraclavicular lymphadenopathy or hepatomegaly
signs of paraneoplastic syndrome
signs of lung cancer
cachexia
anaemia
clubbing
hypertrophic pulmonary osteoarthropathy = wrist pain
supraclavicular or axillary lymph nodes
chest signs: none, consolidation, collapse, pleural effusion
met: bone tenderness, hepatomegaly, confusion, fits, focal CNS signs, cerebellar syndrome, prox myopathy, peripheral neuropathy
Ix for non-small cell lung cancer
CXR - coin lesions, lobar collapse, pleural effusion, features of lymphangitis, carcinomatosis
sputum cytology
bronchoscopy with brushings or biopsy
CT or US guided percutaneous biopsy
lymph node biopsy
TNM staging for non-small lung cell cancer
based on tumour size, nodal involvement and metastatic spread
using CT chest, CT or MRI head and abdomen (or ultrasound), bone scan, PET scan.
can use invasive methods eg mediastinoscopy or video-assisted thoracoscopy
bloods for non-small cell lung cancer
FBC
UE
Ca2+ hypercalcaemia is common
AlkPhos - increased bone met
LFT
pre-op Ix for non-small cell lung cancer
ABG
pul function tests (FEV1>80% predicted to tolerate a pneumectomy, lung resection is contraindicated if FEV1 <30% predicted)
V/Q scan
ECG
echo
general anaesthetic assessment
Ix for small cell lung cancer
diagnosis
- sputum cytology
- bronchoscopy with brushings and biopsy or percutaneous biopsy
- thoracoscopy
staging
- CT of chest, abdo, head
- isotope bone scan
other
lung funct tests
- FBC
- UE
- Ca
- AlkPhos
- LFT
Ix for carcinoma of the bronchus
CXR
cytology - sputum and peripheral fluid (send at least 20mL)
FNAC or biopsy - peripheral lesions/lymph nodes
CT to stage and guide bronchoscopy
bronchoscopy
radionucleotide bone scan if suspected met
Lung function test - help assess suitability for lobectomy
CXR for carcinoma of the bronchus
peripheral nodule
hilar enlargement
consolidation
lung collapse
pleural effusion
bony secondaries
bronchoscopy for carcinoma of the bronchus
give histology and assess operability +- endobronchial US for assessment and biopsy
18F-deoxyglucose PET or PET/CTEBUS scan to help in staging.
mx of small cell lung cancer
- chemo
- radio
- prophylactic cranial irradiation
- consider surgery
- if extensive disease - immunotherapy
chemo or radio if relapse
complications of small cell lung cancer
mx for non-small cell lung ca
Surgical resection:
Lobectomy (with hilar and mediastinal lymph node resection/sampling) - stage I or II cancer who are medically fit for surgery. This surgery is done with curative intent.
Radiotherapy:
stage I-III disease who are not suitable for surgery.
This treatment is given with curative intent.
Chemotherapy:
Is offered to those with stage III or IV disease to improve survival and quality of life.
First line regimes use a combination of:
Third-generation chemotherapy agent: e.g. docetaxel, paclitaxel or gemcitabine
Platinum agent: e.g. carboplatin or cisplatin
- Adjuvant chemotherapy should be offered to patients who have undergone a complete resection
- Adjuvant radiotherapy is offered to patients who have had a incomplete resection of their tumour
complications of non-small cell lung cancer
