Lung cancer: clinical and treatment Flashcards
Is lung cancer common? is it curable? How commonly does it cause cancer death?
- Third most common cancer in the UK
- 90 % incurable at time of diagnosis
- Most common cause of cancer death in men and women in Scotland
- Rates of lung cancer in Scotland are among the highest in the world
What 9 clinical symptoms may cause suspicion of lung cancer?
A cough for 3 weeks or more.
SOB - the tumour can cause a pleural effusion
Recurrent pneumonia/treatment resistant pneuomonia.
haemoptysis - due ulceration of mucosa
Unexplained weight loss.
Chest or shoulder pains - invasion of the chest wall/bony erosion
Unexplained tiredness or lack of energy.
A hoarse voice
stridor
Where are the 6 areas of local invasion for lung cancer?
Recurrent laryngeal nerve - hoarse voice Pericardium - breathless/Atrial fibrillation/pericardial effusion Oesophagus - dysphagia Brachial plexus Pleural cavity Superior vena cava
What is a pancoast tumour? what is pancoast syndrome?
an apical (superior pulmonary sulcus) malignant neoplasm of the lung
Pancoast syndrome results from involvement of brachial plexus and sympathetic chain by a Pancoast tumour, or less commonly from other tumours involving the superior pulmonary sulcus. The syndrome consists of:
shoulder pain C8-T2 radicular pain Horner syndrome
What clinical symptoms/signs can local invasion of a tumour into the superior vena cava cause? why is this?
- obstructs drainage of blood from the arms/head
- puffy eyes/headache
- may see distended veins on abdomen as the blood flow is bypassing the obstructed SVC by opening up anastomoses with the IVC tributaries
What are the common sites for metastases from primary lung cancer? (6)
- liver
- brain
- bone
- adrenal
- skin
- lung
What signs/symptoms may be seen with cerebral metastases of primary lung cancer? what is the nature of onset?
Insidious onset
- Weakness
- Visual disturbance
- Headaches: Worse in the morning, Not photophobic
- Fits
What treatment can be used to relieve symptoms of cerebral metastases?
high dose corticosteroid therapy
Where do tumours have to be located in the liver to produce pain?
-adjacent to liver capsule
What are the two common presentations of bony metastases? What scan can be used to detect these?
- localised pain which is worse at night
- pathological fracture
Isotope bone scan
What is paraneoplastic syndrome? what are the 7 clinical features?
Clinical features which arise from the effects of biochemically active products from the primary tumour: Finger clubbing Hypertrophic pulmonary osteoarthropathy - HPOA (elevation of the periosteum away from the bone surface = pain/tenderness of long bones near the adjacent joints) Weight loss Thrombophlebitis Hypercalcaemia Hyponatraemia - SIADH Weakness - Eaton Lambert syndrome
What investigations are important for suspected lung cancer? (9)
-Full blood count
-Coagulation screen
-Na, K, Ca, Alk Phos
-Spirometry, FEV1
-Chest X-ray
-CT scan of thorax
-PET scan (radiolabelled glucose is taken up by tissues with high metabolic activity = light up)
-Bronchoscopy
-Endobronchial Ultrasound (EBUS)
(NOT sputum cytology)
What is needed to make a diagnosis of lung cancer? what are 6 examples of how this can be done?
A tissue diagnosis: Bronchoscopy CT guided biopsy Lymph node aspirate Aspiration of pleural fluid Endobronchial Ultrasound Thoracoscopy (bronchoscope with US tip, can target and sample lymph nodes)
What is horners syndrome and how is it caused?
Compression of the cervical parts of the sympathetic trunk:
- ipsilateral ptosis: drooping of the upper eyelid due to lack of sympathetic innervation of the smooth muscle within levator palpebrae superioris
- ipsilateral miosis (pinpoint pupil) due to lack of sympathetic innervation of the dilator pupillae
- reduced sweating of the ipsilateral facial skin due to lack of sympathetic innervation of skin sweat glands
For small cell lung cancer:
- what is the progression of disease?
- does it metastasise?
- is it suitable for surgery?
- is it suitable for chemo?
- Rapidly progressive disease
- Early metastases
- Rarely suitable for surgery
- Good initial response to chemotherapy (as it is fast growing this makes it more susceptable) This is often backed up by radiotherapy
For non-small cell lung cancer:
- what are the treatment options?
- sensitive to radiotherapy?
Curative options are surgery or radical radiotherapy
Less responsive to chemotherapy
Is small cell lung cancer or non-small small cell cancers more common in the lung?
non-small cell cancer accounts for the majority of lung cancers
How is staging carried out in lung cancer (5)? Why is this important to do before surgery?
Bronchoscopy:
- Vocal cord palsy
- Proximity to carina (as can’t remove if too close to the carina as there will be a hole in the trachea)
- Cell type
Mediastinoscopy/EBUS:
-Lymph nodes
CT scan of brain:
Metastases
CT scan of thorax: Tumour size Lymph nodes Metastases Local invasion
PET scan:
Positron Emission Tomography
Metastases
It is important to do this before surgery because the surgeon needs to be certain they can remove the entire tumour via operation
What types of surgery are available for lung cancer? what is the main objective? is it common for patients to be suitable for surgery?
- pneumonectomy or lobectomy: requires a thoracotomy or minimal access VATS
- curative objective
- 1 in 20 are fit for surgery
What staging needs to be done for lung cancer before chemotherapy commences?
Bronchoscopy or other tissue sampling:
Small cell / non-small cell (to determine choice of drugs)
CT scan:
- Tumour size
- Local invasion
- Nodes
- Metastases
Performance status ECOG score:
-patient needs to be fairly fit to cope with chemo.
What endobronchial therapy is available for lung cancer?
Stent insertion for stridor
Photodynamic therapy
Other laser therapy
Radioactive pellets
Overall: the treatment of lung cancer is determined by? (4)
- cell type
- extent of disease
- co-morbidity
- patient wishes
