lung cancer - diagnosis and staging Flashcards
what are the 3 subtypes of lung cancer
small cell, non-small cell and carcinoids
what are the 5 sub types of NSC lung cancer
adeno; squaemous; large cell; mixed; undifferentiated
7 risk factors for lung cancer
cigarette smoking; occupational exposure; genetics; low level radiation; smoking/low intake of beta carotene; lung disease history; FH of lung cancer
common signs/symptoms of lung cancer (10)
fever without a known reason; recurring infections (bronchitis, pneumonia etc.); cough that does not go away; change on cough that one has had for a long time; SOB; coughing up phlegm with blood in it; ache/pain in chest/shoulder; loss of appetite; tiredness
less common signs of lung cancer (7)
hoarse voice (compression of recurrent laryngeal nerve); difficulty swallowing; changes in fingernails (clubbing; swollen face (SVC obstruciton); swollen lymphnodes in neck; change in blood tests (raises platelets); pain under ribcgae (swollen liver); fluid in lungs causing SOB
why is early diagnosis needed (3)
- in early stages treatment is most successful
- earlier diagnosis can increase the survival
- to detect the disease at a stage when it is not causing symptoms
why is lung cancer not screened for routinely (4)
high number of pts needed to screen; cost effectivness uncertain; risk over diagnosis and invasive tests for benign disease; smoking cessation and tobacco control are likley to be more cost effective
who should be referred urgently for CXR (suspicion of cancer)
unexplained haemoptysis
or
any of the following unexplained, persisitant (>3wks) symptoms:
chest/shoulder pain
SOB
weight loss
abnormal chest signs
hoarseness
clubbing
cerviacle/supraclavicular lymphadenopathy
cough
features suggestive of a metastasis from a lung cancer
who should be urgently referred to a lung caner specialist (6)
- persisitant haemoptysis in smokers/ex-smokers >40yro
- CXR suggestive of lung cancer
- finger clubbing
- severe weight loss
- superior vena cava obstruction
- neck nodes in smokers
3 types of cancer staging
clinical (CXR/CT/PET etc.)
surgical (bronchoscopy, EBUS-TBA, mediastinoscopy)
pathological (after complete resection and LN sampling)
why is using a CT scan alone not good for clinical staging
40% of suspicious LN are benign according to size criteria
20% of non suspicious LN are malignant
what are the 4 techniques used in surgical staging
brinchoscopy/EBUS-TBA; mediastinotomy/scopy; thoracoscopy; thoracotomy
what is EBUS-TBNA
Endobronchial Ultrasound-guided Transbronchial Needle Aspiration
if the disease is metastatic, where is the biopsy obtained from
the easiest site
what is the TNM staging system
Classification of Malignant Tumors:
T - tumour size (0-4)
N - number of nearby lymphnodes that are cancerous (0-3)
M - metastasis (0-1)
what is T staging (lung)
tumour size (every cm matters)
T0 - no evidence of primary tumour
T1 - tumor 3cm or less
T2 - tumor 3-5cm or has invaded pluera, involves main bronchus, associated w atelectasis
T3 - tumor 5-7cm or has involved the phrenic nerve, chest wall, pericardium
T4 - >7cm or has involved the diaphragm, mediastinum, heart, great vessels, trachea etc.
what is N staging (lung)
lymph node involvement
N0- no regional lymph node metastasis
N1 - metasestis in ipsilateral peribronchial/hilar lymphnodes, intrapulmonary involement
N2 - metastasis in ipsilateral mediastinal lymphnodes
N3 - metastasis in contralateral hilar, ipsilateral/contralateral scalene, supraclavicular lymphnodes
what is M staging
distant metastasis
M0- no distant metastasis
M1- distant metastasis
1a - single tumor nodule in contralteral lobe/pleural/pericardial nodules or malignant pleural/pericardia effusoin
1b - single extrathoracic metastasis in a single organ
1c - multiple extra thoracic metastases in one or several organs
clinical vs pathological size
clinical - size of solid component
pathological - size of invasive component
which stage is the baseline for oligometastases/progression
M1b
how are multiple primary tumors staged
one TNM for each tumor
what is the most common type of lung cancer
non-small cell lung cancer
what are the 3 main types of NSCLC
adenocarcinoma (40%) - form glandular structures and generate mucins
squamous - square shaped cells that produce keratin, deplete calcium levels in bone making them brittle
large cell - lack glandular and squamous differnetiaiton
what are pancoast tumors, what can they damage and what syndrome can they cause
cancers that start in the apex of the lung; cause damage to thoracic inlet, brachial plexus, cerviacle sympathetic nerve -> this results in Horner’s syndrome
what is a key symptom of horner’s syndrome and why does it occur
compression of cervical sympathetic nerve means sweating cannot occur on the affected side; other symptoms include constricted pupil and drooping eyelid
adenocarcinoma facts (9)
slow growin;g
Arises from mucous cells in the bronchial epithelium;
Commonly invades the mediastinal lymph nodes and the pleura, and spreads to the brain and bones;
tends to be in periphery of the lung ;
Does not usually cavitate ;
Most likely to cause pleural effusion;
Proportionally more common in non-smokers, women and in the Far East; usually TTF-1 positive
squamous cell carcinoma facts (6)
commonly starts in the bronchi and may not spread as rapidly as other lung cancers;
On X-ray it is not possible to tell whether it is an abscess or a cancer (the border’s definition cannot be easily seen) but on the CT there is obviously a jagged border – indicating cancer;
Local spread is common, but metastasis are normally late;
Usually present as obstructive lesions of the bronchus leading to infection;
Often causes hypercalcaemia – by bone destruction or production of PTH analogues;
TTF-1 negative, p63 positive and cytokeratin 5/6 positive
large cell carcinoma facts (2)
names after the large, round cells seen in this cancer;
grow quickly and spread => usually diagnoses in layter stages
good prognostic factors for NSCLCs
early stage diagnosis; good performance status; no significant weight loss; female gender
what is a bronchial carcinoid tumor
a low-grade malignancy of neuroendocrine cells - same cell of origin as small-cell carcinomas
pathology of small cell lung cancer (SCLC)
uncontrolled proliferation of small, immature, neuroendocrine cells; usually develops centrally near main bronchus; grows fast and rapidly metasesises to other organs; secretes hormones causing paraneoplastic syndromes
typical presentaiton of SCLC
large hilar mass - bulky mediastinal lymphadenopathy that causes cough and dyspnoea; earlier development of widespread mets
what is SCLC strongly associated with
smoking
what paraneoplastics syndromes may be caused by SCLC
SI-ADH (inappropriate ADH secretion resulting in hyponatraemia); Polyneuropathy (Antibodies against the myelin sheath); Cerebellar degeneration; Eaton-Lambert Myasthenic synrome (proximal muscle weakness that improves on repetition);(Hypertrophic pulmonary osteoarthropathy); Carcinoid syndrome; Ectopic ACTH secretion – causing Cushing’s syndrome; Hypercalcemia; DVT/PE
what are 3 key investigations for SCLC
labs - FBC, LFT, LDH;
CT chest/abdo/plevis;
brain imaging (CT/MRI) - up to 30% have brian mets, esp when pts are symptomatic
where does SCLC commonly metastasize to
B-brain
A-adrenal gland
L- liver
L-lung
S- skeleton
limited and extensive SCLC classifications (TNM)
limited: any T, any N, M0
extensive: an T any N, M1a/b, T3/4 due to multiple lung nodules
limited and extensive SCLC classifications (areas affected)
limited: disease confined to the ipsilateral hemithorax which can be safely encompassed within a radiation field
extensive: disease beyond the ipsilateral hemithorax, including malignant pleural or pericardial effusion
what biomarkers are common in SCLC
all stain positive for: keratin; epitherlial membrane antigen; TTF-1 (thyroid transcription factor-1)
most stain positive for: neuroendocrine differentiation marks (e.g. chromogranin A)
NSCLC management (3)
First-line: lobectomy;
Curative radiotherapy can also be offered to patients with stage I, II and III NSCLC;
Chemotherapy should be offered to patients with stage III and IV NSCLC to control the disease and improve quality of
life
SCLC management
Generally palliative chemotherapy, as tumours are disseminated on presentation
if a tumor compresses a blood vessel e.g. SVC what can occur
back up of blood resulting in facial swelling, SOB
what cancer is most associated with non-smokers
adenocarcinoma
