Lung cancer, Pleural diseases and Palliative Medicine Flashcards
What are the common causes and risk factors for lung cancer?
- smoking (90%)
- environmental - radon exposure, asbestos, polycyclic aromatic hydrocarbons, ionising radiation, occupational exposure to arsenic, chromium, nickel, petroleum products, oils
- host factors - pre existing lung disease (pulmonary fibrosis), HIV infection, genetic factors
describe the prevelance of lung cancer?
- most common malignant tumour worldwide
- 3rd most common UK cause of death
- declining rates in men, increase in women
- men:women 1.2:1
what accounts for >90% of lung cancer?
cigarette smoking including passive smoking
what environmental factors can cause lung cancer?
radon exposure, asbestos, polycyclic aromatic hydrocarbons and ionizing radiation. Occupational exposure to arsenic, chromium, nickel, petroleum products and oils
What host factors can increase risk of lung cancer?
pre-existing lung disease such as pulmonary fibrosis; HIV infection; genetic factors.
describe the pathophysiology of lung cancer?
split into small cell and non small cell based on histological appearances
gives prognostic information
non small cell cancer can be further subdivided into adenocarcinoma, squamous cell carcinoma, large cell carcinoma
what are the clinical features of lung cancer?
- cough
- breathlessness (occlude airway, co existing COPD)
- haemoptysis (tumour bleeding)
- chest pain (in chest wall or pleura)
- wheeze (monophonic-partial airway obstruction)
- hoarse voice
- nerve compression
- recurrent infections
- phrenic nerve involvement
- superior vena caval involvement
what lymph nodes does lung cancer usually spread to?
mediastinal, cervical, axillary, intra-abdominal
what are the common sites of lung cancer metastases?
liver adrenal glands bone brain skin
what symptoms may a patient with lung cancer with liver metastases experience?
anorexia
nausea
weight loss
RUQ pain radiating across abdomen
what symptoms may a patient with lung cancer with bone metastases experience?
bony pain
pathological fractures
spinal cord compression
what symptoms may a patient with lung cancer with adrenal gland metastases experience?
usually asymptomatic
what symptoms may a patient with lung cancer with brain metastases experience?
signs of raised intracranial pressure
carcinomatous meningitis with cranial nerve defects
headache
confusion
rank the types of lung cancer from highest incidence to lowest?
adenocarcinoma
small cell carcinoma
squamous cell carcinoma
large cell carcinoma
describe the features of squamous cell carcinoma?
- arises from epithelial cells associated with keratin production
- occasionally cavities with central necrosis
- obstructing lesions of bronchus with post obstructive infection
- local spread common
- metastasise late
describe the features of adenocarcinoma?
- increasing incidence
- originate from mucus secreting glandular cells
- most common type in non smokers
- peripheral lesions on CXR
- metastases common
describe the features of large cell carcinoma?
- poorly differentiated
- metastasise early
describe the features of small cell carcinoma?
arise from neuroendocrine cells (APUD)
secrete polypeptide hormones
-arise centrally and metastasise early
what are the non-metastatic extra pulmonary manifestations of lung cancer?
- weight loss
- anorexia
- ectopic adrenocorticotrophin syndrome (small cell…)
- hypercalcaemia (squamous cell…)
- encephalopathies
- myelopathies
- neuropathies
- muscular disorders
- clubbing
describe the features of malignant pleural effusion?
present with breathlessness
commonly associated with pleuritic pain
why are investigations necessary in patients with lung cancer?
- stage extent of disease
- make tissue diagnosis
- assess fitness to undergo treatment
what investigations can be used to assess lung cancer?
- CXR
- CT
- PET/CT
- fibreoptic bronchoscopy
- percutaneous aspiration and biopsy
- endobronchial ultrasound
- ultrasound guided supraclavicular node sampling
- video assisted thoracoscopic surgery
- FBC
- liver biochemistry
what is the role of CT in lung cancer?
- indicates extent of disease
- IASLC staging definitions based on CT imaging
- lymph nodes <1cm not classed as being enlarged yet may still be malignant
what are the possible presentations of lung cancer on CXR?
- normal
- mass lesion
- pleural effusion
- mediastinal widening or hilar adenopathy
- slow resolving consolidation
- collapse
- reticular shadowing
what is the TNM staging for occult carcinoma?
TX, N0, M0
what is the TNM staging for stage 0 carcinoma?
Tis, N0, M0
what is the TNM staging for stage IA carcinoma?
T1a, bN0, M0
what is the TNM staging for stage IB carcinoma?
T2a, N0, M0
what is the TNM staging for stage IIA carcinoma?
T2b, N0, M0
T1a, bN1, M0
T2a, N1, M0
what is the TNM staging for IIB carcinoma?
T2bN1M0
T3N0M0
what is the TNM staging for stage IIIA carcinoma?
T1a,b T2a, b N2M0 T3N1 N2M0 T4N0 N1M0
what is the TNM staging for stage IIIB carcinoma?
T4N2M0
any T N3, M0
what is the TNM staging for stage IV carcinoma?
any T NM1
when may surgery be used in lung cancer treatment?
early stage non small cell (stage I, II, and some IIIA)
what treatment is offered to patients with stage III disease?
chemoradiation
aim to downstage the disease and allow for surgical intervention
when may radiation therapy be used with the aim of curing lung cancer?
patients with adequate lung function and early stage NSCLC
high dose radiotherapy or continuous hyper fractionated accelerated regimens-useful if surgery not possible due to comorbidities, outcomes as good as surgical resection
what are the potential complications of radiotherapy in treatment of lung cancer?
radiation pneumonitis
radiation fibrosis
what treatment can be used in patients with early stage I disease with significant cardiovascular or respiratory co morbidities?
stereotactic radiotherapy
radio frequency ablation-image guided technique using heat to destroy small peripheral tumours
describe the role of radiation in the treatment of lung cancer symptoms?
bone and chest wall pain from metastases or direct invasion, haeoptysis, occluded bronchi and superior vena cava obstruction
radiotherapy is given at the end of chemotherapy to consolidate treatment in small cell
what is the role of chemotherapy in treatment of lung cancer?
- adjuvant chemotherapy with radiotherapy improves response rate and extends median survival in non small cell cancer
- newer targeted agents against epidermal growth factor responses and tyrosine kinases in NSCLC offer better outcomes. it can also be used with IV chemotherapy can’t or as second line chemotherapy
when is laser therapy, endobronchial irradiation and tracheobronchial stents used?
palliation of inoperable lung cancer in patients with tracheobronchial narrowing from intraluminal tumour or extrinsic compression causing disabling breathlessness, intractable cough and complications including infection, haemoptysis and respiratory failure
describe laser therapy in treating lung cancer?
Nd-Yag laser passed through fiberoptic bronchoscope to vaporise inoperable fungating intraluminal carcinoma involving segments of trachea or main bronchus
benign tumours, strictures and vascular lesions can also be treated
describe brachytherapy in treating lung cancer?
treatment of intraluminal tumour and malignant extrinsic compression
radioactive source is after loaded into a catheter placed adjacent to carcinoma under fiberoptic bronchoscope control
radiation dose falls with distance from source, minimising damage to normal tissue adjacent
reduction in tumour size 70-95% of times
describe tracheobrachial stents in treating lung cancer?
made of silicone or expandable metal springs inserted into strictures caused by tumour or from external compression or when there is weakening or collapse of tracheobronchial wall
describe palliative care for patients with lung cancer?
lung cancer patients tend to remain relatively independent and pain free but die more rapidly when they reach terminal phase
psychological and emotional support-respiratory team, primary care team, nurses, social workers, hospital chaplains, doctors
how do secondary tumours of the lung usually present?
round shadows 1.5-3cm in diameter on CXR
nearly always develop in parenchyma and often asymptomatic
rarely develop in bronchi- haemoptysis
for patients with secondary lung tumours what are the typical sites for the primary tumour?
kidney prostate breast bone GI tract cervix ovary
what is lymphangitis carcinomatosis?
carcinoma of stomach, pancreas and breast involve mediastinal glands and spread along lymphatics of both lungs
what primary tumour is most likely to present as a solitary round shadow on CXR in asymptomatic patients?
renal cell carcinoma
describe the potential for screening lung cancer?
USA trial - 20% mortality benefit from CT screening in high risk groups aged 55-74
this may be used in future
give examples of benign lung tumours?
- pulmonary hamartoma
- bronchial carcinoid
- cylindroma, chondroma and lipoma
- tracheal tumours
describe the features of pulmonary hamartoma?
- most common benign tumour of lung
- CXR- well defined round lesion in periphery
- slow growth
- can rarely arise from bronchus and cause obstruction
describe the features of bronchial carcinoid?
- resembles intestinal carcinoid tumour
- locally invasive, eventually spread to mediastinal lymph nodes and distant organs
- highly vascular tumour that projects into lumen of major bronchus causing recurrent haemoptysis leading to lobar collapse
- produce ACTH
Describe features cyindroma, chondroma and lipoma?
rare
grow in bronchus or trachea
cause obstruction
describe the features of tracheal tumours?
benign tumours include squamous papilloma, leiomyoma, haemangiomas and tumours of neurogenic origin
describe the features of superior vena caval obstruction?
- can arise from any upper mediastinal mass (most commonly lung cancer and lymphoma)
- difficult breathing/swallowing
- stridor, swollen, oedematous facies and arms with venous congestion in neck and dilated veins in upper chest and arm
what treatment is give for superior vena cabal obstruction?
immediate steroids vascular stents anticoagulation mediastinal radiotherapy or chemotherapy ventilatory support may be needed
what is the typical pathway for a histological sample?
- receive specimen
- dissected by pathologist
- tissue processed overnight
- thin sections cut onto microscope slides
- slides stained with haematoxylin and eosin
- slides to pathologist
- additional investigation if required such as special stains
- report issued
describe the NICE pathway for investigating an adult with suspected lung cancer?
- CXR
- smoking cessation advice
- CT
- factors considered before choosing tests. EITHER peripheral lesions (nodes <10mm-PET) OR peripheral or central lesion (nodes>10mm)
- further tests
- test for brain metastases
- treat
what common investigation method is not usually used assessing the stage of a primary lung tumour?
MRI
describe a bronchoscopy?
- look in airways
- take biopsies
- bronchoscope down trachea
- anti coagulants stopped before
- general or local anaesthetic
- go home same day
- results in 1-2 weeks
what are the potential risks of bronchoscopy?
bleeding teeth damage chest infection extra oxygen needed pneumothorax
