lung cancer symposium Flashcards
what is the epidemiology of lung cancer
leading cause of cancer death
Four people die from lung cancer in the UK every hour
Despite label ‘smokers disease’ 1:8 have never smoked
why are there poor survival of lung cancer rates
Patients present late with advanced stage – 40% via ED
Early symptoms similar to common smokers symptoms
what are causes of lung cancer
70% are caused by smoking
what are types of lung cancer
Usually in a smoker of more than 20 years:
Respiratory
Metastatic- from spread to distant sites
Paraneoplastic/systemic
what are symptoms of lung cancer
Cough haemoptysis dyspnoea wheeze chest pain hoarseness
Common systemic and metastatic presenting symptoms in lung cancer
Weight loss Anorexia, nausea Malaise Fatigue From secondary sites eg CNS, bone, skin
Paraneoplastic syndromes in lung cancer
Frequently seen:
Hyponatraemia- small cell carcinoma
Hypercalcaemia- squamous cell carcinoma
Less commonly- gynaecomastia, pruritis, cerebellar degeneration, peripheral neuropathy
Common signs on examination
clubbing
cachexia
supraclavicular, cervical lymphadenopathy
Stridor due to large airway disease or vocal cord palsy (hoarse voice)
focal chest signs of lung collapse, fixed wheeze
pleural effusion
sub types of cancer
Squamous- central; invade locally, frequent cavitation, hypercalcaemia (20%)
Adenocarcinoma- peripheral lung; more common in non-smokers (40%)
Large cell (5%)
Undifferentiated (18%)
Small cell - central; early lymphatic spread; paraneoplastic syndromes (13%)
investigations to confirm cancer diagnosis
CT
Bronchoscopy
Endobronchial Ultrasound Needle aspiration
Other biopsy procedure eg percutaneous CT thorax, peripheral lymph node/liver
PET scanning- a nuclear medicine scan, utilising the high uptake of a glucose analogue (2,3 FDG) in tumour cells
how is a lung cancer staged
to determine treatment and prognosis
accounts tumour size, involvement of local structures, lymph and blood metastases
what is the T descriptor
T0 no primary
T1 tumour less than 3cm, surrounded by lung
T2 more than 3cm, or extends to visceral pleura, or collapse of part of lung, or tumour in main bronchus
T3 at lung apex, less than 2cm from carina, complete lung collapse, invading mediastinal pleura, chest wall, pericardium, diaphragm, phrenic nerve
T4 invading heart, great vessels, trachea, carina, oesophagus, mediastinum, vertebra, RLN, malignant pleural effusion
what is nodal staging
N0 no regional lymph node metastases
N1 spread to ipsilateral hilar
N2 to ipsilateral mediastinal and sub carinal nodes
N3 to contralateral mediastinal and hilar nodes, supraclavicular nodes
what is M staging
M0 no distant metastases
M1 distant metastases present
Commonly axial skeleton, liver, brain, skin, lung and adrenal glands
how is newly diagnosed lung dealt with
lobectomy or radical treatment (radio or chemotherapy)
radiotherapy in palliative to relieve symptoms
what is palliative care for
Cancer Progressive advanced organ failure Neurodegenerative illness Sudden fatal medical condition e.g. acute stroke, ischaemic limbs, withholding or withdrawing life-saving interventions
When might palliative care have a role in lung cancer management?
In the terminal phase
After active oncological treatment or as only possible treatment
During treatment
Peri-diagnosis
what are types of lung cancer
Carcinoma, Sarcoma, Lymphoma, Mesothelioma
what does small cell carcinoma look like under a microscopic
Widespread bulky disease
Small, dark, delicate cells with little cytoplasm
‘salt and pepper’ chromatin in the nuclei
Azzopardi effect
what might adenocarcinoma first appear
malignant cells lining alveolar spaces
typically peripheral, contains fibrous tissue and shows variable differentiation which correlates with prognosis
where does squamous cell carcinoma begin
arise from squamous metaplasia & dysplasia of bronchial epithelium
Central origin often
Cigarette smoke provokes squamous metaplasia, then dysplasia of bronchial epithelium
how can SCC and AC be distinguished between
can be difficult
Looking for specific proteins can help
eg TTF1 expression is typical of adenocarcinoma
how can therapy of AC be determined
subdivided according to key mutations
EGFR mutations targeted with tyrosine kinase inhibiting agents (eg erlotinib, gefitinib)
ALK fusion proteins (EML4-ALK) targeted with ALK Tki (eg crizotinib)
PD1/PD-L1 (Pembrolizumab)
Precious tissue is prioritized for testing to permit rational therapy
how does lung cancer spread
Local and direct spread
Adjacent lung, Intrapulmonary metastasis
Pleura and Pleural Cavity
Lymphatics within Lung
Lymph Nodes – Hilar,
Mediastinal
Liver, Bone, Brain, Adrenal
How is NSCLC treated
stage 1/2 - lobectomy, radiotherapy +/- chemo
palliative - RT to relive symptoms, chemo can also be used (often in conjunction) to improve QoL/survival
how is SCLC treated
chemo primary treatment (more effective on SC then NSC)
symptom control, remission and enhancing survival
what is fibrosing alveolitis
chronic fibrotic condition
ionising radiation, air pollution, and diesel engine exhaust
Chromium
Iron oxide, nickel
options for treating lung cancer
surgery - robot assisted
radiotherapy
drugs- chemo, immunotherapy, targeted drugs
what are surgical considerations
Operative mortality Cardiovascular mordidity Lung function Post-operative quality-of-life/dyspnoea Surgical approach Chemotherapy – pre or post-op Post-operative radiotherapy
what is SABR
stereotactic ablative body radiotherapy
High energy x-rays delivered via multiple small beams, tracking breathing motion
What are the types of surgery
wedge resection
lobectomy
pneumonectomy
what is palliative radiotherapy used for
Bone pain Spinal cord compression Superior venal caval obstruction Brain metastases Bleeding (haemoptysis)
what is personalised therapy
Tailoring therapy according to tumour gene expression and treatment sensitivities.
Targeting mutations eg EGFR, ALK and Ros1, leading to better outcomes for a proportion of pts with adenocarcinoma
Using the immune system
