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Respiratory > Lung Carcinomas > Flashcards

Lung Carcinomas Flashcards

1
Q

What are the risk factors of lung cancers?

A
  • Tobacco smoking (if > 40 cigarettes/day for several years: 20 x risk) * cause of 85% of lung cancers
  • Occupational hazard: asbestos, crystallin silica, radon, polycyclic aromatic hydrocarbons, heavy metals
  • Scarring
  • Molecular genetics
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2
Q

How do centrally located tumours present clinically?

A
  • cough * most common
  • dyspnoea (due to obstruction)
  • wheezing
  • haemoptysis
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3
Q

How do peripherally located tumours present clinically?

A
  • pleuritic chest pain
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4
Q

How do tumours at the apex present (usually NSCLC)?

A

Pancoast syndrome:

  • Can invade the brachial plexus causing atrophy of the ipsilateral hand
  • Can invade ribs and and pleura causing shoulder and upper extremity pain
  • Can invade paravertebral sympathetic chain or cervical stellate ganglion leading to Horner’s Syndrome (ptosis, miosis and anhydrosis)
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5
Q

What are the common sites of regional tumour spread and what do they cause?

A
  1. Peripheral spread: pleuritic chest pain and development of dyspnoea due to pleural effusion
  2. Compress recurrent laryngeal nerve: voice hoarseness
  3. Compress phrenic nerve leading diaphragm paralysis: hypoxia and dyspnoea
  4. SVC syndrome (also Pemberton’s positive): compression or invasion of leads to head ache or sensation of head fullness, facial swelling, breathless when supine, dilated veins in face and neck, truncal flushing (plethora)
  5. Spread to pericardium can lead to constrictive pericarditis or cardiac tamponade
  6. Esophageal compression leading to dysphagia
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6
Q

What are the common sites of lung cancer metastases? What do they cause?

A

BLAB:

  • Bone: bone pain, pathological fractures (20%)
  • Liver: RUQ pain, n/v, hepatic insufficiency (30-50%)
  • Lung
  • Adrenals: adrenal insufficiency = Addison’s (>50% of cases* common)
  • Brain: space occupying lesion syndrome Sx depend on location - behavioural change, confusion, seizures, head ache, aphasia (20%)
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7
Q

What is meant by paraneoplastic syndrome?

A

Symptoms that occur at distant sites to the tumour and/or its metatstases.
Lung cancers most commonly present with paraneoplastic syndrome

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8
Q

What are the most common endocrine paraneoplastic syndromes?

A

Tumour secreting hormones:

  1. SIADH secreting by small cell tumours: inc Na+ and ADH
  2. ACTH secreting by small cell tumours (Cushing’s)
  3. PTrH secreting by squamous cell tumours
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9
Q

What is the most common paraneoplastic syndromes relating to:

  • rheumatology
  • haematology
  • neuro
A
  • Rheum: finger clubbing with/or without hypertrophic pulmonary osteoarthropathy
  • Haem: hypercoagulability with migratory superficial thrombophlebitis (Trousseau syndrome)
  • Neuro: Eaton Lambert Syndrome = myasthenia gravis like Sx
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10
Q

List most common lung Ca Ix

A
  • Chest x-ray
  • CT or combined PET–CT
  • Cytopathology examination of pleural fluid or sputum
  • Usually bronchoscopy-guided biopsy and core biopsy
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11
Q

What is the most common initial Ix?

A

CXR but,
findings are suggestive but not diagnostic of lung cancer and require follow-up with CT scans or combined PET–CT scans and cytopathologic confirmation.

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12
Q

What is the role of CT and PET CT in lung Ca?

A

CT:

  • anatomic patterns and characteristics that are suggesting of Ca
  • guide biopsy

PET CT: if CXR is highly suggestive, do this. PET and CT are superimposed on each other. The PET shows inflammatory and malignant processes

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13
Q

What the common samples are used for cytology?

A
  • Sputum
  • Pleural fluid
  • Core biopsy (FNA retrieves too little tissue) * gold standard for Dx
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14
Q

What are the common methods of sampling for:

  • Centrally located tumours
  • Peripherally located tumours
  • Large tumours
A

a. Centrally located tumours:
- sputum, bronchial washings or brushings,
- EBUS-TBNA (endobronchial US allows for transbronchial needle aspiration)
- bronchial biopsy

b. Peripherally located tumours
- FNA (CT guided)
- Pleural biopsy

c. Large tumours:
- wedge excision, lobectomy, penumonectomy

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15
Q

When is a percutanous biopsy v bronchoscopy biopsy indicated?

A

Percuatenous: more useful for metastatic sites (eg, supraclavicular or other peripheral lymph nodes, pleura, liver, adrenals) than for lung lesions.

Bronchoscopy: procedure most often used for diagnosing lung cancer. It often combined with less invasive tests i.e. a combination of washings, brushings, and biopsies of visible endobronchial lesions and of paratracheal, subcarinal, mediastinal, and hilar lymph nodes often yields a tissue diagnosis

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16
Q

How are lung Ca classified?

A
  1. Small Cell Lung Carcinoma (SCLC)
  2. Non- Small Cell Lung Carcinoma (NSCLC)
    - Squamous cell carcinoma
    - Large cell carcinoma
    - Adenocarcinoma* most common NSCLC
    - Adenosquamous carcinoma
    - Sarcomatoid carcinoma
17
Q

How is SCLC staged?

A

SCLC: has 2 stages
- Limited: SCLC is confined to one hemithorax (including ipsilateral LNs)
- Extensive (majority of pts): outside a single hemithorax or the presence of malignant cells detected in pleural or pericardial effusions.
NSCLC

18
Q

How is NSCLC staged?

A

Staged I through IV (using the TNM system). TNM staging is based on tumor size, tumor and lymph node location, and the presence or absence of distant metastases

19
Q

What Ix do we use to stage lung Ca?

A
  • whole body imaging is required for patients diagnosed with lung Ca. It is usually a combination of:
  • PET or integrated PET–CT
  • CT from neck to pelvis and bone scan (done if PET–CT is not available)
  • MRI of chest (for tumors near apex or diaphragm to evaluate vascular supply)
  • Biopsy of questionable nodes (if PET is indeterminate)
  • Head CT or brain MRI * must
20
Q

What are the main rule of thumbs for lung Ca treatment?

A
  • Treat early-stage NSCLC with resection when pulmonary reserve is adequate, often followed by chemotherapy.
  • Treat advanced stage SCLC and NSCLC with chemotherapy.
21
Q

Outline the management of SCLC

A
  • Surgery plays no role in SCLC
  • Chemotherapy can be used in all stages but the response is short lived
  • If disease is confined to hemithorax, then radiation improves outcomes
  • Extensive SCLC is usually managed by chemotherapy
  • In mets to bone or brain, radiation therapy is palliative
22
Q

Outline the management of NSCLC if stage I or II (confined to one lobe).

A
  • If Ca confined to one lobe (stage I or II) then:
    a. surgical approach is appropriate (lobectomy or pneumonectomy with +/- complete LN dissection)
    b. adjuvant chemotherapy
23
Q

What is meant by preoperative pulmonary function testing?

A

In stage I or II NSCLC (where Ca is confined to a hemithorax), surgery is considered for either a lobectomy or a pneumonectomy.
The patient however, needs to have sufficient pulmonary reserve. This means FEV1 must be >2 L for pneumonectomy.

24
Q

Outline the management of NSCLC if stage III or IV (spread).

A

Combination of radiation, chemotherapy and surgery depending on where the lesions are.

Stage IV goal is palliation. This includes radio, chemo and other procedures such as: thoracentesis, pleurodesis if recurrent effusions, bronchoscopic fulguration (removal of tissue obstructing).

25
Q

What is the normal location of:

  • Squamous cell carcinoma
  • Adenocarcinoma
  • Large cell carcinoma
  • Small cell carcinoma
A
  • Squamous cell carcinoma: central, frequent involvement of large airways
  • Adenocarcinoma: generally peripheral, well circumscribed mass (most UNrelated to bronchi), may show some pleural involvement
  • Large cell carcinoma: not the others
  • Small cell carcinoma: at presentation, there is often local obstruction (major bronchi and SVC especially), regional LN or distant mets already
26
Q

What is the criteria for diagnosis (histological features) for:

  • Squamous cell carcinoma
  • Adenocarcinoma
  • Large cell carcinoma
  • Small cell carcinoma
A
  • Squamous cell carcinoma: intracellular bridges and keratinisation
  • Adenocarcinoma: well to moderately differentiated tumour with glandular and/or papillary structures
  • Large cell carcinoma: not the others
  • Small cell carcinoma: tumour must have “neuroendocrine” type architecture which includes: nests, trabeculae, ribbons and rosettes. The cells are highly neoplastic in appearance (high N/C ratio, enlarged nuclei, granular nuclear chromatin, inconspicuous nucleoli, many mitoses are seen)
27
Q

What is meant by adenocarcinoma in situ and what is its relevance? When should an adenocarcinoma in situ be suspected?

A

“adenocarcinoma in situ” refers to the premalignant lesion in the lung.
AIS is defined as a localized adenocarcinoma of less than 3 cm, that exhibits a lepidic pattern with neoplastic cells along the alveolar structures but without stromal, vascular, or pleural invasion
AIS should be suspected with there is non-resolving consolidation (pneumonia)

28
Q

Which carcinoma has the strongest association with smoking?

A

Small cell carcinoma

29
Q

What is the definition of a small cell carcinoma?

A

Tumour with neuroendocrine type architecture (this is why small cell carcinomas are likely to have ectopic secretion with paraneoplastic syndrome)

30
Q

What is the definition of large cell carcinoma?

A

Undifferentiated non-small cell carcinoma that lacks cytologic and architectural features of small cell carcinoma, squamous cell carcinoma and adenocarcinoma
i.e. everything else! it is diagnosis by exclusion

31
Q

List the main complications of lung Ca

A
  • Lipoid pneumonia distal to obstructing tumour
  • Atelectasis
  • Bronchitis
  • Bronchiectasis
  • Cavitation and abscess formation
  • Fistula formation
  • Pleuritis, pleural effusion
  • Vascular thrombosis
32
Q

What is the role of immunohistochemistry?

A
  • Detects immuno markers on the primary lung Ca cell surface in order to confirm their Dx or to subtype them for mgmt
  • It is also used to determine the site of tumour origin in the setting of metastatic disease

Examples are:
Squamous cell carcinoma characteristically have CK5/6 and p63
Breast mets have ER, PR, HER2, GCDFP15

33
Q

What does the TNM stand for in TNM stagin?

A

• T – tumour size
• N – number and location (which station) of
lymph node metastases
• M – distant metastases

34
Q

Does molecular genetics play a role in SCLC or NSCLC? What are the two most important mutations?

A
  • NSCLC (mainly adenocarcinomas)
  • The most important mutations are EGFR and ALK (others: K RAS and B RAF)
  • Rx that are inhibitor of these leads to better prognosis
35
Q

Briefly describe what carcinoid tumours are.

A

Carcinoid tumours are a type of neuroendocrine tumour which can occur in a number of locations.
The main sites are the GIT, lung and ovaries.
They are known to be slow growing tumours but have the capacity to metastasise.
In relation to the lungs, they make up a small % of Lung Ca but should still be considered as a DDx for lung Ca.

Respiratory (9 decks)

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