Lung Oncology Flashcards
What are the Stages by primary tumour size?
TIS: tumour in situ, less than 3cm, no invasive component
T1: tumour less than 3cm, invasive component, but not into bronchus
T2: 3-5cm
o invades the main bronchus (but not the carina)
o invades visceral pleura
o associates with atelectasis or obstructive pneumonitis that extends to the hila
T3 5-7cm
o associates with separate tumour nodules in the same lobe
T4 >7cm
o associates with separate tumour nodules in a different ipsilateral lobe
What do you use to assess the potential for curative Rx
PET-CT
What do you do If nodal status affects Rx plan
prioritise high risk intrathoracic lymph nodes > 1o
lesion
What is classed as a Central lesion?
within 3cm proximal bronchial tree, heart, great vessels, trachea, other mediastinal structures
What are features of an Adenocarcinoma?
- location
- smoking/non smoking
- Differentiation
- tumour marker proteins
- precancerous
More peripheral
Most common in non-smokers
Glandular differentiation, mucin-containing elements
Thyroid Transcription Factor 1, Napsin A
Precancerous = adenocarcinoma in situ
What are features of an Squamous cell carcinoma ?
- location
- smoking/non smoking
- Differentiation
- tumour marker proteins
- precancerous
More central- Can grown into lumen (obstruction/infection) or out into parenchyma
Assoc. w/smoking
Keratin production- in form of squamous pearls or eosinophilic cytoplasm
p63 and p40 markers
precancerous = carcinoma in situ
What are features of an Large cell carcinoma ?
- location
- smoking/non smoking
- Differentiation
- tumour marker proteins
Epithelial, undifferentiated malignant tumour
large nuclei, prominent nucleoli, moderate cytoplasm. . Lacks the features of other forms of lung cancer.
diagnosis of exclusion – negative for all characteristic markers
What are features of an Small cell carcinoma ?
- location
- smoking/non smoking
- Differentiation
- tumour marker proteins
Major bronchi/lung periphery
Strong link to smoking, Most aggressive, usually metastasised by diagnosis
Small round/spindle-shaped cells, little cytoplasm, ill-defined
borders, ill-defined borders, and finely granular nuclear chromatin (salt-and-pepper pattern). Shows areas of necrosis.
Non epithelial origin
High expression neuroendocrine markers e.g., chromogranin, CD57
Assoc. w/ectopic hormone production.
What is the ECOG/WHO performance status:
0 → fully active
1 → light work
2 → selfcare but no work activities
3 → limited selfcare, bed/chair
confined >50% of time
4 → completely disabled, no selfcare
5 → dead
What is the investigative methods for Central Lesions
Flexible bronchoscopy if central lesions on CT
What is the investigative methods for Peripheral Lesions
Peripheral 1otumour → CT guided biopsy
What is the investigative methods for Paratracheal and Peri-bronchial intra-parenchymal lesion
EBUS-TBNA (endobronchial ultrasound-guided transbronchial needle aspiration)
What are the different stages of N for TNM staging
- N0
- N1
- N2
- N3
N0: no nodes involved
N1: ipsilateral bronchopulmonary or hilar
N2: ipsilateral mediastinal or subcarinal
N3: contralateral hilar, mediastinal or supraclavicular
What are the different stages of M for TNM staging
- M0
- M1
M: distant metastasis
M0: no distant metastasis
M1: distant metastasis present
o M1a: nodules in a contralateral lobe, the pleura or the pericardium, or effusions in the pleural cavity or pericardium o M1b: single extra-thoracic metastasis o M1c: multiple extra-thoracic metastases in one
When is surgery and radiotherapy w/curative intent offered
Well enough + suitable for curative intent →
offer lobectomy
Only offer more extensive e.g., pneumonectomy
if needed to obtain clear margins
Do hilar + mediastinal lymph node sampling or
en bloc resection
T3 NSCLC w/chest wall involvement, aim for
complete resection using extra pleural or en bloc
chest wall resection.
When is surgery or radiotherapy for people not having lobectomy offered
Stage I-IIA, NSCLC who decline lobectomy or contraindicated then offer radical radiotherapy with stereotactic ablative
radiotherapy (SABR) or sub lobar resection
When is Radical radiotherapy for people not having surgery
Should have pulmonary function tests ) beforehand
If for curative intent should be part of national quality
assurance programme
Stage I-IIA NSCLC who decline surgery/contraindicated,
offer SABR – if SABR contraindicated offer radiotherapy
Eligible stage IIIA or IIIB NSCLC who can’t tolerate/decline chemo, consider radical radiotherapy
What are side effects of radiotherapy ?
inc. pleurisy + fibrosis
What are local complications of Lung Cancer
SOB → e.g., from pleural effusions or airway obstruction
Cough → irritation
Haemoptysis → erosion of tumour into blood vessels
Pancoast tumours →neuropathic pain via brachial plexus
Pleuritic pain → metastases
SVC obstruction → upper limb + facial plethora, more SOB
What are systemic complications of Lung Cancer
Anorexia and altered taste
Bone metastases → pain, risk of fractures and
cord compression
Brain metastases → persistent headaches,
unexplained vomiting, behaviour change, risk
of seizures. Ix w/MRI head rather than PET-CT
(as brain has high metabolic rate)
Hypercalcaemia (oncological emergency) →
nausea, altered mood, confusion, constipation,
from bone metastases or PTH release
Hyponatraemia → can get in small cell lung
cancer due to inappropriate ADH
How do you manage Palliative Symptoms?
Physical symptoms – assess at key points
of illness, enquire about symptoms, avoid
medication not required
Spiritual needs – access to staff sensitive to
spiritual needs, MDTs w/spiritual
caregivers, protecting self-worth, dignity
and identity
Family – when possible invite family
members/carers to be involved in clinical
encounters
Psychological needs – assess at key points,
offer referral to specialists if needed
Social needs – assess at key points, inc.
emotional support, help w/personal care +
caring for dependents etc., support groups,
volunteer visitors etc
How is immunotherapy used to target lung cancer?
Can use immunotherapy to target
predominant molecules in different
types of lung cancers e.g., PDL1
inhibitors can allow the immune
system to target cancer cells.
Often have many side effects
Who is in the Cancer MDT ?
Diagnostics team (radiology, histopathology, general practice)
Interventional team (thoracic surgery, respiratory medicine, anaesthetics)
Medical team (clinical and medical oncology, palliative medicine)
Where do Paratracheal lymph nodes receive lymph from
Paratracheal lymph nodesreceive the lymph from the larynx,hypopharynx, oesophagus, thyroid gland and trachea
What is Thoracoscore
Risk of death after thoracic surgery for lung cancer-score used
Thoracoscore components
Age: >65 - Sex: - ASA Classification - PS - Dyspnoea score - Priority of surgery - Procedure class - Diagnosis group - Comorbidity score
