Management of Lung Cancer Flashcards
How many lung cancer patients will be offered possibly curative treatment?
22%
What are the risk factors for lung cancer?
Smoking Air pollution Nickel, chromium Radiation (radon) Asbestos- if smoker, risk increased 50 fold Family history
Describe the casual link between tobacco smoke and lung cancer
- x20 risk compared to non-smokers
- Passive exposure associated with higher risk of lung cancer
- 10% occurs in never-smokers
- Genetic component suggested by increased risk in those with family history
Describe screening lung cancer
Lung cancer presents late and early stage lung cancer has best outcome
Screening aims to identify lung caner at early stage
How do we screen for lung cancer?
CXR/ sputum cytology as screening no effect on mortality
Several trials have shown screening with LD CT can detect early stage lung cancer
RCT trails of LD CT conducted- primary outcome reduced mortality but false positives
What are the clinical features of lung cancer?
- Cough
- Haemoptysis
- Dyspnoea
- Chest/ shoulder pain
- Wheeze/stridor
- Hoarse voice
- SVC obstruction
- Lymphadenopathy
- Bone pain
- Paraneoplastic syndromes
Describe the histology of lung cancer
Adenocarcinoma= 40%
Squamous cell carcinoma= 30%
Large cell carcinoma= 15%
Small cell= 15%
What does a tumour secrete as it grows?
Tumour angiogenesis factors (TAF) which cause blood vessels to grow into the mass of tumour cells. This allows a tumour to grow more rapidly and increase in size.
What is the process by which squamous cell carcinomas frequently develop into necrotic masses?
If the tumour grows too large for its blood supply then the central areas can become deprived of oxygen and nutrients and will undergo necrosis, they die.growth and spread.
How can TAF be targeted in treatment?
possibility of suppressing or counteracting the effect of TAF in the hope that restricting the flow of blood to a tumour will restrict
How do adenocarcinomas arise?
peripherally from mucous glands and the cells retain some of the tubular, acinar or papillary differentiation and mucus production. Adenocarcinoma commonly arises around scar tissue and is also associated with asbestos exposure.
What do adenocarcinomas invade?
They commonly invade pleura and mediastinal lymph nodes and often metastasise to the brain and bones. They bear similarity to secondary tumours and must be distinguished by CT scans and other investigations to check for presence of a primary.
Which form of adenocarcinoma is often distinguished from others?
bronchiolo-alveolar carcinoma, these characteristically have well differentiated ‘bland’ cells which grow along alveolar ducts. Adenocarcinomas are proportionally less common in non-smokers.
How do we stage lung cancer?
TNM= Tumour, Node, Metastasis
PET CT/ Mediastinal Lymph Node Staging (EBUS/ EUS)
What does Tx mean?
Tumour in sputum/ bronchial washings but not be assessed in imaging or bronchoscopy
What does T0 mean?
No evidence of tumour
What does Tis mean?
Carcinoma in situ
What does T1 mean?
Less than or equal to 3cm surrounded by lung/visceral pleura, not involving main bronchus
T1a(mil)= minimally invasive carcinoma
T1a= less than or equal to 1cm
T1b= greater than 1 cm but less than or equal to 2cm
T1c= greater than 2cm but less than or equal to 3cm
What does T2 mean?
Greater than 3cm but less than or equal to 5cm/ involvement of main bronchus without carina, regardless of distance from carina/ invasion visceral pleural/ atelectasis/ post obstructive pneumonitis extending to hilum
T2a= greater than 3 but less than or equal to 4cm
T2b= greater than 4 but less than or equal to 5cm
What does T3 mean?
Greater than 5cm but less than or equal to 7 cm in greatest dimension/ tumour of any size that involves chest wall, pericardium, phrenic nerve or satellite nodules in the same lobe
What does T4 mean?
Greater than 7cm in the greatest dimension/ any tumour with invasion of mediastinum, diaphragm, heart, great vessels, recurrent laryngeal nerve, carina, trachea, oesophagus, spine/ separate tumour in different lobe of ipsilateral lung
What does N1, 2, 3 mean?
N1= ipsilateral peribronchial and/or hilar nodes and intrapulmonary nodes N2= ipsilateral mediastinal and/or subcarinal nodes N3= Contralateral mediastinal or hilar; ipsilateral/contralateral scalene/ supraclavicular
What does M1 mean?
Distant metastasis
M1a= tumour in contralateral lung or pleural/pericardial nodule/ malignant effusion
M1b= single extrathoracic metastasis, including single non-regional lymph node
M1c= multiple extrathoracic metastases in one or more organs
What is the current treatment and 5 year survival rates for each stage of NSCLC Staging?
1= surgery, 60-70% 2= surgery, 30-50% 3A= Surgery/multimodality regimen, 10-30% 3B= Chemotherapy/ radiation, 5% 4= Chemotherapy, less than 1% Overall 5-year survival 14%
What is used for lymph-nodes evaluation?
PET (67-100%)
Mediastinoscopy (70-95%)
Endobronchial US (EBUS) (84-96%)
What are the treatment options?
- Resection- only 7-10% patients suitable- 70% 5 year survival
- Concurrent Chemo-radiotherapy- 5 yr survive 30%
- Palliative chemotherapy- overall survival benefit, few months
- Palliative radiotherapy- symptom control
- Best supporting care- symptom control
What are the factors affecting operability in lung cancer?
- Age (itself not a risk factor)
- Co-morbidity (COPD, IHD), performance status
- Lung function= lobectomy (early deficit with later recovery and little permanent loss in PFT and no decrease in exercise capacity), pneumonectomy (early permanent deficit 33% loss in PFT and 20% decrease in exercise capacity)
How does EGFR link to lung cancer treatment?
-Subset of patients respond well to EGFR blocking therapy (East Asian, adenocarcinoma, female gender, non-smokers)
These individuals have the highest rate of EGFR tyrosine kinase mutation
Describe small-cell lung cancer
-Approx. 15-20% lung cancers
Very aggressive tumour
-Early dissemination
-Virtually all patients have metastatic spread at presentation
Describe the staging of small cell lung cancer
Limited disease- restricted to one haemithorax +/- ipsilateral nodes
Extensive disease: spread beyond haemithorax
What is the prognosis of small-cell lung cancer?
- Very sensitive to chemotherapy and radiotherapy
- Median survival= limited- 10-15 months, extensive- 7-10 months
- Long term survivors less than 5% of patients
