Neoplasia Flashcards
What % of deaths in the UK are caused by lung cancer?
6%
What are the causes of lung cancer?
Tobacco Asbestos Environmental radon Occupational exposure to carcinogens Ai pollution and urban environment Other radiation Pulmonary fibrosis
What is the most common cause of lung cancer?
Smoking- >85%
What % of smokers get lung cancer?
10%
Who is more susceptible to the carcinogens in cigarettes?
Females
How can the risk of lung cancer from smoking be decreased?
Risk decreases with abstinence, but slowly
Resisting genomic changes mean risk doesn’t full disappear
What carcinogen causes squamous small cell lung carcinoma?
Polycyclic aromatic hydrocarbons
What carcinogen causes adenocarcinoma?
N-nitrosamines
What are the 2 main pathways of carcinogens in the lung?
In the periphery
In the central lung airways
What is the pathway od carcinogenesis in the periphery of lungs?
Bronchioalveolar epithelial stem forms
Adenocarcinoma
Caused by N nitrosamines
What is the pathogenesis of carcinogenesis in the central lung airways?
Bronchial epithelial stem cell forms
Squamous cell carcinoma
Caused by polycyclic aromatic hydrocarbons
What does the KRAS mutation cause in the lungs and what % of patients have this?
Adenocarcinoma
35%
What does the EGFR mutation cause in the lungs and what % of patients have this?
Adenocarcinoma
15%
What does the BRAF mutation cause in the lungs and what % of patients have this?
Adenocarcinoma
2%
What does the HER2 mutation cause in the lungs and what % of patients have this?
Adenocarcinoma
2%
What do ALK rearrangements cause in the lungs and what % of patients have this?
Adenocarcinoma
2%
What genetic mutations are smoking induced?
KRAS
What mutations can be targeted by a therapeutic?
EGFR
ALK
What are the cell types of cancer?
Squamous cell
Adenocarcinoma
Small cell carcinoma
Large cell carcinoma
What % of lung cancer cases are of each cell type?
Squamous- 40%
Adenocarcinoma- 41%
Small cell carcinoma- 15%
Large cell carcinoma- 4%
What are the histological types of lung cancer?
Small cell
Non small cell
What % of patients have each histological type of lung cancer?
Small cell- 15%
Non small cell- 85%
What is non small cell lung carcinoma?
A histological classification of tumour when tumours cannot be exactly identified
What are the local bronchial effects of lung cancer?
Collapse
Endogenous lipid pneumonia
Infection/Abscess
Bronchiectasis
What are the local pleural effects of lung cancer?
Inflammatory
Malignant
What are the local effects of lung cancer by direct invasion of nerves?
Phrenic= diaphragmatic paralysis
Left recurrent laryngeal nerve= hoarse, bovine cough
Brachial plexus= pan coast T1 damage
Cervical sympathetic nerve= Horner’s syndrome
Where can lung cancer directly invade?
Chest wall
Nerves
Medistinum
What are the local effects of lung cancer due to lymph node metastases?
Mass effect
Lymphangitis carcinomatosa
Where are the most common places for lung cancer to metastasise to?
Liver Adrenals Bone Brain Skin
What are the non metastatic skeletal effects of lung cancer?
Clubbing
Hypertrophic pulmonary osteoarthropathy
What are the non metastatic endocrine effects of lung cancer?
Carcinoid syndrome
Gynecomastia
Paraneoplastic syndrome caused by hormone secretion- ACTH, siADH, PTH
What are the non metastatic neurological effects of lung cancer?
Polyneuropathy
Encephalopathy
Cerebellar degeneration
Myasthenia (Eaton Lambert)
What are the non metastatic cutaneous effects of lung cancer?
Acanthosis nigerians
Dermatomyositis
What are the non metastatic haemolytic effects of lung cancer?
Granulocytosis
Eosiophilia
DIC
What are the non metastatic CV effects of lung cancer?
Thrombophlebitis migrans
What are the non metastatic renal effects of lung cancer?
Nephrotic syndrome
What are the non metastatic effects of cancer due to?
Chemical/hormonal effect caused by the cancer other than the spread
How are the non metastatic effects of cancer mediated?
Autoimmune mediated
Immune system “conned” by tumour into attacking its own tissues
What are the most common clinical features of lung cancer?
Chronic cough Haemoptysis Wheeze Chest and bone pain Frequent chest infections
What are the less common features of lung cancer?
Difficulty swallowing Raspy hoarse voice SOB Unexplained weight loss Nail clubbing
What are the metastatic advanced disease symptoms of lung cancer?
Bone pain
Spinal cord compression
Cerebral metastases
Thrombosis
What does spinal cord compression in lung cancer cause?
Limb weakness
Paraesthesia
Bladder/bowel dysfunction
What do cerebral metastases in lung cancer cause?
Headaches Vomiting Dizziness Ataxia Focal weakness
What are the paraneoplastic effects of advanced lung cancer?
Hyponatraemia Anaemia Hypocalcaemia Dermatomyocytosis/polymyositis Cerebellar ataxis Sensorimotor neuropathy
What causes hypercalcaemia in lung cancer?
Parathyroid hormone related protein
Bone metastases
What are the clinical signs of lung cancer?
Chest signs Clubbing Lymphadenopathy Horner's syndrome Pancoast tumour Hepatomegaly Skin nodules
What initial investigations are carried out to investigate for lung cancer?
CXR
CT
Clotting screen
Tissue diagnosis
When is a CT scan carried out?
If CXR abnormal
What are the methods of tissue diagnosis?
Bronchoscopy Image guided lung biopsy Image guided liver biopsy Fine needle aspiration neck node/ skin metastases Excision of cerebral metastases Bone biopsy Mediastinoscopy Surgical excision biopsy Endobronchial ultrasound
When is bronchoscopy used for tissue diagnosis?
Most common
Used for central tumours
What does histology of tumours allow for?
Assessment of most appropriate treatment and prognosis
What type of staging is used for lung cancer?
TNM
What do the 3 areas of TNM staging assess?
Tumour size and proximity to chest wall
Lymph node involvement
Metastasis
What are PET scans used for?
Detect distant micrometastases
How do PET scans work to detect tumours?
Radionucleotide sugary contrast given to “light up” cancer cells
What is stage T1?
Tumour <3cm in greatest dimension, surrounded by lung or visceral pleura, no involvement of main bronchus
T1a <1cm
T1b <2cm
T1c <3cm
What is stage T2?
Tumour 3-5cm, involving visceral pleura and main bronchus but not carina
Associated with atelectasis or obstructive pneumonitis that extends to hilar region
T2a 3-4cm
T2b 4-5cm
What is stage T3?
Tumour 5-7cm or directly invades one of -chest wall -phernic nerve -parietal pericardium or has tumour nodules in same lobe as primary tumour
What is stage T4?
Tumour >7cm of invades one of -diaphragm -mediatinum -heart -great vessels -trachea -recurrent laryngeal -oesophagus -vertebral body -carina or has tumour nodes in a separate lobe
What is stage N0?
No regional lymph node metastases
What is stage N1?
Ipsilateral peribronchial, hilar, or intrapulmonary nodes including by direct extension
What is stage N2?
Ipsilateral mediastinal or subcarinal
What is stage N3?
Contralateral mediastinal, hilar, scalene or supraclavicular
What is stage M0?
No distant metastases
What is stage M1?
Distant metastases
M1a- separate tumour nodules in contralateral lobe, tumour with pleural or pericardial nodules or malignant pleural or pericardial effusion
M1b- single distant metastases
M1c- multiple distant metastases
What is the prognosis for small cell carcinoma?
Bad
What is the prognosis for adenocarcinoma?
Good
What is performance status?
Assessment used to predict how patients will respond to treatment
0-2 likely have good prognosis
What are the performance statuses?
0=fully active 1= symptomatic but ambulatory 2= up and about >50%, unable to work 3= up and about <50%, limited self care 4= bed or chair bound
What are the surgical treatment options?
Wedge resection
Lobectomy
Pneumonectomy
What % of patients can get surgery?
18%
What are the 3 types of radiotherapy?
Radical
Palliative
Sterotactic
How can chemotherapy be used?
Alone
Combined
Adjuvant
What are the 2 types of chemo?
Radical
Palliative
What are the aims of best supportive care?
Reduce pain
Increase quality of life
What is used in symptom control in best supportive care?
Chemo/radiotherapy
Opiates, bisphosphates, benzodiazepines
Treatment of hypercalcarmia, dehydration, hyponatraemia
What are the treatment options for non small cell lung cancer?
Surgery
Chemo
Radiotherapy
What is neoadjuvant and adjuvant therapy?
Pre and post operative therapy to increase chance of cure
What is the treatment of choice for small cell lung carcinoma?
Chemo
What are the ideal concurrent therapies for small cell lung carcinoma?
Chemo
Thoracic radiotherapy
Prophylactic cranial radiation
What is the treatment for expensive small cell lung cancer?
4 cycles of chemo
Singl fraction radiotherapy if not fit for chemo
Radiotherapy and steroids for brain metastases
