Neoplasia (Lung Cancer) Flashcards
What is the aetiology of lung cancer?
- TOBACCOO
- asbestos
- environmental radon
- other occupational exposure (chromates, hydrocarbons, nickel)
- air pollution and urban environment
- other radiation
- pulmonary fibrosis
What percentage of lung cancer is attributed to tobacco?
> 85%
What percentage of smokers get lung cancer?
10%
What are the two main pathways of carcinogenesis in the lung?
- in the lung periphery
- bronchioloalveolar epithelial stem cells transform
- adenocarcinoma
- in the central lung airways
- bronchial epithelial stem cells transform
- squamous cell carcinoma
What are the different types of “tumours” of the lung?
- benign causes of mass lesion
- carcinoid tumour
–> <5% of lung neoplasms
–> low grade malignancy - tumours of bronchial glands (VERY RARE)
–> adenoid cystic carcinoma
–> mucoepidermoid carcinoma
–> benign adenomas - lymphoma
- sarcoma
- METASTASES to lung are common
What are the local effects of lung cancer, due to bronchial obstruction?
- collapse
- endogenous lipid pneumonia
- infection/abscess
- bronchiectasis
What are the local effects of lung cancer, in relation to pleural?
- inflammatory
- malignant
What are the local effects of lung cancer for direct invasion?
- chest wall
- nerves
- phrenic –> diaphragmatic paralysis
- L recurrent laryngeal –> hoarse, bovine cough
- brachial plexus –> pancoast T1 damage
- cervical sympathetic –> horner’s syndrome
- mediastinum (SVC, pericardium)
What are the local effects of lung cancer for lymph node metastases?
- mass effect
- lymphangitis carcinomatosa
What are the distant effects of lung cancer for distant metastases?
- liver
- adrenals
- bone
- brain
- skin
- potential for neural and vascular
What are the different non-metastatic paraneoplastic effects of lung cancer?
Skeletal
- clubbing
- HPOA
Endocrine
- ACTH, siADH, PTH
- carcinoid syndrome
- gynecomastia
Neurological
- polyneuropathy
- encephalopathy
- cerebellar degeneration
- myasthenia (Eaton-Lambert)
Cutaneous
- acanthosis nigricans
- dermatomyositis
Haematologic
- granulocytosis
- eosinophilia
- DIC
Cardiovascular
- thrombophlebitis migrans
Renal
- nephrotic syndrome
What are the different investigations used for lung cancer?
- chest xray
- sputum cytology rarely used
- bronchoscopy
–> bronchial biopsy
–> bronchial brushings and washings
–> endobronchial US-guided aspiration (EBUS) - trans-thoracic fine needle aspiration
- trans-thoracic core biopsy
- pleural effusion cytology and biopsy
- advanced imaging techniques
–> CT scanning
–>MRI, PET scanning
–> other imaging
What are 10 basic symptoms of lung cancer?
- chronic coughing
- coughing up blood
- wheezing sound
- chest and bone pain
- chest infections
- difficulty swallowing
- raspy, hoarse voice
- SOB
- unexplained weight loss
- nail clubbing
What are the symptoms of lung cancer (metastatic)?
- bone pain
- spinal cord compression
–> limb weakness
–> paraesthesia
–> bladder/bowel dysfunction - cerebral metastases
–> headache
–> vomiting
–> dizziness
–> ataxia
–> focal weakness - thrombosis
What are the symptoms of lung cancer (paraneoplastic)?
- hyponatraemia
–> siADH - anaemia
- hypercalcaemia
–> parathyroid hormone related protein
–> bone metastases - dermatomyositis/polymyositis
–> proximal muscle weakness - cerebellar ataxia
- sensorimotor neuropathy
What are the clinical signs of lung cancer?
- chest signs
- clubbing
- lymphadenopathy
- horner’s syndrome
- pancoast tumour
- superior vena cava obstruction
- hepatomegaly
- skin nodules (metastases)
What are the first investigations to be done?
- CXR
- FBC
- renal, liver functions and calcium
- clotting screen
- spirometry
What are the different scores for performance status?
0 = fully active
1 = symptoms 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 different treatments for lung cancer?
SURGERY - 18% of patients
- wedge resection
- lobectomy
- pneumonectomy
RADIOTHERAPY
- radical
- palliative
- stereotactic
CHEMOTHERAPY
- part of radical or palliative treatment
- alone, combined with radiotherapy, adjuvant (after surgery)
- targeted agents e.g. Tyrosine Kinase Inhibitors and monoclonal antibodies
- small cell e.g. cisplatin/pemetrexed
- squamous e.g. cisplatin/gemcitabine
BEST SUPPORTIVE CARE
CO-ORDINATION - lung cancer specialist nurse
What palliative care is put into place for people with end-stage lung cancer?
SYMPTOM CONTROL
- may include chemotherapy
- may include radiotherapy
- opiates, bisphosphonates, benzodiazepines
- treatment of hypercalcaemia, dehydration, hyponatraemia
QUALITY OF LIFE
COMMUNITY SUPPORT
DECISIONS AND PLANNING, RESUSITATION STATUS, END OF LIFE CARE
MULTIDISCIPLINARY TEAM INCLUDING LUNG CANCER NURSE AND HOSPICE
What is a pulmonary mass?
An opacity in lung over 3cm with no mediastinal adenopathy or atelectasis
What is a pulmonary nodule?
An opacity in lung up to 3cm with no mediastinal adenopathy or atelectasis
What is TNM staging?
T –> how big it is and how far has it spread/size and position of the tumour
N –> whether cancer cells have spread into the lymph nodes
M –> whether the tumour has spread anywhere else in the body i.e. metastases
What different scans should be done for each part of TNM staging?
T –> CT, PET-CT, bronchoscopy
N –> PET-CT, mediastinoscopy, CT, EBUS/EUS
M –> PET-CT, CT, bone scan
What is Tx/T0/Tis?
Tx –> primary tumour cannot be assessed
T0 –> no evidence of primary tumour
Tis –> carcinoma in situ
What is a T1 (a/b/c)?
Tumour <= 3cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of involvement of the main bronchus
T1a –> minimally invasive adenocarcinoma tumour <= 1cm in greatest dimension
T1b –> tumour <= 2cm
T1c –> tumour <= 3cm
What is a T2 (a/b)?
Tumour > 3cm but 5cm or tumour with any of the following features (T2 tumours with these features are classified T2a if <= 5cm)
- involves main bronchus, but not carina
- invades visceral pleura
- associated with atelectasis or obstructive pneumonitis that extends to the hilar region involving part or all the lung
T2a –> tumour > 3cm but < 4cm in greatest dimension
T2b –> tumour > 4cm but < 5cm in greatest dimension
What is a T3?
tumour > 5cm but < 7cm or one that directly invades any of the following:
- chest wall (including superior sulcus tumours)
- phrenic nerve
- parietal pericardium
Or separate tumour nodule(s) in the same lobe as the primary
What is a T4?
Tumour > 7cm or invades any of the following:
- diaphragm
- mediastinum
- heart
- great vessels
- trachea
- recurrent laryngeal nerve
- oesophagus
- vertebral body
- carina
Separate tumour nodule(s) in a different ipsilateral lobe
What is N0-3?
N0 –> no regional lymph node metastases
N1 –> ipsilateral peribronchial, hilar or intrapulmonary nodes including by direct extension
N2 –> ipsilateral mediastinal, subcarinal
N3 –> contralateral mediastinal, contralateral hilar, scalene or supraclavicular
What is M0/1?
M0 –> no distant metastasis
M1 –> distant metastasis
What is M1 (a/b/c)?
M1a –> separate tumour nodule(s) in a contralateral lobe, tumour with pleural or pericardial nodules or malignant pleural or pericardial effusion
M1b –> single distant metastasis
M1c –> multiple distant metastases
What does a PET/CT do in staging?
- performs whole body staging in a single study excluding cerebral disease
- discloses metastases and other pathology not detected by other means
–> unexpected metastases in 10-20% - excludes metastases where structural imaging abnormal
- non invasive
What are the limitations of a PET/CT?
- false negative results
- false positive results
- cost
What can be present in a CXR for someone with lung cancer?
- pleural effusion
- chest wall invasion
- phrenic nerve palsy
- collapsed lobe or lung
What can be present in blood tests for someone with lung cancer?
- anaemia
- abnormal LFTs
- abnormal bone profile
What can be present in a CT for someone with lung cancer?
- size of tumour
- mediastinal nodes
- metastatic disease –> other parts of lungs, liver, adrenals, kidneys
- proximity to mediastinal structures
- pleural/pericardial effusion
- diaphragmatic involvement
What does a MRI do for testing for lung cancer?
Useful in determining the degree of vascular and neurological involvement in pancoast tumour
What does a bone scan do for testing for lung cancer?
Good test for chest wall invasion and for bony metastases
What does a ECHO do for testing for lung cancer?
Will demonstrate presence or absence of significant pericardial effusion
What are cardiovascular factors which influence the patients fitness for surgery?
- angina
- heart problems
- high blood pressure
- DM
- PVD
- smoking
- stroke/TIA
- carotid bruits
- previous CABG/angioplasty
- heart murmurs
What are respiratory factors which influence the patients fitness for surgery?
- barrell-chested
- COAD
- still smoking
- asthmatic
- recent URTI
- on oxygen
- exercise capacity
- previous thoracotomy or ICD
What are the psychiatric factors which influence the patients fitness for surgery?
- pH of mental illness
- severe anxiety
- social background
- chronic pain problems
What are other factors which influence the patients fitness for surgery?
- pulmonary hypertension
- permanent tracheostomy
- rheumatoid arthritis
- the immobile patient
- cirrhosis
- h/o radiotherapy to chest
What respiratory testing is done to assess the patients fitness for surgery?
- spirometry
- diffusion studies
- ABG on air/SLV
- fractionated V/Q scan
What cardiovascular testing is done to assess the patients fitness for surgery?
- ECG
- ECHO
- CT scan
- ETT
- coronary angiogram
What is the surgical treatment for lung cancer?
- curative resection is the goal
- remove the minimum amount of lung tissue
- resection of parietal structures is feasible
- firm diagnosis of malignancy is highly desirable before lung resection
What are the reasons for peri-operative death?
- ARDS
- bronchopneumonia
- myocardial infarction (MI)
- PTE
- pneumothorax
- intrathoracic bleeding
What are the non-fatal complications of surgery for lung cancer?
- post thoracotomy wound pain
- empyema
- BPF
- wound infection
- AF
- MI
- post-op respiratory insufficiency
- gastroparesis/constipation
What are the most common problems with staging of lung cancer?
- collapse of a lobe or lung makes tumour size difficult to assess
- presence of another (usually small) pulmonary nodule
- retrosternal thyroid
- adrenal nodule
- CT head is not routinely performed pre-op
What is the operative mortality for a pneumonectomy?
5-10%
What is the operative morality of a lobectomy?
3-5%
What is the operative morality for a wedge resection?
2-3%
What is the operative morality for an open/close thoracotomy?
5%
What are the different types of non-small cell lung cancer and what percentage of of lung cancer is this?
85% total
adenocarcinoma - 55%
squamous - 30%
large cell undifferentiated ~ 5%
others ‘not otherwise specified’ or NOS < 10%
What are the different levels of the Eastern Cooperative Group (ECOG) performance status measurement?
0 = asymptomatic; well
1= symptomatic; able to do light work
2 = has to rest but for <50% of the day
3 = has to rest for >50% of the day
4 = bedbound
5 = dead
What are the side effects of chemotherapy?
- marrow suppression (+ risk of life threatening infection)
- nausea, vomiting, GI upset, mucositis, fatigue, lethargy
- neuropathy, increased risk MI/stroke, renal impairment
- hair loss, nail changes
What are the side effects of radiotherapy?
general - lethargy, risk to surrounding organs
acute - pneumonitis, dysphagia
late - fibrosis, stricture, increased risk MI, 2nd malignancies
What are the side effects of immunotherapy?
(anything-itis)
- colitis
- pneumonitis
- dermatitis
- endocrinopathies
