Oncology - Lung Flashcards
How common is lung cancer?
What is the prognosis of lung cancer?
- lung cancer is the 3rd most common cancer in the UK
- 2nd most common WORLDWIDE
-only 10% of patients who are diagnosed with lung cancer live for 5 years or more
What are the different types of lung carcinoma?
What is the most common type?
- Small cell lung carcinoma (15%)
- Non-small cell lung carcinoma (85%)
a) Squamous cell
b) Adenocarcinoma MOST COMMON
c) Large cell carcinoma
d) Adenocarcinoma in situ - Mesothelioma
- Sarcoma
- Lymphoma
- Carcinoid
What is the most common lung carcinoma?
Non small cell, specifically adenocarcinoma
What does small cell lung cancer arise from?
Endocrine cells called Kulchitsky cells
What type of lung cancer is more aggressive? What is the treatment?
- Small cell lung cancer
- Grows rapidly and is highly malignant
- 70% have metastasised at presentation so often cannot be treated by surgery
Treatment
-They can be very responsive to chemotherapy initially, but often relapse quickly. Overall, prognosis is generally poor
What gene mutations are commonly found in lung adenocarcinomas?
If they have these mutations how does that effect treatment?
Adenocarcinoma
- EGFR
- ALK
- ROS1
Most likely to respond to immunotherapy
Which patients is the EGFR mutation more common in?
EGFR mutation
East Asian, Young, Females who are non smokers
What are the main causes of lung cancer?
Smoking - 90% (most in small cell, then squamous cell)
Occupation:
- asbestos exposure
- uranium mining
- ship building
- petroleum refining
- arsenic
- chromium
- iron oxide
- radiation
How does lung cancer usually present in order of most common symptoms?
Cough - 80%
Haemoptysis - 70%
Dyspnoea - 60%
Chest pain - 40%
Weight loss, anorexia, lethargy
Recurrent pneumonia
How does an apical/pancoast tumour present? (4)
Most pancoast tumours are NSCLC (normally squamous)
Pancoast syndrome
- Hoarseness of voice (compress on RLN)
- Horner’s syndrome-ptosis, miosis, anhidrosis
- Shoulder and arm pain (ipsilateral)
- Abnormal sensation (paresthesias), muscle weakness (paresis) and wasting (atrophy) of the arm and hand muscles
How can a mediastinal tumour present?
- Hoarseness of voice due to recurrent laryngral nerve palsy (urgent Ent referral)
- SVC obstruction
What type of lung cancer can cause paraneoplastic syndromes?
Small cell lung carcinomas can present with non-respiratory symptoms due to tumours secreting hormones
Give examples of paraneoplastic syndromes caused by SMALL CELL CARCINOMA
-Excess ACTH - Cushing’s
-Excess HCG - gynaecomastia
-Excess ADH - SIADH (causes low sodium)
-Lambert-Eaton Syndrome
•Weakness of PROXIMAL lower limbs (difficulty climbing stairs)
•swallowing problems, drooping eye lids, erectile dysfunction)
What are some skin manifestations of lung cancer?
Lung cancer-skin manifestations
- Dermatomyositis
- Herpes zoster
- Acanthosis nigricans
What signs might be seen on inspection of the hands in lung cancer?
- Clubbing (more common in squamous cell carcinoma)
- Anaemia - pale palmar creases
- Pain in the wrist - hypertrophic pulmonary osteoarthropathy
On auscultation of the chest, what sounds would be heard in lung cancer?
Monophonic wheeze due to partial airway obstruction
Biggest risk factor for squamous cell carcinoma?
What factors of the investigations would indicate squamous cell carcinoma? (bloods and chest x ray)
- squamous cell carcinoma is especially linked with cigarette smoking
- SQUAMOUS CELL causes HYPERCALCEAMIA - they secrete PTH-related peptide
- squamous cell carcinomas often found centrally, close to bronchi-cause bronchial obstruction
What factors of the history would indicate adenocarcinoma?
What would the investigations show? (chest x ray and mutations)
Adenocarcinoma (39% of NSCLC) History: - Woman - Non-smoker - Asbestos exposure
Investigations:
- Peripheral tumour
- EGFR, ALK, ROS1 mutations
What might be seen on a chest x-ray in lung cancer?
Chest X ray lung cancer
-Nodule
•central = small cell, squamous cell;
•peripheral = adenocarcinoma, large cell
-Hilar enlargement
-Consolidation (due to post-obstructive pneumonia)
-Pleural effusion UNILATERAL
-Lung collapse (atelectasis)
-Bony mets
If there is suspicion of lung cancer from a CXR, what following investigations should be carried out?
Imaging
- Chest X-Ray - is it central or peripheral?
- CT TAP with contrast - signs of distant disease (also scan brain)
- PET scan -mets not seen on CT
Biopsy
-Bronchoscopy and biopsy
○Endo-bronchial Ultrasound (EBUS) for central nodes
○Trans-thoracic biopsy for peripheral nodes
Lung function
-pulmonary function tests (underlying lung function)
cardiopulmonary exercise testing (are they fit enough for lobectomy)
What is the histopathology for squamous cell lung carcinoma?
Squamous cell
- Small blue oval-shaped cells
- Absent nucleoli
- Decreased cytoplasm
What is the TNM staging for lung cancer?
T1-4: tumour size and invasion
N0:lymph nodes don’t contain cancer cells.
N1: same lung as tumour
N2: nodes in mediastinum on same side as tumour
N3: lymph nodes on other side from tumour or at top of lung/collarbone
M1a: mets to other lung; pleural/pericardial effusion
M1b: single distant met outside thorax (e.g. liver)
M1c: multiple mets in different organs (e.g. liver and brain)
What is the mainstay treatment for small cell lung cancer? What is the response?
- Chemotherapy (SCLC is considered a systemic disease at diagnosis)
- SCLC is one of the most chemo-sensitive solid tumours. Radiotherapy often given at the same time to make more radiosensitive
- Responce is good however most patients will sadly relapse with a chemo resistant disease (within 12 months)
When is radiotherapy used in Small cell lung cancer SCLC?
- Chemo is mainstay for SMALL CELL
- SMALL CELL is also highly radiosensitive
- Treatment of primary tumour
-After or alongside chemo improves survival and makes body more sensitive to chemo
(tumour will relapse, however in different place) - Prophylactic cranial irradiation - brain mets are common. SE of PCI include tiredness, headaches, skin redness, nausea + vomiting, memory
- Palliative- help with symptoms of advance disease when unresponsive to other treatments.
What are the different options for treatment of non-small cell lung carcinoma?
Early stage: surgery and radiotherapy
Late stage: palliative radiotherapy
Stage I and 2 –SURGERY (lobectomy/pneumonectomy) (~80% 5-year survival)
- adjuvant chemo for nodal disease
- adjuvant radiotherapy if resection margins are not tumour free
Stage 3 and 4-PALLIATIVE
Stage III + IV (palliative) - chemotherapy +/- immune targeted therapy
Patients with early disease who can’t have surgery
- Continuous, hyperfractionated accelerated radiotherapy (CHART) – 3times/day for 12 days straight. 20% 5 year survival
- Ablation- stereotactic ablative body radiotherapy (SABR) good for peripheral tumours in patients who aren’t fit for surgery
What is the untreated life expectancy for SCLC? What does chemotherapy increase this to?
Untreated life expectancy = 2-4 months
Chemotherapy increases it to 6-12 months
What are the features of large cell carcinoma
Large cell carcinoma (8% of NSCLC)
-These are less differentiated than other NSCLCs and tend to metastasise early.
Whats the different between palliative care for SCLC and NSCLC?
Treatment of complications e.g. superior vena cava obstruction or spinal cord compression
The opposite of curative treatment:
-NSCLC- chemotherapy (immunotherapy if suitable)
-SCLC- radiotherapy
What is the mainstay treatment for locally advanced/metastatic NSCLC?
Chemotherapy Combination regimens are used: - either Carboplatin and Gemcitabine -or Carboplatin/Cisplatin and Pemetrexed - Docetaxel can be used as a 2nd line option.
What is the treatment for advanced NSCLC with positive ALK/EGFR?
TARGETED THERAPY
Patients with EGFR and ALK positive adenocarcinoma are
treated with tyrosine kinase inhibitors (TKIs) can be used
- Afatinib/Erlotinib/Gefitinib for EGFR mutations
- Crizotinib for ALK mutations
What is the treatment for advanced NSCLC with PLD1 expression?
IMMUNOTHERAPY- Pembrolizumab
-used either before or after chemotherapy
-PDL1 is a molecule involved in controlling the normal immune response
Prognosis of NSCLC?
NSCLC
- Immunotherapy and targeted therapy has greatly improved outcomes
- WITHOUT TREATMENT = 3-6/12
- WITH CHEMO - extend for a few more months possible to a year
- WITH IMMUNOTHERAPY - prognosis of 2 years in some cases
When would you refer for ?lung cancer
Organise urgent 2 week chest X-ray if:
- aged 40+ if they have 2 symptoms (only need 1 symptom if they have EVER smoked):
- Cough.
- Fatigue.
- Shortness of breath.
- Chest pain.
- Weight loss.
- Appetite loss.
