pathological diagnosis of lung cancer Flashcards
how do we form a differential diagnosis of a lung mass? 7
- Neoplastic or non-neoplastic?
- Benign or malignant?
- Primary or secondary?
- Sit of origin?
- Carcinoma, sarcoma, lymphoma, mesothelioma
- Histological type
- Prognostic and predictive features
how do we form a pathological diagnosis of lung cancer? 6
- Histopathology uses the clinical method clinical history, examination, special investigation
- Distribution of tumour, gross appearances, number, shape and size
- Often information from imaging
- Growth pattern at margin of tumour
- Histological type, prognostic and predictive features
- All requires a multidisciplinary approach
what are the main histological types of lung cancer? 2
- Small cell (AKA oat cell) carcinoma (10-15%)
- Non-small cell carcinoma (85-90%) squamous cell carcinoma, adenocarcinoma, undifferentiated/ large cell carcinoma, mixed and others
what does a small cell carcinoma look like? 4
- Widespread bulky disease
- Small, dark, delicate cells with little cytoplasm
- ‘salt and pepper’ chromatin in the nuclei
- Azzopardi effect
describe a squamous cell carcinoma? 2
- Central origin often
- Cigarette smoke provokes squamous metaplasia, then dysplasia of bronchial epithelium
what does an adenocarcinoma begin with? 2
- malignant cells lining alveolar spaces
- Typically, peripheral, contains fibrous tissue and shows variable differentiation which correlates with prognosis
how do we differentiation squamous cell carcinoma and adenocarcinoma? 2
- Looking for specific proteins can help
- TTF1 expression is typical of adenocarcinoma
describe the patterns of spread of lung cancer? 3
- Local and direct spread adjacent lung, intrapulmonary metastasis, pleura and pleural cavity
- Lymphatic lymphatics within lung, lymph nodes hilar, mediastinal
- Systemic spread liver, bone, brain, adrenal
how do we make a diagnosis of lung cancer? 6
- Multidisciplinary effort
- Clinical features, imaging
- Histological type small cell carcinoma non-small cell carcinoma squamous cell carcinoma and adenocarcinoma
- Confirm by looking for proteins
- Prognostic and predicative molecular pathology
- Increasingly diagnosis is made on tiny specimens obtained by minimally invasive procedures
describe palliative care in the management of lung cancer? 6
- An approach which improves the quality of life of patients and their families
- Need based, not diagnosis based
- Role in lung cancer management terminal phase, after active oncological treatment or as only possible treatment, during treatment, peri-diagnosis
- It is holistic care and treatment based on symptoms and suffering, and can be provided alongside life prolonging treatment
- Incurable disease does not mean that nothing can be done
- Your font needs to be dying to benefit
why are survival rates for lung cancer poor? 2
- Patients present late with advanced stage 40% via ED
- Early symptoms similar to common smokers’ symptoms
what can cause lung cancer? 3
- 70% are caused by smoking
- Deaths in men have reduced by more than a quarter
- Lung cancer deaths are increasing in women
describe the respiratory symptoms of lung cancer? 6
- Cough
- Haemoptysis
- Dyspnoea
- Wheeze
- Chest pain
- Hoarseness
what are the metastatic and systemic presenting symptoms of lung cancer? 5
- Weight loss
- Anorexia, nausea
- Malaise
- Fatigue
- From secondary sites, CNS, bone, skin
what are the frequently seen paraneoplastic syndromes in lung cancer? 3
- Hyponatraemia (due to SIADH) small cell carcinoma
- Hypercalcaemia (due to PTH like activity) squamous cell carcinoma
- Less commonly gynaecomastia, prutitis, cerebellar degermation, peripheral neuropathy
how does lung cancer present? 3
- The presenting symptoms are highly variable and may involve sites distant from the chest, or be very non-specific
- The approach is to have a high index of suspicion in any ex-smoker
- Do CXR/CT early
what are the common signs of lung cancer on examination? 6
- Clubbing
- Cachexia
- Supraclavicular, cervical, lymphadenopathy
- Stridor due to large airway disease or vocal cord palsy (hoarse voice)
- Focal chest signs of lung collapse, fixed wheeze
- Pleural effusion
describe non small cell lung cancer?4
- Squamous- central invade locally; frequently cavitation; hypercalcaemia common
- Adenocarcinoma- peripheral lung; more common in non-smokers
- Large cell
- Undifferentiated
what are the investigations to determine tumour cell type and stage? 6
- CT
- Bronchoscopy
- Endobronchial ultrasound needle aspiration
- Another biopsy procedure
- PET scanning nuclear medicine scan, utilising the high uptake of a glucose analogue
- Cell type and stage both determine further treatment, along with general health/coexisting illness
describe TNS staging in cancer? 2
- Staging is one of the important factors in determining treatment and prognosis in lung cancer
- It takes into account tumour size, involvement of local structures, lymph and blood metastases
how do we manage newly diagnosed lung cancer? 3
- Small cell or non-small cell lung cancer
- If NSCLC, is it resectable?
- If NSCLC and not suitable for surgery other radical treatment appropriate
what is the role of surgery in NSCLC? 2
other radical treatments in NSCLC? 3
- Consider surgery for all patients with stage 1 and 2 disease
- Usually involves lobectomy
- Radical radiotherapy
- +/- chemotherapy
- Usually reserved for those with stage 1 or 2 disease who are unfit (or unwilling) for surgery
describe palliative radiotherapy and chemotherapy in NSCLC? 5
- Radiotherapy in palliative doses offers good symptom relief for haemoptysis, intractable cough or dyspnoea from bronchial or tracheal obstruction, chest and skeletal pain
- Not expected to cure
- Chemotherapy regimens can improve quality of life
- Also offer a modest improvement in survival (measured in week)
- May be used in conjunction with radiotherapy
how do we treat small cell lung cancer? 4
outcomes?2
- Chemotherapy is primary treatment, and more effective than in NSCLC
- Excellent for symptom control, can induce remission
- Prolongs survival by months on average
- Some patients with limited disease become long term survivors
- Only 15% 5-year survival
- Slow improvement
