Resp Week 4 Flashcards
How much of LC is attributable to smoking?
85%
How many smokers get LC?
10%
What is a passive smoker?
An individual who has never smoked but who lives in the same household as someone who does smoke and within the confides of the house
How many recognised carcinogens are there in ciggarrettes?
60
What are the 2 recognised families of ciggarettes?
Polycyclic aromatic hydrocarbons and N-nitrosamines
Describe polycyclic aromatic hydrocarbons
- Unfiltered tobacco products, home rolled cigarettes, older type of cigarettes
- More likely to give lung cancer development a boost in the central part of the lung in the bronchi
Describe N-nitrosamines
- New types of cigarette
- more prone to causing adenocarcinomas (Periphery of lung)
Describe how inherited polymorphisms may affect the chances of getting LC
We all inherit a differeing risk of developing lung cancer due to how our body reacts to the carcinogens
for example we all have a different susceptibility to nicotine addiction
What are the 2 main pathways of carcinogens in the lung?
The lung periphery (adenocarcinoma) and the central lung airways (squamous cell carcinoma)
What are the 4 main types of LC and what are their prevelence in respect to each other
Squamous cell - 40% Adenocarcinoma - 41% Small cell carcinoma - 15% Large cell carcinoma - 4% [histologically there are 2 types, small cell and non small cell to which the prevalence is 15% and 85% respectively]
Describe primary LC
- Grows clinically silent for many years, presenting late in its natural history
- May have few, if any signs or symptoms until the disease is very advanced
- May be found incidentally during investigation for something unrelated
- Generally speaking symptomatic LC is fatal
- Central tumours involving large bronchi are more likely to bleed -> Causes haemoptysis-> take very seriously
Describe the effects of bronchial obstruction caused as one of the local effects of LC
- Collapse of the lung
- Leads to the retention of cells and secretions which would normally have been removed by the mucocillary escalator leading to endogenous lipid pneumonia
- Infection/abcess formation
- Bronchiectasis
Describe the pleural effects caused as one of the local effects of LC
- Inflammatory
- Malignant invasion
Describe how LC may directly invade the chest wall
Phrenic nerve -> diaphragmatic paralysis
L recurrent laryngeal nerve -> hoarse, bovine cough
Brachial plexus -> pancoast T1 damage
Cervical sympathetic -> Horners syndrome
What is a pulmonary mass?
An opacity in the lung over 3cm with no mediastinal adenopathy or atelectasis
What is a pulmonary nodule?
An opacity in the lung UP TO 3cm with no mediastinal adenopathy or atelectasis
What are the symptoms of LC
Chronic coughing Coughing up blood Wheeze Chest and bone pain Chest infections Difficulty swallowing Raspy, hoarse voice SOB Unexplained weight loss Nail clubbing
What are the clinical signs of LC
chest signs Clubbing Lymphadenopathy Horners syndrome Pancoast tumour Superior vena cava obstruction Heptaomegaly skin nodules (metastasis)
What are the initial investigations for LC
CXR FBC Spirometry Clotting screen Renal and liver functions Calcium levels
What are some of the more advanced investigations for LC?
Bronchoscopy EBUs Image guided lung biopsy Image guided liver biopsy FNA of neck node of skin metastasis Excision of cerebral metastasis Bone biopsy Mediastinoscopy/otmy Surgical excision biopsy
Describe the performance status for LC
0 = fully active 1 = symptoms but ambulantory 2 = 'up and about' >50%, unable to work 3 = 'up and about' <50%, limited self care 4 = bed or chair bound
What are the treatment options for LC
Surgery
Wedge resection
Lobectomy
Pneumonectomy
What are the 3 types of radiotherapy?
Radical - attempting to cure
Pallitative - symptoms, not attempting to cure
Sterotactic - Not attempting to cure, but trying to stop it getting worse
What are the 3 aspects of TNM staging?
- How big it is and how far it has spread/size and position of tumour (T)
- Whether cancer cells have spread into the lymph nodes (N)
- Whether the tumours have spread anywhere else in the body, i.e metastases (M)
Describe a T1 tumour
- Tumour less than or equal to 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
Describe a T2 Tumour
Tumour >3cm but <=5cm or tumour with any of the following features:
- Involves main bronchus
- Invades visceral pleura
- Associated with atelactasis 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
Describe a T3 tumour
Tumour >5cm but <7cm or one that directly invades any of the following:
- Chest wall
- Phrenic nerve
- Parietal pericardium
Or separate tumour nodules in the same lobe as the primary
Describe a T4 tumour
Tumour >7cm or invades any of the following: - Diaphragm - Mediastium - Heart - Great vessels - Trachea - Recurrent laryngeal nerve - Oesophagus - Vertebral body - Carina Separate tumour nodules in a different ipsilateral lobe
Describe the N staging of a tumour
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
Describe the M staging of a tumour
M0 - no distant metastesis M1- distant metastesis M1a - separate tumour nodules in a contralateral lobe M1b - single distant metastasis M1c - multiple distant metastasis
What are 4 common sites of metastesis?
Cerebral
Skeletal
Adrenal
Liver
How many LC patients are operable?
10%
How many of those who go through surgery are cured from cancer?
1/2
Would you operate for a pleural effusion?
No
Would you operate when there is chest wall invasion in lc
Yes- is possible to resect invaded ribs and soft tissues and reconstruct chest wall
Would you operate in phrenic nerve palsy caused by LC
No, extensive invasion of the mediastinum is inoperable
Would you operate for a collapsed lobe or lung
You could but you would need to be careful about the extent of the tumour
What are you looking for in blood tests for a LC pateint being considered for surgery
anaemia
abnormal LFTs
Abnormal bone profile
What are some common reasons for perioperative death?
ARDS Bronchopneumonia PTE Pneumonthroax Intra-thoracic bleeding
What are some common non fatal complications of surgery
Post thoracotomy wound pain Empyema BPF Wound infection AF MI Post of resp insufficiency Gastroparesis/Constapation
Give the operative mortality for the following procedures:
- Pneumonectomy
- Wedge resection
- Lobectomy
- Open/Close thoracotomy
- Pneumonectomy: 5-10%
- Wedge resection: 3-5%
- Lobectomy: 2-3%
- Open/Close thoracotomy: 5%
What is the doubling time of NSCLC
129days
How many nsclc cases are operable
Max 25%
What is the FEV1 needed for a lobectomy
> 1
What is the FEV1 needed for a pneumonectomy
> 2
Describe adjuvant therapy in LC treatment
= Post op
- Chemotherapy -> to increase chance of cure/reduces risk of reccurence
- Adjuvant Rt detrimental in stage I and II; possible benefit if mediastinal nodes or involved in margins
Describe neoadjuvant therapy in LC treatment
= Pre op
- Not used in clinical practice
- Stage III: Preoperative chemotherapy demonstrates some advantages, non in stage I or II
Describe the variety of regimes in radical rt
55Gy in 20 fractions: treated daily monay - friday for 4 weeks
54Gy in 36 fractions: treated three times daily for 12 consecutive days
Describe the Acute side effects of radical rt
Lethargy
Oesophagitis
SOB due to pneuomonitis
Describe the long term side effects of radical rt
Pul fibrosis
what is the benefit of concurrent chemoRT
4-5% overall survival benifit at 5 years
What are the palliative treatment options for NSCLC
Immunotherapy TKI Palliative rT Combiniation of the above Chemotherapy
Describe palliative chemotherapy in NSCLC
- Given as a doublet regime: two drugs given as IV infusion every 3 weeks
- Most centres give 4 cycles
- Improves survival by further 3-5 months
Describe palliative immunotherapy in NSCLC
- New treatment modality
- PDL1 (programmed death ligand) - protein that prevents immune system attacking cells in the body
- Cancer good at masking themselves from immune system via PDL1 expression (immunotherapy works by upregulating immune system and ‘unmasking’ cancers)
- Can be used first line if PDL1 Score > 50%, otherwise can be used second line
What is the doubling time for patients with SCLC
29 days
What are the different types of pleural effusion?
Transudate: non-inflammatory
Exudate: Inflammatory
Describe lights criteria
=Criteria for determining if exudate
- Protein: Pleural fluid/serum ratio >0.5
- LDH: pleural fluid/serum fluid ration >0/6
- Effusion LDH level greater than two-thirds the upper limit of the laboratory’s reference range of serum LDH.
What are the common causes of transudates
LV failure
Liver cirrhosis
What are the common causes of exudate
Malignancy
Parapneumonic effusions: empyema
TB
What is the investigations for a pleural effusion?
Ultrasound: more sensitive than CXR
CXR
CT thorax
Describe the management of a pleural effusion
- pH less than 7.2 with pneumonia, pus or blood = chest drain
- Transudate, treat the underlying cause, may not need CT imagine
- Exudate: unless cause identified will need futher investigation- further imaging and/or pleural biopsy
What is a pneumothorax?
Collection of air within the pleural space
What are the different types of pneumothorax?
- Primary spontaneous - happens with normal lungs
(Sudden event - weak areas on the lung surface rupture and leak air into the pleural cavity) - Secondary spontaneous - same as primary spontaneous pneumothorax except already has pre-existing condition
- Traumatic - take a guess bud
- Iatrogenic - Trauma but takes place due to medial procedure
- Tension - when air is trapped in the pleural space under positive pressure, displacing mediastinal structure and compromising cardiopulmonary function
