Symposium 2 - Lung cancer Flashcards
Why are there poor survival rates in lung cancer patients?
Patients present late with advanced stage – 40% via ED
Early symptoms similar to common smokers symptoms
_____% of lung cancers are caused by smoking
70%
What are the 3 catagories of lung cancer?
Respiratory
Metastatic- from spread to distant sites
Paraneoplastic/systemic
What are the common respiratory symptoms of lung cancer?
¢Cough
¢haemoptysis
¢dyspnoea
¢wheeze
¢chest pain
¢hoarseness
What are the common systemic and metastatic presenting symptoms in lung cancer?
¢Weight loss
¢Anorexia, nausea
¢Malaise
¢Fatigue
From secondary sites eg CNS, bone, skin
What are the Paraneoplastic syndromes in lung cancer?
Frequently seen:
¢Hyponatraemia (due to SIADH)- small cell carcinoma
¢Hypercalcaemia (due to PTH like activity)- squamous cell carcinoma
Less commonly- gynaecomastia, pruritis, cerebellar degeneration, peripheral neuropathy
What are common signs of lung cancer on examination?
¢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
What are the sub-types of lung cancer?
Non small cell (NSCLC)
¢Squamous- central; invade locally; frequent cavitation; hypercalcaemia common (20%)
¢Adenocarcinoma- peripheral lung; more common in non-smokers Most common (40%)
¢Large cell (5%)
¢Undifferentiated (18%)
Small cell - central; early lymphatic spread; paraneoplastic syndromes (13%)
What’s the diagnosis?
Lung adenocarcinoma
What’s the diagnosis?
Squamous cell carcinoma
Whats the diagnosis?
Small cell carcinoma
What are the investigations- to (i) confirm diagnosis (ii) determine tumour cell type and (iii) stage (extent)?
oCT
oBronchoscopy
¢Endobronchial Ultrasound Needle aspiration
¢Other biopsy procedure eg percutaneous CT thorax, peripheral lymph node/liver
¢PET scanning- a nuclear medicine scan, utilising the high uptake of a glucose analogue (2,3 FDG) in tumour cells
What determines treatment?
**Cell type and stage both determine further treatment, along with general health/coexisting illness**
What is TNM staging?
¢Staging is one of the important factors in determining treatment and prognosis in lung cancer (general fitness and patient wishes being the others)
¢It takes into account tumour size, involvement of local structures, lymph and blood metastases
How is a newly discovered lung cancer managed?
¢?small cell or non small cell lung cancer (NSCLC)
¢If NSCLC is it resectable?
¢If NSCLC and not suitable for surgery ?other radical treatment appropriate eg high dose radiotherapy/stereotactic radio/microwave ablation
What is The role of surgery in NSCLC?
¢Consider surgery for all patients with stage 1 and 2 disease
¢Usually involves lobectomy (pneumonectomy sometimes performed)
¢In practice around 20% in UK undergo potentially curative resection for lung cancer
What are the Other radical treatments (with curative intent) in NSCLC?
¢Radical (high dose) radiotherapy
¢+/- chemotherapy
¢Usually reserved for those with stage 1 or 2 disease who are unfit (or unwilling) for surgery
What is the role of Palliative radiotherapy/chemotherapy in NSCLC?
¢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 (but occasionally does!)
¢Chemotherapy regimens can improve quality of life
¢Also offer a modest improvement in survival (measured in weeks)
May be used in conjunction with radiotherapy
How is small cell lung cancer treated?
¢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 (5%) with limited disease become long term survivors
What are the main histological sub types of lung cancer?
Small Cell (AKA Oat Cell) Carcinoma (10-15%)
Non Small Cell Carcinoma (85-90%)
–Squamous Cell Carcinoma 25-30%
–Adenocarcinoma 40%
–Undifferentiated / Large Cell Carcinoma 10- 5%
–Mixed and others
What lung cancer is this?
Small cell
What are the histological features of small cell cancer?
Widespread bulky disease
Small, dark, delicate cells with little cytoplasm
‘salt and pepper’ chromatin in the nuclei
Azzopardi effect
What are the histological features of squamous cell carcinoma?
Central origin often
Cigarette smoke provokes squamous metaplasia, then dysplasia of bronchial epithelium
What cancer is this?
Squamous cell carcinoma
What lung cancer is this?
Adenocarcinoma
What are the histological features of adenocarcinoma?
Adenocarcinoma may first begin with malignant cells lining alveolar spaces
Adenocarcinoma is typically peripheral, contains fibrous tissue and shows variable differentiation which correlates with prognosis
How can you distinguish between adenocarcinoma and SSC?
lLooking for specific proteins can help
leg TTF1 expression is typical of adenocarcinoma
How is therapy determined in adenocarcinoma?
Molecular pathology is of primary importance in determining therapy of lung adenocarcinoma
What are the patterns of spread of lung cancer?
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
