Thoracic Cancers Flashcards
Lung cancer is the second most common cancer in the UK. Name four linked aetiologies
Cigarette smoking (particularly unfiltered and high nicotine)
Passive smoking
Asbestos
Chest Radiotherapy
Discuss screening and prevention of Lung Cancer
Screening with CXR and sputum cytology doesn’t reduce mortality
Trial with Spiral CT in smokers
2007 smoking ban in public places will reduce rates in future
Describe the histological subtypes of Lung Cancer
Small Cell Carcinoma (15-20%)
Non Small Cell Carcinoma (Squamous 30%, Adenocarcinoma 40%, Large Cell, Adenosquamous)
How does Small Cell Carcinoma present on histology?
Small Purple Cells
Describe the characteristics of Small Cell Carcinoma of the Lung
Derived from Neuroendocrine cells (normally in the large airways) Very aggressive (90% metastasise) Associated with paraneoplastic syndromes
Describe the characteristics of Adenocarcinomas of the Lung
Usually peripheral but even small tumours metastasise
Commonly metastasising to: Liver, Adrenals, Other Lung, Pleura, Bone
Describe the characteristics of Squamous Cell Carcinoma of the Lung
Arise in proximal bronchi and grow slowly, disseminating in late course
What can a Pancoast Tumour compress?
Braciocephalic Vein Subclavian Phrenic Nerve Vagus Nerve RLN
How does a Pancoast Tumour present?
Hoarse Voice
Bovine Cough
SVCO
Hand muscle wasting
Give four genetic mutations that are potentially associated with Lung Cancer
EGFR Overexpression (Oncogene) p53 Inhibition (Tumour Supressor) Increased VEGF (Angiogenesis) Telomerase Activation
Lung Cancer normally presents late as symptoms are often attributed to smoking. Give 5 symptoms
Persistent Cough (>3 weeks) Haemoptysis Recurrent Chest Infections Chest Pain Hoarse Voice
What is the criteria for a 2ww referral along the lung cancer pathway?
CXR showing Lung Cancer or Mesothelioma
OR
Over 40 with unexplained haemoptysis
Describe some different referral criterias for a 2ww CXR for Lung Cancer
Over 40 with: Recurrent chest infection/Finger Clubbing/Cervical LN/Consistent Chest Signs/Thrombocytosis
Over 40 and never smoked with atleast two/used to smoke with atleast one of: Fatigue, Cough, Dyspnoea, Weight Loss, Chest Pain
What are the three main investigations for suspected Lung Cancer?
CXR
CT Staging with Contrast
Biopsy (If central then ideally via bronchoscopy, then if not via sputum, peripheral via needle biopsy)
Give four potential features seen on CXR of Lung Cancer
Circular Opacity
Hilar Enlargement
Consolidation
Pleural Effusion
Describe the WHO Performance Status
0 - Asymptomatic 1 - Symptomatic but ambulatory 2 - In bed < 50% but unable to work 3 - In bed > 50%, no self care 4 - Bedridden
Who is involved in the MDT Lung Cancer team?
Physician Specialist Nurse Radiologist Thoracic Surgeon Oncologist
What investigation can be done to specifically look for Liver and Bone metastases from the Lung?
FDG PET CT
Lung Cancer is staged via TNM. Describe Tx - T2
Tx - Positive malignant cytology, no lesion T0 - No evidence of primary tumour T1a - <2cm T1b -2 to 3 cm T2a - 3 to 5cm T2b - 5 to 7cm
Lung Cancer is staged via TNM. Describe T3 - T4
T3 - >7cm invading, assoicated atelectasis, separate nodules in same lobe
T4 - Invasion of mediastinal organs, malignant effusion, RLN
How is suitability for surgical management of Lung Cancer assessed?
Thoracoscore
What are the surgical options for management of Lung Cancer?
Lobectomy
Pneumonectomy
Wedge resection for small tumours
Patients post op from surgical Lung Cancer management are managed in ICU/HDU, what are further treatment options?
Adjuvant Cis Platin if good performance score
Radiotherapy if incomplete resection
Give two early and two late complications of surgical management of Lung Cancer?
Early - Haemorrhage, Resp Failure
Late - Post Thoracotomy Pain, Late Bronchopulmonary FIstula
Name a biological treatment option for Lung Cancer
Afatinib (eGFR Tyrosine Kinase Inhibitors)
Name an immunotherapy treatment option for Lung Cancer
Pembidizumab (prevents inhibition of T cell response)
What is the preferred Chemotherapy regime for Adenocarcinoma of the lung?
Pemetrexed
Cisplatin (also a radiosensitiser)
Carboplatin
Lung Cancer can also be managed by radical radiotherapy if unsuitable for surgery. Give three disadvantages of this
Frequent hospital attendance Acute toxicities (oesophagitis) Late toxicities (lung fibrosis)
Lung Cancer can also be managed by radical radiotherapy if unsuitable for surgery. Describe the CHART regimen
54Gy in 36 fractions over 12 days (8am, 12pm, 8pm)
Give three prognostic factors of Small Cell Carcinoma of the Lung
Performance Status
LDH
Na+ (SIADH = poor prognosis)
Small Cell Carcinoma of the Lung is staged slightly differently. Describe it
Limited Stage - confined to one hermithorax, ipsilateral hilar LN, supraclavicular and mediastinal nodes
Extensive Stage - Metastatic lesions in contralateral lung, distant metastatic involvment
Surgery is generally not recommended in Small Cell Carcinoma of the lung, describe the use of chemotherapy
Limited Stage: 4-6 cycles of cisplatin combination
Extensive Stage: Maximum 6 cycles of above
Surgery is generally not recommended in Small Cell Carcinoma of the lung, describe the use of radiotherapy
Limited: Thoracic irratiation alonside/after chemotherapy
Extensive: Offered if complete response at distant sites and good response in thorax
Give two local complications of Lung Cancer
Horners Syndrome
RLN Palsy
Give two metastatic complications of Lung Cancer
Confusion
Bone Pain
Give two non metastatic complications of Lung Cancer
SIADH
Lambert Eaton Syndrome
What is Lambert Eaton Syndrome?
Autoimmune targeting of voltage gated sodium channels causing muscular weakness
Associated with Small Cell Carcinoma
Define Mesothelioma
Aggressive tumour arising from serosal lining of chest
Strong association with asbestos exposure
Describe the pathology of Mesotheliomas
Grows diffusely in pleural space
Associated with pleural effusion
3 histological subtypes (epithelioid, sarcomatous, mixed)
What is seen on CXR of Mesothelioma?
Pleural effusion/thickening
What is seen on CT and MRI of Mesothelioma?
CT - Pleural mass and effusion encasing lung
MRI - definition of tissue planes
How is Histology taken for suspected Mesothelioma?
US/CT guided biopsy
OR
Thoracoscopy and Biopsy
(risk of seeding into chest wall)
How are Mesotheliomas staged?
Brigham staging
I - One side of the pleura
II - Intrapleural adenopathy
III - Extension into chest wall/ribs/spine/peritoneum/pericardium
IV - Distant metastatic disease
Surgical management is ideal for Mesothelioma, but only applicable in certain cases, such as:
Stage I if medically fit
Stage II and III as part of multimodal therapy
Extrapleural pneumonectomy
Describe the use of Radiotherapy/Chemotherapy for Mesothelioma
Radiotherapy - short course for painful chests
Chemotherapy - Pemetrexed in combination with Cisplatin/Carboplatin
What is different about the management and paperwork of Mesotheliomas as opposed to other cancers?
Patients are entitiled to compensation
All deaths must be notified to coroner
How does the incidence of Breast Cancer increase with age?
Incidence doubles every decade until menopause
After 50y there is a slower increase
Give 5 risk factors for Breast Cancer
Early Menarche and Late Menopaus Exogenous Oestrogens (COCP, HRT) Obesity Previous breast surgery (eg augmentation) Radiation
How should a family history of breast cancer be managed?
- 45-65% of those who inherit BRCA1/2 will get breast cancer before the age of 70
- Prophylactic mastectomy (+/- Oophorectomy)
- Annual MRI for BRCA1/2 carriers (aged 30-50)
What is the most common type of Breast Cancer?
Ductal Carcinoma
More common in left breast
Define DCIS
- Atypical proliferation of ductal epithelium that eventually plugs ducts with neoplasm
- Remains within basement membrane
- Progression to invasive disease is 30-50%
How does DCIS present on mammography?
Microcalcification
How is LCIS different from DCIS?
Neither palpable nor showing microcalcifcations on mammography
Invasive Ductal Carcinoma accounts for 75% of breast cancers , and is graded from I-III. How is the grade calculated?
Tubule Formation
Nuclear Pleomorphisms
Mitotic Frequency
Name two prognostic markers of Breast Cancer and a score
ER receptor status
HER2 receptor status
Nottingham Prognostic Score
What is a ‘Triple Negative’ Breast Cancer?
ER, PR and HER2 negative
15% of breast cancers
What is Paget’s Disease?
Ductal carcinoma with involvement of nipple skin and areola (presents like nipple eczema)
What are Breast Cysts?
Epithelial lined fluid filled cavities formed when lobules become distended due to blockage
Normally affects perimenopausal age group
How are Breast Cysts investigated?
Mammography (classic halo shape) Needle Aspiration (cytology)
What is Mammary Duct Ectasia?
Dilation and shortening of the lactiferous ducts
Common in the peri-menopausal age group
How does Mammary Duct Ectasia present?
Green/Yellow nipple discharge
Palpable mass
Retracted nipple
How is Mammary Duct Ectasia investigated?
Mammography (dilated calcified ducts)
Biopsy (multiple plasma cells)
Name 5 types of benign breast lumps
Fibroadenoma Adenoma Papilloma Lipoma Phyllodes
How does a Papilloma present?
Typically in sub-areolar region
Clear/bloody nipple discharge
What are Phyllodes tumours?
Rare fibroepithelial tumours that grow rapidly
Should be excised as a 1/3 have malignant potential
Give five presentations of Breast Cancer
Breast Lump Axillary Lump Breast Skin Changes (dimpling, puckering, erythema) Nipple Changes (inversion, discharge) Abnormal mammogram
Name four possible criteria for a 2ww Breast Cancer referral
- Any age with discrete hard lump that is fixated
- > 30 with lump persisting after period
- Unilateral eczematous changes unresponsive to steroids
- Persistent axillary swelling
Name three possible criteria for a routine Breast referral
<30y with a lump (no other concerning features)
<50y with intermittent nipple discharge (non bloody)
Mastalgia and no palpable abnormality
What is a Triple Assessment for Breast Cancer
Examination
Imaging
Biopsy
What is the radiographical choice for Breast Cancer?
Mammography if over 35y (two views - caudiocranial, mediolateral)
USS in younger patients (due to denser tissue)
When would you use an MRI to image breasts?
Familial Cancer Screening
Breast Implants
What is involved in the clinical examination of suspicious Breasts?
Calliper measurement of any lumps
Assessment of fixicity
Lymphadenopathy
Describe the biopsy options for Breast Cancer
Impalpable Lesions use US guided FNA (quicker and less painful)
Ideally use Core Biopsy (allows more information about tumour grade and receptor sensitivity)
What is a Sentinel Node Biopsy?
Removing the first lymph node that the breast tissue drains to, found by injecting radioactive blue dye
Name three adverse effects of Axillary Clearance
Lymphoedema
Arm Pain
Stiff Shoulder
Describe the T of TNM Breast Cancer Staging
T0 - in situ T1 - <2cm T2 - 2-5cm T3 - >5cm T4a - Involvement of chest wall T4b - Involvement of skin T4c - Involvement of chest wall and skin T4d - Inflammatory
What are the management options for In Situ Breast Cancer?
Mastectomy
Wide Excision Alone
Wide Excision and whole Breast Irradiation
What is the role of Adjuvant Hormone Therapy in Breast Cancer?
Aims to eradicate micrometastatic disease
Generally given for 10y
Premenopausal - Tamoxifen
Post menopausal - Anastrazole
Adjuvant chemotherapy for Breast Cancer has a good response in Pre-Menopausal Women. Describe a typical regime
Doxorubicin
Fluorouracil
Cyclophosphamide
What are the key treatments for Advanced Breast Cancer?
Endocrine therapy (if ER positive) Chemotherapy
Give a benefit and disadvantage to immediate breast reconstruction in Breast Cancer
Preserves native skin so more symmetrical outcome
Can delay adjuvant therapy if any post op complications
Give a benefit and disadvantage to delayed breast reconstruction in Breast Cancer
Allows focus on cancer treatment
Extra skin needs to be gathered from other site or donor
Give three reconstructive options post Mastectomy
Lat Dorsi - for smaller breasts, can be free or pedicled
TRAM - Transverse Rectus Abdominus Muscle
DIEP - Deep Inferior Epigastric Perforator
Give an advantage and disadvantage to adjuvant treatment in Breast Cancer
Immediate surgical removal of disease
Can’t assess full efficacy of treatment
Give an advantage and disadvantage to neoadjuvant treatment in Breast Cancer
Allows visualisation of tumour response
Risk of over treatment
