Treatment of Bronchial Carcinoma

Question 1

Lung cancer treatment?

Answer 1

Giving the diagnosis

Surgery

Radiotherapy (can be given in radical or palliative dose)

Chemotherapy

Supportive care (palliative)

Question 2

Types of lung cancer?

Answer 2

Small cell

Non-small cell

Question 3

Characteristics of small cell lung cancer?

Answer 3

Rapidly progressive disease with early metastases; rarely suitable for surgery (at 1st presentation, small cell lung cancer has usually spread beyond primary site)

Good INITIAL response to cytotoxic chemotherapy, due to rapid growth (often backed up with radiotherapy)

Question 4

Describe non-small cell lung cancer

Answer 4

Includes squamous and adenocarcinomas and accounts for the majority of lung cancers

Curative (radical) options are surgery (if disease is recognised before spread beyond primary site) or radical radiotherapy; this type is less responsive to chemotherapy

Question 5

Why are some diagnoses unknown?

Answer 5

Sampling techniques are unable to tell the cell type (perhaps, the only thing that can be obtained is necrotic tissue); also, investigations may not be continued due to patient being unwell/other co-morbidities (shorter prognosis)

Question 6

Types of surgeries available for lung cancer?

Answer 6

Pneumonectomy - lung removal

Lobectomy - lobe removal

Can the cancer be resected, is the disease localised, will the patient survive the operation and what will the residual lung function be?

Question 7

Benefits and complications with patients suitable for surgery?

Answer 7

Median survival rate does increase with surgery (from 4.8 months without to 42.7 months)

Risk of developing a second primary lung cancer later in life; both lungs were exposed to tobacco smoke

Question 8

What does staging for surgery involve?

Answer 8

TNM staging - surgeon needs to be certain that the cancer can be completely removeed by an operation so the pre-operative staging amounts to a thorough search for metastases/local invasion:

Bronchoscopy - vocal cord palsy, proximity to carina, cell type?

Mediastinoscopy/EBUS - lymph nodes

CT scan of brain - check for brain metastases

CT scan of thorax - tumour size, lymph nodes,metastases, local invasion?

PET scan - check for metastases

Question 9

What must the surgeon do after a pneumonectomy?

Answer 9

After removing a lung, the surgeon needs to close up the hole in the bronchial tree

In general, there must be 2 cm of disease free bronchus to close off the hole

So, if the tumour encroaches within 2 cm of the carina, it is impossible to remove it without leaving a hole in the side of the trachea

Question 10

Describe surgery for lung cancer

Answer 10

Thoracotomy (making an incision into the pleural space in the chest)

Video Assisted Thoracic Surgery (VATS - minimal access) is also used

Scars will be left

Objective - curative

Peri-operative mortality and post-operative morbidity

Question 11

Determining stage for chemotherapy?

Answer 11

Bronchoscopy/other tissue sampling (small cell/non-small cell)

CT scan: Tumour size, local invasion, nodes, metastases

Performance status - ECOG score (ranges from 0 to 5, from no symptoms to death, and is used to determine who is fit for treatment)

Question 12

Describe cytotoxic chemotherapy

Answer 12

Whole body treatment that targets rapidly dividing cells

Cannot cross blood-brain barrier so chemo cannot be used for brain cancers /metastases; prophylactic cranial irradiation must be used (radiotherapy)

Rarely curative but does confer longer survival; better response in small cell cancer; there are major side effects

Question 13

Chemotherapy side effects?

Answer 13

Nausea and vomiting Tiredness Bone marrow suppression (opportunistic infection and anaemia) - can lead to neutropenic sepsis; patients told to watch out for even slightest fever Hair loss Pulmonary fibrosis

Question 14

Describe radiotherapy

Answer 14

Uses ionising radiation, usually X-rays as an external beam; can be radical (curative)

Question 15

Disadvantages of radiotherapy?

Answer 15

Maximum cumulative dose has to be given to the tumour but collateral damage does occur to, e.g: spinal cord, oesophagus, adjacent lung tissue

Only goes to where beam is pointed and so is no good for subclinical metastases, except prophyactic cranial irradiation

Question 16

Common side effects of radiotherapy?

Answer 16

Temporary oesophagitis

Normal lung tissue can undergo post-radiation fibrosis; can be a challenge when patient has precarious lung function, e.g: advanced COPD

Question 17

Describe endobronchial therapy

Answer 17

Patient receives a photo-sensitising drug a few days beforehand (told to stay out of sun)

Then phototherapy to tumour occurs in the bronchus, with laser light being transmitted down a fibre optic bundle - only works if tumour is in bronchial mucosa

Question 18

Uses of endobronchial therapy?

Answer 18

Stent insertion for stridor - introducer passed through narrowed section of trachea and stent is deployed into the lumen of the narrow section to open it up (stent will appear on a CT scan)

Photodynamic therapy

Other laser therapy

Radioactive pellets

…all are palliative

Question 19

How is treatment of lung cancer determined?

Answer 19

Patient’s wishes

Cell type

Extent of disease (TNM staging)

Co-morbidity

Question 20

Co-morbidity issues in lung cancer?

Answer 20

Other smoking-related disease can be COPD, ischaemic heart disease, peripheral vascular disease, etc

These co-morbidities often restrict the choice of treatment for lung cancer

Question 21

Aim of palliative care?

Answer 21

To alleviate symptoms, e.g: pain, breathlessness, cough, anxiety and poor mobility

Question 22

Choices in palliative care?

Answer 22

Palliative radiotherapy

Question 23

Lung cancer prognosis?

Answer 23

Poor

Half will be dead in 6 months

Question 24

Causes of lung cancer?

Answer 24

Tobacco smoking - main cause

Asbestos exposure

Radon exposure - gas that is a breakdown product from isotopes found in granite

Prevention is a better option than small chance of cure