week 4 lung cancer and smoking also pleural effusion and asbestos Flashcards
what are the survival rates for cancer?
quite poor, in 2009 less than 10%
How does surgical intervention affect survival curve?
How many patients are suitable for this?
Huge effect, however 2/3 patients present with advanced disease
Pulmonary nodule vs mass?
Mass: opacity in lung over 3cm, with no mediastinal adenopathy or atelectasis
Nodule: opacity in lung up to 3cm with with no mediastinal adenopathy or atelectasis
Causes of localised opacity in X-ray?
Approx method for reviewing a CXR?
Look at:
Name/marker/penetration
Metal work
Mediastinum contours and heart first ( no widening, trachea central, hilar vascular structures crisply defined)
Central airways (any area of increased density? Distorted? Pulled in an inappropriate direction?)
Both lungs: compare upper, middle then lower zones for nodules and mass
Both lungs: anything that indicates lung collapse? (E.g. may be loss of volume, costophrenic angles for blunting which might mean pleural thickening of fluid).
Bones and soft tissues
Final look at apices, hila behind heart, and below hemidiaphragms
What might cause a white out of a hemithorax?
large pleural effusion?
complete collapse of lung?
pneumectomy
pleural effusion or complete collapse of lung?
pleural effusion: mediastinal shift away from that side, pushed away by the fluid
lung collapse: loss of volume on lung collapse side, so mediastinum will be pulled towards that
*same with pneumectomy
If we see a collapsed lung on an x-ray, and they haven’t had a CT for us to discount it, what is the assumptive diagnosis?
central tumour
especially in an older patient, who is a smoker
main bronchus divides into what bronchi sub types
lobar, segmental, sub-segemental
lungs divided into lobes, and then bronchopulmonary segments- remove one, others remain unaltered in their function (good for a surgeon to know)
right = 10, left = 8-10 (some may fuse)
on a chest x-ray, do you define lobes?
No use zones not lobes:
upper, middle, lobar
how could you guess where the pulmonary arteries are
follow the bronchopulmonary segments to find out where the pulmonary arteries are
which ventricle pumps blood into the main pulmonary artery
divides into right and left pulmonary arteries before subdividing into lobar, segmental, and sub-segmental branches.
CT pulmonary angiogram used why
to find a pulmonary embolus
Lymph nodes shown in a CT scan?
potential malignancy, potentially from lung cancer? Or infection? It’s a broad differential
why might we beware the lobar collapse which fails to resolve in 2-3 weeks of a smoker aged over 45
central lung cancer?
can you get more than one lobe collapsing
yes
where might lesions be in particular more subtle and difficult to spot in a CXR
Beware of lesions behind the heart and hila.
(compare with previous films, always look at review areas)
why might you compare with previous films
easier to spot abnormality when you have something to compare to
4 places an abnormality may hide on CXR
Hila, lung apices, behind the heart, behind the diaphragm
which hilum is a bit higher normally, and if they’re not is it okay
left
its okay
but right should never be higher
why is the left hilum usually higher
because the left main pulmonary artery arches over the left main bronchus
should the density behind the heart and below the diaphragm be comparable?
yes
should both hilum’s be equal ‘bulkiness’?
yes otherwise perhaps a mass e.g. ‘left hilar mass’
(unrelated, but remember the name ‘mass, left costophrenic angle)
As well as actually looking at the CXR, what else is important in the diagnosis and staging of lung cancer?
looking at the clinical history
What key info from a clinical history might be useful for staging lung cancer?
Increasing SOB in smoker, history of pulmonary fibrosis, recent haemoptysis
Would the lesion ever be on the breast?
Yes. Important to confirm that lesion is intrapulmonary.
What’s the next step after an X-RAY if there is an uncertainty?
CT
What’s one reason you might see a breast implant in CXR?
If patient has had a mastectomy
What is a pulmonary nodule/mass? (not vs)
opacity in lung with no mediastinal adenopathy or atelectasis
difference between a mass vs nodule
mass = over 3cm
nodule= up to 3cm
so basically it’s a mass if it’s over 3cm
Most common reason for CXR
Diagnosis for pneumonia
You can only asses heart/mediastinum width etc on PA view
True
Why aren’t CXR good for looking for rib fractures
Can’t see 50% of rib fractures in CXR
Pneumothorax- related to rib fractures (air in pleural place)
Subcutaneous emphysema (looks like air outside lung)
Border of heart lost? Might conclude?
Suggests something is in the lung, abutting the left side of the heart
If we can see bronchus?
Usually cant see bc it’s air filled, surrounded by air filled lung. But if:
Surrounded by dense, consolidated lung, full of pus eg due to pneumonia.
No lung markings?
Maybe pneumothorax?
Which hemidiaphragm should be slightly higher than the other?
Right
Pneumoperitanium might look like
Free gas under diaphragm- perforated the bowel.
In lung cancer. Would it often be one or multiple nodules/masses
In the context of lung cancer usually solitary, unless metastatic (could metastasise to another part of the lung).
Could you get benign nodules can you think of four things
Hematoma’s- which have fat/calcium in, or carcinoid tumours, or vascular malformations, foci of calcification.
Is TB a cavitating illness?
Yes
Would the formation of fungal ball or aspergilloma within the cavity be a complication of what type of illness?
Cavitating illness eg
TB
What’s a pulmonary cavitation?
Thick-walled abnormal gas filled spaces within the lung, usually associated with a nodule, mass, or area of consolidation
A fluid level within the space may be present.
What could commonly present with hemoptysis?
Pulmonary cavities
Staging of lung cancer, 4 key stages:
Clinical history/ exam
Performance status
Pulmonary function
TNM International system for staging lung cancer
What’s TNM staging?
Three parts:
- How big / how far spread / size and position of Tumour (T)
- Whether cancer cells have spread to lymph nodes (N)
- Whether rumour has spread anywhere else in body (M)
What’s typical progression of metastasis of lymph nodes from the lungs?
Contra lateral mediastinal nodes
Clavicular nodes
For assessing lymphatic metastasis from the lungs, what three tools could you use?
PET-CT
Mediastinoscopy
CT
What’s a PET/CT for diagnosing lung cancer?
Metabolic assessment of the patient and the disease, using a label glucose analogue FDG, which is attached to fluorine 18, which is taken up most by cells in particular that are metabolically active
Metabolically active cells shown by PET/CT scan could be:
Inflammatory
Malignant
(FDG uptake)
N2 disease means what
2 nodes
What’s the ‘T’ stage of TNM about?
Size when we can’t assess eg because it’s in a collapsed lung or something
What are the measurements/staging of the ‘T’ stage of TNM?
T1 through to T4
T1 up to 3cm
If involvement of chest wall, T3 regardless of size, or separate nodule in same node as primary
T4, 7 cm or more, or invading a structure incl. mediastinum, or separate tumour nodule in different ipsilateral node
Meaning of N1-3 of ‘N’ stage?
N1= ipsilateral peribronchial, hilar, or intrapulmonary nodes
N2=
How do we know if the node is metastatic?
Not if less than 1cm (tho that is an arbitrary cut off)
If not sure if node is malignant?
Node can be targeted for tissue sampling
Could the brain be a common site of metastasis for lung cancer?
Yes
M1 staging?
Metastasis within the thorax
Where is normal FDG uptake?
Heart, GI tract, brain
Limitations of PET CT?
False pos/neg
Cost
Eg nodule too small, inflam, or slow growing malignancy bc it has low metabolic rate
Is it important or not important to get a tissue sample for lung cancer and how?
Yes
Guided by CT or also by PET/CT
Or bronchoscopy
Mediastinoscopy to sample mediastinal nodes
Could CT have a role in screening?
Maybe in the future
what’s the principal reason for undertaking thoracic surgery?
lung cancer
how many patients with lung cancer are operable?
like 10%
if at risk of ischemic heart disease, and COPD, are you as a patient suffering from lung cancer, operable for thoracic surgery?
Chronic obstructive pulmonary disease (COPD) increases the chances of surgical complications, such as infections and respiratory crises. In fact, long-term survival rates for people with severe COPD who have surgery are lower than that of people who do not have COPD.1
Given this, a pre-operative evaluation that screens for lung disease is done in preparation for any surgical procedure.
why not thoracic surgery when you have both lung cancer and COPD?
mucus plugs
brochospasm
pneumothorax
hyperventitlation
How effective is thoracic surgery?
Of the 10% who can actually get operated on, about half are permanently cured of lung cancer
lymph node involvement in lung cancer is sometimes responsible for what?
recurrent laryngeal nerve palsy, or phrenic nerve palsy
Paralysis of the larynx (voice box) caused by damage to the recurrent laryngeal nerve or its parent nerve, the vagus nerve
These nerves are at risk of being destroyed by incoming tumor cells, e.g. those lying between the aortic arch and left pulmonary artery
where is the aortic pulmonary window
Between the aortic arch and left pulmonary artery
Why might clinical staging give a clue as to metastesis?
Because metastesis is often painful, especially if in the bones or the brain, headaches
Why the phenomenon of personality change?
CT scan the norm for lung cancer management.
If personality change, may be a feature of cerebral metastesis.
What do we look for, when doing a radiograph for cerebral metastesis?
Evidence for:
nerve palsy (phrenic nerve) - see in X-Ray
(if hearing hoarseness, it’s recurrent laryngeal nerve palsy)
brachial plexus palsy (from tumor at apex of lung) pancoast syndrome
If tumor is compressing the superior vena cava, what may they have signs of
distended neck veins, and obstruction of the superior vena cava
If a patient has supraclavicular lymph nodes or soft tissue nodules (when possible lung cancer), what does it suggest?
inoperable disease
If there is a malignant pleural effusion present, will surgery get rid of the disease?
no
If chest wall invasion, is it possible to resect invaded ribs and intervening soft tissues?
yes
then reconstruct chest wall with pericardial patch
If phrenic nerve palsy, is it operable situation?
no
Purpose of PET scan with collapsed lung during clinical staging?
help us to evaluate how much of collapsed lung is actually a tumor
Why might it be worth doing a bone scan in a patient with lung cancer?
to see if there is abnormal uptake in the skeleton consistent with metastatic disease
Why might it be worth doing a bone profile in a patient with lung cancer?
bc alkaline phosphate goes up when liver metastasis or bone metastasis
Are mediastinal nodes N1 or N2
N2
Would malignant effusion make the case inoperable?
yes
Can the diaphragm be resected?
yes
but difficult to resect in the costodiaphragmatic recesses
Where are the costodiaphragmatic recesses?
they are ‘potential spaces’, the sharp gutter at the junction of the costal and diaphragmatic pleurae in each pleural cavity
For lung cancer patients, who do you perform an ECHO on?
everyone
What’s the ECHO test?
to determine fitness for surgery. Will demonstrate presence or absence of significant pericardial effusion.
You might do isotope bone scanning to demonstrate invasion of what?
The chest wall
e.g. increased isotope uptake in appropriate bones
can you resect the scapula
not really
tumor in main bronchus, limitations?
hopefully not at carina, wanna see a couple cm before we reach tumor
tumor in lobar bronchus?
need to consider space before carefully resecting
whats a mediastinoscopy
telescope placed to a small incision above the sternum near sternal notch, pass down adjacent to the trachea to take biopsies of the lymph nodes there
do you operate on patients with major mental illness
no, lots of pain after surgery, don’t want to aggravate mental disorder
Why look out for pulmonary hypertension when considering lung cancer operations?
(Pick up on ECHO scan). Fragile arteries, well known cause of death
Would you consider immobility and rheumatoid arthritis for lung cancer operations?
Would you consider a patient with cirrhosis as fit for surgery?
NO WAY HOSE
see week 4 ‘assessment and surgical treatment of lung cancer’
What routine lung function testing would you do on our lung cancer patients?
spirometry and diffusion studies on ALL patients and franctionated V/Q scan
4 fitness for surgery cardiac assessment scans?
ECG
CT (all patients)
ECHO (all patients)
if coronary arteries very calcified, coronary angiogram
How many patients coming in for lung cancer surgery have confirmed lung cancer?
Only like 1/2
need to be clear that they MIGHT NOT NEED TO HAVE LUNG REMOVED so that they don’t sue surgeon
If not confirmed lung cancer, but doing operation anyway, what might you consider doing?
frozen sections during operation to confirm the malignancy is present
Would you consider doing frozen sections during a lobectomy/pneumonectomy?
not essential for lobectomy, certainly consider during pneumonectomy
COPD is not associated with clubbing of the fingers. Is lung cancer?
yes
also of toes
e.g. ‘have you noticed recently it has become more difficult to cut their toe nails?’ as club toenails are more difficult to cut than non-clubbed ones.
What’s a wedge resection/ segmentectomy?
just tryna chop actual tumour out, not even whole lobe
if segmental, ‘dividing up’ surgically,
or if use staple guns, then use wedge resection
Most common reason of peri-operative death?
ARDS, adult respiratory death syndrome
never really know aetiology, but usually had interstitial lung disease alongside cancer, and this was activated by stress of the operation
mortality for ADRS after lung resection?
50%
mycardial infarction and chest infection, occur due to lung resection peri-operational deaths?
yes
What’s post-pneumonectomy empyema?
whole chest cavity is full of pus, very serious
BPF, bronchopleural fistula is what
large space
negative pressure
chest wall partially collapses
But fluid in space where lung was, negative pressure still there causes air to be sucked in through staple lines
whats the commonest type of bronchopleural fistula?
post-pneumonectomy, becomes very difficult to eradicate once established
Why might someone with BPF have repeated chest infections?
Because material in the empyema space leaks into the trachea, and then that infected material can be aspirated into the good lung
What does aspirated mean
can refer to accidental breathing in of food or fluid into the lungs, can cause pneumonia and other lung problems
food’d would need to be removed
If large bronchopleural fistula, inefficient what
inefficient ventilation, because a lot of what they breathe in goes to this dead space , so not much getting to the good lung
would you remove non-functioning adrenal nodules
not really if they’re benign
‘must be fairly central because it’s causing collapse of the lung’ is referring to what
a tumour, get a PET scan now plz
mortality for pneumonectomy
5-10%
They might develop another lung cancer, right? So how often do you follow up with X-Rays
5 years, once a year maybe
What’s the most common thing for what we thought was lung cancer but actually wasn’t?
TB, lung abscess (tho infected lung abscesses can be associated with lung cancer)
then benign tumours
then granulomas
then fibrosis
most common cancer in world?
lung and breast together
Once you see an opacity in a chest X-Ray, what do you do next?
Get tissue sample via Biopsy: Bronchoscopy/EBUS
CT guided
US guided
Once we have a tissue sample from biopsy for lung, what are the two categories we can put them into
non-small cell lung cancer (85%)- adenocarcinoma and squamous mainly
small cell lung cancer (15%)
Is adenocarcinoma and squamous non-small cell or small cell
non-small cell
When would you move onto doing a PET scan?
When we think we need to move the patient onto curative treatment, as a PET scan is more sensitive.
What happens at a MDT meeting?
Discuss new cancer diagnosis (staging, history, wishes and fitness)
Therefore discuss therapeutic options, surgery or not, pallaitive or not, combo etc, or supportive care
ECOG performance status management 0-5 meaning
symptomatic, light work, rest for less than half the day, rest for more than half the day, bedbound, dead.
Doubling time for non-small cell lung cancer
129 days
Remember what the TNM means
size of tumor, nodes involvement, metastasis
Would you other surgery if you have disease elsewhere?
No because it’s a curative treatment option only
Can chemo be given post-operatively or not
yes to reduce chance of recurrence
Is neo-adjuvant therapy pre or post op.
Adjuvant therapy given before the main treatment is called neoadjuvant therapy. This type of adjuvant therapy can also decrease the chance of the cancer coming back, and it’s often used to make the primary treatment — such as an operation or radiation treatment — easier or more effective.
is neo-adjuvant therpy used in lung cancer clinical practice
no, may in future, we’ll see
Why is radical radiotherapy given
With intent to cure
For radical radiotherapy, what type of test is essential?
pulmonary function test is essential
What is concurrent chemotherapy?
It is systemic treatment, RT and chemo (tho addition of chemo increases toxicity, therefore patients have to be quite fit for that)
chemo goes in via drip (more systemic you see)
chemotherapy can radio sensitize, what does that mean?
make cancer cells more sensitive to radiotherapy
Is there a standard chemo regime in the UK?
no
when combining chemotherapy and radiotherapy, is the radiotherapy planning the same as before
yes
To whom is adjuvant immunotherapy available to?
Those who have stage three non-small cell lung cancer, or who have had chemotherapy
Why SABR? (stereotactic ablative radiotherapy)
high dose, so if the lung cancer is quite small and peripheral, useful if not fit for surgery, more peripheral the better, only up to 4cm
Options in palliative treatment?
chemotherapy
immunotherapy
palliative radiotherapy
combo of the above
How is palliative chemotherapy given?
Given as doublet regime, two drugs given as IV infusion every 3 weeks- 3 is as good as 6 months
strike balance, improve quality of life over length of life
Palliative immunotherapy, do patients need to be fit
not as fit as for chemo
How does palliative immunotherapy ‘unmask’ cancers
Cancers are good at masking themselves via PDL1 expression, PDL1 is a protein that prevents immune system attacking cells in the body.
Immunotherapy however upregulates immune cells to unmask cancers
Immunotherapy drug example
nivolumab
What are TKI’s
Tyrosine Kinase Inhibitors, for those who have a targetable mutation.
Example of driver mutation for palliative TKI’s
EGFR, and also BRAF
TKI’s are often for smokers
nah, usually younger non-smokers who weren’t expecting lung cancer, they do well on this
IRESSA specifically targets what type of driver mutation
EGFR
Doubling time of nsclc is 129 days, what is the doubling time of small cell lung cancer?
29 days
Similar or dissimilar symptoms in small cell lung cancer vs not?
similar, but more association with secretory syndromes eg SIADH, Cushing’s
also more often, a shorter duration
is surgery offered for small cell lung cancer?
Not generally unless caught very very early
Curative treatment for SCLC?
CRT, chemo and radiotherapy combo, slightly differnt to nsclc but still doublets
Is there an advantage to high dose chemo therapy in SCLC?
no, nor for alternating chemo
Role of prophylactic cranial radiation?
Prevent development of brain metastases
What type of cell does chemotherapy target?
Cells that are dividing quickly e.g. cancer cells, hair, bone marrow
therefore bone marrow suppression, neutrophils can be low
why neutrophenic sepsis
neutrophils low due to chemotherapy
Immunotherapy side effects:
pretty much anything itis, colitis, pneumonitis, dermatisis (downregulate immune system with steroids)
With either chemotherapy or radiotherapy, is there increased risk of 2nd malignancies?
with radiotherapies eg breast cancers etc
How many patients are diagnosed too late to cure?
80%
Patients on chemotherapy are at risk of neutropaenic sepsis
true
Neo-adjuvant treatment is given after a definitive procedure
false, neo is before
any questions about non surgical management of lung cancer ask:
andrew.duncan@nhs.scot
yeah
What’s in a fag?
Highly engineered products:
tobacco
filter
filler
additives
paper
smoke
Cigarette smoke contain approx 3000 chemicals
more than 4000 actually
Is arsenic, cadmium and hydrogen cyanide in cigarette smoke?
yes all three
Is there CO in cigarette smoke?
yes
Is there acetone in cigarette smoke?
yes
In Scotland, how many deaths a year from smoking?
10,000 deaths a year
On average, how many years of life do patients who smoke lose? Top three causes?
7.5 years (from Lung cancer, COPD, heart disease)
What other cancers could you get from smoking?
upper resp
bladder
pancreas
oesophagus
kidney
Cardiovascular diseases from smoking?
coronary artery disease
peripheral vascular disease
Gastroenterology diseases from smoking?
peptic ulceration
crohn’s disease
Could you get type II diabetes mellatis from smoking?
yes
What dermatology illness could you get from smoking?
psoriasis
You’re less likely to get uterine carcinoma if you smoke
yes
You’re less likely to get peptic ulceration if you smoke
wrong, def more likely
You’re less likely to get ulcerative colitis if you smoke
true
People in deprived areas are how many times more likely to smoke
3 x
Second hand smoke increases the risk of bronchitis, bronchiolitis, cot death true or false
true
How much nicotine do you get from vaping compared to a cig puff
nicotine hit is about 25-50%
Which is worse, second hand smoking or maternal smoking for sudden infant death?
maternal = 3x more likely, 2nd hand = 45% more likely
Stopping smoking: risk of heart attack falls how much after 15 years?
The same as someone who has never smoked
After ten years quitting, risk of lung cancer falls to what?
About half that of a continuing smoker
