Lung Cancer Flashcards
(18 cards)
Clinical presentation of patients with lung cancer
- Primary tumour
- Cough, dyspnoea, haemoptysis, chest pain, wheeze, pneumonia - Regional spread
- SVCO: facial plethora, upper limb and facial swelling, dilated chest veins, dyspnoea, headache, AMS
- Recurrent laryngeal nerve compression: voice hoarseness
- Horner’s syndrome: ptosis, miosis, anhidrosis, T1 wasting
- Pericardial effusion/tamponade
- Pleural effusion
- Phrenic nerve palsy: hiccups, elevated hemidiaphragm
- Oesophageal compression: dysphagia - Distant metastasis
- Constitutional symptoms
- Brain: headache, seizure, gait change, weakness, numbness
- Spinal cord: back and radicular pain, weakness, numbness, sphincter dysfunction
- Bone: bone pain, pathological fracture
- Liver: RUQ pain, jaundice, ascites
- Adrenals: adrenal insufficiency
- Skin: subcutaneous nodules - Paraneoplastic symptoms
- Endocrine: SIADH, Cushing, hypercalcaemia
- Neurologic: LEMS, cerebellar degeneration
- Skeletal: HPOA
Examination findings and clinical signs of lung cancer
General condition
1. Any respiratory distress
2. Any use of oxygen
Peripheral examination
1. Cachexia
2. Hand clubbing
3. Tar staining
4. HPOA (digital clubbing + periostosis of tubular bones)
5. Palpable skin nodules
6. Pallor and jaundice - ACD, liver mets
7. Lymphadenopathy
Possible presentations
A. Pleural effusion
- Asymmetric chest expansion
- Tracheal deviation away
- Stony dullness
- Reduced vocal and tactile fremitus
- Reduced breath sound
B. Collapse +/- consolidation
- Asymmetric chest expansion
- Tracheal deviation towards
- Dullness to percussion
- Increased vocal and tactile fremitus
- Bronchial / reduced breath sound
C. Pancoast tumour
- Horner’s syndrome: ptosis, miosis, anhidrosis
- Small hand muscle wasting (T1 interossei wasting)
Complications
1. Paraneoplastic ACTH: Cushingoid facies
2. LEMS - proximal muscle weakness
3. Spinal cord compression: weakness, sensory level, sphincter dysfunction
4. Dermatomyositis: heliotrope rash, Gottron’s papules
5. Pericardial effusion: muffled heart sound
6. Liver mets: jaundice, hepatomegaly, ascites
What are the complications of lung cancer?
- Pancoast tumour
- Superior vena cava obstruction (SVCO)
- Metastases to LN, hepatosplenomegaly, spine, brain
- Paraneoplastic syndromes
Classification of lung cancer
A. Small cell carcinoma (SCLC) - 20%
- Also known as oat cell carcinoma
- Occurs in smokers
- Arise from Kulchitsy cells (neuroendocrine origin), secrete polypeptide hormone
- Highly aggressive, rapid growing and metastasize early
B. Non-small cell carcinoma (NSCLC) - 80%
1. Adenocarcinoma (50%)
- Smokers and non-smokers
- Often outer or peripheral lung areas
- Bronchoalveolar
- Spreads along alveolar walls - Squamous cell carcinoma (30%)
- Also known as epidermoid carcinoma
- Cavitating lesions - Large cell carcinoma
- Also known as undifferentiated carcinoma
Risk factors for lung cancer
- Smoking
- Chronic inflammatory lung disease
- Occupational exposures
- Heavy metals - chromium, iron oxide
- Coal tar
- Asbestos
- Radon
- Arsenic
- Ionising radiation
Small cell carcinoma and squamous cell carcinoma have the strongest correlation with smoking
What are the broad categories of manifestations in paraneoplastic syndromes?
(Refer other questions for details on the manifestations)
- Endocrine
- Neurological
- Cutaneous
- Musculoskeletal
- Systemic - cardiovascular, renal, haematological
What are the endocrine paraneoplastic manifestations of lung cancer? (6)
- SIADH (small cell)
- Cushing’s syndrome (ACTH producing)
- hypokalaemic met alkalosis - Hypercalcaemia (PTHrP from SqCC)
- Hyperthyroidism
- Hypoglycaemia
- Gynaecomastia
What are the neurological paraneoplastic manifestations of lung cancer? (4)
- Lambert-Eaton myasthenic syndrome
- Sensory peripheral neuropathy
- Limbic encephalopathy
- Subacute cerebellar degeneration
What are the cutaneous (6) and musculoskeletal (2) paraneoplastic manifestations of lung cancer?
Skin
1. Polymyositis
2. Dermatomyositis
3. Migratory venous thrombophlebitis (Trosseau’s sign)
4. Acanthosis nigricans
5. Gynaecomastia
6. Herpes zoster
Musculoskeletal
7. Clubbing
8. Hypertrophic pulmonary osteoarthropathy
What are the systemic manifestation of paraneoplastic syndromes? (5)
- DIC
- Anaemia
- Non-thrombotic endocarditis
- Nephrotic syndrome
- Membranous glomerulonephritis
What is pancoast tumour?
Lung cancer over superior sulcus of lung causing destruction to thoracic inlet, brachial plexus and cervical sympathetic ganglia.
Clinical features due to compression of unilateral nerves and vessels:
1. T1 nerve root - Horner syndrome, wasting of hand muscles
2. Cervical sympathetic ganglia - Horner syndrome
3. Recurrent laryngeal nerve - hoarse voice, bovine cough
4. Subclavian vein - upper limb oedema
Investigations for lung cancer
- Blood test: FBC RP Ca LFT Coag
- FBC: anaemia, thrombocytopenia
- RP: hyponatraemia, alkalosis
- Calcium: hypercalcaemia of malignancy
- LFT: liver mets, ALP in bony mets
- Coag panel: DIC - Chest x-ray
- Location, size of tumour
- Collapse, consolidation, pleural effusion
- Phrenic nerve palsy raised hemidiaphragm - UFEME
- Proteinuria - membranous GN - Sputum cytology
- Good yield in: squamous, small cell - Thoracocentesis and pleural fluid analysis
- Appearance: haemorrhagic, exudative
- Low pH < 7.3
- Low glucose
- Raised amylase
- Cytology and molecular testing - CT TAP
- Lung function test for surgical resection
- FEV1 > 1.5 to permit resection - Bronchoscopy and BAL
- PET-CT and bone scan for staging
Molecular testing and biologics for lung cancer
- PD-L1 expression: atezolimumab
- Driver mutations
- EGFR: osimertinib, gefitinib, erlotinib
- ALK: alectinib, brigatinib, lorlatinib
- ROS1: entrectinib, crizotinib
- BRAF V600E: dabrafenib, trametinib
- MET exon 14 skipping: capmatinib, tepotinib
- RET fusions: selpercatinib, pralsetinib
- NTRK fusions: larotrectinib, entrectinib
- KRAS G12C
General answers for management for all lung cancers
Non-pharmacologic
1. Multidisciplinary team - respiratory, medical oncology, thoracic surgery, chest physiotherapy, dietitian, psychologist
2. Smoking cessation
3. Nutritional support
4. Vaccination
5. Patient education
6. Palliative support
- Pain management
- Oxygen therapy
Definitive
1. Chemotherapy
2. Radiotherapy
3. Surgery
What are the treatment options for non-small cell lung cancer?
Stage 1 & 2:
1. Surgery - lobectomy
2. Adjuvant chemotherapy
- Platinum based: cisplatin+vinorelbine
- Immunotherapy: osimertinib (EGFR) and atezolimumab (anti-PD-L1)
Stage 3 & 4
1. Surgery in selected patient
2. Chemotherapy
In advanced stages, consider:
1. Palliative radiotherapy +/- chemotherapy
- Pain, bone metastasis
- Dyspnoea from bronchial obstruction, dysphagia
- SVCO, pancoast tumour
- Surgery requires FEV evaluation
What is the minimum FEV1 required for surgical treatment of NSCLC?
Lobectomy: > 1.5L
Pneumonectomy: > 2L
(Different guidelines different quotes, and now obsolete - calculate predicted FEV1 after surgery)
Treatment of small cell lung carcinoma
- Chemotherapy
- Platinum (carboplatin or cisplatin) + etoposide (EP regime) (4-6 cycles) - Immunotherapy
- PD-L1 inhibitor (atezolimumab, durvalamab)
- PD-1 inhibitor (nivolumab, pembrolizumab) - Prophylactic cranial irradiation (PCI)
- Role of surgery is rarely useful
- 70% patients have extensive disease at time of diagnosis.
- Only in rare cases of very early disease localised to lung parenchyma
