Symposium 2 - Lung cancer

Question 1

Why are there poor survival rates in lung cancer patients?

Answer 1

Patients present late with advanced stage – 40% via ED

Early symptoms similar to common smokers symptoms

Question 2

_____% of lung cancers are caused by smoking

Answer 2

70%

Question 3

What are the 3 catagories of lung cancer?

Answer 3

Respiratory

Metastatic- from spread to distant sites

Paraneoplastic/systemic

Question 4

What are the common respiratory symptoms of lung cancer?

Answer 4

¢Cough

¢haemoptysis

¢dyspnoea

¢wheeze

¢chest pain

¢hoarseness

Question 5

What are the common systemic and metastatic presenting symptoms in lung cancer?

Answer 5

¢Weight loss

¢Anorexia, nausea

¢Malaise

¢Fatigue

From secondary sites eg CNS, bone, skin

Question 6

What are the Paraneoplastic syndromes in lung cancer?

Answer 6

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

Question 7

What are common signs of lung cancer on examination?

Answer 7

¢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

Question 8

What are the sub-types of lung cancer?

Answer 8

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%)

Question 9

What’s the diagnosis?

Answer 9

Lung adenocarcinoma

Question 10

What’s the diagnosis?

Answer 10

Squamous cell carcinoma

Question 11

Whats the diagnosis?

Answer 11

Small cell carcinoma

Question 12

What are the investigations- to (i) confirm diagnosis (ii) determine tumour cell type and (iii) stage (extent)?

Answer 12

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

Question 13

What determines treatment?

Answer 13

**Cell type and stage both determine further treatment, along with general health/coexisting illness**

Question 14

What is TNM staging?

Answer 14

¢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

Question 15

How is a newly discovered lung cancer managed?

Answer 15

¢?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

Question 16

What is The role of surgery in NSCLC?

Answer 16

¢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

Question 17

What are the Other radical treatments (with curative intent) in NSCLC?

Answer 17

¢Radical (high dose) radiotherapy

¢+/- chemotherapy

¢Usually reserved for those with stage 1 or 2 disease who are unfit (or unwilling) for surgery

Question 18

What is the role of Palliative radiotherapy/chemotherapy in NSCLC?

Answer 18

¢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

Question 19

How is small cell lung cancer treated?

Answer 19

¢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

Question 20

What are the main histological sub types of lung cancer?

Answer 20

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

Question 21

What lung cancer is this?

Answer 21

Small cell

Question 22

What are the histological features of small cell cancer?

Answer 22

Widespread bulky disease

Small, dark, delicate cells with little cytoplasm

‘salt and pepper’ chromatin in the nuclei

Azzopardi effect

Question 23

What are the histological features of squamous cell carcinoma?

Answer 23

Central origin often

Cigarette smoke provokes squamous metaplasia, then dysplasia of bronchial epithelium

Question 24

What cancer is this?

Answer 24

Squamous cell carcinoma

Question 25

What lung cancer is this?

Answer 25

Adenocarcinoma

Question 26

What are the histological features of adenocarcinoma?

Answer 26

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

Question 27

How can you distinguish between adenocarcinoma and SSC?

Answer 27

lLooking for specific proteins can help

leg TTF1 expression is typical of adenocarcinoma

Question 28

How is therapy determined in adenocarcinoma?

Answer 28

Molecular pathology is of primary importance in determining therapy of lung adenocarcinoma

Question 29

What are the patterns of spread of lung cancer?

Answer 29

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