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Respiratory Physiology, Medicine and Critical Care > Lung cancer > Flashcards

Lung cancer Flashcards

1
Q

What is bronchial carcinoma?

A

Carcinoma of the lung

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2
Q

What categories are lung cancers broadly divided into?

A

Based on histological appearence

  • Small cell
  • Non-Small cell
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3
Q

What are the subtypes of non-small cell carcinoma?

A
  • Adenocarcinoma
  • Squamous cell carcinoma
  • Large cell carcinoma
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4
Q

What proportion of lung cancers are adenocarcinoma?

A

30-40%

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5
Q

What proportion of lung cancer is squamous cell carcinoma?

A

20-30%

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6
Q

What proportion of lung cancers are large cell carcinomas?

A

10-15%

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7
Q

What proportion of lung cancers are small-cell lung cancers?

A

10-15%

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8
Q

Where are squamous cell carcinomas most commonly found?

A

Centrally - frequently cavitate

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9
Q

Which type of lung cancer is most associated with smoking?

A

Squamous cell carcinoma

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10
Q

Describe the pathogenesis of squamous cell carcinoma?

A

Cigarette smoke irritates the respiratory tree, which over time results in the development of squamous metaplasia. Squamous cells are then subject to the effect of exposure to the carcinogens in the smoke with accumulation of genetic defects, e.g. mutation of p53 and overexpression of p63:

  1. Normal Pseutostratified squamous ciliated epithelium
  2. Bronchial Squamous Dyslpasia
  3. Squamous Carcinoma-in-situ (in-situ = on site/in position)
  4. Invasive Squamous Cell Carcinoma
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11
Q

What are pathological/histological features of squamous cell carcinoma?

A

The tumours are usually central in location and frequently cavitate. Squamous differentiation is recognised by the presence of keratin or intercellular desmosomes (prickles).

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12
Q

Does squamous cell lung cancer metastasize early or late?

A

Late

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13
Q

What is adenocarcinoma?

A

Carcinomas which are believed to develop from areas of dysplastic alveolar epithelium (atypical adenomatous hyperplasia) analogous to that encountered in other mucosal surfaces such as the colon.

At its most severe, the alveolar walls are lined by a population of atypical glandular cells which previously were regarded as being ‘bronchoalveolar carcinoma’ but are now thought of more as a form of adenocarcinoma in situ.

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14
Q

What proportion of lung cancers are adenocarcinomas?

A

30-40%

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15
Q

Where are adenocarcinomas more likely to occur in the lung?

A

peripherally

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16
Q

What are the histological features of adenocarcinoma of the lung?

A

A glandular growth pattern (acinar or papillary) or evidence of mucin production by the cells

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17
Q

What is the pathogenesis of adenocarcinoma of the lung?

A

Process of formation

  • Normal lung parenchyma
  • Atypical Adenomatous Hyperplasia
  • Localised non-mucinous bronchioalveolar carcinoma (Adenocarcinoma-in-situ)
  • Invasive Adenocarcinoma
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18
Q

What is the most common type of lung cancer in non-smokers?

A

Adenocarcinoma

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19
Q

What is large cell lung cancer?

A

Non-small cell lung cancer

These tumours are poorly differentiated and show no evidence of squamous or glandular differentiation by light microscopy

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20
Q

What are common sites for adenocarcinoma to metastasise to?

A
  • Pleura
  • Lymph nodes
  • Brain
  • Bones
  • Adrenal glands
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21
Q

What is small cell lung carcinoma?

A

Previously also known as ‘oat cell’

Unlike NSCC, they metastasise very early, producing widespread bulky secondary deposits. The cells commonly express neuroendocrine markers, suggesting that this is a form of very poorly differentiated neuroendocrine carcinoma.

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22
Q

Why are SCLC known as neuroendocrine tumours?

A

They arise from neuroendocrine cells - APUD cells

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23
Q

Which types of lung cancer can metastasise early?

A
  • SCLC
  • LCLC
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24
Q

What are the histological features of SCLC?

A

Highly cellular tumour composed of small cells with hyperchromatic nuclei and indistinct nuceloli. The cells are delicate and the chromatin may appear smudged.

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25
Q

What are symptoms of lung cancer?

A
  • Cough
  • Breathlessness
  • Wheeze
  • Haemoptysis
  • Chest pain
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26
Q

What are signs of lung cancer?

A
  • Cachexia
  • Anaemia
  • Clubbing
  • Hypertrophic pulmonary osteoarthropathy
  • Supracalvicular/axillary nodes
  • Consolidation
  • Signs of collapse
  • Pleural effusion
  • Signs of metastases
  • Horners syndrome
  • Recurrent laryngeal nerve palsy
  • Cervical radiculopathy
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27
Q

What is hypertrophic pulmonary osteoarthropathy?

A

A syndrome characterised by excessive proliferation of the skin and bone at distal parts of the extremities, which can include clubbing.

In advanced stages of HPOA, periosteal proliferation of tubular bones and synovial effusions may be present.

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28
Q

What are signs of lobar collapse?

A
  • Deviated trachea
  • Hyperresonance on percussion
  • Reduced/no air entry
  • Decreased vocal fremitus
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29
Q

What are signs of metastasis in lung cancer?

A
  • Bone pain/tenderness +/- pathological fractures
  • Hepatomegaly
  • Confusion/fits/focal CNS signs
  • Cerebellar syndrome
  • Proximal myopathy
  • Peripheral neuropathy
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30
Q

What signs might indicate that a lung cancer has metastasised to bone?

A

Bone tenderness +/- pathological fracture

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31
Q

What signs might indicate that a lung cancer has metastasised to the liver?

A
  • Weight loss
  • Nausea
  • Anorexia
  • Right upper quadrant pain
32
Q

How might metastasis of lung cancer to the brain present?

A
  • Symptoms/Signs of raised ICP
  • Focal nerve palsies
  • Confusion/fits
  • Cerebellar syndrome
33
Q

Why can someone present with a hoarse voice with lung cancer?

A

Mediastinal nodal or direct tumour invasion of the mediastinum results in compression of the left recurrent laryngeal nerve

34
Q

How long does a cough have to be present for before meriting an X-ray?

A

Persistent for 3 weeks

35
Q

How would invasion of the phrenic nerve present?

A

Paralysis of the ipsilateral hemidiaphragm

36
Q

What is Horner’s syndrome?

A

Syndrome of miosis, anhidrosis, ptosis +/- enopthalmos

37
Q

Why can horner’s syndrome occur?

A

Horner syndrome is due to a deficiency of sympathetic activity in the sympathetic trunk. The site of lesion to the sympathetic outflow is on the ipsilateral side of the symptoms

38
Q

Why does breathlessness occur in lung cancer?

A
  • Airway obstruction
  • Pleural Effusion
  • Lympangitis
  • Pericardial effusion
  • Pulmonary embolism
  • Atelectasis
39
Q

Why can wheeze occur in lung cancer?

A

When partial airway obstruction is present

40
Q

Why can chest pain occur in lung cancer?

A
  • Sharp pleuritic pain - Peripheral tumours spread into the chest wall and invade the pleura, resulting in .
  • Dull central chest ache - Large volume mediastinal nodal disease characteristically results in
41
Q

How does superiorvena cava obstruction present?

A

https://www.youtube.com/watch?v=RDHO3FxNT3s

  • Difficulty breathing
  • Headache - cerebral oedema
  • Facial swelling
  • Venous distention in the neck, upper chest and arm
  • Upper limb edema
  • Lightheadedness
  • Cough
  • Collar of stokes - oedema in the neck
  • Pemberton’s sign - facial congestion and cyanosis on elevating both arms to touch side of the face
42
Q

WHat would indicate that a pancoast tumour has invaded the brachial plexus?

A

Wasting, pain, paraethseia and paresis in the muscles of the arm

43
Q

What are extrapulmonary endocrine features of lung cancer?

A

Small cell cancers

  • SIADH
  • ACTH

Squamous cell cancers

  • Hyperparathyroidism -> hypercalcaemia
44
Q

What is SIADH?

A

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is defined by hyponatremia and hypo-osmolality resulting from inappropriate, continued secretion or action of ADH despite normal or increased plasma volume, which results in impaired water excretion

45
Q

What are symptoms of SIADH?

A
  • Mild – Nausea / Vomiting / Headache / Anorexia / Lethargy
  • Moderate – Muscle cramps / Weakness / Confusion / Ataxia
  • Severe – Drowsiness / Seizures / Coma
46
Q

What are signs of SIADH?

A
  • Decreased level of consciousness
  • Cognitive impairment - short term memory loss / disorientation / confusion
  • Focal or generalised seizures
  • Brain stem herniation – severe acute hyponatraemia (coma / respiratory arrest)
47
Q

What features need to be present for the diagnosis of SIADH?

A
  • Hyponatraemia
  • Low plasma osmolality
  • Inappropriately elevated urine osmolality (>plasma osmolality)
  • Urine [Na+] >40 mmol/L with normal salt intake
  • Euvolaemia
  • Normal thyroid and adrenal function
48
Q

What endocrine disorders are associated with small cell lung cancer?

A
  • SIADH
  • Ectopic ACTH secretion
49
Q

What endocrine disorders are associated with ssquamous cell lung cancer?

A

HPTH - hypercalcaemia

50
Q

What are some of the cutaneous symptoms seen in lung cancer?

A
  • Dermatomyositis
  • Acnathosis nigricans
51
Q

Where are the most common sites for metastasis of lung cancers?

A
52
Q

What extrapulmonary neurological problems are associated with lung cancer?

A
  • Lambert eaton syndrome
  • Peripheral sensory neuropathy
  • Cerebellar degeneration
  • Confusion
  • Polymyositis
53
Q

What are risk factors for the development of lung cancer?

A
  • Age > 60
  • Smoking/passive smoking
  • Asbestos exposure
  • Chromium, Nickel
  • Radiation (Radon, Uranium)
  • Genetics
  • Biomass fuels
54
Q

How would you investigate suspected lung cancer?

A
  • Bloods
  • Sputum and pleural fluid sample
  • CXR
  • ECG
  • Lymph node FNA/Biopsy
  • CT Scan - chest and abdomen
  • Bronchoscopy
  • PET Scan
  • Bone scan
  • Lung function tests
55
Q

What might you see on CXR in someone with lung cancer?

A
  • Peripheral nodule
  • Hilar enlargement
  • Consolidation
  • Lung collapse
  • Pleural effusion
  • Bony secondaries
56
Q

What is CT scanning used for in lung cancer?

A

Staging

57
Q

What staging system is used to stage lung cancer?

A

TNM - tumour, node, metastases

58
Q

What does T1 staging of lung cancer mean?

A

Tumour is = 3 cm in greatest dimension.

Surrounded by lung or visceral pleura

No evidence of invasion more proximal than the lobar bronchus

  • T1a - ≤2 cm in greatest dimension
  • T1b - >2 cm but ≤3 cm in greatest dimension
59
Q

What does a T2 staging of lung cancer indicate?

A

>3cm diameter and >2cm distal to carina or any size if pleural involvement or obstructive pneumonitis extending to hilum, but not all the lung

  • T2a - >3 cm but ≤5 cm in greatest dimension
  • T2b - >5 cm but ≤7 cm in greatest dimension
60
Q

What does T3 staging of lung cancer mean?

A

Tumour >7 cm or one that directly invades any of the following:

  • Chest wall
  • Diaphragm
  • Phrenic nerve
  • Mediastinal pleura
  • Parietal pericardium

It can also include:

  • Tumor in main bronchus <2 cm distal to the carina but without carina involvement
  • Associated atelectasis or obstructive pneumonitis of the entire lung
  • Separate tumor nodule(s) in the same lobe
61
Q

What does a T4 staging of lung cancer mean?

A

Tumour of any size that invades any of the following:

  • Mediastinum
  • Heart
  • Great vessels
  • Trachea
  • Recurrent laryngeal nerve
  • Oesophagus
  • Vertebral body
  • Carina
  • Nodules in a separate lobe
62
Q

What does an N1 staging of lung cancer mean?

A

Peribronchial +/- Ipsilateral hilum

63
Q

What does an N2 staging of lung cancer mean?

A

Ipsilateral mediastinal/subcarinal nodes

64
Q

What does an N3 staging of lung cancer mean?

A

Contralateral mediastinal/scalene/supraclavicular nodes

65
Q

What does and M1 staging of lung cancer mean?

A

Distant metastasis

  • M1a
    • Separate tumor nodule(s) in a contralateral lobe
    • Tumor with pleural nodules or malignant pleural (or pericardial) effusion
  • M1b - Distant metastasis
66
Q

What is the purpose of performing lung function testing in lung cancer?

A

Assessing suitability for lobectomy

67
Q

What is the differential diagnosis for a nodule in the lung on CXR?

A
  • Malignancy - 1o or 2o
  • Abscesses
  • Granuloma
  • Carcinoid tumour
  • Pulmonary hamartoma
  • AV malformation
  • Cyst
  • Foreign body
  • Skin tumour
68
Q

What bloods would you do if you suspected lung cancer?

A
  • U+E’s - serum sodium - SIADH
  • Serum calcium - PTH or bone mets
  • FBC - anaemia
  • LFTs - liver involvement
69
Q

Why might you do a bone scan in someone with lung cancer?

A

Look for bony mets

70
Q

When is surgery used in the management of lung cancer?

A

Early stage non-small cell lung cancer (stage I, II and in selected IIIA) with curative intent

71
Q

When would you consider curative radiotherapy in lung cancer?

A

Early stage NSCLC with poor lung function

72
Q

When would you consider using only radio and chemotherapy in NSCLC?

A

Advanced disease

73
Q

What is the doubling time of most NSCLC?

A

129 days

74
Q

What is the doubling time of SCLC?

A

About 29 days

75
Q

What is the pathophysiology of SIADH?

A

Excessive ADH causes an inappropriate increase in the reabsorption of solute-free water (“free water”). This has two consequences. First, in the ECF, there is a dilution of blood solutes, causing hypo-osmolality, including a low sodium concentration - hyponatremia. The ECF volume does not exapnd because as it attempts to expand, aldosterone is suppressed and atrial natriuretic peptide (ANP) is stimulated: both of these hormones cause isotonic ECF fluid to be excreted by the kidneys sufficient to keep ECF volume at a normal level.

Simultaneously to ECF events, the ICF volume expands. This is because the osmolality of the ECF is (transiently) less than that of the ICF; and since water is readily permeable to cell membranes, solute-free water moves from the ECF to the ICF compartment by osmosis: all cells swell. Swelling of brain cells - cerebral oedema - causes various neurological abnormalities which in acute and/or severe cases can result in convulsions, coma, and death.

Respiratory Physiology, Medicine and Critical Care (42 decks)

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