Lung cancer

• Lung cancer


  Genetic alterations in bronchial epithelial cells (carcinogens) → DNA damage → mutations of oncogenes & TSGs (TP53 & KRAS) → transformed cells evade apoptosis → uncontrolled prolif → accumulation of abnormal cells → dysplasia & carcinoma in situ → EMT → malignant cells able to degrade ECM proteins (via MMPs) → invasion beyond BM into adjacent tissues → intravasation in blood vessels or lymphatics → survival & extravasation at distant sites (facilitated by angiogenesis)

  Cancer cells have strategies to evade immune system → downreg of MHC & production of immunosuppressive cytokines
• What are the Inx for lung cancer?


  Obs

  Full Hx & examination

  ECG

  Bloods (FBC, LFTs, U&Es, CRP, others (if worried about paraneoplastic syndromes))

  CXR

  CT thorax

  PET CT

  Biopsy
• What is shown in a CXR of lung cancer?


  Hilar enlargement

  Peripheral opacity (visual lesion in lung field)

  Pleural effusion (usually unilateral)

  Atelectasis
• What are the NICE guidelines for a 2 week wait referral for CXR for lung cancer?


  Pts over 40 with...

  • clubbing
  • lymphadenopathy
  • recurrent or persistent chest infections
  • raised platelets
  • chest signs of lung cancer

  Also in pts over 40 who have...

  • 2 or more unexplained symptoms (pts that have never smoked)
  • 1 or more unexplained symptoms (pts who have smoked)
• What is the classification of lung cancer?


  Non-small cell lung cancer (80% of cases)

  Small cell lung cancer (20% of cases)
• Non-small cell lung cancer


  Squamous cell carcinoma (25% of cases)

  • central in lung parenchyma
  • can release PTH -> hypercalcaemia

  Adenocarcinoma (40% of cases)

  • periphery of lung parenchyma

  Paraneoplastic features & early disease dissemination less likely
• Small cell lung cancer


  Compromised of cells with neuroendocrine differentiation

  • neuroendocrine hormones may be released

  Strongly associated with smoking

  Typically arises in larger airways (central)

  Disseminates early in disease

  Paraneoplastic features are more likely
• What are the symptoms of lung cancer?


  Cough (persistent, > 3 months)

  SOB

  Haemoptysis

  Weight loss

  Night sweats

  Cachexia

  Wheeze/stridor

  Fatigue

  Recurrent chest infections
• What are the signs & symptoms of regional lung cancer spread?


  Hoarseness

  Dysphagia

  SVC obstruction (emergency -> give radiotherapy +/- chemotherapy)

  Pancoast tumour (malignancy in apex) -> can present w/shoulder pain & Horner's syndrome
• What are the signs & symptoms of distant lung cancer metastasis?

  Bone pain

  Neurological symptoms

  Abdo pain

  Jaundice

  Adrenal insufficiency
• What are some common paraneoplastic syndromes?


  Hypercalcaemia

  Cushing's syndrome

  SIADH (inappropriate secretion of ADH)

  Lambert-Eaton myasthenic syndrome
• What are the signs of lung cancer?


  Clubbing

  Dullness to percussion

  Increased vocal resonance

  Lymphadenopathy
• What are the DDx of lung cancer?


  TB

  Sarcoidosis

  Pneumonia
• What are the RFs of lung cancer?


  Smoking

  Male

  Increasing age

  FHx

  Air pollution
• What are the possible complications of lung cancer?

  Metastasis (brain, bone, liver)

  Pneumonia & lung abscess

  Atelectasis

  Pleural effusion

  PE

  SVC syndrome

  Paraneoplastic syndromes
• Prognosis is usually worse for small cell lung cancer
• What is the treatment & management of small cell lung cancer?


  Chemotherapy

  Radiotherapy
• What is the treatment & management of non-small cell lung cancer?


  Stage 1-3

  • surgery (1st line) -> lobectomy (most common), segmentectomy/wedge resection, pneumonectomy
  • chemotherapy
  • radiotherapy

  Stage 4

  • immunotherapy
  • chemotherapy
  • palliative care