Lung Cancer Update Lecture – Y3 Resp – Flashcards
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How common is lung cancer in the world?
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Most common fatal malignancy in the world - 1 million deaths year
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How many people does it kill?
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36,000 people per year in the UK
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What are the statistics for death in men or women?
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LEading cancer killer in the world 1/3 male cancer deaths 1/6 female cancer deaths
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What is the 5 year survival in the UK?
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10%
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What is the 5 year survival in Europe?
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15% or more
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How many patients die within 2 years?
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Over 90% of patients die within 2 years
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What factors should you consider and address to prevent lung cancer?
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Smoking. Air pollution. Nickel, chromium. Radiation (radon). Asbestos - if smoker, risk increased 50 fold. Family history.
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What loci are susceptible in non smokers?
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Susceptibility loci: 6q23-25, 5p15, 6p21 and 15q25.
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Which gene has nicotine receptors?
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15q25
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What proportion of these loci account for familial risk?
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<10% of familial risk
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What effect does CXR and sputum cytology screen have on mortality?
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Mortality can be reduced - but sometimes people have unnecessary thoracotomies
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What is the primary outcome of the trials looking at LD CT?
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Reduced mortality
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What are the clinical features of lung cancer? (10)
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Cough Haemoptysis Dyspnoea Chest/shoulder pain Wheeze/stridor Hoarse voice SVC obstruction Lymphadenopathy Bone pain Paraneoplastic syndromes
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What are the main types of lung cancer histology? 4
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Adenocarcinoma Squamous cell Large cell Small Cell
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How do squamous cell cancers develop into necrotic masses?
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As a tumour grows it secretes substances called tumour angiogenesis factors (TAF) which cause blood vessels to grow into the mass of tumour cells. This allows a tumour to grow more rapidly and increase in size. If the tumour grows too large for its blood supply then the central areas can become deprived of oxygen and nutrients and will undergo necrosis, they die. This is the process by which squamous cell carcinomas frequently develop into necrotic masses.
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How do adenocarcinomas arise?
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Peripherally from mucous glands Retiain some of the tubular, acinar or papillary differentaiton and mucus production
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Where do adenocarcinomas commonly invade?
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Pleura Mediastinal lymph nodes
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Where do adenocarcinomas commonly metastasise?
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Brain Bones
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How do you identify an adenocarcinoma?
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Commonly arises around scar tissue Looks similar to secondary tumours Distinguish by CT scans and other investigations to check for primary Associated with asbestos exposure
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Are adenocarcinomas common or less common in non smokers?
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Most cases are associated with smoking, but they are the most common tumour in non smokers.
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What are the changing patterns in adenocarcinoma incidence?
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- younger patients Female patients More brain metastases MF ratio is 1:1
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What is bronchoscopy good for diagnosing?
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Central tumours
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What is the diagnostic yield of bronchosopy?
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60-90%
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What can increase the diagnostic yield of bronchoscopy?
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Using the CT before doing a bronchoscopy
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What is TNM for Stage 1 of lung cancer?
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Cancer is less than 3 cm No lymph node involvement No mets
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What is the size of tumour if it is stage 2?
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3-7cm
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Where does a T2 cancer invade?
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Atelectasis Invasion of visceral pleura Main bronchus - 2cm from carina
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What nodes are affected with N1?
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Ipsilateral Bronchopulmonary Hilar
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Where would mets go in stage M1?
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Milateral lesions Distant metastases Malignant pleural effusions
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What size is a T3 stage lung cancer?
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Over 7 cm Atelecasis in the whole lung)
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Where does a T3 stage lung cancer invade?
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Phrenic nerve Diaphragm Chest Wall Mediastinal Pleura Main bronchus <2cm from carina Parietal pericardium
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What nodes does N2 affect?
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Ipsilateral Mediastinal Subcarinal
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What nodes does N3 affect?
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Contralateral hilar Contralateral/mediastinal Supraclavicular
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Where does a T4 tumour invade?
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Mediastinal Organs Vertebral bodies Carina Tumour Nodules in different/ipsilateral lobe
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What Treatment is given for stage 1-2 NSCLC?
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Surgery
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What are the 5 year survival rates for NSCLC with surgery?
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1. 60-70% 2. 30-50%
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What is the best treatment for Stage 3A cancer?
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Surgery/multimodality Regimen
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What is the 5 year survival rate for Stage 3A NSCLC?
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10-30%
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What is the usual treatment for Stage 3B NSCLC?
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Chemotherapy and Radiation
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What is the 5 year survival rate for Stage 3B NSCLC?
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5%
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What is the best treatment for Stage 4 NSCLC?
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Chemotherapy... but there is a <1% survival rate in 5 years
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What are the positive and negative predictive values of PET CT?
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75% PPV - false positives include inflammatory lesions Negative predictive value - 96% - slow growing adenocarcinomas
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What are the issues with mediastinoscopy?
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Invasive 2. Under GA 3. Inpatient 4. Some mortality 5. Usually done only once 6. Expensive (ca £3-5K)
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Why would you do EUS?
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Role of endoscopy staging is limited by an inability to see beyond the mucosal surface or assess nodal involvement
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When would you do EBUS FNA?
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Undertaken in conjunction with bronchoscopy Out-patient procedure under conscious sedation Should be safer than bronchoscopy with TBNA
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What is the main complication of CT guided biopsy, bronchoscopy, EBUS/EUS with TBNA or surgery/
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Pneumothorax due to CT Biopsy (up to 25%)
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What size of lymph nodes can be identified by endobronchial ultrasound miniprobes?
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lymph nodes down to 2-3mm
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What is the new diagnostic and staging algorithm for lung cancer?
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1. CXR 2. CT/PET (exluding T4/M1 disease) 3. TIssue diagnosis and evaluation of mediastinum; Bronchoscopy/CT biopsy/EBUS/EUS 4. Mediastinoscopy 5. Treatment
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What are the different tissue diagnosis methods for lung cancer?
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Bronchoscopy CT Biopsy EBUS/EUS
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What are the different treatment options for NSCLC? (5)
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Resection (5 Y S 70%) Concurrent chemo-radiotherapy (5YS 30%) Palliative Chemotherapy (few months) Palliative Radiotherapy Best Supporting Care
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What are the main risk factors for operating in lung cancer?
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OPD, IHD - co morbidities Performance status Lung function
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Is age a risk factor for lung cancer operations?
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Not on its own
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What are the exercise/functional consequences of lung function of lobectomy?
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early deficit with later recovery & little permanent loss in PFT (≤10%) & no decrease in exercise capacity
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What are the consequences of lung function after a pneumonectomy?
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early permanent deficit 33% loss in PFT and 20% decrease in exercise capacity
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WHO performance status? what are the stages?
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5 stages - 0-4 Ranges from asymptomatic to totally bedbound 0 - Asymptomatic (fully active) 1 - Symptomatic but completely ambulatory (ambulatory and able to carry out work of a light or sedentary nature) 2 - Symptomatic, 50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair) 4 - Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair)
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Stage 1 - lung performance status
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Symptomatic but totally able to move around
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Stage 2 - WHO lung performance status lung function
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symptomatic <50% in bed during the day Able to take care of themselves but not able to work
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Stage 3 - WHO performance status lung function
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Symptomatic - over 50% of time is spent in bed Capable of limited self care Patients are confined to bed or chair
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Stage 4 - WHO lung performance status lung function
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Completely disabled patient Can't take care of themselves and they are confined to bed or chair
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How many people with NSCLC relapse after a complete resection?
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50% of patients with early stage NSCLC will relapse after a complete resection
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What are the success rates after a lung resection in non small cell lung cancer with adjuvant chemotherapy?
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13% reduction in the risk of death 5% absolute survival benefit of at 5 years if adjuvant cisplatin chemotherapy is used as well
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If you had a Stage 3A lung cancer, what would the treatment be based on?
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Nodal involvement
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With a Stage 3A NSC lung cancer that has single N2 and non bulky nodes, what is the most appropriate treatment?
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Surgery CT/RT (induction or adjuvant)
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You have a Stage 3A NSCLC with BULKY or multiple N2 nodes. What is the best course of action?
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Chemotherapy Radiotherapy Ct/RT brings 8-17% 5 year survival
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What do you do if you have a weak stage 3A NSCLC patient with multiple or bulky nodes?
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Consider palliative treatment
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WHat proprortion of Stage 3B/IV NSCLC patients are offered curative treatment and why?
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only 20% (1/5) patients are given curative treatment because over 2/3 of these patients present with very advanced disease
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Overview - NSCLC chemotherapy?
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Modest gains in survival 5-12 months extra gained
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What effect does Chemo have on QoL in NSCLC?
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Improvement or no change
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What are the side effects of NSCLC chemotherapy when compared to no treatment?
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Having chemotherapy slightly reduces the effects when compared to uncontrolled spread
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What makes people want chemotherapy?
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Symptom relief mainly Even short gains in lifespan
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What receptor ype do you target in NSCLC?
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EGFR
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Why do you target EGFR in NSCLC?
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EGFR is over-expressed in NSCLC. EGFR promotes tumour cell survival and growth. Over-expression of EGFR has been associated with poor prognosis.
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What medications target EGFR in lung cancer?
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Gefitinib Erlotinib
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What patients respond well to EGFR blocking therapy?
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East asians Adenocarcinoma Female gender NON SMOKERS
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What individuals have the highest rate of EGFR tyrosine kinase mutations?
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East asian adenocarcinoma patients women that don't smoke
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What is the future for targeted EGFR Treatment?
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EGFR mutation assessment New effective targeted therapy with VEGF and P13K Personalised therapy with assessment of important driver mutations
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What percentage of tumours are small cell lung cancer?
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Around 25%
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What are the main characteristics of a SCLC?
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VERY aggressive tumour Early dissemination Metastatic spread present in almost all patients
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What counts as limited disease in SCLC?
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Restricted to one haemithorax WIth or without ipsilateral Nodes
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What counts as extensive disease in SCLC?
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Spread beyond one haemithorax Many nodes present
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Prognosis of SCLC: survival rates?
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Median survival is 10-15 months with limited disease, up to 10 months with extensive disease
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What is the response of SCLC to chemo and radio?
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very sensitive to both
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What is the long term survival rate in SCLC?
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<5% long term survival in small cell lung cancer
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What are the key points to consider when you have a SCLC?
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Smoking cessation is essential. New screening trials are in the pipe-line. Staging is key to management. Minimal invasive staging should be available. Surgical treatment gives the best survival outcome in early stage disease. The role for targeted therapy is being defined.
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What are the new targets form the scottish executive RE GP and referrals for lung cancer?
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Scottish Executive demands that Lung Cancer patients are treated within 62 days from GP referral marked "urgent - suspicious of cancer". All other patients diagnosed with Lung ca have to be treated within 31 days from a "decision to treat". 2 week target from GP referral to appointment
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What is the ideal future for diagnosis according to the government?
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increase 25% of diagnosis in stage 1 by 2015
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What would warrant a chest X ray for diagnosis of lung cancer?
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3 weeks Persistent chest symptoms + associated factors ideally
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How does a malignant mesothelioma present?
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Pleural Effusion Chest Wall pain 40 years after an exposure
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How do you diagnose malignant mesothelioma?
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Thoracotomy/scopy Surgery for early stage disease
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What is the treatment for malignant mesothelioma?
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Chemotherapy Surgery early stages Get compensation!
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What is the median survival for a patient with malignant mesothelioma?
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9-12 months
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How many cases of mesothelioma occur annually?
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190 cases a year
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What is the MF ratio of mesothelioma?
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7:1
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What are the causes and survival rates of M mesothelioma?
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Mortality is similar to incidence Caused by asbestos exposure
