Lung Cancer pdf - علاء الحلي

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Objectives

1- To know the aetiology of lung cancer

2- To know how lung cancer can present

3- To know how to reach the diagnosis

4- To know the main lines of treatment

Aetiology

Cigarette smoking is the most common cause.(responsible for 90%

of cases) . Risk is proportional to amount of smoking and content

of tar. Death rate from the disease in heavy smokers is 40 times

more than non smokers . Risk decreases slowly after cessation . 1 in

2 smokers dies from smoking related disease.
Passive smoking is responsible for 5%
Exposure to radon
A number of industrial materials are associated with lung cancer
More common in urban than rural area due to atmospheric

pollution.

pathology

Lung cancer arise from bronchial epithelium or mucous
gland .
Symptoms occur early when tumor involves large

bronchus.
Peripheral tumor grows slowly and can reach large size

with cavitation ( resemble lung abscess) with little or no

symptoms

Common cell types in lung cancer

Cell type
1-Adenocarcinoma                           35-40%
2-Squamous                                    25-30%
3-Small-cell                                      15%
4-Large – cell                                    10-

15%

Clinical features

Local symptoms
1- Cough….most common early symptom , usually dry ,

can be productive when associated with infection . A

change in character of smokers cough should attract the

attention to investigate for lung cancer
2- Hemoptysis…. especially in central tumor. Hemoptysis

in smokers should attract the attention to investigate

lung cancer

3- Bronchial obstruction ….. the clinical and radiological

manifestation depend on the site and extend of the

obstruction , any infection and coexisting lung disease.

Complete obstruction result in collapse with shortness of

breath , mediastinal shift , dullness percussion notes . Partial

obstruction results in monophonic wheeze that fails to clear

with cough and impair drainage resulting in infection ,

recurrent pneumonia at same site or poorly responding

pneumonia raises possibility of underlying pathology

including lung cancer . Strider ( a harsh inspiratory sound )

occurs when larynx , trachea is narrowed by tumor or

compression by malignant lymph node ( sub carinal or

paratracheal ) .

4-Breathlessness… caused by collapse or pneumonia
or by tumor causing large pleural effusion or by

compressing phrenic nerve resulting in

diaphragmatic paralysis

5- Pain and nerve entrapment…pleural chest pain
usually reflects pleural invasion( although it can occur in

distal infection ).Inter costal nerve involvement results

in chest pain. Cancer in lung apex can result in horner

syndrome( involvement of sympathetic trunk resulting

in miosis , ipsilateral ptosis , enophthalmia , and
hypohidrosis ). Pancost tumor( pain in inner aspect of

the arm with small muscle wasting of the hand due to

involvement of brachial plexus in apical lung tumor).

6- Mediastinal spread … involvement of esophagus
result in dysphagia , spread to pericardium result in

arrhythmia and pericardial effusion Superior vena cava

obstruction by tumor results in suffusion and swelling
in neck and face with conjunctival odema , headache

and dilated veins in chest wall. Left recurrent
laryngeal nerve can be involved by left hilar tumor

resulting in vocal cord paralysis( bovine cough )

.Tumor can spread to supraclavicular nodes, biopsy

from these nodes can reach the diagnosis

Metastatic spread

To liver result in jaundice . To bone result in bone pain .

To brain result in focal neurological defects ,fits ,

personality changes . To adrenal gland and to skin

result in skin nodule . Anorexia and weight loss usually

reflect metastatic spread

Finger clubbing due to over growth of the soft tissue of
terminal phalanx cause increase nerve curvature and

nail bed fluctuation
Hyper trophic pulmonary osteoarthropathy ( painful

swelling of the distal radius , ulna , tibia and fibula due

to subperiosteal new bone formation

Non metastatic extra pulmonary effects

1- endocrine …. ACTH , ADH( associted with small cell
cancer) , hyper calcemia due to secreation of

Parathyroid like peptite ( associated with squamous cell

carcinoma ) , carcinoid syndrome , gynecomastia
2- neurological …. Polyneuropathy , myelopathy ,
cerebellar degeneration , mysthenia
3- others ….digital clubbing, hypertrophic pulmonary

osteoarthropathy , nephrotic syndrome, polymyositis ,

eosinophilia

Investigations

The aim is to establish the diagnosis ,

know cell type and extent of the disease
1-Imaging : including chest x- ray and CT

scan ( may reveal mediastinal spread

and helpful for planning biopsy

procedures
Chest x- ray may show :

1-Unilateral hilar enlargement may

be mass or lymph node

2- Peripheral pulmonary opacity

3- Lung , lobe or segmental

collapse

4- Pleural effusion

5-Paratracheal lymphadenopathy

(show widening mediastinum )

Malignant pericardial effusion

7- A rasied hemi diaphragm

(phrenic nerve palsy )

8- Osteolytic rib destruction

Biopsy and histopathology

More than 50% of tumors can be visualized and take

biopsy from them by flexible bronchoscoy. For

peripheral tumors that cannot be reached by

bronchoscopy , percutaneous lung biopsy by ultrasound

or CT scan guide is the preferred procedure ( with small

risk of pneumothorax ) . In patients who are unfit for

invasive procedure sputum cytology may show

malignant cells . If the patient has pleural effusion ,

pleural biopsy is the preferred procedure . The diagnosis

can be confirmed by biopsy from affected lymph node ,

liver , skin lesion or bone marrow

Staging to guide treatment

Patients with small cell cancer get metastasis early and

so these patients are not suitable for surgery . Non small

cell cancer patients needs to be investigated for extent of

disease to stage it and see it is operable or not , this

requires CT scan of chest to see local and mediastinal

metastasis ,combined CT and whole body PET is used to

detect metastasis. Head CT ,radionuclide bone scan

,liver ultrasound and bone marrow biopsy are done for

patients suspected to have metastases to these sites .

Physiological respiratory

tests are needed to asses

ability for aggressive treatment

Management

1- Surgical treatment : carries the best

hope for long term survival , 5 year

survival in stage one ( no metastasis) is

75%, and 50% in stage two

(involvement of ipsilateral lymph node ).
Lot of patients are not suitable for

operation either because of distant

metastasis or poor lung function or

comorbidity

Radiotherapy

Less effective than surgery but can improve

patients with localized disease and cannot do

surgery because of comorbidity and can be

combined with chemo therapy when there is

lymph node metastasis . The main role of

radio therapy is palliation of distressing

complication such as superior vena cava

obstruction , recurrent hemoptysis and

metastatic pain to chest wall or bone

Chemo therapy

The combination of chemo and radiotherapy

can prolong survival of small cell cancer from

3 months to one year . In non small cell cancer

chemo therapy is less effective , it can be

given prior to surgery and following surgery

can be given if there is nodal involvement ,

platinum based chemotherapy regimen offers

30% response rate in NSCLC

Laser therapy

Laser therapy through bronchscopy

can open air way in collapsed lung

due to tumor obstructing the

bronchus ( palliative treatment ) ,

Stent can be put to maintain airway

patency

Prognosis

The over all prognosis is poor ,

70% die with one year . The

best prognosis is with non

metastatic squamous cell

carcinoma amenable for

surgery