The Diagnosis of Lung Cancer

Sarah Goodall

Different Types of Lung CancerBronchocarcinomas• Non Small Cell Carcinoma

– Squamous Cell Carcinoma, 40%

– Adenocarcinoma, 10%

– Large Cell Carcinoma, 25%

– Bronchoalveolar Cell Carcinoma, 1-2%

• Small Cell Carcinoma, 20-30%– oat cell carcinoma– Endocrine origin– Highly Malignant– Prognosis Poor

Mesothelioma– Tumour of mesothelial cells which

usually occurs in the pleura

Presenting Symptoms• Cough 41%• Chest Pain 22%• Cough and Pain 15%• Haemoptysis 7%• Chest Infection <5%• Malaise <5%• Weight Loss <5%• SOB <5%• Hoarseness <5%• Distant Spread <5%• No Symptoms <5%

Risk Factors

• Smoking • Asbestos Exposure• Chromium Exposure• Arsenic• Iron Oxides• Radiation (Radon

Gas)• Family History

Asbestos

Signs• Cachexia• Anaemia• Clubbing• Hypertrophic pulmonary

oteoarthropathy (causing wrist pain)

• Supraclavicular/Axillary Lymphadenopathy

Chest Signs

• Maybe None• Consolidation• Collapse• Pleural Effusion

Metastasis Signs-Bone Tenderness-Hepatomegally-Confusion-Fits-Focal CNS deficit-Cerebellar Syndrome-Proximal Myopathy-Peripheral Neuropathy

ComplicationsLOCAL

– Recurrent Laryngeal Nerve Palsy– Phrenic Nerve Palsy– SVC Obstruction– Horner’s Syndrome (Pancoasts Tumour)– Rib Erosion– Pericarditis– AF

METASTATIC– Brain– Bone (bone pain, anaemia, increased Ca2+)– Liver (Hepatomegally, Raised LFTs)– Adrenals (Addison’s)

ENDOCRINE– Ectopic Hormone Secretion e.g. SIADH,

ACTH by oat cell carcinoma PTH by squamous cell carcinomas

InvestigationsCytology – Sputum and Pleural FluidFNA– Peripheral Lesions, Superficial Lymph NodesBronchoscopy– For Histological Diagnosis and assessment of

operabilityCT– Stage the TumourRadionuclide Bone Scan– For suspected metastasesLung Function Tests

Looking at the Chest X-Ray• Cell type can’t be diagnosed from

X-Ray• Lesions rarely seen until >1cm• Lesions >4cm be suspicious of

malignancy• 20% cavitate – usually scc• Lobular or irregular edges• Metastasises to Liver, Adrenals,

Bones, Brain• NB: presence of calcification, air

bronchogram – unlikely to be malignancy

Stages of the Tumour• Primary Tumour

– TX malignant cells in bronchial secretions– Tis Carcinoma in situ– T0 Non Evident– T1 < or = 3cm in lobar or more distal airway– T2 > 3cm and >2cm distal to carina or pleural

involvement– T3 Involves chest wall, diaphragm, medistinal pleura,

pericardium or <2cm from carina– T4 Involves mediastinum, heart, great vessels,

trachea, oesophagus, vertebral body, carina or malignant effusion present

Treatment

Non Small Cell Tumours– Excision if no metastatic spread– Curative radiotherapy

Small Cell tumours– Almost always disseminated at presentation– May respond to chemotherapy– Palliation– Radiotherapy for bronchial obstruction, SVC

obstruction, Haemoptysis, Bone Pain, cerebral metastases

Mesothelioma– Diagnosis often only made PM

Prognosis

Non Small Cell – 50% 2 year survival without spread, 10% with spread

Small Cell – 3 months if untreated, 1- 1.5 years if treated

Mesothelioma – Less than 2 years

Prevention

• Discourage Smoking

• Avoid occupational exposure to carcinogens