LUNG CANCER

Prepared by M.Yusuf “Siddiq”

Medical student at K.M.U

2012

Defination:

Uncontrolled growth of malignant cells in one or both lungs and tracheo-bronchial tree.

A result of repeated carcinogenic irritation causing increased rates of cell replication.

Proliferation of abnormal cells leads to hyperplasia, dysplasia or carcinoma in situ.

Picture of the Lungs

Where Does it Come From?(Risk factors)

SmokingRadiation ExposureEnvironmental/Occupational

ExposureAsbestosRadonPassive smoke

Smoking Facts

Tobacco use is the leading cause of lung cancer

87% of lung cancers are related to smoking

Risk related to:age of smoking onsetamount smoked genderproduct smoked depth of inhalation

Women & Lung Cancer

Women are more prone to tobacco effects - 1.5 times more likely to develop lung cancer than men with same smoking habits.

Where does it travel?(Metastasis)

Lymph Nodes, Brain, Liver, Adrenal Gland, Bones

40% of metastasis occurs in the

Adrenal Gland

Classification

According to the cell typeSquamous cell carcinoma 35%Adenocarcinoma 30%Small cell carcinoma 20%Large cell carcinoma 15%

According to the location

1. Centrally located : Squamous cell carcinoma Small cell carcinoma

2. Peripherally located : Adenocarcinoma Large cell carcinomaCentrally located tumors that obstruct segmental, lobar or main stem bronchi may

cause lung collapse as compared to peripherally located tumors that are diagnosed

late.

Squamous cell carcinoma

Occurs most frequently in men and old people.Usually starts on one breathing tubes.Tends to be localized in the chest longer than other types of lung cancer.Does not tend to metastasize early.It is strongly associated with smoking.

AdenocarcinomaMost common cancer among women.Usually started near the outer edges of the lung. Invasion of pleura and mediastinal lymph node is common.

May spread to other parts of the body.

Can be seen in non smokers.

Large cell carcinoma

Less well – differentiated.

May occur at any part of the lung.

Tumors are large by the time they are diagnosed.

Has greater possiblity of spreading to brain and mediastinum.

Small cell lung cancer

Small cell lung cancer also called oat cell because SCLC cells have oat grain appearance.

It arises from endocrine cells [kulchitisky cells] where many hormones are secreted.

Spreads to lymph nodes and other organs

more quickly than NSCLC.

Small cell lung cancer Cont…

Usually starts in one larger breathing tube.

Tends to grow rapidly .

Commonly has spread by the time and is considered a systemic disease.

It is the only one of the bronchial carcinomas that responds to chemotherapy.

Clinical features

Clinical manifestations of lung cancer are

as a result of:

1. Effects of tumor it self.

2. Features of local spread of tumor.

3. Features of metastasis.

4. Features of paraneoplastic syndromes.

Symptoms due to tumor in the bronchus1. Cough (in 80% of cases)

It is the most common early symptom.

Sputum is purulent if there is sec.infection.

A change in the character of the (regular cough) associated with other new respiratory symptoms increases the possiblity of B.C.

2. Hemoptysis (in 70% of cases)

Repeated episodes of scanty cough hemoptysis or blood –streaking of sputum in smokers are highly suggestive of B.C and should be always investigated .

3. Dyspnea (in 60% of cases):

Reflects occlusion of a large bronchus resulting collapse of a lobe of the lung or development of pleural effusion.

4. Pleural pain:

Reflects malignant invasion of the pleura or reflects infection distal to a tumor (which is recurrent and fail to resolve).

Symptoms due to local spread

•Involvement of pleura and ribs.

Causing severe chest pain.

•Pancoast’s tumor:

Involvement of lower part of the brachial plexus (C8,T1,T2) causing severe pain of the shoulder and down inner surface of the arm.

•Horner’s syndrome: Due to involvement of the sympathetic ganglion.

•Recurrent laryngeal nerve palsy:

Causing unilateral vocal cord paresis with hoarseness of voice and a bovine cough.

•Invasion of phrenic nerve:

Causing paralysis of the diaphragm.

•Involvement of esophagus:

Causing dysphagia.

•Cardiovascular:

Atrial fibrillation,Cardiac temponade ,pericarditis,pericardial effusion.

•Superior vena cava obstruction:

Causing early morning headache, facial congestion and edema involving the upper limbs, distention of jugular vein and veins of the chest.

Nonmetastatic extrapulmonary Manifestations

1. Anorexia and loss of weight.

2. Hypercalcemia due to release of PTH related peptide.

3. Gynaecomastia due to release of HCG hormone.

4. Cushing’s syndrome due to ectopic ACTH secretion.

5. Acromegaly due to GHRH secretion.

Para neoplastic syndrome Cont…

6. Clubbing of the fingers.

7. Inappropriate secretion of the ADH.

8. Hypertrophic pulmonary osteo arthropathy and tenderness in the wrist and ankle joints. X-ray of painful bones shows subperiosteal new bone formation.

Blood borne metastasis

Bony metastasis giving severe bony pain and pathological fractures.

Liver metastasis (Jaundice).

Brain metastasis (change in personality,

epilepsy, focal neurological symptoms).

Physical signsExamination is usually normal unless there is significant bronchial obstruction or tumor has spread to pleura or mediastinum.

1.Physical signs of collapse (in large obstructing tumor) which may rise to pneumonia.

2.Monophonic or unilateral wheeze (fixed bronchial obstruction).

Physical signs Cont...

3. Stridor (obstruction at or above the level of carina).

4. Hoarseness of voice associated with bovine cough (recurrent laryngeal nerve palsy).

5. Dullness percussion and absent breath sounds at the lung base (unilateral diaphragmatic palsy due to involvement of phrenic nerve).

Physical signs Cont...

6. Physical signs of pleurisy or pleural effusion (involvement of pleura).

7. Bilateral engorgement of the jugular veins and later edema affecting face, neck and arms.

8. Tenderness and pain of long bones and joints (HPOA).

InvestigationsSputum cytology:

High yield for Endobronchial tumors such as squamous cell and small cell carcinoma.

Chest x-Ray:

Common radiological presentations of bronchial carcinoma includes:

A.Unilateral hilar-enlagement.

B.Peripheral pulmonary opacity.

Chest X-ray Cont...C. Lung, lobe or segmental collapse.

D. Pleural effusion.

E. Broadening of the mediastinum,

enlarged cardiac shadow, elevation

of hemi diaphragm.

F. Rib distraction.

G. Pleural fluid cytology in pleural effusion.

Bronchoscopy :

Gives high yield in excess of 90% (allows biopsy and bronchial brush samples) if fails precautious fine needle aspiration under CT.

Other diagnostic procedures:

CT thorax and upper abdomen.Head CT scan.Radio nuclide bone scanning.Liver ultrasonography.

Bone marrow biopsy.

Staging and Treatment NSCLC

Stage Description Treatment Options

Stage I a/b Tumor of any size is found only in the lung .

Surgery

Stage II a/b Tumor has spread to lymph nodes associated with the lung.

Surgery

Stage III a Tumor has spread to the lymph nodes in the tracheal area, including chest wall and diaphragm.

Chemotherapy followed by radiation or surgery

Stage III b Tumor has spread to the lymph nodes on the opposite lung or in the neck.

Combination of chemotherapy and radiation

Stage IV Tumor has spread beyond the chest Chemotherapy and/or palliative (maintenance) care

SCLC

Limited StageDefined as tumor involvement of one lung, the mediastinum and ipsilateral and/or contralateral supraclavicular lymph nodes or disease that can be encompassed in a single radiotherapy port.

Extensive StageDefined as tumor that has spread beyond one lung, mediastinum, and supraclavicular lymph nodes. Common distant sites of metastasis are the adrenals, bone, liver, bone marrow, and brain.

TreatmentCurative treatment is surgical resection.

Unfortunately the majority of the patients present with evidence of tumor spread at the time of diagnosis and can only be offered palliative therapy.

Surgical resection:

In patients with localized disease and non-small cell lung cancer(NSCLC).

Treatment Cont…

Results of surgical resection are poor in small cell carcinoma.Few patients are suitable for surgery.

5-year survival rate after resection of squamous cell carcinoma can be as high as 75% in stage I and 55% in stage II

Contraindications to surgery:

1. Distant metastasis.

2. Mediastinal involvement.o Esophageal involvement.o Vocal cord paralysis.o Vena cava syndrome.o Involvement of trachea.

3. Advanced age.

4. Poor respiratory function.

5. Small cell carcinoma.

Radiotherapy Radiotherapy is of great value to relieve

distressing complications e.g. superior venacaval obstruction.

It is the treatment of choice, if the tumor

is inoperable. Small cell carcinoma is more

susceptible

to radiotherapy. Prophylactic

radiotherapy to brain is also given in

small cell carcinoma.

Chemotherapy

In small cell carcinoma chemotherapy is combined with radiotherapy. Drugs used are IV vincristine, cyclophosphamide, doxorubicin or cisplatin and etoposide given every 3 weeks for 3-6 cycles.Chemotherapy in non small-cell carcinoma is not much effective.

Laser therapy

This is good for destroying tumor tissue occluding major airways to allow reaction of collapsed lung.

Prognosis:Very poor, less than 10% patients survive 5 years after diagnosis.

Conclusion

Smoking cessation is essential for prevention of lung cancer.

New screening tools under way.Clinical trials under way.New treatments under way.Treatment can palliate symptoms and

improve quality of life.Read first bullet again!!!

THANK YOU