- Commonest malignancy in countries where people smoke. 1/3rd male cancer deaths,1/6th of female.
- Screening asymptomatic smokers with regular CXR has not been shown to improve outcome.
- 20% of smokers will develop lung cancer. The mean survival is 6 months
Pathology: Histologically and Prognostically differentiated into
- Small cell lung cancers
- Small cell or "Oat" cell - arise centrally metastasise early with micrometastases.
- Arise from Kulchitsky cells of APUD system. Secrete peptide hormones.
- Non small cell lung
cancers (NSCLC) 80%
- Adenocarcinoma 35% - Commonest. peripheral tumours
- Squamous 25% central
- Large cell 10%
- Bronchoalveolar cell 5% - mucoid sputum
- Smoking is by far the main cause
- Occupational exposure - Asbestos, arsenic, nickel, silicosis, chromium, radon (and adenocarcinoma)
- Commoner with Idiopathic pulmonary fibrosis and dermatomyositis
- Greater in Urban rather than rural setting
- Mild/no symptoms or a slow to resolve pneumonia or a lesion found on CXR done for another cause.
- Cough, sputum, haemoptysis, weight loss, Cachexia
- Finger clubbing ? Hypertrophic osteoarthopathy (non small cell)
- Chest - Consolidation, collapse or pleural effusion
- Cervical or supraclavicular lymphadenopathy.
- Local effects - SVC obstruction, Hoarseness (Recurrent laryngeal nerve)
- Chest or shoulder pain due to infiltration of brachial plexus
- Horner's syndrome ? infiltration of sympathetic chain and 1st and 2nd rib can be involved as well as shadow at lung apex
- Neurological - Cerebral metastases - weakness, focal seizures, altered personality, lateralising signs
- Cerebellar signs or brainstem encephalitis due to metastasises or immunological (anti-Hu or anti-Yo antibodies) paraneoplastic, Peripheral neuropathy
- Endocrine - Hyponatraemia due to SIADH from small cell, Hypercalcaemia ? Non small cell, Cushing?s syndrome from ACTH secretion by small cells
- Paraneoplastic phenomena where distal effects not due to tumour
themselves are manifest without tumour spread.
- Seen with
- ACTH release and Cushingoid appearance
- Lambert Eaton syndrome
- Hypercalcaemia due to PTH related peptide release
- Clubbing and HPOA
- Cerebellar degeneration
- FBC, U&E, LFTs, Calcium and sputum cytology
- CXR is often diagnostic followed by Bronchoscopy for a central lesion to get a tissue biopsy
- For peripheral lesions a CT guided percutaneous needle biopsy is preferable
- CT chest/liver/adrenals and brain if Symptoms.
- Greater use of PET scanning to identify disease as it is more sensitive and specific than CT for identifying disease and can be combined with CT
- Initial staging by CT which involves thorax and may include brain and adrenals looking for spread
- Decisions are made by using a multidisciplinary team involving respiratory physicians, specialist nurses, oncologists and surgeons and palliative care teams and the patient.
- Underlying Performance status which includes lung function is important if operability is considered.
Non small cell
- Non small cell tumours staged as Tumour/nodes/metastasis (TNM) system. Localised tumours may be considered for surgery. Cure is possible. Those unfit may received radiotherapy. Chemotherapy may be offered as a palliative.
- Surgery is the best chance for cure and all patients with Stage I or II disease should be considered for curative surgery. Different options include wedge resection, lobectomy and pneumonectomy.
- Staging for NSCLC
- Stage I : Mass < 3 cm confined to bronchus with no nodes
- Stage II : Mass > 3 cm in Bronchus with nodes/chest wall or diaphragm
- Stage III : Involves mediastinal nodes or sub carinal nodes or hilar nodes other or any other local infiltration
- Stage IV : Distant metastases
- Contraindications to surgical resection - Liver metastasis, Pancoast tumour, Malignant pleural effusion, FEV < 1.5 L, Vocal cord paralysis, SVC obstruction
- Small cell
- Small cell tumour staged as limited to one hemithorax or widely disseminated. Untreated prognosis is 2 months.
- Chemotherapy can induce remission and increase survival to almost 18 months.
- Inoperable disease can be treated with palliative radiotherapy and sometimes chemotherapy
- Severe hypercalcaemia - Rehydrate, IV N-Saline, IV Pamidronate
- SVC obstruction - radiotherapy and stenting
- Many causes - get a CXR, smoking history, TB?
- Usually when severe is from systemic pressure bronchial arterial supply
- Massive haemoptysis (> 600 ml/day)
- Ask about smoking, weight loss, clubbing, TB, bleeding disorder, Cystic fibrosis or bronchiectasis, HIV.
- Check FBC, U&E, Clotting screen
- Arterial blood gas
- CXR is vital and can quickly identify a lung lesion
- CT chest may be helpful and CT-PA if PE suspected
- Bronchoscopy preferably rigid may be useful if bleeding not massive to look disease
- cANCA if Wegener's suspected, Anti-GBM if Goodpasture's suspected
- Those in extremis involves ABCs give Oxygen and consider nebulized adrenaline 5-10 ml of 1 in 10,000
- Lie patient on their bleeding side (determined with CXR) as this helps aerate and protect the good lung
- Large bore IV cannula or two - Group and cross match check clotting and transfuse
- Fluid replacement, antitussive, sedation, correct clotting e.g warfarin
- Consider oral tranexamic acid 500 mg tds - cautions in renal failure
- Next steps will depend on likely cause.
- Bronchial artery angiography and embolisation should be considered and attempted if indicated.
- Fibreoptic bronchoscopy is usually futile in severe cases as blood obscures view and may need to consider intubation with double lumen tube
- Discuss with local respiratory team and cardiothoracic as surgery indicated in unresponsive cases
- If terminal lung cancer then palliation may be more appropriate with diamorphine