Lung Cancer
Reference: OHCM 182, Lec Not Onc 156,
Mini-Kumar 492
Epidemiology
Causes by far the most deaths due to ca in Europe
Risk Factors
-
Smoking (proportional to cigarettes)
-
Air pollution
-
Asbestos (esp mesothelioma)
-
Chromium
-
Arsenic
-
Iron oxide
-
Radiation
Differential
Bronchiectasis, autoimmune (eg Wegeners/Goodpastures), pulmonary
embolism
Histology
Non-Small Cell
Squamous:
Obstructive lesion. Occassionally cavitatates. Local spread common,
widespread mets late.
Large cell:
Less well differentiated that mets early
Adenocarcinoma:
Proportionately
less common in smokers compared to the other types. Can be associated
with asbestos. Usually peripheral. Local and distant mets.
Alveolar cell:
Periph
solitary nodule or diffuse nodular lesions.
Small Cell
Endocrine
cells, which often secrete polypeptides (paraneoplastic). ACTH
(Cushings). Early development of widespread mets. Responds to chemo.
Clinical
-
Local:
Cough
(80%), haemoptysis (70%), dyspnoea (60%), chest pain (40%)
-
Spread
within
chest:
Pleura (pain), ribs (bone fractures), brachial
plexus (pain in shoulder and Horners), left recurrent laryngeal nerve
(hoarseness, bovine cough), SVC obstruction (upper limb oedema, facial
congestion, distended neck Vs)
-
General
signs
of malignancy:
Malaise, weight loss, lethargy, anorexia,
anaemia
-
Other:
Clubbing,
hypertrophic pulmonary osteoarthropathy (causing wrist pain),
lymphadenopathy, proximal myopathy, periph neuropathy
Investigations
Bedside:
Lung
function tests
Bloods:
FBC
(anaemia), LFT/ALP (bone/liver mets), Liver USS, U+E (↓Na)
Diagnosis:
Sputum
cytology, bronchoscopy + washings, FNA biopsy with CT guiding
Staging:
CXR
(peripheral circular opacity, hilar enlargement, consolidation, lung
collapse, pleural effusion, bone secondaries), CT scan, radionucleotide
bone scan, PET (ideally), mediatinoscopy + LN biopsy.
Management
Surgery can be lobectomy or pneumonectomy. Radiotherapy gives
short-term SEs of tiredness, oesophagitis, skin irritation,
pneumonitis, and long-term SEs of spinal cord myelopathy, radiation
pneumonitis, and strictures.
Non-small
-
Radical
surgery (if limited T1/2 N0M0) + radiotherapy.
20% are
resectable. Radical radiotherapy if inadequate respiratory reserve
(FEV, transfer factor, USS heart).
-
Palliative
radiotherapy
for rest (those w Symptoms like
haemoptysis,
SoB). Chemotherapy.
Small
95% have mets at presentation.
-
Chemotherapy
(etoposide + cisplatin): 60% remission but
majority recur
Palliative
-
Radiotherapy
for bronchial obstruction, SVC obstruction,
haemoptysis, bone pain,
cerebral mets.
-
SVC
obstruction:
SVC stent + radiotherapy + dexamethasone.
Endobronchial therapy: tracheal stenting.
-
Drugs:
analgesia, steroids, antiemetics, codeine for cough,
bronchodilators.
-
Malignant
pleural effusions:
aspirate therapeutically
-
Paraneoplastic
hyponatraemia (↓ADH) :
water restriction,
tetracyclines.
-
Polymyositis,
Eaton-Lambert, peripheral neuropathy:
↑dose
steroids.
-
Ectopic
ADH:
adrenal
enzyme blocking (ketoconazole), adrenalectomy.
Prognosis
Non-Small:
50% 2 year survival without spread, 10% 2 year survival with spread.
Small:
Just
over 1 year with treatment.
