1. LUNG TUMOURS Dr Shiron Saha Consultant Respiratory Physician
Slides courtesy of Dr Jennifer Hill

2. Learning objectives Understand how to classify lung tumours
Increase understanding of causes of, incidence and survival of lung cancer
Understand how to diagnose, investigate and treat lung cancer

3. LUNG TUMOURS
Bronchial
Pleural

4. BRONCHIAL TUMOURS malignant (95%) = lung cancer benign
non small cell cancer
small cell cancer
benign
hamartoma
carcinoid
lipoma
chondroma
leiomyoma
nerve sheath tumours
fibroma

5. Lung cancer epidemiology pathology clinical presentation using cases
diagnosis and staging
management

6. How common is lung cancer in UK compared to rest of Europe?

7. UK male incidence of all cancers 2007

8. UK female incidence of all cancers 2007

9. UK male cancer deaths 2008

10. UK female cancer deaths 2008

11. Time trends in lung cancer incidence in UK

12. What about smoking trends?

13. 5 yr cancer survival 1986-90 (Cancer survival trends, Office for National Statistics 1999)

14. National Comparisons Lung Cancer Survival

15. Causes of lung cancer

16. Causes of lung cancer SMOKING (80-90%) asbestos radon
coal tar and products of coal combustion
chromium
iron oxide
arsenic and arsenic compounds
petroleum products
nickel refining
beryllium, cadmium, aluminium

17. Cell types of lung cancer
small cell lung cancer
non small cell lung cancer
squamous
adenocarcinoma (adenocarcinoma-in situe)

18. Cell Types of Lung Cancer
NSCLC 85%
SCLC 15%
Squamous Cell 20%
Adenocarcinoma 40%
Large cell 5%
NOS 18%
EGFR mutation
15-30% of Adenocarcinoma
6-11% of all cancers

19. Case year old man (1)
incidental finding on CXR before hernia repair
asymptomatic
CT scan
PET scan - hot
surgery performed

22. PET SCANNING Functional rather than anatomical image
Fluoro-2 deoxyglucose (FDG) taken up by rapidly dividing cells and not excreted
FDG half life of 110 minutes
false negatives - BAC, carcinoid, small lesions
false positive - inflammation, infection
useful to detect asymptomatic metastases

23. Case 1 - 63 year old man (2) Stage T1 N0 M0
Right upper lobectomy showed 2cm adenocarcinoma pT1 N0 M0
no further treatment needed
80% 5 year survival

24. TNM staging for NSCLC T=Tumour N=Nodal Involvement M=Metastasis
M0=No Mets
M1A=Lung/Pleura
M1B=Extra thoracic

26. TNM staging and survival for NSCLC
5 year survival
Ia (T1N0) )
Ib (T2N0) )resectable
IIa (T1N1) 30 )
IIb (T2N1, T3N0) 20 )
IIIa(T3N1-2, T3N2) 10
IIIb(T1-4N3, T4N0-3) 5
IV (M1) 1

27. Lesson 1
Some patients are asymptomatic and likely to be the ones with the best chance of cure

28. Should we screen for lung cancer?

29. National lung screening trial
Trial by US national cancer institute
Over 50,000 men/women with >30pk yrs
CT screening reduced lung cancer mortality by 20.3% and all cause mortality by 7% cf with CXR
Cost-benefit being calculated
Needs repeating in UK population

30. Case 2 - 75 year old man (1) 6 months of increasing hip pain
2 months fatigue and weight loss
Minor haemoptysis
Previous history of OA hips and knees
CABG 1999

33. Bone
metastasis

34. CLINICAL PRESENTATION
symptoms due to local disease
symptoms due to metastatic disease
non metastatic manifestations of malignant disease (paraneoplastic syndromes)

35. LOCAL DISEASE cough (40%) breathlessness wheeze haemoptysis (7%)
dysphagia
hoarseness
chest pain (20%)
head, neck and arm swelling (SVCO)

37. SITES OF METASTATIC DISEASE FROM LUNG CANCER
lymph glands
bone
brain
liver
adrenal glands

38. SYMPTOMS OF METASTATIC DISEASE
bone pain
headache
seizures
neurological deficit
hepatic pain
abdominal pain

40. PARANEOPLASTIC SYNDROMES

41. PARANEOPLASTIC SYNDROMES
finger clubbing
hypertrophic pulmonary osteoarthropathy
anorexia
cachexia and weight loss
hypercalcaemia
hyponatraemia (SIADH)
peripheral neuropathy (Eaton Lambert syndrome)

42. Case 2 - 75 year old man (2) Bone biopsy showed squamous cell cancer
T2A N0 M1B - stage IV
given palliative radiotherapy and then palliative chemotherapy

43. TNM staging and survival for NSCLC
5 year survival
Ia (T1N0) )
Ib (T2N0) )resectable
IIa (T1N1) 30 )
IIb (T2N1, T3N0) 20 )
IIIa(T3N1-2, T3N2) 10
IIIb(T1-4N3, T4N0-3) 5
IV (M1) 1

44. NSCLC: stage at presentation7%
Stage II
31%
Stage III
69%
24%
Stage I
38%
Stage IV
Fry WA et al 1996, Cancer 77:

45. Lesson 2
Take a careful history – symptoms may help in staging the patient’s lung cancer

46. Approach when assessing a patient with potential lung cancer
Is it lung cancer?
What is the cell type of the tumour?
What stage is the lung cancer?
Is the patient fit for potentially curative treatment

47. Is it lung cancer and what is the cell type?
CXR
CT scan
Bronchoscopy +/- US guided biopsy
percutaneous (CT guided) needle biopsy
US guided aspirate or biopsy
Surgical biopsy

50. What stage is the tumour?
assess resectability (tumour removability)
bloods, CT thorax/abdo, PET scan,
CT head, medistinoscopy, pleural aspiration,

51. How fit is the patient? assess operability (patient fitness)
ECG, lung function, exercise capacity
performance status

52. WHO PERFORMANCE STATUS
0 - normal activity without restriction
1 - restricted in strenuous work, can do light work
2 - self-caring but no work, up > 50% of day
3 - limited self-care, in bed/chair > 50% of day
4 - no self-care, bed / chair bound

54. Chemotherapy for advanced NSCLC: effect of performance status
ECOG performance status 1 2 3 4
Early deaths, %
5.5 10 26
100
1 year survival, % 35 19 3
O’Brien 2000, Royal Marsden Hospital

55. Non small cell lung cancer (3)
Stage I/II
Stage III/ IV
Surgery
Radical
DXRT
Palliative
chemotherapy
BSC/
palliative
care
Chemotherapy and
radiotherapy
+/- Chemotherapy

56. Lesson 3
Several questions to answer when seeing a patient with lung cancer

57. Case 3 - 56 year old man (1) 1 month cough and breathlessness
increasing swelling of face, neck and arms with headache
heavy smoker
previously well

61. .

63. Case year old man (2)
Bronchoscopy confirmed small cell lung cancer
Limited stage disease
Treated with chemotherapy and thoracic and cranial radiotherapy

64. SMALL CELL LUNG CANCER limited disease extensive disease
disease limited to one hemithorax including ipsilateral supraclavicular lymph nodes
extensive disease
more extensive disease

65. SMALL CELL CANCER (2) Limited disease (1/3) Extensive disease (2/3)
6 x chemotherapy
4 x chemotherapy
BSC
Thoracic and
cranial DXRT

66. Median survival in small cell lung cancer
LIMITED DISEASE
- without treatment mths
- with treatment mths
EXTENSIVE DISEASE
- without treatment 1-3 mths
- with treatment 6-9mths

67. Lesson 4
It is essential to clarify the cell type to decide on best treatment

68. Cancers which spread to the lung
breast
colorectal
prostate
kidney
melanoma
thyroid
lymphoma

71. 4th lesson
Important to ask if the patient has had any previous cancers elsewhere

73. Pleural tumours malignant benign mesothelioma primary lymphoma
pleural thymoma
pleural sarcoma
benign
fibrous

74. Case year old man (1)
6 months increasing right sided chest pain
weight loss
fatigue
Retired railway carriage manufacturer

77. Case year old man (2)
Differential diagnosis of mesothelioma, and carcinoma
CT guided biopsy confirmed mesothelioma
Palliative chemotherapy offered but declined
Median survival of 7 months

78. ASBESTOS AMPHIBOLES SERPENTINE crocidolite (blue) amosite (brown)
tremolite
anthophyllite
actinolite
SERPENTINE
crysotile (white)

79. Blue asbestos fibre

80. PULMONARY CONSEQUENCES OF ASBESTOS EXPOSURE
Pleural plaques
Asbestos effusion
Asbestosis (fibrosis)
Mesothelioma
Bronchial carcinoma

81. Pleural plaques

82. Mesothelioma

83. MESOTHELIOMA Epidemiology Pathology Clinical presentation
Diagnosis and staging
Management

84. YEARS SINCE EXPOSURE

85. INCIDENCE OF MESOTHELIOMA

86. PATHOLOGY
Epithelioid
Sarcomatoid
Desmoplastic
Mixed / biphasic

87. CLINICAL FEATURES breathlessness chest pain weight loss SVCO sweating
abdominal pain

88. DIAGNOSTIC TESTS CXR CT scan Pleural aspiration
Blind or CT guided pleural biopsy
VATS pleural biopsy

89. TREATMENT Symptom control Palliative chemotherapy
Radical surgery/debulking surgery
Palliative radiotherapy