1. Department of Medicine Manipal College of Medical Sciences
LUNG
CANCER
ALOK SINHA
Department of Medicine
Manipal College of Medical Sciences
Pokhara, Nepal

2. Epidemiology One of commonest cause of cancer death
Responsible for 25% of all cancer deaths
More than 3 folds increase in cancer deaths since 1950

3. Male: female - 2: 1 Increasing in women
8% cancer deaths in men and 4% of cancer deaths in women
Increasing in women
increasing smoking

4. Predisposing Factors 1. Cigarette smoking Main predisposing factor
90% smoking-related
Stopping smoking decreases the risk
Passive smoking can also put people at risk
High increases beyond 30 pack years
2. Exposure to Asbestos
Asbestos exposure + cigarette smoking particularly harmful

5. can also increase risk 3. Other occupational exposures Arsenic
preservation of wood
added to a semiconductor like transistors
in the tanning industry as a preservative
anti-friction additive in ball bearings
Chromium
manufacture of stainless steel
electroplating
used as a yellow pigment
Nickel & other heavy metals
Used as alloys in many industries
can also increase risk

6. 4.Radiation exposure
damages the DNA material within the cells and can also cause lung cancer
5.Radon (a radioactive gas)
exposure can predispose to lung cancer. people living in areas with a high radon content are prone to increased incidences of a variety of cancers
Levels high in basement

7. 6. Pre existing non malignant lung diseases associated with increased lung cancer rates
Tuberculosis
Chronic obstructive pulmonary disease
Idiopathic pulmonary fibrosis

8. Classification

9. 1. Non small cell lung cancer (NSCLC) 75 -80% Squamous cell carcinoma
Adenocarcinoma
Alveolar cell carcinoma
Large cell carcinoma
2. Small cell lung cancer (SCLC) %
3. Miscellaneous
Carcinoid
Sarcoma
Unspecified lung cancer
Oat Cell cancer

10. Non-small cell lung cancer (NSCLC)
Squamous cell carcinoma
Commonest histological type
Centrally located
Slow growing
take several years to progress from a confined tumor into invasive cancer
Causes pneumonia atelectasis etc
Presents as a mass on CXR
May cavitate and look like a lung abscess
Response to chemotherapy is poor

11. Adenocarcinoma Not always smoking-related Are peripheral
(NSCLC contd)
Adenocarcinoma
Not always smoking-related
Are peripheral
Can occur in scar tissue
Can be a
lung primary
secondary from adenocarcinomas at other sites, especially if causing pleural infiltration
Have a worse prognosis than squamous cell cancer in all stages

12. Alveolar cell carcinoma
Rare
Can cause copious sputum production (bronchorrhoea)
Fluffy air space shadowing on CXR
Large cell carcinoma
an uncommon NSCLC
similar to that of adenocarcinoma

13. Small cell lung cancer (SCLC or Oat cell )
STRONGLY associated with smoking
More aggressive than NSCLC
Presents as central lesion with hilar & mediastinal invasion along with regional adenopathy
Rapidly growing -usually disseminated by the time of diagnosis (haematogenous spread) to
Liver
Bone & bone marrow
Brain
Adrenals, or elsewhere

14. Paraneoplastic syndromes like SIADH common (except PTH)
Surgery usually not appropriate
Chemo- and radiosensitive
Untreated – rapidly progressive and has a median survival of 6 weeks

15. Common Symptoms Coughing – change in character in a smoker Weight loss
Shortness of breath
Chest pain : often ill-defined and aching
Haemoptysis: sputum may be streaked with blood
Non-specific symptoms: fever, weakness, lethargy
Rarely
difficulty in swallowing
wheezing ?
Monomorphic wheeze

16. Symptoms and signs Due to: Local tumour effects
Metastatic tumour effects
Paraneoplastic manifestations

17. local tumour effects Local involvement of the bronchus
Mediastinal spread
Compression of local nerves
Superior vena cava syndrome
Spread to the chest wall

18. Local involvement of the bronchus
1. Dry cough
Purulent if there is secondary infection
Change in the character of the 'regular' cough of a smoker
2. Haemoptysis (tumours arising in central bronchi)
Repeated episodes of scanty haemoptysis
blood-streaking of sputum
in a smoker are highly suggestive of bronchial carcinoma and should always be investigated
Occasionally massive: large vessels invaded, -may be fatal

19. 3. Bronchial obstruction
Complete
obstruction
Partial
obstruction
Partial – hyperinflation
Complete – atelectasis
dyspnoea

20. 4. Pneumonia
When the obstruction is insufficient to cause collapse
Recurrent pneumonia in the same sight
Delayed resolution of pneumonia
5. Lung abcess
Due to obstruction
Tumor undergoing necrosis
6. Wheeze/stridor due to airway obstruction
Monophonic or unilateral wheeze
failing to clear with coughing suggests presence of fixed bronchial obstruction

21. 2. Mediastinal spread
Oesophahgeal involvement
causing dysphagia

22. 3. Compression of local nerves
Left recurrent laryngeal nerve palsy
hoarse voice with 'bovine' cough
Phrenic nerve paralysis
unilateral diaphragmatic palsy
shoulder pain
dullness to percussion
paradoxical movement of abdominal wall
absent breath sounds at a lung base

23. 4. Superior vena cava syndrome
Bilateral engorgement of the jugular veins
Distended veins over chest wall
Oedema of
Face
Neck
arms
conjunctivae

24. superior vena cava syndrome

25. 5. spread to the chest wall
Pleural pain
Pain due to intercostal nerve involvement
Pancoast tumor (superior sulcus tumor, or tumor of the pulmonary apex)
directly invade
sympathetic chain
Horner's syndrome (meiosis, ptosis, enopthalmos, anhidrosis)
brachial plexus
Cause weakness of small muscles of hand
C5/6, T1 motor loss
shoulder pain

26. Metastatic effects
Local metastasis
Blood born metastases

27. Local metastasis Cervical/supraclavicular lymphadenopathy
common, present in 30%
easy site for diagnostic biopsy

28. Blood born metastases C.N.S. involvement
focal neurological defects
epileptic seizures
personality change
Bone: pain & pathological fracture
Skin nodules
Liver: Jaundice
Lassitude, anorexia and weight loss usually indicate the presence of metastatic spread

29. Non-metastatic extrapulmonary manifestations (Para neoplastic syndrome)
Endocrine
Inappropriate ADH secretion
causing hyponatraemia (SIADH)
Ectopic ACTH secretion – Cushings syndrome
Parathyroid hormone (PTH)-related peptides -
hypercalcaemia
Carcinoid syndrome (Serotinin producing tumor causing diarrhoea brnchospasm)
Gynaecomastia

30. C.N.S. Symptoms precede those of primary tumour itself
Polyneuropathy
Myelopathy
Cerebellar degeneration
Myasthenia (Lambert-Eaton syndrome)
Limbic encephalitis
Limbic system: collection of structures at the base of the brain responsible for emotions and memory
Consists of Hippocampus, amygdala, anterior thalamic nuclei, limbic cortex
Symptoms:
memory loss, personality changes, anxiety or depression, neuropsychiatric disturbances, partial or generalized seizures, olfactory and gustatory hallucinations, sleep disturbances

31. Others Digital clubbing Hypertrophic pulmonary osteoarthropathy
excessive proliferation of skin and bone at the distal parts of extremities, digital clubbing and periostosis of the tubular bones
Nephrotic syndrome
Polymyositis and dermatomyositis
Eosinophilia

32. Differential diagnosis
Large no of conditions having
Cough & haemoptysis
Clubbing & Gynaecomazia
Pneumonic consolidation & collapse
Features due to secondaries & paraneoplastic syndrome – may be the presenting symptoms

33. Investigations

34. 1. CXR (PA and lateral) Normal CXR does not rule it out
location of lesion
pleural involvement, pleural effusion
rib destruction
intrathoracic metastases
mediastinal lymphadenopathy
Normal CXR does not rule it out

35. COMMON RADIOLOGICAL PRESENTATIONS OF BRONCHIAL CARCINOMA
1.Unilateral hilar enlargement
2. Parenchymal shadows 3. Lung, lobe or segmental collapse
4. Pleural effusion
5. Broadening of mediastinum,
6. enlarged cardiac shadow,
7. elevation of a hemidiaphragm
8. Rib destruction

36. 2. Bronchoscopy For centrally located tumors
Visualised directly using a flexible bronchoscope
Bronchio Alveolar Lavage can be done - cytology
Bronchial biopsies (and brush samples) can be taken for pathological examination
direct assessment can be made of operability judged by the proximity of central tumours to the main carina

37. 3. Percutaneous needle biopsy (under CT or ultrasound guidance)
For peripheral lesions not accessible to the bronchoscope
In patients not fit enough for bronchoscopy
sputum cytology valuable diagnostic aid

38. 5. Mediastinoscopy, thoracoscopy or thoracotomy
4. Pleural biopsy
indicated in all patients with pleural effusions
5. Mediastinoscopy, thoracoscopy or thoracotomy
required to obtain a definitive histological diagnosis

39. In patients with metastatic disease diagnosis confirmed by
needle aspiration
biopsy of affected
lymph nodes
skin lesions
liver
bone marrow

40. MANAGEMENT

41. T N M S t a g i n g

42. Extent of primary tumour (T)
Regional lymph nodes (N)
Distant metastasis (M)

43. TX T1 T2 T3 T0 Primary tumor can not be assesed
No evidence of primary tumor T1
Tumor < 3 cm T2
Tumor > 3 cm
more than 2 cm distal to carina T3
Tumor of any size
Invading chest wall & diaphragm
Causing atelectasis or pneumonia
Less than 2 cm distal to carina T4
Tumor invading
Mediastinum
Vertebral bodies
Malignant preural effusion

44. NX N0 N1 N2 N3 Lymph nodes can not be assessed
No regional lymph node metastasis N1
Ipsilateral peribronchial or hilar lymph nodes N2
Ipsilateral mediastinal or subcarinal nodes N3
Contra lateral hilar, mediastinal or
Supraclavicular nodes

45. Distant metastasis – M MX M0 M1 Can not be assessed
No distant metastasis M1
Distant metastasis (including pleural effussion)

46. Stage groupings I T1 or 2 N - 0 M – 0 II T1, 2 or 3 N – 0 or 1 IIIA
IIIB T4
N – 3
M - 0 IV
M - 1

47. Surgical resection

48. In majority of cases (over 85%) surgery not possible due to
Possible only in 15%
In majority of cases (over 85%) surgery not possible due to
extensive spread
co-morbidity
Only palliative surgery possible for them
Best hope of long-term survival in slow growing tumors – squamous cell cancers limited to stage I or II

49. Distant metastasis (M1)
CONTRAINDICATIONS
Distant metastasis (M1)
Invasion of central mediastinal structures including heart, great vessels, trachea and oesophagus (T4)
Malignant pleural effusion
Contralateral mediastinal nodes (N3)
FEV1 < 0.8 litres (severe C.O.P.D.)
Severe or unstable cardiac or other medical condition

50. 5-year survival rates of
Over 75% in stage I disease (N0, tumour confined within visceral pleura)
55% in stage II disease (ipsilateral peribronchial or hilar node involvement)

51. Radiotherapy Much less effective than surgery Radical radiotherapy
offer long-term survival in selected patients with localised disease in whom surgery not possible
Palliative radiotherapy
For distressing complications such as
superior vena caval obstruction
recurrent haemoptysis
Pain (due to chest wall invasion or skeletal metastatic deposits)
Obstruction of the trachea and main bronchi

52. Chemotherapy Use ful in small-cell carcinoma
Cytotoxic drugs + Radiotherapy increase the median survival of patients from 3 months to well over a year

53. Regular cycles of therapy given Combinations of commonly used drugs
Cyclophosphamide
Doxorubicin
Vincristine
Cisplatin
Etoposide

54. Requires considerable medical skill and expertise
Requires considerable medical skill and expertise. should only be given by teams of expert clinicians
Chemotherapy given before surgery may increase survival in small cell carcinoma

55. Prognosis The overall prognosis : very poor
80% of patients dying within a year of diagnosis
less than 6% of patients surviving 5 years after diagnosis
Best prognosis is with well-differentiated squamous cell tumours which have not metastasised and are amenable to surgical treatment

56. Non–small cell lung cancer

57. Non–small cell lung cancer
Non–small cell lung cancer. Left pleural effusion and volume loss secondary to non–small cell carcinoma of the left lower lobe.
pleural effusion was found to be malignant; therefore, the lesion is inoperable.

58. Non–small cell lung cancer.
Left upper collapse secondary to
endobronchial bronchogenic carcinoma.

59. Lung cancer, small cell. A large mass in
left mid lung with an opacity extending
to the upper lung.A small left pleural effusion
is present, with blunting of the costophrenic recess.

60. cavitating right lower lobe squamous cell carcinoma