Lung Cancer

1. Lung Cancer Lorna Roden – October 2012

2. A few facts... • Accounts for 19% of all cancers • 2nd most common cancer in the UK • Most common worldwide. • Most common cause of cancer death in men • 2nd most common cause of cancer death in women after breast cancer • Clinical distinction – small cell tumours or non-small cell tumours

3. Risk factors • Smoking • Industrial dust: asbestos, chromium, arsenic, iron oxides • Radon • Progeny attach to dust particles in the air and are inhaled causing DNA damage • Radiation • Mediastinal tumours • Breast Radiation • Increasing age • COPD • Family Hx • Asbestos (linear relationship) • Diffuse lung fibrosis (‘scar carcinomas’)

4. Pathology • Arise from bronchial epithelium or mucous glands – rarely from the interstitium • Central tumours vs. Peripheral tumours • Large, main bronchus → symptoms arise early • Peripheral bronchus → can be clinically silent for a long time

5. Types (Histology) • Main types: • Squamous (35%) • Adenocarcinoma (30%) • Large cell (undifferentiated) (10%) • Small(oat) cell (10%) • Other (5%) e.g. Alveolar cell • Why? • Important divisions for treatments • Small cell cannot (usually) be treated with excision and are normally disseminated at presentation • ‘Other’ are usually benign

6. Types • Squamous Cell • Most common • Greatest tendency to cavitate • Typically arises centrally • Chest symptoms 1st – haemoptysis, infection • Spread – locally mostly but mets do occur • Associated with the paraneoplastic syndromes • Strongly associated with clubbing • HPOA • Adenocarcinoma • Most common type in non-smokers • Although majority of patients who develop it are smokers • Most common type associated with asbestos • Usually originates in peripheral lung tissue • Grows silently without causing local symptoms until late in the disease • Invasion of pleura and mediastinal lymph nodes • Often metastasise to brain and bones • Large Cell • Less differentiated form of squamous and adenocarcinomas, so often a diagnosis of exclusion. • Metastasise early. • Small Cell • Rapidly growing and highly malignant • Spread early • Most are inoperable at presentation. • Respond to chemotherapy but prognosis is poor. • Arise from endocrine cells called Kulchitsky cells. • Often associated with endocrine syndromes • inappropriate ADH secretion (↓Na+) • ACTH secretion (Cushing's).

7. Symptoms • Cough (80%) – often dry but sputum may be purulent in case of secondary infection. Change in character of regular ‘smokers cough’ should alert to possibility of carcinoma. • Haemoptysis (70%) – common, especially in tumours arising in central bronchi. • Dyspnoea (60%) – may reflect occlusion of large bronchus. • Chest pain (40%) – usually indicates malignant invasion of the pleura. • Recurrent or slow resolving pneumonia – caused by bronchial obstruction. • Anorexia • Weight loss

8. Signs and symptoms • Local symptoms • Cough • Haemoptysis • Dyspnoea • Chest Pain • Recurrent/slowly resolving pneumonia • Constitutional symptoms • Anaemia • Weight loss • Clubbing • Anorexia • Cachexia • Lymphadenopathy (supraclavicular/axillary) • Chest signs • None • Consolidation • Collapse • Pleural effusion

9. Effects…

10. Metastasis and Local Spread Metastases • Brain • Headache • Confusion • Seizures/Fits • Hemiparesis • Cerebellar Syndrome • Bone • Pain and tenderness • Hypercalcaemia • Anaemia • Liver • Hepatomegaly • Jaundice • Adrenals • Addison’s Local Spread • Chest pain (40%) • Usually indicates malignant invasion of the pleura. • Apical (Pancoast’s) tumours • Invasion of brachial plexus (pain radiating down arm) • Horner’s syndrome. • Recurrent laryngeal nerve • Hoarseness • SVC obstruction • Typical appearance • Phrenic nerve • Breathlessness • Oesophageal compression • Dysphagia

12. Criteria for urgent referral under 2ww rules Royal Cornwall Hospital’s Form for GPs/other clinicians to fill out

13. NICE Guidelines for urgent referral/urgent CXR

14. Diagnosis • CXR • Mass – peripheral circular opacity • Nodule – solitary pulmonary nodule (SPN) • Cavity • Atelectic collapse (bronchial obstruction by carcinoma) • Hilar enlargement • Pleural effusion • Mets (to bone, to pleura, to mediastinal structures) • CT • Define extent of spread • Decide on method of obtaining histological diagnosis • Bronchoscopy • Direct visualisation • Biopsy of central tumours – ‘Tissue is the issue’ • Percutaneous needle biopsy • Diagnosis from sites of metastases

15. CXR 1

16. CXR 2

17. Staging (TNM)

18. Paraneoplastic Manifestations • Paraneoplastic syndrome arise at sites distant from the tumour or its metastases and result from the production of hormones, peptides, antibodies, prostaglandins or cytokines by the tumour. • SIADH • ↑ADH, ↓Na+ • Small Cell tumours • ACTH secretion • Cushing’s • Small cell tumours • PTH • Squamous cell • HPOA (Hypertrophic pulmonary osteoarthropathy) • Wrist pain • Eaton-Lambert Myasthenic Syndrome • Dermatomyositis • AcanthosisNigricans • Thrombophlebitis nigricans

21. Treatment Non-small Cell Small Cell Excision for peripheral tumours with no metastatic spread (Stage I/II) Curative radiotherapy – if respiratory reserve is poor Chemoradiotherapy – if more advanced disease Nearly always disseminated May respond to chemotherapy Cyclophosphamide, doxorubicin, vincristine, etoposide

22. Palliation • Radiotherapy • Bronchial obstruction • SVC obstruction • Haemoptysis • Bone pain • Cerebral Mets • Stent • For SVC obstruction with radiotherapy • Endobronchial therapy • Tracheal stenting • Cryotherapy • Laser • Brachytherapy • Pleural drainage • Medications: analgesia, steroids, cough linctus (codeine), bronchodilators, anti-depressants

23. Prognosis • Non-small cell • 50% 2yr survival without spread • 10% with spread • Small cell • Median survival is 3 months if untreated • 1-1.5 months if treated.

24. Question 1 A 54-year-old man is investigated for a chronic cough. A chest x-ray arranged by his GP shows a suspicious lesion in the right lung. In the meantime he notices an itchy, burning rash developing on his knuckles and over the last 2 days has found it more difficult to reach the bowls ontop of the highest cupboard in his kitchen. What is the most likely underlying cause for the rash and other symptoms? • Dermatomyositis • Polymyositis • Lichen Planus • Psoriasis • Rosacea

25. Question 2 A 63-year-old woman is diagnosed at bronchoscopy with a non-small cell bronchial carcinoma. She is otherwise in good health. Staging CT imaging did not reveal any evidence of metastatic disease. Her surgeon has offered a pneumonectomy but wishes for PET to be undertaken. How does this best further assist in patient management? • Identifies blood supply to the tumour • Locates more accurately the primary tumour mass • Labels the tumour for easier identification at surgery • Demonstrates any metastatic disease not found at CT • Shrinks the tumour mass prior to surgery

26. Question 3 Name some of the causes of coin lesions of the lung on CXR… • Malignancy (primary or secondary) • Abscesses • Granuloma • Carcinoid tumour • Pulmonary hamartoma • Arterio-venous malformation • Cyst • Foreign body • Skin tumour e.g. Sebhorroeic wart

27. Which is the most common type of lung cancer in the UK? • What paraneoplastic conditions can you remember that are caused by lung cancer? Which types of cancer cause them?