LUNG CANCER
Tutorial Presentation
12 March 2020
Presented by Amy Isaacs
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Epidemiology
Classification
Clinical features
Investigations
Management
Prognosis
Epidemiology
• Leading cause of cancer death worldwide
• Mostly attributable to smoking (causes approx. 90% of lung cancers)
 About 33.4% of males and 8.3% of females above age of 15 smoke tobacco in South Africa.
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Other factors predisposing to lung cancer are the following:
Family history (genetic predisposition)
Second-hand smoking
Chronic obstructive pulmonary disease(COPD)
Ionising radiation
HIV
Occupational exposures and environmental exposure to carcinogens- passive smoking, asbestos, arsenic,
radon, uranium.
 Idiopathic- particularly adenocarcinoma
Lung Cancer
CLASSIFICATION:
• Small cell lung carcinoma (SCLC) (15% of all lung cancers)- characterised by its central location, rapid
tumour growth, early metastases, and is associated with paraneoplastic syndromes
 Paraneoplastic syndromes: are a group of rare disorders that are triggered by an abnormal immune
system response to a neoplasm(cancerous tumour cell). Paraneoplastic syndromes are thought to
happen when white blood cells (T cells) mistakenly attack normal cells in the nervous system
• Non-Small cell lung cancer (NSCLC) (85% of all lung cancers)- Comprises of several cancer types,
including peripheral adenocarcinoma and central squamous cell carcinoma
Classification
Tumour Type
Localisation Characteristics
Small cell lung cancer
central
Non-Small cell
lung cancer
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Strong correlation with cigarette smoking
Associated with several paraneoplastic syndromes
Very aggressive; early metastases
Adenocarcinoma Peripheral
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Most common type of lung cancer overall, and in women
Distant metastases are common
Squamous cell
carcinoma
Central
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Large cell
cracinoma
Peripheral
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Strong association with smoking
Cavitary lesions are common
Direct spread to hilar lymph nodes
Inc parathyroid hormone-related protein(PTHrP) leads to
hypercalcaemia
Late metastases
Poor prognosis
4. enopthalmous
Clinical features:
Pulmonary symptoms
• Cough (chronic or recently developed)
• Haemoptysis
• Progressive dyspnoea
• Chest pain
Constitutional symptoms
• Malaise
• Weight loss
• Fever
Compressive symptoms
• Superior vena cava syndrome (SVC)- feeling of fullness of the head, plethora
• Recurrent laryngeal nerve compression- Hoarseness
• Phrenic nerve compression- results in diaphragmatic elevation and dyspnoea
• Dysphagia
Paraneoplastic symptoms
• Endocrine- Ectopic ACTH Syndrome (Cushing syndrome), Hypercalcaemia (usually squamous cell ca), Rare:
hypoglycaemia, thyrotoxicosis, gynaecomastia
• Neurological- Encephalopathies, Myelopathies (motor neurone disease), neuropathies (peripheral
sensorimotor neuropathy), muscular disorders (myasthenic syndrome, Eaton-lambert syndrome)
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Skeletal- clubbing, hypertrophic osteoarthropathy (with or without gynaecomastia)
• Cutaneous (rare)- dermatomyositis, ancanthosis nigricans, herpes zoster
• Vascular and haematological (rare)- thrombophlebitis, non-bacterial thrombotic endocarditis, anaemia,
Disseminated intravascular coagulopathy, Thrombotic thrombocytopenic purpura, haemolytic anaemia
• Metabolic- loss of weight, lassitude(lack of energy), anorexia
Metastatic disease symptoms
• Early lymphogenic and hematogenic metastasis (particularly in small cell ca)
• Brain- headaches, behavioural changes, seizures
• Liver- nausea, jaundice, ascites
• Adrenal gland- usually asymptomatic
• Bones- pain
Signs
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Cachexia (muscle wasting and weight loss)
Anaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy (Causing wrist pain)
Supraclavicular or axillary lymph nodes
Chest signs: none, or consolidation; collapse; pleural effusion. Signs of COPD (Side note: COPD doesn’t cause
clubbing, so if pt has COPD and clubbing- most likely has Lung Ca)
• Metastases: bone tenderness; hepatomegaly; confusion; fits; cerebellar syndrome; proximal myopathy;
peripheral neuropathy.
Investigations
• To confirm lung pathology
Chest Xray; PET-CT Scan: diagnosis and differentiating benign from malignant
• To Identify the cause
CT- guided biopsy; Bronchoscopy: to define bronchial anatomy; sputum
• To assess for complications
ECG; Bloods: FBC, CMP, U&E
• To assess for severity
CT Scan- staging of diagnosed tumour(TNM Classification); CT scanning should include liver, adrenal glands and the
brain (as these are common sites for metastases)
• To prognosticate
Lung function tests; CT Scan; Staging of lung cancer: Staging of NSCLC is based on TNM staging system, SCLC staging
mostly depends on whether the tumour is limited to one hemithorax (one side of the chest) or beyond the hemithorax.
Alternatively, TNM staging may also be used.
Management
Treatment involves a multidisciplinary team- doctors nurses, social workers, etc)
• Palliative (many patients will have advanced cancer at the stage of presentation )- aims to improve quality of life;
symptomatic management; morphine or diamorphine is given regularly for pain, daily treatment with prednisolone
may improve appetite.
• Medical- Chemotherapy, targeted therapy and immunotherapy; Laser therapy, cryotherapy and tracheobronchial stents
• Surgical- (performed in early stage NSCLC with curative intent)- rarely appropriate in pts over 65 as he operative
mortality rate exceeds the 5yr survival rate; adjuvant therapy (therapy that is given in addition to initial therapy to
maximise effectiveness) may downstage tumours to render them operable.
Prognosis
• Prognosis for NSCLC is directly related to the stage at the time of diagnosis.
• In SA less than 10% of pts have potentially curable disease at presentation.
Prevention
• Avoid smoking and second-hand smoking
• Take occupational health and safety measures (prevent exposure to carcinogens)
• Regular screening of high risk individuals (older than 55 and have a significant smoking history or who have
quit after many years of smoking)
Case
A 68-year-old female smoker(30 pack years) has expectorated bright red blood. She has had a chronic nonproductive cough and, more recently, some blood-streaked sputum. She reports increased fatigability, reduced
appetite, and unintentional weight loss. She has no fever, chills, or night sweats to suggest infection. On
examination, her chest reveals scattered bronchi bilaterally without wheezes or crackles. She has clubbing of the
fingers.
• What is your next step:
Chest imaging, either x-ray or CT scan
• Most likely diagnosis:
Lung cancer
• How to confirm diagnosis:
sputum cytology then bronchoscopy with biopsy
Resources used:
• Oxford handbook of clinical medicine
• K&C
• Summaries from drive