Respiratory Malignancy
Definition
Neoplasia : Abnormal growth of cells which persists after initial stimulus has been removed
Benign: Compact mass that remains at the site of origin
Malignant:Uncontrolled growth, not organised, necrotic centre, illmargined
Magnificent 7
Self Sufficiency in Growth Signals
Insensitivity to negative signals
Defects in DNA repair
Evasion of Apoptosis
Limitless replication potential
Angiogenesis
Invasion & Metastasis
Classification
Primary
 Small Cell – limited or extensive stage: Endocrine cells which produce hormones  PARANEOPLASTIC
 Non Small Cell
o Squamous - abnormal epithelial cells, M>W, Increase risk in smokers – central area of lung
o Adenocarcinoma – glandular tissue: occurs in non smokers, asbestos – lung peripheries
o Large Cell – diagnosis of exclusion
Secondary
 Breast
 Bone
 Kidney
 Prostate

Thyroid
Presentation
Local effects: Breathlessness, Cough, Chest Pain, Haemoptysis
Spread within the chest: Pancoast tumour, Horners Syndrome, SVC obstruction, Pleural infiltration
Metastatic: Bone(pathological fractures, night pain), Brain (seizures), Lymph Nodes (lumps/bumps)
Non Metastatic: Endocrine (Hypercalcaemia, Cushings, SIADH), Neurological (Myopathy, Eaton Lambert),
Vascular/Haematological (Anaemia, DIC, PE/DVT), Skeletal (Hypertrophic pulmonary osteoarthropathy), Cutaneous (acanthosis
nigrans, Dermatomyositis, Herpes Zoster)
PMHx of Malignancy: Hodgkins, Testicular, Endometrial
Family History: 1st degree increase by 51%
Social History: Smoking, Occupation (Asbestos, Radon Gas, Arsenic, Coal Combustion, Chromium, Iron Oxides)
Signs
 Peripheral : Clubbing, Cyanosis, Hypertrophic Pulmonary Osteoarthropathy, Acanthosis Nigricans
 Central: Lymphadenopathy, Tracheal Deviation, Chest defects
Investigations
 Bedside: Peak Expiratory Flow, Pulse Oximetry, Sputum, ABG
 Bloods: FBC, U+E. LFT, Bone, TFT, CRP, Tumour Markers
 Imaging: CXR, CT-scan, PET
 Special Tests: Spirometry, Trans-thoracic needle biopsy, Bronchial Lavarge,
Light's criteria state that the pleural fluid is an
exudate if >1 of the following criteria are met
Pleural fluid protein / serum protein >0.5
Pleural fluid LDH divided by serum LDH >0.6
Pleural fluid LDH more than two-thirds the
upper limits of normal serum LDH
Management
Biological
 Conservative: Symptom relief (analgesia, anti-emetics, anti-epileptics, supplements – dietary, haematological), Smoking
Cessation
 Medical: Radiotherapy (useful in bone pain, haemoptysis and SVC obstruction; complications include radiation
pneumonitis/ fibrosis), Chemotherapy (varies depending on cell type)
 Surgical: Assessment for surgery (ASA grade), De-bulking. In NSCLC surgery can be curative
Psychological
 Counselling
 Medication (antidepressants)
 End of Life discussion
Social
 Support Networks
 Services for Families / Carers
 Physio/OT
Staging: Tumour (0 no sign of tumour)(1-4 vary upon extension + Size) Nodes (0 none )(1 local)(2 not 1 0r 3)(3- distal/extensive
spread), Metastasis (0 no)(1 yes)
Small cell – @2 years 20% survival rate in extensive disease; @5 years 25% survival rate in limited disease (where localised to
one lobe/local nodes)
Emergencies
SVC Obstruction: Steroids – Dexamethasone, Stent, Oncology R/v – Radiotherapy, Chemotherapy
Erosion of Blood Vessels: Supportive/Palliation