RespNET clinic aide memoire: Lung cancer. September 2015
Suspected lung cancer
General
Based on 2011 data, there are 39000 new cases of lung cancer a year in the UK. Only 5.5% are cured, and more than
35,000 people a year die. This is more than breast and colorectal carcinoma combined. Patients seen in clinic are
subject to targets, with significant consequences for the Trust if these are missed:
 2-week wait urgent suspected cancer referral for specialist appointment
 62 day referral (from GP) until treatment target
 31 day decision-to-treat until treatment target
History
Unexplained symptoms (> 3 weeks) of cough, chest/shoulder pain, dyspnoea, weight loss, hoarseness.
Other symptoms might include bone pain, anorexia, dysphagia, fatigue, or weakness.
Examination
Chest signs, finger clubbing, features suggestive of metastasis, or supraclavicular/cervical lymphadeonopathy are
consistent with possible lung cancer and mandate an urgent Chest X-ray prior to arrival in clinic.
GPs could reasonably also refer patients under the 2 week rule without a chest X-ray with:
 persisting haemoptysis in a smoker over 40
 stridor
 signs of SVC obstruction
(although these might be expected to be sent in on the acute take).
Other examination findings might include hepatomegaly, raised hemidiaphragm, Horner’s syndrome (ptosis, meiosis,
enophthalmos, anhidrosis), focal neurological deficit attributable to a cerebral metastasis or spinal cord
compression, or wasting of small muscles of the hand (Pancoast’s tumour).
Paraneoplastic syndromes may be clinically evident:
 SIADH (hyponatraemia)
 ectopic ACTH (Cushing’s)
 Hypertrophic Pulmonary Osteoarthropathy
 Eaton-Lambert myaesthenic syndrome
 Cerebellar syndromes
 Limbic encephalitis
Alternatively a lung tumour may be discovered incidentally and so far have caused no symptoms or signs at all.
Besides the presenting illness, history needs to explore a patient’s likely fitness for any lung cancer treatment:
 Renal or hepatic dysfunction
 Active infection
 Thrombocytopaenia or other haematological disorders
 Collagen vascular diseases (e.g. lupus, scleroderma) may be associated with exaggerated tissue injury from
radiotherapy
WHO/ECOG performance status:
0. Fully active, able to carry on all pre-disease performance without restriction
1. Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or
sedentary nature, e.g. light housework, office work
2. Ambulatory and capable of self care but unable to carry out any work activities: up and about more than
50% of waking hours
3. Capable of only limited self care, confined to bed or chair more than 50% of waking hours
4. Completely disabled, cannot carry on any self care, totally confined to bed or chair
RespNET clinic aide memoire: Lung cancer. September 2015
Investigations
The purpose of investigations is to diagnose and stage the tumour, and assess the patient’s fitness for possible
treatment options.
 FBC, U&E, LFTs, bone profile
 Serum LDH (overexpressed in small cell lung cancer (SCLC) and has prognostic value, as well as lymphoma)
 Coagulation screen (need prior to Bronchoscopy or radiological percutaneous tissue biopsy). Ensure INR <
1.5. Platelets > 50 x 109
 Sputum cytology
 Lung cancer staging CT (CT neck/chest/abdomen + contrast)
 Abdominal (liver) US may be useful to further characterise hepatic lesions which appear equivocal on CT
 CT (or MRI brain) if features suggestive of intracerebral metastases
 MRI whole spine if features of disease affecting cord
 MRI chest helpful in Pancoast tumour to assess degree of surgical resectability/invasion of structures
 Pleural tap of effusion (cytology – if adequate sample can spin and do immuno)
 Bone scintigraphy if clinical or biochemical features of bony disease (although if having PET no added value)
 Spirometry and TLCO
 Fibreoptic bronchoscopy (possibly including TransBronchial Needle Aspiration (TBNA)/ Endobronchial US
(EBUS)-guided TBNA for mediastinal lymph node sampling – depending on site of disease on CT. Should be
done if intermediate/high risk of nodal disease (>10mm on CT or positive on PET)
 Radiological guided percutaneous biopsy (US or CT-guided, depending on site of disease on CT)
 PET-CT in all patients being considered for radical treatment –discuss at MDT. PET-CT is increasing used to
stage LN and to target biopsies via EBUS or CT-guidance.
 Consider:
o Mediastinoscopy, usually after PET-CT and identification of nodes that are not accessible by
EBUS/EUS to further identify or exclude mediastinal nodal disease –discuss at MDT
o If possible surgical candidates, need to predict level of post resection dyspnoea and operative risk
(discuss at MDT):
 Shuttle walk test (400m cut-off for good function), VQ scan (for ?VQ mismatch), CPET
(>15ml/kg/min cut-off for good function)
 If poor cardiac functional status and risk factors, may need echocardiogram, exercise ECG,
thallium scan, and cardiology opinion.
Treatment
All cases must be discussed at the MDT usually after CT, and always after histology. The further diagnostic pathway
or treatment plan will be defined by consensus at the MDT. It depends on type of cancer, stage of cancer,
performance status, co-morbidities, and patient preference.
Options are:
 radical (including surgery - with the intention of cure or life prolongation)
 palliative (symptom controlling, which may include chemo and/or RTX)
 best supportive care (expectant observation with palliative strategies if and when required)
NB. CT must not be older than 4 weeks when planning radical treatment. Radical treatment is offered up to T3N1M0
and higher than this is considered by MDT (eg some N2 disease, particularly single zone).
7th Edition TNM Classification of Lung Cancer = latest edition
Tumour
 Tx: tumour cannot be assessed. Not seen radiologically or at bronchoscopy (e.g. +ve cytology sputum/BAL)
 T0: no evidence of primary tumour
 Tis: carcinoma in situ
 T1: tumour <3cm surrounded by lung/visceral pleura without bronchoscopic evidence of invasion more
proximal than the lobar bronchus (ie not in main bronchus)
o T1a ≤ 2cm
T1b ≤ 3cm but > 2cm
 T2: tumour > 3cm but ≤ 7cm OR:
o involves main bronchus ≥ 2cm distal to carina
RespNET clinic aide memoire: Lung cancer. September 2015
o
o




invades visceral pleura
assoc with atelectasis/obstructive pneumonitis extending to hilar region but not involving whole
lung
T2a Tumour > 3cm but ≤ 5cm
T2b: Tumour > 5cm but ≤ 7cm
T3: Tumour > 7cm:
o OR invades chest wall, diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium
o OR tumour in main bronchus < 2cm distal to carina (not involving carina)
o OR associated atelectasis or obstructive pneumonitis of the entire lung
o OR separate tumour nodule(s) in the same lobe
T4: Tumour of any size:
o Invading: mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, oesophagus,
vertebral body or carina
o Or separate tumour nodule(s) in different ipsilateral lobe
Nodes
 Nx: Regional lymph nodes cannot be assessed
 N0: No regional lymph node metastasis
 N1: Ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes incl involvement
by direct extension
 N2: Ipsilateral mediastinal and/or subcarinal lymph node(s)
 N3: Contralataral mediastinal, contralateral hilar, any scalene, or any supraclavicular nodes
Metastases
 M0: no metastasis
 M1a: separate tumour nodule(s) in contralateral lobe or tumour with pleural nodules, or malignant pleural
or pericardial effusion
 M1b: distant metastasis (extrathoracic organs)
T1a
T1b
T2a
T2b
T3
T4
N0
IA
IA
IB
IIA
IIB
IIIA
N1
IIA
IIA
IIA
IIB
IIIA
IIIA
M0
N2
IIIA
IIIA
IIIA
IIIA
IIIA
IIIB
N3
IIIB
IIIB
IIIB
IIIB
IIIB
IIIB
M1
N0-3
IV
IV
IV
IV
IV
IV
Non Small Cell Lung Cancer (NSCLC ) treatment options (it’s more complicated than this but in general terms….)
o Surgery: for Stage I-II surgical resection if fit, and acceptable lung function (and some IIIA, as single
zone non-bulky N2 disease may also be amenable to surgery)
 Should not have surgery within 30 days of MI
 If active cardiac condition, >3 risk factors, or poor cardiac functional capacity should see
cardiologist
o Radical Radiotherapy: for Stage I-III disease if PS 0-1, and disease can be encompassed in a
radiotherapy treatment volume
 If stage I-II but inoperable offer CHART
 If stage IIIA-IIIB and eligible for radical RTX but cannot tolerate/do not want
chemoradiotherapy offer CHART
o Chemotherapy: for Stage III-IV but good PS 0-1. Usually etopisode/cisplatin
 Also adjuvant if T1-2 N1-2 M0 and N0 but primary >4cm. Cisplatin-based regime
o Sequential chemoradiotherapy: for Stage III not suitable for surgery but eligible for radical
radiotherapy
o Biologics: gefitinib or erlotinib if EGFR-TK mutation positive adenoca and locally advanced or
metastatic disease
RespNET clinic aide memoire: Lung cancer. September 2015
Small cell lung cancer (SCLC)
Staged more simply:
-Limited Disease: confined to one hemithorax and ipsilateral supraclavicular lymph nodes. T1-3 N0-3 M0
-Extensive Disease: everything else. T1-4 N0-3 M1a-b
SCLC Treatment options:
 Limited Disease: Chemotherapy (cisplatin-based regime) with concurrent (if PS 0-1) or sequential (if unfit)
thoracic radiotherapy. Also prophylactic cranial irradiation for anyone with stable disease on first line
treament. Consider surgery in early disease (T1-2a N0 M0) as part of multi-modality treatment.
 Extensive Disease: Chemotherapy (with thoracic and cranial radiotherapy in those with a good response).
BAC/adenocarcinoma-in-situ/lepidic adenoca: much better prognosis, with excellent post-resection survival.
Resection of multifocal disease by sub-lobar resection may be appropriate.
Prognosis :
In UK, overall 1y survival rates: 27% males, 30% females. Overall 5y survival rates: 7% males, 9% females (Cancer
Research UK 2009).
Screening :
Although some evidence of clinical and cost-effectiveness of low dose CT screening, not yet implemented. Work to
be done on managing increased volume of nodule surveillance and incidentalomas from screening programmes.
Questions to ask yourself before presenting a patient at the MDT:
1. How likely do you think this is cancer? What are the risk factors? Are there alternative diagnoses that need
considering from the history?
2. If this is cancer, what is the stage? Most importantly, is this amenable to radical treatment?
3. How fit is the patient? What is performance status? Do you need further assessments of fitness? Can this be
optimised (eg maximise bronchodilators, course of steroids, treat heart failure)?
4. What are the lung function results? Everyone should have spirometry but if considering surgery will need
TLCO in order to plan lobectomy/parenchymal-sparing surgery.
5. How symptomatic is the patient? Are there particular symptoms that need addressing urgently? Do you
need to involve others (RTX-ist, palliative care) to help with this?
6. What does the patient know? How quickly can they undergo further tests (ie straight to EBUS or needs
another clinic appointment to discuss?)