Transcript Slide 1

ALOK SINHA
Department of Medicine
Manipal College of Medical Sciences
Pokhara, Nepal
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
Male: female - 2: 1
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8% cancer deaths in men and 4% of cancer deaths
in women
Increasing in women
increasing smoking
Predisposing Factors
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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
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Asbestos exposure + cigarette smoking particularly
harmful
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
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Chromium
manufacture of stainless steel
electroplating
preservation of wood
used as a yellow pigment
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Nickel & other heavy metals
Used as alloys in many industries
can also increase risk
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
6. Pre existing non malignant lung diseases
associated with increased lung cancer rates
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Tuberculosis
Chronic obstructive pulmonary disease
Idiopathic pulmonary fibrosis
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) 20 - 25%
Oat Cell cancer
3. Miscellaneous
Carcinoid
Sarcoma
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
(NSCLC contd)
Adenocarcinoma
Not always smoking-related
 Are peripheral
 Can occur in scar tissue
 Can be a
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lung primary
secondary from adenocarcinomas at other sites,
especially if causing pleural infiltration
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Have a worse prognosis than squamous cell
cancer in all stages
Alveolar cell carcinoma
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Rare
Can cause copious sputum production
Fluffy air space shadowing on CXR
Large cell carcinoma
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an uncommon NSCLC
similar to that of adenocarcinoma
(bronchorrhoea)
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
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Liver
Bone & bone marrow
Brain
Adrenals, or elsewhere
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
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
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difficulty in swallowing
wheezing Monomorphic wheeze
Symptoms and signs
Due to:
1. Local tumour effects
2. Metastatic tumour effects
3. Paraneoplastic manifestations
local tumour effects
1. Local involvement of the bronchus
2. Mediastinal spread
3. Compression of local nerves
4. Superior vena cava syndrome
5. Spread to the chest wall
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
Bronchial
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Bronchialobstruction
obstruction
Complete
obstruction
Partial
obstruction
Partial –
hyperinflation
Complete – atelectasis
•dyspnoea
4. Pneumonia
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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
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Monophonic or unilateral wheeze
failing to clear with coughing suggests presence
of fixed bronchial obstruction
2. Mediastinal spread
Oesophahgeal involvement
causing dysphagia
3. Compression of local nerves
Left recurrent laryngeal nerve palsy
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hoarse voice with 'bovine' cough
Phrenic nerve paralysis
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unilateral diaphragmatic palsy
shoulder pain
dullness to percussion
paradoxical movement of abdominal wall
absent breath sounds at a lung base
4. Superior vena cava syndrome
Bilateral engorgement of the jugular veins
Distended veins over chest wall
Oedema of
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Face
Neck
arms
conjunctivae
superior vena cava syndrome
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
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Horner's syndrome (meiosis, ptosis, enopthalmos,
anhidrosis)
brachial plexus
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Cause weakness of small muscles of hand
C5/6, T1 motor loss
shoulder pain
Metastatic effects
Local metastasis
Blood born metastases
Local metastasis
Cervical/supraclavicular lymphadenopathy
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common, present in 30%
easy site for diagnostic biopsy
Blood born metastases
C.N.S. involvement
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focal neurological defects
epileptic seizures
personality change
Bone: pain & pathological fracture
Skin nodules
Liver: Jaundice
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Lassitude, anorexia and weight loss usually
indicate the presence of metastatic spread
Non-metastatic extrapulmonary
manifestations (Para neoplastic syndrome)
Endocrine
Inappropriate ADH secretion
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causing hyponatraemia (SIADH)
Ectopic ACTH secretion – Cushings syndrome
Parathyroid hormone (PTH)-related peptides hypercalcaemia
Carcinoid syndrome (Serotinin producing tumor causing diarrhoea
brnchospasm)
Gynaecomastia
C.N.S.
Symptoms precede those of primary tumour itself
Polyneuropathy
Myelopathy
Cerebellar degeneration
Myasthenia (Lambert-Eaton syndrome)
Limbic encephalitis
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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
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Symptoms:
memory loss, personality changes, anxiety or depression, neuropsychiatric
disturbances, partial or generalized seizures, olfactory and gustatory hallucinations,
sleep disturbances
Others
Digital clubbing
Hypertrophic pulmonary osteoarthropathy
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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
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
Investigations
1. CXR (PA and lateral)
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location of lesion
pleural involvement, pleural effusion
rib destruction
intrathoracic metastases
mediastinal lymphadenopathy
Normal CXR does not rule it out
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
2. Bronchoscopy
• For centrally located tumors
• Visualised directly using a flexible
bronchoscope
a. Bronchio Alveolar Lavage can be done - cytology
b. Bronchial biopsies (and brush samples) can be taken for
pathological examination
c. direct assessment can be made of operability
judged by the proximity of central tumours to the
main carina
3. Percutaneous needle biopsy (under CT or ultrasound
guidance)
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For peripheral lesions not accessible to the
bronchoscope
In patients not fit enough for bronchoscopy
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sputum cytology valuable diagnostic aid
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4. Pleural biopsy
 indicated in all patients with pleural effusions
5. Mediastinoscopy, thoracoscopy or
thoracotomy
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required to obtain a definitive histological
diagnosis
In patients with metastatic disease
diagnosis confirmed by
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needle aspiration
biopsy of affected
lymph nodes
skin lesions
liver
bone marrow
MANAGEMENT
Extent of primary tumour (T)
Regional lymph nodes (N)
Distant metastasis (M)
TX
Primary tumor can not be assesed
T0
No evidence of primary tumor
T1
Tumor < 3 cm
T2
Tumor > 3 cm
T3
T4
more than 2 cm distal to carina
Tumor of any size
•Invading chest wall & diaphragm
•Causing atelectasis or pneumonia
• Less than 2 cm distal to carina
Tumor invading
•Mediastinum
•Vertebral bodies
•Malignant preural effusion
NX
Lymph nodes can not be assessed
N0
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
Distant metastasis – M
MX
Can not be assessed
M0
No distant metastasis
M1
Distant metastasis (including
pleural effussion)
Stage groupings
T1 or 2
II
T1, 2 or 3 N – 0 or 1 M – 0
IIIA
T1, 2 or 3 N – 2
M–0
IIIB
T4
N–3
M-0
IV
N-0
M–0
I
M-1
Surgical resection
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
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
5-year survival rates of
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Over 75% in stage I disease (N0,
tumour confined within visceral pleura)
55% in stage II disease (ipsilateral
peribronchial or hilar node involvement)
Radiotherapy
Much less effective than surgery
Radical radiotherapy
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offer long-term survival in selected patients with
localised disease in whom surgery not possible
Palliative radiotherapy
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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
Chemotherapy
Use ful in small-cell carcinoma
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Cytotoxic drugs + Radiotherapy
increase the median survival of patients
from 3 months to well over a year
Regular cycles of therapy given
Combinations of commonly used drugs
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Cyclophosphamide
Doxorubicin
Vincristine
Cisplatin
Etoposide
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
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
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.
Non–small cell lung cancer.
Left upper collapse secondary to
endobronchial bronchogenic carcinoma.
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.
cavitating right lower lobe squamous cell carcinoma