LUNG CANCER

Respiratory
Plazma University
Dr. Amin M.H
Risk factors
1. Cigarette smoking : The most important single factor
 Smokers have 15 times increase in lung cancer risk compared with
non-smokers.
 Passive smokers also have 2 times increase in risk.
 Stopping smoking decreases the risk, but the risk remains higher than
in people who have never smoked.
2. Air pollution : e.g. from motor vehicles, factory emission, coal
burning.
3. Occupational factors: asbestos exposure, arsenic and heavy metal
exposure.
4. Lung lesions:
 Old fibrosis as in TB may result in scar carcinoma.
 COPD is important risk factor.
5. Genetic factor: may play a role
6. Diet: low vitamins A & C increase the risk of lung cancer
Pathology : WHO classification
Classification Site Incidence

Squamous cell carcinoma Central 35%

Small cell carcinoma ( oat cell Central 20%
carcinoma)
Adenocarcinoma Peripheral 30%
Large cell carcinoma Peripheral 10%
Others: Central or Peripheral 5%
Pulmonary lymphoma, Carcinoid,
sarcoma
 Spread
1) Local spread :
■ To the pleura : in the peripheral types leading to pleural
manifestations.
■ To the mediastinum : in central types leading to mediastinal
syndrome.
2) Hematogenous spread : Liver, bones, brain especially in small cell
carcinoma.
3) Lymphatic spread : to hilar, mediastinal, axillary, cervical lymph
nodes.
 Clinical picture
- The patient is usually an elderly male, who is a chronic heavy smoker.
- He may present with any of the following manifestations:
I. Intra-thoracic manifestations
A) Broncho-pulmonary presentations :
1. Asymptomatic :
 One fourth of patients who have cancer present with no symptoms at the
time of diagnosis.
 Detected accidentally on routine X-ray as a coin shadow in the lung.
2. Primary tumor symptoms: cough, expectoration, dyspnea, chest pain.
3. Hemoptysis: in the form of blood tinged sputum or rarely red current jelly sputum.
4. Bronchial obstruction :
o Partial : Emphysema, Bronchiectasis.
o Complete : collapse.
5. Pneumonia : usually recurrent at the same site.
6. Lung abscess: due to : secondary infection, necrosis of the tumor it
self.
7. Thoracic inlet syndrome ( superior sulcus syndrome) :
due to pancoast tumor
Pancoast tumor is a tumor occupying the apex of one lung and invading the
following :
2 bones, 2 nerves, 2 blood vessels
2 bones : upper 2 ribs.
2 nerves : ( sympathetic chain & lower trunk of brachia/ plexus )
• Sympathetic chain invasion : Homer's syndrome ( ptosis, myosis, enophthalmos,
anhydrosis ).
• Lower trunk of brachiaI plexus : pain along the mediaI aspect of the arm & wasting
of the small muscles of the hand.
2 blood vessels: ( Superior vena cava, Subclavian artery)
• Superior vena cava obstruction : congested non pulsating neck vein.
• Subclavian artery: unequal pulse in both upper limbs.
B) Pleural manifestations :
• Dry pleurisy may occur.
• Malignant effusion: massive, hemorrhagic, rapidly accumulating.
• Transudate: due to compression of azygous vein.
• Chylous effusion : due to obstruction of thoracic duct.
• Empyema : due to rupture of malignant abscess into the pleura.
C) Mediastinal manifestations : cough, dysphagia, hoarseness of voice .
II. Extra-thoracic :
A) Metastatic manifestations :
• Liver: jaundice, palpable tender liver mass.
• Bone : bone pain, pathological fracture.
• Brain : polyneuropathy, myopathy, paralysis or paresis.
• Heart: arrhythmia, pericardiaL effusion.
B) Non-metastatic manifestations : ( Para-malignant syndrome )
These manifestations are mostly common with small cell carcinoma.
Endocrinal: as a result of production of abnormal metabolites.
o Cushing: due to ectopic ACTH secretion.
o Hypercalcemia : due to PTH related peptide secretion
o Inappropriate secretion of ADH hyponatremia.
o Gynecomastia.
Neurological :
o Polyneuropathy.
o Myopathy.
o Myasthenia ( Eaton Lambert syndrome)
Hematological :
o Thromboembolic manifestations.
o Anemia.
o Leukemoid reaction.
Skin:
o Acanthosis nigricans.
o Dermatomyositis.
Others:
o Cachexia.
o Clubbing and hypertrophic pulmonary osteo-arthropathy ( HPOA): more
common in squamous and adenocarcinoma.
Investigations
1- Radiology
a) Chest X-ray : may show :
o Coin shadow in the lung.
o Area of collapse, consolidation, lung abscess, mediastinal mass.
o Pleural effusion.
o Rib erosion.
o Hilar LN enlargement.
o Elevated diaphragm.
b) CT chest : for accurate localization & evaluation LN for staging
2- Sputum examination: for malignant cells.
3- Invasive method:
o Bronchoscopy with BAL : positive especially in central types.
o Transthoracic needle aspiration : for biopsy from peripheral lung
lesions.
o Pleural aspiration.
4- Blood examination:
o Increased ESR.
O Serum electrolytes : Na, Ca.
o Renal & liver function tests.
5- Investigations for metastasis:
o Abdominal Ultrasound.
o Bone scan.
o Brain CT
 Differential diagnosis

o TB, Pneumonia, lung abscess.

o Pulmonary infarction.
o Benign tumors
o Other causes of pleural effusion.
o Other causes of mediastinal syndrome.
Staging

It gives prognostic information and guide treatment decision.

I. Small cell lung cancer :
A. limited: confined to ipsilateral hemi-thorax and supraclavicular
lymph nodes
B. Extensive : everything else
II. Non-small cell lung cancer : is commonly classified using TNM
staging system
Extent of primary tumor (T)

Tx Primary tumor cannot be assessed, or tumor proven by presence of malignant cells in sputum or
bronchial washings but not visualized by imaging or bronchoscopy.

T0 No evidence of primary tumor

Tis Carcinoma in situ
T1 Tumor < 3 cm surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion
more proximal than the lobar bronchus
T2 Tumor > 3 cm, invading visceral pleura or main bronchus > 2 cm distal to carina.
T3 Tumor of any size which invades chest wall, diaphragm, parietal pericardium, mediastinal pleura, or
tumor in main bronchus < 2 cm distal to carina.
T4 Tumor of any size invading: heart, great vessels, trachea, esophagus, carina, vertebral body, or
malignant pleural or pericardia! effusion.
Regional lymph nodes (N)

Nx Cannot be assessed
N0 No regional lymph node metastasis
N1 Ipsilateral peri-bronchial and/or ipsilateral hilar nodes
N2 Ipsilateral mediastinal and/or subcarinal nodes
N3 Contralateral mediastinal hilar node or any scalene or supraclavicular nodes
 Distant metastasis (M)

Mx Cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Staging grouping
 Treatment
I. Surgical resection: therapy of choice for patients with non-small cell carcinoma .
Criteria for operability :
o When the tumor is confined to the lung & away from carina by > 2cm.
o Good lung functions.
o No metastases.
Contraindications to surgery :
o Distant metastases.
o Invasion of the mediastinum.
o Malignant pleural effusion.
o Severe cardiac or other medical problems.
II. Radiotherapy : less effective than surgery.
Ill. Chemotherapy ( cisplatin based chemotherapy) : especially for small
cell carcinoma
using combination of cytotoxic drugs sometimes in combination with
radiotherapy.
IV. Symptomatic treatment: e.g. relieve of pain .
 Treatment of non-small cell lung cancer

Stage I Complete surgical resection

Stage II Surgical resection followed by radiotherapy
Stage IIIA Surgical resection followed by radiotherapy
& chemotherapy
Stage IIIB Chemotherapy with radiotherapy
This stage is inoperable.
Stage IV Cisplatin based chemotherapy
Treatment of small cell lung cancer:
chemo-sensitive
o The major problem in treating small cell carcinoma is the presence of
distance metastases at presentation.
o No role of surgery except in solitary pulmonary nodule with no
evidence of metastases. This is rare.
o Combination chemotherapy ( cisplatin, cyclophosphamide , ... ) : is
used for limited and extensive small cell carcinoma.
Bronchial adenoma ( carcinoid tumor )

• It is a locally malignant tumor, it originates from endocrine cells.

- Pathology: 2 pathological types ( Pedunculated, Sessile)
Clinical picture :
1. Hemoptysis: It is the most important & frequent symptom due to
marked vascularity of the tumor.
2. Bronchial obstruction :
o Partial : Emphysema, Bronchiectasis.
o Complete: collapse.
o Intermittent: fleeting atelectasis.
3. Carcinoid syndrome:
Attacks of flushing, diarrhea, bronchospasm, hypotension, abdominal
cramps & may be associated with cardiac valvular lesions, due to
secretion of serotonin & other substances by the tumor.
4. Carcinoid tumors can also be associated with Cushing's syndrome,
due to ectopic tumor ACTH production
 Investigations

1. X ray:
o May be normal.
o Coin shadow.
o Localized emphysema or lung abscess.
o Fleeting atelectasis.
2. Bronchoscopy: It bleeds easily, so care should be taken.
3. Hydroxy Indol acetic acid ( HIAA) In urine : ( metabolite of serotonin}
This will be raised in Carcinoid tumors.
Differential diagnosis of bronchial
adenoma:
1-Other causes of hemoptysis with normal X-ray:
• TB.
• Bronchiectasis.
• Chronic or acute bronchitis.
2- Causes of fleeting shadow :
• Bronchial adenoma.
• Lung hematoma.
• Lung esinophilia.
• Fissural effusion.
 Treatment
1. Surgical excision : of the lobe or the segment that contain the tumor.
2. Laser therapy may be used.
3. Argon plasma coagulation ( APC )

Prognosis : good
PLEURAL TUMOR ( Mesothelioma)

1- Benign pleural mesothelioma ( pleural fibroma )

o C/P: space occupying lesion, hypoglycemia.
o Chest X-ray : D shape opacity.
o Treatment : surgical excision.
2- Malignant mesothelioma :
o Highly malignant with bad prognosis.
o Most common in men between the age of 50 & 70 years.
o The lesion arises from mesothelial cells of pleura.
o Asbestos exposure is responsible for at least 85% of malignant
mesothelioma.
o C/P: Chest pain, dyspnea, weight loss & pleural effusion.
o Chest X-ray: Pleural effusion with lobulated pleural thickness.
o Treatment: Radiotherapy or chemotherapy with unsatisfactory results
 Smoking
Smoking index : ( Packs-year index )
Average number of packs/day X number of years of smoking
NB : Pack= 20 cigarettes
For example: 20 cigarettes/day for about 20 years. Index: 1 X 20 = 20
• Mild : up to 20
• Moderate: up to 40
• Severe:> 40
Important terminology :
o Non-smoker: is defined as the person who smokes < 1 cigarette/ day
for one year. Or up to one pack/ month or up to 20 pack in life time.
o Current smoker: is a person in regular cigarette smoking up to a
month ago.
o Ex-smoker: is a person who has quit smoking for at least 6 month.
o Passive smoker: second hand smoker
Hazards of smoking :
Chest:
COPD.
Lung cancer: one cigarette contains more than 4000 carcinogenic
compounds.
Cardiovascular:
 Increases incidence of sudden death, coronary artery disease &
malignant hypertension. ( smoking accounts for 30% of all
Cardiovascular deaths).
 It increases platelets adhesion, aggregation & whole blood viscosity.
 It increases carboxyhemoglobin & hematocrite value.
 It increases HR, catecholamine release & sensitivity.
 Decreases threshold of ventricular fibrillation.
 Decreases level of HDL.
 It increases morbidity from peripheral vascular diseases.
 It increases mortality due to aortic aneurysm.
GIT:
 Peptic ulcer.
 Cancer tongue, esophagus & stomach.
Urinary system : cancer bladder.
In female: Osteoporosis, Still birth, Stunted baby growth & congenital
anomalies
Temporal sequences of events following smoking cessation :

1. Heart rate & blood pressure :

- Normal within 30 minutes of last cigarette.
2. Oxyhemoglobin & CO levels :
- Normal within 8 hours of last cigarette.
3. Nicotine level :
- Normal within 3 days of last cigarette.
- Psychological craving within 3 weeks after last cigarette.
4. Myocardial infarction risk:
- Drops to 50% of smoker's risk 5 years after last cigarette.
5. Lung cancer:
- Drops to 50% of smoker's risk 10 years after last cigarette
THANKS