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Lung cancer (Risk factors (Asbestos, Radiation/radiotherapy, Urban, Heavy…
Lung cancer
Risk factors
Asbestos
Radiation/radiotherapy
Urban
Heavy metals
(arsenic, chromium, iron oxides, coal)
Smoking
(active/passive)
Resp disease (COPD)
Immunosuppression
Epidemiology
20% of cancers
27% cancer deaths
3rd most common cause of death
90% smoking related
5.5% cured
Diagnosis
Examination
Resp
Cachexia, pallor, weight loss, clubbing
Lymphadenopathy
Pleural effusion/consolidation/lobar collapse
Abdo
Hepatomegaly (if mets)
Neuro
Spinal cord comp (if mets)
Focal neurology, peripheral neuropathy,
proximal myopathy, seizures (mets)
Investigations
Bedside
Obs - fever if infection
ECG
Bloods
FBC - anemia, high WCC if infection
U+Es, LFTs - deranged if mets
Cancer markers
Imaging
CT thorax
Diagnosis and staging
Identify mets
+/- biopsy
PET scan
Localise tumour and mets
CXR
Mass poorly defined
Enlarged hila
Effusion, collapse, cavitation
Consolidation (2ndary pneumonia)
Lymph node invovlement
Bone scan
Mets
Histology
Cytology
Sputum, pleural aspirate
Bronchoscopy
Proximal lesions
CT or USS guided
Transthoracic fine needle
aspiration biopsy
Peripheral lesions
CT or USS guided
Special tests
LFTs - assess suitability for surgery
History
PC - symptoms (general, lung, systemic)
PMH - resp disease, cancers
DH, allergies
FH - cancers, lung disease
SH - occupation (asbestos, heavy metals etc),
smoking, general fitness (WHO PS)
Staging
NSCLC - TNM staging
SCLC - limited or exensive
Clinical
presentation
Lung symptoms
Cough
Haemoptysis
Chest pain
Recurrent infections
Hoarse voice
SOB
Met symptoms
Bone
Bony pain, compression symptoms
CNS
Personality change
Seizures
Sudden weakness
Liver
Abdo mass
Systemic
Malaise, fatigue
Weight loss
Cachexia
Night sweats
Management
Immediate ABCDE
Definitive
Conservative
Information for patient and family
Support - nurse specialist, charities
End of life care
Surgery
Stenting/laser
Indication: palliative for obstruction
Excision surgery
Indication: 1L early stage NSCLC, SCLC no mets
MOA: remove tumour +/-
adjuvant/neoadjuvant chemo/RT
Drainage/aspiration/pleurodhesis
Indication: palliative for pleural effision
Radiotherapy
Indication: 1L LC unsuitable for surgery,
palliative (bone pain, CNS, SVCO)
MOA: +/- chemo
SE: radiation fibrosis, pneumonitis
Chemotherapy
Indication: 1Lextensive SCLC, late stage NSCLC, palliative
MOA: +/-RT
Outcome: can be curative SCLC, not NSCLC
Other medical
Bronchodilators (cough, SOB)
Opiates (cough, pain)
Steroids (inc appetite)
Dexamethasone (CNS mets)
Antiemetics (nausea)
Antidepressants (mood)
Immunotherapy
Indication: EGFR+ adenocarcinoma
E.g. erlotinib, gefitinib
MOA: anti-EGFR Abs target
EGFR+ cancer cells
Referral
Haemoptysis, 3wk SOB, cough,
weight loss, chest pain, hoarse voice
Pathophysiology
Non-small cell
lung cancer
(NSCLC)
85%
Adenocarcinoma
~35%
Asbestos, non-smokers
Peripheral
Local and distant mets
Alveolar cell carcinoma
~1%, rare
Squamous cell carcinoma (SCC)
~30%
Often obstructive, can cavitate
Local spread, distant mets late
Large cell carcinoma
~10%
Poor differentiation
Early mets
Small cell lung
cancer (SCLC)
15%
Endocrine cells (Kulchitsky), secrete
hormones e.g. ACTH, ADH, PTH, HCG
Early mets
Complications
Local
Pleuritic pain
Brachial plexus
(arm pain, Horner's)
Rib fractures
Left recurrent laryngeal nerve
(hoarseness, bovine cough)
Phrenic nerve
(SOB)
SVCO
(upper limb and face oedema,
distended neck veins)
Systemic
CNS
Confusion
Cerebellar syndrome
Seizures
Proximal myopathy
Peripheral neuropathy
Rheum
Dermatomyositis, polymyositis
Derm
Acanthosis migricans,
thrombophlebitis migricans
Endocrine
Hypercalcemia
Ectopic hormones
Lambert-Eaton
Prevention
Stop smoking
Reduce occupational
exposure
Definition
Malignant neoplasm
of the lungs
Prognosis
NSCLC - 2y if no mets
SCLC - 1y if treated