Ca lung

Dr. D.P. Singh

Professor, Surgery.

Primary lung cancer – risk factors Cigarette smoking

Number of years Number of packs Passive smoking

Atmospheric pollution Occupational (radioactive ore, chromium

mining, asbestos, arsenic) Previous h/o TB with smoking

Pathological types

Small cell lung carcinoma (oat cell carcinoma)

Non Small cell lung carcinoma SCLC:NSCLC :: 1:4

Histological classification

Small cell lung cancer Non small cell lung cancer

Adenocarcinoma 25-40% Large cell undifferentiated 10-20% Squamous cell carcinoma 30-40% Bronchoalveolar carcinoma 5%

Clinical features

Depend on Site of lesion Invasion of neighboring structures Extent of metastases

Clinical features

Symptoms Hemoptysis Cough or changed cough Dyspnoea, wheezing Pleural effusion Severe localized pain suggests chest wall invasion Invasion of mediastinum – hoarseness, dysphagia, SVC

obstruction Pancoast’s syndrome – invasion of brachial plexus Clubbing Small cell carcinoma may cause myopathies.

Paraneoplastic syndrome with lung cancer Endocrine

Hypercalcemia Cushing’s syndrome SIADH Carcinoid syndrome Gynaecomastia Hypercalcitonemia Elevated GH Elevated prolactin, FSH, LH Hypoglycemia hyperthyroidism

Paraneoplastic syndrome contd. Neurologic

Encephalopathy Subacute cerebellar degeneration PML Peripheral neuropathy Polymyositis Autonomic neuropathy Lambert eaton syndrome Optic neuritis

Paraneoplastic syndrome contd. Skeletal

Clubbing Pulmonary hypertrophic osteoarthropathy

Hematologic Anemia Leukemoid reaction Thrombocytosis Thrombocytopenia Eosinophilia Pure red cell aplasia DIC

Paraneoplastic syndrome contd. Cutneous

Hyperkeratosis Dermatomyositis Acanthosis nigricans Hyperpigmentation

Other Nephrotic syndrome Hypouricemia Secretion of VIP with diarrhea Anorexia and cachexia hyperamylasemia

Diagnosis

3 aspects Detecting the primary lesion Tissue diagnosis Staging

Investigations

Chest radiography Computerized tomography MRI EUS PET Bronchoscopy Sputum cytology CT guided biopsy Mediastinoscopy Mediastinotomy Assessment of functional status - spirometry

Cervical Mediastinoscopy

Anterior mediastinoscopy

Staging : T: Tumor status

TX - Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washing but not visualized by imaging or bronchosocopy

T0 - evidence of primary tumor Tis - Carcinoma in situ T1 - 3 cm or less without invasion of visceral pleura T2 - >3 cm or any size with associated atelectasis or obstructive

pneumonitis, or invasion of visceral pleura T3 - Any size with direct extension into chest wall, diaphragm,

mediastinal pleura without involvement of great vessels or vital mediastinal structures and extent of bronchial spread with 2 cm of, but not involving, the carina

T4 - Any size with invasion of the heart or mediastinal vital structures or carina, malignant pleural effusion

N: Nodal involvement

NX - Regional lymph nodes cannot be assessedN0None

N1 - Peribronchial or ipsilateral hilar lymph nodes

N2 - Ipsilateral mediastinal lymph nodes, including subcarinal

N3 - Contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral scalene or supraclavicular lymph nodes

M: Distant metastases

MX - Presence of distant metastases cannot be assessed

M0 - None M1 - Distant metastases present

Stage grouping

0 Carcinoma in situ IA

T1N0M0 IB

T2N0M0 IIA

T1N1M0 IIB

T2N1M0 T3N0M0

Stage grouping

IIIA T3N1M0 T1-3 N2M0

IIIB T4, Any N, M0 Any T, N3, M0

IV Any T, any N, M1

Treatment

Early stage disease (stage I and II) Surgery

Locoregional advanced disease (T3N1 and above)

Surgery – limited role Chemotherapy Radiotherapy

Surgical management

Lobectomy Pneumonectomy Thoracoscopic lung resection

Complications of lung resection Bleeding Respiratory infection Persistant air leak Bronchopleural fistula

Other treatment modalities

Radiotherapy Chemotherapy