Lung cancerLung cancer(types and presentation)(types and presentation)

Bronchial carcinomaBronchial carcinoma

..most common fatal lung malignancy account for 95% of most common fatal lung malignancy account for 95% of lung cancer lung cancer .leading cause of cancer death..leading cause of cancer death..peak incidence occur between ages 55-65 years ..peak incidence occur between ages 55-65 years ..there is a 3:1 male : female ratio..there is a 3:1 male : female ratio.. . Aetiology :Aetiology : - smoking is the most common aetiological factor.- smoking is the most common aetiological factor. -others: passive smokers , exposure to asbestos, -others: passive smokers , exposure to asbestos, chromium , iron oxide and products of cool chromium , iron oxide and products of cool combustion combustion

Types:Types:

There are 4 major types : There are 4 major types :

1- epidermiod [squamous] -35% 1- epidermiod [squamous] -35% 2- adeno carinema -30% 2- adeno carinema -30%

3- large cell carcinoma -15%3- large cell carcinoma -15%

4- small cell lung cancer -20%4- small cell lung cancer -20%

Epidermiod carcinoma -35% :Epidermiod carcinoma -35% :

.occurs most frequently in men and old people.occurs most frequently in men and old people

.usually starts on one breathing tubes..usually starts on one breathing tubes.

.tend to be localized in the chest longer than .tend to be localized in the chest longer than other types of lung cancer.other types of lung cancer...does not tend to metastasize earlydoes not tend to metastasize early..

..It is strongly associated with smoking.It is strongly associated with smoking.

Adenocarcinnoma-30%:Adenocarcinnoma-30%:

.most common cancer among women..most common cancer among women.

.usually started near the outer edges of .usually started near the outer edges of the lung. the lung. .Invasion of pleura and mediastinal .Invasion of pleura and mediastinal lymph node is common.lymph node is common...may spread to other parts of the body.may spread to other parts of the body.

..can be seen in non smoker.can be seen in non smoker.

Large cell carcinoma – 15% :Large cell carcinoma – 15% :

.less well – differentiated..less well – differentiated.

.may occur at any part of the lung..may occur at any part of the lung.

.Tumors are large by the time they are .Tumors are large by the time they are diagnosed.diagnosed..has greater possibility of spreading to .has greater possibility of spreading to brain and mediastinum.brain and mediastinum.

Small cell lung cancer:Small cell lung cancer:

.small cell lung cancer also called oatcell .small cell lung cancer also called oatcell because SCLC cells have oat grain because SCLC cells have oat grain appearance. appearance.

.It arises from endocrine cells [kulchitisky .It arises from endocrine cells [kulchitisky cells] where many hormones are secretedcells] where many hormones are secreted

..spread to lymph nodes and other organs spread to lymph nodes and other organs more quickly than NSCLC .more quickly than NSCLC .

.usually started in one larger breathing tube..usually started in one larger breathing tube.

.Tend to grow rapidly ..Tend to grow rapidly .

.commonly has spread by the time and is .commonly has spread by the time and is considered a considered a systemic diseasesystemic disease. .

.It is the .It is the onlyonly one of the bronchial one of the bronchial carcinomas that respond to carcinomas that respond to chemotherapychemotherapy

presentations:presentations:

.lung cancer may present in number of .lung cancer may present in number of different ways :different ways :.most commonly symptoms reflect local .most commonly symptoms reflect local involvement of the bronchus. involvement of the bronchus. .may also arise from spread to the chest .may also arise from spread to the chest wall or mediastinum or from distant blood-wall or mediastinum or from distant blood-borne spread.borne spread.

Local effects of tumor within the Local effects of tumor within the bronchus :bronchus :

1- cough ( in 80% of cases ) :1- cough ( in 80% of cases ) :

- It is the most common early symptoms.- It is the most common early symptoms.

- sputum is purulant if there is sec. infection. - sputum is purulant if there is sec. infection.

- A change in the character of the (regular cough) - A change in the character of the (regular cough) associated with other new respiratory associated with other new respiratory symptoms increase the possibilityof B.C.symptoms increase the possibilityof B.C.

2- Haemoptysis ( in 70% of cases) :2- Haemoptysis ( in 70% of cases) :

- Repeated episodes of scanty cough - Repeated episodes of scanty cough hemoptysis or blood –streaking of hemoptysis or blood –streaking of sputum in smokers are highly sputum in smokers are highly suggestive of B.C and should be suggestive of B.C and should be always investigated .always investigated .

3- Dyspnea ( 60% of cases ):3- Dyspnea ( 60% of cases ): - reflect occulusion of a large - reflect occulusion of a large bronchus resulting in collapse of a lobe of bronchus resulting in collapse of a lobe of the lung or development of plearal the lung or development of plearal effusion.effusion.4- Plearal pain :4- Plearal pain : reflect malignant invasion of the reflect malignant invasion of the pleura or reflect infection distal to a tumuor pleura or reflect infection distal to a tumuor (wich is recurrent and fail to resolve).(wich is recurrent and fail to resolve).

Direct spread:Direct spread:

.Involvement of .Involvement of pleurapleura and and ribs .ribs .

..Pancoast’s tumourPancoast’s tumour: :

-involvement of lower part of the brachial plexus -involvement of lower part of the brachial plexus ( C8 , T1,T2) causing ( C8 , T1,T2) causing severe pain of the shoulder severe pain of the shoulder and down inner surface of the arm.and down inner surface of the arm.

-Horner syndrom-Horner syndrom: due to involvement of the : due to involvement of the sympathetic ganglion.sympathetic ganglion.

--recurrent laryngeal nerve palsyrecurrent laryngeal nerve palsy : : causing unilateral vocal cord paresis causing unilateral vocal cord paresis with with hoarsness of voice and a bovine hoarsness of voice and a bovine cough.cough.

..Invation of phrenic nerve , causing Invation of phrenic nerve , causing paralysis of the diaghragmparalysis of the diaghragm..

.. Involvement of esophagus , causing Involvement of esophagus , causing dysphagia.dysphagia.

.. CardiovascularCardiovascular:atrial fibrillation, :atrial fibrillation, temponade ,pericarditis ,pericardial temponade ,pericarditis ,pericardial effusion .effusion .

.. Superior vena cava obstructionSuperior vena cava obstruction causing causing early morning headacheearly morning headache, , facial facial congestion and edemacongestion and edema involvinginvolving the the upper limbupper limb, distention of jugular vein , distention of jugular vein and veins of the chest.and veins of the chest.

Nonmetastatic extra pulmonary Nonmetastatic extra pulmonary manifistation:manifistation:

1- Endocrine manifestation:1- Endocrine manifestation:12% of tumors ,in particular small cell 12% of tumors ,in particular small cell tumors present with tumors present with SIADH, ACTHSIADH, ACTH secretion(SCLC), secretion(SCLC), hypercalcemiahypercalcemia(sq.cell (sq.cell carcinoma) ,bone metastasis carcinoma) ,bone metastasis gynaecomastiagynaecomastia(LCLC) .(LCLC) .

2- Neurological manifetation:2- Neurological manifetation: e.g: sensory e.g: sensory polyneuropathy ,myelopathy, polyneuropathy ,myelopathy, cerebellar degeneration.cerebellar degeneration.

3- Others:3- Others:Digital clubbing , hypertrophicDigital clubbing , hypertrophic pulmenary pulmenary osteo-arthropathyosteo-arthropathy (sq.cell cancer) (sq.cell cancer) , nephrotic , nephrotic syndrom, DIC, hypercoagulopathysyndrom, DIC, hypercoagulopathy (adenocarcinoma),(adenocarcinoma), ,thrombophelibitis ,thrombophelibitis migricans.migricans.

Blood borne metastasis:Blood borne metastasis:

..Bony metastasis giving severe Bony metastasis giving severe bony pain bony pain and pathalogical fractures.and pathalogical fractures.

.liver metastasis (.liver metastasis (Jundice)Jundice)

..Brain metastasis (Brain metastasis (change in personality, change in personality,

epilpsy,focalepilpsy,focal neurological symptomsneurological symptoms).).

Physical signs:Physical signs:

Examination is usually normal unless Examination is usually normal unless there is significant bronchial obstruction there is significant bronchial obstruction or tumor has spread to pleura or or tumor has spread to pleura or mediastinum.mediastinum.

1- physical signs of collapse (in large 1- physical signs of collapse (in large obstructing tumor) which may rise to obstructing tumor) which may rise to pneumonia. pneumonia.

2- monophonic or unilateral wheeze (fixed 2- monophonic or unilateral wheeze (fixed bronchial obstruction).bronchial obstruction).

3- stridor (obstruction at or above the lever 3- stridor (obstruction at or above the lever of main carina. of main carina.

4- hoarsness of voice associated with bovine 4- hoarsness of voice associated with bovine cough (recurrent laryngeal nerve cough (recurrent laryngeal nerve palsy).palsy).

5- dullness percussion and absent breath 5- dullness percussion and absent breath sounds at the lung base (unilateral sounds at the lung base (unilateral diaphragmatic palsy due to involvement of diaphragmatic palsy due to involvement of phrenic nerve) phrenic nerve)

6- physical signs of pleursy or pleural 6- physical signs of pleursy or pleural effusion (involvement of pleura).effusion (involvement of pleura).

7- bilateral engorgement of the jangular 7- bilateral engorgement of the jangular vein and later edema affecting face, vein and later edema affecting face, neck, arms.neck, arms.

8- tenderness and pain of long bone and 8- tenderness and pain of long bone and joints (HPOA). joints (HPOA).

Management Management

Investigation:Investigation:

. . Sputum cytologySputum cytology: high yield for : high yield for endobronchial tumors such as endobronchial tumors such as squamous cell and small cell squamous cell and small cell carcinoma.carcinoma.

. . chest x-raychest x-ray::

common radiological presentation of common radiological presentation of bronchial carcinoma. bronchial carcinoma.1- unilateral hilar-enlagement.1- unilateral hilar-enlagement.2- peripheral pulmonary opacity.2- peripheral pulmonary opacity.3- lung, lobe or segmental collapse. 3- lung, lobe or segmental collapse.

4- pleural effusion .4- pleural effusion .5- broadening of the mediastinum, 5- broadening of the mediastinum, enlarged cardiac shadow, elevation enlarged cardiac shadow, elevation of hemidiaphram.of hemidiaphram.6- rib distruction.6- rib distruction.

. . Pleural fluid cytology in pleural effusion .Pleural fluid cytology in pleural effusion .

. . Bronchoscopy Bronchoscopy :: gives high yield in gives high yield in excess of 90% (allows biopsy and bronchial excess of 90% (allows biopsy and bronchial brush samples) if fail brush samples) if fail precautious fine needle aspiration under CT. precautious fine needle aspiration under CT.

..CT thorax and upper abdomen.CT thorax and upper abdomen.

..Head CT scan.Head CT scan.

..Radio nuclide bone scanning.Radio nuclide bone scanning.

..liver US.liver US.

..bone marrow biobsybone marrow biobsy..

Treatment:Treatment:

1- surgery1- surgery : in patient with localized disease : in patient with localized disease and non-small cell cancer.and non-small cell cancer.2- solitary pulmonary nodule ,2- solitary pulmonary nodule , resection if :resection if : 1- age ≥ 351- age ≥ 35 2-segarette smoking.2-segarette smoking.

3- large (>2 cm) lesion. 4-lack of cacification. 3- large (>2 cm) lesion. 4-lack of cacification. 5-chest symptoms. 5-chest symptoms.

6- growth of lesion compared old CXR.6- growth of lesion compared old CXR.

3- for unresectable non-small cell 3- for unresectable non-small cell cancer, metastatic disease, or refusal of cancer, metastatic disease, or refusal of surgery:surgery: radio therapy +chemo therapyradio therapy +chemo therapy may reduce death risk by 13% at 2 may reduce death risk by 13% at 2 years. years.

4- small cell lung cancer : combination4- small cell lung cancer : combination chemotherapychemotherapy is standard mode of is standard mode of therapy with long-term survival.therapy with long-term survival.5- 5- laser obliterationlaser obliteration of tumor though of tumor though bronchoscopy in presence of bronchoscopy in presence of bronchial obstruction.bronchial obstruction.

6- 6- Radio therapyRadio therapy for brain metastasis, for brain metastasis, spinal cord comprission, spinal cord comprission, symptomaticsymptomatic

mass, bone lesion.mass, bone lesion.7- 7- Encourage cessation of smoking.Encourage cessation of smoking.