Lung cancerLung cancer(types and (types and

presentation)presentation)Presented by Dr Presented by Dr ShiryazdiShiryazdi

Bronchial carcinomaBronchial carcinoma..most common fatal lung malignancy account for most common fatal lung malignancy account for

95% of lung cancer95% of lung cancer ..leading cause of cancer deathleading cause of cancer death..

..peak incidence occur between ages 55-65 yearspeak incidence occur between ages 55-65 years. . ..there is a 3:1 male : female ratiothere is a 3:1 male : female ratio..

. .AetiologyAetiology: : - - smoking is the most common aetiological factorsmoking is the most common aetiological factor..- - others: passive smokers , exposure to asbestos, others: passive smokers , exposure to asbestos,

chromium , iron oxide and products of chromium , iron oxide and products of cool combustioncool combustion

TypesTypes::There are 4 major typesThere are 4 major types : :

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

33 - -large cell carcinoma -15%large cell carcinoma -15%

44 - -small cell lung cancer -20%small cell lung cancer -20%

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

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

..usually starts on one breathing tubesusually starts on one breathing tubes....tend to be localized in the chest longer tend to be localized in the chest longer

than other types of lung cancerthan other types of lung cancer....does not tend to metastasize earlydoes not tend to metastasize early..

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

Adenocarcinnoma-30%Adenocarcinnoma-30%::

..most common cancer among most common cancer among womenwomen..

..usually started near the outer usually started near the outer edges of the lungedges of 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 bodymay spread to other parts of the body..

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

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

..less well less well –– differentiated differentiated....may occur at any part of the lungmay occur at any part of the lung....Tumors are large by the time they Tumors are large by the time they

are diagnosedare diagnosed....has greater possibility of spreading has greater possibility of spreading

to brain and mediastinumto brain and mediastinum..

Small cell lung cancerSmall 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 cells] where many hormones are secretedsecreted

..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 usually started in one larger breathing tubetube..

..Tend to grow rapidlyTend to grow rapidly. . ..commonly has spread by the time and commonly has spread by the time and

is considered a is 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

presentationspresentations::

..lung cancer may present in number lung cancer may present in number of different ways of different ways: :

..most commonly symptoms reflect most commonly symptoms reflect local involvement of the bronchuslocal involvement of the bronchus . .

..may also arise from spread to the may also arise from spread to the chest wall or mediastinum or from chest wall or mediastinum or from distant blood-borne spreaddistant blood-borne spread..

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

11 - -cough ( in 80% of cases )cough ( in 80% of cases ): : - - It is the most common early symptomsIt is the most common early symptoms..

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

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

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

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

33 - -Dyspnea ( 60% of cases )Dyspnea ( 60% of cases ):: - - reflect occulusion of a large reflect occulusion of a large

bronchus resulting in collapse of a bronchus resulting in collapse of a lobe of the lung or development of lobe of the lung or development of plearal effusionplearal effusion..

44 - -Plearal painPlearal pain: : reflect malignant invasion of the reflect malignant invasion of the

pleura or reflect infection distal to a pleura or reflect infection distal to a tumuor (wich is recurrent and fail to tumuor (wich is recurrent and fail to resolve)resolve)..

Direct spreadDirect spread::

..Involvement of Involvement of pleurapleura and and ribsribs. .

..PancoastPancoast’’s tumours tumour : :--involvement of lower part of the brachial involvement of lower part of the brachial

plexus ( C8 , T1,T2) causing plexus ( C8 , T1,T2) causing severe pain of severe pain of the shoulder and down inner surface of the the shoulder and down inner surface of the armarm..

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

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

..Invation of phrenic nerve , Invation of phrenic nerve , causing causing paralysis of the paralysis of the diaghragmdiaghragm..

.. Involvement of esophagus , Involvement of esophagus , causing causing dysphagiadysphagia..

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

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

Nonmetastatic extra Nonmetastatic extra pulmonary manifistationpulmonary manifistation::

11 - -Endocrine manifestationEndocrine manifestation::12%12% of tumors ,in particular small of tumors ,in particular small

cell tumors present with cell tumors present with SIADH, SIADH, ACTHACTH secretion(SCLC), secretion(SCLC), hypercalcemiahypercalcemia(sq.cell (sq.cell carcinoma) ,bone metastasis carcinoma) ,bone metastasis gynaecomastiagynaecomastia(LCLC)(LCLC). .

22 - -Neurological manifetationNeurological manifetation:: e.g: sensory e.g: sensory

polyneuropathy ,myelopathy, polyneuropathy ,myelopathy, cerebellar degenerationcerebellar degeneration..

33 - -OthersOthers::Digital clubbing , hypertrophicDigital clubbing , hypertrophic pulmenary osteo-arthropathypulmenary osteo-arthropathy (sq.cell (sq.cell cancer)cancer) , nephrotic syndrom, DIC, , nephrotic syndrom, DIC, hypercoagulopathyhypercoagulopathy (adenocarcinoma),(adenocarcinoma), ,thrombophelibitis ,thrombophelibitis migricansmigricans..

Blood borne metastasisBlood borne metastasis::

..Bony metastasis giving severe Bony metastasis giving severe bony bony pain and pathalogical fracturespain 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 signsPhysical signs::

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

11 - -physical signs of collapse (in large physical signs of collapse (in large obstructing tumor) which may obstructing tumor) which may

rise to pneumoniarise to pneumonia . .22 - -monophonic or unilateral wheeze monophonic or unilateral wheeze

(fixed bronchial obstruction)(fixed bronchial obstruction)..33 - -stridor (obstruction at or above the stridor (obstruction at or above the

lever of main carinalever of main carina . .

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

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

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

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

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

Management Management

InvestigationInvestigation::

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

. .chest x-raychest x-ray:: common radiological presentation common radiological presentation

of bronchial carcinomaof bronchial carcinoma..11 - -unilateral hilar-enlagementunilateral hilar-enlagement..

22 - -peripheral pulmonary opacityperipheral pulmonary opacity..33 - -lung, lobe or segmental collapselung, lobe or segmental collapse . .

44 - -pleural effusionpleural effusion. . 55 - -broadening of the mediastinumbroadening of the mediastinum , ,

enlarged cardiac shadow, enlarged cardiac shadow, elevationelevation

of hemidiaphramof hemidiaphram..66 - -rib distructionrib distruction..

. .Pleural fluid cytology in pleural Pleural fluid cytology in pleural effusioneffusion. .

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

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

..Head CT scanHead CT scan..

..Radio nuclide bone scanningRadio nuclide bone scanning..

..liver USliver US..

..bone marrow biobsybone marrow biobsy..

TreatmentTreatment::

11 - -surgerysurgery : in patient with localized : in patient with localized disease and non-small cell cancerdisease and non-small cell cancer..

22 - -solitary pulmonary nodule ,solitary pulmonary nodule , resection ifresection if: :

11 - -age ≥ 35age ≥ 35 2-segarette smoking2-segarette smoking.. 33 - -large (large (>>2 cm) lesion. 4-lack of cacification2 cm) lesion. 4-lack of cacification . .

55--chest symptomschest symptoms . .

66 - -growth of lesion compared old CXRgrowth of lesion compared old CXR..

33 - -for unresectable non-small cell for unresectable non-small cell cancer, metastatic disease, or cancer, metastatic disease, or refusal of surgeryrefusal of surgery::

radio therapy +chemo therapyradio therapy +chemo therapy may reduce death risk by 13% may reduce death risk by 13%

at 2 yearsat 2 years..

44 - -small cell lung cancer : combinationsmall cell lung cancer : combination chemotherapychemotherapy is standard mode of is standard mode of

therapy with long-term survivaltherapy with long-term survival..55 - -laser obliterationlaser obliteration of tumor though of tumor though

bronchoscopy in presence ofbronchoscopy in presence of bronchial obstructionbronchial obstruction..

66 - -Radio therapyRadio therapy for brain for brain metastasismetastasis,,

spinal cord comprission, spinal cord comprission, symptomaticsymptomatic

mass, bone lesionmass, bone lesion..77 - -Encourage cessation of smokingEncourage cessation of smoking..

Thank youThank you