30,000 new cases of lung cancer per year in
England (6,000 in Scotland)
Commonest cause of cancer death (33%) in men
Commonest cause of cancer death in women in
90% mortality 1 year after diagnosis
The most rapidly increasing cancer in developing
Based on the characteristics of the disease and its
response to treatment -
Small cell lung cancer (SCLC)
Non-small cell lung cancer (NSCLC)
Squamous or epidermoid carcinoma
• The commonest type,
• Accounting for approximately 40% of all carcinomas.
• Most present as obstructive lesions of the bronchus
leading to infection.
• Occasionally cavitates (10%) at presentation.
• The cells are usually well differentiated
• Occasionally anaplastic.
• Local spread is common
• Widespread metastases occur relatively late.
• Arises from mucous cells in the bronchial epithelium.
• Invasion of the pleura and the mediastinal lymph nodes is
common, as are metastases to the brain and bones.
• Accounts for approximately 10% of all bronchial carcinomas.
• The most common bronchial carcinoma associ ated with
• Proportionally more common in
Often called oat-cell carcinoma,
Accounts for 20-30% of all lung cancers.
Arises from endocrine cells(Kulchitsky cells).
Small-cell carcinoma spreads early and is almost
always inoperable at presentation.
Rapidly growing and highly malignant.
Responds to chemotherapy
Prognosis remains poor
Lung cancer presents in many different ways, reflecting
local, metastatic or paraneoplastic tumour effects.
This is the most common early symptom.
It is often dry but secondary infection may cause
Haemoptysis is common, especially with central
Complete obstruction causes
collapse of a lobe or lung
dullness to percussion
reduced breath sounds.
Partial bronchial obstruction may cause
monophonic, unilateral wheeze that fails to clear
with coughing & impair the drainage of secretions to
cause pneumonia or lung abscess
Pneumonia that recurs at the same site or
responds slowly to treatment, particularly in a smoker,
should always suggest an underlying bronchial
Stridor (a harsh inspiratory noise) occurs when the
larynx, trachea or a main bronchus is narrowed by the
primary tumour or by compression from malignant
enlargement of the subcarinal and paratracheal lymph
Breathlessness may be caused by
collapse or pneumonia
tumour causing a large pleural effusion or compressing a
phrenic nerve and leading to diaphragmatic paralysis.
Pain and nerve entrapment.
Pleural pain usually indicates malignant pleural invasion
Intercostal nerve involvement causes pain in the
distribution of a thoracic dermatome.
Carcinoma in the lung apex may cause Horner’s
syndrome (ipsilateral partial ptosis, enophthalmos,
miosis and hypohidrosis of the face) due to
involvement of the sympathetic chain at or above
the stellate ganglion.
Pancoast’s syndrome (pain in the inner aspect of the
arm, sometimes with small muscle wasting in the
hand) indicates malignant destruction of the T1
and C8 roots in the lower part of the brachial
plexus by an apical lung tumour.
Dysphagia (Involvement of the oesophagus )
Arrhythmia or pericardial effusion (If the pericardium
Superior vena cava obstruction by malignant nodes causes
suffusion and swelling of the neck and face,
dilated veins on the chest wall
Involvement of the left recurrent laryngeal nerve by
tumours at the left hilum causes vocal cord paralysis,
voice alteration and a ‘bovine’ cough (lacking the
normal explosive character).
Supraclavicular lymph nodes may be palpably enlarged
or identified using ultrasound
focal neurological defects
Lassitude, anorexia and weight loss usually indicate
Overgrowth of the soft tissue of the terminal phalanx
increased nail curvature
nail bed fluctuation
Hypertrophic pulmonary osteoarthropathy
painful periostitis of the distal tibia, fibula,radius and ulna
sometimes pitting oedema over the anterior shin.
X-rays reveal subperiosteal new bone formation.
Routine Laboratory Tests :
CBC with PBF: Hematocrit less than 40% in males Hematocrit
less than 35% in females
LFT: Elevated alkaline phosphatase, GGT, AST, calcium AST,
aspartate aminotransferase ; GGT, γ- glutamyl transpeptidase.
CxR PA view: The features of bronchial carcinoma on plain X-rays are
CT is usually performed early, as
it may reveal mediastinal or metastatic spread, and
helps to direct histological sampling procedures.
also indicates whether a tumour is likely to be accessible by bronchoscopy.
USG: evidence of tumour spread to sites.
Pleural biopsy: Pleural fluid aspiration and biopsy is the preferred investigation
lymph node biopsy: to give histology
Bronchoscopy: to give histology and operability
Where facilities exist, thoracoscopy increases yield by allowing
targeted biopsies under direct vision.
bone marrow biopsy: evidence of tumour spread to sites.
Combined CT and PET imaging is used increasingly to detect metabolically
active tumour metastases
Radioneuclide bone scanning: if suspected metastasis
Lung function tests:
Radiological Clues to Suspect
1. Mass lesion or coin shadow…..fig 1
2. Mediastinal widening due to enlargement of
lymph nodes ……fig 5
3. Rib erosion and rib fracture….fig 3
4. Phrenic nerve paralysis in the presence of
5. Presence of pleural effusion….fig 6
6. Cannon ball shadows….fig 4
Large cavitated bronchial carcinoma in left
Bronchogenic carcinoma. Left upper/zone
consolidation due to tumor and collapse. Rib erosion (arrow)
suggests malignant lesion—bronchogenic carcinoma….Fig 3
Pulmonary metastases. Bilateral cannon ball
shadows—common primaries thyroid, bone and
Lymphoma. Note: The bilateral paratracheal lym-
phadenopathy (arrowheads) is a common cause of mediastinal
Pleural effusion right. Note: Hazy opacity occupying the right lower part, rising in
the axilla (long arrow 1). The costo-phrenic (short arrow 2) and cardiophrenic
angle (arrowhead 3) are obliterated in massive effusions, mediastinum is
displaced to the opposite side……………………………………fig 6
Common radiological presentations
of bronchial carcinoma
1. Unilateral hilar enlargement: Central tumour. Hilar glandular
involvement. However, a peripheral tumour in the apical segment of a lower
lobe can look like an enlarged hilar shadow on the PA X-ray
2. Peripheral pulmonary opacity: Usually irregular but well circumscribed,
and may contain irregular cavitation. Can be very large
3. Lung, lobe or segmental collapse: Usually caused by tumour within the
bronchus leading to occlusion. Lung collapse may be due to compression of
the main bronchus by enlarged lymph glands
4. Pleural effusion: Usually indicates tumour invasion of pleural space; very
rarely, a manifestation of infection in collapsed lung tissue distal to a bronchial
Common radiological presentations of
Broadening of mediastinum, enlarged cardiac
shadow, elevation of a hemidiaphragm
Paratracheal lymphadenopathy may cause widening of the
A malignant pericardial effusion will cause enlargement of the
Raised hemidiaphragm is caused by phrenic nerve palsy,
screening will show it to move paradoxically upwards when
8. Rib destruction: Direct invasion of the chest wall or
blood-borne metastatic spread can cause osteolytic
lesions of the ribs
Surgery is performed in early stage non-small cell
lung cancer (stage I, II and in selected IIIA)with
Many patients with stage III disease are treated with
chemo-radiation with a view to ‘downstaging’
disease and render it amenable to surgical resection
Accurate pre-operative staging, coupled with improve-
ments in surgical and post-operative care now offers 5-
year survival rates of over………
75% in stage I disease (NO, tumour confined within
55% in stage II disease
resection in patients with ipsilateral peribronchial or
hilar node involvement.
patients who are fit and who have a slowly growing squamous
treatment of choice if surgery is declined.
For symptomatic relief
Superior vena cava obstruction
Mainly for SCLC, less effective for NSCLC.
Vincristine or i.v. cisplatin