Lungs CA

1. LUNG CANCER

4. Lung cancer Types
The most common type of lung cancer
In the UK Squamous cell cancer
In the USA Adenocarcinoma

6. Lung cancer : Non-Small Cell Carcinoma
• There are three main subtypes of non-small cell lung cancer:
1. Squamous cell cancer 2. Adenocarcinoma 3. Large cell lung carcinoma
Squamous cell cancer
Typically central (Squamous= Sentral)
Associated with:
• Parathyroid hormone-related protein (PTHrP) secretion hypercalcaemia
• Strongly associated with Finger clubbing
• Hypertrophic pulmonary osteoarthropathy (HPOA)
The presence of clubbing and tender wrists without synovitis makes pulmonary
osteoarthropathy the most likely diagnosis.
It is usually associated with underlying carcinoma of the lung.
Associated with bronchogenic carcinoma in 90% of cases.
The most sensitive diagnostic investigation is isotope bone scan: increase in the uptake in long
bones, around periarticular surfaces, and also mandible and scapulae
Regression of the pain has been reported with successful resection of the tumor and after vagotomy
• Hyperthyroidism due to Ectopic TSH

7. Most squamous-cell carcinomas present as obstructive lesions, which can manifest as
Infection.
Life threatening haemoptysis
is a medical emergency that requires prompt action.
Pulmonary angiography will identify the blood supply to the tumor and embolization of this vessel(s) will
immediately stem the bleeding.
Histology
will show clusters of lightly stained cells, often associated with groups of partially
keratinized, acidophilic cell clusters.
Pleomorphic cells in cluster with keratin pearls and intercellular bridges

8. Adenocarcinoma
• most common type of lung cancer in non-smokers, although the majority of patients who
develop lung adenocarcinoma are smokers
• Typically located on the lung periphery Normal bronchoscopy.
• May associate with Gynecomastia.
• PET/CT scan offers the best imaging modality to determine LN involvement in bronchial
adenocarcinoma
Histology will show:
• Malignant cells more often arranged in small clusters with an obvious lumen
and duct-like structures.
• Mucin-containing tumor cells with glandular differentiation

9. Bronchioloalveolar cell carcinoma
Bronchioloalveolar cell carcinoma
• It is an adenocarcinoma.
• accounts for around 5% of all primary lung carcinomas.
• 1% of all bronchial carcinomas.
• Growth along the alveolar walls without actually destroying them.
• The classic massive clear frothy sputum (bronchorrhoea) can be up to one liter a
day.
• Other symptoms are dyspnea, weight loss and chest pain.
• Almost a half of patients are diagnosed on routine CXR, usually demonstrating a
peripheral lesion.
• The tumor spreads using the alveolar walls as a frame and the alveoli are often
filled with mucin.
• In those whose tumor is not resect able, prognosis is poor.

10. Management of non-small cell lung cancer
Surgery
• only 20% suitable for surgery
• Stage I (cT1N0 and cT2N0) and stage II (cT1N1, cT2N1 and cT3N0) tumors
should be considered operable.
• Stage IIIA (cT3N1 and cT1-3N2) tumors have a low chance of being cured by
surgery alone, but it can be used in combination with chemotherapy.
• Stage IIIB and IV tumors considered inoperable.
 mediastinoscopy performed prior to surgery as CT does not always show mediastinal
lymph node involvement
The functional criteria for pneumonectomy are:
• Forced expiratory volume in 1 second (FEV-1) of >1.5 litres
• FEV-1 > 50% of the observed forced vital capacity, and
• Normal partial pressure of arterial CO2 (Paco2) with the patient at rest
• Prognosis after surgery is about 50-67% at 5 years with stage 1disease
Curative and palliative radiotherapy

11. Contraindications for surgery include:
• Patient refusal
• Asses general health (age 70+rs IHD,MI recent 6wks,increased PCO2
• FEV1 < 1.5 liters is considered a general cut-off point
• If the tumor necessitates a pneumonectomy, the post-bronchodilator FEV should be more than 2 liters.
• Metastases.
• stage III b or IV (i.e. metastases present)
• tumor near hilum
• vocal cord paralysis (implies extracapsular spread to mediastinal L.N)
• SVC obstruction
• Malignant pleural effusion
• Most pleural effusions associated with lung carcinoma are due to the tumor (and results in classification as a
T4 tumor).
• Spread to involve the C8, T1 and T2 nerve roots occurs by rib erosion by tumor to involve the lower roots of
the brachial plexus and is known as a Pancoast tumor.
• This causes severe pain in the shoulder and down the inner aspect of the
arm on the affected side and is a contraindication to surgery

12. Pancoast tumor
• Neoplasm apex of the lung that typically invades the chest wall and brachial plexus causing a Horner's
syndrome (ptosis and constriction of the pupil).
 compresses the sympathetic fibers (from T1 and T2) as they travel upwards to
superior cervical ganglion and then to the dilator pupillae as the long ciliary
nerve.
• The tumor causes pain in the C8 and T1 distribution and Horner's syndrome.
 pain in the shoulder and the medial surface of the arm.
 Patients may initially present to rheumatologists or orthopedic surgeons.
• It may cause small muscle wasting of the hands and erosion of the first rib
 the investigation of choice CT of chest
 CT is essential to locate the tumor and the extent of rib, vertebral and muscle
involvement.
 Chest x-ray may be normal
• Tumors are most commonly squamous cell and are usually inoperable on
presentation

13. Staging lung carcinoma
• It is important to remember the criteria for staging carcinoma of the lung. TNM staging
takes into account;
The size and position of the tumor (T)
Whether the cancer cells have spread into the lymph nodes (N)
Whether the tumor has spread anywhere else in the body - secondary cancer or
metastases (M)
• Computed tomographic (CT) scanning is recommended as a staging procedure. Where
available, PET scanning may be superior
• CT can be performed with or without contrast enhancement, but Contrast enhancement
makes it easier for inexperienced observers to interpret the CT.
• Overall, preoperative CT staging has been shown to overstage or understage when
compared with operative findings in 40% of patients. So biopsy is also needed.

14. TNM System
The International Association for the Study of Lung Cancer (IASLC) developed a SEVENTH EDITION
OF THE TNM SYSTEM in 2010 replaced earlier editions: as fellow
Primary tumor — (T)
T0 – No evidence of primary tumor.
Tis – Carcinoma in situ.
T1 – Tumor that is ≤3 cm
T1a: Tumor is ≤2 cm
T1b: Tumor is >2 cm, but ≤3 cm
T2 – Tumor that is >3 cm but ≤7 cm
T2a: Tumor is >3 cm, but ≤5 cm
T2b: Tumor is >5 cm, but ≤7 cm
T3 – Tumor that is >7 cm ; invades the chest wall (including superior sulcus tumors),
diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium
T4 – Tumor of any size that invades the mediastinum, heart, great vessels, trachea,
recurrent laryngeal nerve, esophagus, vertebral body, or carina; or separate tumor
nodule(s) located in a different lobe of the ipsilateral lung.

15. Regional lymph nodes — (N)
• N0 – No regional lymph node involvement.
• N1 – Involvement of ipsilateral intrapulmonary, peri bronchial, or hilar lymph
nodes.
• N2 – Involvement of ipsilateral mediastinal or sub carinal lymph nodes.
• N3 – Involvement of contralateral mediastinal or hilar lymph nodes.
Metastasis — (M)
• M0 – No distant metastasis
• M1a – Malignant pleural effusion, pericardial effusion, pleural nodules, or metastatic
nodules in the contralateral lung
• M1b – Distant (extra-thoracic) metastasis
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17. Carcinoid lung
Overview
• Carcinoid tumors are neuroendocrine
• Originate from Kulchitsky (K) cells in the lung
• Slow growing
• Smoking is NOT a risk factor
Incidence: Lung carcinoid accounts
• 1% of lung tumors
• 10% of carcinoid tumors.
• typical age = 40-50 years
• The incidence is equal between men and women

18. FEATURES
• Often asymptomatic
• Long history of cough,
• Recurrent hemoptysis
• Recurrent infections
Carcinoid tumors (80-90%) develops in a bronchus cause bronchial obstruction Lower
respiratory tract infection.
• Carcinoid syndrome (rare)
• Associated conditions with carcinoid tumor in the lung
Carcinoid syndrome (rare)
• Depends on associated liver metastases
• Occurs in less than 10% of patients with carcinoid tumors, but occurs
most commonly in GIT tumors.
• Can secrete a number of vasoactive compounds (including serotonin and
bradykinin), which result in:
bronchospasm, diarrhea, skin flushing, right sided valvular heart lesions
ACTH secretion and subsequent Cushing's syndrome.
Ectopic growth hormone-releasing hormone [GHRH] and subsequent acromegaly
Multiple endocrine neoplasia (MEN) type 1 where pancreatic neuroendocrine

19. Investigation
CXR
• Often centrally located and not seen on CXR.
• Usually occur in the major bronchi, 85% can be seen Bronchoscopically.
• Most often located in the main bronchi, and occur most frequency in the right
middle lobe.
• A carcinoid tumor in the left lower lobe bronchus could cause distal collapse of
the left lower lobe.
Bronchoscopy
• identifies up to 80% of carcinoid tumors in the main bronchi.
• seen as a highly vascular 'cherry-like' tumor ('cherry red ball')Biopsy is usually followed with brisk
bleeding and should be done via rigid bronchoscopy.
• The histological picture of granular eosinophilic staining of the cytoplasm, is highly suggestive of a
carcinoid tumor.
• Histologically, these tumors consist of compact nests of epithelial cells surrounded by neat, delicate
connective tissue capsules.

20. • Plasma chromograffin A is an effective screening test for carcinoid as it is
very
sensitive, but it is not specific.
• 24 hour urinary excretion of 5-hydroxyindoleacetic acid is more specific for
the
diagnosis, but false positives and negatives are present.
• Scintigraphic imaging with labelled somatostatin increases the ability to
diagnose a carcinoid tumor, but biopsy is required to confirm.
Management
• Surgical resection
• A person with an isolated pulmonary carcinoid should be referred for
tumor resection,
• Somatostatin analogues can be used where there is no possibility
Prognosis
• If no metastases then 90% survival at 5 years

21. Small cell Lung CA
• Also known as "oat-cell carcinoma“ usually central
• arise from APUD* cells an acronym for
• Amine - high amine content
• Precursor Uptake - high uptake of amine precursors
• Decarboxylase - high content of the enzyme decarboxylase
• Most aggressive cancer which typically presents with a short history and 80–90% will have metastases at the time of presentation.
Features
• Ectopic ADH hyponatremia (SIADH )occurs in 5–10% of cases
• Ectopic ACTH Cushing's syndrome
• Due to the short natural history of this type of cancer, Cushing syndrome in small cell ca does not manifest classically by buffalo hump, striae
or central obesity.
• Its presence is suspected by arterial hypertension, hyperglycemia,
hypokalemia, alkalosis and muscle weakness.
• ACTH secretion can cause bilateral adrenal hyperplasia,
• The high levels of cortisol can lead to hypokalemic alkalosis
• In case of chronic heavy smoker with chest infection +hyperglycaemia + Ļow K + increase HCO3? Suspect SCLC with ectopic ACTH secretion.
But if with Low Na and increased K think of Adrenal metastasis MRI adrenals
• Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenia like syndrome
• Neuron-specific enolase (NSE) is a tumor marker indicative of small cell carcinoma
• Associated with L-myc amplification.
• Histologically, Small cell carcinoma has clusters of small, basophilic cells and

22. Management
Usually metastatic disease by time of diagnosis and surgery done only for de bulking
Stage
Early stage (T1-
2a,N0,M0)
Surgery
Early stage (T1-
2a,N0,M0)-
Limited disease
(T1-4,N0-3,M0)
4-6 cycles cisplatin based
chemotherapy, carboplatin if poor
renal function/poor performance
status +/- radiotherapy
Extensive disease
(T1-4, N0-3,
M1a/b)
6 cycles platinum based
combination chemotherapy +
thoracic
radiotherapy if good response
Prognosis
Very poor and survival beyond two 2 years is exceptional
Adverse prognostic factors in small cell lung cancer:
• Serum Na < 132 mmol/l
• Weight loss > 10%
• WHO performance status > 2
• Alkaline phosphatase > 1.5 times upper limit of normal
• LDH > 1.5 times upper limit of normal
• Extensive disease (occurring outside one hemi-thorax and ipsilateral supraclavicular fossa
nodes).
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23. ___
Bronchial Carcinoma
• 20-30% of cases with bronchial carcinoma are of small (oat) cell type from endocrine Kcells (Kulchitsky) cells
• Primary bronchial cancer the tumour edge may have a fluffy or spiked
appearance.
• Paraneoplastic manifestations:
 SIADH (5 - 10%)
 ACTH (5 %)
 ANP
• The most appropriate tool to confirm the diagnosis of bronchial carcinoma is
Bronchoscopy ± Trans bronchial biopsy (NOT CT-guided FNA biopsy).
• CT-guided FNA would be useful; however, there is a high risk of pneumothorax
in patients with FEV1 < 1.
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24. Lung cancer: paraneoplastic features
• Paraneoplastic syndromes are a result of antibody generation from or against malignant cells attacking
normal tissue.
• Both non-small cell and small cell lung cancers are associated with Paraneoplastic syndromes, although they
are more common with the small cell due to its neuroendocrine cell origin.
Squamous cell
• Parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcemia
• Occurs in about 15%
• Best treated with intravenous fluids and bisphosphonates
• Clubbing
• Hypertrophic pulmonary osteoarthropathy (HPOA)
(HPOA) is a proliferative peri-ostisis typically involves the long bones.
It is often painful.
• Hyperthyroidism due to ectopic TSH
Adenocarcinoma
• Gynecomastia
• Bronchial carcinoma can presents with ataxia and bilateral Gynecomastia
• It can be painful and may be associated with testicular atrophy.
• Ataxia can occur as a result of a paraneoplastic cerebellar degeneration associated
with the malignancy

25. Small cell
• ADH : Symptomatic hyponatremia due to SIADH is treated with demeclocycline which induces nephrogenic diabetes insipidus leading to
excretion of excess water.
• ACTH : not typical, hypertension, hyperglycemia, hypokalemia, alkalosis and muscle weakness are more common than buffalo hump etc.
 May manifest by Cushingoid facieses and hyperpigmentation of the skin
• Lambert-Eaton syndrome
70% occur in small cell carcinoma
 is a pre-synaptic disorder of auto-antibody IgG directed against the pre-synaptic voltage gated calcium
channel (VGCC) leading to impaired acetylcholine release.
 Characterized by:
• Proximal muscle weakness (the cranial nerves and respiratory muscles are usually spared)
• Depressed or absent tendon reflexes and
• Autonomic features (for example, dry mouth, impotence, etc.).
Weakness and fatigability can be improved with guanidine hydrochloride
Unlike myasthenia gravis exercise is associated with increasing muscle strength and there is a negative
response to Tensilon.
Electromyography is useful in confirming the diagnosis where repeated nerve stimulations cause a
progressive increase in the size of the muscle action potential.
Cerebellar ataxia:
 Paraneoplastic syndromes are a result of antibody generation from or against malignant cells attacking normal tissue.
 Example: anti neuronal antibodies (anti-Hu, anti-Yo, anti-Ri ) directed against the Purkinje cells of the cerebellum
leading to the cerebellar syndrome (truncal ataxia).
 To diagnose this : Anti-Purkinje cell antibody levels.