Lung Carcinoma

Background
Epidemiology
Most common cause of cancer-related death in both men and women.

Pathophysiology
Lung carcinoma was traditionally divided as small cell carcinoma and non-small cell carcinoma. Now
for better determination of prognosis and to deliver personalized therapy non-small cell carcinomas
are further divided.

Cell type Incidence Features

in UK (%)

Squamous cell carcinoma
35 • Remains the most common cell type in Europe
• Arises from epithelial cells, associated with production
of keratin
• Occasionally cavitates with central necrosis
• Causes obstructing lesions of bronchus with post-
obstructive infection
• Local spread common, metastasizes relatively late

Adenocarcinoma 27-30
• Likely to become the most common cell type in the UK in
the near future (most common cell type in the USA)
• Increasing incidence since 2005 possibly linked to low-tar
cigarettes
• Originates from mucus-secreting glandular cells
• Most common cell typo in non-smokers
• Often causes peripheral lesions on chest X-ray/CT
• Subtypes include bronchoalveolar cell carcinoma
(associated with copious mucus secretion. multifocal
disease)
• Metastases common: pleura, lymph nodes, brain,
bones, adrenal glands

Large cell carcinoma 10 - 15 • Often poorly differentiated

• Metastasizes relatively early

Small cell carcinoma 20 • Often secretes polypeptide hormones

• Often arises centrally and metastasizes early
• Arises from neuroendocrine cells(APUD cells)

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Presentation
General symptoms
1. LOW
2. LOA
3. Low grade fever

Respiratory symptoms
1. Cough
2. Breathlessness
3. Haemoptysis
4. Chest pain
5. Wheeze

Local Spread
1. Hoarse voice
2. Small muscle wasting of the hand and pain radiating down the arm
3. Horner’s syndrome
4. Recurrent infections
5. Direct invasion of the phrenic nerve - invading the phrenic nerve causes
paralysis of the ipsilateral hemidiaphragm. It can involve the oesophagus,
producing progressive dysphagia, and the pericardium, resulting in pericardial
effusion and malignant dysrhythmias.
6. SVC obstruction
7. Progressive dyspnoea – Tracheal tumours

Symptoms Metastatic spread

1. Liver - Common symptoms are anorexia, nausea, and weight loss. Right upper
quadrant pain radiating across the abdomen is associated with liver capsular
pain.
2. Bone- Bony pain and pathological fractures occur because of tumour spread. If
the spine is involved, there is a risk of spinal cord compression.
3. Brain- Metastases present as space-occupying lesions with subsequent mass
effect and signs of raised intracranial pressure such as early morning headaches
and vomiting. Less common presentations include carcinomatous meningitis
with cranial nerve defects, headache, and confusion.
4. Malignant pleural effusion. This presents with breathlessness and is commonly
associated with pleuritic pain.

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 Non – metastatic extrapulmonary manifestations

Differential diagnoses
Pulmonary There is night sweating and evening pyrexia. Usually has a past history or a
TB contact hx of TB
Bronchiectasis Chronic cough with large volume of mucopurulent sputum
Lung abscess Fever with chills and rigors and foul-smelling breath
Vasculitis Usually with haematuria
Coagulopathy Other bleeding manifestations

Aetiology (causes)
M Metabolic / endocrine
I Infective / iatrogenic HIV infection
D Degenerative
N Neoplastic
I Inflammatory/ immunological Pre-existing lung disease such as pulmonary fibrosis
G Genetic/ congenital Has genetic component
H Haematological/ vascular
T Traumatic / toxins Smoking
Radon exposure, asbestos, polycyclic aromatic hydrocarbons
and ionizing radiation; occupational exposure to arsenic,
chromium, nickel, petroleum products and oils

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Investigations
Investigations are necessary to:

1. Stage the extent of disease.

• Staging is done according to TNM staging system.

Chest X-ray

CT (chest+ Metastasis
abdomen)
Pet CT
MRI Brain Brain metastasis
Bone scan Bone metastasis

2. make a tissue diagnosis (to differentiate small-cell from non-small-cell lung cancer, as well as
to detail the molecular characteristics – increasingly relevant with newer targeted biologic
agents and immunotherapy)

• Fibreoptic bronchoscopy
• Endobronchial ultrasound
• CT/ultrasound-guided biopsy of lung lesions
• Ultrasound-guided biopsy of lymph nodes, liver metastases or skin lesions
• Ultrasound-guided pleural aspiration
• Medical or video-assisted thoracoscopy
• Mediastinoscopy

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 3. Assess fitness to undergo treatment.
• The Eastern Cooperative Oncology Group (ECOG) performance status should be
recorded for all patients with suspected malignancy.
• Lung function testing with transfer capacity, and if cardiovascular disease is present,
cardiopulmonary exercise testing, stress echo or, occasionally, preoperative
angiography may be required.

Management
Principles
• SCLC are metastasised by the time of diagnosis. So not curable by surgery. Radiation and
chemotherapy needed.
• NSCLC respond poorly to chemotherapy and radiation. So better treated with surgery.
• Palliative treatment for patients with advanced disease.

Surgery
• Surgery is performed in early-stage NSCLC (stages I, II and selected IIIA) with curative intent.
• Many patients with stage III disease are treated with chemoradiation with a view to
downstaging disease and rendering it amenable to surgical resection.
• Where surgical staging of resected lung cancer demonstrates nodal involvement, patients
require adjuvant chemotherapy.

Radiation therapy with curative intent

• In selected patients with adequate lung function and early-stage NSCLC, high-dose
radiotherapy or continuous hyper fractionated accelerated regimens (CHART) provide a
good alternative to surgical resection with almost comparable outcomes.

Palliative care
• Palliative radiotherapy
• Give emotional and psychological support.
• Keep the patient symptom free as far as possible.

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Chemotherapy, targeted therapy, and immunotherapy
• Targeted agents against EGFRs, tyrosine kinases and anaplastic lymphoma kinases (ALK) in
NSCLC
• Immunotherapy with checkpoint inhibitors and PDL-1 inhibitors modulate the immune
response and offers another treatment option in appropriate patient groups.

Laser therapy, cryotherapy, and tracheobronchial stents

• These techniques are used in the palliation of inoperable lung cancer in selected patients
with tracheobronchial narrowing from intraluminal tumour, or extrinsic compression causing
disabling breathlessness, intractable cough and complications including infection,
haemoptysis, and respiratory failure.

References

1. Kumar and Clark’s Clinical Medicine

2. Long Case book (Praveen sir and Sahan ayya )

A Project by the Academic Committee – 2018 AL batch 6