LUNG CANCER

BY: IVAN EMMANUEL

BOKINGKITO
GENERAL DATA

• This is the case of patient T. N. a 72-year old male, married, Roman Catholic from Bacong,
Negros Oriental

• Informant: Patient
• Reliability: 96%
• Chief complaint: Dyspnea
HISTORY OF PRESENT ILLNESS
• 1 year PTA, patient had onset of non-productive cough, patient tolerated symptoms and did not
seek consult.
• 5 months PTA, patient noted dull bone pain with associated headache with a pain scale of 5/10.
• 1 month PTA, patient had noted weight loss, anorexia and sudden onset of exertional dyspnea
with associated acid reflux,this was not associated with chest pain, tightness, headache or fever.
Patient tolerated symptoms and did no self medicate.
• 3 weeks PTA, persistence of symptoms now associated with fatigue. Patient tolerated
symptoms and did not seek consult
• 3 hours PTA, patient had onset of hemoptysis and chestpain which prompted patient to be
brought to the ER.
 PAST MEDICAL HISTORY

• Patient had full childhood vaccinations

• Patient is fully vaccinated for Covid-19 with Sinovac
• Patient is non hypertensive
• Patient is diabetic and is maintained on
– Metformin (GLUMET) 500mg 1 tab OD
PAST MEDICAL HISTORY

• This is the patient’s 1st time being admitted

• Past surgeries:
– None
FAMILY HISTORY

• Maternal side: Hypertension, Diabetes, and Cancer (Lung and Liver)

• Paternal side: Hypertension and Diabetes (Prostate)
PERSONAL AND SOCIAL HISTORY

• Smoker for 58 years with 58 pack years

• Occasional alcoholic beverage drinker
• Denies use of illicit drugs
• He is a retired government employee
REVIEW OF SYSTEMS

General:
(+) Weight loss & trouble sleeping
(-) Fatigue, Fever and Chills
Skin:
(-) Rashes, Lumps, Itching, Dryness, Color changes, Hair and nail changes
Head:
(-) Headache, Lumps and tenderness
Ears:
(-) Decreased hearing, Tinnitus, Earache, Drainage
Eyes:
(+) Blurry vision (-) Redness, pain, Glaucoma, Cataract
REVIEW OF SYSTEMS

Nose:
(-) Stuffiness, discharge, itching, epistaxis
Throat:
(-) Sore throat, dry mouth, bleeding gums, hoarseness
Neck:
(-) Lumps, swollen glands, pain
Respiratory:
(-) wheezing, hemoptysis
Cardiovascular:
(-) Chest tightness, edema, chest pain, palpitations
REVIEW OF SYSTEMS

Gastrointestinal:
(+) GERD, (-) Dysphagia, heartburn, diarrhea, constipation, indigestion, hematemesis
Urinary:
(-) Frequency, urgency, burning pain on urination
Musculoskeletal
(+) Lower back pain and myalgia (-) joint pain, stiffness,
Neurologic:
(-) Fainting, seizures, weakness, dizziness
REVIEW OF SYSTEMS

Hematologic:
(-) easy bruising, abnormal bleeding, ease of bleeding
Endocrine:
(-) heat or cold intolerance, thirst, polyuria
PHYSICAL EXAM
• BP= 120/80 PR = 68 RR= 18 O2sat = 98% Height = 172cm
• Weight = 50kg BMI = 16.9 = Underweight

• General: Alert, awake, coherent, cooperative, responsive, not in respiratory distress

• Skin: No lesions, no cyanosis, no jaundice, warm to the touch, good turgor, clubbing of fingernails and toenails
• Head: Normocephalic, no lesions, no lumps palpated
• Eyes: anicteric sclerae, pale palpebral conjunctiva
• Ears: Symmetric, cutaneous lesions noted on both ears, no gross deformities, ear canal is normal, webers and rinnes
test are normal
• Nose: Symmetric, no gross deformities, no alar flaring, nasal septum in midline, no discharges
• Throat: Tonsils were pink with a grade of 0, no tonsiloparangheal congestion
• Mouth: purple lips, purple discolorations on gums and oral mucosa, teeth incomplete with carries, jaundice noted on
sublingual area of tongue, uvula in midline
• Neck: lymphadenopathies noted on posterior cervical and supraclavicular area, trachea in midline
PHYSICAL EXAM

• Chest and lungs: no lesions, increased tactile fremitus in the right lung, unequal chest expansions, no retractions,
wheezing heard over right lung field.
• Cardiovascular: Adynamic precordium, PMI at the 5th ICS, distinct heart sounds, regular rate and rhythm, no
murmurs
• Abdomen: Flabby, no lesions, normoactive bowel sounds, tympanic on all quadrants, liver span 7cm, spleen and
kidneys are not palpable, no tenderness in deep palpation
• Extremities: Symmetric, without any gross deformities, no weakness, normal muscle tone, normal capillary refill
time, no cyanosis
• GUT: No costovertebral angle tenderness
• Musculoskeletal: No atrophy, no tenderness, no weakness
• Mental status: Oriented to time, place and person, able to recall past and present events, able to calculate simple
math problems
• DRE: No visible lesions, no external hemorrhoids, tight sphincter tone, no palpable masses, rectal walls non-
tender, empty rectal vault, prostate with clearly demarcated borders, was measure to be 2 fingerbreadths, no fresh
blood but with scanty yellow stool on examining finger.
PHYSICAL EXAM
Cranial Nerves
CN1 Olfactory Intact sense of smell
CN2 Optic Pupil 3mm, equally round, brisk reaction to light
CN3 Occulomotor Full EOM, free range of motion
CN4 Trochlear
CN6 Abducens
CN5 Trigeminal (+) Corneal reflex, able to distinguish from sharp from soft stimuli
CN7 Facial No facial asymmetry, able to smile and show teeth, intact facial expression
CN8 Accoustic Gross hearing intact
CN9 Glossopharyngeal (+) Gag reflex, able to swallow, no dysphagia, no hoarseness
CN10 Vagus

CN11 Spinal Accessory Able to shrug shoulders against resistance, able to move head left and right
against resistance
CN12 Hypoglossal Tongue in midline
 PHYSICAL EXAM
Motor:
5/5 for both upper and lower extremities

Sensory:
100% on both upper and lower extremities

Meningeals:
(-) Kernig sign
(-) Brudzinskyi sign

DTR:2+ on all tested tendons

Cerebellar:
Able to do finger to nose test
Heel to chin test
SALIENT FEATURES

• History: • Physical exam:

– Exertional dyspnea – Increased lung fremitus over right lung
– Hemoptysis – Unequal chest expansion
– Anorexia
– Wheezing heard over right lung field
– Weight loss
– Underweight
– Chronic cough
– Chest pain
– Headache
– Dull bone pain
– Smoker – 57 pack years
– Alcohol beverage drinker
LABORATORY EXAMS

Labs Results
Hemoglobin 8 12-14
Hematocrit 31 37-44
Bands 4 0
WBC 10500 4500-11000
Platelet 705 150-400
Alkaline phosphatase 30 38-126
Calcium 8 8.4-10.2
IMAGING

• X-ray : radiopaque area over

right lower lung field and in
mediastinal area
BRAIN CT
HISTOPATHOLOGY

• Small-cell carcinoma
IMPRESSION

• Small-cell carcinoma, ED (extensive disease)

LUNG CANCER
INTRODUCTION

• Disease of the modern man

• 60% of new lung cancers are
from former smokers ( >=
100 cigarettes in a lifetime,
>= a year)
• Uncommon below the age of
40, peak at 80 years old
RISK FACTORS

• Cigarette smoking = 10 fold

or greater risk for developing
lung CA
• One genetic mutation for
every 15 cigarettes smoked
• Former smokers = 9 fold risk
of developing lung CA
• Environmental tobacco smoke
= 20-30% increased risk
RISK FACTORS

• Other causes:
– Asbestos
– Arsenic
– Bischloromethyl ether
– Hexavalent Chromium
– Mustard Gas
– Nickel
RISK FACTORS

• Genetics
• Polymorphisms of the P450
enzyme system, specifically
CYP1A1 and chromosome
fragility
• 1st degree relatives = 2 – 3
fold excess risk of lung
cancer
PATHOLOGY

• Small-cell lung cancer

• Non-small cell lung cancer
– Adenocarcinoma
– Squamous cell carcinoma
– Large-cell carcinoma
PATHOLOGY
• Small-cell carcinomas
– Scant cytoplasm
– Ill-defined cell borders
– Finely granular nuclear
chromatin
– Absent or
inconspicuous nuclei
– High mitotic count
– CD56, NCAM,
synaptophysin and
chromogranin
PATHOLOGY

• Adenocarcinoma
– Glandular differentiation or mucin production
– Acinar, papillary, lepidic, or solid features or a mixture of these patterns

• Squamous cell carcinoma

– Morphologically identical to extrapulmonary squamous cell carcinomas
– Squamous cell tumors show keratinization and/or intercellular bridges

– Consists of sheets of cells rather than the three-dimensional groups of cells characteristic of
adenocarcinomas.
PATHOLOGY

• All histologic types of lung cancer can develop in current and former smokers
• Squamous and small-cell carcinomas are most commonly associated with heavy tobacco use
• Squamous cell is the most common type during the 1st half of the 20th century
• Adenocarcinoma is the most frequent histologic subtype of lung CA

• The diagnosis of lung cancer most often rests on the morphologic or cytologic features
correlated with clinical and radiographic findings.
 MOLECULAR
PATHOGENESIS
• Cancer is a disease involving dynamic
changes in the genome.
• hallmark capabilities:
– Self-sufficiency in growth signals
– Insensitivity to antigrowth signals
– Evading apoptosis
– Limitless replicative potential
– Sustained angiogenesis
– Tissue invasion and metastasis.
MOLECULAR PATHOGENESIS

• Cancers arise as a result from accumulations of:

– Gain-of-function mutations in oncogenes
– Loss-of-function mutations in tumor-suppressor genes
CLINICAL MANIFESTATIONS

• Over half of all patients diagnosed with lung cancer present with locally advanced or metastatic
disease at the time of diagnosis
• Prototypical lung cancer patient
– 7th decade of life
– Current or former smoker
– Chronic cough with or without hemoptysis
– COPD at the age of 40 or older
CLINICAL MANIFESTATIONS
• Lung cancer arising in a lifetime never smoker is more common in women and East
Asians.
– younger than their smoking counterparts at the time of diagnosis.

• Patients with central or endobronchial growth of the primary tumor may present with:
– cough, hemoptysis, wheeze, stridor, dyspnea, or post obstructive pneumonitis.

• Peripheral growth of the primary tumor

– pain from pleural or chest wall involvement, dyspnea on a restrictive basis, and symptoms of a
lung abscess resulting from tumor cavitation.
CLINICAL MANIFESTATIONS

• Constitutional symptoms
– Anorexia, weight loss, weakness, fever, and night sweats.

• Symptoms cannot distinguish SCLC from NSCLC or even from neoplasms

metastatic to lungs
CLINICAL MANIFESTATIONS
• Extrathoracic metastatic disease is found at autopsy in
– More than 50% of patients with squamous carcinoma
– 80% of patients with adenocarcinoma and large-cell carcinoma
– More than 95% of patients with SCLC
• Approximately one-third of patients present with symptoms as a result of distant metastases
• Lung cancer metastases may occur in virtually every organ system
• Site of metastatic involvement largely determines other symptoms
– Brain metastasis
– Bone metastasis
– Liver metastasis
DIAGNOSING
LUNG CANCER
• Tissue sampling is required
to confirm a diagnosis in all
patients with suspected lung
cancer.
• In patients with suspected
metastatic disease, a biopsy
of a distant site of disease is
preferred for tissue
confirmation
• Core biopsy is preferred to
ensure adequate tissue for
analysis for
• Bronchial or transbronchial biopsy
• Fine-needle aspiration (FNA) or percutaneous biopsy using image guidance
• Endobronchial ultrasound (EBUS)-guided biopsy.

• lymph node sampling may occur via transesophageal endoscopic ultrasound-guided biopsy
(EUS), EBUS, or blind biopsy
DIAGNOSING LUNG CANCER

• Suspected metastatic disease

– percutaneous biopsy of a soft tissue mass, lytic bone lesion, bone marrow, pleural or liver lesion, or
an adequate cell block obtained from a malignant pleural effusion.

• Suspected malignant pleural effusion

– if the initial thoracentesis is negative, a repeat thoracentesis
is warranted.
DIAGNOSING LUNG CANCER

• Diagnostic yield depends of several factors:

– Location (accessibility)
– Tumor size
– Tumor type
– Technical aspects – experience of bronchoscopist and pathologist
• Central lesions (Squamous CC and Small CC) – Bronchoscopic examination
• Peripheral lesions (Adenocarcinoma and Large-cell carcinoma) – transthoracic
biopsy
DIAGNOSING LUNG CANCER

• Overall sensitivity for combined use of bronchoscopic methods is 80%, and

together with tissue biopsy, the yield increases to 85–90%
• Sensitivity is highest for larger lesions and peripheral tumors.
• Core biopsy specimens, whether transbronchial, transthoracic, or EUS-guided,
are superior to other specimen types
• Sputum cytology is inexpensive and noninvasive but has a lower yield than
other specimen types
STAGING LUNG CANCER

• Lung cancer staging consists of two parts:

– determination of the location of the tumor and possible metastatic sites (anatomic staging)
– assessment of a patient’s ability to withstand various antitumor treatments (physiologic
staging).

• Staging with regard to a patient’s potential for surgical resection is principally

applicable to NSCLC.
ANATOMIC
STAGING
• The accurate staging of patients with NSCLC is
essential for determining the appropriate
treatment in patients with resectable disease
• All patients with NSCLC should undergo initial
radiographic imaging with CT scan, positron
emission tomography (PET), or preferably CT-
PET.
• For brain metastases, magnetic resonance
imaging (MRI) is the most effective method
ANATOMIC STAGING
• In patients with NSCLC, the following are contraindications to potential curative resection:
– extrathoracic metastases
– superior vena cava syndrome
– vocal cord and, in most cases, phrenic nerve paralysis
– malignant pleural effusion
– cardiac tamponade
– tumor within 2 cm of the carina (potentially curable with combined chemoradiotherapy)
– metastasis to the contralateral lung
– metastases to supraclavicular lymph nodes
– contralateral mediastinal node metastases (potentially curable with combined
chemoradiotherapy)
– and involvement of the main pulmonary artery
ANATOMIC STAGING

• In SCLC patients, current staging recommendations include a PET-CT scan and MRI of the
brain
PHYSIOLOGIC
STAGING
• Patients with lung cancer often have other
comorbid conditions related to smoking
including cardiovascular disease and COPD.
• To improve their preoperative condition,
correctable problems should be addressed,
appropriate chest physical therapy should be
instituted, and patients should be encouraged to
stop smoking
STAGING SYSTEM

• Non-small cell lung cancer

– Tumor-Node-Metastasis (TNM) international staging

• Small-cell lung cancer

– Veterans Administration system and the American Joint Committee on Cancer/International Union
Against Cancer seventh edition system (TNM) be used to classify the tumor stage.
• distinct two-stage system dividing patients into those with limited- or extensive-stage disease.
– Sixty to 70% of patients are diagnosed with ED at presentation.
VETERANS ADMINISTRATION SYSTEM

• Limited disease
– confined to the ipsilateral hemithorax and can be encompassed within a tolerable radiation
port Thus, contralateral supraclavicular nodes, recurrent laryngeal nerve involvement, and
superior vena caval obstruction

• Extensive disease
– overt metastatic disease by imaging or physical examination. Cardiac tamponade, malignant
pleural effusion, and bilateral pulmonary parenchymal involvement generally qualify disease
as ED, because the involved organs cannot be encompassed safely or effectively within a
single radiation therapy port.