Ca lung
Dr. D.P. Singh
Professor, Surgery.
Primary lung cancer – risk factors Cigarette smoking
Number of years Number of packs Passive smoking
Atmospheric pollution Occupational (radioactive ore, chromium
mining, asbestos, arsenic) Previous h/o TB with smoking
Pathological types
Small cell lung carcinoma (oat cell carcinoma)
Non Small cell lung carcinoma SCLC:NSCLC :: 1:4
Histological classification
Small cell lung cancer Non small cell lung cancer
Adenocarcinoma 25-40% Large cell undifferentiated 10-20% Squamous cell carcinoma 30-40% Bronchoalveolar carcinoma 5%
Clinical features
Depend on Site of lesion Invasion of neighboring structures Extent of metastases
Clinical features
Symptoms Hemoptysis Cough or changed cough Dyspnoea, wheezing Pleural effusion Severe localized pain suggests chest wall invasion Invasion of mediastinum – hoarseness, dysphagia, SVC
obstruction Pancoast’s syndrome – invasion of brachial plexus Clubbing Small cell carcinoma may cause myopathies.
Paraneoplastic syndrome with lung cancer Endocrine
Hypercalcemia Cushing’s syndrome SIADH Carcinoid syndrome Gynaecomastia Hypercalcitonemia Elevated GH Elevated prolactin, FSH, LH Hypoglycemia hyperthyroidism
Paraneoplastic syndrome contd. Neurologic
Encephalopathy Subacute cerebellar degeneration PML Peripheral neuropathy Polymyositis Autonomic neuropathy Lambert eaton syndrome Optic neuritis
Paraneoplastic syndrome contd. Skeletal
Clubbing Pulmonary hypertrophic osteoarthropathy
Hematologic Anemia Leukemoid reaction Thrombocytosis Thrombocytopenia Eosinophilia Pure red cell aplasia DIC
Paraneoplastic syndrome contd. Cutneous
Hyperkeratosis Dermatomyositis Acanthosis nigricans Hyperpigmentation
Other Nephrotic syndrome Hypouricemia Secretion of VIP with diarrhea Anorexia and cachexia hyperamylasemia
Diagnosis
3 aspects Detecting the primary lesion Tissue diagnosis Staging
Investigations
Chest radiography Computerized tomography MRI EUS PET Bronchoscopy Sputum cytology CT guided biopsy Mediastinoscopy Mediastinotomy Assessment of functional status - spirometry
Cervical Mediastinoscopy
Anterior mediastinoscopy
Staging : T: Tumor status
TX - Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washing but not visualized by imaging or bronchosocopy
T0 - evidence of primary tumor Tis - Carcinoma in situ T1 - 3 cm or less without invasion of visceral pleura T2 - >3 cm or any size with associated atelectasis or obstructive
pneumonitis, or invasion of visceral pleura T3 - Any size with direct extension into chest wall, diaphragm,
mediastinal pleura without involvement of great vessels or vital mediastinal structures and extent of bronchial spread with 2 cm of, but not involving, the carina
T4 - Any size with invasion of the heart or mediastinal vital structures or carina, malignant pleural effusion
N: Nodal involvement
NX - Regional lymph nodes cannot be assessedN0None
N1 - Peribronchial or ipsilateral hilar lymph nodes
N2 - Ipsilateral mediastinal lymph nodes, including subcarinal
N3 - Contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral scalene or supraclavicular lymph nodes
M: Distant metastases
MX - Presence of distant metastases cannot be assessed
M0 - None M1 - Distant metastases present
Stage grouping
0 Carcinoma in situ IA
T1N0M0 IB
T2N0M0 IIA
T1N1M0 IIB
T2N1M0 T3N0M0
Stage grouping
IIIA T3N1M0 T1-3 N2M0
IIIB T4, Any N, M0 Any T, N3, M0
IV Any T, any N, M1
Treatment
Early stage disease (stage I and II) Surgery
Locoregional advanced disease (T3N1 and above)
Surgery – limited role Chemotherapy Radiotherapy
Surgical management
Lobectomy Pneumonectomy Thoracoscopic lung resection
Complications of lung resection Bleeding Respiratory infection Persistant air leak Bronchopleural fistula
Other treatment modalities
Radiotherapy Chemotherapy