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Lung cancer

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Definition: The term lung cancer is used for tumors arising from the respiratory epithelium (bronchi, bronchioles, and alveoli). Bronchial carcinoma accounts for 95% ... – PowerPoint PPT presentation

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Title: Lung cancer


1
Lung cancer
2
Definition
  • The term lung cancer is used for tumors arising
    from the respiratory epithelium (bronchi,
    bronchioles, and alveoli).
  • Bronchial carcinoma accounts for 95 of all
    primary tumours of the lung.
  • Alveolar cell carcinoma accounts for 2 of lung
    tumours, and other less malignant or benign
    tumours account for the remaining 3.

3
Bronchial carcinoma
  • This is the most common malignant tumour in the
    West and is the third most common cause of death
    in the UK after heart disease and pneumonia.
  • Male-to-female ratio of 3 1. Although the
    mortality rate from this disease has started to
    decrease in men, it continues to rise in women,
    and now causes more deaths from malignant disease
    in women than any other tumour.

4
  • Aetiological factors
  • cigarette smoking, passive smoking (the frequent
    inhalation of other people's smoke by
    non-smokers) increases the risk of bronchial
    carcinoma by a factor of 1.5.
  • Occupational factors include exposure to
    asbestos, and an association is also claimed for
    workers in contact with arsenic, chromium, iron
    oxide, petroleum products and oils, coal tar,
    products of coal combustion, and radiation.
  • Tumours associated with occupational factors are
    mostly adenocarcinomas and appear to be less
    related to cigarette smoking.

5
  • there is a higher incidence of bronchial
    carcinoma in urban compared with rural areas,
    even when allowance is made for cigarette
    smoking.
  • Pathology
  • Four major cell types make up 88 of all primary
    lung neoplasms according to the WHO
    classification.
  • These are
  • squamous or epidermoid carcinoma
  • small cell (also called oat cell) carcinoma
  • adenocarcinoma (including bronchioloalveolar)
  • large cell carcinoma.

6
  • The remainder include
  • undifferentiated carcinomas
  • carcinoids
  • bronchial gland tumors (including adenoid cystic
    carcinomas and mucoepidermoid tumors)
  • Based on the characteristics of the disease and
    its response to treatment bronchial carcinoma may
    be divided into
  • small-cell carcinoma .
  • non-small-cell carcinoma.

7
Small-cell carcinoma
  • This tumour, often called oat-cell carcinoma,
    accounts for 20-30 of all lung cancers.
  • It arises from endocrine cells .These cells are
    members of the APUD system, which explains why
    many polypeptide hormones are secreted by these
    tumours. Some of these polypeptides act in an
    autocrine fashion they feed back on the cells
    and cause cell growth.
  • The tumour is rapidly growing ,highly malignant
    and spreads early so,it is almost always
    inoperable at presentation.
  • It responds to chemotherapy but the prognosis
    remains poor.

8
Non-small-cell carcinoma
  • Squamous or epidermoid carcinoma
  • It is the commonest type, accounting for
    approximately 40 of all carcinomas.
  • Most present as obstructive lesions of the
    bronchus leading to infection.
  • It occasionally cavitates (10) at presentation.
  • The cells are usually well differentiated but
    occasionally anaplastic.
  • Local spread is common but widespread metastases
    occur relatively late.

9
  • Adenocarcinoma
  • 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.
  • It accounts for approximately 10 of all
    bronchial carcinomas.
  • It is the most common bronchial carcinoma
    associated with asbestos and is proportionally
    more common in non-smokers, in women, and in the
    elderly.
  • Large cell carcinomas
  • Are less-differentiated forms of squamous cell
    and adenocarcinomas.
  • These account for about 25 of all lung cancers
    and metastasize early.

10
  • Bronchoalveolar cell carcinoma (also termed
    bronchiolar carcinoma)
  • accounts for only 1-2 of lung tumours and
    occurs either as a peripheral solitary nodule or
    as diffuse nodular lesions of multicentric
    origin.
  • Occasionally this tumour is associated with
    expectoration of very large volumes of mucoid
    sputum.

11
Clinical features
  • Symptom
  • Chest pain and discomfort are often described as
    fullness and pressure in the chest.
  • The pain may be pleuritic owing to invasion of
    the pleura or ribs.
  • signs
  • Often there are no abnormal physical signs.
  • Enlarged supraclavicular lymph nodes may be
    present.
  • There may be signs of a pleural effusion or of
    lobar collapse.
  • Signs of an unresolved pneumonia or of associated
    underlying disease (e.g. diffuse pulmonary
    fibrosis in asbestosis) may be present.

12
The frequency of the common presenting symptoms
of bronchial carcinoma .
13
  • Direct spread
  • The tumour may directly involve the pleura and
    ribs.
  • Carcinoma in the apex of the lung can erode the
    ribs and involve the lower part of the brachial
    plexus (C8, T1 and T2), causing severe pain in
    the shoulder and down the inner surface of the
    arm (Pancoast's tumour).
  • The sympathetic ganglion can also be involved,
    producing Horner's syndrome.
  • Hilar tumours may involve the recurrent
    laryngeal nerve, causing unilateral vocal cord
    paresis with hoarseness and a bovine cough.

14
  • Bronchial carcinoma can also directly invade the
    phrenic nerve, causing paralysis of the
    ipsilateral hemidiaphragm. It can involve the
    oesophagus, producing progressive dysphagia, and
    the pericardium, producing pericardial effusion
    and malignant dysrhythmias.
  • Superior vena caval obstruction causes early
    morning headache, facial congestion and oedema
    involving the upper limbs the jugular veins are
    distended, as are the veins on the chest that
    form a collateral circulation with veins arising
    from the abdomen.

15
  • Metastatic complications
  • Bony metastases are common, giving rise to
    severe pain and pathological fractures.
  • There is frequent involvement of the liver.
  • Secondary deposits in the brain present as a
    change in personality, epilepsy or as a focal
    neurological lesion.
  • Spinal cord compression is not uncommon and
    requires urgent treatment .
  • Secondary deposits in the adrenal gland are a
    very frequent post-mortem finding but are often
    asymptomatic.
  • .

16
  • Non-metastatic extrapulmonary manifestations
  • Although approximately 10 of small-cell tumours
    produce ectopic hormones at some stage, clinical
    extrapulmonary manifestations are relatively rare
    apart from finger clubbing.
  • Hypertrophic pulmonary osteoarthropathy (HPOA)
  • occurs in approximately 3 of all bronchial
    carcinomas, particularly squamous-cell carcinomas
    and adenocarcinomas.
  • Symptoms include joint stiffness and severe pain
    in the wrists and ankles, sometimes associated
    with gynaecomastia.
  • X-rays show a characteristic proliferative
    periostitis at the distal ends of long bones,
    which have an onion-skin appearance.
  • HPOA is invariably associated with clubbing of
    the fingers.
  • It may regress after resection of the lung
    tumour.

17
  • Investigations
  • Chest X-ray
  • Asymptomatic tumours may be seen on chest X-ray
    if they are more than 1 cm in diameter.
  • Lateral views are useful to assess the hilum and
    masses behind the heart.
  • Although investigation of isolated haemoptysis
    with chest X-ray is often negative, a normal
    chest X-ray should not stop further
    investigation, especially in smokers over the age
    of 40y .
  • About 70 of all primary lung cancers present
    with a mass, including all small-cell lung
    cancers and most squamous cell carcinomas.
  • Adenocarcinoma occurs more often in the periphery
    than the other cell types.

18
  • Carcinomas causing partial obstruction of a
    bronchus interrupt the mucociliary escalator, and
    bacteria are retained within the affected lobe.
    This gives rise to the so-called secondary
    pneumonia that is commonly seen on the chest
    X-ray.
  • Bronchial carcinoma can also appear as round
    shadows on a chest X-ray , characteristically the
    edge of the tumour has a fluffy or spiked
    appearance, though sometimes it may be entirely
    smooth with cavitation.
  • The hilar lymph nodes on the side of the tumour
    are frequently involved.
  • Bronchial carcinoma is also a common cause of
    large pleural effusions.

19
  • Carcinoma can spread through the lymphatic
    channels of the lung to give rise to lymphangitis
    carcinomatosa in bronchial carcinoma this is
    usually unilateral and associated with striking
    dyspnoea. The chest X-ray shows streaky shadowing
    throughout the lung.

20
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22
  • Computed tomography CT
  • It is useful for identifying disease in the
    mediastinum, such as enlarged lymph nodes or
    local spread of the tumour, and for identifying
    secondary spread of carcinoma to the opposite
    lung by detecting masses too small to be seen on
    the chest X-ray.
  • CT scanning should include the liver, adrenal
    glands and the brain since these are common sites
    for metastases.

23
  • Fibreoptic bronchoscopy
  • This technique is used to define the bronchial
    anatomy and to obtain biopsy and cytological
    specimens.
  • If the carcinoma involves the first 2 cm of
    either main bronchus, the tumour is inoperable as
    there would be insufficient resection margins for
    pneumonectomy.
  • Widening and loss of the sharp angle of the
    carina indicates the presence of enlarged
    mediastinal lymph nodes, either malignant or
    reactive. These can be biopsied by passage of a
    needle through the bronchial wall.
  • Vocal cord paresis indicates involvement of the
    recurrent laryngeal nerve and inoperability.

24
  • Percutaneous aspiration and biopsy
  • Peripheral lung lesions cannot be seen by
    fibreoptic bronchoscopy and samples may be
    obtained by direct aspiration or biopsy through
    the chest wall under appropriate X-ray or CT
    screening.
  • Fine-needle aspiration samples can be obtained
    from 75 of peripheral lesions that could not be
    biopsied transbronchially. Although useful if
    positive, negative FNA is not very helpful.
  • Biopsies obtained with Trucut needles are usually
    diagnostic.

25
  • Other investigations
  • Full blood count for the detection of anaemia.
  • biochemistry for liver involvement.
  • hypercalcaemia and hyponatraemia.
  • Bone scane for detection of bony metastases.

26
Treatment
  • Treatment of lung cancer involves several
    different modalities and is best planned by a
    multidisciplinary team.
  • Treatment decisions need to reflect the poor
    overall survival rates only 20 of patients are
    alive 1 year after diagnosis and only 6-8 after
    5 years . Patients are staged according to the
    TNM classification for non-small-cell cancer but
    small-cell cancer is treated according to whether
    it is limited or extensive .

27
  • Surgical treatment
  • Preoperative assessment includes exclusion of
    metastatic disease by blood tests and imaging.
  • Lung function tests, including walking oximetry,
    are used to predict postoperative potential.
  • 1- Curative
  • All operable and resectable cases .
  • 2-Palliative
  • a) Infectionhaemoptysis
  • b)Osteoarthropathy
  • c)Pain
  • d)Debulking of the tumour size

28
  • Non surgical lines of therapy could be used in
    Non-small-cell carcinoma
  • Radiotherapy.
  • Radiotherapychemotherapy
  • Laser therapy, endobronchial irradiation and
    tracheobronchial stents

29
Secondary tumours
  • Metastases in the lung are very common and
    usually present as round shadows (1.5-3.0 cm
    diameter). They may be detected on chest X-ray in
    patients already diagnosed as having carcinoma.
  • Typical sites for the primary tumour include the
    kidney, prostate, breast, bone, gastrointestinal
    tract, cervix and ovary.
  • Metastases nearly always develop in the
    parenchyma and are often relatively asymptomatic
    even when the chest X-ray shows extensive
    pulmonary metastases.
  • Rarely metastases may develop in the bronchi,
    when they may present with haemoptysis.

30
  • Carcinoma, particularly of the stomach, pancreas
    and breast, can involve mediastinal glands and
    spread along the lymphatics of both lungs
    (lymphangitis carcinomatosa), leading to
    progressive and severe breathlessness. On the
    chest X-ray, bilateral lymphadenopathy is seen
    together with streaky basal shadowing fanning out
    over both lung fields.
  • Occasionally a pulmonary metastasis may be
    detected as a solitary round shadow on chest
    X-ray in an asymptomatic patient(e.g. renal cell
    carcinom).

31
  • The differential diagnosis of solitary round
    shadow on chest X-ray includes
  • primary bronchial carcinoma
  • tuberculoma
  • benign tumour of the lung
  • hydatid cyst.

32
  • SCREENING FOR LUNG CANCER
  • Screening programme (yearly chest X-ray,
    4-monthly sputum cytology) have been tried in
    high-risk groups but the success rate is minimal,
    underlining the need for prevention.
  • CT screening is currently being evaluated.

33
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