Lung malignancyDr Rachel Cary, FY1 Warwick Hospital

Learning outcomes

Case

72 year old woman, retired post office worker

Worsening SOB 3/12

Haemoptysis 2/52

Dull R sided chest pain, 15kg weight loss over 2/12

PMHx: COPD (seretide 250 TT BD, salbutamol PRN), HTN (ramipril)

Ex-smoker – 40 pack year history, quit 5 years ago

O/E: Cachectic, R base stony dull with no a/e

CXR: R sided pleural effusion

Differential diagnosis?

Malignancy Small cell lung Ca (aka oat cell) Non-small cell lung carcinoma

Large cell carcinoma Squamous cell carcinoma Adenocarcinoma

Unilateral effusion most likely malignancy, but be aware of other rare causes: e.g. empyema, chylothorax, haemothorax

ALARM symptoms

For any malignancy Weight loss Anaemia Loss of appetite

Small cell lung cancer

15% lung cancers

Arise from Kulchitsky cells (part of amine precursor uptake and decarboxylation endocrine system)

Risk factor: smoking (very rare in non smokers)

Commonly presents at an advanced stage with symptoms of a few months duration from local tumour growth, intrathoracic or distant spread, or paraneoplastic syndroms.

Paraneoplastic syndroms

SIADH –dilutional hyponatraemia, tumour secretes ADH

Lambert-Eaton – proximal muscle weakness, due to autoimmune attack on VGCCs on presynaptic neuron (also found in high numbers on tumour cells)

Cushing’s syndrome – Ectopic ACTH/ ACTH-like substance secreted from tumour

Hyperparathyroidism –hypercalcaemia, typically squamous cell tumours secrete PTHrP

Non-small cell lung cancer

Squamous cell (42% of NSCLCs) Often due to smoking Often found near the main bronchi (obstructive)

Adenocarcinoma (39%) Associated with asbestos More common in non-smokers compared to other lung ca Often metastasises to brain and bones

Large cell (8%) Less differentiated forms of squamous/adeno Metastasise early

Returning to the case

Apical tumours – anatomy!

New hoarseness – affected recurrent laryngeal nerve?

Bilaterally emerge from vagus nerve at level of arch of aorta

Left nerve loops under aortic arch

Right nerve travels directly upwards to larynx

Investigation

Bedside

Bloods

Radiology – CXR, CT thorax, CT-PET Can you explain what they are and what they look for?

Special tests – cytology (aspirate, bronchoscopy), BAL

Management

Of any cancer – break it down Conservative Medical Chemotherapy Radiotherapy Surgical

Chemotherapy

Chemotherapy in NSCLC late stage disease – normally third generation drug (e.g. docetaxel) and platinum drug

Post surgery – as adjuvant or after incomplete resection

SCLC respond to chemotherapy (normally multi-agent regimes), but the prognosis is poor

Radiotherapy

NSCLC when patients not suitable for surgery

Surgical

Can be curative in NSCLC

Treatment of choice in early stage disease

Lobar resection

Hilar and mediastinal lymph node sampling to provide accurate staging

Pleural fluid

Exudate – protein >30 g/L

Transudate – protein <30g/L

Light’s criteria (protein 25-35g/L) The fluid is an exudate if one or more of the following

criteria met: Pleural fluid protein/serum protein >0.5 Pleural fluid LDH/serum LDH >0.6 Pleural fluid LDH > 2/3 upper limits normal serum LDH

Any questions?