LUNG NEOPLASMS

DR BINDU CG
ASSISTANT PROFESSOR IN PULMONARY
MEDICINE,MCH ALAPUZHA
EPIDEMIOLOGY

Lung cancer is the most common cause of

cancer death in men in world
in India its incidence is increasing
ABNORMAL PROLIFERATION OF
TISSUE
NEOPLASMBENIGN & MALIGNANT &
SECONDARIES TO THE LUNGS

Lung neoplasms are an abnormal growth in or on the

lungs.
Benign neoplasms are not necessarily harmless , they
can cause pressure symptoms, hemoptysis & can
become malignant
BENIGN NEOPLASMS

Hamartomas
Papilloma
Lipoma
Chondroma
Teratoma
endometrioma
Fibromas
Adenomas
Haemangiomas
HAMARTOMA .55% OF BENIGN LUNG TUMORS & 8% OF ALL LUNG

TUMOR

80% seen in periphery of lungs, rest in

bronchi, small>4 cm, round with popcorn
calcification

PAPILLOMA. It is sticking out from where
it is attached.
Squamous, glandular & mixed
SOLITARY PULMONARY NODULES
ROUND OPACITY >3 CM , NOT ASSOCIATED WITH
LYMPHADENOPATHY, ATELECTASIS & PLEURAL EFFUSION

TB.
FUNGAL INFECTIONS
RHEUMATOID NODULE,
WEGENER'S &
SARCOIDOSIS

AGE > 45
SMOKER
DOUBLING TIME
CALCIFICATION
&based on these & symptoms. .BIOPSY &
REMOVAL
Secondary's to lungs
METASTASIS TO LUNGS ARE
COMMONLY FROM

Lungs
Breast
GI tract
Kidneys
thyroid
Prostrate
mesothelioma
carcinoid
 AETIOLOGY
TOBACCO SMOKING

ATMOSPHERIC POLLUTION

OCCUPATIONAL FACTORS

PULMONARY SCARRING
Smoking of tobacco cigarettes is the most
common cause of lung cancer
8 -20 times more than non smokers
Passive smoking is linked with increased risk
Low tar- filter cigarettes also causes cancer
Pipes &cigar have reduced risk as less smoke is
inhaled
Squamous &small cell carcinoma is clearly
associated with smoking, Adenocarcinoma with
nonsmokers
SMOKING IS INJURIOUS

Tobacco smoke causes lung cancer

in 85%. It contains 73 carcinogens
like benzopyrerne, radioactive
polonium 210
PASSIVE SMOKING
ENVIRONMENTAL TOBACCO SMOKE
SMOKING INDEX / PACK YEARS
 Pulmonary scaring
Lung scars due to PT , ILD
Adenocarcinoma is most common

Atmospheric pollution..
1.26-2.33 times risk
Exposure to residential radon
particles
 Mining, processing ,usage
Metal ore, uranium mining
Asbestos Refining

Radioactivity(radon particles) Metal refining, insecticides

Extraction, usage
Nickel Organic chemical industries
Manufacturing
Arsenic
Chromium salt
Chloro ether
Mustard gas

OCCUPATIONAL
 Occupational
factors

smoking radiation

Oncogenic
events

Pluripoten Small cell

GENETIC t cell Adeno
Large cell
PREDISPOSITION squamous
 K RAS
EGFR
C-MYC
RER
Loss of P53.RB, P16

GENETIC PREDISPOSITION
1. Squamous cell carcinoma (epidermiod CA) , variant :
spindle cell CA
2. Small cell CA ..oat call, intermediate cell type , combined oat
cell variant
3. Adeno CA acinar adenoCA, papillary adenoCA , Broncho
alveolar CA , solid CA with mucous formation
4. Large cell CA giant cell CA , clear cell CA
5. Adenosquamous CA
6. Bronchial gland CA adenoid cystic CA , mucoepidermiod
CA
7. Others

HISTOLOGICAL CLASSIFICATION
 Early recognition of symptoms
improves the outcome

At initial diagnosis
7-10%-asymptomatic
20% have localized disease
25% have regional metastasis
55% have distant spread of the diseases

BRONCHOGENIC CARCINOMA CAN HAVE DIFFERENT

PRESENTATION-
SMOKERS WITH GENETIC PREDISPOSITION
PRESENTING CHEST SYMPTOMS HAS TO BE
EVALUATED
 Primary lung tumour

Local/ regional spread

Metastatic diseases

Ectopic hormone production

SYMPTOMS OF LUNG CANCER

 Symptoms due to primary lung tumour

DEPENDS ON THE LOCATION OF TUMOUR

CENTRAL - SQUAMOUS CELL CARCINOMA, SMALL

CELL LUNG CANCER

PERIPHERAL- ADENO CARCINOMA, LARGE CELL

LUNG CANCER
 Symptoms due to central
lesion
COUGH- 45-75% MOST COMMON PRESENTING
SYMPTOM.

HEMOPTYSIS. (57%) PROMPTS RAPID

PRESENTATION

DYSPNEA -WHEN THERE IS ENDOBRONCHIAL

LESIONS

ATELECTASIS
POST OBSTRUCTION PNEUMONIA

WHEEZING
 Primary lung tumour--peripheral
PERIPHERAL ADENOCARCINOMA CALL FOR ATTENTION ONLY WHEN
CLINICAL SIGNS OF EXTRA THORACIC METASTASIS LIKE BONE OR
INTRACRANIAL METASTASIS ARE SEEN

COUGH

DYSPNEA

CHEST PAIN DUE TO INFILTRATION OF PARIETAL PLEURA & CHEST

WALL

SYMPTOMS OF PLEURAL EFFUSION

 Symptoms due to regional
/mediastinal spread

1)HOARSENESS 43% (L)VC PALSY PRODUCED BY

INFILTRATION OF (L) RECURRENT LARYNGEAL NERVE AS IT
LOOPS ROUND THE ARCH OF AORTA WHERE IT PASSES OVER
(L) MAIN BRONCHUS.
RARELY (R) VC PALSY SEEN ESP. IN THORACIC INLET TUMOUR,
THE (R)RECURRENT L N LOOPS ON SVC AT ROOT OF NECK ,IS
INVOLVED IN (R) SUPRA CLAVICULAR NODE ENLARGEMENT.
BOTH ARE FEATURES OF INOPERABILITY AS IT INDICATES
MEDIASTINAL INFILTRATION
2)STRIDOR- 2-18% due to upper airway obstruction

3)PHRENIC NERVE PALSY- dyspnea

4)DYSPHAGIA & post prandial coughing is s/o enlargement

of subcarinal LN compressing middle 3rd of esophagus

5)PALPITATION & dyspnea- due to pericardial effusion /

tamponade. Or direct infiltration by tumour

6)CHYLOTHORAX- infiltration of thoracic duct

7)SVC OBSTRUCTIONcaused by pressure on the SVC by
primary lung tumor commonly SCLC, mediastinal nodes or
(R) paratracheal nodes
 Clinical symptoms and signs of
SVC obstruction

Feeling of fullness in head

Dyspnoea
Cough
Dilated veins of neck &
Chest, upper extremities
Facial odema
Facial cyanosis
Papilledema/
Conjunctival odema
8)superiorsulcus tumour. .PANCOASTS TUMOUR
Compression of brachial plexus root C8 T1 produce
pain and sensory loss along medial side of forearm
,weakness of small muscles of the hand , weakness wrist
and finger flexors .
 9)HORNERS ..pressure on cervical sympathetic
at or above T1 ( stellate ganglion) level

ipsilateral partial ptosis,

meiosis,
enophthalmos,
anhydrosis
10)Pleural
effusion

Cough
45-75%
Chest pain
27-49%
Dyspnea
37-58%
Symptom due to distant
metastasis
BONES- 6-25%, axial
skeleton and long bones are
commonly involved, if LBA is
present fist percussion to
vertebra

LIVER

ADRENALS

INTRA ABDOMONAL LYMPH

NODES
 PARANEOPLASTIC SYNDROME
Ectopic hormone production seen in 10-20%

Mostly associated with SCLC also in NSCLC

PNS is unrelated to size of tumour

rarely precedes the diagnosis of malignancy

usually occur late in the disease

Sometimes first sign of recurrence

Pts with PNS should be considered for curative

therapy
HYPERCALCEMIA- commonly associated with SCC, due to
osteolytic mets and increase parathyroid like hormone , pt
presents with polyuria, Nocturia , thirst, is dehydrated and
goes for confusion , coma and renal failure.

SIADH-commonly seen in SCLC, due to water retention and

loss of sodium plasma osmolality is reduced, pt present with
hyponatrimia - generalized weakness, altered behavior
,confusion and coma.
CLUBBING

HYPERTROPHIC PULMONARY OSTEOARTHOPATHY - painful

swelling of extremities ie distal end of radius ,ulna, tibia,
fibulafreq seen in adenocarcinoma and other NSCLC

HYPERCOAGULOPATHY- phlebitis & thromboembolism

(trousseau syndrome) also seen in adenocarcinoma
 CUSHING SYNDROME- due to ectopic ACTH production,
commonly seen in pts with SCLC.

EATEN LAMBERTS MYASTHENIA SYNDROME-gradual onset of

proximal lower extremity weakness, symptom worse in
morning improve during day, ptosis is often seen . this is due
to autoantibody mediated blockade of ca channel involved in
release of acetyl choline at nerve terminals. In contrast to
myasthenia gravis muscle weakness improves with effort

ECTOPIC ACTH production produces cushing syndrome, but pt dies

before full manifestation of signs

B-MSH production ..increase pigmentation may be only

manifestation
ENDOCRINE &METABOLIC SYNDROME

Gynecomastia-seen in large cell and adeno carcinoma

Eosinophilia

Peripheral neuropathy-glove and stocking hypoesthesia,

muscle weakness & wasting , loss of tendon reflex

Autonomic neuropathy- symptoms of postural hypotension,

disturbance of GI mobility including intestinal pseudo
obstruction( ogilvies syndrome)
ENT- hoarseness
Gastroenterologist- dysphagia
Orthopediacian-LBA, shoulder pain
Neurologist- sezuires, altered behavior
Ophthalmologist-ptosis
Endocrinologist- Cushing
INVESTIGATIONS
1. Sputum cytology.. For malignant cells ,1st specimen
yields 40%, 4 specimen increases yield to 80%. It
depends on tumour size & location of mass

2. Chest X RAY

3. BRONCHOSCOPY .. transbroncial biopsy <TBNA

,brushings. Washings

4. Mediastinoscopy.. To evaluate mediastinal lymph nodes

5. PET scan, CT brain to r/o metastasis

 c/f s/o lung cancer.CXR
Suitable for
If NO palliative care
investigation

YEShistopathological diagnosis by FOB, CT..FNAC

Non small cell Small cell

Sclc..limited d/s or extensive d/afit for chemotherapy

NO..palliative treatment Chemo & RT

SMALL CELL LUNG CANCER

 Non small cell lung cancer
If operable If not operable

surgery radiotherapy

cure Palliative care

 Fit for surgery
If yes r/o metastasis If NO consider other treatment

PET, CT brain , CT thorax &upper abdomen

Mediastinal nodes> 1cm & mediastinal If distant mets present consider other
involvement treatment

Mediastinal sampling
if negative thoracotomy Inoperable if mediastinal involvement
present
 SURGERY
in NSCLC, the stage is assessed to determine whether the disease is
localized and amenable to surgery or if it has spread to the point where
it cannot be cured surgically.

CT scan and positron emission tomography are used for this

determination.

If mediastinal lymph node involvement is suspected, mediastinoscopy

may be used to sample the nodes and assist staging.

Blood tests and pulmonary function testing are used to assess whether
a person is well enough for surgery.

If pulmonary function tests reveal poor respiratory reserve, surgery

may not be a possibility
 most cases of early-stage NSCLC, removal of a lobe of lung (lobectomy) is
the surgical treatment of choice.

In people who are unfit for a full lobectomy, a smaller sub lobar excision (
wedge resection) may be performed. recurrence.

Rarely, removal of a whole lung (pneumonectomy) is performed.

Video-assisted thoracoscopic surgery (VATS) and VATS lobectomy use a

minimally invasive approach to lung cancer surgery.

In SCLC, chemotherapy and/or radiotherapy is typically used.

However the role of surgery in SCLC is being reconsidered. Surgery might

 Radiotherapy is often given together with chemotherapy, and may be used
with curative intent in people with NSCLC who are not eligible for surgery. this
form of high-intensity radiotherapy is called radical radiotherapy.[92

A refinement of this technique is continuous hyper fractionated accelerated

radiotherapy (CHART), in which a high dose of radiotherapy is given in a short
time period.

Postoperative thoracic radiotherapy generally should not be used after curative

intent surgery for NSCLC.

Some people with mediastinal N2 lymph node involvement might benefit from
post-operative radiotherapy.

For potentially curable SCLC cases, che

st radiotherapy is often recommended in addition to chemotherapy
.
If cancer growth blocks a short section of
bronchus, brachytherapy (localized
radiotherapy) may be given directly inside the
airway to open the passage.

Compared to external beam radiotherapy,

brachytherapy allows a reduction in treatment
time and reduced radiation exposure to
healthcare staff.
Prophylactic cranial irradiation(PCI) is a type of radiotherapy to the brain,
used to reduce the risk of metastasis.

PCI is most useful in SCLC. In limited-stage disease, PCI increases three-year

survival from 15% to 20%; in extensive disease, one-year survival increases
from 13% to 27%
.

Recent improvements in targeting and imaging have led to the development

of stereotactic radiation in the treatment of early-stage lung cancer.

In this form of radiotherapy, high doses are delivered over a number of

sessions using stereotactic targeting techniques. Its use is primarily in
patients who are not surgical candidates due to medical comorbidities.[99]

For both NSCLC and SCLC patients, smaller doses of radiation to the chest
may be used for symptom control (palliative radiotherapy).
 The chemotherapy regimen depends on the tumor type.

Small-cell lung carcinoma (SCLC), even relatively early stage

disease, is treated primarily with chemotherapy and radiation.

In SCLC, cisplatin and etoposide are most commonly used.

Combinations with carboplatin, gemcitabine, paclitaxel,

vinorelbine, topotecan, and irinotecan are also used

In advanced non-small cell lung carcinoma (NSCLC),

chemotherapy improves survival and is used as first-line
treatment, provided the person is well enough for the treatment.

Typically, two drugs are used, of which one is often platinum-

based (either cisplatin or carboplatin).
Adjuvent chemotherapy refers to the use of chemotherapy after
apparently curative surgery to improve the outcome.

In NSCLC, samples are taken of nearby lymph nodes during

surgery to assist staging. If stage II or III disease is confirmed,
adjuvant chemotherapy improves survival by 5% at five years.

combination of vinorelbine and cisplatin is more effective than

older regimens

Adjuvant chemotherapy for people with stage IB cancer is

controversial, as clinical trials have not clearly demonstrated a
survival benefit
Conclusion ..
Pts with suspected lung cancer should receive timely and
efficient care

Symptoms of lung cancer is caused by

1.primary tumor 2. loco regional spread 3. distant metastasis
& 4. paraneoplastic syndrome

Cough is the commonest symptom of lung cancer

Haemoptysis warrants a complete evaluation

Peripheral lung cancer may remain asymptomatic till
distant metastasis is seen

Symptoms of regional and distant spread depends on the

organ affected

At time of diagnosis 20% have localized disease

Regular follow up of patients who have CXR lesions / SPN

where there is no tissue diagnosis is a must and when
symptom persists / lesion increases reevaluation should be
done.
SURGERY

CHEMOTHERAP
Y

RADIOTHERAPY

Lung cancer is curable if detected early.

Chemotherapy may be combined with palliative care in the
treatment of the NSCLC.

In advanced cases, appropriate chemotherapy improves

average survival over supportive care alone, as well as
improving quality of life

With adequate physical fitness maintaining chemotherapy

during lung cancer palliation offers 1.5 to 3 months of
prolongation of survival, symptomatic relief, and an
improvement in quality of life, with better results seen with
modern agents

The NSCLC Meta-Analyses Collaborative Group recommends if

Targeted therapy

Several drugs that target molecular pathways in lung cancer are

available, especially for the treatment of advanced disease.

Erlotinib, gefitinib and afatinib inhibit tyrosine kinase at the

epidermal growth factor receptor.

Denosumab is a monoclonal antibody directed against

receptor activator of nuclear factor kappa-B ligand. It may be
useful in the treatment of bone metastases
Palliative care

when added to usual cancer care benefits people even when

they are still receiving chemotherapy

These approaches allow additional discussion of treatment

options and provide opportunities to arrive at well-
considered decisions

Palliative care may avoid unhelpful but expensive care not

only at the end of life, but also throughout the course of the
illness.

For individuals who have more advanced disease,

Thank
you