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Lung Cancer

Reference: OHCM 182, Lec Not Onc 156, Mini-Kumar 492

Epidemiology

Causes by far the most deaths due to ca in Europe

Risk Factors

Differential

Bronchiectasis, autoimmune (eg Wegeners/Goodpastures), pulmonary embolism

Histology

Non-Small Cell

Squamous: Obstructive lesion. Occassionally cavitatates. Local spread common, widespread mets late.
Large cell: Less well differentiated that mets early
Adenocarcinoma: Proportionately less common in smokers compared to the other types. Can be associated with asbestos. Usually peripheral. Local and distant mets.
Alveolar cell: Periph solitary nodule or diffuse nodular lesions.

Small Cell

Endocrine cells, which often secrete polypeptides (paraneoplastic). ACTH (Cushings). Early development of widespread mets. Responds to chemo.

Clinical

Investigations

Bedside: Lung function tests
Bloods: FBC (anaemia), LFT/ALP (bone/liver mets), Liver USS, U+E (↓Na)
Diagnosis: Sputum cytology, bronchoscopy + washings, FNA biopsy with CT guiding
Staging: CXR (peripheral circular opacity, hilar enlargement, consolidation, lung collapse, pleural effusion, bone secondaries), CT scan, radionucleotide bone scan, PET (ideally), mediatinoscopy + LN biopsy.

Management

Surgery can be lobectomy or pneumonectomy. Radiotherapy gives short-term SEs of tiredness, oesophagitis, skin irritation, pneumonitis, and long-term SEs of spinal cord myelopathy, radiation pneumonitis, and strictures.

Non-small

  1. Radical surgery (if limited T1/2 N0M0) + radiotherapy. 20% are resectable. Radical radiotherapy if inadequate respiratory reserve (FEV, transfer factor, USS heart).
  2. Palliative radiotherapy for rest (those w Symptoms like haemoptysis, SoB). Chemotherapy.

Small

95% have mets at presentation.
  1. Chemotherapy (etoposide + cisplatin): 60% remission but majority recur

Palliative

  1. Radiotherapy for bronchial obstruction, SVC obstruction, haemoptysis, bone pain, cerebral mets.
  2. SVC obstruction: SVC stent + radiotherapy + dexamethasone. Endobronchial therapy: tracheal stenting. 
  3. Drugs: analgesia, steroids, antiemetics, codeine for cough, bronchodilators. 
  4. Malignant pleural effusions: aspirate therapeutically
  5. Paraneoplastic hyponatraemia (↓ADH) : water restriction, tetracyclines. 
  6. Polymyositis, Eaton-Lambert, peripheral neuropathy: ↑dose steroids. 
  7. Ectopic ADH: adrenal enzyme blocking (ketoconazole), adrenalectomy.

Prognosis

Non-Small: 50% 2 year survival without spread, 10% 2 year survival with spread.
Small: Just over 1 year with treatment.
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