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LUNG TUMOURS

LUNG TUMOURS. Dr Shiron Saha Consultant Respiratory Physician Slides courtesy of Dr Jennifer Hill jennifer.hill @sth.nhs.uk. Learning objectives. Understand how to classify lung tumours Increase understanding of causes of, incidence and survival of lung cancer

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LUNG TUMOURS

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  1. LUNG TUMOURS Dr Shiron Saha Consultant Respiratory Physician Slides courtesy of Dr Jennifer Hill jennifer.hill@sth.nhs.uk

  2. Learning objectives • Understand how to classify lung tumours • Increase understanding of causes of, incidence and survival of lung cancer • Understand how to diagnose, investigate and treat lung cancer

  3. LUNG TUMOURS • Bronchial • Pleural

  4. BRONCHIAL TUMOURS • malignant (95%) = lung cancer • non small cell cancer • small cell cancer • benign • hamartoma • carcinoid • lipoma • chondroma • leiomyoma • nerve sheath tumours • fibroma

  5. Lung cancer • epidemiology • pathology • clinical presentation using cases • diagnosis and staging • management

  6. How common is lung cancer in UK compared to rest of Europe?

  7. UK male incidence of all cancers 2007

  8. UK female incidence of all cancers 2007

  9. UK male cancer deaths 2008

  10. UK female cancer deaths 2008

  11. Time trends in lung cancer incidence in UK

  12. What about smoking trends?

  13. 5 yr cancer survival 1986-90(Cancer survival trends, Office for National Statistics 1999)

  14. National Comparisons Lung Cancer Survival

  15. Causes of lung cancer

  16. Causes of lung cancer • SMOKING (80-90%) • asbestos • radon • coal tar and products of coal combustion • chromium • iron oxide • arsenic and arsenic compounds • petroleum products • nickel refining • beryllium, cadmium, aluminium

  17. Cell types of lung cancer • small cell lung cancer • non small cell lung cancer • squamous • adenocarcinoma (adenocarcinoma-in situe)

  18. Cell Types of Lung Cancer NSCLC85% SCLC 15% • Squamous Cell 20% • Adenocarcinoma 40% • Large cell 5% • NOS 18% EGFR mutation 15-30% of Adenocarcinoma 6-11% of all cancers

  19. Case 1 - 63 year old man (1) • incidental finding on CXR before hernia repair • asymptomatic • CT scan • PET scan - hot • surgery performed

  20. PET SCANNING • Functional rather than anatomical image • Fluoro-2 deoxyglucose (FDG) taken up by rapidly dividing cells and not excreted • FDG half life of 110 minutes • false negatives - BAC, carcinoid, small lesions • false positive - inflammation, infection • useful to detect asymptomatic metastases

  21. Case 1 - 63 year old man (2) • Stage T1 N0 M0 • Right upper lobectomy showed 2cm adenocarcinoma pT1 N0 M0 • no further treatment needed • 80% 5 year survival

  22. TNM staging for NSCLC T=Tumour N=Nodal Involvement M=Metastasis M0=No Mets M1A=Lung/Pleura M1B=Extra thoracic

  23. http://www.radiologyassistant.nl/

  24. TNM staging and survival for NSCLC 5 year survival • Ia (T1N0) 80 ) • Ib (T2N0) 40 )resectable • IIa (T1N1) 30 ) • IIb (T2N1, T3N0) 20 ) • IIIa(T3N1-2, T3N2) 10 • IIIb(T1-4N3, T4N0-3) 5 • IV (M1) 1

  25. Lesson 1 • Some patients are asymptomatic and likely to be the ones with the best chance of cure

  26. Should we screen for lung cancer?

  27. National lung screening trial • Trial by US national cancer institute • Over 50,000 men/women with >30pk yrs • CT screening reduced lung cancer mortality by 20.3% and all cause mortality by 7% cf with CXR • Cost-benefit being calculated • Needs repeating in UK population

  28. Case 2 - 75 year old man (1) • 6 months of increasing hip pain • 2 months fatigue and weight loss • Minor haemoptysis • Previous history of OA hips and knees • CABG 1999

  29. Bone metastasis

  30. CLINICAL PRESENTATION • symptoms due to local disease • symptoms due to metastatic disease • non metastatic manifestations of malignant disease (paraneoplastic syndromes)

  31. LOCAL DISEASE • cough (40%) • breathlessness • wheeze • haemoptysis (7%) • dysphagia • hoarseness • chest pain (20%) • head, neck and arm swelling (SVCO)

  32. SITES OF METASTATIC DISEASE FROM LUNG CANCER • lymph glands • bone • brain • liver • adrenal glands

  33. SYMPTOMS OF METASTATIC DISEASE • bone pain • headache • seizures • neurological deficit • hepatic pain • abdominal pain

  34. PARANEOPLASTIC SYNDROMES

  35. PARANEOPLASTIC SYNDROMES • finger clubbing • hypertrophic pulmonary osteoarthropathy • anorexia • cachexia and weight loss • hypercalcaemia • hyponatraemia (SIADH) • peripheral neuropathy (Eaton Lambert syndrome)

  36. Case 2 - 75 year old man (2) • Bone biopsy showed squamous cell cancer • T2A N0 M1B - stage IV • given palliative radiotherapy and then palliative chemotherapy

  37. TNM staging and survival for NSCLC 5 year survival • Ia (T1N0) 60 ) • Ib (T2N0) 40 )resectable • IIa (T1N1) 30 ) • IIb (T2N1, T3N0) 20 ) • IIIa(T3N1-2, T3N2) 10 • IIIb(T1-4N3, T4N0-3) 5 • IV (M1) 1

  38. 69% NSCLC: stage at presentation 7% Stage II 31% Stage III 24% Stage I 38% Stage IV Fry WA et al 1996, Cancer 77:1949-1995

  39. Lesson 2 • Take a careful history – symptoms may help in staging the patient’s lung cancer

  40. Approach when assessing a patient with potential lung cancer • Is it lung cancer? • What is the cell type of the tumour? • What stage is the lung cancer? • Is the patient fit for potentially curative treatment

  41. Is it lung cancer and what is the cell type? • CXR • CT scan • Bronchoscopy +/- US guided biopsy • percutaneous (CT guided) needle biopsy • US guided aspirate or biopsy • Surgical biopsy

  42. What stage is the tumour? • assess resectability (tumour removability) • bloods, CT thorax/abdo, PET scan, • CT head, medistinoscopy, pleural aspiration,

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