CARCINOMA OF THE LUNG - Clinical features, Investigations

Epidemiology

Bronchial carcinoma accounts for 95% of primary lung tumours. The rest are benign tumours and rarer types of cancers, e.g. alveolar cell carcinoma. Bronchial carcinoma is the most common malignant tumour in the Western world, and in the UK is the third most common cause of death after heart disease and pneumonia. There is a 3 : 1 male : female ratio, but although the rising mortality of this disease has levelled off in men, it continues to rise in women.

Aetiology

Smoking is by far the most common aetiological factor, although there is a higher incidence in urban areas than in rural areas even when allowances

Table 11.12 The effects of asbestos on the lung

Disease

Pathology and clinical features

Asbestos bodies No symptoms or change in lung function

 

Serve only as a marker of exposure

Pleural plaques

Fibrotic plaques on parietal and diaphragmatic pleura

  Usually produce no symptoms

Pleural effusion

Pleural biopsy often needed to differentiate from malignant effusion

  Pleuritic pain and dyspnoea

Diffuse pleural thickening*

Thickening of parietal and visceral pleura Effort dyspnoea and restrictive ventilatory defect

Mesothelioma*

Tumour arising from mesothelial cells of pleura, peritoneum and pericardium

  Often presents with dull diffuse Progressive chest pain and a pleural effusion
  Treatment is with chemotherapy or debulking procedures. Prognosis is poor

Asbestosis*

Breathlessness, finger clubbing, bilateral inspiratory crackles

  Pulmonary function tests show a restrictive ventilatory defect

Lung cancer, often adenocarcinoma*

Presentation and treatment is that of lung cancer (see below)

*The diseases indicated are all eligible for compensation under the Social Security Act
of 1975 (UK)

are made for smoking. Other aetiological factors are passive smoking, expo-sure to asbestos and, possibly, also contact with arsenic, chromium, iron oxides and the products of coal combustion.

Pathology

This is broadly divided into small cell and non-small cell cancer (Table 11.13).

Clinical features

Local effects of tumour within a bronchus Cough, chest pain, haemop-tysis and breathlessness are typical symptoms.

Table 11.13 Types of bronchial carcinoma (indicates % lung carcinomas)
Cell type Characteristics
Non-small cell
Squamous (40%) Most present as obstructive lesion leading to
infection
Occasionally cavitates
Local spread common
Widespread metastases occur late
Large cell (25%) Poorly differentiated tumour
Metastasize early
Adenocarcinoma (10%) Most common lung cancer associated with
asbestos exposure
Proportionately more common in non-smokers
Usually occurs peripherally
Local and distant metastases
Small cell (20–30%) Arises from endocrine cells (Kulchitsky cells)
Secretes polypeptide hormones (Table 11.14)
Early development of widespread metastases
Responds to chemotherapy. Poor prognosis

Spread within the chest Tumour may directly involve the pleura and ribs, causing pain and bone fractures. Spread to involve the brachial plexus causes pain in the shoulder and inner arm (Pancoast's tumour), spread to the sympathetic ganglion causes Horner's syndrome (p. 730), and spread to the left recurrent laryngeal nerve causes hoarseness and a bovine cough. In addition, the tumour may directly involve the oesophagus, heart or superior vena cava (causing upper limb oedema, facial congestion and distended neck veins).

Metastatic disease Metastases are most commonly to bone (presenting with pain and sometimes spinal cord compression) and brain (change in personality, epilepsy, focal neurological signs).

Non-metastatic manifestations These are rare apart from finger club-bing (Table 11.14). There may, in addition, be non-specific features such as malaise, lethargy and weight loss.

On examination of the chest there are often no physical signs, although lymphadenopathy signs of a pleural effusion, lobar collapse or unresolved pneumonia may be present.

Table 11.14 Non-metastatic extrapulmonary manifestations of bronchial carcinoma

Endocrine

Ectopic secretion of:
ACTH causing Cushing’s syndrome
ADH causing dilutional hyponatraemia
PTH-like substance causing hypercalcaemia
HCG or related hormones resulting in gynaecomastia

Neurological

Cerebellar degeneration

Myopathy, polyneuropathies

Myasthenic syndrome (Eaton-Lambert syndrome)

Vascular/

haematological (rare)

Thrombophlebitis migrans

Non-bacterial thrombotic endocarditis

Disseminated intravascular coagulation

Anaemia

Skeletal

Clubbing

Hypertrophic pulmonary osteoarthropathy (clubbing, painful wrists and ankles)

Cutaneous (rare)

Dermatomyositis

Acanthosis nigricans (pigmented overgrowth of skin in axillae or groin)

Herpes zoster

Investigations

The aim of investigation is to confirm the diagnosis, determine the histology and assess tumour spread as a guide to treatment.

Contirm the diagnosis The chest X-ray will usually be abnormal by the time a lung cancer is causing symptoms. Tumours usually appear as a round shadow, the edge of which often has a fluffy or spiked appearance. There may be evidence of cavitation, lobar collapse, a pleural effusion or secondary pneumonia. Spread through the lymphatic channels gives rise to lymphangitis carcinomatosis, appearing as streaky shadowing throughout the lung. A minority of tumours is confined to the Central airways and mediastinum without an obvious change on chest X-ray and in patients with suspicious symptoms, e.g. a smoker with haemoptysis, bronchoscopy or CT scanning is necessary to make the diagnosis.

Determine the histology Sputum is examined by a cytologist for malig-nant cells. Bronchoscopy is used to obtain biopsies for histological investiga-tion and washings for cytology. Transthoracic fine needle aspiration biopsy under radiographic or CT screening is useful for obtaining tissue diagnosis from peripheral lesions.

Assess spread of the tumour At bronchoscopy involvement of the first 2 cm of either main bronchus or of the recurrent laryngeal nerve (vocal cord paresis) indicates inoperability. Patients being considered for surgery should have a CT of the thorax to include the liver and adrenal glands to assess the mediastinum and the extent of tumour spread. PET scanning (p. 828) is the investigation of choice for conữmation or exclusion of intrathoracic lymph nodes metastases and is used when available to assess suitability for surgery.

Determine patient suitability for major operation Physical examination and respiratory function tests.

Treatment

Treatment of lung cancer involves several different modalities and is best planned by a multidisciplinary team.

Non-small-cell lung cancer

■ Surgery can be curative in non-small-cell cancer. Neo-adjuvant chemo-therapy may downstage tumours to render them operable. Adjuvant postoperative chemotherapy and radiotherapy improves survival.

■ Radiotherapy in high doses can produce good results in patients with localized squamous carcinoma if surgery is declined. Complications are radiation pneumonitis and fibrosis. Palliative radiotherapy is useful for bone pain, haemoptysis and superior vena cava obstruction (p. 255).

■ Chemotherapy is given in advanced disease and improves median sur-vival from 6 to 10 months.

Small-cell lung cancer

Limited disease (confined to a single anatomical or radiation field) is treated with combined chemo- and radiotherapy with 25% survival at 5 years.

Extensive disease is treated with chemotherapy with a median survival of 9-13 months and 2 year survival of 20%.

Symptomatic treatments

Local treatments such as endoscopic laser therapy, endobronchial irradiation and transbronchial stenting are used to treat distressing symptoms arising from airway narrowing. Malignant pleural effusions should be aspirated to dryness and a sclerosing agent (e.g. tetracycline, bleomycin) instilled into the pleural space. In the terminal stages, the quality of life must be maintained as far as possible. In addition to general nursing, counselling and medical care, patients may need oral or intravenous opiates for pain (given with laxatives to prevent constipation), and prednisolone may improve the appetite.

Differential diagnosis

In most cases the diagnosis is straightforward. The differential diagnosis is usually from other solitary nodules on the chest X-ray (Table 11.3).

Metastatic tumours in the lung

Metastases in the lung are common, usually presenting as round shadows

1.5-3 cm in diameter. The most common primary sites are the kidney, prostate, breast, bone, gastrointestinal tract, cervix or ovary.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology



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