Rich Cole Diane S Parry Stats -

Clinical Lung Cancer

16/09/11

40000 deaths UK annually 2000 deaths in wale Commonest cause of cancer death; but not commonest cancer Largely avoidable

Five-year survival depends on the age at which you are diagnosed; younger people can tolerate more aggressive treatments such as radical radiotherapy First investigation done (someone comes to you with voice change or haemoptysis) is to arrange a chest X-ray (obviously do a history first). You will see a large cavitating lesion and perhaps a lymphadenopathy. You might see a widened mediastinum (bulging) Risk Factors Smoking Age > 40 Environmental o Radon gas o Urban living Occupational o Asbestos o Uranium mining o Tin mining Pulmonary scarring o Cryptogenic fibrosis alveolitis o Sarcoidosis

The Clinic Visit History o Symptoms o Risk factors o Comorbidity o QoL Examination (look for spread) o Signs of spread o Spirometry Patients should be offered urgent referral to chest physician while awaiting results of X-rays if any of the following are present o Persistent haemoptysis in smoker or ex-smokers over 40 years of age o Signs of Superior Vena Cava obstruction (swelling of face/neck and fixed elevation of JVP) Also see conjunctival blood vessels, also see swelling of veins in the upper body o Stridor

Rich Cole Examination Hands (clubbing, muscle wasting) Face (eyes, mucous membranes, Horners syndrome, cyanosis) Neck (lymph nodes, trachea) o Swollen lymph nodes = advanced lung cancer Breast (axillae) Chest signs (collapse, consolidation, stridor, wheeze) Abdomen (hepatomegaly) Neurological assessment o Mental status, muscle wasting, pain, Paraneoplastic manifestations o Skin lesions; primary or secondary o Musculoskeletal; bony tenderness, mobility Spirometry results Performance score o 37% data missing or not recorded 0 = Asymptomatic = 13% 1 = Symptomatic, fully ambulatory = 21% 2 = Symptomatic, in bed <50% of the day = 14% 3 = Symptomatic in bed > 50% of the day, but not bedridden = 11% 4 = Bedridden = 4%

Investigations; Non-invasive Blood tests; FBC, Coag, UEC, LFT, Bone profile CXR CT (chest, abdomen, brain) PET Scan Ultrasound scan

Investigations; Invasive Percutaneous needle biopsy (for peripheral nodules) Bronchoscopy (a fibre-optic kit with a video display; for central nodules) o Purpose of this is diagnostic, as well as therapeutic (we can remove things) Therapeutic Foreign body Stent insertion Removal of tumours EBUS (useful for staging) (endobronchial ultrasound) o Looks like a bronchoscope, but doesnt have a video at the end, but rather an ultrasound attachment; transducer Passed into airway, so you can visualise lymph node sitting outside the main airway in the subcorinal space or the paratracheal space Double benefit of diagnosis AND staging Mediastinoscopy

Bronchoscopy Specimens Histology o Biopsy Cytology o Wash o Brush o Needle Aspirate (bind or EBUS-guided)

CT Scanner 2

Rich Cole - Useful for staging - CT biopsy Biopsies Pleural aspiration/biopsy Lymph node aspiration/biopsy Skin metastasis aspiration/biopsy Surgical biopsy o VATS (video-assisted thoracoscopy) o Medistinoscopy

Cell Types Small cell Non-small cell o Adenocarcinoma o Squamous cell

Staging Non-small cell o TNM (tumour nodes metastases) o Stage I-IV People with stages I & II can get active treatment with curative intent Stage III and IV = palliative care o Stage X means you cant find the tumour Small cell o Limited o Extensive

Treatment for lung cancer has to be delivered by a multi-disciplinary team Surgical treatment Surgical resection, for stages with I and II (only about 8% are suitable) Mediastinoscopy; frozen section wedge resection Lobectomy Pneumonectomy Approximately 8% of patients are suitable

Oncology Treatments Radiotherapy o Radical radiotherapy (only for patients with stage 1 and 2 who arent suitable for surgery) o Palliative radiotherapy (pain, SVCO, Hypercalcaemia) Often see Hypercalcaemia in those with squamous cell carcinoma or bone metastases o Radiosurgery; cyberknife, gammaknife

Treatment for Stage 3 and 4 Chemotherapy for non-small cell lung cancer, PS 0 & 1 Can extend life by 2-3 months Platinum-based doublet therapy Side effects vs. QoL Palliation of symptoms 3