Transcript Document 7182851

Early Detection of Lung Cancer
Dr. Shanthi Paramothayan
Consultant Respiratory Physician
St. Helier University Hospital
14th June 2011
Aim and Objectives of this session
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Aims and Objectives:
Risk Factors: identify high risk patients
 Clinical Presentation of lung cancer
 Classification of lung cancers
 Diagnosis including investigations
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Staging of lung cancers
 Management
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Benign Lung Tumours
Hamartoma
 Arterio-venous malformations (AVMs)
 Carcinoid tumour
 Granuloma
 Patients often asymptomatic. Incidental
finding on CXR (solitary pulmonary
nodule)
 Malignancy needs to be excluded
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Importance of Lung Cancer
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Incidence: 40,000 new cases of lung cancer /year
Leading cause of cancer death world wide
Third commonest cause of death in UK
32,000 deaths/year
North South divide: higher prevalence in North
Higher in lower socio economic groups
 with age
Commoner in men but  in women
Risk Factors for Lung Cancer
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Smoking (pack yrs), early onset worse
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latent period of 30 years
Passive smoking (early exposure)
Asbestos
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latent period of 30-40 years
Radiation
Arsenic
Coal tar
Petroleum products
Family History (genetic factors)
Scar tissue
Poor Prognosis in Lung Cancer
WHY?
No significant improvement in mortality for many years
Poor Prognosis in Lung Cancer
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Why?
 No screening for lung cancer
 Late presentation
 Insufficient resources/emphasis towards
Smoking Cessation
 Poor surgical rates (10-15% v 20% in USA)
 Co-morbidity: limits treatment options
How can we improve mortality in lung cancer in
the 21st Century?
What do you think…….?
Should cigarettes be banned?
 What else can we do to stop smoking?
 Should we screen for lung cancer?
 How can we improve early referral for
suspected lung cancer?
 How can we improve referral for surgery
– hence improve curative rates?
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Smoking Cessation
Stop children/teenagers from starting to
smoke: how?
 Stop current smokers
 Education
 Political willingness: smoking ban
 Resources: smoking cessation clinics
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Doctors: Advise strongly, refer to smoking
cessation clinic, prescribe NRT
Screening For Lung Cancer
How? CXR, CT thorax ? Mobile units
 How Often? yearly?
 In what population? Smokers? Family
history?
 False positives and false negatives
 Cost effective?
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Case 1
50 year old Asian man
 30 pack year history of smoking
 Strong family history of malignancy
 Persistent cough for > 6 months
 Frequent visits to GP: several course of
antibiotics
 Admitted to St. Helier Hospital with
haemoptysis and weight loss
 Cervical lymphadenopathy, clubbed
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Case 1
Tumour seen right upper lobe and right
intermediate bronchus as Bronchoscopy
 Poorly differentiated adenocarcinoma
 Referred to RMH: Stage 4 disease, so
palliative chemotherapy only
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Early chest X-ray and referral after onset of
symptoms may have made a difference !
Case 2
40 year old woman, non smoker
 Persistent productive cough despite several
courses of antibiotics
 CXR abnormality: not resolving after
several weeks
 Admitted to hospital with severe SOB and
chest pain
 Found to have extensive CXR changes and
pericardial effusion
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Case 2
Pericardial effusion drained (pericardial
window)
 Bronchoscopy and BAL: bronchoalveolar
cell carcinoma
 Stage 4 disease
 Referred for palliative chemotherapy
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Case 3
56 year old woman, ex smoker, large goitre
 Found to have a Nodule (Solitary
pulmonary nodule) on CT scan = incidental
 Interval scan if nodule < 1 cm or looks
benign for up to 2 years
 PET scan +/ CT guided biopsy if > 1 cm
 If suspicious, then can consider wedge
resection or lobectomy
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Reasons for Late Presentation
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Patient unaware of importance of symptoms:
presents late to GP
Doctors unaware of early symptoms and signs of
lung cancer: delayed referral to specialist
Many symptoms non-specific and common in
smokers
Delayed investigations: lack of resources
Two week Rule referral
New Initiative: Fast Track of Two Week Rule
Who needs CXR and referral?
Smoking history
 Strong family history
 Symptoms not resolving (eg persistent
cough)
 Haemoptysis
 Systemic symptoms
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The Patient Pathway for suspected lung cancer
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Patient referred as 2 week rule
Seen by specialist within 14 days of receiving
referral
Investigations within 28 days of referral
Treatment within 62 days of referral
All patients discussed at weekly lung cancer MDT
Breaches counted
Tumour working group meet 3 monthly
Reasons for poor surgical rates in UK
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Late presentation
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Co-morbidity: IHD, COPD
Clinical Presentation of Lung Cancer
What is the commonest symptom?
 What sort of patients should you be worried
about?
 Is there a problem with you getting CXR?
 Do you have a problem referring patients to
a respiratory consultant?
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Clinical Presentation of Lung Cancer
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Lung symptoms:
 Persistent cough (80%)
 Dyspnoea (60%)
 Haemoptysis
 Chest pain
 Wheeze (monophonic wheeze)
 Stridor (large airway obstruction)
 Non-resolving pneumonia
Clinical Presentation of Lung Cancer
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Other Symptoms of concern:
 Hoarse voice
 Lymphadenopathy
 Hyponatraemia: inappropriate ADH
 Hypercalcaemia
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Systemic Symptoms
 weight loss
 fever
 lethargy
Clinical Examination
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Weight and height (BMI): weight loss
Hoarse voice
Clubbing and HPOA
Horner’s syndrome
Lymphadenopathy
Tracheal deviation
SVC obstruction
Pleural effusion
Lungs: monophonic wheeze
Liver: hepatomegaly, jaundice
Neurological examination
Performance Status
WHO (Zubrod) scale
0
1
2
3
4
Asymptomatic
Symptomatic but ambulatory (able to carry out light
work)
In bed< 50% of day (unable to work but able to live at
home with some assistance)
In bed > 50% of day (unable to care for self)
Bedridden
Referring patients according to 2 week rule
pathway
MORE LIKELY
LESS LIKELY
Significant smoking history
Older patient
Prolonged history of symptoms
Non-infective symptoms
Radiology: tumour
Non smoker
Younger patient
Short history of symptoms
Infective symptoms
Radiology: infection
Malignant Lung Cancers
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Primary:
 Bronchogenic: from epithelium of bronchial
mucosa (95%)
 Bronchoalveolar: from alveolar cells
 Mesothelioma: from pleura
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Secondary (Metastases):
 Pulmonary
 Breast
 Thyroid
Colon
Kidney
Prostate
Pathophysiology of lung cancer
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Progressive changes in bronchial mucosa
Squamous metaplasia of bronchial epithelium
Dysplasia
Malignant cells
Local invasion:
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adjacent lung
pericardium
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pleura
ribs and muscle
Distant metastases (lymphatics and blood)
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lymph node
adrenals
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liver
bone
brain
Effects of Local Spread
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Pleural involvement: chest pain, pleural effusion
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Rib erosion: bony pain
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Lymphadenopathy: intrathoracic, supraclavicular
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Pancoast’s tumour: apical, involves brachial plexus
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Horner’s syndrome: involvement of lower cervical
sympathetic ganglion (ptosis, miosis, enopthalmos,
anhidrosis)
Effects of Local Spread
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Recurrent Laryngeal nerve palsy: hoarse voice, bovine
cough
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Phrenic nerve palsy: raised hemi-diaphragm
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SVC obstruction: invasion of superior mediastinum
(headache, pain, facial congestion, distended neck veins,
upper limb oedema)
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Oesophageal compression: dysphagia
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Pericardial involvement: cardiac arrhythmias
Distant Metastases
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Bone: pathological fractures, severe pain, hypercalcaemia,
spinal cord compression
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Liver: jaundice, abnormal LFTs
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Brain: convulsions, headaches, confusion, hemiparesis,
personality change
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Lung: Ipsilateral or contralateral lung
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Adrenal: rarely adrenal insufficiency
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Skin: nodules
Bronchogenic Lung Cancer
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Non small cell lung cancer (NSCLC):
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Squamous cell carcinoma
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Adenocarcinoma
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Large cell (undifferentiated)
Small cell lung cancer (SCLC)
NSCLC
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Squamous Cell Carcinoma (30%)
 develops in large central airways
 Cavitating with necrosis and haemorrhage
 PTH secreting: hypercalcaemia
Adenocarcinoma (30%)
 arise from mucous cells of the epithelium
 Less associated with smoking
 More peripheral, grow slowly, metastasize late
 Bronchoalveolar cell carcinoma
Large Cell (15%)
 poorly differentiated
 highly aggressive, metastasize early
SCLC
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Also known as “oat cell carcinoma”
25% of all lung cancers
Arise from the Kulchitsky cells (endocrine cells):
part of APUD
Secrete polypeptide hormones
Highly aggressive, grows rapidly and metastasizes
early
Very poor prognosis
Non-metastatic Manifestations
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SIADH: hyponatraemia (SCLC)
ACTH: Cushing’s syndrome (SCLC)
PTH: hypercalcaemia (SCC)
Clubbing
Hypertrophic pulmonary osteoarthropy (HPOA)
Neurological manifestations:
 Cerebellar degeneration
 Myopathies
 Neuropathies
 Myasthenic syndrome (Eaton-Lambert syndrome)
 DIC and other haematological abnormalities
Investigations
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Radiology:
 CXR
 Staging CT scan (thorax and abdomen)
 Brain CT scan (neurological symptoms or
signs)
 MRI scan (nerve/rib involvement, sc
compression)
 Bone scan (bone pain, hypercalcaemia)
 PET scan (staging)
PET scan
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Essential prior to radical treatment (surgery or
radiotherapy)
May upstage or downstage a tumour
Uptake of 2-deoxyglucose labelled with fluorine18 by metabolically active tissue
Sensitivity for metastases: 95%
Specificity for metastases: 83%
Not good at detecting brain metastases
Not good for slowly growing tumours
Investigations
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Histology / cytology:
 bronchoscopy: biopsy, brushings,
washings
 CT / US guided biopsy (lung mass)
 pleural fluid
 bone biopsy
 lymph node biopsy / FNA
 mediastinoscopy
 liver biopsy
Investigations
Lung function tests (to assess severity of
COPD)
 ECG
 ECHO (LV function)
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BLOODS:
 FBC
 clotting
U+Es
bone profile
LFTs
Ca 2+
Summary
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Lung cancer is an important cause of morbidity
and mortality worldwide
Presentation is late, prognosis is poor
Surgery offers best chance of survival
Radical Radiotherapy is an alternative
Screening not currently done: ? Should we screen
for lung cancer?
How can we improve early referral from primary
care?
Any Questions?
Staging of NSCLC
Staging of NSCLC
Staging of NSCLC
New Classification
T1 a and b (at 2 cm cut point)
 T2a and T2b (at 5 cm cut point)
 T3 > 7 cm, additional tumour nodules in same
lobe as primary lung.
 T4: additional tumour nodules in ipsilateral
lobes
 M1a: tumour nodules in opposite lung and
pleural or pericardial involvement
 M1b: distant metastases
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Staging of SCLC
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Limited:
 Confined to the thorax
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Extensive:
 Distant metastases
Management of lung cancers
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All patients discussed at lung cancer MDT
 respiratory physician
medical oncologist
 radiologist
clinical oncologist
 histopathologist
Lung cancer nurse
 Thoracic surgeon
Palliative physician
 MDT Co-ordinator
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Management depends on:
 histology
radiological staging
 performance status
lung function
Management of NSCLC
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Depends on:
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Radiological Staging
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Histology
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Performance status
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Lung function
Management of NSCLC
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Curative intent:
 Surgery
 Radiotherapy
 Chemotherapy
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Palliative:
 Radiotherapy
 Chemotherapy
 Other: endobronchial stents, laser, pleurodesis
Management of SCLC
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Limited:
 Chemotherapy
 Occasionally radiotherapy
 Palliation
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Extensive:
 Chemotherapy
 Palliation
Surgery for Lung Cancer
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Surgical resection best chance of cure: <15%
rate
Aim: complete resection of all cancer tissue
5 year survival < 25%
Surgical procedures:
 Wedge resection: part of lobe removed
 Lobectomy: one lobe removed
 Pneumonectomy: one lung removed
Morbidity and mortality considerable
 Adjuvant chemotherapy + radiotherapy
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Chemotherapy for lung cancer
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Treatment of NSCLC / SCLC: prolongs life, rarely
curative
Palliative for NSCLC / SCLC: symptom relief
Often used together with radiotherapy
Neo-adjuvant : given prior to surgery to
downstage tumour (inoperable to operable)
Adjuvant: post surgery to reduce risk of
recurrence
Side Effects of Chemotherapy
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Bone marrow :
 Neutropenia
thrombocytopenia
anaemia
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Immunosupression:
 Infection
sepsis
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Other:
 Nausea vomiting
anorexia
 Hair loss
skin changes
 Other symptoms related to specific agents
Radiotherapy for lung cancer
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Radical: high dose, curative intent (CHART)
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Palliative: low dose, symptom control
 Pain at tumour site
Bony metastases
 Spinal cord compression
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Prior to surgery: de-bulking, down-staging tumour
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Combined modality: with chemotherapy
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Post surgery: improve long term survival (27% 5 year
survival)
Side effects of Radiotherapy
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Lung: severe SOB
 Pneumonitis
 fibrosis
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Heart
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Oesophagus:
 Dysphagia
Palliative Care
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Palliative Care Team:
Consultant
 Community nurses
 Occupational therapist
 Inpatient care
 Hospice
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Nurses
Social worker
Physiotherapist
Outpatient care
Home visits
Palliative Care
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Symptom Control:
Pain: pain ladder, opiates, syringe driver
 Cough: opiates
 SOB: O2, morphine, diazepam
 Secretions: hyoscine (pump
 Constipation: laxatives
 Decreased appetite: steroids
 Depression: antidepressants
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Palliative Procedures
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For relief of breathlessness:
Endobronchial stents
 Laser phototherapy
 Drainage of pleural fluid
 Medical or VATS pleurodesis
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Management of SVC Obstruction
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Severe / urgent:
 Radiologist to insert SVC stent
 Radiotherapy
 Dexamethasone
 Anticoagulate
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Non-severe:
 Dexamethasone
 Anticoagulate
 Radiotherapy
 SVC stent
Bronchoalveolar cell carcinoma
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Presents with increasing breathlessness,
productive cough
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CXR: pneumonic process (alveolar shadowing)
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Usually peripheral
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Chemotherapy
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Poor prognosis
Mesothelioma
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Malignant tumour of pleura
Risk factor: asbestos exposure
Lag of 30 – 40 years
Incidence rising until 2015
Very poor prognosis
Clinical presentation and Diagnosis of
Mesothelioma
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Severe chest pain (chest wall)
Anorexia and weight loss
Increasing breathlessness
CXR and CT: thickened pleura, contraction of
hemithorax
Pleural Biopsy:
 Abram’s needle
 VATS
 CT -guided
Histopathology of mesothelioma
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Epithelioid: better prognosis (18 months)
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Sarcomatous: poor prognosis (6 months)
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Mixed: intermediate prognosis (12 months)
Management of mesothelioma
Surgery
 Radiotherapy
 Chemotherapy
 Palliation
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Summary
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Lung cancer is an important cause of morbidity
and mortality worldwide
Presentation is late, prognosis is poor
Surgery offers best chance of survival
Screening not currently done: ? Should we
screen for lung cancer?
How can we improve early referral from
primary care?
Multidisciplinary approach essential
Palliative care important