17. Clinical Features of the Lung Cancer and Staging

Question 1

What are the risk factors?

Answer 1

Smoking (more than 85%)
Passive Smoking
Exposure to asbestos, radon, air pollution and diesel exhaust

Question 2

What are the 10 signs and symptoms of Lung Cancer?

Answer 2

Chronic coughing
Coughing up blood
Wheezing sound
Chest and Bone Pain
Chest Infections
Difficulty swallowing
Raspy, Hoarse voice
Shortness of Breath
Unexplained weight loss
Nail Clubbing

Question 3

What are the advanced disease metastatic symptoms?

Answer 3

Bone pain
Spinal cord compression
- Limb weakness 
- Paraesthesia
- Bladder/bowel dysfunction
Cerebral metastases 
- Headache
- Vomiting
- Dizziness
- Ataxia
- Focal weakness
Thrombosis

Question 4

What are the advanced disease paraneoplastic symptoms?

Answer 4

Hyponatraemia
- SIADH
Anaemia
Hypercalcaemia 
- Parathyroid hormone related protein
- Bone metastases
Dermatomyositis/Polymyositis
- Proximal muscle weakness
Eaton-Lambert Syndrome
- Upper limb weakness
Cerebellar ataxia
Sensorimotor neuropathy

Question 5

What are the clinical signs of lung cancer?

Answer 5

Chest signs
Clubbing
Lymphadenopathy
Horner's syndrome
Pancoast tumour
Superior Vena cava obstruction
Hepatomegaly
Skin nodules (metastases)

Question 6

What are the initial investigations for lung cancer?

Answer 6

CXR
FBC
Renal, Liver functions and Calcium
Clotting screen 
Spirometry

Question 7

What are the investigations for “tissue diagnosis”?

Answer 7

Bronchoscopy
EBUS
Image guided lung biopsy
Image guided liver biopsy
FNA of neck node or skin metastasis
Excision of cerebral metastasis!
Bone biopsy
Mediastinoscopy/otomy
Surgical excision biopsy

Question 8

What is a T1 tumour?

Answer 8

Diam:
T1a <2cm
T1b 2-3cm

Scopy:
No invasion lobar bronchus

Question 9

What is a T2 tumour?

Answer 9

Diam:
T2a 3-5cm
T2b 5-7cm

Scopy:
> 2cm to Carina

Atelectasis:
Lobar atelectasis or obstructive pneumonia to hilus

Question 10

What is a T3 tumour?

Answer 10

Diam:
> 7cm

Scopy:
<2cm to Carina

Atelectasis:
Whole Lung

Invasion:
Chest wall 
Diaphragm
Mediastinum 
Pleura 
Pericard

Nodules:
Nodules in same lobe

Question 11

What is a T4 tumour?

Answer 11

Scopy:
In Carina

Invasion:
Heart 
Great Vessels
Trachea
Esophagus
Spine

Nodules:
Nodules in other ipsilateral lobes

Question 12

What is N0 nodal involvement?

Answer 12

No regional node involvement

Question 13

What is N1 nodal involvement?

Answer 13

Involvement of ipsilateral hilarious or ipsilateral peribronchial nodes

Question 14

What is N2 nodal involvement?

Answer 14

Involvement of ipsilateral mediastinal or subcarinal nodes

Question 15

What is N3 nodal involvement?

Answer 15

Involvement of contralateral mediastinal or hilarious nodes OR Ipsilateral or contralateral scalene or supraclavicular nodes

Question 16

What is M0 metastasis?

Answer 16

Distant Metastasis Absent

Question 17

What is M1 metastasis?

Answer 17

Distant Metastasis Present

Question 18

What must be taken into consideration for treatment decisions?

Answer 18

Performance status
Patient wishes
Histological type and stage
Multidisciplinary team
Aims of treatment e.g. radical or palliative

Question 19

How is performance status marked?

Answer 19

0 = Fully active
1 = Symptoms but ambulatory 
2 = "up and about" > 50%, unable to work
3 = "up and about" < 50%, limited self care 
4 = bed or chair bound

Question 20

What are the treatment options?

Answer 20

Surgery – around 18% of patients – Wedge resection
– Lobectomy
– Pneumonectomy
Radiotherapy – Radical
– Palliative
– Stereotactic
Chemotherapy
– Part of radical or palliative treatment
– Alone, combined with radiotherapy, adjuvant (after surgery)
– Targeted agents e.g Tyrosine Kinase Inhibitors and monoclonal antibodies
• erlotinib, gefitinib, crizotinib
– Small cell e.g. cisplatin/etoposide
– Adenocarcinoma e.g. cisplatin/pemetrexed
– Squamous e.g. cisplatin/gemcitabine
Best supportive care
Co-ordination – Lung Cancer Specialist Nurse

Question 21

What is palliative management?

Answer 21

Symptom control
- May include chemotherapy
- May include radiotherapy e.g. pain, haemoptysis
- Opiates, Biphosphates, Benzodiazepines
- Treatment of hypercalcaemia, dehydration, hypnoatraemia
Quality of life
Community support
Decisions and planning, resuscitation status, end of life care
Multidisciplinary team including lung cancer nurse and hospice