Lung Neoplasms STEP UP

Question 1

Classification?

Answer 1

1. Small cell lung cancers (25%)

2. Non small cell lung cancers (75%):
    Squamous cell carcinoma 
    Adenocarcinoma
    large cell carcinoma
    bronchioalveolar cell carcinoma

Question 2

Staging?

Answer 2

NSCLC: TNM

SCLC:

1. Limited (to chest and supraclavicular nodes)
2. Extended (beyond these)

Question 3

Risk factors?

Answer 3

1. Smoking 85% of cases
2. Second hand smoking (passive)
3. Asbestos (construction workers, car mechanics, painters, ship builders)
4. COPD (independent of smoking)
5. Radon (basements)

Question 4

Clinical features?

Answer 4

1. Local manifestations : cough, hemoptosis, dyspnea, wheezing
2. Constitutional (late) : anorexia, weight loss, weakness
3. Local Invasion :
   Recurrent laryngeal nerve palsy,
   Superior vena cava syndrome,
   Phrenic nerve palsy,
   Horner syndrome,
   Pancoast tumour (associated with Horner in 60% of cases)
   Malignant pulmonary effusion (poor prognosis)
4. Metastatic disease : brain, bones, liver, adrenal glands

4. Paraneoplastic syndromes:
SIADH
Ectopic ACTH
PTH-like harmone secretion
Eadon-Lambart Syndrome (much like myasthenia gravis, with deep tendon reflexes diminished and paresthesia in lower extremities) 
Clubbing

Question 5

Investigations?

Answer 5

1. CXR
2. CT chest with IV contrast
3. Cytological examination of sputum
4. Fiberoptic bronchoscopy
5. Trans thoracic needle biopsy
6. Mediastinoscopy
7. Whole body PET scan (position emitted topography)

Question 6

Treatment?

Answer 6

NSCLC:

1. Surgery with adjunct radiotherapy if no metastasis
2. If metastasis, then no surgery
3. Recurrence may still occur
4. Chemotherapy of little use

SCLC:

1. Limited : radiotherapy + chemotherapy
2. Extended : if respondscro chemotherapy, radiotherapy also done then afterwards to reduce chances of brain abscess.
3. Surgery of little use

Question 7

Prognosis?

Answer 7

Grim:
Overall 5 year survival is 14%
Most die within 2 years

Question 8

Solitary Pulmonary nodules. Benign vs malignant factors?

Answer 8

Benign:

1. Size less than 1 cm
2. Increase in size less than 2 cm in 2 years
3. Regular margins
4. Centralized calcification
5. Non smoker
6. Age less than 50 years

Malignant :

1. Size more than 2 cm
2. Growth more than 2 cm in 2 years
3. Irregular margins
4. Calcification irregular
5. Age more than 50 years
6. Smoker

Question 9

Solitary Pulmonary nodules. Management?

Answer 9

1. If old xray available, it is important, get new xray and compare size. Growth of more than 2 cm in 2 years is malignant. Growth over months points to malignancy. Growth over days Benign (infection, inflammation). No growth is also Benign.
2. If old xray not available, then inquire about factory Benign vs malignant. Then categorize mass as follows:
   A. Low probability malignant : do serial ct scans
   B. Intermediate probability malignant : do pet scan and if pet scan positive, do biopsy
   C. High probability malignant : do biopsy

If lesion is Benign, resect if possible