Lung cancer

Question 1

Lung cancer

Answer 1

Please examine this patient who has had a 3‐month history of chronic cough, malaise and weight loss.

Question 2

Clinical signs

Answer 2

• Cachectic
• Clubbing and tar‐stained fingers
• Lymphadenopthy: cervical and axillary
• Tracheal deviation: towards (collapse) or away (effusion) from the lesion
• Reduced expansion
• Percussion note dull (collapse/consolidation) or stony dull (effusion)
• Absent tactile vocal fremitus (effusion); increased vocal resonance (collapse/consolidation)
• Auscultation:
  ⚬⚬ Crackles and bronchial breathing (consolidation/collapse)
  ⚬⚬ Reduced breath sounds; absent tactile fremitus (effusion)
• Hepatomegaly or bony tenderness: metastasis
• Treatment:
  ⚬⚬ Lobectomy scar
  ⚬⚬ Radiotherapy: square burn and tattoo
• Complications:

Question 3

Complications of lung cancer

Answer 3

• Superior vena cava obstruction: suffused and oedematous face and upper limbs, dilated superficial chest veins and stridor
• Recurrent laryngeal nerve palsy: hoarse with a ‘bovine’ cough
• Horner’s sign and wasted small muscles of the hand (T1): Pancoast’s tumour
• Endocrine: gynaecomastia (ectopic βHCG)
• Neurological: Lambert–Eaton myasthenia syndrome, peripheral neuropathy, proximal myopathy and paraneoplastic cerebellar degeneration
• Dermatological: dermatomyositis (heliotrope rash on eye lids and purple papules on knuckles (Gottron’s papules associated with a raised CK) and acanthosis nigricans

Question 4

Types of lung cancer

Answer 4

• Squamous 35%,
• small (oat) 24%,
• adeno 21%,
• large 19% and
• alveolar 1%

Question 5

Management of lung cancer

Answer 5

1. Diagnosis of a mass:
   * CXR: collapse, mass and hilar lymphadenopathy
   * Volume acquisition CT thorax (so small tumours are not lost between slices) with contrast
2. Determine cell type:
   * Induced sputum cytology
   * Biopsy by bronchoscopy (central lesion and collapse) or percutaneous needle CT guided (peripheral lesion; FEV1 >1 L))
3. Stage (CT/bronchoscopy/endobronchial ultrasound guided biopsy /mediastinoscopy/ thoracoscopy/PET):
   * Non‐small cell carcinoma (NSCLC): TNM staging to assess operability
   * Small cell carcinoma (SCLC): limited or extensive disease
4. Lung function tests for operability assessment:
   * Pneumonectomy contraindicated if FEV1 < 1.2 L
5. Complications of the tumour:
   * Metastasis: ↑ LFTs, ↑ Ca++, ↓ Hb
   * NSCLC: ↑ PTHrP → ↑ Ca++
   * SCLC: ↑ ACTH, SIADH → Na+ ↓

Question 6

Treatment

Answer 6

• NSCLC:
  ⚬⚬ Surgery: lobectomy or pneumonectomy
  ⚬⚬ Radiotherapy: single fractionation (weekly) versus hyper‐fractionation (daily for 10 days)
  ⚬⚬ Chemotherapy: benefit unknown; EGFR Positive – erlotinib
• SCLC:
  ⚬⚬ Chemotherapy: benefit with six courses

Question 7

Multidisciplinary approach

Palliative care

Answer 7

• For brain metastasis: Dexamethasone and radiotherapy
• SVCO: dexamethasone plus radiotherapy or intravascular stent
• For haemoptysis, bone pain and cough: Radiotherapy
• For effusion: Chemical pleurodesis – talc; tetracycline no longer used
• For cough and pain: Opiates