Ca lung Dr. D.P. Singh Professor, Surgery.

Primary lung cancer – risk factors Cigarette smoking Number of years Number of packs Passive smoking Atmospheric pollution Occupational (radioactive ore, chromium mining, asbestos, arsenic) Previous h/o TB with smoking

Pathological types Small cell lung carcinoma (oat cell carcinoma) Non Small cell lung carcinoma SCLC:NSCLC :: 1:4

Histological classification Small cell lung cancer Non small cell lung cancer  Adenocarcinoma 25-40%  Large cell undifferentiated 10-20%  Squamous cell carcinoma 30-40%  Bronchoalveolar carcinoma 5%

Clinical features Depend on  Site of lesion  Invasion of neighboring structures  Extent of metastases

Clinical features Symptoms  Hemoptysis  Cough or changed cough  Dyspnoea, wheezing  Pleural effusion  Severe localized pain suggests chest wall invasion  Invasion of mediastinum – hoarseness, dysphagia, SVC obstruction  Pancoast’s syndrome – invasion of brachial plexus  Clubbing  Small cell carcinoma may cause myopathies.

Paraneoplastic syndrome with lung cancer Endocrine Hypercalcemia Cushing’s syndrome SIADH Carcinoid syndrome Gynaecomastia Hypercalcitonemia Elevated GH Elevated prolactin, FSH, LH Hypoglycemia hyperthyroidism

Paraneoplastic syndrome contd. Neurologic Encephalopathy Subacute cerebellar degeneration PML Peripheral neuropathy Polymyositis Autonomic neuropathy Lambert eaton syndrome Optic neuritis

Paraneoplastic syndrome contd. Skeletal Clubbing Pulmonary hypertrophic osteoarthropathy Hematologic Anemia Leukemoid reaction Thrombocytosis Thrombocytopenia Eosinophilia Pure red cell aplasia DIC

Paraneoplastic syndrome contd. Cutneous Hyperkeratosis Dermatomyositis Acanthosis nigricans Hyperpigmentation Other Nephrotic syndrome Hypouricemia Secretion of VIP with diarrhea Anorexia and cachexia hyperamylasemia

Diagnosis 3 aspects  Detecting the primary lesion  Tissue diagnosis  Staging

Investigations Chest radiography Computerized tomography MRI EUS PET Bronchoscopy Sputum cytology CT guided biopsy Mediastinoscopy Mediastinotomy Assessment of functional status - spirometry

Cervical Mediastinoscopy

Anterior mediastinoscopy

Staging : T: Tumor status TX - Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washing but not visualized by imaging or bronchosocopy T0 - evidence of primary tumor Tis - Carcinoma in situ T1 - 3 cm or less without invasion of visceral pleura T2 - >3 cm or any size with associated atelectasis or obstructive pneumonitis, or invasion of visceral pleura T3 - Any size with direct extension into chest wall, diaphragm, mediastinal pleura without involvement of great vessels or vital mediastinal structures and extent of bronchial spread with 2 cm of, but not involving, the carina T4 - Any size with invasion of the heart or mediastinal vital structures or carina, malignant pleural effusion

N: Nodal involvement NX - Regional lymph nodes cannot be assessedN0None N1 - Peribronchial or ipsilateral hilar lymph nodes N2 - Ipsilateral mediastinal lymph nodes, including subcarinal N3 - Contralateral mediastinal or hilar lymph nodes, ipsilateral or contralateral scalene or supraclavicular lymph nodes

M: Distant metastases MX - Presence of distant metastases cannot be assessed M0 - None M1 - Distant metastases present

Stage grouping 0 Carcinoma in situ IA  T1N0M0 IB  T2N0M0 IIA  T1N1M0 IIB  T2N1M0  T3N0M0

Stage grouping IIIA  T3N1M0  T1-3 N2M0 IIIB  T4, Any N, M0  Any T, N3, M0 IV  Any T, any N, M1

Treatment Early stage disease (stage I and II) Surgery Locoregional advanced disease (T3N1 and above) Surgery – limited role Chemotherapy Radiotherapy

Surgical management Lobectomy Pneumonectomy Thoracoscopic lung resection

Complications of lung resection Bleeding Respiratory infection Persistant air leak Bronchopleural fistula

Other treatment modalities Radiotherapy Chemotherapy