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Lung cancer

Epidemiology

  • Leading cause of cancer-related deaths in western world
  • Affects 1.2 million people annually worldwide
  • 40,000 cases diagnosed in the UK each year
  • Results in 29,000 deaths
  • Commonest malignancy in men
  • Second commonest malignancy in women
  • Male : female ratio = 3:2
  • Overall, 5-year survival is about 6%

Aetiology

  • Smoking is primary risk factor
  • Responsible for 85% cases in UK
  • The incidence of lung cancer is related to the number of cigarettes smoked
  • Other risk factors include
    • Passive smoking
    • Environmental and occupational hazards
    • Diet
    • Genetic factors

Pathology

Adenocarcinoma

  • Accounts for 45% of all cases
  • 75% cases are peripheral
  • Lymph node metastases are common

Squamous cell carcinoma

  • Accounts for 30% of all cases
  • 70% are centrally located near the hilum or major bronchi
  • Often locally invasive

Large cell tumours

  • Account for 5-10% of tumours
  • Usually peripherally located
  • Poorly differentiated tumours may cavitate
  • Early spread to distant sites

Small cell tumours

  • Accounts for 20% of tumours
  • 80% centrally located
  • Can produce neuroendocrine hormones
  • May result in paraneoplastic syndromes
  • Tendency to disseminate early

Management of suspected lung cancer

  • The aims of evaluating a patient with suspected lung cancer are to determine
    • Cell type of the tumour
    • Anatomical extent of the disease
    • Functional status of the patient

Investigation of potential lung cancer

Imaging

  • Chest x-ray
  • CT of chest
  • Positron emission tomography
  • Magnetic resonance imaging

Bronchial carcinoma

Invasive

  • Bronchoscopy
  • CT-guided percutaneous needle biopsy
  • Mediastinoscopy
  • Left anterior mediastinoscopy

Surgical management

  • Only surgery can cure non-small cell lung cancer
  • Only 25% patients have resectable disease at presentation

Preoperative assessment

  • Patients require assessment of
    • Pulmonary function
    • Cardiac status
    • Nutritional and performance status
  • Pulmonary complications are commonest cause of postoperative morbidity and mortality
  • Assessment of respiratory function is important
  • Pulmonary function test are essential before surgery
  • Full respiratory assessment includes:
    • FVC and FEV1
    • Estimation of transfer factor
    • Postoperative lung function prediction using anatomical equations
    • Quantitative isotope perfusions scans
  •  FEV1 and transfer factor less than 40% places patient in high risk group
Surgery
  • Lung resection is best treatment for Stage 1 and 2 disease
  • Most patients with small-cell cancer are no suitable for surgery
  • Five year survival decreases with extent of disease
  • Aims of surgery are complete resection and intrapulmonary lymphatics
  • Can be achieved with
    • Pulmonary lobectomy
    • Pneumonectomy
    • Sublobar resections
    • Bronchoplastic resections
  • Mortality from lobectomy is 2-4%
  • Mortality from pneumonectomy is 6-8%

Bibliography

Jackman D M,  Johnson B E.  Small-cell lung cancer.  Lancet 2005;  366:  1385-1396

Krupnick A S,  Kreisel D,  Hope A et al.  Recent advances and future perspectives in the management of lung cancer.  Curr Probl Surg 2005;  42:  540-610.

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