Carcinoma

Carcinoma

Characteristics

  1. Primary lung cancer represents the leading cause of cancer deaths in both males and females, and is the commonest cancer in males.
  2. Strong association with smoking, exposure to industrial chemicals (e.g. asbestos).
  3. Age of onset usually>40, but beware aggressive forms in a younger age group.
  4. Three main subtypes
  • Small cell (most aggressive) (SCLC).
  • Non-small cell (squamous, large cell and adenocarcinoma) (NSCLC).
  • Bronchoalveolar cell carcinoma (BAC).
  1. Clinical management depends on disease extent (staging) and importantly tumour type.

Clinical features

  1. May be asymptomatic – identified on routine CXR.
  2. Any of the following symptoms, cough, SOB, wheeze and/or haemoptysis, raises the possibility of tumour presence.
  3. Chest pain, dysphagia or a hoarse voice from local extension of the tumour.
  4. Systemic upset – anorexia, cachexia, clubbing.
  5. Associated with metastatic spread – headaches, bone pain.
  6. Associated paraneoplastic syndromes with hormone release (Cushing’s, acromegaly, gynaecomastia).

Radiological features

  1. CXR – solitary peripheral mass. Central in 40%. The mass can be smooth or irregular in outline and can cavitate. Satellite nodules may be present. There may be hilar, paratracheal and/or mediastinal lymphadenopathy. Direct spread may result in rib destruction and extrathoracic extension. There may be distant rib metastases.
  2. Other CXR presentations include patchy consolidation that fails to respond to antibiotics (commonly BAC), pleural effusions, bronchoceles and lung collapse, which may be partial or complete (lobar/segmental).
  3. CT allows characterisation of the mass and full staging of the cancer
  • Size and location of the tumour.
  • Presence of lymphadenopathy.
  • Presence of metastases (bone, adrenals and liver).
  1. PET/CT – increased uptake of FDG tracer in primary cancer and metastases. Sensitive tool for staging tumours and discriminating ambiguous mass lesions.

Differential diagnosis (solitary pulmonary nodule)

  1. Neoplasms – lymphoma, carcinoid, hamartoma and solitary metastasis.
  2. Inflammatory
  3. Infective – granuloma, pneumonia or abscess.
  4. Non-infective – rheumatoid arthritis, sarcoid, Wegener’s.
  5. Congenital – arteriovenous malformation, pulmonary sequestration.
  6. Miscellaneous – pulmonary infarct, rounded atelectasis.

Management

  1. Compare with old films – beware slow-growing squamous cell carcinomas.
  2. Tissue diagnosis is important – either with bronchoscopy or percutaneous biopsy (>90% sensitivity) of the primary tumour or metastatic deposit.
  3. Full tumour staging.
  4. Consideration for surgical resection (potentially curative) and/or chemoradiotherapy.
  5. Palliative treatment of symptoms (pain and hypercalcaemia).
  6. Screening has not shown any benefit in the early detection and treatment of lung cancer.

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