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Lung Cancer

Lung Tumors


Carcinoma of the bronchus

  1. Commonest cancer of lung: Secondaries!!! Q 
  2. Commonest primary lung cancer in the world = adeno carcinoma. Q(AC)
  3. Commonest primary lung cancer in India = squamous cell carcinoma. Q (SCC)
  4. Commonest primary lung cancer in women = adeno carcinoma. Q
  5. Commonest primary lung cancer in non smokers = adeno carcinoma. Q
  6. Commonest primary lung cancer with neuro endocrine features: small cell carcinoma of lung (SCCL)
  7. Central tumors are: SCC, SCCL
  8. Peripheral tumors are: AC, anaplastic
  9. Most common radio sensitive lung tumor SCCL Q
  10. Tumor with best prognosis SCC Q
  11. Pancoast tumour is a peripheral type of squamous cell Ca. Q
  12. Tumour with endocrine manifestation = SCCL
  13. Tumour with maximum metastasis = SCCL
  14. Tumour having cavity –Squamous, large cel 

Extra Edge: Pancoast tumor

  1. A Pancoast tumor is defined as a tumor arising in or near the apex of the lung, at or above the level of the second rib, with involvement of extrathoracic structures of the apical chest wall.
  2. The tumor originates peripherally and extends over the apex of the lung to involve the apical chest wall.
  3. This involvement can be seen by clinical and radiological evidence and can include the parietal pleura, lymphatics, endothoracic fascia, intercostal nerves, ribs, vertebral bodies, lower roots of the brachial plexus, the sympathetic chain (stellate ganglion), and subclavian vessels.
  4. The clinical triad (Pancoast triad, LQ 2012) of shoulder or arm pain, atrophy of the hand muscles, and Horner syndrome is the sine qua non of a Pancoast tumor.
  5. Classic clinical presentation of pain of the eighth cervical or the first and second thoracic trunk distribution that has become known as Pancoast syndrome.
  6. Lack of rib involvement accompanied by these symptoms is frequently included in the definition of a Pancoast tumor. 


  1. This is a malignant epithelial tumor with glandular differentiation or mucin production by the tumor cells.
  2. They show various growth patterns. Acinar, papillary, bronchioloalveolar, and solid with mucin formation.
  3. About 80% contain mucin.
  4. K-RAS mutations are seen primarily in adenocarcinoma
  5. P53, RB, & p16 mutations and inactivation have the same frequency in adenocarcinoma as in squamous cell carcinoma.
  6. Pure bronchioloalveolar growth pattern with no evidence of stromal, vascular, or pleural invasion.
  7. Bronchioloalveolar carcinoma (BAC) is a subtype of adenocarcinoma that grows along the alveoli without invasion and can present radiographically as a single mass; as a diffuse, multinodular lesion; as a fluffy infiltrate; and on screening CT scans as a "ground glass" opacity
  8. The key feature of bronchioloalveolar carcinomas is their growth along preexisting structures with destruction of alveolar architecture.
  9. This growth pattern has been termed “lepidic”, an allusion to the neoplastic cells resembling butterflies sitting on a fence.
  10. It is located in the peripheral area of the lung. 

Characteristic of Small cell carcinoma lung

  1. Usually present as central masses
  2. Cigarette smoking is an important risk factor and association of smoking with small cell carcinoma lung is high.  
  3. Associated with release of ACTH, ADH, calcitonin, ANF and Gastrin releasing peptide and thus may manifest with hypokalemia (ectopic ACTH).
  4. Highly malignant tumors with least five year survival rates.
  5. Highly metastatic lesions with widespread disease at time of diagnosis.
  6. Management is primarily with chemotherapy with or without radiotherapy
  7. 90% regression with chemotherapy
  8. Objective shrinkage in 80% to 90% patients with radiotherapy.
  9. Surgery is unlikely to be curative because disease is usually widespread at presentation.

Important Points:

Hormones produced by SCC

Paraneoplastic syndrome





Cushing's syndrome






Note: Small cell carcinoma causes hypocalcemia because of calcitonin. Hypercalcemia occurs in squamous cell cancer



  1. Most common symptom Cough Q (80%); hemoptysis (70%); dyspnoea (60%); chest pain (40%); recurrent or slowly resolving pneumonia; anorexia; weight loss.
  2. Signs: Cachexia, anaemia; clubbing Q; HPOA (hypertrophic pulmonary osteoarthropathy, causing wrist pain); supraclavicular or axillary nodes. 

Non metastatic neurological:

  1. Confusion; fits; cerebellar syndrome Q; proximal myopathy; Q neuropathy; polymyositis; Eaton-Lambert syndrome. Q
  2. Other: clubbing Q, HPOA Q, dermatomyositis Q; acanthosis nigricans Q, thrombophlebitis migrans Q.  

Metastatic: brain; bone (bone pain, anaemia, hypercalcemia); liver; adrenals (Addison's),

: ectopic hormone secretion, eg SIADH (low serum Na+ Q and raised ADH) and raised ACTH Q (Cushing's) by small cell tumours;

Raised PTH Raised Ca2+ due to PTH like peptide by squamous cell tumours, Q



Note :
Skeletal connective tissue syndromes including clubbing is usually seen in non small cell carcinomas
Clubbing is least common with small cell carcinoma of lung.


Important Points: -

Chest signs: May be normal, or: consolidation; collapse, pleural effusion.

: bone tenderness; hepatomegaly; confusion; fits; focal CNS signs; cerebellar syndrome; proximal myopathy Q; peripheral neuropathy Q.



Recurrent laryngeal nerve palsy

Phrenic nerve palsy

SVC obstruction(non pulsatile raised JVP) Q & prominent upper lobe veins..

Horner's syndrome
(Pancoast's tumour) Q

Rib erosion


Atrial fibrillation


Table - Local Effects of Lung Tumor Spread



Clinical Feature

Pathologic Basis

1.   Pneumonia, abscess, lobar collapse

Tumor obstruction of airway

2.   Lipid pneumonia

Tumor obstruction; accumulation of cellular lipid in foamy macrophages

3.   Pleural effusion

Tumor spread into pleura

4.   Hoarseness

Recurrent laryngeal nerve invasion

5.   Dysphagia

Esophageal invasion

6.   Diaphragm paralysis

Phrenic nerve invasion

7.   Rib destruction

Chest wall invasion

8.   SVC syndrome

SVC compression by tumor

9.   Horner syndrome

Sympathetic ganglia invasion

10. Pericarditis, tamponade

Pericardial involvement


Risk factors:

Cigarette smoking is the major risk factor.

: asbestos, chromium, arsenic, iron oxides, and radiation (radon gas).

: Squamous (30%); adenocarcinoma (32%); small (oat) cell (25%); large cell (15%); alveolar cell carcinoma (rare, <1%).

Most common histological variant associated with clubbing: non small cell carcinoma

Most common histological variant presenting at peripheral location: non small cell carcinoma.



  1. Cytology: sputum & pleural fluid
  2. CXR: peripheral circular opacity; hilar enlargement; consolidation; lung collapse; pleural effusion; bony secondaries. Peripheral lesions and superficial lymph nodes may be amenable to percutaneous fine needle aspiration or biopsy.
  3. Bronchoscopy: to give histology and assess operability.
  4. CT to stage the tumour.
  5. 18F ­deoxyglucose PET scan:  to help in staging (PET = positron emission tomography).
  6. Radionuclide bone scan abnormalities, if suspected bone metastases.
  7. Lung function tests.


Treatment: Non-small cell tumors: Excision is the treatment Q of choice

Curative radiotherapy is an alternative if respiratory reserve is poor.


Seuerity of Small Cell Lung Cancer:
A simple two-stage system is used. In this system, limited-stage disease (seen in about 30% of all patients with SCLC) is defined as disease confined to one hemithorax and regional lymph nodes (including mediastinal, contralateral hilar, and usually ipsilateral supraclavicular nodes), while extensive-stage disease (seen in about 70% of patients) is defined as disease exceeding those boundaries.

+ radiotherapy for more advanced disease.


Table 89–9 Drugs used in First-Line Chemotherapy for Metastatic Non-Small Cell Lung Cancer (Ref. Hari. 18th ed., Pg- 750)

  1. Cisplatin
  2. Paclitaxel
  3. Gemcitabine
  4. Docetaxel
  5. Carboplatin
  6. Vinorelbine
  7. Irinotecan
  8. Pemetrexed
  9. Gefitinib

Extra Edge:  Recent Advances: Vinorelbine (LQ 2012)

It is a new semi-synthetic vinca alkaloid having less toxicity as compare to vincristine. Vinorelbine is used for the treatment of non small cell lung cancer.


Treatment: Small Cell Lung Cancer

  1. Cisplatin or carboplatin and Etoposide
  2. Cyclophosphamide, doxorubicin , and vincristine

Recent advances : Newer drugs

  1. Agents that Inhibit Angiogenesis (Ref. Hari. 18th ed., Pg- 751-52)
    Bevacizumab was the first antiangiogenic agent approved for the treatment of patients with advanced NSCLC. This drug primarily acts by sponging up VEGF and blocking the growth of new blood vessels, which are required for tumor viability.
  2. Agents that Inhibit the Epidermal Growth Factor Receptor
    1. Erlotinib and gefitinib are oral small-molecule kinase inhibitors that inhibit signaling via EGFR.
    2. Cetuximab is an intravenously administered chimeric antibody directed against EGFR. 

Recent Advances: Crizotinib has been approved for advanced non-small cell lung cancer. This is not given Harrison 18th edition also.!!!


Prevention: Quit smoking, Q

Other lung tumours


Bronchial adenoma

Rare, slow-growing. 90% are carcinoid tumours; 10% cylindromas.

Recurrent hemoptysis Q is the presenting features. 

RX surgery.


Rare, benign; CT. lobulated mass flecks of calcification Q;  excise Q to exclude malignancy.


(Ref. Hari. 18th ed., pg - 1978,  2124)


  1. Mesotheliomas both pleural and peritoneal, are also associated with asbestos exposure.
  2. In contrast to lung cancers, these tumors do not appear to be associated with smoking.
  3. Relatively short-term asbestos exposures of 1–2 years or less, occurring up to 40 years in the past, have been associated with the development of mesotheliomas.
  4. Although ~50% of mesotheliomas metastasize, the tumor generally is locally invasive, and death usually results from local extension.
  5. Most patients present with effusions that may obscure the underlying pleural tumor.
  6. In contrast to the findings in effusion due to other causes, because of the restriction placed on the chest wall, no shift of mediastinal structures toward the opposite side of the chest will be seen.
  7. The major diagnostic problem is differentiation from peripherally spreading pulmonary adenocarcinoma or from adenocarcinoma metastasized to pleura from an extrathoracic primary site.
  8. Although cytologic examination of pleural fluid may suggest the diagnosis, biopsy of pleural tissue, generally with video-assisted thoracic surgery, and special immunohistochemical staining is usually required.
  9. Microscopically Malignant mesothelioma may be epithelioid (60% ),Sarcomatoid (20%) or can be mixed i.e biphasic histology seen.
  10. There is no effective therapy.

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