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In this section : Oncology
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Home | Articles | Oncology | Lung Cancer

Lung Cancer

Last updated 3rd November 2023

Incidence

  1. Lung cancer is the commonest cause of cancer death in the UK and worldwide, with an annual incidence of 35 000 and 1.7 million respectively.

Causes

  1. Worldwide, about three quarters of lung cancers are attributable to smoking
  2. Others are caused by occupational workplace exposure eg to asbestos, radon exposure (radon gas is created when natural radioactive uranium slowly decays in the ground under our homes and seeps to the surface) and air pollution eg diesel fumes.
  3. It is more common in men, and incidence increases with age.

Classification

  1. The two main types of lung cancer are non-small cell (NSCLC) and small cell lung cancer. NSCLC accounts for 80-85% of all lung cancers.
  2. Lung cancer is currently classified using the TNM-8 system, in which the size of the primary tumour, the extent of lymph node involvement within the thorax, and the presence of extra-thoracic metastases are used to classify patients into stages

Presentation

  1. Symptoms of non-small cell lung cancer and small cell lung cancer are basically the same.
  2. Haemoptysis is the classical presentation but only occurs in 20%
  3. Other common symptoms include lingering or worsening cough, pleuritic chest pain, shortness of breath, wheeze, weakness, fatigue, loss of appetite and weight loss
  4. Patients may present with recurrent lower respiratory tract infections.
  5. With evidence of spread to lymph nodes, bone pain, brain or liver
  6. Apical tumours may present with Horner’s Syndrome (Pan Coast Tumour)
  7. SVC obstruction can cause swelling of the face, neck, upper chest, and arms.
  8. Paraneoplastic syndromes: the 2 most common are hypercalcemia with squamous cell carcinoma of the lung and SIADH with small cell lung cancer

Diagnosis

  1. CXR is likely to be the initial test and should be considered for patients who have persistent symptoms (above) or thrombocytosis. A solitary pulmonary nodule is characteristic
  2. Contrast CT chest followed by bronchoscopy unless the lesion is peripheral in which case image guided biopsy preferred
  3. The primary tumor may show a wide spectrum of imaging appearances. NSCLCs can be centrally located masses, invading the mediastinum or peripherally situated lesions that invade the chest wall. Tumors can have margins which are smooth, lobulated or irregular and spiculated. They can be uniformly solid or can have central necrosis and cavitation.
  4. Positron emission tomography-computed tomography (PET-CT) is used to identify distant metastases in those eligible for radical treatment after contrast CT.
  5. If there is potential mediastinal node involvement, endobronchial ultrasound guided transbronchial needle aspiration is the optimal initial strategy for nodal sampling

Referral

  1. Patients with lung cancer or suspected lung cancer should be referred to the lung cancer MDT
  2. The MDT takes place every Monday at 1300.
  3. Deadline for referral is 1100 Friday – Click here for the Lung MDTM Referral Form
  4. The referral form should be emailed to [email protected]
  5. Please note patients will not be discussed without a formal referral
  6. A written outcome with advice will be generated following MDT discussion

Staging Non-small Cell Lung Cancer (NSCLC)

  • Stage 1 means the cancer is small and hasn’t spread to lymph nodes or other distant organs.
  • Stage 2: Cancer is found in the lung and nearby lymph nodes.
  • Stage 3: Cancer is in the lung and lymph nodes in the middle of the chest: same side of chest (3A) or opposite side of chest/above clavicle (3B)
  • Stage 4 means the cancer has spread to the other lung, the pleura or pericardium (4A) or beyond the lung to bone, brain, liver, adrenals (4B).

Staging Small-cell Lung Cancer (SCLC)

  1. In the limited stage, cancer is found in only one lung or nearby lymph nodes on the same side of the chest.
  2. The extensive stage means cancer has spread throughout one lung,to the opposite lung, to lymph nodes on the opposite side, to the pleura, to bone marrow or to distant organs. At the time of diagnosis 2/3 patients with SCLC have extensive disease.

Treatment

  1. Patients with stage 1 or 2 non-small cell lung cancer (NSCLC) are offered surgery, which may be followed by adjuvant treatment depending upon the pathological staging. Those not undergoing surgery due to patient physiology or preferences are offered radical radiotherapy
  2. Treatment for stage 3 NSCLC is complex but often includes chemoradiation or surgery followed by adjuvant treatments or chemoradiation followed by surgery
  3. Systemic treatment of patients with stage 4 NSCLC is guided by histology and predictive biomarkers
  4. People with small cell lung cancer are typically treated with chemotherapy and/or radiotherapy, with surgery being offered for selected early tumours

Outcome

  1. Outcomes are among the poorest of all tumour types, with overall five year survival of 10-20%.
  2. Survival is hugely influenced by stage at diagnosis, with five year survival varying from 92% to 0% for the earliest and latest stages respectively

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Content Updated by Gordon Russell