LUNG CANCER
This is what makes Thoracics Anesthesia…
In fact resection of lung tumours presents the most challenging of operations to both Surgeon and Anesthetist. Here is a brief classification of some salient pathological characteristics that will make sense of the preoperative assessment of such patients.
Lung tumours are classified as
Small Cell
Non Small cell
This possibly because the small cell is treated conservatively and the non small cell surgically.
I prefer to think of them as 2 types
Central and Peripheral
- The CENTRAL Types
These are located near the large airways and are of pathological types
Small Cell,
Squamous Cell
Carcinoid
A.The SMALL CELL CARCINOMA
- Fast Growth Rate
- Early metastasis
- Low survival -10%
The PARANEOPLASTIC EFFECTS ARE - SIADH
- Eaton Lambert Syndrome
Chemotherapy and Aggressive radiotherapy is the mainstay
B. The SQUAMOUS CELL CARCINOMA
- These tend to grow large
- Metastasis is late
They are notorious for MASS effects
ie…
• Airway,
• Great vessel involvement
• Superior Vena Cava Syndrome
Ectopic release of PTH - Hypercalcemia
C. CARCINOID
- Fortunately these are benign
- There is no association with smoking
- Highly vascular
- They are however are fraught with Paraneoplastic effects due to the release of biogenic amines
The mainstay in management is use of OCTREOTIDE
5yr survival >90%
2.The PERIPHERAL TYPE-
These are
Adenocarcinoma
Large cell undifferentiated
A. ADENOCARCINOMA
- This is the most common tumour
- Sadly there is early metastasis
More likely areas that are invaded are extrapulmonary structures such as the Chest Wall, diaphragm etc
PANCOAST’S SYNDROME is more likely with these tumours, This is when the tumour in the superior pulmonary sulcus produce a syndrome, which is characterised by pain in the shoulder and along the inner side of the arm and hand due to brachial plexus involvement particularly the ULNAR NERVE.
B. LARGE CELL UNDIFFERENTIATED TYPE
- These are less common
- Large
- They Tends to cavitate
- Large-cell lung carcinoma (LCLC) is a heterogeneous group of undifferentiated malignant neoplasms
- They originate from transformed epithelial cells in the lung.
- They are usually a “diagnosis of exclusion”, as that the tumor cells lack light microscopic characteristics that would classify the neoplasm as a small-cell carcinoma, squamous-cell carcinoma, adenocarcinoma, or other more specific histologic type of lung cancer.
- They are differentiated from small-cell lung carcinoma (SCLC) primarily
• larger size of the anaplastic cells,
• a higher cytoplasmic-to-nuclear size ratio,
• lack of “salt-and-pepper” chromatin.
These Patients typically present with a non-productive cough and weight loss…
THE 4 M’s
In as much as knowing what pathology is involved concerning the tumour to be resected, one can decipher and summarize information relative to the perioperative setting through assessing the 4 M’s.
- M - MASS Effects
Here assessment of Obstructive effects is paramount. Impingement or blockage can occur to the
- Airway
- Oesophagus
- Great Vessels
- M - METASTATIC Effects
This information is vital as it reflects prognosis and reflect whether a curative or palliative procedure is planned. - M - METABOLIC Effects
Lung tumours are often fraught with a host of Paraneoplastic effects.
- Carcinoid Syndrome is more likely to occur with the lung tumours as biogenic amines will not be detoxified by the liver
- SIADH occurs mainly with the small oat cell tumour.
- Eaton Lambert Syndrome - This though Paraneoplastic causes more a problem with the neuromuscular junction
- M - MEDICATION Effects
Here the effects of chemotherapy needs to be assessed as they can cause bone marrow, renal or even cardiac effects. Some like Bleomycin may even affect the Anesthetic as using a high FiO2 with this can cause toxic effects…
Cheers
Dr M. Joosab
(Dr Roc)
Anesthesia