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Late Diagnosis Of Lung Cancer In Resource-poor Centres

Late Diagnosis Of Lung Cancer In Resource-poor Centres. Dr. Audrey Forson Department of Medicine University of Ghana Medical School. AACTS Conference August 2013. Outline. Case Epidemiology Misdiagnosis Clinical similarities/differences Diagnosis of lung cancer. Case .

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Late Diagnosis Of Lung Cancer In Resource-poor Centres

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  1. Late Diagnosis Of Lung Cancer In Resource-poor Centres Dr. Audrey Forson Department of Medicine University of Ghana Medical School AACTS Conference August 2013

  2. Outline • Case • Epidemiology • Misdiagnosis • Clinical similarities/differences • Diagnosis of lung cancer

  3. Case • 77 year old female • Completed Anti-TB medication 6th month, smear negative TB • Cough, weight loss, never smoked • Hemipareisis, weakness Rt sided • CT scan chest • MRI brain

  4. Lung cancer • The most important cause of cancer death in developed countries • High mortality, late diagnosis • Rates are higher in men but declining. • Slowing more in men than in women • Declining in more young age groups • Adenocarcinoma has replaced squamous cell carcinoma as the commonest form of lung cancer. • From 1980s Adenocarcinoma has increased markedly in all subgroups, both male and female

  5. Cancer mortality in Ghana: No. of cases and summary frequency rates in males SITE No. ALL AGES RF % ASCAR • LIVER 428 21.3 21.15 • HAEMATOPOIETIC ORGANS 417 20.8 15.57 • PROSTATE 286 14.2 17.35 • STOMACH 126 6.3 7.26 • PANCREAS 91 4.5 5.22 • BLADDER 91 4.5 5.07 • LUNG 78 3.9 4.56 • BRAIN 67 3.3 2.78 • COLON & RECTUM 53 2.6 2.95 • LARYNX 45 2.2 2.75 • KIDNEY 41 2.0 1.63 • OESOPHAGUS 39 1.9 2.42 • BONE 34 1.7 1.35 • BREAST 12 0.6 0.66 ALL SITES 2008 100 100 • ASCAR - age-standardized cancer ratio Wiredu EK, Armah HB. BMC Public Health. 2006; 6: 159. A 10-year review of autopsies and hospital mortality [1991-2000 (3659 autopsies)]

  6. Epidemiology of Lung Cancer • Cigarette smoking >55 carcinogens eg. polycyclic aromatic hydrocarbons, 20-fold increase in risk vs non-smokers • In Ghana - Smoking among men 10.62%, women 2.6% (World Bank report 2010), 7% • Passive smoking, envoronmental tobacco smoke (ETS) - ¼ of cases in one study • Occupational carcinogens - radon (underground miners), asbestos • synergy with smoking • Indoor pollution – solid fuels for indoor cooking, radon

  7. Epidemiology of Lung Cancer • Air pollution – diesel emissions, hydrocarbons • Outdoor air pollution accounts for about 1 to 2% of lung cancer cases. • Genetics, eg. • K-rasoncogene mutated in about 30% of adenocarcinomas, almost exclusively in heavy smokers , • epidermal growth factor receptor (EGFR) mutation is commonly seen in never smokers and much less common in smokers • Micronutrients – being investigated

  8. In developed countries • Active smoking is responsible for 90% of lung cancer cases, • Occupational exposures to carcinogens account for approximately 9 to 15% of lung cancer cases, • radon causes 10% of lung cancer cases, • Age - Older age group • Race – in USA high prevalence in African-American men and in non-hispanic white men • 50% higher in African-Americans • Low rates of lung cancer in Africa, ?recent studies • Previously incurred lung damage – eg. from COPD and fibrotic diseases such as pneumoconiosis. • COPD a risk factor - to “remove” the effect of cigarette smoking

  9. Diagnostic Dilemma: Pulmonary tuberculosis as differential diagnosis of lung cancer • Low prevalence of lung cancer – estimated 5 per 100,000 • High prevalence of tuberculosis – 106 per 100,000 (60 per 100,000) • Patients with lung cancer are often misdiagnosed as pulmonary tuberculosis, other diagnoses, leading to delay in the correct diagnosis

  10. Lung cancer classification • Non-small cell lung cancer (NSCLC) • Adenocarcinoma • Squamous cell carcinoma Small cell lung cancer (SCLC) • Large cell carcinoma • Squamous cell and small cell carcinoma are more directly linked to smoking than adenocarcinoma • About 10% ‘Never smoked’ - disproportionately present with adenocarcinoma and bronchoalveolar carcinoma

  11. Squamous cell carcinoma tends to be centrally located and may cavitate

  12. Adenocarcinoma of lung

  13. Adenocarcinoma in situ or minimally invasive adenocarcinomain lung- formally known as bronchoalveolar carcinoma . 

  14. Lymphangitiscarcinomatosis is the term given to tumour spread through the lymphatics of the lung and is most commonly seen in secondary metastases usually from adenocarcinoma.

  15. Reasons for Misdiagnosis In developing countries, • Lack of awareness of the diagnosis of lung cancer, • TB and lung cancer have common symptoms • fever, cough, sputum, haemoptysis, weight loss, anorexia, lethargy, chest pain, SOB are common to both tuberculosis and lung cancer. • Common risk factors – smoking, chronic cough diagnosed late, comorbidties • Inadequate infrastructure – • for bronchoscopy, mediastinoscopy, CT guided biopsy, VATS (video assisted thoracoscopic surgery), medical thoracoscopy • Lack of a confirmatory test for smear negative TB

  16. Other factors for TB • Socio-economic factors, overcrowding, history of contact, substance abuse, immune suppressed state • Anaemia- both, no clubbing Other factors for Lung Ca • History of smoking, exposure to carcinogens, passive smoking, lung fibrosis • Nicotine stained fingers, clubbing • Hoarseness - due to vocal cord paralysis due to involvement of left recurrent laryngeal nerve • Ptosis, SVC obstruction • Signs of metastases • Bovine cough, bone/back pain (mets), paraneoplastic disorders

  17. Radiology – Chest Xray • Lung cancer - commonly a mass, +/- lung collapse • Irregular margins – spiculated, but 20% smooth borders • Prominent hilum (+/- hoarsenes), widened mediastinum • Nodules, atelectasis, unresolving consolidation • Rib erosion (+ severe chest pain), • Interstitial shadowing – carcinoma in situ / adenocarcinoma (bronchoalveolar carcinoma) , lymphangitis • Occasionally normal xray • TB - Parenchymal disease (upper lobe predilection) • lymphadenopathy, nodules, miliary disease, pleural effusion, cavitation , dense consolidation, homogeneous, or non-homogenous – air bronchograms, bronchial • Fibrotic changes

  18. Pulmonary TB 35 yr F 2 month history of productive cough, clear sputum, no haemoptysis fever, night sweats, weight loss, anorexia, palpitations, dyspnea no smoking Significant alcohol intake, sells liquor smear positive +++ HIV positive

  19. 18 yr Male Pulmonary TB cough 2/12 , productive clear sputum, no haemoptysis, marked weight loss, anorexia, night sweats, no fever, severe anaemia, SH single, previous smoker 5/day, AFB negative, HIV+

  20. Lung cancer upper lobe mass, hilar shadowing

  21. Diagnosis Radiology • Previous Chest xrays – past 1-2 yrs, serial xrays • Lung cancers typically double in volume (an increase of 26% in diameter) average, 240 days (range 30 -400 days). • Chest CT scan- best to follow-up on abnormal CXR, or symptomatic with normal CXR • Lymph node involvement, size, nodules or masses • PET scan (positron emission tomography scan): a small amount of radioactive glucose is injected into a vein • Increased uptake in Lung Ca, solitary nodules • Detect metastases • MRI (magnetic resonance imaging) • Radionuclide bone scan- detects rapidly dividing cancer cells in bone

  22. Diagnosis – obtain tissue confirmation of lung cancer • Sputum cytology, repeated samples • Fiberopticbronchoscopy • Endobronchial, transbronchial biopsy, FNA, brushings • BAL, washings • Staging – size and location of tumor, extension to carina or trachea useful for staging of lung cancer • Endoscopic ultrasound (EUS), transoesophageal, • fine-needle aspiration, tumour or LN adjacent to oesophagus • Mediastinoscopy • CT guided/ fluoroscopy-guided biopsy • Special stains for detecting mucin , carcinoembryonic antigen and (CEA), Leu-1 – 50-90% of adenocarcinoma,, not in mesothelioma

  23. Preparation - Bronchoscopy pathway • FBC, platelets • INR • Spirometry • ECG • CT scan, (Chest xray) • Sputum AFB smear • Gene Xpert – real-time PCR-based molecular testing • an automated, cartridge-based nucleic acid amplification test (NAAT) for TB - 2hrs

  24. Pleural lesions • Pleural aspirate – 62 – 90% • Pleural biopsy – 44-75% yield, metastatic ds, tuberculosis • closed pleural biopsies are less sensitive than pleural fluid cytology • VATS – video-assisted thoracoscopic surgery • Medical Thoracoscopy – 95% yield • Under conscious sensation • visualised biopsy • Medical thoracoscopy cheaper than VATS Above methods combined – 97% ATS. Management of Malignant Pleural Effusions , American Journal of Respiratory and Critical Care Medicine, Vol. 162, No. 5 (2000), pp. 1987-2001.http://www.atsjournals.org/doi/full/10.1164/ajrccm.162.5.ats8-00

  25. The value of biopsy Tuberculoma Bhatt M, Kant S, Bhaskar R. Pulmonary tuberculosis as differential diagnosis of lung cancer. South Asian J Cancer 2012;1:36-42

  26. In a resource poor setting what are the Alternatives? • In the developing world where TB prevalence is high, ATT ‘trial’ for suspicious lung opacities may be an acceptable practice • We must reach a consensus on the time limit beyond which the diagnosis of TB must be reconsidered for poor or no response. 4-6 weeks • Investigate all patients suspected of TB and having risk factors for lung carcinoma with • 2 sputum AFB, culture, rapid molecular tests as well as sputum cytology for malignant cells. • Yield from sputum cytology? Low - 20%. What risk factors? • Should be referred from DOTS centres for early CT scan followed by bronchoscopy in suspicious cases

  27. References • Wiredu EK, Armah HB. A 10-year review of autopsies and hospital mortality. BMC Public Health. 2006; 6: 159. • Alberg AJ, Samet JM. Epidemiology of Lung Cancer. CHEST 2003; 123:21S–49S • Bhatt M, Kant S, Bhaskar R. Pulmonary tuberculosis as differential diagnosis of lung cancer. South Asian J Cancer 2012;1:36-42 • Singh VK et al. A Common Medical Error: Lung Cancer Misdiagnosed as Sputum Negative Tuberculosis. Asian Pacific J Cancer Prev, 10, 335-338 • ATS. Management of Malignant Pleural Effusions , American Journal of Respiratory and Critical Care Medicine, Vol. 162, No. 5 (2000), pp. 1987-2001

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