How lung cancer metastasizes to the adrenal glands

Lung cancer

Lung cancer(Lung cancer, also Lung cancer): Malignant tumor of the bronchial mucosa and the most common cancer in men, but more and more women are also getting it.

Around 25% of all carcinomas are lung carcinomas. In Germany, ~ 45,000 patients die of lung cancer every year, with a share of 24% it is the most common cause of cancer death in men and with a share of 15% it is the second most common cause of death in women1. Smoking is the main risk for lung cancer. About 90% of men and 40% of women who develop lung cancer have actively smoked. Smoking 20 cigarettes a day for 20 years increases the risk of lung cancer about 20 times, but passive smokers are also at risk, e.g. B. if family members smoke in the apartment every day or smoking is allowed in the office. Pollutants in the workplace such as asbestos, quartz and nickel dust and other air pollutants are responsible for up to 15% of lung cancers. The prognosis for lung carcinoma is very poor and depends on the tissue structure of the carcinoma and the tumor stage at the time of diagnosis.

Benign or only slightly malignant tumors like this are rare Bronchial carcinoidoriginating from specialized cells in the bronchial mucosa. It makes up about 4% of all bronchial tumors and is more likely to occur in young men and women.

Often oppose it Lung metastases (Daughter tumors of other types of cancer such as kidney, colon or breast cancer). They indicate the advanced stage of the original tumor.

Leading complaints

Often no leading complaints; if then:

  • Cough that persists for weeks
  • Coughing up small amounts of blood, saliva with blood deposits or a small amount of glassy sputum
  • Possibly fever, weight loss and profuse sweating at night (B symptoms)
  • Due to the tumor growing into neighboring regions: difficulty swallowing, hoarseness; Pain and weakness in shoulder and arm; Diaphragmatic palsy.

Shortness of breath occurs when large bronchi are partially or fully constricted by the tumor or when a pleural effusion has occurred. Serious lung bleeding can occur as a complication if a large vessel is destroyed by the tumor.

When to the doctor

In the next few days if

  • Cough lasts longer than 3 weeks without any signs of infection or a lot of weight is lost despite a good appetite.

The illness

Lung cancer is a malignant tumor that originates in the bronchial lining. Lung cancer is the most common of all tumors worldwide, killing 1 million people every year.

Risk factors

The main risk factors are:

  • Tobacco smoke (~ 85% of cases): Duration and amount determine the risk (one pack of cigarettes a day for one year counts as one "Pack year" (packyear). Passive smoking increases the risk of lung cancer by a factor of 1.3 to 2.6, depending on the amount of smoke inhaled.
  • Pollutants in the workplace (~ 7% of cases): Risk groups are workers in the rubber processing industry, foundries and mining, welders, painters and workers who handle asbestos, pesticides or herbicides. Additional smoking increases the risk.
  • Other causes such as B. Fine dust pollution.

to shape

A distinction is made according to the fine tissue structure small cell lung cancer (SCLC, small cell lung cancer) and non-small cell lung cancers (NSCLC = non SCL = non-small-cell lung cancer). The latter mainly include squamous cell carcinoma, adenocarcinoma, large cell carcinoma and carcinoid. Small cell lung carcinomas make up about 15-20% of all cancer cases. They tend to grow rapidly and spread to other organs earlier and have an unfavorable prognosis. Non-small cell lung cancers occur in around 80–85% of all cases. They are divided into a wide variety of subtypes, of which squamous cell carcinoma and adenocarcinoma (e.g. bronchio-alveolar carcinoma) are the most common, each with two fifths of NSCLC. NSCLC are the most common lung tumors in nonsmokers, spread relatively late and have a better prognosis.

course

The growing tumor sometimes causes a cough, but is symptom-free for a long time. When small capillaries are destroyed by the tumor, blood is deposited in the sputum. Lung carcinomas that sit on the edge of the lungs do not cause any symptoms for a long time. When they grow into the chest wall or pleura, they cause pain. In later stages, cough appears.

Lung cancer metastases. Lung cancer spreads daughter tumors to other parts of the body in various ways: first to the surrounding lymph nodes, then to the liver, brain or bones. There, the growing metastases cause complaints that massively reduce the patient's quality of life, and from which he ultimately dies.
Georg Thieme Verlag, Stuttgart

If the tumor grows into the area between the two lungs (mediastinum), damage to the vocal cord nerve can lead to hoarseness. If the diaphragmatic nerve is affected, it leads to shortness of breath and hiccups. A spread of the tumor to the pericardium shows up in an effusion and an acute right heart failure. Ingrowth into the esophagus causes difficulty swallowing.

The tumors affect the lymph nodes of the affected region early. Metastases v. a. in the liver, brain, adrenal glands and skeleton. Brain metastases lead to dizziness, headaches, seizures and symptoms of paralysis. Skeletal metastases cause broken bones and pain, liver metastases cause indigestion and jaundice.

Diagnostic assurance

If lung cancer is suspected, a large number of the necessary examinations serve not only to confirm the diagnosis, but also to clarify the type of tumor, its spread and the possibilities of operability.

Imaging diagnostics. If lung cancer is suspected, the doctor will order x-rays of the lungs. Tumors show up inter alia. as nodules in the lungs, as condensation of the lung tissue or as atelectasis (non-ventilated section of the lung) as a result of an obstruction of the bronchus.

Lung cancer typically presents itself as a round focus in X-rays and CT scans. The upper image shows a centrally located cancer near the heart with a large disintegration cavity created by the tumor (arrows). The middle image shows the CT of another patient with centrally located lung cancer. A large peripheral lung cancer can be seen in the picture below. All three cases are men between 58 and 71 years of age with a previous COPD and a history of smoking. In no case was there a cure.
GTVR

CT and bronchoscopy confirm the suspected diagnosis of a malignant tumor. Bone scintigraphy and ultrasound of the abdomen and liver are used to detect metastases.

Biopsy. A tissue sample (biopsy) must be taken from the tumor to determine the fine tissue structure. Further treatment depends on this. The doctor takes the tissue sample either as part of a bronchoscopy or by surgical removal of an enlarged lymph node.

Blood tests. Tumor markers in the blood are meaningless for the diagnosis. One exception is neuron-specific enolase (NSE), which is a very reliable indicator of small cell lung cancer. Otherwise, tumor markers tend to play a role in monitoring the course of lung cancer.

treatment

In the treatment of lung cancer, different procedures are combined or used one after the other, depending on the size, degree of differentiation and spread of the tumor and the condition of the patient.

Treatment of non-small cell lung cancer

Surgery. Non-small cell tumors can often be cured with surgery if they have not yet formed distant metastases and only a few or no lymph nodes are involved. In this case, 40-70% of patients survive the first 5 years. Depending on the size and location of the tumor, possible operations are the removal of a single lobe of the lungLobectomy) or a whole half of the lung (Pneumectomy). Of course, these operations are only possible if it is ensured that the remaining lungs can still supply the body with sufficient oxygen after the operation.

Radiotherapy. In the case of extensive lymph node involvement, the lungs are irradiated about 4–5 weeks after the operation. This adjuvant radiation therapy is also carried out if a residual tumor remains in the lungs after the operation. Radiation also plays an important role in palliative treatment. Symptoms such as coughing up blood, shortness of breath, throat irritation or pain can be significantly alleviated by radiation. It can also be performed when the patient is in very poor condition.

Chemotherapy. Chemotherapy can be used in conjunction with surgery or radiation treatment or as the sole treatment. The decision as to which combination of cytostatic agents makes sense depends on the extent of the tumor, its histological classification and the patient's condition. The adjuvant chemotherapy begins 4–6 weeks after the operation and consists of a combination containing cisplatin. The combination partners depend on the treatment protocol chosen. Cisplatin is combined with a taxane (e.g. docetaxel), a topoisomerase II inhibitor such as etoposide, a pyrimidine analogue (e.g. gemcitabine) or an inhibitor of folinic acid-dependent enzymes such as pemetrexed.

Second line therapy. If the tumor continues to grow despite chemotherapy, the survival period can be extended by up to 9 months by taking other active ingredients such as docetaxel, nivolumab (monoclonal antibody) or so-called tyrosine kinase inhibitors such as crizotinib.

Other substances for primary, adjuvant or combined with radiation therapy chemotherapy are z. B. monoclonal antiangiogenic antibodies, Vinca alkaloids or anti-PD1 antibodies.

Palliative treatment. If distant metastases are already present or if lymph nodes on the other side of the lung are affected, medical efforts are primarily aimed at giving the patient more life with the best possible quality of life.

Treatment of small cell lung cancer

Lung cancer growing into the interior of a bronchus, as shown bronchoscopically.
Georg Thieme Verlag, Stuttgart

Small cell lung cancer is usually advanced when the diagnosis is made and has already formed distant metastases. In these cases, the focus is on palliative therapy.

Surgery. Surgical removal of the tumor is only useful for very small tumors.

Radiation and chemotherapy. Fortunately, small cell lung cancers respond well to chemotherapy and radiation treatment. For therapy planning, a distinction is made between:

  • Very limited disease (small tumors without lymph node involvement): At this stage only about 5% are diagnosed with small cell lung cancer. A timely operation can be promising here.
  • Limited disease (Involvement of one half of the lung with or without lymph node involvement on the same side): At this stage, around a third of patients are diagnosed with small cell lung cancer. Lymph nodes in the middrum and below the collarbone may also be involved here, or a pleural effusion may be present.
  • Extensive disease (all other cases that are neither very limited disease nor limited disease): At this stage, 60–70% of patients are diagnosed with small cell lung cancer.

Chemotherapy for small cell lung cancer is always carried out with a combination of various cytostatics. There are many treatment protocols, the compositions of which change frequently due to new therapeutic studies.

Common protocols are:

  • ACO protocol (adriamycin (doxorubicin) + cyclophosphamide + vincristine)
  • CEV protocol (carboplatin + etoposide + vincristine)
  • PE protocol (cisplatin + etoposide).

Usually 4-6 cycles of chemotherapy every three weeks are required. With very limited disease, the tumor regresses in 40–70% of cases, but in advanced stages only in about 30% of cases. The highest 5-year survival rate of 70% had operated patients with adjuvant chemotherapy and additional prophylactic skull radiation. In the case of limited disease, radiation is carried out every 3–4 weeks after the end of chemotherapy. Here the 5-year survival time is around 20-40%.

Other substances used in chemotherapy for small cell lung cancer are topoisomerase I inhibitors (e.g. irinotecan) and nitrogen mustard derivatives (e.g. bendamustine).

Both after complete tumor regression and after surgical removal of the tumor, the skull is prophylactically irradiated in order to detect possible brain metastases. If chemotherapy is not effective enough or if complications such as shortness of breath, coughing up blood or pain have to be treated, radiation therapy can at least temporarily reduce tumor size and tumor growth.

Treatment of special forms and complications

Pancoast tumor: A special form of lung cancer in the apex of the lung that grows into neighboring ribs, vertebrae or nerves at an early stage and is therefore also known as "breakout cancer". The first thing the patient often notices is pain in the shoulder or arm, discomfort in the arm, or drooping eyelids. Irradiation takes place early for treatment. This is followed by the surgical removal of the tumor. The irradiation is repeated after the operation.

Malignant pleural effusion (Cancer-related fluid accumulation in the pleural space): If the pleural effusion causes shortness of breath or if the cause of the pleural effusion is not yet 100% clear, it must be punctured and suctioned off; the removed liquid is examined microscopically in the laboratory. If an effusion is detectable again after a few days after complete removal of an effusion and causes discomfort, the pleural leaves can be glued together using a special therapy (Pleurodesis) be performed. For this purpose, the fluid is first completely removed by means of an inserted drain and then a chemical or inflammatory reaction between the pleural leaves is triggered with special drugs (tetracycline, bleomycin or talc) - this causes them to stick together and the effusion can no longer run down. This method works about 80% of the time.

Vena Cava Superior Syndrome: In this threatening clinical picture, the cancer constricts the superior vena cava (vena cava superior) and the blood flow is impeded. There is swelling of the arm or face, dizziness and headache. In addition to the rapid insertion of a stent to keep the blood vessel open, the tumor can be reduced in size by emergency irradiation.

Bone metastases: There are several methods available for treating bone metastases. Radiation is used against pain and if there is a risk of fractures; pathological fractures can be surgically stabilized. Bisphosphonates are given for hypercalcaemia.

Brain metastases: If tumor cells settle in the brain, it leads to headaches, paralysis, epileptic seizures or pathological fatigue. The first measure for complaints caused by brain metastases is the administration of cortisone. Thereafter, whole-brain irradiation makes sense, but possibly also the surgical removal of individual metastases or targeted stereotactic irradiation.

Side effects of radiation therapy

The side effects of radiation mainly depend on which part of the body is treated with which radiation dose. In lung cancer, after irradiation, inflammation of the pericardium, increased susceptibility to infection, pneumonitis (inflammation caused by radiation of the lung tissue), pulmonary fibrosis, inflammation of the esophagus (esophagitis) and stomach irritation with nausea and fatigue can occur. Changes in the irradiated skin areas (dry, reddened and sensitive) can often be observed. If you have dry, sensitive skin, good skin care products with a low pH value are helpful. Radiation-induced pneumonitis or pulmonary fibrosis is treated with cortisone. Usually there is a rapid improvement.

Palliative treatment

To alleviate the symptoms and to extend life, the tumor can be reduced in size by laser, chemotherapy or radiation therapy over weeks to months. Special tubes made of metal or silicone (stents) can be used to prevent complete occlusion of the bronchus. In rare cases, surgery is also performed. It is always important to weigh the benefits of therapy (gain in life, alleviation of disease symptoms) against the side effects and risks. The patient's quality of life should be a priority in all therapies.

process control

Follow-up checks and follow-up care after therapy are important for patients. Complications should be recognized and treated at an early stage. Complaints can be alleviated and pain prevented through consistent and effective therapy.In the case of lung cancer, structured follow-up care within the first 5 years after therapy includes the history and physical examination as well as computed tomography of the chest 3, 6, 12, 18 and 24 months after therapy and annually thereafter. Lung function is also checked during follow-up, 3 and 6 months after therapy and thereafter if necessary.

forecast

The prognosis depends largely on the stage at which the lung cancer was diagnosed, on the tissue structure and on the patient's previous illnesses. In the very early stages of non-small cell lung cancer, when no lymph nodes are involved, healing is possible and the 5-year survival rate is up to 70%. Small cell lung cancers grow rapidly and the tumor mass doubles in just 55 days. For this reason the cancer is already in an advanced stage in ~ 70% of cases at the time of diagnosis and has mostly already formed distant metastases; the 5-year survival rate is then only 10%.

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What you can do yourself

For any upcoming surgery, choose a lung specialist clinic or a clinic that has a lot of experience with lung cancer operations. B. has a department for thoracic surgery.

If chemotherapy or radiation is planned, inform yourself beforehand about the process and how these therapies work. Being well informed will help you reduce your anxiety.

Way of life.

Try to strengthen yourself and your body by improving your lifestyle. Change your diet if you have eaten a lot of meat and too few vegetables, reduce your alcohol consumption - and of course: stop smoking completely. Look for relaxation in nature as often as possible and get some exercise. Cycling is a much better cardiovascular exercise than going for a walk. Many patients also benefit from relaxation techniques. Find the interview - you can use the cancer information service to find psycho-oncological support in your area, for example for yourself or for your relatives.

Complementary medicine

There are over 100 complementary medicine cancer therapies. Homeopathy, Traditional Chinese Medicine, Ayurveda and Anthroposophy each have their own concepts for tumor therapy. Acupuncture can be expected to relieve unpleasant symptoms without affecting the course of the disease.

Neither the conventional medical nor the complementary medical procedures should be condemned or lifted to heaven - both should have their success measured according to comprehensible criteria. Mistrust is always appropriate when

  • Unrealistic promises are made (cure in any case, for a wide variety of tumors and / or without side effects)
  • the (so far) treating doctor should not be told anything
  • conventional medical therapies are to be discontinued
  • should be decided under time pressure
  • Advance payments are expected - be it the belief in the healer or the opening of the wallet.

Even if you have a serious illness like cancer, you can afford to wait a few days and get a second opinion. This is especially true for expensive therapies, because precisely there there is a risk that the patient's recovery is not in the foreground.

Prevention

Hedgehog.

Because smokers in particular are at risk of lung cancer, there are special self-pay offers for preventive care (IGeL), according to the Smoking check with blood tests and - most importantly - chest CT. The benefits of these preventive examinations are, however, scientifically controversial. According to recent studies, although more early cancer cases are being detected, the number of lung cancers detected too late and the number of deaths does not change.

Further information

  • www.info-lungenkrebs.de - Website of the pharmaceutical company Roche GmbH, Grenzach-Wyhlen: informative, with topics related to lung cancer, conventional and new therapeutic approaches.
  • www.selbsthilfe-lungenkrebs.de - Website of the nationwide self-help group for lung cancer: Offers a lexicon that explains important medical terms, addresses and many links.
  • www.krebsinformationsdienst.de - offers a lot of important general information on cancer, special information on lung cancer and addresses for psycho-oncological support.
  • www.krebsdaten.de - Website of the center for cancer registry data of the Robert Koch Institute with data on lung cancer.

Authors

Kristine Raether-Buscham; Dr. med. Arne Schäffler in: Gesundheit heute, edited by Dr. med. Arne Schäffler. Trias, Stuttgart, 3rd edition (2014). Revision and update of the introduction and the sections "The Disease", "Confirmation of Diagnosis", "Treatment", "Prognosis" and "Further Information": Dr. med. Sonja Kempinski | last changed on at 08:21


Important note: This article has been written according to scientific standards and has been checked by medical professionals. The information communicated in this article can in no way replace professional advice in your pharmacy. The content cannot and must not be used to make independent diagnoses or to start therapy.