Learning objectives

• Anesthetic management of lung cancer

Definition and mechanisms

• Lung cancer is the most common cause of cancer mortality worldwide for men and women
• Lung cancer or lung carcinoma is a malignant tumor characterized by uncontrolled cell growth in lung tissue
• Lung carcinomas derive from transformed, malignant cells that originate as epithelial cells, or from tissues composed of epithelial cells
• Sarcomas are generated by the malignant transformation of connective tissues, which arise from mesenchymal cells
• Lung cancer often starts in the bronchi, bronchioles, or alveoli
• Two types:
  • Non-small-cell lung cancer
    • The most common form, accounting for around 80% of lung cancer cases
    • Common types include: squamous cell carcinoma, adenocarcinoma, or large-cell carcinoma
  • Small-cell lung cancer 
    • Less common
    • Spreads faster and harder to treat than non-small-cell lung cancer
• Other tumors including large cell, neuroendocrine (carcinoid), bronchioloalveolar and rarer forms can all present as lung malignancies
• The presentation includes airway obstruction, lung collapse, and distal infection or through spread via the peribronchial tissues with subsequent invasion of the mediastinum
• Spreads by both lymphatic and hematological routes and distal metastasis is common in the liver, adrenals, bone, and brain

Signs and symptoms

• A persistent cough
• Shortness of breath
• Chest pain
• Wheezing
• Hemoptysis
• Fatigue
• Hoarseness
• Weight loss
• Bone pain
• Headache
• Swelling in the face, neck, arms, or upper chest (superior vena cava syndrome)

Risk factors

• Smoking
• Older age
• Genetic mutations
• Exposure to harmful substances such as air pollution, radon, asbestos, uranium, silica, coal products
• Previous radiation treatment to the thorax
• Family history of lung cancer

Diagnosis

• Physical exam
• Blood test
• Chest X-ray
• CT/PET
• Biopsy

Management

• Anesthetic involvement is mainly for lung resection (e.g. lobectomy, pneumonectomy)
• Consider: 
  • Potentially compromised respiratory function with risk of perioperative respiratory complications
  • Mass effects: obstructive pneumonia, lung abscess, SVC syndrome, tracheobronchial distortion, Pancoast’s syndrome, recurrent laryngeal nerve or phrenic nerve paresis, chest wall or mediastinal extension
  • Metabolic effects: Lambert–Eaton syndrome, hypercalcemia, hyponatremia, Cushing’s syndrome
  • Metastases: particularly to the brain, bone, liver, & adrenal 
  • Medications: chemotherapy agents, pulmonary toxicity (bleomycin, mitomycin), cardiac toxicity (doxorubicin), renal toxicity (cisplatin)
  • Comorbidities including smoking, chronic obstructive lung disease, coronary artery disease, hypertension

Suggested reading

• Hackett, S., Jones, R., Kapila, R., 2019. Anaesthesia for pneumonectomy. BJA Education 19, 297–304.
• Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.

Clinical updates

Deshpande et al. (Current Opinion in Anesthesiology, 2024) highlight that lung cancer is among the malignancies with the highest risk of cancer-associated coagulopathy, with a 7–11-fold increase in venous thromboembolism and a markedly higher incidence of fatal pulmonary embolism. The review emphasizes perioperative use of risk stratification tools, viscoelastic testing (TEG/ROTEM), and individualized anticoagulation strategies to balance thrombotic and bleeding risks in lung cancer patients undergoing surgery or invasive procedures.

• Read more about this study HERE.