Lung Cancer Complications

Chemotherapy-Induced Infection

Chemotherapy can significantly reduce the number of white blood cells that the body needs to fight infection, most especially neutrophils.

Chemotherapy-induced neutropenia is a condition faced by many people undergoing cancer treatment in which the severe drop of neutrophils leaves a person vulnerable to all sorts of infections.

Around 50% of people undergoing chemotherapy will experience neutropenia to varying degrees during the course of treatment.

Symptoms can vary depending on the site of the infection. For example, a bladder or kidney infection may cause a fever, back pain, and painful urination. Respiratory infections may cause a cough, fever, shortness of breath, and yellowish-green phlegm.

Chemotherapy-induced neutropenia is typically dose-dependent—the risk increases with higher doses of chemotherapy drugs. To avoid this, your healthcare providers will give you a blood test before each treatment session to monitor your white blood cell count and adjust your treatment dose as needed.

Some of the drugs associated with chemotherapy-induced neutropenia are those commonly used to treat lung cancer, including:

• Platinol (cisplatin)
• Taxol (paclitaxel)
• Alkaban-AQ (vinblastine)

If a mild to moderate infection occurs, an oral broad-spectrum antibiotic may be prescribed for several days. With pneumonia and sepsis, more aggressive therapy and hospitalization may be required so you can be treated with intravenous (IV, in a vein) antibiotics, intravenous fluids, and oxygen therapy.

Malignant Pleural Effusion

Malignant pleural effusion (MPE) affects roughly 30% of people with lung cancer. This condition causes an accumulation of fluid and cancer cells in the pleural cavity, which is the space surrounding the lungs.

Malignant pleural effusion is diagnostic of stage 4 (metastatic) lung cancer, the most advanced stage of the disease.

Symptoms include:

• Shortness of breath
• Dry cough (particularly when sitting or lying down)
• Chest pain and tightness
• A general feeling of unwellness

A diagnosis of MPE is confirmed with imaging studies, such as a chest X-ray, computed tomography (CT), or magnetic resonance imaging (MRI).

Malignant pleural effusion can be treated with thoracentesis, a procedure by which a long needle is inserted through the chest wall and into the pleura cavity to extract excess fluid. A fluid sample can then be sent to the lab for analysis.

Malignant pleural effusion is diagnosed when cancer cells are found in the pleural fluid. With that said, not all people with lung cancer who develop pleural effusion will have malignant features. In fact, more than half of those with advanced lung cancer will have no evidence of cancer in the pleural fluid.

If the condition recurs, your healthcare provider may recommend a procedure called pleurodesis in which talc is delivered between the membranes of the pleural cavity (the pleura) to bind the membranes so that there is no longer a space into which fluid can accumulate. Alternatively, a chest tube may be placed in the chest wall, which allows the pleura cavity to be drained when needed.

On rare occasions, the pleura may be surgically removed with pleurectomy surgery.

Hypercalcemia

Hypercalcemia—abnormally high calcium levels in the blood—affects up to 30% of those with advanced lung cancer.

Also referred to as hypercalcemia of malignancy, the condition most commonly occurs when cancer spreads to the bones. The resulting bone metastases can cause calcium to leach into the bloodstream as the bones gradually deteriorate. Hypercalcemia can also occur in people without bone metastases.

Symptoms may include:

• Muscle and joint pain
• Muscle spasms
• Nausea
• Vomiting
• Weakness
• Confusion

If left untreated, hypercalcemia of malignancy can lead to coma and death.

Treatment typically involves rehydration with IV saline fluid combined with IV bisphosphonates to slow the breakdown of bone.

Oral or IV corticosteroids may be used to increases the excretion of calcium in the kidneys. Severe cases may require hemodialysis to help clear calcium from the blood.

Depression

Depression reduces the quality of life in people with cancer. A 2011 study found that clinical depression in people with advanced non-small-cell lung cancer was linked to a 50% reduction in survival times compared to patients without depression (11.83 months versus 24.47 months, respectively).

Overall,15% to 25% of people with cancer are thought to have clinical depression. This number may be higher for people with lung cancer because the stigma of the disease or a poor prognosis can trigger a major depressive episode.

Symptoms of depression can include:

• Hopelessness
• Lack of interest in activities, even those you normally would enjoy
• Crying
• Irritability

To improve your mental health and quality of life, social support and counseling are encouraged. If needed, you may be prescribed an antidepressant, with selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants showing equal efficacy.

If left untreated, cancer-associated depression can increase the risk of suicide. In fact, people with lung cancer have the highest rate of suicide compared to those with any other type of cancer, particularly in the first week following the initial diagnosis.

Malignant Pericardial Effusion

Malignant pericardial effusion is an accumulation of excess fluid around the heart. This condition affects around 15% of people with advanced lung cancer and has a median survival time of 2.1 months in those who require surgery.

And 17% of those affected by this condition live beyond the first year following surgical intervention.

Malignant pericardial effusion is characterized by:

• Severe shortness of breath
• Cough
• Persistent fever
• Lightheadedness
• Weakness
• Chest tightness or pain

It can develop as a direct result of cancer metastasis or be the consequence of prior high-dose radiation therapy to the chest.

If cardiac tamponade (compression of the heart) occurs, a pericardiocentesis procedure will be needed to drain excess fluid from the pericardium (the membrane surrounding the heart). This may be accompanied by the introduction of a sclerosing agent, such as bleomycin or cisplatin, into the pericardium to bind tissues and prevent the accumulation of fluid.

These interventions may not improve the survival times of people with malignant pericardial effusion. In such cases, healthcare providers will discuss palliative care options to reduce the burden of symptoms and improve the overall quality of life as much as possible.

Blood Clots

Blood clots in the legs or pelvis can develop at any time and affect up to 15% of people with lung cancer. Blood clots are sometimes the first symptom of lung cancer.

Deep vein thrombosis (DVTs), clots that develop in the deep veins of the legs or arms, can cause severe pain and swelling. If a portion of the clot breaks off and travels to the lungs, it can block a vital artery and trigger a potentially life-threatening pulmonary embolism (PE).

Factors that can increase the risk of DVT and PE, include:

• Chemotherapy (which reduces the production of proteins that prevent blood clotting)
• Lung cancer surgery
• Insertion of a PICC line (used to deliver chemotherapy drugs)
• Long-distance travel
• Inactivity

People with metastatic lung cancer are especially vulnerable to blood clots.

Symptoms of DVT may include redness or swelling in the calves or legs (although in about a third of cases, there will be a complete absence of symptoms).

When PE occurs, people typically experience sudden, sharp chest pains, severe shortness of breath, and heart palpitations.

People with lung cancer who experience DVT have a 50% increased risk of death compared to those who don't. Up to 10% of those who develop acute PE will die suddenly as a result of the arterial blockage.

Blood clots are most often treated with anticoagulants (blood thinners) like Coumadin (warfarin). People with lung cancer often require extended or permanent anticoagulant therapy to reduce their risk of blood clots. Compression stockings and physical activity can help prevent clots from forming in the first place.

Pulmonary Hemorrhage

Pulmonary hemorrhage—sudden bursting of a major blood vessel of the lungs—is one of the more common causes of death in people with lung cancer. This occurs when the tumor infiltrates the vessel and weakens it.

Pulmonary hemorrhage most commonly occurs with metastatic disease and accounts for 12% of deaths in people with advanced lung cancer.

Death may also occur if a bleed spontaneously develops in the pericardium. Less commonly, the metastasis of lung cancer to the digestive tract can cause gastrointestinal bleeding, sometimes severe.

Hemoptysis involving more than 100 cubic centimeters of blood (roughly 3½ ounces) is considered a medical emergency with no less than a 30% risk of death.

Healthcare providers can usually locate the source of the bleed with imaging studies and bronchoscopy (involving the insertion of a flexible scope through the mouth and into the major airways of the lung). Investigative surgery is sometimes needed. Once located, the bleed may be cauterized (therapeutically burned) or sutured to close the wound.

Spinal Cord Compression

Spinal cord compression can occur when cancer spreads to the bones of the spine, causing them to weaken and collapse. Symptoms usually start with neck or lower back pain. They eventually progress and can include:

• Weakness
• Loss of sensation in the extremities
• Radicular pain (shooting nerve pains felt in another part of the body)

Spinal cord compression is a relatively common but serious complication of lung cancer that affects around 4% of people with metastatic disease.

If the lower (lumbar) spine is damaged, it can cause severe and sometimes permanent nerve injury. The condition, known as cauda equina syndrome, is considered a medical emergency and can lead to the loss of motor function, severe low back pain, and the loss of bladder or bowel function if not treated appropriately.

Emergency treatment is needed to prevent permanent nerve damage in people with cauda equina syndrome. This involves a combination of IV steroids and radiation therapy, although surgery may also be used to help stabilize the spine.

Superior Vena Cava Syndrome

Superior vena cava syndrome (SVCS) occurs in around 2% to 4% of people with lung cancer, especially those with tumors in the upper portions of the lung (referred to as superior sulcus tumors).

These tumors can press directly on the superior vena cava, the large vein that returns blood from the upper body to the heart. The resulting obstruction can cause shortness of breath, dysphagia (difficulty swallowing), hoarseness, and swelling of the face, arms, and upper body.

Even though SVCS occurs infrequently, it can quickly become life-threatening if not treated immediately.

Treatment is aimed at reducing the pressure caused by the tumor, often through the use of chemotherapy or radiation. Anticoagulants may be prescribed to prevent blood clotting. In some cases, a stent may be placed in the superior vena cava to maintain blood flow.

SVCS is associated with a median survival time of 5.5 months and a five-year survival rate of 9%.