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Lung Cancer


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									     Lung Cancer
(Bronchogenic Cancer)

    Joehar Hamdan
• Most common cause of cancer mortality in the United
  States and throughout the world.
• American Cancer Society estimates about 160,000 deaths
  in the US during 2007, in comparison with about 120,000
  deaths from the combined mortality of colorectal, breast
  and prostate cancer.
• Leading cause of cancer death in men.
• Surpassed breast cancer as the leading cause of cancer
  death in women recently.
• In fact, over 50% more women died from lung cancer
  than from breast cancer in 2007
                 Risk Factors
• Cigarette smoking – relative risk 10 to 30 fold in
  comparison with the lifetime nonsmoker. 87% cases of
  lung cancer are due to cigarette smoking.
• Second hand tobacco smoke
• Asbestos
• Radon
• Arsenic
• Ionizing radiation
• Haloethers
• Polycyclic aromatic hydrocarbons
• Nickel
• Adenocarcinoma (30-40 percent)

(High–powered image showing typical acinar
  pattern glandular differentiation in
• Squamous cell(epidermoid) carcinoma(20-30%)

(Keratinization in lung cancer)
• Large cell carcinoma( 10 percent )

(Large cell undifferentiated carcinoma of the lung)
• Small cell carcinoma ( 20 percent )
         Clinical Presentation
90% of patients are symptomatic at the time of
  clinical presenation.
Symtoms related to the primary lesion
• Cough : present in 45-75 percent of all patients,
  non-specific, change in the character of cough
  should raise the suspicion for lung cancer in
  patients with COPD. A new or worsening
  cough is the most common symptom of lung
• Dyspnea : occurs in one-third to one-half of
  patients, mechanisms include, large airway
  obstruction, obstructive pneumonitis or
  atelectasis, lymphangitic spread of tumor,
  pleural or pericardial effusion.
       Clinical Presentation
• Hemoptysis : occurs in 27 to 57 percent of
  patients, volume of blood is generally small.
• Chest pain : occurs in ¼ to ½ of all patients,
  intermittent pain or constant, severe or
  persistent pain indicates chest wall or
  mediastinal invasion, often with rib invasion.
• Wheezing : uncommon, unilateral, localized.
• Weight loss : 8 to 68 percent of patients.
              Clinical Presentation
Symptoms related to intrathoracic spread
• Pleural Effusion : caused by direct pleural extension or
  mediastinal node involvement and lymphatic obstruction.
• Pericardial Effusion : occur by direct extension of tumor to the

• Hoarseness : 2-18 percent of cases, compression of recurrent
  laryngeal nerve, more common in left sided tumor.
• Superior vena cava syndrome : symptoms include headache and
  dyspnea, physical findings include facial or upper extremity
  swelling, plethora, dilated neck veins .
• Brachial plexus involvement : Pancoast syndrome, characterized by
  Horner’s syndrome (unilateral constricted pupil, facial dryness, and
  ptosis caused by damaged sympathetic nerves), rib destruction,
  atrophy of hand muscles and pain in the distribution of C8, T1 and
  T2 nerve roots.
•Superior vena cava syndrome
•Pancoast’s Tumor
•Horner’s Syndrome
•Endocrine (paraneoplastic)
•Recurrent laryngeal symptoms
•Effusions (pleural or pericardial)
    SVC invasion by Lung
• Magnetic resonance imaging (MRI)
  study demonstrating superior vena
  cava (SVC) invasion by lung
Pancoast Tumor on MRI
         Clinical Presentation
Symptoms related to distant metastases

• Bone metastases : vertebrae most commonly involved,
  other common sites include ribs and pelvic bones.
  Primary symptom is pain, may be pleuritic with bone
• Hepatic metastases : weakness and weight loss, poor
• Brain metastasis : nausea, vomiting, focal neurological
  symptoms and signs, seizures, confusion and personality
               Clinical Presentation
Paraneoplastic syndromes
Occurs in 10 – 20 percent of patients.
Biologically active substances either by the tumor or in response to
the tumor.
• Hypercalcemia : related to bone metastases, can also be due to PTH related
   peptide as seen most frequently with squamous cell histology.
• Digital clubbing and hypertrophic pulmonary osteoarthropathy : most
   frequently seen with adenocarcimona.

• SIADH, ACTH : most frequently with small cell cancer.
• HCG mostly seen with large cell cancer resulting in gynecomastia
• Neurological syndromes : include Eaton-Lambert syndrome (seen
  almost exclusively in small cell cancer) , peripheral neuropathy,
  cortical cerebellar degeneration.
      Staging of non-small cell lung
•   Primary tumor (T)
     •   T1 - Tumor <3 cm diameter without invasion more proximal than lobar bronchus
     •   T2 - Tumor >3 cm diameter OR Tumor of any size with any of the following:
           •   Invades visceral pleura
           •   Atelectasis of less than entire lung
           •   Proximal extent at least 2 cm from carina
     •   T3 - Tumor of any size with any of the following:
           •   Invasion of chest wall
           •   Involvement of diaphragm, mediastinal pleura, or pericardium
           •   Atelectasis involving entire lung
           •   Proximal extent within 2 cm of carina
     •   T4 - Tumor of any size with any of the following:
           •   Invasion of mediastinum
           •   Invasion of heart or great vessels
           •   Invasion of trachea or esophagus
           •   Invasion of vertebral body or carina
           •   Presence of malignant pleural or pericardial effusion
           •   Satellite tumor nodule(s) within same lobe as primary tumor
•   Nodal involvement (N)
     •   N0 - No regional node involvement
     •   N1 - Metastasis to ipsilateral hilar and/or ipsilateral peribronchial nodes
     •   N2 - Metastasis to ipsilateral mediastinal and/or subcarinal nodes
     •   N3 - Metastasis to contralateral mediastinal or hilar nodes OR ipsilateral or contralateral scalene or
         supraclavicular nodes
•   Metastasis (M)
     •   M0 - Distant metastasis absent
     •   M1 - Distant metastasis present (includes metastatic tumor nodules in a different lobe from the primary
            Stage groupings of TNM
Stage IA        T1      N0      M0

Stage IB        T2      N0      M0

Stage IIA       T1      N1      M0

Stage IIB       T2      N1      M0

                T3      N0      M0

Stage IIIA      T3      N1      M0

                T1-3    N2      M0

Stage IIIB      Any T   N3      M0

                T4      Any N   M0

Stage IV        Any T   Any N   M1
          Staging of
 Small Cell Carcinoma of Lung
• Limited disease : restricted to the
  ipsilateral hemithorax

• Extensive disease : extending beyond
  the ipsilateral hemithorax
    Treatment of non-small cell lung cancer
Stage I                                  Surgical resection, adjuvant chemotherapy
50-70% long-term disease free survival   in stage IB

Stage II                                 Surgical resection plus adjuvant
20-40% long-term disease free survival   chemotherapy (paclitaxel and carboplatin or
                                         cisplatin with etoposide or vinorelbine)

Stage III A                              Investigational protocol, surgical resection
                                         after chemotherapy, with or without
5-20% long-term disease free survival    radiotherapy

Stage III B                              Palliative therapy or combined
                                         radiotherapy and chemotherapy

Stage IV                                 Chemotherapy or palliative therapy
                                         (depending on performance status)
              Treatment of
          Small Cell Lung Cancer
• Limited stage : response rate 80 – 90 percent with
  chemotherapy plus radiation with 50 - 70 percent complete
  response. Chemotherapy usually consist of cisplatin plus
  etoposide along with concurrent radiation therapy.

• Extensive stage : response rate 60 – 80 percent , complete
  response in 15-20 percent, two drug combination of
  etoposide plus either carboplatin or cisplatin

  Prophylactic Cranial Irradiation ?
      Methods of Palliative
Radiation Therapy : Helpful in symptomatic
  local involvement, such as tracheal or
  bronchial compression, bone metastasis,
  hemoptysis, or superior vena cava syndrome.
Expandable metal stents inserted by
  bronchoscopy can improve pulmonary
Bisphosphonate Therapy : decreases skeletal-
  related events for patients with bony
- Osteonecrosis of Jaw?
Thank You

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