• 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
• 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
• Ionizing radiation
• Polycyclic aromatic hydrocarbons
• 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 )
90% of patients are symptomatic at the time of
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.
• 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.
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
•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
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
Occurs in 10 – 20 percent of patients.
Biologically active substances either by the tumor or in response to
• 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
• 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
Small Cell Carcinoma of Lung
• Limited disease : restricted to the
• 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)
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?