Download Lung Cancer Overview

Lung Cancer
Lung Cancer: Epidemiology
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173,770 new cases and160,440 deaths 2004
More deaths from lung cancer than prostate,
breast and colorectal cancers combined
Number one cause of cancer deaths in the
United states in both men and women
Decreasing incidence and deaths in men;
continued increase in women
Incidence and mortality rates higher for African
Americans than white Americans
Lung Cancer in Women
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Incidence (80,660 new cases in 2004)
Account for 12 percent of all new cases
Deaths increased 150% between 1974 and
1994 (68,510 in 2004)
More deaths from lung cancer than breast,
ovarian and uterine cancers combined
Women are more susceptible to tobacco
effects - 1.5 times more likely to develop
lung cancer than men with same smoking
habits
Lung Cancer: Etiology
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Cigarette smoking
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Accounts for 80-90% of cases.
Risks related to:
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Number of cigarettes per day
Age started smoking
Number of years smoked
Inhalation practices
Content of tar/nicotine
Lung Cancer: Etiology
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Risk of Lung cancer starts declining 5 years after
permanent smoking cessation, but never reaches
level of a lifelong non-smoker.
Other Risk Factors:
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Other inhaled tobacco—pipes, cigars, passive smoking
COPD—even when controlled for cigarette consumption
Asbestos– weak carcinogen alone, but synergistic when
combined with cigarette smoking.
(no link to smoking and mesothelioma)
Lung Cancer
Occupational Risk Factors
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Arsenic
Asbestos
Beryllium
Cadmium
Chloromethylethers
Chromium
Nickel
Polycyclic aromatic
compounds
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Radon
Silica
Vinyl Chloride
Any chronic interstitial
lung disease
Smoking potentates
the risk for any of
the above
Lung Cancer: Screening
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No proven effective screening tool
Chest X-ray commonly used
Clinical trials:
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Low dose spiral chest CT scan
Sputum analysis
Chest X-ray
Lung Cancer: Presentation
I.
Asymptomatic– 10%
Screening—not recommended currently
Incidental finding on CXR
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II.
Symptomatic – 90%
1.
Intrathoracic signs and symptoms
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Cough
Dyspnea, and phrenic nerve paralysis
Hemoptysis
Dysphagia, and Hoarsness
Pleural effusion
Metastatic disease
2.
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Seizures, Bone Pain, Pathologic fractures
Lung Cancer: Presentation
Syndromes/Symptoms secondary to regional metastases:
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Esophageal compression  dysphagia
Laryngeal nerve paralysis  hoarseness
Symptomatic nerve paralysis  Horner’s syndrome
Cervical/thoracic nerve invasion  Pancoast syndrome
Lymphatic obstruction  pleural effusion
Vascular obstruction  SVC syndrome
Pericardial/cardiac extension  effusion, tamponade
Pathology of Lung Cancer
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Non-Small Cell Carcinoma---80% of cases
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Squamous
Adenocarcinoma
Large Cell
Combined types (adenosquamous)
Small Cell Carcinoma—20% of cases
Squamous Cell Carcinoma
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Occurs centrally, often
endobronchial lesion
Commonly cavitates
Associated with
hypercalcemia.
(PTH-like peptide)
Adenocarcinoma
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Most common cell type
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Usually peripheral
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Often a Solitary
Pulmonary Nodule
Cell type least
associated with
smoking (30% have no
smoking link)
Large Cell Carcinoma
Small Cell Carcinoma
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Occurs Centrally, Bulky
mediastinal mass
Aggressive metastasis
early---often systemic at
time of Dx.
Cell type most often
associated with
Paraneoplastic syndromes
Strong Link to smoking
Superior Vena Cava Syndrome
Right upper lobe mass that invades,
compresses and obstructs the SVC
SX: swelling of head and arms, dyspnea,
headache, anxiety
Causes: lung ca #1, lymphoma #2, other
malignant or benign causes
TX: radiation therapy is mainstay;
combination chemotherapy for SCLC
Superior Vena Cava Syndrome
Superior Sulcus Tumor
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Apical lung tumor with:
Pain—arm, shoulder, scapula
Atrophy of hand muscles
Swelling of the arm
Horner’s syndrome
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Miosis, anhydrosis, ptosis
Tx: Pre-op XRT, plus surgery
(Pancoast)
Solitary Pulmonary Nodule
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Spherical, oval or
lobulated intrapulmonary
x-ray abnormality
located in the middle or
lateral one third of the
lung and surrounded by
normal parenchyma.
(<3cm in size)
Solitary Pulmonary Nodule
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Factors favoring a benign etiology
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Smaller size, <3 cm
Sharp boarders
Younger age of pt
Never-smoker
Very short (<30 days), Very Long (<450 days) doubling time--radiographic stability in size > 2 yr
Patterns of calcification-- best evaluated by CT
 Benign: Central, Laminated, popcorn,
 Stippled, Eccentric, & diffuse my be benign or malignant
Lung Cancer: Paraneoplastic
Syndromes
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Non Small Cell Lung Cancer
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Small Cell Lung Cancer
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Hypercalcemia—squmous cell ^PTH
Hypertrophic pulmonary Osteodystrophy
SIADH
Cushings--^ectopic ACTH
Eaton-Lambert—Presynaptic Ca channels
Anorexia/Cachexia with all cell types
Lung Cancer: Staging Workup
Diagnostic tests
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Staging tests
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Chest x-ray
Biopsy (bronchoscopy, needle
biopsy, surgery)—pathologic
confirmation
CT chest/abdomen/brain
Bone scan
Bone marrow aspiration
PET scan
CBC, electrolytes, ca, alk-phos,
albumin, AST, ALT, Bili, Cr on all
pts.
Lung Cancer: Prognostic Factors
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STAGE OF DISEASE IS THE SINGLE
MOST IMPORTANT DETERMINANT OF
SURVIVAL!!!
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Other prognostic factors
Performance status (Karnofsky scale)
 Weight loss (<10% worse Px)
 Age (> 70 worse Px)
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NSCLC: TNM Staging
Stage Ia
Ib
IIa
IIb
IIIa
IIIb
T1
T2
T1
T2
T3
T1-3
Any T4
N0
N0
N1
N1
N0-1
N1
any N3
M0
M0
M0
M0
M0
M0
M0
IV Any M1
T = T1< 3cm,T2 >3cm + atelectasis,
T3 extension to pleura, chest wall, pericardium or total atelectasis) ,
local involvement
T 4 invasion of mediastinum or pleural effusion
N = N1= bronchopulmonary, N2 =ipsilateral mediastinal and N3=
contralateral or supraclavicular
M = absence (M0) or presence (M1) of metastases
NSCLC: Treatment
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Surgery
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Mediastinoscopy
Video-assisted Thoracoscopy (VAT)
Thoracotomy: Lobectomy. Pneumonectomy
Radiation
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External Beam
Brachytherapy
NSCLC: Treatment
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Chemotherapy
 Standard
Cisplatin, Carboplatin
 Newer agents: Gemcitabine, Paclitaxel,
Docetaxel, Vinorelbine, Irinotecan used
alone and in combination
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NSCLC: Treatment by Stage
Stage
Description
Treatment Options
Stage I a/b
Tumor of any size is found only in
the lung
Surgery
Stage II a/b
Tumor has spread to lymph nodes
associated with the lung
Surgery
Stage III a
Tumor has spread to the lymph
nodes in the tracheal area,
including chest wall and
diaphragm
Chemotherapy followed by
radiation or surgery
Stage III b
Tumor has spread to the lymph
nodes on the opposite lung or in
the neck
Combination of chemotherapy
and radiation
Stage IV
Tumor has spread beyond the
chest
Chemotherapy and/or palliative
(maintenance) care
NSCLC: Treatment Outcomes
Stage
I
II
IIIa
IIIb
IV
5-Year Survival
60-80%
40-50%
25-30%
5-10%
<1%
Pre-operative Pulmonary Assessment
Spirometry
FEV1 >60%
predicted
No
ABG
PaO2<60
No
Yes
No
FEV1 >2.0 L
MVV> 50%
Quantitative Lung Perfusion Scan
PPO FEV1 >.8 L and 40% predicted
PaCO2>45
No
Yes
Yes
High Risk, possibly Prohibitive
Consider Exercise Study
VO2 max> 20ml/kg/min=low risk
10-20 = mod risk
Yes
Surgery
Small Cell Lung Cancer (SCLC)
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Most aggressive lung cancer—almost
always metastatic at time of Dx.
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All pt’s receive extensive staging workup
+ Responsive to chemotherapy and
radiation but recurrence rate is high even in
early stage of disease.
SCLC: Cell Types
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Oat Cell
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Intermediate
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Combined
SCLC: Staging
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Limited Stage
Defined as tumor involvement of one lung, the
mediastinum and ipsilateral and/or contralateral
supraclavicular lymph nodes or disease that can be
encompassed in a single radiotherapy port.
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Extensive Stage
Defined as tumor that has spread beyond one lung,
mediastinum, and supraclavicular lymph nodes. Common
distant sites of metastases are the adrenals, bone, liver,
bone marrow, and brain.
SCLC: Treatment
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Limited Disease
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Chemotherapy
Concomitant Radiation
Prophylactic Cranial Irradiation
Extensive Disease
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Chemotherapy
Palliative radiation
SCLC: Treatment
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Chemotherapy:
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Most commonly used initial regimen: Cisplatin
or Carboplatin plus Etoposide x 4-6 cycles
Newer agents under evaluation: Topotecan,
Paclitaxel, Docetaxel, Irinotecan, Gemcitabine
SCLC: Treatment Outcomes
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Limited Disease
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median survival
5-year survival
18 - 20 months
10%
Extensive Disease
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median survival
5-year survival
10 - 12 months
1 - 2%
Advanced Lung Cancer:
Supportive Care
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Treatment Modalities for Palliation
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Chemotherapy
Radiation
Symptom Management
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Dyspnea
Fatigue
Pain
Dyspnea Management
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Assessment
Activity planning
Medications
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Corticosteroids
Opioids
Oxygen therapy
Non-traditional/investigational therapies
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Acupuncture
Massage
Exercise
Fatigue Management
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Assessment
Activity Planning
Exercise
Sleep aids
Stimulants
Anemia management
 Iron supplements
 Epoetin alfa
Pain Management
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Assessment
Medications:
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Opioids
NSAIDS
Corticosteroids
Nonpharmacologic Interventions:
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Heat/cold
Topical agents
Massage
Behavioral Therapy
Lung Cancer: Conclusions
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Smoking cessation is essential for prevention of
lung cancer.
New screening tools offer promise for detection of
early lung tumors.
Clinical trials are testing promising new
treatments.
New treatments offer improved efficacy and fewer
side effects.
Treatment can palliate symptoms and improve
quality of life.
Lung Cancer: Conclusions
A 56 yo male smoker presents with dyspnea & progressively
worsening cough over the past 3 months. Additionally the
pt reports increased confusion, N/V, and constipation.
EKG:shortened QT-I. CXR below. What is the most like
underlying cause of this pt’s presentation.
A.
B.
C.
D.
E.
Adenocarcinoma
Small cell carcinoma
Large cell carcinoma
Squamous cell
carcinoma
Allergic
bronchopulmonary
aspergillosis
A 56 yo male smoker presents with dyspnea & progressively
worsening cough over the past 3 months. Additionally the
pt reports increased confusion, N/V, and constipation.
EKG:shortened QT-I. CXR below. What is the most like
underlying cause of this pt’s presentation
A.
B.
C.
D.
E.
Adenocarcinoma
Small cell carcinoma
Large cell carcinoma
Squamous cell
carcinoma
Allergic
bronchopulmonary
aspergillosis
While dealing with Solitary Pulmonary Nodules,
certain radiographic patterns are uniformly accepted
as signs of benignity, these include all of the
following, EXCEPT:
A.
B.
C.
D.
E.
Very short or very long
doubling times
Popcorn calcification
Central calcificaiton
Laminated calcification
Eccentric calcification
While dealing with Solitary Pulmonary Nodules,
certain radiographic patterns are uniformly accepted
as signs of benignity, these include all of the
following, EXCEPT:
A.
B.
C.
D.
E.
Very short or very long
doubling times
Popcorn calcification
Central calcificaiton
Laminated calcification
Eccentric calcification
In 2005, the NCI approved screening for lung
cancer is ? (m+f,>45, >20PY, q 1yr)
A.
Low dose HRCT of chest
B.
Auto fluorescence bronchoscopy
C.
PET scanning
D.
CXR with sputum cytology
E.
None of the above
In 2005, the NCI approved screening for lung
cancer is ? (m+f,>45, >20PY, q 1yr)
A.
Low dose HRCT of chest
B.
Auto fluorescence bronchoscopy
C.
PET scanning
D.
CXR with sputum cytology
E.
None of the above
In reference to the incidence of lung cancer, all of the
following are true, EXCEPT:
A.
Mortality rates are higher in african americans than
whites
B.
Women are more susceptible to tobacco carcinogen
than men
C.
Recently lung CA deaths have started declining
among white men and women
D.
It is the number one cause of cancer deaths in the
United states in both men and women
In reference to the incidence of lung cancer, all of the
following are true, EXCEPT:
A.
Mortality rates are higher in african americans than
whites
B.
Women are more susceptible to tobacco carcinogen
than men
C.
Recently lung CA deaths have started declining
among white men and women
D.
It is the number one cause of cancer deaths in the
United states in both men and women