Download Lung Cancer

Unit I
Integrative Lecture:
Lung Cancer
Andrew Burkett MD
FRCPC Respirology
Interventional Pulmonology Fellow
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Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Objectives
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Case-Based Review
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Smoking
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Lung nodules
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Lung cancer - types, complications, risk factors
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Pleural Effusions
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 1: Ms. P
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45 year old female
Outpatient clinic
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30 pack year history of smoking
Son is thirteen year old
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How do you approach this patient?
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Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Canadian Tobacco Use Monitoring Survey (CTUMS) 2010
• 17% of the Canadians aged ≥15 years were current smokers
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4.7 million Canadian residents
13% reported smoking daily, while 4% reported smoking occasionally
Males (20%) > females (14%)
Average of 15.1 cigarettes per day
• 12% of youth aged 15 to 19 years were current smokers
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Approximately 268,000 teens
7% of youth reported smoking daily
Average of 11.6 cigarettes per day
Males = females
• Provincial current smoking rates highest in Saskatchewan,
Nova Scotia and Manitoba.
Source: www.hc-sc.gc.ca
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Smoking Prevalence in Canada
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Question 1:
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What is the most common cause of death in a patient with mild COPD?
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A) Heart Disease
B) Lung Cancer
C) Pneumonia
D) Respiratory Failure
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Answer:
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Lung Cancer!
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Was I really going to use this as a bridge to start talking about heart disease?
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In a large cohort study, the most common cause of death in patients with
mild/moderate COPD was lung cancer
Respiratory failure was the most common cause of death in patients with
severe/very severe COPD
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Anthonisen NR, Connett JE, Enright PL, Manfreda J. Hospitalizations and mortality in the Lung Health Study.
Am J Respir Crit Care Med 2002;166:333–339.
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 2: Ms. PN
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62 year old woman
Referred for “spot on her lung”
Ex-smoker, quit 5 years ago, 35 pack year history
Homemaker
Vitals stable O2 sat 97%
No clubbing
Prolonged expiratory time, few wheezes
Exam otherwise unremarkable
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 2
• High risk clinical features
– Age: risk for malignant process increases with age
– Other risk factors
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Smoking
Asbestos
Family history
Previous diagnosis of cancer
• Radiologic features …
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 2: Ms. PN
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 2: Ms. PN
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Solitary Pulmonary Nodule (<3cm) - Benign
• Infectious
– Granulomas (80%)- TB, histo, blasto, coccido, crypto, atypical
mycobacterium
– Bacterial, PJP, aspergilloma
• Inflammatory
– Graulomatosis with polyangiitis, rheumatoid nodule
• Vascular
– AVM, pulmonary varix
• Benign neoplasm
– Harmatoma (10%), fibroma, lipoma
• Developmental
– Bronchogenic cyst
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Solitary Pulmonary Nodule (<3cm) - Malignant
• Primary lung cancer
– NSCLCa
• Adenocarcinoma, Squamous, Large cell
– SCLCa
• Carcinoid tumors
• Metastatic cancer
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Breast
Colon
Melanoma
RCC
Head & neck
Sarcoma
Germ cell tumors
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Solitary Pulmonary Nodule
Malignant features Benign Features
Size
Larger, 50% of
nodules ≥2cm are
malignant
Smaller
<1cm
Boarders
Irregular
Spiculated
Discrete
Smooth
Calcification
Asymmetric
Laminated
Popcorn
Central
Diffuse
Density
Decreased
Increased
Growth
Rapid over time
Stable
Ground glass +
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
--
Back to our case
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Several high risk clinical features
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Radiologic features concerning for malignant nodule
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Lower risk nodules can be followed over time
Higher risk nodules – options include
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surgical section
FNA (CT or fluoroscopy guided)
Bronchoscopy
Ms PN underwent FNA
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Pathology showed adenocarcinoma
Referred to thoracic surgery and medical oncology
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 2: Summary
• For the assessment of pulmonary nodule
1) Think Benign vs. Malignant
2) Determine the risk of the patient
Smoking
Previous cancer
Age
Asbestos exposure
Previous radiation
3) Determine the risk of the nodule
Size
Borders
Calcification
Growth over time
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 3: Mr. VC
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70 yo M
Four week history of progressive dyspnea on exertion, cough
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Swelling of the face and arms
Arm weakness
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Ex-smoker (80 pack years)
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HR 105/min RR 20/min O2 sat 93% on RA
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Ruddy complexion, JVP elevated
Pitting edema of face and upper chest
Dilated superficial veins
Ptosis, miosis noted
Rt Supraclavicular LN
Atrophy of forearm + hand
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 1: Mr. VC
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
http://radonc.wikidot.com/clinical-case-005
Mr. VC has a Pancoast tumor
• Manifestations
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Local – pain; respiratory symptoms
Vascular compromise – SVC obstruction if on right side
Lymphadenopathy – esp supraclavicular
Neurologic compromise
• Recurrent laryngeal nerve  hoarseness
• Horner’s syndrome
– Miosis
– Ptosis
– Anhydrosis
• Brachial plexus involvement
– C8-T2
– Weakness in the hand, ↓ sensation to ulnar forearm + pulp of 5th
digit hand
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Mr. VC has a Pancoast tumor
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Lung Cancer
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1.6 million new cases in 2008
1.38 million deaths in 2008
Rates declining in men (reflects decreased smoking rates)
In Canada, represents 27% of all cancer deaths
#2 cause of cancer death in man & women in 2011
www.cancer.ca The Canadian Cancer Society
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Groome et al. J Thorac Oncol 2007; 2:694.
Risk Factors
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Smoking 90%
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Environment
– 2nd hand smoke, asbestos, radon
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Risk Factors
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Radiation
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Lung disease
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Genetics
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Pulmonary fibrosis
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HIV
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Clinical Manifestations of Lung Cancer
Cough
Hemoptysis
Chest Pain
Intrathoracic Effects
Dyspnea
Hoarseness
SVCO
Pleural Effusion
Pancoast syndrome
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Clinical Manifestations of Lung Cancer
Liver
Extrathoracic Metastases
Bone
Adrenal
Brain
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Non Small Cell Lung Cancer
• 80% of all lung cancers
• 10-15% survival at 5 years
• Staging by TNM system
T = tumour
N = node
M = metastases
Up To Date
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
www.utdol.com
Non Small Cell Lung Cancer
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Subtypes:
- Adenocarcinoma 35%
- Squamous cell carcinoma 20%
- Large cell carcinoma 5%
- Other NSCLCa 18%
Squamous
Small cell
Adenocarcinoma
http://cueflash.com/decks/Pathology_Chapter_15_Lungs_Images*
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Adenocarcinoma
• Increasingly common
• Peripheral
• Has a propensity for aerogenous and lymphatic spead
– nodular or airspace
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Squamous Cell Carcinoma
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Central, may invade airway lumen giving obstruction
Cavitation
Almost exclusively in smokers
Hypercalcemia (PTHrP)
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Large Cell
• Peripheral with prominent necrosis
• Less common
• Slightly worse prognosis than squamous and adenocarcinoma
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
AJCC Cancer Staging Manual, 7th edition. 2010.
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
AJCC Cancer Staging Manual, 7th edition. 2010.
NSCLC Treatment
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Stage I
– Surgery
– If not surgical candidate  RFA or stereotactic body radiation
therapy
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Stage II
– Surgery
– If not surgical candidate  RFA or stereotactic body radiation
therapy
– Adjuvant chemotherapy
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Stage III
– Maybe surgery (if minimal bulk)
– Concurrent chemotherapy + radiation (if non-surgical)
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Stage IV
– Symptom management +/- palliative chemotherapy
Unit 1 – Integrative Lecture: Lung Cancer – J. Block
Small Cell Lung Cancer
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15% of lung cancers
More rapid doubling time, earlier metastases
Responsive to chemotherapy and radiation
Quickly relapses
3-8% survival at 5 years
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
PEIR Digital Library http://peir2.path.uab.edu
Small Cell Lung Cancer
• Smokers
• Central airways, submucosal > endobronchial
• Early invasion of blood vessels and lymphatics, so often present
with metastases
• Paraneoplastic syndromes
• Survival without treatment 2 to 4 months
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
PEIR Digital Library http://peir2.path.uab.edu
Small Cell Lung Cancer
• Limited (30-40%): single radiation field
- concurrent chemo + radiation
- median survival 16-24 months
- 20-40% 2 year survival
• Extensive (60-70%): outside single portal
- chemotherapy
- median survival 6-12 mo
- <5% 2 year survival
PEIR Digital Library http://peir2.path.uab.edu
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 3: Summary
• Lung cancer
– SCLCa
– NSCLCa
• Clinical manifestations
– Intrathoracic
– Extrathoracic
– Paraneoplasic syndromes
• Treatment
– Depends on TNM staging (NSCLCa)
– Surgical lesion, chemotherapy and radiation
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Case 4: Mrs. MG
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35 yo F
Subacute breathlessness over last 2-3 months
No fevers, chills
Some sweats and 5-10 lb weight loss
BP 130/75 HR 90 RR 16 sat 93% RA
No clubbing
No accessory muscle use
Decreased air entry on right
Dull to percussion on right
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Pleural Effusion Evaluation
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Cell count + differential
Gram stain
Culture
AFB
Cytology
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LDH
Total protein
Glucose
pH
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Pleural Fluid Analysis
Light’s Criteria
• Fluid protein/serum protein > 0.5
• Fluid LD/serum LD >0.6
• Fluid LD >2/3 ULN
70/75
559/319
559 (ULN = 205)
Any of these three criteria means fluid is EXUDATE
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Pleural Effusion Etiology
Transudate
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CHF
Nephrotic syndrome
Peritoneal dialysis
Hypoalbumin states
Hepatic hydrothroax
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Exudate
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Infectious
Malignancy
Connective tissue diseases
Lymphatic's
GI sources
Endocrine
PE
Inflammatory
Pleural Effusions
• Negative pleural
cytology should be
confirmed with
pleuroscopy before
being called benign if
malignancy is a concern
Diagnosis and Management of Lung Cancer: ACCP Guidelines.
Chest. 2007;132(3_suppl):1S-19S.
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Pleural Effusion Etiology
• 55 cases where malignancy was diagnosed on the basis of
cytological examination
• 65% were established from the first specimen
• 27% from the second specimen
• 5% from the third specimen
• In that article, a further 55 patients had malignancy and no
cytological diagnosis made, although 40% had suspicious cells
in one or more fluid sample
Garcia, L. The value of multiple fluid specimens in the cytological diagnosis of
malignancy. Mod Pathol1994;7:665–8
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Back to our Case
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Melanoma with pleural mets
Increasing incidence
Risk factors:
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Blond/red hair
Freckling
Light eye colour
Atypical nevi
High nevus count >25
Sun/UV light exposure
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett
Thank you
Unit 1 – Integrative Lecture: Lung Cancer – A. Burkett