Download Lung Cancer

LUNG CANCER
Jennie Hocking, MPAS, PA-C
FIGURE 1 Ten Leading Cancer Types for the Estimated New Cancer Cases and Deaths, by
Sex, United States, 2008
From Jemal, A. et al.
CA Cancer J Clin 2008;58:71-96.
Copyright ©2008 American Cancer Society
EPIDEMIOLOGY
 Men:

Rates declining
 Women


Rates still increasing
More likely to be nonsmokers
United States Cancer Statistics, 2001: Incidence and Mortality
EPIDEMIOLOGY-TEXAS
www.cdc.gov/cancer/lung/statistics/race.htm
ETIOLOGY-GENETICS
 Polyfactorial
Inactivated tumor supressor genes
 Tumor promotors



 Stem
Epidermal growth factor receptor (EGFR)
Vascular endothelial growth factor (VEGF)
cells
Chest. 2006;130:936-937
ETIOLOGY-GENETICS
 Family


First reports >40 years ago
Approx 2-fold increase risk for lung cancer



History/Clustering
Corrected for tobacco usage
10-15% of lung cancer patients have at least
one affected 1st-degree relative
No single gene isolated
ETIOLOGY
 Tobacco
 Cigars
& pipes
 Secondhand smoke
 Cigarettes


directly alter mucosal barriers
Chronic inflammation
Ciliary dysfunction
SMOKING HISTORY
 46
million US smokers (23% of population)
1
pack per day x 40 years = 40 pack years
OR
 2 packs per day x 20 years = 40 pack years
 Greatest


risk for lung cancer: >30 pk yrs
20 year lag period
Risk declines with tobacco cessation

15 year window
SMOKING HISTORY
 Cigarettes/pack

= 20
Marlboro Math
146,000 cigarettes

1 ppd x 20 years =

Retirement Savings: 2ppd x 50 years

Assume 10% annual interest
Retirement savings lost: $2,598,693
ETIOLOGY
 Other
Causes
Asbestos
 Radon
 Silica
 COPD
 Idiopathic

PATHOLOGY
 Two
main categories:

Small Cell (20%)

Non-small Cell (NSCLC)
Large cell (9%)
 Adenocarcinoma (and bronchoalveolar) (32%)
 Squamous (30%)


“Others”

Carcinoid, sarcomas, mucoepidermoid carcinomas and
undifferentiated, mesothelioma
PATHOLOGY
 Small
cell (oat cell)
Extremely rapid
growth
 Central location

http://radiology.rsnajnls.org/content/vol236/issue3/images/s
mall/r05se22g03b.gif
PATHOLOGY
Squamous cell
Central location
Exfoliates
Aggressive
imaging.consult.com
PATHOLOGY

Adenocarcinoma
Slow growing
 Peripheral location
 “Scar” tumor
 More common in
nonsmokers

PATHOLOGY
 Bronchoalveolar
(BAC)
 Form
of adenoca
 Nonsmokers
 Mucous producing
 Peripheral
 ‘Ground glass’
www.argjiro.net/albi/white/path/?album=148photo.id=49
PATHOLOGY
 Large
cell
 Poorly differentiated
 Peripheral
 Rapid growth
CLINICAL PRESENTATION
2-15% asymptomatic
 Symptoms related to:

Local Tumor Growth
 Local Spread of Tumor
 Metastasis
 Paraneoplastic Syndromes

LOCAL TUMOR GROWTH
 Cough:
pleura
irritation of endobronchial mucosa or
 Dyspnea:
obstruction, post-obstructive
pneumonitis
 Hemoptysis:
 Wheezing:
 +/-
minimal or massive
endobronchial obstruction
consolidation on exam
LOCAL SPREAD
OF
TUMOR

Chest pain: chest wall invasion

Hoarseness: left recurrent
laryngeal nerve

Effusion

Axillary/supraclavicular
lymphadenopathy

SVC syndrome: right
paratracheal node or RUL
tumor compression
www.meddean.luc.edu/.../lungca.svcphy.html
LOCAL SPREAD
 Pancoast
OF
TUMOR
Syndrome
 Superior
sulcus tumor
 Compresses brachial &
cervical nerve roots
 Manifestations:
Horner’s
syndrome
 Anhydrosis
 Arm pain/atrophy

www.mrcophth.com/.../oculoplasticgallery.html
DISTANT METASTASES
 Contralateral
lung
 Liver

Elevated LFTs
 Adrenals
 Bone
Elevated Calcium
 Bone pain
 Pathologic fractures

 Brain

±Neurologic signs/symptoms
PARANEOPLASTIC SYNDROMES

Endocrine hormone secretion
PTH-like hormone secretion
 SIADH
 ACTH

Clubbing
 Anorexia, weight loss/cachexia, fever
 Other syndromes

Lambert-Eaton Syndrome
 Hypertrophic pulmonary osteoarthopathy
 Hematological abnormalities

DIAGNOSIS & STAGING
 Goal
#1 Obtain a tissue diagnosis and determine
the stage of malignancy efficiently and safely
 Goal#2 Determine patient candidacy for therapy
CHEST XRAY (CXR)



Relatively low cost
Readily available
Insensitive


Difficult to see all regions
of chest
Non-specific if no
symptoms
<5% of solitary pulmonary
nodules in mass screening
 Screening NOT proven to
impact mortality
Evaluate further w/CT scan


US Preventive Services Task Force, 2004
CHEST CT




More sensitive
Size, shape, and
invasion
Evaluate
lymphadenopathy
Pitfalls:



Radiation exposure
Cost
Moderate specificity
Not recommended for
screening

CHEST CT
 Approach:



Establish chronicity
Incidental,
asymptomatic, <1cm,
benign appearance, low
risk patient
Symptomatic, risk
factors, >1cm or
growing on serial scans
 Definitive workup
DIAGNOSIS-PET
Radiolabeled glucose
 Metabolically active cells




Uses



Heart, brain, kidneys, bladder
Cancer, infection
Determine activity of known
masses
Locate distant metastasis
Pitfalls



Can miss slow growing tumors
Can’t differentiate between
tumor/infection
Doesn’t accurately measure
size, growth
DIAGNOSIS-TISSUE
 Sputum



Cytology
Least invasive
Tumor location
important
Not recommended for
screening
DIAGNOSIS-TISSUE
 Bronchoscopy




Central lesions
Endobronchial tumors
Fluoroscopic guidance
for peripheral tumors
Mediastinal biopsies
DIAGNOSIS-TISSUE
 Needle
Biopsy
Good specificity
 Sensitivity varies
 Operator dependent
 Pneumothorax

DIAGNOSIS-TISSUE
 Surgical
Lung Biopsy
Thoracotomy is gold
standard
 Increased use of VATS
 CME for staging/dx

DIAGNOSIS-OTHER
 Labs:
STAGING STUDIES
CBC, chemistry panel w/calcium, coag
panel, LFTs
 MRI of brain
 CT abdomen/pelvis
 Biopsy of other sites
 ±bone scan, PFTs w/ABGs
echo, V/Q scan
TREATMENT
Smoking cessation
 Nutrition
 Surgery
 Chemotherapy
 Radiation
 Other Palliative Care

Airway stents/laser
 Indwelling pleural catheters
 Pain control
 Hospice


+/- Emotional support
http://www.co.jackson.mi.us/HD/images/PrevNews/GreatAmericanSO.jpg
STAGING-NSCLC

TNM system
T-tumor size &/or location
 N-lymph nodes
 M-metastasis
 Stage I (T1aN0M0)-Stage IV (TanyNanyM1or2)

STAGING, TREATMENT & PROGNOSIS - NSCLC

Stage I disease
No lymph node involvement
 Surgical removal



Follow Up with CT scans

43-64% 5-year survival (surgical)
Stage II & III disease


Lymph nodes involved or larger tumor or multiple lung
tumors
Surgery, radiation & chemotherapy may all play a role
in treatment
STAGING, TREATMENT &

PROGNOSIS-
NSCLC
Inoperable patients
XRT (via stereotactic approach) and chemotherapy
 5-25% long term survival


Stage IV disease
Chemo +/- XRT
 XRT/gamma knife for brain mets
 Occasionally some mets surgically resected
 Increases mean survival from 4-6 mo to 7-9 mo

STAGING & PROGNOSIS - SCLC
Limited: confined to hemithorax, regional nodes
 Extensive: all others (70% at diagnosis)
 Death in weeks to months if untreated


Median survival:
 Limited 16 – 24 months
 10-20% alive at 2 years
 Extensive 9 – 12 months
30% die of local tumor complications
 70% die of carcinomatosis

THERAPEUTICS - SCLC

Highly sensitive to chemo and XRT


Combination chemotherapy regimens best
Surgery not useful
ADDITIONAL REFERENCES



Minna JD, Schiller JH. Neoplasms of the Lung. In: Fauci, AS, Kasper, DL,
Longo, DL, Braunwald, E, Hauser, SL, Jameson, JL, Loscalzo, J. Harrison’s
Principles of Internal Medicine, 17th ed. New York: McGraw Hill; 2008
Detterbeck FC, Boffa DJ, Tanoue LT. The New Lung Cancer Staging System.
Chest. http://chestjournal.chestpubs.org/content/136/1/260.full.pdf+html
PACE curriculum, School of Allied Heath Sciences, Baylor College of Medicine,
2008

Hoopman, Todd, MD. PA lung cancer. 2006

Cedar Bluff CME. Neoplastic Disease. 2007

Humphrey L, Teutsch S, Johnson M. Lung cancer screening with sputum
cytologic examination, chest radiography and computed tomography: An
Update for the US Preventative Services Task Force. Ann Intern Med.
2004;140:740-753.