Lung Cancer

Lung Cancer: Epidemiology

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

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 Cigarette smoking

Accounts for 80-90% of cases.

Risks related to: Number of cigarettes per

day Age started smoking Number of years smoked Inhalation practices Content of tar/nicotine

Lung Cancer: Etiology Risk of Lung cancer starts declining 5 years

after permanent smoking cessation, but never reaches level of a lifelong non-smoker.

Other Risk Factors: 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 CancerOccupational Risk Factors

Arsenic Asbestos Beryllium Cadmium Chloromethylethers Chromium Nickel Polycyclic aromatic

compounds

Radon Silica Vinyl Chloride Any chronic

interstitial lung disease

Smoking potentates the risk for any of the above

Lung Cancer: Screening

No proven effective screening tool Chest X-ray commonly used Clinical trials:

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

II. Symptomatic – 90%

1. Intrathoracic signs and symptoms Cough Dyspnea, and phrenic nerve paralysis Hemoptysis Dysphagia, and Hoarsness Pleural effusion

2. Metastatic disease Seizures, Bone Pain, Pathologic fractures

Lung Cancer: Presentation

Syndromes/Symptoms secondary to regional metastases: 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 Non-Small Cell Carcinoma---80% of

cases Squamous Adenocarcinoma Large Cell Combined types (adenosquamous)

Small Cell Carcinoma—20% of cases

Squamous Cell Carcinoma

Occurs centrally, often endobronchial lesion

Commonly cavitates

Associated with hypercalcemia. (PTH-like peptide)

Adenocarcinoma

Most common cell type

Usually peripheral

Often a Solitary Pulmonary Nodule

Cell type least associated with smoking (30% have no smoking link)

Large Cell Carcinoma

Small Cell Carcinoma

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 (Pancoast)

Apical lung tumor with: Pain—arm, shoulder,

scapula Atrophy of hand muscles Swelling of the arm Horner’s syndrome

Miosis, anhydrosis, ptosis

Tx: Pre-op XRT, plus surgery

Solitary Pulmonary Nodule

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

Factors favoring a benign etiology 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 Non Small Cell Lung Cancer

Hypercalcemia—squmous cell ^PTH Hypertrophic pulmonary Osteodystrophy

Small Cell Lung Cancer SIADH Cushings--^ectopic ACTH Eaton-Lambert—Presynaptic Ca channels

Anorexia/Cachexia with all cell types

Lung Cancer: Staging Workup

Diagnostic tests Chest x-ray Biopsy (bronchoscopy, needle

biopsy, surgery)—pathologic confirmation

Staging tests 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

STAGE OF DISEASE IS THE SINGLE MOST IMPORTANT DETERMINANT OF SURVIVAL!!!

Other prognostic factors Performance status (Karnofsky scale) Weight loss (<10% worse Px) Age (> 70 worse Px)

NSCLC: TNM StagingStage Ia T1 N0 M0

Ib T2 N0 M0IIa T1 N1 M0IIb T2 N1 M0 T3 N0-1 M0  IIIa T1-3 N1 M0IIIb Any T4 any N3 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

Surgery Mediastinoscopy Video-assisted Thoracoscopy (VAT) Thoracotomy: Lobectomy. Pneumonectomy

Radiation External Beam Brachytherapy

NSCLC: Treatment

Chemotherapy Standard

Cisplatin, Carboplatin Newer agents: Gemcitabine, Paclitaxel,

Docetaxel, Vinorelbine, Irinotecan used alone and in combination

NSCLC: Treatment by Stage

Stage Description Treatment Options

Stage I a/bTumor of any size is found only in the lung

Surgery

Stage II a/bTumor 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 bTumor has spread to the lymph nodes on the opposite lung or in the neck

Combination of chemotherapy and radiation

Stage IVTumor 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 >2.0 L

MVV> 50%

Quantitative Lung Perfusion Scan

PPO FEV1 >.8 L and 40% predicted

High Risk, possibly Prohibitive

Consider Exercise Study

VO2 max> 20ml/kg/min=low risk

10-20 = mod risk

<10ml/kg/min = prohibitive

ABG

PaO2<60

PaCO2>45

FEV1 >60% predicted

Surgery

NoYes

YesNo

No

Yes

YesNo

Small Cell Lung Cancer (SCLC)

Most aggressive lung cancer—almost always metastatic at time of Dx. 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

Oat Cell

Intermediate

Combined

SCLC: Staging

Limited StageDefined 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.

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

Limited Disease Chemotherapy Concomitant Radiation Prophylactic Cranial Irradiation

Extensive Disease Chemotherapy Palliative radiation

SCLC: Treatment

Chemotherapy: 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

Limited Disease median survival 18 - 20 months 5-year survival 10%

Extensive Disease median survival 10 - 12 months 5-year survival 1 - 2%

Advanced Lung Cancer: Supportive Care

Treatment Modalities for Palliation Chemotherapy Radiation

Symptom Management Dyspnea Fatigue Pain

Dyspnea Management

Assessment Activity planning Medications

Corticosteroids Opioids Oxygen therapy

Non-traditional/investigational therapies Acupuncture Massage Exercise

Fatigue Management Assessment Activity Planning Exercise Sleep aids Stimulants Anemia management

Iron supplements Epoetin alfa

Pain Management Assessment Medications:

Opioids NSAIDS Corticosteroids

Nonpharmacologic Interventions: Heat/cold Topical agents Massage Behavioral Therapy

Lung Cancer: Conclusions

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. AdenocarcinomaB. Small cell

carcinomaC. Large cell

carcinomaD. Squamous cell

carcinomaE. 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. AdenocarcinomaB. Small cell

carcinomaC. Large cell

carcinomaD. Squamous cell

carcinomaE. 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. Very short or very long doubling times

B. Popcorn calcificationC. Central calcificaitonD. Laminated

calcificationE. 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. Very short or very long doubling times

B. Popcorn calcificationC. Central calcificaitonD. Laminated calcificationE. Eccentric calcification

In 2005, the NCI approved screening for lung cancer is ? (m+f,>45, >20PY, q 1yr)

A. Low dose HRCT of chestB. Auto fluorescence bronchoscopyC. PET scanningD. CXR with sputum cytologyE. 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 chestB. Auto fluorescence bronchoscopyC. PET scanningD. CXR with sputum cytologyE. 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