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Lung cancer Overview - Munireddy - 2009

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  • 1. Lung Neoplasms Sanjay Munireddy Dept of Surgery Sinai Hospital of Baltimore June17, 2008
  • 2. Overview • Leading cause of cancer-related death among men and women and 2nd most common cause of overall mortality in US • Estimated new cases in 2008: 215,020 • Estimated deaths in 2008: 161,840
  • 3. Epidemiology • Recent continued decline in incidence among men (79.4 cases per 100,00) • Stabilization of incidence in women (52.6 cases per 100,00) • Greatest incidence in AA men (107.6 cases per 100,000) NCI SEER Cancer Data
  • 4. Risk Factors • Smoking • Second hand smoke • Sex - men • Race - African American • Environmental gases - Asbestos, radon, tar soot, arsenic, silica etc. • Excessive alcohol use • Radiation therapy to chest • Family history of lung cancer
  • 5. Smoking • Greatest risk factor; dose-response relationship between the number of pack- years smoked and lung cancer risk • 87% of all lung cancer deaths result from smoking • Death rates decrease to that of never- smokers after 10 yrs of smoking cessation
  • 6. 1999 WHO Classification of Lung Tumors • Epithelial – Malignant • Squamous cell carcinoma • Small cell carcinoma • Adenocarcinoma • Large cell carcinoma • Adenosquamous cell carcinoma • Carcinomas with pleomorphic, sarcomatoid or sarcomatous elements • Carcinoid tumor
  • 7. Types • Non-small cell lung cancer (NSCLC) – Comprise 80% of lung tumors – 50% are metastatic at diagnosis • Small cell lung cancer (SCLC) – Comprise 20% – 80% are metastatic at diagnosis
  • 8. Adenocarcinoma of Lung • Most common type of lung cancer • Comprises 30-40% in smokers and 60-80% in non-smokers • Arises from terminal bronchioles • Usually develops in the peripheral portions of the lung • Slow growing than squamous cell ca. • Often is associated with a peripheral scar or honeycombing due to response to tumor
  • 9. Squamous Cell Carcinoma of Lung • Comprise 25-40% of lung cancers; rates are declining due to reduction in smoking • Dose-response relationship of smoking is strongest with this type of cancer • Usually occurs in the lung’s central portions or in one of the main airway branches. • Can form cavities in the lung if they grow to a large size • Slow growing
  • 10. Large Cell Carcinoma of Lung • Accounts for 10-15% of lung tumors • Diagnosis of exclusion; cannot diagnose on small biopsies or in lymph node metastases • Usually large peripheral mass with necrosis • Often associated with peripheral eosinophilia and leukocytosis, due to tumor production of colony stimulating factor
  • 11. Small Cell Carcinoma of Lung • Also called undifferentiated or oat cell carcinoma • Accounts for 10-15% of lung tumors • Almost always caused by smoking • Fast growing compared to NSCLC • Usually metastatic in about 70% of cases at the time of diagnosis • Without treatment, has the most aggressive clinical course of any type of pulmonary tumor • Median survival from diagnosis of only 2 to 4 months.
  • 12. Clinical Presentation • Majority are symptomatic at presentation (>85%) • Symptoms are broadly classified as – Due to lung lesion – Due to intra-thoracic spread – Due to distant mets – Due to paraneoplastic syndrome
  • 13. Clinical Presentation • Symptoms due to lung lesion/primary tumor – Coughing ± sputum – Dyspnea – Hemoptysis – Chest pain – Wheezing – Weight loss
  • 14. Clinical Presentation • Central tumors (squamous cell carcinomas) generally produce symptoms of cough, dyspnea, atelectasis, wheezing, postobstructive pneumonia,, and hemoptysis. • Most peripheral tumors are adenocarcinomas or large cell carcinomas and, in addition to causing cough and dyspnea, can cause symptoms due to pleural effusion and severe pain as a result of infiltration of parietal pleura and the chest wall.
  • 15. Clinical Presentation • Symptoms of intra-thoracic spread – Pleural or pericardial effusion – Compression of RLN (hoarseness), phrenic nerve palsy (elevated diaphragm), pressure on the sympathetic plexus (Horner syndrome) – Tracheal obstruction, esophageal compression, SVC syndrome – Superior sulcus tumors can cause compression of the brachial plexus roots as they exit the neural foramina, resulting in intense, radiating neuropathic pain in the ipsilateral upper extremity.
  • 16. Clinical Presentation • Symptoms of distant spread – May occur in almost every organ system – Bone mets (vertebrae, ribs, pelvis are MC) – Hepatic mets (indicate poor prognosis) – Brain mets (headache, nausea, vomiting, seizures, confusion, personality changes
  • 17. Clinical Presentation • Paraneoplastic syndromes (10%) – Squamous cell carcinoma: hypercalcemia due to parathyroidlike hormone production. – Adenocarcinomas: Clubbing, hypertrophic pulmonary osteoarthropathy and the Trousseau syndrome of hypercoagulability – Small cell carcinomas: SIADH, Ectopic ACTH production, Lambert-Eaton myasthenic syndrome
  • 18. Diagnosis • History & physical – Wt. loss, respiratory distress – Lymphadenopathy – Horner syndrome – SVC syndrome (usually SCLC) – Absence of breath sounds, dullness, pleural effusions – Bone pain – Neurological deficits
  • 19. Diagnosis • CXR • Sputum cytologic studies: centrally located endobronchial tumors exfoliate malignant cells into sputum • Thoracentesis • FNAB • Bronchoscopy with BAL, brushings, biopsies • Staging work-up – Local extent – Distant spread
  • 20. Staging • In the United States, the standard staging workup includes at least the following: – Complete history and physical examination – CT scan of the chest and upper abdomen (including liver and adrenals) – Complete blood cell counts – Liver and kidney functions tests – Serum electrolytes
  • 21. Staging • Local extent – Cervical mediastinoscopy – Left anterior mediastinotomy • Distant spread – CT or Ultrasound of the abdomen • liver, adrenals – Bone scan – CT head – MRI – PET scan
  • 22. Management • Functional Evaluation – Evaluation of performance and pulmonary status should be completed before discussing treatment options – Pulmonary function testing, specifically forced expiratory volume in one second (FEV1) and carbon monoxide diffusion in the lung (DLCO) measurements, is a helpful predictor of morbidity and mortality in patients undergoing lung resection
  • 23. Management • Functional Evaluation – Patients with an FEV1 or DLCO value less than 80 percent of predicted require additional testing. – calculation of postresection pulmonary reserve (with ventilation and perfusion scans or by accounting for the number of segments removed); cardiopulmonary exercise testing; and arterial blood gas sampling – Patients with a predicted postoperative FEV1 or DLCO value less than 40 percent and a VO2max value less than 10 mL per kg per minute or an SaO2 value less than 90 percent are at high risk of perioperative death or complications