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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.  
  • 23. 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
  • 24. 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
  • 25.