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Understanding the basics of lung cancer

Understanding the basics of lung cancer

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  • 1. Lung Cancer Robert Miller MDwww.aboutcancer.com
  • 2. Lung Cancer Understanding the disease Anatomy and Imaging Staging system Treatment options
  • 3. Lung Cancer• Lifetime risk of being diagnosed in men is 1 in 13 (7.77%) and in women 1 in 16 (6.35%)• Most lethal cancer• Accounts for 14% of cancers in men but 28% of cancer deaths, in women also 14% of cases but 26% of all cancer deaths
  • 4. Age standardized lung cancermortality rate per 1000 men/year Non Smoker 0.17 Former smoker 0.68 Current Smoker 2.49 1 – 14 cigarettes/day 1.31 15 – 24 2.33 > 24 4.17The odds of dying of lung cancer goes up 24 X if compare heavysmoker to a non smoker BMJ 2004;328:1519 (26 June)
  • 5. Risk of Getting Lung CancerSmoking Men WomenNon-smoker 0.2% 0.4%Quit 5.5% 2.6%Current 15.9% 9.5%Heavy 24.4% 18.5%European study in 2006, defined heavy as > 5 cigarettes per day
  • 6. Cumulative Risk of Lung Cancer in Men at Age 75 by Smoking History Non-smoker <30y 40 y 50y 60y current Age when they stopped
  • 7. Risk for long termheavy smokers relative risk of lung cancer in the long-term smoker compared with the lifetime nonsmoker vary from 10- to 30-fold. The cumulative lung cancer risk among heavy smokers may be as high as 30 percent, compared with a lifetime risk of lung cancer of 1 percent or less in nonsmokers
  • 8. Effect of Smoking Reduction on Lung Cancer Risk Nina S. Godtfredsen; Eva Prescott; Merete Osler JAMA. 2005;294:1505-1510.
  • 9. Lung Cancer• 5 year survival rate for all• cancers from 1975 to 2008 has gone from 49 to 68%• 5 year survival for lung cancer during this period has gone from 12 to 17%• Most people are diagnosed in advance stages: Local (15%), Regional (22%), Distant (56%)• Cure rate stage is poor: Local (52%), Regional (25%), Distant (4%)
  • 10. Calculate Survival after Surgery with or without adjuvant chemotherapy
  • 11. Symptoms of Lung CancerSymptoms Percent of PatientsCough 45 – 74%Weight Loss 46 – 68%Dyspnea 37 – 58%Chest Pain 27 – 49%Hemoptysis 27 – 29%Bone Pain 20 – 21%Hoarseness 8 – 18%
  • 12. Age and Lung Cancer• Median age at diagnosis is 65y and median age at death is 72yDecade Non Small Small Cell Cell40‟s 5.9% 5.6%50‟s 16% 19%60‟s 30% 33%70‟s 33% 31%80‟s 15% 11%
  • 13. Types of Lung Cancer Non-small cell carcinoma (NSCC) (87%) ◦ Adenocarcinoma (38%) ◦ Squamous cell (20%) ◦ Large cell (5%) Small cell carcinoma (13%)
  • 14. Biopsy - confirm the cancer and determine the typeBronchoscopy CT directed biopsy
  • 15. Histology (NCDB 2000-2010)Non Small Cell 85% Adenocarcinoma 37% Squamous 25% NSCL 19% Other 12% Large Cell 4% Bronchoalveolar 3%Small Cell 15%
  • 16. Pathology Report• Pathological review: histology type and extent of the growth and size of the cancer• Immunohistochemical stains (“special stains”) to better clarify the true source and type of cancer• Molecular diagnostic studies to look for evidence of genetic mutations that would impact on the use of targeted therapies
  • 17. Pathology and the use of targeted therapy• Erlotinib (Tarceva) or Cetuximab (Erbitux) for EGFR mutations• Crizotinib (Xalkori) with ALK gen mutation• Bevacizumab (Avastin) anti angiogenesis but not for squamous cancers• KRAS mutation they would not respond to TKI
  • 18. Basic Lung Anatomy
  • 19. The trachea divides intobranching bronchiole tubes
  • 20. There are extensive bloodvessels in the lungs
  • 21. Three lobes on the right and twoon the left
  • 22. More detailed anatomy
  • 23. Segments of the pulmonarylobes
  • 24. Segments of the Lungs
  • 25. Trachea and Major Bronchi
  • 26. Lymph Nodes and LungCancer
  • 27. Lymph Nodes in the Lung
  • 28. Importance of the LymphNodes Spread to the Nodes on the side (hilar or N1 or Stage II ) is not as serious as if nodes in the middle or higher up are involved (N2 or mediastinal nodes or Stage III)
  • 29. Superior Mediastinal Nodes (1-4)1. Highest Mediastinal: 2. Upper Paratracheal: 3. Pre-vascular or Pre-vertebral4. LowerParatrachealAortic Nodes (5-6)5. Subaortic (A-P window): 6. Para-aorticInferior Mediastinal Nodes (7-9)7. Subcarinal. 8. Paraesophageal 9. Pulmonary LigamentHilar, Interlobar, Lobar, Segmental and Subsegmental Nodes (10-14)10-14: these are located outside of the mediastinum. They are all N1-nodes.
  • 30. Lung Imaging Lung Imaging
  • 31. Reading a Chest X-ray
  • 32. Reading a CT Scan
  • 33. Cross Section Anatomy of theChest
  • 34. Cross Section Anatomy of theChest
  • 35. Cross Section Anatomy of theChest
  • 36. Nodes on cross section
  • 37. PET Scan will „light up‟ areas ofcancer
  • 38. Common Nodes on PET Scanupper para-tracheal node (R2 Node)
  • 39. Common Nodes on PET Scan lower para-tracheal node (R4Node) and AP Window Node (5)
  • 40. Common Nodes on PET Scan left hilar node or L10
  • 41. Same side (N1), nodes in themiddle (N2) and the opposite side (N3)
  • 42. PET Scan will help separate theactive cancer from areas ofcollapse or fluid Squamous cancer left upper lobe bronchus , obstructing the left upper lobe
  • 43. Stages of Lung Cancer Stage I – small spot no nodes Stage II – larger or nodes on the side of the lung (hilar or N1 nodes) Stage III – very large tumor or lymph nodes in the middles of the chest (mediastinum or N2 nodes) Stage IV – metastases to other organs
  • 44. Stage from NCDB60504030 NSCL SCL20100 Stage 1 Stage 2 Stage 3 Stage 4
  • 45. T = Tumor
  • 46. N = Lymph Node and M = metastases
  • 47. Lung Cancer StagesStage TNMIA T1a or T1b N0IB T2a N0IIA T2bN0 or T1a or T1b or T2a N1IIB T2bN1 or T3N0IIIA T1 or T2 N2 or T3 N1 or T3 N2 or T4 N0 or N1IIIB Any N3 or T4N2IV Any M1a or M1b
  • 48. Small Cell Carcinoma of the Lung usuallypresents with a large central tumor (hilar/mediastinal lymphnode mass) and are usually classified as either Limited Stage(LS) or Extensive Stage (ES)
  • 49. Small Cell Lung Cancer PET scan showing a typical small cell cancer with a large mediastinal mass making it hard to even see the heart on the left side
  • 50. NCCN.org
  • 51. The treatment guidelines have become quite complex
  • 52. NCCN.com
  • 53. Treatment of Lung Cancer Stage I and II – surgery (if possible) and sometime postOp chemo or radiation (virtually all small cell cancer patients receive chemotherapy) Stage III – usually chemo plus radiation, sometime followed by surgery Stage IV – chemo or radiation,
  • 54. Lung Cancer Robert Miller MDwww.aboutcancer.com