9. Lung ca.pptx

Epidemiology
 Lung cancer is the most common cause of cancer
death among American men and women
 Lung cancer is rare below age 40, with rates
increasing with age.
 The incidence of lung cancer varies by racial and
ethnic group, with the highest age-adjusted
incidence rates among African Americans.
 -

Risk Factors : Lung Ca
 Large majority (80–90%) of lung cancers is caused by cigarette
smoking
 Cigarette smokers have >/= 10X increase in risk of this cancer
compared to those who have never smoked.
 Cigarette smoking increases the risk of all the major lung
cancer cell types.
 Environmental tobacco smoke (ETS) or secondhand smoke is
also an established cause of lung cancer.
 The risk from ETS is less than from active smoking
 Occupational exposures to asbestos, arsenic, and polycyclic
aromatic hydrocarbons.

Risk Factors : Lung Ca…
 Low fruit and vegetable intake during
adulthood.
 Ionizing radiation is also an established
lung carcinogen
 Prior lung diseases such as chronic
bronchitis, emphysema, and tuberculosis
have been linked to increased risks of lung
cancer as well.

Smoking Cessation
 Smoking cessation can even be beneficial in individuals
with an established Dx of lung cancer, as it is associated
with:
 Improved survival,
 Fewer side effects from therapy, and
 An overall improvement in quality of life.
 Smoking can alter the metabolism of many
chemotherapy drugs,
 Potentially adversely altering the toxicities and therapeutic
benefits of the agents.
 Consequently, it is important to promote smoking
cessation even after the diagnosis of lung cancer is
established.

Inherited Predisposition to Lung Cancer
 First-degree relatives of lung cancer
patients have increased risk of lung cancer
 Individuals with inherited mutations in RB
and p53 genes may develop lung cancer.

Pathology : Lung Ca
 The term lung cancer is used for tumors arising
from the respiratory epithelium (bronchi,
bronchioles, and alveoli).
 Mesotheliomas, lymphomas, and stromal tumors
(sarcomas) are distinct from epithelial lung
cancers.
 According to WHO classification, epithelial lung
cancers consist of four major cell types:
 Small cell lung cancer (SCLC) and
 The so-called non-small cell lung cancer (NSCLC)
histologies including adenocarcinoma, squamous cell
carcinoma, and large cell carcinoma.

Traditional view of lung cancer

Pathology : Lung Ca…
 All histologic types of lung cancer can be
found in current and former smokers.
 In lifetime never smokers,
 All histologic forms of lung cancer can be
found,
 Adenocarcinoma , however tends to
predominate.

 Small cell carcinoma:
 Is a poorly differentiated neuroendocrine tumor
 Tends to occur as a central mass with endobronchial
growth and
 Is strongly associated with smoking.
 Small cell carcinomas, more often than NSCC ,
may produce specific peptide hormones such as
ACTH & AVP.
 These hormones may be associated with distinctive
paraneoplastic syndromes.
-

 Adenocarcinomas
 Often occur in more peripheral lung locations
 & may be associated with a history of
smoking.
 Are the most common type of lung cancer
occurring in never smokers.
 Bronchioloalveolar carcinoma (BAC) is a
subtype of adenocarcinoma that grows
along the alveoli

 Large cell carcinomas:
 Tend to occur peripherally and
 Are defined as poorly differentiated
carcinomas of the lung composed of larger
malignant cells

Pathology : Lung Ca
 Historically, for Rx & prognostication purposes, the
major distinction has been b/n SCLC and NSCLC
 SCLC is typically widely disseminated at diagnosis.
 Even if localized, it is rarely curable by surgery.
 By contrast, NSCLC can be potentially cured by
resection in up to 30% of cases.
 Small cell cancers tend to respond more favorably to
traditional cytotoxic chemotherapy agents.
 Intrinsic drug resistance is the norm for both SCLC and
NSCLC.

Clinical Manifestations : Lung ca
 >1/2 of all patients diagnosed with lung ca
present with advanced disease at the time of
Dx.
 The majority of patients present with signs,
symptoms, or laboratory abnormalities that
can be attributed to:
 The primary lesion,
 Local tumor growth,
 Invasion or obstruction of adjacent structures,
 Growth at distant metastatic sites, or
 A paraneoplastic syndrome

Clinical Manifestations : Lung ca…
 The prototypical lung cancer patient is:
 A current or former smoker of either sex
 Usually in the 7th decade of life.
 A Hx of chronic cough with or w/t hemoptysis in a
current or former smoker with COPD aged 40 yrs
or older
 should prompt a thorough investigation for lung ca
even in the face of a normal CXR.
 A persistent pneumonia w/t constitutional
symptoms & unresponsive to repeated courses of
antibiotics
 also should prompt an evaluation for the underlying
cause.

Presenting Signs and Symptoms of Lung
Cancer
Symptom and Signs Range of frequency
Cough 8–75%
Weight loss 0–68%
Dyspnea 3–60%
Chest pain 20–49%
Hemoptysis 6–35%
Bone pain 6–25%
Clubbing 0–20%
Fever 0–20%
Weakness 0–10%
SVCO 0–4%
Dysphagia 0–2%
Wheezing and stridor 0–2%

Clinical Findings Suggestive of Metastatic
Disease
Symptoms
elicited in Hx
Constitutional: weight loss >10 lb
Musculoskeletal: focal skeletal pain
Neurologic: headaches, syncope, seizures, extremity
weakness, recent change in mental status
Signs on P/E Lymphadenopathy (>1 cm)
Hoarseness, superior vena cava syndrome
Bone tenderness
Hepatomegaly (>13 cm span)
Focal neurologic signs, papilledema
Soft-tissue mass
Routine
laboratory
tests
Hematocrit: <40% in men, <35% in women
Elevated alkaline phosphatase, GGT, SGOT, and calcium
levels

 Lung cancer arising in a lifetime never smoker
is more common in women.
 Such patients also tend to be younger than their
smoking counterparts at the time of diagnosis.
 Patients with central or endobronchial growth
of the primary tumor may present with:
 Cough,
 Hemoptysis,
 Wheeze, stridor,
 Dyspnea, or
 Postobstructive pneumonitis.

 Peripheral growth of the primary tumor may
cause:
 Pain from pleural or chest wall involvement,
 Dyspnea on a restrictive basis, and
 Symptoms of a lung abscess resulting from tumor
cavitation.
 Regional spread of tumor in the thorax (by
contiguous growth or by metastasis to regional
LNs) may cause :
 Tracheal obstruction,
 Esophageal compression with dysphagia,
 Recurrent laryngeal paralysis with hoarseness,
 Phrenic nerve palsy with elevation of the
hemidiaphragm and dyspnea, and

 Malignant pleural effusions can cause pain or dyspnea.
 Pancoast (or superior sulcus tumor) syndromes :
 Result from local extension of a tumor growing in the apex of the
lung
 8th cervical and 1st and 2nd thoracic nerves are involved,
 Shoulder pain that radiates in the ulnar distribution of the arm
occurs,
 Radiologic destruction of the 1st and 2nd ribs is common.
 Often coexist with Horner's syndrome .
 Other problems of regional spread include:
 Superior vena cava syndrome from vascular obstruction;
 Pericardial and cardiac extension with resultant tamponade,
arrhythmia, or cardiac failure;
 Lymphatic obstruction with resultant pleural effusion
 Constitutional symptoms may include anorexia, weight loss,
weakness, fever, and night sweats.

 Extrathoracic metastatic disease is found at autopsy in >50%
of patients with squamous carcinoma, 80% with
adenocarcinoma , and >95% with SCLC.
 ~1/3 of patients present with distant metastases.
 Brain metastases - headache, nausea and vomiting, or
neurologic deficits.
 Bone metastases may present with pain, pathologic fractures,
or cord compression.
 Individuals with bone marrow invasion may present with
cytopenias
 Liver metastases - hepatomegaly, RUQ pain, anorexia, and wt
loss.
 Liver dysfunction or biliary obstructions are rare.

Paraneoplastic syndromes(PS):
 Are common in lung ca , and may be the presenting finding.
 May mimic metastatic disease and, unless detected, lead to
inappropriate palliative rather than curative treatment.
 In some cases, the pathophysiology is known, particularly when a
hormone with biologic activity is secreted by a tumor.
 Systemic symptoms of anorexia, cachexia, wt loss , fever, and
suppressed immunity are PSs of unknown etiology
 Endocrine syndromes
 Hypercalcemia (due to ectopic PTH, or more commonly, PTH-related
peptide), is the most common metabolic complication,
 Clinical symptoms include nausea, vomiting, abdominal pain,
constipation, polyuria, thirst, and altered mental status.

Hyponatremia
 May be caused by SIADH.
 SIADH resolves within 1–4 weeks of initiating
chemotherapy in the vast majority of cases.
 During this period, serum Na can usually be
managed and maintained above 128 meq/L via
fluid restriction.
 Demeclocycline can be a useful adjunctive
measure when fluid restriction alone is
insufficient.

Ectopic secretion of ACTH by SCLC :
 Usually results in hypokalemia, rather than
Cushing's syndrome.
 Rx with standard medications, such as
metyrapone and ketoconazole, is largely
ineffective due to extremely high cortisol levels.
 The most effective strategy for management of
Cushing's syndrome is effective treatment of the
underlying SCLC.
 Bilateral adrenalectomy may be considered in
extreme cases.

 Coagulation, thrombotic, or other hematologic
manifestations occur in 1–8% of patients and
include:
 Migratory venous thrombophlebitis (Trousseau's
syndrome),
 Nonbacterial thrombotic (marantic) endocarditis with
arterial emboli, and
 DIC with hemorrhage, anemia, granulocytosis, and
leukoerythroblastosis.
 Thrombotic disease complicating cancer is usually a
poor prognostic sign.
 Renal manifestations of nephrotic syndrome and
glomerulonephritis are uncommon(1%).

Diagnosing Lung Cancer
 Tissue sampling is required to confirm a diagnosis in all
patients with suspected lung cancer.
 Tumor tissue may be obtained :
 Via bronchial or transbronchial biopsy during fiberoptic
bronchoscopy,
 By FNA or percutaneous biopsy using image guidance, or
 Via endobronchial ultrasound (EBUS)-guided biopsy.
 Lymph node (Intrathoracic) biopsy or FNA from clinically
palpable LN
 In patients with suspected metastatic disease, a diagnosis may
be confirmed by
 Percutaneous biopsy of a soft tissue mass, lytic bone lesion, bone
marrow, pleural or liver lesion , or
 An adequate cell block obtained from a malignant pleural effusion.

Diagnosing Lung Cancer…
Sputum cytology:
 Is inexpensive and noninvasive but has a lower yield
 The yield for sputum cytology is highest for larger and
centrally located tumors such as SCC & SCCL
 Specificity & sensitivity are 100% & less than 70%.
 Accuracy improves with increased numbers of
specimens analyzed.
 Consequently, analysis of at least three sputum
specimens is recommended.

Staging Lung Cancer
 Lung cancer staging consists of two parts:
 1st, a determination of the location of the tumor and possible
metastatic sites (anatomic staging), and
 2nd, an assessment of a patient's ability to withstand various
antitumor treatments (physiologic staging).
 All patients with lung cancer should have
 A complete Hx including Hx of wt loss & P/E,
 Evaluation of all other medical problems, &
 Determination of performance status
 The most significant dividing line is b/n those patients who are
 Candidates for surgical resection and
 Inoperable but will benefit from chemotherapy, radiation Rxy, or
both.
 Staging for surgical resection is principally applicable to
NSCLC.

Staging Lung Cancer…
l. Physiologic staging
 Age
 Hx of smoking
 Performance status
 Pulmonary function
test
 Lab. Tests
 LFT , RFT , CBC
 Serum electrolyte &
calcium
 Comorbidities
 DM
 Cardiovascular e.g. Hx
of AMI
 COPD
ll . Anatomic Staging
 Tumor size
 Lymph node
 Metastasis

Rx Lung ca
 Curative vs palliative
 Surgical resection
 Chemotherapy
 Radiation
 Combination therapy

Left upper lobe mass, which biopsy revealed to be squamous
cell ca

Metastatic sarcoma. Note the multiple, well-circumscribed nodules of
different size

Left lower lobe lung mass (red arrow) abutting pleura. Biopsy
demonstrated small cell lung cancer

9. Lung ca.pptx

Recommended

Recommended

More Related Content

Similar to 9. Lung ca.pptx

Similar to 9. Lung ca.pptx (20)

More from ashenafigezahegn2

More from ashenafigezahegn2 (7)

Recently uploaded

Recently uploaded (20)

9. Lung ca.pptx