Lung cancer is the leading cause of cancer death worldwide. Smoking is responsible for about 90% of lung cancer cases. The risk of lung cancer is greatly increased in current or former smokers. Screening with low-dose CT is recommended for those aged 55-80 with a significant smoking history. The main types of lung cancer are small cell lung cancer and non-small cell lung cancer. Symptoms vary depending on the location and size of the tumor but may include cough, hemoptysis, chest pain, and weight loss. Treatment options include surgery, chemotherapy, and radiation therapy. Prognosis depends on the stage of cancer at diagnosis.

1. Lung Cancer
Jamal Turki

2. • The term lung cancer, or bronchogenic
carcinoma, refers to malignancies that
originate in the airways or pulmonary
parenchyma
• Lung cancer is among the most common
cancers worldwide
• Lung cancer is the leading cause of cancer-
related mortality in both men and women

3. Epidemiology
• In the United States, lung cancer is the second
most common cancer, after prostate cancer in
men and breast cancer in women, and the
most common cause of cancer deaths.

4. Cancer Deaths in U.S.
(2007 American Cancer Society Data)
Lung 160,390
Colorectal 52,180
Breast 40,910
Prostate 27,050

5. RISK FACTORS
• Smoking —account for approximately 90 percent
of all lung cancers
• The risk of developing lung cancer for a current
smoker of one pack per day for 40 years is
approximately 20 times that of someone who has
never smoked
• prevention :In individuals who do quit smoking,
the risk of developing lung cancer gradually falls
for about 15 years before it levels off and remains
about twice that of someone who never smoked

6. • Environmental toxins — These include exposure to second-
hand smoke, asbestos, radon, metals (arsenic, chromium, and
nickel), ionizing radiation, and polycyclic aromatic
hydrocarbons
• Pulmonary fibrosis — Several studies have shown that the risk
for lung cancer is increased about sevenfold patients with
pulmonary fibrosis
• HIV infection —
• Genetic factors — Genetic factors can affect both the risk for
and prognosis
• Dietary factors — Epidemiologic evidence has suggested that
various dietary factors (antioxidants, cruciferous vegetables,
phytoestrogens) may reduce the risk of lung cancer

7. Asbestosis & Lung Cancer
(2007 American Cancer Society Data)
• Prolonged heavy exposure has relative risk
between 2 - 10 of causing lung cancer.
• Peak incidence 15 - 24 years after exposure.
• Fiber type is important:
– Crocidolite & amosite > chrysotile & anthophyllite.

8. SCREENING
Guidelines from the American Cancer Society
(ACS), American College of Chest Physicians
(ACCP), National Comprehensive Cancer Network
(NCCN), and U.S. Preventive Services Task Force
(USPSTF) recommend offering annual screening
with low-dose computed tomography (LDCT)
scanning to patients aged 55 to 74 years (the
USPSTF extends the recommended age range to
80 years) and who have at least a 30 pack-year
smoking history and either continue to smoke or
have quit within the past 15 years.

9. PATHOLOGY
• Adenocarcinoma :40 % , Non-smokers
Peripheral, Preexisting scars, Bronchoalv.
• Squamous cell carcinoma- 25%, smokers,
central, Hypercalcemia, cavitation
• Large cell carcinoma: 5 %
• Small cell carcinoma: 15 %
• Others 15%

10. CLINICAL MANIFESTATIONS
• Persons aged 50-70 years.
• Lung cancer is more common in men than in
women.
• Symptoms may result from local effects of the
tumor, from regional or distant spread, or from
distant effects not related to metastases
(paraneoplastic syndromes).
• Approximately three-fourths of patients have one
or more symptoms at the time of diagnosis.

11. • Cough — Cough is present in 50 to 75 percent
of lung cancer patients at presentation
• Squamous cell and small cell carcinomas
• Bronchorrhea
• Post-obstructive pneumonia
• bronchiectasis is uncommon

12. • Hemoptysis : 25 to 50 percent of patients
• Chest pain : same side of the chest as the primary
tumor. Dull, aching, persistent pain
• Dyspnea : 25 percent of cases
obstructive pneumonitis
Atelectasis
Lymphangitic tumor spread
Pneumothorax
Pleural effusion
Pericardial effusion

13. • Hoarseness : recurrent laryngeal nerve
• Pleural involvement :typically exudates
The yield of pleural fluid cytology after a single
thoracentesis is about 60 percent, and the
yield rises to 85 percent with three
thoracenteses

15. • Superior vena cava syndrome :sensation of
fullness in the head and dyspnea. Cough, pain,
and dysphagia, Physical findings include
dilated neck veins, a prominent venous
pattern on the chest, facial edema, and a
plethoric appearance, more common in
patients with SCLC than NSCLC

17. • Pancoast's syndrome :pain (usually in the
shoulder, and less commonly in the forearm,
scapula, and fingers), Horner's syndrome,
bony destruction, and atrophy of hand
muscles.

18. • miosis (constriction of
the pupils),
• anhidrosis (lack of
sweating),
• ptosis (drooping of the
eyelid)
• enophthalmos (sunken
eyeball)

19. Extrathoracic metastases
• Liver
• Bone
• Adrenal
• Brain

20. Paraneoplastic phenomena
• Hypercalcemia:bony metastasis or secretion of a
parathyroid hormone-related protein (PTHrP),
calcitriol or other cytokines
• SIADH secretion :SCLC, Hyponatremia
• Neurologic: SCLC. Lambert-Eaton myasthenic
syndrome (LEMS), cerebellar ataxia, sensory
neuropathy, limbic encephalitis,
encephalomyelitis, autonomic neuropathy,
retinopathy, and opsomyoclonus

21. Hematologic manifestations — These include the
following:
• Anemia — Anemia is frequent in patients with
lung cancer and can contribute to fatigue and
dyspnea
• Leukocytosis — granulocyte-colony stimulating
factor
• Thrombocytosis — Thrombocytosis
• Eosinophilia
• Hypercoagulable disorders

22. • Hypertrophic osteoarthropathy :clubbing and
periosteal proliferation
• Cushing's syndrome — Ectopic production of
adrenal corticotropin (ACTH)

23. Diagnosis and staging
• HISTORY AND PHYSICAL EXAM
• LABORATORY TESTING: complete blood
count, serum electrolytes, calcium, alkaline
phosphatase, albumin, (ALT), (AST), total
bilirubin, and creatinine

24. Chest radiographs may show the following:
• Pulmonary nodule, mass, or infiltrate
• Mediastinal widening
• Atelectasis
• Hilar enlargement
• Pleural effusion

25. Lung Cancer:
Findings on Chest X-ray
• Nodule (< 3cm) vs. Mass (>= 3cm).
– Location:
• Peripheral (Adenocarcinoma) vs.
• Central (Squamous).
– Single or multiple (metastases).
• Endobronchial obstruction.
– Atelectasis of lobe or lung.
– Pneumonia.

26. IMAGING
• All patients with suspected NSCLC should undergo
contrast-enhanced computed tomography (CT) that
extends through the lungs, liver, and adrenal glands. CT
is ideal for tumor node metastasis (TNM) staging
• It can characterize the primary tumor and define its
relationship to the chest wall and mediastinal
structures
• It can identify mediastinal lymph nodes that are
enlarged and suspicious for malignant involvement
• It can detect contralateral lung, chest wall, or upper
abdominal lesions that are suspicious for metastasis

34. TISSUE SAMPLING
1. Primary tumor — There are several options
for sampling a primary tumor:
Like Bronchoscopy or CT Transthoracic needle
aspiration
Sampling of pleural Effusion
2. Secondary Tumor

39. CT Guided TTNA

40. Common Paraneoplastic Syndromes:
Syndrome Frequent Histology
• Hypercalcemia
• SIADH
• Cushing’s Syndrome
• Eaton-Lambert
• Squamous Cell
• Small Cell
• Small Cell
• Small Cell

42. • Lymph nodes
• Pleural effusion
• Adrenal nodule

44. STAGING
• Based upon this initial evaluation, most
patients require additional imaging. This may
include whole body positron emission
tomography (PET), integratedCT/PET, bone
scanning, magnetic resonance imaging (MRI)
of the chest wall or brain, and/or CT of the
brain.

45. • Staging for NSCLC : TNM classification
• Staging of SCLC uses the Veterans
Administration Lung Study Group designations
of limited (confined to one hemithorax) or
extensive (beyond one hemithorax)

46. Treatment
• Surgery
• Chemotherapy
• Radiation therapy

48. Treatment
• Surgical resection offers the best opportunity
for long-term survival and cure in patients
with resectable NSCLC:
• Lobectomy
Resectability
Operability

49. Non Small Cell Lung Cancer
Contraindications to Surgical Resection
• Stage IIIB or IV.
• Extensive invasion into surrounding
structures:
• Vena cava or atrium involvement.
• Recurrent laryngeal or phrenic nerve involvement.
• SVC obstruction, malignant effusion, pericardial
tamponade.
• Contralateral lymph nodes.

50. Non Small Cell Lung Cancer
Contraindications to Surgical Resection
• Medically unfit:
– Poor cardiac or pulmonary status.
– Predicted postoperative FEV1% < 40%.
– Predicted postoperative DLCO% < 40%.
– Exercise studies for marginal candidates.

51. 1. PREOPERATIVE PULMONARY FUNCTION :
>Spirometry : preop FEV 1 (<60 percent predicted)
>Diffusing capacity

52. • Guidelines from the American College of Chest
Physicians and the British Thoracic Society suggest that
patients with a preoperative FEV 1 in excess of 2 L (or
>80 percent predicted) generally tolerate
pneumonectomy, whereas those with a preoperative
FEV 1 greater than 1.5 L tolerate lobectomy . However,
if there is either undue exertional dyspnea or
coexistent interstitial lung disease, then measurement
of DLCO should also be performed. Patients with
preoperative results for FEV 1 and DLCO that are both
>80 percent predicted do not need further
physiological testing.

53. 2. PREDICTED POSTOPERATIVE PULMONARY
FUNCTION : a combination of spirometry and
quantitative perfusion lung scanning
• Guidelines from the American College of
Chest Physicians consider a patient to be at
increased risk for lung resection with
predicted postoperative values for either
FEV 1 or DLCO <40 percent predicted

54. 3. MEASUREMENT OF GAS EXCHANGE
Arterial PO2
Arterial PCO2

55. 4. EXERCISE TESTING

56. REGIMENS
• Carboplatin plus docetaxel
• Carboplatin plus pemetrexed
• Cetuximab, vinorelbine, and cisplatin
• Cisplatin plus pemetrexed
• Gemcitabine plus carboplatin
• Gemcitabine plus cisplatin (GC)
• Paclitaxel carboplatin
• Paclitaxel, carboplatin, and bevacizumab
• Vinorelbine plus cisplatin

57. RADIOTHERAPY
• SYMPTOM PALLIATION :Short courses of
radiation therapy are useful for patients who
require symptom palliation. This may include
symptoms arising from progressive
intrathoracic disease or disease at other sites
(eg, bone, brain).

58. PALLIATIVE CARE
• Shortness of breath
• Pain
• Psychological Impairment

59. Prognosis of NSCLC
• Stage of disease
• Clinical parameters :Performance status ,
Ethnicity
• Histopathology
• Molecular characterization :(EGFR)
• PET and PET-CT: SUV number
• Recurrence after complete resection

60. • In Europe, the 5-year overall survival rate is
11%. The highest recorded 5-year patient
survival rates are observed in the United
States. US data indicate that the 5-year
relative survival rate for lung cancer was
17.4%,

61. Estimated 5-year survival rates for specific stages of
disease are as follows:
• Stage IA - 75%
• Stage IB - 55%
• Stage IIA - 50%
• Stage IIB - 40%
• Stage IIIA - 10-35%
• Stage IIIB - Less than 5%
• Stage IV - Less than 5%

62. THANK YOU