- Lung cancer is a leading cause of cancer death in the US, with an estimated 215,000 new cases and 162,000 deaths in 2008. Non-small cell lung cancer (NSCLC) accounts for 80% of cases, while small cell lung cancer (SCLC) makes up 20%. - Smoking is the greatest risk factor, responsible for 87% of lung cancer deaths. Other risk factors include exposure to radon, asbestos, or other gases/particles. Symptoms vary depending on location and stage of cancer but often include cough, dyspnea, chest pain, and weight loss. Diagnosis involves imaging tests, sputum/biopsy analysis, and functional testing to evaluate treatment eligibility

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
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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 packyears smoked and lung cancer risk
• 87% of all lung cancer deaths result from
smoking
• Death rates decrease to that of neversmokers after 10 yrs of smoking cessation

6. 1999 WHO Classification of
Lung Tumors
• Epithelial
– Malignant
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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
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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
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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
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Bone scan
CT head
MRI
PET scan

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