Lung Cancer Overview A Slide Presentation for Medical Student Jun Li Tongji Hospital Lung Cancer What is it? nUncontrolled growth of malignant cells in one or both lungs and tracheo-bronchial tree nArises from protective or ciliated cells in the bronchial epithelium nBegins as a result of repeated carcinogenic irritation causing increased rates of cell replication nProliferation of abnormal cells leads to hyperplasia, dysplasia or carcinoma in situ Lung Cancer Incidence in U.S. n170,00 new cases yearly n155,000 deaths yearly nMore deaths from lung cancer than prostate, breast and colorectal cancers combined nClosely correlated with smoking patterns nDecreasing incidence and deaths in men; continued increase in women nIncidence and mortality rates higher for African Americans than white Americans Lung Cancer in Women nIncreased incidence (79,000 new cases yearly) nAccount for more than half of new cases nDeaths increased 50% since 1980 (66,000) nMore deaths from lung cancer than breast, ovarian and uterine cancers combined nWomen are more susceptible to tobacco effects - 1.5 times more likely to develop lung cancer than men with same smoking habits Lung Cancer What Causes It? nSmoking nRadiation Exposure nEnvironmental/ Occupational Exposure nAsbestos nRadon nPassive smoke Lung Cancer and Smoking Facts nTobacco use is the leading cause of lung cancer n80% of lung cancers are related to smoking nRisk related to: namount smoked (pack years- # cigs/day x # yrs) nage of smoking onset nproduct smoked (tar/nicotine content, filters) ndepth of inhalation ngender Lung Cancer Screening nNo proven effective screening tool nChest x-ray commonly used nClinical trials: nLow dose spiral chest CT scan nSputum analysis nChest x-ray Lung Cancer Clinical Presentation Local Symptoms ncough ndyspnea nhemoptysis nrecurrent infections nchest pain Lung Cancer Clinical Presentation Syndromes/Symptoms secondary to regional metastases: nEsophageal compression dysphagia nLaryngeal nerve paralysis hoarseness nSymptomatic nerve paralysis Horners syndrome nCervical/thoracic nerve invasion Pancoast syndrome nLymphatic obstruction pleural effusion nVascular obstruction SVC syndrome nPericardial/cardiac extension effusion,tamponade Lung Cancer Clinical Presentation nSymptoms secondary to distant metastases npain norgan-related nGeneral Symptoms nweight loss nfatigue Lung Cancer Metastatic Sites nLymph nodes nBrain nBones nLiver nLung/pleura nAdrenal gland Lung Cancer Paraneoplastic Syndromes nNon Small Cell Lung Cancer nhypercalcemia nskeletal-connective tissue syndromes nSmall Cell Lung Cancer ninappropriate secretion of ADH nectopic ACTH secretion nneurologic/myopathic syndromes Lung Cancer Diagnosis nHistory and Physical exam nDiagnostic tests nChest x-ray nBiopsy (bronchoscopy, needle biopsy, surgery) nStaging tests nCT chest/abdomen nBone scan nBone marrow aspiration nPET scan Lung Cancer Prognostic Factors nStage at diagnosis nPerformance status Lung Cancer Cell Types Non Small Cell Lung Cancer (NSCLC) Small Cell Lung Cancer (SCLC) Non Small Cell Lung Cancer (NSCLC) n75% - 80% of all Lung Cancers nBetter survival in early stages NSCLC: Histologic Cell Types nAdenocarcinoma nSquamous Cell Carcinoma nLarge Cell Carcinoma NSCLC: TNM Staging Stage Ia T1, N0, M0 Ib T2, N0, M0 IIa T1, N1, M0 IIb T2, N1, M0 T3, N0-1, M0 IIIa T1-3, N1, M0 IIIb Any T4, any N3, M0 Stage IV Any M1 T= tumor size (T13cm + atelectasis), tumor site ( T 3 extension to pleura, chest wall, pericardium or total atelectasis) , local involvement (T 4 invasion of mediastinum or pleural effusion); N= lymph node spread N1 bronchopulmonary, N2 (ipsilateral mediastinal) and N3 (contralateral or supraclavicular); M= absence (M0) or presence (M1) of metastases NSCLC: Treatment nSurgery nMediastinoscopy nVideo-assisted Thoracoscopy (VAT) nThoracotomy: Lobectomy. Pneumonectomy nRadiation nExternal Beam nBrachytherapy NSCLC: Treatment nChemotherapy nStandard nCisplatin, Carboplatin nNewer agents: Gemcitabine, Paclitaxel, Docetaxel, Vinorelbine, Irinotecan used alone and in combination NSCLC: Treatment by Stage nStage I and II - Surgery as primary treatment nStage III - Multimodality Therapy nIII A Neoadjuvant therapy (chemo/radiation) followed by surgery +/- additional therapy nIIIB- Combination chemotherapy and radiation therapy nStage IV - Palliative chemotherapy and/or radiation NSCLC: Treatment Outcomes Stage I II IIIa IIIb IV 5 Year Survival 38-67% 24-37% 9-13% 5% 1% NSCLC: Research nChemotherapy/Biotherapy nNew agents nNovel therapies nRadiation nDosing and scheduling nNew techniques nMultimodality nEarly stage and locally advanced disease nRefining therapies Small Cell Lung Cancer (SCLC) nMost aggressive lung cancer nResponsive to chemotherapy and radiation but recurrence rate is high even in early stage SCL