LUNG CANCER
* Carcinoma of the lung is the
leading cause of cancer death in
USA.
* 171900 new cases in
2003=12.8% of total new cases.
*5-year survival rate for the lung
remains 14% in USA,8%in China
and Europe.
*Factors: tabacco
smoking,COPD,arsenic,
asbestos,beryllium,Chromium,
Nickel, Polycyclic aromatics,
Hydrocarbon compounds, Radon,
Investigation for lung cancer
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Chest X-ray,
Thoracic CT,
Fiberbronchoscopy,with biopsy,
Fine-needle aspiration from a pulmonary nodules,
Ultrasonography – pulmonary/abdominal.
PET,
Mediastinoscopy for mediastinal limph nodes,
VATS for diagnosis of small pulmonary nodules.
Clinical presentation of lung cancer
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Cough,
29-87%
Hemoptysis- 9-57%
Chest pain
6-60%
Dyspnea
3-58%
Wheezing or stridor 2-14%
Pleural effusion 7%
Dysphagia
2%
Superior vena cava syndrome 4-11%
Pancoast syndrome 3-5%
Phrenic nerve paralysis 1%
Symptoms from metastatic disease
Bone metastases: bone pain in hands,feet.
 Neurologic metastases:central nervous
system,spinal cord compression secondary
to epidural or vertebral mts.
 Adrenal mts,
 Liver mts,
 Others sites:soft tissue,etc.
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Paraneoplastic syndromes
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Metabolic:
- hypercalcemia,
- Cushing syndrome,
- carcinoid syndrome,
-gynecomastia,
-elevated growth hormone level,prolactin,folliclestimulating hormone,luteinizing
hormone,antidiuretic hormone production.
- hypoglicemia,
-hypertiroidism
Paraneoplastic syndomes
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Neurologic
-encephalopathy,
- subacute cerebrall degeneration
- peripheral neuropathy,
- polymiosytis,
- autonomic neuropathy,
- myoclonus.
Paraneoplastic syndromes
Skeletal
- clubbing
- pulmonary hypertrophic osteoartropathy
 Hematologic
- anemia,
-leukemoid reactions
-trombocytosis,
-trombocytopenia,
-eosinophilia,
-pure red cell aplasia,
-disseminated intravascular coagulation
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Paraneoplastic syndromes
Cutaneous and muscular
- hyperkeratosis,
- dermatomyositis,
- acanthosis nigricans,
-erytremia gyratum repens,
- hypertricosis lanuginosa acquisita
Other
-nephrotic syndrome,
-hypouricemia,
-hyperamylasemia,
-anorexia-cachexia.
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Diagnosis and staging of lung cancer
Diagnosis : sputum cytology, fiberoptic bronchoscopy,
VATS,CT,Xr
Transthoracic fine-needle aspiration
Indication
1.Patient is a high operative risk,
2.Patient hjas a low risk of malignancy based on clinical and
radiologic characteristics.
3. A definite benigne diagnosis is considered likely,
4. The patient prefers to have a diagnosis of cancer before
proceeding to the operating room.
5.Patient is not an operative candidate, but tissue
confirmation is needed before definitive treatment with
radiation therapy or chemotherapy or both.
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Characteristics of solitary pulmonary
nodules predicting malignancy
Radiologic characteristics
- diameter>2cm,
- spiculation present,
- upper lobe location
Clinical characteristics
- age>40 years
- positive smoking history
History of other cancer
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Radiographic features
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Early signs of a lung tumor are as follows:
1.a density within the lung parenchima,
2. a cavitary mass,
3. a segmental, indistinct, poorly defined dense area,
4. a nodular streaked, local infiltration along the course of a
blood vesel,
5. segmental consolidation,
6 a roughly triangular lesion arising in the apex and
extending toward the hilus,
7. a mediastinal mass,
8.an enlargement of one hilus,
9. segmental or lobar obstructive emphysema,
10. segmental atelectasis.
Chest radiographic presentations of lung
cancer
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Pulmonary nodule<3 cm in size,
Pulmonary or hilar mass,
Pulmonary opacities(lobar, segmental, subsegmental),
Tracheal or bronchial intraluminal opacity, luminal
narrowing or chest wll thickening,
Atelectasis (lung, lobar, segmental, subsegmental)
Pulmonary cavitary lesion,
Air trapping(hyperinflation)
Mediastinal mass,
Pleural lesion,
Pleural effusion,
Pericardial effusion (enlarged cardiac silhouette),
Elevated hemidiaphragm(paralysis or paresis),
Chest wall mass or bone metastases.
Classification of lung carcinoma
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Squamous cell carcinoma,
Small cell carcinoma
- pure small cell carcinoma,
- small- large cell carcinoma,
- combined small cell carcinoma (with areas of
squamous or glandular differentiation),
Adenocarcinoma
- variant: bronchioloalveolar carcinoma,
Large cell carcinoma,
Adenosquamous carcinoma.
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TNM Definition
TNM classification Primary tumour
(T) TxPrimary tumour cannot be assessed or
tumour proven by the presence of malignant cells
in sputum or bronchial washings but not
visualised by imaging or bronchoscopy
T0No evidence of primary tumour
TisCarcinoma in situ
T1Tumour <3 cm in greatest dimension,
surrounded by lung or visceral pleura, without
bronchoscopic evidence of invasion more
proximal than the lobar bronchus
T2Tumour with any of the following features of
size or extent: >3 cm in greatest
dimension involves main bronchus >2 cm distal
to the carina invades the visceral
pleura associated with atelectasis or obstructive
pneumonitis that extends to the hilar region but
does not involve the entire lung
T3Tumour of any size that directly invades the
following: chest wall (including superior sulcus
tumours), diaphragm, mediastinal pleura, parietal
pericardium; or tumour in the main bronchus <2
cm distal to the carina but without involvement of
the carina; or associated atelectasis or obstructive
pneumonitis of the entire lung
T4Tumour of any size that involves any of the
following: mediastinum, heart, great vessels,
trachea, oesophagus, vertebral body, carina; or
tumour with a malignant pleural or pericardial
effusion, or with satellite tumour nodule(s) within
the ipsilateral primary tumour lobe of the lung
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Stage Grouping for Lung Cancer
Regional lymph nodes (N)
 NxRegional lymph nodes cannot be assessed
 N0No regional lymph node metastases
 N1Metastases to ipsilateral
peribronchial and/or ipsilateral hilar lymph nodes
and intrapulmonary nodes involved by direct
extension of primary tumour
 N2Metastases to ipsilateral mediastinal and/or
subcarinal lymph nodes
 N3Metastases to contralateral mediastinal,
contralateral hilar, ipsilateral or contralateral
saclene or supraclavicular lymph nodes
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Distant metastases (M)
Mx Presence of distant metastases cannot be assessed
M0 No distant metastases
M1Distant metastases present
Stage grouping TNM subsets
0Carcinoma in situ
IA T1N0M0 IB T2N0M0
IIA T1N1M0 IIB T2N1M0 T3N0M0
IIIA T3N1M0 T1N2M0 T2N2M0 T3N2M0
IIIB T4N0M0 T4N1M0 T4N2M0 T1N3M0 T2N3M0 T3N3M0
T4N3M0
IV Any T Any N M1
Algoritm for therapy in lung cancer
NSCLC
 Comprehensive clinical evaluation
Clinical examination negative
- Chest CT
*T4 = 1. defined
2. indeterminate : VATS surgery.
** LN Positive = sample LN= a)N2 Positive- unresectable
and induction protocol
b)N3 Positive- unresectable
*** LN Negative = Surgery
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Clinical examination positive suspect M1.
*Organ specific= specific scan=a) negative scan
=follow chest CT sequence,
b) positive
scan= treat M1.
**Organ nonspecific findings= scan succesive
organs= a)negative scan= follow chest CT
sequence,
b) positive scan= treat M1.
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