Lung%20Cancer

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Lung Cancer

• So what?

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Abbreviations

• Bx-biopsy
• CA-cancer
• Ca - serum calcium
• CBC-complete blood count
• CMP-comprehensive metabolic panel
• CP-chest pain
• CT-computerized tomography
• CXR-chest Xray
• DOE-Dyspnea on exertion
• DDX-differential diagnosis
• Dx-diagnosis

• Hx-history
• Na - serum sodium
• NSCLCA-non-small cell lung CA
• RML right middle lobe
• SCLCA-small cell lung CA
• SOB-shortness of breath
• SPN-solitary pulmonary nodule
• Sx-symptoms
• Tx-treatment
• UA-urinalysis
• Yr-year

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Case 1
52 Year old male who presents with slowly
worsening DOE, vague CP, and weigh loss. Hx
reveals long term occupation as auto mechanic
specializing in brake work.
4
Case 2
63 Year old scheduled for knee surgery who had a
1 cm nodule found on CXR during preoperative
medical evaluation.
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Case 3
71 year old female smoker with unexplained weight
loss and RML wheezing unresponsive to
bronchodilators.
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Lung Cancer

• Objectives
• Recognize the most common types of lung cancer
  with respect to the following
• Prevalence/epidemiology
• Pathology
• Presentation
• Diagnosis
• Staging
• Treatment philosophy
• Prognosis

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Objectives (Cont.)

• Recognize essential features distinguishing
  between the most common forms of lung masses
  including
• Solitary pulmonary nodule
• Bronchogenic Carcinoid tumor
• Small cell lung CA
• Non small cell lung CA types

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Lung Cancer

• Cancer Defined
• Progressive, uncontrolled multiplication of
  cells. (neoplasm or tumor)
• Cells lack differentiation
• Bronchogenic tumor
• Arises from the respiratory epithelium
• 99 of all malignant lung tumors

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Epidemiology/Prevalence

• Leading cause of CA death in men and women
  worldwide 1.2 million deaths
• 215,000 new cases and 162,000 deaths in the USA
  in 2007 (124k deaths from colorectal, breast,
  and prostate CA combined)
• Small cell constitutes about 15-20 of all lung
  cancers
• Non-small cell 80-85
• Adenocarcinoma is most prevalent NSC lung CA
  (NSCLCA)
• 97 gt 35 years old

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Etiology

• Smoking
• The most preventable risk factor
• Accounts for 80-90 of all cases of bronchogenic
  CA
• Toxic exposures
• Asbestos
• Other
• Idiopathic

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Lung Mass
Malignant (Cancer)
Benign Bronchogenic
Nonbronchogenic Carcinoid
Small cell Non small cell
Mesothelioma Typical Atypical
Squamous cell Adenocarcinoma
Large cell
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Benign tumor

• Slow or very fast growing
• Usually encapsulated, well demarcated
• NOT invasive or metastatic

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Malignant tumors

• Composed of embryonic, primitive, or poorly
  differentiated cells
• Disorganized growth
• Nutritionally demanding (can find with PET scan-
  looks at metabolism of something)
• May develop anywhere in lung
• Commonly originate in tracheobronchial mucosa
  (bronchgenic carcinoma)

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Pathology associated with growth

• Surrounding airways and alveoli become irritated,
  inflamed and swollen
• Adjacent alveoli may fill with fluid and become
  consolidated or collapse
• Tumor protrudes into tracheobronchial tree
• Excretions common

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Pathology (cont.)

• May invade pleural space and/or mediastinum,
  chest wall, ribs, or diaphragm
• Frequent secondary pleural effusion
• Eventual airway obstruction, atelectasis,
  consolidation, cavitation

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Clinical manifestations-symptoms

• May be assymptomatic with incidental finding on
  CXR
• Cough-onset or change in nature of chronic cough
• Hemoptysis
• Vague non-pleuritic chest pain
• Dyspnea
• Recurrent / persistent pneumonia
• Weight loss / anorexia / asthenia

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Clinical manifestations-signs

• Nodule(s) on imaging study
• Exudative pleural effusion
• Endocrinopathies
• Hyper Ca, hypo Na, Cushings syndrome
• Anemia
• Various coagulopathies
• Tracheal deviation
• Fixed wheeze
• Digital clubbing

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Diagnosis

• Clinical suspicion
• CXR
• Simple labs
• Chest CT
• Cytology - bronchoscopy
• Cytology open Bx
• Cytology pleural effusion

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Solitary pulmonary nodule

• Defined
• Single nodule
• Round or ovoid
• lt 3 cm in diameter
• Distinct margins
• May have calcification, satellite lesions,
  central cavitation

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Solitary pulmonary nodule (cont.)

• Signs and symptoms
• Most assymptomatic
• Rare findings
• Hemoptysis
• Cough
• Clubbing
• Endocrinopathy (suggestive of malignancy)

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Solitary pulmonary nodule (cont.)

• So what about it?
• 60 benign
• 40 malignant
• gt75 of these are primary lung CA
• 25 bronchogenic CA presents as SPN
• gt50 5 yr survival

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Solitary pulmonary nodule (cont.)

• Preop decision benign vs. malignant
• Imaging and comparison with old studies
• Almost always benign if
• Doubling time lt30 or gt500 days
• Calcified
• Likely benign if
• Pt is young
• Assymptomatic
• lt2 cm in diameter
• Smooth margins on CT
• Satellite lesions present

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Solitary pulmonary nodule (cont.)

• Features of malignant SPN
• Symptomatic
• Pt gt45 yrs old
• gt2 cm
• Indistinct margins - spiculation
• Rarely calcified

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Solitary pulmonary nodule (cont.)

• Features of metastatic SPN
• Smooth / lobulated margins
• Located peripherally
• Tends to occur in lower lobe
• Absence of satellite lesions
• Uncommon to be solitary

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Solitary pulmonary nodule (cont.)

• Diagnosis
• CT
• Simple labs
• CBC
• CMP
• UA
• Excision/Bx

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Solitary pulmonary nodule (cont.)

• Tx
• The presence of a SPN warrants discussion with
  the attending physician
• Course of action should never be yours alone
• Watchful waiting if
• Documented stable x 2 yrs
• Calcification on CT
• Otherwise
• Resect

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Types of Lung Cancer

• Bronchogenic-arise from respiratory epithelium
• Carcinoid
• Small cell
• Non-small cell
• Adenocarcinoma
• Squamous cell carcinoma
• Large cell carcinoma
• Dx of exclusion
• Non-bronchogenic-arise from the pleura
• Mesothelioma

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Bronchial carcinoid tumor

• Typical
• Highly differentiated
• Low grade malignant neoplasm
• Tend to occur as sessile (or occasionally as
  pedunculated) growths in central bronchi
• Pts. lt 60 yrs old
• Frequently assymptomatic
• Sx (typically associated with obstruction
  vascular nature)
• Hemoptysis
• Cough
• Wheezing
• Recurrent pneumonias
• Carcinoid syndrome (occurs in approx 2 of
  pulmonary carcinoids)

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Bronchial carcinoid tumor

• Atypical
• 10 of bronchial carcinoid tumors
• More aggressive than typical carcinoid
• More likely to metastasize
• Differentiated by biopsy

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Bronchial carcinoid tumor (cont)

• Tx
• Surgery with resection
• Only curative tx

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Small-Cell Carcinoma

• Originates centrally in bronchial epithelium
• Seen in 15-20 of bronchogenic cases
• Grows rapidly and submucosally

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Small-Cell Carcinoma (cont.)

• Metastasizes early
• Doubling time approx 30 days
• Cells commonly compressed into oval shape (oat
  cell)
• Commonly found near hilum

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Non Small Cell Lung CA (NSCLCA)

• Adenocarcinoma
• Squamous cell carcinoma
• Large cell carcinoma

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Adenocarcinoma

• Most common bronchogenic CA (35-40 of cases)
• Common in non-smokers
• Originates in mucous glands of tracheobronchial
  tree
• Glandular configuration
• Mucus production

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Adenocarcinoma (cont.)

• Moderate growth
• Moderate metastatic rate
• Doubling time approx 180 days
• Commonly found in peripheral lung parenchyma
• Cavitation common

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Squamous (epidermoid) cell carcinoma

• Second most common bronchogenic CA (25-35 of
  cases)
• Originates in basal cells of bronchial epithelium
• Frequently presents w/ hemoptysis
• Grows relatively rapidly

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Squamous (epidermoid) cell carcinoma (cont.)

• Frequently project in bronchi
• Late metastatic tendency
• Doubling time approx 100 days
• Commonly found in large bronchi near hilum

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Large-cell carcinoma

• Lacks glandular or squamous differentiation
• Found peripherally or centrally
• Rapid growth
• Early metastasis
• Doubling time approx 100 days
• Cavitation common
• Seen in 15-35 of bronchogenic cases

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Staging - Small cell lung CA

• Stage Definition 2 Yr. Survival
• Limited stage Tumor confined to the same 20
• disease side of the chest, supraclavicular
• lymph nodes, or both
• Extensive Defined as anything beyond 5
• stage Disease limited stage
• UNTREATED OVERALL SURVIVAL 6-18 WEEKS

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TNM Staging (Non-small cell)

• T Tumor
• N Regional Lymph Nodes
• M Metastasis

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T Tumor

• TX Unassessable.
• Presence in washings or sputum but not visualized
• T0 No evidence of primary tumor
• T1 No local tissue invasion (in situ)
  a.k.a. Tis

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T Tumor (cont.)

• T2 Any of the following
• gt3 cm in greatest dimension
• Involves main bronchus, gt/ 2 cm distal to the
  carina
• Invades visceral pleura
• Assoc with atelectasis or obstructive pneumonitis
  that extends to hilum but does not involve the
  entire lung

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T Tumor (cont.)

• T3
• Any size tumor that invades
• Chest wall
• Diaphragm
• Mediastinal pleura
• Parietal pericardium
• Or In main bronchus lt2 cm from carina but not in
  carina
• Or Assoc atelectasis or obstructive pneumonitis
  of entire lung

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T Tumor (cont.)

• T4 A tumor of any size that invades any of the
  following
• Mediastinum
• Heart
• Great vessels
• Trachea
• Esophagus
• Vertebral body
• Carina
• Or Separate nodules in same lobe
• Or With malignant pleural effusion

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N Regional lymph nodes

• NX Nodes cannot be assessed
• N0 No regional node metastasis
• N1 Mets in ipsilateral peribronchial and/or
  hilar nodes
• N2 Mets in ipsilateral mediastinal and/or
  subcarinal nodes
• N3 Mets in contalateral mediastinal, hilar,
  ipsi/contralateral scalene or supraclavicular
  nodes

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M Distant Metastases

• MX Distant mets cannot be assessed
• M0 No distant mets
• M1 Distant mets present - includes separate
  nodules in different lobe (ipsilateral or
  contralateral)

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Staging - non-small cell lung CA

• Stage Definition 5 year survival
• 1A T1, N0, M0 61
• 1B T2, N0, M0 38
• 2A T1, N1, M0 34
• 2B T2, N1, M0 / T3, N0, M0 24-22
• 3A T3, N1, M0 13
• or T1-T3, N2, M0
• 3B T4, any N, M0 5
• or any T, N3, M0
• 4 any T, any N, M1 1 OVERALL 5 YEAR
  SURVIVAL 15

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Mesothelioma

• Arise from mesothelial cells of
• Lung pleura (80)
• Peritoneum (20)
• Assoc. with asbestos exposure (20-40 yrs prior)

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Mesothelioma (cont)

• Sx
• DOE followed by SOB
• Non-pleuritic chest pain (take a breath and it
  doesnt change)
• Weight loss (metabolism)
• Findings
• Dull percussion
• ? breath sounds
• Pleural thickening on CXR or CT
• Exudative effusion

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Mesothelioma (cont)

• Tx
• Drainage of effusions
• None to limit progression
• Prognosis
• 5-16 months survival from onset of sx
• 75 dead 1 yr from dx

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Patient Education

• So, What do you tell your patients?
• How about, DONT SMOKE!

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So,

• What about the types we didnt discuss?
• What about the types you forgot?
• What will YOU do?

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Remember the cases?

• 52 Year old male who presents with slowly
  worsening DOE, vague CP, and weigh loss. Hx
  reveals long term occupation as auto mechanic
  specializing in brake work.
• 63 Year old scheduled for knee surgery who had a
  1 cm nodule found on CXR during preoperative
  medical evaluation.
• 71 year old female smoker with unexplained weight
  loss and RML wheezing unresponsive to
  bronchodilators.

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Treatment In A Nutshell

• Highly variable
• Surgery (resection)
• Radiation
• Chemotherapy
• Cure unlikely without resection
• Is surgery feasible?
• Can the patient tolerate surgery?

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A Few parting thoughts

• When you think you need to consider cancer in
  your DDx
• Be very careful in the words that you choose with
  your patient
• Dont ever volunteer the word cancer
  until/unless you KNOW its cancer
• If the patient asks if it could be cancer before
  you know, dont lie but focus on alternative
  possibilities

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A Few parting thoughts

• When you know its cancer
• Know that your patient is depending on you
• Meet face-to-face and be upfront DO use the word
  cancer
• Immediately offer what hope that really exists
• Arrange short term follow-up or oncology visit to
  discuss options
• Tailor discussion to the patient and situation
• Stress patient control