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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.

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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% > 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

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+, Cushing’s 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

– < 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

• >75% of these are primary lung CA

– 25% bronchogenic CA presents as SPN

• >50% 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 <30 or >500 days

• Calcified

– Likely benign if:• Pt is young

• Assymptomatic

• <2 cm in diameter

• Smooth margins on CT

• Satellite lesions present

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Solitary pulmonary nodule (cont.)

– Features of malignant SPN

• Symptomatic

• Pt >45 yrs old

• >2 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

http://emedicine.medscape.com/article/426400-overview 28

Bronchial carcinoid tumor

• Typical– Highly differentiated– Low grade malignant neoplasm– Tend to occur as sessile (or occasionally as pedunculated) growths in

central bronchi– Pts. < 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)

http://emedicine.medscape.com/article/426400-overview 29

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:– >3 cm in greatest dimension– Involves main bronchus, >/= 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 <2 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 survival1A 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 doesn’t

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, “DON’T SMOKE!”

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So,

• What about the types we didn’t 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• Don’t ever volunteer the word “cancer” until/unless you

KNOW it’s cancer

• If the patient asks if it could be cancer before you know, don’t lie; but focus on alternative possibilities

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A Few parting thoughts…

• When you know it’s 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