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Lung Cancer

Lung Cancer. So what?. 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

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Lung Cancer

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  1. Lung Cancer • So what?

  2. 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 Abbreviations

  3. 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.

  5. Case 3 71 year old female smoker with unexplained weight loss and RML wheezing unresponsive to bronchodilators.

  6. 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

  7. 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

  8. 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

  9. 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

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

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

  12. Benign tumor • Slow or very fast growing • Usually encapsulated, well demarcated • NOT invasive or metastatic

  13. 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)

  14. 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

  15. Pathology (cont.) • May invade pleural space and/or mediastinum, chest wall, ribs, or diaphragm • Frequent secondary pleural effusion • Eventual airway obstruction, atelectasis, consolidation, cavitation

  16. 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

  17. 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

  18. Diagnosis • Clinical suspicion • CXR • Simple labs • Chest CT • Cytology - bronchoscopy • Cytology – open Bx • Cytology – pleural effusion

  19. Solitary pulmonary nodule • Defined: • Single nodule • Round or ovoid • < 3 cm in diameter • Distinct margins • May have calcification, “satellite” lesions, central cavitation

  20. Solitary pulmonary nodule (cont.) • Signs and symptoms • Most assymptomatic • Rare findings • Hemoptysis • Cough • Clubbing • Endocrinopathy (suggestive of malignancy)

  21. 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

  22. 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

  23. Solitary pulmonary nodule (cont.) • Features of malignant SPN • Symptomatic • Pt >45 yrs old • >2 cm • Indistinct margins - spiculation • Rarely calcified

  24. 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”

  25. Solitary pulmonary nodule (cont.) • Diagnosis • CT • Simple labs • CBC • CMP • UA • Excision/Bx

  26. 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

  27. 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

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

  30. Bronchial carcinoid tumor (cont) • Tx: • Surgery with resection • Only curative tx

  31. Small-Cell Carcinoma • Originates centrally in bronchial epithelium • Seen in 15-20% of bronchogenic cases • Grows rapidly and submucosally

  32. Small-Cell Carcinoma (cont.) • Metastasizes early • Doubling time approx 30 days • Cells commonly compressed into oval shape (oat cell) • Commonly found near hilum

  33. Non Small Cell Lung CA (NSCLCA) • Adenocarcinoma • Squamous cell carcinoma • Large cell carcinoma

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

  35. Adenocarcinoma (cont.) • Moderate growth • Moderate metastatic rate • Doubling time approx 180 days • Commonly found in peripheral lung parenchyma • Cavitation common

  36. 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

  37. Squamous (epidermoid) cell carcinoma (cont.) • Frequently project in bronchi • Late metastatic tendency • Doubling time approx 100 days • Commonly found in large bronchi near hilum

  38. 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

  39. 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

  40. TNM Staging (Non-small cell) • T: Tumor • N: Regional Lymph Nodes • M: Metastasis

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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)

  47. 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%

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

  49. 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

  50. 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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