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LUNG CANCER A COMORBIDITY WITH SEVERE PROGNOSTIC FOR COPD PATIENTS

LUNG CANCER A COMORBIDITY WITH SEVERE PROGNOSTIC FOR COPD PATIENTS. Ruxandra Ulmeanu Visiting Professor, MD, PhD, FCCP Bronchology Department – Institute of Pneumology “Marius Nasta” Bucharest Faculty of Medicine and Pharmacy -University of Oradea Eugenia Halic, MD

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LUNG CANCER A COMORBIDITY WITH SEVERE PROGNOSTIC FOR COPD PATIENTS

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  1. LUNG CANCER A COMORBIDITY WITH SEVERE PROGNOSTIC FOR COPD PATIENTS Ruxandra Ulmeanu Visiting Professor, MD, PhD, FCCP Bronchology Department – Institute of Pneumology “Marius Nasta” Bucharest Faculty of Medicine and Pharmacy-University of Oradea Eugenia Halic, MD Pneumology Department “Maria Burghele” Hospital, Buftea, Ilfov County

  2. COPD - LUNG CANCERTwo ofthe greatest challenges in pulmonary medicine

  3. COPD is independently and closely related to Lung Cancer Skillrud DM, Offord KP, Miller RD, et al. Higher risk of lung cancer in chronic obstructive pulmonary disease: a prospectiv matched controlled study. Ann Intern Med 1986; 105:503–507 R.P. Young, R.J. Hopkins, T. Christmas, P.N. Black, P. Metcalf, G.D. Gamble, COPD prevalence is increased in lung cancer, independent of age, sex and smoking history, Eur Respir J 2009; 34: 380–386

  4. COPD - LUNG CANCER • Lung cancer is the number one cause of death fromcancer worldwide • Approximately 85% of lungcancer occurs in current or former smokers • Lung cancers frequently occurin patients with COPD The correlation of emphysema or airway obstruction with the risk of lung cancer: amatched case-controlled study. K. Kishi, J.W. Gurney, D.R. Schroeder, P.D. Scanlon, Eur Respir J 2002; 19: 1093–1098.

  5. COPD - LUNG CANCER • The riskof lung cancer increases with age and amount ofsmoke exposure • Cigarette smokeis the common aetiologicalfactor for both lung cancerand COPD • Smokingaccounts for an estimated 80–90% of the risk ofdeveloping COPD The correlation of emphysema or airway obstruction with the risk of lung cancer: amatched case-controlled study. K. Kishi, J.W. Gurney, D.R. Schroeder, P.D. Scanlon, Eur Respir J 2002; 19: 1093–1098.

  6. Risk of lung cancer among COPD patients Previously: 2 -fold increased risk associated with COPD Wasswa-Kintu S, Gan WQ, Man SFP, et al., Relationship between reduced forced expiratory volume in one second and the risk of lung cancer: a systematic review and meta-analysis. Thorax 2005;60: 570–575

  7. COPD - LUNG CANCERBoth diseases result from shared pathogenic mechanisms

  8. Both diseases result from shared pathogenic mechanisms • Smoking-related diseases • Genetically-determined diseases • Cluster in families • Worsen with age

  9. The most important underlying Risk factor For Lung Cancer is COPD greater than that attributed to smoking dose or age !

  10. COPD and Riskof Lung Cancer in Population • Every year, over 1 million people die from lung cancer worldwide • Cigarette smoking is the primary etiologic agent in 85–90% of all lung cancers Koshiol J, Rotunno M, Consonni D, Pesatori AC, De Matteis S, et al. (2009) Chronic Obstructive Pulmonary Disease and Altered Risk of Lung Cancer in a Population-Based Case-Control Study. PLoS ONE 4(10): e7380. doi:10.1371/journal.pone.0007380, Neeraj Vij, Johns Hopkins School of Medicine, October 8, 2009

  11. Pathogenic mecanisms COPDExacerbations-Pulmonary infections InflammationLung carcinogenesis Carcinogenesisin general Koshiol J, Rotunno M, Consonni D, Pesatori AC, De Matteis S, et al. (2009) Chronic Obstructive Pulmonary Disease and Altered Risk of Lung Cancer in a Population-Based Case-Control Study. PLoS ONE 4(10): e7380. doi:10.1371/journal.pone.0007380, Neeraj Vij, Johns Hopkins School of Medicine, October 8, 2009

  12. Shared pathogenic mechanisms • Occupational toxins • Community air pollution Accumulated and damaging mutations Inflame and destroy airways alveoli Dysplastic and ultimately neoplastic changes Koshiol J, Rotunno M, Consonni D, Pesatori AC, De Matteis S, et al. (2009) Chronic Obstructive Pulmonary Disease and Altered Risk of Lung Cancer in a Population-Based Case-Control Study. PLoS ONE 4(10): e7380. doi:10.1371/journal.pone.0007380, Neeraj Vij, Johns Hopkins School of Medicine, October 8, 2009 R.P. Young, R.J. Hopkins, T. Christmas, P.N. Black, P. Metcalf, G.D. Gamble, COPD prevalence is increased in lung cancer, independent of age, sex and smoking history, Eur Respir J 2009; 34: 380–386

  13. Smoking-related diseases Smoking exposure is found in 85–90% of those diagnosed with either COPD or lung cancer

  14. COPD – LUNG CANCER MORE THAN A SHARED SMOKING HISTORY?

  15. COPD – LUNG CANCER MORE THAN A SHARED SMOKING HISTORY? Yes !

  16. Risk of lung cancer among COPD patients Six-fold higher R.P. Young, R.J. Hopkins, T. Christmas, P.N. Black, P. Metcalf, G.D. Gamble, COPD prevalence is increased in lung cancer, independent of age, sex and smoking history, EurRespir J 2009; 34: 380-386

  17. COPD – LUNG CANCER • Smoking-induced airway inflammation typically persists in those smokers with COPD for many years after quitting smoking. Ind PW. COPD progression and airway inflammation: uncoupled by smoking cessation. EurRespir J 2005; 26: 764–766 • 50% of lung cancer cases are found in ex-smokers Young RP, Hopkins RJ, Hay BJ, et al. Lung cancer gene associated with COPD: triple whammy or possible confounding effect? EurRespir J 2008; 32: 1158–1164 Yang P, Allen MS, Aubry MC, et al. Clinical features of 5,628 primary lung cancer patients; experience at Mayo clinic from 1997 to 2003. Chest 2005; 128: 452–462

  18. Emphysema - Lung cancer • Asymptomatic lung cancers in 2–5% of patients with severe emphysema evaluated CT for lung volume reduction surgery. Rozenshtein A, White CS, Austin JHM, Roinney BM, Protopapas Z, Krasna MJ. Incidental lung carcinoma detected at CT in patients selected for lung volume reduction surgery to treat severe pulmonary emphysema.Radiology 1998; 207: 487–490.

  19. Lung cancer • remains the largest cause of cancer deaths • worldwide • the overall 5-year survival rate is only 15% • the majority of the lung cancers • are diagnosed at late stages • the treatment outcome is suboptimal. • American Cancer Society Guidelines for the Early Detection of Cancer, 2009 • A. McWilliams, B. Lam and T. Sutedja, Early proximal lung cancer diagnosis and treatment, Eur Respir J 2009; 33: 656–665

  20. Diagnosis and resection of lung cancer early stage dramatically improved survival rates for resected patients compared with patients with no surgery Field JK, Brambilla C, Hirsch FR, Hittelman W, Hogan M, Marshall D, Mulshine JL, Rabbitts P, Sutedja T, Watson A, Weiss S. Molecular Biomarkers Workshop. A European strategy for developing lung cancer molecular diagnostics in high risk populations. Lung Cancer 2001;31:339–345. Suzana Bota, Jean-Bernard Auliac, Christophe Paris, Josette Métayer, Richard Sesboüé, Georges Nouvet, and Luc Thiberville, Follow-up of Bronchial Precancerous Lesions and Carcinoma in Situ Using Fluorescence Endoscopy, American Journal Of Respiratory And Critical Care Medicine Vol 164, 2001, p 1688-1693

  21. Endoscopy-lung cancera.Detection of (pre)cancerous bronchial lesionsb.Palliate inoperable lung cancer

  22. Autofluorescence bronchoscopy (AFB) Normal and abnormal tissues appear different colors when viewed through a specialized bronchoscope • A. McWilliams, B. Lam and T. Sutedja, Early proximal lung cancer diagnosis and treatment, Eur Respir J 2009; 33: 656–665

  23. Bronchus intermedius – middle lobe jonction Biopsy-SCC R Ulmeanu Institutul de Pnemoftiziologie “Marius Nasta”, 2009

  24. Anterior tracheal wall – two cartilages Biopsy-severe displasia R Ulmeanu, Institutul de Pnemoftiziologie “Marius Nasta”, 2009

  25. Trachea - Right Main Bronchus jonction Right pneumonectomy ? NO ! R Ulmeanu , Institutul de Pnemoftiziologie “Marius Nasta”, 2009

  26. Narrow band imaging • Detection of subtle mucosal abnormalities • Utilizes the changes seen in the microvascular network • - Uses a special narrow band filter • Kunst P, With blue light into the depth, Annual Congress of ERS, Vienna 2009, • A. McWilliams, B. Lam and T. Sutedja, Early proximal lung cancer diagnosis and treatment, Eur Respir J 2009; 33: 656–665

  27. Endoscopy-COPD-lung cancera. Detection of cancerous bronchial lesionsb.Palliate innoperable lung cancer

  28. LUNG CANCER INITIAL DIAGNOSIS 75% INOPERABLE William Lunn, Obstruction of central airways: evaluation and management”, in Michael J. Simoff, Daniel H. Sterman, Armin Ernst, Thoracic Endoscopy – Advances in Interventional Pulmonology, 2007, 22: 323-329

  29. LUNG CANCER 75% CASES SIGNIFICANT NEED TREATMENT OPTIONS TO PALLIATE THIS SYMPTOMS William Lunn, Obstruction of central airways: evaluation and management”, in Michael J. Simoff, Daniel H. Sterman, Armin Ernst, Thoracic Endoscopy – Advances in Interventional Pulmonology, 2007, 22: 323-329

  30. Lung cancer OBSTRUCTION > 50% OF NORMAL LUMEN compulsory association ENDOSCOPY CHIMIOTHERAPY RADIOTHERAPY

  31. TRACHEAL METASTASIS (THYROID CARCINOMA) COPD Gold II LOOP ELECTRORESECTION 2006 Ruxandra Ulmeanu, Iolanda Ion, Dan Ioan Ulmeanu, 2006

  32. ADENOCARCINOMA RIGHT MAIN BRONCHUS COPD Gold III 2007 ELECTRORESECTION Ruxandra Ulmeanu, Dan Ioan Ulmeanu, Iolanda Ion 2007

  33. ROMANIA ?

  34. Why a Working Group for Lung Cancer?

  35. It is possible the optimal diagnosis of lung cancer?

  36. ROMANIAN PNEUMOLOGISTS – TRAINED FOR BRONCHOLOGY Ruxandra Ulmeanu, APORTUL BRONHOSCOPIEI SI TOMOGRAFIEI COMPUTERIZATEIN DIAGNOSTICUL CANCERULUi PULMONAR, Teza Doctorat,2006

  37. PERGENTAGE OF THOSE WITH WHO PRACTICEPULMONARY ENDOSCOPY(except Bucharest) Ruxandra Ulmeanu, Eugenia Halic, Situatia Bronhilogiei in Romania-intre realitate si cerinte, a V-a Conferinta Natinala de bronhologie, 14 octombrie 2009

  38. No Bronchology Departments availablein 9 counties october 2009 Ruxandra Ulmeanu, Eugenia Halic, Situatia Bronhilogiei in Romania-intre realitate si cerinte, a V-a Conferinta Natinala de bronhologie, 14 octombrie 2009

  39. POPULATION WITHOUT ACCESS TO BRONCHOSCOPY IN THEIR HOME COUNTY * 22% of general population 4.620.000 RESIDENCE 39.6%000 MORTALITY DUE TO LUNG CANCER Ruxandra Ulmeanu, Eugenia Halic, Situatia Bronhilogiei in Romania-intre realitate si cerinte, a V-a Conferinta Natinala de bronhologie, 14 octombrie 2009

  40. Number of bronchoscopies performed in 2008 in interviewed Counties Ruxandra Ulmeanu, Eugenia Halic, Situatia Bronhilogiei in Romania-intre realitate si cerinte, a V-a Conferinta Natinala de bronhologie, 14 octombrie 2009

  41. In the three “white” Counties are performed approximately 2000 de bronchoscopies/year Ruxandra Ulmeanu, Eugenia Halic, Situatia Bronhilogiei in Romania-intre realitate si cerinte, a V-a Conferinta Natinala de bronhologie, 14 octombrie 2009

  42. THE “OVERLOAD” OF THE BRONCHOLOGY DEPARTMENTS  QUANTITY OVER QUALITY PHYSICAL AND INTELECTUAL STRESS OF THE MEDICAL STAFF NUMBER OF PERFORMED BRONCHOSCOPIES/YEAR 12000 10000 8000 6000 4000 2000 0 1990 1995 2000 2003 2004 2008 Ruxandra Ulmeanu, Eugenia Halic, Situatia Bronhilogiei in Romania-intre realitate si cerinte, a V-a Conferinta Natinala de bronhologie, 14 octombrie 2009

  43. Bronchoscopies - “Marius Nasta” Institute 1999-2000-2001 8856 cases of lung cancer 1417 nonsmokers 16% 84% 7439 smokers Smoker ≥ 10 packs/year Ruxandra Ulmeanu, APORTUL BRONHOSCOPIEI SI TOMOGRAFIEI COMPUTERIZATEIN DIAGNOSTICUL CANCERULUi PULMONAR, Teza Doctorat,2006

  44. LUNG CANCERHIGH RISK OF APPEARENCESMOKER - INDEX ≥ 10 PACKS/YEAROVER 45 YEARS OLDRESPIRATORY SYMPTOMS Ruxandra Ulmeanu, APORTUL BRONHOSCOPIEI SI TOMOGRAFIEI COMPUTERIZATEIN DIAGNOSTICUL CANCERULUi PULMONAR, Teza Doctorat,2006

  45. SURGICAL ELIGIBILITY AFTER BRONCHOSCOPY AND COMPUTER SCAN Ruxandra Ulmeanu, APORTUL BRONHOSCOPIEI SI TOMOGRAFIEI COMPUTERIZATEIN DIAGNOSTICUL CANCERULUi PULMONAR, Teza Doctorat,2006

  46. Lack in apparatus has been incriminated by a majority of interviewed physicians In locations without Bronchoscopy Departments Also, in location with Bronchoscopy Department the number of bronchoscopes had been appreciated as insufficient and with low competitivity Ruxandra Ulmeanu, Eugenia Halic, Situatia Bronhilogiei in Romania-intre realitate si cerinte, a V-a Conferinta Natinala de bronhologie, 14 octombrie 2009

  47. Negative factors in performing a successful bronchoscopy Lack in Departments of Pathological Anatomy and in Cytology Laboratories (with and decrease of diagnosis efficiency) Lack in Intensive Care Departments(avoidance of procedures with high risk of complication) Lack in Thoracic Surgery Departments(avoidance of high risk procedures) Ruxandra Ulmeanu, Eugenia Halic, Situatia Bronhilogiei in Romania-intre realitate si cerinte, a V-a Conferinta Natinala de bronhologie, 14 octombrie 2009

  48. Conclusions

  49. The risk of lung cancer among thosewith COPD may be closer to six-fold higher, much greaterthanthe estimated two-fold increased risk previously associatedwith COPD R.P. Young, R.J. Hopkins, T. Christmas, P.N. Black, P. Metcalf, G.D. Gamble, COPD prevalence is increased in lung cancer, independent of age, sex and smoking history, EurRespir J 2009; 34: 380–386

  50. The routine use of spirometry in smokers. • Identify those with COPD. Young RP, Hopkins RJ, Gamble GD, et al. A gene based risk score identifies smokers and ex-smokers at high risk of lung cancer. Respirology 2008; 13: Suppl. 2, TP143. Young RP, Hopkins RJ, Eaton TE. Forced expiratory volume in one second: not just a lung function test but a marker of premature death from all causes. EurRespir J 2007; 30: 616–622.

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