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Lung Cancer Epidemiology and Diagnostic Procedures

Explore the epidemiology of lung cancer, etiological factors, molecular biology, histology, prognostic factors, symptoms, diagnostic procedures, and treatment options. Learn about the role of surgery, radiotherapy, chemotherapy, molecular-targeted therapy, and immunotherapy in managing lung cancer.

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Lung Cancer Epidemiology and Diagnostic Procedures

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  1. Malignant Neoplasm of Lung Dr Edit Csada 13.09.2017.

  2. Epidemiology Globocan 2012. • Lung cancer is the most frequent malignant disease New cases: 1,82 million/year (13%) Mortality: 1,59 million/year Most frequent cause of death amoung malignant diseases>colon+prostate+breast Europe:~1000 death/day Lung cancer fatality: 1,59/1,82 = 0,87 breast cancer fatality: 0,35 Male/female: 2,4/1

  3. New diseases according to ages • Until 40 years : 1%↓ • 40-49 years: 10%↓ • 50-59 years: ~30% • 60-69 years: ~30% • Above 70 years: 30%↓

  4. Etiologic factors Smoking Athmospheric pollution Ionisation Occupational factors asbestos, radon, etcOther lung diseases tb, COPD, ILDGenetic events

  5. Smoking • 400 chemical materials • 60 carcinogens • Gas and particulate phase • Nitrosamines, aromatic amines, benzopyrene, CO, CO2, aldehids, nicotin, free radicals • Pack-year

  6. Smoking and Lung Cancer • 85-90% of lung cancer patients are smokers • Damages of 10-15 gens have role in the development of lung cancer • 86% of smokers have damages of these gens

  7. Molecular biology of lung cancer • Genetic damages • Deletion • Mutations • Amplifications Tumor suppressor gen injury (p53, RB1) Inhibation of proliferation Repair mechanism Induction of apoptosis Protooncogen abnormalities Autocrine growth factors membran receptors transcription factors

  8. Lung Cancer Mutation Consortium Mutationsfrequency M G Kris ASCO Annual Meeting 2011, June 3–7, Chicago

  9. Histology of lung cancer Non small cell lung cancer Squamous cell carcinoma (30%) Well, or less differentiated, with or without keratinisation Adenocancer (45%) acinar papillary bronchioloalveolar with mucus formation Large cell carcinoma (10%↓) clear cell giant cell

  10. Histology of lung cancer Small cell lung cancer (15%) Oat cell Intermediate cell type Combined type Carcinoid tumor Bronchial gland carcinomas Adenoid cystic carcinoma Mucoepidermoid carcinoma

  11. Histology in Hungary Korányi Bulletin 2014

  12. Pathological prognostic factors • TNM • Histology • Histological differentiation • Invading vessels • Necrosis • Proliferation activity • Prognostic proteins

  13. Symptoms of lung cancer • Regionalspread • Superiorvenacavalsy • Recurrentlaryngealnerveparalysis (hoarsness) • Phrenicnerveparalysis elevatedhemidiaphragm • Horner’s sy • Pancoast’s sy • Trachea obstruction • Oesophagusobstruction • Pleuraleffusion • Lymphatic tumor spread

  14. 17

  15. Vena cava superior sy Sárosi Veronika anyaga

  16. Pancoast tumor Pálföldi Regina anyaga

  17. Digital clubbing Sárosi Veronika anyaga

  18. Diagnostic procedures • Imaging technics • Endoscopy • Pathology • Laboratory tests

  19. Diagnostic procedures • Imaging technics • Chest x-rays • CT • MRI • Isotope scanning • PET/CT • Ultrasound

  20. Bronchoscopy: sampling • Biopsy • Brushing • Transbronchial biopsy • Transbronchial needle aspiration (TBNA, EBUS) • Washing • BAL

  21. Other samplings • TTB, x-ray or CT supervision • Percutan pleura biopsy • Lymphnode aspiration biopsy • Surgical biopsy • Mediastinoscopy • Parasternal mediastinotomy (Stemmer) • VATS • Thoracotomy (10%↓)

  22. Metastases • Liver: CT, ultrasound, PET/CT • Bones: scintigraphy, CT, PET/CT • Adrenals: CT, ultrasound, PET/CT • Brain: MRI, CT

  23. Prognostic factors • Poor performance status • Karnofsky, WHO ECOG • Weight loss, more than 10% • Elevated LDH • Elevated tumormarker (CEA, NSE, SCC) • Old age

  24. Performance status

  25. Performance status

  26. Defining treatment • Tumor specificfactors • TNM stage • Histology • Molecularfeatures • Patientspecificfactors • Age • Performance status • Concomitantdiseases • gender, etnicity, smoking Based on these factors multidisciplinarytumour board decides on curative-palliative therapy

  27. Multimodality treatment Surgery Radiotherapy Chemotherapy Moleculartargettherapy Immunoncology! Supportive therapy

  28. Surgery • Type of surgical procedure depends on • Staging • patient’s performance status • cardiopulmonal function • comorbidities. • Aim is radical resection • Sublobar resection may have a role in very early diseases. • Thoracotomy • Video assisted thoracoscopy (VATS)

  29. Surgery • Absolute contraindications: • haematogen metastases in the lungs • pleuritis carcinomatosa • III.b stage disease • multiplex distant metastases • Relative contraindications

  30. Surgery (20-25%) • NSCLC IIIA stage • Lobectomy, pulmonectomy, sleeve lobectomy, extensive resection – radical • Segmentectomy, wedge resection – mostly non radical • Early stage SCLC, as part of combined therapy • Carina resection? • Before surgery: lung function, Ecg, functional evaluation

  31. Radiation therapy • NSCLC: III.A, III.B stage • SCLC: combined with chemotherapy • Inoperable patient with resecable disease • Resected N2 disease, in combined treatment • Metastasis palliation • Pancoast’s tu • Brain metastasis (stereotactic, whole brain) • PCI • Brachytherapy Radiochemotherapy!

  32. Combination of radio/chemotherapy • Aim • localcontrol • Prevention of toxic sideeffects • Decreasing of distantmetastases • Sequential ChTRT (ChTRTChT) • Concomitant ChT/RT • Timing - Induction: ChTChT/RT - Consolidation: ChT/RT ChT

  33. Chemotherapy • Neoadjuvant treatment • Before surgery IIIa stage • Adjuvant treatment • After surgery II-IIIa stage • First-, second-, thirdline….. • IIIb, IV stage

  34. ESMO guideline: first-line treatment of non-squamous NSCLC Előrehaladott,nem laphám NSCLC Diagnózis Driver mut – /ismeretlen EGFR mut+ ALK fúzió Jó általános állapot(ECOG PS 0-1) Rossz általános állapot(ECOG PS ≥2) Platina-alapú kombináció Monoterápia Platina-alapúkombináció BSC EGFR TKI (erlotinib,gefitinib,afatinib) (I,A) crizotinib (I,A) Cis +gem/taxán (I,B) Pem + cis (II,B) Bev + Platina-kettős (I,A) Gemcitabin, vinorelbin,taxán (I,B) Carbo+pac vagy Pem (II,B) Átvéve: NSCLC ESMO Guidelines, Reck, et al. Ann Oncol 2014

  35. Chemotherapy of NSCLC • First-line • Cis-, carboplatin-gemcitabin • Cis-, carboplatin-paclitaxel • Cisplatin-docetaxel • Cisplatin-vinorelbin • Cisplatin-pemeterexed (non squamous c) • Doublet+bevacizumab(adenoc) • Second-line • Pemetrexed • docetaxel

  36. Molecular target therapy • EGFR tirosin kinase inhibitors • erlotinib (Tarceva) • gefinitib (Iressa) • Afatinib (Giotrif) • Angiogenesis inhibitor • bevacizumab (Avastin) • Alk-EML4 fusion gene inhibitor • Crizotinib (Xalkori) • Ceritinib • alectinib

  37. EGFR-TKI treatment • EGRF activating mutation – first or second line (also PS 3-4!) • Erlotinib (Tarceva) • Gefitinib (Iressa) • Afatinib (Giotrif) • Erlotinib is a potential second line treatment option in pretreated patients with undetermined or wild type EGFR status. (In Hungary KRAS negativity) • Resistence: T790M mutation • osimertinib

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