LUNG CANCERLUNG CANCER* Carcinoma of the lung is the * Carcinoma of the lung is the leading cause of cancer death in leading cause of cancer death in USA.USA.* 171900 new cases in * 171900 new cases in 2003=12.8% of total new cases.2003=12.8% of total new cases.*5-year survival rate for the lung *5-year survival rate for the lung remains 14% in USA,8%in China remains 14% in USA,8%in China and Europe.and Europe.*Factors: tabacco *Factors: tabacco smoking,COPD,arsenic, smoking,COPD,arsenic, asbestos,beryllium,Chromium, asbestos,beryllium,Chromium, Nickel, Polycyclic aromatics, Nickel, Polycyclic aromatics, Hydrocarbon compounds, Radon, Hydrocarbon compounds, Radon, Silica, Formaldehyde, Synthetic Silica, Formaldehyde, Synthetic fiber, Vinyl chloride, chronic lung fiber, Vinyl chloride, chronic lung infections. infections.

Investigation for lung cancerInvestigation for lung cancer

Chest X-ray,Chest X-ray, Thoracic CT,Thoracic CT, Fiberbronchoscopy,with biopsy,Fiberbronchoscopy,with biopsy, Fine-needle aspiration from a pulmonary nodules,Fine-needle aspiration from a pulmonary nodules, Ultrasonography – pulmonary/abdominal.Ultrasonography – pulmonary/abdominal. PET,PET, Mediastinoscopy for mediastinal limph nodes,Mediastinoscopy for mediastinal limph nodes, VATS for diagnosis of small pulmonary nodules.VATS for diagnosis of small pulmonary nodules.

Clinical presentation of lung cancerClinical presentation of lung cancer

Cough, 29-87%Cough, 29-87% Hemoptysis- 9-57% Hemoptysis- 9-57% Chest pain 6-60%Chest pain 6-60% Dyspnea 3-58%Dyspnea 3-58% Wheezing or stridor 2-14%Wheezing or stridor 2-14% Pleural effusion 7%Pleural effusion 7% Dysphagia 2%Dysphagia 2% Superior vena cava syndrome 4-11%Superior vena cava syndrome 4-11% Pancoast syndrome 3-5%Pancoast syndrome 3-5% Phrenic nerve paralysis 1% Phrenic nerve paralysis 1%

Symptoms from metastatic diseaseSymptoms from metastatic disease

Bone metastases: bone pain in hands,feet.Bone metastases: bone pain in hands,feet. Neurologic metastases:central nervous Neurologic metastases:central nervous

system,spinal cord compression secondary system,spinal cord compression secondary to epidural or vertebral mts.to epidural or vertebral mts.

Adrenal mts,Adrenal mts, Liver mts,Liver mts, Others sites:soft tissue,etc.Others sites:soft tissue,etc.

Paraneoplastic syndromesParaneoplastic syndromes

MetabolicMetabolic::

- hypercalcemia,- hypercalcemia,

- Cushing syndrome,- Cushing syndrome,

- carcinoid syndrome,- carcinoid syndrome,

-gynecomastia,-gynecomastia,

-elevated growth hormone level,prolactin,follicle--elevated growth hormone level,prolactin,follicle-stimulating hormone,luteinizing stimulating hormone,luteinizing hormone,antidiuretic hormone production.hormone,antidiuretic hormone production.

- hypoglicemia,- hypoglicemia,

-hypertiroidism-hypertiroidism

Paraneoplastic syndomesParaneoplastic syndomes

Neurologic Neurologic

--encephalopathy,encephalopathy,

- subacute cerebrall degeneration- subacute cerebrall degeneration

- peripheral neuropathy,- peripheral neuropathy,

- polymiosytis,- polymiosytis,

- autonomic neuropathy,- autonomic neuropathy,

- myoclonus.- myoclonus.

Paraneoplastic syndromesParaneoplastic syndromes

SkeletalSkeletal - clubbing- clubbing - pulmonary hypertrophic osteoartropathy- pulmonary hypertrophic osteoartropathy HematologicHematologic - - anemia,anemia, -leukemoid reactions-leukemoid reactions -trombocytosis,-trombocytosis, -trombocytopenia,-trombocytopenia, -eosinophilia,-eosinophilia, -pure red cell aplasia, -pure red cell aplasia, -disseminated intravascular coagulation-disseminated intravascular coagulation

Paraneoplastic syndromesParaneoplastic syndromes

Cutaneous and muscularCutaneous and muscular - hyperkeratosis,- hyperkeratosis, - dermatomyositis,- dermatomyositis, - acanthosis nigricans,- acanthosis nigricans, -erytremia gyratum repens,-erytremia gyratum repens, - hypertricosis lanuginosa acquisita- hypertricosis lanuginosa acquisitaOtherOther -nephrotic syndrome,-nephrotic syndrome, -hypouricemia,-hypouricemia, -hyperamylasemia,-hyperamylasemia, -anorexia-cachexia.-anorexia-cachexia.

Diagnosis and staging of lung cancerDiagnosis and staging of lung cancer

Diagnosis : sputum cytology, fiberoptic bronchoscopy, Diagnosis : sputum cytology, fiberoptic bronchoscopy, VATS,CT,XrVATS,CT,Xr

Transthoracic fine-needle aspirationTransthoracic fine-needle aspiration

IndicationIndication

1.Patient is a high operative risk,1.Patient is a high operative risk,

2.Patient hjas a low risk of malignancy based on clinical and 2.Patient hjas a low risk of malignancy based on clinical and radiologic characteristics.radiologic characteristics.

3. A definite benigne diagnosis is considered likely,3. A definite benigne diagnosis is considered likely,

4. The patient prefers to have a diagnosis of cancer before 4. The patient prefers to have a diagnosis of cancer before proceeding to the operating room.proceeding to the operating room.

5.Patient is not an operative candidate, but tissue 5.Patient is not an operative candidate, but tissue confirmation is needed before definitive treatment with confirmation is needed before definitive treatment with radiation therapy or chemotherapy or both.radiation therapy or chemotherapy or both.

Characteristics of solitary pulmonary Characteristics of solitary pulmonary nodules predicting malignancynodules predicting malignancy

Radiologic characteristicsRadiologic characteristics

- diameter- diameter>2cm,>2cm,

- spiculation present,- spiculation present,

- upper lobe location- upper lobe location

Clinical characteristicsClinical characteristics

- age>40 years- age>40 years

- positive smoking history- positive smoking history

History of other cancerHistory of other cancer

Radiographic featuresRadiographic features

Early signs of a lung tumor are as follows:Early signs of a lung tumor are as follows: 1.a density within the lung parenchima,1.a density within the lung parenchima, 2. a cavitary mass,2. a cavitary mass, 3. a segmental, indistinct, poorly defined dense area,3. a segmental, indistinct, poorly defined dense area, 4. a nodular streaked, local infiltration along the course of a 4. a nodular streaked, local infiltration along the course of a

blood vesel,blood vesel, 5. segmental consolidation,5. segmental consolidation, 6 a roughly triangular lesion arising in the apex and 6 a roughly triangular lesion arising in the apex and

extending toward the hilus,extending toward the hilus, 7. a mediastinal mass,7. a mediastinal mass, 8.an enlargement of one hilus,8.an enlargement of one hilus, 9. segmental or lobar obstructive emphysema,9. segmental or lobar obstructive emphysema, 10. segmental atelectasis.10. segmental atelectasis.

Chest radiographic presentations of lung Chest radiographic presentations of lung cancercancer

Pulmonary nodulePulmonary nodule<3 cm in size,<3 cm in size, Pulmonary or hilar mass,Pulmonary or hilar mass, Pulmonary opacities(lobar, segmental, subsegmental),Pulmonary opacities(lobar, segmental, subsegmental), Tracheal or bronchial intraluminal opacity, luminal Tracheal or bronchial intraluminal opacity, luminal

narrowing or chest wll thickening,narrowing or chest wll thickening, Atelectasis (lung, lobar, segmental, subsegmental)Atelectasis (lung, lobar, segmental, subsegmental) Pulmonary cavitary lesion,Pulmonary cavitary lesion, Air trapping(hyperinflation)Air trapping(hyperinflation) Mediastinal mass,Mediastinal mass, Pleural lesion,Pleural lesion, Pleural effusion,Pleural effusion, Pericardial effusion (enlarged cardiac silhouette),Pericardial effusion (enlarged cardiac silhouette), Elevated hemidiaphragm(paralysis or paresis),Elevated hemidiaphragm(paralysis or paresis), Chest wall mass or bone metastases.Chest wall mass or bone metastases.

Classification of lung carcinomaClassification of lung carcinoma

Squamous cell carcinoma,Squamous cell carcinoma, Small cell carcinomaSmall cell carcinoma

- pure small cell carcinoma,- pure small cell carcinoma,

- small- large cell carcinoma,- small- large cell carcinoma,

- combined small cell carcinoma (with areas of - combined small cell carcinoma (with areas of squamous or glandular differentiation),squamous or glandular differentiation),

AdenocarcinomaAdenocarcinoma

- variant: bronchioloalveolar carcinoma,- variant: bronchioloalveolar carcinoma, Large cell carcinoma,Large cell carcinoma, Adenosquamous carcinoma.Adenosquamous carcinoma.

TNM DefinitionTNM Definition     TNM classification TNM classification Primary tumour (T)Primary tumour (T)   TxPrimary   TxPrimary

tumour cannot be assessed or tumour proven by the tumour cannot be assessed or tumour proven by the presence of malignant cells in sputum or bronchial presence of malignant cells in sputum or bronchial washings but not visualised by imaging or washings but not visualised by imaging or bronchoscopy bronchoscopy

T0T0No evidence of primary tumour No evidence of primary tumour TisTisCarcinoma in situ Carcinoma in situ T1T1Tumour <3 cm in greatest dimension, surrounded by Tumour <3 cm in greatest dimension, surrounded by

lung or visceral pleura, without bronchoscopic evidence lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus of invasion more proximal than the lobar bronchus

T2T2Tumour with any of the following features of size or Tumour with any of the following features of size or extent:   >3 cm in greatest dimension   involves main extent:   >3 cm in greatest dimension   involves main bronchus >2 cm distal to the carina   invades the bronchus >2 cm distal to the carina   invades the visceral pleura   associated with atelectasis or visceral pleura   associated with atelectasis or obstructive pneumonitis that extends to the hilar region obstructive pneumonitis that extends to the hilar region but does not involve the entire lung but does not involve the entire lung

T3T3Tumour of any size that directly invades the Tumour of any size that directly invades the following: chest wall (including superior sulcusfollowing: chest wall (including superior sulcus tumours), diaphragm, mediastinal pleura, parietaltumours), diaphragm, mediastinal pleura, parietal pericardium; or tumour in the main bronchus <2 pericardium; or tumour in the main bronchus <2 cm distal to the carina but without involvement ofcm distal to the carina but without involvement of the carina; or associated atelectasis or obstructivethe carina; or associated atelectasis or obstructive pneumonitis of the entire lung pneumonitis of the entire lung T4T4Tumour of any size that involves any of theTumour of any size that involves any of the following: mediastinum, heart, great vessels, following: mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina; or trachea, oesophagus, vertebral body, carina; or tumour with a malignant pleural or pericardial tumour with a malignant pleural or pericardial effusion, or with satellite tumour nodule(s) within effusion, or with satellite tumour nodule(s) within the ipsilateral primary tumour lobe of the lungthe ipsilateral primary tumour lobe of the lung

Stage Grouping for Lung CancerStage Grouping for Lung Cancer

Regional lymph nodesRegional lymph nodes (N) (N) NxNxRegional lymph nodes cannot be assessed Regional lymph nodes cannot be assessed N0N0No regional lymph node metastases No regional lymph node metastases N1N1Metastases to ipsilateral Metastases to ipsilateral peribronchial and/or ipsilateral hilar lymph nodesperibronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes involved by direct and intrapulmonary nodes involved by direct extension of primary tumourextension of primary tumour N2N2Metastases to ipsilateral mediastinal and/or Metastases to ipsilateral mediastinal and/or

subcarinal lymph nodes subcarinal lymph nodes N3N3Metastases to contralateral mediastinal,Metastases to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral contralateral hilar, ipsilateral or contralateral saclene or supraclavicular lymph nodes saclene or supraclavicular lymph nodes

Distant metastases (M) Distant metastases (M) Mx Presence of distant metastases cannot be assessedMx Presence of distant metastases cannot be assessed M0 No distant metastases M0 No distant metastases M1Distant metastases present M1Distant metastases present Stage grouping TNM subsetsStage grouping TNM subsets 0Carcinoma in situ0Carcinoma in situ IA T1N0M0 IB T2N0M0 IA T1N0M0 IB T2N0M0 IIA T1N1M0 IIB T2N1M0 T3N0M0 IIA T1N1M0 IIB T2N1M0 T3N0M0 IIIA T3N1M0 T1N2M0 T2N2M0 T3N2M0IIIA T3N1M0 T1N2M0 T2N2M0 T3N2M0 IIIB T4N0M0 T4N1M0 T4N2M0 T1N3M0 T2N3M0 T3N3M0 IIIB T4N0M0 T4N1M0 T4N2M0 T1N3M0 T2N3M0 T3N3M0

T4N3M0 T4N3M0 IV Any T Any N M1IV Any T Any N M1

Algoritm for therapy in lung cancerAlgoritm for therapy in lung cancer

NSCLCNSCLC Comprehensive clinical evaluationComprehensive clinical evaluation

Clinical examination negativeClinical examination negative- Chest CTChest CT

*T4 = 1. defined*T4 = 1. defined

2. indeterminate : VATS surgery.2. indeterminate : VATS surgery.

** LN Positive = sample LN= a)N2 Positive- unresectable** LN Positive = sample LN= a)N2 Positive- unresectable

and induction protocol b)N3 Positive- unresectableand induction protocol b)N3 Positive- unresectable

*** LN Negative = Surgery*** LN Negative = Surgery

Clinical examination positive suspect M1.Clinical examination positive suspect M1.

*Organ specific= specific scan=a) negative scan *Organ specific= specific scan=a) negative scan =follow chest CT sequence, b) positive =follow chest CT sequence, b) positive scan= treat M1.scan= treat M1.

**Organ nonspecific findings= scan succesive **Organ nonspecific findings= scan succesive organs= a)negative scan= follow chest CT organs= a)negative scan= follow chest CT sequence,sequence,

b) positive scan= treat M1.b) positive scan= treat M1.