Lung Cancer - Josh Corwin



Lung Cancer

I. Facts

a. Leading cause of cancer deaths in both men and women

b. 173,700 new diagnoses and approximately 160,440 deaths USA in 2004

c. Strikes between ages 50-70

d. Smoking is the number one cause of lung cancer

e. Smoking tobacco is linked to small cell carcinoma, Squamous cell carcinoma and large cell carcinoma

f. Most diagnosed in an advanced

II. Two main categories- small cell carcinoma and non-small cell carcinoma

III. Risk Factors

a. Tobacco smoke- if cease smoking, risk goes down each year as normal cells replace abnormal cells

b. Second hand smoke exposure

c. Industrial carcinogens/air pollutants- radon, asbestos, construction workers

d. Genetics

e. Malignancy of the head, neck, and esophagus

f. Existing lung damage from prior pulmonary fibrosis, COPD, sarcoidosis

IV. Histopathology

a. Non-small cell lung cancer

b. Squamous cell carcinoma

i. Arise from bronchial epithelium

ii. More likely to present with hemoptysis, SOB, cough

iii. Diagnosed with sputum cytology. Also bronchoscopy, examination of pleural fluid, biopsy

iv. Slowly progressive but locally aggressive

v. 5 year survival post surgery is 35-40%

c. Adenocarcinoma

i. Arise from glandular elements of bronchial epithelium

ii. Lesions are peripheral, occurring of bronchial epithelium

iii. Grows slower, but metastasize earlier than Squamous cell

iv. Patient presentation is lymphadenopathy, hepatomegaly, and clubbing

v. Diagnosed with transthoracic biopsy

d. Bronchoalveolar cell carcinoma- not due to smoking

i. Arises in the cells lining the bronchioles and alveoli and causes lobular consolidation on chest x-ray

ii. If detected early there is 50% cure rate after excision. It spreads intra-alveolar and may present as an infiltrate or single pulmonary nodule

e. Large cell carcinoma

i. Fastest growing subtype of NSCLC

ii. Undifferentiated form of Squamous or adenocarcinoma

iii. Originates in the bronchi

iv. Respiratory symptoms, wide spread metastases

v. Central or peripheral mass

f. Small Cell Carcinoma- 75% of lung cancer

i. Three subtypes- oat cell, intermediate cell, mixed

ii. Originate as a hilar or perihilar mass that spreads to mediastinum or causes obstructive pneumonia

iii. Symptoms related to mediastinal involvement such as superior vena cava syndrome, horner’s syndrome, and pleural effusion often present at diagnosis

iv. Commonly associated with paraneoplastic syndrome, SIADH (hyponatremia), proximal muscle weakness (Eaton-Lambert syndrome)

v. Distant metastases is assumed, so staging reflects the overall disease burden rather than the tumor itself

V. Clinical Presentation

a. Endobronchial mass may lead to new cough, change in chronic cough, hemoptysis, obstructive pneumonia, pleural effusion, hoarseness

b. Superior vena cava syndrome, horner’s syndrome, elevated hemidiaphragm, and chest wall pain suggest advanced disease

c. Anorexia, weight loss, bone pain

d. Other systemic signs and symptoms including clubbing, fatigue, and weight loss

e. Lymphadenopathy, skin nodules, bone pain, headache, or seizures indicate metastases

f. Patients with bronchoalveolar cell cancer may have severe cough productive of clear sputum

g. Asymptomatic patients might present due to a finding on chest x-ray or spiral CT

VI. Diagnosis

a. Sputum cytology/bronchoscopy- squamous cell

b. Transthoracic fine needle biopsy- guided by CT (tissue from area)

c. Transbronchial needle aspiration

d. Thoracotomy- useful in diagnosis of SCLC

e. If biopsy or resection is contraindicated high resolution CT scan and positron emission tomography

f. CT for extent of disease, bone scans, MRI

VII. Staging-NSCC- used to guide treatment and prognosis

a. TNM staging- physical description of neoplasm. Used for non-small cell carcinoma (not for small cell)

i. T= size and location of primary tumor

ii. N- presence and location of nodular metastasis (lymph nodes)

iii. M- presence of absence or distant metastasis

b. Grouped into stages I-IV

i. Stage I and II- many cured with surgery

ii. Stage IIIB and IV- do not benefit from surgery

iii. Stage IIIA- locally invasive disease that might benefit from surgery

c. Small cell carcinoma not staged using TMN********************

d. Small cell carcinoma staging

i. Limited disease- Tumor confined to one hemithorax and contralateral mediastinal nodes. These patients benefit from thoracic radiation therapy and chemotherapy. Also prophylactic cranial radiation therapy

1. Not treated in 4 months the patient will die

2. Treatment extends life span to 15 months

ii. Extensive disease- tumor extends beyond hemithorax including pleural effusion. (Even with therapy can only extend life to 7mos.)

VIII. General management

a. CBC- leukemia

b. Electrolytes including calcium, creatinine, liver enzymes and chest x-ray

c. CT- especially if possibility of resection. Tells the size of parenchymal lesions along with atelectasis, and pleural effusion

d. Positron emission tomography (PET)- see metastasis

e. Spirometry prior to surgery- surgical risk identification

f. Non-small cell carcinoma

i. Resection can cure if in stages I or II

ii. Extrathoracic metastases, malignant pleural effusion, tumor involving the heart, pericardium, great vessels, esophagus, laryngeal nerves, trachea, mediastinal nodes

1. Not likely to be cured

iii. Stage IIIA have poor outcome with surgery alone

iv. IIIB need chemo and radiation (most important)

v. Stage IV treated with supportive care

g. Small Cell carcinoma

i. Limited disease- concurrent radiation therapy and chemotherapy may improve outcome

ii. For extensive disease- single agent or combination chemotherapy such as etoposide plus cisplatin or carboplatin

iii. Remission is short lived

IX. Chemotherapy

a. Neoadjuvant chemotherapy

i. Antineoplastic drugs prior to surgery or radiation

ii. IIIA and IIIB

b. Adjuvant chemotherapy

i. Antineoplastic drugs following surgery or radiation

ii. I and II show trend towards improved survival

iii. Stage IIIA and node positive stage II

iv. Stage and IIIB- not surgical candidates improved survival with chemotherapy and radiation compared to no treatment

v. Stage IIIB/IV

X. Palliative Therapy

a. Laser on central tumors to relieve endobronchial obstruction and so relieve dyspnea

b. Pain control

XI. Prognosis

a. Non-SCLC

i. Extent of tumor dissemination, performance status and weight loss

ii. Squamous cell better prognosis than adenocarcinoma, and adenocarcinoma better than large cell

iii. 40-50% in stage I, 15-30% in stage II

iv. Metastatic disease

b. Limited SCLC

i. Long term survival- can improve survival slightly

XII. Prevention

a. Smoking cessation

b. Prevention of nicotine addiction by reducing nicotine in cigarettes

XIII. Bronchial carcinoid tumors

a. Low grade malignant neoplasms- 60 y.o. or less

i. Occur as pedunculated growths in central bronchi

ii. Grow from cells in the body that produce hormones

b. Clinical features include- cough, SOB, hoarseness, sputum production, hemoptysis

c. Laboratory findings include

i. Pink or purple lesion well vascularized

ii. CT will localize the lesion and monitor growth

d. Treatment

i. Surgical excision

ii. Lesions are resistant to radiation and chemotherapy

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