clinical Mohammed O Zeitouni

Lung Cancer
 Background
one of the most common cancers worldwide, account for12.9% of cancer.
Ø Most common cause of cancer deaths in past decades.
Ø Five-year survival rate is much lower than other cancers.
Ø More cancer deaths than breast, colon, prostate, and pancreas cancer combined.
 Lung Cancer Facts
Ø Lung Cancer is the #1 cancer killer in the US
 Survival
Ø Lung cancer five-year survival 18.6%
Ø Colorectal 64.5 %, breast 90% prostate 98.2 %
Ø Only curable when diagnosed early
Ø Mostly diagnosed in advanced stage
Ø Five-year survival rate is 56 % for localized cases (within the lungs). But only
16% of cases are diagnosed when localized.
Ø Five-year survival 5 % when metastatic.
Ø More than half of people with lung cancer die within one year
 Risk Factors
Ø Cigarette smoking is the greatest risk for developing lung cancer
Ø Age, environmental exposure to radon; asbestos; certain metals such as
chromium, cadmium and arsenic; organic chemicals; radiation; coal smoke; and
indoor emission of fuel burning
Ø Genetic influences: Not all people with risk factors develop lung cancer, and
some without any known risk factor do.
Ø Family history is associated with 1.7-fold increased risk of lung cancer
Ø The most effective preventive measure is to stop cigarette smoking.
 tobacco
Ø Cigarette smoking Causes approximately of male and female lung cancer deaths
Ø Cigar smoking is also an established cause of lung cancer
 Age
Ø Incidence and mortality rates begin to increase between the ages of
45 and 54 and rise progressively until age 75
o it more aggressive in younger population
 Exposures
Ø asbestos exposure and lung cancer is greater than a fivefold excess risk
Ø Asbestos and cigarette smoking are both independent causes of lung cancer, but
in combination, they act synergistically to markedly increase lung cancer risk
Ø Radon is Responsible for about 2% of all deaths from lung cancer
Ø Doses from CT scans can be large enough to cause population excess of cancer

Done by Alanoud Adam

clinical Mohammed O Zeitouni

 Types of Lung Cancer

Ø Small Cell Lung Cancer (10-15% of all lung cancers)
Ø Non Small Cell Lung Cancer (most common 80-85%)

 Small Cell Lung Cancer SCLC – smoking-

Ø Neuroendocrine carcinoma with aggressive behavior, rapid
growth, exquisite sensitivity to chemotherapy and radiation
Ø Frequent association with distinct paraneoplastic syndromes
Ø Limited-stage cancer: potentially curable→ chemotherapy and radiation
Ø Extensive-stage cancer is incurable only systemic chemotherapy
 Squamous cell carcinoma – smoking -
Ø Moderate to poor differentiation
Ø makes up 20-30% of all lung cancers
Ø more common in males, central
Ø Slow metastasis: affects the liver, adrenal glands and lymph nodes.
 Adenocacinoma -non-smokers-
Ø Increasing in frequency. Most common type of Lung cancer
Ø Clearly defined peripheral lesions
Ø Glandular appearance under a microscope
Ø Highly metastatic in nature (brain, liver, adrenal or bone)
Ø where does the smoke goes more?
o in the upper lobe, thus lesions in upper lobe usually cancer
 Large cell carcinomas
Ø Makes up 10 % of all lung cancers, rare, Slow metastasis
 Non-small cell lung cancer Staging
Ø Patients with NSCLC require staging workup to evaluate the extent of disease
Ø Stage determines the choice of treatment
Ø Staging system for lung cancer uses the TNM System to estimates prognosis
Ø It is only useful in staging NSCLC
 Signs and Symptoms of Lung Cancer
Ø Localized – involving the lung.
Ø Generalized – involves other areas throughout the body if the cancer has spread.
Ø NSCLC is often insidious, producing no symptoms only in advanced stages

Done by Alanoud Adam

clinical Mohammed O Zeitouni

Ø it depend upon the location, size of the tumor, obstruction and metastases
 Overall Survival for NSCLC by Stage
Ø which one has better prognosis in staging radiologic or pathologic?
o pathological is more accurate and has better prognosis
 Localized Signs and Symptoms
Ø Cough Ø Weight loss
Ø Breathing Problems, SOB, stridor Ø Chest Pain and tightness
Ø Change in phlegm Ø Pancoats Syndrome
Ø Lung infection, hemoptysis Ø Horner’s Syndrome
Ø Hoarseness, Hiccups Ø Pleural Effusion
Ø Fatigue Ø Superior Vena Cava Syndrome
 Generalized Signs and Symptoms
Ø Bone pain + Weight loss
Ø Headaches, mental status
Ø Abdominal pain, elevated liver function tests, enlarged liver, GI
 Diagnostic Tests
Ø CXR
Ø CT Scans
Ø MRI for pancost tumor
Ø Sputum cytology
Ø Fibreoptic bronchoscopy
Ø Transthoracic fine needle aspiration
Ø Bronchoscopy if -ve Mediastinoscopy
Ø VATS (video assisted thoracoscopic surgery)
 Treatment
Ø chemo- and radiotherapy, surgery usually represents the only
potentially curative treatment for patients with localized(NSCLC)
Ø Curative-intent surgical resection is associated with increased risk
Ø Tobacco smoking is a risk factor for lung cancer, CAD andCOPD
Ø Possible short-term perioperative risk from comorbid cardiopulmonary disease
and the long-term risk of pulmonary disability must be balanced against the
possible risk of reduced survival if an oncologically suboptimal treatment
strategy is chosen.
Ø Careful preoperative assessment of the cardio-pulmonary reserves is mandatory
 Workup of patients with suspected bronchogenic carcinoma
Ø Tumor type: Tissue diagnosis
Ø Resectability: Tumor extent/Staging
Ø Operability: Ability to survive surgery
 Systemic therapy
Ø Approximately 80% of all patients with lung cancer are considered for systemic
therapy at some point during the course of their illness
Ø Chemotherapy regimens include a platinum combination

Done by Alanoud Adam

clinical Mohammed O Zeitouni

Ø Depending on the molecular features, may include combinations of targeted

agents with chemotherapy, or targeted agents alone
Ø Standard of care for NSCLC recommends testing for oncogenic drivers such as
epidermal growth factor receptor (EGFR) mutations, anaplastic lymphoma
kinase (ALK) rearrangement, KRAS and BRAF mutations.
 Genetic Alterations in NSCLC
Ø Currently only EGFR and EML4-ALK genetic
alterations are actionable
Ø Most of patients are wildtype or have non-
actionable genetic alterations
 treatment
Ø The actions of PD-1 and its ligands PD-L1 in untreated and ICI-treated NSCLC
Ø EGFR inhibitor
 Radiation
Ø In the treatment of stage I and stage II NSCLC, radiation therapy alone is
considered only when surgical resection is not possible.
Ø Stereotactic radiation is a reasonable option for lung cancer treatment among
those who are not candidates for surgery.
Ø Palliative radiation for brain and painful boney metastasis
 Early Palliative Care
Ø Because most lung cancers cannot be cured with currently available therapeutic
modalities, the appropriate application of skilled palliative care is an important
part of the treatment of patients with NSCLC
 National Lung Screening Trial
Ø People who got low-dose CT scans had a 20% decreased risk of dying from
lung cancer
o 320 people need to be screened to prevent 1 lung cancer death
o More cancers detected at an early stage
Ø First time that lung cancer screening decrease lung cancer deaths!
 Who Should Get Screened?
Ø Age 55-80
Ø Current or former smoker
Ø >30 pack year smoking history
o Packs per day X years smoked
o 1 pack per day for 30 years or 2 packs per day for 15 years
Ø No symptoms of lung cancer
o New or changing cough
o Coughing up blood
o New or increasing shortness of breath

Done by Alanoud Adam

clinical Mohammed O Zeitouni

 What are the Risks?

Ø False positives
o Finding a nodule (spot) that is not cancer
o Most nodules (95%) seen on CT are not cancer
o May require additional testing
Ø False negatives
o A negative screening CT does not mean you don’t have lung cancer or can’t
get lung cancer

Done by Alanoud Adam