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Lung Cancer:: Diagnosis, Staging, and Treatment
Lung Cancer:: Diagnosis, Staging, and Treatment
Lung Cancer:: Diagnosis, Staging, and Treatment
Lung Cancer
Most common cause of cancer death in US
Overall 5 year survival of 15%
More deaths by lung cancer than the next
four most common cancers combined
(Colorectal, Breast, Prostate, & Pancreas)
Lung
160,390
Colorectal
52,180
Breast
40,910
Prostate
27,050
In 2007 estimated:
213,380 new cases
160,390 deaths
Gender
Smoking history
Older age
Presence of airflow obstruction
Genetic predisposition
Occupational exposures
LUNG CANCER
(2007 American Cancer Society Data)
Relationship to Smoking
Etiology
Tobacco
active
passive
Percent
85-87
3-5
Proven
Arsenic
Asbestos
Bischloromethyl ether
Chromium
Mustard gas
Nickel
Polycyclic aromatic
hydrocarbons
Ionizing radiation
Suspected
Acrylonitrile
Beryllium
Vinyl chloride
Silica
Iron ore
Wood dust
5.17
10.85
53.24
Lung Cancer:
Symptoms at Presentation
Due to primary tumor:
Cough, hemoptysis, chest pain, wheezing, dyspnea,
& fever.
Lung Cancer:
Symptoms at Presentation
Metastases:
Lymph node enlargement, bone pain, neurologic
deficits, skin & subcutaneous lesions.
Systemic symptoms:
Anorexia, weight loss, weakness, & paraneoplastic
syndromes
Question
A 65 year old male presents with a
complaint of fevers, chills, a productive
cough and scant hemoptysis. A CXR is
obtained. What diagnostic test do you order
next?
Question
A)
B)
C)
D)
E)
Answer
A)
B)
C)
D)
E)
Lung Cancer:
Findings on Chest X-ray
Nodule (< 3cm) vs. Mass (>= 3cm).
Location:
Peripheral (Adenocarcinoma) vs.
Central (Squamous).
Endobronchial obstruction.
Atelectasis of lobe or lung.
Pneumonia.
Lung Cancer:
The Chest X-ray
Hilar and mediastinal adenopathy.
Pleural effusions.
Elevated hemidiaphragm.
Lung Cancer:
CT Scan of Thorax
Nodule details:
Calcification, spiculation etc..
Evaluation of adenopathy.
Upper abdominal pathology:
Metastatic lesions in liver, adrenals, & kidneys.
Lung Cancer:
Sputum Cytology
Helpful for central lesions.
With three samples:
80% detection rate of centrally located tumors.
50% detection rate of peripheral lesions.
Lung Cancer:
Video Flexible Bronchoscopy
Excellent to evaluate endobronchial disease.
Brushings and bronchial biopsies are high
yield for visible lesions.
Transbronchial biopsies of large peripheral
lesions +/- fluoroscopic guidance.
Evaluation of obstruction for stent
placement & brachytherapy.
Lung Cancer:
Transbronchial Needle Aspiration (TBNA)
Allows biopsy of subcarinal & paratracheal
lymph nodes during flexible bronchoscopy.
Helpful for staging.
Minimal risk to patient.
Lung Cancer:
CT - Guided Transthoracic Needle Biopsy
Peripheral lesions away from diaphragm.
25% pneumothorax risk.
May be beneficial for poor operative
candidates.
Remember:
Negative needle biopsy result may be false
negative.
Question
Patient is a 65 year old smoker with
following CXR and CT scan of chest:
Question
What test do we order next?
A. CT-guided lung biopsy.
B. Video Assisted Thoracic Surgical open
lung biopsy with possible lobectomy.
C. PET scan.
D. PFTs.
E. CT scan of head.
Answer
What test do we order next?
A. CT-guided lung biopsy.
B. Video Assisted Thoracic Surgical open
lung biopsy.
C. PET scan.
D. PFTs.
E. CT scan of head.
Alternative Answer
Mediastinoscopy or Transbronchial Needle
Aspiration (TBNA)
would also have been an appropriate method of
staging mediastinum.
Lung Cancer:
PET Scan
Lung Cancer:
Other Diagnostic Tests
Thoracentesis.
Surgical resection:
Thoracotomy vs. VATS.
Newer Technologies
Endobronchial
Ultrasound (EBUS)
Endoscopic
Ultrasound (EUS)
25
20
15
10
5
0
Adenocarcinoma
Most common cell
type in US.
Peripheral location.
Glandular formation.
Mucin production.
12
24
36
48
60
IA
91
79
71
67
61
IB
72
54
46
41
38
IIA
79
49
38
34
34
IIB
59
41
33
26
24
IIIA
50
25
18
14
13
IIIB
34
13
IV
19
12
24
36
48
60
IA
94
86
80
73
67
IB
87
76
67
62
57
IIA
89
70
66
61
55
IIB
73
56
46
42
39
IIIA
64
40
32
26
23
Malignant
Atypical carcinoid.
Intermediate
Typical carcinoid.
Benign
Aggressive tumor.
Smokers.
Centrally located.
Bulky adenopathy is
common.
Distant metastases
common on
presentation.
Carcinoid
Typical carcinoid:
Usually endobrochial.
Present with
postobstructive
pneumonia.
Surgical resection is
curative.
Atypical carcinoid:
More aggressive.
May require surgery
with chemotherapy.
Extensive:
60-70% of small cell lung cancers.
Any distant spread.
Lung Cancer
Why the Poor Prognosis?
Survival statistics reveal the advanced stage
at time of diagnosis
Presentation is often after the patient
becomes symptomatic
Usually Stages IIIA/B or IV
These stages have poor long term survival
< 10% at 5 years
Lung Cancer
Why the Poor Prognosis?
Successful surgical resection and cure are
only possible at early stages
In U.S. only 20-25% of newly detected lung
cancer is Stage I
Question
Wedge resection.
Lobectomy.
Lobectomy with adjuvant chemotherapy.
Lobectomy with adjuvant radiation.
Lobectomy with adjuvant chemotherapy and
radiation.
Answer
60 yo male smoker with 4.1 cm solitary
adenocarcinoma. What is the best option for
treatment/survival?
A) Wedge resection.
B) Lobectomy.
C) Lobectomy with adjuvant chemotherapy.
D) Lobectomy with adjuvant radiation.
E) Lobectomy with adjuvant chemotherapy and radiation.
NEJM 2004.
ASCO 2004.
Chemotherapy Drugs
Non small cell:
Two drug regimen.
Cis/Carbo platin + 1 other
(Taxol/Taxotere/Gemcitabine)
Small cell:
Cisplatin / Etoposide
Biologic Agents
Avastin
Angiogenesis inhibitor.
Added to chemo.
Bleeding risk.
Contraindicated in squamous cell carcinoma.
Biologic Agents
Tarceva
Epidermal growth factor inhibitor.
Second line therapy.
Asian, never smoking, women,
adenocarcinoma / bronchoalveolar cell CA.
PO.
Rash, diarrhea.
Extensive: Chemotherapy.
7-11 month median survival.
5 year survival < 1%.
Question
A 60 year old white male smoker without
symptoms presents for a routine annual
physical and a CXR is performed. What
test do you order next?
Question
A)
B)
C)
D)
E)
Answer
A)
B)
C)
D)
E)
Ages 35-39
Ages 40-49
Ages 50-59
Ages 60+
:
:
:
:
3% are malignant.
15%
42%
50%
Benign
Characteristics:
Smooth & round.
Well circumscribed.
Central, densely
calcified, laminated, or
popcorn.
< 3 cm.
Solitary Nodule
Follow up CTs:
3, 6, 12, 24 months.
If stable at 2 years, no further follow up.
Common Paraneoplastic
Syndromes:
Syndrome
Frequent Histology
Hypercalcemia
SIADH
Cushings Syndrome
Eaton-Lambert
Squamous Cell
Small Cell
Small Cell
Small Cell
Question
A 55 year old former smoker is concerned
about his risk for lung cancer and seeks
your advice. Which of the following
screening tests is recommended?
Question
A)
B)
C)
D)
E)
Answer
A)
B)
C)
D)
E)