Oncology

Lung cancer
Dmytro Ievtushenko, MD, PhD
N. Mollberg · M. Surati · C. Demchuk et al Mind-Mapping for Lung Cancer: Towards a Personalized Therapeutics Approach
• R lung --> drains entirely into R brachiocephalic vein;
• L lung --> upper lobe drains into L brachiocephalic vein while lower lobe drains across midline
into R brachiocephalic vein
Risk factors
CT and X-RAY
Bronchoscopy
Molecular biomarkers
clinical manifestations by
paraneoplastic phenomena

• Hypercalcemia
• SIADH
• Neurologic
• Lambert-Eaton
• cerebellar ataxie
• Hematologic manifestations
• Hypertrophic osteoarthropathie
• Dermatomyositis
Paraneoplastic syndromes
• Advanced metastatic lung cancer in
a 68-year-old woman,
• cutaneous metastatic nodule (A) on
the right shoulder measuring 3 cm
across; two other similar lesions
were found overlying the left breast
and the right flank. Biopsy- poorly
differentiated carcinoma.
• Chest x-ray (B) showed a left hilar
shadow that had been absent on a
previous chest x-ray eight months
earlier.
• Computed tomography (C) showed
infiltrative consolidation in the left
lung and a cutaneous lesion in the
left chest wall (arrow).
• Magnetic resonance imaging (D)
showed multiple vertebral
metastases and pathological fracture
of T7 vertebra (arrow).
Vena cava syndrome
Pulmonary function

• Bodyplethysmography
• Radionuclide perfusion scintigraphy
• Diffusion capacity for carbon monoxide
• Exercise spirometry VO2 max > 15 ml O2
Right Lung Hilum

Anterior Approach
(Fig. 6-28.1). The most anterior anatomic entity in
the hilum is the superior pulmonary vein. It
partially covers the right pulmonary artery.
Posterior to the pulmonary artery is the bronchus.
The azygos vein and the vagus and phrenic nerves
are nearby.

Interlobar Approach

(Fig. 6-28.2). The interlobar approach to the right

lung hilum is through the oblique fissure. The
pulmonary artery and its branches are the most
superficial structures.

Posterior Approach

(Fig. 6-28.3). The inferior pulmonary vein and/or its

branches are side by side with the intermediate
bronchus. The esophagus, vagus nerve, and azygos
vein are visible
VATS
 Non-Small Cell Lung Cancer

• For people with non-small cell lung tumors that can be surgically removed, evidence
suggests that chemotherapy after surgery, known as “adjuvant chemotherapy,” may
help prevent the cancer from returning. This is particularly true for patients with stage
II and IIIA disease. Questions remain about whether adjuvant chemotherapy applies
to other patients and how much they benefit.
• For people with stage III lung cancer that cannot be removed surgically, doctors
typically recommend chemotherapy in combination with definitive (high-dose)
radiation treatments. In stage IV lung cancer, chemotherapy is typically the main
treatment. In stage IV patients, radiation is used only for palliation of symptoms.
• The chemotherapy treatment plan for lung cancer often consists of a combination of
drugs. Among the drugs most commonly used are cisplatin (Platinol) or carboplatin
(Paraplatin) plus docetaxel (Taxotere), gemcitabine (Gemzar), paclitaxel (Taxol
and others), vinorelbine (Navelbine and others), or pemetrexed (Alimta).
 Non-Small Cell Lung Cancer
Targeted Treatments

•One of the most exciting developments in lung cancer medicine is the introduction of targeted treatments. Unlike chemotherapy drugs, which cannot tell the
difference between normal cells and cancer cells, targeted therapies are designed specifically to attack cancer cells by attaching to or blocking targets that
appear on the surfaces of those cells. People who have advanced lung cancer with certain molecular biomarkers may receive treatment with a targeted drug
alone or in combination with chemotherapy. These treatments for lung cancer include:
•Erlotinib (Tarceva and others). A targeted treatment called erlotinib has been shown to benefit some people with non-small cell lung cancer. This drug
blocks a specific kind of receptor on the cell surface—the epidermal growth factor receptor (EGFR). Receptors such as EGFR act as doorways by allowing
substances in that they can encourage a cancer cell to grow and spread. Lung cancer cells that have a mutation on the EGFR are likely to respond to
treatment with erlotinib instead of chemotherapy. For patients who have received chemotherapy, and are in need of additional treatment, erlotinib can be
used even without the presence of the mutation.
•Afatinib (Gilotrif). In 2013, the FDA approved afatinib for the initial treatment of metastatic NSCLC in patients with the same EGRF gene mutations or
deletions as those who can be treated successfully with erlotinib.
•Gefitinib (Iressa). In 2015, the FDA approved gefitinib for the first-line treatment of patients with NSCLC whose tumors harbor specific types of EGFR
gene mutations, as detected by an FDA-approved test.
•Bevacizumab (Avastin). Just like normal tissues, tumors need a blood supply to survive. Blood vessels grow in several ways. One way is through the
presence of a substance called vascular endothelial growth factor (VEGF). This substance stimulates blood vessels to penetrate tumors and supply oxygen,
minerals, and other nutrients to feed the tumor. When tumors spread throughout the body, they release VEGF to create new blood vessels.Bevacizumab
works by stopping VEGF from stimulating the growth of new blood vessels. (Because normal tissues have an established blood supply, they are not affected
by the drug.) When combined with chemotherapy, bevacizumab has been shown to improve survival in people with certain types of non-small lung cancer,
such as adenocarcinoma and large cell carcinoma.
•Crizotinib (Xalkori). A treatment that has shown benefits for people with advanced non–small cell lung cancer who have the ALK gene mutation.
Crizotinib works by blocking ALK and stopping the growth of the tumor.
•Ceritinib (Zykadia). This was approved in 2014 for people with metastatic ALK-positive lung cancer who cannot tolerate crizotinib or whose cancer
continued to grow while being treated with crizotinib.
 Non-Small Cell Lung Cancer
Immunotherapy

• Immunotherapy has recently emerged as a new treatment option for certain lung cancers. While any cancer treatment can cause side effects,
immunotherapy is generally well-tolerated; this is in part due to its mechanism of action.
• Our immune system is constantly working to keep us healthy. It recognizes and fights against danger, such as infections, viruses, and growing
cancer cells. In general terms, immunotherapy uses our own immune system as a treatment against cancer.
• In March 2015, the FDA approved the immunotherapy nivolumab (Opdivo) for the treatment of metastatic squamous NSCLC which was
unsuccessfully treated with chemotherapy. Nivolumab works by interfering with a molecular “brake” known as PD-1 that prevents the body’s
immune system from attacking tumors.
• In 2016, the FDA approved a new immunotherapy called pembrolizumab (Keytruda) for the treatment of advanced NSCLC as an initial therapy.
Its therapeutic activity is similar to that of nivolumab. Patients are tested for a protein known as PDL-1 and if a sufficient quantity is identified
they may qualify for this treatment.
• Additional approaches to immunotherapy for lung cancer have shown promise in early clinical trials and are now in late-phase development.
Treatments for NSCLC have advanced the furthest; however, a number of new immune-based treatments for SCLC are also in clinical
development. These treatments fall into four main categories:
• Monoclonal antibodies are lab-generated molecules that target specific tumor antigens (a substance that the immune system sees as being
foreign or dangerous).
• Checkpoint inhibitors target molecules that serve as checks and balances in the regulation of immune responses.
• Therapeutic vaccines target shared or tumor-specific antigens.
• Adoptive T-cell transfer is an approach in which T-cells (a type of white blood cell) are removed from the patient, genetically modified or treated
with chemicals to enhance their activity, and re-introduced into the patient with the goal of improving the immune system’s anticancer
response.
 Small Cell Lung Cancer

• For people with small cell lung cancer, regardless of stage, chemotherapy is an
essential part of treatment. Radiation treatment may be used as well depending on
the stage of cancer.

• For people with limited-stage small cell lung cancer, combination chemotherapy plus
radiation therapy given at the same time is the recommended treatment. The most
commonly used initial chemotherapy regimen is etoposide (Toposar or Vepesid)
plus cisplatin (Platinol), known as EP.

• For people with extensive-stage small cell lung cancer, chemotherapy alone using the
EP regimen is the standard treatment. However, another regimen that may be used
is carboplatin (Paraplatin) plus irinotecan (Camptosar)
Before chemo (CT)
After chemo
 Thank You!
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