Scribd
Upload
27 views

Primary Lung Cancer

This document discusses primary lung cancer, including its pathology, risk factors, clinical presentation, investigations, staging, and treatment approaches. It covers the main cell types of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), describing their characteristics, typical locations, associations with smoking, and prognosis. For both NSCLC and SCLC, the summary outlines standard treatment protocols including surgery, chemotherapy, radiation therapy, and targeted therapies. It emphasizes the importance of multidisciplinary care and treatment tailored to the cancer type and stage.

Uploaded by

Isaac Mwangi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
27 views

Primary Lung Cancer

This document discusses primary lung cancer, including its pathology, risk factors, clinical presentation, investigations, staging, and treatment approaches. It covers the main cell types of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), describing their characteristics, typical locations, associations with smoking, and prognosis. For both NSCLC and SCLC, the summary outlines standard treatment protocols including surgery, chemotherapy, radiation therapy, and targeted therapies. It emphasizes the importance of multidisciplinary care and treatment tailored to the cancer type and stage.

Uploaded by

Isaac Mwangi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 53

Primary lung Cancer

Dr Alex Mogere
Consultant Physician
Pathology
• WHO defines lung cancer as tumors arising from the respiratory epithelium
(bronchi, bronchioles, and alveoli
• The WHO classification system divides epithelial lung cancers into four major
cell types:
small-cell lung cancer (SCLC),
adenocarcinoma,
squamous cell carcinoma,
and large-cell carcinoma; the latter three types are collectively known as non-
small-cell carcinomas (NSCLCs)
 In North America, adenocarcinoma is the most common histologic type of
lung cancer
Cont. pathology
• All histologic types of lung cancer can develop in current and former
smokers, although squamous and small-cell carcinomas are most
commonly associated with heavy tobacco use
• However, with the decline in cigarette consumption over the past
four decades, adenocarcinoma has become the most frequent
histologic subtype of lung cancer in the United States
Anatomy of lung
Non small cell lung cancer
• Most common malignancy in males around the world
• Leading cause of cancer elated malignancy
SCC
• Arise centrally within the main ,lobar, segmental or subsegmental
bronchi
• Invasion of the underlying wall with extension intraluminally
• Can be detected by cytological evaluation
• Usually slow growing
• Incidence becoming less compared to adenocarcinoma
Adenocarcinoma
• Usually from the smaller peripheral airways
• Detected earlier by radiology
• Most common in non smokers and women
• Rising incidence associated with different pattern of tobacco
consumption
• More commonly associated with pleural effusions and distant mets
• Premalignant lesion known as atypical alveolar hyperplasia
Risk factors
• Smoking
• Genetic predisposition eg Li Fraumeni syndrome
• Occupational and environmental exposure-asbestos,arsenic,foundry
workers, uranium mine workers- inhaled Radon, air pollution
• Dietary influence-folate/b12 def, low fruit and vegetable intake
Smoking: Association
• Matching rise and fall with changes in smoking habits
• Duration and intensity are both correlated—exponential rise
• Cancer risk declines substantially after cessation
• Stopping tobacco use before middle age avoids more than 90% of the
lung cancer risk attributable to tobacco
• smoking cessation can even be beneficial in individuals with an
established diagnosis of lung cancer
• Passive smoking—associated increased risk(25 %),
• China has the highest incidence of young smokers in the world
Clinical presentation
• Hx of smoking,present, former, either sex
• Prototypical Pt is in the 7th decade of life
Clinical presentation
Cont.Clinical presentation in %
• Cough 8–75%
• Weight loss 0–68%
• Dyspnea 3–60%
• Chest pain 20–49%
• Hemoptysis 6–35%
• Bone pain 6–25%
• Clubbing 0–20%
• Fever 0–20%
• Weakness 0–10%
• Superior vena cava obstruction 0–4%
• Dysphagia 0–2%
• Wheezing and stridor 0–2%
Clinical findings suggestive of metastatic
disease
Symptoms elicited in history
• Constitutional: weight loss >10 lb
• Musculoskeletal: focal skeletal pain
• Neurologic: headaches, syncope, seizures, extremity weakness, recent change in mental status
Signs found on physical examination
• Lymphadenopathy (>1 cm)
• Hoarseness,
• superior vena cava syndrome
• Bone tenderness
• Hepatomegaly (>13 cm span)
• Focal neurologic signs, papilledema
• Soft-tissue mass
Routine laboratory tests
• Hematocrit, <40% in men; <35% in women
• Elevated alkaline phosphatase, GGT, SGOT, and calcium levels
Clinical signs
Investigations

Invxs to confirm the disease Invxs to asses fitness for tx


• Sputum cytology(sensitivity 65- • Renal fxn tests
75%) • LFTs
• Bronchoscopic biopsy(70-80%) • PFTs
Invxs to confirm the stage
• Imaging
• Bronchoscopy
• Mediastinoscopy
• VATS
IMAGING
CXR
Bronchoscopy
• Confirms diagnosis
• Biopsy and brushings 80%
• Low false +ve rates-0.8%
• Stages tumor
• Alleviates symptoms-stenting, bleeding control etc
• Asseses tx response
• Detects preinvasive malignancy(screening)
Staging and prognosis
T2
T3
T4
Nodal staging
Adverse prognostic factors
• Age >65 yrs
• ECOG performance status
• Presence of mediastinal LN
• Tumor hyperca 2+
• Surgical procedure: ltd resection
• +ve resection margins
• Biological markers-p53,EGFR,erB2, COX 2
Early detection and screening
Early detection involves:
Surveillance
Diagnosis
Early tx
• For a screening program to be successful, there must be a high burden of
disease within the target population
• the test must be sensitive, specific, accessible, and cost effective;
• Because a majority of lung cancer patients present with advanced disease
beyond the scope of surgical resection, there is understandable skepticism
about the value of screening in this condition.
Cont. early detection and screening
Mx
• Surgery
• Radiotherapy
• Chemotherapy
• Targeted therapy
• A-algorithm for evaluation of solitary pulmonary nodule(SPN)
• B-algorithm for evaluation of SPN
• C- algorithm for evaluation of semisolid SPN
Mx of stages I and II NSCLC
• Surgical resection, ideally by an experienced thoracic surgeon, is the
treatment of choice for patients with clinical stage I and II NSCLC who
are able to tolerate the procedure
• In patients with stage IA NSCLC, lobectomy is superior to wedge
resection with respect to rates of local recurrence
• In patients with comorbidities, compromised pulmonary reserve, and
small peripheral lesions, a limited resection, wedge resection, and
segmentectomy (potentially by video-assisted thoracoscopic surgery)
may be reasonable surgical option.
• Pneumonectomy is reserved for patients with central tumors
Radiation therapy in stage I and II NSCLC
• Currently no role for postoperative radiation Tx in pts following
resection of stage I or II NSCLC
• However, patients with stage I and II disease who either refuse or are
not suitable candidates for surgery should be considered for radiation
therapy with curative intent.
• Stereotactic body radiation therapy (SBRT) is a relatively new
technique used to treat patients with isolated pulmonary nodules (≤5
cm) who are not candidates for or refuse surgical resection.
Chemotx
Cont. Chemotx regimens
Targeted Therapy
Cont. therapeutic approach
Approach to TX in Stage IV NSCLC
Mx of metastatic NSCLC
• Standard medical management, the judicious use of pain
medications, and the appropriate use of radiotherapy and
chemotherapy form the cornerstone of management.
• Chemotherapy palliates symptoms, improves the quality of life, and
improves survival in patients with stage IV NSCLC, particularly in
patients with good performance status
• The use of chemotx for NSCLC requires clinical experience and careful
judgment to balance potential benefits and toxicities
Small cell lung Cancer disease(SCLC),Mx
SCLC is a highly aggressive disease characterized by :
rapid doubling time,
 high growth fraction,
early development of disseminated disease,
dramatic response to first-line chemotherapy and radiation
• In general, surgical resection is not routinely recommended for
patients because even patients with LD-SCLC still have occult
micrometastases.
Cont. Mx of SCLC
• However, the most recent American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines recommend:
 surgical resection over nonsurgical treatment in SCLC patients with
clinical stage I disease
 after a thorough evaluation for distant metastases and invasive
mediastinal stage evaluation (grade 2C).
• After resection, these patients should receive platinum-based
adjuvant chemotherapy (grade 1C).
Chemotx
• Chemotherapy significantly prolongs survival in patients with SCLC.
• Four to six cycles of platinum-based chemotherapy with either cisplatin
or carboplatin plus either etoposide or irinotecan has been the mainstay
of treatment for nearly three decades and is recommended over other
chemotherapy regimens irrespective of initial stage.
• Cyclophosphamide, doxorubicin (Adriamycin), and vincristine (CAV) may
be an alternative for pts who are unable to tolerate a platinum-based
regimen
• Despite response rates to first-line therapy as high as 80%, the median
survival ranges from 12 to 20 months for patients with LD and from 7 to
11 months for patients with ED.
Cont. Chemotx
• Regardless of disease extent, the majority of patients relapse and
develop chemotherapy-resistant disease.
• Only 6–12% of patients with LD-SCLC and 2% of patients with ED-SCLC
live beyond 5 years.
• Topotecan is the only FDA-approved agent for second-line therapy in
patients with SCLC.
Mx of recurrent small cell lung cancer
Cont. mx of SCLC(Thoracic radiation
therapy(TRT))
• Thoracic radiation therapy (TRT) is a standard component of induction
therapy for good performance status and limited-stage SCLC patients.
• Meta-analyses indicate that chemotherapy combined with chest
irradiation improves 3-year survival by approximately 5% as compared
with chemotherapy alone.
• Most commonly, TRT is combined with cisplatin and etoposide
chemotherapy due to a superior toxicity profile as compared to
anthracycline-containing chemotherapy regimens.
• Ideally TRT should be administered with the first two cycles of
chemotherapy because later application appears slightly less effective.
Prophylactic cranial irradiation
• In patients with ED-SCLC who have responded to first-line
chemotherapy, a prospective randomized phase III trial showed that
PCI reduced the occurrence of symptomatic brain metastases and
prolonged disease-free and overall survival compared to no radiation
therapy.
THANK YOU!

You might also like