Early diagnosis of Lung Cancer Dr. Aparna Sreevatsa Consultant Medical Oncologist Sahyadri Narayana Multispeciality Hospital, Shimoga

Overview Pathogenesis Epidemiology of Lung Cancer in India Differentiate TB from Lung Cancer Recent advances in the management of Lung Cancer

Pathogenesis Genetic disease Imbalance between oncogenes and tumor suppressor genes Deficient DNA repair mechanism Multistep carcinogenesis

Molecular Biology of Lung Ca

Case Scenario 1 A, 60 yr, male Chronic Smoker Cough 15 days Hemoptysis 3 days CXR Right upper zone patch with hilar lymph node

Case Scenario 2 B, 40 yr, female Non Smoker Cough 15 days Hemoptysis 3 days CXR Right upper zone patch with hilar lymph node

Case Scenario 3 50 y, smoker Cough Breathlessness CT Chest- Ca lung with pleural effusion & adrenal mets. ?? Palliative Care ??Cancer directed therapy

Epidemiology of Lung Cancer in India GLOBOCAN 2012 Lung ca the most common cancer in men in India. Changes in the incidence among smokers and non smokers.

Changing Epidemiology of Lung Ca in India

Lung Ca in Non Smokers Incidence increasing in females & never smokers. Adeno carcinoma Younger age Advanced disease EGFR mutation positive.

Histopathological Types

Tuberculosis- A diagnostic chameleon

Difference between pulmonary TB & Lung Cancer

History & Examn. TB Lung Ca Age Smoking fever Weight loss Usually young Middle age/elderly Smoking +/- fever + Weight loss breathlessness Chest pain Clubbing Cervical lymph nodes Hoarseness rare

Radiology TB Lung Cancer Predilection for upper zone CXR features Predilection for upper zone + - Parenchymal infiltrates +/- Lymphadenopathy Cavity Pleural effusion Miliary mottling Rib erosion Mass lesion

CT Chest Pulmonary TB Lung Cancer Centrilobular densities in and around the small airways Tree in bud appearance Mass lesion, spiculated margins Tumor size, site, invasion to adjoining structures Hilar and mediastinal lymph nodes

Histopathology/Cytology FNAC Trucut Biopsy USG/CT guided/Bronchoscopic/BAL AFB staining

Treatment Plan Stage I & Stage II- Surgery/RT Stage III-RT/NACT->RT Stage IV- CT

Management of Metastatic Lung Cancer

Goals of therapy... Palliation of symptoms Improvement in QOL Prolongation of Survival

Therapeutic Options... Chemotherapy Monoclonal Antibodies Tyrosine Kinase Inhibitors Immunotherapy

ROLE OF CHEMOTHERAPY

Agents used over years... First generation 1970s 2nd generation 1980s 3rd generation 1990s Cyclophophamide Doxorubicin Methotrexate Procarbazine Lomustine 5-FU Carmustine Cisplatin Etoposide Vindesine Vinblastine Mitomycin-C Ifosfamide Vinorelbine Gemcitabine Paclitaxel Docetaxel Irinotecan Topotecan

Cis-based regimens 6–8 months Improved OS... Significant Milestones in 1st-Line Therapy -------------------------------------- Median survival (months) P-based doublets 3rd gen. 8–10 months Cis-based regimens 6–8 months BSC 2–4 months 1970s 1980s 1990s

Chemotherapy

Paul Ehrlich German physician Father of Chemotherapy Majic Bullet theory

Targeted Therapy

EGFR mutation Positive Erlotinib Gefitinib Axitinib

ALK positive Crizotinib Ceretinib Alectinib

Monclonal Antibodies Bevacizumab

Immunotherapy Nivolumab Pembrolizumab

Take Home Message Lung Cancer is increasing in females & non-smokers. Cough >3 wks with hemoptysis +/- chest pain requires CXR evaluation. If pt is not improving on ATT, prompt CT Chest to rule out lung cancer. Targeted therapy improves survival to many months to years.

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