1. Prof.Taher El Naggar Professor of pulmonary medicine Ain Shams University

2. Definition of Lung Cancer The term lung cancer is used to describe cancer that arises in airways or pulmonary parenchyma.

3. Epidemiology The Size of the Problem: killing > 85% of those it afflicts within 5 years. Cause of death: 1 st in men & 2 nd or 3 rd in females. Age ~ 50-70 years Male > female, a decade ago 10:1, Now 2:1 Decreasing incidence and deaths in men; continued increase in women

4. Women & Lung Cancer 80,660 new cases were reported in 2004 - Account for 12 % of all new cases 68,510 deaths were reported in 2004 - An increase of 150% between 1974 and 1994 Women are more prone to tobacco effects - 1.5 times more likely to develop lung cancer than men with same smoking habits

5. Etiology: Causes: As the most tumors the causes are unknown. Uncontrolled growth of malignant cells A result of repeated carcinogenic irritation causing increased rates of cell replication Proliferation of abnormal cells leads to hyperplasia, dysplasia or carcinoma in situ

6. Where Does it Come From? (Risk factors) Radiation Exposure Smoking Environmental/ Occupational Exposure Asbestos Radon Passive smoke

7. Risk Factors. ( cont.) Lung lesions: Old fibrosis as in TB may result in scar carcinoma. Genetic factors: Genetic predisposition result from a difference in carcinogen metabolism. Diet: Individuals whose diet is low in (3- carotene and vitamin A are at increased risk for lung cancer.

8. Smoking Facts Tobacco use is the leading cause of lung cancer 87% of lung cancers are related to smoking Risk related to: age of smoking onset amount smoked gender depth of inhalation

10. Pathology of lung cancer: A correct histologic diagnosis of lung cancer is important to determine treatment and prognosis. Histopathologic classification of lung cancer as designed by World Health Organization (WHO).

11. Table (15): Pathological Classification of lung cancer. ClassificationSiteIncidence % 1 -Small-cell lung cancer (SCLC)Central20 2-Non small cell lung cancer (NSCLC) Adenocarcinoma Squamous cell carcinoma Large- cell carcinoma Peripheral Central Peripheral 35 30 10 Others Carcinoid, pulmonary lymphoma, mucoepidermoid carcinoma, sarcoma. Central or peripheral5

12. Spread 1- Local spread: A- To the pleura in the peripheral type leading to pleural effusion as in adenocarcinoma. B- To the mediastinum in the central type leading to mediastinal syndrome. 2- Hematogenous spread: Lead to dissemination all over the body to distant organs e.g; bones, liver, brain, and kidneys, specially in small cell lung cancer. 3- Lymphatic spread: To hilar, mediastinal, axillary, or cervical lymph nodes.

13. Symptoms of lung cancer: 1- History of smoking, occupational exposure to irradiation, history of T.B 2-Asymptomatic presentation : 1/4 of patients are presented with no symptoms at the diagnosis. 3-General non specific symptoms e.g. weight loss, loss of appetite, anorexia, fever, and easy fatigability.

14. Symptoms of lung cancer: 4- Primary tumor symptoms e.g. cough, expectoration, dyspnea, chest pain, and haemoptysis. 5- Symptoms due to intra thoracic spread e.g. hoarseness of voice, dysphagia, chest wall swelling, superior vena caval obstruction with swelling of face or arms. 6. Symptoms due to extra thoracic spread e.g. cervical lymph nodes, bony aches or swelling, pain in right hypochondrium, and neurological symptoms

15. Signs of lung cancer: 1- No signs can be detected in early symptomatic cases; the condition may be detected accidentally on routine chest X-ray. 2- General Examination may show-Inequality in pulse, edema of face and upper limb, palpable cervical lymph node, congested non pulsating neck vein (signs of superior vena cava obstruction and superior sulcus syndrome).

16. 3. Signs due to distant organ metastasis : Liver metastasis : jaundice, palpable tender liver mass. Bone metastasis : bone pain or pathological fracture. C.N.S metastasis: paralysis or paresis, polyneuropathy, myopathy, any area of sensory loss, and any muscular atrophy. C.V.S : arrhythmia or manifestation of pericardial effusion.

17. 4. Systemic non metastatic manifestations (paraneoplastic syndromes) Cachexia. Clubbing of fingers (hypertrophic pulmonary osteo- arthropathy may be found). Endocrine abnormalities e.g. Cushing syndrome, hypercalcaemia, inappropriate antidiuretic hormone.

18. Systemic non metastatic manifestations Neurological abnormalities e.g. polyneuropathy, autonomic neuropathy and myasthenic. Hematologic abnormalities e.g. thromboembolic manifestation, anemia, and leukomoid reaction. Cutaneaues manifestations e.g. acanthosis negricans, dermatomyositis.

19. Cutaneaues manifestations Gottron's papules. Characteristic raised erythematous papule overlying the proximal interphalangeal joint in a patient with dermatomyositis.

20. 5. Local chest signs A- Local signs due to direct effect of the tumor like consolidation, collapse,abscess, and effusion. B- Manifestation of underlying diseases e.g. pneumoconiosis, COPD and old pulmonary TB,IPF (Scar carcinoma). C- Infiltrating the lower trunk of brachial plexus leading to pain, hypothesia, weakness and atrophy of small muscles of the hand, which are supplied the ulnar nerve.

22. 5 - Local chest signs (cont.) D- Obstruction of vessels of the thoracic inlet leading to arterial ischemia and inequality of the pulse and venous engorgement. E- Honer's syndrome: ptosis, myosis, enophthalmos and unilateral anhydrosis due to compression or involvement of cervical sympathetic chain.

23. Superior vena cava obstruction (Superior vena cava syndrome mediastinal syndrome ) : It is a sign of inoperability. It is caused by compression or direct invasion by tumor to: Superior vena cava, Subclavian artery, Trachea, Esophagous, left recurrent laryngial nerve and phernic nerve. The patients with mediastinal syndrome may presents with headach,bull neck, odema of face and upper limb, congested non pulsating neck veins, inequality of radial pulse, stridor, hoarseness of voice and dilated veins on chest wall.