1. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Consultant chest physician
Baghdad College of Medicine
2014
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013
LUNG CANCER

2. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
objectives
At the end of this lecture, the student should be able to:
Define the types of lung cancer.
Describe common clinical symptoms
Relate presentation of the disease to the underlying mechanism.
List radiological abnormalities.
Outline therapeutic lines.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

3. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Case 1
A 55 years-old smoker man presented with cough, hemoptysis, unilateral chest pain and dyspnea for 3 months.
Later on, fever, greenish sputum, and increasing dyspnea developed.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

4. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
He felt unwell and his appetite was decreased.
General examination showed finger clubbing.
Chest examination revealed decreased chest expansion, dull percussion and bronchial breathing on auscultation on one side.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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5. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Chest-X Ray showed an abnormal lung shadow and pneumonia-like lesion.
Antibiotic given but, pneumonia didn’t resolve completely.
How can you manage
this patient?
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

6. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Case 2
A 61 years-old smoker man, presented with left shoulder pain for 4 months that is poorly respond to analgesics.
He also complained from weakness of left upper limb and bone pain in both wrists and feet.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

7. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Later on, swelling in his face, upper chest, and both upper limbs started to develop.
Arrows:
Dilated neck veins
Dilated lower chest veins
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

8. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
On examination, the left eye and pupil looked smaller than the right, and his neck veins looked distended.
Chest X-ray showed right apical abnormal lung lesion with upper rib erosion.
How can you approach this patient problem?
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

9. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Case 3
A non smoker 45 years-old women with history of ovarian tumor presented with mild dyspnea.
OE: Non-specific lung findings.
CXR shows multiple nodules of different size.
What’s your primary impression?
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

10. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Introduction
The term lung cancer, or ’ bronchogenic carcinoma’ refers to malignancies that originate in the airways or pulmonary parenchyma.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

11. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Lung cancer is the most common cause of death from cancer worldwide, causing 1.4 million deaths per year
The prognosis remains poor, with fewer than 30% of patients surviving at 1 year and 6–8% at 5 years.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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12. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Etiological factors
Lung cancer occurs through a complex process that results from the combination of carcinogen exposure and genetic susceptibility.
A number of lifestyle and environmental risk factors have been associated with the development of lung cancer.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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13. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Cigarette smoking is by far the most important cause of lung cancer. It is thought to be directly responsible for at least 90% of lung carcinomas.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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14. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Etiological factors
LUNG CANCER
ENVIRU-MENT
Genetic
SMOKING
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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15. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Smoking
Cigarette smoking responsible for at least 90% of lung carcinomas.
Compared with nonsmokers, smokers have an ,20-fold increase in lung cancer risk, depending on:
Duration of smoking
Number of cigarettes smoked per day.
Passive smoking increases the risk of bronchial carcinoma.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

16. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Other risk factors
Underlying acquired lung diseases (chronic obstructive pulmonary disease and pulmonary fibrosis)
Environmental exposures – often with smoking- (asbestos, radon, metals, ionising radiation including previous radiotherapy and petroleum products ).
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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17. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Pathology
Bronchial carcinomas arise from the bronchial epithelium or mucous glands
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

18. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
The World Health Organization (WHO) Classification of malignant lung tumours
Pre-invasive lesions.
Small cell lung cancer (SCLC).
Non-small cell lung cancer (NSCLC):
1) Squamous cell carcinoma
2) Adenocarcinoma
3) Large cell carcinoma.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

19. Percents of lung cancers histopath. types
Cell type %
Squamous 35
Adenocarcinoma 30
Small-cell 20
Large-cell 15
Recently became the most frequent one
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

20. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Small-cell carcinoma
It arises from endocrine cells .
Many polypeptide hormones are secreted by these tumors
The tumor is rapidly growing ,highly malignant and spreads early so, it is almost always inoperable at presentation.
It responds to chemotherapy but the prognosis remains poor.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

21. Non-small-cell carcinoma
Squamous carcinoma:
Common location is central (in major bronchus).
Most present as obstructive lesions of the bronchus leading to infection.
It occasionally cavitates (10%) at presentation.
Local spread is common but widespread metastases occur relatively late.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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22. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Adenocarcinoma :
Common location is peripheral.
Arises from mucous cells in the bronchial epithelium.
Commonnly metastases to the brain and bones.
More common in non-smokers, in women, and in the elderly.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

23. How can patient with lung cancer present to you?
The majority of patients with lung cancer have advanced disease at clinical presentation, which reflects the frequent asymptomatic course of early stage lung cancer.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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24. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Later on, patient may present with one or more of the following ( according to history and exam.)
General symptoms such as anorexia, weight loss and asthenia.
Intrathoracic tumor effect.
Metastasis
Paraneoplastic syndrom
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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25. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
General symptoms
Such as anorexia, weight loss and weakness, loss of appetite.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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26. 2. Intrathoracic effects
Bronchial obstruction
Common presentation.
May lead to pneumonia, which is often the first clinical manifestation of a bronchial carcinoma,
Recurrent pneumonia at the same site or pneumonia which is slow to respond to treatment, particularly in a smoker, should immediately suggest the possibility of bronchial carcinoma.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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27. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Cough
Is the most common early symptom (central airway or pleural involvement) .
Haemoptysis,
Invasion of a vessel.
Chest pain
Malignant invasion of the pleura, although it can occur with distal infection.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

28. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Dyspnoea
Lobar / total lung collapse or massive pleural effusion.
Hoarseness
Recurrent laryngeal nerve involvement.
Stridor
A harsh inspiratory noise occurs when the lower trachea, carina or main bronchi are narrowed by the primary tumor or by lymph nodes.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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29. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Superior vena cava syndrome
Dilated neck veins, facial oedema occurs due to SVC obstrucion by lung tumor.
Phrenic nerve paralysis
Causes unilateral diaphragmatic palsy
Pleural effusion
Involvement of the pleura may produce a pleural rub or signs of pleural effusion
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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30. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Superior sulcus, or pancoast’s tumor ,
Occur due to tumor present in the upper lung lobe that invades nearby structures. e.g. brachial plexus resulting in neuropathy with pain, numbness, weakness of the arm and hand muscle atrophy (Pancoast's syndrom)
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

31. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Pancoast tumor
In this patient with shoulder pain, a mass (white arrows) is seen in the left lung apex on CXR (A).
Pancoast's syndrom
Pain, numbness, weakness of the arm and hand muscle atrophy
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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32. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Note: A smoker, elderly patient with unilateral shoulder pain may have bronchogenic carcinoma as one diagnostic possibilities.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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33. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Brain metastasis
3) Metastasis
Symptoms occur due to blood-borne metastases. The most frequent sites of distant metastasis are the:
liver: (pain, jaundice, constitutional symptoms).
adrenal glands: usualy asymptomatic.
Bones: (pain),
brain: (headache, paresis, personality change, seizures)
skin: (nodules)
Liver metastasis
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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34. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Metastasis..
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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35. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Metastasis..
lymphangitis carcinomatosa
These lines represent lymphatics infiltrated by tumour.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

36. 4.Paraneoplastic syndrome
Non-metastatic symptoms due to paraneoplastic syndrom include:
Endocrine :
Inappropriate antidiuretic hormone
(ADH) secretion causing hyponatraemia
Ectopic adrenocorticotrophic
hormone (ACTH) secretion leading to Cushing’s syndrom.
small-
cell
lung ca
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

37. Paraneoplastic syndrome…
Hypercalcaemia due to secretion of
parathyroid hormone (PTH)-related
peptides.
Carcinoid syndrome.
Gynaecomastia.
Squamous cell ca
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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38. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Neurological :
Neuropathy
Myelopathy (spinal cord involvement)
Myasthenia (Lambert-Eaton syndrome)
Other :
Digital clubbing (Hypertrophic pulmonary steoarthropathy HPOA)
Eosinophilia
Clubbing
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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39. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Hypertrophic pulmonary osteoarthropathy (HPO)
Characterized by periostitis of the long bones, most commonly the distal tibia, fibula, radius and ulna.
This gives rise to pain and tenderness over the affected bones and often pitting oedema over the anterior aspect of the shin.
X-rays of the painful bones show subperiosteal new bone formation.
Clubbing is part of HPO.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

40. Warning signs of lung ca
Change in respirations
Cough that is persistent
Change in sputum
Weight loss
Chest pain
Recurring respiratory disorders such as pneumonia or bronchitis
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

41. Diagnosis of lung cancer
History and examination
Investigations
Radiology:
CXR
CT and MRI
PET scan
Sputum cytology
Bronchoscopy brush/biopsy
Transthoracic biopsy under-
US or CT guide
Thoracotomy for tumor biopsy
Detecting the tumor site
Detecting the tumor type
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

42. Sputum Squamous cell carcinoma
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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43. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Radiology
Unilateral hilar enlargement
Peripheral pulmonary opacity
Lung, lobe or segmental collapse
Pleural effusion
Broadening of mediastinum,
Enlarged cardiac shadow,
Elevation of a hemidiaphragm
Rib destruction
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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44. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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45. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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46. Large cavitated bronchial carcinoma in left lower lobe.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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47. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Radiology
lobar collapse & pneumonitis
The most frequent finding is a mass in the lung field.
Secondary manifestations seen on the CXR include lobar collapse, total lung collapse, pneumonitis because of endobronchial obstruction, elevation of the hemidiaphragm,
Elevation of the hemidiaphragm
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

48. Radiology.. Computerized Tomography CT- chest
Add more detailed anatomical information and detect pulmonary lymph node enlargement more clearly.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

49. Positron Emition tomography (PET)
May shows markedly increased activity at the same area, indicative of very high metabolic activity and a high probability of malignancy.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

50. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Bronchoscopy
Is the appropriate test for centrally located tumors, where a pathological diagnosis will be obtained in ,90% of cases, by means of forceps biopsy, bronchial brushing or washing.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

51. Staging Non-small cell lung cancer. Small cell lung cancer
TNM (Tumor, lymph Node, Metastasis) classification of Non-small cell lung cancer, e.g. T3N1M0.
Small cell lung cancer
Small cell lung cancer is divided into limited and extensive stage disease.
NB: Tumor staging defines the prognosis and guides management.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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52. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Treatment
Surgery
Chemotherapy
Radiation
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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53. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Treatment of NSCLC
For medically operable patients : surgical resection ± chemotherapy.
Medically inoperable patients: radiotherapy.
In advanced stage: chemotherapy plus radiotherapy.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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54. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Treatment of SCLC
Chemotherapy in combination with thoracic radiotherapy and prophylactic cranial irradiation.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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55. General treatment measures
Radiotherapy plays an important role in palliation of local problems such as superior vena cava syndrome, haemoptysis, postobstructive pneumonia, bone pain and brain metastasis.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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56. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Secondary lung tumors
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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57. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Secondary lung tumors
Metastases in the lung are very common and usually present as round shadows ( cm diameter). They may be detected on chest X-ray in patients already diagnosed as having carcinoma.
Typical sites for the primary tumor include the kidney, prostate, breast, bone, gastrointestinal tract, cervix and ovary.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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58. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Metastases nearly always develop in the parenchyma and are often relatively asymptomatic even when the chest X-ray shows extensive pulmonary metastases
( cannon ball metastasis)
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

59. Now can you answer the questions related to case 1 and 2 ?
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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60. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Summary
Lung cancer is a tumor arising from within the lung.
It may represents the primary site or may be metastatic
Histopath. Types:
Small cell lung cancer (SCLC).
Non-small cell lung cancer (NSCLC):
1) Squamous cell carcinoma:
2) Adenocarcinoma:
3) Large cell carcinoma.
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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61. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Staged by:
Tumor
Node
Metastasis
Treated by:
Radiation
Surgery
Chemotherapy
This is the TNM classification system
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013

62. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
A 68 years old man, with 80 pack-year smoking history presented with dyspnea, cough, blood streaks sputum, and weight loss over the last 4 months. On examination, tempreture 36.90, looks pale, emaciated, with limited chest expansion over right lung, dull percussion and bronchial breathing sound. The most likely diagnosis is:
Pulmonary TB
Post pneumonic effusion
Lung cancer
Pulmonary edema
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
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63. LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
Thank you
LUNG CANCER - Dr. Mustafa Nema- Baghdad College of Medicine
2013