1. Lung cancer

2. Lung cancer
malignant neoplasm, which leading to death 1.1 million people (each year around the world)
most common cause of cancer-related death !
one of the worst prognosis (in oncology)

3. Lung cancer
is the most common cause of cancer deaths in men and women

4. Cancers in Poland Morbidity women 1. Breast cancer - 24% 2
Cancers in Poland Morbidity women 1. Breast cancer - 24% 2. Lung cancer - 8 % 3. Corpus uteri cancer - 7 % 4. Cervix uteri cancer – 6%

5. Morbidity men 1. Lung cancer -21% 2. Prostate cancer -12%
3. Bladder cancer – 7%
3. Colon cancer - 6%

6. Mortality women 2. Breast cancer - 14% 3. Colon cancer - 7%
1. Lung cancer - 15%
2. Breast cancer - 14%
3. Colon cancer - 7%
4. Ovarian cancer – 7%

7. Mortality men 1. Lung cancer – 32% 2. Prostate cancer – 7%
3. Colon cancer – 7%
4. Stomach cancer – 7%

8. Diagnosis and prognosis (number of cases diagnosed at each stage and corresponding survival)
Total Cases
Percentage of Cases
1-Year Survival
5-Year Survival
Stage I
582
14,5%
71,12%
35,33%
Stage II
294
7,3%
48,15%
20,89%
Stage III
1275
31,8%
34,59%
6,32%
Stage IV
1436
35,8%
14,36%
1,51%
Stage Not Known
426
10,6%
16,61%
5,79%
All Stages
4013
100,0%
32,16%
9,68%
Anglia Cancer Network

9. EPIDEMIOLOGY of LUNG CANCER
In Poland (just like the world) is steadily increasing number of cancer patients
It is a disease with almost 100% mortality
5-year survivals is about %
Lung cancer in Poland ranks first among deaths from cancer in men and women

10. EPIDEMIOLOGY of lung cancer in Poland
Annual total approximately new cases of cancers of the respiratory system
For example data from 2012 in Poland - registered cancers of the respiratory system:
(from „Krajowy Rejestr Nowotworów” - National Cancer Registry)
ICD-10 C34 category : Total new cases
Men (70%)
Women (30%)

11. Death from lung cancer (in Poland)
Weekly with lung cancer die
about 400 people
It's like every week crashed two airliners

12. ETIOLOGY
The main risk factor for the incidence of lung cancer is smoking, especially cigarettes.
The risk of lung cancer in a man burning about cigarettes a day for more than 10 years is about 10 times higher than non smoking.
Burn >40 cigarettes a day increases the risk to 60 times.

13. Lung cancer and smoking
more than 92% of patients with lung cancer are current or former smokers
the remaining few percent are mostly passive smokers, such as those working in smoky rooms or spouses of smokers
% of smokers will develop lung cancer

14. Carcinogens 1. Carcinogens contained in tobacco smoke
Polycyclic aromatic hydrocarbons
Radioactive isotopes of polonium (Pl210) and carbon (C14)
2. Occupational factors
asbestos, silicon, uranium (miners, heavy industry)
contact with the dust of iron, arsenic, bismuth, chromium
soot, tar, mineral oils (builders of roads, roofers)
3. Environmental factors
contact with the products of burning of coal and oil
radon
4. Genetic predisposition

15. Molecular disorders Mutations and overexpression of oncogenes:
C-erbB
ras
myc
Loss of tumor suppressor genes:
P53
P16 RB

16. Histopathology of lung cancer (according to WHO 1981)
Squamous cell carcinoma %
Adenocarcinoma %
Large cell carcinoma 10%
Small cell carcinoma 20%

17. In clinical practice :
Non-small cell lung cancer (NSCLC) - 80% of all patients
Small cell lung cancer (SCLC) - 20% of all patients

18. Clinical signs of lung cancer
over a long period of time may be asymptomatic (1-2 years !)

19. Clinical signs of lung cancer
1. Symptoms caused by the tumor:
Cough (alteration its character for dry and tiring)
Recurrences of pneumonia
Pain/discomfort of chest
Hemoptysis
Dyspnoea
2. Symptoms of the regional spread of the tumor:
Hoarseness (depending on the laryngeal nerve paralysis)
Superior vena cava syndrome
Dysphagia
Horner's syndrome - Pancoast tumor

20. Horner's syndrome
- Pancoast tumor

21. Superior vena cava syndrome

22. Superior vena cava syndrome

24. Clinical signs of lung cancer
3. General symptoms:
Weight loss
Weakness
Elevated body temperature unrelated to infection
4. Paraneoplastic syndromes:
Neurological syndromes
Endocrine syndromes (e.g. SIADH)
Symptoms from connective tissue
pulmonary osteoarthropathy
clubbed fingers
Dermatological symptoms
Hematological and vascular symptoms

25. Paraneoplastic syndrome – clubbed fingers

26. The diagnosis of lung cancer can be based on
cytology or histopathological material from respiratory system

27. Even the slightest problem with respiratory system
in the smoker of cigarettes
(more than 10 years)
leads to a suspicion of
lung cancer

28. Diagnosis Physical examination
Symptoms associated with worsening of airway function
Lymph nodes enlargement (especially in the supraclavicular area)
Symptoms of the presence of fluid in the pleural cavity
Signs of superior vena cava syndrome
Liver examination
Chest pain (during pressure)

29. Diagnosis Additional studies Chest X-ray (p-a and lateral)
Presence of a circular shadow
Changes in the contour of the hilus and/or mediastinum
Aeration of lung disorders (emphysema or atelectasis)
Infiltrative changes in the lungs
Bronchoscopy
Cytological examination of sputum, bronchoalveolar lavage, pleural effusion
Fine-needle aspiration biopsy
Endobronchial Ultrasound (EBUS)
Fluorescence bronchofiberoscopy

38. No changes in x-ray

39. No changes in x-ray

41. Diagnosis (more invasive)
Videothoracoscopy
Mediastinoscopy
Thoracotomy

42. Diagnosis - Staging Studies to determine the stage
Physical examination
Bronchoscopy
Chest X-ray
Abdominal ultrasound
Computer tomography of chest
Mediastinoscopy
CT of brain
Bone scintigraphy
Bone marrow aspiration biopsy of iliac
PET

43. CLINICAL EVALUATION OF STAGING
T - tumor
N - nodes
M – metastases
staging → treatment → prognosis

44. PROGNOSIS IA — 50% 38% IB — 47% 21% IIA — 36% 38% IIB — 26% 18%
5-year survival:
IA — 50% 38%
IB — 47% 21%
IIA — 36% 38%
IIB — 26% 18%
IIIA — 19% 13%
IIIB — 7% 9%
IV — 2% 1%
NSCLC SCLC

45. T - tumor
From:

46. T1a T1b

47. T2a T2b

48. T3 .

49. T4

50. N - nodes
From:

51. N N1

52. N2

53. N3

54. M1a

55. M1b

56. Clinical Stages of Lung Cancer
Stage IA T1 N0 M0
Stage IB T2a N0 M0
Stage IIA T1 N1 M0, T2b N0 M0, T2a N1 M0
Stage IIB T2b N1 M0, T3 N0 M0
Stage IIIA T1 N2 M0, T2 N2 M0, T3 N1 M0, T3 N2 M0, T4 N0 M0, T4 N1 M0
Stage IIIB anyT N3 M0, T4 N2 M0,
Stage IV anyT anyN M1
inoperative

57. PROGNOSIS IA — 50% 38% IB — 47% 21% IIA — 36% 38% IIB — 26% 18%
5-year survival:
IA — 50% 38%
IB — 47% 21%
IIA — 36% 38%
IIB — 26% 18%
IIIA — 19% 13%
IIIB — 7% 9%
IV — 2% 1%
NSCLC SCLC

58. Clinical Stages

59. Karnofsky scale Zubrod scale
Before choosing a method of treatment we use the patient's performance scales
Karnofsky scale
Zubrod scale

61. Chemotherapy (most cases)
Treatment of SCLC
Chemotherapy (most cases)
PE cisplatin, etoposide
CAV cyclophosphamide, doxorubicin, vincristine
TOP topotecan
Chemoradiotherapy
= chemotherapy + radiotherapy (a little better effect but worse tolerance)

62. Treatment of SCLC Radiotherapy
if tumor not respond to the chemotherapy
after chemotherapy (as a complement)
elective irradiation of the brain (as a prophylaxis)

63. Effects of chemoterapy

65. The most effective treatment : operation
Treatment of NSCLC
The most effective treatment : operation
but only about 20% patients eligible
Chemotherapy
Neoadjuvant chemotherapy (pre-operative)
Adjuvant chemotherapy (post-operative)
Paliative chemotherapy (most cases)

66. Treatment of NSCLC Chemotherapy protocols (examples):
PN cisplatin, vinorelbine
PG cisplatin, gemcytabine
DOC docetaxel
PEM pemetrexed

67. New drugs – Target therapy
Erlotinib (Tarceva) – cellular tyrosine kinase inhibitor directed against the EGFR (epidermal growth factor receptor)
Gefitinib (Iressa) - cellular tyrosine kinase inhibitor directed against the EGFR
Bevacizumab (Avastin) – monoclonal antibody that inactivates free VEGF (vascular endothelial growth factor)

68. Treatment of NSCLC Radiotherapy
Radical radiotherapy (CS I-II-IIIA, if surgery not possible)
Three-dimensional conformal radiation therapy (3D-CRT)
Intensity modulated radiation therapy (IMRT)
Stereotactic body radiation therapy (SBRT)
Stereotactic radiosurgery (SRS)
Paliative radiotherapy – for symptom control:
hemoptysis
chest pain
superior vena cava syndrome
dysphagia
Post-operative radiotherapy (when neoplasmatic infiltration of the surgical incision line)