1. Lung Cancer
Jamal Turki, M.D

2. The term lung cancer, or bronchogenic carcinoma, refers to malignancies that originate in the airways or pulmonary parenchyma
Lung cancer is among the most common cancers worldwide
Lung cancer is the leading cause of cancer-related mortality in both men and women 

3. Epidemiology
In the United States, lung cancer is the second most common cancer, after prostate cancer in men and breast cancer in women, and the most common cause of cancer deaths.

4. Cancer Deaths in U.S. (2007 American Cancer Society Data)
Lung
160,390
Colorectal
52,180
Breast
40,910
Prostate
27,050

5. RISK FACTORS
Smoking  —account for approximately 90 percent of all lung cancers 
The risk of developing lung cancer for a current smoker of one pack per day for 40 years is approximately 20 times that of someone who has never smoked
prevention :In individuals who do quit smoking, the risk of developing lung cancer gradually falls for about 15 years before it levels off and remains about twice that of someone who never smoked

6. RISK FACTORS
Environmental toxins — These include exposure to second-hand smoke, asbestos, radon, metals (arsenic, chromium, and nickel), ionizing radiation, and polycyclic aromatic hydrocarbons
Pulmonary fibrosis — Several studies have shown that the risk for lung cancer is increased about sevenfold patients with pulmonary fibrosis
HIV infection —
Genetic factors — Genetic factors can affect both the risk for and prognosis
Dietary factors — Epidemiologic evidence has suggested that various dietary factors (antioxidants, cruciferous vegetables, phytoestrogens) may reduce the risk of lung cancer

7. Asbestosis & Lung Cancer (2007 American Cancer Society Data)
Prolonged heavy exposure has relative risk between of causing lung cancer.
Peak incidence years after exposure.
Fiber type is important:
Crocidolite & amosite > chrysotile & anthophyllite.

8. SCREENING
Guidelines : Annual screening with low-dose computed tomography (LDCT) scanning to patients aged 55 to 74 years and who have at least a 30 pack-year smoking history and either continue to smoke or have quit within the past 15 years.

9. PATHOLOGY Adenocarcinoma :40 % , Non-smokers
Peripheral, Preexisting scars, Bronchoalv.
Squamous cell carcinoma- 25%, smokers, central, Hypercalcemia, cavitation
Large cell carcinoma: 5 %
Small cell carcinoma: 15 %
Others 15%

10. CLINICAL MANIFESTATIONS
Persons aged years. 
Lung cancer is more common in men than in women.
Symptoms may result from local effects of the tumor, from regional or distant spread, or from distant effects not related to metastases (paraneoplastic syndromes).
Approximately three-fourths of patients have one or more symptoms at the time of diagnosis.

11. Cough  — Cough is present in 50 to 75 percent of lung cancer patients at presentation 
Squamous cell and small cell carcinomas
Bronchorrhea
Post-obstructive pneumonia
bronchiectasis is uncommon 

12. Hemoptysis : 25 to 50 percent of patients
Chest pain : same side of the chest as the primary tumor. Dull, aching, persistent pain 
Dyspnea : 25 percent of cases
obstructive pneumonitis
Atelectasis
Lymphangitic tumor spread
Pneumothorax
Pleural effusion
Pericardial effusion 

13. Hoarseness : recurrent laryngeal nerve 
Pleural involvement :typically exudates
The yield of pleural fluid cytology after a single thoracentesis is about 60 percent, and the yield rises to 85 percent with three thoracenteses 

15. Superior vena cava syndrome :sensation of fullness in the head and dyspnea. Cough, pain, and dysphagia, Physical findings include dilated neck veins, a prominent venous pattern on the chest, facial edema, and a plethoric appearance, more common in patients with SCLC than NSCLC

17. Pancoast's syndrome :pain (usually in the shoulder, and less commonly in the forearm, scapula, and fingers), Horner's syndrome, bony destruction, and atrophy of hand muscles. 

18. Horner’s Syndrome miosis (constriction of the pupils),
anhidrosis (lack of sweating), 
ptosis (drooping of the eyelid)
enophthalmos (sunken eyeball)

19. Extrathoracic metastases
Liver 
Bone 
Adrenal 
Brain 

20. Paraneoplastic phenomena
Hypercalcemia:bony metastasis or secretion of a parathyroid hormone-related protein (PTHrP), calcitriol or other cytokines
SIADH secretion :SCLC, Hyponatremia
Neurologic: SCLC. Lambert-Eaton myasthenic syndrome (LEMS), cerebellar ataxia, sensory neuropathy, limbic encephalitis, encephalomyelitis, autonomic neuropathy, retinopathy, and opsomyoclonus

21. Hematologic manifestations  — These include the following:
Anemia — Anemia is frequent in patients with lung cancer and can contribute to fatigue and dyspnea
Leukocytosis — granulocyte-colony stimulating factor
Thrombocytosis
Eosinophilia
Hypercoagulable disorders

22. Hypertrophic osteoarthropathy :clubbing and periosteal proliferation

23. Diagnosis and staging HISTORY AND PHYSICAL EXAM
LABORATORY TESTING: complete blood count, serum electrolytes, calcium, alkaline phosphatase, albumin, (ALT), (AST), total bilirubin, and creatinine 

24. DIAGNOSIS Chest radiographs may show the following:
Pulmonary nodule, mass, or infiltrate
Mediastinal widening
Atelectasis
Hilar enlargement
Pleural effusion

25. Lung Cancer: Findings on Chest X-ray
Nodule (< 3cm) vs. Mass (>= 3cm).
Location:
Peripheral (Adenocarcinoma) vs.
Central (Squamous).
Single or multiple (metastases).
Endobronchial obstruction.
Atelectasis of lobe or lung.
Pneumonia.

26. IMAGING 
All patients with suspected NSCLC should undergo contrast-enhanced computed tomography (CT) that extends through the lungs, liver, and adrenal glands. CT is ideal for tumor node metastasis (TNM) staging
It can characterize the primary tumor and define its relationship to the chest wall and mediastinal structures
It can identify mediastinal lymph nodes that are enlarged and suspicious for malignant involvement
It can detect contralateral lung, chest wall, or upper abdominal lesions that are suspicious for metastasis

34. TISSUE SAMPLING 
Primary tumor  — There are several options for sampling a primary tumor depending on the location:
Conventional flexible bronchoscopy with forceps biopsy, blind transbronchial fine needle aspiration (TBNA), or both
CT guided TTNA
Pleural Tap
Secondary Tumor

35. BRONCHOSCOPY

39. CT Guided TTNA

40. Common Paraneoplastic Syndromes: Syndrome Frequent Histology
Hypercalcemia
SIADH
Cushing’s Syndrome
Eaton-Lambert
Squamous Cell
Small Cell

42. Lymph nodes 
Pleural effusion  
Adrenal nodule

44. STAGING
Based upon this initial evaluation, most patients require additional imaging. This may include whole body positron emission tomography (PET), integratedCT/PET, bone scanning, magnetic resonance imaging (MRI) of the chest wall or brain, and/or CT of the brain.

45. Staging for NSCLC : TNM classification
Tumor size, L.Ns, Metastasis
Staging of SCLC uses the Veterans Administration Lung Study Group designations of limited (confined to one hemithorax) or extensive (beyond one hemithorax)

46. Treatment 
Surgery
Chemotherapy
Radiation therapy

48. Treatment
 Surgical resection offers the best opportunity for long-term survival and cure in patients with resectable NSCLC:
Lobectomy
Resectability
Operability

49. Non Small Cell Lung Cancer Contraindications to Surgical Resection
Stage IIIB or IV.
Extensive invasion into surrounding structures:
Vena cava or atrium involvement.
Recurrent laryngeal or phrenic nerve involvement.
SVC obstruction, malignant effusion, pericardial tamponade.
Contralateral lymph nodes.

50. Non Small Cell Lung Cancer Contraindications to Surgical Resection
Medically unfit:
Poor cardiac or pulmonary status.
Predicted postoperative FEV1% < 40%.
Predicted postoperative DLCO% < 40%.
Exercise studies for marginal candidates.

51. 1. PREOPERATIVE PULMONARY FUNCTION :
>Spirometry : preop FEV 1 (<60 percent predicted)
>Diffusing capacity

52. Lung Function to determine Operability
Guidelines from the American College of Chest Physicians and the British Thoracic Society suggest that patients with a preoperative FEV 1 in excess of 2 L (or >80 percent predicted) generally tolerate pneumonectomy, whereas those with a preoperative FEV 1 greater than 1.5 L tolerate lobectomy

53. 2. PREDICTED POSTOPERATIVE PULMONARY FUNCTION :  a combination of spirometry and quantitative perfusion lung scanning 
 Guidelines from the American College of Chest Physicians consider a patient to be at increased risk for lung resection with predicted postoperative values for either FEV 1 or DLCO <40 percent predicted 

54. 3. MEASUREMENT OF GAS EXCHANGE Arterial PO2 Arterial PCO2

55. 4. EXERCISE TESTING

56. REGIMENS Carboplatin plus docetaxel Carboplatin plus pemetrexed
Cetuximab, vinorelbine, and cisplatin  
Cisplatin plus pemetrexed  
Gemcitabine plus carboplatin  
Gemcitabine plus cisplatin (GC)  
Paclitaxel carboplatin  
Paclitaxel, carboplatin, and bevacizumab  
Vinorelbine plus cisplatin  

57. RADIOTHERAPY
SYMPTOM PALLIATION :Short courses of radiation therapy are useful for patients who require symptom palliation. This may include symptoms arising from progressive intrathoracic disease or disease at other sites (eg, bone, brain).

58. PALLIATIVE CARE
Shortness of breath
Pain
Psychological Impairment

59. Prognosis of NSCLC Stage of disease
Clinical parameters :Performance status , Ethnicity 
Histopathology
Molecular characterization :(EGFR), KRas
PET and PET-CT: SUV number
Recurrence after complete resection 

60. In Europe, the 5-year overall survival rate is 11%
In Europe, the 5-year overall survival rate is 11%.  The highest recorded 5-year patient survival rates are observed in the United States. US data indicate that the 5-year relative survival rate for lung cancer was 17.4%, 

61. Estimated 5-year survival rates for specific stages of disease are as follows:
Stage IA - 75%
Stage IB - 55%
Stage IIA - 50%
Stage IIB - 40%
Stage IIIA %
Stage IIIB - Less than 5%
Stage IV - Less than 5%

62. THANK YOU