1. LUNG CANCER * Carcinoma of the lung is the leading cause of cancer death in USA. * 171900 new cases in 2003=12.8% of total new cases. *5-year survival rate for the lung remains 14% in USA,8%in China and Europe. *Factors: tabacco smoking,COPD,arsenic, asbestos,beryllium,Chromium, Nickel, Polycyclic aromatics, Hydrocarbon compounds, Radon, Silica, Formaldehyde, Synthetic fiber, Vinyl chloride, chronic lung infections.

2. Investigation for lung cancer  Chest X-ray,  Thoracic CT,  Fiberbronchoscopy,with biopsy,  Fine-needle aspiration from a pulmonary nodules,  Ultrasonography – pulmonary/abdominal.  PET,  Mediastinoscopy for mediastinal limph nodes,  VATS for diagnosis of small pulmonary nodules.

3. Clinical presentation of lung cancer  Cough, 29-87%  Hemoptysis- 9-57%  Chest pain 6-60%  Dyspnea 3-58%  Wheezing or stridor 2-14%  Pleural effusion 7%  Dysphagia 2%  Superior vena cava syndrome 4-11%  Pancoast syndrome 3-5%  Phrenic nerve paralysis 1%

4. Symptoms from metastatic disease  Bone metastases: bone pain in hands,feet.  Neurologic metastases:central nervous system,spinal cord compression secondary to epidural or vertebral mts.  Adrenal mts,  Liver mts,  Others sites:soft tissue,etc.

5. Paraneoplastic syndromes  Metabolic: - hypercalcemia, - hypercalcemia, - Cushing syndrome, - Cushing syndrome, - carcinoid syndrome, - carcinoid syndrome, -gynecomastia, -gynecomastia, -elevated growth hormone level,prolactin,follicle- stimulating hormone,luteinizing hormone,antidiuretic hormone production. -elevated growth hormone level,prolactin,follicle- stimulating hormone,luteinizing hormone,antidiuretic hormone production. - hypoglicemia, - hypoglicemia, -hypertiroidism -hypertiroidism

6. Paraneoplastic syndomes  Neurologic -encephalopathy, -encephalopathy, - subacute cerebrall degeneration - subacute cerebrall degeneration - peripheral neuropathy, - peripheral neuropathy, - polymiosytis, - polymiosytis, - autonomic neuropathy, - autonomic neuropathy, - myoclonus. - myoclonus.

7. Paraneoplastic syndromes  Skeletal - clubbing - clubbing - pulmonary hypertrophic osteoartropathy - pulmonary hypertrophic osteoartropathy  Hematologic - anemia, - anemia, -leukemoid reactions -leukemoid reactions -trombocytosis, -trombocytosis, -trombocytopenia, -trombocytopenia, -eosinophilia, -eosinophilia, -pure red cell aplasia, -pure red cell aplasia, -disseminated intravascular coagulation -disseminated intravascular coagulation

8. Paraneoplastic syndromes  Cutaneous and muscular - hyperkeratosis, - hyperkeratosis, - dermatomyositis, - dermatomyositis, - acanthosis nigricans, - acanthosis nigricans, -erytremia gyratum repens, -erytremia gyratum repens, - hypertricosis lanuginosa acquisita - hypertricosis lanuginosa acquisitaOther -nephrotic syndrome, -nephrotic syndrome, -hypouricemia, -hypouricemia, -hyperamylasemia, -hyperamylasemia, -anorexia-cachexia. -anorexia-cachexia.

9. Diagnosis and staging of lung cancer  Diagnosis : sputum cytology, fiberoptic bronchoscopy, VATS,CT,Xr Transthoracic fine-needle aspiration Indication 1.Patient is a high operative risk, 2.Patient hjas a low risk of malignancy based on clinical and radiologic characteristics. 3. A definite benigne diagnosis is considered likely, 4. The patient prefers to have a diagnosis of cancer before proceeding to the operating room. 5.Patient is not an operative candidate, but tissue confirmation is needed before definitive treatment with radiation therapy or chemotherapy or both.

10. Characteristics of solitary pulmonary nodules predicting malignancy  Radiologic characteristics - diameter>2cm, - diameter>2cm, - spiculation present, - spiculation present, - upper lobe location - upper lobe location Clinical characteristics - age>40 years - age>40 years - positive smoking history - positive smoking history History of other cancer

11. Radiographic features  Early signs of a lung tumor are as follows:  1.a density within the lung parenchima,  2. a cavitary mass,  3. a segmental, indistinct, poorly defined dense area,  4. a nodular streaked, local infiltration along the course of a blood vesel,  5. segmental consolidation,  6 a roughly triangular lesion arising in the apex and extending toward the hilus,  7. a mediastinal mass,  8.an enlargement of one hilus,  9. segmental or lobar obstructive emphysema,  10. segmental atelectasis.

12. Chest radiographic presentations of lung cancer  Pulmonary nodule<3 cm in size,  Pulmonary or hilar mass,  Pulmonary opacities(lobar, segmental, subsegmental),  Tracheal or bronchial intraluminal opacity, luminal narrowing or chest wll thickening,  Atelectasis (lung, lobar, segmental, subsegmental)  Pulmonary cavitary lesion,  Air trapping(hyperinflation)  Mediastinal mass,  Pleural lesion,  Pleural effusion,  Pericardial effusion (enlarged cardiac silhouette),  Elevated hemidiaphragm(paralysis or paresis),  Chest wall mass or bone metastases.

13. Classification of lung carcinoma  Squamous cell carcinoma,  Small cell carcinoma - pure small cell carcinoma, - pure small cell carcinoma, - small- large cell carcinoma, - small- large cell carcinoma, - combined small cell carcinoma (with areas of squamous or glandular differentiation), - combined small cell carcinoma (with areas of squamous or glandular differentiation),  Adenocarcinoma - variant: bronchioloalveolar carcinoma, - variant: bronchioloalveolar carcinoma,  Large cell carcinoma,  Adenosquamous carcinoma.

14. TNM Definition  TNM classification Primary tumour (T) TxPrimary tumour cannot be assessed or tumour proven by the presence of malignant cells in sputum or bronchial washings but not visualised by imaging or bronchoscopy  T0No evidence of primary tumour  TisCarcinoma in situ  T1Tumour <3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus  T2Tumour with any of the following features of size or extent: >3 cm in greatest dimension involves main bronchus >2 cm distal to the carina invades the visceral pleura associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung

15.  T3Tumour of any size that directly invades the following: chest wall (including superior sulcus following: chest wall (including superior sulcus tumours), diaphragm, mediastinal pleura, parietal tumours), diaphragm, mediastinal pleura, parietal pericardium; or tumour in the main bronchus <2 pericardium; or tumour in the main bronchus <2 cm distal to the carina but without involvement of cm distal to the carina but without involvement of the carina; or associated atelectasis or obstructive the carina; or associated atelectasis or obstructive pneumonitis of the entire lung pneumonitis of the entire lung T4Tumour of any size that involves any of the T4Tumour of any size that involves any of the following: mediastinum, heart, great vessels, following: mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina; or tumour with a malignant pleural or pericardial effusion, or with satellite tumour nodule(s) within the ipsilateral primary tumour lobe of the lung

16. Stage Grouping for Lung Cancer  Regional lymph nodes (N)  NxRegional lymph nodes cannot be assessed  N0No regional lymph node metastases  N1Metastases to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes involved by direct and intrapulmonary nodes involved by direct extension of primary tumour extension of primary tumour  N2Metastases to ipsilateral mediastinal and/or subcarinal lymph nodes  N3Metastases to contralateral mediastinal, contralateral hilar, ipsilateral or contralateral contralateral hilar, ipsilateral or contralateral saclene or supraclavicular lymph nodes saclene or supraclavicular lymph nodes

17.  Distant metastases (M)  Mx Presence of distant metastases cannot be assessed  M0 No distant metastases  M1Distant metastases present  Stage grouping TNM subsets  0Carcinoma in situ  IA T1N0M0 IB T2N0M0  IIA T1N1M0 IIB T2N1M0 T3N0M0  IIIA T3N1M0 T1N2M0 T2N2M0 T3N2M0  IIIB T4N0M0 T4N1M0 T4N2M0 T1N3M0 T2N3M0 T3N3M0 T4N3M0  IV Any T Any N M1

18. Algoritm for therapy in lung cancer  NSCLC  Comprehensive clinical evaluation Clinical examination negative - Chest CT *T4 = 1. defined *T4 = 1. defined 2. indeterminate : VATS surgery. 2. indeterminate : VATS surgery. ** LN Positive = sample LN= a)N2 Positive- unresectable ** LN Positive = sample LN= a)N2 Positive- unresectable and induction protocol b)N3 Positive- unresectable and induction protocol b)N3 Positive- unresectable *** LN Negative = Surgery *** LN Negative = Surgery

19.  Clinical examination positive suspect M1. *Organ specific= specific scan=a) negative scan =follow chest CT sequence, b) positive scan= treat M1. **Organ nonspecific findings= scan succesive organs= a)negative scan= follow chest CT sequence, b) positive scan= treat M1. b) positive scan= treat M1.