1. 1 Lung Cancer So what?

2. 2 Abbreviations Bx-biopsy CA-cancer Ca++ - serum calcium CBC-complete blood count CMP-comprehensive metabolic panel CP-chest pain CT-computerized tomography CXR-chest Xray DOE-Dyspnea on exertion DDX-differential diagnosis Dx-diagnosis Hx-history Na+ - serum sodium NSCLCA-non-small cell lung CA RML right middle lobe SCLCA-small cell lung CA SOB-shortness of breath SPN-solitary pulmonary nodule Sx-symptoms Tx-treatment UA-urinalysis Yr-year

3. 3 Case 1 52 Year old male who presents with slowly worsening DOE, vague CP, and weigh loss. Hx reveals long term occupation as auto mechanic specializing in brake work.

4. 4 Case 2 63 Year old scheduled for knee surgery who had a 1 cm “nodule” found on CXR during preoperative medical evaluation.

5. 5 Case 3 71 year old female smoker with unexplained weight loss and RML wheezing unresponsive to bronchodilators.

6. 6 Lung Cancer Objectives: –Recognize the most common types of lung cancer with respect to the following: Prevalence/epidemiology Pathology Presentation Diagnosis Staging Treatment philosophy Prognosis

7. 7 Objectives (Cont.) Recognize essential features distinguishing between the most common forms of lung masses including: –Solitary pulmonary nodule –Bronchogenic Carcinoid tumor –Small cell lung CA –Non small cell lung CA types

8. 8 Lung Cancer Cancer Defined: Progressive, uncontrolled multiplication of cells. (neoplasm or tumor) Cells lack differentiation Bronchogenic tumor –Arises from the respiratory epithelium –99% of all malignant lung tumors

9. 9 Epidemiology/Prevalence Leading cause of CA death in men and women worldwide – 1.2 million deaths 215,000 new cases and 162,000 deaths in the USA in 2007 (124k deaths from colorectal, breast, and prostate CA combined) Small cell constitutes about 15-20% of all lung cancers Non-small cell 80-85% –Adenocarcinoma is most prevalent NSC lung CA (NSCLCA) 97% > 35 years old

10. 10 Etiology Smoking –The most preventable risk factor –Accounts for 80-90% of all cases of bronchogenic CA Toxic exposures –Asbestos –Other Idiopathic

11. Lung Mass Malignant (Cancer) Benign Bronchogenic Nonbronchogenic Carcinoid Small cell Non small cell Mesothelioma Typical Atypical Squamous cell Adenocarcinoma Large cell

12. 12 Benign tumor Slow or very fast growing Usually encapsulated, well demarcated NOT invasive or metastatic

13. 13 Malignant tumors Composed of embryonic, primitive, or poorly differentiated cells Disorganized growth Nutritionally demanding (can find with PET scan- looks at metabolism of something) May develop anywhere in lung Commonly originate in tracheobronchial mucosa (bronchgenic carcinoma)

14. 14 Pathology associated with growth Surrounding airways and alveoli become irritated, inflamed and swollen Adjacent alveoli may fill with fluid and become consolidated or collapse Tumor protrudes into tracheobronchial tree Excretions common

15. 15 Pathology (cont.) May invade pleural space and/or mediastinum, chest wall, ribs, or diaphragm Frequent secondary pleural effusion Eventual airway obstruction, atelectasis, consolidation, cavitation

16. 16 Clinical manifestations- symptoms May be assymptomatic with incidental finding on CXR Cough-onset or change in nature of chronic cough Hemoptysis Vague non-pleuritic chest pain Dyspnea Recurrent / persistent pneumonia Weight loss / anorexia / asthenia

17. 17 Clinical manifestations-signs Nodule(s) on imaging study Exudative pleural effusion Endocrinopathies –Hyper Ca++, hypo Na+, Cushing’s syndrome Anemia Various coagulopathies Tracheal deviation “Fixed” wheeze Digital clubbing

18. 18 Diagnosis Clinical suspicion CXR Simple labs Chest CT Cytology - bronchoscopy Cytology – open Bx Cytology – pleural effusion

19. 19 Solitary pulmonary nodule Defined: –Single nodule –Round or ovoid –< 3 cm in diameter –Distinct margins –May have calcification, “satellite” lesions, central cavitation

20. 20 Solitary pulmonary nodule (cont.) Signs and symptoms –Most assymptomatic –Rare findings Hemoptysis Cough Clubbing Endocrinopathy (suggestive of malignancy)

21. 21 Solitary pulmonary nodule (cont.) So what about it? –60% benign –40% malignant >75% of these are primary lung CA –25% bronchogenic CA presents as SPN >50% 5 yr survival

22. 22 Solitary pulmonary nodule (cont.) Preop decision: benign vs. malignant –Imaging and comparison with old studies –Almost always benign if: Doubling time 500 days Calcified –Likely benign if: Pt is young Assymptomatic <2 cm in diameter Smooth margins on CT Satellite lesions present

23. 23 Solitary pulmonary nodule (cont.) –Features of malignant SPN Symptomatic Pt >45 yrs old >2 cm Indistinct margins - spiculation Rarely calcified

24. 24 Solitary pulmonary nodule (cont.) –Features of metastatic SPN Smooth / lobulated margins Located peripherally Tends to occur in lower lobe Absence of satellite lesions Uncommon to be “solitary”

25. 25 Solitary pulmonary nodule (cont.) Diagnosis –CT –Simple labs CBC CMP UA –Excision/Bx

26. 26 Solitary pulmonary nodule (cont.) Tx –The presence of a SPN warrants discussion with the attending physician Course of action should never be yours alone –Watchful waiting if: Documented stable x 2 yrs Calcification on CT –Otherwise: Resect

27. 27 Types of Lung Cancer –Bronchogenic-arise from respiratory epithelium Carcinoid Small cell Non-small cell –Adenocarcinoma –Squamous cell carcinoma –Large cell carcinoma Dx of exclusion –Non-bronchogenic-arise from the pleura Mesothelioma

28. http://emedicine.medscape.com/article/426400-overview28 Bronchial carcinoid tumor Typical –Highly differentiated –Low grade malignant neoplasm –Tend to occur as sessile (or occasionally as pedunculated) growths in central bronchi –Pts. < 60 yrs old –Frequently assymptomatic –Sx (typically associated with obstruction & vascular nature): Hemoptysis Cough Wheezing Recurrent pneumonias Carcinoid syndrome (occurs in approx 2% of pulmonary carcinoids)

29. http://emedicine.medscape.com/article/426400-overview29 Bronchial carcinoid tumor Atypical –10% of bronchial carcinoid tumors –More aggressive than “typical” carcinoid –More likely to metastasize –Differentiated by biopsy

30. 30 Bronchial carcinoid tumor (cont) Tx: –Surgery with resection Only curative tx

31. 31 Small-Cell Carcinoma Originates centrally in bronchial epithelium Seen in 15-20% of bronchogenic cases Grows rapidly and submucosally

32. 32 Small-Cell Carcinoma (cont.) Metastasizes early Doubling time approx 30 days Cells commonly compressed into oval shape (oat cell) Commonly found near hilum

33. 33 Non Small Cell Lung CA (NSCLCA) Adenocarcinoma Squamous cell carcinoma Large cell carcinoma

34. 34 Adenocarcinoma Most common bronchogenic CA (35-40% of cases) Common in non-smokers Originates in mucous glands of tracheobronchial tree Glandular configuration Mucus production

35. 35 Adenocarcinoma (cont.) Moderate growth Moderate metastatic rate Doubling time approx 180 days Commonly found in peripheral lung parenchyma Cavitation common

36. 36 Squamous (epidermoid) cell carcinoma Second most common bronchogenic CA (25-35% of cases) Originates in basal cells of bronchial epithelium Frequently presents w/ hemoptysis Grows relatively rapidly

37. 37 Squamous (epidermoid) cell carcinoma (cont.) Frequently project in bronchi Late metastatic tendency Doubling time approx 100 days Commonly found in large bronchi near hilum

38. 38 Large-cell carcinoma Lacks glandular or squamous differentiation Found peripherally or centrally Rapid growth Early metastasis Doubling time approx 100 days Cavitation common Seen in 15-35% of bronchogenic cases

39. 39 Staging - Small cell lung CA StageDefinition2 Yr. Survival Limited stageTumor confined to the same20% diseaseside of the chest, supraclavicular lymph nodes, or both Extensive Defined as anything beyond 5% stage Diseaselimited stage UNTREATED OVERALL SURVIVAL: 6-18 WEEKS

40. 40 TNM Staging (Non-small cell) T: Tumor N: Regional Lymph Nodes M: Metastasis

41. 41 T: Tumor TX: Unassessable. –Presence in washings or sputum but not visualized T0: No evidence of primary tumor T1: No local tissue invasion (in situ) a.k.a.: Tis

42. 42 T: Tumor (cont.) T2: Any of the following: –>3 cm in greatest dimension –Involves main bronchus, >/= 2 cm distal to the carina –Invades visceral pleura –Assoc with atelectasis or obstructive pneumonitis that extends to hilum but does not involve the entire lung

43. 43 T: Tumor (cont.) T3: –Any size tumor that invades: Chest wall Diaphragm Mediastinal pleura Parietal pericardium –Or: In main bronchus <2 cm from carina but not in carina –Or: Assoc atelectasis or obstructive pneumonitis of entire lung

44. 44 T: Tumor (cont.) T4: A tumor of any size that invades any of the following: –Mediastinum –Heart –Great vessels –Trachea –Esophagus –Vertebral body –Carina Or: Separate nodules in same lobe Or: With malignant pleural effusion

45. 45 N: Regional lymph nodes NX: Nodes cannot be assessed N0: No regional node metastasis N1: Mets in ipsilateral peribronchial and/or hilar nodes N2: Mets in ipsilateral mediastinal and/or subcarinal nodes N3: Mets in contalateral mediastinal, hilar, ipsi/contralateral scalene or supraclavicular nodes

46. 46 M: Distant Metastases MX: Distant mets cannot be assessed M0: No distant mets M1: Distant mets present - includes separate nodules in different lobe (ipsilateral or contralateral)

47. 47 Staging - non-small cell lung CA StageDefinition5 year survival 1AT1, N0, M061% 1BT2, N0, M038% 2AT1, N1, M034% 2BT2, N1, M0 / T3, N0, M024-22% 3AT3, N1, M013% or T1-T3, N2, M0 3BT4, any N, M05% or any T, N3, M0 4any T, any N, M11% OVERALL 5 YEAR SURVIVAL: 15%

48. 48 Mesothelioma Arise from mesothelial cells of: –Lung pleura (80%) –Peritoneum (20%) Assoc. with asbestos exposure (20-40 yrs prior)

49. 49 Mesothelioma (cont) Sx: –DOE followed by SOB –Non-pleuritic chest pain (take a breath and it doesn’t change) –Weight loss (metabolism) Findings: –Dull percussion –  breath sounds –Pleural thickening on CXR or CT –Exudative effusion

50. 50 Mesothelioma (cont) Tx: –Drainage of effusions –None to limit progression Prognosis: –5-16 months survival from onset of sx –75% dead 1 yr from dx

51. 51 Patient Education So, What do you tell your patients? –How about, “DON’T SMOKE!”

52. 52 So, What about the types we didn’t discuss? What about the types you forgot? What will YOU do?

53. 53 Remember the cases? 52 Year old male who presents with slowly worsening DOE, vague CP, and weigh loss. Hx reveals long term occupation as auto mechanic specializing in brake work. 63 Year old scheduled for knee surgery who had a 1 cm “nodule” found on CXR during preoperative medical evaluation. 71 year old female smoker with unexplained weight loss and RML wheezing unresponsive to bronchodilators.

54. 54 Treatment In A Nutshell Highly variable –Surgery (resection) –Radiation –Chemotherapy Cure unlikely without resection –Is surgery feasible? –Can the patient tolerate surgery?

55. 55 A Few parting thoughts… When you think you need to consider cancer in your DDx: –Be very careful in the words that you choose with your patient Don’t ever volunteer the word “cancer” until/unless you KNOW it’s cancer If the patient asks if it could be cancer before you know, don’t lie; but focus on alternative possibilities

56. 56 A Few parting thoughts… When you know it’s cancer –Know that your patient is depending on you Meet face-to-face and be upfront: DO use the word cancer Immediately offer what hope that really exists Arrange short term follow-up or oncology visit to discuss options Tailor discussion to the patient and situation Stress patient control