1. Lung Cancer

2. Lung Cancer: Epidemiology 173,770 new cases and160,440 deaths 2004 More deaths from lung cancer than prostate, breast and colorectal cancers combined Number one cause of cancer deaths in the United states in both men and women Decreasing incidence and deaths in men; continued increase in women Incidence and mortality rates higher for African Americans than white Americans

3. Lung Cancer in Women Incidence (80,660 new cases in 2004) Account for 12 percent of all new cases Deaths increased 150% between 1974 and 1994 (68,510 in 2004) More deaths from lung cancer than breast, ovarian and uterine cancers combined Women are more susceptible to tobacco effects - 1.5 times more likely to develop lung cancer than men with same smoking habits

4. Lung Cancer: Etiology Cigarette smoking Accounts for 80-90% of cases. Risks related to: Number of cigarettes per day Age started smoking Number of years smoked Inhalation practices Content of tar/nicotine

5. Lung Cancer: Etiology Risk of Lung cancer starts declining 5 years after permanent smoking cessation, but never reaches level of a lifelong non-smoker. Other Risk Factors: Other inhaled tobacco—pipes, cigars, passive smoking COPD—even when controlled for cigarette consumption Asbestos– weak carcinogen alone, but synergistic when combined with cigarette smoking. (no link to smoking and mesothelioma)

6. Lung Cancer Occupational Risk Factors Arsenic Asbestos Beryllium Cadmium Chloromethylethers Chromium Nickel Polycyclic aromatic compounds Radon Silica Vinyl Chloride Any chronic interstitial lung disease Smoking potentates the risk for any of the above

7. Lung Cancer: Screening No proven effective screening tool Chest X-ray commonly used Clinical trials: Low dose spiral chest CT scan Sputum analysis Chest X-ray

8. Lung Cancer: Presentation I. Asymptomatic– 10% Screening—not recommended currently Incidental finding on CXR II. Symptomatic – 90% 1. Intrathoracic signs and symptoms Cough Dyspnea, and phrenic nerve paralysis Hemoptysis Dysphagia, and Hoarsness Pleural effusion 2. Metastatic disease  Seizures, Bone Pain, Pathologic fractures

9. Lung Cancer: Presentation Syndromes/Symptoms secondary to regional metastases: Esophageal compression  dysphagia Laryngeal nerve paralysis  hoarseness Symptomatic nerve paralysis  Horner’s syndrome Cervical/thoracic nerve invasion  Pancoast syndrome Lymphatic obstruction  pleural effusion Vascular obstruction  SVC syndrome Pericardial/cardiac extension  effusion, tamponade

10. Pathology of Lung Cancer Non-Small Cell Carcinoma---80% of cases Squamous Adenocarcinoma Large Cell Combined types (adenosquamous) Small Cell Carcinoma—20% of cases

11. Squamous Cell Carcinoma Occurs centrally, often endobronchial lesion Commonly cavitates Associated with hypercalcemia. (PTH-like peptide)

12. Adenocarcinoma Most common cell type Usually peripheral Often a Solitary Pulmonary Nodule Cell type least associated with smoking (30% have no smoking link)

13. Large Cell Carcinoma

14. Small Cell Carcinoma Occurs Centrally, Bulky mediastinal mass Aggressive metastasis early---often systemic at time of Dx. Cell type most often associated with Paraneoplastic syndromes Strong Link to smoking

15. Superior Vena Cava Syndrome Right upper lobe mass that invades, compresses and obstructs the SVC SX: swelling of head and arms, dyspnea, headache, anxiety Causes: lung ca #1, lymphoma #2, other malignant or benign causes TX: radiation therapy is mainstay; combination chemotherapy for SCLC

16. Superior Vena Cava Syndrome

17. Superior Sulcus Tumor (Pancoast) Apical lung tumor with: Pain—arm, shoulder, scapula Atrophy of hand muscles Swelling of the arm Horner’s syndrome Miosis, anhydrosis, ptosis Tx: Pre-op XRT, plus surgery

18. Solitary Pulmonary Nodule Spherical, oval or lobulated intrapulmonary x-ray abnormality located in the middle or lateral one third of the lung and surrounded by normal parenchyma. (<3cm in size )

19. Solitary Pulmonary Nodule Factors favoring a benign etiology Smaller size, <3 cm Sharp boarders Younger age of pt Never-smoker Very short ( 2 yr Patterns of calcification-- best evaluated by CT Benign: Central, Laminated, popcorn, Stippled, Eccentric, & diffuse my be benign or malignant

20. Lung Cancer: Paraneoplastic Syndromes Non Small Cell Lung Cancer Hypercalcemia—squmous cell ^PTH Hypertrophic pulmonary Osteodystrophy Small Cell Lung Cancer SIADH Cushings--^ectopic ACTH Eaton-Lambert—Presynaptic Ca channels  Anorexia/Cachexia with all cell types

21. Lung Cancer: Staging Workup Diagnostic tests Chest x-ray Biopsy (bronchoscopy, needle biopsy, surgery)—pathologic confirmation Staging tests CT chest/abdomen/brain Bone scan Bone marrow aspiration PET scan CBC, electrolytes, ca, alk-phos, albumin, AST, ALT, Bili, Cr on all pts.

22. Lung Cancer: Prognostic Factors STAGE OF DISEASE IS THE SINGLE MOST IMPORTANT DETERMINANT OF SURVIVAL!!! Other prognostic factors Performance status (Karnofsky scale) Weight loss (<10% worse Px) Age (> 70 worse Px)

23. NSCLC: TNM Staging Stage Ia T1N0M0 Ib T2N0M0 IIa T1N1M0 IIb T2N1M0 T3N0-1M0 IIIa T1-3N1M0 IIIb Any T4any N3M0 IV Any M1 T = T1 3cm + atelectasis, T3 extension to pleura, chest wall, pericardium or total atelectasis), local involvement T 4 invasion of mediastinum or pleural effusion N = N1= bronchopulmonary, N2 =ipsilateral mediastinal and N3= contralateral or supraclavicular M = absence (M0) or presence (M1) of metastases

24. NSCLC: Treatment Surgery Mediastinoscopy Video-assisted Thoracoscopy (VAT) Thoracotomy: Lobectomy. Pneumonectomy Radiation External Beam Brachytherapy

25. NSCLC: Treatment Chemotherapy Standard Cisplatin, Carboplatin Newer agents: Gemcitabine, Paclitaxel, Docetaxel, Vinorelbine, Irinotecan used alone and in combination

26. NSCLC: Treatment by Stage StageDescriptionTreatment Options Stage I a/b Tumor of any size is found only in the lung Surgery Stage II a/b Tumor has spread to lymph nodes associated with the lung Surgery Stage III a Tumor has spread to the lymph nodes in the tracheal area, including chest wall and diaphragm Chemotherapy followed by radiation or surgery Stage III b Tumor has spread to the lymph nodes on the opposite lung or in the neck Combination of chemotherapy and radiation Stage IV Tumor has spread beyond the chest Chemotherapy and/or palliative (maintenance) care

27. NSCLC: Treatment Outcomes Stage I II IIIa IIIb IV 5- Year Survival 60-80% 40-50% 25-30% 5-10% <1%

28. Pre-operative Pulmonary Assessment Spirometry FEV1 >2.0 L MVV> 50% Quantitative Lung Perfusion Scan PPO FEV1 >.8 L and 40% predicted High Risk, possibly Prohibitive Consider Exercise Study VO2 max> 20ml/kg/min=low risk 10-20 = mod risk <10ml/kg/min = prohibitive ABG PaO2<60 PaCO2>45 FEV1 >60% predicted Surgery No Yes No Yes No

29. Small Cell Lung Cancer (SCLC) Most aggressive lung cancer—almost always metastatic at time of Dx. All pt’s receive extensive staging workup + Responsive to chemotherapy and radiation but recurrence rate is high even in early stage of disease.

30. SCLC: Cell Types Oat Cell Intermediate Combined

31. SCLC: Staging Limited Stage Defined as tumor involvement of one lung, the mediastinum and ipsilateral and/or contralateral supraclavicular lymph nodes or disease that can be encompassed in a single radiotherapy port. Extensive Stage Defined as tumor that has spread beyond one lung, mediastinum, and supraclavicular lymph nodes. Common distant sites of metastases are the adrenals, bone, liver, bone marrow, and brain.

32. SCLC: Treatment Limited Disease Chemotherapy Concomitant Radiation Prophylactic Cranial Irradiation Extensive Disease Chemotherapy Palliative radiation

33. SCLC: Treatment Chemotherapy: Most commonly used initial regimen: Cisplatin or Carboplatin plus Etoposide x 4-6 cycles Newer agents under evaluation: Topotecan, Paclitaxel, Docetaxel, Irinotecan, Gemcitabine

34. SCLC: Treatment Outcomes Limited Disease median survival18 - 20 months 5-year survival10% Extensive Disease median survival10 - 12 months 5-year survival1 - 2%

35. Advanced Lung Cancer: Supportive Care Treatment Modalities for Palliation Chemotherapy Radiation Symptom Management Dyspnea Fatigue Pain

36. Dyspnea Management Assessment Activity planning Medications Corticosteroids Opioids Oxygen therapy Non-traditional/investigational therapies Acupuncture Massage Exercise

37. Fatigue Management Assessment Activity Planning Exercise Sleep aids Stimulants Anemia management Iron supplements Epoetin alfa

38. Pain Management Assessment Medications: Opioids NSAIDS Corticosteroids Nonpharmacologic Interventions: Heat/cold Topical agents Massage Behavioral Therapy

39. Lung Cancer: Conclusions Smoking cessation is essential for prevention of lung cancer. New screening tools offer promise for detection of early lung tumors. Clinical trials are testing promising new treatments. New treatments offer improved efficacy and fewer side effects. Treatment can palliate symptoms and improve quality of life.

40. Lung Cancer: Conclusions

41. A 56 yo male smoker presents with dyspnea & progressively worsening cough over the past 3 months. Additionally the pt reports increased confusion, N/V, and constipation. EKG:shortened QT-I. CXR below. What is the most like underlying cause of this pt’s presentation. A. Adenocarcinoma B. Small cell carcinoma C. Large cell carcinoma D. Squamous cell carcinoma E. Allergic bronchopulmonary aspergillosis

42. A 56 yo male smoker presents with dyspnea & progressively worsening cough over the past 3 months. Additionally the pt reports increased confusion, N/V, and constipation. EKG:shortened QT-I. CXR below. What is the most like underlying cause of this pt’s presentation A. Adenocarcinoma B. Small cell carcinoma C. Large cell carcinoma D. Squamous cell carcinoma E. Allergic bronchopulmonary aspergillosis

43. While dealing with Solitary Pulmonary Nodules, certain radiographic patterns are uniformly accepted as signs of benignity, these include all of the following, EXCEPT: A. Very short or very long doubling times B. Popcorn calcification C. Central calcificaiton D. Laminated calcification E. Eccentric calcification

44. While dealing with Solitary Pulmonary Nodules, certain radiographic patterns are uniformly accepted as signs of benignity, these include all of the following, EXCEPT: A. Very short or very long doubling times B. Popcorn calcification C. Central calcificaiton D. Laminated calcification E. Eccentric calcification

45. In 2005, the NCI approved screening for lung cancer is ? (m+f,>45, >20PY, q 1yr) A. Low dose HRCT of chest B. Auto fluorescence bronchoscopy C. PET scanning D. CXR with sputum cytology E. None of the above

46. In 2005, the NCI approved screening for lung cancer is ? (m+f,>45, >20PY, q 1yr) A. Low dose HRCT of chest B. Auto fluorescence bronchoscopy C. PET scanning D. CXR with sputum cytology E. None of the above

47. In reference to the incidence of lung cancer, all of the following are true, EXCEPT: A. Mortality rates are higher in african americans than whites B. Women are more susceptible to tobacco carcinogen than men C. Recently lung CA deaths have started declining among white men and women D. It is the number one cause of cancer deaths in the United states in both men and women

48. In reference to the incidence of lung cancer, all of the following are true, EXCEPT: A. Mortality rates are higher in african americans than whites B. Women are more susceptible to tobacco carcinogen than men C. Recently lung CA deaths have started declining among white men and women D. It is the number one cause of cancer deaths in the United states in both men and women