What is Lung Cancer?

• Uncontrolled growth of malignant cells in one/both lungs

and tracheo-bronchial tree (bronchial carcinoma)
• A result of repeated carcinogenic irritation causing
increased rates of cell replication
• Proliferation of abnormal cells leads to hyperplasia,
dysplasia or carcinoma in situ
 How Big is the Problem?
• WHO: 1.5 - 2 million new cases/year
1,800,000
1,600,000
1,400,000

• Approx. 1.1 million deaths/year 1,200,000

1,000,000
800,000

• USA (2004): 600,000

400,000
200,000

- 173.770 new cases/year 0

1 3 5 10

- 160.440 deaths/year New Cases

Deaths

• More deaths from lung cancer than Lung cancer - US incidence and
mortality rates (1973-1996)
prostate, breast & colorectal cancers Rate per 100
100,000

combined people
(log scale)
50

• Decreasing incidence & deaths in men; Incidence - males

Mortality - males
Incidence - females

continued increase in women 10

Mortality - females

1974 76 78 80 82 84 86 88 90 92 94 96
Year of diagnosis/death

Ries et al 1999
 Estimated Cancer Death Rates
in the United States 2004
Men 290,890 Women 272,810

Lung & bronchus 32% 25% Lung & bronchus

Prostate 10% 15% Breast
Colon and rectum 10% 10% Colon and rectum
Pancreas 5% 6% Ovary
Leukemia 4% 6% Pancreas
Non-Hodgkin’s 4% 4% Leukemia
lymphoma

Jemal et al. CA Cancer J Clin. 2004;54:8.

 How Does it Happen?
• Cigarette smoking (Active, passive; 87% of lung cancer)
- Age of smoking onset - Product smoked
- Amount smoked - Depth of inhalation
- Gender
• Air pollutions & ionizing radiation
• Environment & occupational associations
- Asbestos, uranium (in miners), arsenical fumes, chrome,
nickel, radon gas
• Oncogenes & suppressor genes
- Ras, myc, bcl-2, c-erbB-2, p53,RB
• Immunity metabolism heredity & chronic bronchitis
Risk of Lung Cancer after Stopping Smoking

Garfinkel L, Silverberg E. CA Cancer J Clin. 1991;41:137-145

 How is it Classified?
• Anatomically:
- Central: mostly squamous & small cell carcinoma
- Peripheral: mostly adenous
• Histologically:
- Small Cell Lung Cancer (SCLC; 15% - 20%):
. Oat cell . Combined
. Intermediate
- Non-Small Cell Lung Cancer (NSCLC; 80% - 85%):
. Squamous . Adenocarcinoma
. Large cell . Adenosquamous
 Small Cell Lung Cancer
• Neuro-endocrine tumor
• Rapid growth SCLC biopsy specimen

• Metastasis to mediastinum, thoracic

& extra thoracic structures
• May narrow bronchi (compression)
• Causes hoarseness (paralysis of laryngeal nerve)
• Highly sensitive to chemotherapy & radiotherapy, but
recurrence is common
• Surgery is not indicated
• Poor prognosis (2-4 months)
 Non Small Cell Lung Cancer (1)
Squamous Cell/Epidermoid
• 30 - 35% of lung cancer
• Arise from bronchial epithelium
• Cavitation may also occur
• Slow growth, metastasis not common
• Secondary infections distal to obstructive tumor in
bronchioles frequently occur
 Non Small Cell Lung Cancer (2)
Adenocarcinoma
• 25 - 30% of lung cancer
• Arise from bronchiole mucus gland
• Slow growth, may metastasize
• Rarely cavity
• Bronchiolo alveolar cell carcinoma is a subtype
Large Cell Carcinoma
• 10 - 20% of lung cancer
• Cavitation common
• Slow, metastasis may occur to kidney, liver & adrenals
• May be located centrally, mid lung or peripherally
How Does It Metastatize?
 Common Signs & Symptoms (1)
• Asymptomatic: early stage of the lung cancer
• Symptoms related to the primary tumor:
– Chronic persistent cough (obstructs airflow)
– Hemoptysis
– Wheeze and stridor, dyspnea,
– Pneumonitis
• Symptoms related to metastases:
– Bone pain, abdominal pain, headache, weakness, confusion,
pleural effusion, chest pain
• Generalized symptoms:
– Fatigue, malaise, weight loss and loss of appetite
 Common Signs & Symptoms (2)
• Paraneoplasic syndromes:
– 2% of lung cancer patients
– Associated with brochogenic carcinoma
– Stem from release of the following hormones:
. ADH (syndrome of inappropriate antidiuretic hormone release)
. ATCH (Cushing’s syndrome)
. Parathormone or PGE (hypercalcemia)
. Calcitonin (hypocalcemia)
– Other paraneoplastic syndromes: myopathy,
peripheral neuropathy, acanthosis nigricans,
and hypertrophic pulmonary osteoarthropathy
(clubbing of fingers)
 Evaluation & Diagnosis
Suspected lung cancer

A: Detecting the tumor

B: Establish the cell type
C. Define stage of the tumor

Initial evaluation:
Peripheral tumor History/physical exam Central tumor
Chest x-ray
CT/MRI scan
PET scan*
Options Options
- Percutaneous fine needle aspiration/mediastinoscopy - Sputum cytology
- Bronchoscopy/sputum cytology - Bronchoscopy/sputum cytology
- Video-assisted thoracoscopy - Percutaneous fine needle
- Thoracotomy aspiration/mediastinoscopy
- Bone scan - Thoracotomy
- Bone marrow aspiration - Bone scan
*Some metastases visible by CT scan only.
- Bone marrow aspiration
CT = computed tomography; PET = positron emission tomography
 Chest X-ray
• The most frequent finding is
a mass in the lung field
• Secondary manifestations:
lobar collapse, pleural
effusion, pneumonitis,
elevation of the
hemidiaphragm, hilar &
mediastinal adenopathy, &
erosion of ribs or vertebrae
due to metastases
 Chest CT-scan
• Most useful in evaluating pulmonary & mediastinal masses
• Also useful for detecting multiple metastases.
• Can show location & size of a mass
• Also shows the nodule in the mediastinum
• Can detect a mass located behind the heart
 Bronchoscopy
• Important for determining if a
tumor is present & for obtaining
tissue for histologic diagnosis
• Usually, the combination of
bronchial brushing & forceps
biopsy is positive 90% – 93% of
the tumors located in proximal
airway
 Lung Cancer diagnosis
Physical examination Detect signs

Chest X-ray Detect position, size, number of tumors

Bronchoscopy Precise location of tumor obtain biopsy

FNA Cytology

CT scan Detect chest wall invasion mediastinal

lymphodenopathy distant metastases
PET scan Lymph node staging

Laboratory analysis Detect changes in hormone production,

and hematological manifestations of lung cancer
Mediastinoscopy Visualize and sample mediasturial lymph nodes

NCCN Guidelines 2000

Complications of Lung Cancer
• Obstruction – emphysema vs. atelectasis
• PNA – abscess formation
• SVC syndrome
• Pericarditis
• Pleuritis
• Neuroendocrine abnormalities
• Hypercoagulable states
 Staging - TNM
• Tumor size:
– T1 ≤ 3cm
– T2 > 3cm
– T3 = local extension (parietal pleura, chest wall or
within 2 cm of carina)
– T4 = spread to great vessels, trachea, mediastinum,
esophagus or malignant effusion (nonresectable)
• Lymph node:
– N0 = no involvement
– N1 = hilar nodes
– N2 = mediastinal nodes
– N3 = contralateral nodes or ipsilateral supraclavicular (nonresectable)
• Metastases:
– M0 = none
– M1 = presence (nonresectable)
 SCLC Stages
SCLC staging

• Limited Stage Extensive:

Tumor not confined to
hemithorax of origin

- Tumor involvement of one lung, the Distant metastasis

mediastinum & ipsilateral and/or Limited:

Tumor confined to
hemithorax of origin

contralateral supraclavicular lymph and/or the

mediastinum and
supraclavicular nodes

nodes/disease that can be PDQ Guidelines 2000

encompassed in a single radiotherapy port

• Extensive Stage
- Tumor that has spread beyond one lung, mediastinum,
& supraclavicular lymph nodes. Common distant sites
of metastases are the adrenals, bone, liver, bone marrow
& brain
 NSCLC stages - an overview
Disease Stage TNM

Early 0 TIS N0 M0 (carcinoma in situ)

IA T1 N0 M0
IB T2 N0 M0

Localized IIA T1 N1 M0
IIB T2 N1 M0
T3 N0 M0
IIIA T3 N1 M0
T1-3 N2 M0

Advanced IIIB T4, Any N, M0

Any T, N3, M0
IV Any T, Any N, M1

Mountain 1997
 Treatment
• Consider:
- General health
- Type of lung cancer (small or non-small cell)
- Size & position of the tumor
- Stage
• Including:
A. Medical
- Chemotherapy - Radiotherapy
B. Surgery
C. Targeted therapy: epidermal growth factor receptor inhibitors,
angiogenesis inhibitors & apoptosis inducers
D. Some other therapy: Immunologic therapy, chinese medicine
 Treatment and Staging NSCLC
Stage Description Treatment 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 Surgery

associated with the lung

Stage III a Tumor has spread to the lymph nodes in Chemotherapy followed by
the tracheal area, including chest wall and radiation or surgery
diaphragm

Stage III b Tumor has spread to the lymph nodes on Combination of

the opposite lung or in the neck chemotherapy and radiation

Stage IV Tumor has spread beyond the chest Chemotherapy and/or

palliative (maintenance) care
 Surgical Management
• Wedge Resection: involves the removal of a small
localized area of diseased tissue near the surface of
the lung. Pulmonary functions & structures remain
unchanged
• Segmental Resection: involves the removal of one
or more lung segments (a bronchiole and its alveoli),
the remaining lung tissue over expands to fill the
space
• Lobectomy: involves removing an entire lobe of one
lung
• Pneumonectomy: an entire lung is removed
 Contraindications for Surgery
• Myocardial infarction within past 3 months, within 6
months only relative
• Major arrhythmias
• Severe pulmonary hypertension
• Pre-operative hypoxia
• Pre-operative FEV1/FVC < 80%
• Pre-operative FEV1 < 1L
• Predictive post-operative FEV1 /FVC < 40% or
FEV1 < 1L
5-Years Survival Rate after Surgery
TNM stage 5 YS（clinical stage） 5YS（pathologic stage）

T1 N0 M0 n=687 61% n=511 67%

T2 N0 M0 n=1189 38% n=549 57%
T1 N1 M0 n=29 34% n=76 55%
T2 N1 M0 n=250 24% n=288 39%
T3 N0 M0 n=107 22% n=87 38%
T3 N1 M0 n=40 9% n=55 25%
T1-3 N2 M0 n=471 13% n=344 23%
T4 N0-2 M0 n=458 7% NA
Any T N3 M0 n=572 3% NA
Any T any N M1 n=1427 1% NA

Mountain CF, Chest 1997.

 Thymoma
• Rare (3.3/1.000.000/year), slow growing
• 20 - 60% have myasthenia gravis
(10 - 15% myasthenia gravis patients have
thymoma, myasthenia gravis less responsive
to resection)
• Masaoka staging
• Thymic carcinoma - low grade, high grade
 Lymphoma

• Hodgkin’s : 25% - 30% all lymphoma, most

common mediastinal lymphoma, bimodal, Reed
Sternberg cells
• Non-Hodgkin’s : large B cell, lymphoblastic
 Germ Cell Tumors
• Uncommon
• Seminomas most common malignant germ cell
tumors (40% - 50%)
• Nonseminomatous- embryonal cell, yolk sac,
choriocarcinoma, mixed (1% - 3%)
• Teratomas
- Mature (3 germ layers: cartilage, fat, epithelium)
- Immature
 Cysts
• Airways/lungs develop from diverticulum of
the anterior foregut with subsequent
branching. Errors in branching
• Esophagus develops from the distal foregut
• Most common:
- Bronchogenic cyst
- Enteric cysts
- Pericardial cyst
- Adenopathy
 Neurogenic Tumors
• Schwannoma : encapsulated, nerve sheath
• Neurofibroma-well marginated, not
encapsulated, 30% - 45% have eurofibromatosis
• 10% dumbbell
 Symptoms
• Cough
• Shortness of Breath
• Chest pain
• Fever
• Chills
• Night Sweats
• Hemoptysis
• Hoarseness
 Diagnostic
• Chest X-Rays
• CT Scan
• MRI
• Ultrasound
• CT guided needle biopsy
• Mediastinoscopy with biopsy
• Radionuclide Scanning
• Biochemical markers
 Biopsy
• FNA, core needle CT guided, EUS
• Cervical mediastinoscopy
• Chamberlain procedure
• Thoracoscopy
 Treatment
• Varies according location of tumors
• Common is surgical resection
– Thymic cancer: surgery follow by radiation/or
chemotherapy
• Exception
– Lymphatic tumors
– Mesenchimal tumors (Rhabdomyosarcoma)
 Prognosis

• Varies depending on type of tumors & resection

• Benign tumors: excellent prognosis
• Malignant tumors: depends on the type
 Pneumothorax

• Air in the chest cavity

• Tension pneumothorax: air in the thoracic cavity
prevented from escaping
• S & S: respiratory difficulty, rapid weak pulse,
cyanosis, low BP, narrow pulse pressure,
distended neck vein, tracheal deviation, reduced
breathing sounds, hyper-resonance
• Tx: ABC, closure of wound, chest drain
 Open Pneumothorax

• Sucking chest wound: an open chest wound in which air

is sucked into the chest cavity
• S & S:
– Presence of chest wound
– Sucking chest wound may or may be not available
– Patient may be gasping for air
• Tx:
– ABC
– Seal open chest wound quickly
– Apply occlusive dressing
– Administer high concentrated oxygen
– Care for shock
– Transport as soon as possible to trauma center
Thank you