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Lung Neoplasms. Sanjay Munireddy Dept of Surgery Sinai Hospital of Baltimore June17, 2008. Overview. Leading cause of cancer-related death among men and women and 2nd most common cause of overall mortality in US Estimated new cases in 2008: 215,020 Estimated deaths in 2008: 161,840.

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Lung neoplasms l.jpg

Lung Neoplasms

Sanjay Munireddy

Dept of Surgery

Sinai Hospital of Baltimore

June17, 2008


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Overview

  • Leading cause of cancer-related death among men and women and 2nd most common cause of overall mortality in US

  • Estimated new cases in 2008: 215,020

  • Estimated deaths in 2008: 161,840


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Epidemiology

  • Recent continued decline in incidence among men (79.4 cases per 100,00)

  • Stabilization of incidence in women (52.6 cases per 100,00)

  • Greatest incidence in AA men (107.6 cases per 100,000)

NCI SEER Cancer Data


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Risk Factors

  • Smoking

  • Second hand smoke

  • Sex - men

  • Race - African American

  • Environmental gases - Asbestos, radon, tar soot, arsenic, silica etc.

  • Excessive alcohol use

  • Radiation therapy to chest

  • Family history of lung cancer


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Smoking

  • Greatest risk factor; dose-response relationship between the number of pack-years smoked and lung cancer risk

  • 87% of all lung cancer deaths result from smoking

  • Death rates decrease to that of never-smokers after 10 yrs of smoking cessation


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1999 WHO Classification of Lung Tumors

  • Epithelial

    • Malignant

      • Squamous cell carcinoma

      • Small cell carcinoma

      • Adenocarcinoma

      • Large cell carcinoma

      • Adenosquamous cell carcinoma

      • Carcinomas with pleomorphic, sarcomatoid or sarcomatous elements

      • Carcinoid tumor


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Types

  • Non-small cell lung cancer (NSCLC)

    • Comprise 80% of lung tumors

    • 50% are metastatic at diagnosis

  • Small cell lung cancer (SCLC)

    • Comprise 20%

    • 80% are metastatic at diagnosis


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Adenocarcinoma of Lung

  • Most common type of lung cancer

  • Comprises 30-40% in smokers and 60-80% in non-smokers

  • Arises from terminal bronchioles

  • Usually develops in the peripheral portions of the lung

  • Slow growing than squamous cell ca.

  • Often is associated with a peripheral scar or honeycombing due to response to tumor


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Squamous Cell Carcinoma of Lung

  • Comprise 25-40% of lung cancers; rates are declining due to reduction in smoking

  • Dose-response relationship of smoking is strongest with this type of cancer

  • Usually occurs in the lung’s central portions or in one of the main airway branches.

  • Can form cavities in the lung if they grow to a large size

  • Slow growing


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Large Cell Carcinoma of Lung

  • Accounts for 10-15% of lung tumors

  • Diagnosis of exclusion; cannot diagnose on small biopsies or in lymph node metastases

  • Usually large peripheral mass with necrosis

  • Often associated with peripheral eosinophilia and leukocytosis, due to tumor production of colony stimulating factor


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Small Cell Carcinoma of Lung

  • Also called undifferentiated or oat cell carcinoma

  • Accounts for 10-15% of lung tumors

  • Almost always caused by smoking

  • Fast growing compared to NSCLC

  • Usually metastatic in about 70% of cases at the time of diagnosis

  • Without treatment, has the most aggressive clinical course of any type of pulmonary tumor

  • Median survival from diagnosis of only 2 to 4 months.


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Clinical Presentation

  • Majority are symptomatic at presentation (>85%)

  • Symptoms are broadly classified as

    • Due to lung lesion

    • Due to intra-thoracic spread

    • Due to distant mets

    • Due to paraneoplastic syndrome


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Clinical Presentation

  • Symptoms due to lung lesion/primary tumor

    • Coughing ± sputum

    • Dyspnea

    • Hemoptysis

    • Chest pain

    • Wheezing

    • Weight loss


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Clinical Presentation

  • Central tumors (squamous cell carcinomas) generally produce symptoms of cough, dyspnea, atelectasis, wheezing, postobstructive pneumonia,, and hemoptysis.

  • Most peripheral tumors are adenocarcinomas or large cell carcinomas and, in addition to causing cough and dyspnea, can cause symptoms due to pleural effusion and severe pain as a result of infiltration of parietal pleura and the chest wall.


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Clinical Presentation

  • Symptoms of intra-thoracic spread

    • Pleural or pericardial effusion

    • Compression of RLN (hoarseness), phrenic nerve palsy (elevated diaphragm), pressure on the sympathetic plexus (Horner syndrome)

    • Tracheal obstruction, esophageal compression, SVC syndrome

    • Superior sulcus tumors can cause compression of the brachial plexus roots as they exit the neural foramina, resulting in intense, radiating neuropathic pain in the ipsilateral upper extremity.


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Clinical Presentation

  • Symptoms of distant spread

    • May occur in almost every organ system

    • Bone mets (vertebrae, ribs, pelvis are MC)

    • Hepatic mets (indicate poor prognosis)

    • Brain mets (headache, nausea, vomiting, seizures, confusion, personality changes


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Clinical Presentation

  • Paraneoplastic syndromes (10%)

    • Squamous cell carcinoma: hypercalcemia due to parathyroidlike hormone production.

    • Adenocarcinomas: Clubbing, hypertrophic pulmonary osteoarthropathy and the Trousseau syndrome of hypercoagulability

    • Small cell carcinomas: SIADH, Ectopic ACTH production, Lambert-Eaton myasthenic syndrome


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Diagnosis

  • History & physical

    • Wt. loss, respiratory distress

    • Lymphadenopathy

    • Horner syndrome

    • SVC syndrome (usually SCLC)

    • Absence of breath sounds, dullness, pleural effusions

    • Bone pain

    • Neurological deficits


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Diagnosis

  • CXR

  • Sputum cytologic studies: centrally located endobronchial tumors exfoliate malignant cells into sputum

  • Thoracentesis

  • FNAB

  • Bronchoscopy with BAL, brushings, biopsies

  • Staging work-up

    • Local extent

    • Distant spread


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Staging

  • In the United States, the standard staging workup includes at least the following:

    • Complete history and physical examination

    • CT scan of the chest and upper abdomen (including liver and adrenals)

    • Complete blood cell counts

    • Liver and kidney functions tests

    • Serum electrolytes


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Staging

  • Local extent

    • Cervical mediastinoscopy

    • Left anterior mediastinotomy

  • Distant spread

    • CT or Ultrasound of the abdomen

      • liver, adrenals

    • Bone scan

    • CT head

    • MRI

    • PET scan


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Management

  • Functional Evaluation

    • Evaluation of performance and pulmonary status should be completed before discussing treatment options

    • Pulmonary function testing, specifically forced expiratory volume in one second (FEV1) and carbon monoxide diffusion in the lung (DLCO) measurements, is a helpful predictor of morbidity and mortality in patients undergoing lung resection


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Management

  • Functional Evaluation

    • Patients with an FEV1 or DLCO value less than 80 percent of predicted require additional testing.

    • calculation of postresection pulmonary reserve (with ventilation and perfusion scans or by accounting for the number of segments removed); cardiopulmonary exercise testing; and arterial blood gas sampling

    • Patients with a predicted postoperative FEV1 or DLCO value less than 40 percent and a VO2max value less than 10 mL per kg per minute or an SaO2 value less than 90 percent are at high risk of perioperative death or complications


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