Lung cancer

1. Lung cancer Prof. G.S. Moroz, MD Department of Oncology & Radiology,Ternopil State Medical University

2. Epidemiology • Worldwide, lung cancer is the most common cancer in terms of both incidence and mortality. • In 2008, there were 1.61 million new cases, and 1.38 million deaths due to lung cancer

3. Epidemiology • The highest rates are in Europe and North America. • In the USA, the lifetime risk of developing lung cancer is 8% in men and 6% in women. • Lung cancer incidence is currently less common in developing countries

4. Epidemiology • Eastern Europe has the highest lung cancer mortality among men, while northern Europe and the U.S. have the highest mortality among women. • In the United States, black men and women have a higher incidence.

5. Ukraine (2009) • There were 17372 (crude rate = 37.80: male/female = 14232/3140; crude rate = 67.18/12.67) new cases, • and 13645 (crude rate = 29.69: male/female= 11425/2220; crude rate= 53.93/8.96) deaths due to lung cancer

6. Etiology. • There is a genetic predisposition to lung cancer. In relatives of people with lung cancer, the risk is increased 2 times • Cancer develops following genetic damage to DNA, programmed cell death (apoptosis) or DNA repair. • As more damage accumulates, the risk of cancer increases

7. Smoking • is the main contributor to lung cancer • The predominant cause of both small-cell lung cancer and non–small-cell lung cancer is tobacco smoking. However, small-cell lung cancer is more strongly linked to smoking than non–small-cell lung cancer. • Cigarette smoke contains over 60 known carcinogens including radioisotopes from the radon decay, nitrosamine, and benzopyrene.

8. The incidence of lung cancer is highly correlated with smoking

9. Smoking • 91% of lung cancer deaths in men during the year 2000 were attributed to smoking (71% for women). • In the United States, smoking accounts for 80–90% of lung cancer cases. • The risk for lung cancer is 10 to 20 times higher in smokers than it is in nonsmokers.

10. Smoking Passive smoke doubles the risk for lung cancer. Those living with a smoker have a 30% increase in their risk of lung cancer. Passive smoking causes about 3,400 deaths from lung cancer each year in the USA.

11. Smoking • After cessation of smoking, the risk steadily declines approaching • that of nonsmokers after 15 years of abstinence for patients who smoked for less than 20 years.

12. Asbestos • is causally linked to malignant mesothelioma. • Asbestos exposure also increases the risk for lung cancer, especially in smokers (three times greater risk than smoking alone). Thus, the risk for lung cancer in smokers who are exposed to asbestos is increased 90-fold.

13. Ionizing radiation • is a proven human carcinogen • The evidence for this comes from • studies of atomic bomb survivors inJapan, people exposed during the Chernobyl nuclear accident, people treated with high doses of radiation for cancer, and people exposed to high levels of radiation at work, such as uranium miners.

14. Radon • Radon is the second commonest cause of lung cancer in the USA, after smoking. • The risk increases 8–16% for every 100 Bq/m3 increase in the radon concentration

15. Other substances • associated with lung cancer include: • arsenic, • nickel, • chromium compounds, • chloromethyl ether, • and air pollutants

16. Air pollution • Outdoor air pollution has a small effect on increasing the risk of lung cancer (1–2%).

17. Other lung diseases • Lung scars and chronic obstructive pulmonary disease are associated with an increased risk for lung cancer

18. Pathology and natural history • Two main types of lung cancer exist: non–small-cell lung cancer (NSCLC)  and small-cell lung cancer (SCLC, also called oat cell cancer). • Small-cell lung cancer accounts for approximately 20%-25% of all cases of lung cancer.

19. Clinico-anatomical classification • Central form • Endobronchial • Peribronchial nodulated • Peribronchial branched

20. Clinico-anatomical classification • Peripheral form • Rounded shadow • Pneumonia-like • Pancoast’s tumor

21. Clinico-anatomical classification • Atypical form • Mediastinal • Miliary carcinomatosis • Cerebral • Hepatic • Osseous

22. Location. • More often central or hilar (95%) than peripheral (5%)

23. Non-small cell lung cancer • There are three main sub-types: adenocarcinoma, squamous cell lung carcinoma, and large cell lung carcinoma. • Nearly 40% of lung cancers are adenocarcinoma. • Squamous cell carcinoma accounts for about 30% of lung cancers. • About 9% of lung cancers are large cell carcinoma.

24. Small cell lung cancer • Small-cell lung cancer differs from non–small-cell lung cancer in the following ways:  • Small-cell lung cancer grows rapidly. • Small-cell lung cancer spreadsquickly.

25. Small cell lung cancer • Small-cell lung cancer responds well to chemotherapy and radiation therapy • Small-cell lung cancer is associated with paraneoplastic syndromes (a collection of symptoms that result from substances produced by the tumor).

26. Uncommon tumors of the lung • Bronchial carcinoids • Cystic adenoid carcinomas ("cylindroma") • Carcinosarcomas • Mesotheliomas

27. Signs and symptoms • One fourth of all people with lung cncer have no symptoms when the cancer is diagnosed • Symptoms and signs that may suggest lung cancer include: • Cough • weight loss • dyspnea (shortness of breath)

28. Signs and symptoms • Chest pain • hemoptysis (coughing up blood) • Bone pain • Clubbing of the fingernails • fever • fatigue • Superior vena cava obstruction • Dysphagia (difficulty swallowing) • Wheezing

29. Symptoms of metastatic cancer • About 30-40% of people with lung cancer have some symptoms or signs of metastatic disease: • Metastatic lung cancer in the liver may cause yellowing of the skin and eyes (jaundice)

30. Symptoms of metastatic cancer • Lung cancer that has metastasized to the bone causes bone pain. • Lung cancer that spreads to the brain can cause difficulties with vision, weakness on one side of the body, and/or seizures.

31. Paraneoplastic syndromes • include the syndrome of inappropriate antidiuretic hormone (SIADH), • hyper-coagulable state • ectopic adrenocorticotropic hormone (ACTH) syndrome • Eaton-Lambert (myasthenic) syndrome

32. Paraneoplastic syndromes • hypertrophic osteoarthropathy, • hypercalcemia • and gynecomastia (large cell).

33. Symptoms of SC L C • Persons with small-cell lung cancer typically have had symptoms for a relatively short time (eight to 12 weeks) before they visit their doctor.   • Symptoms due to local growth of the tumor include the following: • Cough • hemoptysis • dyspnea

34. Symptoms of SC L C • Symptoms due to spread of the cancer to nearby areas include the following:  • Hoarse voice, • dyspnea, • Dysphagia, • Swelling of the face and hands

35. Symptoms of SC L C • Symptoms due to distant cancer spread depend on the site of spread and include the following: • Spread to the brain can cause headache, blurring of vision, nausea, vomiting, weakness of any limb, mental changes, and seizures. • Spread to the vertebral column can cause back pain.

36. Symptoms of SC L C • Spread to the spinal cord can cause paralysis and loss of bowel or bladder function. • Spread to the bone can cause bone pain. • Spread to the liver can cause pain in the right upper part of the abdomen

37. Symptoms of SC L C • Symptoms due to paraneoplastic syndromes include the following: • Symptoms may or may not be characteristic of a specific organ system. • Nonspecific symptoms include: • fatigue, • loss of appetite, • and weight gain or loss.

38. Symptoms of SC L C • Severe muscle weakness. • Trouble with balance or walking. • Changes in mental status. • Changes in skin color, texture, and facial features.

39. Diagnosis • Initial exams and tests for suspected lung cancer may include the following: • Medical, surgical,work, and smoking history • Physical exam to check for general signs of health • Chest X-ray 

40. Diagnosis • CT scan of the chest • Thoracentesis • Bronchoscopy • Mediastinoscopy

41. Diagnosis • Performing a chest radiograph is one of the first investigative steps • This may reveal an obvious mass, widening of the mediastinum • atelectasis (collapse), consolidation (pneumonia), or pleural effusion

42. Diagnosis • CT imaging is typically used to provide more information about the type and extent of disease. • Bronchoscopy or • CT-guided biopsy is often used to take sample the tumor for histopathology

43. Chest X-ray film

44. Chest X-ray film and CT

45. Chest X-ray film

46. X-ray tomogram

47. CT scan showing a cancer tumor in the left lung

48. Diagnosis • Once the patient has been diagnosed with lung cancer, exams and tests are performed to find out whether the cancer has spread (metastasized) to other organs. • Tests used to detect the spread of cancer may include the following:

49. Diagnosis • Blood tests: Complete blood count (CBC) provides information about the type and count of different types of blood cells, serum electrolytes, kidney function, and liver function. • CT scan of the chest and abdomen

50. Diagnosis • MRI of the brain • Radionuclide bone scan.If the cancer has spread to the bones, the radioactive material collects in the bones and is detected by a scanner. • PET scan: a small amount of radioactive material is injected into the bloodstream and measures the metabolism of the organs to see if the cancer has spread.