1 lung cancer so what?. 2 abbreviations bx-biopsy ca-cancer ca++ - serum calcium cbc-complete blood...
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Lung Cancer
• So what?
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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
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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.
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Case 2
63 Year old scheduled for knee surgery who had a 1 cm “nodule” found on CXR during preoperative medical evaluation.
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Case 3
71 year old female smoker with unexplained weight loss and RML wheezing unresponsive to bronchodilators.
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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
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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
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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
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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
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Etiology
• Smoking
– The most preventable risk factor
– Accounts for 80-90% of all cases of bronchogenic CA
• Toxic exposures
– Asbestos
– Other
• Idiopathic
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Lung Mass
Malignant (Cancer) Benign
Bronchogenic Nonbronchogenic
Carcinoid Small cell Non small cell Mesothelioma
Typical Atypical
Squamous cell Adenocarcinoma Large cell
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Benign tumor
• Slow or very fast growing
• Usually encapsulated, well demarcated
• NOT invasive or metastatic
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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)
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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
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Pathology (cont.)
• May invade pleural space and/or mediastinum,
chest wall, ribs, or diaphragm
• Frequent secondary pleural effusion
• Eventual airway obstruction, atelectasis,
consolidation, cavitation
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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
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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
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Diagnosis
• Clinical suspicion• CXR• Simple labs• Chest CT• Cytology - bronchoscopy• Cytology – open Bx• Cytology – pleural effusion
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Solitary pulmonary nodule
• Defined:
– Single nodule
– Round or ovoid
– < 3 cm in diameter
– Distinct margins
– May have calcification, “satellite” lesions, central
cavitation
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Solitary pulmonary nodule (cont.)
• Signs and symptoms
– Most assymptomatic
– Rare findings
• Hemoptysis
• Cough
• Clubbing
• Endocrinopathy (suggestive of malignancy)
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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
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Solitary pulmonary nodule
(cont.)
• Preop decision: benign vs. malignant– Imaging and comparison with old studies
– Almost always benign if:• Doubling time <30 or >500 days
• Calcified
– Likely benign if:• Pt is young
• Assymptomatic
• <2 cm in diameter
• Smooth margins on CT
• Satellite lesions present
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Solitary pulmonary nodule (cont.)
– Features of malignant SPN
• Symptomatic
• Pt >45 yrs old
• >2 cm
• Indistinct margins - spiculation
• Rarely calcified
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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”
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Solitary pulmonary nodule (cont.)
• Diagnosis– CT
– Simple labs• CBC
• CMP
• UA
– Excision/Bx
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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
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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
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http://emedicine.medscape.com/article/426400-overview 28
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)
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http://emedicine.medscape.com/article/426400-overview 29
Bronchial carcinoid tumor
• Atypical– 10% of bronchial carcinoid tumors– More aggressive than “typical” carcinoid– More likely to metastasize– Differentiated by biopsy
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Bronchial carcinoid tumor (cont)
• Tx:– Surgery with resection
• Only curative tx
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Small-Cell Carcinoma
• Originates centrally in bronchial epithelium
• Seen in 15-20% of bronchogenic cases
• Grows rapidly and submucosally
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Small-Cell Carcinoma (cont.)
• Metastasizes early
• Doubling time approx 30 days
• Cells commonly compressed into oval shape
(oat cell)
• Commonly found near hilum
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Non Small Cell Lung CA (NSCLCA)
• Adenocarcinoma
• Squamous cell carcinoma
• Large cell carcinoma
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Adenocarcinoma
• Most common bronchogenic CA (35-40% of cases)
• Common in non-smokers
• Originates in mucous glands of tracheobronchial tree
• Glandular configuration
• Mucus production
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Adenocarcinoma (cont.)
• Moderate growth
• Moderate metastatic rate
• Doubling time approx 180 days
• Commonly found in peripheral lung parenchyma
• Cavitation common
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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
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Squamous (epidermoid) cell carcinoma (cont.)
• Frequently project in bronchi
• Late metastatic tendency
• Doubling time approx 100 days
• Commonly found in large bronchi near
hilum
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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
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Staging - Small cell lung CA
Stage Definition 2 Yr. Survival
Limited stage Tumor confined to the same 20%disease side of the chest, supraclavicular
lymph nodes, or both
Extensive Defined as anything beyond 5%stage Disease limited stage
UNTREATED OVERALL SURVIVAL: 6-18 WEEKS
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TNM Staging (Non-small cell)
• T: Tumor
• N: Regional Lymph Nodes
• M: Metastasis
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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
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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
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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
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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
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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
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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)
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Staging - non-small cell lung CA
Stage Definition 5 year survival1A T1, N0, M0 61%1B T2, N0, M0 38%
2A T1, N1, M0 34%2B T2, N1, M0 / T3, N0, M0 24-22%
3A T3, N1, M0 13%or T1-T3, N2, M0
3B T4, any N, M0 5%or any T, N3, M0
4 any T, any N, M1 1%
OVERALL 5 YEAR SURVIVAL: 15%
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Mesothelioma
• Arise from mesothelial cells of:
– Lung pleura (80%)
– Peritoneum (20%)
• Assoc. with asbestos exposure (20-40 yrs
prior)
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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
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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
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Patient Education
• So, What do you tell your patients?
– How about, “DON’T SMOKE!”
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So,
• What about the types we didn’t discuss?
• What about the types you forgot?
• What will YOU do?
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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.
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Treatment In A Nutshell
• Highly variable– Surgery (resection)– Radiation– Chemotherapy
• Cure unlikely without resection– Is surgery feasible?– Can the patient tolerate surgery?
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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
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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