Lung Cancer

By, Nazneen Chougle

Neha Bhatkal

Nilekha Kalyankar

Nirali Bavaria

Namrata Gaokar1

Contents

IntroductionSigns and SymptomsPathophysiologyStatisticsDiagnosisTreatmentRecent Clinical TrialsPalliative Care and Case StudyEthical Considerations

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Tumorso Benign tumors They are not cancer. Do not spread to other

parts of the body and are not a threat to life.

o Malignant tumors They are cancer. Can invade and damage

tissues and organs near the tumor

The spread of cancer is Called metastasis

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Lung Cancer: Defined

Uncontrolled growth of malignant cells in one or both lungs and tracheo-bronchial tree.

A result of repeated carcinogenic irritation causing increased rates of cell replication.

Proliferation of abnormal cells leads to hyperplasia, dysplasia or carcinoma in situ.

90%-95% of cancers of the lung arise from the epithelial cells, the cells lining the larger and smaller airways .4

Two Types Of Lung Cancer Cells

Non Small Cell Lung Cancer (NSCLC)― Most common type― Grows and spreads more slowly than small cell lung cancer― Three main types • Adenocarcinoma • Squamous Cell Carcinoma (epidermoid carcinoma)• Large Cell Carcinoma

Small Cell Lung Cancer (SCLC)― Called oat cell cancer― Less common ― Grows more quickly ― Spread to other organs in the body

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Where D oes it Come From?

SmokingPassive smokingRadon gasFamilial predispositionLung diseasesPrior history of lung cancerAir pollution

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Signs and symptoms

No symptoms in up to 25% of peopleSymptoms related to the cancer

– cough– dyspnea– hemoptysis– recurrent infections– chest pain

Symptoms related to metastasisParaneoplastic symptoms.Nonspecific symptoms.

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Deaths Due to Lung Cancer

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DIAGNOSIS

H ISTOR Y AN D PH YSICAL E XAMINATION

Cyanosis

Chest x- ray

CT (computerized tomography, computerized

axial tomography, or CAT) scans

L OW- DOSE HELICAL CT SCAN (or spiral CT scan)

MAGNETIC RESONANCE IMAGING(MRI).

P OSITRON EMISSION TOMOGRAPHY (PET)

BLOOD TESTS11

DIAGNOSIS

BONE SCANS: These are used to create images of

bones on a computer screen or on film. Doctors may

order a bone scan to determine whether a lung cancer

has metastasized to the bones.

SPUTUM CYTOLOGY : If a tumor is centrally located

and has invaded the airways, this procedure, known as

a sputum cytology examination, may allow visualization

of tumor cells for diagnosis

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DIAGNOSIS

BRONCHOSCOPY: Examination of the airways by bronchoscopy

(visualizing the airways through a thin, fiberoptic probe inserted through

the nose or mouth) may reveal areas of tumor that can be sampled

(biopsied) for diagnosis by a pathologist.

NEEDLE BIOPSY: Fine needle aspiration (FNA) through the skin,

most commonly performed with radiological imaging for guidance, may

be useful in retrieving cells for diagnosis from tumor nodules in the

lungs.

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DIAGNOSIS

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DIAGNOSIS

Recent Advances

Biomarkers

Fluorescent in-situ hybridization techniques (FISH)

Super Dimension(R)/Bronchus System (SDBS)

Computer-aided detection (CAD)

Breath tests

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Contd….

Auto fluorescence bronchoscopy (AFB)

Endobronchial ultrasound (EBUS)

Coherence tomography (OCT)

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CHEMOTHERAPY

Used for both NSCLC and SCLC Used in combination with radiation therapy and

surgical therapy. Platinum based drugs most effective- Cisplatin May be given as pills, as an intravenous infusion, or

as a combination of the two. Second-line chemotherapy is used to treat recurrent

cancers that have previously been treated with chemotherapy.

Side effects- Nausea, Vomiting, weight loss, hair loss, mouth sores, etc

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RADIATION THERAPY Curative therapy, palliative therapy or as

adjuvant therapy in combination with surgery or chemotherapy.

Used for both NSCLC and SCLC Uses high energy X-rays to kill dividing cells. Brachytherapy Shrinks a tumor or limits its growth when

given as a sole therapy Simulation is necessary prior to treatment. Side effects- fatigue, lack of energy, reduced

WBC count and blood platelet levels, irritation of skin, nausea , Vomiting, diarrhoea.

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SURGERY

Generally performed for limited-stage (stage I or sometimes stage II) NSCLC.

Surgery may not be possible if the cancer is too close to the trachea.

Depends upon the size and location of the tumor. Could require lobectomy (removal of one lobe)

pneumonectomy (removal of an entire lung) or lymphadenectomy (removal of lymph nodes).

If a recurrent cancer is confined to one site in the lung.

Side effects-difficulty breathing, shortness of breath, pain, and weakness.

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PHARMACOTHERAPY

Erlotinib (Tarceva), is used in patients with NSCLC who are no longer

responding to chemotherapy. Also called as “The Targeted Drug”

because it targets a protein called the Epidermal Growth Factor Receptor

(EGFR) that is important in promoting the division of cells.

Iressa (Gefitinib)

Antiangiogenesis drugs- Bevacizumab (Avastin)

Vadimezan – Disrupts Blood Vessels within tumors.

Bisphosphonates.

ARQ 197

Tragedy Exubera –inhaled Insulin ,manufactured by Pfizer had promised of letting

diabetics avoid needle sticks but actually increased the cases of lung cancer in diabetic patients.

Drug has been withdrawn.

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OTHER IMPORTANT DRUGSNON SMALL CELLED LUNG CANCER SMALL CELLED LUNG CANCER

Alimta Erlotinib

Docetaxel Etoposide

Gemzar Hyacamtin

Navelbine Tarceva

Onxol Topotecan

Paclitaxel VePesid

Photofrin

Taxol

Taxotere

Vinorelbine

Gemcitabine

Pemetrexed

Porfimer

Gefitinib21

Other Newer Therapies PHOTODYNAMIC THERAPY (PDT)

RA DIO FREQUENCY ABLATI O N

CHINESE MEDICINESo Ligustrum lucidim Ait. (Tree Pivet), Astragalus membranaceous

Suppress tumor angiogenesis, promote dormancy of cancerous cells,

induce re-differentiation of cancer cell, directly kill cancerous cells ， and it is effective against recurrence and metastases of cancer.

CRYOSURGERY

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IMMUNOTHERAPIES

MONOCLONAL ANTIBODIES “ Humanized” antibodies- Trastuzumab ANTIGEN SPECIFIC VACCINES Incorporating cytokines into anti-tumor vaccines Biomarkers Radioactive agents By cutting off a key gene,14-3-3zeta, lung cancer tumour cells

are left 'homeless‘ and they can't survive on their own.

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Clinical trials for lung cancer

oA Study to Diagnose Lung Cancer by Sputum Cytology. o FR901228 in Treating Patients With Refractory or Progressive Small Cell Lung Cancer or Non-Small Cell Lung Cancer.

o INS316 in Diagnosing Lung Cancer in Patients With Untreated Lung Cancer

o Prevention of Tumour Spread Due to Lung Cancer Surgery.

o Vaccine Therapy in Treating Patients With Colon, Pancreatic, or Lung Cancer.

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Clinical trials for lung cancer- ongoing

oBiomarkers for Early Detection of Lung Cancer in Patients With Lung Cancer, Participants at High-Risk for Developing Lung Cancer, or Healthy Volunteers

oA Clinical Trial to Validate Molecular Targets of Vorinostat in Patients With Stage I-III Non-Small Cell Lung Cancer

oDNA Analysis in Predicting Lung Cancer Risk

oPhase II Study of Dichloroacetate (DCA) in Patients With Previously Treated Metastatic Breast or NSCL Cancer

oSputum Cytology in Screening Heavy Smokers For Lung Cancer

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Recent research

oTumor Growth Pattern May Predict Survival in Non-Small Cell Lung Cancer

oNewer techniques to combact with non-small cell lung cancer and small cell lung cancer.

oHormone with anti cancer effects.

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Quality of life Means how lung cancer survivors feel about different

aspects of life, including physical health, emotional

health, and ability to carry out daily activities. opinions about their quality of life, as well as the factors that affect their quality of life.

Helps to develop new services for lung cancer survivors. Behavioral Questionnaires or Telephonic Interviews are

conducted.

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Palliative Care in Lung CancerSymptom Palliative Recommendations

1) Pain Mild : Acetaminophen or NSAIDsSevere : Opioids

2) Dyspnea Oxygen, Bronchodilators, Corticosteroids, Antibiotics, Opioids

3) Cough Non opioid cough suppressants, Bronchodilators, Corticosteroids, Opioids

4) Bone Metastases External Radiation Therapy + Systemic Corticosteroids (Prednisone 20 to 40 mg)

5) Brain Metastases Dexamethasone (20mg) for 4 weeks

6) Spinal cord Compression

High Dose Steroids + Radiation TherapyAdjunct Therapy : Dexamethasone (60mg)

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Palliative Care Centers

1) Fox Phase Cancer Centre, Philadelphia, USA

2) Barbara Ann Karmanos Cancer Hospice, Southfield, USA

3) John Taylor Hospice, Birmingham, England

4) The Prince of Wales Hospice, Yorkshire, England

5) St. Luke’s Hospice, Plymouth, England

6) Primrose Hospice, Worcestershire, England

7) St. Francis Hospice, Ireland

8) Royal Perth Hospital, Australia

9) Shanti Avedna Ashram

10) Chittaranjan National Cancer Institute

11) Christian Medical Association of India

12) Cipla Foundation's Cancer Palliative Care Centre

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Ethical Considerations Should terminally ill cancer patients be allowed to

try new therapies with no clinical trials? Should they worry about the side effects? Personal Autonomy v/s Justice. Imposing the truth on an unprepared patient. Cultural Sensitivity and Cultural Competence. Special aspects of truth telling in pediatric and geriatric

oncology. Euthanasia and Physician-assisted Suicide

Lung Cancer Awareness

November is Lung Cancer Awareness Month. The colour of lung cancer

awareness is Pearl White. ‘Can Support’ organized

walkathon called “Walk for Life”

on 7th Feb 2010 in New Delhi to

create awareness about

Lung Cancer.

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Case Study In March 2004, 46 yr old non-smoker, Caucasian female, presented

with flu-like symptoms, persistent cough and constant fatigue. Biopsy and CT scan revealed NSCL cancer in the right lung. Surgery was scheduled a month later to remove the nodular mass

and the entire right middle lobe of the right lung. In May 2005, additional nodules appeared in the mediastinal area

and a biopsy and mediastinoscopy revealed mucin- producing adenocarcinoma in stage II B.

PET scan done in May 2006 revealed liver and right pleural space metastasis.

The patient received chemoradiation therapy consisting of weekly Carboplatin (Platinol) plus Paclitaxol (Taxol), concurrent with radiation therapy.

Experimental Phase I/II clinical trial with oral Tarceva (Erlotinib) and oral Vorino stat. Brachytherapy to the trachea.

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Some Interesting Facts

Most common form of cancer worldwide. 1.2 million new cases of lung cancer worldwide every

year. Responsible for 17.8% of all cancer deaths annually. Kills about 9,00,000 men and

3,30,000 women annually In Men smoking causes more than

80% of lung cancer cases. In Women it causes 45% of all

lung cancer cases.

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Summary Lung cancer is the leading cancer-related cause of death. It has become the subject of a great

amount of research. The best way to prevent it is to

quit (or never start) smoking. Treatment depends on the cancer's

specific cell type, how far it has spread

and patient's performance status. It also depends on the stage, or how

advanced it is. Treatment includes chemotherapy,

radiation and surgery. In recent years, various molecular

targeted therapies have been developed

as treatments. 35

REFERENCES

www.cancer.gov/cancertopics/types/lung www.daviddarling.info/encyclopedia/L/lung_cancer_treatment.html www.merck.com/mmhe/sec04/ch057/ch057a.html www.clinicaltrials.gov

Medscape,clin lung cancer 2009-10,

By, Everrete and E.Vokes PNAS journal Volume 100, July 8th, number 14

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T HANK YOU 37

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