Lung Cancer
Dr. Carl Swart
EPIDEMIOLOGY
According to the American cancer
society (2018), Lung cancer is the Developing countries account
most commonly diagnosed cancer in approximately 2.3 million of the
both sexes at about 11.6 % of the global 4.3 million cancer deaths and
total cases. It is the most frequent for 3.2 million of the 6.3 million new
leading cause of cancer death cases worldwide each year.
among males throughout the world.
Epidemiology cont…
Lung cancer is predominantly a
disease of the elderly, almost 70% of
Lung cancer is the second most people are over the age of 65, 3 % of
commonly diagnosed cancer next to lung cancer occur in people
breast cancer in women and underage of 45. The median age is
prostate Cancer in men. 70 years. Lung cancer deaths in
Botswana reached 49 or 0.34% of
total deaths (WHO, 2018).
Age-Standardised Ten-Year Survival for Common Cancers in Males and Females, England
and Wales, 2010-2011
Reasons why • Late presentation
lung cancer • Lack of advocacy & research
survival is • Stigma
still variable • Access to staff, diagnostics and treatment
and poor?
Symptoms in patients who turn out to have lung
cancer
Risk factors for lung
cancer
Ø Cigarette smoking( major risk factor)
Ø Family history
Ø Prior respiratory diseases like asthma,
bronchitis, emphysema and hay fever.
Ø Environmental and occupational exposures
(asbestos, arsenic, nickel).
Ø Nutritional and dietary patterns, fruits,
vegetables and carotenoids reduce the risk of
lung cancer.
Pathophysiology of lung cancer
Lung carcinogenesis is the result of a series of genetic mutations that Mutations in proto-oncogenes and tumor suppressor genes are critical in
accumulate progressively in the bronchial epithelium, first generating the multistep development and progression of lung tumors.
histologically identifiable premalignant lesions and finally resulting in an
invasive carcinoma.
Red flags are not
always reliable
but……NICE says
• Any haemoptysis
• Three weeks of unexplained clubbing or…..
• Cough
• Breathlessness
• Chest or shoulder pain
• Weight loss
• Hoarseness
• Chest signs
• Or just because smokes and tired? Unclear. But probably.
• Don’t wait for antibiotics to work
Risk factors of Lung Cancer
Diagnostic Tests
• CXR
• CT Scans
• MRI
• Sputum cytology
• Fibreoptic bronchoscopy
• Transthoracic fine needle aspiration
Laboratory Tests
Ø Blood Tests
*FBC-to check red/white blood cell & platelets
-to check bone marrow and organ function
*Blood Chemistry Test-to assess how organs
are functioning such as liver and kidney
Ø Biopsy-to determine if the tumor is cancer or not
-to determine the type of cancer
-to determine the grade of cancer (slow
or fast)
Biopsy
Endoscopy
• Bronchoscopy
• Mediastinoscopy
• VATS (video assisted
thoracoscopic surgery)
•
Bronchoscopy
Mediastinoscopy
Diagnosis
2. SPUTUM CYTOLOGY
3. CHEST XRAY
• Most common first diagnosis step
4. CT SCAN for chest and abdomen to examine metastasis
5. MRI
• When precise details about tumor location is needed.
6. BRONCHOSCOPY
• Visualizing the airways through a thin, fiber optic probe
inserted through the nose or mouth may reveal areas of
tumor that can be sampled (biopsied) for diagnosis by a
pathologist.
Diagnosis conti…
7. NEEDLE BIOPSY
• Fine needle aspiration (fNA). Insertion
of a thin needle through the chest wall
into the abnormal area in the lung. Cells
are suctioned into the syringe and are
examined under microscope for tumor
cells.
8. THORACOSYNTHESIS
• Aspiration of pleural fluid with a thin
needle may reveal cancerous cells.
DIAGNOSTIC WORKUP
History: metastasis symptoms
PE: H & N lymph nodes
Chest X-ray
CT: the most valuable radiologic study for evaluation,
staging, and therapeutic planning of lung cancer
MRI: mediastninum or paravetebral region
Bone scans: stage III before curative therapy
PET influenced radiation delivery in 65% for
definitive radiotherapy (Kalff et al.).
Brain CT scan: small cell carcinoma.
Pulmonary function tests: ability to undergo
surgical resection or withstand irradiation
• Sputum cytology: 20% to 30%
sensitivity
• Bronchoscopic examination: 90%
positive
• CT-guided Bx: 95% positive
• Bx: Primary tumor lesion, scalene node
Pathology
• Sputum cytology: 20% to 30%
sensitivity
• Bronchoscopic examination: 90%
positive
• CT-guided Bx: 95% positive
• Bx: Primary tumor lesion, scalene node
Types of lung cancer
Ø Lung cancers are also called bronchogenic
carcinomas because they arise from the
bronchi within the lungs. They are classified
into SMALL-CELL LUNG CANCERS (SCLC) and
NON-SMALL CELL CANCER (NSCLC).
v SMALL-CELL LUNG CANCER
• Comprise of 20% of lung cancer and it’s the
most aggressive and rapidly growing of all
lung cancers.
• Related to cigarette smoking, metastasis
rapidly to many sites within the body and are
discovered after they have spread
extensively.
Types of lung cancer
cont…
v NON –SMALL CELL LUNG CANCER
(NSCLC)
• Most common lung cancer.
• Accounts for 80% of all lung cancers.
• Can be subdivided into several main
subtypes like adenocarcinomas,
squamous cell and large cell
carcinomas
Signs and symptoms of
lung cancer
Ø cough (most common)
Ø hemoptysis (coughing up blood)
Ø Dyspnea
Ø wheezing
Ø chest pains
DIAGNOSIS
1. HX AND PHYSICAL EXAM
• -cyanosis and clubbing may
indicate lung disease
Lung Cancer Re-cap
Small Cell Lung Cancer Non-Small-Cell Lung Cancer
Squamous cell Adenocarinoma
Squamous cell carcinoma
• Moderate to poor differentiation
• makes up 30-40% of all lung cancers
• more common in males
• most occur centrally in the large bronchi
• Uncommon metastasis that is slow effects the
liver, adrenal glands and lymph nodes.
• Associated with smoking
• Not easily visualized on xray (may delay dx)
• Most likely presents as a Pancoasts tumor
Adenocarcinoma
• Increasing in frequency. Most common type of
Lung cancer (40-50% of all lung cancers).
• Clearly defined peripheral lesions (RLL lesion)
• Glandular appearance under a microscope
• Easily seen on a CXR
• Can occur in non-smokers
• Highly metastatic in nature
• Pts present with or develop brain, liver,
adrenal or bone metastasis
Large cell carcinomas
• makes up 15-20% of all lung cancers
• Poorly differentiated cells
• Tends to occur in the outer part
(periphery) of lung, invading sub-
segmental bronchi or larger airways
• Metastasis is slow BUT
• Early metastasis occurs to the kidney,
liver organs as well as the adrenal
glands
TMN Staging
system for Lung
Cancer
• T= Tumors : tumor size, (local
invasion)
•
• N= Node : node involvement
(size and type)
• M= Metastasis : general
involvement in organs and
tissues
Lung Cancer Staging Continued
• T: Tx, T0, Tis, T1-T4 (T3-tumors greater
than 7cm, T4 is a tumor of any size)
• N: N0, N1, N2, N3
• M: M0, M1a, M1b
Stage grouping (AJCC 2002)
T1 T2 T3 T4
N0 IA IB IIB IIIB
N1 IIA IIB IIIA IIIB
N2 IIIA IIIA IIIA IIIB
N3 IIIB IIIB IIIB IIIB
Grade Explanation of activity
0 Fully active, able to carry on all pre-disease performance
without restriction
Treatment 1 Restricted in physically strenuous activity but ambulatory and
able to carry out work of a light or sedentary nature, e.g., light
• Surgery is the preferred house work, office work
radical option
2 Ambulatory and capable of all selfcare but unable to carry out
• ‘Resectable’ versus
‘operable’ any work activities. Up and about more than 50% of waking
hours
• Radical RT (or SBRT) should
be considered even if patient 3 Capable of only limited selfcare, confined to bed or chair more
not fit for surgery than 50% of waking hours
(‘operable’) 4 Completely disabled. Cannot carry on any selfcare. Totally
• Performance status at confined to bed or chair
diagnosis is crucial:
5 Dead
Medical Management
• The three main cancer treatments are:
• *surgery (lung resections)
• *radiation therapy
• *chemotherapy
• Other types of treatment that are used to treat certain cancers are
hormonal therapy, biological therapy, Immunotherapy, targeted
chemotherapy or stem cell transplant.
Prognostic Factors
Ø The best estimate on how a patient will do based on:
*type of cancer cells
*grade of the cancer
*size or location of the tumor
*stage of the cancer at the time of diagnosis
*age of the person
*gender
*results of blood or other tests
*a person’ss specific response to treatment
*overall health and physical condition
Prognosis for lung
• Depends on early detection and immediate
premetastasis stage treatment
v SCLC- Has median survival time of only two to four
months after diagnosis when untreated.
ü When radiation and chemotherapy are used,
survival time can be prolonged to four to fivefold.
v NSCLC – the most prognostic factor is the stage
(extent of spread) of tumor at the time of diagnosis.
ü Results of standard treatment are generally poor.
ü Stage 1 cancer can be removed completely
surgically, five year survival can be achieved.
