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Lung Cancer Overview

John W. Davis, M.D. FACS

February 16th, 2008

Overview

Epidemiology

Clinical Features

Diagnosis

Staging

Surgical Treatment

Lung Anatomy

Surgical Resections

Epidemiology

Definition

Science of identifying thedistribution/determinants of disease

Two study types Case control

Cohort

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Historical Perspectives

Rare in 19th century

20th Century increases Incidence in women 30 years later

Causes uncertain

Car exhaust/air pollution

50s case controls--tobacco

Epidemiology

Second most common cancer in the USA

Most lethal1/4 of all cancer deaths

Most common cause of cancer death inmen

Male:Female 1.2:1

Mortality rate for men is declining

Incidence continues to climb in women

Epidemiology Facts

Since 1987, more women have died of

lung cancer than breast cancer

African-American males have highes risk

Differences in socioeconomic status andsmoking behavior

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Etiology/Risk Factors

Cigarette Smoking 10-25 fold increase risk

Accounts for majority of lung cancer cases (85%)

Risk related to number of cigarettes, duration, age atinitiation, depth of inhalation, tar/nicotine content

More than 40 carcinogens have been identified

Filters/lower tar content help unless smokerscompensate smoking habits

Smoking cessation causes a gradual drop in risk

Passive smoke exposure/particularly children whothen smoke

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Tobacco as Carcinogen

Type

Cigarettes are #1 (British Doctor Cohort, 76) Pipe/Cigar lower risk

Tar/nicotine content

Amount Dose response

Duration Risk proportional to time (years)

Starting age important (15 yo)

Etiology/Risk factors

Inhalation of Asbestos fibers

Non-smokers 5X risk

20X risk with smoking

Dose Resonse

Radon exposure

COPD

Diet

Lung Cancer: Histology

Non-small cell

Adenocarcinoma

Squamous Cell Carcinoma

Bronchioalveolar Carcinoma

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Incidence/Mortality

Trends in Mortality in North America

Mendecreased since 1992 Women plateau 20 years later

International influence

Reflect more recent smokingprevalence/occupational hazards

China/Japan highest

Decreasing in Europe/NA

Clinical Features

Clinical Features

160,000 new cases anually

95% are symptomatic Primary tumor

Disseminated disease Nonspecific

Varied/Unpredictable Stage

Location

Histology

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Pulmonary Manifestations

Cough

Dyspnea Wheezing/Stridor

Hemoptysis

Pneumonic Symptoms

Lung Abscess

Nonpulmonary ThoracicManifestations

Chest wall

Diaphragm invasion

Mediastinal invasion

Superior vena cava syndrome

Pericardial effusions

Esophageal compression (dysphagia)

Vertebral body (severe back pain)

Paraneoplastic syndromes

Paraneoplastic Syndromes

Hypertrophic Pulmonary Osteoarthropathy

and Clubbing (HPO)

SIADH

Hypercalcemia

Ectopic Adrenocorticotropic Syndrome

Neurologic Paraneoplastic Syndromes

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Metastatic Symptoms

CNS

Bone

Hepatic

Adrenal

Skin/soft tissue

Nonspecific Symptoms

Diagnosis

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History and Physical

Age

Tobaccoism Bronchopulmonary symptoms

Chest wall pain/Mediastinal invasion

Bone/CNS involvement

Paraneoplastic Syndromes

Clubbing

Laboratory Evaluation

CBC/LFTs/Renal panel/Serum Calcium

Sputum cytology

Tumor Markers

NSE/CEA

Imaging Evaluation

Chest Xray

CT

MRI PET

Bone Scan

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Positron Emission Test (PET)

Now used commonly

Detects glucose metabolism Sensitive for inflammatory/malignant cells

High sensitivity/specificity with CT

Does NOT replace tissue diagnosis

Tissue Diagnosis

Bronchoscopy

Transthoracic needle biopsy

Mediastinoscopy

Thoracoscopy (VATS)

Lobectomy

Staging

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Treatment Options

Surgical Resection

Lobectomy Pneumonectomy

Segmentectomy

Wedge

Minimally invasive

Chemotherapy

Radiation

Surgical Treatment

Anatomic resection/MLND

Stage I and II

Select IIIA

Pneumonectomy higher risk

Segmentectomy lower risk/higherrecurrence

5 year survival 60-70%/40-55%

Surgical Treatment

Stage III

IIIA

Potentially resectable

Diverse group of patients

IIIB

Not resectable

Stage IV

Widespread disease

Median survival 4 months

Surgery for Palliation

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Anatomy

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Common Surgical Resections

Lobectomy

Pneumonectomy

Segmentectomy

Wedge

Mediastinoscopy

Sleeve Pneumonectomy

Thoracoscopic Procedures (VATS)

Solitary Pulmonary Nodule

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Thank You