Diagnosis and management of lung cancer.

1. Lung Cancer
Presented By
Dr. Md. Shafiqul Islam Dewan
Resident (Pulmonology) - Phase-A
Department Respiratory Medicine
Dhaka Medical College Hospital

2. Epidemiology
 Lung cancer remains the most common cancer worldwide
and the leading cause of cancer death in the world.
 Recent studies showed that incidence of lung cancer is
decreasing in high income countries due to declining rate of
smoking.
 Approximately 15% of lung cancers occur in non-smokers,
which suggests that exposure to carcinogens other than
cigarette smoke at work or home can cause disease in
susceptible individuals.

3. Pathology
 lung cancer is tumors arising from the respiratory
epithelium (bronchi, bronchioles and alveoli) or mucous
glands.
 Lung cancer may involve the pleura directly or by
lymphatic spread and may extend into the chest wall,
invading the intercostal nerves or the brachial plexus.
 Lymphatic spread to mediastinal and supraclavicular
lymph nodes often occurs before diagnosis
 Blood-borne metastases occur most commonly in liver,
bone, brain, adrenals and skin.

4. Classification
 Histological classification:
 Non-small-cell carcinomas (NSCLC) – 85%
 Adenocarcinoma – 35-40%
 Squamous cell carcinoma – 25-30%
 Large-cell carcinoma – 10-15%
 Small-cell lung cancer (SCLC) – 15%

5. Classification
 Anatomical classification
 Central lung cancer: Usually squamous cell
carcinoma and small cell carcinoma
 Peripheral lung cancer : Usually adenocarcinoma.

6. Risk Factors
 Cigarette smoking is the number one cause of lung cancer.
 Asbestos
 Radon exposure in uranium miner
 Arsenic
 Chromium
 Nickel
 Mustard Gas
 Polycyclic Aromatic Hydrocarbons
 Exposure to biomass fuel: Recent studies showed exposure to
biomass fuel for cooking is associated with high risk of lung cancer
in women in developing countries.

7. Clinical Manifestation of Lung Cancer
 Due to primary lesion:
 Cough 8–75%
 Dyspnea 3–60%
 Hemoptysis 6–35%
 Wheezing
 Weight loss
 Fever
 Pneumonia
 Asymptomatic: 5-15%
 Due to local extension:
 Chest pain
 Hoarseness of voice
 Superior vena cava
obstruction 0–4%
 Horner’s syndrome
 Dysphagia 0–2%
 Pericardial effusion
 Pleural effusion
 Diaphragm paralysis

8. Paraneoplastic manifestation
 Endocrine:
 Inappropriate antidiuretic hormone (ADH,
vasopressin) secretion, causing hyponatraemia
 Ectopic adrenocorticotrophic hormone secretion
 Hypercalcaemia due to secretion of parathyroid
hormone-related peptides
 Carcinoid syndrome
 Gynaecomastia

9. Paraneoplastic manifestation
 Neurological:
 Polyneuropathy
 Myelopathy
 Cerebellar degeneration
 Myasthenia (Lambert–Eaton syndrome)

10. Paraneoplastic manifestation
 Other
 Digital clubbing
 Hypertrophic pulmonary osteoarthropathy
 Nephrotic syndrome
 Polymyositis and dermatomyositis
 Eosinophilia

11. Screening of lung cancer
 Outcome of lung cancer is dependent on early detection of disease.
 Early detection is a process that involves screening tests, surveillance,
diagnosis, and early treatment.
 low-dose, non-contrast, thin-slice spiral chest computed tomography
(LDCT) has emerged as an effective tool to screen for lung cancer on
recent studies in united states.
 According to NLST (National Lung Screening Trial) in US, high risk
individual who are eligible for screening programme are individuals
between 55 and 74 years of age, with a ≥30 pack-year history of cigarette
smoking and former smokers must have quit within the previous 15
years.
 It remains unclear whether the benefits of lung cancer screening observed
in the NLST are generalizable to populations outside of the United States

12. Investigation
 To confirm the diagnosis
 Imaging
 Chest x-ray
 CT scan of Chest
 Cytology
 Sputum for malignant cell
 Pleural fluid study
 Fiber optic bronchoscopy with bronchial washing and
brushing study

13. Radiological presentations of lung cancer
 Unilateral hilar enlargement - Central tumour or hilar
glandular involvement.
 Peripheral pulmonary opacity
 Cavitation
 Lung, lobe or segmental collapse - Tumour or enlarged
lymph glands occluding bronchus
 Pleural effusion - Tumour invasion of the pleural space or
very rarely, infection in collapsed lung tissue distal to a lung
cancer.

14. Radiological presentations of lung cancer
 Widening of the upper mediastinum - Paratracheal
lymphadenopathy
 Enlargement of the cardiac shadow-Malignant
pericardial effusion.
 Raised hemidiaphragm - Phrenic nerve palsy
 Osteolytic rib destruction - Direct invasion of the
chest wall or metastatic spread.

20. Investigation
 To establish the histological cell type
 CT guided biopsy
 Bronchoscopy guided biopsy
 EBUS guided biopsy
 TBNA

21. Investigation
 To define the extent of the disease:
 EBUS equipped bronchoscope and Mediastinoscopy:
To sample enlarged upper mediastinal nodes
 Head CT, radionuclide bone scan, liver ultrasound and
bone marrow biopsy: Patients with clinical,
haematological or biochemical evidence of tumour spread
to extra thoracic site

22. Investigation
 To guide therapy and support evidence:
 Complete blood count
 Pulmonary function test: Forced vital capacity >2 litre
and FEV1 > 50% predicted is pre-requisite for surgical
treatment.
 Renal function test
 Liver function test

23. Tumour stage and 5-year survival in
non-small-cell lung cancer

24. Treatment
 Lung cancer should be managed in specialist centers by
multidisciplinary teams, including oncologists, thoracic
surgeons, respiratory physicians and specialist nurses.
 Treatment is dependent on the type and stage of tumour

25. Treatment
 General aspects of management
 Effective communication,
 pain relief
 Nutritional supplements
 Treatment of depression and anxiety

26. Treatment
Specific measures:
Surgical treatment
Radiotherapy
Chemotherapy
Palliative therapy
Treatment of non-metastatic endocrine manifestations

27. Surgical treatment
Surgery is the treatment of choice in Stage I and stage II
NSCLC
 Options are:
 Lobectomy
 Pneumonectomy
 Wedge resection

28. Radiotherapy
 Radical radiotherapy can offer long-term survival in
selected patients with localized disease in whom
comorbidity precludes surgery.
 Radical radiotherapy is usually combined with
chemotherapy when lymph nodes are involved (stage
III). Highly targeted (stereotactic) radiotherapy may be
given in 3–5 sessions for small lesions.

29. Chemotherapy
 In SCLC combinations of cytotoxic drugs, sometimes
with radiotherapy, can increase median survival from 3
months to over a year.
 Combinations of intravenous cyclophosphamide,
doxorubicin and vincristine or intravenous cisplatin and
etoposide, are commonly used

30.  In NSCLC chemotherapy is less effective. there is some
evidence that chemotherapy given before surgery may
increase survival and can effectively ‘down-stage’ disease
with limited nodal spread.
 Post-operative chemotherapy is now proven to enhance
survival rates when operative samples show nodal
involvement by tumour
 Preferred regimen:
 Platinum based chemotherapy regimens: It offers 30%
response rates and a modest increase in survival
 Tyrosine kinase inhibitors (erlotinib) and monoclonal
antibodies to EGFR (bevacizumab): Effective in
adenocarcinomas which carry detectable mutations, e.g. in
the epidermal growth factor receptor (EGFR) gene.

31. Palliative therapy
 Palliative radiotherapy: Palliation of distressing
complications, such as superior vena cava obstruction,
recurrent haemoptysis, and pain caused by chest wall
invasion or by skeletal metastatic deposits.
 Bronchoscopic laser therapy and stenting: Relieve of
major airway obstruction
 Management of malignant pleural effusion: Aspiration
through intercostal chest drain followed by pleurodesis
to prevent recurrent pleural effusion.

32. Management of NSCLC
 N0 or N1 involvement:
 Stage 1A: Surgery alone
 Stage IB: <4 cm surgery alone
>4 cm surgery followed by adjuvant chemotherapy
 Stage II or III: Surgery followed by adjuvant chemotherapy
 N2 or N3 involvement:
 No surgery
 Treatment with combined chemoradiation therapy

33. Small cell carcinoma
 Limited stage SCLC
 Confined to the ipsilateral hemithorax
 Treated with combination of chemotherapy and radiation with
surgical resection reserved for selected patient with stage I
disease
 Extensive stage SCLC
 Beyond ipsilateral hemithorax (malignant pleural or
pericardial effusion or hematogeous metastasis).
 Treated with chemotherapy only to improve quality of life and
prolong survival.

34. Recent Non chemotherapy Drugs for the
Treatment of Lung Cancer

35. Prognosis
 The overall prognosis in lung cancer is very poor
 70% of patients dying within a year of diagnosis
 only 6–8% surviving 5 years after diagnosis
 The best prognosis is with well-differentiated squamous
cell tumours that have not metastasised and are
amenable to surgical resection.