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1 |PULMO
Non small cell CA
• In non-smokers with adenoCA, the possibility of
other primary sites should be considered
• Squamousand small cell CA usu present as central
masses w/ endobronchial growth
Biology of Lung C ancer
• Adenocarcinomasand large cell CA tend to present
as peripheral nodules or masses, frequently with
pleural involvement
• Squamousand large cell CA cavitate in 10-20%of
cases
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Chromosomal Losses Chromosomal Gains
• Non Small Cell Lung Ca • Non Small Cell Lung Ca
–3p, 8p, 9p, 13q, 17p –1q, 3q, 5p, 8q
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p53/ MDM2/ p14ARF Pathway
– Correlates with poor prognosis after surgical • p14ARF
treatment of lung cancers, especially in stage I
cancers. – Exerts growth inhibition by inhibiting the
• MDM2 ubiquitin E3 ligase activity of MDM2
– Ubiquitin E3 ligase; oncogene – Deletion may promote tumor-promoting
– Interacts with p53 and targets the p53 protein for activity of oncogenes
degradation
– Paradoxically in association with a favorable
prognosis
Retinoblastoma Proteins
• p16INK4A • Transforming Growth Factor - β
– Maintains RB in phosphorylated state – Inhibits cell proliferation of normal epithelial cells,
– Exerts tumor suppressor activity only in the including bronchial and peripheral lung epithelial
presence of wild-type RB cells, thru inductions of CDK inhibitors
– p16INK4A-RB: critical regulator of cell cycle • Cell Cycle Check Points
progression – Induce arrests/ delay of cell cycle progression;
– Alterations in RB detected in 90%of SCLCs provide time for DNA repair
Epidemiology of Lung CA
• Most Lung CA are caused by carcinogens and
tumor promoters ingested via cigarette smoking
• Relative risk of developing lung CA is ↑ 13x by
active smoking & 1.5x by long term passive
Epidemiology of Lung C ancer smoking
• Lung CA death rate is related to the total cigarette
pack years ( risk is ↑60-70x for smoking 2
packs/day for 20 yrs compared to non smoker)
• Risk of dev lung CA decreases with cessation of
smoking but may never return to nonsmoker level
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*
Epidemiology of Lung CA Epidemiology of Lung CA
• Increase in lung CA rate in women is • The present pandemic of lung cancer followed
associated with rise in cigarette smoking the introduction of cigarettes
• Women have a higher relative risk per given • Role of carcinogens in disease causation
exposure than men (↑1.5 x) likely due to • First identified occupational respiratory
higher susceptibility to tobacco carcinogens in carcinogen: Radon
women
*
Epidemiology of Lung CA Patterns of Occurrence
• Human occupational causes Temporal Trends
– Arsenic, Asbestos, Chromates, Chloromethyl • Differing epidemic patterns in men and
ethers, Nickel, Polycyclic Aromatic hydrocarbons, women
Radon progeny
• Epidemic among women followed that of men
• Outdoor air pollutants
• Lung Cancer: most frequent cause of female
– Combustion-related carcinogens
cancer mortality
• Indoor air pollution
– Asbestos, Radon, Cigarette smoke, Fumes from
cooking stoves
Epidemiology of Lung CA
*• Older age groups Race and Ethnicity
– Rates continue to increase in both sexes – Rates similar among African American and white
women
– Rates of increase decelerating more significantly
in men – Rates 50%higher among African American men
than among white men
• Younger age groups – Mortality rates:
– Rates decreasing; decreases more pronounced for Hispanics, Native Americans,
men Asians/ Pacific Islanders >African
Americans and non Hispanic whites
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Epidemiology of Lung CA Occurrence by Histologic Type
Geographic Patterns – Dose-response relationship (number of cigarettes
– Most common in developed countries smoked) steepest for Small Cell Undifferentiated
Carcinoma
– North America, Europe >Africa, South America
– Rates tend to be highest in urban areas; costal
areas – Chloromethyl ethers, Radon exposure exhibit
specificity for Small Cell LungCancer
Epidemiology of Lung CA
Occurrence by Histologic Type
• Changes in cigarette characteristics
– Adenocarcinoma: now the most common
– Puff volume increased
histologic type; most common type in females
• Change in deposition patterns (peripheral airways
– SquamousCell: more common type in males and alveoli)
than females
– Nitrate levels in tobacco smoke increased
– Increasing rates of Adenocarcinoma: • Nitrogen oxide production increased
• Changes in cigarette smoking behavior • Increased dose of Nitrosamine 4-
• Features of cigarettes (methylnitrosamino)-1-(3-pyridyl)-1-butanone
(NNK)
*
A Carcinogenic Pathway Etiology of Lung Cancer
• AAH → small, focal BAC invasive
→ AdenoCa
• Exposure to etiologic (or protective) agents
• Atypical AdenomatousHyperplasia (AAH)– • Individual susceptibility to these agents
most common precursor to Adenocarcinoma
• Bronchio-Alveolar CA (BAC) – low prevalence;
includes AAH as precursor step
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Environmental and Occupational Agents Environmental and Occupational Agents
• Compared to never smokers, smokers have a • Tripling the number of cigarettes smoked per
20-fold increase in lung cancer risk day was estimated to triple the risk; tripling
• Risk increases with duration of smoking and the duration of smoking was estimated to
number of cigarettes smoked per day increase the risk 100x
• Stronger effect of duration of smoking than • Starting at younger age have a greater
amount smoked per day likelihood of becoming heavier smokers and
remaining smokers
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• Diet
– Specific micronutrients may have anti
carcinogenic activity *
– Alcohol drinking
– Tomatoes, cruciferous vegetables • Highest consumption categories associated
• Reduces risk with increased risk
– β - carotene
• Increased risk – Lower BMI
– Vitamin C • Increased lung cancer risk relative to heavier
• Protective association persons
– Vitamin A – Concomitant effects of smoking (?)
• Studies yield null findings
*
Asbestos Radiation
• Fibrous, naturally occuringsilicate material • Types of Radiation
• Peak incidence occur 30 -35 years after initial – Low Linear Energy Transfer (LET)
exposure • X-rays
• γ-rays
• In combination with smoking, act • Associated with higher risk when exposure occur at
synergistically to increase lung cancer risk higher dose rate
– Mechanism: – High Linear Energy Transfer (LET)
• Alter deposition pattern in the lung • Neutrons
• Enhance retention of asbestos fibers • Radon
• Nonthreshold dose-response relationship
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Air Pollution Host Factors
• Atmospheric Air Pollution • Genetic susceptibility
• Polycyclic aromatic hydrocarbons, arsenic, – History of lung cancer predicts increased risk;
nickel, chromium mendelian codominant autosomal gene
• Indoor Air Pollution – Genetic factors may be more important at
– Most important indoor air pollutants in younger ages; association stronger in ages 40 – 59
never smokers: years than older persons
• Passive smoking
• Radon
• Others: asbestos, unprocessed solid fuels
• HIV and Lung Cancer • Acquired Lung Diseases and Lung Ca*
– Potential reasons for the increased risk: – Diseases that obstruct airflow
• HIV acting as viral carcinogen • COPD
• Defective immune surveillance – Diseases that restrict lung capacity
• Recurrent opportunistic infections and • Pneumoconioses
parenchymal lung inflammations leading to • Presence of silicosis is associated with an
inflammatory foci and scar carcinomas increased risk
9 |PULMO
• Screening for Lung cancer
Clinical manifestations
Chest Radiograph
• Peripheral growth of primary tumor may
cause: • Demonstrate the size
1. pain from pleural or chest wall involvement of the tumor,
(malignant pleural effusion) especially in
2. cough peripheral lesions
3. dyspnea
4. symptoms of lung abscess resulting from
tumor cavitation
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Clinical manifestations
Chest Radiograph
• Central or endobronchial growth of primary
tumor may cause: • Central tumors may
1. Cough be associated with
2. Hemoptysis atelectasisor
3. Wheeze and stridor obstructive
pneumonitis.
4. Dyspnea
5. Post-obstructive pneumonitis(fever and
productive cough)
• Results from local extension of a tumor (usually Squamous Endocrine and Metabolic Cushing syndrome Small cell CA
cell CA) growing in the apex of the lung SIADH Small cell CA
• Involve the 8th cervical, 1st and 2nd thoracic nerves Hypercalcemia Squamouscell CA
• Present with shoulder pain that cha. radiates in the ulnar Gynecomastia Large cell CA
distribution of the arm
Connective tissue Clubbing & hypertrophic Squamouscell, adenoCA,
• Often with radiologicdestruction of the 1st and 2nd ribs
pulmonary large cell
• Other problems of regional spread: osteoarthropathy
- Superior vena cava syndrome from vascular obstruction Neuromuscular Peripheral neuropathy Small cell CA
- Precordial and cardiac extension w/ tamponade Subacute cerebeller Small cell CA
- Arrhythmia or cardiac failure degeneration,
- Lymphatic obstruction with pleural effusion Myasthenia (Eaton- Small cell CA
- Lymphangitic spread through the lungs with hypoxemia and Lambert),
dyspnea Dermatomyositis
All
11 | P U L M O
Primary Tumor TNM Stagingfor NSCLC
Tx Primary tumor cannot be assessed, or tumor proven by the
Primary Tumor TNM Staging
presence of malignant cells in sputum or bronchial washing but
not visualized by imaging or bronchoscopy
T0 No evidence of primary tumor T3 Tumor >7 cm; or directly invading chest wall, diaphragm,
phrenic nerve, mediastinal pleura, or
T1 Tumor =3cm surrounded by lung or visceral pleura, not more Parietal pericardium
proximal to the lobar bronchus Or tumor in the main bronchus ,< 2 cm distal to the
carina;
T1a Tumor =2 cm
Or atelectasis, obstructive pneumonitis of entire lung;
T1b Tumor >2cm but =3cm Or separate tumor nodules of same lobe
T1
T2
1.8 cm.
4.2cm. spiculatedmass
T3 T4
Right apical carcinoma Involvement of the carina Involvement of the great vessels
Negative for rib or vertebral destruction
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Chest Radiography
• Inferior to CT in the
Staging of M ediastinal detection of
mediastinal lymph
Lymph Nodes node metastases.
*
Computed Tomography
• Use of spiral or multisection CT, thin (5-mm)
sections with IV contrast material.
• Normal-sized nodes may contain metastases
and nodes may be enlarged due to
inflammatory causes although they contain no
malignant cells.
• The short axis diameter is the most reliable
measurement of lymph node size on CT scans.
A short axis diameter of greater than 10 mm is
abnormal regardless of the nodal station
*
NODAL ASSESSMENT:CT Normal Size(Diameter) of Thoracic
LNS
• LYMPH NODE DIAMETER OF 1.0 CM IS USED TO
DISTINGUISH NORMAL FROM ABNORMAL
•Anterior Mediastinum < 6 mm
• SHORT AXIS DIAMETER OF NODE IS USED
•AortopuimonaryWindow <15 mm
• SHORT AXIS MEDIASTINAL NODE CORRELATES MOST
CLOSELY WITH THE ACTUAL NODE DIAMETER •Hilar <10 mm
• UPPER LIMIT OF 1.5 CMS IS USUALLY USED FOR
NODES IN THE SUBCARINAL REGION
•Subcarinal <10 mm
•Para-aortic < 7 mm
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Regional Lymph Node
• N0 - No lymph nodes involved
• N1 - Ipsilateral bronchopulmonaryor perihilar ,
intrapulmonary nodes
• N2 - Ipsilateral mediastinal nodes or ligament
involved
– Upper Paratracheal & Lower Paratracheal Nodes
– Pretracheal and Retrotracheal Nodes
– Aortic and Aortic Window Nodes
– Para-aortic Nodes
– Para-esophageal Nodes
– Pulmonary Ligament
– Subcarinal Nodes
• N3 - contralateral mediastinal or hilar nodes involved
(see or any scalene or supraclavicular nodes involved Left Paratracheal Lymphadenopathy
N3
X
Staging of Distant
M etastases
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Metastatic Involvement
• M0 - No metastases
• M1a – separate tumor nodules in a
contralateral lobe;tumor w/ pleural
nodules; malignant pleural dissemination
• M1b- distant metastasis
Computed Tomography
Magnetic Resonance Imaging
1 3
15 | P U L M O
Pulmonary metastases are usually more numerous in the
lower zones than in the upper zones. Hot spots due to bony metastases in the right second and ninth ribs.
T2b N1 M0
IIB
T3 N0 M0
T3 N1 M0
T1-3 N2 M0
IIIA
T4 N0,1 M0
T4 N2 M0
IIIB
T1-4 N3 M0
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T4
T4
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Staging of Small Cell CA
CT Criteria for Resectability
• Limited Stage
• Contact between
- confined to one hemithoraxand regional mass and
lymph nodes (including mediastinal mediastinumof less
contralateral hilar, and ipsilateral than 3 cm
supraclavicular nodes • Circumferential
contact between the
- Advanced stage mass and aorta of less
- with involvement of contralateral than 90°
hemithorax • Presence of a fat
plane between the
mass and
mediastinum
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CT Criteria for Non-Resectability
Major contraindications to Curative surgery:
• Involvement of the carina
• Tumor surrounding, • Extrathoracic metastases
encasing, or abutting the • Superior vena cava syndrome
aorta. Main or proximal • Vocal cord and phrenicnerve paralysis
portions of the right or • Malignant pleural effusion
left pulmonary arteries, • Cardiac tamponade
or esophagusby more • Tumor w/in 2 cm from the carina
than 180° The left hilar tumor extends to the carina, • Metastasis to supraclavicular lymph node
invades the left pulmonary artery, and is • Contralateral mediastinal node metastasis
contiguous with the descending aorta over
an arc of greater than 180°the stage is T4. • Involvement of main pulmonary artery
The primary tumor is difficult to separate
from the mediastinal lymphadenopathy
(stage Nx) and from the distal atelectasis
and pneumonitis. *notes ni Doc
19 | P U L M O
Treatment modalities Treatment modalities
Stage IV and more advanced IIIBdisease: SMALLCELLLUNG CANCER
• RT to symptomatic local sites • RT for brain metastases, spinal cord compression,
• CRxfor ambulatory patients weight-bearing lytic bony lesions, symptomatic local
lesions (nerve paralyses, obstructed airway,
• Chest tube drainage of large malignant pleural hemoptysis, intrathoracic large venous obstruction,
effusions in non-small cell lung cancer and in small cell cancer
• Consider resection of primary tumor and metastasis not responding to CRx)
for isolated brain or adrenal metastases • Appropriate diagnosis and treatment of other
medical problems and supportive care during CRx
• Encouragement to stop smoking
• Entrance into clinical trial, if eligible
20 | P U L M O
Solitary Pulmonary Nodule
• Radiographic criteria which reliably predict a
benign nature of solitary pulmonary nodule:
1. lack of growth over a period of >2 yrs
2. characteristic patterns of calcification:
a. dense nidus
Th e En d
b. multiple punctate foci God Bless!
c. “bull’s-eye” calcification- (granuloma)
d. “popcorn ball” calcification-
(hamartoma)
KDE, 2009
T2b N1 M0
IIB
T3 N0 M0
T3 N1 M0
T1-3 N2 M0
IIIA
T4 N0,1 M0
T4 N2 M0
IIIB
T1-4 N3 M0
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Primary Tumor TNM Stagingfor NSCLC
Tx Primary tumor cannot be assessed, or tumor proven by the
presence of malignant cells in sputum or bronchial washing but
not visualized by imaging or bronchoscopy
T0 No evidence of primary tumor
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