Uiuc M2 2010 Fcp Lung Cancer

Front 1

5 year cure rate for lung cancer

clinical stage I disease:
"pathologic stage I" cancer:

Back 1

65%
75%

Front 2

Segmentectomy vs. lobectomy in lung cancer

Back 2

Segmentectomy inferior to lobectomy → local recurrence, but overall cure rate same after recurrence resection.

Front 3

Lung cancer increases after # pack years.
lifetime prevalence in 10pack-year history:
Risk if also exposed to asbestos:

Back 3

Lung cancer rare with less than 20 pk-year history.
10 pk-year still have have 1% lifetime

10 fold increase w/asbestos+cancer.

Front 4

Prior history of lung cancer, risk for another:
tx of such individuals:

Back 4

1% annual rate
annual x-ray monitoring

Front 5

Chance that nodule in 20 pack-yr is malignant:

2cm nodule:
>5cm nodule:

Back 5

50% chance its a malignancy
90% chance its a malignancy

Front 6

Majority of lung cancer patients present at what stage:

tx at this stage:

Back 6

Stage IV

if good performance status, chemo (eg: Cisplatinum) and radiation, but not sx.

Front 7

Lung cancer

epidemiology/causes: (8)

Back 7

1) smoking (80-90%)
2) tar and soot (eg:coke/coal oven)
3) arsenic, chromium, nickel
Asbestos
4) Radiation: eg: radon
5) Chloromethyl ethers
6) Polycyclic aromatic hydrocarbons
7) Diesel fumes
8) Passive smoke exposure

Front 8

Number of mutations caused by smoke necessary for malignancy:

Back 8

estimated accumulation of 20-30 mutations.
• Most smokers have multiple foci of mild to moderate dysplasia

Front 9

Cigarette smoke carcinogenesis

pathogenesis:

Back 9

-3000 components, at least 20 known carcinogens.

cause chromosomal damage

Front 10

1 pk/day, change of death from lung cancer:
>25cig/day:

Back 10

9%- dying of lung cancer
18%- dying of cancer

Front 11

Lung cancer rates are increasing/decreasing in

men:
women:
third world:

difference due to:

Back 11

men: have peaked, now decreasing
women: still increasing.
third world: rising spectacularly

smoking patterns in men and women respectively with a 20-40 year lag

Front 12

Genetic abnormalities associated

small cell cancer: (4)
non small cell cancer:

Back 12

1) Rb(90%) 2) p53(80%) 3) myc(40%) 4) 3p(90%)

1) K-ras(30%) 2) myc(10%) 3) Her-2 neu(25%) 4) p53(50%), 5) Rb(15%) 6) 3p (50%)

Front 13

Doubling time for lung cancer:

Days to reach 1cm mass-
small cell:
average non-small cell:

Back 13

Ranges from 15-360 days

small cell: 2 years
non-small cell: 6.5 years

• actively shedding malignant cells during this time, despite being completely asymptomatic.

Front 14

Types of Cancer/% total/location/growth speed

Small Cell:
Squamous cell:
adenocarcinoma:
Large cell:
other non-small cell:

Back 14

Small Cell: 13%
fast growing (doubling time <50 days). central origin.

Squamous cell: 20%, slower growing, less distant mets, central, may cavitate and cause hypercalcemia.

adenocarcinoma: 38%, peripheral in 2/3 of cases, may present with pleural effusion or distant mets

Large cell: 6%, usually peripheral , often large and bulky, resembles adenocarcinoma

other non-small cell: 18%, can't be further differentiated.

Front 15

Clinical presentation of lung cancer:

(8)

Back 15

1) Cough:) 70% of the time)
2) Hemoptysis 40%
3) Dyspnea 40%
4) Chest pain 35%
5) Hoarseness 5%
6) Superior vena caval obstruction 5%
7) Wheezing 2%
8) Pleural effusion, obstructive pneumonia, pericardial effusion, paraneoplastic syndrome, Pancoast syndrome, symptoms of metastases

Front 16

Mechanisms for dyspnea in lung cancer:

(8)

Back 16

1) Central airway obstruction
2) Atelectasis due to lobar obstruction
3) Pleural effusion
4) Phrenic nerve paralysis
5) Superior vena cava obstruction
6) Lymphangitic carcinoma
7) Pericardial effusion
8) Tracheal invasion

Front 17

Diagnosis, what test to use in retrospect:

1) good for central tumors, obstructive tumors, in situ carcinoma, large peripheral cancers
2) best for peripheral coin lesions
3) best in squamous or small cell
4) only good in >1 cm., threshold.
5) major staging imaging test
6) better for dx of coin lesions, staging of mediastinal disease, identification of distant mets
7) test of choice for undiagnosed pleural effusions, peripheral nodules

Back 17

1) Bronchoscopy
2) Fine needle aspiration: 90% sen, 98% spec.
3) Sputum cytology: variable sen and spec.
4) Chest x ray, fails to show 10-15%. In retrospect initial nodule visible but below threshold 25%.
5) CT of chest to include adrenals and liver
6) PET scan
7) VATS (Video-Assisted Thoracoscopic Surgery)

Front 18

Thoracentesis

sensitivity/specificity in adenocarcinoma of the lung:

Back 18

50% sensitivity for single thoracentesis; up to 80-90% for adenocarcinoma with 3 taps

Front 19

Staging (in regular and pleural lung cancer)

To:
Tx:
Tis:
T1a
T1b
T2a:
T2b:
T3:

Back 19

To: No Evidence of primary tumor
Tx: Tumor not apparent radiologically or bronchoscopically( but cytology+)
Tis: Carcinoma in situ
T1a:<=2cm.
T1b >2-3 cm.
T2a:>3-5 cm.
T2b:>5-7 cm.
T3:>7 cm.

T2: visceral pleural invasion
T3: Parietal pleural invasion
M1a: Separate pleural nodules/effusion
Satellite nodules ( same histology)
T3: same lobe
T4: different lobe, same side
M1a: Contralateral

Front 20

Stages in lung cancer:

Stage 1A:
Stage 1B:
Stage IIA:
Stage II B:
Stage IIIA:
Stage IIIB

Back 20

Stage 1A: T1a or T1b, N0
Stage 1B: T2a, N0
Stage IIA: T2b, N0;T1 a/b,T2a+N1
Stage II B: T2b, N1; T3, N0
Stage IIIA: T1a/b,T2a/b+N2
T3+N1/2
T4 N0/1
Stage IIIB Any N3:T4,N2

Front 21

Staging in lung cancer (nodes)

Nx:
N0:
N2:
N3:

Back 21

Nx: regional nodes cannot be assessed
N0: absence of regional lymph node involvement
N1: metastasis to ipsilateral peribronchial and or ipsilateral hilar lymph nodes
N2: Metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes
N3: Metastasis to; contralateral mediastinal nodes,contrateral hilar nodes, any scalene nodes, or supraclavicujlar nodes

Front 22

Screening for lung cancer:

recommended?
Based on 5 more recent published studies:
newest NIH study?

Back 22

No.
-Failed to show impact in lung cancer deaths from chest x-ray screening or sputum cytology despite shift to early stage cancers.

Low dose CT scans of chest done at yearly intervals vs. chest x ray only: 20% reduction in lung cancer deaths, 7% reduction in all cause mortality: still preliminary data, no change in practice yet.

Front 23

Confirmation of diagnosis of lung cancer (sen/spec)

1) Sputum cytology:
2) Bronchoscopy:
3) Transthoracic needle aspiration
4) CT staging of mediastinum
5) PET Scanning of mediastinum
6) Endoscopic ultrasound:
7) normal neurologic exam

Back 23

1) Sputum cytology: high specificity, but low sensitivity. better for central than peripheral.

2) good for central and endobronchial lesions; poor for peripheral nodules, especially under 2 cm

3) 90% sensitivity: 98% specificity.(20-30% pneumothorax rate however)

4) Sensitivity 57%, Specificity 82%

5) Sensitivity 84% specificity 89%

6) ultrasound:Sensitivity 78% specificity 71% (not widely available)

7) Negative predictive value(mets): 94%

Front 24

Clinical approach/steps to staging

(5)

Back 24

1) CT of chest
2) PET scan if available and CT suspicious
3) Tissue sampling of abnormal areas on CT/PET
4) if clinical eval -signs/symptoms mets: bone radio-isotope scan, and head CT or MRI
5) Pulmonary function testing

Front 25

Non-small cell lung cancer, stage I

tx: (4)

Back 25

1) Lobectomy with node sampling
2) surveillance for new primary
3) radiation of some value if non-operative
4) consider adjuvant therapy for stage IB

Front 26

Non-small cell lung carcinoma 5 year cure rate
T1N0M0:
T2N0M0:
T3 N0M0:
T3N1M0:

Back 26

71%
52%
49%
27%

Front 27

Non-small cell lung carcinoma, stage II

tx:

Back 27

(5% of all patients, (T1-2N1M0 or T3N0M0)
1) Sx
2) N1 nodes: post op radiation
3) adjuvant chemo indicated

Front 28

Non-small cell lung carcinoma, stage IIIA and IIIB

tx:

Back 28

IIIA:
1) preop dx of mediastinal mets : undergo chemotherapy before sx, mitomycin, isfosfamide, cisplatin or cytoxan, etoposide, cisplatin

2) maybe postop radation
3) Radiation therapy alone 5-10% survival.
4) Platinum based chemo + radiation 13% (vs 5% radiation alone)

IIIB: (no sx)
1) Optimal current approach: 2 cycles cis platinum+etoposide with once daily chest radiation to 61 gy) with 2 final cycles of cisplatin +etoposide
2) Sx rarely considered (5% survival)
3) seq chemo/radiation- improved early survival, not by 5 years.

Front 29

Non-small cell lung carcinoma, stage IV

tx:
median survival w/tx
1yr survival%
supportive care alone:
drugs used:

Back 29

good performance status: chemo improves duration/quality/survival.

6-l0 mo. with optimal chemotherapy
1yr (with tx): 30-35% survive.
supportive: 3.6 months
1) Cisplatin-vinorelbine
2) carboplatin-paclitaxel
3) cisplatin-gemcitabine
maximum 3-4 cycles.

Front 30

1) Risk: Lobectomy for lung cancer

2) Risk: Pneumonectomy:

3) complications of surgery:

Back 30

1) 2.6% 30 day mortality (experienced centers, up to 7.5% low volume centers)
2) 4-10% (R worse than L)
3) Permanent post thoracotomy pain, usually lifelong (25-50%)

Front 31

Role of radiation therapy in lung cancer

1) operable tumors:
2) inoperable:
3) + nodes or +margins
4) prophylactic cranial irradiation
5) symptoms
6) Brachytherapy with iridium

Back 31

1) only one study, sx better than radiation alone. may improve results if given with chemo before sx.
2) 3% cure rate in tumor can be encompassed within radiation tube
3) may reduce local recurrence, doesn't change overall cure rate.
4) small cell/complete remission: improves overall survival.
5) May control severe cough, hemoptysis , or rarely open up obstructed airways.
6) palliate endobronchial obstruction

Front 32

Pt. with EGFR mutation

tx:

Back 32

(17% of individuals, 2/3 in non smokers with adenocarcinoma)

tyrosin kinase inhibitors (gefitinib/erlotinib) → high response rate

Front 33

COPD

effect on lung cancer:

Back 33

Doubles the risk of developing lung cancer

Front 34

Small cell lung cancer

survival untreated:
tx:

Back 34

3-5 months

Limited stage disease:
1) chemotherapy and radiation (cure rates from 5-20%) (Cisplatinum and etoposide)
2) if achieve remission: offer cranial irradiation.

Extensive disease: chemo
60-70% response, 20-30% complete: median survival 9 months

No role for bone marrow transplant or maintenance chemotherapy

Front 35

Small cell lung cancer

usually presents as:

differential for "small cell" presenting as peripheral coin lesion:

Back 35

bulky central tumor often largely submucosal

bronchial carcinoids and lymphomas may be mistaken by the pathologist: should be resected!

Front 36

Small cell lung cancer

risk of new lung cancer/year:

Back 36

5% new lung cancer /year

quit smoking!