Understanding the basics of lung cancer

1. Lung Cancer
Robert Miller MD
www.aboutcancer.com

2. Lung Cancer
 Understanding the disease
 Anatomy and Imaging
 Staging system
 Treatment options

3. Lung Cancer
• Lifetime risk of being
diagnosed in men is 1 in 13 (7.77%)
and in women 1 in 16 (6.35%)
• Most lethal cancer
• Accounts for 14% of cancers in men
but 28% of cancer deaths, in
women also 14% of cases but 26%
of all cancer deaths

4. Age standardized lung cancer
mortality rate per 1000 men/year
Non Smoker 0.17
Former smoker 0.68
Current Smoker 2.49
1 – 14 cigarettes/day 1.31
15 – 24 2.33
> 24 4.17
The odds of dying of lung cancer goes up 24 X if compare heavy
smoker to a non smoker
BMJ 2004;328:1519 (26 June)

6. Risk of Getting Lung Cancer
Smoking Men Women
Non-smoker 0.2% 0.4%
Quit 5.5% 2.6%
Current 15.9% 9.5%
Heavy 24.4% 18.5%
European study in 2006, defined heavy as > 5 cigarettes per day

7. Cumulative Risk of Lung Cancer in Men
at Age 75 by Smoking History
Non-smoker <30y 40 y 50y 60y current
Age when they stopped

8. Risk for long term
heavy smokers
relative risk of lung cancer in the long-term
smoker compared with the lifetime nonsmoker
vary from 10- to 30-fold.
The cumulative lung cancer risk among heavy
smokers may be as high as 30 percent,
compared with a lifetime risk of lung cancer of
1 percent or less in nonsmokers

9. Effect of Smoking Reduction on Lung Cancer Risk
Nina S. Godtfredsen; Eva Prescott; Merete Osler JAMA. 2005;294:1505-1510.

10. Lung Cancer
• 5 year survival rate for all
• cancers from 1975 to 2008 has gone
from 49 to 68%
• 5 year survival for lung cancer during this
period has gone from 12 to 17%
• Most people are diagnosed in advance
stages: Local (15%), Regional (22%),
Distant (56%)
• Cure rate stage is poor: Local (52%),
Regional (25%), Distant (4%)

11. Calculate Survival after Surgery with
or without adjuvant chemotherapy

12. Symptoms of Lung Cancer
Symptoms Percent of Patients
Cough 45 – 74%
Weight Loss 46 – 68%
Dyspnea 37 – 58%
Chest Pain 27 – 49%
Hemoptysis 27 – 29%
Bone Pain 20 – 21%
Hoarseness 8 – 18%

13. Age and Lung Cancer
• Median age at diagnosis is 65y and median age at
death is 72y
Decade Non Small Small Cell
Cell
40‟s 5.9% 5.6%
50‟s 16% 19%
60‟s 30% 33%
70‟s 33% 31%
80‟s 15% 11%

14. Types of Lung Cancer
 Non-small cell carcinoma (NSCC) (87%)
◦ Adenocarcinoma (38%)
◦ Squamous cell (20%)
◦ Large cell (5%)
 Small cell carcinoma (13%)

15. Biopsy - confirm the cancer and
determine the type
Bronchoscopy CT directed biopsy

16. Histology (NCDB 2000-2010)
Non Small Cell 85%
Adenocarcinoma 37%
Squamous 25%
NSCL 19%
Other 12%
Large Cell 4%
Bronchoalveolar 3%
Small Cell 15%

17. Pathology Report
• Pathological review: histology type and
extent of the growth and size of the cancer
• Immunohistochemical stains (“special
stains”) to better clarify the true source and
type of cancer
• Molecular diagnostic studies to look for
evidence of genetic mutations that would
impact on the use of targeted therapies

18. Pathology and the use of
targeted therapy
• Erlotinib (Tarceva) or Cetuximab (Erbitux) for
EGFR mutations
• Crizotinib (Xalkori) with ALK gen mutation
• Bevacizumab (Avastin) anti angiogenesis but
not for squamous cancers
• KRAS mutation they would not respond to TKI

19. Basic Lung Anatomy

20. The trachea divides into
branching bronchiole tubes

21. There are extensive blood
vessels in the lungs

22. Three lobes on the right and two
on the left

23. More detailed anatomy

24. Segments of the pulmonary
lobes

25. Segments of the Lungs

26. Trachea and Major Bronchi

27. Lymph Nodes and Lung
Cancer

28. Lymph Nodes in the Lung

29. Importance of the Lymph
Nodes
Spread to the Nodes
on the side (hilar
or N1 or Stage II )
is not as serious as
if nodes in the
middle or higher up
are involved (N2 or
mediastinal nodes
or Stage III)

30. Superior Mediastinal Nodes (1-4)
1. Highest Mediastinal: 2. Upper Paratracheal: 3. Pre-vascular or Pre-vertebral4. Lower
Paratracheal
Aortic Nodes (5-6)
5. Subaortic (A-P window): 6. Para-aortic
Inferior Mediastinal Nodes (7-9)
7. Subcarinal. 8. Paraesophageal 9. Pulmonary Ligament
Hilar, Interlobar, Lobar, Segmental and Subsegmental Nodes (10-14)
10-14: these are located outside of the mediastinum. They are all N1-nodes.

31. Lung Imaging Lung
Imaging

32. Reading a Chest X-ray

33. Reading a CT Scan

34. Cross Section Anatomy of the
Chest

35. Cross Section Anatomy of the
Chest

36. Cross Section Anatomy of the
Chest

37. Nodes on cross section

38. PET Scan will „light up‟ areas of
cancer

39. Common Nodes on PET Scan
upper para-tracheal node (R2
Node)

40. Common Nodes on PET Scan
lower para-tracheal node (R4
Node) and AP Window Node (5)

41. Common Nodes on PET Scan
left hilar node or L10

42. Same side (N1), nodes in the
middle (N2) and the opposite side
(N3)

43. PET Scan will help separate the
active cancer from areas of
collapse or fluid
Squamous cancer left upper lobe bronchus ,
obstructing the left upper lobe

44. Stages of Lung Cancer
 Stage I – small spot no nodes
 Stage II – larger or nodes on the
side of the lung (hilar or N1 nodes)
 Stage III – very large tumor or
lymph nodes in the middles of the
chest (mediastinum or N2 nodes)
 Stage IV – metastases to other
organs

47. Stage from NCDB
60
50
40
30 NSCL
SCL
20
10
0
Stage 1 Stage 2 Stage 3 Stage 4

48. T = Tumor

49. N = Lymph Node and M = metastases

50. Lung Cancer Stages
Stage TNM
IA T1a or T1b N0
IB T2a N0
IIA T2bN0 or
T1a or T1b or T2a N1
IIB T2bN1 or
T3N0
IIIA T1 or T2 N2 or
T3 N1 or T3 N2 or
T4 N0 or N1
IIIB Any N3 or
T4N2
IV Any M1a or M1b

51. Small Cell Carcinoma of the Lung usually
presents with a large central tumor (hilar/mediastinal lymph
node mass) and are usually classified as either Limited Stage
(LS) or Extensive Stage (ES)

52. Small Cell Lung Cancer
PET scan showing a
typical small cell
cancer with a large
mediastinal mass
making it hard to even
see the heart on the
left side

54. NCCN.org

55. The treatment guidelines have
become quite complex

56. NCCN.com

57. Treatment of Lung Cancer
 Stage I and II – surgery (if possible)
and sometime postOp chemo or
radiation (virtually all small cell
cancer patients receive
chemotherapy)
 Stage III – usually chemo plus
radiation, sometime followed by
surgery
 Stage IV – chemo or radiation,

58. Lung Cancer
Robert Miller MD
www.aboutcancer.com