Ca lung

ppt

1. Bronchogenic Carcinoma
（Lung Cancer）
DR GORDHAN DAS

2. Outline
 Epidemiology/Classification
 Clinical manifestations
Symptoms
Signs
 Diagnostic workup & Differential Diagnosis
Diagnosis
Differential Diagnosis
 Treatment & Prevention
 Summary

3. Bronchogenic
Carcinoma
（Lung Cancer）— tumor cell
originates from the mucosa or
gland of bronchus.
Definition

4. Epidemiology

5. Global Incidence of Lung Cancer(2001)

6. Global Mortality OF Lung Cancer(2001)

8. Anatomy and
Pathology

9. Thyroid cartilage
Cricothyroid ligament
Cricoid cartilage
Connective tissue
sheath (cut away)
Intercartilaginous
ligaments
Mucosa showing
longitudual folds formed
by dense collections
of elastic fibres
Tracheal cartilages
To
upper
lobe
Eparterial
bronchus
To
middle
lobe
To
lower
lobe
R. main
bronchus
L. main
bronchus
Intrapulmonary Extrapulmonary Intrapulmonary
To
lower
lobe
To
lingula
To
upper
lobe
Trachealis muscle
Oesophageal muscle
Epithelium
Lymph vesselsElastic fibres
Gland
Small arteries
Nerve
Posterior wall
Cross section
through trachea
Anterior wall
Epithelium
Nerve
Lymph vessels
Small artery
Gland
Elastic fibres
Cartilage
Connective tissue sheath
Structure of trachea and major bronchi
© Novartis

10. Classifications of Lung Cancer
Classification by Anatomic Site
–Central Lung Cancer
–Peripheral Lung Cancer
Classification by Histopathology
–Small Cell Lung Cancer (SCLC ,15-20%)
– Non-Small Cell Lung Cancer (NSCLC ,80-
85%)
Squamous epithelial cell cancer ,
Adenocarcinoma , Large Cell Cancer
 adrnosquamous lung cancer etc.

11. Histological Types of Lung Cancer
Relative Incidence

12. Symptoms and Signs

13. Clinical Manifestations
Development of Lung Cancer Symptoms
–Formation of Lung Cancer Asymptomatic

–Bronchia involved Cough
–Mucosa capillary involved Hemoptysis
–Pleura and chest wall involved Dyspnea, chest pain

–Obstruction of bronchus Short breath, fever

–Pleura spreading Pleural effusions
Non-special symptoms: Anorexia, weight loss

14. Clinical Manifestations
Symptoms Caused by Tumor Spreading and Metastasis
–Superior Vena Cava Obstruction Syndrome
–Horner’s Syndrome
–Pancoast’s Syndrome
Extra-pulmonary Manifestations
–Hypertrophic Pulmonary Osteoarthropathy
–Carcinoid Syndrome
–Gynaecomastia

15. Major signs and symptoms of
lung cancer
Baseline major presenting symptoms
0
20
40
60
80
100
HemoptysisLoss of
appetite
PainCoughDyspnea
Patients
(%)
Hollen et al 1999

16. Para-neoplastic syndromes
Not fully understood patterns of organ dysfunction
related to immune-mediated or secretary effects of
neoplasm.
Occur in 10%-20% of lung cancer patients.
 15% of patients with small cell carcinoma will
develop SIADH;
10% of patients with squamous cell carcinoma will
develop hypercalcemia.
Digital clubbing is seen in up to 20% of patients at
diagnosis.
Other common para-neoplastic syndromes include:
increased ACTH production, anemia,
hypercoagulability, peripheral neuropathy

17. Achropachy (clubbed finger )

18. Laboratory Findings
Cytology (tissue samples, Sputum, pleural effusions)
Thoracoscopy
Fine needle aspiration of palpable lymph nodes
Fibrotic bronchoscopy
- fluorescence bronchoscopy
- endoscopic ultrasound
- eBUS-TBNA
Mediastinoscopy, video-assisled thoracoscopic surgery
(VATS), and thoracotomy
Serum tumor markers are neither sensitive nor specific
enough to aid in diagnosis

19. IMAGING X-ray

20. NSCLC CT scans

21. Transthoracic needle aspiration (TTNA) of a
non-small cell Pancoast tumor

24. 涂片可见癌细胞
cancer cells found in the TBNA tissue samples

25. Mediastinoscopy

26. Diagnosis of Lung Cancer
Principles
–Pay attention to the respiratory symptoms
ineffective to treatment
–Pay attention to the extrapulmonary manifestations
–From routine to complicated
From non-invasive to invasive
–Highlight the pathological diagnosis
Cytology , histology

27. NSCLC diagnosis
Physical examination Detect signs
Visualize and sample mediasturial lymph nodes
Detect position, size, number of tumors
Detect chest wall invasion mediastinal
lymphodenopathy distant metastases
Lymph node staging
Detect changes in hormone production,
and hematological manifestations of lung cancer
Precise location of tumor obtain biopsy
Chest X-ray
CT scan
PET scan
Laboratory analysis
Bronchoscopy
Mediastinoscopy
FNA Cytology
NCCN Guidelines 2000

28. Staging and
Prognostication

31. Mountain 1997
NSCLC stages - an overview
Disease
Early
Localized
Advanced
Stage
0
IA
IB
IIA
IIB
IIIA
IIIB
IV
TNM
TIS N0 M0 (carcinoma in situ)
T1 N0 M0
T2 N0 M0
T1 N1 M0
T2 N1 M0
T3 N0 M0
T3 N1 M0
T1-3 N2 M0
T4, Any N, M0
Any T, N3, M0
Any T, Any N, M1

32. NSCLC stages
Stage 0
Stage IA
Stage IIB
Stage IIIB
Stage IV
Lymph nodes
Main
bronchus
Contralateral
lymph node
Metastasis
to distant
organs
Invasion of
chest wall

33. NSCLC: clinical stage as a
prognostic factor
1 year
3 years
5 years
0
10
20
30
40
50
60
70
80
90
100
IA IB IIA
T2N1M0
IVIIB IIIA IIIB
Clinical stage at presentation
Survival
(%)
Mountain 1997
T3N0M0
T3N1M0
T1-3N2M0
T4
N3

34. Probability of survival according to clinical stage

35. Treatment

36. Strategy of Lung Cancer
Treatment
According to the pathological type
–Small Cell Lung Cancer (SCLC)
–Non-Small Cell Lung Cancer (NSCLC)
According to the TNM Clinical Stage
Choose the optimal therapeutic protocols
Follow-up regularly

37. NSCLC: an overview of
treatment options
Localized tumor
surgery
Regional tumor
chemotherapy, radiotherapy (surgery)
Advanced tumor
chemotherapy
PDQ Guidelines

38. Treatment of NSCLC stage 0
Lobectomy, segmentectomy, or wedge
resection
Curative radiotherapy if surgery is
contra-indicated
Endoscopic photodynamic therapy
(under evaluation in selected patients)
PDQ Guidelines

39. Treatment of NSCLC
stage I and stage II
Lobectomy or pneumonectomy
Curative radiotherapy if surgery is contra-
indicated
Adjuvant chemotherapy
Adjuvant radiotherapy
Neoadjuvant chemotherapy
PDQ Guidelines

40. NSCLC stage I: surgery
Locoregional
recurrence
rate
(per person
-year)
Locoregional
recurrence
rate
(% of
patients)
0
10
20
30
40
50
Segmen-
tectomy
(n=68)
Lobectomy
(n=105)
00.0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
0.09
0.10
Limited
resection
(n=122)
Lobectomy
(n=125)
p=0.008
Warren and Faber 1994Ginsberg and Rubinstein1995
p<0.05

41. Treatment of NSCLC stage III
Surgery alone (selected patients in
stage IIIA only)
Postoperative radiotherapy
Chemotherapy + radiotherapy
Radiotherapy alone
Chemotherapy alone (stage IIIB with
malignant pleural effusions)
PDQ Guidelines

42. Treatment of NSCLC stage IV
Chemotherapy (platinum-based),
modest survival benefits
New chemotherapy agents
External beam radiotherapy (palliative
relief)
Endobronchial laser or endobrochial
therapy for obstruction
PDQ Guidelines

43. NSCLC recurrence after
chemotherapy
Surgery (selected patients with isolated
brain metastases)
Palliative radiotherapy
Palliative chemotherapy
Endobronchial laser therapy or
interstitial radiotherapy
PDQ Guidelines

44. Future Developments

45. NSCLC: future developments
Current treatment remains unsatisfactory
 Prevention
 Earlier diagnosis
 Improved treatment
PDQ Guidelines

46. Prevention
Education
–avoidance of environmental
carcinogens such as tobacco smoke
Chemoprevention?
–vitamin A
–isotretinoin

47. Earlier diagnosis
Obstructive lung disease
Genetic risk factors
Sputum cytology
Molecular tumor markers
Computed tomography
Positron emission tomography (PET)
Edell 1997

48. Treatment
NSCLC
Novel
biological
targets
Immunology:
- interleukins
- interferons
- vaccines
New
chemotherapy
drugs
Gene therapy:
- interleukins
- K-ras

49. Novel biological approaches
- molecular target therapy
Epidermal growth factor (EGF) tyrosine
kinase inhibitors (TKI)
Anti-vascular therapy
Metalloproteinase inhibitors

50. Immunotherapy and gene therapy
Immunomodulators
–interferons, interleukins
Vaccination
–passive immunisation
–active immunisation
Gene therapy?
–oncogenes eg K-ras
–immunomodulators eg interleukins

51. Thank You!