2. Lung Cancer
• Most common cause of cancer death in US
• Overall 5 year survival of 15%
• More deaths by lung cancer than the next
four most common cancers combined
(Colorectal, Breast, Prostate, & Pancreas)
3. Lung Cancer Risk Factors
• Gender
• Smoking history
• Older age
• Genetic predisposition
• Occupational exposures
4. Lung Cancer and Gender
• Male predilection, but changing rapidly
• Increase in women smokers
• In 2007:
– 55% Men
– 45% Women
6. Lung Cancer and Smoking
• ~90% of lung cancers attributed to smoking
• However, only 20% smokers will develop
lung cancer in their lifetime.
– ? Death from other causes ie. CAD, COPD
– Genetic predisposition
• Risk decreases when stop smoking
• Yet, 50% of new cases are former smokers
8. Asbestosis & Lung Cancer
• Prolonged heavy exposure has relative risk
between 2 - 10 of causing lung cancer.
• Peak incidence 15 - 24 years after exposure.
• Fiber type is important:
– Crocidolite & amosite > chrysotile &
anthophyllite.
20. Nodal Zone Lymph node station
Upper zone
Low cervical, supraclavicular, sternal notch (1R – 1L)
Upper paratracheal (2R – 2L)
Prevascular (3a) and retrotracheal (3p)
Lower paratracheal (4R – 4L)
Aortopulmonary zone
Subaortic (aortopulmonary window - 5)
Para-aortic (ascending aorta or phrenic nerve - 6)
Subcarinal zone Subcarinal (7)
Lower zone
Paraesophageal (8)
Pulmonary ligament (9)
Hilar zone
Hilar (10)
Interlobar superior (11s) and inferior (11i)
Peripheral zone
Lobar (12)
Segmental (13)
Subsegmental (14)
21.
22. T definitions 6th ed. descriptor 7th ed. descriptor
Tumors = 2 cms. T1 T1a
Tumors > 2 cms and = 3 cms. T1 T1b
Tumors > 3cms and = 5cms. T2 T2a
Tumors > 5 cms and = 7 cms. T2 T2b
Tumors > 7 cms. T2 T3
Separate nodule(s) in the primary lobe. T4 T3
Separate nodule(s) in a different ipsilateral lobe. M1 T4
Malignant pericardial effusion. T4 M1a
Pleural dissemination. T4 M1a
23. M factor definitions 6th ed descriptor 7th ed descriptor
Metastasis cannot be assessed. MX M0
Malignant pericardial effusion. T4 M1a
Pleural dissemination (malignant pleural effusions,
pleural nodules).
T4 M1a
Additional nodules in the contralateral lung (same
histology).
M1 M1a
Distant metastasis. M1 M1b
24. NonSmall Cell Cancer
N Stage
• N0: No nodes.
• N1: Ipsilateral hilar or
peribronchial.
• N2: Ipsilateral
mediastinal, subcarinal.
• N3: Contralateral hilar,
contralateral mediastinal
or supraclavicular/scalene.
25. 6th ed 7th ed
N0 N1 N2 N3
T/M descriptors
T1 (=2cm) T1a IA IIA IIIA IIIB
T1 (>2 cm =3 cm) T1b IA IIA IIIA IIIB
T2 (>3 cm =5 cm) T2a IB IIA IIIA IIIB
T2 (>5 cm = 7 cm) T2b IIA IIB IIIA IIIB
T2 (>7 cm)
T3
IIB IIIA IIIA IIIB
T3 (direct invasion) IIB IIIA IIIA IIIB
T4 (same lobe nodules) IIB IIIA IIIA IIIB
T4 (extension)
T4
IIIA IIIA IIIB IIIB
M1 (ipsilateral nodules)
IIIA IIIA IIIB IIIB
T4 (pleural effusion)
M1a
IV IV IV IV
M1 (contralateral nodules) IV IV IV IV
M1 (distant) M1b IV IV IV IV
26. SCLC Staging
• Limited Stage (1/3)
– confined to 1 hemithorax
– disease fits within a tolerable radiation port
• Extensive Stage (2/3)
– doesn’t fit
• Recommend also use TNM staging, as for
NSCLC
30. ttt
CHT: chemotherapy RT: radiotherapy
Surgery
CHT
Surgery +/-
pre-operative
CHT, RT+/- CHT
40-70%
5yr survival
40-70%
5yr survival
15-30%
5 yr survival
15-30%
5 yr survival
30 – 35%
1 yr survival
30 – 35%
1 yr survival
CHT + RT or CHT
followed by RT
CHT with 2 agents
for 3-4 cycles
10-20%
5 yr survival
10-20%
5 yr survival
Stages IIIa
resectable
Stages IIIa/b
unresectable
Stages IIIb / IVStages I & II
Spira and Ettinger, New Engl J Med 2004; 350: 379
31. Stage 1&2:
– Surgical candidates:
• Lobecomy is the ttt of choice
• Patients with tumor involving the mediastinal lymph
nodes in the final surgical specimen are classified as
pathologic stage III and treated accordingly
Nonsurgical candidates :
• small primary tumors (< 3 to 4 cm) , we suggest
ablative therapy with SBRT or RFA rather than
definitive radiation therapy
• larger primary tumors , we recommend definitive
radiation therapy
32. Adjuvant therapy
• stage IA : no adjuvant ttt
• Stage IB: adjuvant chemotherapy
• stage II : adjuvant chemotherapy
• stage I and II with negative resection margins: no
adjuvant RT
• stage I and II with +ve resection margins: adjuvant
RT
33. Stage III
– Combination chemotherapy with XRT is
treatment of choice.
– Neoadjuvant therapy followed by surgical
resection is option in IIIA.
34. Non Small Cell Lung Cancer
Treatment
• Stage IV:
– Chemotherapy.
35. Non Small Cell Lung Cancer
Contraindications to Surgical Resection
• Stage IIIB or IV.
• Extensive invasion into surrounding
structures:
• Vena cava or atrium involvement.
• Recurrent laryngeal or phrenic nerve involvement.
• SVC obstruction, malignant effusion, pericardial
tamponade.
• Contralateral lymph nodes.
36. Non Small Cell Lung Cancer
Contraindications to Surgical Resection
• Medically unfit:
– Poor cardiac or pulmonary status.
– Predicted postoperative FEV1% < 40%.
– Predicted postoperative DLCO% < 40%.
– Exercise studies for marginal candidates.
37. Small Cell Lung Cancer
Treatment
• Limited: Chemotherapy with XRT.
– 10-20 month median survival.
– 5 year survival ~10%
• Extensive: Chemotherapy.
– 7-11 month median survival.
– 5 year survival < 1%.
38. Chemotherapy Drugs
• Non small cell:
– Two drug regimen.
– Cis/Carbo platin + 1 other
(Taxol/Taxotere/Gemcitabine)
• Small cell:
– Cisplatin / Etoposide
40. Biologic Agents
• Tarceva
– Epidermal growth factor inhibitor.
– Second line therapy.
– Asian, never smoking, women,
adenocarcinoma / bronchoalveolar cell CA.
– PO.
– Rash, diarrhea.
41. Small Cell Lung Cancer
Brain Irradiation
• For known metastatic lesions.
• Prophylaxis in both Limited & Extensive
disease.
– Decreases the risk of developing brain
metastases.
– Improved survival.
