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Its the second most common cancer, after prostate cancer in males and breast
cancer in females, but its the leading cause of cancer death for both genders.
Causes:
1) Smoking: both active and passive smoking cause about 80-90% of all lung
cancers.
2) Occupational: Asbestos (used to be used in heat insulation, now its used in
breaks in cars, it causes both lung cancer and mesothelioma maybe even after
20 years of exposure), radon, polycyclic hydrocarbons, inorganic arsenic, nickel
(used in the gold industry).
3) Genetic predisposition: ras-family and chromosome region 3p.
Pathology:
Small cell carcinoma (SCLC): (18%), its well known to cause paraneoplastic
syndromes because it originates from APUD (amine precursor uptake and
decarboxylation) cells which are of neuro-endocrine origin so they produce
different hormones and enzymes causing such syndromes.
Non-small cell carcinoma (NSCLC), of many subtypes:
1) Squamous cell (30%).
2) Adenocarcinoma (most common) and bronchioalveolar cell carcinoma (30.7%).
3) Large cell undifferentiated carcinoma (9.4%).
4) Carcinoid (very rare).
Symptoms:
5% are asymptomatic.
Cough, hemoptysis, shortness of breath, post-obstructive pneumonia,
malignant pleural effusion, chest pain (maybe on respiration due to metastasis
to the ribs), even shoulder pain, generalized weakness, weight loss
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Metastases:
Most Small Cell carcinomas spread very early to the bone marrow, liver,
adrenal glands and the CNS that by the time of diagnosis its already spread.
We see CNS involvement in adeno, large and small cell carcinoma, but
especially in SCLC; 10% at presentation (50% will have a brain lesion later on).
Head CT- Scan is therefore being done to people diagnosed with SCLC.
Signs of metastasis include: Constitutional symptoms (such as weight loss,
Anorexia, fatigue, weakness), clubbing, skin involvement including metastases,
Erythema Multiforme, Acanthosis Nigricans, Dermatomyositis, scleroderma,
Thrombophlebitis, Tylosis (Hyperkeratosis of palms and soles).
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Tissue diagnosis: in order to have cancer, you have to have cancer cells."
Presence of a mass and/or malignant cells in any of the following is enough to
diagnose lung cancer:
Sputum cytology.
Thoracentesis cytology (pleural tap).
Pleural Biopsy: (Mesothelioma)
Bronchoscopy: BAL, Brush, TBNA, EBBx, TBBx
Thoracoscopy or Open Lung Bx Mediastinoscopy.
CT Chest-Guided Transcutaneous needle Bx.
Bone Scan, when there is severe pain suggesting metastasis to the ribs.
PET (Positron emission tomography) Scan:
For >1 cm lesions.
Less specific in DM and infection.
Not good for Mets. evaluation.
It is rather costy.
Tumor Markers (CEA, PTH, ACTH): theyre not useful.
PFT: to decide if the patient is a candidate for surgery.
Predicted Post-op FEV1 (forced expiratory volume) must be more than
0.8L. This means that if the FEV1 for both lungs is to say 2 L and we have to
remove a mass that's obstructing one of the lungs, we'll end with a FEV1 of
1L at least and that is enough!
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Staging:
SCLC: it has 2 stages, limited to hemithorax Vs Extensive disease going
outside the chest.
NSCLC: TNM system Classification:
T: Primary tumor (size & location).
N: Regional LN involvement.
M: Presence or absence of Metastases. When metastasis is there, the
stage is 4.
Used for prognosis and to guide the treatment plan. There's a table for the real
thing. The doctor went over some of it and very quickly.
,,, ,,,,
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Prognosis:
SCLC:
Median survival is 1-2 years because they somehow respond to
chemotherapy.
30% die from local complications, 70% from carcinomatosis.
50% have a some sort of brain lesion at autopsy.
NSCLC:
Median survival with mets is 6 weeks to 1 year.
Less responsive to Chemo in an advanced stage compared to SCLC.
Depends on Performance status, disease extent, Weight loss
So as a conclusion, if it's an advanced stage (mets) it's better to be SCLC
because it responds to chemotherapy and if it was limited its better to be NSCLC
so we could do surgery and cure it.
Treatment:
SCLC:
Chemotherapy: cisplatin, etoposide.
Radiation: palliative for head lesions.
We cant do surgery because the cancer has already spread on diagnosis.
NSCLC:
Surgery: (lobectomy to pneumonectomy) from stage I to IIIA, needs postop FEV1 > 0.8 L. All stages after IIIA are beyond surgery.
Chemotherapy: stages II to IV.
Radiotherapy: for stage IIIB + palliative.
Adjuvant therapy (combination).
Joe Biden,
Laith Al-Momani
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