06. Malignant neoplasm of lung
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Transcript 06. Malignant neoplasm of lung
Lung cancer
Edit Csada MD
08.10.2014.
1
Epidemiology
Globocan 2012.
Lung cancer is the most frequent malignant disease
New cases:
1,82 million/year
(13%)
Mortality:
1,59 million/year
Most frequent cause of death amoung malignant
diseases>colon+prostate+breast
Europe:~1000 death/day
Lung cancer fatality:
breast cancer fatality:
Male/female: 2,4/1
159/1852 = 0,87
0,35
2
New diseases according to ages
Until 40 years :
40-49 years:
50-59 years:
60-69 years:
Above 70 years:
1%↓
10%↓
~30%
~30%
30%↓
3
Etiologic factors
Smoking
Athmospheric pollution
Ionisation
Occupational factors
asbestos, radon, etc
Other lung diseases
tb, COPD, ILD
Genetic events
4
Smoking
400 chemical materials
60 carcinogens
Gas and particulate phase
Nitrosamines, aromatic amines,
benzopyrene, CO, CO2, aldehids, nicotin,
free radicals
Pack-year
5
Smoking and Lung Cancer
85-90% of lung cancer patients are
smokers
Damages of 10-15 gens have role in the
development of lung cancer
86% of smokers have damages of these
gens
6
Molecular biology of lung
cancer
Genetic damages
Deletion
Mutations
Amplifications
Tumor suppressor gen injury (p53, RB1)
Inhibation of proliferation
Repair mechanism
Induction of apoptosis
Protooncogen abnormalities
Autocrine growth factors
membran receptors
transcription factors
7
A tüdőrák molekuláris biológiája
SQCLC
AC
SCLC
EGFR/TK mutáció
Amplifikáció(?)
30%
HER2ampl./mut.
<5%
<5%
KRAS mut.
5%
20%
CMYC ampl.
20%
20%
LMYC
p53 mut.
50%
50%
90%
Rb(vesztés, metil.)
20%
20%
90%
P16(vesztés, metil.)
50%(?)
50%(?)
<10%
FHIT(vesztés)
80%
80%
80%
BCL2 fokozott
30%
30%
80%
Proliferáció/onkogen
Proliferáció/suppr.
Apoptosis
Kszpáz8(metil)
DAPK(vesztés)
80%
50%
50%
Genetic defects in lung
cancer
SCLC (%)
NSCLC (%)
3p deletion
90
50-80
3p14.2
80
40
Rb
80-90
15-30
P16 (promoter
metilation)
7
16
P53 (mutation)
80
50-60
C-Myc
10-40
5-10
Ras (H,K,N)
0
20-30
HER2/neu
?
25
Bcl-2 expression
75-90
25-30
Procaspase-8
decrease
80
?
Telomerase
100
9
80
Prevention
Primary
Smoking sessation
Secundary
Screening
X-ray
LDCT
10
Histology of lung cancer
Non small cell lung cancer
Squamous cell carcinoma (30%)
Well, or less differentiated, with or without
keratinisation
Adenocancer (45%)
acinar
papillary
bronchioloalveolar
with mucus formation
Large cell carcinoma (10%↓)
clear cell
giant cell
11
12
Histology of lung cancer
Small cell lung cancer (15%)
Oat cell
Intermediate cell type
Combined type
Carcinoid tumor
Bronchial gland carcinomas
Adenoid cystic carcinoma
Mucoepidermoid carcinoma
13
14
Hitology in Hungary
2015.04.13.
15
Korányi Bulletin 2012
Molecular types of adenoc.
2015.04.13.
Tímár József, Magyar Onkológia 57:26-32,16
2013.03.
Pathological prognostic
factors
TNM
Histology
Histological differentiation
Invading vessels
Necrosis
Proliferation activity
Prognostic proteins
17
Symptoms
Frequency (%)
Cough
45 - 75 %
Dyspnoe
37 - 58 %
Haemopthysis
27 – 57 %
Weight loss
8 – 68 %
Chest pain
27 – 49 %
Hoarsness
2 – 18 %
18
Symptoms of lung cancer
Regional spread
Superior vena caval sy
Recurrent laryngeal nerve paralysis
(hoarsness)
Phrenic nerve paralysis
elevated hemidiaphragm
Horner’s sy
Pancoast’s sy
Trachea obstruction
Oesophagus obstruction
Pleural effusion
Lymphatic tumor spread
19
20
Vena cava superior sy
2015.04.13.
21
Sárosi Veronika anyaga
Pancoast tumor
2015.04.13.
22
Pálföldi Regina anyaga
Squamous cell
cancer
Adenocancer
Small cell
cancer
Large cell
cancer
Ectopic parathormon
productin,
hypercalcaemia
+
-
+
-
Ectopic
ACTH
production,
Cushing-syndrom
+
+
+
-
Osteoarthropathy,
digital clubbing
+
++
+
+
Eaton
syndrom
-
-
+++
-
Peripherial neuropathy,
subacut cerebellar
degeneration
+
+
+
+
Polymyositis,
dermatomyositis
+
+
+
+
Thrombophlebitis
migrans, DIC
-
+++
+
+
Nephrosis syndrom
+
+
+
+
Inappropriate
production
(SIADH)
-
-
+
- 23
Lambert
ADH
Dobverő ujj, óraüveg
köröm
2015.04.13.
24
Sárosi Veronika anyaga
Diagnostic procedures
Imaging technics
Endoscopy
Pathology
Laboratory tests (?)
25
Diagnostic procedures
Imaging technics
Chest x-rays
CT
MRI
Isotope scanning
PET/CT
Ultrasound
26
Bronchoscopy: sample taking,
staging
Biopsy
Brushing
Transbronchial biopsy
Transbronchial needle aspiration
(TBNA, EBUS)
Washing
BAL
27
Other sample takings
TTB, x-ray or CT supervision
Percutan pleura biopsy
Lymphnode aspiration biopsy
Surgical biopsy
Mediastinoscopy
Parasternal mediastinotomy
(Stemmer)
VATS
Thoracotomy (10%↓)
28
Staging 1
T1a = Tumor ≤2 cm in greatest dimension,
surrounded by lung or visceral pleura, without
bronchoscopic evidence of invasion more
proximal than the lobar bronchus (i.e., not in
the main bronchus).
T1b = Tumor >2 cm but ≤3 cm in greatest
dimension
29
Staging 2
T2a = Tumor >3 cm but ≤5 cm in greatest
dimension, or tumor with any of the following
features: involves main bronchus, ≥2 cm distal
to the carina; invades visceral pleura (PL1 or
PL2); or is associated with atelectasis or
obstructive pneumonitis that extends to the
hilar region but does not involve the entire
lung.
T2b = Tumor >5 cm but ≤7 cm or less in
greatest dimension
30
Staging 3
T3 = Tumor >7 cm or one that directly invades
any of the following: parietal pleural (PL3)
chest wall (including superior sulcus tumors),
diaphragm, phrenic nerve, mediastinal pleura,
or parietal pericardium or tumor in the main
bronchus (<2 cm distal to the carinab but
without involvement of the carina) or
associated atelectasis or obstructive
pneumonitis of the entire lung or separate
tumor nodule(s) in the same lobe
31
Staging 4
T4 = Tumor of any size that invades any of the
following: mediastinum, heart, great vessels,
trachea, recurrent laryngeal nerve, esophagus,
vertebral body, carina, or separate tumor
nodule(s) in a different ipsilateral lobe.
32
Staging 5
N0 = No regional lymph node metastasis.
N1 = Metastasis in ipsilateral peribronchial
and/or ipsilateral hilar lymph nodes and
intrapulmonary nodes, including involvement
by direct extension.
N2 = Metastasis in ipsilateral mediastinal
and/or subcarinal lymph node(s).
N3 = Metastasis in contralateral mediastinal,
contralateral hilar, ipsilateral or contralateral
scalene, or supraclavicular lymph node(s).
33
Staging 6
M0 = No distant metastasis.
M1a = Separate tumor nodule(s) in a
contralateral lobe tumor with pleural nodules or
malignant pleural (or pericardial) effusion
M1b = Distant metastasis (in extrathoracic
organs).
34
Metastases
Liver:
Bones:
Adrenals:
Brain:
CT, ultrasound, PET/CT
scintigraphy, CT, PET/CT
CT, ultrasound, PET/CT
MRI, CT
36
Prognostic factors
Poor performance status
Karnofsky, WHO ECOG
Weight loss, more than 10%
Elevated LDH
Elevated tumormarker (CEA, NSE, SCC)
Old age
37
Performance status
Grade
ECOG
0
Fully active, able to carry on all pre-disease performance
without restriction
1
Restricted in physically strenuous activity but ambulatory
and able to carry out work of a light or sedentary nature,
e.g., light house work, office work
2
Ambulatory and capable of all selfcare but unable to carry
out any work activities. Up and about more than 50% of
waking hours
3
Capable of only limited selfcare, confined to bed or chair
more than 50% of waking hours
4
Completely disabled. Cannot carry on any selfcare. Totally
confined to bed or chair
5
Dead
38
Performance status
Karnofsky scale
100
90
80
70
Description
Normal; no complaints; no evidence of disease
Able to carry out normal activity; minor signs or symptoms
of disease
Normal activity with effort; some signs or symptoms of
disease
Cares for self; unable to carry on normal activity or do active
work
60
Requires occasional assistance, but is able to care for most
of his/her needs
50
Requires considerable assistance and frequent medical care
40
Disabled; requires special care and assistance
30
20
Severely disabled; hospitalization is indicated although
death not imminent
Very sick; hospitalization necessary, active supportive
treatment necessary
10
Moribund; fatal processes progressing rapidly
0
Dead
39
Therapy of lung cancer
Surgery
Radiotherapy
Radiochemotherapy
Chemotherapy
Molecular target therapy
Supportive treatment
40
Surgery
The type of surgical procedure depends on
staging, the patient’s performance status,
cardiopulmonal function and comorbidities.
The aim is radical resection
Sublobar resection may have a role in very
early diseases.
Thoracotomy
Video assisted thoracoscopy (VATS)
41
Surgery
Absolute contraindications:
haematogen metastases in the lungs
pleuritis carcinomatosa
III.b stage disease
multiplex distanti metastases
Relative contraindications
42
Surgery (20-25%)
NSCLC IIIA stage
Lobectomy, pulmonectomy, sleeve
lobectomy, extensive resection – radical
Segmentectomy, wedge resection – mostly
non radical
Early stage SCLC, as part of combined
therapy
Carina resection?
Before surgery: lung function, Ecg, functional
evaluation
43
Radiation therapy
NSCLC: III.A, III.B stage
SCLC: combined with chemotherapy
Inoperable patient with resecable disease
Resected N2 disease, in combined treatment
Metastasis palliation
Pancoast’s tu
Brain metastasis (stereotactic, whole brain)
PCI
Brachytherapy
Radiochemotherapy!
44
Combination of
radio/chemotherapy
Sequential
ChTRT
(ChTRTChT)
Concomitant
ChT/RT
Timing
- Induction: ChT ChT/RT
- Consolidation: ChT/RT ChT
45
Chemotherapy
Neoadjuvant treatment
Before surgery IIIa stage
Adjuvant treatment
After surgery II-IIIa stage
First-, second-, thirdline…..
IIIb, IV stage
46
First line treatment of NSCLC
Chemotherapy
Cis-, carboplatin-gemcitabin
Cis-, carboplatin-paclitaxel
Cisplatin-docetaxel
Cisplatin-vinorelbin
Cisplatin-pemeterexed (non squamous c)
Doublet+bevacizumab(adenoc)
Adenoc.: EGFR mutácio pozitivitás
Erlotinib, gefitinib, afatinib
47
Second line treatment of NSCLC
Chemotherapy
Docetaxel monoterapy
Pemetrexed monoterapy
Adenoc.: EGFR mutation positivity/KRAS
negativity
gefinitib, erlotinib
48
Maintenance treatment
Klasszikus
kezelés
Elsővonalbeli
kezelés
Kezelési
szünet
Platina-alapú kettős
kombináció
(4–6 ciklus)
Diagnózis
CR/PR/SD
Új
megközelítés
Bevacizumab
Pemetrexed
ellotinib
Másod- és
többedvonalbeli
kezelés
PD
PD
PD-ig eltelt idő
megnyúlik
Fenntartó kezelés
Diagnózis
CR/PR/SD
PD
PD
Surgery in SCLC
I/A-I/B: resection
Postoperative chemotherapy
Adjuvant irradiation in positive node status
Induction chemohterapy
Chemoterapy in SCLC
Absoute indication
Cisplatin/carboplatin-Vepesid
ECO (epirubicin-cyclophoscphamid-vincristin)
Topotecan (Hycamtin) (2. line)
Progression:
Within 3 months (resistant disease): new
combination
Over 3 months (senzitive disease):
reinduction therapy with the original drugs
Radiotherapy in SCLC
LD: radio-chemotherapy
PCI: preventíve cerebral irradiation
In LD and ED
Remission after treatment
Dose: 25-30 Gy
Possible impairment of neurocognitive functions
Molecular target therapy
EGFR tirosin kinase inhibitors
Erlotinib (Tarceva)
Gefinitib (Iressa)
afatinib
Angiogenesis inhibitors (VEGF)
Bevacizumab (Avastin)
Alk-EML4 fusion gen inhibitor
Crizotinib (Xalkori)
53
Supportive treatment
Pain control
WHO suggestion
Adverse events control
Thrombosis prophylaxis
Malignant pleural fluid treatment
Bone metastases treatment
Endobronchial palliation
Nutrition
54
WHO’s pain stairs (1986)
Strong opioid ± non opioid ± adjuvant
III.
Weak opioid ± non opioid ± adjuvant
II.
Non opioid ± adjuvant
I.
24h
24h
24h
55
Supportive treatment
Pain control
Adverse events control
febrile neutopenia
Anaemia (erythropoetin)
Nausea, vomiting
Thrombosis prophylaxis
Malignant pleural fluid treatment
pleurodesis
Bone metastases treatment
bisphosphonat
Endobronchial palliation
56
Prognosis
I. stage:
II. stage:
III.a stage:
III.b stage:
IV. stage:
55-80%
30-50%
10-30%
4%
1%
Five year survival: 15-17%
57
58
Thank you for your attention!