Lung Cancer

Antonette Grandison
Anatomy

2 https://www.webmd.com/lung/picture-of-the-lungs
http://www.surajkc9.com.np/p/lungs-are-important-respiratory-system.html
Classification of Lung Cancers
Small Cell Lung Cancer Non-Small Cell Lung Cancer
(SCLC) (NSCLC)
• 15% of lung cancers • 85% of lung cancers
• Most commonly presents with mets • Includes:
• Squamous Cell
• Spreads very quickly Greater chance of mets
• Adenoacarcinoma
• More aggressive • Large Cell carcinoma
• Adenosquamous
• Carcinoid Tumors
• Bronchial gland tumors
• Mixed tumors
• Mesotheliomas

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Cell Type Incidence

https://en.wikipedia.org/wiki/Non-small-cell_lung_carcinoma
Histology

5 MM.DD.20XX

https://www.labroots.com/trending/immunology/1941/finally-catching-small-cell-lung-cancer-before-metastasis
Epidemiology Etiology
• Lung cancer accounts for 14% of all cancers • Smoking- 80%
• 2nd in cancer incidence but the leading • Radon
cause of cancer related deaths!! • Asbestos
• Affects the older population (65 or older) • Ore and other chemicals (Arsenic)
• Rarely affects those under 45 years old
• Coal products
• Men 1 in 15
• Isopropyl oil
• Women 1 in 17
• Diesel exhaust
• Previous exposure to radiation
• Air pollution
• Genetics

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https://www.mydoorsign.com/No-Smoking-
Sign/SKU-S-9594.aspx
Presenting Symptoms
• Bad cough that won’t go away
• Repeated cases of Pneumonia or Bronchitis
• Fever of unknown origin
• Reoccurring chest pain
• Weight loss and loss of appetite
• Hemoptysis
• Difficulty breathing and wheezing
• Fatigue
• Horner Syndrome, Superior Vena Cava https://www.biovoicenews.com/lung-cancer-incidence-among-non-smoking-
Syndrome and Paraneoplastic Syndrome indians-on-rise/

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Prognosis Survival
• 50% of new lung cancers are diagnosed in • Even early lung cancer with completely resected
advanced stages tumors have a 50% reoccurrence rate
• NSCLC
• Early stages have better prognosis
• IA-83%-92%
• Metastatic disease has the worst prognosis • IB-68%
• IIA-60%
• NSCLC has a better prognosis overall • IIB-53%
• IIIA-B 26%
• IIIC 13%
• IVA-B 1-10%
• SCLC
• I- 31%
• II- 19%
• III- 8%
• IV- 2%

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 Staging
for Non-
Small Cell

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Staging for Small cell

Limited Extensive
• Affecting only one side of the chest, • Cancer has spread to the other lung and
involving just one part of the lung and local lymph nodes on the other side of the chest
lymph nodes. or to distant organs
• 30% of patients • 60% of patients

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 Blood
Direct
vessel Lymphatic
Extensio
s
n s

Routes of Spread

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 Lymph Node Drainage

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https://www.pinterest.co.uk/pin/18507048449864177/
http://www.clinicalexams.co.uk/enlarged-supraclavicular-lymph-nodes-
lymphadenopathy/
 Common
Metastatic Sites

• Brain
• Bone
• Adrenal glands
• Liver

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http://www.onlinepharmacydirect.com/terms/lung_cancer.html
Treatment
chniques Stage Surgery Only
Lobectomy and Mediastinal

1 lymph dissection

Stage Surgery, Chemo, and

RT 60-70 Gy
Dose

II Can be pre or post-surgery

but smaller doses used

Stage A- Combined Chemo and RT,

sometimes Surgery
III B-Chemo, sometimes
Stage RT
Chemo, Targeted Drug
Therapy
IV
Clinical trials
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 Surgery
• Only 20% of lung cancer patients
meet requirement for surgery
• Tumor location
• Tumor characteristics
• Comorbidities
• Removal based on tumor
• Wedge
• Lobectomy (GOLD STANDARD)
• Pneumonectomy

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http://www.heartsurgeryfirst.com/lobectomy.html
Chemotherapy

• Used adjuvant to RT or Surgery

• Systemic Treatment
https://www.webmd.com/drugs/2/drug-8756/cisplatin-intravenous/details

• Most common Drugs:

• Cisplatin (IV) - Alkylating agent
• Vinorelbine (IV) - Cytotoxic plant alkaloid
• Paclitaxel/Taxol (IV) - Cytotoxic plant alkaloid
• Docetaxel (IV) - Cytotoxic plant alkaloid

• Dosage schedules vary but usually given once every 3-4

weeks and can be combined with other agents or alternated.

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http://www.softschools.com/formulas/chemistry/cisplatin_formula/446/
 Immunotherapy
• Stimulates the immune system to recognize and
destroy cancer cells more effectively
• Improves overall survival and prognosis through
good responses and improved patient outcomes
• Uses Immune check point inhibitors
• Considered first line therapy for advanced NSCLC
• Targets PD-1 regulatory pathways which suppress
antitumor killing T cells
• Slows or shrinks tumor growth
• Common drugs:
• Nivolumab (Opdivo) http://trevinomedia.com/keytruda/

• Pembrolizumab (Keytruda)*****
• Atezolizumba (Tecentriq)
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 Oncogene
Targeted Therapy
• Drugs that target specific changes in cancer cells
• Work when chemo may present no results
• Often have less severe side effects
• Most common drug is Epidermal growth factor receptor (EGFR)
inhibitors
• Protein on the surface of cells that help them to grow and
divide
• Cancer cells have increased levels of EGFR so the inhibitors
block this signal
• Common drugs:
• Erlotinib (Tarceva)
• Afatinib (Gilotrif)
• Gefitinib (Iressa)
• Osimertinib (Tagrisso)
• Dacomitinib (Vizimpro)

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https://www.oncology-central.com/2014/08/06/wasp-venom-based-therapy-for-breast-cancer-in-development/
Radiation Therapy **
• May be used pre- or Post surgery or alone • Average Total Doses:
to shrink tumor size
• Categorized as Palliative treatment • Pre-op: 45-50 Gy
• Used either Concurrently or Alternating with • Post-op: 50-54 Gy
Chemo • RT alone: 60-70 Gy
• 3D conformal or Static IMRT most often used • Mets to lung 30-40 Gy
• Allows doses above 70 Gy to tumor but • 1.8 to 2.0 Gy per fraction
sparing OAR
• Motion management devises can be used to
account for lung motion
• 2 cm margin placed around GTV for motion
• Gating or breath-holds • Even more for lower lobes

• SBRT used for small lesions or nonresectable

lesions

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Problems to solve:
Reoccurrence
New
Side Effects Methods
Surgical Qualifications

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Photosensitizing Nanoparticle
• “Ultra-small” porphyrin-lipoprotein nanoparticles (<20
nm)
• Aka porpphyrinHDL
• Molecules dissociate upon tumor cell accumulation to
become fluorescent and photoactive
• Targets scavenger receptor B type protein on lung
cancer cells
• Tumor takes up the photosynthesizers
• Highly selective tumor ablation
• Tumor specific tissue destruction with minimal side effects

• Acts as a photosensitizer for image-guided

photodynamic therapy
• Fluorescent imaging
• Advantages:
• Nonsurgical alternative with wider range of candidates
• Low toxicity
• Limited to centrally located lesions
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• Exposed to a diode laser (nonthermal)
• Increases the sensitivity of PDT treatment
Effectiveness

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 Bronchoscopic
Laser Therapy

• Palliative treatment
• Dyspnea and obstructive symptoms from tumors
• Curative for early stages
• Cure rate 43-97%
• More then half of lung tumors are not resectable
• Less invasive than surgery with immediate results
• Less removal of healthy tissue
• Those with impaired lung function poor clinical status
still candidates
• Good results with less morbidities and low cost
• Better quality of life
• Reoccurrence rate still high, should be combined with other
treatments
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• Limited treatment depth (4cm)
Laser Therapy (cont.)

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Compare and Contrast Side effects
Current Treatments: New Treatments:
• RT- esophagitis, dermatitis, pneumonitis, • Photosensitizing Nanoparticle-animal trials
pulmonary fibrosis, pericarditis, brachial only
plexopathy
• Laser therapy- perforation, hemoptysis,
• Chemo- hair loss, mouth sores, loss of appetite,
nausea and vomiting, diarrhea or constipation, hypoxemia, air embolism airway fire, cough
compromised immune system, easy bruising or
bleeding, fatigue
• Less toxicity than previous treatments
• Immunotherapy- fatigue, cough, nausea, itching,
skin rash, loss of appetite, constipation or
diarrhea, joint pain, Cause the immune system
to attack other parts of the body
• Target Therapy- skin problems, diarrhea, mouth
sources, loss of appetite

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My Opinion

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 References
1. LungCancer.net. (2018). Small Cell Lung Cancer Staging | LungCancer.net . [online] Available at: https://lungcancer.net/basics/small-cell-staging/ [Accessed 30 Oct. 2018].
2. Agarwal, V., Parab, S. and Pramesh, C. (2017). Protective Lung Strategy During Bronchoscopic Laser Resection of Tracheobronchial Tumors: A Case Series.  Journal of
Cardiothoracic and Vascular Anesthesia, 31(6), pp.2161-2166.
3. Baltayiannis, N., Chandrinos, M., Anagnostopoulos, D., Zarogoulidis, P., Tsakiridis, K., Mpakas, A., Machairiotis, N., Katsikogiannis, N., Kougioumtzi, l., Courcoutsakis, N. and
Zarogoulidis, K. (2018). Lung cancer surgery: an up to date . [online] Jtd.amegroups.com. Available at: http://jtd.amegroups.com/article/view/1571/html [Accessed 30 Oct.
2018].
4. Cancer, C. (2018). Cisplatin - Drug Information - Chemocare . [online] Chemocare.com. Available at: http://chemocare.com/chemotherapy/drug-info/cisplatin.aspx
[Accessed 30 Oct. 2018].
5. Cancer, C. (2018). Cisplatin - Drug Information - Chemocare . [online] Chemocare.com. Available at: http://chemocare.com/chemotherapy/drug-info/cisplatin.aspx
[Accessed 30 Oct. 2018].
6. Cancer.org. (2018). Lung Cancer. [online] Available at: https://www.cancer.org/cancer/lung-cancer.html [Accessed 31 Oct. 2018].
7. Hirsch, F., Scagliotti, G., Mulshine, J., Kwon, R., Curran, W., Wu, Y. and Paz-Ares, L. (2018).  Lung cancer: current therapies and new targeted treatments .
8. LungCancer.net. (2018). Small Cell Lung Cancer Staging | LungCancer.net . [online] Available at: https://lungcancer.net/basics/small-cell-staging/ [Accessed 30 Oct. 2018].
9. Scarlata, S., Fuso, L., Lucantoni, G., Varone, F., Magnini, D., Incalz, R. and Galluccio, G. (2018).  The technique of endoscopic airway tumor treatment.. [online] Www-ncbi-
nlm-nih-gov.proxy.lib.ohio-state.edu. Available at: https://www-ncbi-nlm-nih-gov.proxy.lib.ohio-state.edu/pmc/articles/PMC5594167/pdf/jtd-09-08-2619.pdf [Accessed
31 Oct. 2018].
10. Scarlata, S., Fuso, L., Lucantoni, G., Varone, F., Magnini, D., Incalzi, R. and Galluccio, G. (2017). The technique of endoscopic airway tumor treatment.  Journal of Thoracic
Disease, 9(8), pp.2619-2639.
11. Suresh, K., Voong, K., Shankar, B., Forde, P., Ettinger, D., Marrone, K., Kelly, R., Hann, C., Levy, B., Feliciano, J., Brahmer, J., Feller-Kopman, D., Lerner, A., Lee, H., Yarmus,
L., D’Alessio, F., Hales, R., Lin, C., Psoter, K., Danoff, S. and Naidoo, J. (2018).  Pneumonitis in Non–Small Cell Lung Cancer Patients Receiving Immune Checkpoint
Immunotherapy: Incidence and Risk Factors.
12. Ujiie, H., Ding, L., Fan, R., Kato, T., Lee, D., Fujino, K., Kinoshita, T., Lee, C., Waddell, T., Keshavjee, S., Wilson, B., Zheng, G., Chen, J. and Yasufuku, K. (2018).  PorphyrinHDL:
A Novel Photosensitizing Nanoparticle for Lung Cancer Therapy .
13. Vann, A. and Dasher, B. (2013). Portal design in radiation therapy. Augusta, GA: Phoenix Printing.
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THANK
YOU!!!!!

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