Showing posts with label MALIGNANCY. Show all posts
Showing posts with label MALIGNANCY. Show all posts

Survival Rates Have Improved Among Patients With Early Stage NSCLC, Research Indicates

By Dr Deepu
Finally a ray of hope for lung cancer patients, in a finding, researchers report that survival rates have improved among those with early stage disease.
The study included more than 65,000 people diagnosed with stage 1 non-small-cell lung cancer between 2000 and 2010. In that group, 62 percent had surgery, 15 percent received radiation therapy, 3 percent had both surgery and radiation and 18 percent received neither treatment.

The two-year survival rate for people treated with either surgery or radiation therapy rose from 61 percent in 2000 to 70 percent in 2009 -- corresponding to a 3.5 percent annual decrease in death from lung cancer.
Author also noted that while the proportion of patients who did not receive treatment fell from about 20 percent in 2000 to just under 16 percent in 2010, too many still do not receive treatment for "an otherwise highly curable disease."

LUNG METASTASIS

LUNG METASTASIS
Lung is a common site for metastasis from malignancies from other organs.
  • Lung is a capillary bed and the entire cardiac output passes through it, thus it is no surprise tumors get trapped in lungs.
  • Various patterns of metastasis should be recognized. Common patterns are
    • Solitary
    • Cannon balls
    • Lymphangitic
    • Pleural effusions
Clinical Presentation
Mode of clinical presentation varies depending on the pattern of metastasis.
  • Asymptomatic, detected on routine CXR.
  • Cough, hemoptysis, pneumonia, wheezing with endobronchial mets.
  • Shortness of breath, cough with lymphatic spread.
  • Pleuritic pain, cough and shortness of breath with pleural effusions.
Diagnosis
Again depends on the metastatic pattern.
  • FNAB for solitary or multiple lung mets.
  • Sputum cytology and bronchoscopy for endobronchial mets.
  • Pleural fluid cytology for effusions.
  • Tranbronchial lung biopsy for lymphatic spread.
Treatment
Very important treatment issues revolve around the presence and pattern of metastasis.
  • Lung metastasis most often would preclude a surgical curative resection of the primary.
  • Surgical resection of a solitary lung metastasis along with resection of the primary can accomplish cure in certain tumors.
  • Brachytherapy therapy may be useful to relieve symptoms with endobronchial mets.
  • Pleural sclerosis is necessary in pleural effusions.
  • Certain chemotherapeutic agents can sequester in effusions.



MESOTHELIOMA

A mesothelioma is a primary malignant neoplasm of pleura.
Etiology
  • It occurs in patients with prior exposure to asbestos.
  • It has no correlation with cigarette smoking.
Pathology
  • The neoplasm grows to encase the lung and chest wall and spreads locally.
  • Microscopically, the neoplastic cells may resemble mesenchymal stroma (sarcoma) or appear like epithelial cells.
Clinical Features
  • Patients present with SOB, cough, weight loss and chest pain.
  • Pleural effusion is a common mode of presentation.
  • Chest CT reveals pleural effusion and characteristic encasing of lung with tumor mass.
    • CXR
    • CT
  • Diagnosis is difficult with pleural fluid cytology and pleural biopsy.
  • Special stains and an experienced Pathologist are often required for diagnosis.
  • The tumor tends to grow along needle tracks. This is one reason to avoid repeated thoracentesis.
Therapy

  • No therapy has a proven benefit in prolonging life.
  • Patients usually expire within 1-2 years.
  • Extrapleural pneumonectomy is recommended by some centers.

LUNG CANCER

Incidence
It is reported that in 2005, carcinoma of the lung will account for 31% of cancer deaths in males and 27% of cancer deaths in females.
It is estimated that in 2005 there were 92,305 cases of lung cancers in men and 79,544 cases in women.
Age
Seventy percent of all lung cancer deaths occur between the ages of 55 and 74. However, recent trends indicate that both the incidence and mortality of lung cancer is increasing in younger age groups.
Sex
The incidence of lung cancer:
Males  > 70 per 100,000
Females > 22 per 100,000
It is approximately three times more common in men than females. However the incidence of lung cancer in females in increasing in epidemic proportions.
Cancer Death in Women
The incidence of female lung cancer continues to increase and has surpassed breast cancer as a leading cause of cancer deaths among women. Currently, carcinoma of the lung accounts for 12% of all new cancers in women and 27% of all cancer deaths.
Men
Lung cancer has been the leading cause of cancer deaths among males since 1955. However from 1955-1985 the incidence of lung cancer deaths among males has increased from 30 per 100,000 to greater than 70 per 100,000. In 2005 lung cancer accounted for 13% of all new cancers among males and 31% of all cancer deaths.
Countries
The countries with the highest incidence of lung cancer among males is the United Kingdom (90 per 100,000 males). The lowest incidence of lung cancer occurs in Asia and Africa. Rates for most of North America and Europe are between these two extremes. In general, the incidence of lung cancer in industrialized western countries is increased compared to third world countries. This difference is most likely attributable to increased cigarette smoking. However, other factors such as the presence of ceratin industries (chemical, petroleum and shipbuilding) and increased levels of air pollution may play a lesser role.
USA
The highest incidence of lung cancer in the United states, according to a 20 year review of mortality form all the cancers in the United States is in the northern urban areas and along the gulf and south Atlantic Coasts from Texas to Florida. Farming areas were found to have a lower incidence than other areas, including rural non-farm areas.
Etiology
Smoking
Lung cancer is largely attributable to environmental carcinogens. By far, the most important environmental carcinogen is tobacco smoke. Men began smoking cigarettes during World War I. The incidence of lung cancer among men began a rapid rise 20 years later. An identical but similar delayed pattern has been observed in women.
Today, the epidemiology of lung cancer is the epidemiology of smoking. Other factors are relatively of minor importance.
Carcinogens
Cigarette smoke contains a number of proven carcinogens in both the particulate and gaseous phase including:
-Aromatic Hydrocarbons
-Nitrosamines
-Nitrosonormicotine
-Polonium
-Arsenic
Synergic
Exposure to certain substances have a synergic effect in being causatively associated with the use of tobacco products in development of lung cancer.
-Asbestos
-Chloromethyl Ethers
-Mustard Gas
-Radioactive Ore
Host Factors
As with most illnesses, the development of disease depends on a complex interaction between the environment and the host. Specifically with lung cancer, host factors play a relatively minor role.
-Risk of Second Primary
-Associated Malignancies
-CLL
-Aryl Hydrocarbon Hydroxylase
-Scar Carcinoma
-Tuberculosis

Natural History
The natural history of Lung cancercan be described by breaking down its course of existence into a sequence of a few simple phases based on the way we experience the disease clinically.
Pre-Detectable
Carcinoma of the lung always passes through a pre-detectable phase, beginning with its biological onset (the development of the first frankly malignant cell) and beginning when the disease may first be shown to exist whether through sputum cytology or chest radiography. It has been claimed that by the time a tumor is 10 mm in diameter it has already doubled in size 30 times, contains at least one billion cells, and has completed three-fourths of its anticipated existence. It is likely that during the majority of a lung tumor's existence it will be undetectable by any currently available diagnostic technique.
Detectable-Asymptomatic
Most cases of lung carcinoma are felt to enter a phase in which presence of the disease is potentially demonstrable, yet continues to be without symptoms. The disease is detectable if:
·        
The tumor is radiographically evident (5-10 mm in diameter), or
Sputum is positive for malignant cells.
The duration of this "presymptomstic-detectable" phase is heavily dependent on the cell type involved and on location of the primary tumor. Sputum cytology can be positive for several years before symptoms occur in a progress from undetectable to unresectable within a few short months. Unfortunately, only about 5% of lung cancer diagnoses are made in this phase. These findings are typically made through incidental X-Ray findings during workup of an unrelated condition of through sputum and X-Ray screening of high-risk patients.
Symptomatic Phase
About 95% of all lung cancer diagnoses are made during the phase when the disease has become symptomatic. Carcinoma discovered at this point in its natural history is almost always well advanced. With very few but significant exceptions, symptomatic lung cancer carries poor prognosis. This is because the vast majority of symptoms in this disease are caused by either locally unresectable or metastatic tumor.
Symptoms Grouping
Carcinoma of the lung causes on astonishing variety of symptoms. Those which bring about the initial presentation as well as those which develop as the disease progresses are not only remarkably diverse, but vary widely between patients. It is not uncommon for the diagnosis to be made during workup of such conditions as Cushing's syndrome (due to ectopic ACTH production), or of neurological complaints found ultimately to be due to brain metastases! Therefore, in order to study the clinical manifestations of this disease in some productive way, it is helpful to group the symptoms lung cancer may cause into five general categories.
Primary Tumor
Endobronchial location of the tumor explains many of the symptoms related to primary tumor. If the primary is peripheral and the lesion is in the lung, often the symptoms related to primary tumor are absent.
  • Cough
  • Dyspnea
  • Hemoptysis
  • Pso-obstructive Pneumonia
  • Increase in Sputum
Distant Metastasis
Several organs or organ systems clearly emerge as the most common sites of distant metastasis for lung carcinoma. These have great bearing on the clinical manifestations of the disease, and are frequently the cause of the clinical manifestations of the disease, and are frequently the cause of the patient's initial presentation!
  • Brain
  • Liver
  • Bone
  • Skin
  • Adrenals
  • Lymph Node
Paraneoplastic Syndrome
These are an ever-expanding set of intriguing clinical syndromes involving non-metastatic systemic effects which have been noticed to accompany malignant disease on occasion. Some are associated with a specific cell type; others have no such predilection. Most are felt to be biochemically mediated. Some are just plain mysteries.
  • Endocrine
  • Musculoskeletal/Cutaneous
  • Hematologic
  • Neuromuscular
  • Cardiovascular Miscellaneous
  • Hypertrophic Osteoarthropathy
  • Clubbing
  • Acanthosis Nigricans
  • Thrombophlebitis
  • ACTH
  • ADH
  • Hypercalcemia
Intrathoracic Spread
When carcinoma of the lung causes symptoms though intrathoracic spread, it tends to do so in only two primary ways:
  • By Contiguity
  • Nodal Metastasis
Whatever the mode of spread, most of the associated symptoms occur once the disease has reached either the chest wall or the mediastinum. If it was central, mediastinal problems tend to occur. If the tumor was located very inferior, diaphragmatic symptoms may be expected. If it began out in the periphery, chest wall problems are usually noted first.
Clinical problems that result from extension to the chest wall aren't difficult to understand. Since the parietal pleura is one of the few pain-sensitive structures in the area, this may be the first time the patient experiences pain. Pleural effusion is also a common condition related to this process. If the tumor happened to start near the apex of the lung, a syndrome knows as "Pancoast Tumor" may develop, involving complaints related to damage of CB-T1 roots.
Non-Specific
The following are non-specific symptoms due to tumor burden:
  • Weight loss
  • Malaise
  • Loss of appetite
Staging
During the past years, numerous investigators have been endeavoring to establish a standard terminology that would accurately describe the extent of a cancer. One such staging system for lung cancer has been formulated by the Task Force on Lung Cancer of the American Joint Committee for Cancer Staging and End-Results Reporting (AJCF). The AJC staging system employs the T-N-M nomenclature . In this system, the letter T represents the primary tumor N regional node involvement, M.
T. Numerical Suffix Assignment
The criteria are:
·         Size
·         Proximity to Carina
·         Extent of Collapse
·         Invasion of surrounding structures
N Numerical Suffix Assignment
The first station lymph nodes are the intrapulmonary, peribronchial and hilar lymph nodes, which are contained within the visceral reflections. Second station lymph nodes are those in the mediastinum and may be paraesophageal, subcarinal, paratracheal, aortic or retrotracheal. Involvement of scalene, contra-lateral or extra-thoracic nodes is considered distant metastasis.

M Suffix Assignment
The metastatic status is signified by the letter "M" with subscripts O or 1 to indicate absence or presence of metastatic disease. "M1" signifies presence of metastasis in one or more distant organs. The common metastatic sites are Brain, Bone, Liver, Adrenal glands and subcutaneous tissue.

Group Staging
T, N and M combinations are used to group stage lung cancer. The staging is important in planning therapy and for estimating prognosis
Principles of Therapy
Therapeutic options consist of:
Surgery is the best option in:. 
Non-small cell cancer in stages 1, 2, 3a
Acceptable general condition as a surgical candidate 

In general, small cell cancer is not a surgical disease.

Radiation Therapy
If the general condition precludes the patient from being a surgical candidate, Radiation therapy is chosen. 
Palliative Radiation therapy has an important role for relief of symptoms in inoperable cases.

Chemotherapy
Chemotherapy is the treatment of choice for small cell cancer. Its role in NSCC is under investigation.

Supportive Care
One needs to consider the following  to determine the best option.
  • Cell type
  • Stage
  • Clinical status
Prevention

  • Lung cancer is a preventable disease. If cigarette consumption is stopped, we can probably prevent 99% of lung cancers. 
  • As a physician, it is your obligation to set an example by not smoking and to advise patients not to smoke. 
  • You can offer options to aid patients in quitting their habit.
    • Nicotine chewing gum or patches
    • Clinics which specialize in helping patients quit smoking
    • Hypnotherapy
  • Take an active role in bringing legislation to curb the use of cigarettes in public places. 
  • Additionally, advertisements should be discontinued which encourage children to start the habit. 
  • We probably should not attempt to ban cigarettes completely. It is unlikely to succeed, as we have learned from our past experience in trying to ban alcohol.

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