Tumor of lung (lung cancer)Tumor of lung (lung cancer)Tumor of lung (lung cancer)Tumor of lung (lung cancer)

Dr.Ahmed Al-AzzawiDr.Ahmed Al-Azzawi

M.B.Ch.B,F.I.C.M.SM.B.Ch.B,F.I.C.M.S

Cardiothoracic &vascular surgeryCardiothoracic &vascular surgery

University of sulaymaniUniversity of sulaymani

College of medicineCollege of medicine

GOOD MORNINGGOOD MORNING

عليكم عليكم السالم السالم

LUNG CANCERLUNG CANCERLung cancer usually starts in the Lung cancer usually starts in the lining of the bronchi, but can also lining of the bronchi, but can also begin in other areas of the begin in other areas of the respiratory system, including the respiratory system, including the trachea, bronchioles, or alveoli. It is trachea, bronchioles, or alveoli. It is the leading cause of cancer death in the leading cause of cancer death in both men and women. In 2006, both men and women. In 2006, 174,470 new cases of lung cancer 174,470 new cases of lung cancer are expected, according to the are expected, according to the American Cancer Society.American Cancer Society.Lung cancers are believed to Lung cancers are believed to develop over a period of many years develop over a period of many years

Lung cancers are generally Lung cancers are generally divided into two typesdivided into two types

Non-small cell lung cancerNon-small cell lung cancer is more common than is more common than small cell lung cancer. The main kinds of non-small small cell lung cancer. The main kinds of non-small cell lung cancer are named for the type of cells in cell lung cancer are named for the type of cells in the tumor:the tumor:

1.1. Squamous cell carcinoma,Squamous cell carcinoma, also called also called epidermoid carcinomaepidermoid carcinoma, is the most common type , is the most common type of lung cancer in men. It often begins in the bronchi, of lung cancer in men. It often begins in the bronchi, and usually does not spread as quickly as other and usually does not spread as quickly as other types of lung cancer.types of lung cancer.

2.2. AdenocarcinomaAdenocarcinoma usually begins along the outer usually begins along the outer edges of the lungs and under the lining of the edges of the lungs and under the lining of the bronchi. It is the most common type of lung cancer bronchi. It is the most common type of lung cancer in women and in people who have never smoked.in women and in people who have never smoked.

3.Large cell carcinomas3.Large cell carcinomas are a group of are a group of cancers with large, abnormal-looking cancers with large, abnormal-looking cells. These tumors usually begin along cells. These tumors usually begin along the outer edges of the lungs.the outer edges of the lungs.

4. Adenosquamous carcinoma begins in 4. Adenosquamous carcinoma begins in flattened cells when viewed under a flattened cells when viewed under a microscope. These cells also have microscope. These cells also have secretory characteristics. secretory characteristics.

5.Undifferentiated carcinoma 5.Undifferentiated carcinoma involves abnormal-looking cancer involves abnormal-looking cancer cells that tend to multiply quicklycells that tend to multiply quickly

Small cell lung cancerSmall cell lung cancer, sometimes , sometimes calledcalled oat cell canceroat cell cancer because the because the cancer cells may look like oats when cancer cells may look like oats when viewed under a microscope, grows viewed under a microscope, grows rapidly and quickly spreads to other rapidly and quickly spreads to other organs organs

EpidemiologyEpidemiology

Lung cancer has now become the Lung cancer has now become the main cancer killer in both men and main cancer killer in both men and women ,reflecting the changing women ,reflecting the changing smoking habits in women that have smoking habits in women that have occurred since the early 1950s and occurred since the early 1950s and the long exposure required for the the long exposure required for the development of this malignancy ,the development of this malignancy ,the rate in women is rising at an rate in women is rising at an alarming pace.alarming pace.

The histologic changes in the bronchial The histologic changes in the bronchial mucosa occur gradually over many mucosa occur gradually over many years,evolving from metaplasia years,evolving from metaplasia through dysplasia to carcinoma.through dysplasia to carcinoma.

Those who stop smoking reduce but Those who stop smoking reduce but never eliminate,their risk.never eliminate,their risk.

Histologic progression in the Histologic progression in the pathogenesis of lung cancerpathogenesis of lung cancer;;

Basal cell proliferationBasal cell proliferation Hyperplasia of goblet cell.Hyperplasia of goblet cell. Metaplastic stratification of squemaous epitheliumMetaplastic stratification of squemaous epithelium Atypical metaplasiaAtypical metaplasia Carcinoma in situCarcinoma in situ

Infiltration of cancer through basement membraneInfiltration of cancer through basement membrane

Spread to regional lymph nodesSpread to regional lymph nodes

Hematogenous dissemination Hematogenous dissemination

Stages of lung cancerStages of lung cancer

The prognosis of lung cancer is stage-The prognosis of lung cancer is stage-dependant,and is influenced by the dependant,and is influenced by the size and location of the tumor (T size and location of the tumor (T status),the presence or absence of status),the presence or absence of lymph nodes metasteses(N status),and lymph nodes metasteses(N status),and the presence or absence of distant the presence or absence of distant metasteses (M status).For this reason, metasteses (M status).For this reason, the initial clinical staging of the tumor the initial clinical staging of the tumor is important not only for prognosis but is important not only for prognosis but also for decision about treatmentalso for decision about treatment..

..The staging of ca. of the lung is by the TNM The staging of ca. of the lung is by the TNM approach so the summary of stagingapproach so the summary of staging

Occult stage ---malignant cells in Occult stage ---malignant cells in sputum,bronchial wash but tumor not sputum,bronchial wash but tumor not visualized by imaging studies or visualized by imaging studies or bronchoscopy.bronchoscopy.

Stage 0---ca. in situ.Stage 0---ca. in situ. Stage IA---tumor <3cm arising more than 2cm Stage IA---tumor <3cm arising more than 2cm

distal to the carina (T1N0).distal to the carina (T1N0). Stage IB---tumor>3cm with involvement of Stage IB---tumor>3cm with involvement of

visceral pleura arising more than 2cm from visceral pleura arising more than 2cm from carina(T2N0).carina(T2N0).

Stage IIA---tumor <3cm not extended to Stage IIA---tumor <3cm not extended to adjacent organs ,with ipsilateral adjacent organs ,with ipsilateral peribronchial,hilar lymph nodes peribronchial,hilar lymph nodes involvement(T1N1).involvement(T1N1).

Stage IIB---tumor >3cm ,extend to Stage IIB---tumor >3cm ,extend to adjacent organs ,with lymph node (T2N1).adjacent organs ,with lymph node (T2N1).

Stage IIIA---tumor invading chest Stage IIIA---tumor invading chest wall ,pleura,or pericardium and wall ,pleura,or pericardium and nodes(T3N1-2).nodes(T3N1-2).

Stage IIIB---direct extension to Stage IIIB---direct extension to esophagus ,aorta,cava ,heart,diaphragm,oesophagus ,aorta,cava ,heart,diaphragm,or spine (T4orN3).r spine (T4orN3).

Stage IV---any tumor with metastasesStage IV---any tumor with metastases

What are the symptoms of What are the symptoms of lung cancerlung cancer ? ?

Clinical manifestation:Clinical manifestation: Symptoms relating to carcinoma of the lung depend on Symptoms relating to carcinoma of the lung depend on

the antomic location of the tumor,extension into the antomic location of the tumor,extension into surrounding structures,metastatic spread,and the surrounding structures,metastatic spread,and the systemic effects of paraneoplastic syndromes systemic effects of paraneoplastic syndromes

Symptoms is either due to endobronchial Symptoms is either due to endobronchial growth ,extrinsic growth,or regional spread of the growth ,extrinsic growth,or regional spread of the primary tumor.primary tumor.

Centrally located lesions are associated with Centrally located lesions are associated with cough ,stridor,wheezing,hemoptysis,dyspnea,and chest cough ,stridor,wheezing,hemoptysis,dyspnea,and chest pain.The most common symptom is cough due to pain.The most common symptom is cough due to endobronchial erosion and irritation.endobronchial erosion and irritation.

Peripheral tumors are associated with chest Peripheral tumors are associated with chest pain,cough ,and dyspnea,owing to pleural and chest wall pain,cough ,and dyspnea,owing to pleural and chest wall involment.Large peripheral tumor may undergo involment.Large peripheral tumor may undergo cavitation and present as lung abscesses cavitation and present as lung abscesses

The following are the other most common The following are the other most common symptoms for lung cancer; however, each person symptoms for lung cancer; however, each person may experience symptoms differently: may experience symptoms differently:

constant chest painconstant chest pain shortness of breathshortness of breath wheezingwheezing recurring lung infections, such as pneumonia or recurring lung infections, such as pneumonia or

bronchitisbronchitis bloody or rust colored sputumbloody or rust colored sputum hoarsenesshoarseness swelling of the neck and face caused by a tumor swelling of the neck and face caused by a tumor

that presses on large blood vessels near the lung that presses on large blood vessels near the lung pain and weakness in the shoulder, arm, or hand pain and weakness in the shoulder, arm, or hand

caused by a tumor that presses on certain nerves caused by a tumor that presses on certain nerves near the lung near the lung

fever for unknown reasonfever for unknown reason

Like all cancers, lung cancer can Like all cancers, lung cancer can cause: cause:

fatiguefatigue loss of appetiteloss of appetite loss of weightloss of weightheadacheheadachepain in other parts of the body not pain in other parts of the body not

affected by the canceraffected by the cancerbone fractures bone fractures

What are the risk factors for What are the risk factors for lung cancerlung cancer??

A risk factor is anything that A risk factor is anything that increases a person's chance of increases a person's chance of getting a disease such as cancer. getting a disease such as cancer. Different cancers have different risk Different cancers have different risk factors. Several risk factors make a factors. Several risk factors make a person more likely to develop lung person more likely to develop lung cancer: cancer:

What is a risk factor? What is a risk factor? A risk factor is anything that may increase A risk factor is anything that may increase

a person's chance of developing a disease.a person's chance of developing a disease. It may be an activity such as smoking, It may be an activity such as smoking,

diet, family history, or many other things.diet, family history, or many other things. Different diseases, including cancers, Different diseases, including cancers,

have different risk factors.have different risk factors. Although these factors can increase a Although these factors can increase a

person's risk, they do not necessarily person's risk, they do not necessarily cause the disease. Some people with one cause the disease. Some people with one or more risk factors never develop the or more risk factors never develop the disease, while others develop disease and disease, while others develop disease and have no known risk factors have no known risk factors

Smoking is the leading cause of lung cancer, with more than 90 percent of lung cancers thought to be a result of smoking.

Those who stop smoking reduce but never eliminate,their risk.

risk factors include: risk factors include: second-hand smoke - breathing in the smoke of others.second-hand smoke - breathing in the smoke of others. smoking marijuana cigarettes, which:smoking marijuana cigarettes, which:1.1. contain more tar than tobacco cigarettes.contain more tar than tobacco cigarettes.2.2. are inhaled very deeply.are inhaled very deeply.3.3. are smoked all the way to the end where tar content is the are smoked all the way to the end where tar content is the

highest.highest.4.4. Because marijuana is an illegal substance, it is not possible Because marijuana is an illegal substance, it is not possible

to control whether it contains fungi, pesticides and other to control whether it contains fungi, pesticides and other additives. additives.

recurring inflammation, such as from tuberculosis and some recurring inflammation, such as from tuberculosis and some types of pneumonia. types of pneumonia.

asbestos exposure.asbestos exposure. talcum powdertalcum powder While no increased risk of lung cancer has been found from the While no increased risk of lung cancer has been found from the

use of cosmetic talcum powder, some studies of talc miners use of cosmetic talcum powder, some studies of talc miners and millers suggest a higher risk of lung cancer and other and millers suggest a higher risk of lung cancer and other respiratory diseases from their exposure to industrial grade respiratory diseases from their exposure to industrial grade talc. Talcum powder is made from talc, a mineral which in its talc. Talcum powder is made from talc, a mineral which in its natural form may contain asbestos, although by law, all natural form may contain asbestos, although by law, all home-use talcum products (baby, body, and facial powders) home-use talcum products (baby, body, and facial powders) have been asbestos-free. have been asbestos-free.

cancer-causing agents in the workplace, including:cancer-causing agents in the workplace, including:

radioactive ores such as uraniumradioactive ores such as uranium arsenicarsenic vinyl chloridevinyl chloride nickel chromatesnickel chromates coal productscoal products mustard gasmustard gas chloromethyl etherschloromethyl ethers radon - a radioactive gas that cannot been seen, tasted or radon - a radioactive gas that cannot been seen, tasted or

smelled. It is produced by the natural breakdown of smelled. It is produced by the natural breakdown of uranium. uranium.

family historyfamily history personal history of lung cancer personal history of lung cancer vitamin A deficiency.vitamin A deficiency.People who do not get enough vitamin A are at increased risk People who do not get enough vitamin A are at increased risk

of lung cancer. Taking too much vitamin A may also of lung cancer. Taking too much vitamin A may also increase lung cancer risk. increase lung cancer risk.

Air pollution.Air pollution.

How is lung cancer How is lung cancer diagnoseddiagnosed??

In addition to a complete medical history to check for risk In addition to a complete medical history to check for risk factors and symptoms, and a physical examination to factors and symptoms, and a physical examination to provide other information about signs of lung cancer and provide other information about signs of lung cancer and other health problems, procedures used to diagnose lung other health problems, procedures used to diagnose lung cancer include:cancer include:

chest x-raychest x-ray - to look for any mass or spot on the lungs. - to look for any mass or spot on the lungs. other special x-rays and scansother special x-rays and scans (such as the CT (such as the CT

(computed tomography) scan) - can provide more precise (computed tomography) scan) - can provide more precise information about the size, shape, and position of a tumor.information about the size, shape, and position of a tumor.

sputum cytologysputum cytology - a study of phlegm (spit) cells under a - a study of phlegm (spit) cells under a microscope.microscope.

needle biopsyneedle biopsy - a needle is guided into the mass while the - a needle is guided into the mass while the lungs are being viewed on a CT scan and a sample of the lungs are being viewed on a CT scan and a sample of the mass is removed and evaluated in the pathology laboratory mass is removed and evaluated in the pathology laboratory under a microscope.under a microscope.

bronchoscopybronchoscopy - a fiberoptic flexible, lighted tube is passed - a fiberoptic flexible, lighted tube is passed through the mouth or nose into the bronchi to help find through the mouth or nose into the bronchi to help find centrally located tumors or blockages, and gather samples of centrally located tumors or blockages, and gather samples of tissue or fluids to be examined under a microscope.tissue or fluids to be examined under a microscope.

mediastinoscopymediastinoscopy - a process in which a small cut is made - a process in which a small cut is made in the neck so that a tissue sample can be taken from the in the neck so that a tissue sample can be taken from the lymph nodes (mediastinal nodes) along the windpipe and the lymph nodes (mediastinal nodes) along the windpipe and the major bronchial tube areas to evaluate under a microscope.major bronchial tube areas to evaluate under a microscope.

positron emission tomographypositron emission tomography (PET) scan - radioactive- (PET) scan - radioactive-tagged glucose (sugar) is injected into the bloodstream. tagged glucose (sugar) is injected into the bloodstream. Tissues that use the glucose more than normal tissues (such Tissues that use the glucose more than normal tissues (such as tumors) can be detected by a scanning machine. PET as tumors) can be detected by a scanning machine. PET scans can be used to find small tumors or to check if scans can be used to find small tumors or to check if treatment for a known tumor is working.treatment for a known tumor is working.

Magnetic resonance imaging(MRIMagnetic resonance imaging(MRI),it differentiates vascular ),it differentiates vascular from solid structures and demonstrates hilar, mediastinal from solid structures and demonstrates hilar, mediastinal and parenchymal anatomy in both coronal and sagittal and parenchymal anatomy in both coronal and sagittal planes.planes.

ThoracoscopyThoracoscopy.thoracoscopic staging of lung cancer has been .thoracoscopic staging of lung cancer has been demonstrated to be safe and effective in selected patients . demonstrated to be safe and effective in selected patients .

xx--rays and scans of the brain, liver, bone, and adrenal rays and scans of the brain, liver, bone, and adrenal glandsglands - to determine if the cancer has spread from where it - to determine if the cancer has spread from where it started into other areas of the body.started into other areas of the body.

Other tests and procedures may be used as well Other tests and procedures may be used as well

Treatment for lung cancer:Treatment for lung cancer:Specific treatment will be determined by Specific treatment will be determined by

doctor(s) based on: doctor(s) based on: age, overall health and medical history age, overall health and medical history extent of the disease extent of the disease tolerance for specific medications, tolerance for specific medications,

procedures or therapies procedures or therapies expectations for the course of the disease expectations for the course of the disease patient opinion or preference patient opinion or preference Surgery, radiation therapy and Surgery, radiation therapy and

chemotherapy may be used in the chemotherapy may be used in the treatment of lung cancer. treatment of lung cancer.

SurgerySurgery

Three main types of surgery are most often used Three main types of surgery are most often used in lung cancer treatment. The choice depends on in lung cancer treatment. The choice depends on the size and location of the tumor, the extent of the size and location of the tumor, the extent of the cancer, the general health of the patient, and the cancer, the general health of the patient, and other factors. other factors.

segmental or wedge resectionsegmental or wedge resection - to remove only - to remove only a small part of the lunga small part of the lung

lobectomylobectomy - removal of an entire lobe of the lung - removal of an entire lobe of the lung pneumonectomypneumonectomy - removal of an entire lung - removal of an entire lung radiation therapy (also called radiotherapyradiation therapy (also called radiotherapy) - ) -

the use of high-energy rays to damage cancer cells the use of high-energy rays to damage cancer cells and stop them from growing and dividing. and stop them from growing and dividing.

chemotherapychemotherapy - the use of drugs to kill cancer - the use of drugs to kill cancer cells cells

Radiation therapy is the use of high-energy Radiation therapy is the use of high-energy radiation to kill cancer cells and to shrink radiation to kill cancer cells and to shrink tumors. Radiation may also be used with tumors. Radiation may also be used with chemotherapy to treat lung cancer. There chemotherapy to treat lung cancer. There are two ways to deliver radiation therapy, are two ways to deliver radiation therapy, including the following: including the following: external radiation (external beam therapy) - a external radiation (external beam therapy) - a

treatment that precisely sends high levels of treatment that precisely sends high levels of radiation directly to the cancer cells. The radiation directly to the cancer cells. The machine is controlled by the radiation machine is controlled by the radiation therapist. Since radiation is used to kill cancer therapist. Since radiation is used to kill cancer cells and to shrink tumors, special shields may cells and to shrink tumors, special shields may be used to protect the tissue surrounding the be used to protect the tissue surrounding the treatment area. Radiation treatments are treatment area. Radiation treatments are painless and usually last a few minutes. painless and usually last a few minutes.

internal radiation (brachytherapy, implant internal radiation (brachytherapy, implant radiationradiation) - ) - radiation is given inside the body radiation is given inside the body as close to the cancer as possible. as close to the cancer as possible. Substances that produce radiation, called Substances that produce radiation, called radioisotopes, may be swallowed, injected, or radioisotopes, may be swallowed, injected, or implanted directly into the tumor. Some of implanted directly into the tumor. Some of the radioactive implants are called “seeds” or the radioactive implants are called “seeds” or “capsules”. Internal radiation involves giving “capsules”. Internal radiation involves giving a higher dose of radiation in a shorter time a higher dose of radiation in a shorter time span than with external radiation. Some span than with external radiation. Some internal radiation treatments stay in the body internal radiation treatments stay in the body temporarily. Other internal treatments stay in temporarily. Other internal treatments stay in the body permanently, though the the body permanently, though the radioactive substance loses its radiation radioactive substance loses its radiation within a short period of time. In some cases, within a short period of time. In some cases, both internal and external radiation therapies both internal and external radiation therapies are used are used

ChemotherapyChemotherapy

The use of anticancer drugs to treat The use of anticancer drugs to treat cancerous cells. In most cases, cancerous cells. In most cases, chemotherapy works by interfering with the chemotherapy works by interfering with the cancer cell’s ability to grow or reproduce. cancer cell’s ability to grow or reproduce. Different groups of drugs work in different Different groups of drugs work in different ways to fight cancer cells. The oncologist ways to fight cancer cells. The oncologist will recommend a treatment plan for each will recommend a treatment plan for each individual. Chemotherapy may be given individual. Chemotherapy may be given before other treatments, after other before other treatments, after other treatments, or alone for lung cancertreatments, or alone for lung cancer. .

photodynamictherapy(PDT)photodynamictherapy(PDT)

A type of laser treatment that involves injecting A type of laser treatment that involves injecting photosensitizing chemicals into the bloodstream. photosensitizing chemicals into the bloodstream. Cells throughout the body absorb the chemicals. Cells throughout the body absorb the chemicals. The chemicals collect and stay longer in the cancer The chemicals collect and stay longer in the cancer cells, than in the healthy cells. At the right time, cells, than in the healthy cells. At the right time, when the healthy cells surrounding the tumor may when the healthy cells surrounding the tumor may already be relatively free of the chemical, the light already be relatively free of the chemical, the light of a laser can be focused directly on the tumor. As of a laser can be focused directly on the tumor. As the cells absorb the light, a chemical reaction the cells absorb the light, a chemical reaction destroys the cancer cells. For lung cancer, the light destroys the cancer cells. For lung cancer, the light is delivered through a bronchoscope (a small, is delivered through a bronchoscope (a small, flexible tube with a light on the end) that is inserted flexible tube with a light on the end) that is inserted through the mouth or nose through the mouth or nose

Solitary Pulmonary NoduleSolitary Pulmonary Nodule

The solitary pulmonary nodule(SPN) (acoin The solitary pulmonary nodule(SPN) (acoin lesion);has been defined to be an abnormal lesion);has been defined to be an abnormal density up to 4cm in diameter rounded or ovoid in density up to 4cm in diameter rounded or ovoid in appearance,surrounded by azone of lung tissue on appearance,surrounded by azone of lung tissue on x-ray,and free of cavitation or associated lung x-ray,and free of cavitation or associated lung infiltrates .infiltrates .

The differential diagnosis of an SPN The differential diagnosis of an SPN includes :pulmonary includes :pulmonary hamartoma,granuloma,pulmonary hamartoma,granuloma,pulmonary AVfistula,pulmonary infarction and several benign AVfistula,pulmonary infarction and several benign and malignant tumors.and malignant tumors.

Other Lung Ttumor :Carcinoid Tumor,Tumor of Other Lung Ttumor :Carcinoid Tumor,Tumor of bronchial gland origin,Carcinosarcoma bronchial gland origin,Carcinosarcoma

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