1. Lung Cancer By, Nazneen Chougle Neha Bhatkal Nilekha Kalyankar
Nirali Bavaria
Namrata Gaokar

2. Contents Introduction Signs and Symptoms Pathophysiology Statistics
Diagnosis
Treatment
Recent Clinical Trials
Palliative Care and Case Study
Ethical Considerations

3. Tumors Malignant tumors Benign tumors They are cancer.
Can invade and damage tissues and organs near the tumor
The spread of cancer is Called metastasis
Benign tumors
They are not cancer.
Do not spread to other parts of the body and are not a threat to life.

4. Lung Cancer: Defined
Uncontrolled growth of malignant cells in one or both lungs and tracheo-bronchial tree.
A result of repeated carcinogenic irritation causing increased rates of cell replication.
Proliferation of abnormal cells leads to hyperplasia, dysplasia or carcinoma in situ.
90%-95% of cancers of the lung arise from the epithelial cells, the cells lining the larger and smaller airways

5. Two Types Of Lung Cancer Cells
Non Small Cell Lung Cancer (NSCLC)
Most common type
Grows and spreads more slowly
than small cell lung cancer
Three main types
Adenocarcinoma
Squamous Cell Carcinoma
(epidermoid carcinoma)
Large Cell Carcinoma
Small Cell Lung Cancer (SCLC)
Called oat cell cancer
Less common
Grows more quickly
Spread to other organs in the body

6. Where D oes it Come From? Smoking Passive smoking Radon gas
Familial predisposition
Lung diseases
Prior history of lung cancer
Air pollution

7. Signs and symptoms No symptoms in up to 25% of people
Symptoms related to the cancer
cough
dyspnea
hemoptysis
recurrent infections
chest pain
Symptoms related to metastasis
Paraneoplastic symptoms.
Nonspecific symptoms.

9. Deaths Due to Lung Cancer

11. DIAGNOSIS H ISTOR Y AN D PH YSICAL E XAMINATION Cyanosis Chest x- ray
CT (computerized tomography, computerized
axial tomography, or CAT) scans
L OW- DOSE HELICAL CT SCAN (or spiral CT scan)
MAGNETIC RESONANCE IMAGING(MRI).
P OSITRON EMISSION TOMOGRAPHY (PET)
BLOOD TESTS

12. DIAGNOSIS
BONE SCANS: These are used to create images of bones on a computer screen or on film. Doctors may order a bone scan to determine whether a lung cancer has metastasized to the bones.
SPUTUM CYTOLOGY : If a tumor is centrally located and has invaded the airways, this procedure, known as a sputum cytology examination, may allow visualization of tumor cells for diagnosis

13. DIAGNOSIS
BRONCHOSCOPY: Examination of the airways by bronchoscopy (visualizing the airways through a thin, fiberoptic probe inserted through the nose or mouth) may reveal areas of tumor that can be sampled (biopsied) for diagnosis by a pathologist.
NEEDLE BIOPSY: Fine needle aspiration (FNA) through the skin, most commonly performed with radiological imaging for guidance, may be useful in retrieving cells for diagnosis from tumor nodules in the lungs.

14. DIAGNOSIS
DIAGNOSIS
T HORACENTESIS: Aspiration of a sample of this fluid with a thin needle (thoracentesis) may reveal the cancer cells and establish the diagnosis.
MAJOR SURGICAL PROCEDURES
Mediastinoscopy
Thoracotomy

15. Recent Advances Biomarkers
Fluorescent in-situ hybridization techniques (FISH)
Super Dimension(R)/Bronchus System (SDBS)
Computer-aided detection (CAD)
Breath tests

16. Contd….
Auto fluorescence bronchoscopy (AFB)
Endobronchial ultrasound (EBUS)
Coherence tomography (OCT)

17. CHEMOTHERAPY Used for both NSCLC and SCLC
Used in combination with radiation therapy and surgical therapy.
Platinum based drugs most effective- Cisplatin
May be given as pills, as an intravenous infusion, or as a combination of the two.
Second-line chemotherapy is used to treat recurrent cancers that have previously been treated with chemotherapy.
Side effects- Nausea, Vomiting, weight loss, hair loss, mouth sores, etc

18. RADIATION THERAPY
Curative therapy, palliative therapy or as adjuvant therapy in combination with surgery or chemotherapy.
Used for both NSCLC and SCLC
Uses high energy X-rays to kill dividing cells.
Brachytherapy
Shrinks a tumor or limits its growth when given as a sole therapy
Simulation is necessary prior to treatment.
Side effects- fatigue, lack of energy, reduced WBC count and blood platelet levels, irritation of skin, nausea , Vomiting, diarrhoea.

19. SURGERY
Generally performed for limited-stage (stage I or sometimes stage II) NSCLC.
Surgery may not be possible if the cancer is too close to the trachea.
Depends upon the size and location of the tumor.
Could require lobectomy (removal of one lobe) pneumonectomy (removal of an entire lung) or lymphadenectomy (removal of lymph nodes).
If a recurrent cancer is confined to one site in the lung.
Side effects-difficulty breathing, shortness of breath, pain, and weakness.

20. PHARMACOTHERAPY
Erlotinib (Tarceva), is used in patients with NSCLC who are no longer responding to chemotherapy. Also called as “The Targeted Drug” because it targets a protein called the Epidermal Growth Factor Receptor (EGFR) that is important in promoting the division of cells.
Iressa (Gefitinib)
Antiangiogenesis drugs- Bevacizumab (Avastin)
Vadimezan – Disrupts Blood Vessels within tumors.
Bisphosphonates.
ARQ 197
Tragedy
Exubera –inhaled Insulin ,manufactured by Pfizer had promised of letting diabetics avoid needle sticks but actually increased the cases of lung cancer in diabetic patients.
Drug has been withdrawn.

21. NON SMALL CELLED LUNG CANCER SMALL CELLED LUNG CANCER
OTHER IMPORTANT DRUGS
NON SMALL CELLED LUNG CANCER
SMALL CELLED LUNG CANCER
Alimta
Erlotinib
Docetaxel
Etoposide
Gemzar
Hyacamtin
Navelbine
Tarceva
Onxol
Topotecan
Paclitaxel
VePesid
Photofrin
Taxol
Taxotere
Vinorelbine
Gemcitabine
Pemetrexed
Porfimer
Gefitinib

22. Other Newer Therapies PHOTODYNAMIC THERAPY (PDT)
RA DIO FREQUENCY ABLATI O N
CHINESE MEDICINES
Ligustrum lucidim Ait. (Tree Pivet), Astragalus membranaceous
Suppress tumor angiogenesis, promote dormancy of cancerous cells,
induce re-differentiation of cancer cell, directly kill cancerous cells，
and it is effective against recurrence and metastases of cancer.
CRYOSURGERY

24. IMMUNOTHERAPIES MONOCLONAL ANTIBODIES
“ Humanized” antibodies- Trastuzumab
ANTIGEN SPECIFIC VACCINES
Incorporating cytokines into anti-tumor vaccines
Biomarkers
Radioactive agents
By cutting off a key gene,14-3-3zeta, lung cancer tumour cells are left 'homeless‘ and they can't survive on their own.

25. Clinical trials for lung cancer
A Study to Diagnose Lung Cancer by Sputum Cytology.
FR in Treating Patients With Refractory or Progressive Small Cell Lung Cancer or Non-Small Cell Lung Cancer.
INS316 in Diagnosing Lung Cancer in Patients With Untreated Lung Cancer
Prevention of Tumour Spread Due to Lung Cancer Surgery.
Vaccine Therapy in Treating Patients With Colon, Pancreatic, or Lung Cancer.

26. Clinical trials for lung cancer- ongoing
Biomarkers for Early Detection of Lung Cancer in Patients With Lung Cancer, Participants at High-Risk for Developing Lung Cancer, or Healthy Volunteers
A Clinical Trial to Validate Molecular Targets of Vorinostat in Patients With Stage I-III Non-Small Cell Lung Cancer
DNA Analysis in Predicting Lung Cancer Risk
Phase II Study of Dichloroacetate (DCA) in Patients With Previously Treated Metastatic Breast or NSCL Cancer
Sputum Cytology in Screening Heavy Smokers For Lung Cancer

27. Recent research
Tumor Growth Pattern May Predict Survival in Non-Small Cell Lung Cancer
Newer techniques to combact with non-small cell lung cancer and small cell lung cancer.
Hormone with anti cancer effects.

28. Quality of life Means how lung cancer survivors feel about different
aspects of life, including physical health, emotional
health, and ability to carry out daily activities. opinions about their quality of life, as well as the factors that affect their quality of life.
Helps to develop new services for lung cancer survivors.
Behavioral Questionnaires or Telephonic Interviews are conducted.

29. Palliative Care in Lung Cancer
Symptom
Palliative Recommendations
1) Pain
Mild : Acetaminophen or NSAIDs
Severe : Opioids
2) Dyspnea
Oxygen, Bronchodilators, Corticosteroids, Antibiotics, Opioids
3) Cough
Non opioid cough suppressants, Bronchodilators, Corticosteroids, Opioids
4) Bone Metastases
External Radiation Therapy + Systemic Corticosteroids (Prednisone 20 to 40 mg)
5) Brain Metastases
Dexamethasone (20mg) for 4 weeks
6) Spinal cord Compression
High Dose Steroids + Radiation Therapy
Adjunct Therapy : Dexamethasone (60mg)

30. Palliative Care Centers
Fox Phase Cancer Centre, Philadelphia, USA
Barbara Ann Karmanos Cancer Hospice, Southfield, USA
John Taylor Hospice, Birmingham, England
The Prince of Wales Hospice, Yorkshire, England
St. Luke’s Hospice, Plymouth, England
Primrose Hospice, Worcestershire, England
St. Francis Hospice, Ireland
Royal Perth Hospital, Australia
Shanti Avedna Ashram
Chittaranjan National Cancer Institute
11) Christian Medical Association of India
12) Cipla Foundation's Cancer Palliative Care Centre

31. Ethical Considerations
Should terminally ill cancer patients be allowed to
try new therapies with no clinical trials?
Should they worry about the side effects?
Personal Autonomy v/s Justice.
Imposing the truth on an unprepared patient.
Cultural Sensitivity and Cultural Competence.
Special aspects of truth telling in pediatric and geriatric oncology.
Euthanasia and Physician-assisted Suicide

32. Lung Cancer Awareness November is Lung Cancer Awareness Month.
The colour of lung cancer
awareness is Pearl White.
‘Can Support’ organized
walkathon called “Walk for Life”
on 7th Feb 2010 in New Delhi to
create awareness about
Lung Cancer.

33. Case Study
In March 2004, 46 yr old non-smoker, Caucasian female, presented with flu-like symptoms, persistent cough and constant fatigue.
Biopsy and CT scan revealed NSCL cancer in the right lung.
Surgery was scheduled a month later to remove the nodular mass and the entire right middle lobe of the right lung.
In May 2005, additional nodules appeared in the mediastinal area and a biopsy and mediastinoscopy revealed mucin- producing adenocarcinoma in stage II B.
PET scan done in May 2006 revealed liver and right pleural space metastasis.
The patient received chemoradiation therapy consisting of weekly Carboplatin (Platinol) plus Paclitaxol (Taxol), concurrent with radiation therapy.
Experimental Phase I/II clinical trial with oral Tarceva (Erlotinib) and oral Vorino stat. Brachytherapy to the trachea.

34. Some Interesting Facts
Most common form of cancer worldwide.
1.2 million new cases of lung cancer worldwide every year.
Responsible for 17.8% of all cancer deaths annually.
Kills about 9,00,000 men and
3,30,000 women annually
In Men smoking causes more than
80% of lung cancer cases.
In Women it causes 45% of all
lung cancer cases.

35. Summary Lung cancer is the leading cancer-related cause of death.
It has become the subject of a great
amount of research.
The best way to prevent it is to
quit (or never start) smoking.
Treatment depends on the cancer's
specific cell type, how far it has spread
and patient's performance status.
It also depends on the stage, or how
advanced it is.
Treatment includes chemotherapy,
radiation and surgery.
In recent years, various molecular
targeted therapies have been developed
as treatments.

36. REFERENCES www.cancer.gov/cancertopics/types/lung
Medscape,clin lung cancer ,
By, Everrete and E.Vokes
PNAS journal Volume 100, July 8th, number 14

37. T HANK YOU