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Malignant Neoplasm of Lung

Malignant Neoplasm of Lung. Dr Edit Csada 13.09.2017. 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

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Malignant Neoplasm of Lung

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  1. Malignant Neoplasm of Lung Dr Edit Csada 13.09.2017.

  2. 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: 1,59/1,82 = 0,87 breast cancer fatality: 0,35 Male/female: 2,4/1

  3. New diseases according to ages • Until 40 years : 1%↓ • 40-49 years: 10%↓ • 50-59 years: ~30% • 60-69 years: ~30% • Above 70 years: 30%↓

  4. Etiologic factors Smoking Athmospheric pollution Ionisation Occupational factors asbestos, radon, etcOther lung diseases tb, COPD, ILDGenetic events

  5. Smoking • 400 chemical materials • 60 carcinogens • Gas and particulate phase • Nitrosamines, aromatic amines, benzopyrene, CO, CO2, aldehids, nicotin, free radicals • Pack-year

  6. 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

  7. 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

  8. Lung Cancer Mutation Consortium Mutationsfrequency M G Kris ASCO Annual Meeting 2011, June 3–7, Chicago

  9. 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

  10. 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

  11. Histology in Hungary Korányi Bulletin 2014

  12. Pathological prognostic factors • TNM • Histology • Histological differentiation • Invading vessels • Necrosis • Proliferation activity • Prognostic proteins

  13. Symptoms of lung cancer • Regionalspread • Superiorvenacavalsy • Recurrentlaryngealnerveparalysis (hoarsness) • Phrenicnerveparalysis elevatedhemidiaphragm • Horner’s sy • Pancoast’s sy • Trachea obstruction • Oesophagusobstruction • Pleuraleffusion • Lymphatic tumor spread

  14. 17

  15. Vena cava superior sy Sárosi Veronika anyaga

  16. Pancoast tumor Pálföldi Regina anyaga

  17. Digital clubbing Sárosi Veronika anyaga

  18. Diagnostic procedures • Imaging technics • Endoscopy • Pathology • Laboratory tests

  19. Diagnostic procedures • Imaging technics • Chest x-rays • CT • MRI • Isotope scanning • PET/CT • Ultrasound

  20. Bronchoscopy: sampling • Biopsy • Brushing • Transbronchial biopsy • Transbronchial needle aspiration (TBNA, EBUS) • Washing • BAL

  21. Other samplings • TTB, x-ray or CT supervision • Percutan pleura biopsy • Lymphnode aspiration biopsy • Surgical biopsy • Mediastinoscopy • Parasternal mediastinotomy (Stemmer) • VATS • Thoracotomy (10%↓)

  22. Metastases • Liver: CT, ultrasound, PET/CT • Bones: scintigraphy, CT, PET/CT • Adrenals: CT, ultrasound, PET/CT • Brain: MRI, CT

  23. Prognostic factors • Poor performance status • Karnofsky, WHO ECOG • Weight loss, more than 10% • Elevated LDH • Elevated tumormarker (CEA, NSE, SCC) • Old age

  24. Performance status

  25. Performance status

  26. Defining treatment • Tumor specificfactors • TNM stage • Histology • Molecularfeatures • Patientspecificfactors • Age • Performance status • Concomitantdiseases • gender, etnicity, smoking Based on these factors multidisciplinarytumour board decides on curative-palliative therapy

  27. Multimodality treatment Surgery Radiotherapy Chemotherapy Moleculartargettherapy Immunoncology! Supportive therapy

  28. Surgery • Type of surgical procedure depends on • Staging • patient’s performance status • cardiopulmonal function • comorbidities. • Aim is radical resection • Sublobar resection may have a role in very early diseases. • Thoracotomy • Video assisted thoracoscopy (VATS)

  29. Surgery • Absolute contraindications: • haematogen metastases in the lungs • pleuritis carcinomatosa • III.b stage disease • multiplex distant metastases • Relative contraindications

  30. 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

  31. 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!

  32. Combination of radio/chemotherapy • Aim • localcontrol • Prevention of toxic sideeffects • Decreasing of distantmetastases • Sequential ChTRT (ChTRTChT) • Concomitant ChT/RT • Timing - Induction: ChTChT/RT - Consolidation: ChT/RT ChT

  33. Chemotherapy • Neoadjuvant treatment • Before surgery IIIa stage • Adjuvant treatment • After surgery II-IIIa stage • First-, second-, thirdline….. • IIIb, IV stage

  34. ESMO guideline: first-line treatment of non-squamous NSCLC Előrehaladott,nem laphám NSCLC Diagnózis Driver mut – /ismeretlen EGFR mut+ ALK fúzió Jó általános állapot(ECOG PS 0-1) Rossz általános állapot(ECOG PS ≥2) Platina-alapú kombináció Monoterápia Platina-alapúkombináció BSC EGFR TKI (erlotinib,gefitinib,afatinib) (I,A) crizotinib (I,A) Cis +gem/taxán (I,B) Pem + cis (II,B) Bev + Platina-kettős (I,A) Gemcitabin, vinorelbin,taxán (I,B) Carbo+pac vagy Pem (II,B) Átvéve: NSCLC ESMO Guidelines, Reck, et al. Ann Oncol 2014

  35. Chemotherapy of NSCLC • First-line • Cis-, carboplatin-gemcitabin • Cis-, carboplatin-paclitaxel • Cisplatin-docetaxel • Cisplatin-vinorelbin • Cisplatin-pemeterexed (non squamous c) • Doublet+bevacizumab(adenoc) • Second-line • Pemetrexed • docetaxel

  36. Molecular target therapy • EGFR tirosin kinase inhibitors • erlotinib (Tarceva) • gefinitib (Iressa) • Afatinib (Giotrif) • Angiogenesis inhibitor • bevacizumab (Avastin) • Alk-EML4 fusion gene inhibitor • Crizotinib (Xalkori) • Ceritinib • alectinib

  37. EGFR-TKI treatment • EGRF activating mutation – first or second line (also PS 3-4!) • Erlotinib (Tarceva) • Gefitinib (Iressa) • Afatinib (Giotrif) • Erlotinib is a potential second line treatment option in pretreated patients with undetermined or wild type EGFR status. (In Hungary KRAS negativity) • Resistence: T790M mutation • osimertinib

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