Lung cancer MUDr. Monika Bratová Department of Respiratory Diseases and TB University Hospital Brno Masaryk University, Faculty of Medicine Introduction •Lung cancer = bronchogenis carcinoma - include tumors of lung and brochi • •In 1912 all cases of lung cancer worldwide were documentated, it was 374 cases x in 2018 according to WHO there are 2 093 876 new cases of lung cancer in the world • •Smoking is still a main risk factor • Demography in CR (2016) •The highest incidence and mortality from oncological diagnosis in men and women in the Czech Republic • •Incidence 6 782 cases (♂4478, ♀2304) • •While incidence in men decreased, in women it is still increasing (!) Demografic data 2014 •Lung cancer is most common in 7th decenium, the bigger increase of incidence was in 2014 around 55 years • •A lot of cases are diagnosed in the locally advanced and metastatic stages (IIIB a IV), 5-year survival is 10% • • •Some areas of our country have higher incidence because of mining expecially Distribution in the Czech republic Th TNM Classification CLassification •The most useful classification of lung cancer reflects its biological properties is into: • • Non-small cell lung cancer (NSCLC) • • • Small cell lung cancer (SCLC) NSCLC •80% of all lung cancers •TNM classification •Histological types – squamous cell carcinoma, adenocarcinoma, large cell carcinoma •Some types of carcinomas can be mixed (squamous/adeno, NSCSL/SCLC) • •Biological features: slow growth, lower sensitivity to chemo and radiotherapy • SCLC •20% of all lung cancers •Stage – limited disease or extensive disease (ED) •No further histological subclassification • •Biological features: rapid growth, huge tendency to metastatise early (ussually bones and brain), paneoplastic signs, sensitivity to chemo and radiotherapy •Ussualy central tumours, can cause vena cava superior syndrome Lung cancer - Pacients history •The most important is well done history and physical examination of a patient! • •History: • family history, other oncological disesases, smoking, professional risks, cough, hemoptysis, chest pain, dyspnoe, dysfagia, recurent pneumonias • Lung cancer – Physical examination •We can observe: •Cyanosis, ikterus •Edema of extremities, vena cava syndrome •Dyspnoe, stridor •Peripheral lymfadenopathy •Rarely Claude-Bernard-Horner syndrome •Any kind of paraneoplastic syndrome •Physiological breathing, weakened or non-audible, wheezes, dull percussion Diagnosis •Postero-anterior and lateral chest X-rays •CT scan of lung and abdomen •Bronchoscopy and its modifications •Transparietal punction biopsy •Thoracoscopy (VATS or mediastinoscopy) •Cytological examination of pleural fluid •MR of a brain (SCLC), scintigraphy of bones (SCLC) • •Final diagnosis is allways based on histological or cytological findings • X-rays P2120013 P2120008 CT scans P2120015 882-4703-1-SP.jpg MRI of the brain P2210022 Scintigraphy of bones Scintigraphy_pelvis_with_bone_metastasis_01.jpg Bronchoscopy before and today h3 P1010783 Bez názvu 2 Bez ná1 Endobronchial finding EBUS Figure 2 Figure-6a Tumor markers •Are importatnt in a monitoring of the disease not for the diagnosis • •NSCLC: • CEA (cancer embryonal antigen) • CYFRA 21-1 (fragment of cytokeratine 21) • SCC Ag (squamos cell antigen) • •SCLC: • NSE (neuron specific enolase), • Pro GRP (pro-gastrine realising peptide) • Oncological treatment •According to the clinical stage of the disese (and performance status of the patient): • •Curative for I-IIIA (operation or curative radiotherapy) •Palliative for IIIB-IV (chemo or radiotherapy) •Supportive for anyone (management of the symptoms) Treatment of NSCLC •Adjuvant chemotherapy - following a radical surgery (stage IB, IIA, IIB, IIIA) •Neo-adjuvant chemotherapy before surgery • (IIIA, IIIB) •Chemotherapy + radiotherapy concurrently or following (IIIB) •Chemotherapy alone (IIIB, IV) • Mutation analysis of NSCLC • Treatment of NSCLC •Adenoca without driver mutation: •pemetrexed (Alimta®) + cisplatine •Bevacizumab (VEGFR inhibitor) + chemo • •Adenoca EGFR +: •TKI´s (gefitinib, erlotinib, afatinib, osimertinib) • •Adenoca ALK+: •ALK inhibitors (crizotinib, alectinib) • •Adenoca PD-L1 more than 50%: •Imunotherapy (pembrolizumab, nivolumab in the further lines) • •Squamous carcinoma: •Standard chemo Immunotherapy • •New type of treatment in last 5 years •Attack a blocage of PD-1 receptor at T-cells by PD-L1 ligand at the surfice of tumor cells •Indication: NSCLC stage IV according to expression of PD-L1 •Contraindication: autoimunity, high dose of steroids •Various side effects, so called pseudoprogression • • • • SCLC - Treatment •The same from 1970´s • •Limited disease: chemo+ radiotherapy of the chest •Extensive disease: standard chemotherapy (platine+etoposid, hycamtin in the second line) • •Imunotherapy for SCLC in progress (?) Bad prognostic farctors •Stage of disease •Performance status •Weight loss •Paraneoblastic signs •Comorbidities •Sociodemographic characteristics Palliative treatment • •Opioid´s, antitusics and others • •Palliative radiotherapy of bone, brain metastasis or malignant lymphadenopathy • •Management of malignant pleural effusion (pleural punctions, drenage, pleurodesis, tunelized catheter, pleuroscopy) • •Treatment of symptomatic tumour obstruction (endobronchial treatment, laser therapy, stents) • Laser therapy P1060054 P1060058 Brachytherapy P4140091 Future? •New biological drugs – TKI´s (dacotinib), ALK inhibitors (brigatinib) •Immunotherapy – atezolizumab for NSCLC and SCLC ? •Cyber-knife of brain metastasis, protontherapy •Improvement of palliative care (hospices, mobile hopsice care) Thank you for your attention