10 lung cancer
TRANSCRIPT
肺 癌
LUNG CANCER
中山大学肿瘤医院王 思 愚
Lung cancer – China incidence and mortality rates (1990-2009)
– 90 年后肺癌占恶性肿瘤死因第 1 位的省市 :
上 海 : 43.53/10 万 天 津 : 38.86
辽 宁 : 32.07
黑龙江 : 29.06
吉 林 : 28.06
云 南 : 23.07
北 京 : 22.25
内蒙古 : 22.04
Lung cancer - US incidence andmortality rates (1973-1996)
10
50
100
Incidence - malesMortality - malesIncidence - femalesMortality - females
Rate per 100,000 people(log scale)
1974 76 78 80 82 84 86 88 90 92 94 96
Year of diagnosis/death
Ries et al 1999
lung cancer cases diagnosed in Cancer Center of Sun Yat-sen University
0
2
4
6
8
10
12
14
65 75 85 95 2000
lung cancer cases diagnosed in Cancer Center of Sun Yat-sen University
70'S
鼻咽癌 肝 癌 肺 癌
食管癌 乳腺癌 其它
21'S
鼻咽癌 肝 癌 肺 癌
食管癌 乳腺癌 其它
Etiology of Lung Cancer
Cigarette smoking– FHIT gene
• Air pollutions and ionizing radiation• Occupational associations asbestos, uranium( in miners), arsenical fumes, nickel, radon gas Oncogenes and suppressor genes ras,myc,bcl-2,c-erbB-2 p53,RB
Garfinkel L, Silverberg E. CA Cancer J Clin. 1991;41:137-145.
The risk of lung cancer after stoping smoking
Classifications
According to anatomy
Central lung cancer:
mostly is squamous and small cell carcinoma.
Peripheral lung cancer:
mostly is adenous.
According to histologic classification
--SCLC (15-20%)
--NSCLC (80-85%)
includes squamous 、 large cell, adenocarcinoma, adenosquamou
s .
SquamousSquamousNon-squamousNon-squamous
Clinical Manifestations Development and symptoms
– usually asymptomatic :early stage of the lung cancer
– Cough: invasion of small bronchi
– hemoptysis: erosion into vessels
– chest pain: invasion of the pleura, chest wall, or mediastinu
m
– dyspnea and fever :obstruct airway:
– pleural effusion :invasion of the pleura
Other symptoms: inappetence ,weight loss
Clinical Manifestations
Paraneoplasic syndromes
associated with brochogenic carcinoma often stem fro
m release of the following hormones:
① ADH (syndrome of inappropriate antidiuretic hormon
e reslease).
② ATCH (Cushing’s syndrome).
③ Parathormone or PGE (hypercalcemia).
④ Calcitionin (hypocalcemia).
Other paraneoplastic syndromes include myopathy, peri
pheral neuropathy, acanthosis nigricans, and hypertrop
hic pulmonary osteoarthropathy (clubbing of fingers).
Diagnosis of lung cancer requires:
A: detecting the tumor.
B: establish the cell type.
C: define the stage of the tumor.
determing cell type is the most important becau
se it influences the treatment !
Lung Cancer diagnosis
Physical examination Detect signs
Visualize and sample mediasturial lymph nodes
Detect position, size, number of tumors
Detect chest wall invasion mediastinallymphodenopathy distant metastases
Lymph node staging
Detect changes in hormone production, and hematological manifestations of lung cancer
Precise location of tumor obtain biopsy
Chest X-ray
CT scan
PET scan
Laboratory analysis
Bronchoscopy
Mediastinoscopy
FNA Cytology
NCCN Guidelines 2000
Physical examinations
Usually in early stage, most of the patients with lung cancer have
no positive physical findings.
General findings include abnormal percussion, breath sounds ch
anges, moist rales (when pneumonia happens)
Digital clubbing, superior vena cava syndrome, horner’s syndrom
e (unilaterally constricted pupil, enophthalmos, narrowed palpebr
al fissure and loss of sweating on the same side of the face.
Physical examinations
Endobronchial obstruction may result in a localiz
ed wheeze
Lobar collapse may result in an area of decreas
ed breath sounds and dullness to percussion.
Chest X-ray
It is the most important method to find lung ca
ncer. If a patient with chronic cough, sputum wit
h few blood, and dyspnea, lower fever he should
adopt a chest X-ray. The most frequent finding is
a mass in the lung field.
chest X-ray
Secondary manifestations include lobar collaps
e, pleural effusion, pneumonitis, elevation of the
hemidiaphragm, hilar and mediastinal adenopath
y, and erosion of ribs or vertebrae due to metasta
ses.
Lung Cancer X-ray
Lung Cancer CT scans
Lung cancer on CT
CT is the most useful in evaluating patients with pulmonar
y and mediastinal masses.
It is also useful for detecting multiple metastases.
CT can show a mass to be located in which lobe of lung fie
ld and the size of the mass. It also shows the nodule in the
mediastinum.
Sometimes, when a mass locate behind the heart, chest X-r
ay can`t detect it .CT can detect some secret sites of lung c
ancer.
Bronchoscopy
It is important both for determining if a tumor is
present and for obtaining tissue for histologic di
agnosis.
Usually, the combination of bronchial brushing a
nd forceps biopsy is positive 90 to 93 percent of t
he tumors located in proximal airway.
Transbronchial lung biopsy
It may be utilized when tumor located
in peripheral airway.
Transthoracic needle with guidance
by CT can be used to detect lesions
located near the chest wall
Lung Cancer diagnosis
Physical examination Detect signs
Visualize and sample mediasturial lymph nodes
Detect position, size, number of tumors
Detect chest wall invasion mediastinallymphodenopathy distant metastases
Lymph node staging
Detect changes in hormone production, and hematological manifestations of lung cancer
Precise location of tumor obtain biopsy
Chest X-ray
CT scan
PET scan
Laboratory analysis
Bronchoscopy
Mediastinoscopy
FNA Cytology
NCCN Guidelines 2000
2008 年 8 月 28 日
Bronchoscopy
Pathology
NSCLC: squamous cell carcinoma
2008 年 11 月 19 日
What should we do before treament ?
Histology classification
– SCLC
– NSCLC
Staging
Treatment based on Evidenced Medicine
Follow up plan
Staging of lung cancer
TNM stage: CTNM, PTNM
– T: Primary Tumor (TX, T0) T1, T2, T3, T4
– N: Nodal Involvement N0, N1, N2, N3
– M: Distant metastasis M0, M1
– The relationship of clinical stage and TNM stage
Staging of small cell lung cancer
– limited stage
– extensive stage.
Stage process
Chest CT (include adrenal gland )
Bone scan
Magnetic resounce imaging (MRI)
PET: positron emission tomogra
py
Bronchoscopic techniques
Video-assisted thoracic surgery
Lung Cancer stages
Stage 0
Stage IA
Stage IIB
Stage IIIB
Stage IV
Lymph nodes
Mainbronchus
Contralaterallymph node
Metastasisto distant
organs
Invasion ofchest wall
SCLC staging
Extensive:Tumor not confined tohemithorax of originDistant metastasis
PDQ Guidelines 2000
Limited:Tumor confined tohemithorax of originand/or themediastinum andsupraclavicular nodes
Stage grouping
T1 T2 T3 T4
N0 IA IB IIB IIIB
N1 IIA IIB IIIA IIIB
N2 IIIA IIIA IIIA IIIB
N3 IIIB IIIB IIIB IIIB
Mountain CF. Chest. 1997;111:1710-1717.
Mountain 1997
NSCLC stages - an overview
Disease
Early
Localized
Advanced
Stage
0IAIB
IIAIIB
IIIA
IIIB
IV
TNM
TIS N0 M0 (carcinoma in situ)T1 N0 M0T2 N0 M0
T1 N1 M0T2 N1 M0T3 N0 M0T3 N1 M0
T1-3 N2 M0
T4, Any N, M0Any T, N3, M0
Any T, Any N, M1
Treatment
Including:
A: Surgery
B: Chemotherapy
C: Radiation therapy
D: Targeted therapy
E: Some other therapy
immunologic therapy
chinese medicine
Surgery
Non-small cell lung cancer:
patients with stage I and II are considered
candidates for surgical resection, with stage III
cancer may be candidates for surgery.
Surgery
More than 90 percent of small cell lung cancer ha
s often metastasized at the time of diagnosis.
So these patients usually adopt radiation therapy
or chemotherapy before surgery.
We must measure pulmonary function before sur
gical therapy.
5-years survival rate after surgery
TNM stage 5 YS( clinical stage)
5YS( pathologic stage)
T1 N0 M0 n=687 61% n=511 67%
T2 N0 M0 n=1189 38% n=549 57%
T1 N1 M0 n=29 34% n=76 55%
T2 N1 M0 n=250 24% n=288 39%
T3 N0 M0 n=107 22% n=87 38%
T3 N1 M0 n=40 9% n=55 25%
T1-3 N2 M0 n=471 13% n=344 23%
T4 N0-2 M0 n=458 7% NA
Any T N3 M0 n=572 3% NA
Any T any N M1 n=1427 1% NA
Mountain CF , Chest 1997.
Radiation therapy
Radiotherapy plays a major role in the
treatment of lung cancer.
It is divided into curative treatment and
palliative treatment.
It is of proven benefit in controlling bone
pain, spinal cord compression, superior vena
cava syndrome and bronchial obstruction.
Chemotherapy
Non-small cell lung cancer
•Adjuvant chem.
•Chem. for stage IV disease
Small-cell lung cancer
it is highly responsive to chemotherapy.
The newest evidence for Adjuvant chemotherapy
2007 update meta-analysis
2007’s ASCO
LACE meta-analysis : OS
HR=0.8995%CI=0.82-0.96P=0.005
100
80
60
40
20
0 1 2 3 4 5 ≥6
Time From Randomization (years)
Chem.Control
总体
生存
(%
)
Pignon JP, et al. J Clin Oncol 2008; 26:3552-3559
LACE meta-analysis : DFS
Time From Randomization (years)
100
80
60
40
20
0 1 2 3 4 5 ≥6
Chem.
Control
无病
生存
(%
)
HR=0.8495%CI=0.78-0.91P<0.001
Pignon JP, et al. J Clin Oncol 2008; 26:3552-3559.
LACE meta-analysis : Survival according to type of death.
Decreases lung cancer–related death (HR=0.83, 95%CI=0.76-0.90, P<0.001)
Increase noncancer-related death (HR=1.36, 95%CI=1.10-1.69, P=0.004)
– 主要出现在前 6 个月 (HR=2.41, 95%CI=1.64-3.55, P<0.001)
100
80
60
40
20
0 1 2 3 4 5 ≥6Time From Randomization (years)
Sur
viva
l (%
) Chem. (noncancer-related death )
Cont (noncancer-related death )化疗 ( 癌症相关死亡 )不化疗 ( 癌症相关死亡 )
Pignon JP, et al. J Clin Oncol 2008; 26:3552-3559.[ 临床肿瘤学杂志中文版 2009; 3(1): 10-17.]
IIIA-N2:Overall survival at 5 years withchemotherapy improved by 12%
31.1% vs 19.1%MS:33m vs 24m
Questions :
Why the benefits of adjuvant chemotherapy is limited ? The direction of our following research:
- Do we continue to adopt chemotherapy to all patients just for
the improved 6%-12% total survival rate ?
- Or can we pick out those patients who is sensitive to adjuva
nt chemotherapy ,then the other patients can avoid the unne
cessary toxicity of chemotherapy.
Chemotherapy for advanced stage of lung cancer
BMJ, 1995
NSCLC Meta-analyses
NSCLC Meta-analyses Collaborative Group. JCO 2008; 26:4617-25.[ 临床肿瘤学杂志中文版 2009; 3(2): 45.]
16 项 RCT 2714 例患者 IPD 资料
HR=0.7795%CI=0.71-0.83P≤0.00011YS: 29% vs. 20%
1.0
0.8
0.6
0.4
0.2
0 3 6 9 12 15 18 21 24
时间 ( 月 )
概率
事件数 患者总数
1240
1293
1315
1399
SC+CT
仅 SC
First-line chemotherapy options in NSCLC (E1594): comparable efficacy with platinum doublets
Schiller, et al. NEJM 2002
1.0
0.8
0.6
0.4
0.2
0
0 5 10 15 20 25 30Time (months)
Cisplatin/paclitaxelCisplatin/gemcitabineCisplatin/docetaxelCarboplatin/paclitaxel
Pro
bab
ilit
y o
f su
rviv
al
Therapeutic plateau: overall survival <12 months
Overall Survival by Histology
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 480.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 480.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Pemetrexed 15.5 mos Pemetrexed 9.9 mos
Placebo 10.3 mos
Placebo 10.8 mos
Non-squamous (n=481)Non-squamous (n=481) Squamous (n=182)Squamous (n=182)
HR=0.70 (95% CI: 0.56-0.88) P =0.002
HR=1.07 (95% CI: 0.49–0.73) P =0.678
Su
rviv
al P
rob
ab
ilit
y
Time (months) Time (months)
2009 ASCO
Targeted therapy
Such as epidermal growth factor rece
ptor inhibitors, angiogenesis inhibito
rs and apoptosis inducers ects.
晚期非小细胞肺癌 front-line 治疗策略
EGFR 突变者
30 %
TKIMST : 20 - 24 月
EGFR 野生者70 %
腺癌35 %
鳞癌35 %
第三代+铂类10 月
维持治疗13 月
培美曲塞+铂类:11.8 月
西妥昔单抗或贝伐单抗12 - 16 月
+
ERCC1BRCA1: 选择铂类药物
RRMI :选择 Gemcitabine
TS :选择 Pemetrexed
Treatment of Lung Cancer
NSCLC
– Ⅰ, ,N0N1 of a stage: surgery + adjuvant chemotherapyⅡ Ⅲ for those patients who is N0-1 and had radical resection of lung cancer, adjuvant rad
iotherapy is not only inefficacy but do harm to patients.
– N2 of A stage: neoadjuvant chemotherapyⅢ– ⅢB stage: chemotherapy + radiotherapy (surgery when it is
needed.)
– Ⅳstage: chemotherapy and targeted therapy.
SCLC
– limited stage: chemotherapy + surgery / radiotherapy -- chemotherapy
– extensive stage : chiefly chemotherapy
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