LUNG CANCER (BRONCHOGENIC CARCINOMA)

"DONT LET BREATHING BECOME A BATTLE, UNDERSTAND LUNG CANCER"

Early awareness and timely care can change the FIGHT into HOPE!

LUNG CANCER is one of the most common cancers world wide (12.4 % of all cancers). It is the leading cause of death among the cancer diseases. Lung cancer results from "uncontrolled multiplication of abnormal cancerous cells" in lung tissues (bronchi and alveoli), leading to development of a tumour or mass that destroys lungs and also spreads to the other parts of body like brain, liver, bone, adrenals and lymphnodes. Therefore EARLY DIAGNOSIS AND TREATMENT is of utmost importance.

WHAT CAUSES LUNG CANCER ?

90% of the lung cancer cases are attributed to smoking. The toxins like hydrocarbons in the cigarette smoke damage lung cell DNA .

Other causes are Second hand smoking, Exposure to radiation , for example, in people who received Radiotherapy for Lymphoma and Breast cancer, Occupational diseases like silicosis, asbestosis, Exposure to resedential radons, Air pollution and Genetic predisposition.

Diseases like IPF, TB can also develop lung cancer.

In pratical terms, lung cancer is divided mainly into two types.

Non Small Cell Lung Cancer ( NSCLC) - 85%;

Small Cell Lung Cancer (SCLC)-15%.

LUNG CANCER : Tumour occuping right upper lobe

WHAT ARE THE SYMPTOMS IN A PATIENT WITH LUNG CANCER?

Cough (50% to 75%)

Large volumes of thin mucoid secretions called as BRONCHORRHEA is seen in some cases of Bronchoalveolar cell carcinoma (Invasive Mucinous Adenocarcinoma)

Haemoptysis or coughing out blood (15% to 30 %)

Chest pain (20% to 40%)

Breathing difficulty (25% to 40%)

Persistent cough, especially with recent change in character, change in voice,

noisy breathing ( loud wheeze or stridor) ,recurrent pneumonia, difficulty in swallowing, shoulder pain and bone pain are the other symptoms.

Can be associated with weight loss and fatigue.

Patients may consult PULMONOLOGIST for symptoms that arise due to COMPLICATIONS of lung cancer also.

LUNG CANCER spreading to other parts of the lung

LUNG CANCER spreading to other parts of the lung and distant organs like liver and brain

SVCO (SUPERIOR VENA CAVA OBSTRUCTION) is a serious complication in which a large vein called superior vena cava, is compressed and return of the blood to heart from all organs is obstructed by the tumour. It results in swelling in face, neck, both arms and prominent veins on the chest and both arms.

CUSHING'S SYNDROME: SCLC can cause Cushing's Syndrome due to excess secretion of ACTH hormone, resulting in muscle weakness, Low potassium levels and hypertention.

PANCOAST TUMOR (lung cancer) of the apex of the lung can compress sympathetic chain and cause disrupted sympathetic pathway resulting in small pupil (MIOSIS), drooping of upper eyelid (PTOSIS), absence of sweating of the face (ANHYDROSIS ), and sinking of eyeball (ENOTHTHALMOS).Patient may have extreme pain of the whole arm on the affected side.

DIAGNOSIS AND STAGING OF LUNG CANCER :

IMAGIVE and INVASIVE investigations are the tools in the DIAGNOSIS and STAGING of lung cancer.

After history details and carefull examination of the patient ,the PULMONOLOGIST will advise investigations step by step as needed.

IMAGING TOOLS:

They are CHEST X ray,

Ultrasound of Chest ,Neck and Liver,

CT Scan of the CHEST with contrast ( CECT chest) including neck, liver and adrenals. By imaging the size, location and extention of the tumour regionally and distally (spread to distant organs) is identified.

PET- CT SCAN : Accurately identifies spread to both regional and distant organs and also identifies easiest access to the tumour or a secondary ,for diagnostic biopsy.

INVASIVE TOOLS:

CONFIRMATORY DIAGNOSIS OF CANCER is made by extracting a tissue specimen by any of the suitable methods and histopathological examination.

1. BRONCHOSCOPY :

   Bronchoscopic TBNA ( Transbronchial needle aspiration ) or

   TBLB( Transbronchial lung biopsy) or Endobronchial biopsies.

   CONVEX PROBE EBUS (CP-EBUS): TBNA/Biopsy

   RADIAL EBUS: TBNA or biopsy

   Navigation Bronchoscopy.

2. PERCUTANEOUS CT or US guided biopsy, CRYOBIOPSY of peripheral tumours Others are THORACOSCOPY, MEDIASTINOSCOPY, Supraclavicular Lymphnode biopsy.

   
   

   After one or more of the diagnositic procedures and Histopathological examination, the cell type of the lung cancer ( NSCLC( squamous cell/ adeno, large cell/adenosquamous etc ) or SCLC) is identified.

   
   

   As a next step the following advanced tests are often necessary.

   1. MOLECULAR PROFILING for genetic alterations (EGFR, ALK, ROS1, KRAS) for TARGETED THERAPY.

   2. IMMUNOHISTOCHEMISTRY for IMMUNOTHERAPY.

   
   

STAGING OF LUNG CANCER INTO STAGE 1-4 .

STAGING is done with the help of CECT, PET-CT SCANS, Bone scintigraphy and rarely MRI.( stage1/2/3/4)

After RADIOLOGICAL and INVASIVE CONFIRMATORY DIAGNOSIS of lung cancer and its stage by the Pulmonologist, appropriate treatment for the stage will be decided by the Pulmonologist and Oncologist.

TREATMENT OF NSCLC:

Stage 1 and Stage 2 are early disease of cancer. Surgery is the main stay of treatment

Stage 1. Treatment in surgically fit patients is by removal of the cancer containing lobe or lung ie, Lobectomy or Pnemonectomy. In stage 1 the 5year survival rate is 50 to 80%.

In stage 2 : Treatment involves surgery followed by adjuant chemotherapy. Here 5 year survival rate is 35 to 46%.

Stage 3 : surgery or chemoradiotherapy or both.

Stage 4 : ( ADVANCED STAGE) . It is considered incurable. Only 1 -3% survive for 5 years.

TREATMENT IN ADVANCED LUNG CANCER

The latest advances in the management of lung cancer include TARGETED THERAPY and IMMUNOTHERAPY which are highly individualised and personalised.

TARGETED THERAPY : Tumors with specific mutations like EGFR, ALK, ROS1, can be treated with drugs which block the mutation pathways and improve survival. There are better outcomes and lesser side effects with these drugs.

EGFR: Treated by TKI like Erlotanib, Gefitinib, Afatinib.

ALK: Treated by Crizotinib, Ceritinib, Alectinib.

ROS1: Treated by Crizotinib

IMMUNOTHERAPY: In Immunotherapy , the drugs identify immune check points like PD-1/PD-L1 and block them and allow body's immune system to kill the cancer cells. Therefore they are called Check Point Inhibitors ( CPI) and they play a revolutionary role in treating NSCLC. Example: Pembrolizumab, Nivolumab, Atezolizumib.

Bevacizumab is an anti angiogenesis antibody that inhibits VEGF and is also widely used in lung cancer.

NOVEL RADIOTHERAPY TREATMENT:

STERIOTACTIC BODY RADIOTHERAPY (SBRT)/

STERIOTACTIC ABLATIVE RADIOTHERAPY(SABR): This involves delivering very high doses over a few sessions,particularly effective for small,well localised tumors or early stage non surgical cases.

TREATMENT OF SMALL CELL LUNG CANCER( SCLC):

This type of lung cancer has good response to chemotherapy but unfortunatly has a very high recurrance rate.

The SCLC is divided into Limited stage (LS) and Extenseve stage ( ES) SCLC.

These cases are treated with Platinum based chemotherapy or immunotherapy (Durvalumab) after chemoradiation therapy. The survival rate is only 8 to 12 months. Only 5% of SCLC live upto 2 years. Both LS and ES SCLC are treated with Prophylactic whole brain radiation therapy because brain metastasis is extremely common.

THE SINGLE MOST IMPORTANT PREVENTIVE MEASURE IS

"SMOKING CESSATION IN ALL INDIVIDUALS."

IS THERE A SCREENING TEST FOR LUNG CANCER?

YES, it is called Low Dose Computed Tomography (LDCT) Screening Test : This test of yearly screening by LDCT is recommended for adults aged 50-80 years,who have a minimum 20 pack year smoking history and currently smoke or have quit smoking within past 15 years. A pack year is calculated as smoking one pack of cigarettes per day for a year.

EMERGING TREATMENTS IN LUNG CANCER:

NEW DRUGS AND MODALITIES:

KRAS inhibitor. ZOLDONRASIB

ADCS - Antibody-Drug-Conjugates( Dato- DXd)

NEOADJUANT Immunotherapy

ZONGERTINIB -Oral management for HER2mutant NSCLC

TARLATAMAB +PDL1 inhibitirs in SCLC

LIQUID BIOPSY analysing blood for circulating tumor DNA (ctDNA) and CTCs,

is an important diagnostic and monitoring tool in lung cancer

ADVANCED radiotherapy types: IMRT, VMAT,SBRT,IGRT, have increased precision and improved outcomes.

"THE GOOD NEWS IS......"

Currently with increasing awareness,timely chekups,Lung screening tests, advanced precision treatments like Target therapy and Immunotherapy ,many patients are LIVING BETTER AND LONGER.

YOUR LUNGS ARE PRECIOUS, PROTECT THEM TODAY,

SO THEY CAN PROTECT YOU TOMORROW.