Fræðigrein

Lung cancer is the second most common cancer in Iceland and the most frequent cause of cancer related deaths. Smoking is by far the most important cause but familial factors also contribute. The symptoms of lung cancer are often subtle and the diagnosis, in about 70% of cases, is made when metastases have occurred. Curative surgical treatment is therefore only possible in about a third of the cases whereas other patients receive chemotherapy and/or radiation therapy. In recent years some important advances have been made in the diagnostic and therapeutic approaches to lung cancer. New imaging techniques have improved diagnosis and staging practices and consequently also treatment. Recent evidence suggests that screening with low dose CT may improve survival. New approaches to chemotherapy have been shown to improve survival and well being of patients with advanced disease. Chemotherapeutic agents are now being used in conjunction with surgery to reduce the risk of tumour spread. Furthermore, advances in surgical techniques have made resections possible in cases deemed inoperable in the past. In this review we present important advances in the diagnosis and treatment of lung cancer as reflected by recent literature that should be of interest to a wide variety of specialists.

Figure 1: Age standardized incidence (world) for lung cancer in

Iceland, both in males and females.

Table I. Symptoms in patients diagnosed with lung cancer (22).

Symptoms and signs Range of frequency, %

Cough 8-75

Weight loss 0-68

Dyspnea 3-60

Chest pain 20-49

Hemoptysis 6-35

Bone pain 6-25

Clubbing 0-20

Fever 0-20

Weakness 0-10

Superior vena cava obstrucion 0-4

Dysphagia 0-2

Wheezing and stridor 0-2

Table II. Paraneoplastic syndromes in lung cancer patients.

Figure 2. Clubbing in a male with small cell lungcancer.

Figure 3. The four major histology types of lungcancer; a) Small cell

undifferentiated carcinoma. Small tumor cells growing in tight solid sheets.

Nuclear chromatin is dark and nucleoli inconspicuous.H&E 400X, b) Squamous cell carcinoma. Tumor cells showing single cell keratinisation and scattered intercellular bridges.H&E 400X, c) Adenocarcinoma. Large tumor cells with prominent nucleoli forming glandular spaces.H&E 250X, c) Large cell undifferentiated carcinoma. Large tumor cells growing in solid sheets without evidence of squamous or glandular differentiation. H&E 400X.

Table III. 2004 WHO Classification (abbreviated) of malignant

epithelial lung tumors (28).

Figure 4. A Chest X-ray showing an infiltration in the apex of the

right lung, later confirmed with biospsy to be NSCLC.

Figure 5. A chest CT showing a NSLC in the right lung.

Figure 6. PET CT showing a centrally located tumor in the left

lung, with secondary atelectasis more peripherally in the upper left lobe.

Table IV. Current staging system for primary non small cell lung

cancer together with stage grouping. Based on Myrdal (50) and Mountain et al. (38).

Table V. TNM staging and survival of patients with non-small cell lung cancer.

Figure 7. A flow chart showing staging of patients with non-small

cell lung carcinoma.

 

Figure 8. A MRI of a right sided Pancoast tumor.

Figure 9. Bronchoscopic view of a lung carcinoma in the left main

bronchus.

Figure 10. Transbronchial needle aspiration from a mediastinal lymph

node during bronchoscopy.

Figure 11. Map of regional mediastinal lymph nodes. Based on Naruke et

al. (63).

Figure 12. A CT scan showing enlarged mediastinal lymph nodes that

were shown to be metastases at mediastinoscopy from NSCLC in the left lung.

Figure 13. Mediastinoscopy.

Figure 14. A CT scan of the abdomen showing a metastasis in the right suprarenal gland.

Figure 15. A CT scan showing a squamous cell lungcancer in the right

upper lobe, infiltrating the chest wall (T3 tumor). The tumor was radically resected en block, including the right upper lobe and part of the chest wall.

Figure 16. A Goretex®-patch used for covering a diaphragmatic defect

after radical resection of an invasive non-small cell lung cancer. Similar patch can also be used for closing defects of the pericardium or chest wall.

Figure 17 a,b: (a) A CT scan of a 64 year old male with squamous cell

lung cancer invading the mediastinum (T4 tumor) (fig. 20a). Mediastinoscopy was negative and then he received a neoadjuvant radiotherapy (a total of 44

Gy) that reduced the size of the tumor (fig. 20b). Four months later pneumonectomy was performed with resection of right mediastinal lymph nodes and part of the pericardium. Histology confirmed clean resection marginals and no mediastinal lymph node metastases were found. He received postoperative chemotherapy and today, two years postoperatively, he is doing well with no signs of recurrent disease.

Table VI. Overview of treatment for patients with non-small cell

lungcancer.

Stage Treatment

I Surgery only Inoperable: Radiotherapy

II Surgery + adjuvant chemotherpy Inoperable: Radiotherapy

IIIA Combined chemo- and radiotherapy (surgery in selected cases

within trials)

IIIB Combined chemo- and radiotherapy

IV Chemothearpy