Cancer, Lung


Article Author:
Faraz Siddiqui


Article Editor:
Abdul Siddiqui


Editors In Chief:
Alexandra Caley
Sameh Boktor


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/14/2019 4:48:08 PM

Introduction

Lung cancer or bronchogenic carcinoma refers to tumors originating in the lung parenchyma or within bronchi. It is one of the leading causes of cancer-related deaths in the United States. Since 1987, lung cancer is responsible for more deaths in women than breast cancer. It is estimated that there are 225,000 new cases of lung cancer in the United States annually and approximately 160,000 die because of lung cancer. It is interesting to note that at the beginning of the 20th century, lung cancer was a relatively rare disease. Its dramatic rise in later decades is mostly attributable to the increase in smoking among both males and females[1][2].

Etiology

Smoking is the most common cause of lung cancer. It is estimated that 90% of the cases of lung cancer are attributable to smoking. The risk is highest in males who smoke. The risk is further compounded with exposure to other carcinogens, such as asbestos. There is no correlation between lung cancer and the number of packs smoked per year due to the complex interplay between smoking and environmental and genetic factors. The risk of lung cancer by passive smoking increases by 20% to 30%. Other factors include radiation for non-lung cancer treatment, especially non-Hodgkins lymphoma and breast cancer. Exposure to metals, such as chromium, nickel, and arsenic, and polycyclic aromatic hydrocarbons also is associated with lung cancer. Lung diseases like idiopathic pulmonary fibrosis increase risk of lung cancer independent of smoking[3].

Epidemiology

Lung cancer is the most commonly diagnosed cancer worldwide, accounting for 12.4% of all cancers diagnosed. It also is responsible for the most cancer-related deaths, 17.6%. Historically, the lung cancer epidemic seems to involve the developed world only. Recent data suggest that the incidence of lung cancer is dramatically rising with nearly half of new cases, 49.9%, diagnosed in the under-developed world. In the United States, mortality is high in men compared to women. Overall, there is no difference between blacks and whites, but age-adjusted mortality is higher in black males than their white counterparts. No such distinction exists between black and white women[4].

Pathophysiology

The pathophysiology of lung cancer is very complex and incompletely understood. It is hypothesized that repeated exposure to carcinogens, cigarette smoke in-particular, leads to dysplasia of lung epithelium. If the exposure continues, it leads to genetic mutations and affects protein synthesis. This, in turn, disrupts the cell cycle and promotes carcinogenesis. The most common genetic mutations responsible for lung cancer development are MYC, BCL2, and p53 for small cell lung cancer (SCLC) and EGFR, KRAS, and p16 for non-small cell lung cancer (NSCLC)[5][6][7].

Histopathology

The broad divisions of SCLC and NSCLC represent more than 95% of all lung cancers.

Small Cell Lung Cancer

Histologically, SCLC is characterized by small cells with scant cytoplasm and no distinct nucleoli. The WHO (World Health Organization) classifies SCLC into three cell subtypes: oat cell, intermediate cell, and combined cell (SCLC with NSCLC component, squamous, or adenocarcinoma).

SCLC is almost usually with smoking. It has a higher doubling time and metastasizes early; therefore, it is always considered a systemic disease on diagnosis. The central nervous system, liver, and bone are the most common sites. Certain tumor markers help differentiate SCLC from NSCLC. The most commonly tested tumor markers are thyroid transcription factor-1, CD56, synaptophysin, and chromogranin. Characteristically, NSCLC is associated with a paraneoplastic syndrome which could be the presenting feature of the disease

Non-Small Cell Lung Cancer

Five Types of NSCLC

  1. Squamous cell carcinoma is characterized by the presence of intercellular bridges and keratinization. These NSCLCs are associated with smoking and occur predominantly in men. Squamous cell cancers can present as Pancoast tumor and hypercalcemia. Pancoast tumor is the tumor in the superior sulcus of the lung. The brain is the most common site of recurrence postsurgery in cases of Pancoast tumor.
  2. Adenocarcinoma is the most common histologic subtype of NSCLC. It is also the most common cancer in women and non-smokers. Classic histochemical markers include Napsin A, Cytokeratin-7, and thyroid transcription factor-1. Lung adenocarcinoma is further subdivided into acinar, papillary and mixed subtypes.
  3. Adenosquamous carcinoma comprises 0.4 % to 4% of diagnosed NSCLC. It is defined as having more than 10% mixed glandular and squamous components. It has a poorer prognosis than either squamous and adenocarcinomas. Molecular testing is recommended for these cancers.
  4. Large cell carcinoma lacks the differentiation of a small cell and glandular or squamous cells[8].
  5. Carcinoid tumors include two subtypes: typical and atypical. Typical carcinoid carries relatively better prognosis and is only occasionally associated with carcinoid syndrome.
  6. Apart from this, there is anecdotal evidence of rare and unusual forms of non-small cell lung cancer which includes but are not limited to giant cell carcinoma of the lung and sarcomatoid carcinoma of the lung[9][10]

Toxicokinetics

Multiple compounds have been implicated as the cause of lung cancer. In reality, it is hard to establish a causal relationship due to a battery of other confounding factors, such as the difference in the quantity of exposure time, smoking status.

Among the chemicals considered responsible, asbestos is only one that has a clear causal relationship with the development of lung cancer.

Asbestos and Lung Cancer

Risk depends on exposure time and type of asbestos. Amphibole fibers confer much higher risk of lung cancer than chrysotile fibers. The risk increases considerably with concurrent smoking. In non-smokers who are exposed to asbestos, there is a six-fold increase in the risk of lung cancer; whereas, in smokers, this risk is 16-fold if a minimum of 20 cigarettes smoked per day and nine-fold increase with less than 20 cigarettes per day. Other compounds that may increase the risk of lung cancer include radon, nickel, cadmium, chromium, silica, and arsenic.

History and Physical

No specific signs and symptoms exist for lung cancer. Most patients already have advanced disease at the time of presentation. Lung cancer symptoms occur due to local effects of the tumor, such as a cough due to bronchial compression by the tumor, due to distant metastasis, stroke-like symptoms secondary to brain metastasis, paraneoplastic syndrome, and kidney stones due to persistent hypercalcemia[11]. Specifically:

  • A cough, dyspnea, and hemoptysis are the common presenting symptoms.
  • A cough is the most common symptom, accounting for 50% to 75% of cases. It is sensitive but not specific. Squamous cell and small cell cancers usually cause a cough early due to the involvement of the central airways.
  • Dyspnea or shortness of breath represents lung cancer in 25% to 40% of cases.
  • Hemoptysis is an important symptom in anyone with a history of smoking. Although bronchitis is the most common cause of hemoptysis, 20% to 50% of patients with underlying lung cancer present with hemoptysis.
  • Rarely, patients present with shoulder pain, Horner syndrome, and hand muscles atrophy. This constellation of symptoms is called Pancoast syndrome. It is due to lung cancers arising in the superior sulcus[12].

Evaluation

Lung cancer is the leading cause of death in both men and women. NSCLC accounts for 85% of diagnosed cases of lung cancer in the United States. The overall goal is a timely diagnosis and accurate staging. As per the American College of Chest Physicians (ACCP) guidelines, the initial evaluation should be complete within 6 weeks in patients with tolerable symptoms and no complications. Only 26% and 8% of cancers are diagnosed at stages I and II, whereas 28% and 38% are diagnosed at stages III and IV respectively. Therefore, curative surgery is an option for a minority of patients.

Lung cancer evaluation can be divided in 2 ways:

  1. Radiological staging
  2. Invasive staging

Goals of Initial Evaluation

  • Clinical extent and stage of the disease
  • Optimal target site and modality of 1st tissue biopsy
  • Specific histologic subtypes
  • Presence of co-morbidities, para-neoplastic syndromes
  • Patient values and preferences regarding therapy

Radiologic Staging

Every patient suspected of having lung cancer should undergo the following tests:

  • Contrast-enhanced CT chest with extension to upper abdomen up to the level of adrenal glands
  • Imaging with PET or PET-CT directed at sites of potential metastasis when symptoms or focal findings are present or when chest CT shows evidence of advanced disease

CT Scan

Intravenous (IV) contrast enhancement is preferable as it may distinguish mediastinal invasion of the primary tumor or metastatic lymph nodes from vascular structures.

The major advantage of CT is that it provides an accurate anatomic definition of the tumor within the thorax which helps clinicians to decide the optimal biopsy site.

CT can also identify the following:

  • Tumor-related atelectasis
  • Post obstructive pneumonitis
  • Intra- or extrathoracic metastatic disease
  • Co-existing lung disease

The main objective of a CT scan is to identify the extent of the tumor, its anatomical location, and the lymph node involvement. TNM staging relies heavily on lymph node involvement. Therefore, most of the societies in Europe and the United States agree to regard a lymph node of 1 centimeter or more in the short axis to be considered as highly suspicious for malignancy. Lymph nodes can be enlarged secondary to acute inflammation, such as with congestive heart failure exacerbation or recent viral infection. The overall sensitivity and specificity of CT scan to identify malignancy are 55% and 81% respectively. Hence, CT is not a good test for lung cancer staging.

Radiological Groups

The American College of Chest Physicians (ACCP) has proposed grouping patients based on tumor extent and lymph node involvement. Although CT is not the right staging tool, it helps the clinician select the site for tissue biopsy. In other words, based on these groups, further staging via non-invasive or invasive methods is planned.

Group A

  • Patients with bulky tumor encircling/invading mediastinal structures such that remote lymph nodes cannot be distinguished from the primary tumor. 
  • Mediastinal invasion is implied, therefore, no need for LN sampling. Tissue diagnosis suffices.

Group B

  • Patients with discrete lymph node enlargement greater than 1 centimeter such that an isolated lymph node can be distinguished from the primary tumor
  • Lymph node sampling is required for pathologic confirmation before curative intent therapy.

Group C

  • Patients with a central tumor and elevated risk of nodal disease despite normal-sized nodes, such as high risk for N2/3 disease. 
  • Lymph node sampling is needed even if CT/PET negative due to a high risk of N2/N3 disease.

Group D

  • Patients with low risk of N2/3 involvement or distant metastatic disease, such as peripheral T1 tumors. 
  • Invasive testing is not done routinely except if suspicion of N1 disease is high or patient is not a candidate for surgery but going for Stereotactic Body Radiation Therapy (SBRT).

Pet Scan

PET scanning allows in vivo determination of metabolic and pathologic processes. It provides limited anatomic resolution but does provide information on the metabolic activity of the primary tumor, mediastinal involvement, and potential distant metastases. The new integrated PET/CT scanners have eliminated the problem of unclear anatomy.

The primary advantage of PET scanning is that it has reduced the number of futile thoracotomies by accurately identifying metastasis and thus excluding curative surgery as an option.

PET scan is also helpful in excluding recurrent tumors after initial therapy. It also can identify recurrence versus metabolic changes post radiation therapy. False positives occur in patients with active infection and inflammation with increased glycolysis. In cases of recent lymph node sampling, a PET scan may be falsely positive. False-negative PET scans occur when there are impaired blood flow and low metabolic activity, such as with carcinoid and some adenocarcinomas, and smaller lymph nodes.

PET scan has a sensitivity of 80% and specificity of 88%, which is higher than CT but not sufficient to stage lung cancer on its own. Therefore, the ACCP recommends that, except for group A disease, a positive PET does not obviate the need for lymph node sampling.

Invasive Staging[13]

After CT and PET scans, the next step is to obtain tissue or pathologic confirmation of malignancy, confirm staging, and histological differentiation of cancer. One of the following procedures achieves this.

  • Bronchoscopic Endobronchial Ultrasound-Transbronchial Needle Aspiration (TBNA)
  • Endoscopic-TBNA
  • Mediastinoscopy
  • Thoracoscopy or video-assisted thoracoscopy(VATS)

CT guided a transthoracic biopsy is an option for peripheral lesions with a low risk of pneumothorax. Certain older procedures, such as Chamberlain procedure, is sometimes required[14].

Bronchoscopic TBNA

  • Convex Probe-Endobronchial Ultrasound guided (EBUS)-TBNA
  • Radial Probe-EBUS-TBNA
  • Navigation Bronchoscopy

CP-EBUS Bronchoscopy

This is a bronchoscopic technique in which a miniature convex ultrasound of 7.5 MHZ is attached to the tip of the bronchoscope. It provides direct visualization of structures in the mediastinum or lung parenchyma through the bronchial wall. A biopsy is performed in real time. It mainly is used to sample the mediastinal and hilar lymph nodes. The image can be frozen and measured, and there is also Doppler available to identify blood vessels. It is the procedure of choice for this purpose. CP-EBUS is also the procedure of choice postinduction chemotherapy before surgery to confirm complete remission. CP-EBUS can be used to sample upper and lower paratracheal nodes as well as stations 10, 11 and 12. Stations 3, 5, and 6 are not accessible via CP-EBUS.

RP-EBUS Bronchoscopy

Instead of a convex probe, there is a miniature (20 to 30 MHz) probe. The advantages are that smaller lesions or lesions that are more peripheral can be reached, and it provides a 360-degree view of lung parenchyma. A real-time biopsy cannot be performed.

Navigation Bronchoscopy

The concept is to construct a navigational map of airways using either CT scan or electromagnetic field. After the map is constructed, the software creates the path to reach the location of the nodule. The bronchoscopist can create the pathway, and the software then navigates the bronchoscopist to the biopsy site.

Endoscopic-TBNA

Endoscopic ultrasonography (EUS) is becoming an increasingly useful tool for the diagnosis and staging of lung cancer. It can sample lymph nodes through the esophageal wall and provides a real-time sampling of stations 2, 4, 7, 8, and 9. The latter 2 stations cannot be sampled by Endobronchial ultrasound (EBUS). It has the same sensitivity and specificity of EUS, 89%, and 100% respectively. There is also a growing trend to combine EBUS and EUS as a minimally invasive technique for lung cancer staging[14].

Mediastinoscopy

Mediastinoscopy was formerly the gold standard for lung cancer diagnosis and staging. Now it is mainly used to sample lymph nodes after negative needle technique and when the patient is still at high risk for cancer due to lymph node size or FDG uptake on PET scan. Most commonly, para-tracheal lymph nodes are sampled. Alternatively, an anterior mediastinoscopy (Chamberlain procedure) can be performed to access subaortic and para-aortic nodes, stations 5 and 6 respectively. Mediastinoscopy has a sensitivity of 78% and specificity of 100%. Like all surgical procedures, mediastinoscopy has some risks. General anesthesia is required, and the procedure carries a mortality risk of 0.08%[13][15].

Thoracoscopy

Traditionally, thoracoscopy was performed by dividing the ribs and opening the chest cavity. Like laparoscopic surgery, it has largely replaced open abdominal surgeries. Video-assisted thoracoscopy surgery (VATS) has replaced thoracoscopy. It is used to treat a number of chest wall, pleural, pulmonary, and mediastinal conditions. Mediastinal lymph node sampling, as well as full dissection during lung resection for cancer, can be performed with VATS. A newer version of VATS is called RATS (robotic-assisted thoracoscopy). There are no trials comparing VATS and RATS for mediastinal lymph node biopsy.

Treatment / Management

Treatment of Non-Small Cell Lung Cancer

Stage I

Surgery is the mainstay of treating stage 1 NSCLC. The procedure of choice is either lobectomy or pneumonectomy with mediastinal lymph node sampling. The 5-year survival is 78% for IA and 53% for IB disease. In patients who do not have the pulmonary reserve to tolerate pneumonectomy or lobectomy, a more conservative approach with wedge resection or segmentectomy can be done. The disadvantage is a higher local recurrence rate, but survival is the same. Local postoperative radiation therapy or adjuvant chemotherapy has not shown to improve outcomes in stage I disease.

Stage II

The survival of stage IIA and IIB lung is 46% and 36% respectively. The preferred treatment is surgery followed by adjuvant chemotherapy.

If the tumor has invaded the chest wall, then an en-bloc resection of the chest wall is recommended. Pancoast tumor is a unique tumor of stage II. It arises from the superior sulcus and usually diagnosed at a higher stage, IIB or IIIA. The treatment of choice in cases of Pancoast tumor is neoadjuvant chemotherapy usually with etoposide and cisplatin and concurrent radiotherapy followed by resection. Overall survival is 44% to 54% depending on postsurgery presence or absence of microscopic disease in the resected specimen.

Stage III

This is the most heterogeneous group, consisting of a wide variation of tumor invasion as well as lymph node involvement.

Stage IIIA disease with N1 lymph nodes surgery with curative intent is the treatment of choice. Unfortunately, a significant number of patients are found to have an N2 disease at the time of resection. The current consensus is to perform surgery as planned followed by adjuvant chemotherapy. For patients with stage IIIA tumors with N2/N3 lymph nodes, there is no agreement on treatment. If the patient has good performance status and no weigh-loss, then concurrent chemo-radiotherapy affords the best outcome. However, concurrent chemo-radiotherapy is not as tolerated and can cause severe esophagitis. Sequential therapy is better tolerated. Survival is 40% to 45% in the first two years, but five-year survival is only 20%.

T4 tumors are usually treated exclusively with chemoradiation. Surgery may be an option in T4 N0-1 tumors with carinal involvement. The operative mortality of carinal resection is 10% to 15%, and survival is approximately 20%. If a tumor is T4 due to ipsilateral nonprimary lobe nodules with no mediastinal involvement, then surgery alone renders five-year survival of 20%

Stage IIIB tumors are treated the same way unresectable IIIA cancers are treated, with concurrent chemoradiotherapy. For a select few patients postinduction chemoradiotherapy, surgery might be an option. The trials on the survival of patients with IIIB tumors also included inoperable IIIA tumors; therefore, the survival in IIIB patients is not known.

Stage IV

Stage IV disease is considered incurable, and therapy is aimed at improving survival and alleviating symptoms. Only 10% to 30% of patients respond to chemotherapy, and only 1% to 3% survive 5 years after diagnosis. Single or double drug-based chemotherapy is offered to patients with functional performance status. There is a small survival benefit from chemotherapy.

In highly select patients, non-squamous NSCLC without brain metastasis or hemoptysis might benefit from the addition of bevacizumab, a vascular endothelial growth factor (VEGF) inhibitor[16].

Targeted therapy for NSCLC

In the early 2000s, researchers discovered that specific mutations encode for proteins that are critical for cell growth and replication. These mutations were named “driver mutations.” It was proposed that blocking these mutation’s pathways may improve survival in lung cancer patients. The current practice is to check for the following mutations in every advanced NSCLC. Each of these mutations has a specific inhibitor available:

  1. EGFR (epidermal growth factor receptor) is a mutation inhibited by tyrosine kinase inhibitors Erlotinib, gefitinib, and afatinib[17].
  2. ALK (Anaplastic lymphoma kinase) includes the specific inhibitors crizotinib, ceritinib, and alectinib. A structurally similar mutation is ROS-1. The FDA recently approved crizotinib for treating cancers expressing ROS-1 mutation.

Immunotherapy for NSCLC

Immunotherapy, in a simple version, boost the immune system and helps the immune system recognize cancer cells as foreign and increase its responsiveness. There are several check-points to decrease autoimmunity and autodestruction of the body’s cells by the immune system. Malignant cells co-opt these check-points and create tolerance in the immune system.

Of these check-points, programmed-death receptor 1 (PD-1) is of particular interest recently. PD-1 plays an important role in down-regulating T-cells and promotes self-tolerance. However, it also renders the immune system less effective against tumor cells. PD-1 interacts with two proteins: PD-L1 and PD-L2. This binding results in the inactivation of activated T-cells.

At the moment, there are antibodies approved for PD-1 and its ligand, PD-L1 only. They inhibit the PD-1 receptor directly or bind to PD-L1 thus preventing it from inactivating the activated T-cell.

Nivolumab

It is an IgG4 monoclonal antibody against PD-1. It is approved by the FDA for squamous and non-squamous NSCLC that has progressed after platinum-based chemotherapy. It can be used in patients with high or low PD-L1 expression status.

Pembrolizumab

It is also an IgG4 monoclonal antibody against PD-1. It is approved for pre-treated metastatic NSCLC with greater than 50% expression of PD-L1 and does not harbor EGFR and ALK mutations. It is also used in combination with pemetrexed and carboplatin for metastatic non-squamous NSCLC with less than 50% expression of PD-L1.

Atezolizumab

It is an IgG1 antibody against PD-L1. It is approved for use in metastatic, progressive NSCLC during or following treatment with platinum-based chemotherapy. It can be used in patients who express EGFR and ALK mutations and fail targeted therapy.

Bevacizumab

It is not considered immune therapy. It is an anti-angiogenesis antibody that inhibits vascular endothelial growth factor A (VEGF-A). It is primarily used in combination with platinum-based chemotherapy for the treatment of non-squamous NSCLC. It is contraindicated in squamous cell NSCLC due to the risk of severe and often fatal hemoptysis. It is also used to treat breast, renal, colon, and brain cancers[18][6].

Small Cell Lung Cancer Treatment

SCLC is very sensitive to chemotherapy, but unfortunately, has a very high recurrence rate. Treatment for SCLC is according to the stage of the disease.

Treatment of limited-stage small cell lung cancer

Stage I limited-stage small cell lung cancer (LS-SCLC) is lobectomy followed by adjuvant chemotherapy. These include SCLC presenting as peripheral nodules without mediastinal or hilar lymphadenopathy. Care should be taken in completely ruling out lymph node involvement, and this is done by PET-CT followed by lymph node sampling by EBUS bronchoscopy or mediastinoscopy even if PET-CT was negative for lymph node size or FDG uptake.

LS-SCLC with mediastinal or hilar lymph node involvement is 4 to 6 cycles of chemotherapy followed by radiation therapy. Radiation therapy is indicated to avoid recurrence since nearly 80% of SCLC will recur locally without radiation therapy. There are multiple approaches to treatment, including concurrent and alternate chemoradiotherapy or sequential treatments. Concurrent and alternative paths have slightly better outcomes, although they are more toxic than other approaches. Sequential therapy is much better tolerated.

In patients who achieve remission, prophylactic whole brain radiation is also done. This significantly reduces symptomatic brain metastasis and increases overall survival.

Treatment of extensive stage small cell lung cancer (ES-SCLC)

Extensive stage small cell lung cancer (ES-SCLC) includes distant metastasis, malignant pleural or pericardial effusions, contralateral hilar, or supraclavicular lymph node involvement.

Treatment is with platinum-based chemotherapy. Up to 50% to 60% of patients show remission and should be offered radiation therapy followed by prophylactic whole-brain irradiation. Median survival from the time of diagnosis of ES-SCLC is only 8 to 13 months, and only about 5% of patients survive two years postdiagnosis.

Staging

Lung Cancer Staging

After the diagnosis of lung cancer, the most crucial step is to stage the disease because the state dictates treatment options, morbidity, and survival. It is of paramount importance that this is done with utmost vigilance. Staging is primarily done for NSCLC using the TNM classification. SCLC also can be staged in the same way, but a much more straightforward approach is used for limited disease and extensive disease.

Tumor, node, metastasis staging of non-small cell lung cancer

Tumor (T), node (N), and metastasis (M) is an internationally accepted way of staging NSCLC. It is comprehensive in defining tumor size and extent, location, and distant spread which helps clinicians draw meaningful conclusions regarding the best treatment, avoid unnecessary surgeries and provide a timely referral to palliative care if the cure is not an option. Most recent TNM classification is the eighth edition, and it is effective in the United States from January 1, 2018. Outside the United States, it was accepted on January 1, 2017, by Union of International Cancer Control (UICC).

For the eighth edition, Ithe International Association of the Study of Lung Cancer (IASLC) studied and analyzed data from 16 countries including approximately 95,000 patients from 1999 to 2010[19].

Tumor

A primary tumor is divided into 5 categories, and each category is then further subdivided depending on the size, location and invasion of surrounding structures by the tumor.

T0

  • No primary tumor
  • T Carcinoma in situ

T1 (less than 3 cm)

  • T1mi: minimally invasive tumor
  • T1a: superficial tumor confined to central airways (tracheal or bronchial wall)
  • T1a: Less than 1 cm
  • T1b: Greater than 1 cm but less than 2cm
  • T1C: Greater than 2 cm but less than 3cm

T2

  • T2: Greater than 3 cm but less than 5 cm
  • T2a: Greater than 3 cm but less than 4cm
  • T2b: Greater than 4 cm but less than 5cm
  • Also considered a T2 tumor if involving main bronchus but not carina, visceral pleura or causes atelectasis to the hilum

T3

  • T3: Greater than 5 cm but less than 7 cm)
  • T3 Inv: invasion of the chest wall, pericardium or phrenic nerve
  • T3 Satell: separate tumor nodules in the same lobe
  • Also considered T3 tumor if involving the pericardium, phrenic nerve, chest wall or separate tumor nodules in the same lobe

T4

  • T4: Greater than 7 cm)
  • T4inv: Invading above structures
  • T4Ipsi nod: Nodules in an ipsilateral lobe

Also considered T4 tumor if involving heart, esophagus, trachea, carina, mediastinum, great vessels, recurrent laryngeal nerve, spine or tumor nodules in the different ipsilateral lobe. Invasion of Diaphragm is now considered a T4 tumor as compared to a T3 tumor in the seventh edition of TNM classification25[20].

Thoracic Lymph Nodes

Lung cancer staging also depends upon the extension of cancer to the lymph nodes corresponding to the primary tumor as well as the opposite hemithorax. It is extremely important to rule out lymph node metastasis before attempting curative surgery. Lung resection in itself carries high morbidity and mortality, therefore, should not be attempted if a cure is not possible.

Historically, thoracic lymph nodes were first classified in the 1960s by Naruke. This map was accepted by North America, Europe, and Japan. Later, in the 1980s and early 90s, further refinements were made in response to better imaging and invasive testing improvements. Hence, two lymph node maps gained popularity in North America.

  1. American thoracic society (ATS-Map)
  2. American Joint Committee on Cancer (AJCC). This was an adaptation of the Naruke map.

In 1996, the differences in the above 2 were resolved in the form of Mountain-Dressler modification, MD-ATS Map. It was accepted in North America but only sporadically in Europe.

The International Association of Study of Lung Cancer (IASLC) attempted to resolve the differences between the MD-ATS map and the Naruke map. The IASLC lymph node map is now the most widely accepted lymph node classification system utilized all over the world.

Thoracic lymph nodes can be divided into mediastinal or N2 and hilar or N1 lymph nodes. N2 nodes are more important because they differentiate in cancer stages and, therefore, treatment options.

Much care has been taking in defining the N2 nodes in all the lymph node maps. We will attempt to explain the classification under the broad headings of Mediastinal and Hilar groups and then further explain the individual mediastinal stations as per IASLC map.

Mediastinal Lymph Nodes

They are sub-divided into the following groups or stations[21]:

  • Supraclavicular nodes, station 1
  • Superior mediastinal nodes, station 2 to 4
  • Aortic nodes, station 3
  • Inferior mediastinal lymph nodes, station 4

Supraclavicular Nodes (Station 1)

It includes lower cervical, supraclavicular and sternal notch nodes. Lymph nodes are further divided into 1R and 1L corresponding to right and left the side of the body respectively. The distinction between 1R and 1L is an imaginary midline of trachea serves as the boundary. Below station 1, the left tracheal border is considered the boundary is differentiating between right and left sided lymph nodes.

Superior Mediastinal Lymph Nodes (Station 2 to 4)

These lymph nodes occupy the superior mediastinum, hence, named accordingly. They are further subdivided into the following groups:

Upperparatracheall (station 2R and 2L)

  • 2R nodes extend to the left lateral border of the trachea.

From the upper border of manubrium to the intersection of caudal margin of the innominate (left brachiocephalic) vein with the trachea.

  • 2L nodes extend from the upper border of manubrium to the superior border of the aortic arch. 2L nodes are located to the left of the left lateral border of the trachea

Pre-vascular (station 3A)

These nodes are not adjacent to the trachea like the nodes in station 2, but they are anterior to the vessels

Pre-vertebral (station 3P)

Nodes not adjacent to the trachea like the nodes in station 2, but behind the esophagus, which is pre-vertebral

Lower para-tracheal (station 4R and 4L)

  • 4R nodes extend from the intersection of the caudal margin of the innominate (left brachiocephalic) vein with the trachea to the lower border of the azygos vein. 4R nodes extend from the right to the left lateral border of the trachea.
  • 4L nodes extend from the upper margin of the aortic arch to the upper rim of the left main pulmonary artery

Aortic Lymph Nodes (5 and 6)

This group includes:

Sub-aortic nodes (station 5)

These nodes are located lateral to the aorta and pulmonary trunk in the so-called AP window

Para-aortic node (station 6)

These are ascending aorta or phrenic nodes lying anterior and lateral to the ascending aorta and the aortic arch

Inferior Mediastinal Lymph Nodes (Station 7 to 9)

This group includes sub-carinal and para-esophageal nodes:

Sub-carinal nodes (station 7)

They extend in a triangular fashion from the division of carina superiorly to the lower border of the bronchus intermedius on the right and the upper border of the lower lobe bronchus on the left.

Para-esophageal nodes (station 8)

 These nodes are situated adjacent to the right and left the side of the esophageal wall. Both, station 7 and eight are located below carina.

Pulmonary Ligament (station 9) They are located within the pulmonary ligaments extending from inferior pulmonary vein up to the diaphragm.

Hilar Lymph Nodes (Station 10 to 14)

These are all N1 nodes. These include nodes adjacent to the main stem bronchus and hilar vessels. On the right, they extend from the lower rim of the azygos vein to the interlobar region. On the left from the upper rim of the pulmonary artery to the inter-lobar region. 

Lymph Node Classification (N)

N0: No lymph node involvement

N1: Involvement of ipsilateral hilar nodes

  • N1a: single station N1 nodes
  • N1b: multiple station N1 nodes

N2: Involvement of mediastinal nodes

  • N2a1: Single station N2 nodes without N1 involvement (skip metastasis)
  • N2a2: Single station N2 nodes with N1 involvement
  • N2b: Multiple station N2 involvement

N3: Involvement of contralateral mediastinal or hilar lymph nodes[22]

Metastasis (M)

  • M0: No distant metastasis
  • M1a: Malignant pleural / pericardial effusion or nodules
  • M1b: Single extra-thoracic metastasis
  • M2: Multiple extra-thoracic metastases

Tumor Node Metastasis Staging of Lung Cancer

Occult cancer: TX N0 M0

Primary cancer not found. No lymph node or distant metastasis.

Stage 0

  • T is N 0 M 0

Stage I

IA1

  • T1mi N 0 M 0
  • T1a  N 0 M 0

IA2

  • T1b N 0 M 0

IA3

  • T1c N 0 M 0

IB

  • T2a N 0 M 0

Stage II

IIA

  • T2b N 0 M 0

IIB

  • T1a / T1b / T1c N 1 M 0
  • T2a / T2b N 1 M 0
  • T3 N 0 M 0

Stage III

IIIA

  • T1a / T2b / T2c N 2 M 0
  • T2a / T2b N2 M 0
  • T3 N 1 M 0
  • T4 N 0 / N 1 M0

IIIB

  • T1a / T1b / T1c N 3 M 0
  • T2a / T2b N 3 M0
  • T3 N 2 M 0
  • T4 N 2 M 0

IIIC

  • T3 N 3 M 0
  • T4 N 3 M 0

Stage IV

IVA

  • Any T / Any N M1a or M1b

IV B

  • Any T / Any N M1c

Staging for all Small Cell Lung Cancer

  • SCLC staging can be done using the TNM system, but since SCLC is considered a systemic disease, a much more straightforward classification has been used successfully since the 1950s. There is a growing body of evidence that TNM rating may be better in defining SCLC, but there is consensus on this approach yet.
  • SCLC is classified as LS-SCLC and ES-SCLC small cell based on the Veterans Affairs Lung study group (VALSG) classification.
  • LS-SCLC is confined to the ipsilateral hemithorax, and local lymph nodes, both mediastinal and hilar and supraclavicular nodes can be included in a single tolerable radiotherapy port (corresponding to TNM stages I through IIIB).
  • ES-SCLC has tumor beyond the boundaries of limited disease including distant metastases, malignant pericardial, or pleural effusions, and contralateral supraclavicular and contralateral hilar involvement.[7]

Pearls and Other Issues

Palliative Care in Lung Cancer

All therapeutic options, surgery, chemotherapy, and radiation have a role in managing pain and other symptoms in terminal lung cancer patients.

Surgery results in better outcomes in patients with at least three months expected survival and good performance status. Surgical procedures for palliation includes tumor bypass procedures, partial resection of the tumor, and removal of metastasis. Surgical intervention may be beneficial in patients with lung cancer if there is airway obstruction, hemoptysis, pleural or pericardial exudate, or metastases to the brain or bone. Almost 30% of lung cancer patients experience central airway occlusion, and bronchoscopic laser destruction followed by stent placement provides immediate relief in such patients.

Chemotherapy helps alleviate symptoms of pain and cough and may prolong survival.

Palliative radiation provides symptomatic relief in 41% to 95% of lung cancer patients. Almost 60% of lung cancer patients, regardless of type and stage, receive radiation treatments during their course of illness. Radiation plays a crucial role in alleviating symptoms of pain due to metastasis, particularly brain and bone metastasis. Endoscopic treatment, such as brachytherapy, helps control symptoms due to airway narrowing[23][24][25].

 

Enhancing Healthcare Team Outcomes

Lung cancer is best managed with a multidisciplinary team that includes the primary care physician, oncologist, radiologist, radiation therapist, nurse practitioner, thoracic surgeon, palliative care, pain specialist and an internist. Besides urging patients to quit smoking, screening may be useful in selective patients. 

Due to high incidence and mortality, there has been a worldwide interest in developing a screening program for lung cancer. A landmark study, the National Lung Screening Trial, showed an overall decrease in mortality of 6.7%. Currently, lung cancer screening is offered to men and women who are 55 years or older who have smoked 30 pack years or more or have quit smoking less than 15 years ago. It is done every year until the minimum age of 74 years.[26][27]

Lung cancer screening uses a low-dose helical CT scan of the chest which takes less than 25 seconds. A major drawback of screening is the detection of benign lesions, resulting in a relatively high number of unnecessary biopsies, surgeries, or continued radiological follow-up[3].


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Cancer, Lung - Questions

Take a quiz of the questions on this article.

Take Quiz
What is the second most common malignancy in white women?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which malignancy is most commonly associated with hypercalcemia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 62-year-old man who is a heavy smoker presents with complaints of general malaise, occasional cough, and weight loss of 10 lbs over the last 2 months. He does not report any travel, recent infections, or use of any medications. He does have borderline diabetes that he controls with diet. Examination reveals that he has some mild peripheral edema in the extremities and clubbing bilaterally. Blood work shows mild anemia and sodium of 122. What test should be done next?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A surgeon performs a chest wall excision and removes stage IIIA lung cancer. The frozen section comes back with clear margins. What is the next step in the management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient with lung cancer presents for evaluation. X-rays reveal a large pleural effusion. Thoracentesis is done and reveals a cytology negative, non-bloody fluid. What should be the next step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Chest x-ray of a long term smoker shows a 2-cm spiculated mass in the right parahilar lung. A barium esophagram shows an extrinsic impression in the region of the carina. Which of the following choices would be most helpful at this point?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A thoracotomy for a possible lobectomy is performed. After opening the chest, the affected lobe is examined. Besides the primary tumor, which measures 4 centimeters, another 1-centimeter, malignant lesion is palpated in the same lobe. What is the staging for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has a chest wall tumor (stage IIIA). Which of the following is related to a poor prognosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common cause of cancer related death in men and women living in United States?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In a limited pulmonary resection for a malignancy, what is the major factor limiting therapy?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is used for the treatment of post-lung transplant malignancy?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the rationale of using tumor markers in patients with lung cell carcinomas?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is having a thoracotomy for lung cancer. The primary tumor localized in the right upper lobe is 3 centimeters. Palpation of the rest of the lung reveals two small masses, one in the right middle lobe and one in the right lower lobe. There are no regional node or distant metastasis. Which of the following is the correct staging of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has a 3-cm right lung cancer and a positive lymph node in the supraclavicular area. What is the correct staging of this cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common cause of cancer-related death in men and women in the United States?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Exposure to which of the following is the most common cause of lung cancer worldwide?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Lung cancers most commonly spread to which organ?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is rarely employed in diagnosing lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most important prognostic indicator for lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the estimated 5-year survival for a patient with stage one lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements about lung cancer is true?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 58-year-old with a lung mass presents with hoarseness. What is the reason for the hoarseness?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
How often should follow up be scheduled after a pneumonectomy for lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Enlargement of which of the following groups of mediastinal nodes may be an indication for surgery in a patient with a diagnosis of lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old patient with a right upper lobe carcinoma in situ, metastasis to the right hilar region, and distant metastasis to the vertebral body has what stage of cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Of the following, which group is at the greatest risk for lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is most likely to cause lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65 year old male is brought to the emergency room with increasing shortness of breath over the last ten days. He reports a nonproductive cough and left sided pleuritic chest pain without fever or chills. He has a 50 pack year history of smoking and a history of hypertension on hydrochlorothiazide. Vital signs: temperature 37 degrees C, heart rate 100, respirations 22, and oxygen saturation 92 percent on room air. The left lung is dull to percussion at the lower third with decreased breath sounds. Chest radiograph shows mediastinal lymphadenopathy and a large pleural effusion that layers out on decubitus films. 1250 ml of bloody fluid is removed. An analysis shows pH7.42, full field of RBCs, WBC 230 with 82 percent lymphocytes, 13 percent PMNs, and 5 percent mesothelial cells. LDH is 320 U/L; glucose is 40 mg/dL, and protein 4.4 g/dL. Serum labs show glucose 120, LDH 340 U/L, and total protein 7.0 g/dL. CT of the chest after the procedure shows persistent pleural fluid, mediastinal lymphadenopathy, and collapse of the left lower lobe. Select the best diagnostic test.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 72-year-old female with lung cancer has nausea, vomiting, and then lethargy. She is arousable, inattentive, and disoriented. There are diminished reflexes and proximal weakness. What is the most likely etiology?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which screening test is the gold standard for lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which cancer causes the most deaths in patients over 65 in the U.S.?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What percentage of lung cancer in the US is attributable to smoking?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following TNM classifications would correspond to Stage 0 lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What percentage of cases of lung cancer occurs in nonsmokers?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common cancer causing death, worldwide?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is the most common hormone or hormone-like substance produced by pulmonary carcinoma?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
In a patient with lung cancer, what is the one group of positive mediastinal nodes where surgical excision may be of benefit to the patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which one the following medications is used in EGFR positive lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male presented with a cough and hemoptysis for 4 weeks. CT showed 1.5 cm right upper lobe lesion and normal-sized lymph nodes. PET-CT showed fludeoxyglucose (FDG) uptake in the mass and right hilar lymph node. What is the next step in his care?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 52-year-old female presented with 26 Ibs unintentional weight loss over the past 1 year and cough for 3 months. She has had 3 courses of different antibiotics and oral corticosteroids with no improvement. She has 25 pack year history of smoking cigarettes and occasional marijuana. CT chest showed a 5.2 cm mass in the left upper lobe and mediastinal lymphadenopathy. PET revealed uptake in left upper lobe mass and in stations 7 and 10L. There was an area of uptake in her spleen as well. What would the TNM stage of her cancer based on PET findings?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 67-year-old male presents to the hand clinic with complaints of a bump and pain in his right hand. He initially started to feel the pain about three months ago but thought he might have bruised the hand and did not seek help. Now the pain is continuous. He is a type 2 diabetic, has hypertension, eczema, and peripheral vascular disease. He is a 1 ppd smoker x 30 years and drinks alcohol regularly. His medications include metformin, enalapril, HCTZ, topical hydrocortisone, and aspirin. The x-ray of his hand is shown below. What is the next step in his investigation?

(Move Mouse on Image to Enlarge)
  • Image 6774 Not availableImage 6774 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What are the two groups of lung cancer?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Cancer, Lung - References

References

Cancer treatment and survivorship statistics, 2016., Miller KD,Siegel RL,Lin CC,Mariotto AB,Kramer JL,Rowland JH,Stein KD,Alteri R,Jemal A,, CA: a cancer journal for clinicians, 2016 Jul     [PubMed]
Longitudinal analysis of 2293 NSCLC patients: a comprehensive study from the TYROL registry., Kocher F,Hilbe W,Seeber A,Pircher A,Schmid T,Greil R,Auberger J,Nevinny-Stickel M,Sterlacci W,Tzankov A,Jamnig H,Kohler K,Zabernigg A,Frötscher J,Oberaigner W,Fiegl M,, Lung cancer (Amsterdam, Netherlands), 2015 Feb     [PubMed]
Clinical manifestations of lung cancer., Hyde L,Hyde CI,, Chest, 1974 Mar     [PubMed]
Epidemiology of lung cancer., Alberg AJ,Samet JM,, Chest, 2003 Jan     [PubMed]
Primary prevention, smoking, and smoking cessation: implications for future trends in lung cancer prevention., Burns DM,, Cancer, 2000 Dec 1     [PubMed]
Updated Molecular Testing Guideline for the Selection of Lung Cancer Patients for Treatment With Targeted Tyrosine Kinase Inhibitors: Guideline From the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology., Lindeman NI,Cagle PT,Aisner DL,Arcila ME,Beasley MB,Bernicker E,Colasacco C,Dacic S,Hirsch FR,Kerr K,Kwiatkowski DJ,Marc Ladanyi,Nowak JA,Sholl L,Temple-Smolkin R,Solomon B,Souter LH,Thunnissen E,Tsao MS,Ventura CB,Wynes MW,Yatabe Y,, The Journal of molecular diagnostics : JMD, 2018 Jan 23     [PubMed]
Lung cancer biomarkers: present status and future developments., Cagle PT,Allen TC,Olsen RJ,, Archives of pathology & laboratory medicine, 2013 Sep     [PubMed]
Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology., Lindeman NI,Cagle PT,Beasley MB,Chitale DA,Dacic S,Giaccone G,Jenkins RB,Kwiatkowski DJ,Saldivar JS,Squire J,Thunnissen E,Ladanyi M,College of American Pathologists International Association for the Study of Lung Cancer and Association for Molecular Pathology,, The Journal of molecular diagnostics : JMD, 2013 Jul     [PubMed]
Habib S,Leifer LE,Azam M,Siddiqui AH,Rajdev K,Chalhoub M, Giant cell carcinoma of the lung successfully treated with surgical resection and adjuvant vinorelbine and cisplatin. Respiratory medicine case reports. 2018;     [PubMed]
Rajdev K,Siddiqui AH,Ibrahim U,Agarwal S,Ding J,Chalhoub M, Sarcomatoid Carcinoma of the Lung Presenting as Localized Bronchiectasis: A Case Report and Review of Literature. Respiratory medicine case reports. 2018;     [PubMed]
Soneji S,Yang J,Tanner NT,Silvestri GA, Occurrence of Discussion about Lung Cancer Screening Between Patients and Healthcare Providers in the USA, 2017. Journal of cancer education : the official journal of the American Association for Cancer Education. 2019 Mar 9;     [PubMed]
Elia S,Loprete S,De Stefano A,Hardavella G, Does aggressive management of solitary pulmonary nodules pay off? Breathe (Sheffield, England). 2019 Mar;     [PubMed]
Rajdev K,Siddiqui AH,Ibrahim U,Patibandla P,Khan T,El-Sayegh D, An Unusually Aggressive Large Cell Carcinoma of the Lung: Undiagnosed until Autopsy. Cureus. 2018 Feb 19     [PubMed]
Chute CG,Greenberg ER,Baron J,Korson R,Baker J,Yates J, Presenting conditions of 1539 population-based lung cancer patients by cell type and stage in New Hampshire and Vermont. Cancer. 1985 Oct 15     [PubMed]
Fréchet B,Kazakov J,Thiffault V,Ferraro P,Liberman M, Diagnostic Accuracy of Mediastinal Lymph Node Staging Techniques in the Preoperative Assessment of Nonsmall Cell Lung Cancer Patients. Journal of bronchology & interventional pulmonology. 2018 Jan     [PubMed]
Labarca G,Caviedes I,Folch E,Majid A,Fernández-Bussy S, [Endobronchial ultrasound-guided transbronchial needle aspiration]. Revista medica de Chile. 2017 Sep     [PubMed]
Heineman DJ,Beck N,Wouters MW,van Brakel TJ,Daniels JM,Schreurs WH,Dickhoff C, The dutch national clinical audit for lung cancer: A tool to improve clinical practice? An analysis of unforeseen ipsilateral mediastinal lymph node involvement in the Dutch Lung Surgery Audit (DLSA). European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2018 Jun     [PubMed]
Mulvenna P,Nankivell M,Barton R,Faivre-Finn C,Wilson P,McColl E,Moore B,Brisbane I,Ardron D,Holt T,Morgan S,Lee C,Waite K,Bayman N,Pugh C,Sydes B,Stephens R,Parmar MK,Langley RE, Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet (London, England). 2016 Oct 22     [PubMed]
Créquit P,Chaimani A,Yavchitz A,Attiche N,Cadranel J,Trinquart L,Ravaud P, Comparative efficacy and safety of second-line treatments for advanced non-small cell lung cancer with wild-type or unknown status for epidermal growth factor receptor: a systematic review and network meta-analysis. BMC medicine. 2017 Oct 30     [PubMed]
Ramos-Esquivel A,van der Laat A,Rojas-Vigott R,Juárez M,Corrales-Rodríguez L, Anti-PD-1/anti-PD-L1 immunotherapy versus docetaxel for previously treated advanced non-small cell lung cancer: a systematic review and meta-analysis of randomised clinical trials. ESMO open. 2017     [PubMed]
Rusch VW,Asamura H,Watanabe H,Giroux DJ,Rami-Porta R,Goldstraw P, The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2009 May     [PubMed]
Eberhardt WE,De Ruysscher D,Weder W,Le Péchoux C,De Leyn P,Hoffmann H,Westeel V,Stahel R,Felip E,Peters S, 2nd ESMO Consensus Conference in Lung Cancer: locally advanced stage III non-small-cell lung cancer. Annals of oncology : official journal of the European Society for Medical Oncology. 2015 Aug     [PubMed]
Lizama C,Slavova-Azmanova NS,Phillips M,Trevenen ML,Li IW,Johnson CE, Implementing Endobronchial Ultrasound-Guided (EBUS) for Staging and Diagnosis of Lung Cancer: A Cost Analysis. Medical science monitor : international medical journal of experimental and clinical research. 2018 Jan 29     [PubMed]
Bugalho A,de Santis M,Slubowski A,Rozman A,Eberhardt R, Trans-esophageal endobronchial ultrasound-guided needle aspiration (EUS-B-NA): A road map for the chest physician. Pulmonology. 2017 Dec 11     [PubMed]
Stevens R,Macbeth F,Toy E,Coles B,Lester JF, Palliative radiotherapy regimens for patients with thoracic symptoms from non-small cell lung cancer. The Cochrane database of systematic reviews. 2015 Jan 14     [PubMed]
Yang GM,Teo I,Neo SH,Tan D,Cheung YB, Pilot Randomized Phase II Trial of the Enhancing Quality of Life in Patients (EQUIP) Intervention for Patients With Advanced Lung Cancer. The American journal of hospice & palliative care. 2018 Aug     [PubMed]
    [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of CNS-Public Community Health. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for CNS-Public Community Health, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in CNS-Public Community Health, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of CNS-Public Community Health. When it is time for the CNS-Public Community Health board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study CNS-Public Community Health.