This Presentation gives a concise summary of the various aspects related to Lung cancer. it will be more helpful for the Clinical Pharmacy student as well as other medical student.

1. By;
Amjad Anwar
Department Of Pharmacy, UOM

2.  Lung cancer is a solid tumor originating from
the bronchial epithelial cells.
 The second most common cancer in both
men and women.
 Accounts for an estimated 25% of all cancer
diagnoses.
 Lung cancer mainly occurs in older people.
 For smokers the risk is much higher.
 Lung cancer accounts for about 1 in 4 cancer
deaths each year.

3.  There are 2 major types of lung cancer
 Small Cell Lung Cancer (SCLC)
◦ It generally starts in one of the larger breathing
tubes, grows fairly rapidly, and is likely to be
large by the time of diagnosis.
◦ Spreads more quickly and aggressively
◦ Accounts for 15% of cases
◦ Found mostly in heavy smokers

4.  Non-Small Cell Lung Cancer (NSCLC)
◦ Most common type (About 80-85% are NSCLC)
◦ Grows more slowly
 It is further classified into the following
 Epidermoid carcinoma or Squamous cell carcinoma
◦ <30% of lung cancer
◦ Arise from bronchial epithelium
◦ Cavitation may also occur
◦ Slow growth, metastasis not common

5.  Adenocarcinoma:
◦ ~50% of lung cancer
◦ Arise from bronchiole mucus gland
◦ Slow growth,
◦ Rarely cavity
◦ Strongly linked to cigarette smoking
 Large cell caracinoma:
◦ 10-20% of lung cancer
◦ Cavitation common
◦ Slow, metastasis may occur to kidney, liver and
adrenals
◦ May be located centrally, mid lung or peripherally

6.  If a lung cancer has characteristics of both
types it is called a mixed small cell/large cell
cancer --this is not common.

8.  Cigarette smoking (approximately 80% of lung
cancer cases)
 Exposure to environmental respiratory carcinogens
◦ Asbestos, Benzene, and Arsenic
◦ Radioactive such as uranium
◦ Inhaled chemicals such as beryllium, silica , coal
products, mustard gas.
 Certain dietary supplements (beta carotene
supplements)
 Genetic risk factors
 History of other lung diseases (e.g. chronic
obstructive pulmonary disease [COPD] and asthma)

9.  Initial signs and symptoms
◦ Cough
◦ Dyspnea
◦ Hoarseness
◦ Chest pain/discomfort,
◦ with or without hemoptysis.
◦ Systemic symptoms such as anorexia, weight loss, and
fatigue.
 Disseminated disease
◦ Neurologic deficits from CNS metastases
◦ Bone pain or pathologic fractures secondary to bone
metastases
◦ liver dysfunction from hepatic involvement.
 Paraneoplastic syndromes may be the first sign of an
underlying malignancy (cachexia, hypercalcemia,
syndrome of inappropriate antidiuretic hormone secretion,
and Cushing syndrome.

10.  TNM staging classification based on;
◦ Primary tumor size and extent (T)
◦ Regional lymph node involvement (N)
◦ Presence or absence of distant metastases (M).
 Stage I (Tumors confined to the lung without
lymphatic spread)
 Stage II (Large tumors with ipsilateral peribronchial
or hilar lymph node involvement)
 Stage III (Other lymph node and regional
involvement)
 Stage IV (Any tumor with distant metastases)

11.  Thorough history and physical examination
 IMAGING TESTS
◦ Chest radiographs
◦ Endobronchial ultrasound
◦ Computed tomography (CT) scan
◦ Positron emission tomography (PET)
 Integrated CT–PET technology appears to improve
diagnostic accuracy in staging NSCLC over CT or
PET alone.
 Pathologic confirmation
◦ Examination of sputum cytology
◦ Tumor biopsy by bronchoscopy, mediastinoscopy,
percutaneous needle biopsy, open-lung biopsy.

12.  Local disease (stages IA and IB)
◦ Surgery is the mainstay of treatment and may be used
alone or with radiation therapy (RT) and/ or
chemotherapy.
 Stages IIA and IIB disease
◦ primarily treated with surgery followed by adjuvant
chemotherapy
◦ Chemoradiotherapy is recommended for stage II
medically inoperable patients.
◦ Combination of cisplatin and etoposide is preferred and
should be given concurrently rather than sequentially
with RT.

13.  Resectable stage IIIA disease
◦ Optimal outcomes are achieved with chemotherapy
plus either radiation or surgery, depending on
patient and tumor features.
 Un-resectable stage IIIB or IV NSCLC.
◦ Chemotherapy is administered to select patients
with intent to palliate symptoms, improve quality of
life, and increase duration of survival.

14.  Three main types of surgery are most often used in
lung cancer treatment.
 The choice depends on the size and location of the
tumor, the extent of the cancer, the general health
of the patient
 Segmental or wedge resection
◦ To remove only a small part of the lung
 Lobectomy
◦ Removal of an entire lobe of the lung
 Pneumonectomy
◦ Removal of an entire lung

16.  The use of high-energy rays to damage cancer
cells and stop them from growing and dividing.
 Two ways to deliver radiation therapy
◦ External radiation (external beam therapy)
 A treatment that precisely sends high levels of
radiation directly to the cancer cells
◦ Internal radiation (brachytherapy, implant
radiation)
 Radiation is given inside the body as close to
the cancer as possible.
 Substances that produce radiation, called
radioisotopes may be swallowed, injected, or
implanted directly into the tumor.

17.  The use of anticancer drugs to treat cancerous
cells.
 DOUBLET CHEMOTHERAPY
◦ Four to six cycles of cisplatin or carboplatin plus
docetaxel, gemcitabine, paclitaxel, pemetrexed, or
vinorelbine are recommended as first-line palliative
chemotherapy for patients with un-resectable stage III
or IV disease.
◦ Non–platinum-based combination regimens (eg,
gemcitabine–paclitaxel and gemcitabine–docetaxel)
are recommended as first-line therapy of advanced
NSCLC in patients with a contraindication to a
platinum (cisplatin or carboplatin) agent.

18. Docetaxel/Cisplatin (DC)
Docetaxel 75 mg/m2 IV on day 1
Cisplatin 75 mg/m2 IV on day 1
Repeat cycle every 21 days
Cisplatin/Paclitaxel (CP)
Cisplatin 75 mg/m2 IV on day 1
Paclitaxel 175 mg/m2 over 24 h IV on day 1
Repeat cycle every 21 days
Gemcitabine/Docetaxel (GD)
Gemcitabine 1000 mg/m2 IV on days 1 and 8
Docetaxel 100 mg/m2 IV on day 8
Repeat cycle every 21 days

19.  Docetaxel, pemetrexed, and an oral EGFR inhibitor,
erlotinib, are options for second-line therapy in
patients with good performance status who
progress during or after first-line therapy.
◦ Patients with squamous histology should not receive
pemetrexed or erlotinib (prolongs overall survival in patient
with non-squamous histology, patients with
adenocarcinoma)
 Standard of care for advanced-stage squamous cell
lung cancer is a platinum doublet described
previously.
 Addition of cetuximab, a monoclonal antibody that
binds to the extracellular portion of the EGFR
receptor, to cisplatin and vinorelbine prolonged
median overall survival

20. Cetuximab/Cisplatin/Vinorelbine
Cetuximab 400 mg/m2 IV first dose on day 1,
then 250 mg/m2 IV weekly
Cisplatin 80 mg/m2 IV on day 1
Vinorelbine 25 mg/m2 IV on days 1 and 8
Repeat cycle every 3 weeks
Carboplatin/Paclitaxel/Bevacizumab
Carboplatin AUC 6 mg/mL/min IV on day 1
Paclitaxel 200 mg/m2 IV on day 1
Bevacizumab 15 mg/kg IV on day 1
Repeat cycle every 3 weeks. Continue Bevacizumab until progression
Bevacizumab, a recombinant, humanized monoclonal antibody,
neutralizes vascular endothelial growth factor.
NCCN guidelines recommend addition of bevacizumab to carboplatin–
paclitaxel in advanced NSCLC of nonsquamous cell histology in
patients with no history of hemoptysis and no CNS metastasis who are
not receiving therapeutic anticoagulation.

21.  Surgery
◦ Use of surgery in SCLC is limited to solitary nodules
without evidence of metastasis to lymph nodes.
 Radiation Therapy
◦ SCLC is very radiosensitive. Radiation is always
combined with chemotherapy (EP is preferred
regimen) to treat limited disease SCLC.
◦ Radiotherapy is used to prevent and treat brain
metastases, a frequent occurrence with SCLC.
◦ Prophylactic cranial irradiation (PCI) is used in
patients with limited or extensive disease to reduce
the risk of brain metastases.

22.  Chemotherapy
◦ The most frequently used regimen for limited- and
extensive-stage SCLC is cisplatin or carboplatin
combined with etoposide (EP).
◦ Recurrent SCLC is usually less sensitive to
chemotherapy. Topotecan (IV and oral) is the only
FDA-approved second-line therapy for SCLC
◦ Patients with SCLC that recurs within 3 months of
first-line chemotherapy are considered refractory to
chemotherapy and unlikely to respond to a second-
line regimen
Etoposide/Cisplatin (EP)
Cisplatin 80 mg/m2 IV on day 1
Etoposide 100 mg/m2 IV on days 1–3
Repeat cycle every 3 weeks