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Chapter 23: Lung Cancer

Enriqueta Felip; Rafael Rosell

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INTRODUCTION

Epidemiology

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Epidemiology
Incidence:

228,150 (male: 116,440; female: 111,710. Estimated new cases for 2019 in the United States)

228,820 (male: 116,300; female: 112,520) in 2020

54.9 per 100,000 male and female per year (63.0 per 100,000 men, 48.9 per 100,000 women)
Deaths: Estimated 142,670 in 2019 (male: 76,650; female: 66,020)
Median age: 70 years

Stage at Presentation

Localized (confined to primary site): 20.1%

Regional (spread to regional lymph nodes): 21.9%

Distant (cancer has metastasized): 51.4%

 

Siegel R et al. CA Cancer J Clin 2019;69:7–34

Surveillance, Epidemiology and End Results (SEER) Program, available from http://seer.cancer.gov (accessed in 2019)

Pathology

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Pathology
Lung cancer is divided into two major classes:

1. Non–small cell lung cancer (NSCLC):

  • Squamous cell carcinoma

  • Adenocarcinoma

  • Large-cell carcinoma

 80–85%
2. Small cell lung cancer (SCLC) 15–20%
Brambilla E et al. Eur Respir J 2001;18:1059–1068

NON–SMALL CELL LUNG CANCER (NSCLC)

Work-up

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  1. History and physical examination including performance status and weight loss

  2. Chest x-ray, PA and lateral

  3. CT scan of chest and upper abdomen including adrenals

  4. CBC, serum electrolytes, BUN, creatinine, calcium, magnesium, and LFTs

  5. CT scan and/or MRI of brain if neurologic history or examination is abnormal

  6. Bone scan if there is bone pain, elevated calcium level, or elevated alkaline phosphatase level

  7. Assessment of perioperative risks for potential candidates for surgery, including pulmonary function tests (PFTs)
Stages I–II

  1. Bronchoscopy

  2. FDG-PET scan
Stages IIIA–IIIB

  1. Bronchoscopy

  2. FDG-PET scan

  3. MRI of the chest in superior sulcus tumors

  4. MRI of brain

  5. Bone scan

  6. Mediastinal lymph node biopsy if CT scan shows nodes >1 cm

Invasive tests: Mediastinoscopy, thoracoscopy, transbronchial needle aspiration, and endoscopic ultrasound and needle aspiration
Stage IV Biopsy for otherwise potentially resectable patient with isolated adrenal mass or liver lesion

Staging

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Staging
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (ie, not in the main bronchus)1
T1mi Minimally invasive adenocarcinoma2
T1a Tumor ≤1 in greatest dimension1
T1b Tumor >1 cm but not >2 cm in greatest dimension1
T1c Tumor >2 cm but not >3 cm in greatest dimension1
T2

Tumor >3 cm but not >5 cm in greatest dimension or tumor with any of the following features3

Involves main bronchus regardless of distance to the carina, but without involving the carina

Invades visceral pleura

Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, either involving part of the lung or the entire lung
T2a Tumor >3 cm but not >4 cm in greatest dimension
T2b Tumor >4 cm but ...

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