Definition
Carcinoma of the lung
etymology Cancer named as such by Hippocrates as “karkinos,” meaning crab, because the blood vessels surrounding malignat tumors resembled crabs. (32222)
aka cancer abbreviated as lung ca, SCLC (small cell lung carcinoma) and NSCLC (non small cell lung carcinoma)
is a malignant disease originating in the epithelium of the airways or respiratory alveoli, with the exact cause not known but with multiple well known high risk factors including
cigarette smoking as the major contributor.
The result is a space occupying abnormality in the lung or bronchus with both mechanical, and functional effects.
The patient is usually asymptomatic in the early stages, but as the disease progresses symptoms may include coughing, shortness of breath, hemoptysis, chest pain, weight loss, loss of appetite, wheezing, fever, hoarseness.
The diagnosis is initially suspected based on the patients clinical background and a suapicious CXR, and then may be confirmed by sputum cytology, computerized CT scan, bronchoscopy, positron tomogrophy (PET) scan, lung biopsy, or mediastinoscopy.
Treatment options include surgery, radiotherapy, chemotherapy. Stenting of occluded bronchi with metallic stents helps open obstructed bronchi.
Overview
In this section we discuss an expanded version of the definition using the format of what type of disease it is, the causes and predisposing factors, the result, which may include characteristic clinical scenarios or pathological characteristics, the mechanisms of diagnosis and the usual treatment. Expansion of this information takes place in the rest of the document at large. This overview section is in fact a summary of the document on lung carcinoma.
Overview of carcinoma of the lung
aka cancer abbreviated as lung ca, SCLCA (small cell lung carcinoma) and NSCLCA (non small cell lung carcinoma)
is a malignant disease originating in the endodermal epithelium of the airways or respiratory epithelium
with the exact cause not known but with multiple well known high risk factors including
cigarette smoking, exposure to secondhand smoke, asbestos, and radon.
Hereditary factors may also play a role.
RESULT
The result is a space occupying abnormality in the lung or bronchus with both mechanical, and functional effects.
The patient is usually asymptomatic in the early stages, but as the disease progresses symptoms may include coughing, shortness of breath, hemoptysis, chest pain, weight loss, loss of appetite, wheezing, fever, hoarseness.
It is characterised by its “insidious and aggressive” nature, in that it presents in a non dramatic and insidious manner. It may just present as a cough, not unlike a cough from an URI. Once the patient seeks medical attention and the disease is uncovered and diagnosed, it seemingly has has a rapid and aggressive downhill course.
DIAGNOSIS
In the asymptomatic patient the disease is usually first suspected as an incidental nodule or mass on a CXR. Patients who are symptomatic, may have the diagnosis confirmed after undergoing a CXR or a sputum evaluation.
Once the disease becomes a focused concern and carcinoma is strongly considered, computerized tomogrophy (CT), bronchoscopy, positron tomogrophy (PET) scan, lung biopsy, and mediastinoscopy are used in the diagnosis with the aim of pathological confirmation, and typing, as well as staging.
TREATMENT
Lung cancer is treated according to the histological type and the stage of the disease. Small cell carcinoma is managed primarily by chemotherapy and sometimes radiotherapy while non small cell carcinoma has a wider variety of options including surgery, radiotherapy, and chemotherapy. Stenting of occluded bronchi with metallic stents helps open obstructed bronchi.
PRINCIPLES
In this section we discuss the principles of malignant growth and the structural changes that occur.
Mallignant cells are space occupying and do not contriute to the welfare of the body system at large. They arise in the lung more commonly in the proximal airways and either occupy the lumen or extend beyond the lumen and occupy parenchymal space, or cause mass effect on other neighbouring structures including blood vessels, lymphatics, pericardium, pleura, heart, and esophagus.
Partial or total blockage of the bronchi results in obstruction and atelectasis, which can be complicated by secondary infection, and bleeding.
Normal cells reproduce about 50 times before dying. Malignant cells, however, grow uncontrollably.
Malignant cells lack contact inhibition, meaning that they do not stop growing when they make contact with another object. The tumor may invade a neighbouring tissue or organ and impede its function.
A malignant tumor may release an angiogenetic growth factor, enabling the formation of feeding blood vessels.
Invasion of the lymphatics and venous structures is inevitable though inavsion of arterioles does not usually occur. Once in the mainstream of the venous or lymphatic system they can metastasize and restablish a new colony with similarly aggressive and parasitic features. The usual “next stop” for hematogenously spread lung primaries is the brain. In the end malignant disease dominates the body and the healthy structures succumb to the unbearable burden.
HISTORICAL ASPECTS
In this section we trace the earliest origins of cancer as a disease and more specifically of lung cancer, although there is not abundant material about the historical evolution of lung cancer. We also explore the history of the origins of tobacco which is much richer in content.
3000-1500 BC
The oldest description of human cancer was found in an Egyptian papyri written between 3000-1500 BC. It referred to tumors of the breast. The oldest specimen of a human cancer was found in the remains of a female skull dating back to the Bronze Age (1900-1600 BC).
Hippocrates (460-377 BC), a Greek physician, was the Father of Medicine and was the first to recognize the difference between malignant and benign tumors. He named the malignant type “karkinos,” meaning crab, because the blood vessels surrounding malignant tumors resembled crabs.
Galen (129-210AD )was acutely aware of the disease and insightfully identified it as an incurable disease.
Morgagni (1682-1771), an Italian anatomist and pathologist from Padua, gained some insight by pioneering post mortem study.
In the 17th and 18th century many thought cancer was caused by a parasite, and was contagious.
Sir John Percivall Pott (1714-1788) a British surgeon described cancer in chimney sweepers and ascribed carcinoa of the scrotum to the accumulation of soot in the body. This landmark observation was the first identification of enviromental factors as a cause of cancer.
John Hunter (1728-1793) was a Scottish anatomist and surgeon who was comitted to the surgical role in the cure of cancer.
Rudolf Virchow (1821-1902) a German pathologist was the first to study cancer in a scientific manner with the use of microscope. He believed that cancer was caused by chronic irritation.
Stephen Paget, an English surgeon lived in the era of Virchow. His “seed and soil theory” suggested that metastatic deposits would only migrate to, and grow in an area that was fertile to support growth.
1896
After Willian Roentgen pioneered the X-ray use, radiation began to be used for cancer diagnosis and treatment.
Mustard gas used in World War II was noted to lower white blood cell counts. This led to research in the use of other drugs and substances for cancer treatment.
HISTORY OF LUNG CANCER
1992
since 1976, steady decline in
the per capita cigarette consumption dropped 37% from 1973 to 1992
1999
“171,600 new cases of lung cancer would account for 31% of cancer deaths in men and 25% cancer deaths in women, total of 158,900 deaths.”
– 1900 only references to a total of 100 cases of lung cancer
1912 374 cases in the literature
1914 WW I – Smoking is rife – wait for a 15-20 year latency
1920’s Primary carcinoma of the lung – an uncommon cancer
1924 73 billion cigarettes sold in US
1929 Frederick Hoffman- no definite evidence that smoking related to lung cancer
1930 major hazard following a marked increase in smoking in the male population
1930 German researchers make statistical correlation between cancer and smoking
1930 Lung cancer is on the rise
1939-45 WW II Smoking is rife – wait for a 15-20 year latency
1941 Dr. DeBakey correlation- sale of tobacco and prevalence of lung cancer
1948 Lung cancer grows 5 times faster than other cancers since 1938
1950 Epidemiological studies provide powerful links – smoking and lung cancer
1950 Doll and Hill BMJ heavy smokers 50X increase in lung cancer.
1950 18,000 deaths in the US from lung cancer
1960′ Incidence of lung cancer peaks
1992 Incidence dropped 37% from 1973 to 1992
1997 158,000 deaths in the US from lung cancer
1999 171,600 new cases of lung cancer accounts for 31% of cancer deaths in men and 25% cancer deaths in women, total of 158,900 deaths.”
2000 smoking is responsible for 1/6 deaths in the United States.
45million Americans smoke;
about 2.4 million are teenagers
2001 +/-160,000 people died-600% increase-age-adjusted death rate vs 1930.
The relationship between cigarette smoking and lung cancer was first suspected over 60 years ago by Muller and Ochsner and DeBakey.
HISTORY OF TOBACCO
Prehistory nicotine metabolites were found in human remains and pipes in the Near East and Africa
6000 BC tobacco plant growing in the Americas.
1492 AD Columbus Discovers Tobacco
1575 Roman Catholic Church passes a law against smoking in certain place
1577 tobacco – panacea for toothache, worms, halitosis, lockjaw & cancer
1600s Popes ban smoking in holy places
1604 ENGLAND King James I increase import tax on tobacco 4,000%
1606 SPAIN King restricts tobacco being grown in specific locations.
1619 Berkeley VA . first American Thanksgiving celebrates a good tobacco crop
1638 In China, use or distribution of tobacco – a crime punishable by decapitation
1639 New York governor Kieft bans smoking in New Amsterdam
1647 Colony of Connecticut bans public smoking
1650 Colony of Connecticut General Court orders no smoking under age of 21
1665 mortal effect of “a drop of distilled oil of tobacco.” on a cat is noted
The Eighteenth Century- era of snuff
1761 John Hill, London physician notes vulnerability of snuff users to nose cancer
1762 General Israel Putnam introduces cigar-smoking to the US
1781 Jefferson – tobacco cultivation in the western regions on the Mississippi.
1788 New Orleans – Americans export tobacco from the Mississippi valley
1794 U.S Congress passes the first federal excise tax on tobacco products,
1798 physician Benjamin Rush warns medical dangers of tobacco
The Nineteenth Century- era of the Cigar
1800’s cigars smoked by gentlemen -cigarettes- sweepings off floor of the cigar factory, were only smoked by the very poor.
1800 Tobacco commercially grown in Canada
1809 FRANCE Louis Nicolas Vanquelin first isolates nicotine from tobacco smoke
1830s First organized anti-tobacco movement in US begins
1843 The correct molecular formula of nicotine is established
1845 Prosper Merimee’s publishes, “Carmen”-cigarette girl in an Andalusian factory
1846-1848 MEXICAN WAR US soldiers bring back cigar.
1847 Philip Morris opens shop; sells hand-rolled Turkish cigarettes
1849 J.E. Liggett and Brother is established in St. Louis, Mo.
1852 Matches are introduced, making smoking more convenient
1855 J.E. Lundstrom invents the safety match, – requires a special striking surface
1860 The Census for Virginia and North Carolina list 348 tobacco factories
1860 Manufactured cigarettes appear (popular brand Bull Durham)
1861-1865 THE CIVIL WAR Tobacco is given with rations by both North and South
1863 US Mandates Cigar Boxes.
1864 1st American cigarette factory opens- produces almost 20 million cigarettes
1875 Allen and Ginter offer a reward of $75,000 for cigarette rolling machine
1880 Bonsack machine granted first cigarette machine patent
1886 Tampa, FL Don Vicente Martinez Ybor opens his first cigar factory.
1887 “If you think smoking injurious to your health, stop smoking in the morning”.
1890 26 states and territories outlaw the sale of cigarettes to minors
Twentieth Century – The Rise of the Cigarette
1900 4.4 billion cigarettes are sold
1901 anti-cigarette activity in 43/45 states except Wyoming and Louisiana
1904 New York woman jailed for 30 days for smoking in front of her children
1905 “Tobacco” struck from US Pharmacopoeia – government listing of drugs.
1909 Baseball great Honus Wagner orders American Tobacco Company to take his picture off their “Sweet Caporal” cigarette packs, fearing they would lead children to smoke. The shortage makes the Honus Wagner card the most valuable of all time, worth close to $500,000.
1911 Tobacco -growing allowed in England for the first time in more than 250 years
1921 Iowa adds its own cigarette tax (2c a pack) onto federal excise levy (6c)
1922 15 states ban sale, manufacture/possession/advertising and use of cigarettes.
1924 73 billion cigarettes sold in US
1927 Kansas is the last state to drop its ban on cigarette sales
1929 Frederick Hoffman- no definite evidence that smoking habits are a direct contributory cause toward malignant growths in the lungs.”
1930 German researchers make statistical correlation between cancer and smoking
1934 Garrison Act – outlaws marijuana & other drugs; tobacco not considered
1939-1945 WWII Roosevelt makes tobacco a protected crop.
1939-1945 WWII Cigarettes included in GI’s C-Rations.
1941 Dr. DeBakey correlation- sale of tobacco and prevalence of lung cancer
1948 Lung cancer grows 5 times faster than other cancers since 1938
1950 Epidemiological studies provide powerful links – smoking and lung cancer
1950 Doll and Hill BMJ heavy smokers 50X increase in lung cancer.
1957 Surgeon General Burney – Joint Report -PHS a first stand against smoking
1961 The presidents of the American Cancer Society, the American Heart Association, the National Tuberculosis Association, and the American Public Health Association submit a joint letter to President Kennedy, pointing out the increasing evidence of the health hazards of smoking and urging the President to establish a commission.
1963 FDA – General’s Report linking smoking and lung cancer
1966 Congress votes to send 600 million cigarettes to flood disaster victims in India
1966 Health warnings on cigarette packs begin
1969 Pan American Airlines creates the first nonsmoking section on its airplane
1970’s Cigarettes are the most heavily advertised product in America
1970 President Nixon signs a measure banning cigarette advertising on radio and TV
1970 Stronger mandatory cigarette label is required
1971 Cigarette manufacturers agree to put health warnings on advertisements
1973 Surgeon General Steinfeld fired after urging restrictions on secondhand smoke
1973 Civil Aeronautics Board requires all airlines to create nonsmoking sections. 1973 Arizona first state in modernity-passes law restricting smoking in public places
1975 Military stops distribution of free cigarettes in C-rations and K-rations
1979 Minneapolis and St. Paul – first U.S. cities to ban free cigarette samples
1983 San Francisco bans smoking in private workplaces
1985 Lung cancer surpasses breast cancer as #1 killer of women
1990 surpasses breast cancer as #1 killer of women
1990 NYC Prohibits free/discounted distribution of tobacco products in public places
1990 Smoking banned all domestic flights less than 6 hours, and interstate buses.
1993 Incoming President Bill CLINTON bans smoking in the White House
1993 US POST OFFICE bans smoking in its facilities.
1994 NY State passes PRO-KIDS Law. No smoking on school grounds
1996 FDA authorised to regulate cigarettes as a “drug delivery device.”
1997 Liggett Tobacco and 22 states settle lawsuits; Liggett admits smoking is addictive, can cause cancer; agrees to turn over documents.
1997 Cigarette companies fined -money for anti-smoking ed, bans on vending machines and outdoor advertising