Lung Cancer: Clinical and Surgical Specifications

Pulmonary carcinoma is the most commonly diagnosed cancer in worldwide, and it is the most common cause of cancer death. A variety of factors, such as ethnicity, age, gender, geographic location, and socioeconomic status, influence the rate in spesific groups. The known behavioral and environmental causes--cigarette smoking, diet, asbestos and other occupational carcinogens, radon, and environmental tobacco smoke--are responsible for the majority of cases. Passive smoking, the involuntary inhalation of tobacco smoke by nonsmokers, has also been found to cause lung cancer. Moreover familial aggregation and increased familial risk for lung cancer have been reported.

Lung cancer is one of the most common cancers and is the leading cause of cancer mortality worldwide. The development of lung cancer is a multifactorial process that involves a series of genetic and epigenetic changes. Smoking tobacco is an important etiologic risk factor for lung cancer. Other risk factors include occupational and environmental long-term exposure, diet, familial aggregation, and genetic factors. Lung carcinogenesis involves identified genetic alterations, namely oncogenes, tumour suppressor genes, epigenetic alterations, and chromosomal abnormalities. New diagnostic and therapeutic approaches to lung cancer are urgently needed. Molecular genetic studies have focused on oncogenes, tumour suppressor genes, and chromosomal abnormalities.

Lung cancer is one of the leading cause of cancer death in the world today. The predominant cause of the lung cancer is tobacco smoking. The other main causative agents are asbestos, silica, radon and heavy metals. Histologically carcinomas comprise nearly 99% of lung cancers. Lung carcinomas have two major groups in the classification of the World Health Organization [WHO]. There is a new multidisciplinary classification of lung adenocarcinomas published by the International Association for the Study of Lung Cancer, American Thoracic Society and European Respiratory Society. With the improvements in the knowledge of the lung cancer biology, there may be more changes in the histological classification and the treatment.

Lung cancer is developed through the accumulation of genetic alterations. The number of potential lung cancer-related genes have been enlightened over the last 20 years. Several molecular genetic abnormalities have been described in the pathogenesis of lung cancer, including the mutational activations of oncogenes, the inactivation of tumour suppressor genes and the alterations in the genes responsible for cell cycle regulation and DNA repair. Lung cancer progression is characterised by cumulative alterations in key molecules involved in the cell cycle, signaling and angiogenesis pathways. The identification of developmentally regulated pathways active in tumourigenesis provides insights into lung carcinogenesis and suggests early steps may differ according to the eventual tumour morphology. Developing novel biological agents to target lung cancer, and new microarray-based technologies provide new methods for predicting prognosis and response to treatment. In this chapter, particulars that have been focus on major recent advances in the molecular study of the origins and biology of lung cancer.

Signs and symptoms of lung tumours depend on tumour location and size, extent of the tumour or its stage and presence or absence of metastasis. Common symptoms are Cough (especially persistent cough), Hemoptysis, Dyspnea, Wheezing, Chest pain, and, Hoarseness. Less commonly, symptoms may arise due to introthoracic tissue and organ involvement, superior vena cava syndrome, Horner’s syndrome or distance metastasis. Systemic effects like weight loss, anorexia, weakness may be seen and symptoms of paraneoplastic syndrome observed.

On physical examination, findings are due to the extent of the disease such as crackles, ronchi, and localised wheeze. If there is collapse of lung tissue or pleural effusions, dullness in precussion and decreased breath sounds will be found. Rarely, findings of paraneoplastic syndromes may dominate the picture. If there is respiratory failure its signs can be found on physical examination. The most important finding is finger clubbing.

Chest radiography is often the first imaging study performed in patients with lung cancer. Average size at detection is approximately 2.5 cm by radiography. Multidetector computed tomography (CT) is widely available, fast, offers excellent spatial resolution and with current scanners is able to provide multiplanar reconstructions. Contrast enhanced computed tomography of the chest should be performed in patients who have known or suspected lung carcinoma who are eligible for treatment. A definitive surgical staging of lung cancer is possible with contrast enhanced computed tomography. Magnetic resonance imaging has no advantage over CT in staging of the mediastinum.

Adenocarcinoma is typically a peripheral nodule or mass of subpleural location and occurs primarily in the upper lobes. Squamous cell carcinomas usually manifests as a hilar or perihilar mass lesion with cavitation. Bronchial obstruction is common and may result in atelectasis or post-obstructive pneumonia. Large mediastinal mass extending to at least one hilum is characteristic of small-cell lung cancer on radiography. Computed tomography reveals bulky mediastinal mass, post-obstructive pneumonitis or collapse, bronchial encasement or obstruction, pleural effusion and pulmonary nodule.

Bronchial carcinoids are lobular central mass which may have an endobronchial component and may demonstrate intense contrast enhancement and variable patterns of calcification.

In recent years, conventional scintigraphical techniques are rarely used in lung cancer patients except the whole body bone scanning and preoperative quantitative lung scintigraphy. With the introduction of positron emission tomography (PET) and more recently PET/CT, management of the lung cancer patients and of the patients with solitary pulmonary nodule has extremely changed from diagnosis to prognosis. The combination of PET with CT scanning allows the integration of metabolic and morphological image information. Nowadays, PET/CT is an accepted modality for lung cancer patients, for many cancer patients, in terms of diagnosis, staging, therapy/radiotherapy planning, prognostic prediction, response monitoring and assessment of recurrence, and becomes widespread throughout the world. In this chapter PET and PET/CT are mainly mentioned as the up-to-date nuclear medicine modalities for diagnostic and therapeutic management in lung cancer.

Staging of lung cancer was first made in 1973 and was revised according to new information obtained by case series. The last staging was proposed by IASCL in 2007 [1] and accepted in 2009 [2]. New regulations are made in T and M descriptors in the new TNM staging but no change is made in N descriptor.

Solitary pulmonary nodule (SPN) is a challenging problem especially for the chest physicians and thoracic surgeons. Radiologic diagnosis and classification of an SPN in terms of margins, size and doubling time are very important but insufficient. Definitive diagnosis of an SPN depends on histopathologic examination. Differntial diagnosis of an SPN less than 10 mm is more difficult because sensitivity and accuracy of the diagnostic methods will also decrease with decreasing dimension. Conventional radiologic methods as chest X-ray and low dose CT have been widely used for screening high risk patients for lung cancer however this methods are insufficient for small SPN. Latest method, FDG PET CT, also depends on the size of the lesion. The sensitivity, specificity, and accuracy were 85%, 36% and 54% respectively for nodules smaller than 10 mm, compared to 91%, 47%, and 79% for nodules between 1.1-2.0 cm. Sensivity and accuracy of histopathologic diagnosis with fine needle biopsy for small SPN depend on the location of the lesion. The accuracy of the biopsy improves in peripheral nodules. Surgical excision of the SSPN via VATS can provide definitive diagnosis and treatment, however major lung resection and mediastinal lymph node dissection are the most effective treatment methods for malign nodules.

Non-small cell lung cancer is the most common malignancy in the world and accounts for an estimated 1 million deaths each year. Metastasis to the mediastinal lymph nodes is one of the most important factors in determining resectability and prognosis. It also influences staging algorithms. Non-invasive radiographic imaging investigations have their limitations, so tissue sampling is needed. Sampling can be achieved both by invasive surgical or non-surgical techniques. According to the ESTS guidelines, among invasive surgical techniques, mediastinoscopy is still considered to be the gold standard in the mediastinal staging in non-small cell lung cancer. This chapter deals with invasive surgical techniques.

Reconstruction of the pulmonary artery in association with lung resection is technically feasible with some morbidity and mortality. To obtain complete resection is always main aim. Non-small cell carcinoma of the lung invading the PA has traditionally been treated by pneumonectomy. Sleeve resection and prosthetic reconstruction of the pulmonary artery (PA) has progressively gained acceptance as an alternative to pneumonectomy in lung cancer surgery. When the tumour involves the central PA, lobectomy associated with reconstruction of the PA with or without bronchoplasty is the only alternative to pneumonectomy. Pulmonary arterioplasty has come into more widespread use to achieve R0 resections while preserving lung parenchyma in patients with central primary cancers or metastatic N1 disease. This procedure preserves the lung parenchyma safely, resulting in a better postoperative quality of life.

The results of resection of non-small cell lung cancer depend on its stage. The 5-year survival of patients with stage I and II non-small cell lung cancer is 70 and 50%, respectively; therefore, surgical treatment is thought to be indicated in these patients. However, in patients with stage IIIa and IIIb non-small cell lung cancer 5-year survival is as low as 20 and 6%, respectively. There are especially few long-term survivors with stage IIIb non-small cell lung cancer. On the other hand, stage IIIb non-small cell lung cancer can be classified into T4 and N3, with the former considered to be operable in selected patients. The symptoms and prognosis of T4 cancer vary depending on the region invaded: trachea, esophagus, vertebral column, superior vena cava (SVC), aorta, left atrium (LA). Good survival rates are obtained by upfront resection (excluding pancoast tumours) of T4 tumours in cases of NO or N1 nodal status and if complete resection is achieved, and resection should be recommended in patients fit for surgery. Therefore, the indications for surgical operation should be determined by taking into consideration the region of invasion, the degree of invasion, lymph node involvement and curability by surgery [1-4]. Most of these cancers are staged T3 or T4. Therefore, it is mandatory that all patients undergo extensive staging, including mediastinoscopy, before an attempt at resection. Operative planning is critical because only a complete resection provides the patient with any opportunity for cure.

The standard treatment for stage I NSCLC is lobectomy with mediastinal lymph node sampling or dissection. The role of limited resection for stage IA lesions, especially those ≤ 2 cm in diameter is controversial despite many proponents. Patients with physiologic limitation prohibiting lobectomy should be evaluated for sublobar resection, as it seems to offer increasingly similar overall and cancer-free survival rates. Limited resection should be done with systematic or complete lymph node sampling.

As limited resection leads to better postoperative lung function of pulmonary function and decreased morbidity, it may become the preferred strategy for these patients in the future. Non-randomized series comparing patients undergoing sublobar resection because of compromised lung function and those undergoing formal lobectomy show similar long-term survival and cancer-free survival especially for stage IA tumours less than 2 cm.

The aim of surgical treatment of NSLC is complete resection. Lobectomy remains the definitive resections because it is an anatomic resection that assures the regional lymph nodes that course along the lobar bronchus and thus provides the best staging information and local control. The risk of pulmonary resection depends on both patient characteristics (i.e. FEV1, DLCO etc.), and type of resection (i.e. pneumonectomy, lobectomy, segmentectomy; open thoracotomy vs. VATS). The posterolateral position is used for lobectomy because it gives the surgeon the greatest maneuverability. Key points in the performance of lobectomy are mobilization of the lobe, fissure dissection and management of the vessels and bronchus.

The aim of surgical treatment of non-small cell lung cancer is complete resection. Lately, the number of patients in whom pneumonectomy is necessary is decreasing attributable to advances in diagnostic imaging and improved techniques for surgery such as bronchoplasty. The risk of pulmonary resection depends on both patient characteristics, and type of resection. The type of surgical procedure affects mortality. The fact that patients undergoing a right-sided pneumonectomy have a higher mortality than those undergoing a left one. Patients who will undergo pneumonectomy first must undergo preoperative staging. Considering the prominent decreases in quality of life after pneumonectomy, most surgeons tend to avoid the indication of pneumonectomy whenever possible.

Pulmonary metastasectomy has been widely used treatment modality in selected patients with pulmonary metastases due to primary tumour, initiated at some other site. Presence of any metastases in a view may yield an uncontrolled tumoural disease, isolated pulmonary metastases do not consistently represent a systemic or untreatable spread of a primary neoplasm. Making an appropriate surgical resection for isolated pulmonary metastases may help in patients’ survival positively. Approach to pulmonary metastases including patient selection, surgical treatment modalities and outcomes of surgery will be discussed in this chapter.

Superior sulcus tumours were first described by “a radiologist” Henry Pancoast. These rare tumours have typical presentation as causing “Pancoast-Tobias” syndrome. The management and outcome of superior sulcus tumours remained nearly unchanged in the last 40 years. Patients with, extrathoracic metastases, proven N2 disease, invasion of the superior and middle trunk of the brachial plexus, spinal canal, esophagus and trachea are not suitable for resection. All the diagnosed patients who do not have absolute contraindications for surgery should be evaluated for combined therapy including surgical excision.

In this chapter, we discussed the superior sulcus tumours with diagnosis, treatment and results with the current literature.

The field of interventional bronchoscopy includes several endobronchial treatment techniques that are used to relieve obstruction of the trachea and large bronchi secondary to either benign or malignant process. Balloon dilatation, endobronchial laser therapy, electrocautery, argon plasma coagulation, cryotherapy, photodynamic therapy, brachytherapy and stent application are all frequently used in the management of these disorders. Each technique has a unique set of characteristics that may make it the more or less appropriate modality to use for a specific patient and condition.

These procedures are performed using either rigid or flexible bronchoscopy depending on the particular patient and disease process involved, as well as the bronchoscopist’s experience. Indications of interventional bronchoscopy are [1] malignant airway obstruction, [2] troubleshooting of benign airway obstruction, [3] foreign body aspiration, [4] hemoptysis, and [5] rarely the other applications.

Bronchial carcinoid tumours were in the past defined as benign and classified as “bronchial adenomas”. Currently bronchial carcinoid tumours are considered to be part of a spectrum of malignant neoplasms with neuroendocrine differentiation. Bronchial carcinoid tumours are classified by pathologic features as typical carcinoid tumours or atypical carcinoid tumours with different clinical course prognosis. The most common symptoms are cough, hemoptysis and recurrent pulmoner infection. Paraneoplastic syndromes are uncommon and include Carcinoid syndrome, Cushing’s syndrome, and ectopic growth hormone-releasing hormone secretion. Bronchial carcinoid tumours are generally central location for this reason being visible by bronchoscopy. Endobronchial biopsy via bronchoscopy is safe, with a very low risk of bleeding. Atypical carcinoid tumours affected preferentially patients older than typical carcinoid tumours and demonstrated a more aggressive oncological behaviour with a high percentage of nodal involvement and distant metastases. The primary treatment is complete surgical resection (especially parenchymasparing procedures for typical carcinoid tumours) and formal mediastinal lymph node dissection. Long term prognosis is excellent in typical carcinoid tumours, although it is worse in atypical carcinoid tumours.

Although bronchoplasty for malignant lung lesions is common, bronchoplasty for benign lung lesions is relatively rare. Bronchoplasty is a parenchyma–saving operation in which a segment of main bronchus is removed in continuity with a lobe. Bronchoplastic procedures can be achieved by both two main bronchus and five major lobe bronchus. In all reported series, lesions in the hilum of the right upper lobe represent the most common indication for sleeve lobectomy. High-dose corticosteroid therapy, active bronchial inflammation, and prior high-dose irradiation are principal relative contraindications. Occasionally, sleeve resections can be indicated for patients with low respiratory capacity, a condition that contraindicates pneumonectomy. Local recurrence is low as long as the margins are free of disease. Sleeve lobectomy was strongly favored over pneumonectomy.

Nodal status at the time of staging is a critical determinant of survival in non-small cell lung cancer [NSCLC]. Despite the fact that the use of positron emission tomography [PET] scan and cervical mediastinoscopy–whether in combination or not—in staging has shown an acceptable accuracy rate, the extent of dissection still remains a problem. To date, there has been no consensus among either thoracic surgeons or oncologists regarding the optimal dissection of mediastinal lymph nodes [MLNs] in the early stages of NSCLC. Mediastinal lymph node dissection [MLND] is one of the techniques for MLN assessment and is not dependent on the location of the tumour or the lobe. All mediastinal fatty tissue containing lymphatics and lymph nodes is dissected from surrounding anatomical landmarks by either sharp or blunt dissection. Another technique is mediastinal lymph node sampling [MLNS], in which all mediastinal fatty tissue that potentially contains lymph nodes is not removed. The lymph nodes to be resected are determined preoperatively or intraoperatively. Because of the aggressiveness of MLND and the relative subjectivity of MLNS, some surgeons prefer dissection of the lymphatic pool and do no further dissection if that pool is negative. It is also important to consider N1 disease, and fixed lymph nodes to the bronchus usually necessitate more extensive surgery than lobectomy alone. In brief, questions still remain regarding the extent of lymph node removal. In patients undergoing resection for stage I and stage II NSCLC, it is recommended that intraoperative systematic MLNS or MLND be performed for accurate pathologic staging. Grade of recommendation: 1B.

Lung cancer remains the most common malignancy and the most common cause of cancer mortality worldwide for both men and women. In 2008, an estimated 1.6 million new cases of lung cancer were diagnosed and an estimated 1.4 million deaths from lung cancer occurred. Nearly 85 % of lung cancers are diagnosed as Non- Small Cell Lung Cancer. The mortality from advanced stage Non-Small lung cancer is still high even with new therapeutic agents. The chemotherapy and palliative radiotherapy are the only treatment options at the advanced stage of the disease. Surgical resection and adjuvant chemotherapy is the mainstay of treatment at early stage disease and concomitant curative chemoradiotherapy is the recommended treatment modality in locally advanced stage. The neoadjuvant chemotherapy is shown to be useful for various types of cancer. The benefit of neoadjuvant chemotherapy in Non- Small cell lung cancer is being investigated in ongoing phase II and III trials.

Lung cancer is the primary reason for cancer related mortality in the world. Although initial treatment for early stage Non-small Cell Lung Cancer (NSCLC) is a complete surgical resection, the recurrence rate of NSCLC in its early stages remains high. Even after a complete resection, the 5-year survival rates range from 67% to 23% for Stage IA to Stage IIIA disease, respectively. Recurrences, which are the primary factor for reduced survival rates, generally occur at distant, extra thoracic sites. As a result, even within its early stages, NSCLC is considered as a systemic disease at diagnosis and further improvement in survival rate can only be achieved with the eradication of micrometastatic disease to reduce the risk of distant recurrences.

Several recent phase III trials provide robust evidence for chemotherapy in adjuvant settings. In the meta-analysis of these trials, pooled analysis of LACE, cisplatin based adjuvant chemotherapy showed 5.4% of absolute benefit in 5-year survival rates. The effectiveness of the chemotherapy strongly depends upon the stage of the disease as well as the performance status of the patient. While patients with performance scale 0-1 gain significant overall survival (OS) benefit from chemotherapy, one should be very careful about patients with performance scale of 2 or greater. There were significant OS benefits for stage II and III disease, while chemotherapy may have detrimental effects on OS in Stage IA patients. Based on the subgroup analysis of CALGB 9633 trial, adjuvant chemotherapy may be offered to Stage IB patients with a big tumour.

Further improvements can be achieved by defining reliable and clinically approved predictive and prognostic factors and tailor treatment by using these parameters. RAS, p53 ERCC1, and gene expression profiles are all seemed to be reliable predictive and prognostic factors, but to the best of the authors' knowledge, there are no prospective data to support routine their clinical use.

Radiotherapy is an important component of non-small cell lung cancer (NSCLC) treatment for both curative and palliative purposes. Regarding the curative intent, radiotherapy of inoperable tumours can be performed preoperatively, postoperatively, or definitively. For patients with early-stage NSCLC that is unsuitable for resection, local high-dose radiotherapy is the treatment of choice. Stereotactic radiotherapy has been demonstrated to be an effective treatment approach for early-stage tumours, combining the accurate focal dose delivery of stereotactic techniques with the biological advantages of dose-escalated hypofractionated radiotherapy, achieving local control rates of up to 90% and favorable results, especially for patients with a good performance status. Postoperative radiotherapy should not be used for stage I or II NSCLC, and its use remains controversial for resected stage IIIA (N2) disease. To increase the efficacy of radiotherapy, chemotherapy can be used concurrently, resulting in better results as well as increased toxicity. Concurrent chemoradiotherapy is presently the standard treatment for stage III inoperable NSCLC. Within this treatment framework, conventional fractionated radiotherapy at a total dose of 60–66 Gy has proven effective. The chemotherapy should be performed using a cisplatin-based regimen or, if contraindicated, a carboplatin-based regimen. For metastatic disease, short-course palliative treatment with hypofractionated schemas is preferred, and prolonged palliation effects (6–12 months) can be achieved in many cases. There is a close relationship between dose escalation and efficacy; that is, a better outcome is achieved with higher doses. New drug combinations with better radiotherapy techniques will result in better local control and overall survival without increasing toxicity.

Surgical resection for lung cancer remains the mainstay of therapy for earlystage non–small cell lung cancer (NSCLC) and provides the best opportunity for cure. Every patient with locoregional NSCLC should be approached as a potential candidate for resection. For stage 1A, 1B, 2A and 2B NSCLC, an operation is the treatment of choice [1-5].

Patients with clinical stage I non-small cell lung cancer (NSCLC) can be considered falling into three treatment groups: (1) good-risk patients, who are usually treated with lobectomy; (2) high-risk patients, who are usually treated with sublobar (segmental or wedge) resection; and (3) medically inoperable patients, who traditionally have been treated with external beam radiation therapy [6]. Stereotactic body radiation therapy (SBRT) and radiofrequency ablation (RFA) are two nonoperative approaches that are gaining increasing popularity for the treatment of NSCLC. Radiofrequency ablation (RFA) therapy is a minimally invasive technique that can be used in the management of inoperable non-small-cell lung cancer and for palliation in selected patients with pulmonary metastases. Surgical resection remains the gold standard of treatment; however, many patients are ineligible due to comorbidities or poor cardiopulmonary reserve. Some have claimed that SBRT is superior to sublobar resection and may even be equivalent to lobectomy. This assumption is incorrect. At best, stereotactic body radiation therapy and radiofrequency ablation can only approximate a wedge resection if it is assumed that 100% tumour destruction has occurred. Lymph node dissection and sampling can also be undertaken at the time of sublobar resection, potentially improving outcomes and allowing identification of unsuspected nodal disease. Despite this, stereotactic body radiation therapy and radiofrequency ablation may be clinically equivalent to sublobar resection for the high-risk patient because of lower procedural morbidity and more rapid return to normal function [6, 7].

Immune system direct or indirectly can be effective in the movement of cancer.A lot of moleculer study was made for explaining immune mechanism of lung cancer. Different immune mechanisms and tumour factors relating the existence mechanism of the disease are examined in this manuscript.

Lung cancer is a disease with very high morbidity and mortality rate. In spite of aggressive treatment modalities, the long- term survival is very low, and these treatments have many toxic adverse effects. Immunological therapies or briefly “immunotherapy” is a promising new therapeutic modality for lung cancer; it can be in the form of active immunization (cancer vaccines), passive immunization (adoptive cell therapy or antibody-based treatment) or immunostimulation.

Despite the fact that, approximately, one-seventh of all lung cancers are small cell lung carcinoma (SCLC), it is the fifth leading cause of cancer mortality. Histologically it represents small (<20 microns) cells with scanty cytoplasm with neuroendocrine properties. It is usually hilar tumour with early and multiple metastasis. The major symptoms are chest pain, dyspnea, wheezing and dysphonia. Paraneoplastic syndromes such as Cushing syndrome, secretion of Inappropriate ADH syndrome and some dramatic signs of tumours such as vena cava superior syndrome are not uncommon. Malignant pleural effusion develops in up to 35% of patients.The latest (seventh) TNM staging systems is defined to be applicable to SCLC, but they have been used very frequently in clinical practice because patients with SCLC seldom present at a stage for which surgery is appropriate and oncologists anonymously refused to stratify the patients according to these comprehensive staging systems. Nevertheless stratification by stages I–III should be used in all patients for early-stage SCLC whether treatment is surgical or not and full details of TNM staging should be reported.

Although, very small fraction of patients with T1N0 disease could be amenable to surgical resection, major treatment modalities for SCLC are chemotherapy and radiotherapy with elective cranial irradiation. Studies showed significantly superior survival for thoracic irradiation and adjuvant chemotherapy when compared with radiotherapy alone.

Patients with early-stage SCLC (T1–2 N0) may benefit from a combined modality approach that includes surgery. Neoadjuvant chemo/radiotherapy could possibly provide better survival in these patients.

As conclusion, SCLC is a very aggressive histologic type of lung cancer which develops metastasis rapidly and leads to very dismal prognosis. Challenging treatment approach is usually needed including chemotherapy, radiotherapy, surgery and new treatment modalities. Strategies for prohibition of smoking has been reduced and will reduce the incidence of SCLC.

Acute pain is a form of pain that starts suddenly. Chronic pain arises when pain continues after an acute disease or a reasonable recovery period. This period varies between 1 and 6 months. Visceral pain is an acute pain that develops depending on abnormal functioning or disorder of viscera or their membranes (parietal pleura, pericardia, peritonea). Lung cancer related pain depends on the location of the primary tumour, its regional invasion and metastatic spread. Pain may develop secondarily, depending on the peripheral growth of the primary tumour (spread to pleura or chest wall) or nerve invasion (pain which spreads to the arms or shoulders, known as Pancoast syndrome). While visceral pain is experienced slightly in the ipsilateral hemithorax independent of the regional spread, it may also cause non-specific chest pain symptoms. Pain may be located at the metastasis as with the bone metastases seen in one-third of patients and brain metastases, which progresses with headache and intracranial hypertension.

Lung cancer rate in all cancer types is 21% in men and 5 % in women in European Union Countries. Smoking is the most important factor of lung cancer etiology [1]. The rate of Turkey is found 63% in men and 14% in women in 1988. 88.7% of the patients in Turkey have got smoking story. Lung cancer risk increases 3.5 times in passive smoking. Because there are carcinogens in air and they are not filtered; therefore, they are denser on air [2].

The primary care practitioner must maintain a close working relationship with medical and surgical oncologists to help guide patients and families through various treatment options.

In the lung cancer patients, the pain occurred based upon the oncologic period in 77 % percentage. Moreover, it depends on cancer treatment in 19 % percentage and the other effects which are not depending on cancer in 4 %. It is hard to join the analgesic aims if the innovations related to cancer pain control are not heard, the doctors and the other medicine workers are not trained well and if some legal problems exist while finding the drugs which are used in the pain control.