Lung cancer pathophysiology: Difference between revisions

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{{Lung cancer}}
{{Lung cancer}}


{{CMG}}; '''Associate Editor(s)-In-Chief:''' Kim-Son H. Nguyen, M.D., M.P.A., Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, {{CZ}}
{{CMG}}; {{AE}} {{KSH}} {{CZ}} {{SH}} [[User:Michael Maddaleni|Michael Maddaleni, B.S.]]


==Overview==
==Overview==
{{main|Carcinogenesis}}
The [[pathophysiology]] of lung cancer includes both [[genetic]] and [[Environmental factor|environmental factors]]. [[Causality]] of the majority of lung cancer is linked to [[Tobacco|tobacco usage.]] [[Carcinogen|Carcinogenic]] effects of [[tobacco smoking]] may result in [[DNA]] mis-replication and [[mutation]]. [[Smoking]] starts a [[cascade]] of events that leads to [[cancer]] development, even decades after [[smoking cessation]]. Besides [[Smoking|smokers]], [[Patient|patients]] with the history of prior [[Respiratory tract neoplasm|respiratory tract]] or [[gastrointestinal tract cancer]] comprise a high-risk population. Other [[Environmental factor|environmental factors]] include [[radon]], [[asbestos]], [[viral infections]], and states of [[Pulmonary inflammation|chronic lung inflammation]], all of which may [[Predisposition|predispose]] to [[cellular]] damage and [[DNA mutations]] that [[Predisposition|predispose]] to the development of lung cancers.


Similar to many other cancers, lung cancer is initiated by activation of [[oncogene]]s or inactivation of [[tumor suppressor gene]]s.<ref name="Fong">{{cite journal | last =Fong | first =KM | coauthors = Sekido Y, Gazdar AF, Minna JD | title =Lung cancer. 9: Molecular biology of lung cancer: clinical implications | journal =Thorax | volume =58 | issue =10 | pages =892–900 | publisher = BMJ Publishing Group Ltd. | date =Oct 2003 | pmid =14514947 }}</ref> Oncogenes are [[gene]]s that are believed to make people more susceptible to cancer. [[Proto-oncogene]]s are believed to turn into oncogenes when exposed to particular carcinogens.<ref name="Salgia">{{cite journal | last =Salgia | first =R | coauthors =Skarin AT | title =Molecular abnormalities in lung cancer |journal =Journal of Clinical Oncology | volume =16 | issue =3 | pages =1207–1217 | date =Mar 1998 | pmid =9508209 }}</ref>[[Mutation]]s in the ''[[Ras|K-ras]]'' proto-oncogene are responsible for 20–30% of non-small cell lung cancers.<ref name="Aviel-Ronen">{{cite journal | last =Aviel-Ronen | first =S | coauthors = Blackhall FH, Shepherd FA, Tsao MS | title =K-ras mutations in non-small-cell lung carcinoma: a review | journal =Clinical Lung Cancer | volume =8 | issue =1 | pages =30–38 |publisher =Cancer Information Group | date =Jul 2006 | pmid =16870043 }}</ref> [[Chromosome|Chromosomal]] damage can lead to [[loss of heterozygosity]]. This can cause inactivation of tumor suppressor genes. Damage to chromosomes 3p, 5q, 13q and 17p are particularly common in small cell lung carcinoma. The ''[[TP53]]'' tumor suppressor gene, located on chromosome 17p, is often affected.<ref name="Devereux">{{cite journal | last =Devereux | first =TR | coauthors = Taylor JA, Barrett JC | title =Molecular mechanisms of lung cancer. Interaction of environmental and genetic factors | journal =Chest | volume =109 | issue =Suppl. 3 | pages =14S-19S | publisher =American College of Chest Physicians | date =Mar 1996 | url =http://www.chestjournal.org/cgi/reprint/109/3/14S| pmid =8598134 | accessdate =2007-08-11 }}</ref>
==Pathophysiology==
The [[pathophysiology]] of lung cancer includes both [[genetic]] and [[Environmental factor|environmental factors]].<ref name="KanwalDing2017">{{cite journal|last1=Kanwal|first1=Madiha|last2=Ding|first2=Xiao-Ji|last3=Cao|first3=Yi|title=Familial risk for lung cancer|journal=Oncology Letters|volume=13|issue=2|year=2017|pages=535–542|issn=1792-1074|doi=10.3892/ol.2016.5518}}</ref><ref name="KadaraScheet2016">{{cite journal|last1=Kadara|first1=H.|last2=Scheet|first2=P.|last3=Wistuba|first3=I. I.|last4=Spira|first4=A. E.|title=Early Events in the Molecular Pathogenesis of Lung Cancer|journal=Cancer Prevention Research|volume=9|issue=7|year=2016|pages=518–527|issn=1940-6207|doi=10.1158/1940-6207.CAPR-15-0400}}</ref><ref name="RasoWistuba2007">{{cite journal|last1=Raso|first1=Maria Gabriela|last2=Wistuba|first2=Ignacio I.|title=Molecular Pathogenesis of Early-Stage Non-small Cell Lung Cancer and a Proposal for Tissue Banking to Facilitate Identification of New Biomarkers|journal=Journal of Thoracic Oncology|volume=2|issue=7|year=2007|pages=S128–S135|issn=15560864|doi=10.1097/JTO.0b013e318074fe42}}</ref>
* Lung cancer consists of several [[Histologically|histological types]].
* Main [[Histological|histological types]] of lung cancer include:
** [[Small cell lung cancer]]
** [[Non small cell lung cancer]]
*** [[Adenocarcinoma of the lung]]
*** [[Squamous cell carcinoma of the lung]]
*** [[Large cell carcinoma of the lung]]
*** [[Sarcomatoid carcinoma of the lung]]
* [[Smoking]] starts a [[cascade]] of events that leads to [[cancer]].


Several [[genetic polymorphism]]s are associated with lung cancer. These include polymorphisms in [[gene]]s coding for[[interleukin]]-1,<ref name="Engels">{{cite journal | last =Engels | first =EA | coauthors =Wu X, Gu J et al. | title =Systematic evaluation of genetic variants in the inflammation pathway and risk of lung cancer | journal =Cancer Research | volume =67 | issue =13 | pages =6520–6527 | publisher =American Association for Cancer Research | date =Jul 2007 | pmid =17596594 }}</ref> [[cytochrome P450]],<ref name="Wenzlaff">{{cite journal | last =Wenzlaff | first =AS | coauthors =Cote ML, Bock CH et al. | title =CYP1A1 and CYP1B1 polymorphisms and risk of lung cancer among never smokers: a population-based study | journal =Carcinogenesis | volume =26 |issue =12 | pages =2207–2212 | publisher =Oxford University Press | date =Dec 2005 | pmid =16051642 }}</ref> [[apoptosis]] promoters such as [[caspase]]-8,<ref name="Son">{{cite journal | last =Son | first =JW | coauthors =Kang HK, Chae MH et al. | title =Polymorphisms in the caspase-8 gene and the risk of lung cancer | journal =Cancer Genetics and Cytogenetics | volume =169 | issue =2 | pages =121–127 | date =Sep 2006 | pmid =16938569 }}</ref> and DNA repair molecules such as [[XRCC1]].<ref name="Yin">{{cite journal | last =Yin | first =J | coauthors =Vogel U, Ma Y et al. | title =The DNA repair gene XRCC1 and genetic susceptibility of lung cancer in a northeastern Chinese population | journal =Lung Cancer | volume =56 | issue =2 | pages =153–160 | date =May 2007 |pmid =17316890 }}</ref> People with these polymorphisms are more likely to develop lung cancer after exposure to [[carcinogen]]s.
=== Lung Cancer Pathogenesis ===
* Lung cancer [[pathogenesis]] can be understood with the help of the following [[hypothesis]]:


The main causes of lung cancer (and cancer in general) include [[carcinogen]]s (such as those in tobacco smoke), [[ionizing radiation]], and [[virus (biology)|viral]] infection. This exposure causes cumulative changes to the [[DNA]] in the tissue lining the [[bronchi]] of the lungs (the bronchial [[epithelium]]). As more tissue becomes damaged, eventually a cancer develops.
===== '''Familial lung cancer''' =====


===Smoking===
**[[Chromosome 6 (human)|6q23–25]] [[Locus (genetics)|locus]] has been identified as a [[Susceptible individual|susceptibility]] [[gene]] for familial lung cancer.
[[File:Cancer smoking lung cancer correlation from NIH.svg|The incidence of lung cancer is highly correlated with smoking. Source: NIH.]]
 
[[Tobacco smoking|Smoking]], particularly of [[cigarette]]s, is by far the main contributor to lung cancer. In the United States, smoking is estimated to account for 87% of lung cancer cases (90% in men and 85% in women).<ref name="Samet2">{{cite journal | last =Samet | first =JM | coauthors =Wiggins CL, Humble CG, Pathak DR | title =Cigarette smoking and lung cancer in New Mexico | journal =American Review of Respiratory Disease | volume =137 | issue =5 | pages =1110–1113 | date =May 1988 | pmid =3264122 }}</ref>  
===== '''Multistep tumorigenesis''' =====
 
**[[Tumor|Tumors]] of [[Organ (anatomy)|organs]] such as [[Skin cancer|skin]], [[lung]] and [[Colorectal cancer|colon]] are developed through a process called [[Tumorigenesis|multistep tumorigenesis]].
** As with other [[Epithelium|epithelial]] [[Cancer|malignancies]], lung cancers are believed to arise from [[Precancerous|preneoplastic]] or precursor [[lesions]] in the [[Respiratory system|respiratory]] [[mucosa]].
**[[Tumorigenesis|Multistep tumorigenesis]] is the development of [[tumor]] through a series of progressive [[Pathological|pathologic]] events such as [[Precancerous|preneoplastic]] or [[Precursor|precursor lesions]] with corresponding [[genetic]] and [[Epigenetic|epigenetic aberrations]].
**[[Hyperplasia]], [[squamous metaplasia]], [[Dysplasia|squamous dysplasia]], and [[Carcinoma in situ|carcinoma ''in situ'' (CIS)]] comprise changes in the [[Bronchus|large airways]] that precede or accompany [[squamous cell carcinoma of the lung|invasive squamous cell carcinoma of the lung]].<ref name="pmid18039118">{{cite journal |vauthors=Wistuba II, Gazdar AF |title=Lung cancer preneoplasia |journal=Annu Rev Pathol |volume=1 |issue= |pages=331–48 |date=2006 |pmid=18039118 |doi=10.1146/annurev.pathol.1.110304.100103 |url=}}</ref>
** Multistep [[tumorigenesis]] explains [[pathogenesis]] of centrally located [[squamous cell carcinoma of the lung]] very well but fails to explain the [[pathogenesis]] of [[Large cell carcinoma of the lung|large cell lung carcinomas]], [[Adenocarcinoma of the lung|lung adenocarcinomas]], and [[small cell lung cancer]].
 
===== '''Accumulation of Molecular Abnormalities''' =====
 
** Another [[theory]] on the [[pathogenesis]] of lung cancer is the accumulation of [[Molecule|molecular]] abnormalities beyond a certain threshold point, rather than the sequence of alterations.
** There are no known [[Precancerous|preneoplastic lesions]] for the most common type of [[Carcinoid syndrome|neuroendocrine lung tumors]], [[Small cell lung cancer|small cell carcinoma of the lung]],
**[[Adenocarcinoma of the lung pathophysiology|Atypical adenomatous hyperplasia (AAH)]] is the only sequence of [[Morphology (biology)|morphologic]] change identified leading to the development of [[Adenocarcinoma of the lung|invasive adenocarcinoma of the lung.]]
*[[Pathogenesis]] of lung cancer is thought to be result of both due to stepwise, sequence-specific and multistage [[Molecular pathology|molecular pathogenesis]] and due to accumulation and combination of [[Genetics|genetic]] and [[Epigenetics|epigenetic]] abnormalities.


Among male smokers, the lifetime risk of developing lung cancer is 17.2%. Among female smokers, the risk is 11.6%. This risk is significantly lower in non-smokers: 1.3% in men and 1.4% in women.<ref name="Villeneuve">{{cite journal | last =Villeneuve | first =PJ | coauthors =Mao Y | title =Lifetime probability of developing lung cancer, by smoking status, Canada | journal =Canadian Journal of Public Health | volume =85 | issue =6 | pages =385–388 | publisher = | date =Nov 1994 | pmid =7895211 }}</ref> Cigarette smoke contains over 60 known carcinogens<ref name="Hecht">{{cite journal | last =Hecht | first =S | title =Tobacco carcinogens, their biomarkers and tobacco-induced cancer | journal =Nature Reviews. Cancer | volume =3 | issue =10 | pages =733–744 | publisher =Nature Publishing Group | date =Oct 2003 | url =http://www.nature.com/nrc/journal/v3/n10/abs/nrc1190_fs.html;jsessionid=A78B217DFCAD36DD965F2DBA685CF121 | doi =10.1038/nrc1190 |pmid =14570033 | accessdate =2007-08-10 }}</ref> including [[radioisotopes]] from the [[radon]] decay sequence, [[nitrosamine]], and[[benzopyrene]].
=== Field of Injury and Field Cancerization ===


Additionally, nicotine appears to depress the immune response to malignant growths in exposed tissue. The length of time a person smokes as well as the amount smoked increases the person's chance of developing lung cancer. If a person stops smoking, this chance steadily decreases as damage to the lungs is repaired and contaminant particles are gradually removed. Across the developed world, almost 90% of lung cancer deaths are caused by smoking.<ref name="Peto">{{cite book | last = Peto R | first = R | coauthors = Lopez AD, Boreham J et al. | title = Mortality from smoking in developed countries 1950–2000: Indirect estimates from National Vital Statistics | publisher = Oxford University Press | date = 2006 | url=http://www.ctsu.ox.ac.uk/~tobacco/ | id = ISBN 0-19-262535-7 |accessdate =2007-08-10 }}</ref>  
*[[Premalignant condition|Preneoplastic lung lesions]] frequently extend throughout the [[respiratory epithelium]], indicating a field effect in which much of the [[respiratory epithelium]] has been [[Mutagen|mutagenized]], presumably from exposure to [[tobacco]]-related [[Carcinogen|carcinogens]].<ref name="DevarakondaMorgensztern2015">{{cite journal|last1=Devarakonda|first1=Siddhartha|last2=Morgensztern|first2=Daniel|last3=Govindan|first3=Ramaswamy|title=Genomic alterations in lung adenocarcinoma|journal=The Lancet Oncology|volume=16|issue=7|year=2015|pages=e342–e351|issn=14702045|doi=10.1016/S1470-2045(15)00077-7}}</ref><ref name="pmid27006378">{{cite journal |vauthors=Kadara H, Scheet P, Wistuba II, Spira AE |title=Early Events in the Molecular Pathogenesis of Lung Cancer |journal=Cancer Prev Res (Phila) |volume=9 |issue=7 |pages=518–27 |date=July 2016 |pmid=27006378 |doi=10.1158/1940-6207.CAPR-15-0400 |url=}}</ref><ref name="AuerbachStout1961">{{cite journal|last1=Auerbach|first1=Oscar|last2=Stout|first2=A. P.|last3=Hammond|first3=E. Cuyler|last4=Garfinkel|first4=Lawrence|title=Changes in Bronchial Epithelium in Relation to Cigarette Smoking and in Relation to Lung Cancer|journal=New England Journal of Medicine|volume=265|issue=6|year=1961|pages=253–267|issn=0028-4793|doi=10.1056/NEJM196108102650601}}</ref>
*[[Epithelium|Epithelial cells]] lining the entire [[respiratory tract]] that have been exposed to [[smoking]] show [[Molecular pathology|molecular alterations]] that may signify the onset of lung cancer, a [[paradigm]] known as the "airway field of injury”.
*
*[[Premalignant]] [[airway]] fields in the [[molecular]] [[pathogenesis]] of lung cancer:
**[[Smoking]] induces widespread [[Molecular pathology|molecular alterations]], such as [[gene expression]] changes in exposed [[Epithelium|epithelia]] throughout the [[Respiratory tract|respiratory tract.]]
** The [[airway]] field of [[injury]] can be seen in [[Smoking|smokers]] with or without lung cancer and is highly relevant for the identification of [[Tumor marker|markers]] for [[Minimally invasive adenocarcinoma of the lung|minimally invasive]] and early detection of lung cancer.
** The adjacent [[airway]] field of [[Oncogenesis|carcinoma]] represents the field in normal appearing [[Airway|airways]] adjacent to [[lung]] [[Tumor|tumors]].
** It has been suggested that in this adjacent field of [[tumor]], there is closer [[Molecular pathology|molecular genealogy]] between lung cancers and [[Airway|airways]] that are in closest proximity to the [[Tumor|tumors]] compared to [[Airway|airways]] that are more distant from the [[tumors]].
** The progression of the [[molecular]] [[airway]] field of [[injury]] to [[Precancerous|preneoplasia]] and [[lung]] [[malignancy]] is still not clear.
**[[Molecular pathology|Molecular changes]] involved in the development of the [[airway]] field of [[injury]] and changes mediating progression of this field to [[lung]] [[Precancerous|preneoplasia]] may help the identification of early [[Marker|markers]] for lung cancer detection and [[Chemoprophylaxis|chemoprevention]].


In addition, there is evidence that lung cancer in never-smokers has a better prognosis than in smokers,<ref name="Nordquist">{{cite journal | last =Nordquist | first =LT | authorlink = | coauthors =Simon GR, Cantor A et al. | title =Improved survival in never-smokers vs current smokers with primary adenocarcinoma of the lung | journal =Chest | volume =126 | issue =2 | pages =347–351| publisher = American College of Chest Physicians | date =Aug 2004 | url =http://www.chestjournal.org/cgi/content/full/126/2/347 |pmid =15302716 | accessdate =2007-08-10 }}</ref> and that patients who smoke at the time of diagnosis have shorter survival than those who have quit.<ref name="Tammemagi">{{cite journal | last =Tammemagi | first =CM | authorlink = | coauthors =Neslund-Dudas C, Simoff M, Kvale P | title =Smoking and lung cancer survival: the role of comorbidity and treatment | journal =Chest | volume =125 |issue =1 | pages =27–37 | publisher =American College of Chest Physicians | date =Jan 2004 | url =http://www.chestjournal.org/cgi/content/full/125/1/27 | pmid =14718417 | accessdate =2007-08-10 }}</ref>
==Genetics==
*Lung cancer development is initiated by the activation of [[oncogene]]s or inactivation of [[tumor suppressor gene]]s.<ref name="Fong">{{cite journal | last =Fong | first =KM | coauthors = Sekido Y, Gazdar AF, Minna JD | title =Lung cancer. 9: Molecular biology of lung cancer: clinical implications | journal =Thorax | volume =58 | issue =10 | pages =892–900 | publisher = BMJ Publishing Group Ltd. | date =Oct 2003 | pmid =14514947 }}</ref>
*[[Mutation]]s in the ''[[Ras|K-ras]]'' [[proto-oncogene]] are responsible for 20% to 30% of non-small cell lung cancer cases.<ref name="Aviel-Ronen">{{cite journal | last =Aviel-Ronen | first =S | coauthors = Blackhall FH, Shepherd FA, Tsao MS | title =K-ras mutations in non-small-cell lung carcinoma: a review | journal =Clinical Lung Cancer | volume =8 | issue =1 | pages =30–38 |publisher =Cancer Information Group | date =Jul 2006 | pmid =16870043 }}</ref><ref name="pmid23122493">{{cite journal |vauthors=Karachaliou N, Mayo C, Costa C, Magrí I, Gimenez-Capitan A, Molina-Vila MA, Rosell R |title=KRAS mutations in lung cancer |journal=Clin Lung Cancer |volume=14 |issue=3 |pages=205–14 |year=2013 |pmid=23122493 |doi=10.1016/j.cllc.2012.09.007 |url=}}</ref>
*[[Chromosome|Chromosomal]] damage may also result in the [[loss of heterozygosity]], which subsequently leads to the inactivation of [[tumor suppressor genes]].
*Damage to the following [[chromosomes]] are particularly common in small cell lung carcinoma:
**[[Chromosome 3|Chromosome 3p]]
**[[Chromosome 5 (human)|Chromosome 5q]]
**[[Chromosome 13|Chromosome 13q]]
**[[Chromosome 17 (human)|Chromosome 17p]]
*The ''[[TP53]]'' [[tumor suppressor gene]], located on [[chromosome]] 17p, is often [[mutated]] in lung cancers.<ref name="Devereux">{{cite journal | last =Devereux | first =TR | coauthors = Taylor JA, Barrett JC | title =Molecular mechanisms of lung cancer. Interaction of environmental and genetic factors | journal =Chest | volume =109 | issue =Suppl. 3 | pages =14S-19S | publisher =American College of Chest Physicians | date =Mar 1996 | url =http://www.chestjournal.org/cgi/reprint/109/3/14S| pmid =8598134 | accessdate =2007-08-11 }}</ref>
*Several [[genetic polymorphism]]s are associated with lung cancer. These include [[polymorphisms]] in [[gene]]s coding for:<ref name="Engels">{{cite journal | last =Engels | first =EA | coauthors =Wu X, Gu J et al. | title =Systematic evaluation of genetic variants in the inflammation pathway and risk of lung cancer | journal =Cancer Research | volume =67 | issue =13 | pages =6520–6527 | publisher =American Association for Cancer Research | date =Jul 2007 | pmid =17596594 }}</ref><ref name="Wenzlaff">{{cite journal | last =Wenzlaff | first =AS | coauthors =Cote ML, Bock CH et al. | title =CYP1A1 and CYP1B1 polymorphisms and risk of lung cancer among never smokers: a population-based study | journal =Carcinogenesis | volume =26 |issue =12 | pages =2207–2212 | publisher =Oxford University Press | date =Dec 2005 | pmid =16051642 }}</ref><ref name="Son">{{cite journal | last =Son | first =JW | coauthors =Kang HK, Chae MH et al. | title =Polymorphisms in the caspase-8 gene and the risk of lung cancer | journal =Cancer Genetics and Cytogenetics | volume =169 | issue =2 | pages =121–127 | date =Sep 2006 | pmid =16938569 }}</ref><ref name="Yin">{{cite journal | last =Yin | first =J | coauthors =Vogel U, Ma Y et al. | title =The DNA repair gene XRCC1 and genetic susceptibility of lung cancer in a northeastern Chinese population | journal =Lung Cancer | volume =56 | issue =2 | pages =153–160 | date =May 2007 |pmid =17316890 }}</ref>  
**[[Interleukin 1|Interleukin-1]]
**[[Cytochrome P450]]
**[[Caspase]]-8, an [[apoptosis]] promoter
**[[XRCC1]], a [[DNA]] repair molecule
*Individuals with these [[polymorphisms]] are thought to be more likely to develop lung cancer following exposure to [[Carcinogen|carcinogens]].


[[Tobacco smoking#Passive smoking|Passive smoking]]&mdash;the inhalation of smoke from another's smoking&mdash;is a cause of lung cancer in non-smokers. Studies from the U.S.,<ref>{{cite web | last =CDC | authorlink =Centers for Disease Control and Prevention |title =1986 Surgeon General's report: the health consequences of involuntary smoking | publisher =CDC | date =Dec 1986 | url =http://www.cdc.gov/mmwr/preview/mmwrhtml/00000837.htm | pmid =3097495 | accessdate =2007-08-10 }}<br />* {{cite book | last =National Research Council | title =Environmental tobacco smoke: measuring exposures and assessing health effects | publisher =National Academy Press | date =1986 | url =http://www.nap.edu/catalog.php?record_id=943#toc | isbn =0-309-07456-8 }}<br />* {{cite paper | author =EPA | authorlink=United States Environmental Protection Agency | title =Respiratory health effects of passive smoking: lung cancer and other disorders | publisher =EPA | date =1992 | url =http://cfpub2.epa.gov/ncea/cfm/recordisplay.cfm?deid=2835 | accessdate =2007-08-10 }}<br />* {{cite journal | last =California Environmental Protection Agency | title =Health effects of exposure to environmental tobacco smoke | journal =Tobacco Control | volume =6 | issue =4 | pages =346–353 | date =1997 |url =http://www.druglibrary.org/schaffer/tobacco/caets/ets-main.htm | pmid =9583639 | accessdate =2007-08-10 }}<br />* {{cite journal | last =CDC | authorlink=Centers for Disease Control and Prevention | title =State-specific prevalence of current cigarette smoking among adults, and policies and attitudes about secondhand smoke—United States, 2000 | journal =Morbidity and Mortality Weekly Report | volume =50 | issue =49 | pages =1101–1106 | publisher =CDC | date =Dec 2001 | url =http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5049a1.htm | pmid =11794619 | accessdate =2007-08-10 }}<br />* {{cite journal | last =Alberg | first =AJ | coauthors =Samet JM | title =Epidemiology of lung cancer | journal =Chest | volume =123 | issue =S1 | pages =21S-49S | publisher =American College of Chest Physicians | date =Jan 2003 | url =http://www.chestjournal.org/cgi/content/full/123/1_suppl/21S | pmid =12527563 | accessdate =2007-08-10 }}</ref> Europe,<ref name="Boffetta">{{cite journal | last =Boffetta | first =P | coauthors = Agudo A, Ahrens W et al. | title =Multicenter case-control study of exposure to environmental tobacco smoke and lung cancer in Europe | journal =Journal of the National Cancer Institute |volume =90 | issue =19 | pages =1440–1450 | publisher =Oxford University Press | date =Oct 1998 | url =http://jnci.oxfordjournals.org/cgi/reprint/90/19/1440 | pmid =9776409 | accessdate =2007-08-10 }}</ref> the UK,<ref name="Committee">{{cite web | title =Report of the Scientific Committee on Tobacco and Health | publisher =Department of Health |date =Mar 1998 | url =http://www.archive.official-documents.co.uk/document/doh/tobacco/contents.htm | accessdate =2007-07-09 }}<br />* {{cite journal | last =Hackshaw | first =AK | title =Lung cancer and passive smoking | journal =Statistical Methods in Medical Research | volume =7 | issue =2 | pages =119–136 | date =Jun 1998 | pmid =9654638 }}</ref> and Australia<ref name="NHMRC">{{cite paper | author =National Health and Medical Research Council | title =The health effects and regulation of passive smoking |publisher =Australian Government Publishing Service | date =Apr 1994 | url =http://www.obpr.gov.au/publications/submission/healthef/index.html | accessdate =2007-08-10 }}</ref> have consistently shown a significant increase in [[relative risk]] among those exposed to passive smoke. Recent investigation of sidestream smoke suggests it is more dangerous than direct smoke inhalation.<ref name="Schick">{{cite journal | last=Schick | first=S |coauthors=Glantz S|title=Philip Morris toxicological experiments with fresh sidestream smoke: more toxic than mainstream smoke |journal=Tobacco Control |volume=14 |issue=6 |pages=396–404 |date =Dec 2005 | pmid =16319363 }}</ref>
==Environment==
Although genetics play a significant role in the [[pathogenesis]] of lung cancer, it is thought that exposure to environmental [[Risk factor|risk factors]] plays an equally important role in the development of lung cancer. The main causes of lung cancer include [[carcinogen]]s (such as those present in [[tobacco smoke]]), [[ionizing radiation]], and [[virus (biology)|viral]] infections. [[Chronic (medical)|Chronic]] exposure results in cumulative alterations to the [[DNA]] in the [[Tissue (biology)|tissue]] lining the [[bronchi]] of the [[Lung|lungs]] (the [[bronchial]] [[epithelium]]). Irreversible [[DNA]] changes following exposure to [[carcinogens]] are directly associated with the development of lung cancer.<ref name="pmid22054876">{{cite journal |vauthors=Dela Cruz CS, Tanoue LT, Matthay RA |title=Lung cancer: epidemiology, etiology, and prevention |journal=Clin. Chest Med. |volume=32 |issue=4 |pages=605–44 |year=2011 |pmid=22054876 |pmc=3864624 |doi=10.1016/j.ccm.2011.09.001 |url=}}</ref>


===Radon gas===
===Smoking===
[[Radon]] is a colorless and odorless [[gas]] generated by the breakdown of radioactive [[radium]], which in turn is the decay product of [[uranium]], found in the earth's crust. The radiation decay products [[ion]]ize genetic material, causing mutations that sometimes turn cancerous. Radon exposure is the second major cause of lung cancer after smoking.<ref name="Catelinois">{{cite journal | last =Catelinois | first =O | coauthors = Rogel A, Laurier D et al. | title =Lung Cancer Attributable to Indoor Radon Exposure in France: Impact of the Risk Models and Uncertainty Analysis | journal =Environmental Health Perspectives | volume =114 |issue =9 | pages =1361–1366 | publisher =National Institute of Environmental Health Science | date =May 2006 | url =http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16966089 | doi =10.1289/ehp.9070 | pmid =16966089 |accessdate =2007-08-10 }}</ref>
*[[Cigarette]] [[smoking]] is a leading cause of lung cancer.<ref name="pmid10413421">{{cite journal |vauthors=Hecht SS |title=Tobacco smoke carcinogens and lung cancer |journal=J. Natl. Cancer Inst. |volume=91 |issue=14 |pages=1194–210 |year=1999 |pmid=10413421 |doi= |url=}}</ref><ref>Kluger, R. (1996). Ashes to ashes: America's hundred-year cigarette war, the public health, and the unabashed triumph of Philip Morris. New York: Alfred A. Knopf.</ref><ref>{{cite book | last = Proctor | first = Robert | title = The Nazi war on cancer | publisher = Princeton University Press | location = Princeton, N.J. Oxford | year = 2000 | isbn = 978-0691070513 }}</ref><ref name="Morabia2012">{{cite journal|last1=Morabia|first1=Alfredo|title=Quality, originality, and significance of the 1939 “Tobacco consumption and lung carcinoma” article by Mueller, including translation of a section of the paper|journal=Preventive Medicine|volume=55|issue=3|year=2012|pages=171–177|issn=00917435|doi=10.1016/j.ypmed.2012.05.008}}</ref><ref>Mueller F. Tabakmissbrauch und Lungencarcinom. Z. Krebsforsch. 1939;49:57–85.</ref><ref>Wynder, E. L. (1994). Prevention and cessation of tobacco use: Obstacles and challenges. J. Smoking-Related Dis. 5(Suppl. 1), 3–8.</ref><ref>Hanspeter Witschi ITEH and Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, California 95616</ref><ref name="Hecht">{{cite journal | last =Hecht | first =S | title =Tobacco carcinogens, their biomarkers and tobacco-induced cancer | journal =Nature Reviews. Cancer | volume =3 | issue =10 | pages =733–744 | publisher =Nature Publishing Group | date =Oct 2003 | url =http://www.nature.com/nrc/journal/v3/n10/abs/nrc1190_fs.html;jsessionid=A78B217DFCAD36DD965F2DBA685CF121 | doi =10.1038/nrc1190 |pmid =14570033 | accessdate =2007-08-10 }}</ref><ref name="Nordquist">{{cite journal | last =Nordquist | first =LT | authorlink = | coauthors =Simon GR, Cantor A et al. | title =Improved survival in never-smokers vs current smokers with primary adenocarcinoma of the lung | journal =Chest | volume =126 | issue =2 | pages =347–351| publisher = American College of Chest Physicians | date =Aug 2004 | url =http://www.chestjournal.org/cgi/content/full/126/2/347 |pmid =15302716 | accessdate =2007-08-10 }}</ref><ref name="Peto">{{cite book | last = Peto R | first = R | coauthors = Lopez AD, Boreham J et al. | title = Mortality from smoking in developed countries 1950–2000: Indirect estimates from National Vital Statistics | publisher = Oxford University Press | date = 2006 | url=http://www.ctsu.ox.ac.uk/~tobacco/ | id = ISBN 0-19-262535-7 |accessdate =2007-08-10 }}</ref>
*[[Cigarette smoke]] contains over 60 known [[Carcinogen|carcinogens]] including [[radioisotopes]] from the [[radon]] decay sequence, [[nitrosamine]], and [[benzopyrene]].
*[[Nicotine]] is thought to reduce the [[immune response]] to [[malignant]] growths in the exposed [[Tissue (biology)|tissue]]. The length of time an individual [[Smoking|smokes]], as well as the amount, significantly increases the person's chance of developing lung cancer.
*Among individuals who stopped [[smoking]], the risk of lung cancer steadily decreases as [[lung]] [[Tissue (biology)|tissue]] repairs itself and as contaminant particles are eliminated from the [[lungs]].
*It is thought that the risk of lung cancer among persons with a history of [[smoking]] (even when stopped) is always higher than those who never [[Smoke|smoked]].


Radon gas levels vary by locality and the composition of the underlying soil and rocks. For example, in areas such as Cornwall in the UK (which has granite as substrata), radon gas is a major problem, and buildings have to be force-ventilated with fans to lower radon gas concentrations. The [[United States Environmental Protection Agency]] (EPA) estimates that one in 15 homes in the U.S. has radon levels above the recommended guideline of 4 pico[[Curie]]s per liter (pCi/L).<ref name="EPA radon">{{cite web | last =EPA |authorlink =United States Environmental Protection Agency | title =Radiation information: radon | publisher =EPA | date =Oct 2006 |url =http://www.epa.gov/radiation/radionuclides/radon.htm | accessdate =2007-08-11 }}</ref> Iowa has the highest average radon concentration in the United States; studies performed there have demonstrated a 50% increased lung cancer risk with prolonged radon exposure above the EPA's action level of 4 pCi/L.<ref name="Field">{{cite journal | last =Field | first =RW | coauthors = Steck DJ, Smith BJ et al. | title =Residential radon gas exposure and lung cancer: the Iowa Radon Lung Cancer Study | journal =American Journal of Epidemiology | volume =151 | issue =11 | pages =1091–1102 | publisher =Oxford Journals | date =Jun 2000 | url =http://aje.oxfordjournals.org/cgi/reprint/151/11/1091  | pmid =10873134 | accessdate =2007-08-11 }}</ref><ref name="EPA Iowa">{{cite web | last =EPA | authorlink =United States Environmental Protection Agency | title =Iowa Radon Lung Cancer Study |publisher =EPA | date =Jun 2000 | url =http://www.epa.gov/radon/iowastudy.html | accessdate =2007-08-11 }}</ref>
===Radon Gas===
The association of [[radon]] [[gas]] exposure to lung cancer is described below:<ref name="Catelinois">{{cite journal | last =Catelinois | first =O | coauthors = Rogel A, Laurier D et al. | title =Lung Cancer Attributable to Indoor Radon Exposure in France: Impact of the Risk Models and Uncertainty Analysis | journal =Environmental Health Perspectives | volume =114 |issue =9 | pages =1361–1366 | publisher =National Institute of Environmental Health Science | date =May 2006 | url =http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16966089 | doi =10.1289/ehp.9070 | pmid =16966089 |accessdate =2007-08-10 }}</ref><ref name="radon">University of Minnesota.http://enhs.umn.edu/hazards/hazardssite/radon/radonmolaction.html#Anchor-Molecular-23240/</ref>
*[[Radon]] is a colorless and odorless [[gas]] generated by the breakdown of [[radioactive]] [[radium]] (decay product of [[uranium]]) found in the Earth's crust. The [[radiation]] decay products [[Ionization|ionize]] [[genetic]] material, causing [[mutations]] that sometimes turn [[cancerous]].
*[[Radon]] exposure is the second major cause of lung cancer following [[smoking]].
*The [[Mechanism (biology)|mechanism]] of [[lung]] damage following [[radon]] exposure is not thought to be due to the [[radon]] [[gas]] itself, but due to the short-lived alpha decay products that cause [[Cell (biology)|cellular]] damage and [[DNA]] [[mutations]].


=== Asbestos ===
===Asbestos===
[[Asbestos]] can cause a variety of lung diseases, including lung cancer. There is a synergistic effect between tobacco smoking and asbestos in the formation of lung cancer.<ref name="O'Reilly">{{cite journal | last=O'Reilly | first=KM | coauthors =Mclaughlin AM, Beckett WS, Sime PJ | title =Asbestos-related lung disease | journal=American Family Physician | volume=75 | issue=5 | pages=683–688| date=Mar 2007 | url=http://www.aafp.org/afp/20070301/683.html | pmid=17375514 | accessdate=2007-08-18 }}</ref> In the UK, asbestos accounts for 2–3% of male lung cancer deaths.<ref name="Darnton">{{cite journal | last=Darnton | first=AJ | coauthors =McElvenny DM, Hodgson JT | title =Estimating the number of asbestos-related lung cancer deaths in Great Britain from 1980 to 2000 | journal=Annals of Occupational Hygiene | volume=50 | issue=1 | pages=29–38 | date=Jan 2006 |url=http://annhyg.oxfordjournals.org/cgi/content/full/50/1/29 | pmid=16126764 | accessdate=2007-09-07 }}</ref> Asbestos can also cause cancer of the [[pleura]], called [[mesothelioma]] (which is different from lung cancer).
*[[Asbestos]] exposure is associated with many [[lung diseases]], including lung cancer.<ref name="JärvholmÅström2014">{{cite journal|last1=Järvholm|first1=Bengt|last2=Åström|first2=Evelina|title=The Risk of Lung Cancer After Cessation of Asbestos Exposure in Construction Workers Using Pleural Malignant Mesothelioma as a Marker of Exposure|journal=Journal of Occupational and Environmental Medicine|volume=56|issue=12|year=2014|pages=1297–1301|issn=1076-2752|doi=10.1097/JOM.0000000000000258}}</ref>
*Tiny [[asbestos]] fibers released into the [[air]] are [[Breathing|breathed]] into the [[lungs]]. The fibers become lodged in the [[lungs]] and are stuck for an indefinite amount of time. They can eventually lead to [[Scar|scarring]] and [[inflammation]].


=== Viruses ===
=== Viruses ===
[[Virus]]es are known to cause lung cancer in animals<ref name="Leroux">{{cite journal | last =Leroux | first =C | coauthors =Girard N, Cottin V et al. | title =Jaagsiekte Sheep Retrovirus (JSRV): from virus to lung cancer in sheep |journal =Veterinary Research |volume =38 | issue =2 | pages =211–228 | date =Mar-Apr 2007 | pmid =17257570 }}</ref><ref name="Palmarini">{{cite journal | last =Palmarini | first =M | coauthors =Fan H | title =Retrovirus-induced ovine pulmonary adenocarcinoma, an animal model for lung cancer| journal =Journal of the National Cancer Institute | volume =93 | issue =21 | pages =1603–1614 | publisher =Oxford University Press| date =November 2001 | url =http://jnci.oxfordjournals.org/cgi/content/full/93/21/1603 | pmid =11698564 | accessdate =2007-08-11}}</ref> and recent evidence suggests similar potential in humans. Implicated viruses include [[human papillomavirus]],<ref name="Cheng">{{cite journal | last =Cheng | first =YW | coauthors = Chiou HL, Sheu GT et al. | title =The association of human papillomavirus 16/18 infection with lung cancer among nonsmoking Taiwanese women | journal =Cancer Research | volume =61 | issue =7| pages =2799–2803 | publisher = American Association for Cancer Research | date =Apr 2001 | url =http://cancerres.aacrjournals.org/cgi/content/full/61/7/2799 | pmid =11306446 | accessdate =2007-08-11 }}</ref> [[JC virus]],<ref name="Zheng">{{cite journal | last =Zheng | first =H | coauthors =Aziz HA, Nakanishi Y et al. | title =Oncogenic role of JC virus in lung cancer | journal =Journal of Pathology | volume =212 | issue =3 | pages =306–315 | date =May 2007 | pmid =17534844 }}</ref>[[SV40|simian virus 40]] (SV40), [[BK virus]] and [[cytomegalovirus]].<ref name="Giuliani">{{cite journal | last =Giuliani | first =L | coauthors =Jaxmar T, Casadio C et al. | title =Detection of oncogenic viruses (SV40, BKV, JCV, HCMV, HPV) and p53 codon 72 polymorphism in lung carcinoma | journal =Lung Cancer | volume=57 | issue=3 | pages=273–281 | date =Sep 2007 | pmid =17400331}}</ref> These viruses may affect the [[cell cycle]] and inhibit [[apoptosis]], allowing uncontrolled cell division.
*[[Virus]]es known to be associated with the development of lung cancer in [[animals]] and [[Human|humans]] include:<ref name="Leroux">{{cite journal | last =Leroux | first =C | coauthors =Girard N, Cottin V et al. | title =Jaagsiekte Sheep Retrovirus (JSRV): from virus to lung cancer in sheep |journal =Veterinary Research |volume =38 | issue =2 | pages =211–228 | date =Mar-Apr 2007 | pmid =17257570 }}</ref><ref name="Palmarini">{{cite journal | last =Palmarini | first =M | coauthors =Fan H | title =Retrovirus-induced ovine pulmonary adenocarcinoma, an animal model for lung cancer| journal =Journal of the National Cancer Institute | volume =93 | issue =21 | pages =1603–1614 | publisher =Oxford University Press| date =November 2001 | url =http://jnci.oxfordjournals.org/cgi/content/full/93/21/1603 | pmid =11698564 | accessdate =2007-08-11}}</ref><ref name="Cheng">{{cite journal | last =Cheng | first =YW | coauthors = Chiou HL, Sheu GT et al. | title =The association of human papillomavirus 16/18 infection with lung cancer among nonsmoking Taiwanese women | journal =Cancer Research | volume =61 | issue =7| pages =2799–2803 | publisher = American Association for Cancer Research | date =Apr 2001 | url =http://cancerres.aacrjournals.org/cgi/content/full/61/7/2799 | pmid =11306446 | accessdate =2007-08-11 }}</ref><ref name="Zheng">{{cite journal | last =Zheng | first =H | coauthors =Aziz HA, Nakanishi Y et al. | title =Oncogenic role of JC virus in lung cancer | journal =Journal of Pathology | volume =212 | issue =3 | pages =306–315 | date =May 2007 | pmid =17534844 }}</ref><ref name="Giuliani">{{cite journal | last =Giuliani | first =L | coauthors =Jaxmar T, Casadio C et al. | title =Detection of oncogenic viruses (SV40, BKV, JCV, HCMV, HPV) and p53 codon 72 polymorphism in lung carcinoma | journal =Lung Cancer | volume=57 | issue=3 | pages=273–281 | date =Sep 2007 | pmid =17400331}}</ref><ref name="Engels 2">Eric A Engels.11/30/11. Inflammation in the development of lung cancer:epidemiological evidence.Expert Review of Anticancer Therapy.Apr.2008.p605</ref>
**[[Human papillomavirus]]
**[[JC virus]]
**[[SV40|Simian virus 40 (SV40)]]
**[[BK virus]]
**[[Cytomegalovirus]]
**[[HIV]]
*These [[viruses]] may affect the [[cell cycle]] and [[Inhibition|inhibit]] [[apoptosis]], allowing uncontrolled [[cell division]].
*[[HIV]] has also been thought to increase the risk of developing lung cancer. Although the [[Mechanism (biology)|mechanism]] is unknown, [[HIV]] is thought to be associated with a state of [[Chronic (medical)|chronic]] [[lung]] [[inflammation]] that may potentiate [[cellular]] damage and [[DNA mutations]].
 
===Infection and Inflammation===
*There may be a correlation between general [[inflammation]] of [[lung]] [[Tissue (biology)|tissue]] and the development of lung cancer.<ref name="Engels 2" />
*[[Neutrophils]] are released in response to [[bacterial]] [[infection]] and are considered to be the initial responders during [[inflammation]].
*The [[hypothesis]] is that [[neutrophils]] may activate [[Reactive oxygen species|reactive oxygen]] or [[nitrogen]] species, which can bind to [[DNA]] and lead to [[genomic]] alterations. Accordingly, [[inflammation]] may be thought of as an initiator or [[promoter]] of lung cancer development. Also, [[Tissue (biology)|tissue]] repair from [[inflammation]] is associated with [[cellular]] [[Cell growth|proliferation]]. During [[cellular]] [[proliferation]] there may be errors in [[chromosomal]] [[replication]] that can cause further [[DNA mutations|DNA mutation]].
*[[Angiogenesis]], a significant process during [[tumor]] growth, may be promoted by [[Chronic (medical)|chronic]] states of [[inflammation]], which often require increased [[blood flow]] to sites of [[inflammation]].


==Gross Pathology Images==
[[File:Cancerous lung.jpg|left|thumb|250px|Cross section of a human lung. The white area in the upper lobe is cancer; the black areas indicate the patient was a smoker]]
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==References==
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Latest revision as of 20:22, 2 July 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kim-Son H. Nguyen M.D. Cafer Zorkun, M.D., Ph.D. [2] Dildar Hussain, MBBS [3] Michael Maddaleni, B.S.

Overview

The pathophysiology of lung cancer includes both genetic and environmental factors. Causality of the majority of lung cancer is linked to tobacco usage. Carcinogenic effects of tobacco smoking may result in DNA mis-replication and mutation. Smoking starts a cascade of events that leads to cancer development, even decades after smoking cessation. Besides smokers, patients with the history of prior respiratory tract or gastrointestinal tract cancer comprise a high-risk population. Other environmental factors include radon, asbestos, viral infections, and states of chronic lung inflammation, all of which may predispose to cellular damage and DNA mutations that predispose to the development of lung cancers.

Pathophysiology

The pathophysiology of lung cancer includes both genetic and environmental factors.[1][2][3]

Lung Cancer Pathogenesis

Familial lung cancer
Multistep tumorigenesis
Accumulation of Molecular Abnormalities

Field of Injury and Field Cancerization

Genetics

Environment

Although genetics play a significant role in the pathogenesis of lung cancer, it is thought that exposure to environmental risk factors plays an equally important role in the development of lung cancer. The main causes of lung cancer include carcinogens (such as those present in tobacco smoke), ionizing radiation, and viral infections. Chronic exposure results in cumulative alterations to the DNA in the tissue lining the bronchi of the lungs (the bronchial epithelium). Irreversible DNA changes following exposure to carcinogens are directly associated with the development of lung cancer.[16]

Smoking

Radon Gas

The association of radon gas exposure to lung cancer is described below:[27][28]

Asbestos

Viruses

Infection and Inflammation

References

  1. ↑ Kanwal, Madiha; Ding, Xiao-Ji; Cao, Yi (2017). "Familial risk for lung cancer". Oncology Letters. 13 (2): 535–542. doi:10.3892/ol.2016.5518. ISSN 1792-1074.
  2. ↑ Kadara, H.; Scheet, P.; Wistuba, I. I.; Spira, A. E. (2016). "Early Events in the Molecular Pathogenesis of Lung Cancer". Cancer Prevention Research. 9 (7): 518–527. doi:10.1158/1940-6207.CAPR-15-0400. ISSN 1940-6207.
  3. ↑ Raso, Maria Gabriela; Wistuba, Ignacio I. (2007). "Molecular Pathogenesis of Early-Stage Non-small Cell Lung Cancer and a Proposal for Tissue Banking to Facilitate Identification of New Biomarkers". Journal of Thoracic Oncology. 2 (7): S128–S135. doi:10.1097/JTO.0b013e318074fe42. ISSN 1556-0864.
  4. ↑ Wistuba II, Gazdar AF (2006). "Lung cancer preneoplasia". Annu Rev Pathol. 1: 331–48. doi:10.1146/annurev.pathol.1.110304.100103. PMID 18039118.
  5. ↑ Devarakonda, Siddhartha; Morgensztern, Daniel; Govindan, Ramaswamy (2015). "Genomic alterations in lung adenocarcinoma". The Lancet Oncology. 16 (7): e342–e351. doi:10.1016/S1470-2045(15)00077-7. ISSN 1470-2045.
  6. ↑ Kadara H, Scheet P, Wistuba II, Spira AE (July 2016). "Early Events in the Molecular Pathogenesis of Lung Cancer". Cancer Prev Res (Phila). 9 (7): 518–27. doi:10.1158/1940-6207.CAPR-15-0400. PMID 27006378.
  7. ↑ Auerbach, Oscar; Stout, A. P.; Hammond, E. Cuyler; Garfinkel, Lawrence (1961). "Changes in Bronchial Epithelium in Relation to Cigarette Smoking and in Relation to Lung Cancer". New England Journal of Medicine. 265 (6): 253–267. doi:10.1056/NEJM196108102650601. ISSN 0028-4793.
  8. ↑ Fong, KM (Oct 2003). "Lung cancer. 9: Molecular biology of lung cancer: clinical implications". Thorax. BMJ Publishing Group Ltd. 58 (10): 892–900. PMID 14514947. Unknown parameter |coauthors= ignored (help)
  9. ↑ Aviel-Ronen, S (Jul 2006). "K-ras mutations in non-small-cell lung carcinoma: a review". Clinical Lung Cancer. Cancer Information Group. 8 (1): 30–38. PMID 16870043. Unknown parameter |coauthors= ignored (help)
  10. ↑ Karachaliou N, Mayo C, Costa C, Magrí I, Gimenez-Capitan A, Molina-Vila MA, Rosell R (2013). "KRAS mutations in lung cancer". Clin Lung Cancer. 14 (3): 205–14. doi:10.1016/j.cllc.2012.09.007. PMID 23122493.
  11. ↑ Devereux, TR (Mar 1996). "Molecular mechanisms of lung cancer. Interaction of environmental and genetic factors". Chest. American College of Chest Physicians. 109 (Suppl. 3): 14S–19S. PMID 8598134. Retrieved 2007-08-11. Unknown parameter |coauthors= ignored (help)
  12. ↑ Engels, EA (Jul 2007). "Systematic evaluation of genetic variants in the inflammation pathway and risk of lung cancer". Cancer Research. American Association for Cancer Research. 67 (13): 6520–6527. PMID 17596594. Unknown parameter |coauthors= ignored (help)
  13. ↑ Wenzlaff, AS (Dec 2005). "CYP1A1 and CYP1B1 polymorphisms and risk of lung cancer among never smokers: a population-based study". Carcinogenesis. Oxford University Press. 26 (12): 2207–2212. PMID 16051642. Unknown parameter |coauthors= ignored (help)
  14. ↑ Son, JW (Sep 2006). "Polymorphisms in the caspase-8 gene and the risk of lung cancer". Cancer Genetics and Cytogenetics. 169 (2): 121–127. PMID 16938569. Unknown parameter |coauthors= ignored (help)
  15. ↑ Yin, J (May 2007). "The DNA repair gene XRCC1 and genetic susceptibility of lung cancer in a northeastern Chinese population". Lung Cancer. 56 (2): 153–160. PMID 17316890. Unknown parameter |coauthors= ignored (help)
  16. ↑ Dela Cruz CS, Tanoue LT, Matthay RA (2011). "Lung cancer: epidemiology, etiology, and prevention". Clin. Chest Med. 32 (4): 605–44. doi:10.1016/j.ccm.2011.09.001. PMC 3864624. PMID 22054876.
  17. ↑ Hecht SS (1999). "Tobacco smoke carcinogens and lung cancer". J. Natl. Cancer Inst. 91 (14): 1194–210. PMID 10413421.
  18. ↑ Kluger, R. (1996). Ashes to ashes: America's hundred-year cigarette war, the public health, and the unabashed triumph of Philip Morris. New York: Alfred A. Knopf.
  19. ↑ Proctor, Robert (2000). The Nazi war on cancer. Princeton, N.J. Oxford: Princeton University Press. ISBN 978-0691070513.
  20. ↑ Morabia, Alfredo (2012). "Quality, originality, and significance of the 1939 "Tobacco consumption and lung carcinoma" article by Mueller, including translation of a section of the paper". Preventive Medicine. 55 (3): 171–177. doi:10.1016/j.ypmed.2012.05.008. ISSN 0091-7435.
  21. ↑ Mueller F. Tabakmissbrauch und Lungencarcinom. Z. Krebsforsch. 1939;49:57–85.
  22. ↑ Wynder, E. L. (1994). Prevention and cessation of tobacco use: Obstacles and challenges. J. Smoking-Related Dis. 5(Suppl. 1), 3–8.
  23. ↑ Hanspeter Witschi ITEH and Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, California 95616
  24. ↑ Hecht, S (Oct 2003). "Tobacco carcinogens, their biomarkers and tobacco-induced cancer". Nature Reviews. Cancer. Nature Publishing Group. 3 (10): 733–744. doi:10.1038/nrc1190. PMID 14570033. Retrieved 2007-08-10.
  25. ↑ Nordquist, LT (Aug 2004). "Improved survival in never-smokers vs current smokers with primary adenocarcinoma of the lung". Chest. American College of Chest Physicians. 126 (2): 347–351. PMID 15302716. Retrieved 2007-08-10. Unknown parameter |coauthors= ignored (help)
  26. ↑ Peto R, R (2006). Mortality from smoking in developed countries 1950–2000: Indirect estimates from National Vital Statistics. Oxford University Press. ISBN 0-19-262535-7. Retrieved 2007-08-10. Unknown parameter |coauthors= ignored (help)
  27. ↑ Catelinois, O (May 2006). "Lung Cancer Attributable to Indoor Radon Exposure in France: Impact of the Risk Models and Uncertainty Analysis". Environmental Health Perspectives. National Institute of Environmental Health Science. 114 (9): 1361–1366. doi:10.1289/ehp.9070. PMID 16966089. Retrieved 2007-08-10. Unknown parameter |coauthors= ignored (help)
  28. ↑ University of Minnesota.http://enhs.umn.edu/hazards/hazardssite/radon/radonmolaction.html#Anchor-Molecular-23240/
  29. ↑ Järvholm, Bengt; Åström, Evelina (2014). "The Risk of Lung Cancer After Cessation of Asbestos Exposure in Construction Workers Using Pleural Malignant Mesothelioma as a Marker of Exposure". Journal of Occupational and Environmental Medicine. 56 (12): 1297–1301. doi:10.1097/JOM.0000000000000258. ISSN 1076-2752.
  30. ↑ Leroux, C (Mar–Apr 2007). "Jaagsiekte Sheep Retrovirus (JSRV): from virus to lung cancer in sheep". Veterinary Research. 38 (2): 211–228. PMID 17257570. Unknown parameter |coauthors= ignored (help)
  31. ↑ Palmarini, M (November 2001). "Retrovirus-induced ovine pulmonary adenocarcinoma, an animal model for lung cancer". Journal of the National Cancer Institute. Oxford University Press. 93 (21): 1603–1614. PMID 11698564. Retrieved 2007-08-11. Unknown parameter |coauthors= ignored (help)
  32. ↑ Cheng, YW (Apr 2001). "The association of human papillomavirus 16/18 infection with lung cancer among nonsmoking Taiwanese women". Cancer Research. American Association for Cancer Research. 61 (7): 2799–2803. PMID 11306446. Retrieved 2007-08-11. Unknown parameter |coauthors= ignored (help)
  33. ↑ Zheng, H (May 2007). "Oncogenic role of JC virus in lung cancer". Journal of Pathology. 212 (3): 306–315. PMID 17534844. Unknown parameter |coauthors= ignored (help)
  34. ↑ Giuliani, L (Sep 2007). "Detection of oncogenic viruses (SV40, BKV, JCV, HCMV, HPV) and p53 codon 72 polymorphism in lung carcinoma". Lung Cancer. 57 (3): 273–281. PMID 17400331. Unknown parameter |coauthors= ignored (help)
  35. ↑ 35.0 35.1 Eric A Engels.11/30/11. Inflammation in the development of lung cancer:epidemiological evidence.Expert Review of Anticancer Therapy.Apr.2008.p605

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