Lung cancer

1. Lung cancer

2. NSCLC Small cell lung cancer

3. Incidence Lung cancer common leading cause of cancer – related deaths worldwide. Second of ten sites of cancer in men(Thailand)

4. Etiology Smoking passive smoker has 1.5 fold increased risk Occupational : asbestos environmental radon, nickel diet : b-carotene in smoker

5. investigation Chest film: PA, lateral, apical CT chest Mediastinoscopy PET/CT scan Central lesion Sputum cytology bronchoscopy Peripheral lesion FNA

6. Sputum cytology high yield for central lesion & for squamous pathology 70% +ve after 3 samples

7. Pathology squamous cell (30%): can cavitate and mimic lung abscess adenoCA(40%): commonly seen subtype in non-smokers bronchioalveolar : higher in women, non-smoker, bilateral, multifocal large cell CA (10-15%) Peripheral lesion

8. PATHO

10. TNM T1= mass diameter=3 cms T2= = 3 cms or any size that Invade visceral pleura Atelectasis of less than entire lung Proximal < 2 cm from carina T3= any size that invade chest wall, diaphragm, mediastinal pleura, pericardium Atelectasis entire lung Proximan within 2 cm from carina T4 = invade mediastinum, great vessel, trachea, esophagus, vertebral body, carina Presence malignant pleura, pericardial effusion, pleural effusion Satellite tumor in same lobe

11. TNM N N1 = ipsilateral hilar, peribronchial node N2= ipsilateral mediastinal, subcarinal node N3= contralaterl mediastinal, hilar node Ipsilateral/contralateral scalene, SPC

12. LN

13. Survival by staging

15. Prognosis stage Performance status weight loss > 10% in 6 months systemic sx histology large cell & adeno =>bad squamous & bronchoalveolar => better sex : women better

16. Treatment Surgery: Lobectomy : stage IIIa Radiotherapy Chemotherapy

17. SURGERY FOR LUNG CANCER

18. Patient selection to Sx FEV1 & DLCO > 60 % => LOW RISK FEV1 & DLCO < 60 % => V/Q scan for pulmonary reserve FEV1 & DLCO < 40 % if maximal O2 consumption > 15 ml/kg can Sx with acceptable risk FEV1 & DLCO < 40 % and maximal O2 consumption < 15 ml/kg=> non surgical

19. Chemotherapy Adjuvant Neoadjuvant Induction Concurrent chemoRT Seq chemoRT Palliative chemotherapy

20. Pancoast’s syndrome Shoulder and arm pain Horner’s syndrome (ipsilateral ptosis, miosis, anhidrosis) Weakness and atrophy of hand muscles Pain in C8-T2 distribution mass at apical lung : lordotic view +/- rib or vertebra destruction

21. Small cell lung cancer represents 15 - 25 percent of all lung cancers Occur common in smokers. Character : rapid doubling time, high growth fraction, and the early development of widespread metastases. Hilar and mediastinal adenopathy no role of surgery in general usually relapses within two years despite treatment.

22. Staging by the Veterans' Affairs Lung Study Group (VALSG) Limited disease : 60-70 percent Disease confined to ipsilateral hemithorax and within a single radiotherapy port Extensive disease :30-40 percent Any disease beyond limited disease sites 40. Small Cell Lung Cancer: Staging Because virtually all SCLC patients will receive chemotherapy, staging is not usually used as the basis for choosing primary treatment. For this reason, the simple 2-stage system of the Veterans Administration Lung Group has been adopted. In this system, patients are classified into limited or extensive disease stages. These stages are useful, however, in deciding whether additional local treatment, such as surgery or radiation, should be administered. In fact, the limited-stage disease area has been defined as the area that can be encompassed in one radiation port. Patients with malignant pleural effusion or supraclavicular node involvement have been classified as either limited or extensive disease stage by different treatment centers. 40. Small Cell Lung Cancer: Staging Because virtually all SCLC patients will receive chemotherapy, staging is not usually used as the basis for choosing primary treatment. For this reason, the simple 2-stage system of the Veterans Administration Lung Group has been adopted. In this system, patients are classified into limited or extensive disease stages. These stages are useful, however, in deciding whether additional local treatment, such as surgery or radiation, should be administered. In fact, the limited-stage disease area has been defined as the area that can be encompassed in one radiation port. Patients with malignant pleural effusion or supraclavicular node involvement have been classified as either limited or extensive disease stage by different treatment centers.

23. SMALL CELL LUNG CANCERSurvival by stage 45. Small Cell Lung Cancer: Survival by Stage SCLC is an aggressive disease characterized by rapid tumor progression and early metastatic spread. Patients randomized to supportive care in a clinical trial experienced extremely short median survival after diagnosis. Treatment does improve survival, and a subset of patients with limited stage disease may experience long-term survival with aggressive therapy. Long-term remissions are rarely seen in patients with extensive disease. 45. Small Cell Lung Cancer: Survival by Stage SCLC is an aggressive disease characterized by rapid tumor progression and early metastatic spread. Patients randomized to supportive care in a clinical trial experienced extremely short median survival after diagnosis. Treatment does improve survival, and a subset of patients with limited stage disease may experience long-term survival with aggressive therapy. Long-term remissions are rarely seen in patients with extensive disease.

24. Treatment Chemotherapy : Platinum based Radiotherapy Limited stage: Prophylaxis whole brain radiation

25. Parneoplastic syndromes Small cell lung cancer: Cushing’s syndromeSyndrome of inappropriate antidiuretic hormoneCarcinoid syndromeEncephalopathyEaton-Lambert syndrome Adenocarcinoma Clubbing of digitsPulmonary hypertrophic osteoarthropathy Squamous cell lung Hypercalcemia