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I-ELCAP

. 213000 new case of lung cancer , 5 years survival just only 15%\Past few decade is staticBecause 50% case was advance cancer when they come to DrIn the past decade increase interest in the role of low dose spiral CTCXR missed 70-80% of lung cancer detect by the CT. . CT screening trials have r

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I-ELCAP

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    1. I-ELCAP

    2. 213000 new case of lung cancer , 5 years survival just only 15%\ Past few decade is static Because 50% case was advance cancer when they come to Dr In the past decade increase interest in the role of low dose spiral CT CXR missed 70-80% of lung cancer detect by the CT

    3. CT screening trials have report higher rate of early lung cancer 70-80%(stage Ia) Average size of CT :1.5cm Average size of CXR : 3cm SEER new diagnosed lung cancer stage I ONLY 25% SURVIVAL < 2cM IS BETTER THAN > 2-3CM

    4. Can increase 10x of operation But not all screen detect cancer are curable some were stage III at the time of diagnosis Interval lung cancer (cancer that develop between annual screening CT scan) rapid growth and frequently small cell lung cancer Most controversial is cost effect

    5. www.I-ELCAP.org From 1993 ELCAP..I-ELCAP CT screen for lung cancer 15% has positive result 6% has repeat positive result

    6. Definition of Positive result? At least I solid pr part solid noncalcified nodule 5mm or more in diameter Or at least one nonsolid noncalcified nodule 8mm or more in diameter If there is noncalcified nodule but too small ,…semipositive ..calling for repeat one year later.

    7. Repeat screening; positive? Growth in size Growth in consistency Growth in soilid componant in semi-solid or previois non solid nodule

    8. The I-ELCAP regimen provides recommendation for the work up Follow their protocol 90% of biopsy result in malignancy Recommendation turned out to be quite successful None of biopsy without recommendation was cancer

    9. 85% of the screen–diagnosis is stage I Also found the tumor size in this stage I cancer is more smaller The % of stage I lung cancer were much higher than SEER data(surveillance,epidermiology, and end result )program. Long term F/U10 years survival rate regardless of stage and tx was 80% Clinical stage I 10 years survival was 92 %

    10. Pathology of lung adenocarcinoma and CT screening specimens Major subtype of adenocarcinoma 2004 WHO major subtype : mixed subtype,acinar, papillary, BAC (mucinous nonmucinous, mix) Some subtype is more invasive and some are sensitive to iressa EGFR and K ras mutation CT screening 94% was adenocarcinoma

    11. Molecular pathways to lung adenocarcinoma Adenocarcinoam is more and or esp in women and young patient and nonsmoker Microarray expression studies demonstrate that gene expression is very different in smoker and nonsmoker Smoking activation to RAS signaling Non-smoking associated activation of EGFR signaling

    12. Limited resection for small peripheral carcinoma Systematic nodal dissection could improved stage-specific survival and may improved overall survival. So lobectomy and SND still is standard choice <1cm tumor has 10 % node metastasis 2cm tumor has 20-40% has node metastasis and 2/3 is N2

    13. But due to CT screening: the tumor is more smaller so limited resection could we try in select case? GGA( Ground glass attenuation )>50% of the total tumor size have a similary good prognosis (Noguchi classification)sublobar resection may be appropriate in selected case, but can cure? Wary .

    14. Pre-invasive lesion (patho) 1999: squamous dysplasia and carcnoma in situs 2004: atypical adenomatous hyperplasia, diffuse idiopathic pulmonary neuroendocrine cell hyperplasia May be multicentri

    15. Iatrogenic contribution to thoracic neoplasm Given continuing advances od early detection and supportive care and therapy : cancer survivor in USA is 3x since 1971 and increasing by 2% each year Cancer survivor is about 3.5% of US population We will meet second primary or late sequelae or treatment relate problem Treatment-associated lung tumor: such as R/T and C/T

    16. Lung cancer staging: intrathoracic nodal assessment 1982 a landmark paper by Dr pearson: mediastinal nodal metastasis could elude pre-op staging even in CT become routine and in which mediastinoscopy was well established 38% of case were upstaged at thoracotomy..Unexpect n2 disease N2 has only 20% 5 years survival Correct staging may improve survival

    17. Radical or en block to describe nodal dissection technique. 1996 workshop: SND Definition: number or node and at lease three mediastinal nodal station, and include one subcarina region Review SND . Find 18% unexpect n2, no rescue SND : better staging and find more ln deposit .

    18. But early concern is add the morbility of surgery. N0 survival was related to the number of node excised at thoracotomy

    19. Definition of complete resection Lns specimens should include at lease six lymph node, three removed from intrapulmonary or hilar status and three removed from mediastinal station,one of which must be the subcarina station.

    20. Other suggest: more extensive sectioning and immunohistochemical stain will find more subtle nodal deposit

    21. PET CT 18-FDG Phosphorylate 18-FDG-6-phosphate Inside the tumor cell could not degrade and trapped in cell and accumulated

    22. For SPN or lung mass 0.7cm -4cm can confirmed the maliganant Sensitivity 92-94% Specificity 86-90% Duke : only 5% stage Ia is negative

    23. False positive and negative False positive:TB or other grnulomatous disease; such as histoplasmosis coccidiomycosis or inflammatory process ;rheumatoid nodule, sarcoidosis or cryptogenic organizing pneumonia ,BOOP False negative: carcinoid tumor BAC well differential adenocarcinoma or metastatic tumor from renal cell ca of testicular ca( most carcinoid are positive)

    24. <1cm may not be detect Limit is 7-8mm Serum glucose result in decrease intracellular FDG uptake At Mayo clinic do not perform PET scan unless blood glucose <150mg/dl

    25. PET in staging or node or metas CT sensitivity 61% ,specificity 79% PET 80% 90% Due to false positive, if there are no documented distal metastasis , must be biopsy before patient be judge as unresectable 10-15% false positive , so if identified distal metas, esp one site metas, we would perform biopsy to get the potential curative thoracotomy

    26. PET vs isotope bone scan Isotope bone scan have larger bone scan If we already have PET scan , we have no reason obtaining a bone scan But except brain . MRI or brain scan is better.

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