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NON  SMALL  CELLLUNGE  CANCERDR…OMARHASHIM<br />
Most  common  noncutaneous  cancer  in  the  world . The  2nd  common  cancer<br />In us . The  lunge  cancer  is  the  mo...
Pathogenesis<br />Two theories were proposed to explain lung cancer:<br />Multicellular model: considering small cell carc...
In  the  NSCLC  proto-oncogene  activation  ras  +ve ……. C-erb-b 1 , C-erb –b2  + ve<br />Oncosuppressor  gene  inactivati...
Workup ;-<br />H &P  ………. Performance  status , wt  los , smoking  status <br />... Labs CBC….  BUN ….  Cr …  LFT  …. Alkl...
Staging ;-<br />T1 ;-tumor  3cm  or  less  in  diameter , surrounded  by  lunge  or  visceral  pleura<br />Distal  to  the...
N0 ;-…  no  regional  node  metastases<br />……………………………………………………………<br />N1  ;- Ipsilateral  peribronchial  or  hilar  nod...
TREATMENT  RECOMMDATION ;-<br />Stage 1 , 2 ;- operable  <br />Lobectomy ;-  ….. Wedge  resection  only  if  physiological...
Outcome  ;-  5  yrs  os  N1  50 %
………………………………………………………………………………………………  </li></ul>Stage 1,2 ;- inoperable ;-  definitive  RT  to  1ry  &  LN<br />Convention...
if  peripheral  tumour  or  poor  PS  may  hypofractionate  with  4Gy /fx  to  45 Gy<br />To  1ry  tumour  only.<br />Outc...
Outcome ;-  <br />5 yrs  os  20 – 25 % , MS . 16 -17  months  inducation  chemo –RT pcR  rate  15-<br />20%  post- op  RT ...
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Non small cell

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Transcript of "Non small cell"

  1. 1. NON SMALL CELLLUNGE CANCERDR…OMARHASHIM<br />
  2. 2. Most common noncutaneous cancer in the world . The 2nd common cancer<br />In us . The lunge cancer is the most frequent cause of cancer death.<br />Etiology ;-<br />80—90 % of cases due to smoking .<br />Is related to the number of cigarettes … number of yrs …. Type of cigarette<br />Asbestos .<br />previous radiotherapy to the chest .<br />Inhalation of radon gas , polycyclic aromatic hydrocarbon , nickel ,chromate<br />Inorganic arsenical .<br />Types of NSCLC ;-<br />Adenocarcinoma<br />Bronchioalveolar carcinoma .<br />Squamous cell carcinoma .<br />Large cell carcinoma<br />
  3. 3. Pathogenesis<br />Two theories were proposed to explain lung cancer:<br />Multicellular model: considering small cell carcinoma of neural crest (neuroectodermal) origin and other carcinomas of endodermal origin<br />Unicellular model: considering that all types of carcinomas arise from a single multipotent stem cell capable of variety of phenotypes<br />Carcinogenesis is a multistep process including activation of proto oncogenes and loss of tumor suppressor genes <br />
  4. 4. In the NSCLC proto-oncogene activation ras +ve ……. C-erb-b 1 , C-erb –b2 + ve<br />Oncosuppressor gene inactivation P 53 -> 50 % …………. RP -> O.O% .<br />CLINICAL FEATURE;- <br />Persistent cough …. Recurrent chest pain …. Pleural effusion …. Hoarse of<br />Voice ….wheeze , strider . … superior vena cava obs - …… horner s syndrome .<br />wt loss … anorexia ……<br /><ul><li>Paraneoplastic syndromes ;- ( restricted ) </li></ul>1- hypercalcemia . <br />2- hypertrophic pul osteoarthropathy . ….. adenocarcinoma<br />3-Gynecomastia ,…..large cell <br />4- hypercoagulable …… adenocarcinoma <br />5- carcinoid = VIP dirrhea <br />
  5. 5. Workup ;-<br />H &P ………. Performance status , wt los , smoking status <br />... Labs CBC…. BUN …. Cr … LFT …. Alkline phosphate . <br />Imaging ;- CT chest & abd ;- size &site of 1ry tumor …. Relationship to<br />Lunge fissure , mediastinum , chest wall ….. Mediastinal or other l ns <br />Metastatic disease (lunge ,, liver ,, adrenal ,, bone ) <br />CT brain &bone scan if clinical suspicion<br />PET scan for more sensitivity and specificity for pathological confir - than CT<br />MRI brain for LNs + non squ and all stage 3 & 4 <br />MRI ;-of the thoracic inlet for superior sulcus tumors to assess vertebral<br />Body & brachial plexus invasion .<br />Pathology ;-- <br /> thoracentesis for pleural effusion . For central lesions . Perform bronchoscope<br />CT guided biopsy for peripheral lesion , perform Ct guided biopsy .<br />Mediastinoscopy or bronchoscopic biopsy <br />
  6. 6. Staging ;-<br />T1 ;-tumor 3cm or less in diameter , surrounded by lunge or visceral pleura<br />Distal to the main bronchus .<br />………………………………………………………………………………<br />T2 ;- tumour > 3cm diameter , involving main bronchus 2cm or more distal <br />To the carina , or invading visceral pleura , or associated with atelectasis<br />Which extends to the hilum but not involve the whole lunge .<br />……………………………………………………………………………………….<br />T3 ;-tumour invading chest wall , diaphragm . Mediastinal pleura ,or peri –<br />Cardium ,or tumour in main bronchus < 2cm distal to carina or atelectasis<br />Of the whole lunge .<br />………………………………………………………………………………<br />T4 ;- tumour invading , mediastinum , heart , great vessels , trachea , oesophagus<br />Vertebra , or carina , or intralober tumour , or malignant pleura effusion .<br />
  7. 7. N0 ;-… no regional node metastases<br />……………………………………………………………<br />N1 ;- Ipsilateral peribronchial or hilar node involvement<br />………………………………………………………<br />N2 ;- Ipsilateral mediastinal or sub carinal nodes .<br />…………………………………………………<br />N3;- contra- lateral mediatinal nodes or supraclavicular nodes .<br />………………………………………………………………………………………………………………………..<br />Staging grouping ;-<br /> T1 -2 N0 .<br />T1-2N1 or T3 N0 .<br /> a ]T1-2N2 , or T3 N1-2 b ] T 4 any N M0 , or any N3 M0 .<br />Any M1<br />
  8. 8. TREATMENT RECOMMDATION ;-<br />Stage 1 , 2 ;- operable <br />Lobectomy ;- ….. Wedge resection only if physiologically compromised , LN<br />Sampling or resection general indicated . For completely resected T1-2N1 <br />Give adjuvant chemo . <br />Aduj- CH for T2N0 if > 4cm .<br />Aduj CH for completely resectable T3N0 .<br />RT for close +ve sm .<br />Outcome ;- LRF …lobectomy 6% ….wedge 18% … 5 yrs os & CSS stage 1 50- 70 %<br />………………………………………………………………………………..<br />Stage 1,2 ;- marginally operable ;-<br />Pre-op chemo -> surgery -> chemo .<br />Chemo ;-.. Cisplatin com- or carboplatin-paclitaxel .<br /><ul><li>For close + ve sm -> post op RT
  9. 9. Outcome ;- 5 yrs os N1 50 %
  10. 10. ……………………………………………………………………………………………… </li></ul>Stage 1,2 ;- inoperable ;- definitive RT to 1ry & LN<br />Conventional fractionation is 2gy /fx to 66 Gy<br />
  11. 11. if peripheral tumour or poor PS may hypofractionate with 4Gy /fx to 45 Gy<br />To 1ry tumour only.<br />Outcome ;- std RT 5 yrs T1N0 ; 30 – 50 % .<br />Hypo-fx 2-3 yrs os 40 --- 50 % .<br />SBRT ;- 2-3 Yrs lc 85 -95 % …os 55 % . <br />Dose escalation > 70 Gy & SBRT TECH- 60 Gy/3fx improved LC compared to<br />Conventional tech- & dose . If pts can tolerate it , give chemo ( inducation<br />Concurrent and cnsolidation ) if T3N0 chemo should be avoided concurrently<br />With dose escalated RT or SBRT until further data are available .<br />…………………………………………………………………………………………………………<br />Stage 3 a ( operable – marginally operable ) ;-concurrent chemo – RT (45 Gy )<br />Restage -> if no progression -> surgery -> chemo specially if inilially<br />Bulky or multipl N2 nodes .<br />Alternatively , chemo alone ->retage ->if no progression -> surgery -> chemo<br />And post op RT for close < 5mm or +vesm , ECE or N2 disease .<br /><ul><li>If unresectable after restaging -> complete definitive concurrent chemo </li></ul>--RT ( 63Gy) . .<br />
  12. 12. Outcome ;- <br />5 yrs os 20 – 25 % , MS . 16 -17 months inducation chemo –RT pcR rate 15-<br />20% post- op RT possible 5 – 10 % os benefit for N2<br />…………………………………………………………………………………………….<br />Stage 3 ( inoperable ) ;-<br />Concurrent chemo –RT ( 63 Gy ) -> aduj chemo . If unacceptable risk of <br />Pneumonitis with upfront RT , consider inducation chemo for down staging<br />->concurent chemo –RT to ( to postchemo volume ) . If no progression .<br />Outcome ;-<br />5 yrs osandMS concurrent chemo- RT 20 -25 % , 16 – 17 months .<br />Sequential chemo –RT 20% , 13 -15 months , RT alone <10 % , 10 -12 months<br />……………………………………………………………………………………………………………<br />Stage 3 b ( no pleural effusion ) ;-<br />Concurrent chemo –RT ( 61-63 ) , IF unacceptable risk of pneumonitis with<br />Upfront RT, consider induction chemo for down- staging -> concurrent<br />Chemo-RT (to postchemo volume ) if no progression .<br />If T4 N0 may treated with surgery -> chemo ± RT ( if residual or ± SM ) or<br />Chemo ±RT -> surgery -> chemo<br />
  13. 13. Typical chemo;- postsurgery ;-<br />Cisplatin 100mg/mxm d1 & etoposide 100mg/m xm d1-3 every 4 week x<br />4Cycle . <br />Other combinations with vinorelbine , vinblastine , gemcitabine & docetaxel<br />May be consider .<br />Alternatives ;- if not able to tolerate cisplatin ; carboplatin , paclitaxel every<br />3week for 4 cycles .<br />Concurrent with RT ;<br />Cisplatin 50mg/mxm d1 , 8 , 29 & 36 and etoposide 50mg/mxm d1 -5 &<br />29-33 .<br />Alternative ; cisplatin week 1 & 4 vinblastine weekly , or carboplatin &pacli-<br />Taxel weekly .<br />Sequential chemo – RT <br />Cisplatin 100 mg/ mxm d1 , 29 & vinblastine 5mg/ mxm weekly x 5 week<br />Alternative carboplatin & paclitaxel every 3week x2 cycles .<br />Consolidation chemo after chemo –RT ;-<br />Carboplatin & paclitaxel every 3 week x 2 cycles .<br />Local treatment as necessary (E.G pleurodesis ) & treat as stage 4 .<br />
  14. 14. Stage 4 ;-<br />Platinum – based chemo ± bevacizumab ± palliative RT . Frist line chemo<br /> uses 2agents with response assessment after each cycle , for up to 4-6<br />Cycles or until progression .<br />
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