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Lung Cancer:  Update on Diagnosis and Treatment John Thomas Phelan II, MD
Epidemiology <ul><li>1.5 – 2 million new cases / yr worldwide </li></ul><ul><li>In US, 164,100 new cases / yr; 156,900 dea...
Epidemiology <ul><li>In US, rising incidence in women </li></ul><ul><li>In US, lung cancer mortality in women > breast ca ...
Epidemiology <ul><li>In US, only 1/3 of pts are eligible for surgery w/ curative intent </li></ul><ul><li>10% - 20% occur ...
Etiology <ul><li>Tobacco smoke !!!! </li></ul><ul><li>Increased risk for GU, upper respiratory tract and upper GI ca </li>...
Classification:  Non small cell lung ca vs small cell lung ca <ul><li>NSCLC = 80% of cases, small cell lung ca = 20% of ca...
Classification:  Non small cell lung ca vs small cell lung ca <ul><li>Squamous cell:  50% - 60% = proximal / hilar in loca...
Classification:  Non small cell lung ca vs small cell lung ca <ul><li>Bronchioloalveolar:  Originates in alveolar cells.  ...
Classification:  Non small cell lung ca vs small cell lung ca <ul><li>Small cell:  Usually proximal / central.  Rapidly gr...
Diagnostic / Presenting Features <ul><li>Change in pulmonary habits, especially in established smoker (ie cough, shortness...
Diagnosis / Staging  <ul><li>Chest  X-ray: Ease.  Assess atelectasis, peripheral nodules, rib erosion </li></ul><ul><li>Ch...
Staging  <ul><li>Stage = anatomic extent of disease (ie, thoracic cavity vs extrathoracic) </li></ul><ul><li>AJCC, UICC em...
Staging studies <ul><li>Tissue confirmation:  sputum cytology, CT guided needle biopsy, bronchoscopy w / brushing / lavage...
Staging mediastinoscopy <ul><li>Right sided mediastinal lymph node sampling to carina.  Aortic arch limits left sided samp...
TNM categories in lung cancer <ul><li>T1-T4: T1:  < 3cm, surr by lung </li></ul><ul><li>T2:  > 3cm / main bronchus / </li>...
TNM categories in lung cancer <ul><li>N1-N3: N1:  intrapulm / peribronch / hilar  </li></ul><ul><li>N2:  ipsilateral media...
TNM categories in lung cancer <ul><li>M0 –M1: M0: No distant mets </li></ul><ul><li>M1: Distant mets  </li></ul>
Staging in small cell lung cancer <ul><li>Limited stage:  Disease limited to single hemithorax / encompassable by single r...
Treatment Principles (NSCLC) <ul><li>Stage 1 (T1-2N0M0), stage 2 (T1-2N1M0; T3N0M0): Lobectomy, pneumonectomy, segmentecto...
Treatment Principles (NSCLC) <ul><li>Stage 3 (T3N0-2M0): Not absolute contraindication to surgery.  Successful outcome dep...
Treatment Principles (NSCLC) <ul><li>Unresectable stage III disease: radiation therapy alone or concurrent chemoradiation ...
Treatment Principles (SCLC) <ul><li>Considered unresectable, even in seemingly early stage </li></ul><ul><li>Limited stage...
Treatment Principles (SCLC) <ul><li>Extensive stage (extrathoracic / not encompassable by single radiation port):  palliat...
Treatment Facts <ul><li>1)  Stage 1 I NSCLC 5yr survival = 47%; stage </li></ul><ul><li>III/IV = 2%.  </li></ul><ul><li>2)...
Promising developments <ul><li>1)  Adjuvant chemotherapy improves survival in resected stage I / II pts </li></ul><ul><li>...
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Lung Cancer : Update on Diagnosis and Treatment Lung Cancer : Update on Diagnosis and Treatment

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Lung Cancer : Update on Diagnosis and Treatment Lung Cancer : Update on Diagnosis and Treatment

  1. 1. Lung Cancer: Update on Diagnosis and Treatment John Thomas Phelan II, MD
  2. 2. Epidemiology <ul><li>1.5 – 2 million new cases / yr worldwide </li></ul><ul><li>In US, 164,100 new cases / yr; 156,900 deaths per year </li></ul>
  3. 3. Epidemiology <ul><li>In US, rising incidence in women </li></ul><ul><li>In US, lung cancer mortality in women > breast ca mortality </li></ul><ul><li>In US, lung cancer = 15% of cancer in men and women </li></ul>
  4. 4. Epidemiology <ul><li>In US, only 1/3 of pts are eligible for surgery w/ curative intent </li></ul><ul><li>10% - 20% occur in nonsmokers </li></ul><ul><li>25% - 35% of these can be attributable to secondhand smoke inhalation </li></ul>
  5. 5. Etiology <ul><li>Tobacco smoke !!!! </li></ul><ul><li>Increased risk for GU, upper respiratory tract and upper GI ca </li></ul><ul><li>Stopping smoking reduces risk, but only after > 6 yrs </li></ul><ul><li>Inc’d death rate w/ increased exposure (ie, more smoked = greater risk of death from lung cancer) </li></ul>
  6. 6. Classification: Non small cell lung ca vs small cell lung ca <ul><li>NSCLC = 80% of cases, small cell lung ca = 20% of cases </li></ul><ul><li>NSCLC: 4 histologic subtypes: squamous cell, adenocarcinoma, large cell, bronchioloalveolar </li></ul>
  7. 7. Classification: Non small cell lung ca vs small cell lung ca <ul><li>Squamous cell: 50% - 60% = proximal / hilar in location. Produce obstruction / pneumonitis / hemoptysis </li></ul><ul><li>Adenocarcinoma: More likely peripheral </li></ul>
  8. 8. Classification: Non small cell lung ca vs small cell lung ca <ul><li>Bronchioloalveolar: Originates in alveolar cells. Most common lung ca in nonsmokers. </li></ul>
  9. 9. Classification: Non small cell lung ca vs small cell lung ca <ul><li>Small cell: Usually proximal / central. Rapidly growing / disseminating. Limited to thorax in only 25% of cases </li></ul>
  10. 10. Diagnostic / Presenting Features <ul><li>Change in pulmonary habits, especially in established smoker (ie cough, shortness of breath, shoulder pain, hoarseness) </li></ul><ul><li>Extrapulmonary: paraneoplastic syndromes (2% of lung cancer pts), bone pain, CNS sxs, unexplained wt loss </li></ul>
  11. 11. Diagnosis / Staging <ul><li>Chest X-ray: Ease. Assess atelectasis, peripheral nodules, rib erosion </li></ul><ul><li>Chest CT: Assess mediastinum, vertebral bodies, chest wall. </li></ul><ul><li>PET scan: Cases by case basis </li></ul>
  12. 12. Staging <ul><li>Stage = anatomic extent of disease (ie, thoracic cavity vs extrathoracic) </li></ul><ul><li>AJCC, UICC employ TNM (T (primary tumor), N (nodes), M (mets)) nomenclature </li></ul><ul><li>Staging guides treatment, establishes prognostic / outcome groups </li></ul>
  13. 13. Staging studies <ul><li>Tissue confirmation: sputum cytology, CT guided needle biopsy, bronchoscopy w / brushing / lavage and biopsy, VATS, open thoracotomy </li></ul><ul><li>Abd CT: Eval for liver / adrenal mets </li></ul><ul><li>Bone scan: Eval for occult bone mets </li></ul><ul><li>Head MRI: Eval for occult brain mets </li></ul>
  14. 14. Staging mediastinoscopy <ul><li>Right sided mediastinal lymph node sampling to carina. Aortic arch limits left sided sampling </li></ul><ul><li>Mediastinal LN involvement contraindication for surgical resection </li></ul>
  15. 15. TNM categories in lung cancer <ul><li>T1-T4: T1: < 3cm, surr by lung </li></ul><ul><li>T2: > 3cm / main bronchus / </li></ul><ul><li>visceral pleura </li></ul><ul><li>T3: any size / invades chest wall / diaph </li></ul><ul><li>mediast pleura / parietal pericard </li></ul><ul><li>T4: any size / invades </li></ul><ul><li>mediastinum /malignant effusion </li></ul>
  16. 16. TNM categories in lung cancer <ul><li>N1-N3: N1: intrapulm / peribronch / hilar </li></ul><ul><li>N2: ipsilateral mediastinal / </li></ul><ul><li>subcarinal </li></ul><ul><li>N3: ipsilateral or contralateral </li></ul><ul><li>scalene / supraclavic / contralateral </li></ul><ul><li>mediastinal / contralateral hilar </li></ul>
  17. 17. TNM categories in lung cancer <ul><li>M0 –M1: M0: No distant mets </li></ul><ul><li>M1: Distant mets </li></ul>
  18. 18. Staging in small cell lung cancer <ul><li>Limited stage: Disease limited to single hemithorax / encompassable by single radiation port </li></ul><ul><li>Extensive stage: Extrathoracic disease </li></ul>
  19. 19. Treatment Principles (NSCLC) <ul><li>Stage 1 (T1-2N0M0), stage 2 (T1-2N1M0; T3N0M0): Lobectomy, pneumonectomy, segmentectomy </li></ul><ul><li>Principle goal: Resect all disease, preserve maximum normal lung function </li></ul>
  20. 20. Treatment Principles (NSCLC) <ul><li>Stage 3 (T3N0-2M0): Not absolute contraindication to surgery. Successful outcome dependent on careful pt selection </li></ul><ul><li>Stage IIIB/IV (N3 or metastatic disease): usually not surgical candidate </li></ul>
  21. 21. Treatment Principles (NSCLC) <ul><li>Unresectable stage III disease: radiation therapy alone or concurrent chemoradiation therapy </li></ul><ul><li>Stage IV disease: palliative chemotherapy alone +/- radiation to palliate select sites (ie bone, brain) </li></ul><ul><li>Treatment goals in unresectable disease = palliation/symptom control </li></ul>
  22. 22. Treatment Principles (SCLC) <ul><li>Considered unresectable, even in seemingly early stage </li></ul><ul><li>Limited stage (confined to single hemithorax / radiation port): concurrent chemoradiation therapy with cisplatin /VP-16 / XRT </li></ul><ul><li>Prophylactic cranial radiation: Controversial, but more widely accepted </li></ul>
  23. 23. Treatment Principles (SCLC) <ul><li>Extensive stage (extrathoracic / not encompassable by single radiation port): palliative chemotherapy alone with palliative radiation to selected sites </li></ul>
  24. 24. Treatment Facts <ul><li>1) Stage 1 I NSCLC 5yr survival = 47%; stage </li></ul><ul><li>III/IV = 2%. </li></ul><ul><li>2) Stage 1 SCLC 5 yr survival = 20%; stage III/IV = 1% </li></ul><ul><li>3) Take home message: In NSCLC, > 50% of early stage pts die of lung ca after 5 yrs; even worse for SCLC </li></ul>
  25. 25. Promising developments <ul><li>1) Adjuvant chemotherapy improves survival in resected stage I / II pts </li></ul><ul><li>2) Small molecules / antibodies targeting EGFR (Epidermal Growth Factor Receptor) effects NSCLC clinical course </li></ul>

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