ALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar, profile picture
Uploaded byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
PPTX, PDF11,263 views

Carcinoma lung

This document summarizes key information about the management of lung carcinoma: 1. Lung cancer is the leading cause of cancer death worldwide. Smoking is the primary risk factor. Other risk factors include asbestos, radon gas, and genetic mutations. 2. Lung cancers commonly spread to local lymph nodes and distant sites like the brain, bones, liver and adrenal glands. Squamous cell carcinoma and small cell lung cancer often present with central masses while adenocarcinoma presents more peripherally. 3. Staging workup includes chest X-ray, sputum cytology, bronchoscopic biopsy, CT scans, and PET scans to determine the extent of disease for treatment planning.

Embed presentation

Downloaded 768 times
Management of Carcinoma lung Moderator : Dr Seema Gupta Presenter : Dr Sandip Barik Dept of Radiotherapy CSMMU
EPIDEMIOLOGY • Lung cancer is the most common cancer worldwide contributing about 12.2% of all new case diagnosed • It is the most common cause of cancer in men worldwide(about 16.5% ) • It is the most common cause of cancer related death world wide about(18.2% of all death) • In India incidence is about 12.1 men /100,000 population • Change in trend is seen with incidence increasing in women (0.4% per year)and decreasing in men from year 1990 • Occurs most commonly between 40-70 yrs of age with peak incidence at 50s or 60s
RISK FACTORS • Smoking is the primary risk factor(87% of lung cancer occur in smokers • Average smokers have 10 fold greater risk,while heavy smokers(40 cigarettes/day) have 60 fold greater risk • Women have higher susceptibility to tobacco carcinogen than men do • Introduction of filter cigarettes entices smokers to take larger puffs and retain smoke longer • Second hand smoke or environmental tobacco smoke is estimated to cause about 3000 deaths/year
Risk factor cont… • Industrial agents like asbestos,coaltar fumes,nickle ,chromium,arsenic,radioactive materials,radon gas are carcinogenic • Genetic alterations with mutations in p53,RB1,p16(INK4a) • Dominant oncogenes frequently involved include c- MYC,KRAS,EGFR,c-MET and c-KIT • Precursors lesions like squamousdysplasia,atypical adenomatous hyperplasia,diffuse idiopathic pulmonary neuroendocrine cell hyperplasia • Vitamin A,C,E have protective effect
NATURAL HISTORY • Lung carcinoma arise most often in and about the hilus of lung • About 3/4th of the lesion originate from 1st,2nd,3rd order bronchi • Local spread to intrathoracic areas • The incidence of scalene (supraclavicular)node ranges from 2% to 35% • Metastasis to these nodes are from ipsilateral upper lobes • Metastasis also occur in cervical,axillary and inguinal lymphnodes
Natural hist cont… • Extrathoracic spread • Undifferentiated small cell cancer (oat cell variant) has a higher incidence of distant metastasis than nonsmall cell types • Among Non small cell group Adenocarcinoma have a greater propensity for distant metastases
LYMPHATIC DRAINAGE • During the past three decades two different lymphnode station have been used • 1st was the Japanese Lung Cancer Society Classification • 2nd was the Mountain Dressler Modification of the American Thoracic Society(MDATS) • Recently the International Association For The Study Of Lung Cancer(IASLC) proposed a lymphnode map • It provides more detailed nomenclature for the anatomic boundaries of lymphnode station • The IASLC is now the recommended means of describing regional lymphnode in lung cancer
LYMPHNODE STATION Supraclavicular 1.Low cervical,supraclavi cular,sternal notch Superior (2R,2L)Upper Mediastinal Paratracheal (3a,3p)Pre vascular,Retrotrach eal (4R,4L)Lower paratracheal Aortic (5,6)Subaortic,Par aaortic Inferior Mediastinal 7 Subcarinal (8,9)Paraoesophag eal,pulmonary ligament N1 nodes (10,11,12,13,14) Hilar,interlobar,loba r,segmental,subse gmental
• The lymph from right lung involves lower paratracheal nodes(iv) followed by subcarinal (vii) • The lymph from left upper lobe involve subaortic nodes(v) • The left lower lobe drains to subcarinal lymphnodes(vii)
WORLD HEALTH ORGANISATION CLASSIFICATION OF MALIGNANT LUNG • MALIGNANT CANCER 1. SQUAMOUS CELL CARCINOMA 5 ADENOSQUAMOUS a Spindle cell variant 6 CARCINOID 2. SMALL CELL CARCINOMA 7 BRONCHIAL GLAND a Oat cell CARCINOMA b Intermediate cell C Combined 3. ADENOCARCINOMA A Acinar B Papillary C Bronchioalveolar D Solid carcinoma with mucin 4. LARGE CELL CARCINOMA A Giant cell B Clear cell
PATHOLOGICAL CLASSIFICATION • Squamous cell carcinoma is the most commonly found in men • It is closely related with smoking history • Adenocarcinoma has been common type of lung cancer in women and nonsmokers since 1950* • From 1990’s adenocarcinoma is the most common diagnosis in men*i • Currently Adenocarcinoma has surpassed Squamous cell type
Classification (cont…) Non Small Cell Small Cell Lung Lung Cancer Cancer (SCLC) (NSCLC) • Oat Cell • Adenocarcinoma • Intermediate • Squamous Cell Carcinoma • Combined • Large Cell Carcinoma
CLINICAL PRESENTATION • Although no set of signs and symptoms are pathognomic for carcinoma lung they can be broadly divided into three categories 1. Due to local tumour growth and intrathoracic spread 2. Due to distant metastasis 3. Nonspecific systemic symptoms or paraneoplastic syndromes
Due to local tumor and intrathoracic spread • Squamous and small cell cancers usually present as central mass • They produce cough,wheeze,hemoptysis • Symptoms and signs of airway obstruction &postobstructive pneumonitis(dyspnoea,fever,productive cough) • Adenocarcinoma and large cell tumour present as peripheral mass with pleural involvement • More likely to be asymtomatic but may cause pleuritic chest pain,cough • Squamous and large cell cavitate in 10-20% of cases
Intrathoracic spread • Usually causes nerve entrapment • Most commonly causes left recurrent laryngeal nerve palsy leads to hoarseness, dysphagia recurrent aspirations • Phrenic nerve entrapment leads to hiccups • Apical tumours causes Pancoast syndrome, lower brachialplexopathy(C8,T1), Horners syndrome, shoulder pain • Most superior sulcus tumour are squamous cell type
Intrathoracic spread • Compression of esophagus dysphagia recurrent aspirations tracheoesophageal fistula bronchoesophageal fistula • Principal vascular syndrome caused is Superior vena cava syndrome • Usually caused by tumour on right upper lobe or right main bronchus • Most commonly caused by small cell type followed by squamous cell
Intrathoracic spread • 50% of patients with disseminated lung cancer develops pleural effusion • Lung cancer is the single most cause of pericardial metastases
SYMPTOMS DUE TO METASTASIS • Most common sites of haematogenous spread that are clinically apparent are brain,bones,liver,adrenals • Extrathoracic metastatic disease found at autopsy in 50% with squamous cell carcinoma 80% with adenocarcinoma and large cell 95%with small cell cancer • Symptoms are according to the organ involved • Adrenal metastases are common but rarely cause adrenal insufficiency
NONSPECIFIC AND PARANEOPLASTIC SYNDROMES • Paraneoplastic syndrome refer to the disorders that accompany tumours but not directly related to mass effect or invasion • Endocrine syndromes hypercalcaemia,hypophosphataemia due to parathyroid hormones by squamous cell. Hyponatraemia with SIADH by small cell hypokalemia due to ACTH by small cell • Clubbing in non small cell type • Hypertrophic pulmonary osteoarthropathy in adeno carcinoma • Neurologic myopathic syndromes like Eaton lambert • Trousseau’s syndrome • Dermatomyositis and Acanthosis nigricans
• Detail History • Physical Examination • Chest xray 1. It is the single most important and initial investigation 2. It can present in different ways depending on the region of lung involved and histology Hilus Hilar prominence,hilar mass,perihilar mass Pulmonary Mass,apical mass,multiple parenchyma masses,bronchial obstruction,collapse,consolidation Intrathoracic Mediastinal widening or mass,chest extrapulmonary wall erosion,pleural effusion,elevation structure of diaphragm
Chest x-ray cont.. Squamous cell Collapse,consolid carcinoma ation,cavitation,hil ar abnormality Adenocarcinoma Peripheral mass,hilar abnormality,obstr uctive lesion,no cavitation Large cell Peripheral carcinoma mass,cavitation and hilar abnormalities rare Small cell Hilar prominence tumours
Confirmatory workup • Sputum cytology:it has a posive predictivity value of 100%,but sensitivity of 10-15% • Bronchoscopic biopsy • Transbronchial fine needle aspiration Used for central lesions Evaluation of mediastinal lymphadenopathy • Bronchoalveolar lavage peripheral regions not visible endoscopically • CT guided transthoracic percutaneous fnac/biopsy
Staging workup 1. CECT THORAX Sensitivity 75%,specificity 66% CT scan should extend inferiorly to include upper abdomen and adrenal glands 2. FDG PET SCAN Sensitivity 91%,specificity 86% Can detect lesions >5 to 8 mm on basis of FDG uptake Combinations of CT scan and PET scan has greater sensitivity and specificity than CTscan along 3. FIBREOPTIC BRONCHOSCOPY Most important procedure for determining the endobronchial extent of the disease,measuring tumour proximity to carina 4. MEDIASTINOSCOPY Best method to evaluate the upper,middle peritracheal and subcarinal lymphnodes 5. BONE SCAN/CT-MRI OF BRAIN 6. ULTRASONOGRAPHY WHOLE ABDOMEN
Blood • Haemogram • Kidney func test • Liver func test • Serum electrolytes • Hormones like parathyroid,ACTH Urine • Routine & microscopic
AJCC STAGING(2010) Tx Primary cannot be accessed or positive cytology To No evidence of primary tumour Tis Carcinoma in situ T1 Tumour <3cm greatest dimention surrounded by lung or visceral pleura without bronchoscopic evidence of invasion more proximal than lobar T1a bronchus(i.e not in main bronchus) Tumout 2 cm or less in greatest dimention T1b Tumour >2cm but 3cm or less in greatest dimention T2 Tumour >3cm but 7cm or less or involves main bronchus,>2cm from the carina,invades visceral pleura associated with partial atelactasis T2a Tumour more than 3cm but 5cm or less T2b Tumour more than 5 cm but 7 cm or less T3 Tumour more than 7 cm or one directly invading the parietal pleura,chest wall,diaphragm,phrenic nerve,mediastinal pleura,parietal pericardium or tumour in the main bronchus<2cm from the carina but without involvement of carina,associated total atelectasis T4 Tumour of any size invading the mediastinum,heart,great vessels,trachea,recurrent laryngeal nerve,esophagus,vertebral body,carina,separate tumour nodule in tha same lobe,malignant effusion
Regional lymphnodes Nx Regional node cannot be accessed No No regional node metastasis N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar node and intrapulmonary nodes including involvement by direct extention N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymphnodes N3 Metastasis in contralateral mediastinal,contralateral hilar.ipsilateral or contralateral scalene or supraclavicular node Distant Metastasis Mo No distant metastasis M1 Distant metastasis M1a Separate tumour nodule in a contralateral lobe tumour with pleural nodule or malignant pleural or pericardial effusion M1b Distant metastasis in extrathoracic organs
PROGNOSTIC FACTORS • Epidermoid carcinoma has the best prognosis followed by adenocarcinoma and undifferentiated large cell cancer • Undifferentiated small cell cancer has the poorest prognosis • In Lung cancer the most important prognostic factor is tumor stage • In SCLC pure cell carcinomas are more sensitive to chemotherapy and radiotherapy than variant cell.
Negative prognostic factors are 1. Mutations in Kras oncogene 2. Deletion of p53,NCAM molecule 3. Expression,elevated neuron specific enolase level 4. Over expression of erb1,erb2 5. Increased proliferative 6. Markers(ki67,cyclinD1,E,B1,p16 loss 7. Angiogenesis markers like VEGF 8. Decreased apoptotic markers like caspase 3
Management of NSCLC Stage I-II : Early stage(T1-2, N1) Stage IIIA : Locally advanced (surgery feasible)(T3,N2) Stage IIIB : Locally advanced (surgery not feasible)(T4,N3)  Stage IV : Metastatic disease
For Non Small Cell Cancer • Surgery usually a multimodality • Chemotherapy approach is • Radiotherapy used
Surgery • Indications 1. Stage I , II 2. Stage IIIA(T1-3 N2,T3N1) 3. Medically fit 4. Good performance scale
Surgery(cont…) • Surgery is the standard treatment of choice for patients with stage I,II and IIIA tumours. • Lobectomy with nodal dissection is the method of chioce • Pneumonectomy is done only when Involves proximal bronchus or proximal pulmonary artery Crosses major fissure • Wedge resection is only restricted to persons who are not able to tolerate lobectomy
Lymphnode dissection The current minimum standard is a systemic sampling of each lymph node station of tumor Rt sided tumors – 2,3,4,7,8, 9,tracheobronchial angle and interlobar area (10,11) Lt sided tumors – sub aortic, ant med nodes (5,6), 7,8,9
Results • 5 yrs survival for patients with Stage I is 65%,Stage II is 60% ,Stage IIIA( N1 disease is 34%,N2 is 24%) • Various studies also concluded that lymphnode dissection is necessary for accurate staging. • Lesser resections like wedge resection result in higher recurrence rate and reduced survival. • Survival is longer in clinical (pre op)N0 or N1 disease but pathological(post resection N2) than clinical N2 disease
RADIOTHERAPY Radiation is used in following forms in NSCLC A. AS ADJUVANT * Post Operative * Pre Operative B. PRIMARY RADIATION * Radical * Palliative C. CHEMO-RADIATION NSCLC is a radio responsive tumor but not radiosensitive
Role of pre op irradiation • Indications 1. In stage I,II,III tumours • Dose :20 Gy in 5# • Results • Multi institutional trail compared preop RT vs surg alone • No added benefits was found in stage I,II Tumours • But a significant 3 yr survival rate (49.4% vs 28.1%) was observed in stage III
Role of Post op RT • Indications 1. Incomplete resection 2. Close or positive margins 3. Positive mediastinal metastases 4. Resected N2 disease 5. Chest wall involvement 6. Superior sulcus tumour • Contraindications 1. Currently contraindicated in patients with stage I completely resected
Post op RT(cont…) Dose for potential microscopic Dose for margins positive 60 to disease 50 GY 66 Gy RESULTS TRIALS •PORT Meta Analysis •SEER Database •British Medical Research CONCLUSIONS •Role of PORT in positive N1 disease is controversial •More data supporting role in N2 •The studies used conventional technique •Modern tech like IMRT,3D CRT hopefully will increase the result in favour of PORT
Definitive radiotherapy in NSCLC (early stage) INDICATIONS : • 1. Medically inoperable T1-T3 lesions. • 2. Patient refuses surgery. • 3. Critically located lesion. • 4. Non-resectable Stage-II & Stage-IIIA • • 5. Patient with incomplete resection. • 6. Localized recurrent lung cancer.
RADIOTHERAPY TECHNIQUES  Conventional External beam radiotherapy • VOLUME 2 cm around the tumour margin • ENERGY 6-10 Mev linac • PORTALS 2 to 3 fields depending on tumour and lymphnodes • DOSE 60-66 GY @1.8-2 GY/#
Results of Radiotherapy in early stage • Local control is poor and results are not very encouraging for NSCLC • 5yr local control and overall survival rates ranges from 30 to 50% and 10-30% • Results of conventional RT is certainly inferior when compared with other modality
STEREOTACTIC BODY RADIATION THERAPY • SBRT is a combination of multiple beam angles to achieve sharp dose gradients,high precision localisation and a high dose per fraction in extracranial locations. • Delivers a high biologic effective dose BED to target • Minimise normal tissue toxicity • Reduced treatment volume • Reducing treatment time
SBRT
• Results of SBRT  Image guided SBRT with delivery of BED>100 GY is feasible and produces better results than <100 gy  3 to 5 yr survival rate and local control is much more better than those for conventional RT  For stage I A disease results are comparable with surgery  Emerging as the standard treatment for inoperable stage I NSCLC.
Definitive RT In Advanced NSCLC(stage III) • Larger unresectable tumours T4N0-1 or T1-4 N2-3. • Dose given is 60 GY @2GY/# • A higher dose upto 80 to 100 gy is required to improve local control and potential survival but toxicity is main limiting factor here. • However advanced such as 3D crt and imrt have provided a way for dose escalation with out toxicity.
non small cell lung cancer newer radiation techniques 1. 3-Dimentional Conformal Therapy. 2. Intensity Modulated Radiation Therapy. 3. IGRT and Gated Radiotherapy. 4. Interstitial Brachytherapy. 5. Endobronchial Brachytherapy. 6. Intra Operative Radiotherapy.
3-D CRT & IMRT IN LUNG CANCER Goal: To increase dose delivery to tumour To minimize dose to normal tissues. Advantages 1. Better conformity of radiation dose to the tumour. 2. Sparing of all the vital structures around tumour. 3. Escalation of dose is possible. 4. Better control of disease. 5. Reduced morbidity.
3-D CRT & IMRT IN LUNG CANCER TREATMENT PLANNING
Radiotherapy planning • GTV (Gross Tumor volume) • CTV (Clinical Target volume) • PTV (Planning Target volume) • GTV Visible tumor by any imaging modality including the lesion and lymphnode > 1 cm.
RT-Planning – Defining the CTV CTV is the volume that contains gross and microscopic disease A Radiographic histopathologic study demonstrated that CTV varies with histologic type Microscopic extension Adeno Squamos mean value 2.69mm 1.48mm 5mm margin covers: 80% 91% margin to cover 95% 8mm 6mm
PTV • One of the important reason of uncertainty in ca lung is motion of the tumor during respirations • PTV is defined as CTV with a margin to account for daily set up error and target motion
NON SMALL CELL LUNG CANCER RADICAL RADIATION Image Guided RadiationTherapy-IGRT: It is defined as the use of modern imaging modalities specially those incorporating functional and biological information. 1. To augment target delineation 2. Use of imaging to adjust to target motion and positional uncertainty- respiratory gated therapy 3. Potential to adopt treatment to tumor response.
IMAGE GUIDED RADIATION THERAPY EQUIPMENT REQUIRED CT-SCAN MRI PET-CT Linac with on Tomotherapy Cyber knife Board imaging
Chemotherapy (NCCN Guidelines 2010) • Indicated in all stages above stage Ib, significant improvement in survival. • First line - Premetrexate + cisplatin is superior to Gemcitabine + cisplatin in non sq cell tumors. - Paclitaxal + carboplatin for sq cell tumors. - Bevacizumab and Erlotinib combined with chemotherapy. - No use of using a third drug in the regime. - Older patients single agent chemotherapy is adviced
• Second line (in combination with platinum) - Docetaxal - Premetrexate - Irinotecan - Erlotonib • Third line - Erlotinib - Vinorelabine
SMALL CELL LUNG CANCER
Staging of SCLC Veterans Administration Lung Study Group (VALG) staging system • Limited-Stage Disease (LD SCLC ) - Confined to the hemithorax of origin, the mediastinum, or the supraclavicular nodes, which can be encompassed within a tolerable radiation therapy port. • Extensive-Stage Disease (ED SCLC) - Any disease not meeting limited stage criteria - Distant metastasis. •
Staging of SCLC • The International Association for the Study of Lung Cancer (IASLC) revised the VALG classification in accordance with the TNM system. - LD definition is consistent with TNM stages I to IIIB. - ED is limited to patients with distant metastases.
Management of SCLC • SURGERY 1. Stage I(T1-2,N0) 2. Lobectomy with mediastinal nodal dissection is the surgery of choice 3. Early stage SCLC is diagnosed in fewer than 5% of SCLC patients,limits the scope of surgery 4. The trial by Medical Research Council led to abandonment of surgery as a primary modality of treatment
Combined Chemotherapy and Radiation therapy • Indications 1. To decrease the local recurrence 2. To improve survival 3. Positive lymphnode involvement after surgery
Role of Radiotherapy • Meta-analysis by Warde and Payne - 11 prospective trials of chemotherapy with or without RT were analysed - Results : Absolute increase of OS by 5.4 % at 2 years Local control of 25 % with limited stage disease • Pignon et al - 16 randomized studies with 2,140 patients - improvement in abolute survival of 5.4 % at 3 years Definite role for RT in local control of disease which leads to increase in overall survival
Role of chemo radiotherapy McCracken et al (154 patients) Results Cisplatin , Etoposide Time Survival & vincristine 2 cycles 2 yr 42 % with RT 1.8 Gy per 4 yr 30 % day upto 45 Gy 5 yr 26 % Concurrent chemo radiotherapy provides good survival advantage with tolerable toxicity to the patient
Concurrent Chemoradiation • Advantages 1. Overall shorter treatment time 2. High dose intensity 3. Sensitisation of tumours • Disadvantages 1. Enhanced normal tissue toxicity 2. Treatment breaks 3. Inability to access response to either mode
Sequential vs Concurrent chemoradiotherapy Japanese Clinical Oncology Group Arm 1 Paclitaxel 80 mg/m2 on d1 and etoposide 100 mg/m2 d1-3 (2 cycles) Results showed significant improvement of survival in RT 45 GY CRT arm Conclusion:CRT is better Arm 2 than sequential chemo and Paclitaxel 80 mg/m2 on d1 and etoposide radiotherapy 100 mg/m2 d1-3 + RT was started along with chemo from day1
Timing of Chemo Radiotherapy • NCI Canada trial 40 Gy in 15 fractions over 3 weeks to the primary site concurrent with the first cycle of EP All 308 eligible patients received (week 3) cyclophosphamide, doxorubicin, and vincristine (CAV) alternating with etoposide and cisplatin (EP) every 3 weeks for three cycles of each late TI patients received chemotherapy regimen. the same radiation concurrent with the last cycle of EP (week 15) Overall survival better in Early RT arm
Altered fractionation Turrisi et al Once-daily therapy received 1.8 Gy daily in 25 treatments 417 patients with limited over a period of five weeks. small-cell lung cancer. Patients with a All the patients received four complete response 21-day cycles of Received prophylactic cisplatin 60 mg/m2 and cranial irradiation 25 Etoposide 120 mg/m2 Gy 1n 10 # RT started with CT in first week Accelerated twice-daily thoracic radiotherapy involved the administration of 1.5 Gy in 30 # over a period of three weeks Conclusion : 10% absolute increase in overall survival @ 5yrs with15% increase in high grade esophagitis in Acc RT arm
Prophylactic cranial irradiation Metaanalysis conducted in 1999 studied 7 prospectively randomised trail They found a disease free and overall survival advantage in those patients who under went prophylactic cranial irradiation Dose is still a matter of debate however there is a trend in reduction of brain relapses at 36 GY @ 2 GY /# Prophylactic cranial irradiation should be consideredfor complete clinical responders
CONCLUSION • NSCLC 1.STAGE I&II  Surgery if feasible followed by adjuvant chemotherapy when indicated  SBRT if not medically fit 2.STAGE IIIA  Surgery with adj chemotherapy + PORT  EBRT with chemotherapy if not fit 3.STAGE IIIB  EBRT with chemotherapy 4.STAGE IV  Chemotherapy with EBRT for palliation
CONCLUSION SCLC;Limited disease CONCURRENT CHEMORADIATION IS CONSIDERED • Dose of Radiotherapy should be delivered at 45 GY with1.5 GY/#,twice daily with concurrent Cisplatin and Etoposide. • Prophylactic cranial irradiation should be considered for complete clinical responders. • Patients should be encouraged to participate in newer protocol  Extensive disease • Chemotherapy • Prophylactic cranial irradiation for responders • Palliation
THANKYOU

More Related Content

PPT
ANATOMY,PATHOLOGY, INVESTIGATIVE WORK –UP AND STAGING OF LUNG CANCER
byLAKSHMI DEEPTHI GEDELA
 
PPTX
Lung cancer anatomy to pathological classification
byDrAyush Garg
 
PPTX
8th Edition of the TNM Classification for Lung Cancer
byMauricio Lema
 
PPTX
Lung cancer
byJyotindra Singh
 
PPTX
Ppt lung carcinoma part1
byJuned Khan
 
PPTX
Treatment of-lung-cancer
byHari Prakash
 
PDF
Lung cancer
byAreej Abu Hanieh
 
PPTX
LUNG cancer
byNeeraj Nagar
 
ANATOMY,PATHOLOGY, INVESTIGATIVE WORK –UP AND STAGING OF LUNG CANCER
byLAKSHMI DEEPTHI GEDELA
 
Lung cancer anatomy to pathological classification
byDrAyush Garg
 
8th Edition of the TNM Classification for Lung Cancer
byMauricio Lema
 
Lung cancer
byJyotindra Singh
 
Ppt lung carcinoma part1
byJuned Khan
 
Treatment of-lung-cancer
byHari Prakash
 
Lung cancer
byAreej Abu Hanieh
 
LUNG cancer
byNeeraj Nagar
 

What's hot

PPT
Lung Cancer
byRobert J Miller MD
 
PPTX
Medulloblastoma
byDrAyush Garg
 
PPTX
Small Cell Lung Cancer Management by Dr.Tinku Joseph
byDr.Tinku Joseph
 
PPT
Non Small Cell Lung Cancer
byfondas vakalis
 
PPTX
Small Cell Lung Cancer
byRobert J Miller MD
 
PPTX
Non small cell lung cancer copy
byankitapandey63
 
PPTX
Management of small cell lung cancer
byDeepak Agrawal
 
PPT
Brain metastasis
byKiran Ramakrishna
 
PPTX
Management of Non Small Cell Lung Cancers
byPradeep Dhanasekaran
 
PPTX
lung cancer ppt.pptx
bymadurai
 
PPTX
Pineoblastoma
byParneet Singh
 
PPTX
Principles of chemoradiations
byDr Abani Kanta Nanda
 
PPTX
HOLISTIC APPROACH IN WHOLE BRAIN RADIATION IN BRAIN METS
byKanhu Charan
 
PPTX
Organ preservation by radiotherapy
byKanhu Charan
 
PPT
Diagnosis, Treatment & Management of Medulloblastoma
byDr Vandana Singh Kushwaha
 
PPTX
Prophylactic cranial irradiation
byShreya Singh
 
PPTX
Radiotherapy in CA Penis
byDrAyush Garg
 
PPTX
Radiotherapy in leukemias kiran
byKiran Ramakrishna
 
PDF
Induction chemotherapy followed by concurrent ct rt versus ct-rt in advanced ...
bySantam Chakraborty
 
PPTX
Small cell lung cancer
byDrAyush Garg
 
Lung Cancer
byRobert J Miller MD
 
Medulloblastoma
byDrAyush Garg
 
Small Cell Lung Cancer Management by Dr.Tinku Joseph
byDr.Tinku Joseph
 
Non Small Cell Lung Cancer
byfondas vakalis
 
Small Cell Lung Cancer
byRobert J Miller MD
 
Non small cell lung cancer copy
byankitapandey63
 
Management of small cell lung cancer
byDeepak Agrawal
 
Brain metastasis
byKiran Ramakrishna
 
Management of Non Small Cell Lung Cancers
byPradeep Dhanasekaran
 
lung cancer ppt.pptx
bymadurai
 
Pineoblastoma
byParneet Singh
 
Principles of chemoradiations
byDr Abani Kanta Nanda
 
HOLISTIC APPROACH IN WHOLE BRAIN RADIATION IN BRAIN METS
byKanhu Charan
 
Organ preservation by radiotherapy
byKanhu Charan
 
Diagnosis, Treatment & Management of Medulloblastoma
byDr Vandana Singh Kushwaha
 
Prophylactic cranial irradiation
byShreya Singh
 
Radiotherapy in CA Penis
byDrAyush Garg
 
Radiotherapy in leukemias kiran
byKiran Ramakrishna
 
Induction chemotherapy followed by concurrent ct rt versus ct-rt in advanced ...
bySantam Chakraborty
 
Small cell lung cancer
byDrAyush Garg
 

Viewers also liked

PPT
Lung Cancer: Diagnosis, Staging, and Treatment
byDene W. Daugherty
 
PPTX
Lung cancer
byMagdalena Ravagnan
 
PPT
Lungcancer
bySumudu Himesha Meawela
 
PDF
Carcinoma - Lung
byPrasad CSBR
 
PPTX
Cars 2015 classification and staging of lung cancer 1.6
byDr. Josep Morera Prat
 
PPTX
All About Lung Cancer
byAndrea Borondy Kitts
 
PDF
Lung cancer, 3rd ed
byMulkan Fadhli
 
PPTX
Lung Cancer
byguestaa82de
 
PPTX
Lung Cancer Pathology & Clinical
byShahd Al Ali
 
PPTX
Cáncer de mama
byMauricio Lema
 
ODP
Small Cell Carcinoma of Lung
bySantam Chakraborty
 
PPTX
Lung Cancer Stages, Treatments and Targeted Therapies
byDana-Farber Cancer Institute
 
PPTX
Lung cancer: a 2014 update with information about immunotherapies
byZeena Nackerdien
 
PPT
SMALL CELL LUNG CANCER (SCLC)
byfondas vakalis
 
PPT
lung cancer
byAshraf Hefny
 
PPT
Seminario anatomia
byMaredinverno
 
PPTX
4 diffuse reticular or reticulonodular pattern
byDr. Muhammad Bin Zulfiqar
 
PPTX
Tumors of lung seminar dr. swarupa
bySwarupa Chakma
 
PPT
lung carcinoma
byForensic Pathology
 
PPTX
Surgical Management of Bronchogenic Carcinoma
byDr. Valluri Mukesh
 
Lung Cancer: Diagnosis, Staging, and Treatment
byDene W. Daugherty
 
Lung cancer
byMagdalena Ravagnan
 
Lungcancer
bySumudu Himesha Meawela
 
Carcinoma - Lung
byPrasad CSBR
 
Cars 2015 classification and staging of lung cancer 1.6
byDr. Josep Morera Prat
 
All About Lung Cancer
byAndrea Borondy Kitts
 
Lung cancer, 3rd ed
byMulkan Fadhli
 
Lung Cancer
byguestaa82de
 
Lung Cancer Pathology & Clinical
byShahd Al Ali
 
Cáncer de mama
byMauricio Lema
 
Small Cell Carcinoma of Lung
bySantam Chakraborty
 
Lung Cancer Stages, Treatments and Targeted Therapies
byDana-Farber Cancer Institute
 
Lung cancer: a 2014 update with information about immunotherapies
byZeena Nackerdien
 
SMALL CELL LUNG CANCER (SCLC)
byfondas vakalis
 
lung cancer
byAshraf Hefny
 
Seminario anatomia
byMaredinverno
 
4 diffuse reticular or reticulonodular pattern
byDr. Muhammad Bin Zulfiqar
 
Tumors of lung seminar dr. swarupa
bySwarupa Chakma
 
lung carcinoma
byForensic Pathology
 
Surgical Management of Bronchogenic Carcinoma
byDr. Valluri Mukesh
 

Similar to Carcinoma lung

PPTX
CARCINOMA OF LUNG.pptx
bymanjunathpandit1
 
PPTX
lung cancer for M.M.E.D and Undergraduates
byKesheniLemi
 
PPTX
LUNG TUMORS (1).pptx, pathology pathology pathology
bychourasiyakumkum0
 
PPTX
lung cancer central seminar lung cancer.pptx
byAbhilashYadav31
 
PPTX
Radiological imaging of pulmonary neoplasms
byPankaj Kaira
 
PPT
NSCLC DR ANJALI.ppt NSCLC NSCLC NSCLC NSCLC
bydranjalikrishnanp
 
PPT
non-small-cell-lung-cancer-100303173219-phpapp02.ppt
bydranjalikrishnanp
 
PPSX
lung neoplasms
bybbxoxo
 
PPTX
lungcancer-140104125933-phpapp02.pptx and
byAnmolChauhan67
 
PPTX
Tumurs of the lung
byNikhil Murkey
 
PPTX
Presentation1.pptx. radiological imaging of bronchogenic carcinom.
byAbdellah Nazeer
 
PPTX
Lung maligncy updated 27 04-18 dr jarisha miot radiology
byJarisha Vj
 
PPTX
Carcinoma lung clinical and radiology ct
byVISHNUJS11
 
PPTX
CLINICAL PRESENTATION ,DIAGNOISIS AND STAGING OF LUNGCANCER.pptx.pptx
bykhondekarsaleha
 
PPTX
lung tumors.pptx
byAbdisalamSaza
 
PPT
Lung cancer.
byYusufSiddiq
 
PPT
4 lung cancer
byClaudiu Cucu
 
PPTX
imaging_in_lung_cancer[1] - Read-Only.pptx
bykrishnaswethakota
 
PPTX
Lung Tumours, classification and its pathology
byTharindaAbeysekara
 
PPTX
Lung_cancer_presentation- oncology .pptx
byNadeenJamal
 
CARCINOMA OF LUNG.pptx
bymanjunathpandit1
 
lung cancer for M.M.E.D and Undergraduates
byKesheniLemi
 
LUNG TUMORS (1).pptx, pathology pathology pathology
bychourasiyakumkum0
 
lung cancer central seminar lung cancer.pptx
byAbhilashYadav31
 
Radiological imaging of pulmonary neoplasms
byPankaj Kaira
 
NSCLC DR ANJALI.ppt NSCLC NSCLC NSCLC NSCLC
bydranjalikrishnanp
 
non-small-cell-lung-cancer-100303173219-phpapp02.ppt
bydranjalikrishnanp
 
lung neoplasms
bybbxoxo
 
lungcancer-140104125933-phpapp02.pptx and
byAnmolChauhan67
 
Tumurs of the lung
byNikhil Murkey
 
Presentation1.pptx. radiological imaging of bronchogenic carcinom.
byAbdellah Nazeer
 
Lung maligncy updated 27 04-18 dr jarisha miot radiology
byJarisha Vj
 
Carcinoma lung clinical and radiology ct
byVISHNUJS11
 
CLINICAL PRESENTATION ,DIAGNOISIS AND STAGING OF LUNGCANCER.pptx.pptx
bykhondekarsaleha
 
lung tumors.pptx
byAbdisalamSaza
 
Lung cancer.
byYusufSiddiq
 
4 lung cancer
byClaudiu Cucu
 
imaging_in_lung_cancer[1] - Read-Only.pptx
bykrishnaswethakota
 
Lung Tumours, classification and its pathology
byTharindaAbeysekara
 
Lung_cancer_presentation- oncology .pptx
byNadeenJamal
 

More from ALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar

PPTX
Recent Advances in Radiation Therapy for Rectal Cancer.pptx
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
PPTX
Hodgkins lymphoma
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
PPT
Hormonal and targeted therapy dr sandip
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
PPTX
Radiation protection
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
PPTX
Beam modifications
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
PPTX
Pituitary tumours
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
Recent Advances in Radiation Therapy for Rectal Cancer.pptx
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
Hodgkins lymphoma
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
Hormonal and targeted therapy dr sandip
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
Radiation protection
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
Beam modifications
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 
Pituitary tumours
byALL INDIA INSTITUTE OF MEDICAL SCIENCES,Bhubaneswar
 

Recently uploaded

PPT
Innovation Takes the Lead in SCLC: Leveraging Evolving Advances to Drive Impr...
byPVI, PeerView Institute for Medical Education
 
PDF
MENTAL HEALTH TEAM PSYCHIATRIC NURSING TW
byTaterao Wagalgave
 
PDF
Dawn Buckley - A Professional In Medicine And Business
byDawn Buckley
 
PPTX
Biomechanical principles in removable partial dentures (rpd)
byShwetaPatil220579
 
PPTX
How to Transform Clinical Practice into Evidence: A Practical Guide to Eviden...
byDaradia: The Pain Clinic
 
PPTX
ELECTRON TRANSPORT CHAIN.complete overview pptx
bysfarzanazubair
 
PPTX
LOKAKARYAMINI BULANAN PUSKESMAS TAHUN 2022
byfilepentingsarah2023
 
DOCX
Lesson plan on Malaria diagnosis to health professionals
byGeetha Raj
 
PPTX
INTRODUCTION TO DENTAL X-RAY, HISTORY, PROPERTIES AND USES OF X-RAY
byDr. Sakshat Lamichhane
 
PDF
lec3.Triangles of the neck...... (1).pdf
byeimili1234err
 
PPT
Benjamin Best -- Bedford Day 2026 presentation
byChurch Of Perpetual Life
 
PDF
Airway Obstruction Management Techniques and strategies
byemaanarif2004
 
PPTX
OSPE in Pharmacology | Complete Guide for II MBBS Students 2026
byShivankan Kakkar
 
PPTX
Physiology Of Respiratory System Pediatric View.pptx
bydoshiharsh814
 
PPTX
ANATOMY OF THE PERICARDIUM OF THE HEART
bySanyamarora25
 
PDF
Regulatory Guidelines for Biosimilars.pdf
byManoj Konde
 
PDF
spirometry workshop, physiology department, GMC surat.pdf
bydralpnamathur
 
PPTX
LIPIDS Homeostasis (digestion, metabolism, absorption and excretion.pptx
bysfarzanazubair
 
PPTX
Sweet Dreams - an ILC Partners webinar on sleep
byILC- UK
 
PPTX
JANUARY 2026 ONCOLOGY CARTOONS BY DR KANHU CHARAN PATRO
byKanhu Charan
 
Innovation Takes the Lead in SCLC: Leveraging Evolving Advances to Drive Impr...
byPVI, PeerView Institute for Medical Education
 
MENTAL HEALTH TEAM PSYCHIATRIC NURSING TW
byTaterao Wagalgave
 
Dawn Buckley - A Professional In Medicine And Business
byDawn Buckley
 
Biomechanical principles in removable partial dentures (rpd)
byShwetaPatil220579
 
How to Transform Clinical Practice into Evidence: A Practical Guide to Eviden...
byDaradia: The Pain Clinic
 
ELECTRON TRANSPORT CHAIN.complete overview pptx
bysfarzanazubair
 
LOKAKARYAMINI BULANAN PUSKESMAS TAHUN 2022
byfilepentingsarah2023
 
Lesson plan on Malaria diagnosis to health professionals
byGeetha Raj
 
INTRODUCTION TO DENTAL X-RAY, HISTORY, PROPERTIES AND USES OF X-RAY
byDr. Sakshat Lamichhane
 
lec3.Triangles of the neck...... (1).pdf
byeimili1234err
 
Benjamin Best -- Bedford Day 2026 presentation
byChurch Of Perpetual Life
 
Airway Obstruction Management Techniques and strategies
byemaanarif2004
 
OSPE in Pharmacology | Complete Guide for II MBBS Students 2026
byShivankan Kakkar
 
Physiology Of Respiratory System Pediatric View.pptx
bydoshiharsh814
 
ANATOMY OF THE PERICARDIUM OF THE HEART
bySanyamarora25
 
Regulatory Guidelines for Biosimilars.pdf
byManoj Konde
 
spirometry workshop, physiology department, GMC surat.pdf
bydralpnamathur
 
LIPIDS Homeostasis (digestion, metabolism, absorption and excretion.pptx
bysfarzanazubair
 
Sweet Dreams - an ILC Partners webinar on sleep
byILC- UK
 
JANUARY 2026 ONCOLOGY CARTOONS BY DR KANHU CHARAN PATRO
byKanhu Charan
 

Carcinoma lung

  • 1.
    Management of Carcinomalung Moderator : Dr Seema Gupta Presenter : Dr Sandip Barik Dept of Radiotherapy CSMMU
  • 2.
    EPIDEMIOLOGY • Lung cancer is the most common cancer worldwide contributing about 12.2% of all new case diagnosed • It is the most common cause of cancer in men worldwide(about 16.5% ) • It is the most common cause of cancer related death world wide about(18.2% of all death) • In India incidence is about 12.1 men /100,000 population • Change in trend is seen with incidence increasing in women (0.4% per year)and decreasing in men from year 1990 • Occurs most commonly between 40-70 yrs of age with peak incidence at 50s or 60s
  • 3.
    RISK FACTORS • Smokingis the primary risk factor(87% of lung cancer occur in smokers • Average smokers have 10 fold greater risk,while heavy smokers(40 cigarettes/day) have 60 fold greater risk • Women have higher susceptibility to tobacco carcinogen than men do • Introduction of filter cigarettes entices smokers to take larger puffs and retain smoke longer • Second hand smoke or environmental tobacco smoke is estimated to cause about 3000 deaths/year
  • 4.
    Risk factor cont… •Industrial agents like asbestos,coaltar fumes,nickle ,chromium,arsenic,radioactive materials,radon gas are carcinogenic • Genetic alterations with mutations in p53,RB1,p16(INK4a) • Dominant oncogenes frequently involved include c- MYC,KRAS,EGFR,c-MET and c-KIT • Precursors lesions like squamousdysplasia,atypical adenomatous hyperplasia,diffuse idiopathic pulmonary neuroendocrine cell hyperplasia • Vitamin A,C,E have protective effect
  • 5.
    NATURAL HISTORY • Lungcarcinoma arise most often in and about the hilus of lung • About 3/4th of the lesion originate from 1st,2nd,3rd order bronchi • Local spread to intrathoracic areas • The incidence of scalene (supraclavicular)node ranges from 2% to 35% • Metastasis to these nodes are from ipsilateral upper lobes • Metastasis also occur in cervical,axillary and inguinal lymphnodes
  • 6.
    Natural hist cont… •Extrathoracic spread • Undifferentiated small cell cancer (oat cell variant) has a higher incidence of distant metastasis than nonsmall cell types • Among Non small cell group Adenocarcinoma have a greater propensity for distant metastases
  • 7.
    LYMPHATIC DRAINAGE • Duringthe past three decades two different lymphnode station have been used • 1st was the Japanese Lung Cancer Society Classification • 2nd was the Mountain Dressler Modification of the American Thoracic Society(MDATS) • Recently the International Association For The Study Of Lung Cancer(IASLC) proposed a lymphnode map • It provides more detailed nomenclature for the anatomic boundaries of lymphnode station • The IASLC is now the recommended means of describing regional lymphnode in lung cancer
  • 8.
    LYMPHNODE STATION Supraclavicular 1.Low cervical,supraclavi cular,sternal notch Superior (2R,2L)Upper Mediastinal Paratracheal (3a,3p)Pre vascular,Retrotrach eal (4R,4L)Lower paratracheal Aortic (5,6)Subaortic,Par aaortic Inferior Mediastinal 7 Subcarinal (8,9)Paraoesophag eal,pulmonary ligament N1 nodes (10,11,12,13,14) Hilar,interlobar,loba r,segmental,subse gmental
  • 9.
    • The lymphfrom right lung involves lower paratracheal nodes(iv) followed by subcarinal (vii) • The lymph from left upper lobe involve subaortic nodes(v) • The left lower lobe drains to subcarinal lymphnodes(vii)
  • 10.
    WORLD HEALTH ORGANISATION CLASSIFICATION OF MALIGNANT LUNG • MALIGNANT CANCER 1. SQUAMOUS CELL CARCINOMA 5 ADENOSQUAMOUS a Spindle cell variant 6 CARCINOID 2. SMALL CELL CARCINOMA 7 BRONCHIAL GLAND a Oat cell CARCINOMA b Intermediate cell C Combined 3. ADENOCARCINOMA A Acinar B Papillary C Bronchioalveolar D Solid carcinoma with mucin 4. LARGE CELL CARCINOMA A Giant cell B Clear cell
  • 11.
    PATHOLOGICAL CLASSIFICATION • Squamous cell carcinoma is the most commonly found in men • It is closely related with smoking history • Adenocarcinoma has been common type of lung cancer in women and nonsmokers since 1950* • From 1990’s adenocarcinoma is the most common diagnosis in men*i • Currently Adenocarcinoma has surpassed Squamous cell type
  • 12.
    Classification (cont…) Non Small Cell Small Cell Lung Lung Cancer Cancer (SCLC) (NSCLC) • Oat Cell • Adenocarcinoma • Intermediate • Squamous Cell Carcinoma • Combined • Large Cell Carcinoma
  • 13.
    CLINICAL PRESENTATION • Although no set of signs and symptoms are pathognomic for carcinoma lung they can be broadly divided into three categories 1. Due to local tumour growth and intrathoracic spread 2. Due to distant metastasis 3. Nonspecific systemic symptoms or paraneoplastic syndromes
  • 14.
    Due to localtumor and intrathoracic spread • Squamous and small cell cancers usually present as central mass • They produce cough,wheeze,hemoptysis • Symptoms and signs of airway obstruction &postobstructive pneumonitis(dyspnoea,fever,productive cough) • Adenocarcinoma and large cell tumour present as peripheral mass with pleural involvement • More likely to be asymtomatic but may cause pleuritic chest pain,cough • Squamous and large cell cavitate in 10-20% of cases
  • 15.
    Intrathoracic spread • Usuallycauses nerve entrapment • Most commonly causes left recurrent laryngeal nerve palsy leads to hoarseness, dysphagia recurrent aspirations • Phrenic nerve entrapment leads to hiccups • Apical tumours causes Pancoast syndrome, lower brachialplexopathy(C8,T1), Horners syndrome, shoulder pain • Most superior sulcus tumour are squamous cell type
  • 16.
    Intrathoracic spread • Compression of esophagus dysphagia recurrent aspirations tracheoesophageal fistula bronchoesophageal fistula • Principal vascular syndrome caused is Superior vena cava syndrome • Usually caused by tumour on right upper lobe or right main bronchus • Most commonly caused by small cell type followed by squamous cell
  • 17.
    Intrathoracic spread • 50%of patients with disseminated lung cancer develops pleural effusion • Lung cancer is the single most cause of pericardial metastases
  • 18.
    SYMPTOMS DUE TO METASTASIS • Most common sites of haematogenous spread that are clinically apparent are brain,bones,liver,adrenals • Extrathoracic metastatic disease found at autopsy in 50% with squamous cell carcinoma 80% with adenocarcinoma and large cell 95%with small cell cancer • Symptoms are according to the organ involved • Adrenal metastases are common but rarely cause adrenal insufficiency
  • 19.
    NONSPECIFIC AND PARANEOPLASTIC SYNDROMES • Paraneoplastic syndrome refer to the disorders that accompany tumours but not directly related to mass effect or invasion • Endocrine syndromes hypercalcaemia,hypophosphataemia due to parathyroid hormones by squamous cell. Hyponatraemia with SIADH by small cell hypokalemia due to ACTH by small cell • Clubbing in non small cell type • Hypertrophic pulmonary osteoarthropathy in adeno carcinoma • Neurologic myopathic syndromes like Eaton lambert • Trousseau’s syndrome • Dermatomyositis and Acanthosis nigricans
  • 20.
    • Detail History • Physical Examination • Chest xray 1. It is the single most important and initial investigation 2. It can present in different ways depending on the region of lung involved and histology Hilus Hilar prominence,hilar mass,perihilar mass Pulmonary Mass,apical mass,multiple parenchyma masses,bronchial obstruction,collapse,consolidation Intrathoracic Mediastinal widening or mass,chest extrapulmonary wall erosion,pleural effusion,elevation structure of diaphragm
  • 21.
    Chest x-ray cont.. Squamouscell Collapse,consolid carcinoma ation,cavitation,hil ar abnormality Adenocarcinoma Peripheral mass,hilar abnormality,obstr uctive lesion,no cavitation Large cell Peripheral carcinoma mass,cavitation and hilar abnormalities rare Small cell Hilar prominence tumours
  • 22.
    Confirmatory workup • Sputum cytology:it has a posive predictivity value of 100%,but sensitivity of 10-15% • Bronchoscopic biopsy • Transbronchial fine needle aspiration Used for central lesions Evaluation of mediastinal lymphadenopathy • Bronchoalveolar lavage peripheral regions not visible endoscopically • CT guided transthoracic percutaneous fnac/biopsy
  • 23.
    Staging workup 1. CECT THORAX Sensitivity 75%,specificity 66% CT scan should extend inferiorly to include upper abdomen and adrenal glands 2. FDG PET SCAN Sensitivity 91%,specificity 86% Can detect lesions >5 to 8 mm on basis of FDG uptake Combinations of CT scan and PET scan has greater sensitivity and specificity than CTscan along 3. FIBREOPTIC BRONCHOSCOPY Most important procedure for determining the endobronchial extent of the disease,measuring tumour proximity to carina 4. MEDIASTINOSCOPY Best method to evaluate the upper,middle peritracheal and subcarinal lymphnodes 5. BONE SCAN/CT-MRI OF BRAIN 6. ULTRASONOGRAPHY WHOLE ABDOMEN
  • 25.
    Blood • Haemogram • Kidneyfunc test • Liver func test • Serum electrolytes • Hormones like parathyroid,ACTH Urine • Routine & microscopic
  • 26.
    AJCC STAGING(2010) Tx Primary cannot be accessed or positive cytology To No evidence of primary tumour Tis Carcinoma in situ T1 Tumour <3cm greatest dimention surrounded by lung or visceral pleura without bronchoscopic evidence of invasion more proximal than lobar T1a bronchus(i.e not in main bronchus) Tumout 2 cm or less in greatest dimention T1b Tumour >2cm but 3cm or less in greatest dimention T2 Tumour >3cm but 7cm or less or involves main bronchus,>2cm from the carina,invades visceral pleura associated with partial atelactasis T2a Tumour more than 3cm but 5cm or less T2b Tumour more than 5 cm but 7 cm or less T3 Tumour more than 7 cm or one directly invading the parietal pleura,chest wall,diaphragm,phrenic nerve,mediastinal pleura,parietal pericardium or tumour in the main bronchus<2cm from the carina but without involvement of carina,associated total atelectasis T4 Tumour of any size invading the mediastinum,heart,great vessels,trachea,recurrent laryngeal nerve,esophagus,vertebral body,carina,separate tumour nodule in tha same lobe,malignant effusion
  • 27.
    Regional lymphnodes Nx Regional node cannot be accessed No No regional node metastasis N1 Metastasis in ipsilateral peribronchial and/or ipsilateral hilar node and intrapulmonary nodes including involvement by direct extention N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymphnodes N3 Metastasis in contralateral mediastinal,contralateral hilar.ipsilateral or contralateral scalene or supraclavicular node Distant Metastasis Mo No distant metastasis M1 Distant metastasis M1a Separate tumour nodule in a contralateral lobe tumour with pleural nodule or malignant pleural or pericardial effusion M1b Distant metastasis in extrathoracic organs
  • 29.
    PROGNOSTIC FACTORS • Epidermoid carcinoma has the best prognosis followed by adenocarcinoma and undifferentiated large cell cancer • Undifferentiated small cell cancer has the poorest prognosis • In Lung cancer the most important prognostic factor is tumor stage • In SCLC pure cell carcinomas are more sensitive to chemotherapy and radiotherapy than variant cell.
  • 30.
    Negative prognostic factorsare 1. Mutations in Kras oncogene 2. Deletion of p53,NCAM molecule 3. Expression,elevated neuron specific enolase level 4. Over expression of erb1,erb2 5. Increased proliferative 6. Markers(ki67,cyclinD1,E,B1,p16 loss 7. Angiogenesis markers like VEGF 8. Decreased apoptotic markers like caspase 3
  • 31.
    Management of NSCLC StageI-II : Early stage(T1-2, N1) Stage IIIA : Locally advanced (surgery feasible)(T3,N2) Stage IIIB : Locally advanced (surgery not feasible)(T4,N3)  Stage IV : Metastatic disease
  • 32.
    For Non SmallCell Cancer • Surgery usually a multimodality • Chemotherapy approach is • Radiotherapy used
  • 33.
    Surgery • Indications 1. Stage I , II 2. Stage IIIA(T1-3 N2,T3N1) 3. Medically fit 4. Good performance scale
  • 34.
    Surgery(cont…) • Surgery isthe standard treatment of choice for patients with stage I,II and IIIA tumours. • Lobectomy with nodal dissection is the method of chioce • Pneumonectomy is done only when Involves proximal bronchus or proximal pulmonary artery Crosses major fissure • Wedge resection is only restricted to persons who are not able to tolerate lobectomy
  • 35.
    Lymphnode dissection The currentminimum standard is a systemic sampling of each lymph node station of tumor Rt sided tumors – 2,3,4,7,8, 9,tracheobronchial angle and interlobar area (10,11) Lt sided tumors – sub aortic, ant med nodes (5,6), 7,8,9
  • 36.
    Results • 5 yrssurvival for patients with Stage I is 65%,Stage II is 60% ,Stage IIIA( N1 disease is 34%,N2 is 24%) • Various studies also concluded that lymphnode dissection is necessary for accurate staging. • Lesser resections like wedge resection result in higher recurrence rate and reduced survival. • Survival is longer in clinical (pre op)N0 or N1 disease but pathological(post resection N2) than clinical N2 disease
  • 37.
    RADIOTHERAPY Radiation is usedin following forms in NSCLC A. AS ADJUVANT * Post Operative * Pre Operative B. PRIMARY RADIATION * Radical * Palliative C. CHEMO-RADIATION NSCLC is a radio responsive tumor but not radiosensitive
  • 38.
    Role of preop irradiation • Indications 1. In stage I,II,III tumours • Dose :20 Gy in 5# • Results • Multi institutional trail compared preop RT vs surg alone • No added benefits was found in stage I,II Tumours • But a significant 3 yr survival rate (49.4% vs 28.1%) was observed in stage III
  • 39.
    Role of Postop RT • Indications 1. Incomplete resection 2. Close or positive margins 3. Positive mediastinal metastases 4. Resected N2 disease 5. Chest wall involvement 6. Superior sulcus tumour • Contraindications 1. Currently contraindicated in patients with stage I completely resected
  • 40.
    Post op RT(cont…) Dosefor potential microscopic Dose for margins positive 60 to disease 50 GY 66 Gy RESULTS TRIALS •PORT Meta Analysis •SEER Database •British Medical Research CONCLUSIONS •Role of PORT in positive N1 disease is controversial •More data supporting role in N2 •The studies used conventional technique •Modern tech like IMRT,3D CRT hopefully will increase the result in favour of PORT
  • 41.
    Definitive radiotherapy inNSCLC (early stage) INDICATIONS : • 1. Medically inoperable T1-T3 lesions. • 2. Patient refuses surgery. • 3. Critically located lesion. • 4. Non-resectable Stage-II & Stage-IIIA • • 5. Patient with incomplete resection. • 6. Localized recurrent lung cancer.
  • 42.
    RADIOTHERAPY TECHNIQUES  ConventionalExternal beam radiotherapy • VOLUME 2 cm around the tumour margin • ENERGY 6-10 Mev linac • PORTALS 2 to 3 fields depending on tumour and lymphnodes • DOSE 60-66 GY @1.8-2 GY/#
  • 44.
    Results of Radiotherapyin early stage • Local control is poor and results are not very encouraging for NSCLC • 5yr local control and overall survival rates ranges from 30 to 50% and 10-30% • Results of conventional RT is certainly inferior when compared with other modality
  • 45.
    STEREOTACTIC BODY RADIATIONTHERAPY • SBRT is a combination of multiple beam angles to achieve sharp dose gradients,high precision localisation and a high dose per fraction in extracranial locations. • Delivers a high biologic effective dose BED to target • Minimise normal tissue toxicity • Reduced treatment volume • Reducing treatment time
  • 46.
  • 47.
    • Results ofSBRT  Image guided SBRT with delivery of BED>100 GY is feasible and produces better results than <100 gy  3 to 5 yr survival rate and local control is much more better than those for conventional RT  For stage I A disease results are comparable with surgery  Emerging as the standard treatment for inoperable stage I NSCLC.
  • 48.
    Definitive RT InAdvanced NSCLC(stage III) • Larger unresectable tumours T4N0-1 or T1-4 N2-3. • Dose given is 60 GY @2GY/# • A higher dose upto 80 to 100 gy is required to improve local control and potential survival but toxicity is main limiting factor here. • However advanced such as 3D crt and imrt have provided a way for dose escalation with out toxicity.
  • 49.
    non small celllung cancer newer radiation techniques 1. 3-Dimentional Conformal Therapy. 2. Intensity Modulated Radiation Therapy. 3. IGRT and Gated Radiotherapy. 4. Interstitial Brachytherapy. 5. Endobronchial Brachytherapy. 6. Intra Operative Radiotherapy.
  • 50.
    3-D CRT &IMRT IN LUNG CANCER Goal: To increase dose delivery to tumour To minimize dose to normal tissues. Advantages 1. Better conformity of radiation dose to the tumour. 2. Sparing of all the vital structures around tumour. 3. Escalation of dose is possible. 4. Better control of disease. 5. Reduced morbidity.
  • 51.
    3-D CRT &IMRT IN LUNG CANCER TREATMENT PLANNING
  • 52.
    Radiotherapy planning • GTV(Gross Tumor volume) • CTV (Clinical Target volume) • PTV (Planning Target volume) • GTV Visible tumor by any imaging modality including the lesion and lymphnode > 1 cm.
  • 53.
    RT-Planning – Definingthe CTV CTV is the volume that contains gross and microscopic disease A Radiographic histopathologic study demonstrated that CTV varies with histologic type Microscopic extension Adeno Squamos mean value 2.69mm 1.48mm 5mm margin covers: 80% 91% margin to cover 95% 8mm 6mm
  • 54.
    PTV • One ofthe important reason of uncertainty in ca lung is motion of the tumor during respirations • PTV is defined as CTV with a margin to account for daily set up error and target motion
  • 55.
    NON SMALL CELLLUNG CANCER RADICAL RADIATION Image Guided RadiationTherapy-IGRT: It is defined as the use of modern imaging modalities specially those incorporating functional and biological information. 1. To augment target delineation 2. Use of imaging to adjust to target motion and positional uncertainty- respiratory gated therapy 3. Potential to adopt treatment to tumor response.
  • 56.
    IMAGE GUIDED RADIATIONTHERAPY EQUIPMENT REQUIRED CT-SCAN MRI PET-CT Linac with on Tomotherapy Cyber knife Board imaging
  • 61.
    Chemotherapy (NCCN Guidelines 2010) • Indicated in all stages above stage Ib, significant improvement in survival. • First line - Premetrexate + cisplatin is superior to Gemcitabine + cisplatin in non sq cell tumors. - Paclitaxal + carboplatin for sq cell tumors. - Bevacizumab and Erlotinib combined with chemotherapy. - No use of using a third drug in the regime. - Older patients single agent chemotherapy is adviced
  • 62.
    • Second line (in combination with platinum) - Docetaxal - Premetrexate - Irinotecan - Erlotonib • Third line - Erlotinib - Vinorelabine
  • 63.
  • 64.
    Staging of SCLC Veterans Administration Lung Study Group (VALG) staging system • Limited-Stage Disease (LD SCLC ) - Confined to the hemithorax of origin, the mediastinum, or the supraclavicular nodes, which can be encompassed within a tolerable radiation therapy port. • Extensive-Stage Disease (ED SCLC) - Any disease not meeting limited stage criteria - Distant metastasis. •
  • 65.
    Staging of SCLC •The International Association for the Study of Lung Cancer (IASLC) revised the VALG classification in accordance with the TNM system. - LD definition is consistent with TNM stages I to IIIB. - ED is limited to patients with distant metastases.
  • 66.
    Management of SCLC •SURGERY 1. Stage I(T1-2,N0) 2. Lobectomy with mediastinal nodal dissection is the surgery of choice 3. Early stage SCLC is diagnosed in fewer than 5% of SCLC patients,limits the scope of surgery 4. The trial by Medical Research Council led to abandonment of surgery as a primary modality of treatment
  • 67.
    Combined Chemotherapy andRadiation therapy • Indications 1. To decrease the local recurrence 2. To improve survival 3. Positive lymphnode involvement after surgery
  • 68.
    Role of Radiotherapy •Meta-analysis by Warde and Payne - 11 prospective trials of chemotherapy with or without RT were analysed - Results : Absolute increase of OS by 5.4 % at 2 years Local control of 25 % with limited stage disease • Pignon et al - 16 randomized studies with 2,140 patients - improvement in abolute survival of 5.4 % at 3 years Definite role for RT in local control of disease which leads to increase in overall survival
  • 69.
    Role of chemoradiotherapy McCracken et al (154 patients) Results Cisplatin , Etoposide Time Survival & vincristine 2 cycles 2 yr 42 % with RT 1.8 Gy per 4 yr 30 % day upto 45 Gy 5 yr 26 % Concurrent chemo radiotherapy provides good survival advantage with tolerable toxicity to the patient
  • 70.
    Concurrent Chemoradiation • Advantages 1. Overall shorter treatment time 2. High dose intensity 3. Sensitisation of tumours • Disadvantages 1. Enhanced normal tissue toxicity 2. Treatment breaks 3. Inability to access response to either mode
  • 71.
    Sequential vs Concurrent chemoradiotherapy Japanese Clinical Oncology Group Arm 1 Paclitaxel 80 mg/m2 on d1 and etoposide 100 mg/m2 d1-3 (2 cycles) Results showed significant improvement of survival in RT 45 GY CRT arm Conclusion:CRT is better Arm 2 than sequential chemo and Paclitaxel 80 mg/m2 on d1 and etoposide radiotherapy 100 mg/m2 d1-3 + RT was started along with chemo from day1
  • 72.
    Timing of ChemoRadiotherapy • NCI Canada trial 40 Gy in 15 fractions over 3 weeks to the primary site concurrent with the first cycle of EP All 308 eligible patients received (week 3) cyclophosphamide, doxorubicin, and vincristine (CAV) alternating with etoposide and cisplatin (EP) every 3 weeks for three cycles of each late TI patients received chemotherapy regimen. the same radiation concurrent with the last cycle of EP (week 15) Overall survival better in Early RT arm
  • 73.
    Altered fractionation Turrisi et al Once-daily therapy received 1.8 Gy daily in 25 treatments 417 patients with limited over a period of five weeks. small-cell lung cancer. Patients with a All the patients received four complete response 21-day cycles of Received prophylactic cisplatin 60 mg/m2 and cranial irradiation 25 Etoposide 120 mg/m2 Gy 1n 10 # RT started with CT in first week Accelerated twice-daily thoracic radiotherapy involved the administration of 1.5 Gy in 30 # over a period of three weeks Conclusion : 10% absolute increase in overall survival @ 5yrs with15% increase in high grade esophagitis in Acc RT arm
  • 74.
    Prophylactic cranial irradiation Metaanalysisconducted in 1999 studied 7 prospectively randomised trail They found a disease free and overall survival advantage in those patients who under went prophylactic cranial irradiation Dose is still a matter of debate however there is a trend in reduction of brain relapses at 36 GY @ 2 GY /# Prophylactic cranial irradiation should be consideredfor complete clinical responders
  • 75.
    CONCLUSION • NSCLC 1.STAGE I&II Surgery if feasible followed by adjuvant chemotherapy when indicated  SBRT if not medically fit 2.STAGE IIIA  Surgery with adj chemotherapy + PORT  EBRT with chemotherapy if not fit 3.STAGE IIIB  EBRT with chemotherapy 4.STAGE IV  Chemotherapy with EBRT for palliation
  • 76.
    CONCLUSION SCLC;Limited disease CONCURRENT CHEMORADIATION IS CONSIDERED • Dose of Radiotherapy should be delivered at 45 GY with1.5 GY/#,twice daily with concurrent Cisplatin and Etoposide. • Prophylactic cranial irradiation should be considered for complete clinical responders. • Patients should be encouraged to participate in newer protocol  Extensive disease • Chemotherapy • Prophylactic cranial irradiation for responders • Palliation
  • 77.

Editor's Notes

  • #12 *Int journal radnonco 1992-24:11-16