This document discusses lung cancer, including its anatomy, staging, diagnostic imaging, and treatment options. It provides details on the lobes of the lungs, lymph node stations, and the importance of lymph node involvement in staging. Imaging techniques like CT, PET, and PET/CT are described. Treatment depends on cancer type and stage, and may involve surgery, chemotherapy, radiation therapy, or a combination. Side effects of radiation treatment are also outlined.

1. Lung Cancer Understanding the disease Treatment options Side effects of treatment

3. Three lobes on the right and two on the left

4. Three lobes on the right and two on the left

9. Lung Lymph Nodes

10. Importance of the Lymph Nodes Nodes on the side (hilar or N1) are not as significant if nodes in the middle or higher up are involved (N2 or mediastinal nodes)

13. Lymph Node Stations N2 Nodes: all N2 nodes lie within the mediastinal pleural envelope on the ipsilateral side 10. hilar, 11. interlobar, 12 lobar nodes bronchi, 12 segmental, 14. subsegmental N1 Nodes: all N1 nodes lie distal to the mediastinal pleural reflection and within the visceral pleura 1. highest mediastinal, 2. upper paratracheal, 3. prevascular/ retrotracheal, 4. lower paratracheal, 5. subaortic/AP window, 6. para-aortic, 7.subcarcinal, 8. paraesophageal, 9. pulmonary ligament

14. Superior Mediastinal Nodes (1-4) 1. Highest Mediastinal: above the left brachiocephalic vein. 2. Upper Paratracheal: above the aortic arch, but below the left brachiocephalic vein. 3. Pre-vascular or Pre-vertebral: these nodes are not adjacent to the trachea like the nodes in station 2. They are either anterior to the vessels (3A) or behind the esophagus, which is prevertebral (3P). 4. Lower Paratracheal (including Azygos Nodes): below upper margin of aortic arch down to level of main bronchus. Aortic Nodes (5-6) 5. Subaortic (A-P window): nodes lateral to ligamentum arteriosum. These nodes are not located between the aorta and the pulmonary trunk, but lateral to these vessels. 6. Para-aortic (ascending aorta or phrenic): nodes lying anterior and lateral to the ascending aorta and the aortic arch. Inferior Mediastinal Nodes (7-9) 7. Subcarinal. 8. Paraesophageal (below carina). 9. Pulmonary Ligament: nodes lying within the pulmonary ligaments. Hilar, Interlobar, Lobar, Segmental and Subsegmental Nodes (10-14) 10-14: these are located outside of the mediastinum. They are all N1-nodes.

15. Reading a Chest Xray

16. Reading a CT Scan

17. Cross Section Anatomy of the Chest

18. Cross Section Anatomy of the Chest

19. PET Scan Anatomy spine Spinal cord ribs

20. Xray versus CT versus PET scan

21. PET/CT Scan showing lung cancer in three different planes

22. Types of Lung Cancer Non-small cell carcinoma (NSCC) Adenocarcinoma Squamous cell Large cell Small cell carcinoma

23. Stages of Lung Cancer Stage I – small spot no nodes Stage II – larger or nodes on the side of the lung (hilar or N1 nodes) Stage III – very large tumor or lymph nodes in the middles of the chest (mediastinum or N2 nodes) Stage IV – metastases to other organs

29. Treatment of Lung Cancer Stage I and II – surgery (if possible) and sometime postOp chemo or radiation Stage III – usually chemo plus radiation, sometime followed by surgery Stage IV – chemo or radiation, depending on the site of spread

30. In the simulation process the CT and PET scan images are used to create a computer plan

31. PET/CT Lung Cancer Image

32. Initial CT Lung Image Prior to PET Fusion

33. Initial CT PET Scan Fused on Treatment Planning Computer

34. In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment

36. Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)

37. Computer generated images of small lung cancer (in blue) in the left upper lung and the radiation target zone (green) that surrounds it

38. Computer generated images showing the radiation beam passing through the patient to hit the small lung cancer

39. Computer generated images showing the volume and dose of normal lung receiving radiation The computer monitors the total lung dose to keep it below a dose level that could cause problems

40. Computer generated lung cancer target in red and radiation zone (yellow) surrounds it

41. Using CT scans the computer can generate the target for a cancer in the upper part of the lung

42. Using CT scans the computer can generate the target for a small cancer growing inside the trachea

43. Computer generated images to target the tumor

44. Tomotherapy images showing the radiation zone in red surrounds the cancer area (in blue) and limits the dose of radiation that hits the normal lung, heart or spinal cord

45. Cyberknife of Tampa Bay

46. Cyberknife for Lung Cancer

47. Radiation Results Some lung cancers (like small cell) shrink quickly, other cancers may take weeks or months to slowly regress

48. PET Scan showing complete remission of the cancer in the left lung at 7 months

49. PET scan showing near complete remission, 2 months after radiation alone for NSCL

50. PET scan showing degree of tumor shrinkage 6 weeks after completion chemoradiation for NSCL lung cancer (the tumor will continue to shrink for weeks to months)

51. Very large lung cancer, prior to radiation

52. PET scan of the same patients, 2 years later, there is still a large density in the lung, but it is ‘cold’ on the PET scan, so just radiation fibrosis or scar tissue

53. Side Effects of Lung Radiation

54. Side Effects of Lung Radiation Esophagus – sore throat or trouble swallowing Trachea or lungs – cough or shortness of breath Chest wall – tenderness Skin – sunburn Fatigue

55. Radiation Prescription for # Cancer Target diagnosis: Stage # NSCL of # number of radiation treatments: #