2. INTRODUCTION
• 15 % bronchogenic carcinomas
• 100% cases attributed to cigarette smoking
• Originates from neuroendocrine precursor cells
• High propensity for distant metastasis
• Chemo and radiosensitive but high recurrence rate
• Most common tumour associated with Paraneoplastic
syndromes
3. INVESTIGATIONS
• History and physical examination
• Blood investigations
• Imaging
- CXR
- CT Chest/MRI Thorax
- PET scan
- Endobronchial USG
• Histologic diagnosis
- Sputum cytology
- Flexible fiberoptic bronchoscopy
(cytology and biopsy)
- FNAC ( US / CT guided )
- VATS
• Metastatic workup
- Mediastinoscopy
- CT abdomen
- MRI Brain
- Bone marrow
aspiration
- Bone scan
4. Chest Xray CT Chest
• Cheap, easily available
• Tumour advanced if
seen on CXR
• Pulmonary densities ,
atelectasis and pleural
effusion is seen
• More than 77% of CT
detected tumours < 2
cm missed on CXR
• IOC
• Confirms CXR findings
• Detects tumours < 1 cm
• Local invasion to chest
wall, vertebrae
• Spread to mediastinum
5. CT Chest vs MRI Thorax
• Lower sensitivity to detect
mediastinal invasion
• Spatial resolution better
• Cost effective
• No artifacts
• Higher sensitivity to detect
mediastinal invasion
• Spatial resolution inferior to CT
• Expensive
• Artifacts
• For thoracic inlet and
para vertebral detail
6. Fibreoptic bronchocopy
• For visualisation of the
tracheobronchial tree
Diagnostic
- bronchial washings
- brush cytology can be
obtained
- biopsies of suspicious areas
Therapeutic
- EL Brachytherapy
- Endobronchial stents
7. CT guided FNAC Sputum cytology
• 80 % detection rates
• Risk of pneumothorax –
25 % resolve
spontaneously
• Rapid and inexpensive
• Sensitivity of sputum
cytology -65 %
• Diagnostic yield of
sputum cytology is
enhanced with centrally
located intraluminal
cancers e.g squamous
cell ca
8. PET CT
• More accurate than CT
for the detection of-
- N1
- mediastinal metastases
- involved lymph nodes
although normal in size
- Extrathoracic mets
• Detect tumours as small
as 0.5 cm
• 19 % pts upstaged from
limited to extensive
disease whereby 8% are
downstaged from ED to
LD
• Incorporating FDG-PET
information-in RT
planning- changed the
treatment plan in 24 %
pts compared to CT
9. CT Head/ MRI Brain
• To rule out metastatic
lesions
• Detects the presence ,
number and location
10. Endobronchial ultrasound
• Safe & minimally invasive
• More accurate than CT in
identifying mediastinal nodal
metastases
• To assess locations hard to
accessduring mediastinoscopy
such as subcarina,
aortopulmonary window ,
paraesophageal area
11. ENDOSCOPIC FINE NEEDLE ASPIRATION
Sampling of ultrasound
suspicious LNs -especially
located in para tracheal ,
sub carinal , hilar LN.
Accuracy 98 %
Specificity –100 %
13. Video assisted thoracoscopic surgery
(VATS)
• Resect tumour in its
entirety
• Frozen section to confirm
diagnosis
• Smaller tumours difficult
to resect by VATS
• For solitary tumours in
good resectable condition
with no metastasis on
staging investigations
14. STAGING
Veterans Administration Lung Study Group :
IASLC modification ( international association for study
of lung cancer
• Limited stage (LS)
Disease confined to one hemithorax and regional nodes
(historically defined as fitting into a single radiation
port) Exclude
• T3-4 with multiple lung nodules.
• T3-4 with tumor/nodal volume that does not fit in
tolerable radiation plan
• Extensive stage (ES)
Any disease not meeting limited stage criteria
15. AJCC TNM Staging
Limited stage
Stage I-III
Exclude
• T3-4 with multiple lung nodules.
• T3-4 with tumor/nodal volume that does not fit in
tolerable radiation plan.
Extensive stage
Stage IV
• T3-4 with multiple lung nodules.
• T3-4 with tumor/nodal volume that does not fit in
tolerable
16. WILL ROGERS PHENOMENON
• Many patients previously believed to have L-SCLC are up
staged to the extensive disease category because of more
sensitive staging
• So their inclusion in the extensive stage group and exclusion
from the L-SCLC improves survival rates in both the groups
30. 231 patients with LD
CONCURRENT SEQUENTIAL
4 x EP + RT 4 EP RT
• RT dose was 45 Gy / 30F / 3 weeks (1.5Gy/F)
• Significant increase in MS , 5 year OS
• Severe esophagitis and haematologic toxicity
in the concurrent arm.
31. irinotecan 60 mg/m2 d 1,8,15; cisplatin 60 mg/m2 d 1 q 4 weeks
etoposide 100 mg/m2 d 1,2,3; cisplatin 80 mg/m2 d 1 q 3 weeks
154 patients (planned 230)
median survival IP 12.8 months; EP 9.4 months
at 2 years 19.5% versus 5.2% alive
Noda K et al. New Engl J Med
2002
32. RADIOTHERAPY
Curative
– With Chemotherapy in limited disease SCLC
– Limited role in extensive disease SCLC
Palliative
– For palliation of symptoms due to primary growth
– In SVCO
– For palliation of bone/ brain mets
Preventive
– For prophylactic cranial irradiation
33. Chemotherapy alone versus Chemoradiation
2 meta-analyses: Pinon et al, NEGM, 1992
Warde et al, JCO, 1992
5 % improvement of 2 year OS
34. DOSE
45 Gy/30 F at 1.5Gy /F in 3 weeks twice daily
45 Gy/25F in 5 weeks once daily
1.8Gy/F
60-70 Gy once daily regimen
36. INTERGROUP 0096
412 patients with LD
Twice daily Once daily
45 Gy/30F in 3 weeks 45 Gy/25F in 5 weeks
@ 1.5Gy/F @1.8Gy/F
• MS 23 months vs 19 months
• 5 year OS 26% vs 16%
• Cisplatin – etoposide given with both RT course
• PCI given after completion to patients with CR
37. Conventional RT technique
Positioning- Supine with arms above head /
arms by the side
Fields: AP/PA portals
Energy: both cobalt or LINAC used with equal
efficacy
38. UPPER LOBE PRIMARY
RT portals : Field borders
Superior – cover I/L
supraclav fossa
Inferior – 4 cm below carina
Medial – 2.5 to 3 cm across
midline to the opp. side
to include C/L hilar node
Lateral – 2 cm margin
39. • MIDDLE LOBE PRIMARY
RT portals : Field borders
Sup – thoracic inlet or SSN
Inf – 8-9 cm below carina
Medial – 2 cm across midline
on opp side
Lateral – 2 cm margin
beyond the tumour
40. LOWER LOBE PRIMARY
RT portals :Field borders :
Superior – thoracic inlet
or SSN
Inferior – vertebral origin
of diaphragm
Medial – 2 cm across
midline on opp. Side
Lateral – 2 cm margin
41. 3DCRT technique
• Most commonly utilized technique for the
treatment of lung cancer
Goal – Increase dose to gross tumour &
minimise dose to normal tissue
PLANNING CT:
• Technique – CECT of thorax is to be taken
• Position – Supine
• Extent – Cricoid cartilage to L2 vertebra
• Slice thickness - ≤3mm
42. 3DCRT
• GTV : primary tumor & any gross lymph nodes
Gross tumour + LN with SAD >1cm or FDG avid LN
• CTV : Area thought to harbor micrometastasis (hilar
/ mediastinal LN, Margin)
GTV +1.5 cm ( and elective hilum and MN regions +
8mm)
• PTV: Margin for physiologic organ motion during
treatment and daily inaccuracies.
CTV + 1cm
44. IMRT VS 3DCRT ?????
Retrospective review of MDACC experience – no local control or
overall survival when IMRT was compared with 3DCRT.
• Consider IMRT IF V20 % > 30 % OR FEV1 < 1L
46. Prophylactic cranial irradiation
INDICATIONS
- Those who achieved complete response or partial
response to chemoRT
CONTRAINDICATIONS
- Low PS
- Age > 60 years
- Impaired neurocognitive functions
- With chemotherapy
DOSE
- 25 Gy/10F
- 30 Gy/10F
47. • CTV should encompass the whole brain
• Field edges should be atleast 1 cm from the
outer skull margin or if conformal technique
then 3 – 5 mm margin to become PTV if no
image guided RT is used
48. SCLC - Meta-analysis of PCI
From 7 randomised trials of PCI vs no-PCI
Patients 987 (140 patients had ED-SCLC)
Chemo- & RT schemes various
Overall survival benefit +5% (95% CI: 1 -10%)
3 year survival 20 vs 15%
Incidence of brain mets 33 vs 59%
Auperin et al. NEJM 1999
49. • A randomized study (RTOG-0212) of 720 patients
with LD SCLC in complete remission after
chemoradiation therapy demonstrated that
standard-dose PCI (25 Gy in 10 fractions) was as
effective as and less toxic than higher doses of
brain radiation.
• Randomized trials such as EORTC-22003-
08004 (NCT00005062) showed that doses higher
than 25 Gy in 10 daily fractions do not improve
long-term survival.
