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LUNG CANCER (Treatment (NSCLC (Metastatic NSCLC (stage IV) (Targeted
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LUNG CANCER
Treatment
- NSCLC is less sensitive to chemotherapy and/or radiation, so surgery is the treatment of choice in these tumors
- SCLC, initially responds well to chemotherapy and/or radiation, but has usually metastases widely by the time it is discovered, making surgery ineffective.
- Surgery:
wedge resection
sleeve resection
lobectomy
pneumonectomy
- Radiation:
1.High dose radiotherapy
2.Paliative:
Haemoptysis
SVCS
Bone pain
- Paliative techniques
Laser therapy
Brachytherapy
Tracheobronchial stents
NSCLC
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take home messages
Advanced (stage IV)
- Incurable disease
- Some patients may benefit from chemotherapy or targeted therapy
- Majority will necessitate palliative therapy
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Early (operable) disease (stage I, II, selected IIIA)
- The mainstay of treatment: pulmonary resection (lobectomy or pneumonectomy)
- Long-term survival after surgery in 40% of patients
- No defined role of pre- or postoperative radiotherapy
- The role of preoperative chemotherapy debatable
- Postoperative chemotherapy recommended in selected patients
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symptoms
- systemic:
Weight loss
Fever
Fatigue
Loss of appetite
due to local compress
- Chest pain 25-35%
- Bone pain
- Superior vena cava syndrome commonly occurs with SCLC
- dysphagia
- Horner’s syndrome
- Irregular heartbeat
- Cardiac tamponade
- Thoracic outlet syndrome
- Wheezing, Hoarseness
- Respiratory:
Coughing (most common) >50%
Dyspnea 30-40%
Hemoptysis 15-30%
Recurring pneumonia 15-20%
pleural effusion
Paraneoplastic syndrome
- disease or symptom that is the consequence of cancer in the body but, unlike mass effect, is not due to the local presence of cancer cells.
- These phenomena are mediated by humoral factors (by hormones or cytokines) excreted by tumor cells or by an immune responce against the tumor.
- Neurological:
Lambert-Eaton myasthenic syndromemost common in SCLC
Paraneoplastic cerebellar degeneration
Encephalomyelitis
Polymyositis
- Mucocutaneous:
Acantosis nigricans
Dermatomyositis
Urticaria
Acquired hyperhrychosis
Lupus erythematosus
Erythroderma
- Hematological:
Trousseau sign (associated with venous thrombosis and hypercoagulability)
Anemia
Disseminated intravascular coagulation
Leukocytosis
Thrombocytosis
- Endocrine
Cushing syndrome
Hypercalcemia
Carcinoid syndrome
SIADH
Horner’s syndrome
- combination of:
Droping of the eyelid (ptosis)
Constriction of the pupil (miosis)
Enophthalmos
Mesothelioma malignum
- rare and malignant cancer caused by asbestos.
- form in the pleura.
- Symptoms: As the disease mostly affects the lungs, the primary symptoms affect the respiratory system, such as shortness of breath, or the thoracic cavity, such as chest pain.
Pleural effusion is the most common presentation (blood)
- Treatment: surgery, which includes removal of some or all of the pleura and possibly part of the lung, combined with chemotherapy and/or radiation.
- Survival: The prognosis is poor, with a median survival time of about 1 year.
- Relatively uncommon tumor
- Incresing incidence
- Average age at diagnosis: 60 years
- Long latency period (20-40 years)
- Men constitute 70–80% of cases
locations
pleura (>90%), peritoneum, pericardium, tunica testis
Malignant
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major differences
- NSCLC
Tumor growth: Slow
Type of growth: Mainly loco- regional
Sensitivity to chemotherapy: Low/moderate
Main treatment modality: Surgery
- SCLC
Tumor growth: Rapid
Type of growth: Rapid dissemination
Sensitivity to chemotherapy: High
Main treatment modality: Chemotherapy
Diagnostic tools
chest radiograph
CT imaging
bronchoscopy
magnetic resonance imaging
positron emission tomography
sputum cytology
needle biopsy
mediastinoscopy
video-assisted thoracoscopy
thoracotomy
NSCLC
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second step
- Bronchoscopy for pat with Central tumor
- Transthoracic fine needle biopsy for pat with Peripheral tumor
- CT chest and upper abdomen for All patients
- Bone scan If symptoms present
- Brain (CT) or MRI Advisable in high risk groups
- PET/CT In patients considered for radical surgery or radiotherapy
first step
Clinical examination
- General status, Lung signs
- Aching pain associated with bone invasion (rib, vertebrae...)
- Tamponade (pericardium),
hoarseness (recurrent laryngeal nerve), Horner’s syndrome...
- Superior vena cava syndrome
- Enlarged nodes (cervical, supraclavicular...)
- Liver enlargement...
- Clinical history (smoking, symptoms, weight loss, performance status...)
- Clinical examination
- Chest radiography
SCLC
- Main aim: establishing the presence of extrathoracic spread (limited vs. extensive disease)
- History and clinical examination, Pathology, Chest X-ray.
- CT chest and abdomen, Bone scan, Brain CT or MRI (As soon as ED is demonstrated, stop further investigations)
- CBC, platelets, Electr., liver function tests, Ca, LDH, urea, creat.
- PET (optional)
- Limited disease (LD) (limited to one hemithorax)
- Extensive disease (ED) (distant metastases)
aetiology
- common:
1.Cigarette smoking (90%), Passive smoking (33%)
2.Genetic
3.Radon gas
4.Asbestos
5.Air pollution
- other:
pre-existing lung disease such as pulmonary fibrosis;
HIV infection
Pancoast tumor
- situated at the top of lung.
- can cause compression of a brachiocephalic vein, subclavian artery, phrenic nerve, recurrent laryngeal nerve,vagus nerve, or, characteristically , characteristically, compression of a sympathetic ganglion resulting in a range of symptoms known as Horner’s syndrome (Droping of the eyelid (ptosis), Constriction of the pupil (miosis), Endophthalmos).
- the most common cancer in terms of both incidence and mortality.
- 90% of patients who develop lung cancer will die of the disease
- classification:
1.Epithelial tumours: malignant, bening
2.Lymphoproliferative tumours
3.Miscellaneous tumours
4.Metastatic tumours