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LUNG CANCER MANAGEMENT
METHODS AND PHILOSOPHY
DR. D. R. JOSHI
B. J. MEDICAL COLLEGE, PUNE
= SYMPTOMATIC & PHYSICAL
ASSESSMENT,
= RADIOLOGICAL ASSESSMENT,
* PLAIN CHEST FILMS,
* C.T.SCANS
* RADIONUCL.BONE SCANS
= Th’centesis, B’scopy, Med‘scopy
= And …. U S G ABDOMEN.
FOR NEW PATIENTS ---
High index of suspicion
Try to define anatomic extent
Find cell-type of lesion
Patient's GC for aggressive Rx
Plan for the Rx.
STAGING & 5-Yrs SURVIVAFOR NSCLC (1986)
I T1_2 no mo …… 60-80 %
II T1_2 N1 mo …… 25-50 %
IIIa T3 N0- mo …… 25-40 %
T1-3 N2 mo …… 10-30 %
IIIb Any T4/N3 mo …... < 5 %
IV Any M1 …… < 5 %
AJCC –RECOMMENDED STAGING …
# Clinical –diagnostic
# Post-surgical – pathologic stage
# Re-treatment stage
# Autopsy stage
PERFORMANCE INDEX ….
*** KARNOFSKY SCALE
*** ECOG (Zubrod) SCALE
Record At Diagnosis stage
Correlate with apparent stage of the Disease.
PRE-OP EVALUATION
- CARDIOPULM STATUS
HIGH RISK :
Recent MI, Arrhythmias
Congestive Cardiac Failure,
Systemic Hypertension …
Pulmonary Hypertension,
FEV1 < 35 %
High PCO2 …
INDICATIONS FOR SURGERY ..
NSCLC : 1. TIS
2. Stage I, II
3. Stage III a
4. Assoc Effusion transudate
clear, no malignant cell
SCLC : 1. Solitary pulmonary nodule,
2. Stage I (T1NOMO)
SURGERY IN UNDIAGNOSED SPN INDICATIONS …..
• H/O SMOKING
• AGE > 35 YRS
• SIZE > 3 CMS
• LACK OF CALCIFICATION
• H/O PREVIOUS OR CURRENT MALIGNANCY
• GROWTH OF LESION
• CHEST SYMPTOMS
• ASSOCIATED PNEUMONIA, COLLAPSE, ADENOPATHY …..
EXTENT OF RESECTION ….. DEPENDS ON EXTENT OF LESION
* Wedge resection * Segmentectomy * Lobectomy * Sleeve resection * Pneumonectomy
# PALLIATIVE RESECTION - NO ROLE
NSCLC : CONTRAINDICATIONS FOR CURATIVE SURGERY
…
STAGE IIIb - N3 disease STAGE IV Recurrent Lary / Phrenic N palsy Vena cava / Lt Atrium involvement SVC Obstruction T3 Disease Card. tamponade, Malignant Effusion. Cardiac arrythmias
MVV <40%, FEV1<1.5L
Split PFT by V / Q scan < 1 Ltr.
CHEMOTHERAPY PATIENT …..
* Fully ambulatory * Evaluable tumor mass * No prior chemotherapy * No medical problem * PaO2 at room temperature >50 * No CO2 retention
CHEMOTHERAPY IN NSCLC … … MAXIMUM BENEFIT WHEN
* CHEMOTH added to RADIOTH. Locally advanced – IIIb & few IIIa * Neo-adjuvant Chemo Pre-operative Rx for STAGE IIIa – some new drugs - Docetaxel, Paclitaxel Gemcitabine, Topotecan Tirapazamine, etc…
CHEMOTHERAPY IN SCLC …
WIDELY USED : CISPL, ETOP. Every 3 weeks* oral / single / old pt OR poor performance pt : ETOP.* Single agent chemo : ETOPOSIDE TENOPOSIDE* Salvage : ETOP + CISPL ( EP ) Cycloph+Adria+Vincrist (CAV)
NOW : intensive initial OR re-induction Rx with autologous bone marrow infusion
NEO-ADJUVANT CHEMOTHERAPY
Assess drug sensitivity of cells
Render unresectable resectable Better tolerated before surgery
Slows growth after primary Tumour is removed
Preserve blood supply – good drug delivery Increase survival in N2 than surgery alone
RELATIVE CONTRAINDICATIONS FOR RADIOTHERAPY ….. # Prior HIGH - DOSE RADIATION
# Connective Tissue Disorders
# FEV1 < 800 cc
# Tracheo – Esophageal Fistula
# Projected Radiation Therapy field to
include > 40% Normal Lung
and > 50% Heart vol.
RADIATION - THERAPY
I. Neoadjuvant Pancoast * N2 4500 II. Adjuvant N+
T3 Incom.resection 5000 III. Palliative Stage III Stage IV 2-5000 (local symptoms) IV. Definitive T1-2N0-1
No/refuse Surg 6000 V. SCLC (+chemo) Ltd stage 5000
ADVANCES IN RADIOTHERAPY..
# BIOLOGIC
* Hyper - fractionation
* Accelerated Therapy
# TECHNICAL
* 3- Dimensional Conf.
Radiation Therapy
RESPONSE TO PALLIATIVE RADIATION ….. Haemoptysis ………. 75-85 % SVC obstruction … 60-80 % Pain ………………… 50-75 % Cough ………………. 35-65 % Dyspnoea ………….. 35-50 % Wt.loss / anorexia .. 30-50 % Atelectasis ………… 20 % V.Cord palsy ………. 5 %
OVERALL RELIEF = 60-70 %
SUPPORTIVE CARE …
# Encourage to STOP SMOKING
# During CHEMOTHERAPY --
* ANTI – EMETICS,
* BLOOD COUNTS & CHEMISTRY
* MONITOR FOR INFECTION AND
BLEEDING
* ROUTINE BOLUS / FLUIDS WITH
CISPLATIN
PSYCHOLOGICAL SUPPORT..
# FEAR, ANXIETY, DEPRESSION
# COMPROMISED SELF IMAGE
# CANCER SURVIVORS
# PHYSICAL HANDICAPS
-- REAL
-- PERCEIVED
FEAR OF RELAPSE
DEALING WITH DEATH …..
# THREE PHASES OF UNSUCCESSFUL CANCER Rx _
- OPTIMISM AT HOPE OF CURE - ACKNOWLEDGEMET OF INCURABLE DISEASE AT RECURRENCE - DENIAL, ISOLATION, ANGER, DEPRESSION, BARGAINING, AT DISCLOSURE OF IMMINENT DEATH ………….
contd ..
# SPEAK FRANKLY REGARDING
LIKELY COURSE OF DISEASE
# RE - ASSURE PATIENT & FAMILY
# SURROGATE DECISION
# LEGAL DOCUMENTS
# DNR ORDERS
Any suggestions / feedback is welcome
And may please be communicated to