Page 1276 - TNFlipTest

R30 Respirology
Neoplasms
Toronto Notes 2019
Table 30. SCLC vs. NSCLC
Stage
Limited stage
Extensive stage
Stage
IA IB IIA
IIB IIIA
IIIB IV
* Depends on clinical vs. pathologic stage
Treatment
Definition
Confined to single radiation port (one hemithorax and regional lymph nodes)
Extension beyond a single radiation port
TNM
T1a-1bN0M0 T2aN0M0 T1a-T2a,N1M0 or T2bN0M0
T2bN1M0 or T3N0M0
T1a-T2bN2M0 or T3N1- 2M0 or T4N0-1M0
T4N2M0 or T1-4N3M0 T1-4N0-3M1a-1b
Treatment
Radiation ± chemotherapy ± prophylactic to brain
Chemotherapy
Treatment
1st line is complete surgical resection (VATS or open thoracotomy) with possible post-operative adjuvant chemotherapy with stage IB and stage II; radiotherapy for non-surgical candidates
Combined modality approach (chemotherapy, radiation therapy and sometimes surgical resection)
Systemic therapy or molecularly targeted therapy or symptom-based palliative management (radiation); isolated metastasis may be resected
Median Survival
1-2 yr (12 wk without treatment)
6 mo (5 wk without treatment)
5 Yr Survival (%)*
50-73 43-58 36-46
25-36 19-24
7-9 2-13
2/3 of primary lung cancer is found in the upper lung; 2/3 of metastases occur in the lower lung (hematogenous spread secondary to increased blood flow to the base of the lung)
Postoperative Radiotherapy for NSCLC
Cochrane DB Syst Rev 2016; CD002142. Objective: Evaluate effects of postoperative radiotherapy on survival and recurrence in patients with completely resected NSCLC.
Methods: MEDLINE and CANCERLIT searches and trial registers for trials of surgery vs. surgery plus radiotherapy in patients with NSCLC.
Results: 14 trials, 2343 participants. Postoperative radiotherapy had a significant adverse effect
on survival (HR 1.18, 95% CI 1.07-1.31). This
was equivalent to an absolute detriment of 5%
at two years, reducing survival from 58 to 55%. Postoperative radiotherapy increased risk of recurrence (HR 1.10, 95% CI 0.99-1.21). Conclusions: Postoperative radiotherapy is detrimental to those with completely resected NSCLC and should not be used in the routine treatment.
SCLC
NSCLC
Prevention
Smoking cessation Avoidance of exposures Early detection
Terminology
• “nodule” <3 cm • “mass” >3 cm
Hamartomas
• 10% of benign lung lesions
• Composed of tissues normally present in
lung (fat, epithelium, fibrous tissue, and cartilage), but they exhibit disorganized growth
• Peak incidence is age 60, more common in men
• Usually peripheral and clinically silent
• CXR shows clustered “popcorn” pattern
of calcification (pathognomonic for hamartoma)
• optionsincludesurgery,radiotherapy,chemotherapy,andpalliativecareforend-stagedisease • surgerynotusuallyperformedforSCLCsinceitisgenerallynon-curable
• contraindicationsforsurgery
■ spread to contralateral lymph nodes or distant sites
◆ patients with potentially resectable disease must undergo mediastinal node sampling since CT
thorax is not accurate in 20-40% of cases
■ poor pulmonary status (e.g. unable to tolerate resection of lung)
◆ post-op estimated FEV1 and DLCO must be at least 40% of predicted to tolerate surgery • chemotherapy(usedincombinationwithothertreatments)
■ common agents: etoposide, platinum agents (e.g. cisplatinum), ifosfamide, vincristine, anthracyclines, paclitaxel, irinotecan, gefitinib (an endothelial growth factor receptor inhibitor)
■ complications
◆ acute: tumour lysis syndrome, infection, bleeding, myelosuppression, hemorrhagic cystitis
(cyclophosphamide), cardiotoxicity (doxorubicin), renal toxicity (cisplatin), peripheral
neuropathy (vincristine)
◆ chronic: neurologic damage, leukemia, additional primary neoplasms
Approach to the Solitary Pulmonary Nodule
• seeMedicalImaging,MI7
Definition
• aroundoroval,sharplycircumscribedradiographiclesionupto3cm,whichmayormaynotbe calcified, and is surrounded by normal lung
Refer to AJCC Cancer Staging Manual, 7th ed. 2010 for complete TNM classification
• canbebenignormalignant
Table 31. Differential Diagnosis for Benign vs. Malignant Solitary Nodule
Benign (70%)
Infectious granuloma (histoplasmosis, coccidiomycosis, TB, atypical mycobacteria) - most common
Other infections (bacterial abscess, PCP, aspergilloma)
Benign neoplasms (hamartoma, lipoma, fibroma)
Vascular (AV malformation, pulmonary varix)
Developmental (bronchogenic cyst)
Inflammatory (granulomatosis with polyangiitis, rheumatoid nodule, sarcoidosis, amyloidosis)
Other (infarct, pseudotumour, rounded atelectasis, lymph nodes, amyloidoma)
Malignant (30%)
Bronchogenic carcinoma
Adenocarcinoma Squamous cell carcinoma Large cell carcinoma Small cell carcinoma
Metastatic lesions
Breast
Head and neck Melanoma
Colon
Kidney
Sarcoma
Germ cell tumours Pulmonary carcinoid