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Lung cancer and pulmonary nodules

Lung cancer and pulmonary nodules

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Lung cancer and pulmonary nodules

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  1. Lung cancer and pulmonary nodules Resident’s seminar 02/01/2006 Elsa B. Valsdottir

  2. Lung nodules In the general population, what percentage of asymptomatic solitary lung nodules are carcinoma? • 5% • 20% • 35% • 50% • 75%

  3. Lung nodules In the general population, what percentage of asymptomatic solitary lung nodules are carcinoma? • 5% • 20% • 35% • 50% • 75%

  4. Benign nodules Hamartoma 8% (popcorn lesion) Granuloma Scarring Hemangioma Schwannoma Fibroma Lipoma Leiomyoma Clear cell tumor Teratoma

  5. Pulmonary nodule A healthy 59 yoM with 40 pack year hx has a new 1 cm nodule in the RUL on routine CXR. CT confirmes a spikulated lesion with lymphadenopathy. His PFTs are normal. The most appropriate management would be: • chemotherapy • CT guided needle bx • thoracoscopic wedge resection • RU lobectomy • radiotherapy

  6. Algorithm from Greenfield

  7. Pulmonary nodule A healthy 59 yoM with 40 pack year hx has a new 1 cm nodule in the RUL on routine CXR. CT confirmes a spikulated lesion with lymphadenopathy. His PFTs are normal. The most appropriate management would be: • chemotherapy • CT guided needle bx • thoracoscopic wedge resection • RU lobectomy • radiotherapy

  8. Lung cancer: Incidence, epidemiology • Leading cause of cancer death (28%) • 2nd most common cancer • >173,000 cases/year • Overall 5 year survival 12% • Decreasing incidence and mortality in men • Incidence plateaued in women but mortality still rising • Cause: TOBACCO (85-90%) • arsenic, asbestos, genetics, COPD, CLL, AIDS

  9. Lung cancer: Classification • Small cell carcinoma 20% • Non-small cell carcinoma: • Adenocarcinoma 40% • Squamous cell carcinoma 20-25% • Adenosquamous carcinoma • Large cell carcinoma • Carcinoid • Carcinoma of salivary gland type • Unclassified

  10. Small cell lung cancer Which of the following statements about small cell lung cancer is NOT true? • Surgical therapy is rarely indicated • The etiology is unknown • Paraneoplastic endocrine syndromes are common • Chemotheraputic agents are generally effective • Prophylactic radiotion therapy can reduce brain metastasis

  11. Small cell lung cancer Which of the following statements about small cell lung cancer is NOT true? • Surgical therapy is rarely indicated • The etiology is unknown • Paraneoplastic endocrine syndromes are common • Chemotheraputic agents are generally effective • Prophylactic radiotion therapy can reduce brain metastasis

  12. Cough Hemoptysis Dyspnea Pain Dysphagia Horner’s syndrome Pancoast’s syndrome SVC obstruction Signs and symptoms

  13. Staging

  14. Lung cancer: nodal stations

  15. Nodal stations, cont

  16. Survival

  17. Resectable tumors • Stages I and II • Stage IIIA? • N2 dz • Downstaging with neoadjuvant tx • Selected cases of IIIB (T4)

  18. Lung cancer: Pre-operative workup • CT (brain) • PET: 97% sensitive, 78% specific • Bronchoscopy • Mediastinoscopy • PFTs • FEV1 • DLCO (diffusing capacity for carbon monoxide) • Oxygen consumption

  19. PFTs Which one of the following inducates a high risk for RF after pulmonary resection? • Preoperative FEV1 = 500 ml • Preoperative PaCO2 = 38 mm Hg • V/Q scan showing 30% perfusion to operative side • Predicted postop FEV1 = 1.1L

  20. PFTs Which one of the following inducates a high risk for RF after pulmonary resection? • Preoperative FEV1 = 500 ml • Preoperative PaCO2 = 38 mm Hg • V/Q scan showing 30% perfusion to operative side • Predicted postop FEV1 = 1.1L

  21. Lung cancer: Surgical options • VATS • Segmentectomy • Lobectomy • Sleeve resection • Pneumonectomy

  22. VATS for Stage 1 lung cancer Pros:Cons: less pain oncologic validity less LOS tech. difficult better cosmesis seeding of tumor • Better survival due to less immunologic response (IgG, CRP, IL-6, TNF etc)? Roviaro et al: Long-term Survival After VATS Lobectomy for Stage 1 Lung Cancer. CHEST 2004;126:725-732

  23. Lung cancer screening

  24. Lung cancer screening Take home message: New CT techniques detect suspicious nodules 3x more than CXR, malignant tumors 4x and stage 1 tumors 6x Henschke et al: Early Lung Cancer Action Project: overall design and findings from baseline screening. Lancet, 1999;354:99-105

  25. Surgery after Chemo/XRT for Stage IIIA Can be considered in fit patients but does not neccessarily increase overall survival Albain et al: Phase III study of consurrent chemotherpy and radiotherapy (CT/RT) vs CT/RT followed by surgical resection for stage IIIA (pN2) non-small cell lung cancer (NSCLC): Outcomes update of NOrth American Intergroup 0139 (RTOG 9309). ASCO Annual Meeting 2005

  26. Adjuvant chemo for resected Stages IB-II lung ca Newer adjuvant chemo prolongs overall and recurrence free survival Winton et al: A prospective randomised trial of adjuvant vinorelbine (VIN) and cisplatin (CIS) in completely resected stage IB and II non small cell lung cancer (NSCLC) Intergroup JRB.10. J Clin Onc 2004;22:7018