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Phase III Lecture Programme Oncology lung cancer

General Thoracic Surgery Cardio-Thoracic Department Papworth Hospital University of Cambridge Hospital Trust Cambridge, UK. Phase III Lecture Programme Oncology lung cancer. Marcello Migliore. History. In 1910 Alton Oschner, esteemed surgeon, recalled that as a student at

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Phase III Lecture Programme Oncology lung cancer

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  1. General Thoracic Surgery Cardio-Thoracic Department Papworth Hospital University of Cambridge Hospital Trust Cambridge, UK Phase III Lecture Programme Oncology lung cancer Marcello Migliore

  2. History In 1910 Alton Oschner, esteemed surgeon, recalled that as a student at Washington University he was asked to witness an autopsy of a patient with lung cancer, having been told lung cancer was so rare that he may never see another case. He saw the next case 17 years later. Within the next 6 months 8 more cases were seen at that hospital and this began what he called an epidemic.

  3. IA IIA IB IIB IIIA

  4. Epidemiology • 1950 Doll and Hill in the British Medical Journal confirmed suspicions that lung cancer was associated with cigarette smoking

  5. Epidemiology • In 1930 in the USA, lung cancer rates were less than 5 per 100,000 • In 1998 the death rate per 100,000 population for men reached 77.2 in Belgium and 75.5 in Scotland.

  6. EpidemiologyWhat is going on in the developing countries • In 1994 the rate of lung cancer was similar to that of the USA in 1930 • In 1999 the rate of lung cancer was 14.1 per 100,000 in developing countries and 71.4 in developed countries

  7. Lung cancer Only 25% of patients will undergo surgery with the hope of curing the disease Most75% will not have surgery

  8. Lung cancer TNM TNM c p

  9. TNM T factor T1 < 3 cm> 3 cm, invading visceral pleura, > 2 cm from carina spread to the chest wall, < 2 cm from carinaspread to the heart, two nodules in the same lobe, + pleural fluid for malignant cell T2 T3 T4

  10. T factor T2 : > 3 cm, or invading visceral pleura, > 2 cm from carina

  11. T factor T3 spread to the chest wall, < 2 cm from carina T4 spread to the heart, two nodules in the same lobe, + pleural fluid for malignant cell

  12. TNM N factor N0 Absence of nodal metastasis (MTS)MTS peribronchial and ilar nodes - same sideMTS mediastinal (same side) and sub carinal nodesMTS mediastinal and ilar contro lateral, supraclavear and scalene N1 N2 N3

  13. Lung cancer Why it is important to know the status of nodal diseases Ann Thorac Surg 2002;73:1545-51

  14. cTNM N T2 N2 N3

  15. VIDEO - MEDIASTINOSCOPY Washington University School of Medicine review of 2137 mediastinoscopies Morbidity and mortality rates was 0.6% and 0.2% respectively   Sensitivity of 85.2% in the accurate staging of N2 and N3 disease when used preoperatively in patients with lung cancer.

  16. TNM M factor Distant MTS Or two nodules in different lobes

  17. Lung cancer - STAGE and T N M STAGE Tumor Nodes Metastasis IA T1 N0 M0 IB T2 N0 M0 IIA T1 N1 M0 IIB T2 N1 M0 T3 N0 M0 III A T3 N1 M0 T1-3 N2 M0 IIIB T1-4 N3 M0 T4 N0-3 M0 IV T1-4 N0-3 M1 Mountain 1997,AJCC,UICC

  18. Lung cancer Pathological and clinical characteristics 1. Squamous a. Obctructive pneumonitis b. Lung or lobar collapse d. 1/3 are in the periphery of the lung e. 20% are escavated 2. Adenocarcinoma a. 2/3 are in the periphery b. < 3 cm c. Bronchioloalveolar type have diffuse pattern 3. A great cell (undifferenciated) 1. 60% are in the periphery 2. 2/3 > 4 cm 4. Small cell 1. 80% abnormal lung ilum 2. 2/5 parecnchimal changes 25-40% 30-50% 10-20 % 15-25 %

  19. Lung cancer Clinical presentation 1. Broncho-pulmonary 2. Extrapulmonary but intrathoracic 3. Extrapulmonary metastatic 4. Extra pulmonary non metastatic ( i.e. paraneoplastic)

  20. Lung cancer Bronchopulmonary Symptoms Cough (tosse) (most common 75%) Hemoptysis (33%) Pain (dolore) (50% poor prognostic sign) Anorexia and weight loss (poor prognostic sign) Shortness of breath Hoarseness (1-8%)

  21. Lung cancer • Clinical Signs • “clubbing” is the most common • Pleural effusion • Pulmonary hypertrophic osteopathy (2-12% of all patients with lung cancer)

  22. Extra pulmonary non metastatic ( i.e. paraneoplastic) 1) syndromes similar to myasthenia gravis 2) polimyositis b. Cushing Syndrome - small cell c. SIADH – small cell d. Hypercalcemia – squamous cell e. Gynecomastia – small cell f. Gonadotropin – indifferenciated great cell

  23. Lung cancer Diagnosis Invasive Not invasive

  24. EVIDENCE BASED MEDICINE .......................In every new lung nodule it is necessary to achieve a final pathologic diagnosis to exclude the presence of cancer

  25. Lung cancer – diagnosis Chest x ray Generally radiographic alterations are present 7 months before symptoms reveal the tumor It shows nodules > 1 cm The most common finding is the coin lesion It failed to demonstrate a reducing in lung cancer mortality

  26. CHEST X RAY

  27. Lung cancer - diagnosis • CT of the chest • The best method to evaluate mediastinal adenopathy and renal glands • b. Invasion of thoracic wall is not always correctly diagnosed • c. Paraesophageal nodes and inferior pulmonary vein are not visible • d. Nodes < 1 cm have 7% possibility to be malignant • e. Nodes > 1 cm have 55-65% possibility to be malignant

  28. Lung cancer Diagnosis CT of the chest Three studies revealed that using Spiral CT as a screening method it was possible to discover 84-93 % of lung cancer in the initial stage (IA) with a low percentage of false positive (20%).

  29. Lung cancer Diagnosis Magnetic Resonance (MR) It is better to evaluate the vascular invasion

  30. MR – Brain metastasis

  31. PET (Positron Emission Tomography) Higher specificity has the PET con FDG (F18 fluoro deossiglucosio) (sensibility 95% - specificity 85%) but it is useful in nodules greater than 6 mm. It reduces the need to send the patient for an invasive method such as mediastinoscopy.

  32. CT thorax PET PET scan N3

  33. Lung cancer Diagnosis Sputum cytology Sensitive in 20- 70%, but it is correlated with the position of the tumour Squamous carcinoma is more common to be positive than small cell or adenocarcinoma. When cytology is positive a final diagnosis in 85% is possible

  34. Lung cancer Diagnosis Invasive diagnosis

  35. RIGID FLEXIBLE

  36. BRONCOSCOPY Haemoptsis Intraluminal mass Biopsy

  37. Lung cancer and pleural effusion Thoracocentesis

  38. Lung cancer - diagnosis CT GUIDED BIOPSY Percutaneous o transbronchial In peripheric lesion is accurate in 85-95%

  39. CT- FNA: 85-95% sensitive Complications ?

  40. Lung cancer – invasive diagnosis VATS Thoracotomy

  41. Lung cancer TREATMENT SURGERY

  42. Lung cancer – preoperative tests Lung function is mandatory if the patient needs an operation High surgical risk 1. FEV1 < 40% 2. Predicted postoperative FEV1 < 30% 4. DLCO < 40% 5. PCO2 > 45 mmHg

  43. The goal of surgical treatment in oncology is twofold • to achieve long term survival with a good quality of life • to avoid recurrence

  44. Surgical treatment of lung cancerIndications • cTNM • Lung Function Tests • Intra-operative

  45. Lung cancer - Surgical treatment • Wedge • Segmentectomy • Lobectomy • Pneumonectomy • Sleeve Resection • Limphadenectomy • Lung transplantation (Bronchioloalveolar ca.) VATS - ?

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