9. dx, eval, and staging

7/29/2019 9. Dx, Eval, and Staging

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3/5/13

Lung Neoplasms

Reported by:Venus L:orraine B.

Datud, MD2a

DiagnosisEv

aluationStaging


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3 areas of

assessment:1. Primary tumor

2. Presence ofmetastatic disease

3. Functional status


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1.

Assessmentof Primary

Tumor HISTORY symptoms, PE

LOCATION oftumor

CXR, CT Scan


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Determination ofInvasion

Presence of pain

Chest CT with contrast

delineation of mediastinal LN

Invasion of contiguousstructures

MRI

No improvement over CT scan

for those with allergies to


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Tissue Diagnosis


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Thoracotomy

Occasionally necessary Deep-seated lesions:

a. indeterminated needlebiopsy result,

Lobectomy may benecessary

b. could not be biopsiedfor technical reasons

excisional biopsy is

preferred


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. ssessmenof MetastaticDse

Presence imply inoperability

Historynew bone pain,neurologic symptoms, skinlesions

Evidence of weight loss

PE: Evaluation of cervical andsupraclavicular LN andoropharynx


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MediastinalLymph Nodes

MetastasisCT Scanmosteffective non-invasive

methodPositive CT:

nodal diameter >

1cm30% due to noncancerous

reactive causes

Requires histologic confirmation


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PET Scan

Detection of positronsemitted byfluorodeoxyglucose

glucose analogue labelledwith positron-emittingfluorine

Accumulate in cancers


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A single FDG injection allowsevaluation of whole body:

lung cancer in leftupper lobe (arrow)as well as within 2small ipsilateralmediastinal lymphnodes (arrowheads)


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CT Scan vs. PET Scan

PET scan has higher sensitivity &accuracy

Recent development of combinedPET-CT Scanners may improve

accuracy


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Endoesophagealultrasound (EUS) Recently emerged as method of

staging in NSCLC Visualize mediastinal paratracheal

LN, and lesions contiguous or nearesophagus

Obtain tissue samples

Unable to visualize anterior(pretracheal) mediastinum


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Cervicalmediastinoscopy standard method of tissue

staging of the mediastinum Suprasternal skin incision


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sampling of paratracheal andsubcarinal LNvisual determination ofpresence of extracapsularextension of nodal metastases


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**It is particularly important toprovepathologicallythat

mediastinal lymph nodes areinvolved before deciding that thepatient is not a candidate for

resection

t


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a gnant euraEffusion


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Distant Metastases

Combination of chest CT scanand multiorgan scanning

Chest CT Scan

Always include upper abdomenand visualization of liver andadrenal glands

Further evaluation by MRIscanning

Bone Scans

High sensitivity but low


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PET Scan

Metastases to liver, adrenalglands and bones

Combined with CT Scan for

routine evaluation of patientswith lung cancer

Integrated PET-CT Scanners

demonstrate better accuracy Brain MRI if with risk of

brain metastases


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**With any radiologicassessment, accuracy must beensured. The patient must be

given the benefit of any doubtabout the accuracy of the scan;the result must be proven, most

often by biopsy, to be true-positive.


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3. Assessment of

Functional Status Historymost important tool for

gauging risk

Clinical assessment entailsobservation of the patientsvigor and attitude

Patients attitude toward thedisease was the best indicator forlong term survival

Except in life-threateningsituations, atients should never


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Determining patient tolerancefor resection

Walk on flat surface indefinitelywithout dyspnea > thoractomy

and lobectomy

Can walk up to 2 flight of stairswithout dyspnea>

pneumonectoomy Nearly all patient can tolerate

periods of single-lung ventilationand wedge resection


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Increased risk of postopcomplications

Significant risk reductionrequires cessation ofsmoking at least 8 weeks

preoperatively In cancer patients,

ideally for 2 weeks

before sur er


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Physical Examshouldfocus on signs of COPD orairflow limitation:

Cyanosis

Peripheral edema

Mild post-cough SOB Wheezes, crackles

Wet cough


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Pulmonary function

studiesused when resectiongreater than wedge resection willbe performed

FEV1 and DLCO are most valuable

FEV1 Volume that has been exhaled atthe end of the first second of forcedexpiration

DLCOdiffusing capacity of CO2

FEV1 guidelines:

>2 L can tolerate pneumonectomy

< 1.5 L can tolerate lobectomy

corrections made for age, height and


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Quantitative perfusionscanningestimatefunctional contribution of a lobeor whole lung

Exercise testingyieldmaximum oxygen consumption(VO2max)

15ml/kg/minutetolerate


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**Risk assessment is based on acombination of clinical judgementand data. This risk assessment

must be integrated with theexperienced clinicians sense ofthe patient and with the patientsattitude toward the disease and

toward life

L C


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Lung Cancer

StagingSystems Based on tumor, node and

metastasis (TNM) system

T: size and relationship ofprimary tumor to surrounding

structures

N: regional lymph nodes

M: presence or absence ofmetastatic disease


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7th Edition of TNM in Lung Cancerof theInternational Association for the Study of

Lung Cancer (IASLC) Staging Committee


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American Joint Committee on CancerStaging System for Lung Cancer

Any M = Stage IV


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End ofreport.

Thank

Y

9. dx, eval, and staging

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