lung cancer management methods and philosophy dr. d. r. joshi b. j. medical college, pune
TRANSCRIPT
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
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