siriraj cancer registry

LUNG CANCERSuparauk Geanphun,MD

CVT Siriraj Hospital

Siriraj Cancer Registry

Lung Cancer

Lung cancer is the most common cancer in men worldwide with an age-standardized rate (ASR) of 33.8 per 100,000

The highest incidence rates are observed in North America, East Asia, central-eastern and southern Europe (48.5 to 56.5 per 100,000)

In developed countries, the highest rates are seen in West Asia, South Africa, and the Caribbean (25.7 to 32.2 per 100,000).


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SPECIFIC CONSIDERATIONSUNIT IIPART II

trachea in the superior mediastinum. Those on the right side form a chain with the tracheobronchial nodes inferiorly and with some of the deep cervical nodes above (scalene lymph nodes).

Lymphatic drainage to the mediastinal lymph nodes from the right lung is ipsilateral, except for occasional bilateral drain-age to the superior mediastinum. In contrast, in the left lung, particularly the left lower lobe, lymphatic drainage occurs with equal frequency to ipsilateral and contralateral superior medi-astinal nodes.

Normal Lung HistologyThe lung can be conveniently viewed as two linked compo-nents: the tracheobronchial tree (or conducting airways com-ponent) and the alveolar spaces (or gas exchange component). The tracheobronchial tree consists of approximately 23 airway divisions to the level of the alveoli. It includes the main bronchi, lobar bronchi, segmental bronchi (to designated bronchopulmo-nary segments), and terminal bronchioles (i.e., the smallest air-ways still lined by bronchial epithelium and without alveoli). The tracheobronchial tree is normally lined by pseudostratified ciliated columnar cells and mucous (or goblet) cells, which both derive from basal cells (Fig. 19-10). Ciliated cells predominate. Goblet cells, which release mucus, can significantly increase in number in acute bronchial injury, such as exposure to cigarette smoke. The normal bronchial epithelium also contains bron-chial submucosal glands, which are mixed salivary-type glands containing mucous cells, serous cells, and neuroendocrine cells called Kulchitsky cells, which are also found within the surface epithelium. The bronchial submucosal glands can give rise to salivary gland–type tumors, including mucoepidermoid carci-nomas and adenoid cystic carcinomas.

Two cell types, called type I and type II pneumocytes, make up the alveolar epithelium. Type I pneumocytes comprise 40% of the total number of alveolar epithelial cells, but cover 95% of the surface area of the alveolar wall. These cells are not

Right lung and bronchi

Left lung and bronchi

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* Medial basal (7) not present in left lung

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Figure 19-7. Segmental anatomy of the lungs and bronchi.

Figure 19-8. The location of regional lymph node stations for lung cancer. (Reproduced with permission from Mountain CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest. 1997;111:1718.)

VRG RELEASE: tahir99https://kickass.to/user/tahir99/uploads/

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4-6 cm1.2 cm

45o25o

2 cm

0.5 cm

bronchus intermedius

Middle lobe VS

Sup. segment


Invasive malignant lesion

• Non-Small Cell Lung Carcinoma.

-Adenocarcinoma ; frequent incidental finding, periphery location.

-Squamous cell carcinoma; smoking, central location.

-Large cell carcinoma.


Invasive malignant lesion

• Neuroendocrine Carcinoma (NEC)

-Gr I NEC; typical carcinoid, low grade, central.

-Gr II NEC; atypical carcinoid, higher malignant, periphery

-Gr III NEC; large cell type, heavy smoking.

-Gr IV NEC, small cell carcinoma, most malignant

-Ge V; smaller cell, high mitotic rate


Solitary Pulmonary Nodule(SPN)

• A single, well-circumscribed, spherical lesion that is 3 cm or less in diameter and completely surrounded by normal aerated lung parenchyma.

• CXR, Low dose CT screening.• CT, PET/CT for characterization.


Pulmonary Metastasis625

CHEST WALL, LUNG, M

EDIASTINUM, AND PLEURA

CHAPTER 19and conjunctival edema. It is seen most commonly with NEC grade IV (small cell) lung cancer.

5. Pericardial tamponade. Pericardial effusions (benign or malignant), associated with increasing levels of dyspnea and/or arrhythmias, and pericardial tamponade occur with direct pericardial invasion. Diagnosis requires a high index of suspicion in the setting of a medially based tumor with symptoms of dyspnea and is confirmed by CT scan or echocardiography.

6. Back pain. Results from direct invasion of a vertebral body and is often localized and severe. If the neural foramina are involved, radicular pain may also be present.

7. Other local symptoms. Dysphagia is usually secondary to external esophageal compression by enlarged lymph

Table 19-6

General principles governing appropriate selection of patients for pulmonary metastasectomy1. Primary tumor must already be controlled.2. Patient must be able to tolerate general anesthesia,

potential single-lung ventilation, and the planned pulmonary resection.

3. Metastases must be completely resectable based on computed tomographic imaging.

4. There is no evidence of extrapulmonary tumor burden.5. Alternative superior therapy must not be available.

Table 19-7

Clinical presentation of lung cancer

CATEGORY SYMPTOM CAUSE

Pulmonary symptoms

Cough Bronchus irritation or compression

Dyspnea Airway obstruction or compression

Wheezing >50% airway obstruction

Hemoptysis Tumor erosion or irritation

Pneumonia Airway obstruction

Nonpulmonary thoracic symptoms

Pleuritic pain Parietal pleural irritation or invasion

Local chest wall pain

Rib and/or muscle involvement

Radicular chest pain

Intercostal nerve involvement

Pancoast’s syndrome

Stellate ganglion, chest wall, brachial plexus involvement

Hoarseness Recurrent laryngeal nerve involvement

Swelling of head and arms

Bulky involved mediastinal lymph nodes

Medially based right upper lobe tumor

nodes involved with metastatic disease, usually with lower lobe tumors. Finally, dyspnea, pleural effusion, or referred shoulder pain can result from invasion of the diaphragm by a tumor at the base of a lower lobe.

Associated Paraneoplastic Syndromes All lung cancer his-tologies are capable of producing a variety of paraneoplastic syndromes, most often from systemic release of tumor-derived biologically active materials (Table 19-8). Paraneoplastic

Table 19-8

Paraneoplastic syndromes in patients with lung cancerEndocrineHypercalcemia (ectopic parathyroid hormone)Cushing’s syndromeSyndrome of inappropriate secretion of antidiuretic hormoneCarcinoid syndromeGynecomastiaHypercalcitoninemiaElevated growth hormone levelElevated levels of prolactin, follicle-stimulating hormone, luteinizing hormoneHypoglycemiaHyperthyroidism

NeurologicEncephalopathySubacute cerebellar degenerationProgressive multifocal leukoencephalopathyPeripheral neuropathyPolymyositisAutonomic neuropathyEaton-Lambert syndromeOptic neuritis

SkeletalClubbingPulmonary hypertrophic osteoarthropathy

HematologicAnemiaLeukemoid reactionsThrombocytosisThrombocytopeniaEosinophiliaPure red cell aplasiaLeukoerythroblastosisDisseminated intravascular coagulation

CutaneousHyperkeratosisDermatomyositisAcanthosis nigricansHyperpigmentationErythema gyratum repensHypertrichosis lanuginosa acquista

OtherNephrotic syndromeHypouricemiaSecretion of vasoactive intestinal peptide with diarrheaHyperamylasemiaAnorexia or cachexia



Pulmonary Metastasis623

CHEST WALL, LUNG, M


CHAPTER 19disease is resectable, solitary, and identified 36 or more months after initial treatment. When any or all of these optimal charac-teristics are absent, survival progressively declines.

The general principles of patient selection for metasta-sectomy are listed in Table 19-6. The technical aim of pulmo-nary metastasectomy is complete resection of all macroscopic tumors. In addition, any involved adjacent structures should be resected en bloc (i.e., chest wall, diaphragm, and pericardium). Multiple lesions and/or hilar lesions may require lobectomy. Pneumonectomy is rarely justified or employed.

Pulmonary metastasectomy can be approached through a thoracotomy or via video-assisted thoracic surgery (VATS) techniques. McCormack and colleagues reported their experi-ence at Memorial Sloan-Kettering in a prospective study of 18 patients who presented with no more than two pulmonary metastatic lesions and underwent VATS resection.32 A thora-cotomy was performed during the same operation; if palpa-tion identified any additional lesions, they were resected. The study concluded that the probability that a metastatic lesion will be missed by VATS excision is 56%. Patients in the Memo-rial study were evaluated before the advent of spiral CT scan-ning, however, and it remains controversial whether metastasis resection should be performed via VATS. Proponents of VATS argue that the resolution of spiral CT scanning is so superior that prior studies using standard CT scanners are no longer relevant. Indeed, a recent study suggested that only 18% of malignant nodules would be missed using a VATS approach in the current era while another study from the United Kingdom found equiv-alent outcomes with regard to missed lesions and pulmonary progression comparing open and VATS approaches. To date, no prospective study using spiral CT scan has been performed to resolve this clinical dilemma.

Primary Lung Cancer-Associated Signs and SymptomsLung cancer displays one of the most diverse presentation pat-terns of all human maladies (Table 19-7). The wide range of symptoms and signs is related to (a) histologic features, which often help determine the anatomic site of origin in the lung; (b) the specific tumor location in the lung and its relationship to surrounding structures; (c) biologic features and the production of a variety of paraneoplastic syndromes; and (d) the presence or absence of metastatic disease. Symptoms related to the local intrathoracic effect of the primary tumor can be conveniently divided into two groups: pulmonary and nonpulmonary thoracic.

Pulmonary Symptoms. Pulmonary symptoms result from the direct effect of the tumor on the bronchus or lung tissue. Symp-toms (in order of frequency) include cough (secondary to irritation

Table 19-5

Actuarial survival data from the International Registry of Lung Metastases

SURVIVALCOMPLETE RESECTION (%)

INCOMPLETE RESECTION (%)

5 years 36 13

10 years 26 7

15 years 22 —

or compression of a bronchus), dyspnea (usually due to central airway obstruction or compression, with or without atelectasis), wheezing (with narrowing of a central airway of >50%), hemop-tysis (typically, blood streaking of mucus that is rarely massive; indicates a central airway location), pneumonia (usually due to airway obstruction by the tumor), and lung abscess (due to necro-sis and cavitation, with subsequent infection).

Nonpulmonary Thoracic Symptoms. Nonpulmonary tho-racic symptoms result from invasion of the primary tumor directly into a contiguous structure (e.g., chest wall, diaphragm, pericardium, phrenic nerve, recurrent laryngeal nerve, superior vena cava, and esophagus), or from mechanical compression of a structure (e.g., esophagus or superior vena cava) by enlarged tumor-bearing lymph nodes.

Peripherally located tumors (often adenocarcinomas) extending through the visceral pleura lead to irritation or growth into the parietal pleura and potentially to continued growth into the chest wall structures. Three types of symptoms, depending on the extent of chest wall involvement, are possible: (a) pleu-ritic pain, from noninvasive contact of the parietal pleura with inflammatory irritation or direct parietal pleural invasion; (b) localized chest wall pain, from deeper invasion and involve-ment of the rib and/or intercostal muscles; and (c) radicular pain, from involvement of the intercostal nerve(s). Radicular pain may be mistaken for renal colic in the case of tumors invad-ing the inferoposterior chest wall.

Other specific nonpulmonary thoracic symptoms include:

1. Pancoast’s syndrome. Tumors originating in the supe-rior sulcus (posterior apex) elicit: apical chest wall and/or shoulder pain (from involvement of the first rib and chest wall); Horner’s syndrome (unilateral enophthalmos, pto-sis, miosis, and facial anhidrosis from invasion of the stel-late sympathetic ganglion); and radicular arm pain (from invasion of T1, and occasionally C8, brachial plexus nerve roots).

2. Phrenic nerve palsy. The phrenic nerve traverses the hemithorax along the mediastinum, parallel and posterior to the superior vena cava and anterior to the pulmonary hilum. Tumors at the medial lung surface or anterior hilum can directly invade the nerve; symptoms include shoulder pain (referred), hiccups, and dyspnea with exertion because of diaphragm paralysis. Radiographically, unilateral dia-phragm elevation on CXR is present; the diagnosis is con-firmed by fluoroscopic examination of the diaphragm with breathing and sniffing (the “sniff” test).

3. Recurrent laryngeal nerve palsy. Recurrent laryngeal nerve (RLN) involvement most commonly occurs on the left side, given the hilar location of the left RLN as it passes under the aortic arch. Paralysis results from: (a) invasion of the vagus nerve above the aortic arch by a medially based left upper lobe tumor; or (b) direct invasion of the RLN by hilar tumor and/or hilar or aortopulmonary lymph node metastases. Symptoms include voice change, often referred to as hoarseness, but more typically a loss of tone asso-ciated with a breathy quality, and coughing, particularly when drinking liquids.

4. Superior vena cava (SVC) syndrome. As a result of bulky enlargement of involved mediastinal lymph nodes com-pressing or a medially based right upper lobe tumor invad-ing the SVC, SVC syndrome symptoms include variable degrees of swelling of the head, neck, and arms; headache;



DIAG-1

aMultidisciplinary evaluation including thoracic surgeons, thoracic radiologists, and pulmonologists to determine the likelihood of a cancer diagnosis and the optimal diagnostic or follow-up strategy.

bRisk calculators can be used to quantify individual patient and radiologic factors but do not replace evaluation by a multidisciplinary diagnostic team with substantial experience in the diagnosis of lung cancer.

cSee Principles of Diagnostic Evaluation (DIAG-A 1 of 2).dThe most important radiologic factor is change or stability compared with a previous imaging study.

CLINICAL PRESENTATION RISK ASSESSMENTb

Incidental finding of nodule suspicious for lung cancer

• Multidisciplinary evaluationa

• Smoking cessation counseling

Patient factors• Age• Smoking history• Previous cancer history• Family history• Occupational exposures• Other lung disease (chronic obstructive pulmonary

disease [COPD], pulmonary fibrosis)• Exposure to infectious agents (eg, endemic areas

of fungal infections, tuberculosis) or risk factors or history suggestive of infection (eg, immune suppression, aspiration, infectious respiratory symptoms)

Radiologic factorsc,d

• Size, shape, and density of the pulmonary nodule • Associated parenchymal abnormalities (eg,

scarring or suspicion of inflammatory changes)• Fluorodeoxyglucose (FDG) avidity on PET imaging

Solid nodules See Follow-up (DIAG-2)

Subsolid nodulesSee Follow-up (DIAG-3)

Lung nodules in asymptomatic, high-risk patients detected during lung cancer screening with LDCT

NCCN Guidelines for Lung Cancer Screening

Version 4.2018, 05/21/18 © National Comprehensive Cancer Network, Inc. 2018, All rights reserved. The NCCN Evidence BlocksTM, NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.

NCCN Guidelines Version 4.2018Non-Small Cell Lung CancerNCCN Evidence BlocksTM

NCCN Guidelines IndexTable of Contents

Discussion

Note: For more information regarding the categories and definitions used for the NCCN Evidence Blockstm, see page EB-1. All recommendations are category 2A unless otherwise indicated.Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

Printed by Suparauk Geanphun on 6/1/2018 6:13:09 AM. For personal use only. Not approved for distribution. Copyright © 2018 National Comprehensive Cancer Network, Inc., All Rights Reserved.

DIAG-1





















Discussion




DIAG-1





















Discussion



DIAG-2

FINDINGS FOLLOW-UPc,d,g,h

cSee Principles of Diagnostic Evaluation (DIAG-A 1 of 2).dThe most important radiologic factor is change or stability compared with a previous

imaging study.eLow risk = minimal or absent history of smoking or other known risk factors.fHigh risk = history of smoking or other known risk factors. Known risk factors include

history of lung cancer in a first-degree relative; exposure to asbestos, radon, or uranium.

gNon-solid, partially solid, or ground-glass nodules may require longer follow-up to exclude indolent adenocarcinoma.

hAdapted from Fleischner Society Guidelines: MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: From the Fleischner Society 2017. Radiology 2017;284:228-243. ©Radiological Society of North America. Fleischner Society Guidelines do not direct whether or not contrast is necessary or if an LDCT is appropriate. LDCT is preferred unless there is a reason for contrast enhancement for better diagnostic resolution.

iPET/CT performed skull base to knees or whole body. A positive PET result is defined as a standardized uptake value (SUV) in the lung nodule greater than the baseline mediastinal blood pool. A positive PET scan finding can be caused by infection or inflammation, including absence of lung cancer with localized infection, presence of lung cancer with associated (eg, postobstructive) infection, and presence of lung cancer with related inflammation (eg, nodal, parenchymal, pleural). A false-negative PET scan can be caused by a small nodule, low cellular density (nonsolid nodule or ground-glass opacity [GGO]), or low tumor avidity for FDG (eg, adenocarcinoma in situ [previously known as bronchoalveolar carcinoma], carcinoid tumor).

jPatients with a suspicion of lung cancer after PET/CT require histologic confirmation before any nonsurgical therapy. When a biopsy is not possible, a multidisciplinary evaluation should be done including radiation oncology, surgery, and interventional pulmonology.

Incidental finding: solid nodule(s) on chest CT

High riskf

Low riske

<6 mm

6–8 mm

>8 mm

<6 mm

6–8 mm

>8 mm

No routine follow-up

CT at 6–12 mo Stable Consider CT at 18–24 mo

Consider CT at 3 mo, PET/CT,i,j or biopsy

CT at 12 mo (optional) Stable

CT at 6–12 mo Stable Repeat CT at 18–24 mo


Consider CT at 3 mo, PET/CT,i,j or biopsy




Discussion



Low risk & high risk : smoking, first relative cancer history, chemical expose etc


DIAG-1





















Discussion



cSee Principles of Diagnostic Evaluation (DIAG-A 1 of 2).dThe most important radiologic factor is change or stability compared with a previous imaging study.gNon-solid, partially solid, or ground-glass nodules may require longer follow-up to exclude indolent adenocarcinoma. hAdapted from Fleischner Society Guidelines: MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images:

From the Fleischner Society 2017. Radiology 2017;284:228-243. ©Radiological Society of North America. Fleischner Society Guidelines do not direct whether or not contrast is necessary or if an LDCT is appropriate. LDCT is preferred unless there is a reason for contrast enhancement for better diagnostic resolution.

iPET/CT performed skull base to knees or whole body. A positive PET result is defined as a standardized uptake value (SUV) in the lung nodule greater than the baseline mediastinal blood pool. A positive PET scan finding can be caused by infection or inflammation, including absence of lung cancer with localized infection, presence of lung cancer with associated (eg, postobstructive) infection, and presence of lung cancer with related inflammation (eg, nodal, parenchymal, pleural). A false-negative PET scan can be caused by a small nodule, low cellular density (nonsolid nodule or ground-glass opacity [GGO]), or low tumor avidity for FDG (eg, adenocarcinoma in situ [previously known as bronchoalveolar carcinoma], carcinoid tumor).

jPatients with a suspicion of lung cancer after PET/CT require histologic confirmation before any nonsurgical therapy. When a biopsy is not possible, a multidisciplinary evaluation should be done including radiation oncology, surgery, and interventional pulmonology.

Incidental finding: subsolid nodule(s) on chest CT

Solitary pure ground-glass nodules

<6 mm

≥6 mm


DIAG-3

Solitary part-solid nodules

Multiple subsolid nodules

Persistent and <6 mm

Persistent and ≥6 mm

CT at 6–12 mo to confirm persistence, then CT every 2 y until 5 y

• CT at 3–6 mo to confirm persistence�If unchanged and solid component

remains <6 mm, annual CT for 5 y�If solid component ≥6 mm, consider

PET/CTi,j or biopsy

<6 mm

• CT at 3–6 mo�If stable, consider CT at

2 and 4 y

≥6 mm• CT at 3–6 mo• Subsequent management

based on most suspicious nodule(s)


FINDINGS FOLLOW-UPc,d,g,h




Discussion



Key = 6 mm


Lung cancer staging

• T : Tumor size and relationship to surround structures.

• N : Nodal status; regional and distant nodal status.

• M : Metastasis.

• NOW—> AJCC* 8th edition

* American Joint Committee on Cancer


*Rami-Porta R, Asamura H, Travis WD, Rusch VW. Lung cancer - major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA Cancer J Clin 2017;67:138-155.

Table 3. Comparison of the Descriptors in the Eighth Edition of the TNM Classification of Lung Cancer Compared with the Seventh Edition*

ST-3

Descriptor 7th Edition T/N/M 8th Edition T/N/M

T component

0 cm (pure lepidic adenocarcinoma ≤3 cm in total size) T1a if ≤2 cm; T1b if >2-3 cm Tis (AIS)

≤0.5 cm invasive size (lepidic predominant adenocarcinoma ≤3 cm total size) T1a if ≤2 cm; T1b if >2-3 cm T1mi

≤1 cm T1a T1a

>1-2 cm T1a T1b

>2-3 cm T1b T1c

>3-4 cm T2a T2a

>4-5 cm T2a T2b

>5-7 cm T2b T3

>7 cm T3 T4

Bronchus <2 cm from carina T3 T2

Total atelectasis/pneumonitis T3 T2

Invasion of diaphragm T3 T4

Invasion of mediastinal pleura T3 —

N component

No assessment, no involvement, or involvement of regional lymph nodes NX, N0, N1, N2, N3 No change

M component

Metastasis within the thoracic cavity M1a M1a

Single extrathoracic metastasis M1b M1b

Multiple extrathoracic metastasis M1b M1c




Discussion



ST-1

Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing.

Table 1. Definitions for T, N, MT Primary TumorTX Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not

visualized by imaging or bronchoscopyT0 No evidence of primary tumorTis Carcinoma in situ

Squamous cell carcinoma in situ (SCIS)Adenocarcinoma in situ (AIS): adenocarcinoma with pure lepidic pattern, ≤3 cm in greatest dimension

T1 Tumor ≤3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)

T1mi Minimally invasive adenocarcinoma: adenocarcinoma (≤3 cm in greatest dimension) with a predominantly lepidic pattern and ≤5 mm invasion in greatest dimension

T1a Tumor ≤1 cm in greatest dimension. A superficial, spreading tumor of any size whose invasive component is limited to the bronchial wall and may extend proximal to the main bronchus also is classified as T1a, but these tumors are uncommon.

T1b Tumor >1 cm but ≤2 cm in greatest dimensionT1c Tumor >2 cm but ≤3 cm in greatest dimension

T2 Tumor >3 cm but ≤5 cm or having any of the following features: (1) Involves the main bronchus, regardless of distance to the carina, but without involvement of the carina; (2) Invades visceral pleura (PL1 or PL2); (3) Associated with atelectasis or obstructive pneumonitis that extends to the hilar region, involving part or all of the lung

T2a Tumor >3 cm but ≤4 cm in greatest dimensionT2b Tumor >4 cm but ≤5 cm in greatest dimension

T3 Tumor >5 cm but ≤7 cm in greatest dimension or directly invading any of the following: parietal pleura (PL3), chest wall (including superior sulcus tumors), phrenic nerve, parietal pericardium; or separate tumor nodule(s) in the same lobe as the primary

T4 Tumor >7 cm or tumor of any size invading one or more of the following: diaphragm, mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina; separate tumor nodule(s) in a ipsilateral lobe different from that of the primary

aMost pleural (pericardial) effusions with lung cancer are a result of the tumor. In a few patients, however, multiple microscopic examinations of pleural (pericardial) fluid are negative for tumor, and the fluid is nonbloody and not an exudate. If these elements and clinical judgment dictate that the effusion is not related to the tumor, the effusion should be excluded as a staging descriptor.




Discussion



ST-2

Used with permission of the American College of Surgeons, Chicago, Illinois. The original source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing.

Table 2. AJCC Prognostic GroupsT N M

Occult Carcinoma

TX N0 M0

Stage 0 Tis N0 M0Stage IA1 T1mi N0 M0

T1a N0 M0Stage IA2 T1b N0 M0Stage IA3 T1c N0 M0Stage IB T2a N0 M0Stage IIA T2b N0 M0Stage IIB T1a N1 M0

T1b N1 M0T1c N1 M0T2a N1 M0T2b N1 M0T3 N0 M0

Stage IIIA T1a N2 M0T1b N2 M0T1c N2 M0T2a N2 M0T2b N2 M0T3 N1 M0T4 N0 M0T4 N1 M0

T N MStage IIIB T1a N3 M0

T1b N3 M0T1c N3 M0T2a N3 M0T2b N3 M0T3 N2 M0T4 N2 M0

Stage IIIC T3 N3 M0T4 N3 M0

Stage IVA Any T Any N M1aAny T Any N M1b

Stage IVB Any T Any N M1c

Table 1. Definitions for T, N, M (continued)N Regional Lymph NodesNX Regional lymph nodes cannot be assessedN0 No regional lymph node metastasisN1 Metastasis in ipsilateral peribronchial and/or ipsilateral

hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension

N2 Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)

N3 Metastasis in contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph node(s)

M Distant MetastasisMX Distant metastasis cannot be assessedM0 No distant metastasisM1 Distant metastasis

M1a Separate tumor nodule(s) in a contralateral lobe; tumor with pleural or pericardial nodules or malignant pleural or pericardial effusiona

M1b Single extrathoracic metastasis in a single organ (including involvement of a single nonregional node)

M1c Multiple extrathoracic metastases in a single organ or in multiple organs




Discussion



DIAG-1





















Discussion



NSCL-2

eT3, N0 related to size or satellite nodules.gTesting is not listed in order of priority and is dependent on clinical circumstances,

institutional processes, and judicious use of resources.hMethods for evaluation include mediastinoscopy, mediastinotomy, EBUS, EUS, and CT-

guided biopsy.iThere is low likelihood of positive mediastinal lymph nodes when these nodes are CT

and PET negative in solid tumors <1 cm and purely non-solid tumors <3 cm. Thus, pre-resection pathologic mediastinal evaluation is optional in these settings.

jPET/CT performed skull base to knees or whole body. Positive PET/CT scan findings for distant disease need pathologic or other radiologic confirmation. If PET/CT scan is positive in the mediastinum, lymph node status needs pathologic confirmation.

kSee Principles of Surgical Therapy (NSCL-B).

lSee Principles of Radiation Therapy (NSCL-C).mInterventional radiology ablation is an option for selected patients.nAfter surgical evaluation, patients likely to receive adjuvant chemotherapy may be treated

with induction chemotherapy as an alternative.oSee Chemotherapy Regimens for Neoadjuvant and Adjuvant Therapy (NSCL-D).pExamples of high-risk factors may include poorly differentiated tumors (including lung

neuroendocrine tumors [excluding well-differentiated neuroendocrine tumors]), vascular invasion, wedge resection, tumors >4 cm, visceral pleural involvement, and unknown lymph node status (Nx). These factors independently may not be an indication and may be considered when determining treatment with adjuvant chemotherapy.

qSee Chemotherapy Regimens Used with Radiation Therapy (NSCL-E).

CLINICAL ASSESSMENT PRETREATMENT EVALUATIONG INITIAL TREATMENT

Stage IA (peripheral T1abc, N0)

Stage IB (peripheral T2a, N0) Stage I (central T1abc–T2a, N0)Stage II (T1abc–2ab, N1; T2b, N0)Stage IIB (T3, N0)eStage IIIA (T3, N1)

• PFTs (if not previously done)

• Bronchoscopy (intraoperative preferred)

• Consider pathologic mediastinal lymph node evaluationh,i

• FDG PET/CT scanj (if not previously done)

• PFTs (if not previously done)

• Bronchoscopy• Pathologic mediastinal

lymph node evaluationh • FDG PET/CT scanj (if not

previously done)• Brain MRI with contrast

(Stage II, IIIA) (Stage IB [optional])

Negative mediastinal nodes

Positive mediastinal nodes

Operable

Medically inoperablek

Negative mediastinal nodes

Positive mediastinal nodes

Operable

Medically inoperablek

Surgical exploration and resectionk + mediastinal lymph node dissection or systematic lymph node sampling

Definitive RT including stereotactic ablative radiotherapy (SABR)l,m

See Stage IIIA/IIIB (NSCL-7) or Stage IIIB/IIIC (NSCL-11)

Surgical exploration and resectionk,n + mediastinal lymph node dissection or systematic lymph node sampling

See Adjuvant Treatment (NSCL-3)

See Adjuvant Treatment (NSCL-3)

N0

N1

Definitive RT including SABRl

Definitive chemoradiationl,q

Consider adjuvant chemotherapyo (category 2B) for high-risk stages IB-IIBp

Durvalumabq

See Stage IIIA/IIIB (NSCL-7) or Stage IIIB/IIIC (NSCL-11)




Discussion




DIAG-1





















Discussion



NSCL-4

CLINICAL ASSESSMENT

PRETREATMENT EVALUATION CLINICAL EVALUATION

Stage IIB (T3 invasion, N0) Stage IIIA (T4 extension, N0-1; T3, N1; T4, N0-1)

• PFTs (if not previously done)• Bronchoscopy• Pathologic mediastinal lymph node

evaluationh • Brain MRI with contrast• MRI with contrast of spine +

thoracic inlet for superior sulcus lesions abutting the spine or subclavian vessels


Superior sulcus tumor

Chest wall

Proximal airway or mediastinum

Unresectable disease

Metastatic disease

hMethods for evaluation include mediastinoscopy, mediastinotomy, EBUS, EUS, and CT-guided biopsy.jPET/CT performed skull base to knees or whole body. Positive PET/CT scan findings for distant disease need pathologic or other radiologic confirmation. If PET/CT

scan is positive in the mediastinum, lymph node status needs pathologic confirmation.

See Treatment (NSCL-5)




See Treatment for Metastasis limited sites (NSCL-13) or distant disease (NSCL-16)

Stage IIIA (T4, N0-1) See Treatment (NSCL-6)




Discussion




DIAG-1





















Discussion



NSCL-7

hMethods for evaluation include mediastinoscopy, mediastinotomy, EBUS, EUS, and CT-guided biopsy.jPET/CT performed skull base to knees or whole body. Positive PET/CT scan findings for distant disease need pathologic or other radiologic confirmation. If PET/CT

scan is positive in the mediastinum, lymph node status needs pathologic confirmation.

CLINICAL ASSESSMENT

PRETREATMENT EVALUATION MEDIASTINAL BIOPSY FINDINGSAND RESECTABILITY

Separate pulmonary nodule(s) (Stage IIB, IIIA, IV)

• PFTs (if not previously done)• Bronchoscopy• Pathologic mediastinal lymph node

evaluationh


• Brain MRI with contrast

• PFTs (if not previously done)• Bronchoscopy • Pathologic mediastinal lymph node

evaluationh • Brain MRI with contrast• FDG PET/CT scanj (if not previously

done)

N2, N3 nodes negative

N2 nodes positive, M0

N3 nodes positive, M0

Metastatic disease

See TreatmentT1-3, N0-1 (NSCL-8)


See Stage IIIB (NSCL-11)


Separate pulmonary nodule(s), same lobe (T3, N0-1) or ipsilateral non-primary lobe (T4, N0-1)

Stage IVA (N0, M1a): Contralateral lung (solitary nodule)

Extrathoracic metastatic disease




Stage IIIA (T1-2, N2)Stage IIIB (T3, N2)




Discussion




DIAG-1





















Discussion



NSCL-9

hMethods for evaluation include mediastinoscopy, mediastinotomy, EBUS, EUS, and CT-guided biopsy.

jPET/CT performed skull base to knees or whole body. Positive PET/CT scan findings for distant disease need pathologic or other radiologic confirmation. If PET/CT scan is positive in the mediastinum, lymph node status needs pathologic confirmation.

kSee Principles of Surgical Therapy (NSCL-B).lSee Principles of Radiation Therapy (NSCL-C).oSee Chemotherapy Regimens for Neoadjuvant and Adjuvant Therapy (NSCL-D).

qSee Chemotherapy Regimens Used with Radiation Therapy (NSCL-E).rR0 = no residual tumor, R1 = microscopic residual tumor, R2 = macroscopic

residual tumor.xLesions with different cell types (eg, squamous cell carcinoma, adenocarcinoma)

may be different primary tumors. This analysis may be limited by small biopsy samples. However, lesions of the same cell type are not necessarily metastases.

yFor guidance regarding the evaluation, workup, and management of subsolid pulmonary nodules, please see the diagnostic evaluation of a nodule suspicious for lung cancer (DIAG-1).

CLINICAL PRESENTATION ADJUVANT TREATMENT

Separate pulmonary nodule(s), same lobe (T3, N0-1), or ipsilateral non-primary lobe (T4, N0-1)

Stage IVA (N0, M1a): Contralateral lung (solitary nodule)

Suspected multiple lung cancers (based on the presence of biopsy-proven synchronous lesions or history of lung cancer)x,y

Surgeryk

Treat as two primary lung tumors if both curable

• Chest CT with contrast

• FDG PET/CT scan (if not previously done)j

• Brain MRI with contrast

N0–1

N2

Chemotherapyo Surveillance (NSCL-15)

Margins negative (R0)r

Margins positive

Chemotherapyo (category 1) or Sequential chemotherapyo + RTl

Surveillance (NSCL-15)

R1r

R2r

Chemoradiationl (sequentialo or concurrentq)

Concurrent chemoradiationl,q



See Evaluation (NSCL-1)

Disease outside of chest

No disease outside of chest

See Systemic Therapy for Metastatic Disease (NSCL-17)

Pathologic mediastinal lymph node evaluationh

N2-3

N0-1

See Systemic Therapy for Metastatic Disease (NSCL-17)

See Initial Treatment (NSCL-10)




Discussion




647

CHEST WALL, LUNG, M


CHAPTER 19

incision can be used for most pulmonary resections, esophageal operations, and operations in the posterior mediastinum and ver-tebral column (Fig. 19-28). The anterolateral thoracotomy has traditionally been used in trauma victims. This approach allows quick entry into the chest with the patient supine. In the face of hemodynamic instability, the lateral decubitus position signifi-cantly compromises control over the patient’s cardiopulmonary system and resuscitation efforts, whereas the supine position allows the anesthesiologist full access to the patient. A bilat-eral anterior thoracotomy incision with a transverse sternotomy (“clamshell” thoracotomy) is a standard operative approach to the heart and mediastinum in certain elective circumstances. It is the preferred incision for double-lung transplantation in many

Trapezius

Latissimus dorsidivided

Latissimus dorsi

BA

DC

Serratus anterior

5th rib

6th ribRhomboidmajor

Scapularetracted Incision

Trapezius

Figure 19-28. The posterolateral thoracotomy incision. A. Skin incision from the anterior axillary line to the lower extent of the scapula tip. B and C. Division of the latissimus dorsi and shoulder girdle musculature. D. The pleural cavity is entered after dividing the intercostal muscles along the lower margin of the interspace, taking care not to injure the neurovascular bundle lying below each rib.

centers. A partial median sternotomy can also be added to an anterior thoracotomy (“trap-door” or “hemiclamshell” thoracot-omy) for access to mediastinal structures. A hypesthetic nipple is a frequent complication of this approach. The median sternot-omy incision allows exposure of anterior mediastinal structures and is principally used for cardiac operations. Although the sur-geon has access to both pleural cavities, incision into the pleural cavity can be avoided if entry is unnecessary (Fig. 19-29).

Postoperative CareChest Tube Management. At the conclusion of most thoracic operations, the pleural cavity is drained with a chest tube(s). If the visceral pleura has not been violated and there is no concern



Lung Cancer


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