Chapter 085. Neoplasms of the Lung (Part 8) ppsx

Chapter 085. Neoplasms of the Lung (Part 8) Small Cell Lung Cancer A simple two-stage system is used. In this system, limited-stage disease (seen in about 30% of all patients with SCLC) is defined as disease confined to one hemithorax and regional lymph nodes (including mediastinal, contralateral hilar, and usually ipsilateral supraclavicular nodes), while extensive-stage disease (seen in about 70% of patients) is defined as disease exceeding those boundaries. Clinical studies such as physical examination, x-rays, CT and bone scans, and bone marrow examination are used in staging. In part, the definition of limited- stage disease relates to whether the known tumor can be encompassed within a tolerable radiation therapy port. Thus, contralateral supraclavicular nodes, recurrent laryngeal nerve involvement, and superior vena caval obstruction can all be part of limited-stage disease. However, cardiac tamponade, malignant pleural effusion, and bilateral pulmonary parenchymal involvement generally qualify disease as extensive-stage because the organs within a curative radiation therapy port cannot safely tolerate curative radiation doses. Lung Cancer Staging Procedures (Table 85-3) All patients with lung cancer should have a complete history and physical examination, with evaluation of all other medical problems, determination of performance status and history of weight loss, and a CT scan of the chest and abdomen with contrast. Positron emission tomography (PET) scans are sensitive in detecting both intrathoracic and metastatic disease. PET is useful in assessing the mediastinum and solitary pulmonary nodules. A standardized uptake value (SUV) of >2.5 is highly suspicious for malignancy. False negatives can be seen in diabetes, in slow-growing tumors such as BAC, in concurrent infection such as tuberculosis, and in lesions <8 mm. False positives can also be seen in infections and granulomatous disease. Thus, PET should never be used alone to diagnose lung cancer, mediastinal involvement, or metastases. Instead, its primary function is to help guide a mediastinal biopsy for staging purposes and to help identify sites of metastatic disease. Fiberoptic bronchoscopy obtains material for pathologic examination and information on tumor size, location, degree of bronchial obstruction (i.e., assesses resectability), and recurrence. Table 85- 3 Pretreatment Staging Procedures for Patients with Lung Cancer All Patients Complete history and physical examination Determination of performance status and weight loss Complete blood count with platelet determination Measurement of serum electrolytes, glucose, and calcium; renal and liver function tests Electrocardiogram Skin test for tuberculosis Chest x-ray CT scan of chest and abdomen CT or MRI scan of brain and radionuc lide scan of bone if any finding suggests the presence of tumor metastasis in these organs Fiberoptic bronchoscopy with washings, brushings, and biopsy of suspicious lesions unless medically contraindicated or if it would not alter therapy (e.g., very late stage patient) X-rays of suspicious bony lesions detected by scan or symptom Barium swallow radiographic examination if esophageal symptoms exist Pulmonary function studies and arterial blood gas measurements if signs or symptoms of respiratory insufficiency are present Biopsy of accessible lesions suspicious for cancer if a histologic diagnosis is not yet made or if treatment or staging decisions would be based on whether or not a lesion contained cancer Patients with Non-small Cell Lung Cancer Who Have No Contraindication a to Curative Surgery or Radiotherapy with or without Chemotherapy All the above procedures, plus the following: PET scan to evaluate mediastinum and detect metastatic disease Pulmonary function tests and arterial blood gas measurements Coagulation tests CT or MRI scan of brain if symptoms suggestive Cardiopulmonary exercise testing if performance status or pulmonary function tests are borderline If surgical resection is planned: surgical evaluation of the mediastinum at mediastinoscopy or at thoracotomy If the patient is a poor surgical risk or a candidate for curative radiotherapy: transthoracic fine- needle aspiration biopsy or transbronchial forceps biopsy of peripheral lesions if material from routine fiberoptic bronchosc opy is negative Patients Presenting with Small Cell or Advanced Non- small Cell Lung Cancer For proven small cell lung cancer, all the procedures under "All Patients," plus the following: CT or MRI scan of brain Bone marrow aspiration and biopsy (if peripheral blood counts abnormal) For non- small cell lung cancer or cancer of unknown histology, all the procedures under "All Patients," plus the following: Fiberoptic bronchoscopy if indicated by hemoptysis, obstruction, pneumonitis, or no histologic diagnosis of cancer Biopsy of accessible lesions suspicious for tumor to obtain a histologic diagnosis or if therapy would be altered by finding of tumor Transthoracic fine- needle aspiration biopsy or transbronchial forceps biopsy of peripheral lesions if fi beroptic bronchoscopy is negative and no other material exists for a histologic diagnosis Diagnostic and therapeutic thoracentesis if a pleural effusion is present a Patients with non- small cell lung cancer and extrathoracic metastatic disease, malignan t pleural effusion, or intrathoracic disease beyond the bounds of a tolerable radiotherapy port. Note: CT, computed tomography; PET, positron emission tomography. . Chapter 085. Neoplasms of the Lung (Part 8) Small Cell Lung Cancer A simple two-stage system is used. In this system, limited-stage disease (seen in about 30% of all patients. physical examination, with evaluation of all other medical problems, determination of performance status and history of weight loss, and a CT scan of the chest and abdomen with contrast. Positron. tuberculosis Chest x-ray CT scan of chest and abdomen CT or MRI scan of brain and radionuc lide scan of bone if any finding suggests the presence of tumor metastasis in these organs Fiberoptic bronchoscopy