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Lung Cancer: I Gede Ketut Sajinadiyasa
Lung Cancer: I Gede Ketut Sajinadiyasa
Lung Cancer: I Gede Ketut Sajinadiyasa
Asbestos exposure 5
Asbestos and tobacco 90
60
40
20
0
Dyspnoea Cough Pain Loss of Haemoptysis
appetite
FNAB
NSCLC stages
Lymph nodes
Invasion of
chest wall
Metastasis
to distant
organs
Main
bronchus
Stage 0
Stage IA
Stage IIB
Stage IIIB
Contralateral Stage IV
lymph node
Stage groupings in 7th TNM classification
Stage T N M
Occult Tx N0 M0
0 Tis N0 M0
IA T1a,b N0 M0
IB T2a N0 M0
IIA T1a,b N1 M0
T2a N1 M
T2b N0 M0
IIB T2b N1 M0
T3 N0 M0
IIIA T1,T2 N2 M0
T3 N1,N2 M0
T4 N0,N1 M0
IIIB T4 N2 M0
Any T N3 M0
IV Any T Any N M1a, b
AJCC Cancer Staging Manual. 7th ed. 2010
Definitions of TNM (1)
TX = 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 bronchoscopy.
Tis = Carcinoma in situ.
T1a = Tumor ≤2 cm in greatest dimension.
T1b = Tumor >2 cm but ≤3 in greatest dimension.
T2a = Tumor >3 cm but ≤5 cm in greatest dimension
T2b = Tumor >5 cm but ≤7 cm in greatest dimension.
T3 = Tumor >7 cm or one that directly invades any of the following:
parietal pleural (PL3) chest wall (including superior sulcus tumors),
diaphragm, phrenic nerve, mediastinal pleura, or parietal pericardium.
Tumor in the main bronchus (<2 cm distal to the carinab but without
involvement of the carina). Associated atelectasis or obstructive
pneumonitis of the entire lung or separate tumor nodule(s) in the same
lobe.
T4 = Tumor of any size that invades any of the following: mediastinum,
heart, great vessels, trachea, recurrent laryngeal nerve, esophagus,
vertebral body, carina, or separate tumor nodule(s) in a different
ipsilateral lobe.
AJCC Cancer Staging Manual. 7th ed. 2010
Definitions of TNM (2)
N0 = No regional lymph node metastasis.
N1 = 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.
N3 = Metastasis in contralateral mediastinal, contralateral
hilar, ipsilateral or contralateral scalene, or supraclavicular
lymph node.
M0 = No distant metastasis.
M1a = Separate tumor nodule(s) in a contralateral lobe tumor
with pleural nodules or malignant pleural (or pericardial)
effusion.
M1b = Distant metastasis.
AJCC Cancer Staging Manual. 7th ed. 2010
SCLC stages
Extensive
Tumour not confined
to hemithorax of
origin
Distant metastasis
Limited
Tumour confined to
hemithorax of origin
and/or the
mediastinum and
supraclavicular nodes
Platinum-based doublets:
1990s 8–10 months
Single-agent platinum:
1980s
6–8 months
1970s BSC:
2–5 months
0 2 4 6 8 10 12 14
Median survival (months)
Extensive-stage disease
– combination chemotherapy +/- PCI
– radiotherapy + combination chemotherapy
SMOKING CESSATION
Health Effects of Smoking
Heart disease Osteoporosis
Lung disease – COPD, asthma Wound healing
Cancer Anxiety
– Lung, ENT, pancreas Miscarriage
– Cervix, colorectal SIDS
– Skin (squamous cell) Hearing loss
Vascular disease - impotence Rheumatoid arthritis
Stroke Macular degeneration
Cataracts Tooth decay
Gum disease Depression
Dementia Multiple sclerosis
Early menopause
Smoking kills more people
each year than
alcohol homicide
cocaine suicide
crack car accidents
heroin fires
AIDS
Health benefits after quitting
cough, DOE resolve in weeks
exercise tolerance improves rapidly
bladder cancer: 50% reduction in 5 years
lung cancer: 50% reduction in 10 years
heart disease: 50% reduction in 1 year!
No excess risk of heart disease by 10-15 years
vascular disease: 50% reduction in 5 years
mortality - same as never smokers by 10-15 yrs
Changes in relative risk (RR) for lung cancer after
cessation between former and
persistent smokers
Impact of smoking and smoking cessation on survival in men
Approach of Smoking Cessation
5 A’s (Ask, Advise, Assess,
Assist, Arrange)
5 R’s (Relevance, Risks, Rewards,
Roadblocks, Repetition)
Approach Model of Smoking Cessation
General
Population
Patient presents
to a health care
setting (clinic,
hospital, work site,
Relapse
others)
Prevent
Relapse
Patient remains
unwilling
Unwilling to quit
(5 R’s Approach.)
Relevance :Encourage the smoker to identify why quitting is
personally relevant
Risks :Ask the smoker to identify negative consequences of
continued tobacco use for them in both the short and long
term
Rewards :Ask the smoker to identify and discuss specific
benefits of quitting
Roadblocks :Assist the smoker to identify barriers and
specific impediments to quitting
Repetition : Reinforce the motivational message at every
opportunity and reassure that repeated quit attempts are not
unusual
FDA-approved medications for smoking cessation
Transdermal NRT
Varenicline Tartrate
Thank you
Predictors of quit attempts and
cessation success
Fagerström test for nicotine dependence
(FTND)
Earlier diagnosis
Obstructive lung disease (chronic bronchitis and
emphysema)
Genetic risk factors
Sputum cytology
Low-dose spiral computed tomography
Positron emission tomography
Laser-induced fluorescence endoscope (LIFE)
bronchoscopy
White-light LIFE
bronchoscopy image bronchoscopy image
Prevention
Education and primary prevention
– avoidance of environmental carcinogens,
eg tobacco smoke
Chemoprevention
– retinoids
– EGFR inhibitors
– selenium
– COX-2 inhibitors
– green tea
Staging - TNM
Tumor size:
– T1 < or = to 3cm
– T2 > 3cm
– T3 = local extension (parietal pleura,
chest wall or within 2cm of carina)
– T4 = spread to great vessels, trachea,
mediastinum, esophagus or malignant
effusion (nonresectable)
Staging - TNM
Lymph Node
– N0 = no involvement
– N1 = hilar nodes
– N2 = mediastinal nodes
– N3 = contralateral nodes or ipsilateral
supraclavicular (nonresectable)
Staging Continued
Stage IA - T1 N0 M0
Stage IB - T2 N0 M0 (T >
3cm)
Staging Continued
Stage IIA - T1 N1 M0
Stage IIB - T2 N1 M0
T3 N0 M0
Staging Continued
Stage IIIA - T3 N1 M0
T1-3 N2 M0
T4 Any N M0
Staging Continued
Stage IV - Any T Any N M1
5-year survival by TNM status in
NSCLC
Stage TNM classification 5-year survival
(%)
IA T1N0M0 61
IB T2N0M0 38
IIA T1N1M0 34
IIB T2N1M0 or T3N0M0 24
IIIA T1-3N2M0 orT3N1M0 13
IIIB T4NanyM0 or TanyN3M0 5
IV TanyNanyM1 1
Mountain 1997
NSCLC: treatment options overview
Stage I Stage II
• Lobectomy or segment/wedge • Lobectomy, pneumonectomy,
resection segment/wedge resection as
• Curative radiotherapy if surgery is appropriate
contraindicated • Curative radiotherapy if surgery
• Adjuvant chemotherapy contraindicated
• Adjuvant radiotherapy • Adjuvant chemotherapy
• Adjuvant radiotherapy