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

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

Any suggestions / feedback is welcome

And may please be communicated to

< drjaydr@pn3.vsnl.net.in >