Non small cell
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Non-small cell lung cancer is the most common cancer worldwide and the leading cause of cancer death. The majority of cases are caused by smoking. There are several types of NSCLC, including adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. Staging involves assessing the size and spread of the primary tumor and lymph node involvement. Treatment depends on the stage and includes surgery, chemotherapy, radiation therapy, or a combination. Advanced or metastatic disease is generally treated with platinum-based chemotherapy, with or without other agents or palliative radiation. The document provides details on diagnostic testing, staging criteria, and treatment recommendations for each stage of NSCLC.
![N0 ;-… no regional node metastases……………………………………………………………N1 ;- Ipsilateral peribronchial or hilar node involvement………………………………………………………N2 ;- Ipsilateral mediastinal or sub carinal nodes .…………………………………………………N3;- contra- lateral mediatinal nodes or supraclavicular nodes .………………………………………………………………………………………………………………………..Staging grouping ;- T1 -2 N0 .T1-2N1 or T3 N0 . a ]T1-2N2 , or T3 N1-2 b ] T 4 any N M0 , or any N3 M0 .Any M1](https://image.slidesharecdn.com/nonsmallcell-110917091803-phpapp01/85/Non-small-cell-7-320.jpg)
Non small cell
- 1. NON SMALL CELLLUNGE CANCERDR…OMARHASHIM
- 2. Most common noncutaneous cancer in the world . The 2nd common cancerIn us . The lunge cancer is the most frequent cause of cancer death.Etiology ;-80—90 % of cases due to smoking .Is related to the number of cigarettes … number of yrs …. Type of cigaretteAsbestos .previous radiotherapy to the chest .Inhalation of radon gas , polycyclic aromatic hydrocarbon , nickel ,chromateInorganic arsenical .Types of NSCLC ;-AdenocarcinomaBronchioalveolar carcinoma .Squamous cell carcinoma .Large cell carcinoma
- 3. PathogenesisTwo theories were proposed to explain lung cancer:Multicellular model: considering small cell carcinoma of neural crest (neuroectodermal) origin and other carcinomas of endodermal originUnicellular model: considering that all types of carcinomas arise from a single multipotent stem cell capable of variety of phenotypesCarcinogenesis is a multistep process including activation of proto oncogenes and loss of tumor suppressor genes
- 4. In the NSCLC proto-oncogene activation ras +ve ……. C-erb-b 1 , C-erb –b2 + veOncosuppressor gene inactivation P 53 -> 50 % …………. RP -> O.O% .CLINICAL FEATURE;- Persistent cough …. Recurrent chest pain …. Pleural effusion …. Hoarse ofVoice ….wheeze , strider . … superior vena cava obs - …… horner s syndrome .wt loss … anorexia ……Paraneoplastic syndromes ;- ( restricted ) 1- hypercalcemia . 2- hypertrophic pul osteoarthropathy . ….. adenocarcinoma3-Gynecomastia ,…..large cell 4- hypercoagulable …… adenocarcinoma 5- carcinoid = VIP dirrhea
- 5. Workup ;-H &P ………. Performance status , wt los , smoking status ... Labs CBC…. BUN …. Cr … LFT …. Alkline phosphate . Imaging ;- CT chest & abd ;- size &site of 1ry tumor …. Relationship toLunge fissure , mediastinum , chest wall ….. Mediastinal or other l ns Metastatic disease (lunge ,, liver ,, adrenal ,, bone ) CT brain &bone scan if clinical suspicionPET scan for more sensitivity and specificity for pathological confir - than CTMRI brain for LNs + non squ and all stage 3 & 4 MRI ;-of the thoracic inlet for superior sulcus tumors to assess vertebralBody & brachial plexus invasion .Pathology ;-- thoracentesis for pleural effusion . For central lesions . Perform bronchoscopeCT guided biopsy for peripheral lesion , perform Ct guided biopsy .Mediastinoscopy or bronchoscopic biopsy
- 6. Staging ;-T1 ;-tumor 3cm or less in diameter , surrounded by lunge or visceral pleuraDistal to the main bronchus .………………………………………………………………………………T2 ;- tumour > 3cm diameter , involving main bronchus 2cm or more distal To the carina , or invading visceral pleura , or associated with atelectasisWhich extends to the hilum but not involve the whole lunge .……………………………………………………………………………………….T3 ;-tumour invading chest wall , diaphragm . Mediastinal pleura ,or peri –Cardium ,or tumour in main bronchus < 2cm distal to carina or atelectasisOf the whole lunge .………………………………………………………………………………T4 ;- tumour invading , mediastinum , heart , great vessels , trachea , oesophagusVertebra , or carina , or intralober tumour , or malignant pleura effusion .
- 7. N0 ;-… no regional node metastases……………………………………………………………N1 ;- Ipsilateral peribronchial or hilar node involvement………………………………………………………N2 ;- Ipsilateral mediastinal or sub carinal nodes .…………………………………………………N3;- contra- lateral mediatinal nodes or supraclavicular nodes .………………………………………………………………………………………………………………………..Staging grouping ;- T1 -2 N0 .T1-2N1 or T3 N0 . a ]T1-2N2 , or T3 N1-2 b ] T 4 any N M0 , or any N3 M0 .Any M1
- 8. TREATMENT RECOMMDATION ;-Stage 1 , 2 ;- operable Lobectomy ;- ….. Wedge resection only if physiologically compromised , LNSampling or resection general indicated . For completely resected T1-2N1 Give adjuvant chemo . Aduj- CH for T2N0 if > 4cm .Aduj CH for completely resectable T3N0 .RT for close +ve sm .Outcome ;- LRF …lobectomy 6% ….wedge 18% … 5 yrs os & CSS stage 1 50- 70 %………………………………………………………………………………..Stage 1,2 ;- marginally operable ;-Pre-op chemo -> surgery -> chemo .Chemo ;-.. Cisplatin com- or carboplatin-paclitaxel .For close + ve sm -> post op RT
- 9. Outcome ;- 5 yrs os N1 50 %
- 10. ……………………………………………………………………………………………… Stage 1,2 ;- inoperable ;- definitive RT to 1ry & LNConventional fractionation is 2gy /fx to 66 Gy
- 11. if peripheral tumour or poor PS may hypofractionate with 4Gy /fx to 45 GyTo 1ry tumour only.Outcome ;- std RT 5 yrs T1N0 ; 30 – 50 % .Hypo-fx 2-3 yrs os 40 --- 50 % .SBRT ;- 2-3 Yrs lc 85 -95 % …os 55 % . Dose escalation > 70 Gy & SBRT TECH- 60 Gy/3fx improved LC compared toConventional tech- & dose . If pts can tolerate it , give chemo ( inducationConcurrent and cnsolidation ) if T3N0 chemo should be avoided concurrentlyWith dose escalated RT or SBRT until further data are available .…………………………………………………………………………………………………………Stage 3 a ( operable – marginally operable ) ;-concurrent chemo – RT (45 Gy )Restage -> if no progression -> surgery -> chemo specially if iniliallyBulky or multipl N2 nodes .Alternatively , chemo alone ->retage ->if no progression -> surgery -> chemoAnd post op RT for close < 5mm or +vesm , ECE or N2 disease .If unresectable after restaging -> complete definitive concurrent chemo --RT ( 63Gy) . .
- 12. Outcome ;- 5 yrs os 20 – 25 % , MS . 16 -17 months inducation chemo –RT pcR rate 15-20% post- op RT possible 5 – 10 % os benefit for N2…………………………………………………………………………………………….Stage 3 ( inoperable ) ;-Concurrent chemo –RT ( 63 Gy ) -> aduj chemo . If unacceptable risk of Pneumonitis with upfront RT , consider inducation chemo for down staging->concurent chemo –RT to ( to postchemo volume ) . If no progression .Outcome ;-5 yrs osandMS concurrent chemo- RT 20 -25 % , 16 – 17 months .Sequential chemo –RT 20% , 13 -15 months , RT alone <10 % , 10 -12 months……………………………………………………………………………………………………………Stage 3 b ( no pleural effusion ) ;-Concurrent chemo –RT ( 61-63 ) , IF unacceptable risk of pneumonitis withUpfront RT, consider induction chemo for down- staging -> concurrentChemo-RT (to postchemo volume ) if no progression .If T4 N0 may treated with surgery -> chemo ± RT ( if residual or ± SM ) orChemo ±RT -> surgery -> chemo
- 13. Typical chemo;- postsurgery ;-Cisplatin 100mg/mxm d1 & etoposide 100mg/m xm d1-3 every 4 week x4Cycle . Other combinations with vinorelbine , vinblastine , gemcitabine & docetaxelMay be consider .Alternatives ;- if not able to tolerate cisplatin ; carboplatin , paclitaxel every3week for 4 cycles .Concurrent with RT ;Cisplatin 50mg/mxm d1 , 8 , 29 & 36 and etoposide 50mg/mxm d1 -5 &29-33 .Alternative ; cisplatin week 1 & 4 vinblastine weekly , or carboplatin &pacli-Taxel weekly .Sequential chemo – RT Cisplatin 100 mg/ mxm d1 , 29 & vinblastine 5mg/ mxm weekly x 5 weekAlternative carboplatin & paclitaxel every 3week x2 cycles .Consolidation chemo after chemo –RT ;-Carboplatin & paclitaxel every 3 week x 2 cycles .Local treatment as necessary (E.G pleurodesis ) & treat as stage 4 .
- 14. Stage 4 ;-Platinum – based chemo ± bevacizumab ± palliative RT . Frist line chemo uses 2agents with response assessment after each cycle , for up to 4-6Cycles or until progression .