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• Lung
• NSCLC

Lung Cancer

Non-Small Cell Lung Cancer

Amoung the most common malignancies. Is the leading cause of cancer deaths in the world. Lung cancer is usually not diagnosed early and has an OS₅ approaching 15%.

Lung cancer treatment depends on the extent of disease, location of the primary tumor and medical co-morbidities. The assessment of extra-pulmonary intrathoracic and extrathoracic disease is essential for staging and evaluation for determination of treatment.

70-80% NSCLC

NSCLC: Squamous Cell

• Central, cavitating lesions
• hypercalcemia associated
• Incidence decreasing
• least likely to metastasize to brain

NSCLC: Adenocarinoma

• peripheral
• hypertrophic, pulmonary ostesarcoma
• Dermatomyositis
• Incidence increasing/worse prognosis
• second most common metastases to brain (39%) after SCLC

NSCLC: Bronchoalveolar

• Bliateral, women predominate
• Peripheral nodule, multifocal or pneumonic adenocarcinoma arising form Type II pneumocytes

NSLCL: Large Cell

Peripheral

Natural History

• Most common non-skin cancer in the world
• 2^ndmost common cancer in the US (prostate and breast)
• #1 cause of cancer death in the world and USA
• >90% caused by smoking & tobacco exposure
• Adenocarcinoma is 40-50% of NSCLC and is more often peripherally located
• BAC is an adenoCA subtype
• Squamous Cell CA is more likely to be centrally located
• Large cell like adenocarcinoma is more often peripheral and has a high tendancy to metastastize
• Carcinoid tumors are rare, tend to be endobronchial and rarely metastasize.
• about half are localized or locally advanced at diagnosis (compared to SCLC where 80% are advanced)

Lung cancers arise from either the alveolar lining cells of the pulmonary parenchyma or the mucosa of the tracheobronchial tree.

Common distant metastatic sites are:

• brain
• bones
• adrenal glands
• contralateral lung
• liver
• pericardium
• kidneys

Anatomy

Staging Workup

• HP: KPS & weight loss
• Sputum x3 80% reliable for large, central tumors, 20% for small distal tumors.
• FNA; Bronchoscopy
• Labs
• Imaging:
  • CT/PET
  • MRI Brain (if stage >IIB (T2N1 or T3N0) or neurologic signs)
  • MRI Chest (if Thoracic Inlet tumor)
• PFTs:
  • FEV1<0.8 l may be a candidate if related to tumor-- get quant V/Q
  • DLCO <40% only with highly conformal RT and with close attention to V20.
  • Goals for FEV1: ≥ 75% of predicted, DLCO ≥60%
• Thoracentesis if effusion: Malignant Effusion is a wet IIIB and will be a Stage IV at next staging
• Bronchoscophy for central lesions, CT guided biopsy for peripheral lesions
• Mediastinoscopy/Bronchoscopy to confirm PET/CT Positive nodes
• Mediastinoscopy to evaluate upper mediastinal (Level 1-2) nodes for all superior suclus tumors, large (T3) or central T1/T2
  • Mediastinoscopy evaluates Lvl 1-2 Nodes
  • Chamberlain evaluates Lvl 5-6 nodes (AP window) and differs primarily by its incision at the 3rd intercostal space instead of a cervical incision.

Syndromes

• Horner's: ptosis, partial anhydrosis, meiosis: arises from primary disease, not lymph nodes
• SVC: from Mediastinal LN. Lung cancer #1 cause, Lymphoma #2 cause
• Pancoast: Upper lobe tumor C1-T8 (brachial plexus) with ulnar pain
  • Shoulder pain
  • brachial plexus palsy
  • Horner's Syndrome

Staging

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Radiation Oncology Synopsis