BRONCHOIAL BRONCHOIAL TUMOURSTUMOURS

• STAGING OF BRONCHOGENIC CANCER- Small cell lung cancer is staged as;

Limited , when the tumour confined to the ipsilateral hemi-thorax and supra clavicular LNs .

Extended , everything else.

- Non – small cell lung cancer , is commonly classified as TNM staging system,

Primary tumour (T).• Tx primary tumour cannot be assessed , or tumour

proven by presence of malignant cell in sputum or bronchial washing, but not visualized by imaging or bronchoscopy.

• T0 no evidence of primary tumour• Tis carcinoma in situ• T1 tumour <3 cm surrounded by lung or viceral pleura.• T2 tumour >3 cm , or >2 cm from main carina, or

invading viceral pleura , or associate with atelectasis or obstructive pneumonitis, that extend to the hilum.

• T3 tumour of any size invading chest wall , diaphragm, parietal pericardium, mediastinal pleura, or tumour in the main bronchus < 2cm from main carina.

• T4 tumour of any size invading, mediastinum, heart, great vessels , trachea, oesophagus, carina, vertebral body, or malignant pleural or pericardial effusion.

Regional nodes (N)• Nx can’t be assessed• N0 no regional LN metastasis• N1 ipsilateral peribronchial and/or ipsilateral hilar nodes• N2 ipsilateral mediastinal and/or subcarinal nodes.• N3 contralateral mediastinal or hilar nodes , or any

scalene or supra clavicular nodes.

Distant metastasis (M)• Mx cannot be assessed• M0 no distant metastasis• M1 distant metastasis present , including separate nodes

in different lung lobes.

Stage TNM subset 0 Tis I A T1 M0 N0 l B T2 M0 N0 ll A T1 N1 M0 ll B T2 N1 M0 T3 N0 M0 lllA T1 N2 M0 T2 N2 M0 T3 N1-2 M0 lllB T4 N0-2 M0 T1-4 N3 M0lV any T, any N , M1

Management of primary lung cancer

1- Non – small cell cancer

A- surgery

The aims of surgery for lung cancer are to completely excise the tumour and local lymphatics, with minimal removal of functioning lung parenchyma.

Stage l and ll NSCLC are usually amenable to surgery if the patient is fit enough , therefore careful staging and assessment of the patient's respiratory reserve and cardiac status are essential requirement to surgery.

Surgery will offer 5 year survival rates of over 75% in stage l and 55% in stage ll disease .

Contra indications to surgical resection in Lung Ca.

1- Distant Metastasis

2- Invasion of central mediastainum structures(T4)

3- Malignant pleural effusion (T4)

4- Contralateral mediastinal nodes (N3)

5-FEV1<0.8L

6- Unstable or severe cardiac or other medical conditions

B- Radiotherapy;

Radical radiotherapy can offer long term survival in selected patients with localised disease in whom co-morbidity precludes surgery. The greatest value of radiotherapy is in palliation of distressing complications such as, spinal cord compression , superior vena caval obstruction, severe haemoptysis, pain caused by chest wall invasion or skeletal metastasis, or trachea or main bronchial obstruction.

Now a days there is CHART radiotherapy which is

( continuous hyper fractionated radiotherapy), in which a similar dose of radical radiotherapy given in smaller and frequent fractions.

C- Chemotherapy

Usually considered in patient with stage lll and lV disease and only 40% respond to it temporarily.

Combination chemotherapy is usually superior to single chemotherapy and the survival gained is usually 6-7 weeks compare with best supportive care only.

Adjuvant chemotherapy following surgery has been found to have significant survival advantages.

2- Small cell lung cancer

A- Chemotherapy

The treatment of SCLC with combination cytotoxic drug and some time in combination with radiotherapy, can increase the median survival with this highly malignant tumour from 3 months to over a year. regular cycle of chemotherapy are usually used and nausea and vomiting are the common side effects.

The combined chemotherapy are either (cyclophosphamide , doxorubicin and vincristine) or (cisplatin and etoposide).

B- Radiotherapy

Patient with limited disease will benefit from consolidation radiotherapy following chemotherapy ,some times palliative radiotherapy can be given in patient with extensive diseased.

• Prognosis

The overall prognosis in all types of lung cancer are poor , around 80% of patients die with in one year from diagnosis , less than 6% surviving 5 years following diagnosis.

The best prognosis is with well differentiated Squamas cell cancer which have not metastasised and amenable to surgery.