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Lung Neoplasms

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Diagnosis Evaluation Staging

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Reported by: Venus L:orraine B. Datud, MD2a

3 areas of assessment:
1. 2.

3.

Primary tumor Presence of metastatic disease Functional status


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1. Assessment of Primary Tumor HISTORY

symptoms, PE

LOCATION of tumor

CXR, CT Scan

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Determination of Invasion

Presence of pain Chest CT with contrast


delineation of mediastinal LN Invasion of contiguous structures No improvement over CT scan for those with allergies to

MRI

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Tissue Diagnosis

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Thoracotomy

Occasionally necessary Deep-seated lesions:


a.

indeterminated needle biopsy result,

Lobectomy may be necessary

b.

could not be biopsied for technical reasons

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excisional biopsy is preferred

2. Assessment of Metastatic Dse imply inoperability Presence


Historynew bone pain, neurologic symptoms, skin lesions

Evidence of weight loss

PE: Evaluation of cervical and supraclavicular LN and oropharynx

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CT Scanmost effective non-invasive method


Positive CT: nodal diameter > 1cm 30% due to noncancerous reactive causes Requires histologic confirmation

Mediastinal Lymph Nodes Metastasis

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PET Scan

Detection of positrons emitted by fluorodeoxyglucose glucose analogue labelled with positron-emitting fluorine Accumulate in cancers

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A single FDG injection allows evaluation of whole body:

lung cancer in left upper lobe (arrow) as well as within 2 small ipsilateral mediastinal lymph nodes (arrowheads)
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CT Scan vs. PET Scan

PET scan has higher sensitivity & accuracy Recent development of combined PET-CT Scanners may improve accuracy

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Endoesophageal ultrasound (EUS)

Recently emerged as method of staging in NSCLC Visualize mediastinal paratracheal LN, and lesions contiguous or near esophagus Obtain tissue samples Unable to visualize anterior (pretracheal) mediastinum

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Cervical mediastinoscopy

standard method of tissue staging of the mediastinum Suprasternal skin incision

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sampling of paratracheal and subcarinal LN visual determination of presence of extracapsular extension of nodal metastases

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**It is particularly important to prove pathologically that mediastinal lymph nodes are involved before deciding that the patient is not a candidate for resection

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Malignant Pleural Effusion

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Distant Metastases

Combination of chest CT scan and multiorgan scanning Chest CT Scan

Always include upper abdomen and visualization of liver and adrenal glands Further evaluation by MRI scanning High sensitivity but low

Bone Scans

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PET Scan

Metastases to liver, adrenal glands and bones Combined with CT Scan for routine evaluation of patients with lung cancer Integrated PET-CT Scanners demonstrate better accuracy

Brain MRI if with risk of brain metastases

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**With any radiologic assessment, accuracy must be ensured. The patient must be given the benefit of any doubt about the accuracy of the scan; the result must be proven, most often by biopsy, to be truepositive.
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3. Assessment of Functional Status

Historymost important tool for gauging risk Clinical assessment entails observation of the patients vigor and attitude

Patients attitude toward the disease was the best indicator for long term survival Except in life-threatening situations, patients should never

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Determining patient tolerance for resection

Walk on flat surface indefinitely without dyspnea > thoractomy and lobectomy Can walk up to 2 flight of stairs without dyspnea> pneumonectoomy Nearly all patient can tolerate periods of single-lung ventilation and wedge resection

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Increased risk of postop complications Significant risk reduction requires cessation of smoking at least 8 weeks preoperatively In cancer patients,

ideally for 2 weeks


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before surgery

Physical Examshould
focus on signs of COPD or airflow limitation:

Cyanosis Peripheral edema Mild post-cough SOB Wheezes, crackles Wet cough

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Pulmonary function studiesused when resection


greater than wedge resection will be performed

FEV1 and DLCO are most valuable

FEV1 Volume that has been exhaled at the end of the first second of forced expiration DLCOdiffusing capacity of CO2

FEV1 guidelines:

>2 L can tolerate pneumonectomy < 1.5 L can tolerate lobectomy

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corrections made for age, height and

Quantitative perfusion scanningestimate


functional contribution of a lobe or whole lung

Exercise testingyield
maximum oxygen consumption (VO2max)

<10 ml/kg/ minuteprohibits any


major pulmonary resection due to mortality rate of 26%

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>15ml/kg/minutetolerate

**Risk assessment is based on a combination of clinical judgement and data. This risk assessment must be integrated with the experienced clinicians sense of the patient and with the patients attitude toward the disease and toward life

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Lung Cancer Staging Systems Based on tumor, node and


metastasis (TNM) system

T: size and relationship of N: regional lymph nodes

primary tumor to surrounding structures


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M: presence or absence of
metastatic disease

7th Edition of TNM in Lung Cancer of the International Association for the Study of Lung Cancer (IASLC) Staging Committee

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American Joint Committee on Cancer Staging System for Lung Cancer

Any M = Stage IV
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End of report.
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Thank You.