Lung

• True / False: lung cancer is the most commonly diagnosed cancer in males only

  • false: most commonly diagnosed cancer in males and females
• True / False: lung cancer is the leading cause of cancer death for males and females in Canada

  • true
• Adults > 65 years old
• smoking is the single largest risk factor

  • 90% in men
  • 80% in women
• Presenting symptoms:

  • shortness of breath
  • cough
  • dyspnea
  • chest pain
  • hemoptysis
• Pancoast tumour symptoms:

  • brachial plexopathy
  • Horner's syndrome
• Lung mets have more generalized symptoms

  • fatigue
  • weight loss
  • bone pain
  • headaches
• Clubbing:

  • enlargement of tips of fingers / toes
  • change in angle where nails emerge
  • paraneoplastic syndrome
  • hypercalcemia
  • superior vena cava syndrome
  • consequence of cancer cells but not due to local presence of tumour
  • tumour cells secrete factors → body creates immune response
• Superior vena cava obstruction

  • common with right upper lobe lesions extending into mediastinum
  • more common in SCLC
  • symptoms:
  • facial and arm swelling
  • blue neck and chest veins
  • shortness of breath
• Diagnostic tests:

  • CT or MRI with contrast → nerves vessels
  • bronchoscopy
  • thoracentesis → pleural effusion
  • pulmonary function test → for surgical candidates
  • molecular tissue tests (EGFR: NSCLC + BRAF and ROS1: SCLC)
  • renal function test → handle IV contrast (for CT and chemo)
  • history and physical
• Routes of spread:

  • direct extension: through visceral pleura into pleural cavity
  • malignant pleural effusion may occur
  • local extension:
  • ribs, heart, esophagus, vertebral column, opposite lung via hilum
  • non -encapsulated:
  • invade and attach to chest wall, diaphragm, pleura, pericardium
  • hematogenous:
  • bifurcation of trachea
  • lymphatic drainage from lung → circulatory system
• Lymphatic spread:

  • sub pleural plexus → hilar / bronchopulmonary nodes → mediastinal nodes → right or thoracic lymphatic duct
  • deep plexus → pulmonary nodes → hilar nodes → mediastinal nodes → right or thoracic lymphatic duct
• Metastatic sites:

  • cervical lymph nodes
  • opposite lung
  • brain (most common site for SCLC)
  • bone
• NSCLC

  • central and peripheral tumours = 80 - 85%
  • adenocarcinoma (peripheral)
  • squamous cell (bronchi)
  • large cell = uncommon
  • sarcoma and sarcomatoid = rare
  • slower metastases but less responsive to chemo
• SCLC

  • central tumours = 10 - 15%
  • oat cell (round blue cell)
  • responsive to chemo
  • can be fatal very fast
• Staging: NSCLC

  • stage 1: only in lung, no spread to lymph nodes
  • stage 2: lung + nearby lymph nodes
  • stage 3: lung + lymph nodes in middle of chest = locally advanced disease
  • 3A: lymph nodes on same side
  • 3B: lymph nodes on opposite / above collar bone
  • stage 4: = advanced disease
  • both lungs, fluid, another part of body (ex. liver)
• Staging: SCLC → very aggressive disease

  • limited stage
  • limited to one hemithorax, regional mediastinal lymph nodes, ipsilateral supraclavicular lymph nodes
  • extensive stage
  • overt metastatic disease identified through imaging and physical
  • no TNM staging - relies on surgical confirmation
  • only used to guide clinical decision making
• Stage I and II NSCLC management:

  • if operable:
  • surgical resection + adjuvant chemo (6 - 8 weeks post surgery)
  • lobectomy, pneumonectomy, mediastinal lymph node dissection, wedge resection
  • + margins: resection again or RT
  • "-" margins: adjuvant chemo + SBRT or EBRT
  • if inoperable:
  • chemo - platinum based
  • radiation therapy (stage I, II, III NSCLC)
  • EBRT or SBRT
  • fit, node positive, < 5 cm = SBRT
  • fit, node positive, > 5 cm = chemo RT
  • not fit, node positive, > 5 cm = radical RT
• Stage III NSCLC management:

  • if operable:
  • surgery + adjuvant chemo
  • if inoperable: performance status, weight loss, pulmonary reserve
  • poor: sequential chemo RT, hypo fractionated RT, palliative RT
  • good: concurrent chemo RT = 55 - 66 Gy / 25 - 33 fractions
  • N2:
  • initial staging: concurrent chemo RT = 55 - 66 Gy / 25 - 33 fractions
  • inoperative: full resection → adjuvant chemo +/- adjuvant RT
  • if palliative: symptom control
  • 20 Gy / 5 fractions or 30 Gy / 10 fractions → 2 week break → single fraction
• Acute esophagitis

  • due to increased toxicity from treatment
  • can delay treatment
• Stage IV NSCLC management:

  • clinical trial
  • if good ECOG, resectable, limited thoracic disease → surgery +/- SBRT
  • standard of care: combination chemo (4 cycles)
  • tyrosine kinase inhibitor: EGFR
  • palliative EBRT → specific symptoms and prophylactic prevention of symptom development
• Limited stage SCLC management:

  • surgery not recommended
  • "-" nodes: chemo only
  • + nodes: chemo + RT (mediastinum)
  • 4 - 6 cycles chemo + RT (40 Gy / 15 fr or 50 Gy / 25 fr)
  • stable: prophylactic cranial irradiation = 25 Gy / 10 fr
  • relapse disease free survival:
  • > 3 months: 4 cycles cisplatin - etoposide
  • < 3 months: palliative chemo for symptom control or RT (if tolerable = 25 Gy / 10 fr
  • clinical trial
  • if curative: thoracic irradiation + chemo
• Extensive stage SCLC management: T3 - T4 (multiple lung nodules)

  • analyze performance status, heart function, renal function
  • good: 4 - 6 cycles cisplatin + etoposide
  • poor: 4 - 6 cycles carboplatin + etoposide
  • stable disease: prophylactic cranial irradiation
  • relapse disease free survival:
  • > 3 months: 4 cycles cisplatin
  • < 3 months: palliative RT = 25 Gy / 10 fr
  • clinical trial
  • thoracic irradiation → symptom control only
• SABR / SBRT:

  • NSCLC
  • criteria: "-" nodes, tumour < 5 cm (stage I), inoperable / decline surgery
  • peripheral tumour = 48 Gy / 4 fr (every second day)
  • going through ribs → cause breakages
  • central tumour = 60 Gy / 8 fr (consecutive days)
  • preferred over conventionally fractionated RT
• EBRT:

  • NSCLC stage II and III
  • 4DCRT: radical, target close to diaphragm
  • continuous delivery throughout breathing cycle
  • radical standard dose: 60 Gy / 30 fr
  • CHART (continuous hyper fractionated accelerated radiotherapy)
  • 1.5 Gy / 3 times daily / 12 days
  • patient position
  • supine
  • AIO board, head rest, arms up with cushions, knee rest
  • energy: 6 or 15 MV or combo
  • IMRT or VMAT
• 4DCRT:

  • large ITV: highest and lowest extent of where tumour could be → should still be within volume with breathing motion
  • scan 1: breathe normal
  • scan 2: full breath + hold
  • scan 3: hold on exhale
  • add time to the scan in correlation with breathing motion
• abdominal compression: thorax + abdomen

  • limit breathing motion
  • smaller ITV
• DIBH:

  • hold breath at defined place
  • only treat when threshold is met
• PCI: for limited stage SCLC

  • whole brain (but not palliative fields) → MLC in place
  • collimator at 0
  • lateral POP fields
  • isocenter: midhead or below eye
  • inferior border → half beam blocked (protect eye)
  • shield: eye
  • treat frontal sinus
  • clearance all the way around
  • 25 Gy / 10 fractions
  • goal: sterilize brain against risk of recurrence
• Alternative to PCI:

  • VMAT for hippocampus avoidance (25 Gy / 10 fr)
  • prophylactic treatment
  • SRS - decrease neurotoxicity
  • responds to mets
  • does not prophylactically treat
  • medication trials - minimize neurocognitive decline
• Good Prognostic Indicators: NSCLC

  • early stage disease at diagnosis
  • ECOG: 0 - 2
  • no significant weight loss
  • female
  • absence of gene mutations (EGFR)
• Prevention:

  • smoking cessation → able to tolerate chemo toxicity
  • increased vegetable consumption for women

  Screening:

  • low risk: < 50 years + < 20 pack year
  • high risk:
  • 55 - 75 years + > 30 pack year
  • > 50 years + > 20 pack year + other risk factors
  • annual low dose CT scans - catch things early
• TD 5/5:

  • esophagus = 55 → stricture
  • heart = 60 → pericarditis
  • lungs:
  • 17 (3/3) = pneumonitis
  • spinal cord: myelitis
  • 50 (5 cm)
  • 50 (10 cm)
  • 47 (20 cm)
  • larynx = 45 → edema
  • brachial plexus
  • 60 (3/3) = brachial plexopathy (tingling, motor weakness in upper limb)
• Acute side effects of RT:

  • fatigue
  • alopecia of chest
  • erythema + dry desquamation
  • loss of appetite
  • esophagitis
  • especially if centralized tumour
  • radiation pneumonitis
• more than half of people diagnosed with lung cancer die within 1 year
• Pancoast tumour:

  • superior sulcus tumour in apex of chest
  • most are NSCLC
  • age: 60 years
  • men more
  • etiology: smoking, high levels of radon
  • symptoms:
  • sharp shoulder pain
  • arm weakness
  • tingling and numbness in hand
  • Horner's syndrome - miosis, anhidrosis, pytosis
  • invasion: chest wall and brachial plexus
• True / false: pancoast tumours are the least challenging thoracic tumours to treat

  • False: pancoast tumours are the MOST challenging thoracic tumours to treat - involvement with adjacent vital structures
• True / false: 60% of pancoast tumours are adenocarcinomas

  • true: 60% of pancoast tumours are adenocarcinomas
• True / false: pancoast tumours can only be NSCLC

  • false: most are NSCLC but some can also be SCLC
• Pancoast tumour management:

  • if caught early: operable
  • chemo RT (sterilize and shrink mass) → 3 - 7 weeks → surgery
  • RT dose: 45 Gy / 25 fr
  • delineate spinal cord and brachial plexus
  • chemo: cisplatin + etoposide
  • if inoperable (+ nodes and margins): RT
  • palliative: pulmonary function is poor / pleural effusion → Chemo RT
  • radial: chemo RT (no surgery)
  • chemo: cisplatin
  • RT: 66 Gy / 33 fractions (high dose since no surgery)